Mental Health Plan and Organized Delivery System Network Providers

Thank you for your interest in working with Placer County Medi-Cal beneficiaries. To become an Organizational Provider for Placer County, visit the Procurement Open Bids & RFP page. Any additional questions can be emailed to [email protected].

QUALITY IMPROVEMENT/ASSURANCE REPORTS

All organizational providers are required to submit quarterly and annual reports. These reports will be revied by the contract monitor and the Quality Improvement (QI) Committee. During the QI Committee quarterly meeting, the QI Committee members prepare and report on their quality improvement goals and plans and making adjustment to improve our care and services. Committee members discuss, make recommendations, and explore creative solutions and support each other.

All quarterly reports are due to [email protected] by the end of the month following the end of the quarter and must contain all elements identified on the QI Quarterly Report template.

NOTICES OF ADVERSE BENEFIT DETERMINATION (NOABD)

Any time there is a change to a client’s treatment they are to be issued a NOABD. An Adverse Benefit Determination is defined to mean any of the following actions taken by a Plan:

1. The denial or limited authorization of a requested service, including determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
2. The reduction, suspension, or termination of a previously authorized service;
3. The denial, in whole or in part, of payment for a service;
4. The failure to provide services in a timely manner;
5. The failure to act within the required timeframes for standard resolution of grievances and appeals; or
6. The denial of a beneficiary’s request to dispute financial liability.

For more information regarding NOABS please refer to DHCS IN 18-010 or you may request access to the Placer County training by emailing [email protected].

MENTAL HEALTH PLAN

The MHP requires all organizational providers to maintain a safe facility meeting ADA requirements. Providers must store and dispense medications according to state and federal requirements, and store medical records according to state and federal requirements. For contracted organizational providers, the medication storage review is conducted at Medi-Cal certification and re-certification site visits.

All providers must comply with the MHP quality management standards. Providers shall meet the MHP requirements, which include cultural competency standards, staff training requirements, patients’ rights procedures according to the Patients’ Rights Manual and other contractual requirements. MHP agencies are encouraged to have beneficiaries and representatives from the geographic areas served by the agency on their boards of directors and/or advisory boards.

Providers are required to have accounting and fiscal practices that meet the DHCS standards and have a head of service that meets Title 9 requirements. Inpatient psychiatric facilities must be currently licensed by the State of California as a hospital and accredited by the Joint Commission Accreditation of Health Care Organizations.

All providers of mental health services, whether in network or out of network are required to obtain authorization to provide services through the Systems of Care. Organizational providers are required to submit a detailed invoice that is reviewed and approved by the Contract monitor prior to authorization of payment. The payments of subsequent claims are processed, depending upon the type of provider, as describe in accordance with the MHP claiming process. Payment invoices will be paid within 30 days of final approval.

MENTAL HEALTH PLAN DOCUMENTS AND TEMPLATES

Template to create Biopsychosocial Assessment which is required to be in every client’s chart. Children update annually and Adult update every two year. Care 015e (DOC).

Template to create Unified Service Plan which is required to be in every client’s chart. Care 008e (DOC).

Template to create a Progress Note. To bill Medi-Cal the progress note must be written to Medi-Cal standards. Care 041e (DOC). Example of well written progress notes.

DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM

The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care. This approach provides the beneficiary with access to the care and system interaction needed to achieve sustainable recovery.

Placer County services are recovery focused, client centered, and based on individual needs. Placer County has a “no wrong door” approach that focuses on connecting people to the appropriate services and level of care regardless of where they first show up.

Substance Use Disorder Services administered in Placer County are held to varying, and at times overlapping, regulations depending on, but not limited to, the service modality, activities being performed, and funding source. The Placer County DMC-ODS will operate according to the regulations set forth by the Federal Government Special Terms and Conditions, the State of California Intergovernmental Agreement, as well as its own provisions outlined in specific provider contracts. It is common for providers in Placer County to offer a variety of services each of which with their own set or multiple sets of regulations to follow. No one set of regulations addresses all components of the provision of Substance Use Disorder Services and at times differences in regulatory language may create multiple interpretations on how regulations may apply. Whenever questions regarding regulation interpretation arise, the more stringent regulation applicable shall apply as this is how Placer County Quality Management and the Department of Health Care Services will evaluate providers. Should a question arise, Providers are encouraged to seek clarification by Placer County Quality Management at [email protected]

The DMC-ODS Practice Guidelines is available for further guidance.
Placer County Drug Medi-Cal Beneficiary Handbook (PDF)
Placer County Drug Medi-Cal Beneficiary Handbook-Large Print (PDF)

CONCURRENT REVIEW REQUEST PROCESSING

On May 31, 2019, California Department of Healthcare Services (DHCS) issued DHCS IN 19-026 requirement for concurrent review authorization of psychiatric inpatient hospital services and psychiatric health facility services. We are excited to announce Placer-Sierra MHP will begin the concurrent review process for Placer County contracted providers effective April 12, 2021.

