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Integrated Policies & Procedures

42 CFR 438 Medicaid/Medi-Cal Managed Care Policies – MHD and SUTS
Credentialing and Re-Credentialing Policy
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Provider Network
Credentialing and Re-Credentialing Policy
The Santa Clara County Behavioral Health Services Department (BHSD) ensures that its county-owned and operated providers (i.e., BHSD employees) and contract organizational providers that deliver Medi-Cal-covered services are qualified in accordance with current legal, professional, and technical standards, and -are appropriately licensed, registered, waivered, and/or certified. The term provider is used in this document to refer to clinicians or counselors who provide direct services to plan beneficiaries.
Provider Directory
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Provider Directory
Provider Directory
It is BHSD’s practice to adhere to DHCS requirements in developing and maintaining the Provider Directory in accordance with the State and Federal requirements, including directory content, type, language, and format.
Use of Electronic Health Records and Password
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Security Addendum
Use of Electronic Health Records and Password
Behavioral Health Services Department (BHSD) policy to ensure BHSD and its subcontractor have adequate method to secure and protect ePHI and PHI in accordance with applicable laws and regulations. Access to ePHI/PHI is based on a staff person’s role. BHSD will adhere to the Security of ePHI/PHI as described in 42 CFR Part 2, 45 CFR Parts 160 and 164, HIPAA, HITECH Act, SCVHHS PP 585.23, and will require its subcontractors to adhere to above laws, regulations and county policy. Subcontractors are required to create and maintain and provide applicable Policies and Procedures in accordance with all applicable Privacy and Security Rules, including the transmission of ePHI/PHI and password protections.
Cultural Competency and Non-Discrimination
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Access and Availability of Services
Cultural Competency and Non-Discrimination
BHSD shall participate in the state's efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity. BHSD shall accept beneficiary applicants in the order they applied and shall not discriminate regardless of health status or need for health care services, race, color, national origin, sex, gender, sexual orientation, gender identity, or disability, and ensure high quality services that are equitable to underserved, accessible and responsive to socially disadvantaged and ethnically diverse groups, which include culturally and linguistically appropriate services.
Beneficiary Problem Resolution
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Beneficiary Problem Resolution
Beneficiary Problem Resolution
Beneficiaries that receive BHSD services may file a grievance or appeal and have their concerns addressed through a clearly defined problem resolution process if they are not satisfied with their behavioral health services or steps taken by BHSD.
SUTS Beneficiary Request for 2nd Opinion
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Beneficiary Rights
SUTS Beneficiary Request for 2nd Opinion
Per 42 CFR 438.206 (b) (3), at the request of a beneficiary, Behavioral Health Services Department (BHSD) shall provide for a second opinion by a licensed professional of the healing arts (LPHA) either employed by or contracted with BHSD, when BHSD or one of its providers determine that the medical necessity criteria as described in 42 CFR 438.210 have not been met [specifically, criteria from the Diagnostic Statistical Manual Version 5 (DSM 5) and American Society of Addiction Medicine (ASAM)
Advance Directive
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Beneficiary Rights
Advance Directive
Behavioral Health Services Department values and upholds the right and freedom of the individual person to decide on every aspect of their life, including end of life decisions. BHSD recognizes and accepts all instruments that protect and safeguard this right and freedom of the individual to decide, including the right to have an Advance Directive. In addition, BHSD provides education about Advance Directive policies and procedures.
Beneficiary Rights
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Beneficiary Rights
Beneficiary Rights
DHCS defines beneficiary rights to include but not be limited to: • Be treated with personal respect and respect for your dignity and privacy. • Receive information on available treatment options and alternatives; and have them presented in a manner they can understand.
Notification of Material Changes
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Beneficiary Rights
Notification of Material Changes
Within 15 calendar days of receipt of a contracted provider’s valid formal termination notice, BHSD shall make a good faith effort to give written notice of the termination of the contracted provider to each beneficiary who received behavioral health services from, or was seen on a regular basis by the terminated contract provider.
Providing Language Services
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Beneficiary Rights
Providing Language Services
BHSD makes services available to all beneficiaries who need them in a manner that promotes, facilitates, and provides the opportunity for their use. Services shall be delivered in ways which recognize, are sensitive to, and respectful of individual and cultural differences.
Care Coordination and Continuity of Care
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Coordination and Continuity of Care
Care Coordination and Continuity of Care
The Behavioral Health Services Department (BHSD) will ensure: 1. Each beneficiary has an ongoing source of care appropriate to his or her needs. 2. A person or entity is formally designated as primarily responsible for coordinating services accessed by the beneficiary. 3. The beneficiary is provided information on how to contact their designated person or entity. 4. Each beneficiary’s right to change the designated network provider when such change is clinically appropriate and possible. Care Coordination
Claims Adjudication Process
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Documentation Requirements
Claims Adjudication Process
The Behavioral Health Services Department (BHSD) shall comply with all eligibility, service, and payment data certification requirements under applicable federal and state law, for all claims submitted for federal financial participation (FFP).
Cost Sharing and Payment of Services
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Financial Reporting Requirements
Cost Sharing and Payment of Services
The Department Policy on Cost Sharing and Payment of Services will follow 42 CFR 438 with regards Emergency and Post Stabilization Services, Cost Sharing, Non-Payment, Treatment of Recoveries, Insolvency, and Payments.
