Staff/Provider Information

Big 8 - Medi-Cal Final Rule Memorandums

• Change in Billable Services Before Treatment Plan is Finalized
• Documentation Requirement Changes
• Engagement Attempts Template
• Outreach Program Treatment Plan Changes
• Pre-Consumer Process
• Psychiatric Referral Template
• Timeline Requirements

Continuum of Care (CCR)/Pathways to Well-Being

• Integrated Core Practice Model
• Medi-Cal Manual 3rd Edition
• DHCS/CDSS Integrated Training Guide
• Information Notice 18-022
• Katie A Pathways to Well-Being Mental Health Services Operational Manual
  

CPS Surveys

• CPS Frequently Asked Questions
• CPS Instructions for Staff
• CPS Survey Announcement for Staff
• Consumer flyers to post in lobbies English | Spanish

Staff Credentialing

• Provider Credentialing and Re-Credentialing Attestation
  
• Mental Health Professional Licensing Waiver Instructions
  
• Mental Health Professional Licensing Waiver Requirements
  
• CMS855i Initial Request 
• CMS855r Reassignment
  
• Electronic Signature Form 
  
• New Hire Regular Flow Chart
• New Hire Temp Flow Chart
• P&P Staff Credentialing and Licensing
  
• RxNT Form
  
• Service Provider Update Form.
• Service Code Matrix
• SPID Application 
  
• Staff Separation Checklist
• Staff Separation Memo
• Welcome Letter for New Staff

Staff Re-Credentialing

• Re-Credentialing Memo 
• Staff Credentialing P&P
  • Att. A - Databases and Lists
  • Att. B - Unlicensed Staff
  • Att. C - AOD Counselors
• Re-Credentialing Attestation Form
• Re-Credentialing Appeal Form
  

Suggestion Box Forms   English | Spanish

Site Certification

• Memoranda
  
  • Posted Brochures and Notices Memorandum
• Site Certification Policy
• Posted Brochures and Notices checklist/Quarterly Inspection Report
  
  DHCS Required Posted Notices & Brochures
  • Medi-Cal Beneficiary Booklet (aka Guide to Medi-Cal Mental Health Services)
    • English |  Spanish
    • English large font | Spanish large font
  • Posters
    
    • Compliance Hotline flyer ( English) ( Spanish)
    • Notice of Privacy Practices ( English) ( Spanish)
    • Patient Rights ( English) ( Spanish)
    • Non-Discrimination Notice
    • Problem Resolution poster ( English) ( Spanish)
    • Notice of Language Notices ( English) ( Spanish) – Must be posted prominently in all client-accessible spaces per contract requirements
    • Language Assistance Taglines
      
      
  • Brochures
    • Advanced Directives ( English) ( Spanish)
    • Beneficiary Booklet ( English) ( Spanish)
    • Network Provider Directory ( English ) ( Spanish )
    • Network Provider Directory Large Print ( English) ( Spanish)
      
      Note: Written notice of termination of a contracted provider will be provided, within 15 calendar days after receipt or issuance of the termination notice, to each beneficiary who was seen on a regular basis by the terminated provider. (42 C.F.R. § 438.10(f)(1).) 
      
      
    • Patients Rights and Responsibilities ( English) ( Spanish)
  • Forms
    • Beneficiary Request for Second Opinion ( English) ( Spanish)
    • Quality Care Management Return Address Labels
    • Behavioral Wellness Appeal ( English) ( Spanish) 
    • Behavioral Wellness Grievance ( English) ( Spanish) 
    • Mental Health Request for Change of Provider ( English) ( Spanish)
    • State Fair Hearing ( English) ( Spanish)
    • Provider Complaint Form
      

Documentation Training Requirements

• Process for Becoming a Note Reviewer
• Trainings memorandum
• Note Review Process- Updated
• Documentation Manual
  

Notice of Action Requirements and Forms

• Notice of Adverse Benefit Determination Policy
• NOABD Denial  English    English Word Format     Spanish
• NOABD Payment Denial  English     English Word Format      Spanish
• NOABD Delivery System  English     English Word Format      Spanish
• NOABD Modification  English     English Word Format      Spanish
• NOABD Termination  English     English Word Format      Spanish
• NOABD Authorization Delay  English     English Word Format      Spanish
• NOABD Timely Access  English     English Word Format      Spanish
• NOABD Financial Liability  English     English Word Format      Spanish
• NOABD Grievance & Appeal Timely Resolution  English     English Word Format      Spanish
• NOABD Citation Reference List

Concurrent Review Forms

• Inpatient Concurrent Review Submission Form
• ART/CRT Authorization Request Form