Behavioral Health Information Notice – Table of Contents​​ 

Application for Certification of Social Rehabilitation Program Services DHCS 1734 and Application for Change in Certified Social Rehabilitation Program DHCS 1732
DHCS 1732 Application for Change in Certified Social Rehabilitation Program
DHCS 1734 Application for Certification of Social Rehabilitation Program Services​​ 

Application for Renewal of Special Treatment Program Approval DHCS 1731
DHCS 1731 Application for Renewal of Special Treatment Program Approval​​ 

Special Treatment Program Form 1733 Submission Requirements
DHCS 1733 Application for Initial Approval of Special Treatment Program Services​​ 

Updated 8/20/2021: Level of Care Designations/Certifications for AOD Treatment Facilities (Implementation of Senate Bill 823)
Exhibit A – DHCS Level of Care Designation Requirements
Exhibit B – Required Documentation for DHCS Level of Care Designation Flow Chart​​ 

Supersedes BHIN 17-048 Naloxone in Licensed Residential and Certified AOD Programs​​ 

Alcohol and/or Other Drug Program Certification Standards
Enclosure​​ 

Behavioral Health Services Act Administrative Expenses Claiming and Reimbursement
Please email BHFSOps@dhcs.ca.gov for updated claim forms while they are still in the process of being published to the MedCCC Library.​​ 

Modifications to the Rate Methodology for Fee-for-Service Medi-Cal Contract (FFS/MC) Hospitals and Reporting Requirement Submissions.Informs Mental Health Plans (MHP) of modifications to the rate methodology for rates negotiated between MHPs and FFS/MC Contract Hospitals and the new requirements for reporting those rates to DHCS.
Enclosure 1: DHCS 3144 (Revised 12/04/2025)
Enclosure 2: DHCS 3145 – Rate Change Form (Revised 12/04/2025)
Enclosure 3: DHCS 3146 – Request for an Alternative Standardized Cost of Living Index (Revised 12/04/2025)​​ 

Instructions for Reporting Rates Negotiated for Psychiatric Inpatient Hospitals Services Contracts for Fiscal Year 2022-23
Enclosure 1
Enclosure 2
Enclosure 3​​ 

Regional Average Rates For Non-Contract Psychiatric Inpatient Hospitals For Fiscal Year (FY) 2021-22
Enclosure – Medi-Cal Psychiatric Inpatient Hospital Services Regional Average Non-Negotiated Rates​​ 

FY 21-22 SPA and MAT Rates
FY 21-22 SPA and MAT Rates – Exhibit A
FY 21-22 SPA and MAT Rates – Exhibit B​​  

Supersedes MHSUDS IN 19-013.  International Classification of Diseases, Tenth Revision
(ICD-10) Included Code Sets and System Edit for Short Doyle II Medi-Cal Billing
Enclosure 1​​ 

Instructions for Reporting Rates Negotiated for Psychiatric Inpatient Hospitals Services Contracts for Fiscal Year 2020-21
Enclosure 1
Enclosure 2
Enclosure 3​​ 

Revised Medication Assisted Treatment Reimbursement Rates for Fiscal Year 2020-21 under the Drug Medi-Cal Organized Delivery System
Exhibit – Drug Medi-Cal Rates for Fiscal Year 2020-21: Additional Medication Assisted Treatments Available in Waiver Opt-In Counties for Narcotic Treatment Programs​​ 

Regional Rates for Non-Contract Psychiatric Inpatient Hospitals
Enclosure 1 – Regional Average Non-Negotiated Rates​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment, and Recovery Services, State Fiscal Year 2020-21 Governor’s Approved Budget, v2.0
Exhibit A – State Fiscal Year 2020-21 Governor’s Approved Budget Allocation Overview of Programs, Funding and Allocation Methodologies
Exhibit B – SFY 2020-21 Governor’s Approved Budget Statewide Allocation Summary
Exhibit C – Exchange Program Summary – Part I
Exhibit C – Exchange Program Summary – Part II​​ 

Regional Average Rates for Non-Contract Psychiatric Inpatient Hospitals for Fiscal Year (FY) 2019-2020
Enclosure 1 – Regional Average Rates​​ 

Establishing a County Contract Rate in the Short Doyle/Medi-Cal Claiming and Payment System for Fiscal Year (FY) 2020-21
Enclosure 1 – SMHS County Contracted Rates FY 20-21​​ 

Drug Medi-Cal Reimbursement Rates for Fiscal Year 2020-21
Exhibit A – DMC SPA Rates FY 20-21​​ 

Drug Medi-Cal Organized Delivery System 837 Institutional (837I) Claims for American Society of Addiction Medicine (ASAM) Level of Care 3.7 and 4.0
Exhibit A – 837I Billing Combination
Exhibit B – Procedure Coding System Codes
Exhibit C – CARC RARC​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment and Recovery Services, State Fiscal Year 2015-16 Budget Act Allocation, Version 2.0
Exhibit A
Exhibit B
Exhibit C (1 of 2)
Exhibit C (2 of 2)
Exhibit D​​ 

International Classification of Diseases, Tenth Revision (ICD-10) Included Code Sets and System Edit for Short Doyle Medi-Cal II Billing
Enclosure 1
Enclosure 2
Enclosure 3
Enclosure 4​​ 

Electronic Funds Transfer Enrollment Process and Health Care Claim Payment/Advice (835) Changes
Encl. 1
Encl. 2​​ 

6/12/2015​​ 

Revised Certified Public Expenditure (CPE) Submission
Exhibit 1 (Revised 04/2025)
Exhibit 2​​ 

Superseded by MHSUDS IN 15-041. Short-Doyle/Medi-Cal Denied Claim Adjustment Code, Subsequent Implementation Changes for 2015, Quarterly Revisions
Encl. 1
Encl. 2​​ 

Claiming Drug Medi-Cal Services for Beneficiaries with Medicare Advantage Plans
Exhibit​​ 

Clarification of the Availability of Therapeutic Behavioral Services to Class Members
Enclosure – County Operations Medi-Cal Contract Managers​​ 

Institutions for Mental Diseases Provider Numbers
Enclosure 1 – Inactive Provider Numbers​​  

Supersedes MHSUDS IN 18-049. Delegation of Mental Health Program Approval Tasks of Short-Term
Residential Therapeutic Programs
Enclosure 1​​ 

Statewide Criteria for Mental Health Program Approval for Short-Term Residential Therapeutic Program
Enclosure 1
Enclosure 2​​ 

