家 CalAIM行为健康计划常见问题解答​​ 

CalAIM 行为健康计划常见问题解答​​ 

返回 CalAIM 常见问题解答​​ 

以下是从技术援助和信息网络研讨会以及提交至BHCalAIM@dhcs.ca.gov电子邮件中收集的常见问题列表。 DHCS 将每季度更新此列表。​​  

二甲基碳酸钠​​ 

临床医生咨询可以在同一机构内的持牌机构工作人员之间进行吗？还是这种咨询必须发生在持牌机构工作人员和县签约的外部顾问之间？​​ 

参考BHIN 24-001和DMC-ODS 服务表​​ 

Clinician Consultations may occur between licensed agency staff within the same agency as well as between licensed agency staff and consultants outside of their agency, given both clinicians are qualified to provide Drug Medi-Cal Organized Delivery System (DMC-ODS) services. Page 22 of Behavioral Health Information Notice (BHIN) 24-001 provides authority for Clinician Consultation under the DMC-ODS program. This includes consultations between clinicians designed to assist Drug Medi-Cal (DMC) clinicians with seeking expert advice on treatment needs for specific DMC-ODS members while also permitting DMC-ODS plans to contract with one or more physicians, clinicians, or pharmacists specializing in addiction in order to provide consultation services. Enclosure 5 of BHIN 24-001 lists the types of providers that are qualified to deliver each DMC-ODS service.​​ 

根据药物 Medi-Cal 有组织配送系统 (DMC-ODS)，临床医生咨询服务如何计费？​​ 

Reference: BHIN 24-001, BHIN 23-017, DMC-ODS Billing Manual, DMC-ODS Service Table.​​ 

临床医生咨询不是向 DMC-ODS 会员提供的直接服务。 这项服务允许临床医生向其他有执照的专业人士寻求治疗建议和专业知识，以支持为特定 DMC-ODS 成员提供护理。​​ 

只有向会员寻求建议并直接提供护理的 DMC-ODS 提供商才可以收取临床医生咨询费用。 渲染 DMC-ODS 提供商可以使用临床医生咨询程序代码（99367、99368 或 99451）来申请该活动。 提供建议的临床医生不能为临床医生咨询收取费用。​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Clinician Consultation services.​​ 

执业治疗师 (LPHA) 和执业临床咨询师 (LPCC) 之间为确定诊断和医疗必要性而进行的咨询是否可以使用评估代码进行计费？​​ 

Reference: BHIN 24-001, BHIN 23-068, DMC-ODS Billing Manual, DMC-ODS Service Table.​​ 

No. The assessment code would not be used to bill for the consultation. Consultation between an LPHA and a LPCC that occurs during a DMC-ODS member’s assessment would be billed as Clinician Consultation using a separate code.​​ 

临床医生咨询不是向 DMC-ODS 会员提供的直接服务。 这项服务允许临床医生向其他有执照的专业人士寻求治疗建议和专业知识，以支持为特定 DMC-ODS 成员提供护理。​​ 

只有向会员寻求建议并直接提供护理的 DMC-ODS 提供商才可以收取临床医生咨询费用。 渲染 DMC-ODS 提供商可以使用临床医生咨询程序代码（99367、99368 或 99451）来申请该活动。 提供建议的临床医生不能为临床医生咨询收取费用。​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Clinician Consultation services.​​ 

住院治疗服务提供商何时会根据药物 Medi-Cal 有组织递送系统 (DMC-ODS) 为康复服务开具账单？​​ 

Reference: BHIN 24-001, BHIN 22-005, DMC-ODS Billing Manual, DMC-ODS Service Table.​​ 

住院治疗服务的每日捆绑费率包括：​​ 

  • 评估​​ 
  • 咨询（个人和团体）​​ 
  • 家庭治疗​​ 
  • 医疗服务​​ 
  • 患者教育​​ 
  • 物质使用障碍危机干预服务​​ 

Members may receive Recovery Services under DMC-ODS in three ways: as a standalone service, separately but concurrently with the other DMC-ODS levels of care listed in BHIN 24-001’s “Covered DMC-ODS Services” section (including Residential Services), or as a component of these DMC-ODS levels of care.​​ 

