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HomeMy WebLinkAboutAgreement A-18-361-1 with CalViva Health.pdf-1 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AMENDMENT I TO AGREEMENT THIS AMENDMENT I TO AGREEMENT (hereinafter “Amendment”) is made and entered into this _____ day of ___________, 2021, by and between COUNTY OF FRESNO, a Political Subdivision of the State of California, Fresno, California (hereinafter “COUNTY”), and the Fresno-Kings-Madera Regional Health Authority (RHA), a California Joint Powers Authority and Medi-Cal Managed Care Plan dba CalViva Health, whose address is 7625 N. Palm avenue, Suite 109, Fresno, California 93711 (hereinafter “CALVIVA HEALTH”). WITNESSETH: WHEREAS, COUNTY and CALVIVA HEALTH entered into Agreement number 18-361, dated July 10th, 2018 (hereinafter “Agreement”), pursuant to which COUNTY and CALVIVA HEALTH 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 CALVIA HEALTH 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 CALVIVA HEALTH 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 nine (9), line eight (8) as follows: “10. INSURANCE Each party shall insure its activities in connection with this Agreement and maintain at all times 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.” Agreement No. 18-361-1 8th June -2 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3.That section twelve (12) NON-DISCRIMINATION of the Agreement, located on page nine (9), beginning on line twelve (12) through line seventeen (17), is deleted in its entirety and replaced with the following: “12. NON-DISCRIMINATION During the performance of this Agreement, COUNTY and CALVIVA HEALTH 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 -3 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 handwritten signature. COUNTY and CALVIVA HEALTH agree that this Amendment is sufficient to amend the Agreement and, 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. // // // // // // // 1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I as of the day and 2 year first hereinabove written. 3 CALVIVA HEALTH: FRESNO,~NGS,MADERA 4 REGIONAL HEAL TH AUTHORITY 5 dba CAL IVA HEALTl:I 6 lr-:77"':..,....~~----=-::--------- 7 8 9 10 11 12 13 14 15 16 17 18 FOR ACCOUNTING USE ONLY: 19 ORG No .: 56302666 ($0) Account No.: 7295 ($0) 20 Fund/Subclass: 0001/10000 21 22 23 24 25 26 27 28 COUNTY OF FRESNO Steve Brandau , Cha 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 -4- Revised Exhibit A Page 1 of 32 MEMORANDUM OF UNDERSTANDING (MOU) DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY) AND CALVIVA HEALTH CATEGORY COUNTY CALVIVA HEALTH A. Liaison 1.COUNTY’s Administrative Staff is the liaison to coordinate activities with CALVIVA HEALTH and to notify COUNTY providers and relevant staff of their roles and responsibilities 2.COUNTY Liaison will provide CALVIVA HEALTH with an updated list of approved COUNTY providers, specialists and behavioral health care centers in the county. 3.Information for mental health 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 is also available on the COUNTY’s Substance Use Disorders Services Webpage and is updated at a minimum on a 30 day basis. 1.CALVIVA HEALTH has a liaison that coordinates activities with the COUNTY and COUNTY Liaison. 2.The Liaison will notify CALVIVA HEALTH staff and CALVIVA HEALTH providers of their responsibilities to coordinate services with the COUNTY. 3.A printable downloadable CALVIVA HEALTH Provider Directory is available on line and updated at a minimum on a monthly basis. CALVIVA HEALTH also maintains an online searchable provider directory that is updated at least weekly. 4. The CALVIVA HEALTH 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 mental health services 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, 1.CALVIVA HEALTH will utilize the COUNTY to identify COUNTY providers who are willing to accept Medi-Cal fee for service reimbursement to provide services for mental health 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.CALVIVA HEALTH 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 Substance Use Disorder services, CALVIVA HEALTH will screen and offer brief intervention. For clients who appear to need further assessment and more Revised Exhibit A Page 2 of 32 CATEGORY COUNTY CALVIVA HEALTH attached hereto. 3.For Substance Use Disorder, COUNTY will provide a centralized intake function that will screen clients using the ASAM criteria and determine a presumptive level of 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 CALVIVA HEALTH in arranging for a specific COUNTY provider or community service. 