|City and County of San Francisco
Department of Public Health
POPULATION HEALTH AND PREVENTION
COMMUNITY BEHAVIORAL HEALTH SERVICES
1380 Howard Street, 5th Floor
San Francisco, CA 94103
POLICY/PROCEDURE REGARDING: CBHS Organizational Provider Medi-Cal Certification & Recertification
|Issued By: Jo Ruffin, LCSW
Deputy Director of Health for Mental Health
Date: February 2, 2000
(Substantive revision. Replaces Policy 2.01-2 of 1/26/96.)
To bill for Medi-Cal services, all programs except inpatient and outpatient hospital services operating under the license of the hospital, must be certified according to the standards of the Short-Doyle/Medi-Cal (SD/MC) Manual for Rehabilitation Option and Targeted Case Management. (Copies available from Jon Blackner, 255-3771) In addition to provider certification standards in the SD/MC Manual, all providers must conform to staffing standards and other service requirements, as described in the Service Definitions Section of the SD/MC Manual. Psychiatric inpatient and outpatient hospital services will continue to be licensed by the State Department of Health Services, Licensing and Certification Division, and do not come under the purview of this Manual or policy. Requests for certification in the Medi-Cal program must be submitted to the San Francisco Mental Health Plan, care of the local mental health director or designee. Requests submitted directly to State Department of Mental Health (DMH) from providers will not be accepted.
The designated Program Monitor is required to work with the Program Director or representative in order to obtain Medi-Cal certification.
Provider certification for Medi-Cal services that are reimbursable under the Medi-Cal Specialty Mental Health Services Consolidation program shall occur in accordance with the following:
I. Planning to Set-up a New Medi-Cal Program
Prior to submitting the Medi-Cal forms, Program Monitors must complete the CBHS 100 forms (see Policy 2.01-5) with regard to Provider information, including approval signatures and the provision of a provider number. Prior to completing the application forms, programs are required to complete I.A., as well as obtain a fire clearance as cited in II.B.:
A. Program monitors must obtain a Medi-Cal provider number through the CBHS Information Systems (IS) office, prior to submitting SD/MC certification forms. (Contact: Retha Pedigo - 255-3787)
B. Program monitors must coordinate with the CBHS Billing Information Systems (IS) office
to confirm how billing will occur, and to obtain the necessary information regarding
computer hardware requirements, software, and training in a timely manner prior to actual
(Contact: Retha Pedigo - 255-3787)
C. To obtain SD/MC certification, a program must be in actual operation, providing mental health services as described in the SD/MC Manual (2-10, and 2-11) (Manual may be obtained from Jon Blackner - 255-3771)
II. Submission of Forms to Set-up Medi-Cal Programs
It is the responsibility of the Program Monitor to submit the following forms, completed, dated, and signed to the Medi-Cal Provider Certification Coordinator in the Quality Management Section of CBHS for the Director's review and signature. For new providers, these forms must be submitted at the time potential Medi-Cal services begin.
A. SD/MC Provider Certification Application (7-16)
SD/MC Provider Agreement (7-17)
Medi-Cal Provider Data Form (7-18)
Medi-Cal Provider Disclosure Statement
Medi-Cal Point of Service (POS) Network Agreement
(Forms attached - see Attachment 1)
B. Current Fire Clearance Certificate and a documented visit by a local fire official with a Plan of Correction pending, or evidence of compliance. (obtainable from the local Fire Department - SFFD Office of Fire Prevention - 558-3300 ask for the District Inspector for the site address)
III. Recertification of Medi-Cal Programs
Medi-Cal organizational provider recertification reviews may be done every two years
based on SFMHP's review schedule. Additional certification reviews may become necessary
under circumstances listed below. For recertification, forms (listed in II. A.) must be
submitted to Jim Gilday at least 70 days before a significant programatic change takes place
that requires recertification. The local mental health director or designee shall be
notified by the Program Director or Program Monitor 70 days prior to the
changes noted below. The notification must include the effective date, and a description of
changes. (use CBHS 100 forms (see Policy 3.07-6))
Additional certification reviews may become necessary if:
A. There is change of legal entity or ownership. This will require a new certification application process.
B. There is change of location. (Involuntary changes of location due to disasters must be reported as soon as possible and are not subject to the 60 day prior notification requirement.) This will require a new fire clearance of the new site, but may not require a full re-submission of certification forms. Programs may expect a certification site visit by State DMH Medi-Cal officials for CBHS programs, or Quality Management Section (QMS) officials for contract programs.
