HomeMy WebLinkAboutMOU Amendment II - Blue Cross Anthem A-22-258.pdf Agreement No. 22-258
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
4 Subdivision of the State of California, Fresno, California (hereinafter "COUNTY"), and Blue Cross of
5 California Partnership Plan, Inc., a Medi-Cal Managed Care Plan, whose address is 3330 W. Mineral
6 King Avenue, Visalia, Ca 93291 (hereinafter "ANTHEM").
7 WITNESSETH:
8 WHEREAS, COUNTY and ANTHEM entered into Agreement number 18-362, dated July 101"
9 2018 and COUNTY Amendment No. 18-362-1, dated June 8, 2021 (hereinafter "Agreement"),
10 pursuant to which COUNTY and ANTHEM identified responsibilities and protocols in the delivery of
11 specialty mental health and alcohol and other drug services to Medi-Cal Members served by both
12 parties; and
13 WHEREAS, COUNTY and ANTHEM now desire to amend the Agreement in order to update
14 the agreement with current requirements related to clinical integration between COUNTY and
15 ANTHEM and the Specialty Mental Health Dispute Resolution Process.
16 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which
17 is hereby acknowledged, COUNTY and ANTHEM agree as follows:
18 1. That Section Seven (7) MODIFICATION of the Agreement, located on page Seven (7),
19 beginning on line Eight (8) through line Ten (10), be deleted in its entirely and replaced with the
20 following:
21 7. MODIFICATION
22 Any matters of this Agreement may be modified from time to time by the written consent of all
23 the parties without, in any way, affecting the remainder. Notwithstanding the above, changes to the
24 "MEMORANDUM OF UNDERSTANDING (MOU): SCOPE OF WORK DEPARTMENT OF
25 BEHAVIORAL HEALTH (COUNTY) AND BLUE CROSS OF CALIFORNIA PARTNERSHIP PLAN,
26 INC. ("ANTHEM")" (Revised Exhibit A), as needed, to accommodate changes in the law and state-
27 mandated requirements related to mental health and substance use disorder treatment services be
28 made with the written approval of the COUNTY's DBH Director, or designee, and ANTHEM through an
- 1 -
1 amendment approved by County's County Counsel and the County's Auditor-Controller/Treasurer-Tax
2 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 ANTHEM agree that this Amendment is sufficient to amend the Agreement and,
23 that upon execution of this Amendment, the Agreement, Amendment I and this Amendment II
24 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
27 remain in full force and effect.
28 H
- 2 -
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment II as of the day and
2 year first hereinabove written.
3
4 BLUE CROSS OF CALIFORNIA: COUNTY OF FRESNO
PARTNERSHIP PLAN, INC.:
5 Digitally signed by Les Ybarra '
Date:2022.052519:36:07
-07"001 /
6 (Authorized Signature) Brian Pacheco, Chairman of the Board of
7 Supervisors of the County of Fresno
Les Ybarra, President, CA Medicaid
8 Print Name & Title
9 425 E. Colorado St., Ste. 600
10 Glendale, CA 91205
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: �—
Deputy
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
-3 -
Revised Exhibit A
Page 1 of 35
MEMORANDUM OF UNDERSTANDING (MOU): SCOPE OF WORK
DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY)
AND
BLUE CROSS OF CALIFORNIA PARTNERSHIP PLAN, INC. ("ANTHEM")
CATEGORY COUNTY ANTHEM
A. Liaison 1. COUNTY's Administrative Staff is 1. ANTHEM has a liaison that coordinates
the liaison to coordinate activities activities with the COUNTY and
with ANTHEM and to notify COUNTY Liaison.
COUNTY providers and relevant 2. The Liaison will notify ANTHEM staff
staff of their roles and and ANTHEM providers of their
responsibilities responsibilities to coordinate services
2. COUNTY Liaison will provide with the COUNTY.
ANTHEM with an updated list of 3. A printable downloadable ANTHEM
approved COUNTY providers, Provider Directory is available online
specialists, and behavioral health and updated at a minimum on a monthly
care centers in the county. basis. ANTHEM also maintains an
3. Information for mental health is online searchable provider directory that
also available on the COUNTY's is updated at least weekly.
managed care website and is 4. The ANTHEM Provider Operations
updated at a minimum on a Manual is available online.
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. ANTHEM will utilize the COUNTY to
Health Service contract with sufficient numbers identify COUNTY providers who are
of licensed behavioral health willing to accept Medi-Cal fee for service
professionals to maintain a reimbursement to provide services for
COUNTY provider network mental health services to Members who
sufficient to meet the needs of do not meet COUNTY medical necessity
Members. criteria for COUNTY services and
2. COUNTY will assist with require services outside the scope of
identification of COUNTY practice of the PCP per Exhibit B,
providers who have the capacity attached hereto.
and willingness to accept Medi- 2. ANTHEM will coordinate care with the
Cal Fee for Service appropriate COUNTY provider or
reimbursement to serve provider organization as recommended
Members in need of mental by the COUNTY for those services that
health services who do not meet do not meet the COUNTY medical
the COUNTY medical necessity necessity criteria.
criteria and require services 3. For Substance Use Disorder services,
outside the scope of practice of ANTHEM will screen and offer brief
the Primary Care Physicians intervention. For clients who appear to
(PCP) per Exhibit B, attached need further assessment and more
hereto. intensive services, a referral to
Revised Exhibit A
Page 2 of 35
CATEGORY COUNTY ANTHEM
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. ANTHEM will collaborate with COUNTY
will screen clients using the to maintain a list of COUNTY providers
ASAM criteria and determine a or provider organizations to be made
presumptive level of care. Once available to Members upon request.
the client attends an intake at a 5. Any updates to the list will be provided
COUNTY contracted provider, to ANTHEM liaison quarterly and upon
they will be assessed for medical request.
necessity including diagnosis.
COUNTY centralized intake will
approve services through a
Treatment Authorization Request
process.
4. COUNTY will continually monitor
the COUNTY provider network to
ensure Member access to quality
behavioral health care.
