HomeMy WebLinkAboutAgreement A-18-362-1 with Blue Cross Anthem.pdf1
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Agreement No . 18-362-1
AMENDMENT I TO AGREEMENT
THIS AMENDMENT I TO AGREEMENT (hereinafter "Amendment") is made and entered into
this~ day of June , 2021, by and between COUNTY OF FRESNO, a Political
Subdivision of the State of California, Fresno, California (hereinafter "COUNTY"), and Blue Cross of
California Partnership Plan , Inc., a Medi-Cal Managed Care Plan , whose address is 3330 W. Mineral
King Avenue , Visalia, Ca 93291 (hereinafter "ANTHEM ").
WITNESSETH:
WHEREAS, COUNTY and ANTHEM entered into Agreement number 18-362 , dated July 10th ,
2018 (hereinafter "Agreement"), pursuant to which COUNTY and ANTHEM identified responsibilities
and protocols in the delivery of specialty mental health and alcohol and other drug services to Medi-
Cal Members served by both parties ; and
WHEREAS , COUNTY and ANTHEM now desire to amend the Agreement in order to update
the agreement with current requirements.
NOW, THEREFORE , for good and valuable consideration , the receipt and adequacy of which
is hereby acknowledged , COUNTY and ANTHEM agree as follows :
1. That Section ten (10) CONFIDENTIALITY through Section nineteen (19) ENTIRE
AGREEMENT shall be renumbered to read as Sections eleven (11) through twenty (20).
2 . That a new Section ten (10) shall be added to the agreement, located on page seven
(7), beginning on line twenty-three (23) as follows:
"10. INSURANCE
Each party shall insure its activities in connection with this Agreement and maintain
at all t imes insurance in coverage and limit amounts reasonably necessary to protect itself against
injuries and damages arising from the acts or omissions caused by each party, their respective
Boards , officers , employees and agents in the performance of this Agreement. This insurance
requirement may be satisfied through a program of self-insurance , or insurance coverage afforded
to public entities through a Joint Powers Authority (JPA) risk pool."
3. That Section twelve (12) NON-DISCRIMINATION of the Agreement , located on page
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seven (7), beginning on line twenty-seven (27) through page eight (8), line three (3), is deleted in its
entirety and replaced with the following:
“12. NON-DISCRIMINATION
During the performance of this Agreement, ANTHEM shall not unlawfully discriminate
against any employee or applicant for employment, or recipient of services, because of sex, race,
religion, color, national origin, ancestry, ethnic group identification, physical disability, mental
disability, medical condition, genetic information, sexual orientation, marital status, age, gender or
gender identity, pursuant to all applicable State of California and Federal statutes and regulations.”
4. That “Exhibit A” be deleted and replaced with “Revised Exhibit A”, which is attached
hereto and incorporated herein by this reference. All references to “Exhibit A” in the Agreement are
deleted and replaced with “Revised Exhibit A.”
5. The parties agree that this Amendment may be executed by electronic signature as
provided in this section. An “electronic signature” means any symbol or process intended by an
individual signing this Amendment to represent their signature, including but not limited to (1) a digital
signature; (2) a faxed version of an original handwritten signature; or (3) an electronically scanned
and transmitted (for example by PDF document) of a handwritten signature. Each electronic signature
affixed or attached to this Amendment (1) is deemed equivalent to a valid original handwritten
signature of the person signing this Amendment for all purposes, including but not limited to
evidentiary proof in any administrative or judicial proceeding, and (2) has the same force and effect
as the valid original handwritten signature of that person. The provisions of this section satisfy the
requirements of Civil Code section 1633.5, subdivision (b), in the Uniform Electronic Transaction Act
(Civil Code, Division 3, Part 2, Title 2.5, beginning with section 1633.1). Each party using a digital
signature represents that it has undertaken and satisfied the requirements of Government Code
section 16.5, subdivision (a), paragraphs (1) through (5), and agrees that each other party may rely
upon that representation. This Amendment is not conditioned upon the parties conducting the
transactions under it by electronic means and either party may sign this Amendment with an original
handwritten signature.
COUNTY and ANTHEM agree that this Amendment is sufficient to amend the Agreement and,
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that upon execution of this Amendment, the Agreement and this Amendment together shall be
considered the Agreement.
The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
covenants, conditions and promises contained in the Agreement and not amended herein shall
remain in full force and effect.
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1 IN WITNESS WHEREOF , the parties hereto have executed this Amendment I as of the day and
2 year first hereinabove written .
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4 BLUECROSSOFCALIFORN~:
PARTNERSHIP PLAN, INC.:
5 L0--
6 (Aufhorized Signature)
7
Les Ybarra President CA Medicaid Interim
8 Print Name & Title
9 425 E. Colorado St , Suite 600
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Glendale CA 91205
Mailing Address
18 FOR ACCOUN TING USE ONLY :
19 ORG No .: 56302666 ($0)
Account No .: 7295 ($0)
20 Fund/Subclass : 0001/10000
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COUNTY OF FRESNO
VJ--
Steve Bra au , ha irman of the Board
of Supervisors of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno , State of California
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Revised Exhibit A
Page 1 of 25
MEMORANDUM OF UNDERSTANDING (MOU)
DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY)
AND
ANTHEM
CATEGORY COUNTY ANTHEM BLUE CROSS
A. Liaison 1.COUNTY’s Administrative Staff is
the liaison to coordinate activities
with ANTHEM and to notify
COUNTY providers and relevant
staff of their roles and
responsibilities
2.COUNTY Liaison will provide
ANTHEM with an updated list of
approved COUNTY providers,
specialists and behavioral health
care centers in the county.
3.Information for Mental Health
(MH) services is also available on
the COUNTY’s managed care
website and is updated at a
minimum on a quarterly basis.
4.Information for Substance Use
Disorder (SUD) treatment and
recovery services is also available
on the COUNTY’s Substance Use
Disorders Services Webpage and
is updated at a minimum on a 30
day basis.
1.ANTHEM has a liaison that coordinates
activities with the COUNTY and COUNTY
Liaison.
2.The Liaison will notify ANTHEM staff and
ANTHEM providers of their responsibilities to
coordinate services with the COUNTY.
3.The ANTHEM Provider Directory is available
on line and updated at a minimum on a
quarterly basis.
4. The ANTHEM Provider Operations Manual is
available on line.
B. Behavioral
Health Service
1.COUNTY will credential and
contract with sufficient numbers of
licensed behavioral health
professionals to maintain a
COUNTY provider network
sufficient to meet the needs of
Members.
2.COUNTY will assist with
identification of COUNTY
providers who have the capacity
and willingness to accept Medi-
Cal Fee for Service
reimbursement to serve Members
in need of MH services MH
service who do not meet the
COUNTY medical necessity
criteria and require services
outside the scope of practice of
the Primary Care Physicians
(PCP) per Exhibit B, attached
hereto.
3.For SUD services, COUNTY will
provide a centralized intake
function that will screen clients
using the ASAM criteria and
determine a presumptive level of
1.ANTHEM will utilize the COUNTY to identify
COUNTY providers who are willing to accept
Medi-Cal fee for service reimbursement to
provide services for MH services to Members
who do not meet COUNTY medical
necessity criteria for COUNTY services and
require services outside the scope of
practice of the PCP per Exhibit B, attached
hereto.
2.ANTHEM will coordinate care with the
appropriate COUNTY provider or provider
organization as recommended by the
COUNTY for those services that do not meet
the COUNTY medical necessity criteria.
3.For SUD services, ANTHEM will screen and
offer brief intervention. For clients who
appear to need further assessment and
more intensive services, a referral to
COUNTY centralized intake or a provider on
the list will be required.
4.ANTHEM will collaborate with COUNTY to
maintain a list of COUNTY providers or
provider organizations to be made available
to Members upon request.
5.Any updates to the list will be provided to
ANTHEM liaison quarterly and upon request.
Revised Exhibit A
Page 2 of 25
care. Once the client attends an
intake at a COUNTY contracted
provider, they will be assessed for
medical necessity including
diagnosis. COUNTY centralized
intake will approve services
through a Treatment Authorization
Request process.
4.COUNTY will continually monitor
the COUNTY provider network to
ensure Member access to quality
behavioral health care. COUNTY
will assist ANTHEM in arranging
for a specific COUNTY provider or
community service.
