HomeMy WebLinkAboutMOU Amendment II - CalViva Health A-22-257.pdf Agreement No. 22-257
1 AMENDMENT II TO AGREEMENT
2 THIS AMENDMENT II TO AGREEMENT (hereinafter"Amendment") is made and entered into
3 this 21st day of June , 2022, by and between COUNTY OF FRESNO, a Political Subdivision
4 of the State of California, Fresno, California (hereinafter"COUNTY"), and the Fresno-Kings-Madera
5 Regional Health Authority (RHA), a California Joint Powers Authority and Medi-Cal Managed Care
6 Plan dba CalViva Health, whose address is 7625 N. Palm avenue, Suite 109, Fresno, California
7 93711 (hereinafter"CALVIVA HEALTH").
8 WITNESSETH:
9 WHEREAS, COUNTY and CALVIVA HEALTH entered into Agreement number 18-361, dated
10 July loth, 2018 and COUNTY Amendment No. 18-361-1 dated June 8, 2021 (hereinafter "Agreement"),
11 pursuant to which COUNTY and CALVIVA HEALTH identified responsibilities and protocols in the
12 delivery of specialty mental health and alcohol and other drug services to Medi-Cal Members served
13 by both parties; and
14 WHEREAS, COUNTY and CALVIA HEALTH now desire to amend the Agreement in order to
15 update the agreement with current requirements related to clinical integration between COUNTY and
16 CALVIVA HEALTH and the Specialty Mental Health Dispute Resolution Process.
17 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which
18 is hereby acknowledged, COUNTY and CALVIVA HEALTH agree as follows:
19 1. That Section Seven (7) MODIFICATION of the Agreement, located on page Eight (8),
20 beginning on line Thirteen (13) through line Fifteen (15), be deleted in its entirely and replaced with
21 the following:
22 7. MODIFICATION
23 Any matters of this Agreement may be modified from time to time by the written consent of all
24 the parties without, in any way, affecting the remainder. Notwithstanding the above, changes to the
25 "MEMORANDUM OF UNDERSTANDING (MOU): SCOPE OF WORK DEPARTMENT OF
26 BEHAVIORAL HEALTH (COUNTY) AND CALVIVA HEALTH" (Revised Exhibit A), as needed, to
27 accommodate changes in the law and state-mandated requirements related to mental health and
28 substance use disorder treatment services be made with the written approval of the COUNTY's DBH
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1 Director, or designee, and CALVIVA HEALTH through an amendment approved by County's County
2 Counsel and the County's Auditor-Controller/Treasurer-Tax Collector's Office.
3 2. That "Exhibit A" be deleted and replaced with "Revised Exhibit A", which is attached
4 hereto and incorporated herein by this reference. All references to "Exhibit A" in the Agreement are
5 deleted and replaced with "Revised Exhibit A."
6 3. The parties agree that this Amendment may be executed by electronic signature as
7 provided in this section. An "electronic signature" means any symbol or process intended by an
8 individual signing this Amendment to represent their signature, including but not limited to (1) a digital
9 signature; (2) a faxed version of an original handwritten signature; or (3) an electronically scanned
10 and transmitted (for example by PDF document) of a handwritten signature. Each electronic signature
11 affixed or attached to this Amendment (1) is deemed equivalent to a valid original handwritten
12 signature of the person signing this Amendment for all purposes, including but not limited to
13 evidentiary proof in any administrative or judicial proceeding, and (2) has the same force and effect
14 as the valid original handwritten signature of that person. The provisions of this section satisfy the
15 requirements of Civil Code section 1633.5, subdivision (b), in the Uniform Electronic Transaction Act
16 (Civil Code, Division 3, Part 2, Title 2.5, beginning with section 1633.1). Each party using a digital
17 signature represents that it has undertaken and satisfied the requirements of Government Code
18 section 16.5, subdivision (a), paragraphs (1) through (5), and agrees that each other party may rely
19 upon that representation. This Amendment is not conditioned upon the parties conducting the
20 transactions under it by electronic means and either party may sign this Amendment with an original
21 handwritten signature.
22 COUNTY and CALVIVA HEALTH agree that this Amendment is sufficient to amend the
23 Agreement and, that upon execution of this Amendment, the Agreement, Amendment I and this
24 Amendment 11 together shall be considered the Agreement.
25 The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
26 covenants, conditions and promises contained in the Agreement and not amended herein shall remain
27 in full force and effect.
28
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I IN WITNESS WHEREOF, the parties hereto have executed this Amendment II as of the day and
2 year first hereinabove written.
3 CALVIVA HEALTH: COUNTY OF FRESNO
FRESNO, KINGS, MADERA
4 REGIONAL HEALTH AUTHORITY
5 dba CALV VA HEALTH 1
6 Au o zed( gnature) Brian Pacheco, Chairman of the Board of
7 Supervisors of the County of Fresno
8 � �� I<unsu�+ C�0
Print Name& Title
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10 F(eiAo' G(A 9 37 I t
11 Mailing Address ATTEST:
Bernice E. Seidel
12 Clerk of the Board of Supervisors
County of Fresno, State of California
13
14
15
16
17 By:
18 FOR ACCOUNTING USE ONLY: Deputy
19 ORG No.: 56302666($0)
Account No.:7295($0)
20 Fund/Subclass:0001/10000
21
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Revised Exhibit A
Page 1 of 35
MEMORANDUM OF UNDERSTANDING (MOU): SCOPE OF WORK
DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY)
AND
CALVIVA HEALTH
CATEGORY COUNTY CALVIVA HEALTH
A. Liaison 1. COUNTY's Administrative Staff is 1. CALVIVA HEALTH has a liaison that
the liaison to coordinate activities coordinates activities with the COUNTY
with CALVIVA HEALTH and to and COUNTY Liaison.
notify COUNTY providers and 2. The Liaison will notify CALVIVA
relevant staff of their roles and HEALTH staff and CALVIVA HEALTH
responsibilities providers of their responsibilities to
2. COUNTY Liaison will provide coordinate services with the COUNTY.
CALVIVA HEALTH with an 3. A printable downloadable CALVIVA
updated list of approved HEALTH Provider Directory is available
COUNTY providers, specialists on line and updated at a minimum on a
and behavioral health care monthly basis. CALVIVA HEALTH also
centers in the county. maintains an online searchable provider
3. Information for mental health is directory that is updated at least weekly.
also available on the COUNTY's 4. The CALVIVA HEALTH Provider
managed care website and is Operations Manual is available on line.
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.
B. Behavioral 1. COUNTY will credential and 1. CALVIVA HEALTH will utilize the
Health Service contract with sufficient numbers COUNTY to identify COUNTY providers
of licensed behavioral health who are willing to accept Medi-Cal fee
professionals to maintain a for service reimbursement to provide
COUNTY provider network services for mental health services to
sufficient to meet the needs of Members who do not meet COUNTY
Members. medical necessity criteria for COUNTY
2. COUNTY will assist with services and require services outside
identification of COUNTY the scope of practice of the PCP per
providers who have the capacity Exhibit B, attached hereto.
and willingness to accept Medi- 2. CALVIVA HEALTH will coordinate care
Cal Fee for Service with the appropriate COUNTY provider
reimbursement to serve or provider organization as
Members in need of mental recommended by the COUNTY for
health services who do not meet those services that do not meet the
the COUNTY medical necessity COUNTY medical necessity criteria.
criteria and require services 3. For Substance Use Disorder services,
outside the scope of practice of CALVIVA HEALTH will screen and offer
the Primary Care Physicians brief intervention. For clients who
(PCP) per Exhibit B, attached appear to need further assessment and
Revised Exhibit A
Page 2 of 35
CATEGORY COUNTY CALVIVA HEALTH
hereto. more intensive services, a referral to
3. For Substance Use Disorder, COUNTY centralized intake or a
COUNTY will provide a provider on the list will be required.
centralized intake function that 4. CALVIVA HEALTH will collaborate with
will screen clients using the COUNTY to maintain a list of COUNTY
ASAM criteria and determine a providers or provider organizations to be
presumptive level of care. Once made available to Members upon
the client attends an intake at a request.
