CBHS100 MENTAL HEALTH SERVICES (MHS) & DRUG AND ALCOHOL SERVICES (DAS) PROVIDER DATA FORM
|
|
- Samson McCoy
- 6 years ago
- Views:
Transcription
1 CBHS100 MENTAL HEALTH SERVICES (MHS) & DRUG AND ALCOHOL SERVICES (DAS) PROVIDER DATA FORM The purpose of this Provider Data Form (CBHS100) is to facilitate and track the set up of a new Mental Health (MHS) or Substance Abuse (DAS) provider 1 and to update provider setup information. This form is not intended for use in setting up or implementing individual Fee for Service Practitioner Providers who are managed by the Provider Systems Office (PSO.) Behavioral Health Program Managers should contact Fiscal Reporting Unit ( ) for Legal Entity (LE 2 ) number (for MHS) and Provider number (for DAS) to set up or, to change or add Mode/ to an existing Program, before filling out and submitting this CBHS100 form when appropriate. Instructions for NEW Provider Set-up The CBHS Program Managers are responsible for completing and distributing this form as follows: 1. Initiate the contract process 2. MHS programs must attach a copy of the CRDC as developed through the contract process. Substance Abuse programs must attach a copy of the Contract Budget Summary. 3. Obtain Fire Clearance for the proposed address as needed. 4. For Short Doyle Providers, initiate the certification process. Contact CBHS Performance & Compliance Unit, Provider Relations Provider Certifications Office 5. If the Provider is MediCare certified or if certification is required, contact Provider Certifications Office 6. Complete the information in Part I, and Part II (MHS) or III (Drug and Alcohol Services), include any Provider/ RU attributes that may affect billing. 7. Determine the name for the new Reporting Unit using the following criteria: - Name cannot exceed 38 characters - Names may not be duplicated - Contact the BHBIS Business Analyst for an RU 3 number 8. Obtain signatures on Part IV and distribute the form as indicated in the Distribution list (last page). 9. The BHBIS Business Analyst will notify the concerned parties when the setup is complete in InSyst Instructions for CHANGES in Provider Data The purpose of the change in Provider Data process is to facilitate and track changes to add, close, or change information for Providers. CBHS Program Managers are responsible for filling out a CBHS100 form and retaining a copy of the form. Follow the instructions below and send copies to the distribution list. 1. To Close an RU: Attach a copy of the original CBHS100 form 4 Part I and Part II (Mental Health Services) or Part III (Drug and Alcohol Services) page for each mode of service to be closed. Write CLOSE RU at the top of the page with the effective closing date.. 2. To Add, Delete, Change Procedure Codes: Attach Part II (Mental Health Services) or Part III (Drug and Alcohol Services) with notes indicating what services are to be added or changed and attach the CRDC sheet (Mental Health Services). 3. To Change Populations Served or Payor Sources: Attach Part II (Mental Health Services) or Part III (Drug and Alcohol Services) with notes indicating changes 4. To Change Legal Entity (LE) or Address Information: If a program is changing to a different LE, you must get a new Provider Number and complete a CBHS100 as a new provider (for MHS). 5. To Change Address Information: For programs, a re-certification is required when the provider site address changes. Attach Part I with notes indicating all changes needed. 6. To Change Complete Part I and check the appropriate MHS or DAS box. 7. To Change Head of Service (Clinical, Medical Director), Program Director or Legal Entity Director: Complete Part I and check the appropriate MHS or DAS box. Note: Part IV Signature page is required for all changes. SUBMIT ONLY THE PAGES YOU FILLED OUT. 1 A provider is defined as the directing Organizational Healthcare entity. State assigns a 4-digit number for each single address site. 2 LE is the corporate entity with fiduciary responsibility for a program. LE has a 5-character number assigned by the State. 3 Reporting Unit is defined as a Healthcare delivery entity, having a 5- or 6-character Reporting Unit (RU) number assigned by the BHBIS unit, based on the 4-digit provider number and a 1 or 2 digit qualifying suffix. Reporting Units must be set up at the time the Provider is established. Generally, a separate RU number is required for each mode of service planned. 4 If you do not have the original CBHS100 form, please contact BHBIS Business Analyst 1380 Howard St, 3 rd floor.
