POLICIES AND PROCEDURES

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CalAIM
BHIN#	Policy Description	Created	Updated
23-063	County Behavioral Health Intergovernmental Transfers (IGT)	7/01/2023
	Utilization Management (UM), Audit, Oversight and Recoupment Standards for Specialty Mental Health Services (SMHS)	1/31/2023
22-065	CalAIM - Adult and Youth Screening and Transition of Care Tools	1/01/2023
22-017	CalAIM Concurrent Review Standards for Psychiatric Inpatient Hospital and Psychiatric Health Facility Services	7/06/2022
23-068	CalAIM - Documentation Requirements for all Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services	7/01/2022	1/01/2024
22-011	CalAIM - No Wrong Door for Mental Health Services Policy	7/01/2022
21-075	CalAIM - Drug Medi-Cal Organized Delivery System (DMC-ODS) Requirements for the Period of 2022 – 2026	4/01/2022	9/19/2023
21-073	CalAIM - Medical Necessity and Level of Care Determination for SMHS	4/01/2022
21-071	CalAIM - Medical Necessity and Level of Care Determination for DMC-ODS	4/01/2022

CLIENT CARE
Policy Number	Policy Description	Created	Updated	Policy Number	Policy Description	Created	Updated
104	Compliance Plan Policy Monterey County Compliance Plan	2/26/2015	12/2020
120	Notice of Adverse Benefit Determination Forms	10/01/1997	02/06/2024	421	Referral of Cases to Behavioral Health Division Adult Services	9/01/1989	10/31/2017
123	Unusual Incident Reporting	3/15/2001	2/26/2015	422	Utilization Review	9/01/1989	9/26/2019
128	Beneficiary Problem Resolution Process (Grievance, Standard Appeals, Expedited Appeals) Problem Resolution Attachment (letters) Click here to view the Problem Resolution Forms	1/1/2004	04/19/2023	432	Adult Services Case Management Representative Payee Services Delegation Of Authority For Representative Payee Services	10/1/1991	N/A
129	Medical Records Documentation	3/01/2005	6/21/2019	433	AS CM Rep Payee Services Eligibility	10/1/1991	N/A
130	Practice Guidelines	12/06/2017	N/A	434	CM Rep Payee Services Intake Procedure
144	Disclosure of Unlicensed Status for License Eligible Clinicians	2/26/2015	N/A	435	Representative Payee Case Action	10/1/1991	N/A
145	Productivity (formerly known as “Expected Levels of Achievement”)	3/01/2011	6/27/2019	436	Adult Services Case Management Representative Payee Services Reporting Responsibilities To Social Security Administration	10/1/1991	N/A
146	Sentinel Events	6/22/2015	N/A	437	Adult Services Case Management Representative Payee Services Deceased Client Accounts	10/01/1991	N/A
147	Out of Network	2/27/2018	N/A	438	Medical Waste Management	4/01/1992	12/04/2002
148	Network Adequacy and Timeliness Standards	3/7/2018	12/28/2021
149	Telehealth Telehealth Consent Acknowledgement English Spanish	3/08/2018	3/18/2024
152	Continuity of Care Policy Continuity of Care request Form ENGLISH Continuity of Care request form SPANISH	8/01/2021
153	Written Notification of Reason Not to Contract	11/01/2021
202	Safety Practices for Field Visits	4/01/1998	4/01/2009
207	Continuing Education Credits	2/27/2017	N/A	441	Medication Refills	1/1/1993	7/31/2001
208	ASAM Training	11/29/2017		443	Scope of Practice	7/01/1993	2/26/2015
300	Reporting of Child Abuse and Neglect Suspected Child Abuse Report Form BCIA 8572 -ADA	3/01/1991	12/01/2023	444	Physician Availability	7/01/1993	4/16/2003
300B	Reporting of Elder And Dependent Adult Abuse Report of Suspected Dependent Adult-Elder Abuse Form SOC341 -ADA	3/01/1991	02/22/2024	452	Distribution of Translated Materials	7/01/1998	11/14/2017
301	Filming Photographing Audio of Clinical Activities	9/08/1986	12/17/2012	454	Reporting of Quality Improvement Time	1/1/2000	2/02/2011
304	Direct Patient Access to Treatment Records	3/01/1991	4/20/2011	457 & 457B	TBS & TBS Eligibility	9/06/1999	3/10/2017
305	Patient’s Rights	3/01/1991	3/01/2009	460	Mobile Crisis Services	1/28/2016	12/31/2023
306	Duty to Warn English – Duty to Warn Letter Spanish – Duty to Warn Letter	N/A	N/A	471	Advance Health Care Directive Advance Directive Brochure English Advance Directive Brochure Spanish	3/01/2009 8/18/2022	N/A
307	Reporting of Lapses of Consciousness	9/11/1991	4/06/2006	477	Therapy Dogs	1/1/2011	N/A