COUNTY contracted provider, 5. Any updates to the list will be provided
they will be assessed for medical to CALVIVA HEALTH liaison quarterly
necessity including diagnosis. and upon request.
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.
C. Medical 1. COUNTY will follow all applicable 1. CALVIVA HEALTH and contracted
Records laws pertaining to the use and providers are allowed to release medical
Exchange of disclosure of protected health information under HIPAA regulations
Information information including but not limited specific to the HIPPA Privacy Rule (45
to: C.F.R. Part 164.)
. HIPAA/45 C.F.R. Parts 160 and 2. CALVIVA HEALTH will follow procedures
Revised Exhibit A
Page 3 of 35
CATEGORY COUNTY CALVIVA HEALTH
164 for exchanges of medical information that
. LPS /W & I Code Sections 5328- allow for care coordination and effective
5328.15 communication among COUNTY, CALVIVA
• 45 C.F.R. Part 2 HEALTH, and contracted providers.
• HITECH Act (42. U.S.C. Section
17921 et. seq.
• CMIA (Ca Civil Code 56 through
56.37)
2. COUNTY will follow procedures
for exchanges of medical information
that allow for care coordination and
effective communication among
COUNTY, CALVIVA HEALTH, and
contracted providers.
D. Scope of 1. COUNTY has a toll-free 1. CALVIVA HEALTH PCPs will be
Service telephone number available 24 responsible for providing 24 hours a
hours a day, seven days a week day, seven days a week, access to
for access to emergency, health care services for Members as
specialty mental health and specified in the CALVIVA HEALTH
Substance Use Disorder services contract with Department of Health Care
for Members who meet the Services (DHCS).
medical necessity criteria as 2. PCP will refer to the COUNTY for
identified in Exhibit B, attached assessment and appropriate services.
hereto. PCP's will refer Members for:
2. COUNTY maintains responsibility a. An assessment to confirm or
for: arrive at a diagnosis
a. Medication treatment for b. Behavioral health services other
behavioral health than medication management
conditions that would not are needed for a Member with a
be responsive to physical diagnosis included in the
healthcare-based responsibilities of the COUNTY.
treatment and the c. For identification of conditions
condition meets COUNTY not responsive to physical
medical necessity criteria. healthcare-based treatment.
b. All other outpatient 3. PCP's will provide primary care
specialty mental health behavioral health treatment which
and Substance Use includes:
Disorder services covered a. Basic education, assessment
by the COUNTY when the (mental health services only),
Member's behavioral counseling (mental health
health condition meets services only) and referral and
COUNTY medical linkage to other services for all
necessity criteria, such as Members
individual and group b. Medication and treatment for
therapies, case i. Behavioral health
management, crisis conditions that would be
intervention, treatment responsive to physical
Revised Exhibit A
Page 4 of 35
CATEGORY COUNTY CALVIVA HEALTH
plan, assessment, and healthcare-based
linkage with community treatment
resources. ii. Behavioral health
c. Consultation and training disorders due to a
services to PCPs, general medical condition
particularly related to c. Medication-induced reactions
specialty mental health from medications prescribed by
and Substance Use physical health care providers.
Disorder issues and 4. PCPs will provide or arrange for:
treatments, including a. Covered medical services
medication consultation. b. Primary behavioral health
3. To receive behavioral health intervention for Member with
services, the Member must meet "Excluded Diagnosis" as
the criteria for each of the identified in Specialty Mental
following categories for mental Health Services identified in
health services: ATTACHMENT A, Page 17 of
a. Category A—Included this Exhibit A.
Diagnosis c. Screening and brief intervention
b. Category B—Impairment for behavioral health services
Criteria within the PCP's scope of
c. Category C—Intervention practice
Related Criteria 5. CALVIVA HEALTH and COUNTY
Per Enclosure 1a of Exhibit recognize that the PCP's ability to treat
A. behavioral health disorders will be
4. To receive behavioral health limited to each provider's training and
services, the Member must meet scope of practice.
the criteria for each of the 6. When the Member does not meet
following categories for mental health medical necessity,
Substance Use Disorder CALVIVA HEALTH and PCP will be
services: responsible for coordinating a referral in
a. Early Intervention Services accordance with Category B2 "Mental
b. Outpatient/Intensive Health Services" or an CALVIVA
Outpatient HEALTH contracted provider.
c. Residential Services (ASAM 7. When the member meets Substance
Levels 3.1, 3.3, 3.5, 3.7 and Use Disorder medical necessity for
4.0) COUNTY contracted services, CALVIVA
d. Withdrawal Management HEALTH and PCP will refer client to a
e. Opioid Treatment county provider or coordinate care with
f. Recovery Services inpatient facilities and out-of-county
For further details on SUD ASAM facilities accepting Fresno County
levels of care please see Exhibit clients as appropriate.
C. For SUD ICD-10 Diagnostic 8. CALVIVA HEALTH will implement the
Codes see Enclosure 1 b. following elements at the point of care to
5. COUNTY providers will refer ensure clinical integration between the
Members back to their identified Drug Medi-Cal Organized Delivery
PCP for medical and non- System and CALVIVA HEALTH
specialty behavioral health providers:
conditions that would be a. Comprehensive substance use,
responsive to appropriate physical and mental health
Revised Exhibit A
Page 5 of 35
CATEGORY COUNTY CALVIVA HEALTH
physical health care. screening
6. COUNTY will implement the b. Member engagement and
following elements at the point of participation in an integrated care
care to ensure clinical integration program as needed
between the Drug Medi-Cal c. Shared development of care plans
Organized Delivery System and by the Member, caregivers, and all
CALVIVA HEALTH providers: providers
a. Comprehensive d. Delineation of case management
substance use, physical responsibilities
and mental health e. Navigation support for patients and
screening. caregivers
b. Member engagement and f. CALVIVA HEALTH will work
participation in an collaboratively with COUNTY and
integrated care program contracted providers in the
as needed. development of Member treatment
c. Shared development of planning.
care plans by the
Member, caregivers, and
all providers.
d. Delineation of case
management
responsibilities.
e. Navigation support for
patients and caregivers.
f. COUNTY will work
collaboratively with
CALVIVA HEALTH and
contracted providers in
the development of
Member treatment
planning.
E. Ancillary 1. When medical necessity criteria 1. CALVIVA HEALTH must cover and pay
Behavioral Health are met and services are for medically necessary laboratory,
Services approved by the COUNTY, the radiological, and radioisotope services
COUNTY and its contracted described in Title 22, CCR, Section
providers will provide hospital 51311. CALVIVA HEALTH will cover
based specialty mental health and pay for related services for
ancillary services, which include, Electroconvulsive Therapy (ECT),
but are not limited to anesthesiologist services provided on an
Electroconvulsive therapy (ECT) outpatient basis, per Exhibit B, attached
and magnetic resonance imaging hereto.
