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BHS Policies and Procedures

Behavioral Health Services General Policies and Procedures

  1. Care and Treatment Policy
  2. Client Rights
  3. Human Resources
  4. Administration
  5. Information Management
  6. Quality Improvement
  7. Compliance
  8. Plans
  9. Medi-Cal Managed Care

I. Care and Treatment Policy

Title Number Last Revised
Access to Specialty Mental Health Services for out of County Beneficiaries 01.01.01 8/3/16
Presumptive Transfer (AB 1299) UPDATED 01.01.02 2/14/23
Services Authorization Requests for Out-of-County Medi-Cal Beneficiaries (SB 785) UPDATED 01.01.03 2/14/23
Continuity of Care and Referrals in SUD Programs UPDATED 01.01.04 12/10/19
Substance Use Disorder (SUD) Residential Treatment Authorization and Re-authorization UPDATED 01.01.05 10/7/21
Electro-Convulsive Treatment (ECT) for individuals in the Mental Health Plan 01.02.01  
Compliance with Adolescent SUD Best Practice Guidelines UPDATED 01.02.02 2/9/2024
Perinatal Practice Guidelines UPDATED 01.02.03 2/13/2024
BHS Medication Monitoring Practices UPDATED 01.02.04 7/20/22
Courtesy Dosing at Narcotic Treatment Program 01.02.05 11/20/17
Pathways to Well Being Intensive Services & Therapeutic Foster Care UPDATED 01.02.06 2/14/23
Practice Guidelines Development and Implementation UPDATED 01.02.07 2/7/23
BHS Outpatient Clinic Psychiatric Nurse Practitioners UPDATED
BHS Standardized Procedures for Psychiatric Nurse Practitioners in County Outpatient NEW!
Welcoming and Customer Service 01.03.01 10/5/16
Access to Substance Use Disorder Services for Persons with Disabilities UPDATED 01.03.02 2/14/23
Admission and Readmission in Substance Use Disorder Programs UPDATED 01.03.03 1/11/23
Telehealth Services in the Mental Health Plan NEW! 01.03.04 7/20/22
Telehealth Services in Drug Medi-Cal Organized Delivery System NEW! 01.03.05 7/20/22
Access Criteria for Specialty Mental Health Services NEW! 01.03.06 9/14/2022
Access Criteria for Drug Medi-Cal Organized Delivery System UPDATED 01.03.07 1/30/2023
CalOptima OneCare/OneCare Connect Referrals 01.04.01 11/19/18
OneCare/OneCare Connect Client Assessment for Specialty Mental Health Services 01.04.02 10/19/18
OneCare/OneCare Connect Coordination of Care with CalOptima 01.04.03 10/19/18
Quality Improvement for Mental Health and Substance Use Disorder Treatment Coordination with CalOptima UPDATED 01.04.04 2/14/23
Assisting Consumers in Applying for SSI Benefits 01.05.01 5/18/15
Duty to Protect 01.06.01 8/9/13
Mandated Dependent Adult/Elder Abuse Reporting 01.06.02 11/3/17
Mandated Child Abuse Reporting 01.06.03 4/24/18
Youth Under the Influence Adolescent Substance Use Disorder Programs 01.07.01 4/4/18
Care and Supervision of Youth in Adolescent Substance Use Disorder Programs 01.07.02 5/13/18
Possessions and Prohibition of Weapons at BHS Programs NEW! 01.07.03 4/18/19
Use of Naloxone Hydrochloride (Narcan) in BHS Programs UPDATED 01.07.04 2/9/2024
Procedures for Conducting CLIA Waived Tests in SUD Programs NEW! 01.07.05 2/9/2022
Medications for Addiction Treatment (MAT) Services Requirements for County Substance Use Disorder (SUD) Recovery or Treatment Facilities NEW! 01.07.06 12/28/2023