Mental Health Program Approval of Children’s Crisis Residential Programs
Enclosure 1 – Application for Children’s Crisis Residential Mental Health Program Approval
Enclosure 2 – Children’s Crisis Residential Mental Health Program Interim Standards​​ 

Supersedes MHSUDS IN 19-013.  International Classification of Diseases, Tenth Revision
(ICD-10) Included Code Sets and System Edit for Short Doyle II Medi-Cal Billing
Enclosure 1​​ 

Supersedes MHSUDS IN 18-053.  2020 International Classification of Diseases, Tenth Revision (ICD-10) Included Code Sets Effective October 1, 2019, remaining in effect until new guidance is issued.
Enclosure 1 – ICD-10 Inpatient/Outpatient Diagnosis Codes and Descriptions​​ 

National Drug Codes for Medication Assisted Treatment Services in Drug Medi-Cal Organized Delivery System Counties
Exhibit A – National Drug Code List for Medication Assisted Treatment Services​​ 

Short-Doyle Medi-Cal Claim Adjustment Reason Code and Remittance Advice Remark Code Revisions for 2018
Enclosure 1 – Core Rule 360 Requirement Changes for CARC/RARC​​ 

International Classification of Diseases, Tenth Revision (ICD-10) Included Code Sets and System Edit for Short-Doyle Medi-Cal II Billing
Enclosure 1​​ 

International Classification of Diseases, Tenth Revision (ICD-10) Included Code Sets and System Edit for Short Doyle Medi-Cal II Billing
Enclosure 1
Enclosure 2
Enclosure 3
Enclosure 4​​ 

Transition to International Classification of Diseases, Tenth Revision (ICD-10) Clinical Modification Codes for the Client and Services Information (CSI) System
Encl. 1
Encl. 2
Encl. 3
Encl. 4​​ 

Supercedes ADP Bulletins 10-08 and 11-10. Update to Protocols for Collecting and Reporting Discharge Data in California Outcomes Measurement System Treatment (CalOMS Tx)
Attachment A: CalOMS Tx Data Collection Guide Section 8 Discharge Data Collection Excerpt​​ 

24-041​​ 

ਕਮਿਊਨਿਟੀ ਸਹਾਇਤਾ, ਰਿਕਵਰੀ, ਅਤੇ ਸਸ਼ਕਤੀਕਰਨ (CARE) ਐਕਟ ਡੇਟਾ ਅਤੇ ਰਿਪੋਰਟਿੰਗ ਦਿਸ਼ਾ-ਨਿਰਦੇਸ਼​​ 

Behavioral Health Information Notice 
Attachment A: Annual Performance Measure Reporting
Attachment B: Quality Measures: Reporting Year 2024​​ 

Drug Medi-Cal Organized Delivery System (DMC-ODS) Treatment Perceptions Survey (TPS) for Youth Attachment​​ 

International Classification Of Diseases, Tenth Revision (ICD-10) Included Code Sets And Test Plan For Short Doyle Medi-Cal II Billing
Encl. 1
Encl. 2
Encl. 3
Encl. 4​​ 

Transition to International Classification of Diseases, Tenth Revision (ICD-10) Clinical Modification Codes for the Client and Services Information (CSI) System
Encl. 1
Encl. 2
Encl. 3
Encl. 4​​ 

Supersedes​​  ਭੀਨ 24-034​​  effective February 1, 2026. 2026 Integrated Behavioral Health Member Handbook Requirements and Templates

For copies of the BHIN enclosures listed below, please contact CountySupport@dhcs.ca.gov: 
Enclosure 1: Mental Health Plan and Drug Medi-Cal Member Handbook Template
Enclosure 2: Mental Health Plan and Drug Medi-Cal Organized Delivery Systems Member Handbook Template
Enclosure 3: Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Enclosure 4: Nondiscrimination Notice​​  

Supersedes BHIN 22-045. Enforcement Actions: Administrative and Monetary Sanctions and Contract Termination for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
Attachment A: Network Adequacy Certification Enforcement Actions
Attachment B: Timely Access Enforcement Actions​​ 

Supersedes MHSUDS 18-010E. Mental Health Plan and Drug Medi-Cal Organized Delivery System Plan Grievance and Appeal Requirements with Revised Member Notice Templates
Enclosure 1 – Notice of Grievance Resolution
Enclosure 2 – Denial Notice
Enclosure 3 – Payment Denial Notice
Enclosure 4 – Delivery System Notice
Enclosure 5 – Modification Notice
Enclosure 6 – Termination Notice
Enclosure 7 – Delay in Processing Authorization of Services
Enclosure 8 – Timely Access Notice
Enclosure 9 – Financial Liability Notice
Enclosure 10 – Failure to Timely Resolve Grievances and Appeals NOABD
Enclosure 11 – NOABD Your Rights Attachment
Enclosure 12 – Adverse Benefit Determination Upheld NAR
Enclosure 13 – NAR Your Rights Attachment
Enclosure 14 – Adverse Benefit Determination Overturned NAR
Enclosure 15 – Non-Discrimination Notice
Enclosure 16 – Notice of Availability​​ 

Supersedes BHIN 24-020. 2025 Network Certification Requirements for County Mental Health Plans (MHPs), Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans, Drug Medi-Cal (DMC) State Plan Counties, Integrated Behavioral Health Plans (IBHPs) and Integrated DMC Behavioral Health Delivery Systems (DMC-IBHDS)
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A – DMC-ODS Expected Utilization (DMC-ODS_IBHP)
Attachment B – Time or Distance Standards
Attachment C.1– Alternative Access Standards Request Template (BHP)
Attachment C.2 – Alternative Access Standards Request Template (IBHP)
Attachment C.3 – Alternative Access Standards Request Template (DMC-IBHDS)
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment D.3 – Timely Access Data Tool (DMC State Plan County)
Attachment D.4 – Timely Access Data Tool (IBHP)
Attachment D.5 – Timely Access Data Tool (DMC-IBHDS)
Attachment E – Certification of Network Adequacy Data
Attachment F.1 – Continuity-Transition of Care Report Template (BHP)
Attachment F.2 – Continuity-Transition of Care Report Template (IBHP)
Attachment G.1 – Language Line Encounter Template (BHP)
Attachment G.2 – Language Line Encounter Template (IBHP)
Attachment H – Supplemental Data Tool
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Template​​ 

Superseded by BHIN 25-042. Supersedes BHIN 23-048. Integrated BH Member Handbook Requirements and Templates
Enclosure 1: Integrated MHP and DMC Handbook
Enclosure 2: Integrated Handbook MHP and ODS
Enclosure 3: Language Taglines
Enclosure 4: Non-Discrimination Notice​​ 