5.COUNTY will assist CALVIVA HEALTH to develop and update a list of providers or provider organizations to be made available to Members. For mental health services this list is available on the COUNTY’s managed care website. Any updates to the list will be forwarded to the CALVIVA HEALTH liaison quarterly and upon request. For Substance Use Disorder services, this list is available on the COUNTY’s Substance Use Disorder Services Webpage. Any updates to the list will be forwarded to the CALVIVA HEALTH liaison quarterly and upon request. intensive services, a referral to COUNTY centralized intake or a provider on the list will be required. 4.CALVIVA HEALTH 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 CALVIVA HEALTH 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 1.CALVIVA HEALTH and contracted providers are allowed to release medical information under HIPAA regulations specific to the HIPPA Privacy Rule (45 C.F.R. Part Revised Exhibit A Page 3 of 32 CATEGORY COUNTY CALVIVA HEALTH 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) 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 mental health and Substance Use Disorder services for Members who meet the medical necessity criteria as identified in Exhibit B, attached hereto. 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 mental health and Substance Use Disorder 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 1.CALVIVA HEALTH 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 CALVIVA HEALTH contract with Department of Health Care Services (DHCS). 2.PCP will refer to the COUNTY for assessment and appropriate services. PCP’s 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 (mental health services only), counseling (mental health 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 Revised Exhibit A Page 4 of 32 CATEGORY COUNTY CALVIVA HEALTH resources. c.Consultation and training services to PCPs, particularly related to specialty mental health and Substance Use Disorder 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 mental health 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 Substance Use Disorder 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 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 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 Mental Health 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.CALVIVA HEALTH 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 mental health medical necessity, CALVIVA HEALTH and PCP will be responsible for coordinating a referral in accordance with Category B2 “Mental Health Services” or an CALVIVA HEALTH contracted provider. 7.When the member meets Substance Use Disorder medical necessity for COUNTY contracted services, CALVIVA HEALTH 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 appropriate. Revised Exhibit A Page 5 of 32 CATEGORY COUNTY CALVIVA HEALTH responsive to appropriate physical health care. 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 mental health 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 Substance Use Disorder 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 CALVIVA HEALTH. 3.COUNTY will make training available for community based physicians interested in providing Medically Assisted Treatment (MAT) services, including an eight hour Buprenorphine Waiver Training required to become a community based MAT provider. 1.CALVIVA HEALTH must cover and pay for medically necessary laboratory, radiological, and radioisotope services described in Title 22, CCR, Section 51311. CALVIVA HEALTH will cover and pay for related services for Electroconvulsive Therapy (ECT), anesthesiologist services provided on an outpatient basis, per Exhibit B, attached hereto. 2.CALVIVA HEALTH 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.CALVIVA HEALTH 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.CALVIVA HEALTH will provide Substance Use Disorder 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.CALVIVA HEALTH will provide Substance Use Disorder treatment for Members who meet medical necessity for Medically Managed Intensive Inpatient Revised Exhibit A Page 6 of 32 CATEGORY COUNTY CALVIVA HEALTH Services (ASAM Level 4.0) which includes 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.CALVIVA HEALTH will provide Substance Use Disorder 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.CALVIVA HEALTH will provide Substance Use Disorder 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 CALVIVA HEALTH will refer to a lower level of care to increase the likelihood of successful recovery. 