CalAIM Behavioral Health Initiative Frequently Asked Questions
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Below is a list of frequently asked questions have been collected from technical assistance and informational webinars and submissions to the BHCalAIM@dhcs.ca.gov email. DHCS will update this list on a quarterly basis.
Claiming
Can administrative day services be claimed in circumstances or facilities other than when in connection to a member moving from an acute psychiatric hospital setting to a non-acute residential treatment facility?
No. Only a hospital may claim for administrative day services. A hospital may claim for administrative days when a member no longer meets medical necessity for acute psychiatric hospital services but has not yet been accepted for placement at a non-acute residential treatment facility that meets the needs of the member.
If a client requests services with a different county Medi-Cal but does not follow through on transferring their Medi-Cal within the 30 days, will their services be covered for the previous months?
In accordance with ACWDL 18-02E, BHIN 21-032 and BHIN 21-072, there would be no interruption in benefits for the Medi-Cal beneficiary in the months prior to, during, or after an intercounty transfer (ICT) is initiated. There are also no restrictions in the Short Doyle/Medi-Cal (SD/MC) claiming system that will prevent claims from being approved while an ICT is in process. For substance use disorder claims, SD/MC is programed to accept claims submitted by either the county of responsibility or the county of residence. For specialty mental health services claims, SD/MC does not check the submitting county against the member’s county of residence or county of responsibility when the claim is for specialty mental health claims. SD/MC does verify that the submitting county matches either the member’s county of residence or county of responsibility for DMC and DMC-ODS claims. SD/MC does not apply any edits that require the beneficiary’s county of responsibility to change within any amount of time after the county of residence is updated.
Are designated mental health workers who are not license-eligible or waivered able to bill the “assessment" code at the same rate as an LPHA?
No. Services provided by individuals who are not licensed-eligible, waivered or a clinical trainee are not reimbursed at the same rate as an LPHA. Prior to payment reform, the rate reimbursed for an assessment was the same regardless of the individual who performs the assessment. As of July 1, 2023, when the Department implemented Payment Reform, reimbursement for an assessment performed by an LPHA is at a different rate than an assessment performed by a non-licensed individual who is not licensed-eligible, waivered, or a clinical trainee. The reimbursement rates to counties by procedure code, and provider type can be found on the Fee Schedule page on the DHCS website.
Each claim for a SMHS submitted by a MHP through the Short-Doyle system must include an ICD-10-CM diagnosis/ reason for encounter code. Can a claim be submitted with only a substance use disorder diagnosis code?
Reference BHIN 21-071; BHIN 21-075; BHIN 23-068;
No, a claim for a SMHS service cannot be submitted with only a substance use disorder diagnosis code. The reason for the encounter (ICD-10-CM code) must correspond to the medically necessary service provided to the beneficiary. If the service is a SMHS, then the reason for the encounter must include an ICD-10-CM code that corresponds to their mental health diagnosis or an ICD-10-CM code that indicates the reason for the service encounter that is related to the mental health condition (see BHIN 22-013). Please see question #1 above regarding the use of ICD-10-CM codes, including Z codes, even if a diagnosis of a mental health disorder is not established.
If the service is a SUD service (DMC/DMC-ODS), the claim must include an ICD-10-CM code that indicates a SUD diagnosis or an ICD-10-CM code that indicates the reason for the service encounter that is related to the SUD condition (see BHIN 22-013). Inpatient and residential claims must have at least one DMC covered substance use disorder ICD-10 diagnosis code as indicated in “Appendix 5-Covered Diagnoses" of the DMC-ODS and DMC State Plan Billing Manuals located on the MedCCC Library page. If the service is a inpatient or residential service and the diagnosis code is not a covered ICD-10 code, the service will be denied.
For further guidance on the use of ICD-10-CM diagnosis codes /reason for the encounter, please refer to the CMS code tabular (list of included diagnoses/reason for service encounter for SMHS and DMC / DMC-ODS services) and the CMS coding guidelines for 2024. These guidelines are updated at least annually.