如果会员接受康复服务作为其住院治疗服务的一部分，则住院提供者应针对康复服务提交单独的索赔。 门诊治疗服务和住院治疗服务提供者可在同一天为同一会员申请康复服务，也可为同一住院治疗服务申请康复服务。​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Recovery Services.​​ 

如果索赔当日未提供任何住宅覆盖服务，服务提供商应如何收取住宅治疗服务捆绑费用？​​ 

Reference MHSUDS 19-010; MHSUDS 18-058; DMC-ODS Billing Manual; SUBG Policy Manual; § 1915(c) of the Social Security Act​​ 

当服务提供者在 Medi-Cal 索赔之日向会员提供捆绑费率中包含的至少一项服务时，他们可以按照住院治疗服务的每日捆绑费率收费。 此每日捆绑价格包括以下服务/服务组件：​​ 

  • 评估​​ 
  • 咨询（个人和团体）​​ 
  • 家庭治疗​​ 
  • 医疗服务​​ 
  • 患者教育​​ 
  • 物质使用障碍危机干预服务​​ 

Please refer to the DMC-ODS Billing Manual and Service Table for guidance on billing for Residential Treatment Services.​​ 

Medi-Cal does not reimburse for room and board (e.g. housing and routine living expenses) in accordance with § 1915(c) of the Social Security Act. California offers separate funding streams that counties can utilize to reimburse for room and board for Residential Treatment Services, including the Substance Use Prevention, Treatment and Recovery Services Block Grant (SUBG). However, counties must develop guidelines for and monitor their use of block grant funding to ensure appropriate use. As noted in MHSUDS 18-058, SUBG funding may be used for the following services:​​ 

  • DMC-ODS 提供的住院治疗服务的食宿，​​ 
  • 药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划中的 Recovery Residences 1计划（最长 24 个月），或​​ 
  • 为在药物医疗补助 (DMC) 县的过渡性住房2中接受服务的会员提供食宿（最长 24 个月）。​​ 

While not a part of DMC-ODS, Children’s Crisis Residential Programs (CCRP) are California Department of Social Services licensed Short-Term Residential Therapeutic programs that are certified by DHCS to provide Medicaid covered services, primarily crisis residential treatment services. CCRPs are part of a community care delivery system that provide non-medical care for children experiencing mental health crises that can serve as an alternative to psychiatric hospitalization.​​ 

Eligible costs for crisis residential treatment services are costs for direct practitioners, medical equipment, medical supplies, and overhead; eligible costs do not include room and board. Counties are responsible to pay for the cost of room and board when a CCRP admits a Medi-Cal member. Counties may pay for the cost of room and board with funds the county receives from the State to provide community mental health services through 1991 Realignment or the Mental Health Services Act (MHSA). Counties must develop guidelines for and monitor their use of MHSA funds. As noted on page 3 and 4 of MHSUDS 19-010, Counties may use 1991 Realignment Funds or Mental Health Services Act funds to pay for the following services:​​ 

  • 1991 重新调整基金可用于支付以 CCRP 形式运营的 STRTP 中符合条件的人员（包括 Medi-Cal 受益人）的危机住院治疗服务、食宿和 24 小时护理和监督费用。​​ 
  • MHSA 基金可支付 CCRP 中为社区服务和支持部分全方位服务合作伙伴服务类别下的儿童提供的危机住院治疗服务以及食宿费用。 一般服务发展基金可以支付危机住院治疗服务的费用，但不能支付食宿费用。 各县必须按照利益相关者流程制定的计划使用 MHSA 资金，该计划由其监事会批准，并提交给 DHCS 和精神卫生服务监督和问责委员会。​​ 

总之，住院治疗服务的捆绑费率仅在提供承保服务的日子才适用。 DMC-ODS 住院治疗服务的报销费用由 SUBG 和 MHSA 资金单独报销，可用于住院治疗期间的食宿费用。 每个县都必须制定指导方针并监控其用于这些目的的资金使用情况。​​ 

1有关康复住宅资金应急计划的更多信息，请参阅MHSUDS IN 18-058 。​​ 

2 Please see MHSUDS IN 18-058 for additional information regarding funding contingencies for Transitional Housing.​​ 

初始安置简要问卷 (BQuIP) 工具可以用来完成多维护理水平 (LOC) 评估吗？​​ 

Reference: BHIN 24-001, BHIN 23-068​​ 

No. The BQuIP tool cannot be used to complete the multidimensional level of care (LOC) assessment. Providers are required to use an American Society of Addiction Medicine (ASAM) Criteria assessment to determine DMC-ODS members’ placement into the appropriate level of care.​​ 

