State of california

Recovery from Other Sources or Providers.

1. 
   The Contractor shall recover the value of covered services rendered to beneficiaries whenever the beneficiaries are covered for the same services, either fully or partially, under any other state or federal medical care program or under other contractual or legal entitlement including, but not limited to, a private group or indemnification program, but excluding instances of the tort liability of a third party or casualty liability insurance.
   

2. 
   The monies recovered are retained by the Contractor; however, Contractor’s claims for federal financial participation for services provided to beneficiaries under this contract shall be reduced by the amount recovered.
   

3. 
   The Contractor shall maintain accurate records of monies recovered from other sources.
   

4. 
   Nothing in this section supersedes the Contractor's obligation to follow federal requirements for claiming federal financial participation for services provided to beneficiaries with other coverage under this contract.
   

6. 
   Subrogation.
   

In the event a beneficiary is injured by the act or omission of a third party, or has a potential or existing claim for a workers’ compensation award, or a claim/recovery through uninsured motorist coverage, the right to pursue subrogation and the receipt of payments shall be as follows:

1. 
   Contractor may submit to the Department claims for Medi-Cal covered services rendered, but Contractor shall not make claims to or attempt to recoup the value of these services from the above-referenced entities.
   

2. 
   Contractor shall notify the California Department of Health Care Services within 10 days of discovery of all cases that could reasonably result in recovery by the beneficiary of funds from a third party, third party insurance carrier, workers’ compensation award, and/or uninsured motorist coverage.
   

3. 
   If the Contractor receives any requests by subpoena from attorneys, insurers, or beneficiaries for copies of bills, the Contractor shall provide the Department of Health Care Services with a copy of any document released as a result of such request. Additionally, the Contractor shall provide the name, address and telephone number of the requesting party.
   

4. 
   The Contractor also agrees to assist the Department of Health Care Services, upon request, to provide within thirty (30) days, payment information and copies of paid invoices/claims for covered services.
   

5. 
   The value of the covered services shall be calculated as the usual, customary and reasonable charge made to the general public for similar services or the amount to subcontracted providers or out-of-plan providers for similar services.
   

6. 
   The information provided to the Department of Health Care Services shall include the following data:
   

1. 
   Beneficiary name;
   
2. 
   14-digit Medi-Cal number;
   
3. 
   Social security number or Client Identification Number (CIN);
   
4. 
   Date of birth;
   
5. 
   Contractor name;
   
6. 
   Provider name (if different from Contractor);
   
7. 
   Dates of service;
   
8. 
   Diagnosis code and/or description of illness;
   
9. 
   Procedure code and/or description of services rendered;
   
10. 
    Amount billed by a Subcontractor or out-of-plan provider to the Contractor (if applicable);
    
11. 
    Amount paid by other health insurance to the Contractor or Subcontractor;
    
12. 
    Amount and date paid by the Contractor to subcontractor or out-of-plan provider (if applicable); and
    
13. 
    Date of denial and reasons (if applicable).
    

7. 
   The Contractor shall also provide the Department of Health Care Services with the name, address, and telephone number of the person responsible for receiving and complying with requests for mandatory and/or optional at-risk service information.
   

8. 
   Information sent to the Department of Health Care Services, pursuant to this section, shall be sent to: California Department of Health Care Services, Third Party Liability Branch, 1500 Capitol Ave., Suite 320, Sacramento, CA 95814.
   

6. 
   Beneficiary Brochure and Provider List.
   

1. 
   The Contractor shall be responsible for the production and update of its booklet and provider list in accordance with Title 42, CFR, Section 438.10 and Title 9, CCR, Section 1810.360. The Contractor shall establish criteria to update its booklet and provider list.
   

Pursuant to Title 42, CFR, 438.10, the Contractor shall:

1. 
   Notify all beneficiaries of their right to change providers;
   

2. 
   Notify all beneficiaries of their right to request and obtain the following information:
   

1. 
   Names, locations, telephone numbers of, and non-English languages spoken by current contracted providers in the beneficiary’s service area, including identification of providers that are not accepting new patients.
   