2 RU#: Part I: New Provider Information Check the box that applies This provider is MHS Provider DAS Provider Civil service Contract Private Hospital/Facility Do not use this form for Private Provider Network (PPN) individual practitioner providers. Contact CBHS Provider Relations Office, (415) for PPN Providers. Provider Name Address: City: State Zip Phone: Fax: TT/TDD: Language Capacity At this address services are available in English and the following additional languages: Program Director Name: Phone: Director Name: Phone: Contact Person (if different from Director) Phone: CBHS Program Manager : Phone: Data Entry Person 1: Phone: Current BIS User New User (Contact the IS Help Desk (415) for assistance) Data Entry Person 2: Phone: Current BIS User New User (Contact the IS Help Desk (415) for assistance) Data Entry Person 3: Phone: Current BIS User New User (Contact the IS Help Desk (415) for assistance) It is highly recommended for Providers to have more than one BIS Data Entry person to ensure adequate coverage for this task. Legal Entity/Agency number Legal Entity/ Agency Name Start Date for Reporting Unit (RU): (The date the Provider is scheduled to open its doors or the effective date for the new RU) CBHS100 (Rev 04/06) Page 2 of 18
3 RU#: Part II (Mental Health Services): 24-Hour Services (Mode 05 include Mode 60 if applicable) Number of Beds: Define services (using Service Function Codes []) to be provided by the Program/RU Special Instructions: Attach a copy of the CRDC and complete information below from the CRDC. Be sure all Service Function Codes (s) assigned to the RU are included in the final contract. Place a check mark ( ) to indicate YES if service applies to this RU. Y E S Range Description Y E S Range Description Hospital Inpatient 35 IMD (no patch) 19 Hospital Administrative Day IMD with patch Adult Crisis Residential SNF Intensive Adult Residential Residential --Other MH Rehab Center Psychiatric Health Facility Semi-Supervised Living Independent Living MODE Life Support Board & Care RU Target Population ADULT GERIATRICS (Age 60+) HIV+ MENTALLY ILL/SUBSTANCE ABUSERS MINORITY DEVELOPMENTALLY DISABLED CHILDREN (Age 0-17) AB3632 RU Billing/Payor Sources (FRC) SF County Grant Funded (Name & Time Period) MediCal (requires cert) (from to ) Medicare Federal: Insurance State: Client Other: Other: Work Order Not for billing, for tracking only CBHS100 (Rev 04/06) Page 3 of 18
4 RU#: Part II (Mental Health Services): Outpatient Services (Mode 15 or Mode 45 added if shows in CRDC) Define services to be provided by the Program/RU Special Instructions: Attach a copy of the CRDC and complete information below from the CRDC. Be sure all Service Function Codes (s) assigned to the RU are included in the final contract. Place a check mark ( ) to indicate YES if service applies to this RU. Y E S Range Mental Health Services Collateral Assessment Individual Description Group Case Management Brokerage Medication Support Crisis Intervention 40, 50 Children's Wrap Around Services 58 TBS Indirect Services/Mode 45 (not MAA funded) Mental Health Promotion Community Client Contact Staff Training Given Clinical Staff Development Other Service Codes Added: CPT Codes Non MediCal Codes Other Codes (Please list) RU Target Population ADULT GERIATRICS (Age 60+) HIV+ MENTALLY ILL/SUBSTANCE ABUSERS (Dually Diagnosed) MINORITY DEVELOPMENTALLY DISABLED CHILDREN (Age 0-17) AB3632 RU Billing/Payor Sources (FRC) SF County Grant Funded (Name & Time Period) MediCal (requires cert) (from to ) Medicare Federal: Insurance State: Client Other: Other: Work Order Not for billing, for tracking only CBHS100 (Rev 04/06) Page 4 of 18
5 Part II (Mental Health Services): Day Treatment Services (Mode 10) RU#: Define services to be provided by the Program/RU Special Instructions: Attach a copy of the CRDC and complete information below from the CRDC. Be sure all Service Function Codes (s) assigned to the RU are included in the final contract. Place a check mark ( ) to indicate YES if service applies to this RU. Y E S Range Description Day TX Intensive-Half Day (Up to 4 hours) Day TX Intensive-Full Day (More than 4 hours) Day TX Rehabilitative-Half Day (Up to 4 hours) Day TX Rehabilitative-Full Day (More than 4 hours) Socialization Crisis Stabilization-Emergency Room. (Must have Staff Physician) Crisis Stabilization-Urgent Care. (Must have Staff Physician) Vocational Services SNF Augmentation RU Target Population ADULT GERIATRICS (Age 60+) HIV+ MENTALLY ILL/SUBSTANCE ABUSERS MINORITY DEVELOPMENTALLY DISABLED CHILDREN (Age 0-17) AB3632 RU Billing/Payor Sources (FRC) SF County Grant Funded (Time Period & Name) MediCal (requires cert) (from to ) Medicare Federal: Insurance State: Client Other: Other: Work Order Not for billing, for tracking only CBHS100 (Rev 04/06) Page 5 of 18
6 RU#: Part II (Mental Health Services): Only Indirect Services Mode 45 Place a check mark ( ) to indicate YES if service applies to this RU. Y E S Range Description Indirect Services 11 Mental Health Promotion 21 Community Client Contact 28 Staff Training Given 29 Clinical Staff Development CBHS100 (Rev 04/06) Page 6 of 18
7 Part III (Drug and Alcohol Services): Intensive Outpatient Services RU#: Place a check mark ( ) if service applies to this RU. Intensive Outpatient Modality /Description of Service Procedure Code(s) Home Visit 130 Min. IOP Individual Counseling 131 IOP Group Counseling () 132 IOP Group Couns (Non ) 133 IOP Assessment () 134 Education/Life Skills Group 135 IOP Collateral () 136 IOP Treatment Planning () 137 Crisis Intervention () 138 Acupuncture 139 Case Management 140 Alternative Therapies 141 Court Appearance for client 142 Urinalysis 157 Psychiatry/Psychology Services 180 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 7 of 18