(MRI) that are received by a 2. CALVIVA HEALTH will cover and pay
Member admitted to a psychiatric for all medically necessary professional
inpatient hospital other than services to meet the physical health
routine services, per Exhibit B, care needs of the Members who are
attached hereto. admitted to the psychiatric ward of a
2. When Substance Use Disorder general acute care hospital or to a
medical necessity criteria is met freestanding licensed psychiatric
Revised Exhibit A
Page 6 of 35
CATEGORY COUNTY CALVIVA HEALTH
and services are approved by the inpatient hospital or Psychiatric Health
COUNTY for ASAM levels 3.7 Facility (PHF). These services include
and 4.0 and medical detox, the initial health history and physical
COUNTY will refer Member to assessment required within 24 hours of
CALVIVA HEALTH. admission and any medically necessary
3. COUNTY will make training physical medicine consultation, per
available for community based Exhibit B, attached hereto.
physicians interested in providing 3. CALVIVA HEALTH is not required to
Medically Assisted Treatment cover room and board charges or
(MAT) services, including an behavioral health services associated
eight hour Buprenorphine Waiver with a Member's admission to a hospital
Training required to become a or inpatient psychiatric facility for
community based MAT provider. 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 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
Revised Exhibit A
Page 7 of 35
CATEGORY COUNTY CALVIVA HEALTH
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 have the ability
to prescribe, dose and/or refer adult and
youth Members with an Opioid Use
Disorder to Medication Assisted
Treatment (MAT) in person or via
telehealth when appropriate. CALVIVA
HEALTH will encourage its physicians to
complete an eight hour Buprenorphine
Waiver Training course required to
prescribe and dispense Buprenorphine
(required for physicians treating more
than thirty Members). 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 1. The COUNTY toll free 24 hour 1. CALVIVA HEALTH will maintain a 24
Room Urgent line is available to Members. hour member service and Nurse Advice
Behavioral Health 2. The COUNTY shall cover and Line.
Care pay for the professional services 2. CALVIVA HEALTH shall cover and pay
of a behavioral health specialist for all professional services, except the
provided in an emergency room professional services of a behavioral
to a Member whose condition health specialist when required for the
meets COUNTY medical emergency services and care of a
necessity criteria or when member whose condition meets
behavioral health specialist COUNTY medical necessity criteria.
services are required to assess 3. CALVIVA HEALTH shall cover and pay
whether COUNTY medical for the facility charges resulting from the
necessity is met, per Exhibit B, emergency services and care of a
attached hereto. Member whose condition meets
3. The COUNTY is responsible for COUNTY medical necessity criteria
the facility charges resulting from when such services and care do not
the emergency services and care result in the admission of the member
of a Member whose condition for psychiatric and/or Substance Use
meets COUNTY medical Disorder inpatient hospital services or
Revised Exhibit A
Page 8 of 35
CATEGORY COUNTY CALVIVA HEALTH
necessity criteria when such when such services result in an
services and care do result in the admission of the member for psychiatric
admission of the Member for and/or Substance Use Disorder inpatient
psychiatric and/or Substance hospital services at a different facility.
Use Disorder inpatient hospital 4. CALVIVA HEALTH shall cover and pay
services at the same facility. The for the facility charges and the medical
facility charge is not paid professional services required for the
separately, but is included in the emergency services and care of a
per diem rate for the inpatient Member with an excluded diagnosis or a
stay, per Exhibit B, attached Member whose condition does not meet
hereto. COUNTY medical necessity criteria and
4. The COUNTY is responsible for such services and care do not result in
facility charges directly related to the admission of the Member for
the professional services of a psychiatric and/or Substance Use
behavioral health specialist Disorder inpatient hospital services.
provided in the emergency room 5. Payment for the professional services of
when these services do not result a behavioral health specialist required
in an admission of the member for the emergency services and care of
for psychiatric and/or Substance a Member with an excluded diagnosis is
Use Disorder inpatient hospital the responsibility of CALVIVA.
services at that facility or any
other facility, per Exhibit B,
attached hereto.
E2. Home Health 1. COUNTY shall cover and pay for 1. CALVIVA HEALTH will cover and pay for
Agency Services medication support services, prior authorized home health agency
case management, crisis services as described in Title 22, CCR,
intervention services, or any Section 51337 prescribed by an
other specialty mental health CALVIVA HEALTH provider when
services as provided under medically necessary to meet the needs
Section 1810.247, which are of homebound Members. CALVIVA
prescribed by a psychiatrist and HEALTH is not obligated to provide
are provided to a Member who is home health agency services that would
homebound. COUNTY will not otherwise be authorized by the Medi-
collaborate with CALVIVA Cal program.
HEALTH on any specialty mental 2. CALVIVA HEALTH will refer Members
health services being provided to who may be at risk of institutional
a Member. placement to the Home and Community
Based services (HCBS) Waiver Program
(CALVIVA/DHCS Contract 6.7.3.8) if
appropriate.
E3. Nursing and 1. COUNTY will arrange and 1. CALVIVA HEALTH will arrange and pay
Residential coordinate payment for nursing for nursing facility services for Members
Facility Services facility services, i.e., Augmented who meet the medical necessity criteria
Board and Care (ABC), Skilled for the month of admission plus one
Nursing Facility (SNF), Institution month, per Title 22, CCR, Section
for Mental Disease (IMD), etc., 51335.
for Members who meet medical 2. CALVIVA HEALTH will arrange for
Revised Exhibit A
Page 9 of 35
CATEGORY COUNTY CALVIVA HEALTH
necessity criteria and who disenrollment from managed care if
require a special treatment Member needs nursing services for a
program [Title 22, California longer period of time.
Code of Regulations (CCR), 3. CALVIVA HEALTH will pay for all
Section 51335(k)]. medically necessary DHCS contractually
2. COUNTY's provide medically required Medi-Cal covered services until
necessary specialty mental the disenrollment is effective.
health services, typically visits by
psychiatrists and psychologists.
E4. Emergency 1. Medical transportation services 1. CALVIVA HEALTH will arrange and pay
Transportation, as described in Title 22, Section for transportation of Members needing
Non-Emergency 51323 are not the responsibility medical transportation from:
Medical of the COUNTY except when the a. The emergency room for medical
Transportation purpose of the medical evaluation.
(NEMT and Non- transportation service is to b. A psychiatric inpatient hospital to
Medical transport a Medi-Cal beneficiary a medical inpatient hospital
Transportation from a psychiatric inpatient required to address the
(NMT) hospital to another psychiatric Member's change in medical
inpatient hospital or another type condition.
of 24 hour care facility because c. A medical inpatient hospital to a
the services in the facility to psychiatric inpatient hospital
which the beneficiary is being required to address the
transported will result in lower Member's change in psychiatric
costs to the COUNTY. 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
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
Revised Exhibit A
Page 10 of 35
CATEGORY COUNTY CALVIVA HEALTH
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 NEW 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 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
Revised Exhibit A
Page 11 of 35
CATEGORY COUNTY CALVIVA HEALTH
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. 1. COUNTY will refer Members with 1. CALVIVA HEALTH PCP will refer
Developmentally developmental disabilities to the Members with developmental disabilities
Disabled Services Central Valley Regional Center to the Central Valley Regional Center for
for non-medical services such as non-medical services such as respite,
respite, out-of-home placement, out-of-home placement supportive living,
supportive living, etc., if such etc., if such services are needed.
services are needed. 2. CALVIVA HEALTH will maintain a
2. COUNTY has a current list of current MOU with Central Valley
names, addresses and telephone Regional Center
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.
