卡拉伊姆行為健康計劃常見問題
以下是從技術支援和資訊網路研討會收集的常見問題清單，並提交至 BHCalAIM@dhcs.ca.gov 電子郵件中的提交內容。 DHCS 將每季更新此列表。
DMC-ODS
臨床醫生諮詢是否可以在同一機構內的持牌代理人員之間進行，還是該諮詢是否必須在持牌機構員工和縣內簽約的外部顧問之間進行？
參考品展示品 24-001 & 抗氧化劑服務台
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.
加州醫療補助健康保健計劃組織交付系統 (DMC-ODS) 下的臨床醫生諮詢服務如何計費？
Reference: BHIN 24-001, BHIN 23-017, DMC-ODS Billing Manual, DMC-ODS Service Table.
臨床醫生諮詢不是向 DMC-ODS 會員提供的直接服務。 此服務允許臨床醫生向其他持牌專業人士尋求治療建議和專業知識，以支持為特定 DMC-ODS 會員提供護理。
只有在尋求建議並直接向會員提供護理的 DMC-ODS 提供商才能收取臨床醫生諮詢費用。 彩現 DMC-ODS 提供者可使用臨床醫生諮詢程序代碼 (99367、99368 或 99451) 申請活動。 提供建議的臨床醫生不能收取臨床醫生諮詢費用。
Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Clinician Consultation services.
醫療藝術持牌專業人士（LPHA）與持牌專業臨床顧問（LPCC）之諮詢，以確定診斷和醫療必要性的諮詢是否可以使用評估代碼計費？
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.
臨床醫生諮詢不是向 DMC-ODS 會員提供的直接服務。 此服務允許臨床醫生向其他持牌專業人士尋求治療建議和專業知識，以支持為特定 DMC-ODS 會員提供護理。
只有在尋求建議並直接向會員提供護理的 DMC-ODS 提供商才能收取臨床醫生諮詢費用。 彩現 DMC-ODS 提供者可使用臨床醫生諮詢程序代碼 (99367、99368 或 99451) 申請活動。 提供建議的臨床醫生不能收取臨床醫生諮詢費用。
Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Clinician Consultation services.
住院治療服務提供者何時會根據藥物加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 收取復健服務費用？
Reference: BHIN 24-001, BHIN 22-005, DMC-ODS Billing Manual, DMC-ODS Service Table.
住宿治療服務的每日套票價包括：
- 評估
- 諮詢（個人和團體）
- 家庭治療
- 藥物服務
- 病人教育
- 物質使用障礙危機干預服務
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.
如果會員接受復康服務作為其住宿治療服務的一部分，住宅提供者應為恢復服務提交單獨申請。 門診治服務及住宿治療服務供應商可於同一會員申請復康服務及住宿治療服務提供者。
Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Recovery Services.
在索償當日沒有提供住宅保障服務的日期，提供者應該如何計算住宅治療服務套餐費率？
Reference MHSUDS 19-010; MHSUDS 18-058; DMC-ODS Billing Manual; SUBG Policy Manual; § 1915(c) of the Social Security Act
當在 Medi-Cal 索償日期內至少提供一項包含的服務給會員時，提供者可以按住宅治療服務的每日套餐費用收取費用。 此每日套餐費率包括以下服務/服務元件：
- 評估
- 諮詢（個人和團體）
- 家庭治療
- 藥物服務
- 病人教育
- 物質使用障礙危機干預服務
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:
- 根據 DMC-ODS 提供的住宿治療服務的住宿和膳食，
- 藥物醫療有組織送貨系統 (DMC-ODS) 計劃中的復康住所 1 計劃（最長 24 個月），或
- 為藥物醫藥（DMC）縣的過渡性房屋 2 接受服務的成員的房間和膳食（最長 24 個月）。
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 年重新調整資金可以支付危機住宿治療服務、住宿和膳食以及 24 小時照顧和監督，包括醫療服務受益人，以及以 CCRP 為合資格人士提供服務。
- MHSA 基金可支付 CCRP 中為社區服務和支持組件「全服務夥伴關係服務」類別下的兒童提供的危機住宿治療服務和住宿費用。 一般服務發展基金可能支付危機住宅治療服務的費用，但不支付住宿費用。 各縣必須根據利害關係人流程擬備的計劃一致，經其監事委員會批准，並提交給 DHCS 和心理健康服務監督和問責委員會的計劃一致。
總而言之，住宿治療服務的綜合費率僅適用於提供受保服務的日期。 DMC-ODS 住宿治療服務的索償將與 SUBG 和 MHSA 資助流分開補償，這些資助可用於住宿治療期間的房間和膳食費用。 每個縣必須制定指引並監控他們為這些目的使用資金。
1 有關復康住宅應急資金的更多資訊，請參閱 MHSUDS IN 18-058 號。
2 Please see MHSUDS IN 18-058 for additional information regarding funding contingencies for Transitional Housing.
初始安置簡要問卷 (BQuIP) 工具可以用於完成多維護等級（LOC）評估嗎？
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 代碼可以用作加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 服務的主要診斷嗎？
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 聲明必須包括臨床適當的國際疾病分類、第十次修訂 (ICD-10) 代碼與每次服務遇到相關。 為了讓 DHCS 獲得聯邦財務參與，索賠上需要 ICD 代碼。
授權加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 客戶接受美國成癮醫學協會 (ASAM) 3.1 和 3.5 護理等級時，需要進行什麼類型的評估？
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.