Z 代码可以用作药物 Medi-Cal 有组织配送系统 (DMC-ODS) 服务的主要诊断吗？​​ 

Reference BHIN 24-001, BHIN 22-013​​ 

Certain Z-codes may be used during a DMC-ODS member’s assessment services when a diagnosis has yet to be established, per BHIN 22-013. Z-codes meet the federal requirement for claims. The medical record should support any Z-codes that are used in an assessment.​​ 

DMC-ODS 索赔必须包括与每次服务相关的临床适当的国际疾病分类第十修订版 (ICD-10) 代码。 为了让 DHCS 获得联邦财政参与，索赔中必须有 ICD 代码。​​ 

在授权药物 Medi-Cal 有组织递送系统 (DMC-ODS) 客户接受美国成瘾医学协会 (ASAM) 3.1 和 3.5 级护理时，需要进行哪种类型的评估？​​ 

Reference BHIN 24-001, Exhibit A of BHIN 21-001, BHIN 23-068​​ 

DMC-ODS ASAM 3.1 and 3.5 Levels of Care require a multidimensional assessment to be conducted and completed within 72 hours following the member’s admission to the program, per Exhibit A of BHIN 21-001.​​ 

如果在进入戒毒服务后 72 小时内完成了预评估，并且有应急计划将会员转移到将进行全面评估的护理级别，则入院时接受戒毒服务的会员可免于多维评估要求。​​ 

药物 Medi-Cal 有组织配送系统 (DMC-ODS) 住院治疗和住院服务是否需要事先授权？​​ 

Reference: BHIN 24-001​​ 

Yes. DMC-ODS plans shall provide independent review of authorization requests for residential and inpatient services (excluding withdrawal management services) and notify the provider of the plan’s decision within 24 hours of the submission of the request by the provider.​​  

请注意，DMC-ODS 计划不得对非住院和非住院评估和治疗服务（包括戒断管理服务）实施预先授权。​​ 

会员是否需要接受全面的美国成瘾医学协会 (ASAM) 标准评估才能获得康复服务？​​ 

Reference: BHIN 24-001, BHIN 22-005, BHIN 23-068​​ 

无论交付方式如何，恢复服务都不需要会员进行全面的 ASAM 评估即可获得服务。​​ 

Members may receive Recovery Services based on self-assessment or a provider’s assessment of relapse risk. Members do not have to be diagnosed as being in remission in order to access Recovery Services.​​ 

Recovery Services under DMC-ODS can be delivered in three ways: as a standalone service; separately but concurrently with the other DMC-ODS levels of care listed in BHIN 24-001’s “Covered DMC-ODS Services” section; or as a component of these DMC-ODS levels of care. DMC-ODS providers should use their clinical expertise, in accordance with each member’s clinical needs and generally accepted standards of practice, to determine the appropriate delivery method of Recovery Services for their members.​​ 

请注意，会员无需进行全面的 ASAM 评估即可开始接受 DMC-ODS 服务。​​  

Medi-Cal 会员在住院物质滥用障碍 (SUD) 治疗计划中的住院时长要求是什么？ 对于怀孕和产后会员，这些要求是否有所不同？​​  

Reference BHIN 21-021; BHIN 24-001​​ 

Medi-Cal 会员（包括孕妇和产后会员）可以留在住院 SUD 治疗计划中，时间长短由执业治疗师 (LPHA) 确定，且临床适用。 虽然全州范围内药物医疗补助有组织配送系统 (DMC-ODS) 各县提供的住院治疗服务的平均住院天数目标是 30 天或更短，但对于会员接受住院治疗的最长天数没有限制。​​ 

Please see BHIN 21-021 for additional information on the removal of a former length of stay requirement.​​ 

如果会员从住院服务转为门诊药物 Medi-Cal 有组织配送系统 (DMC-ODS) 服务，那么在会员技术上仍在参加住院服务的情况下，门诊提供者和住院提供者是否可以收取护理协调费用？​​ 

Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table​​ 

住院治疗服务捆绑费率不包括护理协调服务。 因此，住院治疗或门诊提供者可以将护理协调作为一项非捆绑服务进行计费和报销，与住院治疗或门诊服务的计费分开。​​ 

如果住院治疗提供者有资格提供门诊服务，则该提供者可以将护理协调作为门诊服务申请（使用修饰符 U7 或 U8），并按照门诊费率报销该服务。 住院治疗提供者还可以通过住院计划认证申请护理协调（即 您可以使用 U1 修饰符代替门诊治疗，并享受相同的门诊费率。​​ 

住院治疗服务捆绑费率包括以下部分：​​ 

  • 评估​​ 
  • 咨询​​ 
  • 家庭治疗​​ 
  • 医疗服务​​ 
  • 患者教育​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Care Coordination services.​​ 

对于药物 Medi-Cal 有组织配送系统 (DMC-ODS)，是否仍需要出院计划和出院摘要？​​ 

参考： BHIN 19-003 ；宾 23-068 ,宾 24-001​​ 

DMC-ODS plans and providers should follow documentation requirements set forth in BHIN 23-068, which does not include discharge plans and discharge summaries. Discharge planning is a component of Care Coordination services for DMC-ODS and should be provided based on member need. Discharge planning can include coordination with substance use disorder (SUD) treatment providers to support transitions between levels of care and to recovery resources, referrals to mental health providers, and referrals to primary or specialty medical providers. For certified only programs, discharge plans and summaries are required per Alcohol and/or other Drug (AOD) Certification Standard 7120.​​ 

Further, licensed residential programs shall update resident records as necessary to ensure current accuracy and include data and reason for termination of services, per CCR Title 9, Chapter 5, Section 10568. Additionally, BHIN 19-003 updates H&S Code 11834.26(d) to include resident discharge and continuation of care as part of the required written plan to address resident relapse.​​ 

无家可归是否可以成为延长物质使用障碍（SUD）治疗甚至提高护理水平（LOC）的理由？​​ 

Reference: BHIN 24-001​​ 

会员必须符合药物医疗补助 (DMC) 或药物医疗补助有组织配送系统 (DMC-ODS) 的访问标准，才能通过 DMC/DMC-ODS 计划访问 SUD 服务。 美国成瘾医学协会 (ASAM) 标准用于确定所有通过 DMC 或 DMC-ODS 接受服务的成员是否被安置到适当的 LOC。 多维 ASAM 评估的第 5 维度（恢复环境交互）包括可能影响恢复的因素，例如无家可归，以帮助确定适当的安置地点。 会员安置和 LOC 确定应确保会员能够在临床上适合治疗其病情的最低强度 LOC 中接受护理。​​ 

通过提供含有丁丙诺啡和纳洛酮的丁丙诺啡 (Suboxone ® ) 是否能满足在麻醉品治疗计划 (NTP) / 阿片类药物治疗计划 (OTP) 提供纳洛酮的要求？​​ 

参考： BHIN 24-001 ， BHIN 23-064​​ 

不可以。虽然 NTP/OTP 可能会提供含纳洛酮的丁丙诺啡配方，但这不能替代纳洛酮。 纳洛酮（单独使用）用于逆转阿片类药物过量服用。 在丁丙诺啡/纳洛酮组合产品中加入纳洛酮是为了防止丁丙诺啡药物的转移和滥用；并不是为了逆转阿片类药物引起的过量用药。​​ 

How should a provider bill for Narcotic Treatment Program (NTP) dosing when a member temporarily receives services in a county that they do not reside in, and the member’s home NTP does not have a contract with that county? – September 17, 2024​​ 

Reference BHIN 24-001, DMC-ODS Billing Manual​​ 

As noted on page 31 of BHIN 24-001, The Drug Medi Cal-Organized Delivery System (DMC-ODS) plan is responsible for ensuring that members receiving NTP services and working in or traveling to another county (including a county that does not opt into the DMC-ODS program) do not experience a disruption of NTP services.​​ 

If the member is traveling out of the county and requires medications from an NTP, the DMC-ODS plan shall cover these services out-of-network for the member, for as long as the DMC-ODS plan’s provider network is unable to provide them. In these cases, the DMC-ODS plan shall coordinate and cover the out-of-network NTP services for the member. Per page 44 of the DMC-ODS Billing Manual, the NTP dosing should be billed using the modifiers UA and HG.​​ 