E6. History and 1. COUNTY will utilize CALVIVA 1. CALVIVA HEALTH will cover and pay
Physical for HEALTH network providers to for all medically necessary professional
Psychiatric perform medical histories and services to meet the physical health
Hospital physical examinations required care needs of Members who are
Admission for behavioral health admitted to the psychiatric ward of a
examinations required for general acute care hospital or
behavioral health and psychiatric freestanding licensed psychiatric
hospital admissions for CALVIVA inpatient hospital. These services
HEALTH members. 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 1. COUNTY will cover and pay for 1. CALVIVA HEALTH is responsible for
Outpatient all psychiatric professional services separately billable outpatient services
Revised Exhibit A
Page 12 of 35
CATEGORY COUNTY CALVIVA HEALTH
Department associated with electroconvulsive related to electroconvulsive therapy,
Services therapy. Per Title 9, CCR Section such as anesthesiologist services, per
(Electroconvulsive 1810.350 Exhibit B, attached hereto.
Therapy) 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 3. COUNTY or COUNTY provider 1. CALVIVA HEALTH will provide
Assessment and will screen and apply ASAM Members with Substance Use Disorder
Triage criteria for level of care screenings, brief intervention (SBIRT),
placement. When Member is referral and assessment. If it is found
determined to meet medical that a Member preliminarily meets
necessity for a level of care not medical necessity for COUNTY provided
provided by COUNTY Member services CALVIVA HEALTH will refer
will be referred to CALVIVA. the Member to an appropriate COUNTY
4. COUNTY will arrange and pay access point (24/7 Access Line, Urgent
for specialty COUNTY provider Care Wellness Center or COUNTY
services for Members whose provider) for further assessment and
psychiatric condition may not be treatment.
responsive to physical health 2. CALVIVA HEALTH will arrange and pay
care. for assessments of CALVIVA HEALTH
a. Initial access and members by PCPs to:
availability will be via the a. Rule out general medical
COUNTY Access Unit (a conditions causing psychiatric
twenty-four hour toll free and/or Substance Use Disorder
telephone triage system) symptoms.
b. Crisis/emergency triage b. Rule out behavioral health
via COUNTY provider is disorders caused by a general
available 24 hours a day. medical condition.
5. COUNTY provider will assess 3. The PCP will identify those general
and diagnose Member's medical conditions that are causing or
symptoms, level of impairment exacerbating psychiatric and/or
and focus of intervention. Substance Use Disorder symptoms.
Included ICD-9 Diagnoses codes 4. The PCP will be advised to identify and
are identified in Enclosure 1 a, treat non-disabling psychiatric conditions
attached hereto and incorporated which may be responsive to primary
herein. care, i.e., mild to moderate anxiety
6. COUNTY provider assessments and/or depression.
will: 5. When medically necessary CALVIVA
c. Determine if Member HEALTH will cover and pay for
meets medical necessity physician services provided by
criteria (See Attachment specialists such as neurologists, per
B, attached hereto and Exhibit B, attached hereto.
incorporated herein by
reference.
Revised Exhibit A
Page 13 of 35
CATEGORY COUNTY CALVIVA HEALTH
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.
G. Referrals 1. COUNTY will accept referrals 1. Following the PCP assessment,
from CALVIVA HEALTH staff and CALVIVA HEALTH staff and/or PCP will
providers. CALVIVA HEALTH refer those Members whose psychiatric
providers and Members will be condition or Substance Use Disorder
referred to determine medical would not be responsive to physical
necessity for specialty mental health care to the COUNTY to
health services. For Substance determine if specialty mental health
Use Disorder members, and/or Substance Use Disorder services
screening will be completed to medical necessity criteria are met.
determine if further assessment 2. CALVIVA HEALTH and PCP will
is necessary. If so clients will be coordinate and assist the COUNTY and
referred to the 24/7 Access Line. Member to keep their appointments and
2. COUNTY will coordinate with referrals back to their PCP as
CALVIVA HEALTH Customer appropriate for all other services not
Care Center to facilitate covered by the COUNTY.
appointment and referral a. CALVIVA HEALTH may request
verification assistance as assistance from the COUNTY
needed. Liaison to facilitate removal of
3. When all medical necessity barriers to a successful referral
criteria are met, COUNTY will such as transportation
arrange for specialty mental difficulties, resistance to
health and/or Substance Use treatment or delays to access.
Disorder services by COUNTY 3. Members not meeting COUNTY medical
provider. necessity guidelines will be referred by
4. When Member is appropriately CALVIVA HEALTH to appropriate
treated and/or stabilized, community resources for assistance in
Member may be referred back, if identifying programs available for low
Revised Exhibit A
Page 14 of 35
CATEGORY COUNTY CALVIVA HEALTH
appropriate to PCP for income Medi-Cal beneficiaries.
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
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 1. For mental health services, 1. CALVIVA HEALTH will authorize
Authorizations COUNTY will authorize medical assessment and/or treatment
assessment and/or treatment services by CALVIVA HEALTH network
services by COUNTY providers providers who are credentialed and
Revised Exhibit A
Page 15 of 35
CATEGORY COUNTY CALVIVA HEALTH
who are credentialed and contracted with CALVIVA HEALTH for
contracted with COUNTY for covered medically necessary services.
services that meet specialty 2. CALVIVA HEALTH will inform PCPs that
mental health services medical they may refer Members to the
necessity criteria. COUNTY for initial diagnosis and
2. For Substance Use Disorder assessment of the Member.
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.
I. Consultation 1. COUNTY encourages 1. PCP providers will be available to
consultations between COUNTY consult with COUNTY and COUNTY
providers, specialty providers providers regarding Members who are
and CALVIVA HEALTH PCP treated by both, in accordance with
providers as it relates to specialty HIPAA federal and state regulations
mental health and/or Substance regarding confidentiality, per HIPPA
Use Disorder issues including but Privacy Rule 45 C.F.R. Part 164.
not limited to medication issues, 2. For those Members who meet COUNTY
linkage with community medical necessity criteria and whose
resources, etc., in accordance psychiatric symptoms and/or Substance
with HIPAA federal and state Use Disorder will be treated by a
regulations regarding COUNTY provider, CALVIVA HEALTH
confidentiality per HIPPA Privacy and/or PCP will provide consultation to
Rule 45 C.F.R. Part 164. COUNTY providers and/or COUNTY
2. For those Members who are staff on the following topics:
excluded from COUNTY a. Acquiring access to covered
services, COUNTY will provide CALVIVA HEALTH medical
clinical consultation and training services.
to the CALVIVA HEALTH PCPs, b. Treatment of physical symptoms
other behavioral health providers precipitated by medications used
and/or CALVIVA HEALTH staff to treat behavioral health
on the following topics: disorders.
a. Recommended physical c. Treatment of complicated sub-
healthcare-based syndrome medical symptoms.
treatment for diagnosed d. Complex medication interactions
conditions with medications prescribed by
b. Complex diagnostic PCP not commonly used in
assessment of behavioral psychiatric or Substance Use
health disorders (e.g., Disorderspecialty practice.