Fax 24-hour TAR notifications to 530-886-2940 or speak to an agent at 530-886-2929. Once your notification has been received you will be contacted by Placer County for additional information or an authorization for a date range. Additional paperwork is required for continued authorization.

Concurrent review documentation can be securely faxed to 530-886-2940.

Once the Placer County beneficiary has been discharged, you are required to submit the TAR within 14 days of the discharge date.

RETROSPECTIVE TREATMENT AUTHORIZATION REQUEST (TAR) PROCESSING

Fax 24-hour TAR notifications to 530-886-2940 or speak to an agent at 530-886-2929.

Contact Information

Mail Medi-Cal charts and claims to:
Placer County Mental Health
ATTN: TAR Processing
11512 B Avenue
Auburn, CA 95603

Concurrent Review Letter
DHCS IN 19-026 Concurrent Review Requirements

MENTAL HEALTH PLAN LINKS

• Mental Health Provider Newsletters  
• Mental Health Provider Notice of Attestation (DOC)
• Behavioral Health QA Report Template (DOC)
• Mental Health Provider Quarterly Meeting Minutes
• Network Provider Satisfaction Survey
• Network Provider Manual (PDF)
• Placer Clinical and Documentation Practice Guidelines (PDF)

DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM

• Behavioral Health QA Report Template (DOC)

• Substance Use Disorder Services Resource Guide (PDF)

SOC PROVIDER FORMS

• Care 041e (DOC) - Progress Note
• Care 041ge (DOC) - Group Progress Note
• Care 207 (DOC) - Consent for Medication
• Care 214 (DOC) - Care Plan
• Care 215 (DOC) - Problem List
• Provider Initial Assessment Forms Bundle (ZIP) - Bundle of forms includes the Care 010e, Care 011, Care 015, Care 015a, Care 015e, Care 024, Care 036, Care 141e and HIPAA 05 
• Care 009e Network Provider Request for Authorization - Treatment Report (DOC)
• Care 010e (DOC) - Data used to track Child treatment outcomes or treatment planning (This form is to be downloaded and used as a Template)
• Care 011 (PDF) - Data used to track Adult treatment outcomes or treatment planning
• Care 015 (PDF) - Required Biopsychosocial Assessment 
• Care 015e (DOC) - Required Biopsychosocial Assessment (This form is to be downloaded and used as a Template) 
• Care 015a (PDF) - Completed with the Care 15, contains CSI data and cultural services
• Care 020 (PDF) - English version Appeal/Grievance Form used for both clients and providers to file a complaint 
• Care 020sp (PDF) - Spanish version Appeal/Grievance Form used for both clients and providers to file a complaint 
• Care 024 (PDF) - Contains required CSI data
• Care 036 (DOC) - Consent to treat a minor (This form is to be downloaded and used as a Template)
• Care 053e (DOC) - Systems of Care ICD-10 Diagnosis Form (This form is to be downloaded and used as a Template)
• Care 084 (PDF) - English version Request for Change of Service Provider - Second Opinion
• Care 084sp (PDF) - Spanish version Request for Change of Service Provider - Second Opinion
• Care 141e (DOC) - Child/Youth Biopsychosocial Assessment (This form is to be downloaded and used as a Template)
• Care 441 (DOC) - Psychiatric Consultation Request Adult Medi-Cal Beneficiaries (This form is to be downloaded and used as a Template)
• CLAS (DOC) - CLAS Standards Monitoring Mental Health Provider (This form is to be downloaded and used as a Template)
• HIPAA 05 (PDF) - Required when communicating with others regarding a client
• HIPAA 05 -Spanish (PDF) - Required when communicating with others regarding a client
• CPT/HCPCS Codes (PDF) - Schedule of Contracted Rates Using Standardized CPT/HCPCS Codes
• CMS-1500 (PDF) - This is only an example, the areas in yellow should be filled in on the CMS-1500
• Beneficiary Protection English and Spanish 2018 Update (ZIP) - Required Provider Posting Materials for Beneficiary Protection in English and Spanish
• DSM-IV-TR to ICD-9-CM Crosswalk (PDF) - DSM-IV-TR to ICD-9-CM Crosswalk, ICD-9-CM Fifth-Digit Descriptions and Criteria, and Global Assessment of Functioning (GAF) Scale
• Provider Attestation (DOC) - Placer County provider attestation 1.31.17
• Provider Audit Tool (PDF) - Placer County Provider Audit Tool
• Tax Forms (PDF) - County of Placer required Tax Forms