8 Part III (Drug and Alcohol Services): Outpatient Services RU#: Place a check mark ( ) if service applies to this RU. Outpatient Mark appropriate procedure code with (v) (v ) Description of Service Procedure Code(s) Group Counseling (Non ) 102 Home Visit Counseling 104 Court Appearance for client 142 Individual Counseling 151 Group Counseling () 152 Assessment () 154 Physical Exam/MD Visit 155 Collateral () 156 Assessment (Detoxification) 158 Opiate Detoxification 159 Alcohol/Sedative-Hypnotic Detox 160 Stimulant Detoxification 161 Dual Diagnosis Med. Maintenance 162 Acupuncture 163 Crisis Intervention () 164 Medication Management 166 Treatment Planning () 167 Case Management 168 Relapse Prevention 169 Urinalysis 170 TB Services 190 HIV services 191 Min. DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 8 of 18
9 RU#: Part III (Drug and Alcohol Services): Residential/ Residential Detoxification Services Place a check mark ( ) if service applies to this RU. Residential Modality /Description of Service Procedure Code(s) Residential Day (Non ) 288 Min. Residential Day (Perinatal ) 244 Residential Detoxification Modality /Description of Service Procedure Code(s) Resid. Detox (Social Model) 241 Min. Resid. Detox (Medically Managed) 254 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 9 of 18
10 Part III (Drug and Alcohol Services): Methadone Detoxification Services RU#: Place a check mark ( ) if service applies to this RU. Methadone Detoxification ( ) Description of Service Procedure Code(s) M Detox Indiv. Couns: Office/Hosp 301/311 Min. Acupuncture 302 M Detox Group Couns: Office/Hosp 312/332 M Detox dosing 321 Urinalysis 330 TB Services 390 HIV services 391 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 10 of 18
11 Part III (Drug and Alcohol Services): Methadone Maintenance Services RU#: Place a check mark ( ) if service applies to this RU. Methadone Maintenance Modality /Description of Service Procedure Code(s) MM Individual Couns: Office/Hosp. 401/411 Min. MM Group Couns: Office/Hosp. (Non Medi-cal) 402/432 MM Group Couns: Office/Hosp.(Medi-cal) 452/472 MM Dosing: Office/Hosp. 420/421 Urinalysis 430 Acupuncture 414 TB Services 490 HIV Services 491 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 11 of 18
12 Part III (Drug and Alcohol Services): Prevention Services RU#: Place a check mark ( ) if service applies to this RU. Prevention Modality /Description of Service Procedure Code(s) Childcare 507 Min. Child Early Intervention OP 578 Child Early Intervention Resid. 579 Prevention Education 576 Alternative Services 574 Early Intervention 571 Referral, Screening, Intake 572 Outreach and Intervention 573 IVDU Services 575 Group Intervention 583 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 12 of 18
13 Part III: (Drug and Alcohol Services):Clean and Sober Living RU#: Place a check mark ( ) to indicate YES if service applies to this RU. Clean and Sober Living ( ) Modality /Description of Service Procedure Code(s) Min. One Day or Less 750 Two Days 751 Three Days 752 More than Three Days 753 Overnight, Full Day Services 770 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 13 of 18
14 Part III (Drug and Alcohol Services): Ancillary Services RU#: Place a check mark ( ) if service applies to this RU. Ancillary Modality /Description of Service Procedure Code(s) Acupuncture only 781 Min. Case Management (Ancillary) 782 CM Assessment/Screening(Ancillary) 783 Ancillary CM Group 784 TB Services 790 HIV Services 791 Perinatal Outreach N/A DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 14 of 18
15 Part III (Drug and Alcohol Services): Day Care Rehabilitative(DCR) RU#: Place a check mark ( ) to indicate YES if service applies to this RU. Day Care Rehabilitative(DCR) ( ) Modality /Description of Service Procedure Code(s) Min. Day Care Rehabilitative(DCR)-Non 898 DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 15 of 18
16 RU#: Part III (Drug and Alcohol Services): Drinking Diving Programs Place a check mark ( ) to indicate YES if service applies to this RU. Drinking Driving Program ( ) Modality /Description of Service Procedure Code(s) Min. DUI Education & Counseling N/A DRUG Number: Cert Date: Perinatal Number: Cert Date: 1. Grant Fund covers: Full cost Partial General Fund Grant Single Adult Women & Children/Families CBHS100 (Rev 04/06) Page 16 of 18
17 Part IV: Attachments, Signatures and Distribution Check off as attached: CPT Code Crosswalk for providers who will be reimbursed on the basis of claims submitted on HCFA1500 (MHS only). CRDC Worksheet (MHS only) Fire clearance certificate (required for all new Organizational Providers) Please note: Provider information or other circumstances for the RU that may affect Billing, examples include but are not limited to, if the RU is County-funded only, if client services are partially funded by a Grant, if clients served are for a special population or eligibility category, if the RU is for tracking purposes only and no services will be entered, etc. Please attach supporting documents when appropriate or if helpful for documenting these special circumstances. Reporting Unit Notes: Signatures Signature signifies approval of New or Changes in Provider information contained on this form: Completed by CBHS Program Manager (Monitor) Date Approved by SOC & Service Director Date Approved by Assistant Director, SOC, for Contract Coordination Date CBHS100 (Rev 04/06) Page 17 of 18
18 Distribution List 1. BHBIS, 1380 Howard St., 3 rd Floor, Estifanos Tsegay (DAS), Pat Reynolds (MHS) 2. Program Review, Compliance & Performance, 1380 Howard St., 4 th Floor, Carlos Balladares 3. Data Manager, 1380 Howard St., 2 nd Floor, Jose Castro 4. Compliance & Performance, 1380 Howard St., Room 437, Jim Gilday 5. Manager, Contracts Unit, 1380 Howard St., 4 th Floor (Only if the Provider is a contractor). 6. Fiscal Reports, 101 grove St. Room 110, Annabel Martinez 7. BHIS, 1380 Howard St., 3 rd Floor, Nan Dame 8. Children s Programs, 1380 Howard St., 5 th floor, Philip Tse, 9. Adult & Older Adult, 1380 Howard St., 5 th floor, Kanwar Singh 10. Other Program Managers and lead Contract Administrator as listed on this form 11. CBHS Program Manager or Contract Monitor retains a file copy 12. Quality Management Unit, 1380 Howard St., 5 th Floor (Provider database) CBHS100 (Rev 04/06) Page 18 of 18
AVATAR Billing Providers Bulletin Medicare-MediCal Issue