II. Client Rights

Title Number Last Revised
Cultural Competency UPDATED 02.01.01 2/14/23
Meeting Beneficiary/Client Language Needs UPDATED 02.01.02 2/14/23
Distribution of Translated Materials UPDATED 02.01.03 2/14/23
MHP and DMC-ODS Provider Directory (formerly titled Mental Health Plan Provider List) UPDATED 02.01.04 2/14/23
Field Testing of Written Materials 02.01.05 9/21/16
Cultural Competence Committee 02.01.06 10/12/16
Meeting Deaf and Hard of Hearing Language Needs at Key Points of Contact UPDATED 02.01.07 2/14/23
Procedures for Change of Provider and Second Opinion Requests UPDATED 02.02.01 2/14/23
Beneficiary/Client Problem Resolution, Grievance Process and Logging Procedures in Outpatient County and Contracted Clinics and Inpatient Treatment Programs UPDATED 02.02.02 2/14/2024
Notice of Adverse Benefit Determination (NOABD) (formerly titled Notice of Action Forms) UPDATED 02.02.04 1/19/22
Beneficiary Problem Resolution/Grievance Process/Log Procedures in MHSA Funded Outpatient County and Contracted Programs 02.02.05 10/18/16
Continuation of Benefits Pending Appeal Resolution (AKA "Aid Paid Pending") UPDATED 02.02.06 2/14/23
Informed Consent for Mental Health and Recovery Services UPDATED
Informed Consent (F346-301)
Psychiatric Medication Consent Forms UPDATED
Psychotropic Medication Consent Form (F346-745)
Prescribing Physician's Statement–Attachment JV-220(A)
Consent to Record Consumers for Clinical Supervision and Training
Consent to Record Form (F346-474)
Notice of Privacy Practices 02.05.01  
Advance Directives UPDATED 02.06.01 2/14/23
Informing Materials for Mental Health Plan Beneficiaries - Clients Intake - Advisement Checklist UPDATED 02.06.02 2/22/23
Medi-Cal Consumer Rights Under the Orange County Mental Health Plan 02.06.03 8/3/16
Mandatory Postings for Providers 02.06.04  

III. Human Resources

Title Number Last Revised
Continuing Education Course Approval for HCA Programs UPDATED 03.01.01 7/24/23
Compliance Orientation, Education and Training UPDATED 03.01.02 2/15/23
Trainings Specifically Pertaining to Cultural Competency 03.01.03 9/21/16
Drug Medi-Cal Organized Delivery System Provider Training Requirements UPDATED 03.01.04 10/8/20
Mental Health and Recovery Services Sponsored & Hosted Training Attendance UPDATED 03.01.05 2/14/23
Individual Provider Transitions Affecting HCA BHS Beneficiaries/Clients UPDATED 03.02.01 2/14/2024
BHS Non-Blood Borne Pathogen Exposure Control Plan 03.03.02  

IV. Administration

Title Number Last Revised
OCTA Application for Disabled Persons Reduced Fare Card
OCTA Reduced Fare ID Card Assessed Eligibility Form
Approval for use of Electronic Signatures by BHS Contracted Providers UPDATED
Form F346-781 Electronic Signature Application
Office Support Staff Involvement with Verifying Financial Information 04.02.01  
Communication between Behavioral Health Administration and Medical Billing Unit Personnel 04.02.02  
Review of Medicare Billing Prior to Submission 04.02.03  
Procedures for Obtaining, Maintaining, and Deleting Medicare Provider Transaction Access Number (PTAN) 04.02.04  
Therapeutic Charge Adjustment
Therapeutic Charge Adjustment form
Billing Compliance, Recoveries and Reporting of Overpayments NEW! 04.02.08 7/1/20
Medical Necessity & Concurrent Authorization of Psychiatric Inpatient Hospital Services UPDATED 04.02.09 3/2/23
No Wrong Door Mental Health Services NEW! 04.02.10 9/28/22
Authorization of Medi-Cal Beneficiaries for Crisis Residential Treatment Services and Concurrent Review Procedures NEW! 04.02.11 6/1/23
Lanterman-Petris-Short Act (LPS) Designation of BHS County and Outpatient Contract Providers 04.03.01 4/28/16
Lanterman-Petris-Short Act (LPS) Designation of Individuals 04.03.02 8/30/17
Lanterman-Petris-Short Act (LPS) Designation Privileges 04.03.03 8/30/17
Designation of Facility Lanterman-Petris-Short Act (LPS) Trainers 04.03.04 8/30/17
Lanterman-Petris-Short Act (LPS) Designation of Facilities in Orange County 04.03.05 2/18/16
Use and Disclosure OF PHI for Research Purposes 04.05.01  
Use and Disclosure of Protected Health Information-General Rules UPDATED 04.05.03 3/9/23

V. Information Management

Title Number Last Revised
Recording Requests for Specialty Mental Health Services On Access Logs 05.01.01 8/9/16
Use and Flow of the Encounter Document: Outpatient Clinic 05.01.02  
Documentation of Services and Assessment Standards UPDATED! 05.01.03 1/30/2023
Advance Beneficiary Notice of Non-coverage (ABN)
Announcement of the Implementation of the Revised ABN
Corrections/Amendments to Encounter Document when Provider No Longer a County Employee 05.01.05  
Office Staff Phone Financial Evaluations 05.01.06  
Missing/Lost Charts 05.01.07  
Transport of Clinical Records 05.01.08 3/8/16
Document Destruction - Paper charts held in the clinics for clients discharged prior to 9/23/2003 05.01.09  
Use of Electronic Signatures In the BHS Electronic Health Record UPDATED
Electronic Signature Agreement
BHS Clinical Record Keeping Standards For Clinics Using Paper Charts 05.01.11 8/7/15
Corrections/Amendments to Chart Documentation - Audits 05.01.12 12/2/15
Use and Processing of the Lanterman-Petris-Short Act (LPS) 5150/5585 Hold Form 05.01.13 3/7/16
Substance Use Disorder Treatment Services Chart Order 05.01.14 10/31/18
DMC-ODS Documentation of Services and Assessment Standards UPDATED! 05.01.15 1/30/23
BHS and CalOptima OneCare/OneCare Connect Information Exchange 05.02.01 10/19/18
IRIS Entry of Encounter Document Information by Office Support Staff – For Non-Electronic Health Record Clinics 05.03.01  
CalOMS California Outcome Measurement System (CalOMS) Integrated Records Information System (IRIS) Electronic Operational Procedures for Treatment Data Submission to Department of Health Care Services 05.03.02 8/12/15
Tracking Disclosures of PHI
PHI Disclosure Tracking Log
Accounting for Disclosures of PHI 05.05.03  