5.COUNTY will assist ANTHEM to
develop and update a list of
providers or provider
organizations to be made
available to Members. For MH
services this list is available on
the COUNTY’s managed care
website. Any updates to the list
will be forwarded to the ANTHEM
liaison quarterly and upon
request. For SUD services, this
list is available on the COUNTY’s
SUD Services Webpage. Any
updates to the list will be
forwarded to the ANTHEM liaison
quarterly and upon request.
C. Medical
Records
Exchange of
Information
1.COUNTY will follow all applicable
laws pertaining to the use and
disclosure of protected health
information including but not limited
to:
•HIPAA / 45 C.F.R. Parts 160 and
164
•LPS / W & I Code Sections 5328-
5328.15
•45 C.F.R. Part 2
•HITECH Act (42. U.S.C. Section
17921 et. seq.
•CMIA (Ca Civil Code 56 through
56.37)
1.ANTHEM and contracted providers are
allowed to release medical information under
HIPAA regulations specific to the HIPPA Privacy
Rule (45 C.F.R. Part 164.)
D.Scope of
Service
1.COUNTY has a toll-free telephone
number available 24 hours a day,
seven days a week for access to
emergency, specialty MH and
SUD services for Members who
meet the medical necessity
criteria as identified in Exhibit B,
attached hereto.
1.ANTHEM PCPs will be responsible for
providing 24 hours a day, seven days a
week, access to health care services for
Members as specified in the ANTHEM
contract with Department of Health Care
Services (DHCS).
2.PCP will refer to the COUNTY for
assessment and appropriate services. PCP’s
Revised Exhibit A
Page 3 of 25
2.COUNTY maintains responsibility
for:
a.Medication treatment for
behavioral health
conditions that would not
be responsive to physical
healthcare-based
treatment and the
condition meets COUNTY
medical necessity criteria.
b.All other outpatient
specialty MH and SUD
services covered by the
COUNTY when the
Member’s behavioral
health condition meets
COUNTY medical
necessity criteria, such as
individual and group
therapies, case
management, crisis
intervention, treatment
plan, assessment, and
linkage with community
resources.
c.Consultation and training
services to PCPs,
particularly related to
specialty MH and SUD
issues and treatments,
including medication
consultation.
3.To receive behavioral health
services, the Member must meet
the criteria for each of the
following categories for MH
services:
a.Category A—Included
Diagnosis
b.Category B—Impairment
Criteria
c.Category C—Intervention
Related Criteria
Per Enclosure 1a of Exhibit A.
4.To receive behavioral health
services, the Member must meet
the criteria for each of the
following categories for SUD
services:
a.Early Intervention Services
b. Outpatient/Intensive
Outpatient
c.Residential Services (ASAM
Levels 3.1, 3.3, 3.5, 3.7 and
4.0)
d.Withdrawal Management
will refer Members for:
a.An assessment to confirm or arrive
at a diagnosis
b. Behavioral health services other
than medication management are
needed for a Member with a
diagnosis included in the
responsibilities of the COUNTY.
c.For identification of conditions not
responsive to physical healthcare-
based treatment.
3.PCP’s will provide primary care behavioral
health treatment which includes:
a.Basic education, assessment (MH
services only), counseling (MH
services only) and referral and
linkage to other services for all
Members
b.Medication and treatment for
i.Behavioral health conditions
that would be responsive to
physical healthcare-based
treatment
ii.Behavioral health disorders
due to a general medical
condition
c.Medication-induced reactions from
medications prescribed by physical
health care providers.
4.PCPs will provide or arrange for:
a.Covered medical services
b.Primary behavioral health
intervention for Member with
“Excluded Diagnosis” as identified in
Specialty MH Services identified in
ATTACHMENT A, Page 17 of this
Exhibit A.
c.Screening and brief intervention for
behavioral health services within the
PCP’s scope of practice
5.ANTHEM and COUNTY recognize that the
PCP’s ability to treat behavioral health
disorders will be limited to each provider’s
training and scope of practice.
6.When the Member does not meet MH
medical necessity, ANTHEM and PCP will be
responsible for coordinating a referral in
accordance with Category B2 “Mental Health
Services” or an ANTHEM contracted
provider.
7.When the member meets SUD medical
necessity for COUNTY contracted services,
ANTHEM and PCP will refer client to a
county provider or coordinate care with
inpatient facilities and out-of-county facilities
accepting Fresno County clients as
Revised Exhibit A
Page 4 of 25
e.Opioid Treatment
f.Recovery Services
For further details on SUD ASAM
levels of care please see Exhibit
C.For SUD ICD-10 Diagnostic
Codes see Enclosure 1b.
5.COUNTY providers will refer
Members back to their identified
PCP for medical and non-
specialty behavioral health
conditions that would be
responsive to appropriate physical
health care.
appropriate.
E. Ancillary
Behavioral Health
Services
1.When medical necessity criteria
are met and services are
approved by the COUNTY, the
COUNTY and its contracted
providers will provide hospital
based specialty MH ancillary
services, which include, but are
not limited to Electroconvulsive
therapy (ECT) and magnetic
resonance imaging (MRI) that are
received by a Member admitted to
a psychiatric inpatient hospital
other than routine services, per
Exhibit B, attached hereto.
2.When SUD medical necessity
criteria is met and services are
approved by the COUNTY for
ASAM levels 3.7 and 4.0 and
medical detox, COUNTY will refer
Member to ANTHEM.
3.COUNTY will make training
available for community based
physicians interested in providing
MAT services, including an eight
hour Buprenorphine Waiver
Training required to become a
community based MAT service
provider.
1.ANTHEM must cover and pay for medically
necessary laboratory, radiological, and
radioisotope services described in Title 22,
CCR, Section 51311. ANTHEM will cover
and pay for related services for
Electroconvulsive Therapy (ECT),
anesthesiologist services provided on an
outpatient basis, per Exhibit B, attached
hereto.
2.ANTHEM will cover and pay for all medically
necessary professional services to meet the
physical health care needs of the Members
who are admitted to the psychiatric ward of a
general acute care hospital or to a
freestanding licensed psychiatric inpatient
hospital or Psychiatric Health Facility (PHF).
These services include the initial health
history and physical assessment required
within 24 hours of admission and any
medically necessary physical medicine
consultation, per Exhibit B, attached hereto.
3.ANTHEM is not required to cover room and
board charges or behavioral health services
associated with a Member’s admission to a
hospital or inpatient psychiatric facility for
psychiatric inpatient services, per Exhibit B,
attached hereto.
4.ANTHEM will provide SUD treatment for
Members who meet medical necessity for
Medically Monitored Intensive Inpatient
Services (ASAM Level 3.7) which includes
24 hour nursing care with physician
availability for significant problems with acute
intoxication and/or withdrawal potential,
biomedical conditions and emotional,
behavioral or cognitive conditions and
complications and 16 hour/day counselor
availability.
5.ANTHEM will provide SUD treatment for
Members who meet medical necessity for
Medically Managed Intensive Inpatient
Services (ASAM Level 4.0) which includes
Revised Exhibit A
Page 5 of 25
24 hour nursing care and daily physician
care for severe, unstable problems with
acute intoxication and/or withdrawal
potential, biomedical conditions and
emotional, behavioral or cognitive conditions
and complications with counseling available
to engage Member in treatment.
6.ANTHEM will provide SUD treatment for
Members who meet medical necessity for
Medically Monitored Inpatient Withdrawal
Management (ASAM Level 3.7 – WM) which
includes severe withdrawal needing 24-hour
nursing care and physician visits.
7.ANTHEM will provide SUD treatment for
Members who meet medical necessity for
Medically Managed Intensive Inpatient
Withdrawal Management (ASAM Level 4 –
WM) which includes severe, unstable
withdrawal needing 24-hour nursing care and
daily physician visits to modify withdrawal
management regimen and manage medical
instability. Once the client has stabilized
ANTHEM will refer to a lower level of care to
increase the likelihood of successful
recovery.
8.ANTHEM Providers will have the ability to
prescribe, dose and/or refer Members with
an Opioid Use Disorder to Medication
Assisted Treatment (MAT) when appropriate.
ANTHEM will encourage its physicians to
complete an eight hour Buprenorphine
Waiver Training course required to prescribe
and dispense Buprenorphine. This training
is available through SAMHSA.
9.ANTHEM shall coordinate with COUNTY
NTP providers when medically indicated for
MAT services.