DPH Fiscal - CBHS Billing Page 1 of 5 What is Medicare? Medicare is a health insurance program for: people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage
More informationSANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery. o--,-.m-a----,laa~-d-c~~~~~~~~~~-
Page 11 of 8 SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Departmental Policy and Procedure Section Sub-section Alcohol and Drug Program (ADP) Policy Drug Medi-Cal
More informationTreatment Planning. General Considerations
Treatment Planning CBH Compliance has been tasked with ensuring that our providers adhere to documentation standards presented in state regulations, bulletins, CBH contractual documents, etc. Complying
More informationCONTRA COSTA MENTAL HEALTH
WILLIAM B. WALKER, M.D. Health Services Director DONNA M. WIGAND, L.C.S.W. Mental Health Director CONTRA COSTA MENTAL HEALTH ADMINISTRATION 1340 Arnold Drive, Suite 200 Martinez, California 4553 Ph (925)
More informationAVATAR Billing Providers Bulletin
DPH Fiscal - CBHS Billing Page 1 of 6 HIPAA 5010 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary
More informationVolume 26 No. 05 July Providers of Behavioral Health Services For Action Health Maintenance Organizations For Information Only
Newsletter Published by the N.J. Dept. of Human, Div. of Medical Assistance & Health & the Division of and Volume 26 No. 05 July 2016 TO: SUBJECT: Providers of Behavioral Health For Action Health Maintenance
More informationOptum/OptumHealth Behavioral Solutions of California Facility Network Request Form / Credentialing Application
Optum/OptumHealth Behavioral Solutions of California Is the facility currently in the Optum network? Yes No Acceptance into the Optum/OptumHealth Behavioral Solutions of California (Optum) provider network
More informationMedicare Behavioral Health Authorization List Effective 5/26/18
100 All inclusive room and board 101 All inclusive room and board 104 Anesthesia, ECT 114 Room and Board- private psychiatric 116 Room and Board- private room detoxification 118 Room and Board- private
More informationBehavioral Health Covered Benefits
https://providers.amerigroup.com Behavioral Health Covered Benefits The matrix below lists the available behavioral health benefits for members enrolled in the Iowa Health and Wellness Plan. Outpatient
More informationI. General Instructions
Contra Costa Behavioral Health Services Request for Proposals (RFP) Outpatient Mental Health Services September 30, 2015 I. General Instructions Contra Costa Behavioral Health Services (CCBHS, or the County)
More informationDrug Medi-Cal Organized Delivery System
Drug Medi-Cal Organized Delivery System Presented by Elizabeth Stanley-Salazar, MPH CMS Approval of DMC-ODS Waiver under ACA August 13, 2015 Pathway to Parity 2010 President Obama Signs the Affordable
More informationMAGELLAN UNIVERSAL SERVICES LIST - Includes Preferred HIPAA Compliant Codes. UB-04 Revenue Codes
Service Name & Detailed Magellan Description (see column heading explanations at end of this document) MAGELLAN UNIVERSAL SERVICES LIST - Includes Preferred HIPAA Compliant Codes Codes Used to Determine
More informationFacility-Based Behavioral Health Program Professional Fees Reimbursement Policy Annual Approval Date. Approved By
Policy Number 2016RP505A Facility-Based Behavioral Health Program Professional Fees Reimbursement Policy Annual Approval Date 09/30/2016 Approved By Optum Behavioral Reimbursement Committee IMPORTANT NOTE
More informationBehavioral Health Services in Ohio Hospitals Ohio Hospital Association. Ohio Department of Medicaid January 23, 2018
Behavioral Health Services in Ohio Hospitals Ohio Hospital Association Ohio Department of Medicaid January 23, 2018 1 Outpatient Hospital Behavioral Health Services 2 OPHBH Services in Hospitals Outpatient
More informationFacility/Agency Change Form
Facility/Agency Change Form Submit a Facility/Agency Change Form (FCF) per TIN. Do not submit changes for multiple TINs on FCF. The preferred method for completing the FCF is electronically. Hand written
More informationLETTER OF INTENT TO CONTRACT WITH AMERIHEALTH CARITAS VIRGINIA FOR THE PROVISION OF SERVICES TO VIRGINIA MEDICAID RECIPIENTS
LETTER OF INTENT TO CONTRACT WITH AMERIHEALTH CARITAS VIRGINIA FOR THE PROVISION OF SERVICES TO VIRGINIA MEDICAID RECIPIENTS AmeriHealth Caritas Virginia, Inc., a member of the AmeriHealth Caritas Family
More information907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services.
907 KAR 1:044. Coverage provisions and requirements regarding community mental health center behavioral health services. RELATES TO: KRS 194A.060, 205.520(3), 205.8451(9), 422.317, 434.840-434.860, 42
More informationAlliance Behavioral Healthcare Level of Care Guidelines for State Funded Adult Mental Health and Substance Abuse Services
Alliance Behavioral Healthcare of Care Guidelines for State Funded Adult Mental Health and Substance Abuse s Mental Health (Effective 10/1/2012) The levels of care criteria provide a framework for the
More informationTBH Medicaid Participating Provider ARQ Page 1
TBH Medicaid Participating Provider ARQ Page 1 Room & Board Inpatient 90785 Interactive complexity code 90791 90792 90832 Room & Board Inpatient Psych Per Diem Psychiatric diagnostic evaluation Psychiatric
More informationBehavioral Health Covered Benefits
https://providers.amerigroup.com Behavioral Health Covered Benefits The matrix below lists the available behavioral health benefits for members enrolled in Medicaid programs. Iowa Health and Wellness enrollees
More informationCQRT/Documentation Training Q & A May, June and July 2004
CQRT/Documentation Training Q & A May, June and July 2004 These responses do not supersede any and all contracts and agreements between an agency and ACBHCS Children s Services Operations. In addition,
More informationSUBSTANCE ABUSE & HEALTH CARE SERVICES HEALTH SERVICES. Fiscal Year rd Quarter
HEALTH SERVICES To administer and manage contracted services to eligible persons in need of health care or related support services, and to promote health maintenance through education and intervention.