Emergency and Post Stabilization Services
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Financial Reporting Requirements
Emergency and Post Stabilization Services
1. BHSD does not deny payment for behavioral health treatment obtained in the following circumstances: a. An emergency behavioral health condition including cases in which absent immediate medical attention would place the beneficiary in serious jeopardy, seriously impair bodily functions or serious dysfunction of any bodily organ or part. b. Where a representative of the MCP instructs the beneficiary to seek emergency behavioral health services.
Provider Beneficiary Communication
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Provider Network
Provider Beneficiary Communication
County and/or Contractor will not prohibit nor otherwise restrict, a licensed, waivered, or registered professional who is acting within the lawful scope of practice from advising or advocating on behalf of a beneficiary for whom the provider is providing behavioral health services.
Provider Network Enrollment and Screening
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Provider Network
Provider Network Enrollment and Screening
To ensure that providers are enrolled as Medi-Cal providers and are appropriately screened, Behavioral Health Services Department (BHSD) requires that all providers must be enrolled as Medi-Cal providers with the State and meet federal disclosure, screening, and enrollment requirements.
Provider Network Selection and Retention
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Provider Network
Provider Network Selection and Retention
To ensure that network providers understand the elements of the provider selection process and maintain compliance with state and federal Medicaid regulations, BHSD established policies and processes to ensure that providers are equitably selected. Following BHSD Provider Standards, BHSD does not: a. Contract with providers beyond the number necessary to meet the needs of its enrollees.
Network Adequacy and Timely Access
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Provider Network
Network Adequacy and Timely Access
To ensure that throughout the geographic regions of Santa Clara County (SCC), the Behavioral Health Services Department (BHSD) will comply with network adequacy standards developed pursuant to Title 42 of the Code of Federal Regulations Part 438.68, as specified in Chapter 738, Statutes of 2017 (Assembly Bill 205), for all beneficiaries.
Evidence-Based Practice
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Quality Improvement System
Evidence-Based Practice
The Behavioral Health Services Department (BHSD) will integrate current evidence-based knowledge into the provision of services to support continued beneficiary outcome improvement. This will include training in evidenced-based practices; clinical supervision to support and develop practices including fidelity monitoring as appropriate for the beneficiary; and monitoring of training, supervision, and practice use.
Data Entry and Data Reporting Requirements
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Reporting Requirements
Data Entry and Data Reporting Requirements
Pursuant to 42 C.F.R. § 438.242 and consistent with Cal. Code Regs., tit. 9, § 1810.376, the Behavioral Health Services Department (BHSD) shall maintain a health information system that collects, analyzes, integrates, and reports data. BHSD’s health information will: (1) collect data on beneficiary and provider characteristics and on services furnished to beneficiaries as specified by DHCS, (2) verify the accuracy and timeliness of data reported by its providers, and if applicable, data from network providers receiving capitation payments; (3) screen the data received from providers for completeness, logic, and consistency, and (4) collect data from providers in standardized formats to the extent feasible and appropriate, including via secure information exchanges and technologies utilized for state Medicaid quality improvement and care coordination efforts.
Limitation on Moral or Religious Grounds
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Scope of Services
Limitation on Moral or Religious Grounds
Providers will not be required to deliver, reimburse for, or offer coverage of a counseling or referral service if the provider objects to the service on moral or religious grounds. Beneficiaries will know which providers have objections based on religious or moral grounds prior to referral or change.
Medical Necessity
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Scope of Services
Medical Necessity
BHSD will adhere to clear parameters around medical necessity criteria for inpatient, outpatient, EPSDT and substance use treatment services, including providing, arranging and paying for all demonstrated medically necessary covered behavioral health services given to beneficiaries with covered diagnoses, as set forth by Federal and State regulations, by industry criteria such as ASAM, and by its own Utilization Management Program and Clinical Practice Guidelines.
Out of Plan Services
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Scope of Services
Out of Plan Services
BHSD is responsible for providing or arranging medically necessary behavioral health services for beneficiaries outside their county of origin for emergency and post stabilization services. If BHSD is unable to provide outpatient medically necessary covered services to a beneficiary it will provide timely and adequate out of plan services for as long as BHSD is unable to provide these services. BHSD will arrange for medically necessary behavioral health services for children in foster care residing outside their county of origin. BHSD will provide medically necessary behavioral health services to foster care children placed in Santa Clara County.
Telehealth Policy for Psychiatry (Outpatient Services)
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Telehealth
Telehealth Policy for Psychiatry (Outpatient Services)
Upon approval by the BHSD System of Care Executive Director (or designee), Medi-Cal eligible telemedicine services (e.g. Psychotherapy, Pharmacologic Management, Consultations, etc.) may be provided to clients when equivalent in-person services are not available.
Utilization Management
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Utilization Management Program
Utilization Management
The Behavioral Health Services Department (BHSD) Utilization Management (UM) program supports the delivery of services provided by its County and Contracted partners, and ensures delivery of high quality, medically necessary care through appropriate utilization of resources in a cost effective and timely manner. The UM program is a key component of the BHSD's "Quality Assessment and Performance Improvement" (QAPI) Division. The UM Program operates under the guidance of the BHSD’s Director, Quality Management Executive Director, Medical Director, and Utilization Management Division Director. The program is designed to detect and address over and underutilization of services, and evaluates medical necessity and appropriateness of services provided to Medi-Cal beneficiaries prospectively, concurrently, and retrospectively. This policy outlines the standards and guidelines that detail how the BHSD and its provider network system comply with the federal laws and Department of Health Care Services (DHCS) contract requirements pertaining to UM responsibilities.
Last updated: 5/17/2019 3:10 PM