E1. Emergency
Room Urgent
Behavioral Health
Care
1.The COUNTY toll free 24 hour
line is available to Members.
2. The COUNTY shall cover and pay
for the professional services of a
behavioral health specialist
provided in an emergency room to
a Member whose condition meets
COUNTY medical necessity
criteria or when behavioral health
specialist services are required to
assess whether COUNTY medical
necessity is met, per Exhibit B,
attached hereto.
3. The COUNTY is responsible for
the facility charges resulting from
the emergency services and care
of a Member whose condition
meets COUNTY medical
1.ANTHEM will maintain a 24 hour member
service and Nurse Advice Line.
2.ANTHEM shall cover and pay for all
professional services, except the
professional services of a behavioral health
specialist when required for the emergency
services and care of a member whose
condition meets COUNTY medical necessity
criteria.
3.ANTHEM shall cover and pay for the facility
charges resulting from the emergency
services and care of a Member whose
condition meets COUNTY medical necessity
criteria when such services and care do not
result in the admission of the member for
psychiatric and/or SUD inpatient hospital
services or when such services result in an
admission of the member for psychiatric
Revised Exhibit A
Page 6 of 25
necessity criteria when such
services and care do result in the
admission of the Member for
psychiatric and/or SUD inpatient
hospital services at the same
facility. The facility charge is not
paid separately, but is included in
the per diem rate for the inpatient
stay, per Exhibit B, attached
hereto.
4. The COUNTY is responsible for
facility charges directly related to
the professional services of a
behavioral health specialist
provided in the emergency room
when these services do not result
in an admission of the member for
psychiatric and/or SUD inpatient
hospital services at that facility or
any other facility, per Exhibit B,
attached hereto.
and/or SUD inpatient hospital services at a
different facility.
4.ANTHEM shall cover and pay for the facility
charges and the medical professional
services required for the emergency services
and care of a Member with an excluded
diagnosis or a Member whose condition
does not meet COUNTY medical necessity
criteria and such services and care do not
result in the admission of the Member for
psychiatric and/or SUD inpatient hospital
services.
5.Payment for the professional services of a
behavioral health specialist required for the
emergency services and care of a Member
with an excluded diagnosis is the
responsibility of ANTHEM.
E2. Home Health
Agency Services
1.COUNTY shall cover and pay for
medication support services, case
management, crisis intervention
services, or any other specialty
MH services as provided under
Section 1810.247, which are
prescribed by a psychiatrist and
are provided to a Member who is
homebound. COUNTY will
collaborate with ANTHEM on any
specialty MH services being
provided to a Member.
1.ANTHEM will cover and pay for prior
authorized home health agency services as
described in Title 22, CCR, Section 51337
prescribed by an ANTHEM provider when
medically necessary to meet the needs of
homebound Members. ANTHEM is not
obligated to provide home health agency
services that would not otherwise be
authorized by the Medi-Cal program.
2.ANTHEM will refer Members who may be at
risk of institutional placement to the Home
and Community Based services (HCBS)
Waiver Program (ANTHEM/DHCS Contract
6.7.3.8) if appropriate.
E3. Nursing and
Residential
Facility Services
1.COUNTY will arrange and
coordinate payment for nursing
facility services, i.e., Augmented
Board and Care (ABC), Skilled
Nursing Facility (SNF), Institution
for Mental Disease (IMD), etc., for
Members who meet medical
necessity criteria and who require
a special treatment program [Title
22, California Code of Regulations
(CCR), Section 51335(k)].
2.COUNTY’s provide medically
necessary specialty MH services,
typically visits by psychiatrists and
psychologists.
1.ANTHEM will arrange and pay for nursing
facility services for Members who meet the
medical necessity criteria for the month of
admission plus one month, per Title 22,
CCR, Section 51335.
2.ANTHEM will arrange for disenrollment from
managed care if Member needs nursing
services for a longer period of time.
3.ANTHEM will pay for all medically necessary
DHCS contractually required Medi-Cal
covered services until the disenrollment is
effective.
E4. Emergency
and Non-
Emergency
1.Medical transportation services as
described in Title 22, Section
51323 are not the responsibility of
1.ANTHEM will arrange and pay for
transportation of Members needing medical
transportation from:
Revised Exhibit A
Page 7 of 25
Medical
Transportation
the COUNTY except when the
purpose of the medical
transportation service is to
transport a Medi-Cal beneficiary
from a psychiatric inpatient
hospital to another psychiatric
inpatient hospital or another type
of 24 hour care facility because
the services in the facility to which
the beneficiary is being
transported will result in lower
costs to the COUNTY.
a.The emergency room for medical
evaluation.
b.A psychiatric inpatient hospital to a
medical inpatient hospital required to
address the Member’s change in
medical condition.
c.A medical inpatient hospital to a
psychiatric inpatient hospital
required to address the Member’s
change in psychiatric condition.
2.ANTHEM will cover and pay for all medically
necessary emergency transportation (per
CCR Title 22, 51323). Ambulance services
are covered when the Member’s medical
condition contraindicates the use of other
forms of medical transportation.
3.Emergency medical transportation is
covered, without prior authorization, to the
nearest facility capable of meeting the
medical needs of the Member as per CCR
Title 22, 51323.
4.Ambulance, litter van and wheelchair van
medical transportation services are covered
when the Member’s medical and physical
condition is such that transport by ordinary
means of public or private conveyance is
medically contraindicated, and transportation
is required for the purpose of obtaining
needed medical care. Ambulance services
are covered when the member’s medical
condition contraindicates the use of other
forms of medical transportation
5.ANTHEM will cover all nonemergency
medical transportation, necessary to obtain
program covered services
a.When the service needed is of such
an urgent nature that written
authorization could not have been
reasonably submitted beforehand,
the medical transportation provider
may request prior authorization by
telephone. Such telephone
authorization shall be valid only if
confirmed by a written request for
authorization.
b.Transportation shall be authorized
only to the nearest facility capable of
meeting the member’s medical
needs.
6.ANTHEM will cover and pay for medically
necessary non-emergency medical
transportation services when prescribed for a
Member by a Medi-Cal behavioral health
provider outside the COUNTY when
authorization is obtained. ANTHEM will
maintain a policy of non-discrimination
Revised Exhibit A
Page 8 of 25
regarding Members with behavioral health
disorders who require access to any other
transportation services provided by
ANTHEM.
7.ANTHEM will assure that SUD clients
receive Non-Emergency medical
transportation services when prescribed for a
Member as described in APL 17-010,
attached as Exhibit E. These transportation
services will be provided when the SUD
services are medically necessary and the
Non-Emergency medical transportation has
prior authorization.
E5.
Developmentally
Disabled Services
1.COUNTY will refer Members with
developmental disabilities to the
Central Valley Regional Center for
non-medical services such as
respite, out-of-home placement,
supportive living, etc., if such
services are needed.
2.COUNTY has a current list of
names, addresses and telephone
numbers of local providers,
provider organizations, and
agencies that is available to a
Member when that Member has
been determined to be ineligible
for COUNTY covered services
because the Member’s diagnosis
is not included in Exhibit B Pages
32 to 36.
1.ANTHEM PCP will refer Members with
developmental disabilities to the Central
Valley Regional Center for non-medical
services such as respite, out-of-home
placement supportive living, etc., if such
services are needed.
2.ANTHEM will maintain a current MOU with
Central Valley Regional Center
E6. History and
Physical for
Psychiatric
Hospital
Admission
1.COUNTY will utilize ANTHEM
network providers to perform
medical histories and physical
examinations required for
behavioral health examinations
required for behavioral health and
psychiatric hospital admissions for
ANTHEM members.
1.ANTHEM will cover and pay for all medically
necessary professional services to meet the
physical health care needs of Members who
are admitted to the psychiatric ward of a
general acute care hospital or freestanding
licensed psychiatric inpatient hospital. These
services include the initial health history and
physical assessment required within 24
hours of admission and any necessary
physical medicine consultations, per Exhibit
B attached hereto.
E7. Hospital
Outpatient
Department
Services
(Electroconvulsive
Therapy)
1.COUNTY will cover and pay for all
psychiatric professional services
associated with electroconvulsive
therapy. Per Title 9, CCR Section
1810.350
1.ANTHEM is responsible for separately
billable outpatient services related to
electroconvulsive therapy, such as
anesthesiologist services, per Exhibit B,
attached hereto.