Updated Guidance for the Recovery Incentives Program: California’s Contingency Management Benefit​​ 

Supersedes BHIN 23-041. 2024 Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A.2 – DMC-ODS NACT
Attachment B – Time or Distance Standards
Attachment C – Alternative Access Standards Request Template
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity-Transition of Care Report Template
Attachment G – Language Line Encounter Template
Attachment H – Supplemental Data Tool
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Template​​ 

Supersedes BHIN 23-001. Drug Medi-Cal Organized Delivery System (DMC-ODS) Requirements for the Period of 2022 – 2026. 
Enclosure 1: Definitions
Enclosure 2: ASAM Criteria Continuum of Care Services and the DMC-ODS Program
Enclosure 3: County Implementation Plan Template
Enclosure 4: Provider Appeals Process
Enclosure 5: DMC-ODS Provider Qualifications
Enclosure 6: Readiness Review – DHCS Requirements
Enclosure 7: Readiness Review – Questions
Enclosure 8: Readiness Review – Document Checklist​​ 

Supersedes 22-060. Mental Health Plan and Drug Medi-Cal Organized Delivery System Beneficiary Handbook Requirements and Templates 
Enclosure 1: MHP Beneficiary Handbook
Enclosure 2: DMC-ODS Beneficiary Handbook
Enclosure 3: Language Taglines
Enclosure 4: Nondiscrimination Notice​​ 

Supersedes 22-043. Annual County Monitoring Activities (ACMA) for Mental Health Plans (MHP), Drug Medi-Cal Organized Delivery System (DMC-ODS), and Drug Medi-Cal (DMC) for Fiscal Year (FY) 2022/23.
Enclosure 1: DHCS 1738- MHP Attestation 
Enclosure 2: DMC and DMC-ODS County Annual County Monitoring Activities Attestation Fiscal Year 2023/2024 ​​ 

Supersedes BHIN 22-033. 2023 Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A.1 – MHP Network Adequacy Certification Tool (NACT)
Attachment A.2 – DMC-ODS Plan NACT
Attachment B – Time or Distance Standards
Attachment C – Alternative Access Standard Request Template (by request)
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity-Transition of Care Report Template
Attachment G – Language Line Encounter Template
Attachment H – Supplemental Data Tool (if applicable)
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Form (if applicable)​​ 

CalAIM Behavioral Health Payment Reform Allocation
Enclosure 1: Allocation of Start Up Funds​​ 

Mental Health Plan and Drug Medi-Cal Organized Delivery System Beneficiary Handbook Requirements and Templates 
Enclosure 1: MHP Beneficiary Handbook
Enclosure 2: DMC-ODS Beneficiary Handbook
Enclosure 3: Language Taglines
Enclosure 4: Nondiscrimination Notice​​ 

Updated Guidance for CalAIM Behavioral Health Quality Improvement Program (BHQIP). 
DHCS-8762: September 2022 Reporting Template
DHCS-8763: Participating Entity Policies and Procedures Template
DHCS-8764: Performance Improvement Project Templates​​ 

Annual County Monitoring Activities (ACMA) for Mental Health Plans (MHP), Drug Medi-Cal Organized Delivery System (DMC-ODS), and Drug Medi-Cal (DMC) for Fiscal Year (FY) 2022/23.
Enclosure 1: DHCS 1738- MHP Attestation 
Enclosure 2: DHCS 1730- DMC-ODS Attestation​​  

Supersedes BHIN 21-023. 2022 Federal Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery Systems (DMC-ODS)
Attachment A.1 – MHP NACT    
Attachment A.2 – DMC-ODS NACT
Attachment B – Time and Distance Standards 
Attachment C – Alternative Access Standards Request Template
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity of Care Report Template
Attachment G – Network Adequacy Annual Certification Inventory
Attachment H – DMC-ODS Supplemental Data Tool
Attachment I – Provider Contract Cover Sheet
Attachment J – DMC-ODS CAP Resolution Proposal Instructions and Template  
For a copy of the attachments listed above, please contact NAOS@dhcs.ca.gov.​​ 

CalAIM Behavioral Health Quality Improvement Program (BHQIP)
Enclosure 1- Please email BHQIP@dhcs.ca.gov to obtain the CalAIM BHQIP Funds Availability Schedule
Enclosure 2- BH-QIP Program Implementation Plan and Instructions for County Behavioral Health Plans
Enclosure 3- BHQIP Program Funding Claiming Form​​ 

Ongoing Compliance Monitoring Activities
DHCS 1738 Ongoing Compliance Monitoring Activities Form​​ 

Behavioral Health Quality Improvement Program (BH-QIP) Start-Up Funds
Enclosure: Behavioral Health Quality Improvement Program (BH-QIP) Startup Funding Claiming Form​​ 

Supersedes BHIN 20-012 & MHSUDS IN 18-011.  2021 Federal Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery Systems (DMC-ODS)
Attachment A.1 – MHP NACT  – Please contact MHSDFinalRule@dhcs.ca.gov
Attachment A.2 – DMC-ODS NACT – Please contact ODSSubmissions@dhcs.ca.gov
Attachment B – Time and Distance Standards
Attachment C – Alternative Access Standards Request Template – Please contact MHSDFinalRule@dhcs.ca.gov or ODSSubmissions@dhcs.ca.gov
Attachment D – Timely Access Data Tool – Please contact MHSDFinalRule@dhcs.ca.gov
Attachment E – Certification of Network Adequacy Data​​ 

Supersedes MHSUDS IN 16-042.  Drug Medi-Cal Organized Delivery System – Updated Policy on Residential Treatment Limitations​​ 

BHIN 17-034 ਨੂੰ ਛੱਡ ਦਿੱਤਾ ।  ਡਰੱਗ ਮੈਡੀ-ਕੈਲ ਆਰਗੇਨਾਈਜ਼ਡ ਡਿਲੀਵਰੀ ਸਿਸਟਮ - ਰਿਕਵਰੀ ਸੇਵਾਵਾਂ 'ਤੇ ਸਪੱਸ਼ਟੀਕਰਨ​​ 

Drug Medi-Cal Organized Delivery System (DMC-ODS) Treatment Perceptions Survey (TPS) for Youth
Attachment​​ 

Federal Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Pilot Counties
Enclosure 1- contactDHCS MHSD Final Rule for a copy
Enclosure 2
Enclosure 3​​ 

