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

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I. Care and Treatment Policy

Title	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	2/14/23
Services Authorization Requests for Out-of-County Medi-Cal Beneficiaries (SB 785) UPDATED	01.01.03	2/14/23
Continuity of Care and Referrals in SUD Programs UPDATED	01.01.04	12/10/19
Substance Use Disorder (SUD) Residential Treatment Authorization and Re-authorization UPDATED	01.01.05	10/7/21
Electro-Convulsive Treatment (ECT) for individuals in the Mental Health Plan	01.02.01
Compliance with Adolescent SUD Best Practice Guidelines UPDATED	01.02.02	2/9/2024
Perinatal Practice Guidelines UPDATED	01.02.03	2/13/2024
BHS Medication Monitoring Practices UPDATED	01.02.04	7/20/22
Courtesy Dosing at Narcotic Treatment Program	01.02.05	11/20/17
Pathways to Well Being Intensive Services & Therapeutic Foster Care UPDATED	01.02.06	5/22/2024
Practice Guidelines Development and Implementation UPDATED	01.02.07	2/7/23
BHS Outpatient Clinic Psychiatric Nurse Practitioners UPDATED BHS Standardized Procedures for Psychiatric Nurse Practitioners in County Outpatient NEW!	01.02.08 form	2/9/2024
Welcoming and Customer Service	01.03.01	10/5/16
Access to Substance Use Disorder Services for Persons with Disabilities UPDATED	01.03.02	2/14/23
Admission and Readmission in Substance Use Disorder Programs UPDATED	01.03.03	10/15/24
Telehealth Services in the Mental Health Plan NEW!	01.03.04	7/20/22
Telehealth Services in Drug Medi-Cal Organized Delivery System NEW!	01.03.05	7/20/22
Access Criteria for Specialty Mental Health Services NEW!	01.03.06	9/14/2022
Access Criteria for Drug Medi-Cal Organized Delivery System UPDATED	01.03.07	1/30/2023
Authorization for Outpatient Specialty Mental Health Services (SMHS) within the County of Orange Behavioral Health Plan NEW!	01.03.08	12/10/2024
CalOptima OneCare/OneCare Connect Referrals	01.04.01	11/19/18
OneCare/OneCare Connect Client Assessment for Specialty Mental Health Services	01.04.02	10/19/18
OneCare/OneCare Connect Coordination of Care with CalOptima	01.04.03	10/19/18
Quality Improvement for Mental Health and Substance Use Disorder Treatment Coordination with CalOptima UPDATED	01.04.04	2/14/23
Assisting Consumers in Applying for SSI Benefits	01.05.01	5/18/15
Violence Risk Assessment and Duty to Protect UPDATED	01.06.01	1/7/2025
Mandated Dependent Adult/Elder Abuse Reporting	01.06.02	11/3/17
Mandated Child Abuse Reporting	01.06.03	4/24/18
Youth Under the Influence Adolescent Substance Use Disorder Programs	01.07.01	4/4/18
Care and Supervision of Youth in Adolescent Substance Use Disorder Programs	01.07.02	5/13/18
Possessions and Prohibition of Weapons at BHS Programs NEW!	01.07.03	4/18/19
Use of Naloxone Hydrochloride (Narcan) in BHS Programs UPDATED	01.07.04	2/9/2024
Procedures for Conducting CLIA Waived Tests in SUD Programs NEW!	01.07.05	2/9/2022
Medications for Addiction Treatment (MAT) Services Requirements for County Substance Use Disorder (SUD) Recovery or Treatment Facilities UPDATED	01.07.06	10/16/2024
Distribution of Harm Reduction Supplies in BHS Programs and Outreach Events to Community Members UPDATED	01.07.07	11/21/2024
Behavioral Health Services Employee-Led Program Outings in the Community NEW!	01.07.08	06/14/2024
Long-Acting Injectable Medication Administration NEW!	01.07.09	01/14/2025