COUNTY will assist ANTHEM in
arranging for a specific COUNTY
provider or community service.
5. COUNTY will assist ANTHEM to
develop and update a list of
providers or provider
organizations to be made
available to Members. For
mental health services this list is
available on the COUNTY's
managed care website. Any
updates to the list will be
forwarded to the ANTHEM liaison
quarterly and upon request. For
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 ANTHEM liaison
quarterly and upon request.
C. Medical 1. COUNTY will follow all applicable 1. ANTHEM and contracted providers are
Records laws pertaining to the use and allowed to release medical information
Exchange of disclosure of protected health under HIPAA regulations specific to the
Information information including but not HIPPA Privacy Rule (45 C.F.R. Part
limited to: 164.)
• HIPAA/45 C.F.R. Parts 160 2. ANTHEM will follow procedures for
and 164 exchanges of medical information that
• LPS /W & I Code Sections allow for care coordination and effective
5328-5328.15
Revised Exhibit A
Page 3 of 35
CATEGORY COUNTY ANTHEM
• 45 C.F.R. Part 2 communication among COUNTY,
• HITECH Act (42. U.S.C. ANTHEM, and contracted providers.
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,
ANTHEM, and contracted
providers.
D. Scope of 1. COUNTY has a toll-free 1. ANTHEM PCPs will be responsible for
Service telephone number available 24 providing 24 hours a day, seven days a
hours a day, seven days a week week, access to health care services for
for access to emergency, Members as specified in the ANTHEM
specialty mental health and contract with Department of Health Care
Substance Use Disorder services Services (DHCS).
for Members who meet the 2. PCP will refer to the COUNTY for
medical necessity criteria as assessment and appropriate services.
identified in Exhibit B, attached PCP's will refer Members for:
hereto. a. An assessment to confirm or
2. COUNTY maintains responsibility arrive at a diagnosis
for: b. Behavioral health services other
a. Medication treatment for than medication management
behavioral health are needed for a Member with a
conditions that would not diagnosis included in the
be responsive to physical responsibilities of the COUNTY.
healthcare-based c. For identification of conditions
treatment and the not responsive to physical
condition meets COUNTY healthcare-based treatment.
medical necessity criteria. 3. PCP's will provide primary care
b. All other outpatient behavioral health treatment which
specialty mental health includes:
and Substance Use a. Basic education, assessment
Disorder services covered (mental health services only),
by the COUNTY when the counseling (mental health
Member's behavioral services only) and referral and
health condition meets linkage to other services for all
COUNTY medical Members
necessity criteria, such as b. Medication and treatment for
individual and group i. Behavioral health
therapies, case conditions that would be
management, crisis responsive to physical
intervention, treatment healthcare-based
plan, assessment, and treatment
linkage with community
resources.
Revised Exhibit A
Page 4 of 35
CATEGORY COUNTY ANTHEM
c. Consultation and training ii. Behavioral health
services to PCPs, disorders due to a
particularly related to general medical condition
specialty mental health c. Medication-induced reactions
and Substance Use from medications prescribed by
Disorder issues and physical health care providers.
treatments, including 4. PCPs will provide or arrange for:
medication consultation. a. Covered medical services
3. To receive behavioral health b. Primary behavioral health
services, the Member must meet intervention for Member with
the criteria for each of the "Excluded Diagnosis" as
following categories for mental identified in Specialty Mental
health services: Health Services identified in
d. Category A—Included ATTACHMENT A, Page 17 of
Diagnosis this Exhibit A.
e. Category B—Impairment c. Screening and brief intervention
Criteria for behavioral health services
f. Category C—Intervention within the PCP's scope of
Related Criteria practice
Per Enclosure 1a of Exhibit 5. ANTHEM and COUNTY recognize that
A. the PCP's ability to treat behavioral
4. To receive behavioral health health disorders will be limited to each
services, the Member must meet provider's training and 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 ANTHEM and PCP will be responsible
services: for coordinating a referral in accordance
a. Early Intervention Services with Category B2 "Mental Health
b. Outpatient/Intensive Services" or an ANTHEM contracted
Outpatient 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, ANTHEM
d. Withdrawal Management and PCP will refer client to a county
e. Opioid Treatment 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. ANTHEM will implement the following
Codes see Enclosure 1 b. elements at the point of care to ensure
2. COUNTY providers will refer clinical integration between the Drug
Members back to their identified Medi-Cal Organized Delivery System
PCP for medical and non- and ANTHEM providers:
specialty behavioral health a. Comprehensive substance use,
conditions that would be physical and mental health
responsive to appropriate screening
physical health care. b. Member engagement and
3. COUNTY will implement the participation in an integrated care
following elements at the point of program as needed
Revised Exhibit A
Page 5 of 35
CATEGORY COUNTY ANTHEM
care to ensure clinical integration c. Shared development of care plans
between the Drug Medi-Cal by the Member, caregivers, and all
Organized Delivery System and providers
ANTHEM providers: d. Delineation of case management
a. Comprehensive responsibilities
substance use, physical e. Navigation support for patients and
and mental health caregivers
screening. f. ANTHEM will work collaboratively
b. Member engagement and with COUNTY and contracted
participation in an providers in the development of
integrated care program Member treatment planning.
as needed.
c. Shared development of
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
ANTHEM and contracted
providers in the
development of Member
treatment planning.
E. Ancillary 1. When medical necessity criteria 1. ANTHEM must cover and pay for
Behavioral Health are met and services are 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. ANTHEM will cover and pay for
based specialty mental health related services for Electroconvulsive
ancillary services, which include, Therapy (ECT), anesthesiologist
but are not limited to services provided on an outpatient
Electroconvulsive therapy (ECT) basis, per Exhibit B, attached hereto.
and magnetic resonance imaging 2. ANTHEM will cover and pay for all
(MRI) that are received by a medically necessary professional
Member admitted to a psychiatric services to meet the physical health
inpatient hospital other than care needs of the Members who are
routine services, per Exhibit B, admitted to the psychiatric ward of a
attached hereto. general acute care hospital or to a
2. When Substance Use Disorder freestanding licensed psychiatric
medical necessity criteria is met inpatient hospital or Psychiatric Health
and services are approved by the Facility (PHF). These services include
COUNTY for ASAM levels 3.7 the initial health history and physical
and 4.0 and medical detox, assessment required within 24 hours of
admission and any medically necessary
Revised Exhibit A
Page 6 of 35
CATEGORY COUNTY ANTHEM
COUNTY will refer Member to physical medicine consultation, per
ANTHEM. Exhibit B, attached hereto.