2. 
   Any restrictions on the beneficiary’s freedom of choice among network providers.
   

3. 
   Beneficiary rights and protections, as specified in Title 42, CFR 438.100.
   

4. 
   The amount, duration, and scope of benefits available under this Contract in sufficient detail to ensure that beneficiaries understand the benefits to which they are entitled.
   

5. 
   Procedures for obtaining benefits, including authorization requirements.
   

6. 
   The extent to which, and how, beneficiaries may obtain benefits.
   

7. 
   The extent to which, and how, after-hours and emergency coverage are provided, including:
   

1. 
   What constitutes an emergency medical condition, emergency services, and post-stabilization services, with reference to the definitions in Title 42, CFR, 438.114(a).
   

2. 
   The fact that prior authorization is not required for emergency services.
   

3. 
   The process and procedures for obtaining emergency services, including use of the 911-telephone system or its local equivalent.
   

4. 
   The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under the contract.
   

5. 
   The fact that, subject to the provisions of Title 42, CFR, 438.10(f)(6), the beneficiary has a right to use any hospital or other setting for emergency care.
   

6. 
   The post-stabilization care services rules set forth in Title 42, CFR, 422.113(c).
   

8. 
   Cost sharing, if any.
   

9. 
   How and where to access any benefits that are available under the State Plan but are not covered under this Contract, including any cost sharing, and how any necessary transportation is provided. Pursuant to Title 42, CFR, Section 438.102(a)(2), for a counseling or referral service that the Contractor does not cover because of moral or religious objections, the Contractor need not furnish information on how and where to obtain the service. Pursuant to Title 42, CFR, Section 438.102(b)(1), the Contractor must provide information about the services it does not cover on moral or religious grounds.
   

2. 
   The Contractor shall ensure that the general program literature it uses to assist beneficiaries in accessing services including, but not limited to, the booklet required by Title 9, CCR, Section 1810.360(d), materials explaining the beneficiary problem resolution and fair hearing processes required by Section 1850.205(c)(1), and mental health education materials used by the Contractor are available in the threshold languages of the County in compliance with Title 42, CFR, 438.10.
   

Pursuant to Title 42, CFR, 438.10(g) and Title 9, CCR 1850.205(c)(1), the booklet shall include grievance, appeal and fair hearing procedures and timeframes, as provided in Title 42, CFR, 438.400 through 438.424, using a Department-developed or Department-approved description that must include the following:

1. 
   For State Fair Hearing (Title 42, CFR 431 Subpart E):
   

1. 
   The right to hearing;
   

2. 
   The method for obtaining a hearing; and
   

3. 
   The rules that govern representation at the hearing.
   

2. 
   The right to file grievances and appeals.
   

3. 
   The requirements and timeframes for filing a grievance or appeal
   

4. 
   The availability of assistance in the filing process.
   

5. 
   The toll-free numbers that the beneficiary can use to file a grievance or an appeal by phone.
   

6. 
   The fact that, when requested by the beneficiary —
   

1. 
   Benefits will continue if the beneficiary files an appeal or a request for State Fair Hearing within the timeframes specified for filing; and,
   

2. 
   The beneficiary may be required to pay the cost of services furnished while the appeal is pending, if the final decision is adverse to the beneficiary.
   

7. 
   The appeal rights that the Department has chosen to make available to providers in Title 9, CCR 1850.315 to challenge the Contractor's failure to cover a service.
   

8. 
   Advance Directives, as set forth in Title 42, CFR, 438.6(i)(1).
   

9. 
   Additional information that is available upon request, including the following:
   

1. 
   Information on the structure and operation of the Contractor.
   

2. 
   Physician incentive plans as set forth in Title 42, CFR, Section 438.6(h), if they are used by Contractor.
   

3. 
   The Contractor shall provide beneficiaries with a copy of the booklet and provider list when the beneficiary first accesses services and thereafter upon request in accordance with Title 9, CCR, Sections 1810.360 and 1810.110.
   