II. Client Rights

Title	Number	Last Revised
Cultural Competency UPDATED	02.01.01	2/14/23
Meeting Beneficiary/Client Language Needs UPDATED	02.01.02	2/14/23
Distribution of Translated Materials UPDATED	02.01.03	2/14/23
MHP and DMC-ODS Provider Directory (formerly titled Mental Health Plan Provider List) UPDATED	02.01.04	2/14/23
Field Testing of Written Materials	02.01.05	9/21/16
Cultural Competence Committee	02.01.06	10/12/16
Meeting Deaf and Hard of Hearing Language Needs at Key Points of Contact UPDATED	02.01.07	2/14/23
Procedures for Change of Provider and Second Opinion Requests UPDATED	02.02.01	2/14/23
Beneficiary/Client Problem Resolution, Grievance Process and Logging Procedures in Outpatient County and Contracted Clinics and Inpatient Treatment Programs UPDATED	02.02.02	2/14/2024
Notice of Adverse Benefit Determination (NOABD) (formerly titled Notice of Action Forms) UPDATED	02.02.04	1/19/22
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") UPDATED	02.02.06	2/14/23
Informed Consent for Mental Health and Recovery Services UPDATED Informed Consent (F346-301)	02.04.01 form	2/14/23
Psychiatric Medication Consent Forms UPDATED 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 Practices	02.05.01
Advance Directives UPDATED	02.06.01	2/14/23
Informing Materials for Mental Health Plan Beneficiaries - Clients Intake - Advisement Checklist UPDATED	02.06.02	2/22/23
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

Title	Number	Last Revised
Continuing Education Course Approval for HCA Programs UPDATED	03.01.01	5/22/2024
Compliance Orientation, Education and Training UPDATED	03.01.02	2/15/23
Trainings Specifically Pertaining to Cultural Competency	03.01.03	9/21/16
Drug Medi-Cal Organized Delivery System Provider Training Requirements UPDATED	03.01.04	10/8/20
Mental Health and Recovery Services Sponsored & Hosted Training Attendance UPDATED	03.01.05	2/14/23
Individual Provider Transitions Affecting HCA BHS Beneficiaries/Clients UPDATED	03.02.01	2/14/2024
BHS Non-Blood Borne Pathogen Exposure Control Plan	03.03.02

IV. Administration

Title	Number	Last 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 UPDATED Form F346-781 Electronic Signature Application	04.01.02 form	2/15/23
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	11/13/24
Therapeutic Charge Adjustment Therapeutic Charge Adjustment form	04.02.06 form
Billing Compliance, Recoveries and Reporting of Overpayments NEW!	04.02.08	7/1/20
Medical Necessity & Concurrent Authorization of Psychiatric Inpatient Hospital Services UPDATED	04.02.09	12/6/24
No Wrong Door Mental Health Services NEW!	04.02.10	9/28/22
Authorization of Medi-Cal Beneficiaries for Crisis Residential Treatment Services and Concurrent Review Procedures NEW!	04.02.11	6/1/23
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	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	04.03.04	8/30/17
Lanterman-Petris-Short Act (LPS) Designation of Facilities in Orange County	04.03.05	2/18/16
Use and Disclosure OF PHI for Research Purposes	04.05.01
Use and Disclosure of Protected Health Information-General Rules UPDATED	04.05.03	3/9/23

V. Information Management

Title	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 and Assessment Standards UPDATED!	05.01.03	1/30/2023
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 Employee	05.01.05
Office Staff Phone Financial Evaluations	05.01.06
Missing/Lost Charts	05.01.07
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	05.01.09
Use of Electronic Signatures In the BHS Electronic Health Record UPDATED Electronic Signature Agreement	05.01.10 form	2/22/23
BHS Clinical Record Keeping Standards For Clinics Using Paper Charts	05.01.11	8/7/15
Corrections/Amendments to Chart Documentation - Audits	05.01.12	12/2/15
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	05.01.14	10/31/18
DMC-ODS Documentation of Services and Assessment Standards UPDATED!	05.01.15	1/30/23
BHS and CalOptima OneCare/OneCare Connect Information Exchange	05.02.01	10/19/18
IRIS Entry of Encounter Document Information by Office Support Staff – For Non-Electronic Health Record Clinics	05.03.01
CalOMS California Outcome Measurement System (CalOMS) Integrated Records Information System (IRIS) Electronic Operational Procedures for Treatment Data Submission to Department of Health Care Services	05.03.02	8/12/15
Tracking Disclosures of PHI PHI Disclosure Tracking Log	05.05.02 form
Accounting for Disclosures of PHI	05.05.03

