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BHS Policies and Procedures

Behavioral Health Services General Policies and Procedures

  1. Care and Treatment Policy
  2. Client Rights
  3. Human Resources
  4. Administration
  5. Information Management
  6. Quality Improvement
  7. Compliance
  8. Plans
  9. Medi-Cal Managed Care

I. Care and Treatment Policy

TitleNumberLast Revised
Access to Specialty Mental Health Services for out of County Beneficiaries01.01.018/3/16
Presumptive Transfer (AB 1299) 01.01.022/14/23
Services Authorization Requests for Out-of-County Medi-Cal Beneficiaries (SB 785) 01.01.032/14/23
Continuity of Care and Referrals in SUD Programs 01.01.0412/10/19
Substance Use Disorder (SUD) Residential Treatment Authorization and Re-authorization 01.01.0510/7/21
Electro-Convulsive Treatment (ECT) for individuals in the Mental Health Plan01.02.01 
Compliance with Adolescent SUD Best Practice Guidelines 01.02.022/9/2024
Perinatal Practice Guidelines 01.02.032/13/2024
BHS Medication Monitoring Practices 01.02.047/20/22
Courtesy Dosing at Narcotic Treatment Program01.02.0511/20/17
Pathways to Well Being Intensive Services & Therapeutic Foster Care 01.02.065/22/2024
Practice Guidelines Development and Implementation 01.02.072/7/23
BHS Outpatient Clinic Psychiatric Nurse Practitioners 
BHS Standardized Procedures for Psychiatric Nurse Practitioners in County Outpatient 		01.02.08
form		2/9/2024
Welcoming and Customer Service01.03.0110/5/16
Access to Substance Use Disorder Services for Persons with Disabilities 01.03.022/14/23
Admission and Readmission in Substance Use Disorder Programs 01.03.0310/15/24
Telehealth Services in the Mental Health Plan 01.03.047/20/22
Telehealth Services in Drug Medi-Cal Organized Delivery System 01.03.057/20/22
Access Criteria for Specialty Mental Health Services 01.03.069/14/2022
Access Criteria for Drug Medi-Cal Organized Delivery System 01.03.071/30/2023
Authorization for Outpatient Specialty Mental Health Services (SMHS) within the County of Orange Behavioral Health Plan 01.03.0812/10/2024
CalOptima OneCare/OneCare Connect Referrals01.04.0111/19/18
OneCare/OneCare Connect Client Assessment for Specialty Mental Health Services01.04.0210/19/18
OneCare/OneCare Connect Coordination of Care with CalOptima01.04.0310/19/18
Quality Improvement for Mental Health and Substance Use Disorder Treatment Coordination with CalOptima 01.04.042/14/23
Assisting Consumers in Applying for SSI Benefits01.05.015/18/15
Violence Risk Assessment and Duty to Protect 01.06.011/7/2025
Mandated Dependent Adult/Elder Abuse Reporting01.06.0211/3/17
Mandated Child Abuse Reporting01.06.034/24/18
Youth Under the Influence Adolescent Substance Use Disorder Programs01.07.014/4/18
Care and Supervision of Youth in Adolescent Substance Use Disorder Programs01.07.025/13/18
Possessions and Prohibition of Weapons at BHS Programs 01.07.034/18/19
Use of Naloxone Hydrochloride (Narcan) in BHS Programs 01.07.042/9/2024
Procedures for Conducting CLIA Waived Tests in SUD Programs 01.07.052/9/2022
Medications for Addiction Treatment (MAT) Services Requirements for County Substance Use Disorder (SUD) Recovery or Treatment Facilities 01.07.0610/16/2024
Distribution of Harm Reduction Supplies in BHS Programs and Outreach Events to Community Members 01.07.0711/21/2024
Behavioral Health Services Employee-Led Program Outings in the Community 01.07.0806/14/2024
Long-Acting Injectable Medication Administration 01.07.0901/14/2025