3. COUNTY will make training 3. ANTHEM is not required to cover room
available for community based and board charges or behavioral health
physicians interested in providing services associated with a Member's
Medically Assisted Treatment admission to a hospital or inpatient
(MAT) services, including an psychiatric facility for psychiatric
eight hour Buprenorphine Waiver inpatient services, per Exhibit B,
Training required to become a attached hereto.
community based MAT provider. 4. ANTHEM 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. ANTHEM 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. ANTHEM 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. ANTHEM 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
Revised Exhibit A
Page 7 of 35
CATEGORY COUNTY ANTHEM
care and daily physician visits to modify
withdrawal management regimen and
manage medical instability. Once the
client has stabilized ANTHEM will refer
to a lower level of care to increase the
likelihood of successful recovery.
8. ANTHEM 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. ANTHEM
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. ANTHEM shall coordinate with
COUNTY Narcotic Treatment Program
providers when medically indicated for
MAT services.
E1. Emergency 1. The COUNTY toll free 24 hour 1. ANTHEM will maintain a 24 hour
Room Urgent line is available to Members. member service and Nurse Advice Line.
Behavioral Health 2. The COUNTY shall cover and 2. ANTHEM shall cover and pay for all
Care pay for the professional services professional services, except the
of a behavioral health specialist professional services of a behavioral
provided in an emergency room health specialist when required for the
to a Member whose condition emergency services and care of a
meets COUNTY medical member whose condition meets
necessity criteria or when COUNTY medical necessity criteria.
behavioral health specialist 3. ANTHEM shall cover and pay for the
services are required to assess facility charges resulting from the
whether COUNTY medical emergency services and care of a
necessity is met, per Exhibit B, Member whose condition meets
attached hereto. COUNTY medical necessity criteria
3. The COUNTY is responsible for when such services and care do not
the facility charges resulting from result in the admission of the member
the emergency services and care for psychiatric and/or Substance Use
of a Member whose condition Disorder inpatient hospital services or
meets COUNTY medical when such services result in an
necessity criteria when such admission of the member for psychiatric
services and care do result in the and/or Substance Use Disorder inpatient
admission of the Member for hospital services at a different facility.
psychiatric and/or Substance 4. ANTHEM shall cover and pay for the
Use Disorder inpatient hospital facility charges and the medical
services at the same facility. The professional services required for the
Revised Exhibit A
Page 8 of 35
CATEGORY COUNTY ANTHEM
facility charge is not paid emergency services and care of a
separately, but is included in the Member with an excluded diagnosis or a
per diem rate for the inpatient Member whose condition does not meet
stay, per Exhibit B, attached COUNTY medical necessity criteria and
hereto. such services and care do not result in
4. The COUNTY is responsible for the admission of the Member for
facility charges directly related to psychiatric and/or Substance Use
the professional services of a Disorder inpatient hospital services.
behavioral health specialist 5. Payment for the professional services of
provided in the emergency room a behavioral health specialist required
when these services do not result for the emergency services and care of
in an admission of the member a Member with an excluded diagnosis is
for psychiatric and/or Substance the responsibility of ANTHEM.
Use Disorder inpatient hospital
services at that facility or any
other facility, per Exhibit B,
attached hereto.
E2. Home Health 1. COUNTY shall cover and pay for 1. ANTHEM will cover and pay for prior
Agency Services medication support services, authorized home health agency services
case management, crisis as described in Title 22, CCR, Section
intervention services, or any 51337 prescribed by an ANTHEM
other specialty mental health provider when medically necessary to
services as provided under meet the needs of homebound
Section 1810.247, which are Members. ANTHEM is not obligated to
prescribed by a psychiatrist and provide home health agency services
are provided to a Member who is that would not otherwise be authorized
homebound. COUNTY will by the Medi-Cal program.
collaborate with ANTHEM on any 2. ANTHEM will refer Members who may
specialty mental health services be at risk of institutional placement to
being provided to a Member. the Home and Community Based
services (HCBS) Waiver Program
(ANTHEM/DHCS Contract 6.7.3.8) if
appropriate.
E3. Nursing and 1. COUNTY will arrange and 1. ANTHEM will arrange and pay for
Residential coordinate payment for nursing 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. ANTHEM will arrange for disenrollment
necessity criteria and who from managed care if Member needs
require a special treatment nursing services for a longer period of
program [Title 22, California time.
Code of Regulations (CCR), 3. ANTHEM will pay for all medically
Section 51335(k)]. necessary DHCS contractually required
2. COUNTY's provide medically Medi-Cal covered services until the
necessary specialty mental disenrollment is effective.
Revised Exhibit A
Page 9 of 35
CATEGORY COUNTY ANTHEM
health services, typically visits by
psychiatrists and psychologists.
E4. Emergency 1. Medical transportation services 1. ANTHEM will arrange and pay for
Transportation, as described in Title 22, Section 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. ANTHEM will cover and pay for all
medically necessary emergency
transportation (per CCR Title 22,
51323). Ambulance services are
covered when the Member's medical
condition contraindicates the use of
other forms of medical transportation.
3. Emergency medical transportation is
covered, without prior authorization, to
the nearest facility capable of meeting
the medical needs of the Member as per
CCR Title 22, 51323.