如果在入院排毒服務後 72 小時內完成預先評估，並有應急計劃將會員轉移到護理級別的情況下，即可獲得排毒服務的會員免除多維度評估要求，並進行全面評估。
藥物加州醫療補助健康保健計劃有組織的交付系統（DMC-ODS）住院治療和住院服務是否需要事先授權？
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.
請注意，DMC-ODS 計劃可能不會對非住院和非住院評估和治療服務（包括戒斷管理服務）實施事先授權。
會員是否需要全面的美國成癮醫學協會（ASAM）標準評估才能獲得恢復服務？
Reference: BHIN 24-001, BHIN 22-005, BHIN 23-068
無論交付方式如何，恢復服務都不需要全面的 ASAM 評估才能接收服務。
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.
請注意，會員不需要進行全面的 ASAM 評估才能開始接受 DMC-ODS 服務。
加州醫療補助健康保健計劃成員在住宅藥物使用障礙 (SUD) 治療專案中的住院時間要求是多少？ 孕婦和產後成員這些要求是否有所不同？
Reference BHIN 21-021; BHIN 24-001
Medi-Cal 會員，包括孕婦和產後成員，可以在醫療藝術持牌執業者（LPHA）確定臨床適當的情況下繼續在住宿 SUD 治療計劃中。 儘管 Drug Medi-Cal 有組織送遞系統（DMC-ODS）縣提供的住宿治療服務平均逗留時間的全州目標為 30 天或更短，但會員可以在住宿治療中居住的天數上限沒有限制。
Please see BHIN 21-021 for additional information on the removal of a former length of stay requirement.
如果會員從住院轉到門診 藥物加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 服務，門診提供者和住院提供者是否可以在該會員在技術上仍參加住院服務時收取護理協調費用？
Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table
住宿治療服務套餐價格不包括護理協調服務。 因此，住宿治療或門診服務提供者可以將照護協調作為一項不包裝服務的收費，並可以另外收取住宿治療或門診服務的帳單。
如住宿治療服務提供者獲認證提供門診服務，該服務提供者可以申請護理協調作為門診服務（使用修改符號 U7 或 U8），並將按門診費率獲賠償。 住宿治療提供者也可以通過住宿計劃認證申請護理協調（即 修正因子 U1）而不是門診，並且有權享有相同的門診率。
住宿治療服務套餐價格包括以下組成部分：
- 評估
- 輔導
- 家庭治療
- 藥物服務
- 病人教育
Please see the DMC-ODS Billing Manual and separate DMC-ODS Service Table for directions on billing Care Coordination services.
對於藥物加州醫療補助健康保健計劃有組織的交付系統（DMC-ODS），還需要出院計劃和出院摘要嗎？
參考資料：BHIN 19-003; BHIN 23-068,BHIN 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.
無家可歸是擴展藥物使用障礙（SUD）治療，甚至提高護理水平（LOC）的理由嗎？
Reference: BHIN 24-001
會員必須符合藥物醫療服務（DMC）或藥物醫藥有組織傳遞系統（DMC-ODS）的訪問條件，才能通過 DMC/DMC-ODS 計劃訪問 SUD 服務。 美國成癮醫學會（ASAM）標準用於確定所有通過 DMC 或 DMC-ODS 接受服務的成員在適當的 LOC 中。 多維 ASAM 評估的維度 5（恢復環境互動）包括可能影響恢復的因素，例如無家可歸，以幫助確定適當的位置。 會員安置及定義會員須確保會員能夠在臨床適合治療其病情的最低密集性的 LOC 接受治療。
能否透過提供同時含有丁丙諾啡和納洛酮的丁丙諾啡 (Suboxone ® ) 來滿足麻醉治療專案 (NTP) / 阿片類藥物治療專案 (OTP) 中提供納洛酮的要求？
參考： BHIN 24-001 ， BHIN 23-064
不雖然 NTPS/OTP 可能提供含有納洛克遜的布普倫奧芬配方，但這不是納洛克遜的替代品。 納洛克森（本身）用於逆轉涉及阿片類藥物的過量。 將納洛克森納入布普倫諾芬/納洛克森的組合產品中，旨在防止轉移和濫用布普倫奧芬藥物；並不旨在逆轉涉及阿片類藥物的過量。
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.