4. 
   The Contractor shall not make changes to any of the content in the statewide section of the booklet unless directed to do so, in writing, by the Department;
   

5. 
   The Contractor shall ensure any changes to the English version of the booklet are also included in the county’s threshold languages and made available in alternate formats appropriate to the beneficiary population;
   

6. 
   The Contractor shall ensure written materials are produced in a format that is easily understood;
   

7. 
   The Contractor shall ensure that the booklet above includes the current toll-free telephone number(s) that provides information in threshold languages and is available twenty-four hours a day, seven days a week.
   

8. 
   The Contractor shall ensure that provider directories:
   

1. 
   Include information on the category or categories of services available from each provider;
   

2. 
   Contain the names, locations, and telephone numbers of current contracted providers by category;
   

3. 
   Identify options for services in languages other than English and services that are designed to address cultural differences and;
   

4. 
   Provide a means by which a beneficiary can identify which providers are not accepting new beneficiaries.
   

When there is a change in the scope of specialty mental health services covered by the Contractor, the update, in the form of a booklet insert, shall be provided to beneficiaries at least 30 days prior to the change.

6. 
   Requirements for Day Treatment Intensive and Day Rehabilitation.
   

1. 
   The Contractor shall require providers to request MHP payment authorization for day treatment intensive and day rehabilitation services:
   

1. 
   In advance of service delivery when day treatment intensive or day rehabilitation will be provided for more than five days per week.
   

2. 
   At least every three months for continuation of day treatment intensive.
   

3. 
   At least every six months for continuation of day rehabilitation.
   

4. 
   Contractor shall also require providers to request MHP authorization for mental health services (as defined in Title 9, CCR, Section 1810.227) provided concurrently with day treatment intensive or day rehabilitation, excluding services to treat emergency and urgent conditions as defined in Title 9, CCR, Sections 1810.216 and 1810.253. These services shall be authorized with the same frequency as the concurrent day treatment intensive or day rehabilitation services.
   

2. 
   The Contractor shall not delegate the MHP payment authorization function to providers. When the Contractor is the day treatment intensive or day rehabilitation provider, the Contractor shall assure that the MHP payment authorization function does not include staff involved in the provision of day treatment intensive, day rehabilitation services, or mental health services provided concurrent to day treatment intensive or day rehabilitation services.
   

3. 
   The Contractor shall require that providers of day treatment intensive and day rehabilitation meet the requirements of Title 9, CCR, Sections 1840.318, 1840.328, 1840.330, 1840.350 and 1840.352.
   

4. 
   The Contractor shall require that providers include, at a minimum, the following day treatment intensive and day rehabilitation service components:
   

1. 
   Community meetings. These meetings shall occur at least once a day to address issues pertaining to the continuity and effectiveness of the therapeutic program, and shall actively involve staff and clients. Relevant discussion items include, but are not limited to: the day’s schedule, any current event, individual issues that clients or staff wish to discuss to elicit support of the group and conflict resolution. Community meetings shall:
   

1. 
   For day treatment intensive, include a staff person whose scope of practice includes psychotherapy.
   

2. 
   For day rehabilitation, include a staff person who is a physician, a licensed/waivered/registered psychologist, clinical social worker, or marriage and family therapist; and a registered nurse, psychiatric technician, licensed vocational nurse, or mental health rehabilitation specialist.
   

2. 
   Therapeutic milieu. This component must include process groups and skill-building groups. Specific activities shall be performed by identified staff and take place during the scheduled hours of operation of the program. The goal of the therapeutic milieu is to teach, model, and reinforce constructive interactions by involving clients in the overall program. (For example, clients are provided with opportunities to lead community meetings and to provide feedback to peers.) The program includes behavior management interventions that focus on teaching self-management skills that children, youth, adults and older adults may use to control their own lives, to deal effectively with present and future problems, and to function well with minimal or no additional therapeutic intervention. Activities include, but are not limited to, staff feedback to clients on strategies for symptom reduction, increasing adaptive behaviors, and reducing distress.
   