8.CALVIVA HEALTH will prescribe, dose and/or refer Members with an Opioid Use Disorder to Medication Assisted Treatment (MAT) when appropriate. CALVIVA 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.CALVIVA HEALTH shall coordinate with COUNTY Narcotic Treatment Program 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 1.CALVIVA HEALTH will maintain a 24 hour member service and Nurse Advice Line. 2.CALVIVA HEALTH shall cover and pay Revised Exhibit A Page 7 of 32 CATEGORY COUNTY CALVIVA HEALTH 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 necessity criteria when such services and care do result in the admission of the Member for psychiatric and/or Substance Use Disorder 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 Substance Use Disorder inpatient hospital services at that facility or any other facility, per Exhibit B, attached hereto. 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.CALVIVA HEALTH 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 Substance Use Disorder inpatient hospital services or when such services result in an admission of the member for psychiatric and/or Substance Use Disorder inpatient hospital services at a different facility. 4.CALVIVA HEALTH 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 Substance Use Disorder 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 CALVIVA. E2. Home Health Agency Services 1.COUNTY shall cover and pay for medication support services, case management, crisis intervention services, or any other specialty mental health services as provided under Section 1810.247, which are prescribed by a psychiatrist and are provided to a Member who 1.CALVIVA HEALTH will cover and pay for prior authorized home health agency services as described in Title 22, CCR, Section 51337 prescribed by an CALVIVA HEALTH provider when medically necessary to meet the needs of homebound Members. CALVIVA HEALTH is not obligated to provide home health agency services that would not Revised Exhibit A Page 8 of 32 CATEGORY COUNTY CALVIVA HEALTH is homebound. COUNTY will collaborate with CALVIVA HEALTH on any specialty mental health services being provided to a Member. otherwise be authorized by the Medi-Cal program. 2.CALVIVA HEALTH will refer Members who may be at risk of institutional placement to the Home and Community Based services (HCBS) Waiver Program (CALVIVA/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 mental health services, typically visits by psychiatrists and psychologists. 1.CALVIVA HEALTH 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.CALVIVA HEALTH will arrange for disenrollment from managed care if Member needs nursing services for a longer period of time. 3.CALVIVA HEALTH will pay for all medically necessary DHCS contractually required Medi-Cal covered services until the disenrollment is effective. E4. Emergency Transportation, Non-Emergency Medical Transportation (NEMT and Non- Medical Transportation (NMT) 1.Medical transportation services as described in Title 22, Section 51323 are not the responsibility of 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. 1.CALVIVA HEALTH will arrange and pay for transportation of Members needing medical transportation from: 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.CALVIVA HEALTH 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 Revised Exhibit A Page 9 of 32 CATEGORY COUNTY CALVIVA HEALTH 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.CALVIVA HEALTH will cover all nonemergency medical transportation, necessary to obtain program covered services. A completed, signed CALVIVA HEALTH Physician Certification Statement (PCS) Form must be submitted to CALVIVAHEALTH for the NEMT services to be arranged. 6.CALVIVA HEALTH 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 a PCS is submitted. 7.CALVIVA HEALTH will maintain a policy of non-discrimination regarding Members with behavioral health disorders who require access to any other transportation services provided by CALVIVA. 8.CALVIVA HEALTH shall/will provide Non- Medical Transport (NMT) for all Medi-Cal services including services not covered by the CALVIVA HEALTH contract. These services include but are not limited to; Specialty Mental Health, Substance Use Disorder, dental and any other benefits delivered through the Medi-Cal delivery system. 9.NMT does not include transportation of the sick, injured, invalid, convalescent, infirm or otherwise incapacitated members who need to be transported by ambulance, litter vans, or wheelchair vans Revised Exhibit A Page 10 of 32 CATEGORY COUNTY CALVIVA HEALTH licensed, operated and equipped in accordance with the State and Local statutes, ordinance, or regulations. Physicians may authorize NMT for members if they are currently using a wheelchair but the limitation is such that the member is able to ambulate without assistance from the driver. The NMT requested must be the least costly method of transportation that meets the member’s needs. 10.CALVIVA HEALTH may use prior authorization processes for NMT services. The member’s needs for NMT or NEMT services do not relieve CALVIVA HEALTH from complying with their timely access standards obligation. 