藥物加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 提供者如何利用加州醫療補助健康保健計劃為患者開處方和配藥納洛酮？
Reference: BHIN 24-001 , BHIN 23-064
DMC-ODS 供應商可以靈活地利用 Medi-Cal Rx，提供或安排給每個 DMC-ODS 成員處方或安排給每個 DMC-ODS 成員。 Medi-Cal Rx 是所有 Medi-Cal 會員的門診藥房福利。 Medi-Cal Rx 涵蓋處方和非處方門診藥物，包括納洛克遜。
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.
加州醫療補助健康保健計劃會員如何獲得成癮治療藥物 (MAT)？
Reference BHIN 24-001, BHIN 23-064, BHIN 23-054, BHIN 22-011, and the MCP Contracts.
藥物加州醫療補助健康保健計劃有組織的交付系統（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).
需要或使用 MAT 的會員必須服務。 成員不得拒絕 DMC-ODS 治療服務、要求減少劑量或減少藥物，作為接受或繼續接受 DMC-ODS 服務的條件。 提供 MAT 的 DMC-ODS 供應商不得拒絕接受藥物或從行政上解除拒絕諮詢服務的會員。
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.
在 DMC-ODS 以外的不同場地也可以向 Medi-Cal 會員提供 MAT，包括：
- 醫療管理護理計劃（MCP）。Medi-Cal 會員可以通過基層醫療、社區診所、聯邦優質健康中心（FQHC）、住院醫院、急診部和其他合 約醫療機構提供的臨床適當和涵蓋的 SUD 服務（例如：酒精和毒品篩查、評估、簡短介入和轉介治療），MCP 還必須安排在基層醫療中提供的 MAT、住院、急診部等 簽約醫療設施。
- 急診部門（ED）和醫院。 ED 可以成為具有 OUD 成員的穩定點。 任何醫院或 ED 提供者都可以根據 CA 橋接治療程序服用布 PRENORFIN，以緩解急性戒斷症狀並促進患者轉介治療。 加利福尼亞州超過 240 名醫生通過在 ED 中的現場 MAT 感應和短期處方的布普倫奧芬提供 MAT，以連接成員直到他們的第一次跟進訪。 請訪問加州橋樑計劃網站以查找在整個加利福尼亞州提供 MAT 的資源、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.
訪問 MAT 的其他資源
- DHCS 阿片類藥物反應旨在通過專注於預防、治療和康復活動的計劃來增加對 MAT 的接觸，減少未滿足的治療需求，以及減少與阿片類藥物過量相關的死亡率。 許多基層醫療服務提供者，FQHC，特殊 SUD 治療提供者和其他組織正在通過該項目獲得資金，這可以幫助為無保險或未受保險的個人支付藥物和服務費用。
- 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.
加州醫療補助健康保健計劃組織交付系統 (DMC-ODS) 如何承保附帶服務？
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.
要透過加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 專案提供部分住院服務，DMC-ODS 計劃必須滿足哪些認證要求？
Reference: BHIN 24-001
DMC-ODS 計劃可選擇部分住院服務。 沒有專門針對部分住院的 DMC 認證類別。 為了透過 DMC-ODS 提供局部住院服務，DMC-ODS 計劃或 DMC-ODS 合約提供者必須：
- 獲得 DMC 密集門診治（IOT）提供者認證；
- 能夠每週提供 20 小時或更多的臨床密集程序；以及
- 展示有助於根據需要獲得精神科、醫療和實驗室服務的能力。
與申訴相關的加州醫療補助健康保健計劃有組織交付系統 (DMC-ODS) 計劃文件要求有哪些？
Reference: BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract
根據政府間協議（DMC-ODS 合約）規定，每個 DMC-ODS 計劃均須保存投訴和上訴的記錄，並作為其持續監察程序的一部分，以及對本署質量策略的更新和修訂。
每宗投訴或上訴的記錄必須至少包含下列所有資料：
- 上訴或投訴原因的一般描述。
- 收到日期。
- 每次審查或 (如適用) 審核會議的日期。
- 上訴或投訴的每個層級的解決方案（如適用）。
- 各級別的解決日期（如適用）。
- 提出上訴或投訴的受保人的姓名。
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.