Revised Exhibit A
Page 16 of 35
CATEGORY COUNTY CALVIVA HEALTH
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
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 1. COUNTY will utilize Medi-Cal 1. When CALVIVA HEALTH determines
Screening, medical necessity criteria that EPSDT supplemental services
Diagnosis and established for EPSDT criteria are not met and the Member
treatment supplemental services to child's condition is not CCS eligible,
Revised Exhibit A
Page 17 of 35
CATEGORY COUNTY CALVIVA HEALTH
(EPSDT) determine if a child, 21 years of CALVIVA HEALTH will refer the Member
Supplemental age and under, meets those child to the PCP for treatment of
Services. criteria. conditions within the PCP's scope of
2. When EPSDT supplemental practice.
criteria are met, COUNTY is 2. Referrals to the COUNTY for an
responsible for arranging and appropriate linked program will be made
paying for EPSDT supplemental for treatment of conditions outside the
services provided by COUNTY PCP's scope of practice. CALVIVA
specialty mental health and HEALTH will assist the COUNTY and
Substance Use Disorder Members by providing links to known
providers. community providers of supplemental
3. When EPSDT supplemental services.
criteria are not met, COUNTY will 3. CALVIVA HEALTH will cover all
refer Member children as follows: medically necessary professional
a. For mental health services to meet the physical health care
services, Referral to needs of Members admitted to a general
California Children's acute care hospital ward or to a
Services (CCS)- for those freestanding licensed psychiatric
children who have a CCS inpatient hospital.
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. 1. COUNTY providers will prescribe 1. CALVIVA HEALTH will:
Pharmaceutical and monitor the effects and side a. Allow COUNTY credentialed
Services and effects of psychotropic providers access to pharmacy
Prescribed Drugs medications for Members under and laboratory services as
their treatment. specialty providers.
2. COUNTY will coordinate with b. Will make available a list of
CALVIVA HEALTH participating pharmacies and
representatives to ensure that laboratories on the internet.
psychotropic drugs prescribed by c. Will make available the formulary
COUNTY providers are included and information regarding drug
in the CALVIVA HEALTH formulary procedures on the
formulary and/or available for internet.
dispensing by CALVIVA HEALTH d. Consider recommendations from
network pharmacies unless COUNTY for utilization
Revised Exhibit A
Page 18 of 35
CATEGORY COUNTY CALVIVA HEALTH
otherwise stipulated by state management standards for
regulation. behavioral health, pharmacy and
3. COUNTY will inform COUNTY laboratory services.
providers regarding process and e. Provide the process for obtaining
procedure for obtaining timely authorization and delivery
prescribed medications for of prescribed drugs and
Members. laboratory services to the
4. COUNTY providers will utilize COUNTY.
CALVIVA HEALTH contracted 2. CALVIVA HEALTH will coordinate with
laboratories for laboratory tests COUNTY to ensure that covered
required for medication psychotropic drugs prescribed by
administration and management COUNTY providers are available
of psychotropic medications. through the authorization process or
5. COUNTY will assist CALVIVA formulary for dispensing by CALVIVA
HEALTH in the utilization review HEALTH network pharmacies unless
of psychotropic drugs prescribed otherwise stipulated by state regulation.
by out-of-network psychiatrists. (See Enclosure2, "Drugs Excluded from
6. COUNTY will share with Plan Coverage" of Exhibit B)
CALVIVA HEALTH a list of non- 3. CALVIVA HEALTH will apply utilization
contracted psychiatrist COUNTY review procedures when prescriptions
providers contracted to provide are written by out-of-network
behavioral health services in psychiatrists for the treatment of
areas where access to psychiatric conditions.
psychiatrists is limited, on a a. Covered psychotropic drugs
quarterly basis. 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.
Revised Exhibit A
Page 19 of 35
CATEGORY COUNTY CALVIVA HEALTH
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, 1. COUNTY or a Medi-Cal FFS 1. CALVIVA HEALTH will cover and pay
Radiological and behavioral health services for medically necessary laboratory,
Radioisotope provider needing laboratory, radiological and radioisotope services
Services radiological, or radioisotope when ordered by a COUNTY or a Medi-
services for a Member when Cal FFS behavioral health services
necessary for the diagnosis, provider for the diagnosis, treatment or
treatment or monitoring of a monitoring of a behavioral health
behavioral health condition will condition (and side effects resulting from
utilize the list of CALVIVA medications prescribed to treat the
HEALTH contract providers. behavioral health diagnosis) as
described 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 1. COUNTY will share with 1. CALVIVA HEALTH has in place a
and Complaints CALVIVA HEALTH its written process for the submittal,
established processes for the processing and resolution of all member
submittal, processing and and provider grievances and complaints
resolution of all member and which is inclusive of any aspect of the
provider grievances and health care services or provision of
complaints regarding any aspect services.
of the behavioral health care 2. CALVIVA HEALTH liaison will
services in accordance with CFR coordinate and share the established
42 Part 438. These processes complaint and grievance process for its
include timelines/deadlines and Members with the COUNTY
member information that must be
provided.
2. COUNTY and CALVIVA
HEALTH will work collaborative)
Revised Exhibit A
Page 20 of 35
CATEGORY COUNTY CALVIVA HEALTH
to resolve any formal grievance
or complaint brought to the
attention of either plan.
N. Appeal 1. COUNTY will ensure that the 1. CALVIVA HEALTH will ensure that
Resolution Members and providers are Members and providers are given an
Process given an opportunity for opportunity for reconsideration and an
reconsideration and appeal for appeal for denied, modified or delayed
denied, modified or delayed services
services. 2. CALVIVA HEALTH will ensure that
2. COUNTY will ensure that the medically necessary services continue
Members receive specialty to be provided to Members while the
mental health and/or Substance dispute is being resolved. CALVIVA's
Use Disorder services and appeal process will be shared with the
prescription drugs while the COUNTY.
dispute is being resolved.
3. COUNTY will identify and provide
CALVIVA HEALTH 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 CALVIVA HEALTH provider
responsible for the beneficiary's
care.
O. Conflict 1. COUNTY Liaison will meet with 1. Local CALVIVA HEALTH liaison will
Resolution/MOU the CALVIVA HEALTH Liaison to meet with the COUNTY Liaison to
Monitoring monitor this MOU quarterly monitor this MOU quarterly and/or upon
and/or upon request. request.
a. Within two weeks of a a. Within two weeks of a formal
formal request, COUNTY request, CALVIVA HEALTH
Liaison will meet with Liaison will meet with the
CALVIVA HEALTH COUNTY Liaison when the
Liaison when COUNTY or COUNTY or CALVIVA HEALTH
CALVIVA HEALTH management identifies problems
management identifies requiring resolution through the
problems requiring MOU.
resolution through the b. CALVIVA HEALTH Liaison will
MOU. be responsible for coordinating,
b. COUNTY Liaison will be assisting and communicating
responsible for suggestions for MOU changes
coordinating, assisting for to CALVIVA HEALTH and the
and communicating COUNTY leadership.
suggestions for MOU c. CALVIVA HEALTH will
changes to the COUNTY coordinate and communicate
leadership and CALVIVA. MOU changes to the California
Revised Exhibit A
Page 21 of 35
CATEGORY COUNTY CALVIVA HEALTH
c. COUNTY Liaison will Department of Health Care
communicate and Services (DHCS), COUNTY
coordinate MOU changes providers and CALVIVA
to the State Department HEALTH network services
of Health Care Services providers.