C. The provider makes major staffing changes. All providers must conform to staffing standards as described in Service Definitions for Rehabilitation Option and Targeted Case Management. SD/MC Manual (2-12, and 2-13 and 7-6) The requirement for certification review in this situation is at the State Medi-Cal Field Office or the local mental health director or designee's discretion.
D. The provider makes organizational and/or corporate structure changes
(example: conversion from non-profit status). This will require a new certification application process as would change of ownership.
E. The provider adds Day Treatment or Medication Support services
when Day Treatment or medications were not previously certified to be administered or dispensed from the provider site. This requires notification and may involve a site visit.
F. There are significant changes in the physical plant of the provider site. (some physical plant changes could require a new fire clearance, but may not require a full re-submission of certification forms.)
G. There are complaints regarding the provider. Depending on the gravity of the complaints, it may require a certification review at the SFMHP or State's discretion.
H. There are unusual events, accidents, or injuries requiring medical treatment
for clients, staff or members of the community. When persons are injured on a program site,
it usually involves a certification review as a matter of course.
(see SD/MC Manual 7-12)
IV. Site Visits Required to Certify or Recertify Medi-Cal Programs
Representatives of the Quality Management Section (QMS) will visit Medi-Cal organizational program sites for the purposes of certification at least every two years based on SFMHP's review schedule. The certification site visits will include a review of items contained in the Medi-Cal certification check list, and program description documents (see attachment II and III).
Contact Person: James T. Gilday, M.S.W.,
Medi-Cal Provider Certification Coordinator
V. Notification of Certification Status
Upon completion of the necessary documents and after a certification site visit has been completed, the Medi-Cal Certification Coordinator will send a letter of certification citing the date, conditions and term of certification to the Program Monitor, Program Director, BIS office, Budget Manager, and if necessary, to the State Medi-Cal office. All records must be complete to assure a clear audit trail for State Medi-Cal officials or CBHS risks denial of Medi-Cal claims. Subsequent communications to or from the State Medi-Cal office, the State Electronic Data System office, or any external interested party should be copied to the Medi-Cal Certification Coordinator in order to assure a complete record.
VI. Adult Residential Treatment Services (Transitional and Long-Term)
As a precondition to SD/MC provider certification, programs providing Adult Residential
Treatment Services must be certified as a Social Rehabilitation Program by the Department of
Mental Health as either a Transitional Residential Treatment Program or a Long-Term
Residential Treatment Program. Facility capacity must be limited to a maximum of 16 beds.
Services shall be consistent with Section 532 of Title 9, California Code of Regulations. In
addition to the routine forms required for application for SD/MC certification (see II. A.)
proof of certification as a Social Rehabilitation Program by the State Department of Mental
Health (DMH), Licensing and Certification Unit must accompany the application.
In addition to Social Rehabilitation Program Certification, programs providing Adult Residential Treatment Services must be licensed as a Social Rehabilitation Facility or Community Care Facility by the Department of Social Services or authorized to operate as a mental Health Rehabilitation Center by the Department of Mental Health.
VII. Out of County Provider Certification
Out of County providers may be certified as SD/MC providers for the SFMHP if the appropriate application forms and fire clearance is submitted, as well as verification of their current SD/MC provider certification status in their home county. If a provider is currently certified in their home county, we may forego the site visit requirement at the discretion of the Medi-Cal Certification Coordinator.
IX. Program Certification Documents and Records
Information obtained during the certification process may be used during subsequent Quality Improvement/Quality Management activities. The information obtained in this process is intended only for the use of the Medi-Cal Certification Coordinator, the , the Director of Mental Health, the State DMH or Medi-Cal officials in the performance of their duties.
Administrative Manual Holders
SD/MC Certified Organizational Providers
for Attachments I, II, and III,
contact James T. Gilday, M.S.W., Medi-Cal Provider Certification Coordinator(415) 255-3661
CBHS policies and procedures are distributed by the Quality Management Section, Lucy Arellano, 415-255-3687.