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.
Access Criteria to the Specialty Mental Health Services (SMHS) Delivery System
Is a mental health diagnosis required for access to covered SMHS?
Reference WIC section 14184.402
No. Per WIC section 14184.402, subdivision (f)(1)(a), a mental health diagnosis is not a prerequisite to accessing covered SMHS.
How long can SMHS be provided prior to a member receiving a mental health diagnosis?
Reference BHIN 23-068
Per BHIN 23-068, providers shall complete assessments within a reasonable time and in accordance with generally accepted standards of practice.
For members who begin specialty mental health services with Z codes, will they eventually require a mental health diagnosis, or can Z codes be the only diagnosis that is submitted for reimbursement? Can a Z code be the primary diagnosis?
Reference BHIN 26-001; BHIN 22-013; BHIN 26-002; W&I Code section 14184.402(f)(1)(A)
A mental health disorder diagnosis is not required to initiate medically necessary SMHS. Z-codes may be used during the assessment phase of SMHS when a formal diagnosis has not yet been established. Using Z-codes in this context meets federal requirement for claims documentation.
CMS reimburses medically necessary, covered services provided to eligible members when a Z code is used as the primary diagnosis. However, Z-codes do not independently justify payment; documentation must support medical necessity.
Z codes may also be used after the assessment phase, even if a mental health disorder diagnosis has not been established. This is particularly relevant for medically necessary SMHS provided to members under age 21, for whom access to the SMHS delivery system includes the ability to receive medically necessary SMHS based on high risk for a mental health disorder due to the experience of trauma, as specified in BHIN 26-002 or superseding guidance.
All SMHS must be medically necessary and clinically appropriate. Assessments or other documentation in the medical record should substantiate the use of a Z code.
For additional guidance on Z codes, including when they may be used as a primary diagnosis, please refer to the CMS coding guidelines.
What does DHCS mean by “scoring in the high-risk range under a trauma screening tool approved by the department"?
Reference BHIN 26-002; W&I Code section 14184.402(f)(1)(A)
If a practitioner uses a DHCS-approved youth trauma screening tool to assess whether a youth member meets access criteria to the SMHS delivery system, the practitioner must use the scoring methodology associated with the tool to determine whether a youth member falls within the 'high-risk range." Please refer to the Youth Trauma Screening Tool Enclosure 1 for a list of DHCS-approved youth trauma screening tools and corresponding references to these tools.
In the limited cases where standard tool-based scoring methodology is unavailable, Behavioral Health Plans (BHPs) must establish a process for determining whether a youth member meets access criteria for SMHS delivery system. This may include using a different DHCS-approved youth trauma screening tool and/or clinical judgement to determine whether a member may meet access criteria for the SMHS delivery system.
Are DHCS-approved youth trauma screening tools required to establish whether a member meets access criteria to the SMHS delivery system?
Reference BHIN 26-002; Enclosure 1; W&I Code section 14184.402(f)(1)(A)
Members may meet access criteria for the SMHS delivery system through multiple pathways. If a provider determines that a youth trauma screening tool is necessary to identify whether a member under 21 years of age meets SMHS delivery system access criteria, only DHCS-approved tools listed in Enclosure 1, effective April 1, 2026, may be used.
Which youth trauma screening tools have been approved by DHCS?
Reference BHIN 26-002; Enclosure 1
DHCS-approved youth trauma screening tools are listed in BHIN 26-002 in Enclosure 1.
In what settings may a DHCS-approved youth trauma screening tool be used?
Reference BHIN 26-002; W&I Code section 14184.402(f)(1)(A)
There are no exclusions or restrictions regarding which settings the DHCS-approved youth trauma screening tools may be used. DHCS anticipates these tools may be used in clinical settings (e.g., during a pediatrician or primary care visit) or in community-based settings (e.g., school or community organization). Due to the highly sensitive nature of youth trauma screenings, DHCS strongly recommends that any individual administering a youth trauma screening tool has appropriate training.