4. Ambulance, litter van and wheelchair
van medical transportation services are
covered when the Member's medical
and physical condition is such that
transport by ordinary means of public or
private conveyance is medically
contraindicated, and transportation is
required for the purpose of obtaining
needed medical care. Ambulance
services are covered when the
member's medical condition
contraindicates the use of other forms of
medical transportation
5. ANTHEM will cover all nonemergency
medical transportation, necessary to
obtain program covered services. A
completed, signed ANTHEM Physician
Certification Statement (PCS) Form
Revised Exhibit A
Page 10 of 35
CATEGORY COUNTY ANTHEM
must be submitted to ANTHEM for the
NEW services to be arranged.
6. ANTHEM will cover and pay for
medically necessary non-emergency
medical transportation services when
prescribed for a Member by a Medi-Cal
behavioral health provider outside the
COUNTY when a PCS is submitted.
7. ANTHEM will maintain a policy of non-
discrimination regarding Members with
behavioral health disorders who require
access to any other transportation
services provided by ANTHEM.
8. ANTHEM shall/will provide Non-Medical
Transport (NMT) for all Medi-Cal
services including services not covered
by the ANTHEM 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. ANTHEM may use prior authorization
processes for NMT services. The
member's needs for NMT or NEW
services do not relieve ANTHEM from
complying with their timely access
standards obligation.
11. ANTHEM 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
Revised Exhibit A
Page 11 of 35
CATEGORY COUNTY ANTHEM
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. ANTHEM PCP will refer Members with
Developmentally developmental disabilities to the developmental disabilities to the Central
Disabled Services Central Valley Regional Center Valley Regional Center for non-medical
for non-medical services such as services such as respite, out-of-home
respite, out-of-home placement, placement supportive living, etc., if such
supportive living, etc., if such services are needed.
services are needed. 2. ANTHEM will maintain a current MOU
2. COUNTY has a current list of with Central Valley Regional Center
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.
E6. History and 1. COUNTY will utilize ANTHEM 1. ANTHEM will cover and pay for all
Physical for network providers to perform medically necessary professional
Psychiatric medical histories and physical services to meet the physical health
Hospital examinations required for care needs of Members who are
Admission behavioral health examinations admitted to the psychiatric ward of a
required for behavioral health general acute care hospital or
and psychiatric hospital freestanding licensed psychiatric
admissions for ANTHEM inpatient hospital. These services
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. ANTHEM is responsible for separately
Outpatient all psychiatric professional services billable outpatient services related to
Department associated with electroconvulsive electroconvulsive therapy, such as
Services therapy. Per Title 9, CCR Section anesthesiologist services, per Exhibit B,
(Electroconvulsive 1810.350 attached hereto.
Therapy) 2. ANTHEM will cover and pay for
professional services and associated
room charges for hospital outpatient
department services consistent with
medical necessity and ANTHEM`s
Revised Exhibit A
Page 12 of 35
CATEGORY COUNTY ANTHEM
contract with its contractors and DHCS,
per Exhibit B, attached hereto.
F. Diagnostic 3. COUNTY or COUNTY provider 1. ANTHEM will provide Members with
Assessment and will screen and apply ASAM Substance Use Disorder screenings,
Triage criteria for level of care brief intervention (SBIRT), referral and
placement. When Member is assessment. If it is found that a Member
determined to meet medical preliminarily meets medical necessity for
necessity for a level of care not COUNTY provided services ANTHEM
provided by COUNTY Member will refer the Member to an appropriate
will be referred to ANTHEM. COUNTY access point (24/7 Access
4. COUNTY will arrange and pay Line, Urgent Care Wellness Center or
for specialty COUNTY provider COUNTY provider)for further
services for Members whose assessment and treatment.
psychiatric condition may not be 2. ANTHEM will arrange and pay for
responsive to physical health assessments of ANTHEM members by
care. PCPs to:
a. Initial access and a. Rule out general medical
availability will be via the conditions causing psychiatric
COUNTY Access Unit (a and/or Substance Use Disorder
twenty-four hour toll free symptoms.
telephone triage system) b. Rule out behavioral health
b. Crisis/emergency triage disorders caused by a general
via COUNTY provider is medical condition.
available 24 hours a day. 3. The PCP will identify those general
5. COUNTY provider will assess medical conditions that are causing or
and diagnose Member's exacerbating psychiatric and/or
symptoms, level of impairment Substance Use Disorder symptoms.
and focus of intervention. 4. The PCP will be advised to identify and
Included ICD-9 Diagnoses codes treat non-disabling psychiatric conditions
are identified in Enclosure la, which may be responsive to primary
attached hereto and incorporated care, i.e., mild to moderate anxiety
herein. and/or depression.
6. COUNTY provider assessments 5. When medically necessary ANTHEM
will: will cover and pay for physician services
c. Determine if Member provided by specialists such as
meets medical necessity neurologists, per Exhibit B, attached
criteria (See Attachment hereto.
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
Revised Exhibit A
Page 13 of 35
CATEGORY COUNTY ANTHEM
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 ANTHEM staff and ANTHEM staff and/or PCP will refer
providers. ANTHEM providers those Members whose psychiatric
and Members will be referred to condition or Substance Use Disorder
determine medical necessity for would not be responsive to physical
specialty mental health services. health care to the COUNTY to
For Substance Use Disorder determine if specialty mental health
members, screening will be and/or Substance Use Disorder services
completed to determine if further medical necessity criteria are met.
assessment is necessary. If so 2. ANTHEM and PCP will coordinate and
clients will be referred to the 24/7 assist the COUNTY and Member to
Access Line. keep their appointments and referrals
2. COUNTY will coordinate with back to their PCP as appropriate for all
ANTHEM Customer Care Center other services not covered by the
to facilitate appointment and COUNTY.
referral verification assistance as a. ANTHEM may request
needed. assistance from the COUNTY
3. When all medical necessity Liaison to facilitate removal of
criteria are met, COUNTY will barriers to a successful referral
arrange for specialty mental such as transportation
health and/or Substance Use difficulties, resistance to
Disorder services by COUNTY treatment or delays to access.
provider. 3. Members not meeting COUNTY medical
4. When Member is appropriately necessity guidelines will be referred by
treated and/or stabilized, ANTHEM to appropriate community
Member may be referred back, if resources for assistance in identifying
appropriate to PCP for programs available for low income Medi-
maintenance care. The COUNTY Cal beneficiaries.
and ANTHEM will coordinate
services as necessary in such
cases
5. COUNTY and COUNTY provider
will track referrals to PCP to
verify that Member has access to
Revised Exhibit A
Page 14 of 35
CATEGORY COUNTY ANTHEM
appointment and assistance to
keep appointment as needed.
a. COUNTY provider will
have the option of contacting
the ANTHEM Health Services
for information and
assistance concerning a
referred Member.
