ACBH Policies & Procedures Manual

The Alameda County Behavioral Health (ACBH) Policies & Procedures (P&P) Manual is a compilation of all the policies and procedures that apply to ACBH staff and contractors. The purpose of the P&P Manual is to ensure that everyone associated with ACBH operations is aware of and consistently implements the requirements under federal, state, and local laws and regulations.

ACBH P&Ps are developed through a procedure outlined in Policy 000-1-1, “Development, Approval, Dissemination, and Revision of Alameda County Behavioral Health Policies and Procedures.”

The ACBH P&P Manual is organized by category, and the Table of Contents is available below.

TABLE OF CONTENTS

• 000-1 POLICY ON POLICIES
  • 000-1-1 “Development, Approval, Dissemination, and Revision of Alameda County Behavioral Health Policies & Procedures” (8/28/24)
  • 100-1 ACCESS TO MH SERVICES
    • 100-2-5 “Adult and Older Adult System of Care Coordination Medi-Cal Specialty Mental Health Services” (12/16/19)
    • 100-2-6 “Adult and Older Adult Specialty Mental Health Consumer Care Transitions” (12/16/19)
    • 100-2-1 “Out of Network Access and Continuity of Care for Specialty Mental Health Services and Substance Use Disorder Services” (1/24/20)
    • 100-2-2 “24/7 Language Assistance to Beneficiaries” (1/27/20)
    • 100-2-3 “Timely Access to Service Standards and Tracking Requirements” (6/6/19)
    • 100-2-4 “Accessibility of Services” (12/16/19)
    • 100-2-5 “Telehealth Policy” (7/9/24)
    • 100-3 CALAIM
      • 100-3-1 “Criteria for Beneficiary Access to SMHS” (5/13/22)
      • 100-3-2 “No Wrong Door for Mental Services” (6/28/22)
      • 100-3-3 “Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services” (01/11/23)
      • 150-1 ACCESS TO SUD SERVICES
        • 150-1-1 “Interim Services Management for SUD Treatment Programs” (10/24/16)
        • 150-1-2 “Charitable Choice” (4/28/21)
        • 150-1-3 “Drug Medi-Cal Organized Delivery System (DMC-ODS) Care Coordination, Continuity of Care, and Transition of Care of Medi-Cal Specialty Mental Health, Substance Use Disorder, and Primary Care Services” (12/16/19)
        • 150-1-4 “Expanding Access to Medications for Addiction Treatment (MAT)” (8/26/22)
        • 150-1-5 “Naloxone Distribution Program (NDP)” (3/2/2023)
        • 150-2-1 “Drug Medi-Cal Organized Delivery System (DMC-ODS) Requirements for the Period of 2022 – 2026” (5/13/22)
        • 200-1 “Psych Testing Authorization” (3/24/21)
        • 200-2 “Authorization of Specialty Mental Health Services” (1/18/24)
        • 200-3 “Prior Authorizations for Day Rehabilitation and Day Treatment Intensive” (10/22/22)
        • 300-1 CONSUMER GRIEVANCE AND APPEAL PROCESSES
          • 300-1-1 “Consumer Grievance and Appeal Processes” (6/5/18)
          • 300-1-2 “Notices of Adverse Benefit Determination for Medi-Cal Beneficiaries” (2/15/19)
          • 300-2-1 “Advance Directive” (7/11/22)
          • 300-3-1 “Client Right to Request Amendment of Health Records” (12/16/19)
          • 300-4-1 “Beneficiary Rights” (4/28/2023)
          • 300-5-1 “Interoperability and Patient Access P&P” (5/10/2024)
          • 350-2 CONSUMER SAFETY AND WELL-BEING
            • 350-2-1 “Protection of Trafficking Victims” (8/3/23)
            • 350-2-2 “Medication Monitoring for Drug Medi-Cal Organized Delivery System” (6/1/2021)
            • 350-3-1 “Privacy Security and Confidentiality Statement of Client Services Records and Information" (5/10/2024)
            • 400-1-1 “24/7 Coverage Requirement for Children, TAY, Adult, and Older Adults Full Service Partnerships” (6/19/20)
            • 401 SERVICE DEFINITIONS
              • 401-1 “Adult/Older Adult Outpatient Levels of Care Determination” (7/06/21)
              • 401-2 “Full Service Partnership Implementation" (5/16/2024)
              • 401-3 “Therapeutic Behavioral Services Implementation” (6/1/2021)
              • 403-2-1 “Obtaining Authorization for Prescribing Psychotropic Medication to Youth in Out of Home Placement Under the Protection of the Juvenile Court” (12/5/16)
              • 403-3-1 “Implementing Mental Health Child & Family Teams” (12/16/19)
              • 403-4-1 “Provisions, Protocols, and Criteria for Identifying and Providing Intensive Services to Children/Youth in the Katie A. Subclass” (12/16/19)
              • 403-5-1 “Implementation of AB 1299 Presumptive Transfer for Foster Youth Placed Out of County” (12/16/19)
              • 403-6-1 “Early Periodic Screening Diagnosis and Treatment (EPSDT) Notification” (09/27/21)
              • 403-7-1 “Families First Prevention Services Act, Qualified Individual Assessment Process” (10/26/22)
              • 403-8-1 “Criteria for Therapeutic Foster Care Services” (10/26/22)
              • 403-9-1 “Implementing Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS)” (10/31/22)
              • 403-10-1 “Child, Adolescent, and Young Adult System of Care (CYASOC) Level of Care Transfer” (10/31/22)