(DHCS), COUNTY d. CALVIVA HEALTH Liaison will
service providers and to make a good faith effort to agree
CALVIVA HEALTH and to resolutions that are in the best
its providers. interest of Members and are
2. COUNTY Liaison will participate agreeable to all parties involved.
in an annual review, update 2. CALVIVA HEALTH Liaison will conduct
and/or renegotiations with an annual review, update and/or
CALVIVA, as mutually agreed. renegotiations of this MOU, as mutually
3. COUNTY management will agreed.
provide 60 days advance written 3. CALVIVA HEALTH management will
notice to CALVIVA HEALTH provide 60 day advance written notice to
should the COUNTY decide to COUNTY should CALVIVA HEALTH
modify this MOU. [Unless decide to modify this MOU.
mandated by the Department of
Behavioral Health directives,
Department of Health Care
Services mandated requirements
and/or Federal guidelines.]
P. Protected 1. COUNTY will comply with all 1. CALVIVA HEALTH will comply with
Health applicable laws pertaining to use and Confidentiality of Medical Information Act
Information disclosure of PHI including but not [California Civil Code 56 through 56.37] the
limited to: Patient Access to Health Records Act
• HIPAA/45 C.F.R. Parts 160 and (California Health and Safety Code 123100,
164 et seq) and the Health Insurance Portability
• LPS /W & I Code Sections 5328- and Accountability Act (Code of Federal
5328.15 Regulations Title 45 Parts 160 and 164).
• 45 C.F.R. Part 2 2. CALVIVA HEALTH will train its workforce
• HITECH Act (42. U.S.C. Section in policies and procedures regarding
17921 et. seq. Protected Health Information (PHI) as
• CMIA (Ca Civil Code 56 through necessary and appropriate to perform
56.37) processes and functions within the scope of
2. COUNTY will train its workforce in duties under this MOU.
policies and procedures regarding 3. CALVIVA HEALTH will encrypt any data
Protected Health Information (PHI) transmitted via Electronic Mail (Email)
as necessary and appropriate to containing confidential data of Members
perform processes and functions such as PHI and Personal Confidential
within the scope of duties under this Information (PCI) or other confidential data
MOU. to CALVIVA HEALTH or anyone else
3. Only encrypted PHI as specified including state agencies.
in the HIPAA Security Rule will be 4. CALVIVA HEALTH will notify COUNTY
transmitted via email. Unsecured within 24 hours during a work week of any
PHI will not be transmitted via email. suspected or actual breach of security,
intrusion or unauthorized use or disclosure
Revised Exhibit A
Page 22 of 35
CATEGORY COUNTY CALVIVA HEALTH
4. COUNTY will notify CALVIVA of PHI and/or any actual or suspected use
HEALTH within 24 hours during a or disclosure of data in violation of any
work week of any suspected or applicable Federal and State laws or
actual breach of security, intrusion or regulations.
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. COUNTY Liaison will participate 1. CALVIVA HEALTH liaison will conduct
Q. Routine in an annual review, update an annual review, update and/or
Dispute and/or renegotiations with renegotiations of this agreement with the
Resolution CALVIVA HEALTH on this COUNTY as is mutually agreed.
Process agreement as is mutually agreed. 2. When CALVIVA HEALTH has a dispute
2. When the COUNTY has a with the COUNTY that cannot be
dispute with CALVIVA HEALTH resolved to the satisfaction of CALVIVA
that cannot be resolved to the HEALTH concerning the obligations of
satisfaction of the COUNTY the COUNTY or CALVIVA HEALTH
concerning the obligations of the under their respective contracts with the
COUNTY or CALVIVA HEALTH DHCS, State Medi-Cal laws and
under their respective contracts regulations, or with this MOU as
with the DHCS, State Medi-Cal described in Section 1810.370*,
laws and regulations, or with this CALVIVA HEALTH may submit a request
MOU as described in Section for resolution to the Department.
1810.370*, the COUNTY may 3. Regardless of MOU status, CALVIVA
submit a request for resolution to HEALTH and COUNTY must complete
the Department. the plan level dispute resolution process
3. Regardless of MOU status, in paragraph 2 above, within 15 business
COUNTY and CALVIVA days of identifying the dispute. Within
HEALTH must complete the plan three business days after a failure to
level dispute resolution process resolve the dispute during that
in paragraph 2 above, within 15 timeframe, either the COUNTY or
business days of identifying the CALVIVA HEALTH must submit a written
dispute. Within three business "Request for Resolution" to DHCS.
days after a failure to resolve the 4. If CALVIVA HEALTH submits the
dispute during that timeframe, Request for Resolution it must be signed
either the COUNTY or CALVIVA by CALVIVA HEALTH's Chief Executive
HEALTH must submit a written Officer (CEO) or the CEO's designee.
"Request for Resolution" to The Request for Resolution must
DHCS. include:
4. If COUNTY submits the Request a. A summary of the disputed issue(s)
for Resolution it must be signed and a statement of the desired
by COUNTY Director or remedies, including any disputed
designee. The Request for services that have been or are
Resolution must include: expected to be delivered to the
a. A summary of the disputed member by either CALVIVA
issue(s) and a statement of HEALTH or the COUNTY and the
the desired remedies, expected rate of payment for each
including any disputed
Revised Exhibit A
Page 23 of 35
CATEGORY COUNTY CALVIVA HEALTH
services that have been or type of service;
are expected to be b. A history of the attempts to resolve
delivered to the member by the issue(s)with the COUNTY;
either CALVIVA HEALTH or c. Justification for CALVIVA
the COUNTY and the HEALTH's desired remedy; and
expected rate of payment d. Any additional documentation that
for each type of service; CALVIVA HEALTH deems relevant
b. A history of the attempts to to resolve the disputed issue(s), if
resolve the issue(s) with applicable.
CALVIVA HEALTH; 5. The Request for Resolution must be
c. Justification for COUNTY's submitted via secure email to:
desired remedy; and MCQMD(a)dhcs.ca.gov.
d. Any additional 6. Within three business days of receipt of
documentation that a Request for Resolution from CALVIVA
COUNTY deems relevant to HEALTH, DHCS will forward a copy of
resolve the disputed the Request for Resolution to the
issue(s), if applicable. Director of the affiliated COUNTY via
secure email ("Notification"). The
5. The Request for Resolution must COUNTY will have three business days
be submitted via secure email to: from the receipt of Notification to submit
Countysupport dhcs.ca.gov. a response to CALVIVA HEALTH's
6. Within three business days of Request for Resolution and to provide
receipt of a Request for any relevant documents to support the
Resolution from COUNTY, COUNTY's position. If the COUNTY fails
DHCS will forward a copy of the to respond, DHCS will render a decision
Request for Resolution to on the disputed issue(s) based on the
CALVIVA HEALTH via secure documentation submitted by CALVIVA
email ("Notification"). CALVIVA HEALTH.