药物 Medi-Cal 有组织配送系统 (DMC-ODS) 提供商如何利用 Medi-Cal 为患者开具和分发纳洛酮？​​ 

Reference: BHIN 24-001 , BHIN 23-064​​ 

DMC-ODS 提供商可以灵活地利用 Medi-Cal Rx 为每个 DMC-ODS 成员提供或安排纳洛酮的处方和提供。 Medi-Cal Rx 是所有 Medi-Cal 会员的门诊药房福利。 Medi-Cal Rx 涵盖处方药和非处方门诊药，包括纳洛酮。​​ 

DMC-ODS providers that are authorized to prescribe the medication can prescribe naloxone to each member who is under their care and arrange for staff to routinely fill these naloxone prescriptions at a pharmacy on behalf of the members, as a best practice overdose prevention measure. DMC-ODS providers can also coordinate delivery of the naloxone from a pharmacy to the member’s location or refer members to pharmacies that will dispense naloxone directly to the member. Furthermore, DMC-ODS counties may cover drug product costs for treatment when the medications are purchased and administered or dispensed in a nonclinical setting (e.g., criminal justice settings or street-based outreach). Finally, medical directors and prescribing clinicians of DMC-ODS providers are also able to establish a standardized protocol that authorizes designated staff working in a DMC-ODS provider agency to issue prescriptions on behalf of the medical directors or prescribing clinicians to a local pharmacy for naloxone.​​ 

The Naloxone Distribution Project (NDP) is a project DHCS established in 2018 to reduce opioid-related overdose deaths through the provision of free naloxone, directly shipped to eligible entities. The NDP supports eligible entities, including, but not limited to, law enforcement, schools, tribal entities, county public health and behavioral health departments, and community organizations. The NDP is not the primary source for naloxone in California and other available funding sources should be used to obtain naloxone prior to utilizing the NDP.​​ 

Medi-Cal 会员如何获得成瘾治疗药物 (MAT)？​​ 

Reference BHIN 24-001, BHIN 23-064, BHIN 23-054, BHIN 22-011, and the MCP Contracts.​​ 

药物 Medi-Cal 有序配送系统 (DMC-ODS)​​ 

DMC-ODS providers can administer medications for Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD). All FDA-approved medications and biological products to treat these disorders are covered, including buprenorphine and naltrexone. MAT is covered, reimbursable, and can be provided in most DMC-ODS levels of care, including outpatient treatment, intensive outpatient treatment, partial hospitalization, residential treatment1,  inpatient treatment, and withdrawal management. MAT is also covered, reimbursable, and can be provided by DMC-ODS providers in non-clinical settings (such as mobile clinics and street medicine teams) and when provided as a standalone service outside of these levels of care. Methadone maintenance treatment must be provided by a Narcotic Treatment Program (NTP).​​ 

必须为需要或使用 MAT 的会员提供服务。 会员不能被拒绝 DMC-ODS 治疗服务、被要求减少剂量或逐渐减少药量作为接受或继续 DMC-ODS 服务的条件。 提供 MAT 的 DMC-ODS 提供商不得拒绝提供药物或行政解雇拒绝咨询服务的成员。​​ 

As described in BHIN 24-001, DMC-ODS plans shall ensure that all DMC-ODS providers, at all levels of care, either offer MAT services directly or have an effective referral process in place to the most clinically appropriate MAT services, pursuant to the requirements set forth in BHIN 23-054. An effective referral process shall include an established relationship with a MAT provider and transportation to appointments for MAT, regardless of whether the provider seeks reimbursement through DMC-ODS. Simply providing a member with the contact information for a MAT provider does not meet the requirement of an effective referral.​​ 