VI. Quality Improvement

Title Number Last Revised
Reporting of Unusual Occurrences to Department of Health Care Services UPDATED 06.01.01 2/15/23
Posting of Mental Health Plan System Metrics UPDATED 06.01.02 2/15/23
Test Call Procedure for Monitoring Administrative Service Organization (ASO) Access Quality and Compliance UPDATED 06.02.01 2/14/23
Quality Management and Community Quality Improvement Committee UPDATED 06.03.01 2/15/23
Sentinel Events Review Committee NEW 06.03.02 4/27/23

VII. Compliance

Title Number Last Revised
Fraud and Abuse 07.01.01 3/7/16
Billing Compliance 07.01.02 3/7/16
Development of Certified Reviewers UPDATED 07.01.03 3/29/19
Postmortem Claiming 07.01.04 9/6/18
Compliance with Federal Award Requirements for Substance Abuse Programs 07.02.01 8/13/15
Title 22 Regulations Compliance 07.02.02 10/7/15
Substance Use Disorder Drug Medi-Cal Organized Delivery System Provider Monitoring NEW! 07.02.03 2/1/22
Trafficking Victims Protection Act Compliance 07.03.01 12/2/15
Mental Health and Recovery Services Compliance Officer UPDATED 07.03.02 2/15/23
Organizational Commitment to Medi-Cal Managed Care Requirements UPDATED 07.03.03 2/14/23
Outpatient Clinic Medication Rooms - Receipt, Storage, Administration, Disposal and Accountability of Medication UPDATED 07.03.04 5/17/23
Substance Use Disorder Medical Director Roles and Responsibilities NEW! 07.03.05 8/5/19
Role of the Behavioral Health Nurse in Substance Use Disorder Programs NEW! 07.03.06 12/17/20
Nondiscrimination & Institutional Safeguards for Religious Providers & Charitable Choice Reporting for SABG Funded Programs NEW! 07.03.07 2/1/22
Verification of Individual NPI Numbers and Professional Licenses at Initial Medi-Cal Certification and Medi-Cal Re-Certification 07.04.01 11/7/17
Verification of Individual NPI Numbers and Professional Licenses at Initial Drug Medi-Cal Certification and Drug Medi-Cal Re-Certification 07.04.02 11/13/17
Drug Medi-Cal Organized Delivery System Provider Selection and Retention Practices 07.04.03 11/13/17
Credentialing and Re-Credentialing Requirements of Individual Providers UPDATED 07.04.04 4/20/23
Individual Provider Credentialing Committee UPDATED 07.04.05 06/01/23

VIII. Plans

Title Number Last Revised
BHS Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP) UPDATED 08.01.01 02/04/19
BHS/Conditional Release Program Bloodborne Pathogens Exposure Control Program Plan (BBP-ECPP) UPDATED   02/03/20

IX. Medi-Cal Managed Care

Title Number Last Revised
Mental Health Plan Out-of-Network Services 09.01.01 1/19/22
Mental Health Plan and Drug Medi-Cal Organized Delivery System Network Adequacy Monitoring UPDATED 09.01.02 2/7/23
Access to Mental Health Services for Persons with Disabilities UPDATED 09.01.03 2/15/23
Meeting Medi-Cal Beneficiary Language Assistance Needs UPDATED 09.01.04 2/8/23
Mental Health and Recovery Services 24/7 Access Line Requirements UPDATED 09.01.05 2/8/23
Medi-Cal Timely Access and Service Availability UPDATED 09.01.06 1/31/22
Out-of-Network Services for Drug Medi-Cal Organized Delivery System (DMC-ODS) UPDATED 09.01.07 2/14/23
Continuity of Care for Medi-Cal beneficiaries receiving Specialty Mental Health Services within the County of Orange Mental Health Plan UPDATED 09.01.08 2/7/23
Beneficiary Problem Resolution and Grievance Process UPDATED 09.02.01 11/06/19
Beneficiary-Client Appeal of Actions Process UPDATED 09.02.02 2/14/2024
Clinical Supervision Requirements UPDATED 09.03.01 8/11/23