BHS Policies and Procedures

Behavioral Health Services General Policies and Procedures

I. Care and Treatment Policy


Number Last Revised
Access to Specialty Mental Health Services for out of County Beneficiaries 01.01.01 8/3/16
Presumptive Transfer (AB 1299) updated 01.01.02 2/19/19
Services Authorization Requests for Out-of-County Medi-Cal Beneficiaries (SB 785) new 01.01.03 11/2/17
Continuity of Care and Referrals in SUD Programs new 01.01.04 11/14/17
Substance Use Disorder (SUD) Residential Treatment Authorization and Re-authorization updated 01.01.05 7/23/19
Electro-Convulsive Treatment (ECT) for individuals in the Mental Health Plan 01.02.01
Adolescent/Youth Treatment Guidelines 01.02.02 8/7/15
Perinatal Services Network Guidelines 01.02.03 8/7/15
Medication Monitoring updated 01.02.04 12/5/17
Courtesy Dosing at Narcotic Treatment Program new 01.02.05 11/20/17
Pathways to Well Being and Intensive Services new 01.02.06 08/06/19
Welcoming and Customer Service 01.03.01 10/5/16
Access to Substance Use Disorder Services for Persons with Disabilities updated 01.03.02 4/30/19
Admission and Readmission in Substance Use Disorder Programs new 01.03.03 7/24/19
CalOptima OneCare/OneCare Connect Referrals updated 01.04.01 11/19/18
OneCare/OneCare Connect Client Assessment for Specialty Mental Health Services updated 01.04.02 10/19/18
OneCare/OneCare Connect Coordination of Care with CalOptima updated 01.04.03 10/19/18
Quality Improvement for Mental Health and Substance Use Disorder Treatment Coordination with CalOptima new 01.04.04 04/12/19
Assisting Consumers in Applying for SSI Benefits 01.05.01 5/18/15
Duty to Protect 01.06.01 8/9/13
Mandated Dependent Adult/Elder Abuse Reporting updated 01.06.02 11/3/17
Mandated Child Abuse Reporting new 01.06.03 4/24/18
Youth Under the Influence Adolescent Substance Use Disorder Programs new 01.07.01 4/4/18
Care and Supervision of Youth in Adolescent Substance Use Disorder Programs updated 01.07.02 5/13/18
Possessions and Prohibition of Weapons at BHS Programs new 01.07.03 4/18/19

II. Client Rights


Number Last Revised
Cultural Competency 02.01.01 9/21/16
Meeting Consumers Language Needs 02.01.02 9/21/16
Distribution of Translated Materials 02.01.03 8/3/16
Mental Health Plan Provider List (formerly titled Provider List-Cultural/Linguistic Proficiency) 02.01.04 8/3/16
Field Testing of Written Materials 02.01.05 9/21/16
Cultural Competence Committee 02.01.06 10/12/16
Procedures for Change of Provider and Second Opinion Requests 02.02.01 8/8/19

Beneficiary Problem Resolution and Grievance Process and Log Procedure in Out patient County and Contracted Clinics. and Inpatient Treatment Programs updated

02.02.02 9/8/17

Beneficiary Appeal of Actions Process updated

02.02.03 9/8/17
Notice of Action Forms 02.02.04 9/27/16
Beneficiary Problem Resolution/Grievance Process/Log Procedures in MHSA Funded Outpatient County and Contracted Programs 02.02.05 10/18/16
Continuation of Benefits Pending Appeal Resolution (AKA "Aid Paid Pending") new 02.02.06 9/8/17

Informed Consent for Behavioral Health Services
Informed Consent (F346-301)


Psychotropic Medication Consent Forms
Psychotropic Medication Consent Form (F346-745)
Prescribing Physician's Statement–Attachment JV-220(A)


Consent to Record Consumers for Clinical Supervision and Training
Consent to Record Form (F346-474)


Notice of Privacy Practices


Advance Directives

02.06.01 8/8/19
Informing Materials for Mental Health Plan Consumers
MHP Intake/Advisement Checklists
Medi-Cal Consumer Rights Under the Orange County Mental Health Plan 02.06.03 8/3/16
Mandatory Postings for Providers 02.06.04