Drug Medi-Cal Organized Delivery System Waiver County Implementation Fiscal Plan Guide
 Attachment​​ 

Superseded by BHIN 21-075. Medication Assisted Treatment in Narcotic Treatment Programs Under the Drug Medi-Cal Organized Delivery System Pilot Program
Exhibit​​  

Supersedes​​  ਭੀਨ 24-034​​  effective February 1, 2026. 2026 Integrated Behavioral Health Member Handbook Requirements and Templates

For copies of the BHIN enclosures listed below, please contact CountySupport@dhcs.ca.gov: 

Enclosure 1: Mental Health Plan and Drug Medi-Cal Member Handbook Template
Enclosure 2: Mental Health Plan and Drug Medi-Cal Organized Delivery Systems Member Handbook Template
Enclosure 3: Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Enclosure 4: Nondiscrimination Notice​​  

Supersedes BHIN 22-070 and Superseded by BHIN 25-026. Parity Requirements for Drug Medi-Cal State Plan Counties
Enclosure 1 – Notice of Grievance Resolution
Enclosure 2 – Denial Notice
Enclosure 3 – Payment Denial Notice
Enclosure 4 – Delivery System Notice
Enclosure 5 – Modification Notice
Enclosure 6 – Termination Notice
Enclosure 7 – Delay in Processing Authorization of Services
Enclosure 8 – Timely Access Notice
Enclosure 9 – Financial Liability Notice
Enclosure 10 – Failure to Timely Resolve Grievances and Appeals NOABD
Enclosure 11 – NOABD Your Rights Attachment
Enclosure 12 – Adverse Benefit Determination Upheld NAR
Enclosure 13 – NAR Your Rights Attachment
Enclosure 14 – Adverse Benefit Determination Overturned NAR
Enclosure 15 – Non-Discrimination Notice
Enclosure 16 – Notice of Availability​​ 

Supersedes BHIN 24-020. 2025 Network Certification Requirements for County Mental Health Plans (MHPs), Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans, Drug Medi-Cal (DMC) State Plan Counties, Integrated Behavioral Health Plans (IBHPs) and Integrated DMC Behavioral Health Delivery Systems (DMC-IBHDS)
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A – DMC-ODS Expected Utilization (DMC-ODS_IBHP)
Attachment B – Time or Distance Standards
Attachment C.1– Alternative Access Standards Request Template (BHP)
Attachment C.2 – Alternative Access Standards Request Template (IBHP)
Attachment C.3 – Alternative Access Standards Request Template (DMC-IBHDS)
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment D.3 – Timely Access Data Tool (DMC State Plan County)
Attachment D.4 – Timely Access Data Tool (IBHP)
Attachment D.5 – Timely Access Data Tool (DMC-IBHDS)
Attachment E – Certification of Network Adequacy Data
Attachment F.1 – Continuity-Transition of Care Report Template (BHP)
Attachment F.2 – Continuity-Transition of Care Report Template (IBHP)
Attachment G.1 – Language Line Encounter Template (BHP)
Attachment G.2 – Language Line Encounter Template (IBHP)
Attachment H – Supplemental Data Tool
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Template​​ 

CalAIM Behavioral Health Payment Reform Allocation
Enclosure 1: Allocation of Start-Up Funds​​ 

Superseded by BHIN 25-015. Parity Requirements for Drug Medi-Cal State Plan Counties
Enclosure-1-Notice-of-Grievance-Resolution-NGR-Final.docx
Enclosure-2-Denial-Notice-NOABD-Final.docx
Enclosure-3-Payment-Denial-Notice-NOABD-Final.docx
Enclosure-4-Modification-Notice-NOABD-Final.docx
Enclosure-5-Termination-Notice-NOABD-Final.docx
Enclosure-6-Timely-Access-Notice-NOABD-Final.docx
Enclosure-7-NOABD-Financial-Liability-Final.docx
Enclosure-8-Your Rights-Attachment-NOABD-Final.docx
Enclosure-9-Adverse-Benefit-Determinat-Upheld-Final.docx
Enclosure-10-NAR-Your-Rights-Attachment-Final.docx
Enclosure-11-Adverse-Benefit-Determinat-Overturned-Final.docx
Enclosure-12-Nondiscrimination-Final.docx
Enclosure-13-Language-Taglines-Final.docEnclosure-14-Authorization-Delay-Notice-Final.docx
Enclosure-14-Authorization-Delay-Notice-Final.docx
Enclosure-15-NOABD-Grievance-and-Appeal-Final.docx
Enclosure-16-Timely-Access-Data-Tool-Final.xlsx​​ 

Ongoing Compliance Monitoring Activities
DHCS 1738 Ongoing Compliance Monitoring Activities Form​​ 

Drug Medi-Cal Reimbursement Rates for Fiscal Year 2020-21
Exhibit A – DMC SPA Rates FY 20-21​​ 

Negotiated Rates for Short-Doyle/Medi-Cal (SD/MC) Services for State Fiscal Year (SFY) 2001-2002
Enclosure A (Rates by Service Function) (Excel)
Enclosure B (Rate Establishment Procedures)​​  

ਅੱਪਡੇਟ ਕੀਤਾ ਗਿਆ: ਕੋਵਿਡ-19 ਟੀਕਾਕਰਨ, ਬੂਸਟਰ, ਟੀਕਾਕਰਨ ਤਸਦੀਕ, ਵਿਵਹਾਰ ਸੰਬੰਧੀ ਸਿਹਤ ਸੁਵਿਧਾ ਕਰਮਚਾਰੀਆਂ ਲਈ ਮਾਸਕਿੰਗ ਅਤੇ ਟੈਸਟਿੰਗ ਲਈ ਲੋੜਾਂ​​ 

MHSA-related Flexibilities during the COVID-19 Public Health Emergency
DHCS Form 5510: MHSA County Plan (FY 2020-21)
Please submit DHCS Form 5510 with an electronic signature. For posting purposes, DHCS will only accept forms completed electronically.​​ 

ACL 25-52 BHIN 25-031 Quality Assessment
Quality Assessment Report
Quality Referral Form​​ 

FFPSA Part IV Aftercare Requirements 
Attachment A Wraparound County Plan Template
Attachment B CWS CMS Documentation​​  

Assessments by a Qualified Individual (QI) for placements in Short-Term Residential Therapeutic Programs (STRTPs) under the Requirements of the Family First Prevention Services Act (FFPSA) and Assembly Bill (AB) 153 (Chapter 86, Statutes of 2021)
Attachment Importing a File Guide
Attachment QI Assessment Report
Attachment Qualified Individual Referral Form​​ 