II. Client Rights

TitleNumberLast Revised
Cultural Competency 02.01.012/14/23
Meeting Beneficiary/Client Language Needs 02.01.022/14/23
Distribution of Translated Materials 02.01.032/14/23
MHP and DMC-ODS Provider Directory (formerly titled Mental Health Plan Provider List) 02.01.042/14/23
Field Testing of Written Materials02.01.059/21/16
Cultural Competence Committee02.01.0610/12/16
Meeting Deaf and Hard of Hearing Language Needs at Key Points of Contact 02.01.072/14/23
Procedures for Change of Provider and Second Opinion Requests 02.02.012/14/23
Beneficiary/Client Problem Resolution, Grievance Process and Logging Procedures in Outpatient County and Contracted Clinics and Inpatient Treatment Programs 02.02.022/14/2024
Notice of Adverse Benefit Determination (NOABD) (formerly titled Notice of Action Forms)02.02.041/19/22
Beneficiary Problem Resolution/Grievance Process/Log Procedures in MHSA Funded Outpatient County and Contracted Programs02.02.0510/18/16
Continuation of Benefits Pending Appeal Resolution (AKA "Aid Paid Pending") 02.02.062/14/23
Informed Consent for Mental Health and Recovery Services 
Informed Consent (F346-301)		02.04.01
form		2/14/23
Psychiatric Medication Consent Forms 
Psychotropic Medication Consent Form (F346-745)
Prescribing Physician's Statement–Attachment JV-220(A)		02.04.02
form
form		2/22/23
Consent to Record Consumers for Clinical Supervision and Training
Consent to Record Form (F346-474)		02.04.03
form		 
Notice of Privacy Practices02.05.01 
Advance Directives 02.06.012/14/23
Informing Materials for Mental Health Plan Beneficiaries - Clients Intake - Advisement Checklist02.06.022/22/23
Medi-Cal Consumer Rights Under the Orange County Mental Health Plan02.06.038/3/16
Mandatory Postings for Providers02.06.04 

III. Human Resources

TitleNumberLast Revised
Continuing Education Course Approval for HCA Programs 03.01.015/22/2024
Compliance Orientation, Education and Training 03.01.022/15/23
Trainings Specifically Pertaining to Cultural Competency03.01.039/21/16
Drug Medi-Cal Organized Delivery System Provider Training Requirements 03.01.0410/8/20
Mental Health and Recovery Services Sponsored & Hosted Training Attendance03.01.052/14/23
Individual Provider Transitions Affecting HCA BHS Beneficiaries/Clients03.02.012/14/2024
BHS Non-Blood Borne Pathogen Exposure Control Plan03.03.02 

IV. Administration

TitleNumberLast Revised
OCTA Application for Disabled Persons Reduced Fare Card
OCTA Reduced Fare ID Card Assessed Eligibility Form		04.01.01
form		 
Approval for use of Electronic Signatures by BHS Contracted Providers 
Form F346-781 Electronic Signature Application		04.01.02
form		2/15/23
Office Support Staff Involvement with Verifying Financial Information04.02.01 
Communication between Behavioral Health Administration and Medical Billing Unit Personnel04.02.02 
Review of Medicare Billing Prior to Submission04.02.03 
Procedures for Obtaining, Maintaining, and Deleting Medicare Provider Transaction Access Number (PTAN)04.02.0411/13/24
Therapeutic Charge Adjustment
Therapeutic Charge Adjustment form		04.02.06
form		 
Billing Compliance, Recoveries and Reporting of Overpayments04.02.087/1/20
Medical Necessity & Concurrent Authorization of Psychiatric Inpatient Hospital Services04.02.0912/6/24
No Wrong Door Mental Health Services04.02.109/28/22
Authorization of Medi-Cal Beneficiaries for Crisis Residential Treatment Services and Concurrent Review Procedures04.02.116/1/23
Lanterman-Petris-Short Act (LPS) Designation of BHS County and Outpatient Contract Providers04.03.014/28/16
Lanterman-Petris-Short Act (LPS) Designation of Individuals04.03.028/30/17
Lanterman-Petris-Short Act (LPS) Designation Privileges04.03.038/30/17
Designation of Facility Lanterman-Petris-Short Act (LPS) Trainers04.03.048/30/17
Lanterman-Petris-Short Act (LPS) Designation of Facilities in Orange County04.03.052/18/16
Use and Disclosure OF PHI for Research Purposes04.05.01 
Use and Disclosure of Protected Health Information-General Rules04.05.033/9/23