HEALTH will have three business 7. If CALVIVA HEALTH requests a rate of
days from the receipt of payment in its Request for Resolution,
Notification to submit a response and CALVIVA HEALTH prevails, the
to COUNTY's Request for requested rate shall be deemed correct,
Resolution and to provide any unless the COUNTY disputes the rate of
relevant documents to support payment in its response. If the
the CALVIVA HEALTH's position. COUNTYfails to respond, DHCS will
If CALVIVA HEALTH fails to render a decision on the disputed
respond, DHCS will render a issue(s) based on the documentation
decision on the disputed issue(s) submitted by CALVIVA HEALTH.
based on the documentation 8. At its discretion, DHCS may allow
submitted by COUNTY. representatives of CALVIVA HEALTH
7. If COUNTY requests a rate of and COUNTY the opportunity to present
payment in its Request for oral arguments.
Resolution, and the COUNTY 9. The Managed Care Quality and
prevails, the requested rate shall Monitoring Division and the Medi-Cal
be deemed correct, unless Behavioral Health Division will make a
CALVIVA HEALTH disputes the joint recommendation to DHCS'
rate of payment in its response. If Director, or the Director's designee,
CALVIVA HEALTH fails to based on their review of the submitted
respond, DHCS will render a documentation; the applicable statutory,
Revised Exhibit A
Page 24 of 35
CATEGORY COUNTY CALVIVA HEALTH
decision on the disputed issue(s) regulatory, and contractual obligations of
based on the documentation CALVIVA HEALTH and the COUNTY;
submitted by the COUNTY. and any oral arguments presented.
8. At its discretion, DHCS may 10. Within 20 business days from the third
allow representatives of CALVIVA business day after the Notification date,
HEALTH and COUNTY the DHCS will communicate the final
opportunity to present oral decision via secure email to CALVIVA
arguments. HEALTH's CEO (or the CEO's
9. The Managed Care Quality and designee, if the designee submitted the
Monitoring Division and the Medi- Request for Resolution) and the
Cal Behavioral Health Division COUNTY's Director (or the Director's
will make a joint recommendation designee, if the designee submitted the
to DHCS' Director, or the Request for Resolution). DHCS'
Director's designee, based on decision will state the reasons for the
their review of the submitted decision, the determination of rates of
documentation; the applicable payment (if the rates of payment were
statutory, regulatory, and disputed), and any actions CALVIVA
contractual obligations of HEALTH and COUNTY are required to
CALVIVA HEALTH and the take to implement the decision. Any
COUNTY; and any oral such action required from either
arguments presented. CALVIVA HEALTH or the COUNTY
10. Within 20 business days from the must be taken no later than the next
third business day after the business day following the date of the
Notification date, DHCS will decision.
communicate the final decision 11. A dispute between CALVIVA HEALTH
via secure email to CALVIVA and the COUNTY will not delay
HEALTH's CEO (or the CEO's medically necessary specialty mental
designee, if the designee health services, physical health care
submitted the Request for services, or related prescription drugs
Resolution) and the COUNTY's and laboratory, radiological, or
Director (or the Director's radioisotope services to beneficiaries,
designee, if the designee when it is reasonably foreseeable that
submitted the Request for delay in the provision of services is likely
Resolution). DHCS' decision will to harm the beneficiary.
state the reasons for the 12. Nothing in this section will preclude a
decision, the determination of beneficiary from utilizing CALVIVA
rates of payment (if the rates of HEALTH's beneficiary problem
payment were disputed), and any resolution process or any similar
actions CALVIVA HEALTH and process offered by the COUNTY or to
COUNTY are required to take to request a fair hearing.
implement the decision. Any 13. If a dispute occurs between the member
such action required from either and CALVIVA HEALTH or COUNTY, the
CALVIVA HEALTH or the member will continue to receive
COUNTY must be taken no later medically necessary health care and
than the next business day mental health care services, including
following the date of the decision. prescription drugs until the dispute is
11. A dispute between the COUNTY resolved.
and CALVIVA HEALTH will not
delay medically necessary
Revised Exhibit A
Page 25 of 35
CATEGORY COUNTY CALVIVA HEALTH
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.
12. 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.
13. 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.
14. When the dispute involves
CALVIVA HEALTH continuing to
provide services to a beneficiary
that 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.
R. Expedited 1. COUNTY and CALVIVA 1. CALVIVA HEALTH and COUNTY may
Dispute HEALTH may seek to enter seek to enter into an expedited dispute
Resolution into an expedited dispute resolution process if a member has not
Process resolution process if a member received a disputed service(s) and
has not received a disputed CALVIVA HEALTH and/or COUNTY
service(s) and CALVIVA determine that the Routine Dispute
HEALTH and/or COUNTY Resolution Process timeframe would
determine that the Routine result in serious jeopardy to the
Dispute Resolution Process member's life, health, or ability to
timeframe would result in attain, maintain, or regain maximum
serious jeopardy to the function.
member's life, health, or ability 2. Under this expedited process,
to attain, maintain, or regain CALVIVA HEALTH and COUNTY will
Revised Exhibit A
Page 26 of 35
CATEGORY COUNTY CALVIVA HEALTH
maximum function. have one business day after
2. Under this expedited process, identification of a dispute to attempt to
COUNTY and CALVIVA resolve the dispute at the plan level.
HEALTH will have one Within one business day after a failure
business day after identification to resolve the dispute in that
of a dispute to attempt to timeframe, both plans will separately
resolve the dispute at the plan submit a Request for Resolution to
level. Within one business day DHCS, as set out above, including an
after a failure to resolve the affirmation of the stated jeopardy to
dispute in that timeframe, both the member.
plans will separately submit a 3. If CALVIVA HEALTH fails to submit a
Request for Resolution to Request for Resolution, DHCS will
DHCS, as set out above, render a decision on the disputed
including an affirmation of the issue(s) based on the documentation
stated jeopardy to the member. submitted by the COUNTY.
3. If the COUNTY fails to submit a 4. DHCS will provide a decision no later
Request for Resolution, DHCS than one business day following
will render a decision on the DHCS' receipt of Request for
disputed issue(s) based on the Resolution from both parties and
documentation submitted by affirmation of the stated jeopardy to
CALVIVA HEALTH. the member.
4. DHCS will provide a decision
no later than one business day
following DHCS' receipt of
Request for Resolution from
both parties and affirmation of
the stated jeopardy to the
member.
S. Financial 1. If DHCS' decision includes a 1. If DHCS' decision includes a finding
Liability finding that the unsuccessful that the unsuccessful party is
party is financially liable to the financially liable to the other party for
other party for services, services, CALVIVA HEALTH or
COUNTY or CALVIVA HEALTH COUNTY is required to comply with
is required to comply with the the requirements in Title 9, California
requirements in Title 9, Code of Regulations (CCR), section
California Code of Regulations 1850.530. If necessary, DHCS will
(CCR), section 1850.530. If
necessary, DHCS will enforce enforce the decision, including
the decision, including withholding funds to meet any
withholding funds to meet any financial liability.
financial liability.
Revised Exhibit A
Page 27 of 35
Enclosure la.
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 28 of 35
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 Excluded Diagnosis:
• Elimination Disorders Mental Retardation
• Other Disorders of Infancy, Childhood or Adolescence Learning Disorder
• Schizophrenia & Other Psychotic Disorder Motor Skills Disorder
• Mood Disorders Communications Disorders
• Anxiety Disorders Autistic Disorder, Other Pervasive
• Somatoform Disorders Developmental Disorders are
• Factitious Disorders included.