Presumptive Transfer Policy Guidance
Attachment A – AB 1299 Flow Chart
Attachment B – AB 1299 Flow Chart Waiver Scenarios
Attachment C – Presumptive Transfer Informing Notice (Template)
Attachment D – Notice of Transfer of Responsibility for Specialty Mental Health Services (Template)
Attachment E – Presumptive Transfer Waiver Request Form (Template)
Attachment F – Presumptive Transfer Waiver Determination Notification (Template)​​ 

Requirements and Guidelines for Creating and Providing a Child and Family Team
Enclosure 1​​ 

Therapeutic Foster Care (TFC) Service Model and Continuum of Care Reform (CCR)
Draft TFC Service Model
Draft TFC Service Model Parent Qualifications​​ 

Clarification Re Continuing Therapeutic Behavioral Services to Class Members
Enclosure – County Operations Medi-Cal Contract Managers​​ 

Clarification of the Availability of Therapeutic Behavioral Services to Class Members
Enclosure – County Operations Medi-Cal Contract Managers​​ 

Negotiated Rates for Short-Doyle/Medi-Cal (SD/MC) Services for State Fiscal Year (SFY) 2001-2002
Enclosure A (Rates by Service Function) (Excel)
22-007Enclosure B (Rate Establishment Procedures)​​  

Regional Rates for Non-Contract Psychiatric Inpatient Hospitals
Enclosure 1 – Regional Average Non-Negotiated Rates​​ 

Reporting and Claiming for Beneficiaries in Institutions for Mental Diseases
Enclosure​​ 

Superseded by BHIN 21-003.Notification of Amendments to Senate Bill 364 (Chapter 567) and Changes to Welfare and Institutions Code Section 5150 Regarding 72-Hour Involuntary Detention For Mental Health Evaluation and Treatment​​ 

Institutions for Mental Diseases Provider Numbers
Enclosure 1 – Inactive Provider Numbers​​  

BHIN 25-012 Facility Referrals to the Community Assistance, Recovery, and Empowerment (CARE) Act Process. Provides guidance to counties and facilities on the referral procedures and form for the CARE Act. Attachment:
DHCS 8050 CARE Facility Referral Form TEMPLATE  For training and technical assistance, please visit CARE Act Resource Center.​​ 

Supercedes BHIN 20-075. Implementation and Reporting Requirements of the Assisted Outpatient Treatment (AOT) Program
Enclosure I. AOT Data Dictionary​​ 

Minor Consent to Outpatient Mental Health Treatment or Counseling
AB 665 FAQ​​ 

Assessments by a Qualified Individual (QI) for placements in Short-Term Residential Therapeutic Programs (STRTPs) under the Requirements of the Family First Prevention Services Act (FFPSA) and Assembly Bill (AB) 153 (Chapter 86, Statutes of 2021)
Enclosure A: Qualified Individual Referral Form
Enclosure B: Qualified Individual Assessment Report
Enclosure C: CWS/CMS Application File Import Guide​​ 

Assembly Bill 2083 (2018) Memorandum of Understanding Guidance
Attachment – Trauma Informed System of Care Memorandum of Understanding Guidance​​ 

Presumptive Transfer Policy Guidance
Attachment A – AB 1299 Flow Chart
Attachment B – AB 1299 Flow Chart Waiver Scenarios
Attachment C – Presumptive Transfer Informing Notice (Template)
Attachment D – Notice of Transfer of Responsibility for Specialty Mental Health Services (Template)
Attachment E – Presumptive Transfer Waiver Request Form (Template)
Attachment F – Presumptive Transfer Waiver Determination Notification (Template)​​ 

Mental Health Facilities Criminal Record Checks
Enclosure 1 – Assembly Bill (AB) 1454​​ 

Revised Medication Assisted Treatment Reimbursement Rates for Fiscal Year 2020-21 under the Drug Medi-Cal Organized Delivery System
Exhibit – Drug Medi-Cal Rates for Fiscal Year 2020-21: Additional Medication Assisted Treatments Available in Waiver Opt-In Counties for Narcotic Treatment Programs​​ 

National Drug Codes for Medication Assisted Treatment Services in Drug Medi-Cal Organized Delivery System Counties
Exhibit A – National Drug Code List for Medication Assisted Treatment Services​​ 

Medication Assisted Treatment Reimbursement Rates for Fiscal Year 2018-19 Under the Drug Medi-Cal Organized Delivery System
Exhibit​​ 

Superseded by BHIN 21-075. Medication Assisted Treatment in Narcotic Treatment Programs Under the Drug Medi-Cal Organized Delivery System Pilot Program
Exhibit​​  

Memorandum of Understanding Requirements for Medi-Cal Managed Care Plans and Drug Medi-Cal State Plan Counties
Attachment 1: Memorandum of Understanding Template​​ 

Memorandum of Understanding Requirements for Medi-Cal Managed Care Plans and Drug Medi-Cal Organized Delivery System Counties
Attachment 1: Memorandum of Understanding between Medi-Cal Managed Care Plan (MCP)  and DMC-ODS​​ 

Memorandum of Understanding Requirements for Medi-Cal Managed Care Plans and Medi-Cal Mental Health Plans
Attachment 1: Memorandum of Understanding between Medi-Cal Managed Care Plan (MCP) and Mental Health Plan (MHP)​​ 

Mental Health Facilities Criminal Record Checks
Enclosure 1 – Assembly Bill (AB) 1454​​ 

Notification of Approved Permanent Mental Health Rehabilitation Center (MHRC) Regulations
Enclosure (5.7 Mb)​​ 

Supersedes​​  ਭੀਨ 24-034​​  effective February 1, 2026. 2026 Integrated Behavioral Health Member Handbook Requirements and Templates

For copies of the BHIN enclosures listed below, please contact CountySupport@dhcs.ca.gov: 
Enclosure 1: Mental Health Plan and Drug Medi-Cal Member Handbook Template
Enclosure 2: Mental Health Plan and Drug Medi-Cal Organized Delivery Systems Member Handbook Template
Enclosure 3: Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Enclosure 4: Nondiscrimination Notice​​  

Supersedes BHIN 22-045. Enforcement Actions: Administrative and Monetary Sanctions and Contract Termination for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
Attachment A: Network Adequacy Certification Enforcement Actions
Attachment B: Timely Access Enforcement Actions​​ 

