Managed Care
SMHS
MHSA
Problem Resolution
Call Protocols
100
The clinical criteria used to determine if a Medi-Cal beneficiary should receive mental health services through their Managed Care Plan.
What is the level of impairment?
100
A specific covered diagnosis, functional impairment, and meeting intervention criteria
What is Medical Necessity criteria
100
Cultural Competence
What is one of the "MHSA Guiding Principles"
100
A written notice that gives Medi-Cal applicants and beneficiaries an explanation of their eligibility for Medi-Cal coverage or benefits.
What is a "Notice of Action (NOA)"
100
877-245-0386
What is the "Language Line"
200
A hold placed on enrollment into a managed care plan. The Ombudsman have the ability to “lift” this hold by re-enrolling the beneficiary back into the managed care plan.
What is a "59 hold"
200
Provided under the federal requirements of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit
What is "Children’s SMHS"
200
TO GUIDE DMH IN THE IMPLEMENTATION OF COMMUNITY SERVICES AND SUPPORTS
What is "MHSA's VISION STATEMENT"
200
When a Medi-Cal service a beneficiary wants is not approved by a Medi-Cal field office or their managed care plan, beneficiaries have the right to ask for a…
What is "a State Fair Hearing"
200
Social Security/Medi-Cal Number, Phone Number, Address, Date of Birth
What is "Protected Identifying information (PII) - NOT releasable to anyone under any circumstances."
300
A capitated health care delivery system organized to manage cost, utilization, and quality
What is "managed care"
300
· Adult Residential Treatment Services · Crisis Intervention · Crisis Stabilization · Crisis Residential Treatment Services · Day Rehabilitation · Day Treatment Intensive · Medication Support Services · Psychiatric Health Facility Services · Psychiatric Inpatient Hospital Services · Targeted Case Management · Therapy and Other Service Activities
What is "MediCal SMHS available for adults"
300
•Intensive services in the Community Services and Supports component •Prevention and Early Intervention components, •Exploring creative approaches to mental health services in the Innovation component. •Expanding, educating, and training the local public mental health workforce •Improving mental health infrastructure
What is "5 components that address a broad continuum of service needs"
300
Once beneficiaries receive a Notice Of Action (NOA) and they are dissatisfied with the response, beneficiaries can submit this to the Director of Behavioral Health
What is an "Appeal"
300
This information may be released only after the individual has been authorized
What is "Protected Health Information (PHI)"
400
• Dual Eligibles, or those with Medicare • Foster Children • Identified as Long Term Care (LTC) • Those with Other Health Insurance • Share of Cost (SOC) Medi-Cal
What is "Groups considered voluntary, and participation to enroll into managed care is not mandatory"
400
The formal mechanism by which states assure compliance with federal Medicaid requirements in order to be eligible for federal funding
What is the "State Plan Amendments (SPA)"
400
This Act imposes a 1% income tax on personal income in excess of $1 million.
What is the "Mental Health Services Act or MHSA"
400
Beneficiaries can contact this county entity regarding issues or concerns about their services
What is the "Patients Rights Advocate"
400
In the event the database is not functioning, use this document to track caller information
What is the "Ombudsman Contact Sheet"
500
Two-Plan, County Organized Health Systems (COHS), Geographic Managed Care (GMC), Regional Model (RM), Imperial, and San Benito
What is "six main models of managed care"
500
Each MHP shall provide a statewide, toll-free telephone number 24 hours a day, seven days per week, with language capability in all languages spoken by beneficiaries of the county, that will provide information to beneficiaries about how to access specialty mental health services, including specialty mental health services required to assess whether medical necessity criteria are met and services needed to treat a beneficiary’s urgent condition, and how to use the beneficiary problem resolution and fair hearing processes.
What is one of "Title 9, Article 4 standards"
500
Beneficiaries should contact their local county Mental Health Departments to find their local MHSA partners who may provide a case manager or personal services coordinator to identify and coordinate needed services
What is "How services are accessed"
500
Department that handles State Fair Hearings
What is the "California Department of Social Services (CDSS)"
500
If a call comes from security alerting us of an individual wishing to meet us is downstairs, ascertain the following: 1. How many people are there? 2. Visitor(s) name(s) 3. They wish to meet the mental health ombudsman? Instruct the security officer to have the visitors to take a seat & to tell them we will be down in a few moments
What is "Walk In procedures"
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