3. 
   Process groups. These groups, facilitated by staff, shall assist each client to develop necessary skills to deal with his/her problems and issues. The group process shall utilize peer interaction and feedback in developing problem-solving strategies to resolve behavioral and emotional problems. Day rehabilitation may include psychotherapy instead of process groups, or in addition to process groups.
   

4. 
   Skill-building groups. In these groups, staff helps clients identify barriers related to their psychiatric and psychological experiences. Through the course of group interaction, clients identify skills that address symptoms and increase adaptive behaviors.
   

5. 
   Adjunctive therapies. These are non-traditional therapies, in which both staff and clients participate, that utilize self-expression (art, recreation, dance, music, etc.) as the therapeutic intervention. Participants do not need to have any level of skill in the area of self-expression, but rather should be able to utilize the modality to develop or enhance skills directed towards client plan goals.
   

5. 
   Day treatment intensive shall additionally include:
   

1. 
   Psychotherapy. Psychotherapy is the use of psychological techniques designed to encourage communication of conflicts and insight into problems with the goal of relieving symptoms, changing behavior leading to improved social and vocational functioning, and personality growth. Psychotherapy shall be provided by licensed, registered, or waivered staff practicing within their scope of practice.
   

2. 
   Mental Health Crisis Protocol. This is an established protocol for responding to clients experiencing a mental health crisis. The protocol shall assure the availability of appropriately trained and qualified staff and include agreed upon procedures for addressing crisis situations. The protocol may include referrals for crisis intervention, crisis stabilization, or other specialty mental health services necessary to address the client's urgent or emergency psychiatric condition (crisis services). If the protocol includes referrals, the day treatment intensive or day rehabilitation program staff shall have the capacity to handle the crisis until the client is linked to an outside crisis service.
   

3. 
   Written Weekly Schedule. The program shall have a detailed schedule that identifies when and where the service components of the program will be provided and by whom. The program staff, their qualifications, and the scope of their responsibilities are specified. The schedule is available to clients and, as appropriate, to their families, caregivers or significant support persons.
   

6. 
   Staffing ratios shall be consistent with the requirements in Title 9, CCR, Section 1840.350, for day treatment intensive, and Section 1840.352 for day rehabilitation. For day treatment intensive, staff shall include at least one staff person whose scope of practice includes psychotherapy.
   

7. 
   Program staff may be required to spend time on day treatment intensive and day rehabilitation activities outside the hours of operation and therapeutic program (e.g., time for travel, documentation, and caregiver contacts).
   

8. 
   The Contractor shall require that at least one staff person be present and available to the group in the therapeutic milieu for all scheduled hours of operation.
   

9. 
   The Contractor shall require day treatment intensive and day rehabilitation programs to maintain documentation that enables Contractor and the Department to audit the program if it uses day treatment intensive or day rehabilitation staff who are also staff with other responsibilities (e.g., as staff of a group home, a school, or another mental health treatment program). There shall be documentation of the scope of responsibilities for these staff and the specific times in which day treatment intensive or day rehabilitation activities are being performed exclusive of other activities.
   

10. 
    If a beneficiary is unavoidably absent for some part of the hours of operation, the Contractor shall ensure that the provider receives Medi-Cal reimbursement only if the beneficiary is present for at least 50 percent of scheduled hours of operation for that day.
    

11. 
    The Contractor shall ensure day treatment intensive and day rehabilitation documentation meets the documentation standards described in Section 13 of this Exhibit.
    

12. 
    The Contractor shall ensure that day treatment intensive and day rehabilitation have at least one contact per month with a family member, caregiver or other significant support person identified by an adult client, or one contact per month with the legally responsible adult for a client who is a minor. This contact may be face-to-face, or by an alternative method (e.g., e-mail, telephone, etc.). Adult clients may decline this service component. The contacts should focus on the role of the support person in supporting the client's community reintegration. The Contractor shall ensure that this contact occurs outside hours of operation and outside the therapeutic program for day treatment intensive and day rehabilitation.
    

13. 
    Written Program Description. Day treatment intensive and day rehabilitation providers, including Contractor staff, shall develop and maintain a written program description that describes the specific activities of each service and reflects each of the required components of the services as described in this section. The Contractor shall review the description for compliance with this section prior to the date the provider begins delivering day treatment intensive or day rehabilitation.
    