ਦੋ ਨਵੇਂ ਪ੍ਰੋਵਾਈਡਰ ਫਾਈਲ ਅਤੇ ਤਿੰਨ ਮੈਡੀ-ਕੈਲ ਸਰਟੀਫਿਕੇਸ਼ਨ ਵੈੱਬ-ਅਧਾਰਿਤ ਫਾਰਮਾਂ ਦੇ ਲਾਂਚ ਦੀ ਸੂਚਨਾ ਪ੍ਰਦਾਨ ਕਰਦਾ ਹੈ।​​  ਜੁਲਾਈ 01, 2025 ਤੋਂ ਪ੍ਰਭਾਵੀ, ਸਾਰੇ ਫਾਰਮ ਨਿਰਧਾਰਤ ਵੈੱਬ-ਅਧਾਰਿਤ ਫਾਰਮਾਂ ਦੀ ਵਰਤੋਂ ਕਰਕੇ ਜਮ੍ਹਾਂ ਕਰਵਾਏ ਜਾਣੇ ਚਾਹੀਦੇ ਹਨ। ਈਮੇਲ ਰਾਹੀਂ ਜਮ੍ਹਾਂ ਕਰਵਾਏ ਗਏ ਕੋਈ ਵੀ ਦਸਤੀ ਫਾਰਮ​​  ProviderFile@dhcs.ca.gov​​  ਇਸ ਮਿਤੀ ਨੂੰ ਅਤੇ/ਜਾਂ ਬਾਅਦ ਇਨਬਾਕਸ ਵਿੱਚ ਭੇਜੇ ਗਏ ਪੱਤਰਾਂ ਨੂੰ ਵੈੱਬ-ਅਧਾਰਿਤ ਫਾਰਮਾਂ ਦੀ ਵਰਤੋਂ ਕਰਕੇ ਦੁਬਾਰਾ ਜਮ੍ਹਾਂ ਕਰਨ ਦੀਆਂ ਹਦਾਇਤਾਂ ਦੇ ਨਾਲ ਵਾਪਸ ਕਰ ਦਿੱਤਾ ਜਾਵੇਗਾ।​​  ਵਾਧੂ ਜਾਣਕਾਰੀ ਅਤੇ ਵੈੱਬ-ਅਧਾਰਿਤ ਫਾਰਮਾਂ ਦਾ ਲਿੰਕ ਹੇਠਾਂ ਦਿੱਤਾ ਗਿਆ ਹੈ।​​ 
LEFU ਅਤੇ PFU​​ 
DHCS 1735, 1736, 1737​​ 

Supersedes MHSUDS 18-010E. Mental Health Plan and Drug Medi-Cal Organized Delivery System Plan Grievance and Appeal Requirements with Revised Member Notice Templates
Enclosure 1 – Notice of Grievance Resolution
Enclosure 2 – Denial Notice
Enclosure 3 – Payment Denial Notice
Enclosure 4 – Delivery System Notice
Enclosure 5 – Modification Notice
Enclosure 6 – Termination Notice
Enclosure 7 – Delay in Processing Authorization of Services
Enclosure 8 – Timely Access Notice
Enclosure 9 – Financial Liability Notice
Enclosure 10 – Failure to Timely Resolve Grievances and Appeals NOABD
Enclosure 11 – NOABD Your Rights Attachment
Enclosure 12 – Adverse Benefit Determination Upheld NAR
Enclosure 13 – NAR Your Rights Attachment
Enclosure 14 – Adverse Benefit Determination Overturned NAR
Enclosure 15 – Non-Discrimination Notice
Enclosure 16 – Notice of Availability​​ 

Supersedes BHIN 24-020. 2025 Network Certification Requirements for County Mental Health Plans (MHPs), Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans, Drug Medi-Cal (DMC) State Plan Counties, Integrated Behavioral Health Plans (IBHPs) and Integrated DMC Behavioral Health Delivery Systems (DMC-IBHDS)
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A – DMC-ODS Expected Utilization (DMC-ODS_IBHP)
Attachment B – Time or Distance Standards
Attachment C.1– Alternative Access Standards Request Template (BHP)
Attachment C.2 – Alternative Access Standards Request Template (IBHP)
Attachment C.3 – Alternative Access Standards Request Template (DMC-IBHDS)
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment D.3 – Timely Access Data Tool (DMC State Plan County)
Attachment D.4 – Timely Access Data Tool (IBHP)
Attachment D.5 – Timely Access Data Tool (DMC-IBHDS)
Attachment E – Certification of Network Adequacy Data
Attachment F.1 – Continuity-Transition of Care Report Template (BHP)
Attachment F.2 – Continuity-Transition of Care Report Template (IBHP)
Attachment G.1 – Language Line Encounter Template (BHP)
Attachment G.2 – Language Line Encounter Template (IBHP)
Attachment H – Supplemental Data Tool
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Template​​ 

Superseded by BHIN 25-042. Supersedes BHIN 23-048. Integrated BH Member Handbook Requirements and Templates
Enclosure 1: Integrated MHP and DMC Handbook
Enclosure 2: Integrated Handbook MHP and ODS
Enclosure 3: Language Taglines
Enclosure 4: Non-Discrimination Notice​​ 

Supersedes BHIN 23-041. 2024 Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A.2 – DMC-ODS NACT
Attachment B – Time or Distance Standards
Attachment C – Alternative Access Standards Request Template
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity-Transition of Care Report Template
Attachment G – Language Line Encounter Template
Attachment H – Supplemental Data Tool
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Template​​ 

Supersedes 22-060. Mental Health Plan and Drug Medi-Cal Organized Delivery System Beneficiary Handbook Requirements and Templates 
Enclosure 1: MHP Beneficiary Handbook
Enclosure 2: DMC-ODS Beneficiary Handbook
Enclosure 3: Language Taglines
Enclosure 4: Nondiscrimination Notice​​ 

Supersedes 22-043.Annual County Monitoring Activities (ACMA) for Mental Health Plans (MHP), Drug Medi-Cal Organized Delivery System (DMC-ODS), and Drug Medi-Cal (DMC) for Fiscal Year (FY) 2022/23.
Enclosure 1: DHCS 1738- MHP Attestation 
Enclosure 2: DMC and DMC-ODS County Annual County Monitoring Activities Attestation Fiscal Year 2023/2024 ​​ 

Supersedes BHIN 22-033. 2023 Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Plans
For copies of the BHIN attachments listed below, please contact NAOS@dhcs.ca.gov:
Attachment A.1 – MHP Network Adequacy Certification Tool (NACT)
Attachment A.2 – DMC-ODS Plan NACT
Attachment B – Time or Distance Standards
Attachment C – Alternative Access Standard Request Template (by request)
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS Plan)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity-Transition of Care Report Template
Attachment G – Language Line Encounter Template
Attachment H – Supplemental Data Tool (if applicable)
Attachment I – Significant Change Attestation Template
Attachment J – Significant Change Disclosure Form (if applicable)​​ 