6. The COUNTY will refer the
Member to a source of treatment
or a source of referral for
treatment outside the COUNTY
when the COUNTY determines
that the Member's diagnosis is
not included in Title 9, CCR,
Section 1830.205.
7. Per Welfare & Institution Code,
Section 5777.5 (b)(1) for
behavioral health services the
COUNTY will designate a
process or entity to receive
notice of actions, denials, or
deferrals from ANTHEM, and to
provide any additional
information requested in the
deferral notice as necessary for a
medical necessity determination.
8. Per Welfare & Institution Code,
Section 5777.5(b) (2) for
behavioral health services the
COUNTY will respond by the
close of business day following
the day the deferral notice is
received.
H. Service 1. For mental health services, 1. ANTHEM will authorize medical
Authorizations COUNTY will authorize assessment and/or treatment services
assessment and/or treatment by ANTHEM network providers who are
services by COUNTY providers credentialed and contracted with
who are credentialed and ANTHEM for covered medically
contracted with COUNTY for necessary services.
services that meet specialty 2. ANTHEM will inform PCPs that they
mental health services medical may refer Members to the COUNTY for
necessity criteria. initial diagnosis and assessment of the
2. For Substance Use Disorder Member.
services, COUNTY will perform
screening and referral to
treatment. Once the provider
assessment is complete
Revised Exhibit A
Page 15 of 35
CATEGORY COUNTY ANTHEM
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 ANTHEM PCP providers as treated by both, in accordance with
it relates to specialty mental HIPAA federal and state regulations
health and/or Substance Use regarding confidentiality, per HIPPA
Disorder issues including but not Privacy Rule 45 C.F.R. Part 164.
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, ANTHEM and/or
confidentiality per HIPPA Privacy 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 ANTHEM medical services.
clinical consultation and training b. Treatment of physical symptoms
to the ANTHEM PCPs, other precipitated by medications used
behavioral health providers to treat behavioral health
and/or ANTHEM staff on the disorders.
following topics: c. Treatment of complicated sub-
a. Recommended physical syndrome medical symptoms.
healthcare-based d. Complex medication interactions
treatment for diagnosed with medications prescribed by
conditions PCP not commonly used in
b. Complex diagnostic psychiatric or Substance Use
assessment of behavioral Disorder specialty practice.
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,
Revised Exhibit A
Page 16 of 35
CATEGORY COUNTY ANTHEM
polypharmacy, use of
novel psychotropic
medication)
e. Treatment of complicated
sub-syndrome psychiatric
symptoms
f. Treatment of psychiatric
symptoms precipitated by
medications used to treat
medical conditions
g. Treatment of outpatient
behavioral health services
that are within the
ANTHEM PCP's scope of
practice.
3. For those Members who are
excluded from COUNTY
services, COUNTY will provide
clinical consultation and training
to the ANTHEM PCPs, and/or
ANTHEM staff on the following
topics:
a. ASAM Multidimensional
Assessment
b. From Assessment to
Service Planning and
Level of Care
c. Title 22/Documentation
d. Evidence Based
Practices
e. DSM-5
f. Co-occurring Disorders
g. Medication Assisted
Treatment
J. Early Periodic 1. COUNTY will utilize Medi-Cal 1. When ANTHEM determines that EPSDT
Screening, medical necessity criteria supplemental services criteria are not
Diagnosis and established for EPSDT met and the Member child's condition is
treatment supplemental services to not CCS eligible, ANTHEM will refer the
(EPSDT) determine if a child, 21 years of Member child to the PCP for treatment
Supplemental age and under, meets those of conditions within the PCP's scope of
Services. criteria. practice.
2. When EPSDT supplemental 2. Referrals to the COUNTY for an
criteria are met, COUNTY is appropriate linked program will be made
responsible for arranging and for treatment of conditions outside the
paying for EPSDT supplemental PCP's scope of practice. ANTHEM will
services provided by COUNTY assist the COUNTY and Members by
specialty mental health and providing links to known community
providers of supplemental services.
Revised Exhibit A
Page 17 of 35
CATEGORY COUNTY ANTHEM
Substance Use Disorder 3. ANTHEM will cover all medically
providers. necessary professional services to meet
3. When EPSDT supplemental the physical health care needs of
criteria are not met, COUNTY will Members admitted to a general acute
refer Member children as follows: care hospital ward or to a freestanding
a. For mental health licensed psychiatric inpatient hospital.
services, Referral to
California Children's
Services (CCS)-for those
children who have a CCS
medically eligible
condition and require
behavioral health provider
services related to the
eligible condition
b. For 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
ANTHEM of the referral.
K. 1. COUNTY providers will prescribe 1. ANTHEM 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
ANTHEM representatives to participating pharmacies and
ensure that psychotropic drugs laboratories on the internet.
prescribed by COUNTY c. Will make available the formulary
providers are included in the and information regarding drug
ANTHEM formulary and/or formulary procedures on the
available for dispensing by internet.