14. 
    Additional higher or more specific standards. The Contractor shall retain the authority to set additional higher or more specific standards than those set forth in this contract, provided the Contractor's standards are consistent with applicable state and federal laws and regulations and do not prevent the delivery of medically necessary day treatment intensive and day rehabilitation.
    

6. 
   Therapeutic Behavioral Services.
   

1. 
   Therapeutic Behavioral Services (TBS) are supplemental specialty mental health services covered under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit as defined in Title 9, CCR, Section 1810.215.
   

2. 
   TBS is an intensive, one-to-one, short-term outpatient treatment intervention for beneficiaries under age 21 with serious emotional disturbances (SED) who are experiencing a stressful transition or life crisis and need additional short-term support services.
   

3. 
   TBS shall not be provided unless it is necessary to prevent a beneficiary’s placement in a group home at Rate Classification Level (RCL) 12 through 14 or a locked facility for the treatment of mental health needs or to enable a transition from any of those levels to a lower level of residential care, or for a beneficiary who has undergone at least one emergency psychiatric hospitalization related to their current presenting disability within the preceding 24 months.
   

6. 
   Procedures for Serving Child Beneficiaries Placed Out-of-County.
   

1. 
   The Contractor in the child’s county of origin shall provide or arrange for medically necessary specialty mental health services for children in a foster care aid code residing outside their county of origin.
   

2. 
   The Contractor shall use the standard forms issued by the Department when a child in a foster care aid code is placed outside of his/her county of origin. The standard forms are:
   

1. 
   Client Assessment,
   
2. 
   Client Plan,
   
3. 
   Service Authorization Request,
   
4. 
   Client Assessment Update,
   
5. 
   Progress Notes – Day Treatment Intensive Services,
   
6. 
   Progress Notes – Day Rehabilitation Services,
   
7. 
   Organizational Provider Agreement (Standard Contract).
   
1. 
   For children in a foster care aid code, the Contractor in the child’s county of origin shall make payment arrangements with the host county Mental Health Plan or with the requesting provider within 30 days of the date that the MHP in the child’s county of origin authorized services. If the Contractor requires the use of a contract, the contract must be executed within 30 days of the date services were authorized.
   

4. 
   The Contractor may request an exemption from using the standard documents if the Contractor is subject to an externally placed requirement (such as a federal integrity agreement) that prevents the use of the standardized forms. The Contractor shall request this exemption from the Department in writing.
   

5. 
   The Contractor shall ensure that the MHP in the child’s adoptive parents’ county of residence provides medically necessary specialty mental health services to a child in an AAP aid code residing outside his or her county of origin in the same way as the MHP would provide services to an in-county child for whom the MHP is listed as the county of responsibility on the Medi-Cal Eligibility Data System (MEDS).
   

6. 
   The MHP in the child’s legal guardians’ county of residence shall provide medically necessary specialty mental health services to a child in a Kin-GAP aid code residing outside his or her county of origin in the same way that it would provide services to any other child for whom the MHP is listed as the county of responsibility on the Medi-Cal Eligibility Data System (MEDS).
   

7. 
   The Contractor shall comply with timelines specified in Title 9, CCR, Section 1830.220(b)(4)(A)(1-3), when processing or submitting authorization requests for children in a foster care, Adoption Assistance Program (AAP), or Kinship Guardian Assistance Payment (Kin-GAP) aid code living outside his or her county of origin.
   

8. 
   The Contractor shall submit changes to its procedures for serving beneficiaries placed outside their counties of origin pursuant to Welfare and Institutions Code Section 5777.6(a) and(b) when those changes affect 25 percent or more of the Contractor’s beneficiaries placed out of county. The Contractor’s submission shall also include significant changes in the description of the Contractor’s procedures for providing out-of-plan services in accordance with Title 9, CCR, Section 1830.220, when a beneficiary requires services or is placed in a county not covered by the Contractor’s normal procedures.
   

6. 
   Quality Management (QM) Program.