2.ANTHEM will cover and pay for professional
services and associated room charges for
hospital outpatient department services
consistent with medical necessity and
ANTHEM‘s contract with its contractors and
Revised Exhibit A
Page 9 of 25
DHCS, per Exhibit B, attached hereto.
F. Diagnostic
Assessment and
Triage
1.COUNTY or COUNTY provider
will screen and apply ASAM
criteria for level of care
placement. When Member is
determined to meet medical
necessity for a level of care not
provided by COUNTY Member
will be referred to ANTHEM.
2.COUNTY will arrange and pay for
specialty COUNTY provider
services for Members whose
psychiatric condition may not be
responsive to physical health
care.
a.Initial access and
availability will be via the
COUNTY Access Unit (a
twenty-four hour toll free
telephone triage system)
b.Crisis/emergency triage
via COUNTY provider is
available 24 hours a day.
3.COUNTY provider will assess and
diagnose Member’s symptoms,
level of impairment and focus of
intervention. Included ICD-9
Diagnoses codes are identified in
Enclosure 1a, attached hereto
and incorporated herein.
4.COUNTY provider assessments
will:
a.Determine if Member
meets medical necessity
criteria (See Attachment
B, attached hereto and
incorporated herein by
reference.)
b.Provide a resolution of
diagnostic dilemmas not
resolved by consultations
(e.g., multiple interacting
syndromes, patient’s
symptoms interfere with
the diagnostic conclusion
and has a bearing on the
primary care physician’s
treatment plan or if the
diagnostic conclusion is
needed to determine
appropriateness for
specialized MH care.
c.Identify stability level, if
the result is needed to
determine
1.ANTHEM will provide Members with SUD
screenings, brief intervention (SBIRT),
referral and assessment. If it is found that a
Member preliminarily meets medical
necessity for COUNTY provided services
ANTHEM will refer the Member to an
appropriate COUNTY access point (24/7
Access Line, Urgent Care Wellness Center
or COUNTY provider)for further assessment
and treatment.
2.ANTHEM will arrange and pay for
assessments of ANTHEM members by
PCPs to:
a.Rule out general medical conditions
causing psychiatric and SUD
symptoms.
b.Rule out behavioral health disorders
caused by a general medical
condition.
3.The PCP will identify those general medical
conditions that are causing or exacerbating
psychiatric and/or SUD symptoms.
4.The PCP will be advised to identify and treat
non-disabling psychiatric conditions which
may be responsive to primary care, i.e., mild
to moderate anxiety and/or depression.
5.When medically necessary ANTHEM will
cover and pay for physician services
provided by specialists such as neurologists,
per Exhibit B, attached hereto.
Revised Exhibit A
Page 10 of 25
appropriateness for
specialty MH services.
G. Referrals 1.COUNTY will accept referrals
from ANTHEM staff and
providers. ANTHEM providers and
Members will be referred to
determine medical necessity for
specialty MH services. For SUD
members, screening will be
completed to determine if further
assessment is necessary. If so
clients will be referred to the 24/7
Access Line.
2.COUNTY will coordinate with
ANTHEM Customer Care Center
to facilitate appointment and
referral verification assistance as
needed.
3.When all medical necessity
criteria are met, COUNTY will
arrange for specialty MH and/or
SUD services by COUNTY
provider.
4. When Member is appropriately
treated and/or stabilized, Member
may be referred back, if
appropriate to PCP for
maintenance care. The COUNTY
and ANTHEM will coordinate
services as necessary in such
cases
5.COUNTY and COUNTY provider
will track referrals to PCP to verify
that Member has access to
appointment and assistance to
keep appointment as needed.
a.COUNTY provider will have
the option of contacting the
ANTHEM Health Services for
information and assistance
concerning a referred
Member.
6. The COUNTY will refer the
Member to a source of treatment
or a source of referral for
treatment outside the COUNTY
when the COUNTY determines
that the Member’s diagnosis is not
included in Title 9, CCR, Section
1830.205.
7.Per Welfare & Institution Code,
Section 5777.5 (b)(1) for
behavioral health services the
COUNTY will designate a process
or entity to receive notice of
1.Following the PCP assessment, ANTHEM
staff and/or PCP will refer those Members
whose psychiatric condition or SUD would
not be responsive to physical health care to
the COUNTY to determine if specialty MH
and/or SUD services medical necessity
criteria are met.
2.ANTHEM and PCP will coordinate and assist
the COUNTY and Member to keep their
appointments and referrals back to their PCP
as appropriate for all other services not
covered by the COUNTY.
a.ANTHEM may request assistance
from the COUNTY Liaison to
facilitate removal of barriers to a
successful referral such as
transportation difficulties, resistance
to treatment or delays to access.
3.Members not meeting COUNTY medical
necessity guidelines will be referred by
ANTHEM to appropriate community
resources for assistance in identifying
programs available for low income Medi-Cal
beneficiaries.
Revised Exhibit A
Page 11 of 25
actions, denials, or deferrals from
ANTHEM , and to provide any
additional information requested
in the deferral notice as necessary
for a medical necessity
determination.
8.Per Welfare & Institution Code,
Section 5777.5(b) (2) for
behavioral health services the
COUNTY will respond by the
close of business day following
the day the deferral notice is
received.
H. Service
Authorizations
1.For MH services, COUNTY will
authorize assessment and/or
treatment services by COUNTY
providers who are credentialed
and contracted with COUNTY for
services that meet specialty MH
services medical necessity
criteria.
2.For SUD services, COUNTY will
perform screening and referral to
treatment. Once the provider
assessment is complete COUNTY
will authorize a Treatment
Authorization Request (TAR) for
level of care to receive treatment
by COUNTY providers who are
Drug Medi-Cal certified and
contracted with the COUNTY for
SUD services that meet medical
necessity criteria.
1.ANTHEM will authorize medical assessment
and/or treatment services by ANTHEM
network providers who are credentialed and
contracted with ANTHEM for covered
medically necessary services.
2.ANTHEM will inform PCPs that they may
refer Members to the COUNTY for initial
diagnosis and assessment of the Member.
I. Consultation 1.COUNTY encourages
consultations between COUNTY
providers, specialty providers and
ANTHEM PCP providers as it
relates to specialty MH and/or
SUD issues including but not
limited to medication issues,
linkage with community
resources, etc., in accordance
with HIPAA federal and state
regulations regarding
confidentiality per HIPPA Privacy
Rule 45 C.F.R. Part 164.
2.For those Members who are
excluded from COUNTY services,
COUNTY will provide clinical
consultation and training to the
ANTHEM PCPs, other behavioral
health providers and/or ANTHEM
staff on the following topics:
a.Recommended physical
1.PCP providers will be available to consult
with COUNTY and COUNTY providers
regarding Members who are treated by both,
in accordance with HIPAA federal and state
regulations regarding confidentiality, per
HIPPA Privacy Rule 45 C.F.R. Part 164.
2.For those Members who meet COUNTY
medical necessity criteria and whose
psychiatric symptoms and/or SUD will be
treated by a COUNTY provider, ANTHEM
and/or PCP will provide consultation to
COUNTY providers and/or COUNTY staff on
the following topics:
a.Acquiring access to covered
ANTHEM medical services.
b.Treatment of physical symptoms
precipitated by medications used to
treat behavioral health disorders.
c.Treatment of complicated sub-
syndrome medical symptoms.
d.Complex medication interactions
Revised Exhibit A
Page 12 of 25
healthcare-based
treatment for diagnosed
conditions
b. Complex diagnostic
assessment of behavioral
health disorders (e.g.,
multiple co-occurring
diagnosis, atypical
symptom patterns)
c.Treatment of stabilized
but serious and
debilitating mental
disorders
d.Complex psychotropic
medications practices
(medication interactions,
polypharmacy, use of
novel psychotropic
medication)
e.Treatment of complicated
sub-syndrome psychiatric
symptoms
f.Treatment of psychiatric
symptoms precipitated by
medications used to treat
medical conditions
g.Treatment of outpatient
behavioral health services
that are within the
ANTHEM PCP’s scope of
practice.
3.For those Members who are
excluded from COUNTY services,
COUNTY will provide clinical
consultation and training to the
ANTHEM PCPs, and/or ANTHEM
staff on the following topics:
a.ASAM Multidimensional
Assessment
b.From Assessment to
Service Planning and
Level of Care
c.Title 22/Documentation
d.Evidence Based Practices
e.DSM-5
f.Co-occurring Disorders
g.Medication Assisted
Treatment
with medications prescribed by PCP
not commonly used in psychiatric or
SUD specialty practice.