VI. Quality Improvement

Title	Number	Last Revised
Reporting of Unusual Occurrences to Department of Health Care Services UPDATED	06.01.01	2/15/23
Posting of Mental Health Plan System Metrics UPDATED	06.01.02	2/15/23
Test Call Procedure for Monitoring Administrative Service Organization (ASO) Access Quality and Compliance UPDATED	06.02.01	2/14/23
Quality Management and Community Quality Improvement Committee UPDATED	06.03.01	2/15/23
Sentinel Events Review Committee NEW	06.03.02	4/27/23

VII. Compliance

Title	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	07.01.03	3/29/19
Postmortem Claiming	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
Substance Use Disorder Drug Medi-Cal Organized Delivery System Provider Monitoring NEW!	07.02.03	2/1/22
Trafficking Victims Protection Act Compliance	07.03.01	12/2/15
Mental Health and Recovery Services Compliance Officer UPDATED	07.03.02	2/15/23
Organizational Commitment to Medi-Cal Managed Care Requirements UPDATED	07.03.03	2/14/23
Outpatient Clinic Medication Rooms - Receipt, Storage, Administration, Disposal and Accountability of Medication UPDATED	07.03.04	10/15/24
Substance Use Disorder Medical Director Roles and Responsibilities NEW!	07.03.05	8/5/19
Role of the Behavioral Health Nurse in Substance Use Disorder Programs NEW!	07.03.06	12/17/20
Nondiscrimination & Institutional Safeguards for Religious Providers & Charitable Choice Reporting for SABG Funded Programs NEW!	07.03.07	2/1/22
Verification of Individual NPI Numbers and Professional Licenses at Initial Medi-Cal Certification and Medi-Cal Re-Certification	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	07.04.02	11/13/17
Drug Medi-Cal Organized Delivery System Provider Selection and Retention Practices	07.04.03	11/13/17
Credentialing and Re-Credentialing Requirements of Individual Providers UPDATED	07.04.04	4/20/23
Individual Provider Credentialing Committee UPDATED	07.04.05	06/01/23

VIII. Plans

Title	Number	Last Revised
BHS Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP) UPDATED	08.01.01	02/04/19
BHS/Conditional Release Program Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP) UPDATED		02/03/20

IX. Medi-Cal Managed Care

Title	Number	Last Revised
Mental Health Plan Out-of-Network Services	09.01.01	1/19/22
Mental Health Plan and Drug Medi-Cal Organized Delivery System Network Adequacy Monitoring UPDATED	09.01.02	2/7/23
Access to Mental Health Services for Persons with Disabilities UPDATED	09.01.03	2/15/23
Meeting Medi-Cal Beneficiary Language Assistance Needs UPDATED	09.01.04	2/8/23
Mental Health and Recovery Services 24/7 Access Line Requirements UPDATED	09.01.05	2/8/23
Medi-Cal Timely Access and Service Availability UPDATED	09.01.06	12/6/24
Out-of-Network Services for Drug Medi-Cal Organized Delivery System (DMC-ODS) UPDATED	09.01.07	2/14/23
Continuity of Care for Medi-Cal beneficiaries receiving Specialty Mental Health Services within the County of Orange Mental Health Plan UPDATED	09.01.08	2/7/23
Adult and Youth Screening and Transition of Care Tools NEW	09.01.09	2/27/2024
Beneficiary Problem Resolution and Grievance Process UPDATED	09.02.01	11/06/19
Beneficiary-Client Appeal of Actions Process UPDATED	09.02.02	2/14/2024
Clinical Supervision Requirements UPDATED	09.03.01	8/11/23