              • 404-1-1 “Mobile Crisis Team Services Policy and Procedure” (12/16/19)
              • 406-1-1 Eating Disorders (12/16/19)
              • 501 PHARMACY SERVICES OFFICE
                • 501-1 SCOPE OF PRACTICE
                  • 501-1-1 “Clinical Psychiatric Pharmacist Scope of Practice for Medication Therapy Management” (5/22/17)
                  • 503-1 DESIGNATION & REPORTING
                    • 503-1-1 “Designation for Mental Health Professionals to Initiate 5150/5585 Holds” (12/16/19)
                    • 503-1-2 “Reporting Disorders Characterized by Lapses of Consciousness” (01/25/22)
                    • 901 BHCS STAFF
                      • 901-1 BHCS STAFF SKILL DEVELOPMENT
                        • 901-1-1 “Approval and Tuition Payment Policy for BHCS Staff to Attend Specialized Training Programs for Skill Development for Behavioral Health Care Services” (9/19/17)
                        • 1302 NETWORK OFFICE
                          • 1302-1 CONTRACT MONITORING
                            • 1302-1-1 “Contract Compliance and Sanctions for BHCS-Contracted Providers” (12/14/22)
                            • 1303-1 “Provider Problem Resolution and Appeals” (12/16/19)
                            • 1350-1 FINANCE OFFICE
                              • 1350-1-3 Expending and Reporting Perinatal Funding (2/23/17)
                              • 1350-1-5 Identifying, Reporting and Expending SUBG Funds P&P (8/13/24)
                              • 1601 QUALITY IMPROVEMENT OFFICE
                                • 1601-1 BENEFICIARY CARE AND OUTCOME
                                  • 1601-1-1 “CANS (Child and Adolescent Needs and Strengths), ANSA (Adult Needs and Strengths Assessment), and Pediatric Symptom Checklist (PSC-35) Implementation” (rev. 6/19/20)
                                  • 1602-1 CULTURAL COMPETENCE WITH CLIENTS
                                    • 1602-1-1 “Integration of Spiritual Interests in Recovery & Wellness” (10/25/16)
                                    • 1603-1 CALAIM:DOCUMENTATION
                                      • 1603-1-3 “Documentation Requirements for all Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services” (6/28/22)
                                      • 1603-2-1 “Audit of Medical Charts of Providers for Services Funded by Medi-Cal and Non-Medi-Cal Sources” (12/5/16)
                                      • 1603-3-1 “Professional Licensing Waiver” (5/2/23)
                                      • 1603-3-2 “Credentialing & Re-Credentialing Verification for ACBH Mental Health & Substance Use Service Providers” (rev. 10/25/22)
                                      • 1603-3-3 “ACBHD Clinical Trainee Policy” (8/28/24)
                                      • 1603-4-1 “Unusual Occurrence and Death Reporting” (4/25/22)
                                      • 1603-5-1 “Medi-Cal Site Certification for Providers of Mental Health Services” (8/15/2022)
                                      • 1603-6 “Concurrent Review of Crisis Residential Treatment Services and Adult Residential Treatment Services” (10/07/22)
                                      • 1650-1 SUD PROGRAM ADMINISTRATION
                                        • 1650-1-1 “Drug Medi-Cal Compliance & Administrative Quality Management” (5/1/15)
                                        • 1702
                                          • 1702-1 “Record and Data Retention and Destruction of Protected Health Information” (6/11/21)
                                          • 1703 PROGRAM INTEGRITY
                                            • 1703-1 SERVICE VERIFICATION
                                              • 1703-1-1 “Service Verification for Medi-Cal Reimbursed Services” (5/16/24)
                                              • OCS.C.001 "EXCLUSION SCREENING" (09/01/21)
                                              • 1703-3-1 “Whistleblower Program for Fraud, Waste, and Abuse” (8/13/24)
                                              • 1704-1 BREACHES
                                                • 1704-1-1 “Privacy and Security Incident Reporting” (7/6/18)
                                                • 1901 CONSUMER AND STAFF WELLNESS
                                                  • 1901-1 TOBACCO POLICIES
                                                    • 1901-1-1 “Tobacco Policies and Consumer/Client Treatment Protocols” (11/10/16)
                                                    • 2050 SAFETY & RISK MANAGEMENT
                                                      • 2050-1 WORKPLACE SAFETY
                                                        • 2050-1-1 “Drug Free Workplace” (10/24/16)
                                                        • 2101 EXECUTIVE ADMINISTRATION
                                                          • 2101-2 EMERGENCY RESPONSE
                                                            • 2101-2-1 “BHCS Internal Critical Incident Response Policy” (10/21/16)