J. Early Periodic
Screening,
Diagnosis and
treatment
(EPSDT)
Supplemental
Services.
1.COUNTY will utilize Medi-Cal
medical necessity criteria
established for EPSDT
supplemental services to
determine if a child, 21 years of
age and under, meets those
criteria.
1.When ANTHEM determines that EPSDT
supplemental services criteria are not met
and the Member child’s condition is not CCS
eligible, ANTHEM will refer the Member child
to the PCP for treatment of conditions within
the PCP’s scope of practice.
2. Referrals to the COUNTY for an appropriate
Revised Exhibit A
Page 13 of 25
2.When EPSDT supplemental
criteria are met, COUNTY is
responsible for arranging and
paying for EPSDT supplemental
services provided by COUNTY
specialty MH and SUD providers.
3.When EPSDT supplemental
criteria are not met, COUNTY will
refer Member children as follows:
a.For MH services, Referral
to California Children’s
Services (CCS)- for those
children who have a CCS
medically eligible
condition and require
behavioral health provider
services related to the
eligible condition
b.For SUD services, ASAM
criteria will be applied,
level of care will be
determined and a referral
to treatment will be made.
c.When a referral is made,
the COUNTY will notify
ANTHEM of the referral.
linked program will be made for treatment of
conditions outside the PCP’s scope of
practice. ANTHEM will assist the COUNTY
and Members by providing links to known
community providers of supplemental
services.
3.ANTHEM will cover all medically necessary
professional services to meet the physical
health care needs of Members admitted to a
general acute care hospital ward or to a
freestanding licensed psychiatric inpatient
hospital.
K.
Pharmaceutical
Services and
Prescribed Drugs
1.COUNTY providers will prescribe
and monitor the effects and side
effects of psychotropic
medications for Members under
their treatment.
2.COUNTY will coordinate with
ANTHEM representatives to
ensure that psychotropic drugs
prescribed by COUNTY providers
are included in the ANTHEM
formulary and/or available for
dispensing by ANTHEM network
pharmacies unless otherwise
stipulated by state regulation.
3.COUNTY will inform COUNTY
providers regarding process and
procedure for obtaining prescribed
medications for Members.
4.COUNTY providers will utilize
ANTHEM contracted laboratories
for laboratory tests required for
medication administration and
management of psychotropic
medications.
5.COUNTY will assist ANTHEM in
the utilization review of
psychotropic drugs prescribed by
out-of-network psychiatrists.
6.COUNTY will share with ANTHEM
1.ANTHEM will:
a.Allow COUNTY credentialed
providers access to pharmacy and
laboratory services as specialty
providers.
b.Will make available a list of
participating pharmacies and
laboratories on the internet.
c.Will make available the formulary
and information regarding drug
formulary procedures on the internet.
d.Consider recommendations from
COUNTY for utilization management
standards for behavioral health
pharmacy and laboratory services.
e.Provide the process for obtaining
timely authorization and delivery of
prescribed drugs and laboratory
services to the COUNTY.
2.ANTHEM will coordinate with COUNTY to
ensure that covered psychotropic drugs
prescribed by COUNTY providers are
available through the authorization process
or formulary for dispensing by ANTHEM
network pharmacies unless otherwise
stipulated by state regulation. (See
Enclosure2, “Drugs Excluded from Plan
Coverage” of Exhibit B)
3.ANTHEM will apply utilization review
Revised Exhibit A
Page 14 of 25
a list of non-contracted
psychiatrist COUNTY providers
contracted to provide behavioral
health services in areas where
access to psychiatrists is limited,
on a quarterly basis.
procedures when prescriptions are written by
out-of-network psychiatrists for the treatment
of psychiatric conditions.
a.Covered psychotropic drugs written
by out-of-network psychiatrists will
be filled by ANTHEM network
pharmacies.
b.ANTHEM will provide Members with
the same drug accessibility written
by out-of-network psychiatrists as in-
network providers.
c.ANTHEM will not cover and pay for
behavioral health drugs written by
out-of-network physicians who are
not psychiatrists unless these
prescriptions are written by non-
psychiatrists contracted by the
COUNTY to provide behavioral
health services in areas where
access to psychiatrists is limited per
Exhibit B, attached hereto.
4.ANTHEM PCPs will monitor the effects and
side effects of psychotropic medications
prescribed for those members whose
psychiatric conditions are under their
treatment.
5.Reimbursement to pharmacies for new
psychotropic drugs classified as
antipsychotics and approved by the FDA will
be made through the Medi-Cal FFS system
whether these drugs are provided by a
pharmacy contracting with ANTHEM or by a
FFS pharmacy, per Enclosure 2 of this
Exhibit A, attached hereto and incorporated
herein.
L. Laboratory,
Radiological and
Radioisotope
Services
1.COUNTY or a Medi-Cal FFS
behavioral health services
provider needing laboratory,
radiological, or radioisotope
services for a Member when
necessary for the diagnosis,
treatment or monitoring of a
behavioral health condition will
utilize the list of ANTHEM contract
providers.
1.ANTHEM will cover and pay for medically
necessary laboratory, radiological and
radioisotope services when ordered by a
COUNTY or a Medi-Cal FFS behavioral
health services provider for the diagnosis,
treatment or monitoring of a behavioral
health condition (and side effects resulting
from medications prescribed to treat the
behavioral health diagnosis) as described in
Title 22, CCR Section 51311 and Exhibit B,
attached hereto.
2.ANTHEM will coordinate and assist the
COUNTY or Medi-Cal FFS behavioral health
provider in the delivery of laboratory
radiological or radioisotope services.
3.A list of ANTHEM contracted providers is
available on-line.
4.Provide the process for obtaining timely
authorization and delivery of prescribed
drugs and laboratory services.
Revised Exhibit A
Page 15 of 25
M. Grievances
and Complaints
1.COUNTY will share with ANTHEM
its established processes for the
submittal, processing and
resolution of all member and
provider grievances and
complaints regarding any aspect
of the behavioral health care
services in accordance with CFR
42 Part 438. These processes
include timelines/deadlines and
member information that must be
provided.
2.COUNTY and ANTHEM will work
collaboratively to resolve any
formal grievance or complaint
brought to the attention of either
plan.
1.ANTHEM has in place a written process for
the submittal, processing and resolution of all
member and provider grievances and
complaints which is inclusive of any aspect
of the health care services or provision of
services.
2.ANTHEM liaison will coordinate and share
the established complaint and grievance
process for its Members with the COUNTY
N. Appeal
Resolution
Process
1.COUNTY will ensure that the
Members and providers are given
an opportunity for reconsideration
and appeal for denied, modified or
delayed services.
2.COUNTY will ensure that the
Members receive specialty MH
and/or SUD services and
prescription drugs while the
dispute is being resolved.
3.COUNTY will identify and provide
ANTHEM with the name and
telephone number of a
psychiatrist or other qualified
licensed mental health
professional available to provide
clinical consultation, including
consultation on medications to
the ANTHEM provider
responsible for the
beneficiary’s care.
1.ANTHEM will ensure that Members and
providers are given an opportunity for
reconsideration and an appeal for denied,
modified or delayed services
2.ANTHEM will ensure that medically
necessary services continue to be provided
to Members while the dispute is being
resolved. ANTHEM’s appeal process will be
shared with the COUNTY.
3.ANTHEM will work with the licensed mental
health professional designated by COUNTY.
O.
Conflict
Resolution/MOU
Monitoring
1.COUNTY Liaison will meet with
the ANTHEM Liaison to monitor
this MOU quarterly and/or upon
request.
a.Within two weeks of a
formal request, COUNTY
Liaison will meet with
ANTHEM Liaison when
COUNTY or ANTHEM
management identifies
problems requiring
resolution through the
MOU.
b.COUNTY Liaison will be
responsible for
1.Local ANTHEM liaison will meet with the
COUNTY Liaison to monitor this MOU
quarterly and/or upon request.
a.Within two weeks of a formal
request, ANTHEM Liaison will meet
with the COUNTY Liaison when the
COUNTY or ANTHEM management
identifies problems requiring
resolution through the MOU.
b.ANTHEM Liaison will be responsible
for coordinating, assisting and
communicating suggestions for MOU
changes for to ANTHEM and the
COUNTY leadership.
c.ANTHEM will coordinate and
Revised Exhibit A
Page 16 of 25
coordinating, assisting
and communicating
suggestions for MOU
changes to the COUNTY
leadership and ANTHEM.
c.COUNTY Liaison will
communicate and
coordinate MOU changes
to the State Department
of Health Care Services
(DHCS), COUNTY
service providers and to
ANTHEM and its
providers.