ANTHEM network pharmacies d. Consider recommendations from
unless otherwise stipulated by COUNTY for utilization
state regulation. management standards for
3. COUNTY will inform COUNTY behavioral health, pharmacy and
providers regarding process and laboratory services.
procedure for obtaining e. Provide the process for obtaining
prescribed medications for timely authorization and delivery
Members. of prescribed drugs and
4. COUNTY providers will utilize laboratory services to the
ANTHEM contracted laboratories COUNTY.
for laboratory tests required for 2. ANTHEM will coordinate with COUNTY
medication administration and to ensure that covered psychotropic
Revised Exhibit A
Page 18 of 35
CATEGORY COUNTY ANTHEM
management of psychotropic drugs prescribed by COUNTY providers
medications. are available through the authorization
5. COUNTY will assist ANTHEM in process or formulary for dispensing by
the utilization review of ANTHEM network pharmacies unless
psychotropic drugs prescribed by otherwise stipulated by state regulation.
out-of-network psychiatrists. (See Enclosure2, "Drugs Excluded from
6. COUNTY will share with Plan Coverage" of Exhibit B)
ANTHEM a list of non-contracted 3. ANTHEM will apply utilization review
psychiatrist COUNTY providers procedures when prescriptions are
contracted to provide behavioral written by out-of-network psychiatrists
health services in areas where for the treatment of psychiatric
access to psychiatrists is limited, conditions.
on a quarterly basis. a. Covered psychotropic drugs
written by out-of-network
psychiatrists will be filled by
ANTHEM network pharmacies.
b. ANTHEM will provide Members
with the same drug accessibility
written by out-of-network
psychiatrists as in-network
providers.
c. ANTHEM will not cover and pay
for behavioral health drugs
written by out-of-network
physicians who are not
psychiatrists unless these
prescriptions are written by non-
psychiatrists contracted by the
COUNTY to provide behavioral
health services in areas where
access to psychiatrists is limited
per Exhibit B, attached hereto.
4. ANTHEM PCPs will monitor the effects
and side effects of psychotropic
medications prescribed for those
members whose psychiatric conditions
are under their treatment.
5. Reimbursement to pharmacies for new
psychotropic drugs classified as
antipsychotics and approved by the FDA
will be made through the Medi-Cal FFS
system whether these drugs are
provided by a pharmacy contracting with
ANTHEM or by a FFS pharmacy, per
Enclosure 2 of this Exhibit A, attached
hereto and incorporated herein.
L. Laboratory, 1. COUNTY or a Medi-Cal FFS 1. ANTHEM will cover and pay for
Radiological and behavioral health services medically necessary laboratory,
Revised Exhibit A
Page 19 of 35
CATEGORY COUNTY ANTHEM
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 ANTHEM medications prescribed to treat the
contract providers. behavioral health diagnosis) as
described in Title 22, CCR Section
51311 and Exhibit B, attached hereto.
2. ANTHEM will coordinate and assist the
COUNTY or Medi-Cal FFS behavioral
health provider in the delivery of
laboratory radiological or radioisotope
services.
3. A list of ANTHEM contracted providers
is available on-line.
4. Provide the process for obtaining timely
authorization and delivery of prescribed
drugs and laboratory services.
M. Grievances 1. COUNTY will share with 1. ANTHEM has in place a written process
and Complaints ANTHEM its established for the submittal, processing and
processes for the submittal, resolution of all member and provider
processing and resolution of all grievances and complaints which is
member and provider grievances inclusive of any aspect of the health
and complaints regarding any care services or provision of services.
aspect of the behavioral health 2. ANTHEM liaison will coordinate and
care services in accordance with share the established complaint and
CFR 42 Part 438. These grievance process for its Members with
processes include the COUNTY
timelines/deadlines and member
information that must be
provided.
2. COUNTY and ANTHEM will work
collaboratively to resolve any
formal grievance or complaint
brought to the attention of either
plan.
N. Appeal 1. COUNTY will ensure that the 1. ANTHEM will ensure that Members and
Resolution Members and providers are providers are given an opportunity for
Process given an opportunity for reconsideration and an appeal for
reconsideration and appeal for denied, modified or delayed services
denied, modified or delayed 2. ANTHEM will ensure that medically
services. necessary services continue to be
2. COUNTY will ensure that the provided to Members while the dispute
Members receive specialty is being resolved. ANTHEM's appeal
mental health and/or Substance
Revised Exhibit A
Page 20 of 35
CATEGORY COUNTY ANTHEM
Use Disorder services and process will be shared with the
prescription drugs while the COUNTY.
dispute is being resolved.
3. COUNTY will identify and provide
ANTHEM with the name and
telephone number of a
psychiatrist or other qualified
licensed mental health
professional available to provide
clinical consultation, including
consultation on medications to
the ANTHEM provider
responsible for the beneficiary's
care.
O. Conflict 1. COUNTY Liaison will meet with 1. Local ANTHEM liaison will meet with the
Resolution/MOU the ANTHEM Liaison to monitor COUNTY Liaison to monitor this MOU
Monitoring this MOU quarterly and/or upon quarterly and/or upon request.
request. a. Within two weeks of a formal
a. Within two weeks of a request, ANTHEM Liaison will
formal request, COUNTY meet with the COUNTY Liaison
Liaison will meet with when the COUNTY or ANTHEM
ANTHEM Liaison when management identifies problems
COUNTY or ANTHEM requiring resolution through the
management identifies MOU.
problems requiring b. ANTHEM Liaison will be
resolution through the responsible for coordinating,
MOU. assisting and communicating
b. COUNTY Liaison will be suggestions for MOU changes
responsible for for to ANTHEM and the
coordinating, assisting COUNTY leadership.
and communicating c. ANTHEM will coordinate and
suggestions for MOU communicate MOU changes to
changes to the COUNTY the California Department of
leadership and ANTHEM. Health Care Services (DHCS),
c. COUNTY Liaison will COUNTY providers and
communicate and ANTHEM network services
coordinate MOU changes providers.
to the State Department d. ANTHEM Liaison will make a
of Health Care Services good faith effort to agree to
(DHCS), COUNTY resolutions that are in the best
service providers and to interest of Members and are
ANTHEM and its agreeable to all parties involved.
providers. 2. ANTHEM Liaison will conduct an annual
2. COUNTY Liaison will participate review, update and/or renegotiations of
in an annual review, update this MOU, as mutually agreed.
and/or renegotiations with 3. ANTHEM management will provide 60
ANTHEM, as mutually agreed. day advance written notice to COUNTY
Revised Exhibit A
Page 21 of 35
CATEGORY COUNTY ANTHEM
3. COUNTY management will should ANTHEM decide to modify this
provide 60 days advance written MOU.