310	Contact With The News Media	10/01/2008	N/A	478	Milestones of Recovery	1/1/2011	N/A
				480	Natividad Medical Center Mental Health unit Record Documentation Policy	8/10/2017	N/A
312	Firearms Possession	1/01/2001	4/01/2008	490	Collaborative Case Conferences Request for QI Consultation	6/20/2012	N/A
314	Subpoenas	11/20/2001	1/23/2019	492	Co-Signatures	4/25/2014	N/A
319	Onset of Services	9/26/2013	N/A	493	QI Action Request	5/23/2013	N/A
320	Minor Consent Policy Clarification Memo – Minor Consent – Effective July 1, 2015 Minor Consent 2015 Revision Power Point (PDF)	N/A	N/A	494	Service Verification Policy Procedure	6/10/2013	N/A
321	Obtaining Authorization to Use, Exchange, and Disclose Confidential Behavioral Health Information	12/05/2013	N/A	495	Projects within MCBH	7/28/2016	N/A
322	Protected Health Information Breach Notification and Mandatory Reporting	1/16/2014	4/24/2014	496	496 Communication With Persons in Care Electronic Communication Consent Form	7/28/2016 10/01/2024	N/A
324	Consent for Minors by Parent Legal Guardian When Parents are Divorced	7/23/2015	N/A	497	Master & Bachelor Level Internship Program (MCBH)	8/24/2016	N/A
333	Involuntary Treatment for Individuals with Mental Health Disorders	5/22/2014	9/19/2023	498	Verification of Work Experience Hours	N/A	N/A
334	Staff Authorized to Initiate Involuntary Holds	5/22/2014	1/23/2019	499	Continuum of Care	10/25/2017	N/A
335	Assessing and Initiating 5150 in Outpatient and Integrated Care Clinics	10/22/2015	12/3/2018	500	Consent for Psychotropic Medication	9/21/2004	10/12/2018
336	Advisement of Rights to Involuntary Patients (5250)	11/25/2015	N/A	501	Psychotropic Medication Monitoring Plan	8/06/1993	10/16/2018
337	Risk Assessment of Minors in School Setting	9/27/2017	N/A	506	Control of Medications and Supplies Memorandum – Medical Assistant Access to Medication Room – May 28, 2015	7/01/1988	5/27/2015
338	Risk Assessment, Safety Planning, & Subsequent Services C-SSRS Ages 6+ English C-SSRS Ages 6+ Spanish C-SSRS Ages Under 6 & Cognitively Impaired Stanley Brown Safety Plan - English Stanley Brown Safety Plan - Spanish	12/29/2023
350 & 350-B	Confidentiality of Protected Health Information Within Authorization – Confidentiality of Protected Health Information	2/01/2019	4/27/2017	507	Prescription of Benzodiazepines (currently under review for updates 8/12/2020)	11/25/2015	6/23/2017
351	Confidentiality of Protected Health Information – Substance Abuse Treatment Programs	8/28/2014	N/A	508	Administration of Vivitrol	11/25/2015	N/A
352	Confidentiality of Protected Health Information – Multi-Disciplinary Teams	8/28/2014	N/A	509	Controlled Substance Utilization Review System (CURES) and Prescription Drug Monitoring Program (PDMP)	7/28/2016	10/04/2018
356	PHI Taken to Off-Site Locations	8/28/2014	N/A	510	Medication Authorization for Dependent Children	10/28/2017	N/A
				511	Psychiatric Mental Health Nurse Practitioner (NP)	5/31/2018	N/A
				512	Open Payments Database Open Payments Database Notice (bilingual document) Open Payments Database Poster	7/01/2023
407	Cancellation No Show	9/08/1986	10/01/2008	700	Alcohol and Other Drugs Programs Universal Policies – Change in Certification Form	5/22/2014	7/27/2017
				701	Administration of Naloxone in the Event of a Suspected Overdose	12/21/2023
				702	Narcan Distribution: Non-Emergency	12/21/2023
408	Protection of Sensitive Records	2/01/1987	9/15/2011	705	Alcohol and Other Drug Programs – Substance Abuse Prevention and Treatment Block Grant (SAPT)	5/22/2014	N/A
				706	Perinatal Policy	1/1/2023
				707	Youth Policy	11/21/2023
409	Case Closing	N/A	N/A	710	Driving Under the Influence (DUI) Programs	5/22/2014	N/A
416	Medical Records Requirements for Crisis Unit (NMC-ER) Attached	11/16/1988	3/23/2017	715	Narcotic Treatment Programs	5/22/2014	N/A
417	Change of Clinician English Spanish	11/16/1988	4/01/2009	720	Residential Alcoholism or Drug Abuse Recovery or Treatment Facilities	5/22/2014	N/A
				726	Coordination and Continuity of Care	11/29/2017	1/6/2020
				730	DMC-ODS Residential Authorization	1/01/2018	8/12/2020
				731	Medication Compliance for NTP and Residential SUD programs	9/24/2020
				732	DMC ODS Medication Assisted Treatment	01/01/2022	7/3/2024