2.COUNTY Liaison will participate
in an annual review, update
and/or renegotiations with
ANTHEM, as mutually agreed.
3.COUNTY management will
provide 60 days advance written
notice to ANTHEM should the
COUNTY decide to modify this
MOU. [Unless mandated by the
Department of Health Care
Services directives, state
mandated requirements and/or
Federal guidelines.]
communicate MOU changes to the
California Department of Health
Care Services (DHCS), COUNTY
providers and ANTHEM network
services providers.
d.ANTHEM Liaison will make a good
faith effort to agree to resolutions
that are in the best interest of
Members and are agreeable to all
parties involved.
2.ANTHEM Liaison will conduct an annual
review, update and/or renegotiations of this
MOU, as mutually agreed.
3.ANTHEM management will provide 60 day
advance written notice to COUNTY should
ANTHEM decide to modify this MOU.
P. Protected
Health
Information
1.COUNTY will comply with all
applicable laws pertaining to use and
disclosure of PHI including but not
limited to:
•HIPAA / 45 C.F.R. Parts 160 and
164
•LPS / W & I Code Sections 5328-
5328.15
•45 C.F.R. Part 2
•HITECH Act (42. U.S.C. Section
17921 et. seq.
•CMIA (Ca Civil Code 56 through
56.37)
2.COUNTY will train its workforce in
policies and procedures regarding
Protected Health Information (PHI) as
necessary and appropriate to perform
processes and functions within the
scope of duties under this MOU.
3. Only encrypted PHI as specified in
the HIPAA Security Rule will be
transmitted via email. Unsecured PHI
will not be transmitted via email.
4.COUNTY will notify ANTHEM within
24 hours during a work week of any
suspected or actual breach of
security, intrusion or unauthorized use
1.ANTHEM will comply with Confidentiality of
Medical Information Act [California Civil Code 56
through 56.37] the Patient Access to Health
Records Act (California Health and Safety Code
123100, et seq) and the Health Insurance
Portability and Accountability Act (Code of
Federal Regulations Title 45 Parts 160 and
164).
2.ANTHEM will train its workforce in policies
and procedures regarding Protected Health
Information (PHI) as necessary and appropriate
to perform processes and functions within the
scope of duties under this MOU.
3.ANTHEM will encrypt any data transmitted via
Electronic Mail (Email) containing confidential
data of Members such as PHI and Personal
Confidential Information (PCI) or other
confidential data to ANTHEM or anyone else
including state agencies.
4. ANTHEM will notify COUNTY within 24 hours
during a work week of any suspected or actual
breach of security, intrusion or unauthorized use
or disclosure of PHI and/or any actual or
suspected use or disclosure of data in violation
of any applicable Federal and State laws or
regulations.
Revised Exhibit A
Page 17 of 25
or disclosure of PHI and/or any actual
or suspected use of disclosure of data
in violation of any applicable Federal
and State laws and regulations.
Revised Exhibit A
Page 18 of 25
Enclosure 1a
Table 1 - Included ICD-10 Diagnoses - All Places of Services except Hospital Inpatient
F20.0-F29 F60.0-F60.1 F98.0-F98.4
F30.10-F30.9 F60.3-F68.13 G21.0-G25.9
F31.10-F39 F80.82-F80.9 R15.0-R69
F40.00-F45.1 F84.2-F84.9 Z03.89
F45.22-F50.9 F90.0-F94.1
Revised Exhibit A
Page 19 of 25
ATTACHMENT A
Medical Necessity For Specialty MH Services That Are The Responsibility Of MH Plan
Must have all, A, B and C:
A.Diagnoses
Must have one of the following DSM IV diagnoses, which will be the focus of the intervention being provided:
Included Diagnosis:
•Pervasive Development Disorders, except Autistic Disorder which is excluded.
•Attention Deficit and Disruptive Behavior Disorders
•Feeding & Eating Disorders of Infancy or Early Childhood
•Elimination Disorders
•Other Disorders of Infancy, Childhood or Adolescence
•Schizophrenia & Other Psychotic Disorder
•Mood Disorders
•Anxiety Disorders
•Somatoform Disorders
•Factitious Disorders
•Dissociative Disorders
•Paraphilias
•Gender Identify Disorders
•Eating Disorders
•Impulse-Control Disorders Not Elsewhere Classified
•Adjustment Disorders
•Personality Disorders, excluding Antisocial Personality Disorder
•Medication-Induced Movement Disorders (related to other
included diagnoses).
B.Impairment Criteria
Must have one of the following as a result of the mental disorder(s)
identified in the diagnostic (“A”) criteria; must have one, 1, 2 or 3:
1 A significant impairment in an important area of life
functioning, or
2 A probability of significant deterioration in an important
area of life functioning, or
3 Children also qualify if there is a probability the child will
not progress developmentally as individually appropriate.
Children covered under EPSDT qualify if they have a mental disorder which can be corrected or
ameliorated (current DHS EPSDT regulations also apply).
C.Intervention Related Criteria
Must have all, 1, 2 and 3 below:
1 The focus of proposed intervention is to address the condition identified in impairment criteria “B” above
and
2 It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the
impairment, or preventing significant deterioration in an important area of life functioning, and/or for
children it is probable the child will progress developmentally as individually appropriate (or if covered by
EPSDT can be corrected or ameliorated), and
3 The condition would not be responsive to physical health care based treatment.
EPSDT beneficiaries with an included diagnosis and a substance related disorder may receive specialty mental
health services directed at the substance use component. The intervention must be consistent with, and
necessary to the attainment of, the specialty MH treatment goals.
Excluded Diagnosis:
•Mental Retardation
•Learning Disorder
•Motor Skills Disorder
•Communications Disorders
•Autistic Disorder, Other Pervasive
Developmental Disorders are included.
•Tic Disorders
•Delirium, Dementia, and Amnestic and
Other Cognitive Disorders
•Mental Disorders Due to a General
Medical Condition
•Substance-Related Disorders
•Sexual Dysfunctions
•Sleep Disorders
•Antisocial Personality Disorder
•Other Conditions that may be a focus of
clinical attention, except Medication
induced Movement Disorders which are
included.
__________________________________
A beneficiary may receive services for an
included diagnosis when an excluded
diagnosis is also present.