notice to ANTHEM should the
COUNTY 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 1. COUNTY will comply with all 1. ANTHEM will comply with Confidentiality
Health applicable laws pertaining to use of Medical Information Act [California
Information and disclosure of PHI including Civil Code 56 through 56.371 the Patient
but not limited to: Access to Health Records Act
• HIPAA/45 C.F.R. Parts (California Health and Safety Code
160 and 164 123100, et seq) and the Health
• LPS /W & I Code Insurance Portability and Accountability
Sections 5328-5328.15 Act (Code of Federal Regulations Title
45 C.F.R. Part 2 45 Parts 160 and 164).
• HITECH Act (42. U.S.C. 2. ANTHEM will train its workforce in
Section 17921 et. seq. policies and procedures regarding
• CMIA (Ca Civil Code 56 Protected Health Information (PHI) as
through 56.37) necessary and appropriate to perform
2. COUNTY will train its workforce processes and functions within the
in policies and procedures scope of duties under this MOU.
regarding Protected Health 3. ANTHEM will encrypt any data
Information (PHI) as necessary transmitted via Electronic Mail (Email)
and appropriate to perform containing confidential data of Members
processes and functions within such as PHI and Personal Confidential
the scope of duties under this Information (PCI) or other confidential
MOU. data to ANTHEM or anyone else
3. Only encrypted PHI as specified including state agencies.
in the HIPAA Security Rule will 4. ANTHEM will notify COUNTY within 24
be transmitted via email. hours during a work week of any
Unsecured PHI will not be suspected or actual breach of security,
transmitted via email. intrusion or unauthorized use or
4. COUNTY will notify ANTHEM disclosure of PHI and/or any actual or
within 24 hours during a work suspected use or disclosure of data in
week of any suspected or actual violation of any applicable Federal and
breach of security, intrusion or State laws 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. ANTHEM liaison will conduct an annual
Revised Exhibit A
Page 22 of 35
CATEGORY COUNTY ANTHEM
Q. Routine in an annual review, update review, update and/or renegotiations of
Dispute and/or renegotiations with this agreement with the COUNTY as is
Resolution ANTHEM on this agreement as is mutually agreed.
Process mutually agreed. 2. When ANTHEM has a dispute with the
2. When the COUNTY has a COUNTY that cannot be resolved to the
dispute with ANTHEM that satisfaction of ANTHEM concerning the
cannot be resolved to the obligations of the COUNTY or ANTHEM
satisfaction of the COUNTY under their respective contracts with the
concerning the obligations of the DHCS, State Medi-Cal laws and
COUNTY or ANTHEM under regulations, or with this MOU as
their respective contracts with the described in Section 1810.370*, the
DHCS, State Medi-Cal laws and COUNTY may submit a request for
regulations, or with this MOU as resolution to the Department.
described in Section 1810.370*, 3. Regardless of MOU status, ANTHEM
the COUNTY may submit a and COUNTY must complete the
request for resolution to the dispute resolution process in paragraph
Department. 2 above, within 15 business days of
3. Regardless of MOU status, identifying the dispute. Within three
COUNTY and ANTHEM must business days after a failure to resolve
complete the plan level dispute the dispute during that timeframe, either
resolution process in paragraph 2 the COUNTY or ANTHEM must submit
above, within 15 business days a written "Request for Resolution" to
of identifying the dispute. Within DHCS.
three business days after a 4. If ANTHEM submits the Request for
failure to resolve the dispute Resolution it must be signed by
during that timeframe, either the ANTHEM's Plan President or designee.
COUNTY or ANTHEM must The Request for Resolution must
submit a written "Request for include:
Resolution" to DHCS. a. A summary of the disputed
4. If COUNTY submits the Request issue(s) and a statement of the
for Resolution it must be signed desired remedies, including any
by COUNTY Director or disputed services that have been
designee. The Request for or are expected to be delivered to
Resolution must include: the member by either ANTHEM or
a. A summary of the disputed the COUNTY and the expected
issue(s) and a statement of rate of payment for each type of
the desired remedies, service;
including any disputed b. A history of the attempts to resolve
services that have been or the issue(s)with the COUNTY;
are expected to be c. Justification for
delivered to the member by ANTHEMHEALTH's desired
either ANTHEM or the remedy; and
COUNTY and the expected d. Any additional documentation that
rate of payment for each ANTHEM deems relevant to
type of service; resolve the disputed issue(s), if
b. A history of the attempts to applicable.
resolve the issue(s) with the 5. The Request for Resolution must be
COUNTY; submitted via secure email to:
c. Justification for ANTHEM's MCQMD dhcs.ca. ov.
Revised Exhibit A
Page 23 of 35
CATEGORY COUNTY ANTHEM
desired remedy; and 6. Within three business days of receipt of
d. Any additional a Request for Resolution from
documentation that ANTHEM, DHCS will forward a copy of
COUNTY deems relevant the Request for Resolution to the
to resolve the disputed Director of the affiliated COUNTY via
issue(s), if applicable. 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(a-dhcs.ca.gov. a response to ANTHEM's Request for
6. Within three business days of Resolution and to provide any relevant
receipt of a Request for documents to support the COUNTY's
Resolution from COUNTY, position. If the COUNTY fails to
DHCS will forward a copy of the respond, DHCS will render a decision on
Request for Resolution to the disputed issue(s) based on the
ANTHEM via secure email documentation submitted by ANTHEM.