Which DHCS-approved youth trauma screening tools included in Enclosure 1 are Medi-Cal reimbursable? Which tools are free to use?
Reference BHIN 26-002; Enclosure 1
SMHS providers may be reimbursed for administering the youth trauma screening tools and coordinating referrals, as appropriate, through a variety of existing pathways, such as Medi-Cal administrative costs, Mental Health Medi-Cal Administrative Activities (MH AA), and/or Targeted Case Management, when applicable. Pathways utilized by SMHS providers may vary depending on individual county processes, member eligibility for services, and other factors.
For reimbursements under MH MAA, Activity 4: Medi-Cal Outreach (MH-MAA Implementation Plan, p. 8) is appropriate to claim for screening and referrals by non-licensed staff, whereas Activity 16: Case Management of Non-Open Cases (p. 14) is appropriate to claim when the screening and referral coordination is performed by Skilled Professional Medical Personnel.
Please see APL 23-017, or superseding guidance, and the Preventive Services section of the Provider Manual, to identify youth trauma screening tools eligible for reimbursement in the Medi-Cal managed care and fee-for-service delivery systems under the Adverse Childhood Experiences (ACEs) screening services benefit.
Refer to Enclosure 1 and the individual references for each DHCS-approved youth trauma screening tool to determine potential user costs.
How does this access criteria to SMHS policy relate to other policies like the Screening and Transition of Care Tools?
Reference BHIN 26-002; W&I Code section 14184.402(f)(1)(A); BHIN 25-020
Access criteria to the SMHS delivery system policy as described in BHIN 26-002 provides guidance to Behavioral Health Plans (BHPs) on the access criteria to the SMHS delivery system, for both adults and youth under age 21 and establishes the definition of medical necessity. In addition, updates also include a list of DHCS-approved youth trauma screening tools, which can be found in Enclosure 1.
BHIN 26-002 and the DHCS-approved youth trauma screening tools listed in Enclosure 1 are distinct from the Youth Screening Tool for Medi-Cal Mental Health Services (Youth Screening Tool) described in the Screening and Transition of Care BHIN 25-020 or superseding guidance.
The Youth Screening Tool is meant to determine the most appropriate Medi-Cal mental health delivery system (e.g., BHP or Medi-Cal Managed Care Plan [MCP]) for members who are not currently receiving mental health services when they contact the BHP or MCP seeking mental health services for the first time. If it has already been determined that a member meets access criteria (via a DHCS-approved youth trauma screening tool or other pathway), completion of the Youth Screening Tool is not necessary.
Can a SMHS provider submit a claim for a SMHS provided to a member who also has a substance use disorder (SUD) diagnosis?
Reference BHIN 22-011; BHIN 26-002
Yes. As described in the “Co-Occurring Substance Use Disorder" section of BHIN 22-011, a SMHS is covered when provided to a member who meets access criteria to SMHS even if they also have a SUD diagnosis.
Behavioral Health Plans (BHPs) must cover SMHS for members with a SUD if they also have a mental health condition (or suspected mental health condition not yet diagnosed) and meet access criteria to the SMHS delivery system as described in BHIN 26-002 or superseding guidance. The service provided must match the reason for the service encounter using the CMS-approved ICD diagnostic codes.
How do providers ensure members with a co-occurring substance use disorder (SUD) are referred appropriately to access SUD services?
Reference BHIN 21-071; BHIN 24-001; BHIN 26-002
Mental health providers serving members with a co-occurring SUD should provide a referral to the Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS) county or provider for an initial screening or assessment using the American Society of Addiction Medicine (ASAM) criteria to determine the appropriate level of SUD treatment. For DMC counties, see BHIN 21-071 or superseding guidance. For DMC-ODS counties, see BHIN 24-001 or superseding guidance. Members are not obligated to start or enroll in DMC/DMC-ODS services for their SUD condition as a requirement to receive SMHS for their mental health condition.