SUD ICD 10 Analysis Included Codes
Revised Exhibit A
Page 20 of 25
ICD 10 Code ICD 10 Code Descriptions
F10.10 Alcohol abuse, uncomplicated
F10.11 Alcohol abuse, in remission
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.129 Alcohol abuse with intoxication, unspecified
F10.14 Alcohol Abuse With Alcohol-Induced Mood Disorder
F10.150 Alcohol Abuse With Alcohol-Induced Psychotic Disorder With Delusions
F10.151 Alcohol Abuse With Alcohol-Induced Psychotic Disorder With Hallucinations
F10.159 Alcohol abuse with alcohol-induced psychotic disorder, unspecified
F10.180 Alcohol Abuse With Alcohol-Induced Anxiety Disorder
F10.20 Alcohol dependence, uncomplicated
F10.21 Alcohol dependence, in remission
F10.220 Alcohol dependence with intoxication, uncomplicated
F10.229 Alcohol dependence with intoxication, unspecified
F10.230 Alcohol dependence with withdrawal, uncomplicated
F10.239 Alcohol dependence with withdrawal, unspecified
F10.24 Alcohol Dependence With Alcohol-Induced Mood Disorder
F10.250 Alcohol Dependence With Alcohol-Induced Psychotic Disorder With Delusions
F10.251 Alcohol Dependence With Alcohol-Induced Psychotic Disorder With Hallucinations
F10.259 Alcohol dependence with alcohol-induced psychotic disorder, unspecified
F10.280 Alcohol Dependence With Alcohol-Induced Anxiety Disorder
F10.920 Alcohol use, unspecified with intoxication, uncomplicated
F10.929 Alcohol use, unspecified with intoxication, unspecified
F10.94 Alcohol Use, Unspecified, With Alcohol-Induced Mood Disorder
F10.950 Alcohol Use, Unspecified, With Alcohol-Induced Psychotic Disorder With Delusions
F10.951 Alcohol Use, Unspecified, With Alcohol-Induced Psychotic Disorder With Hallucinations
F10.959 Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified
F10.980 Alcohol use, unspecified with alcohol-induced anxiety disorder
F11.10 Opioid abuse, uncomplicated
F11.11 Opioid abuse, in remission
F11.120 Opioid abuse with intoxication, uncomplicated
F11.129 Opioid abuse with intoxication, unspecified
F11.14 Opioid Abuse With Opioid-Induced Mood Disorder
F11.150 Opioid Abuse With Opioid-Induced Psychotic Disorder With Delusions
F11.151 Opioid Abuse With Opioid-Induced Psychotic Disorder With Hallucinations
F11.159 Opioid abuse with opioid-induced psychotic disorder, unspecified
F11.20 Opioid dependence, uncomplicated
F11.21 Opioid dependence, in remission
F11.220 Opioid dependence with intoxication, uncomplicated
F11.229 Opioid dependence with intoxication, unspecified
F11.23 Opioid dependence with withdrawal
F11.24 Opioid Dependence With Opioid-Induced Mood Disorder
F11.250 Opioid Dependence With Opioid-Induced Psychotic Disorder With Delusions
F11.251 Opioid Dependence With Opioid-Induced Psychotic Disorder With Hallucinations
F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified
F11.90 Opioid use, unspecified, uncomplicated
F11.920 Opioid use, unspecified with intoxication, uncomplicated
Page 1 of 6
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 21 of 25
ICD 10 Code ICD 10 Code Descriptions
F11.929 Opioid use, unspecified with intoxication, unspecified
F11.93 Opioid use, unspecified with withdrawal
F11.94 Opioid Use, Unspecified, With Opioid-Induced Mood Disorder
F11.950 Opioid Use, Unspecified, With Opioid-Induced Psychotic Disorder With Delusions
F11.951 Opioid Use, Unspecified, With Opioid-Induced Psychotic Disorder With Hallucinations
F11.959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified
F11.988 Opioid-Induced Anxiety Disorder Without Opioid Use Disorder
F12.10 Cannabis abuse, uncomplicated
F12.11 Cannabis abuse, in remission
F12.120 Cannabis abuse with intoxication, uncomplicated
F12.129 Cannabis abuse with intoxication, unspecified
F12.150 Cannabis Abuse With Psychotic Disorder With Delusions
F12.151 Cannabis Abuse With Cannabis-Induced Psychotic Disorder With Hallucinations
F12.159 Cannabis abuse with psychotic disorder, unspecified
F12.180 Cannabis Abuse With Cannabis-Induced Anxiety Disorder
F12.20 Cannabis dependence, uncomplicated
F12.21 Cannabis dependence, in remission
F12.220 Cannabis dependence with intoxication, uncomplicated
F12.229 Cannabis dependence with intoxication, unspecified
F12.23 Cannabis dependence with withdrawal
F12.250 Cannabis Dependence With Psychotic Disorder With Delusions
F12.251 Cannabis Dependence With Cannabis-Induced Psychotic Disorder With Hallucinations
F12.259 Cannabis dependence with psychotic disorder, unspecified
F12.280 Cannabis Dependence With Cannabis-Induced Anxiety Disorder
F12.90 Cannabis use, unspecified, uncomplicated
F12.920 Cannabis use, unspecified with intoxication, uncomplicated
F12.929 Cannabis use, unspecified with intoxication, unspecified
F12.93 Cannabis use, unspecified with withdrawal
F12.950 Cannabis Use, Unspecified, With Psychotic Disorder With Delusions
F12.951 Cannabis Use, Unspecified, With Cannabis-Induced Psychotic Disorder With Hallucinations
F12.959 Cannabis use, unspecified with psychotic disorder, unspecified
F12.980 Cannabis Use, Unspecified, With Cannabis-Induced Anxiety Disorder
F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated
F13.11 Sedative, hypnotic or anxiolytic abuse, in remission
F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated
F13.129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified
F13.14 Sedative, Hypnotic or Anxiolytic Abuse with Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
F13.150 Sedative, Hypnotic, or Anxiolytic Abuse with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder With
F13.151 Sedative, Hypnotic, or Anxiolytic Abuse With Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder With
F13.159 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder,
F13.180 Sedative, Hypnotic or Anxiolytic Abuse With Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder
F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated
F13.21 Sedative, hypnotic or anxiolytic dependence, in remission
F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated
F13.229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified
F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated
Page 2 of 6
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 22 of 25
ICD 10 Code ICD 10 Code Descriptions
F13.239 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified
F13.24 Sedative, Hypnotic or Anxiolytic Dependence With Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
F13.250 Sedative, Hypnotic, or Anxiolytic Dependence With Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.251 Sedative, Hypnotic, or Anxiolytic Dependence With Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder,
F13.280 Sedative, Hypnotic or Anxiolytic Dependence With Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety Disorder
F13.90 Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated
F13.920 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, uncomplicated
F13.921 Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium
F13.929 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, unspecified
F13.930 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, uncomplicated
F13.939 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, unspecified
F13.94 Sedative, Hypnotic or Anxiolytic Use, Unspecified, With Sedative-, Hypnotic-, or Anxiolytic-Induced Mood
F13.950 Sedative, Hypnotic, or Anxiolytic Use, Unspecified, With Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.951 Sedative, Hypnotic, or Anxiolytic Use, Unspecified, With Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.959 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic
F13.980 Sedative, Hypnotic or Anxiolytic Use, Unspecified, With Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety
F14.10 Cocaine abuse, uncomplicated
F14.11 Cocaine abuse, in remission
F14.120 Cocaine abuse with intoxication, uncomplicated
F14.129 Cocaine abuse with intoxication, unspecified
F14.14 Cocaine Abuse With Cocaine-Induced Mood Disorder
F14.150 Cocaine Abuse With Cocaine-Induced Psychotic Disorder With Delusions
F14.151 Cocaine Abuse With Cocaine-Induced Psychotic Disorder With Hallucinations
F14.159 Cocaine abuse with cocaine-induced psychotic disorder, unspecified
F14.180 Cocaine Abuse With Cocaine-Induced Anxiety Disorder
F14.20 Cocaine dependence, uncomplicated
F14.21 Cocaine dependence, in remission
F14.220 Cocaine dependence with intoxication, uncomplicated
F14.229 Cocaine dependence with intoxication, unspecified
F14.23 Cocaine dependence with withdrawal
F14.24 Cocaine Dependence With Cocaine-Induced Mood Disorder
F14.250 Cocaine Dependence With Cocaine-Induced Psychotic Disorder With Delusions
F14.251 Cocaine Dependence With Cocaine-Induced Psychotic Disorder With Hallucinations
F14.259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified
F14.280 Cocaine Dependence With Cocaine-Induced Anxiety Disorder
F14.90 Cocaine use, unspecified, uncomplicated
F14.920 Cocaine use, unspecified with intoxication, uncomplicated
F14.929 Cocaine use, unspecified with intoxication, unspecified
F14.94 Cocaine Use, Unspecified, With Cocaine-Induced Mood Disorder