More informationNot Covered HCPCS Codes Reimbursement Policy. Approved By
Policy Number 2017RP506A Annual Approval Date Not Covered HCPCS Codes Reimbursement Policy 6/27/2017 Approved By Optum Behavioral Reimbursement Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
More information907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services.
907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services. RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 1396a(a)(23) STATUTORY AUTHORITY:
More informationTitle 22 Background & Updated Information State Plan Amendments Roles and Responsibilities Provider SUD Medical Director Physician Department of
Title 22 Background & Updated Information State Plan Amendments Roles and Responsibilities Provider SUD Medical Director Physician Department of Health Care Services (DHCS) County DMC Substance Use Disorder
More informationDrug Medi-Cal Organized Delivery System Implementation Plan. Imperial County Behavioral Health Services
Drug Medi-Cal Organized Delivery System Implementation Plan Behavioral Health Services Contents Page Number Part I Plan Questions 2 Part II Plan Description: Narrative Description of the County s Plan
More information#14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT)
COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - Policy- QUALITY ASSURANCE #14 AUTHORIZATION FOR MEDI-CAL SPECIAL TY MENTAL HEAL TH SERVICES (OUTPATIENT) Director's /{A A.. \
More informationDrug Medi-Cal Organized Delivery System (DMC-ODS) Waiver
Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver Medi-Cal Managed Care Advisory Committee Uma K. Zykofsky, LCSW Director, Behavioral Health Services Alcohol & Drug Administrator Waiver Authority
More informationMaine s Co- occurring Capability Self Assessment 1
Maine s Co- occurring Capability Self Assessment August 2009 Version 3.3 Date: Rater(s): Time Spent: Agency Name: Program Name: Program Type(s): Level of Care: Address: Contact Person: Title: Telephone:
More informationDepartment of Health & Human Services Division of Behavioral Health Services Alcohol & Drug Services. Uma K. Zykofsky, LCSW Behavioral Health Director
Department of Health & Human Services Division of Behavioral Health Services Alcohol & Drug Services April 24, 2017 Presentation to Geographic Managed Care Providers Uma K. Zykofsky, LCSW Behavioral Health
More informationMolina Healthcare of Ohio Behavioral and Mental Health Molina Dual Options MyCare Ohio 2014
Molina Healthcare of Ohio Behavioral and Mental Health Molina Dual Options MyCare Ohio 2014 1 Headline Goes Here Mental Health/Behavioral Health Services Cont. Mental and emotional well-being is essential
More informationBehavioral Health Providers: Frequently Asked Questions (FAQs)
Behavioral Health Providers: Frequently Asked Questions (FAQs) Q. What has changed as far as behavioral health services? A1. Effective April 1, 2012, the professional and outpatient facility charges for
More informationServices and Supports for People with Dual Diagnosis
RIGHTS UNDER THE LAN TERMAN ACT Services and Supports for People with Dual Diagnosis Chapter 10 This chapter explains: - Dual diagnosis - Mental health services and supports - Regional Center responsibilities
More informationAges Ages 3 through 64.
Medicaid: Follow-Up After Discharge from Community Hospitals, State Psychiatric Hospitals, and Facility Based Crisis Services for Mental Health Treatment The percentage of discharges for individuals ages
More informationSan Francisco Whole Person Care California Medi-Cal 2020 Waiver Initiative
San Francisco Whole Person Care California Medi-Cal 2020 Waiver Initiative Update April 3, 2018 Health Commission Maria X Martinez, Director Whole Person Care Barry Zevin, MD, Medical Director Street Medicine
More informationThe Money Follows the Person Demonstration in Massachusetts
The Money Follows the Person Demonstration in Massachusetts Use of Concurrent 1915(b)(c) Waivers to Serve Elders and Adults with Disabilities Transitioning from Long-Stay Facilities HCBS Conference Arlington,
More informationSan Diego County Funded Long-Term Care Criteria
San Diego County Funded Long-Term Care Criteria Prepared By: 6/23/16 Table of Contents San Diego County Funded Long Term Care Criteria... 2 Referral Criteria by Level of Care: Institute of Mental Disease
More informationPeach State Health Plan Covered Services & Authorization Guidelines Programs for Behavioral Health
Peach State Health Plan Covered s & Guidelines Programs for Health n-participating providers (those that are not contracted and credentialed with Peach State Health Plan) require prior authorization for
More informationImproving Service Delivery for Medicaid Clients Through Data Integration and Predictive Modeling
Improving Service Delivery for Medicaid Clients Through Data Integration and Predictive Modeling Getty Images David Mancuso, PhD July 28, 2015 1 The Medicaid Environment Program costs are often driven
More informationDrug/Medi-Cal Organized Delivery System (DMC-ODS) Waiver County Implementation Plan. Submitted By: Ventura County Behavioral Health Department
Drug/Medi-Cal Organized Delivery System (DMC-ODS) Waiver County Implementation Plan Submitted By: Ventura County Behavioral Health Department June 2016 1 Drug Medi-Cal Organized Delivery System Implementation
More informationDocumentation Training
Welcome to Documentation Training Please sign in Put cell phones on silence/vibrate Find a seat and buckle up for the ride 1 Documentation Training Quality Improvement Program (408) 793-5894 www.sccmhd.org.