MAT 还可在 DMC-ODS 之外的各种环境中向 Medi-Cal 会员提供，包括：​​ 

  • Medi-Cal 管理医疗计划 (MCP)。Medi-Cal 会员可以通过初级保健、社区诊所、联邦质量健康中心 (FQHC)、住院医院、急诊科和其他合同医疗环境获得由 MCP 网络提供商提供的临床适当且承保的 SUD 服务（例如酒精和药物筛查、评估、简短干预和转诊治疗），根据BHIN 22-011和MCP 合同，MCP 还必须安排在初级保健、住院医院、急诊科和其他合同医疗环境中提供 MAT。​​ 
  • 急诊室 (ED) 和医院。 ED 可以成为 OUD 患者的稳定点。 任何医院或急诊室提供者都可以根据CA Bridge 治疗方案施用丁丙诺啡，以缓解急性戒断症状并方便患者转诊接受治疗。 加利福尼亚州的 240 多家急诊科通过现场 MAT 诱导和丁丙诺啡短期处方提供 MAT，以帮助会员度过第一次随访时间。 请访问加州桥梁计划网站，查找整个加州提供 MAT 的资源、工具和 ED。​​ 
  • Pharmacies. Medi-Cal members can receive medications for the treatment of substance use disorders similar to any other maintenance medication from a Medi-Cal enrolled pharmacy.  All medications and biological products utilized to treat SUDs, including long-acting injectables, are available through Medi-Cal Rx without prior authorization. Medications can also be delivered directly to provider offices for onsite administration. Medi-Cal Rx pharmacies can be found by visiting the Medi-Cal Rx website, and provider training resources can be found on the Medi-Cal Rx Education & Outreach website. The complete list of approved medications for the Medi-Cal Rx program can be found on the Medi-Cal Rx Contract Drugs List website.​​ 

访问 MAT 的其他资源​​ 

  • DHCS 阿片类药物应对计划旨在通过专注于预防、治疗和恢复活动的项目，增加获得 MAT 的机会，减少未满足的治疗需求，并减少阿片类药物过量相关的死亡。 许多初级保健提供者、FQHC、专业 SUD 治疗提供者和其他组织正在通过该项目获得资金，这可以帮助没有保险或保险不足的个人支付药物和服务费用。​​ 
  • The Tribal MAT Project is a unified response designed to meet the specific opioid use disorder prevention, treatment, and recovery needs of California’s Tribal and Urban Indian communities. The Tribal MAT Project promotes opioid safety, improves the availability and provision of MAT, and facilitates wider access to naloxone with special consideration for Tribal and Urban Indian values, culture, and treatments.​​ 
  • Treatment Locators: Please visit http://choosemat.org/ for a list of providers and facilities offering MAT in your area. The organization Shatterproof has also created a treatment locator with questions to help individuals and families access treatment that is suited to their needs, via the ATLAS platform.​​ 

1 Licensed residential treatment programs that are authorized to provide incidental medical services (IMS) may also offer MAT.​​ 

药物 Medi-Cal 有组织投放系统 (DMC-ODS) 如何承保附带服务？​​ 

Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table​​ 

A collateral is a family member or other person supporting the DMC-ODS member. “Collateral services” is no longer defined as a unique service component of the DMC-ODS service modalities.  As described in BHIN 24-001, the concept of including a collateral in a member’s substance use disorder treatment has been incorporated into assessment services, individual counseling, Medi-Cal Peer Support Services, and family therapy. There may be times when, based on clinical judgment, the member is not present during the delivery of this service, but the service is for the direct benefit of the member.​​ 

Assessment services may include contact with family members or other collaterals if the purpose of the collateral’s participation is to focus on the treatment needs of the member. Individual counseling services and Medi-Cal Peer Support Services can also include contact with family members or other collaterals if the purpose of the collateral’s participation is to focus on the treatment needs of the member by supporting the achievement of the member’s treatment goals.​​ 

Family therapy is a rehabilitative service that includes family members in the treatment process, providing education about factors that are important to the member’s recovery as well as the holistic recovery of the family system. Family members can provide social support to the member and help motivate their loved one to remain in treatment.​​ 

BHIN 24-001 and the DMC-ODS Medi-Cal Billing Manual detail which DMC-ODS service modalities include assessment services, individual counseling services, Medi-Cal Peer Support Services and family therapy as billable service components.​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing services involving a member’s collaterals.​​ 

要通过药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划提供部分住院服务，DMC-ODS 计划必须满足哪些认证要求？​​ 

Reference: BHIN 24-001​​ 

对于 DMC-ODS 计划来说，部分住院服务是可选的。 没有专门针对部分住院的 DMC 认证类别。 为了通过 DMC-ODS 提供部分住院服务，DMC-ODS 计划或 DMC-ODS 签约提供商必须：​​ 