11.CALVIVA HEALTH will assure that Substance Use Disorder 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 a PCS is submitted. 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.CALVIVA HEALTH 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.CALVIVA HEALTH will maintain a current MOU with Central Valley Regional Center Revised Exhibit A Page 11 of 32 CATEGORY COUNTY CALVIVA HEALTH E6. History and Physical for Psychiatric Hospital Admission 1.COUNTY will utilize CALVIVA HEALTH network providers to perform medical histories and physical examinations required for behavioral health examinations required for behavioral health and psychiatric hospital admissions for CALVIVA HEALTH members. 1.CALVIVA HEALTH 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.CALVIVA HEALTH is responsible for separately billable outpatient services related to electroconvulsive therapy, such as anesthesiologist services, per Exhibit B, attached hereto. 2.CALVIVA HEALTH will cover and pay for professional services and associated room charges for hospital outpatient department services consistent with medical necessity and CALVIVA‘s contract with its contractors and DHCS, per Exhibit B, attached hereto. F. Diagnostic Assessment and Triage 3.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 CALVIVA. 4.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. 1.CALVIVA HEALTH will provide Members with Substance Use Disorder screenings, brief intervention (SBIRT), referral and assessment. If it is found that a Member preliminarily meets medical necessity for COUNTY provided services CALVIVA HEALTH 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.CALVIVA HEALTH will arrange and pay for assessments of CALVIVA HEALTH members by PCPs to: a.Rule out general medical conditions causing psychiatric and/or Substance Use Disorder 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 Revised Exhibit A Page 12 of 32 CATEGORY COUNTY CALVIVA HEALTH 5.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. 6.COUNTY provider assessments will: c. Determine if Member meets medical necessity criteria (See Attachment B, attached hereto and incorporated herein by reference.) d.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 mental health care. e.Identify stability level, if the result is needed to determine appropriateness for specialty mental health services. exacerbating psychiatric and/or Substance Use Disorder 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 CALVIVA HEALTH will cover and pay for physician services provided by specialists such as neurologists, per Exhibit B, attached hereto. G. Referrals 1.COUNTY will accept referrals from CALVIVA HEALTH staff and providers. CALVIVA HEALTH providers and Members will be referred to determine medical necessity for specialty mental health services. For Substance Use Disorder members, screening 1.Following the PCP assessment, CALVIVA HEALTH staff and/or PCP will refer those Members whose psychiatric condition or Substance Use Disorder would not be responsive to physical health care to the COUNTY to determine if specialty mental health and/or Substance Use Disorder services medical necessity criteria are met. Revised Exhibit A Page 13 of 32 CATEGORY COUNTY CALVIVA HEALTH 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 CALVIVA HEALTH 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 mental health and/or Substance Use Disorder 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 CALVIVA HEALTH 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 CALVIVA HEALTH 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 2.CALVIVA HEALTH 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.CALVIVA HEALTH 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 CALVIVA HEALTH to appropriate community resources for assistance in identifying programs available for low income Medi-Cal beneficiaries. Revised Exhibit A Page 14 of 32 CATEGORY COUNTY CALVIVA HEALTH behavioral health services the COUNTY will designate a process or entity to receive notice of actions, denials, or deferrals from CALVIVA HEALTH, 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 mental health services, COUNTY will authorize assessment and/or treatment services by COUNTY providers who are credentialed and contracted with COUNTY for services that meet specialty mental health services medical necessity criteria. 2. For Substance Use Disorder 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 Substance Use Disorder services that meet medical necessity criteria. 1.CALVIVA HEALTH will authorize medical assessment and/or treatment services by CALVIVA HEALTH network providers who are credentialed and contracted with CALVIVA HEALTH for covered medically necessary services. 