                                                            Original Policy #	Policy Title	Superseding Policy #	Superseding Policy Title	Date Superseded
                                                            1350-1-4	Identifying, Reporting, and Recovering Overpayments P&P	1350-1-5	Identifying, Reporting and Expending SUBG Funds P&P	8/13/24
                                                            1350-1-2	Documenting & Reporting SAPT Block Grant Expenditures P&P	1350-1-5	Identifying, Reporting and Expending SUBG Funds P&P	8/13/24
                                                            1350-1-1	Expenditure of SAPT Block Grant	1350-1-5	Identifying, Reporting and Expending SUBG Funds P&P	8/13/24
                                                            1603-1-1	Progress Notes for Mental Health Services: Timeline for Completion and Documentation Requirement	1603-1-3	Documentation Requirements for all Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services	6/28/22
                                                            1603-1-2	Specialty Mental Health Services (SMHS) Clinical Documentation Standards Policy & Procedure Manual	1603-1-3	Documentation Requirements for all Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services	6/28/22
                                                            1603-4-2	Formalized Case Review	1603-4-1	Unusual Occurrence and Death Reporting	3/11/22
                                                            1650-1-2	Verification of Professional Credentials for Substance Use Disorder Treatment Services	1603-3-2	Credentialing & Re-Credentialing Verification for ACBH Mental Health & Substance Use Service Providers	12/16/19
                                                            350-1-1	Reserve for Complaint Process	300-1-1	Consumer Grievance and Appeal Processes	7/1/18
                                                            350-1-2	Beneficiary Fair Hearing Rights	300-1-1	Consumer Grievance and Appeal Processes	7/1/18