ADMINISTRATIVE
Policy Number	Policy Description	Created	Updated	Policy Number	Policy Description	Created	Updated
100	Division Policies and Procedures	9/8/1986	11/25/2015	316	Medical Records ERE Submit	9/12/2011	N/A
100B	Implementation Plan Updated 2020	N/A	5/18/2022
102	Organizational Communication Guidelines	9/8/1986	4/1/2009	323	Coroner’s Office Request for Protected Health Information	5/28/2015	N/A
103	Program Audits By Outside Agencies	9/8/1986	10/1/2008	400	Hours Of Clinic Operation	9/8/1986	9/1/2008
105	Loan of County Equipment	9/8/1986	4/1/2009	401	Psychological Testing	9/8/1986	9/1/2008
106	Employee Volunteer Responsible For Supplies And Equipment	9/8/1986	1/11/2008	402	Dangerous Consumers And Those In Possession Of Weapons	9/8/1986	9/1/2008
107	Licensure Requirement and Verification of Licensure	9/8/1986	9/25/2014	404	Behavioral Health Adult Services Authorization For Admission To Napa State Hospital	9/8/1986	10/1/2008
108	Medicaid Managed Care Plan	N/A	05/17/2022	405	Behavioral Health Adult Services Authorization For Placement In Locked Skilled Nursing Facilities Or Mental Health Rehabilitation Centers	9/16/1986	11/16/2017
109	Contract Monitoring	11/21/1986	4/1/2010	406	Mental Health Adult Services Short Doyle Medi-cal Administrative Days	2/1/1987	4/4/2006
110	Use Of Medical Transport	3/21/1990	4/1/2009	410	Committee And Staff meetings	2/1/1987	9/1/2008
111	Authorization For Short-Doyle Funding For Psychiatric Patients Transferred From Monterey County (Hospitalization And Transportation)	5/15/1991	7/1/2007	412	Determination Of Appropriate Level Of Care For Public Conservatee Or Voluntary Consumer	8/30/1995	4/1/2009
113	Guidelines For Retrospective Claims Review For Inpatient Psychiatric Hospital Services	1/1/1995	7/1/2007	413	Assessment Of Needs For Placement Of Behavioral Health Adult Services Consumers In Board And Care Facilities	8/30/1988	9/1/2008
115	Amendment of Protected Health Information (PHI) Request to Amend Protected Health Information	7/30/2021		414	Placement Procedures For Voluntary Consumers	8/30/1988	9/01/2008
116	Provider Appeal	1/1/1995	3/1/2009	415	Requests For Interim Assistance Funds	9/1/1988	9/1/2008
118	Emergency Management System	1/1/95	4/1/2008	423	Medical Records Purging	9/15/1989	4/6/2006
119	Overpayments	11/6/2017	1/30/2020	445	Fire Evacuation Plan	3/15/1994	7/31/2001
121	Time Card Submission Procedure	8/1/1998	4/1/2008	446	Bomb Threat Procedure	4/1/1994	8/15/1997
124	Location of New Facilities	7/1/2001	7/1/2008	448	Transfer Of Clients From Provider To System-Of-Care	12/1/1997	N/A
125	Medi-Cal Site Certification	7/1/2001	4/1/2008	450	Persons with Disabilities	12/6/2017	N/A
126	Posting of Grievance Process Procedure	8/17/2001	4/20/2011	451	Cultural and Linguistic Services	7/1/1998	12/8/2021
127	Medicare Billing Control	9/15/1994	4/1/2009	453	Monterey County Medi-cal Fee For Service Inpatient Procedure At Community Hospital Of The Monterey Peninsula	7/1/1999	N/A
131	FSP Policy	9/24/2020	06/14/2024
132	Credentialing And Recredentialing	4/6/2006	5/17/2022	455	Interface With Physical Health Care For Short Doyle Clients And Excluded Diagnosis Clients	8/7/2000	3/27/2003
141	Health Service Records Retention	4/25/2013	1/12/2023	458	Service Delivery	1/1/1998	4/10/2006
142	Excluded Providers	1/8/2014	11/23/2021	459	Mental Health Linkage	7/1/2001	4/3/2006
143	Psychologist Waiver and Licensure Requirement	9/25/2014	1/30/3023	460	Mobile Crisis Services	1/28/2016	12/31/2023
150	Americans with Disabilities (ADA)	3/8/2018	N/A	462	Termination of Contracted Provider	10/27/2021
151	Presumptive Transfer	12/03/2020	1/11/2021	463	Destruction Of Medical Records With Approved Tar And Paid Ancillary Services For Inpatient Services	3/8/2001	N/A
200	Request For Vacation	9/8/1986	9/15/2011	464	Change Of Diagnosis	4/16/2002	4/10/2006
205	Granting Exceptions To The Employment Of Spouses Or Relatives	10/1/2008	N/A	466	Coordination Of Psychiatric Medication Services Adult Services	8/25/2004	N/A
206	Staff Identification Cards	9/25/2014	N/A	468	Cultural Competence Training Requirements Policy	9/24/2020	N/A
302	Legal Liability For Employees Volunteers Actions	9/8/1986	9/1/2008	469	Community Program Planning Process Policy	9/24/2020	N/A
				601	Staff Termination and Out-processing Policy

POLICIES AND PROCEDURES

CalAIM

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ADMINISTRATIVE

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