  • 获得 DMC 强化门诊治疗 (IOT) 提供者认证；​​ 
  • 每周能够提供 20 小时或以上的临床密集型课程；并且​​ 
  • 展示根据需要方便获取精神病、医疗和实验室服务的能力。​​ 

与申诉相关的药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划文件要求是什么？​​ 

Reference:  BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract​​ 

根据政府间协议（DMC-ODS 合同）的规定，每个 DMC-ODS 计划应保存申诉和上诉记录，并应作为其持续监测程序的一部分审查这些信息，以及对部门质量战略进行更新和修订。​​ 

每项申诉或上诉的记录至少应包含以下所有信息：​​ 

  • 上诉或申诉原因的一般描述。​​ 
  • 收到日期。​​ 
  • 每次审查或审查会议（如果适用）的日期。​​ 
  • 如果适用，则解决每个级别的上诉或申诉。​​ 
  • 各层级解决日期（如适用）。​​ 
  • 提出上诉或申诉的受保人的姓名。​​ 

Each record shall be accurately maintained in a manner accessible to the Department of Health Care Services (DHCS) and available upon request to the Centers for Medicare and Medicaid Services (CMS). The written record of grievances and appeals shall be submitted at least quarterly to the plan’s quality improvement committee for systematic aggregation and analysis for quality improvement. Grievances and appeals reviewed shall include, but not be limited to, those related to access to care, quality of care, and denial of services. Appropriate action shall be taken to remedy any problems identified.​​ 

药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划对上诉有哪些要求？​​ 

Reference:  BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract​​ 

根据政府间协议（DMC-ODS 合同）的规定，会员或提供商和/或授权代表可以亲自、口头或书面提出上诉。 如果他们要求加快解决，成员或代表必须在亲自或口头提交后提交书面签名的上诉。 上诉不得以任何方式对会员或授权代表产生不利影响。 决定申诉解决方案的个人必须具备相应资格，且不参与任何先前级别的审查或决策。​​ 

会员和/或其授权代表必须：​​ 

  • 有权在上诉前和上诉过程中检查他们的案件档案，包括他们的医疗记录和上诉过程中考虑的任何其他文件或记录。​​ 
  • 有合理的机会亲自或书面提供事实或法律的证据和指控。​​ 
  • Be allowed to have a legal representative and/or legal representative of a deceased member’s estate included as parties to the appeal.​​ 
  • 获悉他们的上诉正在通过书面确认的方式进行审核。​​ 
  • 在完成上诉程序后，被告知他们有权要求举行州听证会。​​ 

药物 Medi-Cal 有组织投放系统 (DMC-ODS) 计划的要求和州听证会的时间表是什么？​​ 

Reference: BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract​​ 

根据政府间协议 (DMC-ODS 合同) 的规定，会员只有在收到计划维持不利福利裁定的通知后，才可以申请州听证会。​​ 

自计划亲自向成员下达决定之日起，或上诉决定邮寄后的第二天起，成员有 120 天的时间申请举行州听证会。 如果会员没有收到不利福利裁定通知 (NOABD)，他们可以随时申请州听证会。​​ 

加州社会服务部将在收到请求后的 90 天内进行独立审查。 成员可以请求加快州听证会。 如果请求符合加快州听证会的条件，则州听证部门将在收到请求之日起三个工作日内发布决定。​​ 

药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划和提供商可以在哪里找到有关不利利益裁定通知 (NOABD) 申诉和上诉要求的指导？​​ 

Reference: MHSUDS IN 18-010E​​ 

Please refer to MHSUDS IN 18-010E: Federal Grievance and Appeal System Requirements with Revised Beneficiary Notice Templates for clarification and guidance regarding the application of revised federal regulations for processing grievances and appeals.​​ 

药品 Medi-Cal 有组织配送系统 (DMC-ODS) 计划的质量改进 (QI) 计划中必须包含哪些申诉和上诉信息？​​ 

Reference: BHIN 24-001​​ 

质量改进计划必须包括如何收集、分类和评估会员投诉数据以进行监控的信息。 至少，QI 计划必须包括以下信息：​​ 

  • 如何提交申诉、上诉和州听证请求​​ 
  • 解决上诉的时间框架；​​ 
  • 申诉决定的内容；​​ 
  • 记录保存；​​ 
  • 继续享受福利；以及​​ 
  • 州听证会的要求。​​ 