More informationCalifornia Medi-Cal 2020 Demonstration Page 89 of 307 Approved December 30, 2015 through December 31, 2020
X. DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM 127. Drug Medi-Cal Eligibility and Delivery System. The Drug Medi-Cal Organized Delivery System (DMC-ODS) is a Pilot program to test a new paradigm for the organized
More informationIV. Clinical Policies and Procedures
A. Introduction The role of ValueOptions NorthSTAR is to coordinate the delivery of clinical services. There are three parties to this care coordination process: the Enrollee, the Provider(s), and the
More informationMedicaid Funded Services Plan
Clinical Communication Bulletin 007 To: From: All Enrollees, Stakeholders, and Providers Cham Trowell, UM Director Date: May 10, 2016 Subject: Medicaid Funded Services Plan benefit changes, State Funded
More informationDr. Nancy G. Burlak, EdD, LMFT
CURRICULUM VITAE Dr. Nancy G. Burlak, EdD, LMFT EDUCATION/LICENSE 2011-2014 Ed.D. (Counseling Psychology 4.0 GPA) ARGOSY UNIVERSITY, San Diego, CA Clinical Research Project: Optimal Duration of Treatment
More informationService Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note:
Service Array: Mental Health Medicaid Specialty Supports and Services Descriptions Note: If you are a Medicaid beneficiary and have a serious mental illness, or serious emotional disturbance, or developmental
More informationPartial Hospitalization. Shelly Rhodes, LPC
Partial Hospitalization Shelly Rhodes, LPC Shelly.Rhodes@beaconhealthoptions.com Transition and Certification 2 Transition and Certification Current Rehabilitative Services for Persons with Mental Illness
More informationOverview of California External Quality Review Activities
Overview of California External Quality Review Activities CBHDA Fiscal Administrator Conference Rama Khalsa, Director Drug Medi-Cal EQRO Bill Ullom, Information Systems Chief December 11, 2017 Review Activities
More informationo Recipients must coordinate these testing services with other HIV prevention and testing programs to avoid duplication of efforts.
E. GENERAL SERVICE DEFINITIONS & SERVICE DELIVERY The following section provides specific service definitions, service delivery and any special reporting requirements for each of the services funded in
More informationMaryland Medicaid Program. Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012
Maryland Medicaid Program Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012 1 Maryland Medicaid In Maryland, Medicaid is also called Medical Assistance or MA. MA is a joint
More informationCovered Service Codes and Definitions
Covered Service Codes and Definitions [01] Assessment Assessment services include the systematic collection and integrated review of individualspecific data, such as examinations and evaluations. This
More informationRehabilitative Behavioral Health Providers Frequently Asked Questions
Rehabilitative Behavioral Health Providers Frequently Asked Questions Q. What has changed regarding rehabilitative behavioral health services? A. Effective July 1, 2016, South Carolina Department of Health
More informationKERN HEALTH SYSTEMS PARTICIPATING HOSPITAL/FACILITY APPLICATION
KERN HEALTH SYSTEMS PARTICIPATING HOSPITAL/FACILITY APPLICATION Facility Name: Chief Administrative Officer: Chief Financial Officer: Chief Medical Officer: Corporate Tax Status: If Facility Medi-cal Certified?
More informationDrug Medi-Cal Organized Delivery System Demonstration Waiver
Drug Medi-Cal Organized Delivery System Demonstration Waiver All County Orientation to Standard Terms and Conditions & Fiscal Provisions Presentation by DHCS and Harbage September 28, 2015 Overview of
More informationSUD Rate Matrix - Treatment Services
SUD Rate Matrix - Treatment Services Alcohol or Drug Assessment Updated Assessment BILLABLE ITEM & RATE Code w/ H0001 15 min. Duration $12.40 H0001.HF 15 min. Duration $12.40 FY18 SUD CLINICAL TREATMENT
More informationDivision of Mental Health, Developmental Disabilities & Substance Abuse Services NC Mental Health and Substance Use Service Array Survey
Table 1 Service Name Include any subcategories of service on a separate line In Table 2, please add service description and key terms Outpatient Treatment Behavioral Health Urgent Care (a type of outpatient)
More informationAcute Crisis Units. Shelly Rhodes, Provider Relations Manager
Acute Crisis Units Shelly Rhodes, Provider Relations Manager Shelly.Rhodes@beaconhealthoptions.com Training Agenda Agenda: Transition and Certification Coverage of Services Service Code Definition Documentation
More informationState-Funded Enhanced Mental Health and Substance Abuse Services
and and Contents 1.0 Description of the Service... 3 2.0 Individuals Eligible for State-Funded Services... 3 3.0 When State-Funded Services Are Covered... 3 3.1 General Criteria... 3 3.2 Specific Criteria...
More informationVSHP/ Behavioral Health
VSHP/ Behavioral Health Deb Dukes & Dr Kelly Askins The contact numbers in the presentation apply to WEST Member Services ONLY. New numbers for EAST Member Services will be published and distributed by
More informationHours: Monday Friday, 8 AM to 5 PM. Evening hours available at all sites.
Chestnut Health Systems Inc. 50 Northgate Industrial Drive Granite City, Il 62040 Phone: 618. 877.4420 Crisis hotline: 618.877.0316 www.chestnut.org Contact: Susan Taylor staylor@chestnut.org 618.877.4420
More informationDRUG MEDI-CALWAIVER STAKEHOLDER FORUM
October 27, 2015 DRUG MEDI-CALWAIVER STAKEHOLDER FORUM Patrick Zarate Division Manager, Alcohol & Drug Programs Objectives for Today Learn About the Drug Medi-Cal Organized Delivery System waiver Gain
More informationSection V: To be completed by the PIHP contract manager as applicable. Section VI: To be completed by the PIHP Credentialing Committee as applicable.