2.CALVIVA HEALTH 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 CALVIVA HEALTH PCP providers as it relates to specialty mental 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 Revised Exhibit A Page 15 of 32 CATEGORY COUNTY CALVIVA HEALTH health and/or Substance Use Disorder 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 CALVIVA HEALTH PCPs, other behavioral health providers and/or CALVIVA HEALTH staff on the following topics: a. Recommended physical 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 C.F.R. Part 164. 2.For those Members who meet COUNTY medical necessity criteria and whose psychiatric symptoms and/or Substance Use Disorder will be treated by a COUNTY provider, CALVIVA HEALTH and/or PCP will provide consultation to COUNTY providers and/or COUNTY staff on the following topics: a.Acquiring access to covered CALVIVA HEALTH 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 with medications prescribed by PCP not commonly used in psychiatric or Substance Use Disorder specialty practice. Revised Exhibit A Page 16 of 32 CATEGORY COUNTY CALVIVA HEALTH behavioral health services that are within the CALVIVA HEALTH PCP’s scope of practice. 3.For those Members who are excluded from COUNTY services, COUNTY will provide clinical consultation and training to the CALVIVA HEALTH PCPs, and/or CALVIVA HEALTH 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 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. 2.When EPSDT supplemental criteria are met, COUNTY is responsible for arranging and paying for EPSDT supplemental services provided by COUNTY specialty mental health and Substance Use Disorder providers. 3.When EPSDT supplemental criteria are not met, COUNTY will refer Member children as follows: a.For mental health services, Referral to California Children’s Services (CCS)- for those children who have 1.When CALVIVA HEALTH determines that EPSDT supplemental services criteria are not met and the Member child’s condition is not CCS eligible, CALVIVA HEALTH 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 linked program will be made for treatment of conditions outside the PCP’s scope of practice. CALVIVA HEALTH will assist the COUNTY and Members by providing links to known community providers of supplemental services. 3.CALVIVA HEALTH 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. Revised Exhibit A Page 17 of 32 CATEGORY COUNTY CALVIVA HEALTH a CCS medically eligible condition and require behavioral health provider services related to the eligible condition b. For Substance Use Disorder 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 CALVIVA HEALTH of the referral. 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 CALVIVA HEALTH representatives to ensure that psychotropic drugs prescribed by COUNTY providers are included in the CALVIVA HEALTH formulary and/or available for dispensing by CALVIVA HEALTH 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 CALVIVA HEALTH contracted laboratories for laboratory tests required for medication administration and management of psychotropic medications. 5.COUNTY will assist CALVIVA HEALTH in the utilization review of psychotropic drugs prescribed by out-of-network 1.CALVIVA HEALTH 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.CALVIVA HEALTH 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 CALVIVA HEALTH network pharmacies unless otherwise stipulated by state regulation. (See Enclosure2, “Drugs Excluded from Plan Coverage” of Exhibit B) 3.CALVIVA HEALTH will apply utilization Revised Exhibit A Page 18 of 32 CATEGORY COUNTY CALVIVA HEALTH psychiatrists. 6.COUNTY will share with CALVIVA HEALTH 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. review 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 CALVIVA HEALTH network pharmacies. b.CALVIVA HEALTH will provide Members with the same drug accessibility written by out-of- network psychiatrists as in- network providers. c.CALVIVA HEALTH 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.CALVIVA HEALTH 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 CALVIVA HEALTH 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 CALVIVA HEALTH contract providers. 1.CALVIVA HEALTH 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 Revised Exhibit A Page 19 of 32 CATEGORY COUNTY CALVIVA HEALTH in Title 22, CCR Section 51311 and Exhibit B, attached hereto. 2.CALVIVA HEALTH 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 CALVIVA HEALTH contracted providers is available on-line. 4.Provide the process for obtaining timely authorization and delivery of prescribed drugs and laboratory services. M. Grievances and Complaints 1.COUNTY will share with CALVIVA HEALTH 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 CALVIVA HEALTH will work collaboratively to resolve any formal grievance or complaint brought to the attention of either plan. 1.CALVIVA HEALTH 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.CALVIVA HEALTH 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 mental health and/or Substance Use Disorder services and prescription drugs while the dispute is being resolved. 