V. Information Management

TitleNumberLast Revised
Recording Requests for Specialty Mental Health Services On Access Logs05.01.018/9/16
Use and Flow of the Encounter Document: Outpatient Clinic05.01.02 
Documentation of Services and Assessment Standards05.01.031/30/2023
Advance Beneficiary Notice of Non-coverage (ABN)
Announcement of the Implementation of the Revised ABN		05.01.04
letter		 
Corrections/Amendments to Encounter Document when Provider No Longer a County Employee05.01.05 
Office Staff Phone Financial Evaluations05.01.06 
Missing/Lost Charts05.01.07 
Transport of Clinical Records05.01.083/8/16
Document Destruction - Paper charts held in the clinics for clients discharged prior to 9/23/200305.01.09 
Use of Electronic Signatures In the BHS Electronic Health Record
Electronic Signature Agreement		05.01.10
form		2/22/23
BHS Clinical Record Keeping Standards For Clinics Using Paper Charts05.01.118/7/15
Corrections/Amendments to Chart Documentation - Audits05.01.1212/2/15
Use and Processing of the Lanterman-Petris-Short Act (LPS) 5150/5585 Hold Form05.01.133/7/16
Substance Use Disorder Treatment Services Chart Order05.01.1410/31/18
DMC-ODS Documentation of Services and Assessment Standards05.01.151/30/23
BHS and CalOptima OneCare/OneCare Connect Information Exchange05.02.0110/19/18
IRIS Entry of Encounter Document Information by Office Support Staff – For Non-Electronic Health Record Clinics05.03.01 
CalOMS California Outcome Measurement System (CalOMS) Integrated Records Information System (IRIS) Electronic Operational Procedures for Treatment Data Submission to Department of Health Care Services05.03.028/12/15
Tracking Disclosures of PHI
PHI Disclosure Tracking Log		05.05.02
form		 
Accounting for Disclosures of PHI05.05.03 

VI. Quality Improvement

TitleNumberLast Revised
Reporting of Unusual Occurrences to Department of Health Care Services06.01.012/15/23
Posting of Mental Health Plan System Metrics06.01.022/15/23
Test Call Procedure for Monitoring Administrative Service Organization (ASO) Access Quality and Compliance UPDATED06.02.012/14/23
Quality Management and Community Quality Improvement Committee06.03.012/15/23
Sentinel Events Review Committee06.03.024/27/23

VII. Compliance

TitleNumberLast Revised
Fraud and Abuse07.01.013/7/16
Billing Compliance07.01.023/7/16
Development of Certified Reviewers 07.01.033/29/19
Postmortem Claiming07.01.049/6/18
Compliance with Federal Award Requirements for Substance Abuse Programs07.02.018/13/15
Title 22 Regulations Compliance07.02.0210/7/15
Substance Use Disorder Drug Medi-Cal Organized Delivery System Provider Monitoring 07.02.032/1/22
Trafficking Victims Protection Act Compliance07.03.0112/2/15
Mental Health and Recovery Services Compliance Officer 07.03.022/15/23
Organizational Commitment to Medi-Cal Managed Care Requirements 07.03.032/14/23
Outpatient Clinic Medication Rooms - Receipt, Storage, Administration, Disposal and Accountability of Medication 07.03.0410/15/24
Substance Use Disorder Medical Director Roles and Responsibilities 07.03.058/5/19
Role of the Behavioral Health Nurse in Substance Use Disorder Programs 07.03.0612/17/20
Nondiscrimination & Institutional Safeguards for Religious Providers & Charitable Choice Reporting for SABG Funded Programs 07.03.072/1/22
Verification of Individual NPI Numbers and Professional Licenses at Initial Medi-Cal Certification and Medi-Cal Re-Certification07.04.0111/7/17
Verification of Individual NPI Numbers and Professional Licenses at Initial Drug Medi-Cal Certification and Drug Medi-Cal Re-Certification07.04.0211/13/17
Drug Medi-Cal Organized Delivery System Provider Selection and Retention Practices07.04.0311/13/17
Credentialing and Re-Credentialing Requirements of Individual Providers 07.04.044/20/23
Individual Provider Credentialing Committee 07.04.0506/01/23

VIII. Plans

TitleNumberLast Revised
BHS Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP)08.01.0102/04/19
BHS/Conditional Release Program Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP) 02/03/20

IX. Medi-Cal Managed Care

TitleNumberLast Revised
Mental Health Plan Out-of-Network Services09.01.011/19/22
Mental Health Plan and Drug Medi-Cal Organized Delivery System Network Adequacy Monitoring09.01.022/7/23
Access to Mental Health Services for Persons with Disabilities09.01.032/15/23
Meeting Medi-Cal Beneficiary Language Assistance Needs09.01.042/8/23
Mental Health and Recovery Services 24/7 Access Line Requirements09.01.052/8/23
Medi-Cal Timely Access and Service Availability09.01.0612/6/24
Out-of-Network Services for Drug Medi-Cal Organized Delivery System (DMC-ODS) 09.01.072/14/23
Continuity of Care for Medi-Cal beneficiaries receiving Specialty Mental Health Services within the County of Orange Mental Health Plan 09.01.082/7/23
Adult and Youth Screening and Transition of Care Tools09.01.092/27/24
Beneficiary Problem Resolution and Grievance Process09.02.0111/06/19
Beneficiary-Client Appeal of Actions Process09.02.022/14/24
Clinical Supervision Requirements09.03.018/11/23