Integrated Policies & Procedures

PROVIDER NETWORK

Credentialing and Re-Credentialing Policy

The Santa Clara County Behavioral Health Services Department (BHSD) ensures that its county-owned and operated providers (i.e., BHSD employees) and contract organizational providers that deliver Medi-Cal-covered services are qualified in accordance with current legal, professional, and technical standards, and -are appropriately licensed, registered, waivered, and/or certified. The term provider is used in this document to refer to clinicians or counselors who provide direct services to plan beneficiaries.

Provider Directory

It is BHSD’s practice to adhere to DHCS requirements in developing and maintaining the Provider Directory in accordance with the State and Federal requirements, including directory content, type, language, and format.

Use of Electronic Health Records and Password

Behavioral Health Services Department (BHSD) policy to ensure BHSD and its subcontractor have adequate method to secure and protect ePHI and PHI in accordance with applicable laws and regulations. Access to ePHI/PHI is based on a staff person’s role.
BHSD will adhere to the Security of ePHI/PHI as described in 42 CFR Part 2, 45 CFR Parts 160 and 164, HIPAA, HITECH Act, SCVHHS PP 585.23, and will require its subcontractors to adhere to above laws, regulations and county policy. Subcontractors are required to create and maintain and provide applicable Policies and Procedures in accordance with all applicable Privacy and Security Rules, including the transmission of ePHI/PHI and password protections.

Cultural Competency and Non-Discrimation

BHSD shall participate in the state's efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity. BHSD shall accept beneficiary
applicants in the order they applied and shall not discriminate regardless of health status or need for health care services, race, color, national origin, sex, gender, sexual orientation, gender identity, or disability, and ensure high quality services that
are equitable to underserved, accessible and responsive to socially disadvantaged and ethnically diverse groups, which include culturally and linguistically appropriate services.

Beneficiary Problem Resolution

Beneficiaries that receive BHSD services may file a grievance or appeal and have their concerns addressed through a clearly defined problem resolution process if they are not satisfied with their behavioral health services or steps taken by BHSD.

Advance Directive

Behavioral Health Services Department values and upholds the right and freedom of the
individual person to decide on every aspect of their life, including end of life decisions. BHSD
recognizes and accepts all instruments that protect and safeguard this right and freedom of the individual to decide, including the right to have an Advance Directive. In addition, BHSD provides education about Advance Directive policies and procedures.

Beneficiary Rights

DHCS defines beneficiary rights to include but not be limited to:
• Be treated with personal respect and respect for your dignity and privacy.
• Receive information on available treatment options and alternatives; and have them presented in a manner they can understand.

Notification of Material Changes

Within 15 calendar days of receipt of a contracted provider’s valid formal termination notice, BHSD shall make a good faith effort to give written notice of the termination of the contracted provider to each beneficiary who received behavioral health services from, or was seen on a regular basis by the terminated contract provider.

Providing Language Services

Care Coordination and Continuity of Care

The Behavioral Health Services Department (BHSD) will ensure:
1. Each beneficiary has an ongoing source of care appropriate to his or her needs.
2. A person or entity is formally designated as primarily responsible for coordinating services accessed by the beneficiary.
3. The beneficiary is provided information on how to contact their designated person or entity.
4. Each beneficiary’s right to change the designated network provider when such change is clinically appropriate and possible.

Claims Adjudication Process

The Behavioral Health Services Department (BHSD) shall comply with all eligibility, service, and payment data certification requirements under applicable federal and state law, for all claims submitted for federal financial participation (FFP).

Cost Sharing and Payment of Services

The Department Policy on Cost Sharing and Payment of Services will follow 42 CFR 438 with regards Emergency and Post Stabilization Services, Cost Sharing, Non-Payment, Treatment of Recoveries, Insolvency, and Payments.

Emergency and Post Stabilization Services

1. BHSD does not deny payment for behavioral health treatment obtained in the following circumstances:
a. An emergency behavioral health condition including cases in which absent immediate medical attention would place the beneficiary in serious jeopardy, seriously impair bodily functions or serious dysfunction of any bodily organ or part.
b. Where a representative of the MCP instructs the beneficiary to seek emergency behavioral health services.

Provider Beneficiary Communication

County and/or Contractor will not prohibit nor otherwise restrict, a licensed, waivered, or registered professional who is acting within the lawful scope of practice from advising or advocating on behalf of a beneficiary for whom the provider is providing behavioral health services.

Provider Network Enrollment and Screening

To ensure that providers are enrolled as Medi-Cal providers and are appropriately screened, Behavioral Health Services Department (BHSD) requires that all providers must be enrolled as Medi-Cal providers with the State and meet federal disclosure, screening, and enrollment requirements.

Provider Network Selection and Retention

To ensure that network providers understand the elements of the provider selection process and maintain compliance with state and federal Medicaid regulations, BHSD established policies and processes to ensure that providers are equitably selected. Following BHSD Provider Standards, BHSD does not: a. Contract with providers beyond the number necessary to meet the needs of its enrollees.

Network Adequacy and Timely Access

To ensure that throughout the geographic regions of Santa Clara County (SCC), the Behavioral Health Services Department (BHSD) will comply with network adequacy standards developed pursuant to Title 42 of the Code of Federal Regulations Part 438.68, as specified in Chapter 738, Statutes of 2017 (Assembly Bill 205), for all beneficiaries.

Good Neighbor Policy

The Santa Clara County Behavioral Health Services Department (BHSD) provides neighborhood-based residential facilities for clients with mental health and/or substance use disorders, both as County-operated facilities and through contractors (“BHSD residential facilities”). It is BHSD policy that each BHSD residential facility is committed to be an integral part of the neighborhoods and communities in which they are located and will implement measures in order to minimize any potential negative impacts to the neighborhoods and communities in which they operate.

