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Fee for Service Providers

TERM Specialty Network Applications
 

Please Read: Provider Services Communications during the COVID-19 Crisis

This page is utilized by Fee For Service MediCal Providers to obtain documentation related to participation on the MediCal panel and continued authorizations for treatment.

Applications
1 Instructions and FAQs Credentialing and Contracting (pdf)
Revised 12/31/2020 2020-12-31
2 Credentialing Criteria (pdf)
2020-01-30
3 Credentialing Application Instructions (pdf)
2020-02-19
4 Provider Clinical Application Medi-Cal (docx)
Revised 10/22/2021 2021-10-29
5 FFS Specialty Addition App (docx)
12/28/2020 2020-12-31
6 Medi-Cal Documentation Training (pdf)
12/29/2020 2020-12-31
7 Form W-9 (pdf)
2017-11-02

Beneficiary Materials
ACL Poster (pdf)
2016-10-12
ACL Poster - Lo-Res (pdf)
English 2019-04-26
Advance Directive - English (pdf)
2021-09-17
Beneficiary Form Tables.xlsx
2020-04-14
Beneficiary Non-Discrimination Notice - ENGLISH (pdf)
English 2018-08-07
Full Guide English 2019 (pdf)
English 2019-02-01
Grievance and Appeal Form - CCHEA Advocacy English (pdf)
Revised 01/15/2016 2018-05-25
Grievance and Appeal Form - JFS Advocacy (pdf)
Revised 01/15/2016 2018-05-25
Grievance and Appeal Process (pdf)
English 2017-12-13
Limited English Proficiency Poster - English (pdf)
English 2018-05-25
NOABD Delivery System Notice - ENGLISH (doc)
English 2018-08-07
NOABD Language Assistance Notice - ENGLISH (pdf)
English 2018-08-07
NOABD Your Rights Notice - ENGLISH (pdf)
English 2018-08-07
NPP Acknowledgement - English (pdf)
English 2021-09-15
Notice of Privacy Practices English (pdf)
Revised 12/16/2014 2018-05-25
Quick Guide to MH Services - English (pdf)
2021-09-15
SD Grievance-Appeal POSTER English (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER English LARGE FONT (pdf)
Revised 03/05/2019 2021-07-14
SD Grievance-Appeal POSTER English LARGE FONT (pdf)
Revised 03/05/2019 2021-07-15

Claims
LMFT/LCSW/LPCC Billing Codes (pdf)
09/01/2021 2021-09-07
MD/DO Billing Codes (pdf)
09/01/2021 2021-09-07
PNP/PA Billing Codes (pdf)
09/01/2021 2021-09-07
PhD/PsyD Billing Codes (pdf)
09/01/2021 2021-09-07

Communications/Updates
CPT Codes 90846 and 99201 REMOVED from Fee Schedule (pdf)
Effective 04/01/2021 2022-01-27
CalAIM Changes to Medical Necessity, Diagnosis & Reasons for Recoupment (pdf)
Effective 01/01/2022 2022-01-27
False Claims Act Requirement 2022 (pdf)
Effective 01/13/2022 2022-01-27
HSD Pharmacy Benefit Quick Guide (pdf)
Effective 01/01/2022 2022-01-27
Mandatory E-Prescriptions (pdf)
Effective 01/01/2022 2022-01-27
Microsoft Word - Optum Response to Presumptive Transfer Inquiries in SD -3.9.18
OPTUMIST Newsletter Fall 2021 (pdf)
10/29/2021 2021-11-02
OPTUMIST Newsletter Spring 2021 (pdf)
2021-05-03
OPTUMIST Newsletter Summer 2021 (pdf)
07/31/2021 2021-09-08
OPTUMIST Newsletter Winter 2021 (pdf)
2021-01-29
Request to Complete Short Questionnaire (pdf)
Sent - 10/19/2021 2021-10-19
Therapeutic Behavioral Services Prior Authorization Request & Referral Process (pdf)
Memo - August 9, 2019 2019-08-09

