FFS2 Provider Manual - Department of Mental Health

Local Mental Health Plan Medi-Cal Specialty Mental Health Services Fee-For-Service Network Provider Manual, 9th Edition

Document Name	Revision Date	Comments
Front Cover	09/27/22
Introduction	09/27/22
Important Phone Numbers	09/27/22
Table of Contents	09/27/22
Section I – Purpose, principles, and goals	09/27/22
Section II- The Provider Network Attachment I-FFS2 Contract Workflow Attachment II-Network Adequacy and Cultural Competence Plan Requirements for Cultural Competency Training Attachment III- Board of Behavioral Sciences (BBS) Attachment IV-Contract Address Attachment V-Sample Beneficiary Notification Letter Figure A- County of Los Angeles Department of Mental Health Service Map	09/27/22
Section III- The Provider Relations Unit	09/27/22
Section IV- Access to Services	09/27/22
Section V- Confirmation of Medi-Cal Eligibility and Electronic Medi-Cal Beneficiary Enrollment	09/27/22
Section VI- The Beneficiary Services Program and Requirements for Providing Medi-Cal Beneficiary Material to Clients	09/27/22
Section VII- Consents and Authorization Standards for Client Access to Health Information and Use/Disclosure of Health Information Attachment I- Consent for Services (English) and (Spanish) Attachment II-Consent of Minor Attachment III-Medication Consent and Treatment Plan Attachment IV- Outpatient Medication Review Attachment V-Authorization for Use or Disclosure of Protected Health Information (PHI)	09/27/22
Section VIII- Documentation Standards, Treatment Standards and Medical Necessity Criteria Attachment I- Quality Assurance Bulletin 21-07 Attachment II- Quality Assurance Bulletin 21-08 Attachment III- Child/Adolescent Full Assessment Attachment IV- Adult/Full Assessment Attachment V- Child/Adolescent Assessment Addendum Attachment VI- Adult Addendum Attachment VII- Progress Note Attachment VIII- Initial Medication Support Service Attachment IX- Complex Medication Support Service Attachment X- Brief Follow-Up Medication Support Service Attachment XI- Network Provider Discharge Summary	09/27/22
Section IX- Procedure Codes, Diagnosis Codes and Rates Attachment I- FFS Procedure Codes, Durations & Rates Attachment II- FFS Telehealth and Telephone Procedure Codes	01/01/23	Supersedes publication posted 09/27/2022. For more details see Provider Bulletin, 9th Edition, Issue 1- Procedure Code Updates posted on January 05, 2023.
Section X- Quality Improvement	09/27/22
Section XI- Financial Screening Attachment I- Payor Financial Screening	09/27/22
Section XII- Claiming Information	09/27/22
Section XIII- Provider Fiscal Problem Resolution Process Attachment I- Appeal Request	09/27/22
Section XIV- Care Coordination between Physical Health and Mental Health Providers Attachment I- Provider Communication & Instructions Attachment II- Authorization for Use or Disclosure of Protected Health Information (PHI) Attachment III- HIPAA Compliant Fax Cover Sheet for Transmitting PHI	09/27/22
Section XV- Over-Threshold and Inpatient Professional Services	09/27/22
Section XVI- Psychological Testing Services Attachment I- Psychological Testing Request (PTR) Form Attachment II- Psychological Testing Request Response (PTR-Response) Form Attachment III- Quality Assurance: The Clinical Evaluation Form	09/27/22
Section XVII- Notice of Adverse Benefit Determination Attachment I- Notice of Adverse Benefit Determination – About Treatment Request and (3) Enclosures Attachment II- Notice of Adverse Benefit Determination- Acknowledgement of Receipt Attachment III- Notice of Appeal Resolution	09/27/22
Section XVIII- Medication, Pharmacy, Laboratory and Medicare Part D	09/27/22
Section XIX- Medical Transportation Services	09/27/22
Section XX- Out-of-County Services Figure A- Out-Of-County Flow Chart	09/27/22
Glossary of Terms	09/27/22
Acronyms & Abbreviations	09/27/22
Attachments, Policies, and Figures	09/27/22

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