Evidence-Based Practice

The Behavioral Health Services Department (BHSD) will integrate current evidence-based knowledge into the provision of services to support continued beneficiary outcome improvement. This will include training in evidenced-based practices; clinical supervision to support and develop practices including fidelity monitoring as appropriate for the beneficiary; and monitoring of training, supervision, and practice use.

Data Entry and Data Reporting

Pursuant to 42 C.F.R. § 438.242 and consistent with Cal. Code Regs., tit. 9, § 1810.376, the Behavioral Health Services Department (BHSD) shall maintain a health information system that collects, analyzes, integrates, and reports data. BHSD’s health information will: (1) collect data on beneficiary and provider characteristics and on services furnished to beneficiaries as specified by DHCS, (2) verify the accuracy and timeliness of data reported by its providers, and if applicable, data from network providers receiving capitation payments; (3) screen the data received from providers for completeness, logic, and consistency, and (4) collect data from providers in standardized formats to the extent feasible and appropriate, including via secure information exchanges and technologies utilized for state Medicaid quality improvement and care coordination efforts.

Limitation on Moral or Religious Grounds

Providers will not be required to deliver, reimburse for, or offer coverage of a counseling or referral service if the provider objects to the service on moral or religious grounds. Beneficiaries will know which providers have objections based on religious or moral grounds prior to referral or change.

Medical Necessity

BHSD will adhere to clear parameters around medical necessity criteria for inpatient, outpatient, EPSDT and substance use treatment services, including providing, arranging and paying for all demonstrated medically necessary covered behavioral health services given to beneficiaries with covered diagnoses, as set forth by Federal and State regulations, by industry criteria such as ASAM, and by its own Utilization Management Program and Clinical Practice Guidelines.

Out of Plan Services

BHSD is responsible for providing or arranging medically necessary behavioral health services for beneficiaries outside their county of origin for emergency and post stabilization services. If BHSD is unable to provide outpatient medically necessary covered services to a beneficiary it will provide timely and adequate out of plan services for as long as BHSD is unable to provide these services. BHSD will arrange for medically necessary behavioral health services for children in foster care residing outside their county of origin. BHSD will provide medically necessary behavioral health services to foster care children placed in Santa Clara County.

Telehealth Policy for Psychiatry (Outpatient Services)

Upon approval by the BHSD System of Care Executive Director (or designee), Medi-Cal eligible telemedicine services (e.g. Psychotherapy, Pharmacologic Management, Consultations, etc.) may be provided to clients when equivalent in-person services are not available.

Telehealth Policy for Outpatient Therapy (Outpatient Services)

Upon approval by the BHSD System of Care Executive Director (or designee), telehealth services (e.g. psychotherapy, pharmacologic management, consultations, etc.) may be provided to clients when equivalent in-person services are not available or when such services are deemed appropriate.

Utilization Management

The Behavioral Health Services Department (BHSD) Utilization Management (UM) program supports the delivery of services provided by its County and Contracted partners, and ensures delivery of high quality, medically necessary care through appropriate utilization of resources in a cost effective and timely manner. The UM program is a key component of the BHSD's "Quality Assessment and Performance Improvement" (QAPI) Division. The UM Program operates under the guidance of the BHSD’s Director, Quality Management Executive Director, Medical Director, and Utilization Management Division Director. The program is designed to detect and address over and underutilization of services, and evaluates medical necessity and appropriateness of services provided to Medi-Cal beneficiaries prospectively, concurrently, and retrospectively. This policy outlines the standards and guidelines that detail how the BHSD and its provider network system comply with the federal laws and Department of Health Care Services (DHCS) contract requirements pertaining to UM responsibilities.

Incident Report

Integrated Policies & Procedures

PROVIDER NETWORK

Credentialing and Re-Credentialing Policy

PROVIDER DIRECTORY

Provider Directory

SECURITY ADDENDUM

Use of Electronic Health Records and Password

ACCESS AND AVAILABILITY OF SERVICES

Cultural Competency and Non-Discrimation

BENEFICIARY PROBLEM RESOLUTION

Beneficiary Problem Resolution

BENEFICIARY RIGHTS

Advance Directive

BENEFICIARY RIGHTS

Beneficiary Rights

BENEFICIARY RIGHTS

Notification of Material Changes

BENEFICIARY RIGHTS

Providing Language Services

COORDINATION AND CONTINUITY OF CARE

Care Coordination and Continuity of Care

DOCUMENTATION REQUIREMENTS

Claims Adjudication Process

FINANCIAL REPORTING REQUIREMENTS

Cost Sharing and Payment of Services

FINANCIAL REPORTING REQUIREMENTS

Emergency and Post Stabilization Services

PROVIDER NETWORK

Provider Beneficiary Communication

PROVIDER NETWORK

Provider Network Enrollment and Screening

PROVIDER NETWORK

Provider Network Selection and Retention

PROVIDER NETWORK

Network Adequacy and Timely Access

PROVIDER NETWORK, SCOPE OF SERVICES

Good Neighbor Policy

QUALITY IMPROVEMENT SYSTSEM

Evidence-Based Practice

REPORTING REQUIREMENTS

Data Entry and Data Reporting

SCOPE OF SERVICES

Limitation on Moral or Religious Grounds

SCOPE OF SERVICES

Medical Necessity

SCOPE OF SERVICES

Out of Plan Services

TELEHEALTH

Telehealth Policy for Psychiatry (Outpatient Services)

TELEHEALTH

Telehealth Policy for Outpatient Therapy (Outpatient Services)

UTILIZATION MANGEMENT PROGRAM

Utilization Management

BHSD 2800: Good Neighbor Policy Arrchments