如果药物 Medi-Cal 有组织配送系统 (DMC-ODS) 计划设有综合行为健康部门，它是否可以使用精神健康计划合同所要求的相同质量改进 (QI) 委员会来满足 DMC-ODS QI 委员会的要求？​​ 

Reference: BHIN 24-001​​ 

是的。 对于设有综合行为健康部门的县，DMC-ODS 计划可能会使用同一个委员会，并由其参与物质使用障碍问题。​​ 

实习学生或受训人员是否被视为执业医术师（LPHA）？​​ 

Reference: BHIN 24-001, SPA 23-0026​​ 

不是。执业治疗师 (LPHA) 包括以下任何一种：医生、执业护士 (NP)、医师助理 (PA)、注册护士、注册药剂师、执业临床心理学家 (LCP)、执业临床社会工作者 (LCSW)、注册 CSW、执业专业临床咨询师 (LPCC)、注册 PCC、执业婚姻家庭治疗师 (LMFT)、注册 MFT、执业职业护士 (LVN)、执业职业治疗师 (LOT) 和执业精神病技术员 (LPT)。​​ 

A clinical trainee is an unlicensed individual who is enrolled in a post-secondary educational degree program in the State of California that is required for the individual to obtain licensure as an LPHA; is participating in a practicum, clerkship, or internship approved by the individual’s program; and meets all relevant requirements of the program and/or applicable licensing board to participate in the practicum, clerkship, or internship and provide substance use disorder treatment services, including, but not limited to, all coursework and supervised practice requirements.​​ 

SPA 23-0026 allows CSW, MFT, and PCC candidates to provide DMC-ODS services if the candidate:​​ 

  • Submitted their application for associate registration to Board of Behavioral Sciences (BSS) within 90 days of their master’s program degree award date,​​ 
  • 正在完成执照所需的监督时间，并且​​ 
  • 根据加州法律在其执业范围内行事。​​ 

The BSS’ “90 Day Rule” allows CSW, MFT, and PCC candidates who have submitted their applications for associate registration within 90 days of the degree award date to count supervised experience gained during the window of time between the degree award date and the issue date of the associate registration number toward their licensure.​​ 

非围产期医疗服务提供者可以为怀孕的药物 Medi-Cal 有组织分娩系统 (DMC-ODS) 成员提供服务吗？ 申请这些服务的流程是怎样的？​​ 

参考资料围产期实践指南​​ 

是的。怀孕的会员可以选择接受非围产期医疗服务提供者提供的服务。如果 DMC-ODS 会员通过怀孕援助代码获得资格，报销单必须包含病人信息（也称为 PAT）9 怀孕指标才有效。请参阅《围产期实践指南》，该指南适用于为寻求或转介接受药物使用障碍治疗的孕妇和养育子女者提供服务的医疗服务提供者。​​ 

药物医疗补助有组织配送系统 (DMC-ODS) 团体咨询服务的账单是如何计算的？​​ 

Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table​​ 

DMC-ODS 团体咨询服务的单位应使用以下公式计算：（团体咨询会议的分钟数/15 分钟增量=使用程序代码 H0005 提交的总单位。 DMC-ODS 计划应为接受团体咨询的每个成员分别提交索赔。​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing group counseling services.​​ 

Can you submit a claim for a member’s “room and board” during residential treatment if the member received no residential treatment covered services on the date of service for the claim?​​ 

Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table​​ 

No. “Room and board” cannot be claimed separately. In order to claim for residential treatment, a member must receive at least one residential treatment covered service (i.e. required structured activity) on the date of service for the claim. BHIN 24-001 outlines the services covered under Residential Treatment.​​ 

Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Residential Services.​​ 

2011 年调整资金以外的收入是否有资格获得联邦配套资金？​​ 

参考资料：SSA § 1903(w)(6)； 42 CFR § 433.51。​​ 

是的。 其他地方资金只要是非联邦公共资金，也有资格用作非联邦配套资金，并且符合 SSA §1903(w)(6) 和 42 CFR §433.51 中概述的要求。​​