Sections I-IV: To be completed by the organizational provider at the time of initial network application for enrollment and credentialing; or at the time of the biennial re-credentialing. Section I. Agency
More informationExhibit A Language Changes Summary (FY 14-15) Mental Health
Exhibit A Language Changes Summary (FY 14-15) Mental Health I. Ex A - Standard Changes Changed HealthPac to HealthPac County Added Site under Certification/Licensure section to make the distinction versus
More information2/18/2014. Trudy Raymundo, Director, San Bernardino County Department of Public Health
Trudy Raymundo, Director, San Bernardino County Department of Public Health Daniel Perez, Division Chief of Disease Control and Prevention, San Bernardino County Public Health Department Vickie Baumbach,
More informationMental Health Board Member Orientation & Training
1 Mental Health Board Member Orientation & Training See Tab 1 Mental Health Timeline 1957 Sources: California Legislative Analyst Office & California Department of Health Care Services to Prior to 1957
More informationCertified Community Behavioral Health Clinics (CCBHCs): Overview of the National Demonstration Program to Improve Community Behavioral Health Services
Certified Community Behavioral Health Clinics (CCBHCs): Overview of the National Demonstration Program to Improve Community Behavioral Health Services Cynthia Kemp (SAMHSA) Mary Cieslicki (Center for Medicaid
More informationPlace of Service Code Description Conversion
Place of Conversion CMS Place of Code Place of Name The place of service field indicates where the services were performed Possible values include: Code Description Inpatient Outpatient Office Home 5 Independent
More informationSanta Clara County, California Medicare- Medicaid Plan (MMP)
Santa Clara County, California Medicare- Medicaid Plan (MMP) Behavioral health overview topics Topics covered: o Behavioral health (BH) covered services overview o BH noncovered services o Early and Periodic
More informationMental Health Updates. Presented by EDS Provider Field Consultants
Mental Health Updates Presented by EDS Provider Field Consultants October 2007 Agenda Session Objectives Outpatient Mental Health Medicaid Rehabilitation Option (MRO) Somatic Treatment Assertive Community
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor DATE: OCTOBER 28, 2013 ALL PLAN LETTER 13-014 SUPERSEDES ALL PLAN
More informationBenefits are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES Annual Deductible The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Hearing aid reimbursement does not apply to the out-of-pocket
More informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2011 December 31, 2011 Los Angeles County This publication is a supplement to the 2011 Positive (HMO SNP) Evidence
More informationFacility and Ancillary Credentialing Application INSTRUCTIONS
Facility and Ancillary Credentialing Application INSTRUCTIONS Please complete the application thoroughly in its entirety. The checklist below may not be exhaustive of all materials, but is provided as
More information12. Additional Service Specific Information
12. Additional Service Specific 12.1 General Assistance for SNFs SNFs can contact their local KP Skilled Nursing Department for general assistance and requesting Authorizations for ancillary services to
More informationMBHP FISCAL YEAR 2015 PROVIDER RATE INCREASES AND INCENTIVES
ALERT # 149 September 9, 2014 MBHP FISCAL YEAR 2015 PROVIDER RATE INCREASES AND INCENTIVES The following information should be noted immediately by your chief executive officer, chief medical officer,
More informationPROS Clarification. Structured Skill Development and Support
PROS Clarification Guidance 1: Guidance 2: Guidance 3: Guidance 4: Guidance 5: Guidance 6: Guidance 7: Guidance 8: Guidance 9: IRP Development and Timeframes The PROS Assessment and Timeframes Progress
More informationSummary of the Low Income Health Program Applications
Summary of the Health Program Applications California s Section 1115 Medicaid waiver creates the opportunity for counties to develop Low Income Health Programs (LIHPs) to provide coverage for childless
More informationAlcohol Drug & Mental Health Services INPATIENT SERVICES
Alcohol Drug & Mental Health Services INPATIENT SERVICES WHEN MUST COUNTY FUND MENTAL HEALTH SERVICES? 2 INPATIENT INCREASES DRIVERS Lack of psychiatric beds state & nation Increase in patients Court Ordered
More informationHamilton County Municipal and Common Pleas Court Guide
Hamilton County Municipal and Common Pleas Court Guide Updated May 2017 PREVENTION ASSESSMENT TREATMENT REINTEGRATION MUNICIPAL & COMMON PLEAS COURT GUIDE Table of Contents Table of Contents... 2 Municipal
More informationShort-term Intensive Residential Remediation Treatment
Short-term Intensive Residential Remediation Treatment LETTER OF INTENT Signal Behavioral Health Network 6130 GREENWOOD PLAZA BLVD, #150, GREENWOOD VILLAGE, CO 80111 1 LETTER OF INTENT SCOPE This Letter
More informationLCSW, RN Ther, LCPC. PHD Psych CRNP - PMH APRN - PMH
non-facili facili On- Off- OTHER PROFESSIONAL SERVICES FOR IOP, PHP & CRS 90791 iatric diagnostic evaluation 157.80 110.29 128.49 112.50 180.74 90791 C&A iatric diagnostic evaluation 157.80 110.29 128.49
More informationStanislaus County Drug Medi-Cal Organized Delivery System (DMC- ODS)
Stanislaus County Drug Medi-Cal Organized Delivery System (DMC- ODS) BHRS Vision Our vision is to continue to be a leader in behavioral health and to be recognized for excellence in our community, state,