加州醫療補助健康保健計劃有組織交付系統 (DMC-ODS) 計劃的上訴要求是什麼？
Reference: BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract
根據政府間協議（DMC-ODS 合約）中的規定，會員或提供商和/或授權代表可以親自、口頭或書面提出上訴。 如果他們要求加快解決，則會員或代表必須在面對面或口頭提交後，並提交書面簽名的上訴。 上訴不得以任何方式對成員或授權代表計算。 決定上訴決議的個人必須具備資格，並且不參與任何過往任何等級的審查或決策。
會員及 ／ 或其授權代表必須：
- 有權查閱其案件檔案，包括他們的病歷，以及在上訴過程中，在上訴過程中考慮的任何其他文件或記錄。
- 有合理機會親自或書面提交有關事實或法律的證據和指控。
- Be allowed to have a legal representative and/or legal representative of a deceased member’s estate included as parties to the appeal.
- 請注意，他們的上訴正在通過書面確認審查。
- 在上訴程序完成後，獲知他們要求國家聆訊的權利。
國家聽證會的藥物醫療有組織配送系統（DMC-ODS）計劃要求和時間範圍是什麼？
Reference: BHIN 24-001, July 1, 2022 – July 1, 2027 DMC-ODS Contract
根據政府間協議（DMC-ODS 合約）中的規定，成員只有在收到有關計劃維持不利益裁定的通知後，才能要求國家聆訊。
議員有 120 天的時間要求國家聆訊，從計劃親自發出決定給成員的日期，或上訴決定被郵寄標記後的一天開始。 如果成員沒有收到不利益判定通知（NOABD），他們可以隨時提出國家聆訊。
加州社會服務部將在收到請求後 90 天內進行獨立審查。 議員可要求加快國家聆訊。 如要求符合加快國家聆訊的資格，則該決定將在國家聽證部收到要求的日期起計三個工作日內發出。
加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 計劃和提供者在哪裡可以找到有關不利福利確定通知 (NOABD) 申訴和上訴要求的指導？
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.
哪些申訴和上訴資訊必須包含在加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 計劃的品質改進 (QI) 計劃中？
Reference: BHIN 24-001
QI 計劃必須包含有關會員投訴數據將如何收集、分類和評估以進行監控的信息。 QI 計劃至少必須包含以下資訊：
- 如何提交申訴、上訴和要求國家聆訊
- 解決上訴的時間範圍；
- 上訴決議的內容；
- 記錄保存；
- 保持福利；以及
- 國家聽證會的要求。
如果藥物加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 計劃設有綜合行為健康部門，它是否可以使用精神健康計劃合約要求的相同品質改進 (QI) 委員會來履行 DMC- ODS QI 委員會的要求？
Reference: BHIN 24-001
是的 DMC-ODS 計劃可以使用相同的委員會（含有物質使用障礙參與），對於具有綜合行為健康部門的縣。
實習生或實習生是否被視為治療藝術的持牌執業者？
Reference: BHIN 24-001, SPA 23-0026
不醫療藝術持牌執業者包括以下任何一項：醫生、護士（NP）、醫生助理（PA）、註冊護士、註冊藥劑師、持牌臨床心理學家（LCP）、持牌臨床社會工作者（LCSW）、註冊 CSW、持牌專業臨床顧問（LPCC）、註冊婚姻和家庭治療師（LMFT）、註冊 MFT、持牌職業護士（LVN），持牌職業治療師（LOT）和持牌精神科技師（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,
- 正在完成授權的監督時間，以及
- 根據加州法律的行業範圍內行為。
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.
非圍產期提供者可以為懷孕的藥物加州醫療補助健康保健計劃有組織的分娩系統 (DMC-ODS) 成員提供服務嗎？ 申請這些服務的程序是什麼？
參考資料：圍產期實務指南
是的。懷孕的會員可以選擇接受非婦產科醫療服務提供者的服務。如果 DMC-ODS 會員透過懷孕援助代碼獲得資格，索賠必須包含「病人資訊」（也稱為 PAT）9 懷孕指標才有效。請參閱《圍產期執業指導方針》（Perinatal Practice Guidelines），該指導方針適用於為尋求或轉介接受藥物使用障礙治療的孕婦和育兒者提供服務。
藥物加州醫療補助健康保健計劃有組織的交付系統 (DMC-ODS) 團體諮詢服務的帳單如何計算？
Reference: BHIN 24-001, DMC-ODS Billing Manual, DMC-ODS Service Table
DMC-ODS 團體輔導服務的單位應使用以下公式計算：(小組諮詢會的分鐘數/15 分鐘增量 = 使用程序代碼 H0005 提交的總單位。 DMC-ODS 計劃應為每位接受團體諮詢的成員分別提交申請。
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.
除 2011 年重新調整基金以外的收入是否符合聯邦比賽資格？
參考：SSA § 1903(w)(6)； 42 CFR § 433.51。
是的 其他本地基金只要是非聯邦公共基金，並且符合 SSA §1903 (w) (6) 和 42 CFR §433.51 中規定的要求，則其他本地基金有資格用作非聯邦比賽。