CalAIM Behavioral Health Payment Reform Allocation
Enclosure 1: Allocation of Start Up Funds​​ 

Annual Review Protocol for Specialty Mental Health Services (SMHS) and Other Funded Services for Fiscal Year 2022-2023.
Enclosure 1- SMHS Protocol FY 22-23
Enclosure 2 – FY 22-23 SMHS Triennial Schedule
Enclosure 3 – SMHS Reasons for Recoupment FY 22-23
Enclosure 4 – SMHS TA Schedule FY 22-23​​ 

Mental Health Plan and Drug Medi-Cal Organized Delivery System Beneficiary Handbook Requirements and Templates 
Enclosure 1: MHP Beneficiary Handbook
Enclosure 2: DMC-ODS Beneficiary Handbook
Enclosure 3: Language Taglines
Enclosure 4: Nondiscrimination Notice​​ 

Supersedes BHIN 21-023. 2022 Federal Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery Systems (DMC-ODS)
Attachment A.1 – MHP NACT    
Attachment A.2 – DMC-ODS NACT
Attachment B – Time and Distance Standards 
Attachment C – Alternative Access Standards Request Template
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity of Care Report Template
Attachment G – Network Adequacy Annual Certification Inventory
Attachment H – DMC-ODS Supplemental Data Tool
Attachment I – Provider Contract Cover Sheet
Attachment J – DMC-ODS CAP Resolution Proposal Instructions and Template  
For a copy of the attachments listed above, please contact NAOS@dhcs.ca.gov.​​ 

Ongoing Compliance Monitoring Activities
DHCS 1738 Ongoing Compliance Monitoring Activities Form​​ 

Supersedes BHIN 20-061 Annual Review Protocol for Specialty Mental Health Services (SMHS) and Other Funded Services for Fiscal Year 2021-2022
Enclosure 1 Annual Review Protocol for Specialty Mental Health Services and Other Funded Services Fiscal Year 2021-2022
Enclosure 2 Triennial Review Schedule Fiscal Year 2021/2022
Enclosure 3 Medi-Cal Specialty Mental Health Reasons for Recoupment Fiscal Year 2021/2022​​ 

Behavioral Health Quality Improvement Program (BH-QIP) Start-Up Funds
Enclosure: Behavioral Health Quality Improvement Program (BH-QIP) Startup Funding Claiming Form​​ 

Mental Health Services Act (MHSA) Allocation and Methodology for Fiscal Year (FY) 2024-25
Enclosure 1: Need for Services
Enclosure 2: Population Most Likely to Apply for Services
Enclosure 3: Population Most Likely to Access Services
Enclosure 4: Self Sufficiency Standard
Enclosure 5: Adjustments Self Sufficiency
Enclosure 6: Resources
Enclosure 7: Resource Adjustment Opt 1
Enclosure 8: Resource Adjustment Opt 2
Enclosure 9: Resource Adjustment Opt 3
Enclosure 10: Resource Adjustment Summary
Enclosure 11: Component Allocation Percentages
Enclosure 12: FY 23-24 Allocation Percentages​​ 

Prudent Reserve Funding Levels
Enclosure 1: FY 23-24 PR Maximum​​ 

Mental Health Services Act County Population
Enclosure 1: Population Estimate​​ 

Mental Health Services Act (MHSA) Allocation and Methodology for Fiscal Year (FY) 2023-24
Enclosure 1: Need for Services
Enclosure 2: Population Most Likely to Apply for Services
Enclosure 3: Population Most Likely to Access Services
Enclosure 4: Self Sufficiency Standard
Enclosure 5: Adjustments Self Sufficiency
Enclosure 6: Resources
Enclosure 7: Resource Adjustment Opt 1
Enclosure 8: Resource Adjustment Opt 2
Enclosure 9: Resource Adjustment Opt 3
Enclosure 10: Resource Adjustment Summary
Enclosure 11: Component Allocation Percentages
Enclosure 12: FY 23-24 Allocation Percentages​​ 

Mental Health Services Act County Population
Enclosure 1: Population Estimate, January 1, 2023, Fiscal Year 2022-23​​ 

Mental Health Services Act (MHSA) Allocation and Methodology for Fiscal Year (FY) 2022-23
Enclosure 1: Need for Services
Enclosure 2: Population Most Likely to Apply for Services
Enclosure 3: Population Most Likely to Access Services
Enclosure 4: Self Sufficiency Standard
Enclosure 5: Adjustments Self Sufficiency
Enclosure 6: Resources
Enclosure 7: Resources Adjustment Option 1
Enclosure 8: Resources Adjustment Option 2
Enclosure 9: Resources Adjustment Option 3
Enclosure 10: Resource Adjustment Summary
Enclosure 11: Component Allocation Percentages
Enclosure 12: Allocation Schedule​​ 

Mental Health Services Act (MHSA) Allocation and Methodology for Fiscal Year (FY) 2021-22
Enclosure 1: Need for Services
Enclosure 2: Population Most Likely to Apply for Services
Enclosure 3: Population Most Likely to Access Services
Enclosure 4: Self Sufficiency Standard
Enclosure 5: Adjustments Self Sufficiency
Enclosure 6: Resources
Enclosure 7: Resources Adjustment Option 1
Enclosure 8: Resources Adjustment Option 2
Enclosure 9: Resources Adjustment Option 3
Enclosure 10: Resource Adjustment Summary
Enclosure 11: Planning Estimates
Enclosure 12: Allocation Schedule​​ 

Mental Health Services Act County Population
Enclosure 1: Population Estimate, January 1, 2021 Fiscal Year 2021-22​​ 

MHSA-related Flexibilities during the COVID-19 Public Health Emergency
DHCS Form 5510: MHSA County Plan (FY 2020-21)
Please submit DHCS Form 5510 with an electronic signature. For posting purposes, DHCS will only accept forms completed electronically.​​ 

Mental Health Services Act (MHSA) Allocation and Methodology for Fiscal Year (FY) 2020-21
Enclosure 1- Need for Services
Enclosure 2- Population Most Likely to Apply for Services
Enclosure 3- Population Most Likely to Access Services
Enclosure 4- Self-Sufficiency Standard
Enclosure 5- Adjustments Self-Sufficiency
Enclosure 6- Resources
Enclosure 7- Resources Adjustment Option 1
Enclosure 8- Resources Adjustment Option 2
Enclosure 9- Resources Adjustment Option 3
Enclosure 10- Resources Adjustment Summary
Enclosure 11- Planning Estimates
Enclosure 12- Allocation Percentages 2020-21​​ 