More informationDrug Medi-Cal Organized Delivery System Evaluation: Baseline
Drug Medi-Cal Organized Delivery System Evaluation: Baseline Darren Urada, Ph.D., Cheryl Teruya, Ph.D., Valerie P. Antonini, M.P.H., Elise Tran, B.A., David Huang, Ph.D., Howard Padwa, Ph.D., June Lim,
More informationSan Francisco Whole Person Care California Medi-Cal 2020 Waiver Initiative
San Francisco Whole Person Care California Medi-Cal 2020 Waiver Initiative February 2, 2018 COIT Budget & Performance Subcommittee SF WHOLE PERSON CARE Background: What is it? Targeted Population in SF:
More informationLONG TERM & RESIDENTIAL CARE IN SAN DIEGO COUNTY. April 2018 Dr. Michael Krelstein, Clinical Director Behavioral Health Services
LONG TERM & RESIDENTIAL CARE IN SAN DIEGO COUNTY April 2018 Dr. Michael Krelstein, Clinical Director Behavioral Health Services 1 BEHAVIORAL HEALTH CONTINUUM OF CARE Independent Living Licensed Board and
More informationHUMMINGBIRD PLACE PSYCHIATRIC RESPITE Behavioral Health Navigation Center
HUMMINGBIRD PLACE PSYCHIATRIC RESPITE Behavioral Health Navigation Center San Francisco Department of Public Health SFHN TRANSITIONS DIVISION Presented by: Luis Calderon, Transitions Care Coordinator Director
More informationCovered Behavioral Health Services
Behavioral Health Services Covered Behavioral Health Services Cenpatico, Buckeye s behavioral health affiliate, has been delegated the provision of covered mental health and substance use disorder services
More informationUpdates: BHCS Mental Health Contracting for FY Frequently Asked Questions Last Update: 4/6/17
Updates: BHCS Mental Health Contracting for FY 17-18 Frequently Asked Questions Last Update: 4/6/17 Purpose: It is the charge of BHCS and other public agencies to be prudent purchasers of high quality
More informationDrug Medi-Cal Organized Delivery System Implementation Plan
California Department of Health Care Services Drug Medi-Cal Organized Delivery System Waiver NEVADA COUNTY BEHAVIORAL HEALTH Drug Medi-Cal Organized Delivery System Implementation Plan Submitted July 14,
More informationPO AILANI, INC. CONTINUUM OF CARE. Applicant s Data Descriptor Information (Please Complete Entire Form)
PO AILANI, INC. CONTINUUM OF CARE SCREENING FORM 74 KIHAPAI STREET TELEPHONE (808) 262-2799 KAILUA, HAWAII 96734 FAX (808) 262-0970 Referral Source Name/Title Date Funding Source (circle appropriate source)
More informationThe IMD Exclusion What Is It? Why Is It Important? John O Brien Senior Advisor SAMHSA
The IMD Exclusion What Is It? Why Is It Important? John O Brien Senior Advisor SAMHSA The IMD Exclusion An Institution for Mental Diseases (IMD) is any inpatient or residential facility of more than 16
More information1. SMHS Section of CCR Title 9 (Division 1, Chapter 11): this is the regulation created by the California Department of Health Care Services (DHCS).
Clinical Documentation Tool This tool compares the definitions of outpatient Specialty Mental Health s (SMHS) that appear in two different sources: 1. SMHS Section of CCR Title 9 (Division 1, Chapter 11):
More informationState Resources, Policy, and Reimbursement Information
State Resources, Policy, and Reimbursement Information Policies, billing procedures, and referral procedures related to suicide prevention in primary care vary significantly across states. Understanding
More informationPROVIDER INFORMATION UPDATE FORM CURRENT CONTRACT INFORMATION - ALL FIELDS IN THIS SECTION ARE REQUIRED
PROVIDER INFORMATION UPDATE FORM CURRENT CONTRACT INFORMATION - ALL FIELDS IN THIS SECTION ARE REQUIRED 1. Type of Group: Ancillary Specialist PCP Hospital Urgent Care FQHC/RHC QFPP/ X Contracted Entity/Name:
More informationFlorida Medicaid. Therapeutic Group Care Services Coverage Policy
Florida Medicaid Therapeutic Group Care Services Coverage Policy Agency for Health Care Administration July 2017 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal
More informationBehavioral Health Initial Review Form
Behavioral Health Initial Review Form https://providers.amerigroup.com This form is for inpatients, the Partial Hospitalization Program and the Intensive Outpatient Program. Please submit this form on
More informationSTAR+PLUS through UnitedHealthcare Community Plan
STAR+PLUS through UnitedHealthcare Community Plan Optum 06012014 Who We Are United Behavioral Health (UBH) was created February 2, 1997, through a merger of U.S. Behavioral Health, Inc. (USBH) and United
More informationELMR. Provider Connect. Training Manual (v.2.0) Electronic Management of Records. Substance Abuse Program
ELMR Electronic Management of Records Substance Abuse Program Provider Connect Training Manual (v.2.0) March 2013 Table of Contents Section 1 Introduction & Updates Section 2 Getting Started & Navigating
More informationHours: Monday Friday, 8 AM to 5 PM. Evening hours available at all sites.
Chestnut Health Systems Inc. 50 Northgate Industrial Drive Granite City, Il 62040 Phone: 618. 877.4420 Crisis hotline: 618.877.0316 www.chestnut.org Contact: Susan Taylor staylor@chestnut.org 618.877.4420
More informationState of New Jersey Department of Human Services Division of Medical Assistance & Health Services (DMAHS)
State of New Jersey Department of Human Services Division of Medical Assistance & Health Services (DMAHS) Outpatient Facility Behavioral Health Integration Billing Frequently Asked Questions (FAQs) 1.
More information