Forms

Ancillary Specialty Mental Health Services Request (docx)
Revised 01/01/20 2019-12-31
Authorization to Use of Disclose PHI - ARABIC (pdf)
Arabic 2017-02-17
Authorization to Use or Disclose PHI - CHILD (dot)
2017-02-17
Authorization to Use or Disclose PHI - ENGLISH (pdf)
English 2017-02-17
Authorization to Use or Disclose PHI - SPANISH (pdf)
Spanish 2017-02-17
Authorization to Use or Disclose PHI - TAGALOG (pdf)
Tagalog 2017-02-17
Authorization to Use or Disclose PHI - VIETNAMESE (pdf)
Vietnamese 2017-02-17
BHS Serious Incident Report (docx)
2021-02-17
BHS Serious Incident Report of Findings (docx)
2021-02-17
Coordination of Care Form - Arabic (doc)
Arabic 2018-05-25
Coordination of Care Form - Arabic (pdf)
Arabic 2019-01-23
Coordination of Care Form - English (doc)
English 2019-01-23
Coordination of Care Form - English (pdf)
English 2019-03-06
Coordination of Care Form - Spanish (doc)
Spanish 2019-03-06
Coordination of Care Form - Spanish (pdf)
Spanish 2019-03-06
Coordination of Care Form - Tagalog (doc)
Tagalog 2019-03-06
Coordination of Care Form - Tagalog (pdf)
Tagalog 2019-03-06
Coordination of Care Form - Vietnamese (doc)
Vietnamese 2019-03-06
Coordination of Care Form - Vietnamese (pdf)
Vietnamese 2019-03-06
Demographic Form Fill (docx)
Revised 06/21/2021 2021-07-29
Discharge Summary (docx)
2021-11-03
Discharge Summary (pdf)
2021-08-12
ECT Authorization Request Form (pdf)
Revised 10/16/2020 2020-10-22
Example - Outpatient Authorization Request Form - Therapists (pdf)
Revised 10/06/2021 2021-10-26
Initial Assessment (docx)
2021-08-19
Initial Assessment (pdf)
2021-08-12
Interpreter Services Request Form (pdf)
2019-07-29
JV-220 Application For Psychotropic Medication
2016-07-01
JV-220(A) Physician's Statement—Attachment
Judicial Council forms 2018-03-01
JV-220(B) Physician's Request to Continue Medication—Attachment
Judicial Council forms 2018-03-01
MFT Eligibility Verification Form (pdf)
2019-03-06
Med Management Progress Note (pdf)
2021-08-12
Med Management-Psychotherapy Note (pdf)
2021-08-12
Medi-Cal Behavioral Health Transition of Care Form (doc)
2019-03-06
NOABD Your Rights Notice - VIETNAMESE (pdf)
Vietnamese 2018-08-07
Progress Note (docx)
2021-08-16
Progress Note (pdf)
2021-08-12
Psych Testing Request Form (docx)
2019-01-24
Psychotropic Medication Informed Consent Guide (pdf)
2020-05-13
Serious Incident Report - Explanation (pdf)
2020-10-08
Serious Incident Report of Findings Explanation (pdf)
2020-11-05
TBS Prior Authorization Request and Referral Form (docx)
Revised 07/26/2019 2020-07-07
Treatment Plan (docx)
Templates 2017-04-25
Treatment Plan and Informed Consent for Psychotropic Medication (pdf)
Templates 2020-05-13

Manuals

FFS Operations Handbook (pdf)
Revised 01/31/2021 2021-01-13
Inpatient Operations Manual (pdf)
Revised 07/30/2020 2021-10-26

Quick Reference

Adult MediCal Mental Health Severity Analysis Tool (pdf)
2016-08-30
Demographic Form Fill - Required Fields (pdf)
Revised 06/01/2021 2021-10-14
MediCal Behavioral Health Quick Guide (pdf)
2016-08-10
MediCal Quick Reference Guides (pdf)
2015-10-09
Mild-Moderate-Severe FAQs (pdf)
Effective 09/01/2016 2016-10-24
Timely Access to Care (pdf)
2018-04-30

Review - Outpatient
Beneficiary Form Tables.xlsx
2020-04-14
DHCS Reasons for Recoupment FY 19-20 (pdf)
2020-05-22
DHCS Reasons for Recoupment FY 20-21 (pdf)
2021-03-19
Documentation Tip Sheet (pdf)
Revised 04/13/2020 2020-04-13
Initial Client Checklist (pdf)
Revised 04/2020 2020-04-09
Pre-Credentialing_Site_Review_Tool_(pdf)
2019-10-30
Reasons for Recoupment Quick Guide FY 18-19 (pdf)
2019-02-01
Record Keeping and Treatment Record Requirements (pdf)
2017-08-07
Site Review Tool (pdf)
2020-09-17
Treatment Record Review Tool (pdf)
Revised 07/07/2021 2021-07-07

Review - Inpatient
Inpatient Professional Service Documentation Guide (pdf)
2018-07-12
Inpatient Review Tool (pdf)
2017-08-07

Training
Optum San Diego Website Provider Registration Instructions (pdf)
Updated 08/19/2019 2019-08-19
Federal and State False Claims Act - Contractor Roles and Responsibilities (pdf)
PowerPoint Presentation 2020-04-03
New Provider Orientation
PowerPoint Presentation 2018-11-16
Privacy and Security Training (pdf)
Presentation 2019-08-14
Provider Orientation Presentation (pdf)
Revised 10/21/2021 2021-10-21
Quick Guide to Provider Orientation (pdf)
2019-02-13

CANS/PSC
CANS Instructions and Process (pdf)
Updated 08/01/2019 2019-08-05
CANS User Guide (pdf)
v1.0 July 2019 2019-09-16
CANS-PSC Completion Tip Sheet with link to Tools (pdf)
Updated 08/01/2019 2019-08-05
CYF mHOMS Client Information Sheet (pdf)
Revised 07/01/2020 2020-08-06
Electronic CANS & PSC Resources (pdf)
04/02/2020 2020-04-02
Electronic CANS Form (pdf)
04/02/2020 2020-04-02
Electronic CANS Form – Early Childhood Version (pdf)
2020-04-22
Electronic PSC - Parent Form (pdf)
04/02/2020 2020-04-02
Electronic PSC - Parent Form - Spanish (pdf)
04/02/2020 2020-04-02
Electronic PSC - Youth Form (pdf)
04/02/2020 2020-04-02
Electronic PSC - Youth Form - Spanish (pdf)
04/02/2020 2020-04-02

COVID-19
BHS Provider Notice #2 - COVID-19 Guidance Best Practice (pdf)
2020-03-25
BHS Provider Notice #3 - COVID-19 Guidance Best Practice (pdf)
2020-04-02
Outpatient Authorizations for Continuing Services during COVID-19 (pdf)
04/01/2020 2020-04-01
Telephone Telehealth Approved Notification (pdf)
2020-03-25
Working Remotely Business as Usual (pdf)
2020-03-25

Provider Services Info
Change From a Group to a Private Practice (pdf)
05/01/2020 2020-05-05
Change of Address, Phone, Demographics Form (pdf)
05/01/2020 2020-05-05