F14.950 Cocaine Use, Unspecified, With Cocaine-Induced Psychotic Disorder With Delusions
F14.951 Cocaine Use, Unspecified, With Cocaine-Induced Psychotic Disorder With Hallucinations
F14.959 Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified
F14.980 Cocaine Use, Unspecified, With Cocaine-Induced Anxiety Disorder
F15.10 Other stimulant abuse, uncomplicated
F15.11 Other stimulant abuse, in remission
Page 3 of 6
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 23 of 25
ICD 10 Code ICD 10 Code Descriptions
F15.120 Other stimulant abuse with intoxication, uncomplicated
F15.129 Other stimulant abuse with intoxication, unspecified
F15.14 Other Stimulant Abuse With Stimulant-Induced Mood Disorder
F15.150 Other Stimulant Abuse With Stimulant-Induced Psychotic Disorder With Delusions
F15.151 Other Stimulant Abuse With Stimulant-Induced Psychotic Disorder With Hallucinations
F15.159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified
F15.180 Other Stimulant Abuse With Stimulant-Induced Anxiety Disorder
F15.20 Other stimulant dependence, uncomplicated
F15.21 Other stimulant dependence, in remission
F15.220 Other stimulant dependence with intoxication, uncomplicated
F15.229 Other stimulant dependence with intoxication, unspecified
F15.23 Other stimulant dependence with withdrawal
F15.24 Other Stimulant Dependence With Stimulant-Induced Mood Disorder
F15.250 Other Stimulant Dependence With Stimulant-Induced Psychotic Disorder With Delusions
F15.251 Other Stimulant Dependence With Stimulant-Induced Psychotic Disorder With Hallucinations
F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified
F15.280 Other Stimulant Dependence With Stimulant-Induced Anxiety Disorder
F15.90 Other stimulant use, unspecified, uncomplicated
F15.920 Other stimulant use, unspecified with intoxication, uncomplicated
F15.929 Other stimulant use, unspecified with intoxication, unspecified
F15.93 Other stimulant use, unspecified with withdrawal
F15.94 Other Stimulant Use, Unspecified, With Stimulant-Induced Mood Disorder
F15.950 Other Stimulant Use, Unspecified, With Stimulant-Induced Psychotic Disorder With Delusions
F15.951 Other Stimulant Use, Unspecified, With Stimulant-Induced Psychotic Disorder With Hallucinations
F15.959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified
F15.980 Other Stimulant Use, Unspecified, With Stimulant-Induced Anxiety Disorder
F16.10 Hallucinogen abuse, uncomplicated
F16.11 Hallucinogen abuse, in remission
F16.120 Hallucinogen abuse with intoxication, uncomplicated
F16.129 Hallucinogen abuse with intoxication, unspecified
F16.14 Hallucinogen Abuse With Hallucinogen-Induced Mood Disorder
F16.150 Hallucinogen Abuse With Hallucinogen-Induced Psychotic Disorder With Delusions
F16.151 Hallucinogen Abuse With Hallucinogen-Induced Psychotic Disorder With Hallucinations
F16.159 Hallucinogen abuse with hallucinogen-induced psychotic disorder, unspecified
F16.180 Hallucinogen Abuse With Hallucinogen-Induced Anxiety Disorder
F16.183 Hallucinogen Abuse With Hallucinogen Persisting Perception Disorder (Flashbacks)
F16.20 Hallucinogen dependence, uncomplicated
F16.21 Hallucinogen dependence, in remission
F16.220 Hallucinogen dependence with intoxication, uncomplicated
F16.229 Hallucinogen dependence with intoxication, unspecified
F16.24 Hallucinogen Dependence With Hallucinogen-Induced Mood Disorder
F16.250 Hallucinogen Dependence With Hallucinogen-Induced Psychotic Disorder With Delusions
F16.251 Hallucinogen Dependence With Hallucinogen-Induced Psychotic Disorder With Hallucinations
F16.259 Hallucinogen dependence with hallucinogen-induced psychotic disorder, unspecified
F16.280 Hallucinogen Dependence With Hallucinogen-Induced Anxiety Disorder
F16.283 Hallucinogen Dependence With Hallucinogen Persisting Perception Disorder (Flashbacks)
Page 4 of 6
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 24 of 25
ICD 10 Code ICD 10 Code Descriptions
F16.90 Hallucinogen use, unspecified, uncomplicated
F16.920 Hallucinogen use, unspecified with intoxication, uncomplicated
F16.929 Hallucinogen use, unspecified with intoxication, unspecified
F16.94 Hallucinogen Use, Unspecified, With Hallucinogen-Induced Mood Disorder
F16.950 Hallucinogen Use, Unspecified, With Hallucinogen-Induced Psychotic Disorder With Delusions
F16.951 Hallucinogen Use, Unspecified, With Hallucinogen-Induced Psychotic Disorder With Hallucinations
F16.959 Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder, unspecified
F16.980 Hallucinogen Use, Unspecified, With Hallucinogen-Induced Anxiety Disorder
F16.983 Hallucinogen Use, Unspecified, With Hallucinogen Persisting Perception Disorder (Flashbacks)
F18.10 Inhalant abuse, uncomplicated
F18.11 Inhalant abuse, in remission
F18.120 Inhalant abuse with intoxication, uncomplicated
F18.129 Inhalant abuse with intoxication, unspecified
F18.14 Inhalant Abuse With Inhalant-Induced Mood Disorder
F18.150 Inhalant Abuse With Inhalant-Induced Psychotic Disorder With Delusions
F18.151 Inhalant Abuse With Inhalant-Induced Psychotic Disorder With Hallucinations
F18.159 Inhalant abuse with inhalant-induced psychotic disorder, unspecified
F18.180 Inhalant Abuse With Inhalant-Induced Anxiety Disorder
F18.20 Inhalant dependence, uncomplicated
F18.21 Inhalant dependence, in remission
F18.220 Inhalant dependence with intoxication, uncomplicated
F18.229 Inhalant dependence with intoxication, unspecified
F18.24 Inhalant Dependence With Inhalant-Induced Mood Disorder
F18.250 Inhalant Dependence With Inhalant-Induced Psychotic Disorder With Delusions
F18.251 Inhalant Dependence With Inhalant-Induced Psychotic Disorder With Hallucinations
F18.259 Inhalant dependence with inhalant-induced psychotic disorder, unspecified
F18.280 Inhalant Dependence With Inhalant-Induced Anxiety Disorder
F18.90 Inhalant use, unspecified, uncomplicated
F18.920 Inhalant use, unspecified with intoxication, uncomplicated
F18.929 Inhalant use, unspecified with intoxication, unspecified
F18.94 Inhalant Use, Unspecified, With Inhalant-Induced Mood Disorder
F18.950 Inhalant Use, Unspecified, With Inhalant-Induced Psychotic Disorder With Delusions
F18.951 Inhalant Use, Unspecified, With Inhalant-Induced Psychotic Disorder With Hallucinations
F18.959 Inhalant use, unspecified with inhalant-induced psychotic disorder, unspecified
F18.980 Inhalant Use, Unspecified, With Inhalant-Induced Anxiety Disorder
F19.10 Other psychoactive substance abuse, uncomplicated
F19.11 Other psychoactive substance abuse, in remission
F19.120 Other psychoactive substance abuse with intoxication, uncomplicated
F19.129 Other psychoactive substance abuse with intoxication, unspecified
F19.14 Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Mood Disorder
F19.150 Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder With Delusions
F19.151
Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder With
Hallucinations
F19.159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecified
F19.180 Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Anxiety Disorder
Page 5 of 6
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 25 of 25
ICD 10 Code ICD 10 Code Descriptions
F19.20 Other psychoactive substance dependence, uncomplicated
F19.21 Other psychoactive substance dependence, in remission
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.229 Other psychoactive substance dependence with intoxication, unspecified
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.239 Other psychoactive substance dependence with withdrawal, unspecified
F19.24 Other Psychoactive Substance Dependence With Psychoactive Substance-Induced Mood Disorder
F19.250
Other Psychoactive Substance Dependence With Psychoactive Substance-Induced Psychotic Disorder With
Delusions
F19.251
Other Psychoactive Substance Dependence With Psychoactive Substance-Induced Psychotic Disorder With
Hallucinations
F19.259 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder, unspecified
F19.280 Other Psychoactive Substance Dependence With Psychoactive Substance-Induced Anxiety Disorder
F19.90 Other psychoactive substance use, unspecified, uncomplicated
F19.920 Other psychoactive substance use, unspecified with intoxication, uncomplicated
F19.929 Other psychoactive substance use, unspecified with intoxication, unspecified
F19.930 Other psychoactive substance use, unspecified with withdrawal, uncomplicated
F19.939 Other psychoactive substance use, unspecified with withdrawal, unspecified
F19.94 Other Psychoactive Substance Use, Unspecified, With Psychoactive Substance-Induced Mood Disorder
F19.950
Other Psychoactive Substance Use, Unspecified, With Psychoactive Substance-Induced Psychotic Disorder With
Delusions
F19.951
Other Psychoactive Substance Use, Unspecified, With Psychoactive Substance-Induced Psychotic Disorder With
Hallucinations
F19.959
Other psychoactive substance use, Unspecified with psychoactive substance-induced psychotic disorder,
unspecified
F19.980 Other Psychoactive Substance Use, Unspecified, With Psychoactive Substance-Induced Anxiety Disorder
Page 6 of 6