3.COUNTY will identify and provide CalViva Health with the name and telephone number of 1.CALVIVA HEALTH will ensure that Members and providers are given an opportunity for reconsideration and an appeal for denied, modified or delayed services 2.CALVIVA HEALTH will ensure that medically necessary services continue to be provided to Members while the dispute is being resolved. CALVIVA’s appeal process will be shared with the COUNTY. 3.CalViva Health will work with the licensed mental health professional designated by COUNTY. Revised Exhibit A Page 20 of 32 CATEGORY COUNTY CALVIVA HEALTH a psychiatrist or other qualified licensed mental health professional available to provide clinical consultation, including consultation on medications to the CalViva Health provider responsible for the beneficiary’s care. O.Conflict Resolution/MOU Monitoring 1.COUNTY Liaison will meet with the CALVIVA HEALTH Liaison to monitor this MOU quarterly and/or upon request. a.Within two weeks of a formal request, COUNTY Liaison will meet with CALVIVA HEALTH Liaison when COUNTY or CALVIVA HEALTH management identifies problems requiring resolution through the MOU. b.COUNTY Liaison will be responsible for coordinating, assisting and communicating suggestions for MOU changes to the COUNTY leadership and CALVIVA. c.COUNTY Liaison will communicate and coordinate MOU changes to the State Department of Health Care Services (DHCS), COUNTY service providers and to CALVIVA HEALTH and its providers. 2.COUNTY Liaison will participate in an annual review, update and/or renegotiations with CALVIVA, as mutually agreed. 3.COUNTY management will provide 60 days advance written notice to CALVIVA HEALTH should the COUNTY 1.Local CALVIVA HEALTH liaison will meet with the COUNTY Liaison to monitor this MOU quarterly and/or upon request. a.Within two weeks of a formal request, CALVIVA HEALTH Liaison will meet with the COUNTY Liaison when the COUNTY or CALVIVA HEALTH management identifies problems requiring resolution through the MOU. b.CALVIVA HEALTH Liaison will be responsible for coordinating, assisting and communicating suggestions for MOU changes for to CALVIVA HEALTH and the COUNTY leadership. c.CALVIVA HEALTH will coordinate and communicate MOU changes to the California Department of Health Care Services (DHCS), COUNTY providers and CALVIVA HEALTH network services providers. d.CALVIVA HEALTH 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.CALVIVA HEALTH Liaison will conduct an annual review, update and/or renegotiations of this MOU, as mutually agreed. 3.CALVIVA HEALTH management will provide 60 day advance written notice to COUNTY should CALVIVA HEALTH decide to modify this MOU. Revised Exhibit A Page 21 of 32 CATEGORY COUNTY CALVIVA HEALTH decide to modify this MOU. [Unless mandated by the Department of Behavioral Health directives, Department of Health Care Services mandated requirements and/or Federal guidelines.] 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 CALVIVA HEALTH 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 of disclosure of data in violation of any applicable Federal and State laws and regulations. 1.CALVIVA HEALTH 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.CALVIVA HEALTH 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.CALVIVA HEALTH 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 CALVIVA HEALTH or anyone else including state agencies. 4.CALVIVA HEALTH 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. Q. Dispute Resolution The COUNTY will provide a resolution of dispute process in accordance to Title 9, Section 1810.370. When the COUNTY has a CALVIVA HEALTH will provide a resolution of dispute process in accordance with CCR Title 9, Section 1810.370, and the Medi-Cal contract between CALVIVA HEALTH and the State Department of Health Care Revised Exhibit A Page 22 of 32 CATEGORY COUNTY CALVIVA HEALTH dispute with CALVIVA HEALTH that cannot be resolved to the satisfaction of the COUNTY, the COUNTY may submit a request for resolution to the State Department of Mental Health (DMH) A request for resolution by either the COUNTY or the CALVIVA HEALTH will be submitted to the respective department within 30 calendar days of the completion of the dispute resolution process between both parties. The request for resolution will contain the following information: 1.A summary of the issues anda statement of desiredremedy, including anydisputed services that haveor are expected to bedelivered to the beneficiaryand the expected rate ofpayment for each type ofservice.2.History of attempts to resolvethe issue.3.Justification for the desiredremedy. 