("Notification").ANTHEM will 7. If ANTHEM requests a rate of payment
have three business days from in its Request for Resolution, and
the receipt of Notification to ANTHEM prevails, the requested rate
submit a response to COUNTY's shall be deemed correct, unless the
Request for Resolution and to COUNTY disputes the rate of payment
provide any relevant documents in its response. If the COUNTYfails to
to support the ANTHEM's respond, DHCS will render a decision on
position. If ANTHEM fails to the disputed issue(s) based on the
respond, DHCS will render a documentation submitted by ANTHEM.
decision on the disputed issue(s) 8. At its discretion, DHCS may allow
based on the documentation representatives of ANTHEM and
submitted by COUNTY. COUNTY the opportunity to present oral
7. If COUNTY requests a rate of arguments.
payment in its Request for 9. The Managed Care Quality and
Resolution, and the COUNTY Monitoring Division and the Medi-Cal
prevails, the requested rate shall Behavioral Health Division will make a
be deemed correct, unless joint recommendation to DHCS'
ANTHEM disputes the rate of Director, or the Director's designee,
payment in its response. If based on their review of the submitted
ANTHEM fails to respond, DHCS documentation; the applicable statutory,
will render a decision on the regulatory, and contractual obligations of
disputed issue(s) based on the ANTHEM and the COUNTY; and any
documentation submitted by the oral arguments presented.
COUNTY. 10. Within 20 business days from the third
8. At its discretion, DHCS may business day after the Notification date,
allow representatives of DHCS will communicate the final
ANTHEM and COUNTY the decision via secure email to ANTHEM's
opportunity to present oral Plan President (or designee, if the
arguments. designee submitted the Request for
9. The Managed Care Quality and Resolution) and the COUNTY's Director
Monitoring Division and the Medi- (or the Director's designee, if the
Cal Behavioral Health Division designee submitted the Request for
will make a joint recommendation Resolution). DHCS' decision will state
to DHCS' Director, or the the reasons for the decision, the
Revised Exhibit A
Page 24 of 35
CATEGORY COUNTY ANTHEM
Director's designee, based on determination of rates of payment (if the
their review of the submitted rates of payment were disputed), and
documentation; the applicable any actions ANTHEM and COUNTY are
statutory, regulatory, and required to take to implement the
contractual obligations of decision. Any such action required from
ANTHEM and the COUNTY; and either ANTHEM or the COUNTY must
any oral arguments presented. be taken no later than the next business
10. Within 20 business days from the day following the date of the decision.
third business day after the 11. A dispute between ANTHEM and the
Notification date, DHCS will COUNTY will not delay medically
communicate the final decision necessary specialty mental health
via secure email to ANTHEM's services, physical health care services,
Plan President (or designee, if or related prescription drugs and
the designee submitted the laboratory, radiological, or radioisotope
Request for Resolution) and the services to beneficiaries, when it is
COUNTY's Director (or the reasonably foreseeable that delay in the
Director's designee, if the provision of services is likely to harm the
designee submitted the Request beneficiary.
for Resolution). DHCS' decision 12. Nothing in this section will preclude a
will state the reasons for the beneficiary from utilizing ANTHEM's
decision, the determination of beneficiary problem resolution process
rates of payment (if the rates of or any similar process offered by the
payment were disputed), and any COUNTY or to request a fair hearing.
actions ANTHEM and COUNTY 13. If a dispute occurs between the member
are required to take to implement and ANTHEM or COUNTY, the member
the decision. Any such action will continue to receive medically
required from either ANTHEM or necessary health care and mental health
the COUNTY must be taken no care services, including prescription
later than the next business day drugs until the dispute is resolved.
following the date of the decision.
11. A dispute between the COUNTY
and ANTHEM 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.
12. Nothing in this section will
preclude a beneficiary from
utilizing the COUNTY's
beneficiary problem resolution
process or any similar process
offered by ANTHEM or to request
a fair hearing.
Revised Exhibit A
Page 25 of 35
CATEGORY COUNTY ANTHEM
13. If a dispute occurs between the
member and the COUNTY or
ANTHEM, 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
ANTHEM continuing to provide
services to a beneficiary that
ANTHEM believes requires
specialty mental health services
from the COUNTY, the COUNTY
shall identify and provide
ANTHEM with the name and
telephone number of a
psychiatrist or other qualified
licensed mental health.
R. Expedited 1. ANTHEM and COUNTY may 1. ANTHEM and COUNTY may seek to
Dispute seek to enter into an expedited enter into an expedited dispute
Resolution dispute resolution process if a resolution process if a member has not
Process member has not received a received a disputed service(s) and
disputed service(s) and ANTHEM and/or COUNTY determine
ANTHEM and/or COUNTY that the Routine Dispute Resolution
determine that the Routine Process timeframe would result in
Dispute Resolution Process serious jeopardy to the member's life,
timeframe would result in health, or ability to attain, maintain, or
serious jeopardy to the regain maximum function.
member's life, health, or ability 2. Under this expedited process,
to attain, maintain, or regain ANTHEM and COUNTY will have one
maximum function. business day after identification of a
2. Under this expedited process, dispute to attempt to resolve the
ANTHEM and COUNTY will dispute at the plan level. Within one
have one business day after business day after a failure to resolve
identification of a dispute to the dispute in that timeframe, both
attempt to resolve the dispute plans will separately submit a Request
at the plan level. Within one for Resolution to DHCS, as set out
business day after a failure to above, including an affirmation of the
resolve the dispute in that stated jeopardy to the member.
timeframe, both plans will 3. If ANTHEM fails to submit a Request
separately submit a Request for for Resolution, DHCS will render a
Resolution to DHCS, as set out decision on the disputed issue(s)
above, including an affirmation based on the documentation submitted
of the stated jeopardy to the by the COUNTY.
member. 4. DHCS will provide a decision no later
3. If the COUNTY fails to submit a than one business day following
Revised Exhibit A
Page 26 of 35
CATEGORY COUNTY ANTHEM
Request for Resolution, DHCS DHCS' receipt of Request for
will render a decision on the Resolution from both parties and
disputed issue(s) based on the affirmation of the stated jeopardy to
documentation submitted by the member.
ANTHEM.
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, ANTHEM or COUNTY is
ANTHEM or COUNTY is required to comply with the
required to comply with 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 1 a.
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
Para hilias Delirium, Dementia, and Amnestic
• P 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
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 Opioid 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 ISeclative, 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 10ther Psychoactive Substance Dependence with Withdrawal, Unspecified
F19.24 10ther 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