' Dissociative Disorders Tic Disorders
Delirium, Dementia, and Amnestic
• Paraphilias and Other Cognitive Disorders
• Gender Identify Disorders Mental Disorders Due to a General
• Eating Disorders Medical Condition
• Impulse-Control Disorders Not Elsewhere Classified Substance-Related Disorders
• Adjustment Disorders Sexual Dysfunctions
• Personality Disorders, excluding Antisocial Personality Disol Sleep Disorders
• Medication-Induced Movement Disorders (related to other Antisocial Personality Disorder
included diagnoses). Other Conditions that may be a focus
of clinical attention, except
Medication induced Movement
B. Impairment Criteria Disorders which are included.
Must have one of the following as a result of the mental disorder
identified in the diagnostic ("A") criteria; must have one, 1, 2 or 3
1 A significant impairment in an important area of life A beneficiary may receive services for an
functioning, or included diagnosis when an excluded
2 A probability of significant deterioration in an important diagnosis is also present.
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.
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 29 of 35
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
F10.13 Alcohol Abuse, with Withdrawal
F10.130 Alcohol Abuse with Withdrawal, Uncomplicated
F10.131 Alcohol Abuse with Withdrawal, Delirium
F10.132 Alcohol Abuse with Withdrawal with Perceptual Disturbance
F10.139 Alcohol Abuse with Withdrawal, 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
F10.93 Alcohol Use, Unspecified with Withdrawal
F10.930 Alcohol Use, Unspecified with Withdrawal, Uncomplicated
F10.931 Alcohol Use, Unspecified with Withdrawal Delirium
F10.932 Alcohol Use, Unspecified with Withdrawal with Perceptual Disturbance
F10.939 Alcohol Use, Unspecified with Withdrawal, 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
F11.13 Opioid Abuse with Withdrawal
F11.14 Opioid Abuse with Opioid-Induced Mood Disorder
F11.150 Opioid Abuse with Opioid-Induced Psychotic Disorder with Delusions
F11.151 10pioid Abuse with Opioid-Induced Psychotic Disorder with Hallucinations
F11.159 10pioid Abuse with Opioid-Induced Psychotic Disorder, Unspecified
Page 1 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 30 of 35
ICD 10 Code ICD 10 Code Descriptions
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
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
F12.13 Cannabis Abuse with Withdrawal
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
Page 2 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 31 of 35
ICD 10 Code ICD 10 Code Descriptions
F13.120 Sedative, Hypnotic or Anxiolytic Abuse with Intoxication, Uncomplicated
F13.129 Sedative, Hypnotic or Anxiolytic Abuse with Intoxication, Unspecified
F13.13 Sedative, Hypnotic or Anxiolytic Abuse with Withdrawal
F13.130 Sedative, Hypnotic or Anxiolytic Abuse with Withdrawal, Uncomplicated
F13.131 Sedative, Hypnotic or Anxiolytic Abuse with Withdrawal Delirium
F13.132 Sedative, Hypnotic or Anxiolytic Abuse with Withdrawal with Perceptual Disturbance
F13.139 Sedative, Hypnotic or Anxiolytic Abuse with Withdrawal, Unspecified
F13.14 Sedative, Hypnotic or Anxiolytic Abuse with Sedative-, Hypnotic-, or Anxiolytic-Induced Mood Disorder
Sedative, Hypnotic, or Anxiolytic Abuse with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder with
F13.150 Delusions
Sedative, Hypnotic, or Anxiolytic Abuse with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder with
F13.151 Hallucinations
Sedative, Hypnotic or Anxiolytic Abuse with Sedative, Hypnotic or Anxiolytic-Induced Psychotic Disorder,
F13.159 Unspecified
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
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
Sedative, Hypnotic, or Anxiolytic Dependence with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder
F13.250 with Delusions
Sedative, Hypnotic, or Anxiolytic Dependence with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder
F13.251 with Hallucinations
Sedative, Hypnotic or Anxiolytic Dependence with Sedative, Hypnotic or Anxiolytic-Induced Psychotic Disorder,
F13.259 Unspecified
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
Sedative, Hypnotic or Anxiolytic Use, Unspecified,with Sedative-, Hypnotic-, or Anxiolytic-Induced Mood
F13.94 Disorder
Sedative, Hypnotic, or Anxiolytic Use, Unspecified, with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.950 Disorder with Delusions
Sedative, Hypnotic, or Anxiolytic Use, Unspecified, with Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic
F13.951 Disorder with Hallucinations
Sedative, Hypnotic or Anxiolytic Use, Unspecified with Sedative, Hypnotic or Anxiolytic-Induced Psychotic
F13.959 Disorder, Unspecified
Page 3 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 32 of 35
ICD 10 Code ICD 10 Code Descriptions
Sedative, Hypnotic or Anxiolytic Use, Unspecified, with Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety
F13.980 Disorder
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
F14.13 Cocaine Abuse, Unspecified with Withdrawal
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
F14.93 Cocaine Use, Unspecified with Withdrawal
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
F15.120 Other Stimulant Abuse with Intoxication, Uncomplicated
F15.129 Other Stimulant Abuse with Intoxication, Unspecified
F15.13 Other Stimulant Abuse with Withdrawal
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 10ther Stimulant Dependence with Intoxication, Unspecified
F15.23 10ther Stimulant Dependence with Withdrawal
Page 4 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 33 of 35
ICD 10 Code ICD 10 Code Descriptions
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)
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
Page 5 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 34 of 35
ICD 10 Code ICD 10 Code Descriptions
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
F19.13 Other Psychoactive Substance Abuse with Withdrawal
F19.130 Other Psychoactive Substance Abuse with Withdrawal, Uncomplicated
F19.131 Other Psychoactive Substance Abuse with Withdrawal Delirium
F19.132 Other Psychoactive Substance Abuse with Withdrawal with Perceptual Disturbance
F19.139 Other Psychoactive Substance Abuse with Withdrawal, 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
Other Psychoactive Substance Abuse with Psychoactive Substance-Induced Psychotic Disorder with
F19.151 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
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
Page 6 of 7
SUD ICD 10 Analysis Included Codes Revised Exhibit A
Page 35 of 35
ICD 10 Code ICD 10 Code Descriptions
Other Psychoactive Substance Dependence with Psychoactive Substance-Induced Psychotic Disorder with
F19.250 Delusions
Other Psychoactive Substance Dependence with Psychoactive Substance-Induced Psychotic Disorder with
F19.251 Hallucinations
F19.259 Other Psychoactive Substance Dependence with Psychoactive Substance-Induced Psychotic Disorder,
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
Other Psychoactive Substance Use, Unspecified, with Psychoactive Substance-Induced Psychotic Disorder with
F19.950 Delusions
Other Psychoactive Substance Use, Unspecified, with Psychoactive Substance-Induced Psychotic Disorder with
F19.951 Hallucinations
Other Psychoactive Substance Use, Unspecified with Psychoactive Substance-Induced Psychotic Disorder,
F19.959 Unspecified
F19.980 Other Psychoactive Substance Use, Unspecified, with Psychoactive Substance-Induced Anxiety Disorder
Z03.89 Encounter for Observation for Other Suspected Diseases and Conditions Ruled Out
Page 7 of 7