III. Human Resources back to top

IV. Administration


Number Last Revised
OCTA Application for Disabled Persons Reduced Fare Card
OCTA Reduced Fare ID Card Assessed Eligibility Form
Approval for use of Electronic Signatures by BHS contracts
Form F346-781 Electronic Signature Application
Office Support Staff Involvement with Verifying Financial Information 04.02.01
Communication between Behavioral Health Administration and Medical Billing Unit Personnel 04.02.02
Review of Medicare Billing Prior to Submission 04.02.03
Procedures for Obtaining, Maintaining, and Deleting Medicare Provider Transaction Access Number (PTAN) updated 04.02.04

Therapeutic Charge Adjustment
Therapeutic Charge Adjustment form

Lanterman-Petris-Short Act (LPS) Designation of BHS County and Outpatient Contract Providers 04.03.01 4/28/16
Lanterman-Petris-Short Act (LPS) Designation of Individuals updated 04.03.02 8/30/17
Lanterman-Petris-Short Act (LPS) Designation Privileges 04.03.03 8/30/17
Designation of Facility Lanterman-Petris-Short Act (LPS) Trainers updated 04.03.04 8/30/17
Lanterman-Petris-Short Act (LPS) Designation of Facilities in Orange County
Criteria for Designating and Re-designating Facilities form

Use and Disclosure OF PHI for Research Purposes


Use and Disclosure of PHI - General Rules

04.05.03 3/7/16

V. Information Management back to top


Number Last Revised
Recording Requests for Specialty Mental Health Services On Access Logs 05.01.01 8/9/16
Use and Flow of the Encounter Document: Outpatient Clinic 05.01.02
Documentation of Services 05.01.03
Advance Beneficiary Notice of Non-coverage (ABN)
Announcement of the Implementation of the Revised ABN
Corrections/Amendments to Encounter Document when Provider No Longer a County Employee 05.01.05
Office Staff Phone Financial Evaluations 05.01.06

Missing/Lost Charts


Transport of Clinical Records

05.01.08 3/8/16

Document Destruction - Paper charts held in the clinics for clients discharged prior to 9/23/2003


Use of Electronic Signatures In the BHS Electronic Health Record
Electronic Signature Agreement


BHS Clinical Record Keeping Standards For Clinics Using Paper Charts

05.01.11 8/7/15

Corrections/Amendments to Chart Documentation - Audits

Use and Processing of the Lanterman-Petris-Short Act (LPS) 5150/5585 Hold Form 05.01.13 3/7/16
Substance Use Disorder Treatment Services Chart Order updated 05.01.14 10/31/18
BHS and CalOptima OneCare/OneCare Connect Information Exchange updated 05.02.01 10/19/18

IRIS Entry of Encounter Document Information by Office Support Staff – For Non-Electronic Health Record Clinics


CalOMS California Outcome Measurement System (CalOMS) Integrated Records Information System (IRIS) Electronic Operational Procedures for Treatment Data Submission to Department of Health Care Services

05.03.02 8/12/15

Tracking Disclosures of PHI
PHI Disclosure Tracking Log


Accounting for Disclosures of PHI


VI. Quality Improvement


Number Last Revised
Reporting of Unusual Occurrences to Department of Health Care Services 06.01.01
Posting of Mental Health Plan System Metrics 06.01.02 10/12/16
Test Call Procedure for Monitoring Administrative Service Organization (ASO) Access Quality and Compliance 06.02.01

VII. Compliance


Number Last Revised
Fraud and Abuse 07.01.01 3/7/16
Billing Compliance 07.01.02 3/7/16
Development of Certified Reviewers updated
Postmortem Claiming updated 07.01.04 9/6/18
Compliance with Federal Award Requirements for Substance Abuse Programs 07.02.01 8/13/15
Title 22 Regulations Compliance 07.02.02 10/7/15
Trafficking Victims Protection Act Compliance 07.03.01 12/2/15
Behavioral Health Services Compliance Officer new 07.03.02 10/30/17
Organizational Commitment to Medi-Cal Managed Care Requirements new 07.03.03 10/31/17
Outpatient Clinic Medication Rooms - Receipt, Storage, Administration, Disposal and Accountability of Medication new 07.03.04 4/4/18
Substance Use Disorder Medical Director Roles and Responsibilities new 07.03.05 8/5/19
Verification of Individual NPI Numbers and Professional Licenses at Initial Medi-Cal Certification and Medi-Cal Re-Certification new 07.04.01 11/7/17
Verification of Individual NPI Numbers and Professional Licenses at Initial Drug Medi-Cal Certification and Drug Medi-Cal Re-Certification new 07.04.02 11/13/17
Drug Medi-Cal Organized Delivery System Provider Selection and Retention Practices new 07.04.03 11/13/17