Mental Health Services Act: Release of Unencumbered Funds Dedicated to the Special Needs Housing Program (SNHP)
Enclosure 1 – SNHP Funds Balance Report
Enclosure 2 – MHSA Fund Release and Transfer Form​​ 

Mental Health Services Act (MHSA) County Population for Fiscal Year 2019-20
Enclosure​​ 

MHSA Prudent Reserve Maximum Funding Level
Enclosure​​ 

Mental Health Services Act (MHSA): Program Review Implementation
Enclosure – MHSA Program Review Schedule​​ 

Mental Health Services Act (MHSA): Implementation of Welfare and Institutions Code (W&I) Sections 5892 and 5892.1
DHCS 1819 MHSA Prudent Reserve Assessment/Reassessment
DHCS 1820: Annual MHSA Revenue and Expenditure Report (RER) and Adjustment Worksheet County Certification
DHCS 1821: MHSA: Adjustments to Revenue and Expenditure Summary Worksheet
DHCS 1822A: Annual MHSA Annual RER Report Template and Instructions​​ 

Mental Health Services Act: Methodology For Distributions To Local Mental Health Services Fund
Enclosure 1
Enclosure 2​​ 

Supersedes BHIN 22-064. Medi-Cal Mobile Crisis Services Benefit Implementation
Enclosure 1: Attestation Letter​​ 

22-064​​ 

Superseded by BHIN 23-025. Medi-Cal Mobile Crisis Services Benefit Implementation
Enclosure 1: Attestation Letter​​ 

12/19/2022​​ 

Superseded by BHIN 21-075. Medication Assisted Treatment in Narcotic Treatment Programs Under the Drug Medi-Cal Organized Delivery System Pilot Program
Exhibit​​  

Supersedes BHIN 21-023. 2022 Federal Network Certification Requirements for County Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery Systems (DMC-ODS)
Attachment A.1 – MHP NACT    
Attachment A.2 – DMC-ODS NACT
Attachment B – Time and Distance Standards 
Attachment C – Alternative Access Standards Request Template
Attachment D.1 – Timely Access Data Tool (MHP)
Attachment D.2 – Timely Access Data Tool (DMC-ODS)
Attachment E – Certification of Network Adequacy Data
Attachment F – Continuity of Care Report Template
Attachment G – Network Adequacy Annual Certification Inventory
Attachment H – DMC-ODS Supplemental Data Tool
Attachment I – Provider Contract Cover Sheet
Attachment J – DMC-ODS CAP Resolution Proposal Instructions and Template  
For a copy of the attachments listed above, please contact NAOS@dhcs.ca.gov.​​ 

Supersedes MHSUDS IN 18-011.  2020 Federal Network Certification Requirements for County Mental Health Plans (MHPs)
Enclosure 1 – Please  contact MHSDFinalRule@dhcs.ca.gov for a copy
Enclosure 2
Enclosure 3 – Please  contact MHSDFinalRule@dhcs.ca.gov for a copy
Enclosure 4 ​​ 

Federal Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Cal Organized Delivery System (DMC-ODS) Pilot Counties
Enclosure 1- contact DHCS MHSD Final Rule for a copy
Enclosure 2
Enclosure 3​​ 

24-044​​ 

22- 065​​ 

Supersedes MHSUDS IN 18-049. Delegation of Mental Health Program Approval Tasks of Short-Term Residential Therapeutic Programs
Enclosure 1​​ 

Statewide Criteria for Mental Health Program Approval for Short-Term Residential Therapeutic Program
Enclosure
Enclosure 2​​ 

Mental Health Program Approval of Children’s Crisis Residential Programs
Enclosure 1 – Application for Children’s Crisis Residential Mental Health Program Approval
Enclosure 2 – Children’s Crisis Residential Mental Health Program Interim Standards​​ 

Allocation of Funding for Substance Use Prevention, Treatment, and Recovery Services, State Fiscal Year 2024-25 and 2025-26 Preliminary Allocations
Exhibit A
Exhibit B
Exhibit C Part 1
Exhibit C Part 2​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment, and Recovery Services, State Fiscal Year 2022-23 and 2023-24 Preliminary Allocations
Exhibit A
Exhibit B – Statewide Allocation Summary
Exhibit C Part 1
Exhibit C Part 2​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment, and Recovery Services, State Fiscal Year 2022-23 and 2023-24 Preliminary Allocations
Exhibit A
Exhibit B – Statewide Allocation Summary
Exhibit C Part 1
Exhibit C Part 2​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment, and Recovery Services, State Fiscal Year 2021-22 Governor’s Approved Budget, v2.0
Enclosure A – Overview of Programs, Funding, and Allocation Methodologies
Enclosure B – Statewide Allocation Summary
Enclosure C part 1 – Substance Abuse and Treatment Block Grant Exchange Program
Enclosure C part 2 – SABG Exchange Program Summary of Exchanges​​ 

Allocation of Funding for Substance Use Disorder Prevention, Treatment, and Recovery Services, State Fiscal Year 2021-22 Governor’s Preliminary Budget, v1.0.
Exhibit A – FY 2021-22 Preliminary Allocation Summary Overview
Exhibit B – Statewide Allocation Summary
Exhibit C – Exchange Program Summary – Part I
Exhibit C – Exchange Program Summary – Part II​​ 

Instructions for Reporting Rates Negotiated for Psychiatric Inpatient Hospital Services Contracts
Enclosure ​​  

ਯੁਵਾ
ਅਟੈਚਮੈਂਟਲਈ ਡਰੱਗ ਮੈਡੀ-ਕੈਲ ਆਰਗੇਨਾਈਜ਼ਡ ਡਿਲੀਵਰੀ ਸਿਸਟਮ (DMC-ODS) ਟ੍ਰੀਟਮੈਂਟ ਪਰਸੈਪਸ਼ਨ ਸਰਵੇ (TPS)​​ 

Requirements for Implementing the Child and Adolescent Needs and Strengths Assessment Tool within a Child and Family Team
Attachment 1
Attachment 2
Attachment 3​​ 

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) – Specialty Mental Health Services Performance Outcomes System Functional Assessment Tools for Children and Youth
Enclosure 1
Enclosure 2
Enclosure 3​​