4.Documentation regarding theissue. Upon receipt of a request for resolution, the department receiving the request will notify the other department and the other party within seven calendar days. The notice to the other party will include a copy of the request and will ask for a statement of the party's position on the issues. The other party will submit the requested documentation within 21 calendar days or the Services (DHCS). When CALVIVA HEALTH has a dispute with the COUNTY that cannot be resolved to the satisfaction of the Plan, CALVIVA HEALTH may submit a request for resolution to the State DHCS. A request for resolution by either the COUNTY or CALVIVA HEALTH will be submitted to the respective department within 30 calendar days of the completion of the dispute resolution process between both parties. The request for resolution will contain the following information: 1.A summary of the issues and a statement of the desired remedy including any disputed services that have or are expected to be delivered to the beneficiary and the expected rate of payment for each type of service. 2.History of attempts to resolve the issue. 3.Justification for the desired remedy. 4.Documentation regarding the issue. Upon receipt of a request for resolution, the agency receiving the request will notify the other agency and the other party within seven calendar days. The notice to the other party will include a copy of the request and will ask for a statement of the party's position on the issues. The other party will submit the requested documentation within 21 calendar days, or the agencies will decide the dispute based solely on the documentation filed by the initiating party. A dispute between the CALVIVA HEALTH Revised Exhibit A Page 23 of 32 CATEGORY COUNTY CALVIVA HEALTH departments will decide the dispute based solely on the documentation filed by the initiating party. A dispute between the COUNTY and CALVIVA HEALTH will not delay medically necessary specialty mental health services, physical health care services, or related prescription drugs and laboratory, radiological, or radioisotope services to beneficiaries, when it is reasonably foreseeable that delay in the provision of services is likely to harm the beneficiary. Nothing in this section will preclude a beneficiary from utilizing the COUNTY's beneficiary problem resolution process or any similar process offered by CALVIVA HEALTH or to request a fair hearing. If a dispute occurs between the member and the COUNTY or CALVIVA HEALTH, the member will continue to receive medically necessary health care and mental health care services, including prescription drugs until the dispute is resolved. When the dispute involves CALVIVA HEALTH continuing to provide services to a beneficiary CALVIVA HEALTH believes requires specialty mental health services from the COUNTY, the COUNTY shall identify and provide CALVIVA HEALTH with the name and telephone number of a psychiatrist or other qualified licensed mental health and the COUNTY will not delay medically necessary specialty mental health services, physical health care services, or related prescription drugs and laboratory, radiological, or radioisotope services to beneficiaries, when it is reasonably foreseeable that delay in the provision of services is likely to harm the beneficiary. Nothing in this section will preclude a beneficiary from utilizing the Plan's beneficiary problem resolution process or any similar process offered by the COUNTY or to request a fair hearing. If a dispute occurs between the member and CALVIVA HEALTH or COUNTY, the member will continue to receive medically necessary health care and mental health care services, including prescription drugs until the dispute is resolved. Revised Exhibit A Page 24 of 32 CATEGORY COUNTY CALVIVA HEALTH professional available to provide clinical consultation, including consultation on medications to CALVIVA HEALTH provider responsible for the beneficiary's care. Revised Exhibit A Page 25 of 32 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 26 of 32 ATTACHMENT A Medical Necessity For Specialty Mental Health Services That Are The Responsibility Of Mental Health 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 27 of 32 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 28 of 32 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 29 of 32 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 30 of 32 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 31 of 32 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 32 of 32 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