Policy/Procedure Number: MCUP3127 / Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and MHPs in Delivery of Behavioral Health Services / ☒External Policy
☐ Internal Policy
Original Date: 01/21/2015 / Next Review Date: 06/13/2019
Last Review Date: 06/13/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MCUP3127 / Lead Department: Health Services
Policy/Procedure Title:Dispute Resolution Between PHC and MHPs in Delivery of Behavioral Health Services / ☒External Policy
☐Internal Policy
Original Date: 01/21/2015 / Next Review Date:06/13/2019
Last Review Date:06/13/2018
Applies to: / ☒Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC
☐OPerations / ☐Executive / ☐Compliance / ☐Department
Approving Entities: / ☐BOARD / ☐COMPLIANCE / ☐FINANCE / ☒ PAC
☐ CEO / ☐COO / ☐Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date:06/13/2018
  1. RELATED POLICIES:
  2. County specific Mental Health Plan MOUs
  3. PHC Member Grievance System
  1. IMPACTED DEPTS:
  2. Health Services
  3. Compliance
  1. DEFINITIONS:
  2. A Member is a Medi-Cal eligible client who is a member of Partnership HealthPlan of California (PHC).
  3. A Potential Dispute Issue (PDI) is defined as a suspected issue impacting continuity of care and/or delivery of services to members at an appropriate level which requires further investigation to avoid escalation to a Formal Dispute Resolution Procedure or presents an opportunity to improve current processes put in place to avoid disputes.
  4. A Dispute Resolution (DR) is defined as the formal process specified in Memoranda of Understanding (MOUs) between PHC and Mental Health Plans (MHPs) to resolve disputes between Managed Care Plans (MCPs) and MHPs in the delivery of Behavioral Health Services in accordance with Title 9, CCR, §1850.505 and §1850.525 and in the California Department of Health Care Services (DHCS) All Plan Letter (APL) 15-007 Dispute Resolution Process for Mental Health Services.
  5. A Care Delivery System is defined as an entity that is mandated by the DHCS to deliver specific behavioral health services to Medi-Cal members. Two Care Delivery Systems are defined in this policy:
  6. Partnership HealthPlan of California (PHC) through its Delegated Vendor, Beacon Health Options (Beacon), providing Managed Care mental health services to clients with mild to moderate impairment of function who do not qualify for Specialty Mental Health Services.
  7. County Mental Health Plans (MHPs) providing Specialty Mental Health Services to clients with serious and persistent psychiatric conditions and significant impairment of function with or without substance use disorderservices through County Alcohol and Drug Services Programs (either through separate departments or through a single Integrated Behavioral Health Department)
  8. A Delegated Vendor is an entity contracted and engaged by PHC to deliver Medi-Cal managed care behavioral health services to PHC Medi-Cal members.
  9. Adult Behavioral Health Screening Form for Assessment and Treatment as Medically Necessary (Behavioral Health Screening Form), is defined as the tool agreed to by PHC/Beacon and the MHPs to make appropriate referral decisions per DHCS definitions. Includes versions: Child 0 – 5, Child 6 – 17 and Adult (see Attachment A) and Screening and Referral Instructions.
  10. An Initial Screening is defined as the event that takes place when a member seeks or is referred to behavioral health services and undergoes a brief screening to determine appropriate referral based on diagnosis and level of functional impairment
  11. A Care Transition is defined as the event that takes place when a member in current treatment under one Care Delivery System is referred on the basis of level of impairment and/or clinical necessity to another Care Delivery System
  12. A Behavioral Health Service is defined as the diagnosis and/or treatment of behavioral health issues provided by a credentialed or otherwise approved behavioral health care provider.
  13. A Warm Transfer is defined as a direct person-to-person or phone contact used to facilitate referral to a different Care Delivery System.
  1. ATTACHMENTS:
  2. Behavioral Health ScreeningForms: Adult, Child 0-5, Child 6-17
  3. DHCS All Plan Letter 17-018 Medi-Cal Managed Care Health Plan Responsibilities for Outpatient Mental Health Services (10/27/17)
  4. DHCS All Plan Letter 13-018 MOU Requirements for Medi-Cal MCPs (11/27/13)
  5. Title 9, CCR,§1850.505 and §1850.525
  6. Authorization for Provider to Release Confidential Information to Beacon
  7. DHCS All Plan Letter 15-007 Dispute Resolution Process for Mental Health Services (04/01/15)
  1. PURPOSE:
  1. POLICY / PROCEDURE:
  2. GUIDING PRINCIPLES FOR AVOIDING POTENTIAL DISPUTE RESOLUTION ISSUES
  3. Emphasis on Local Resolution
  4. Every effort should be made to address concerns at the local level with an emphasis of timely access to the appropriate level of care for the member.
  5. Initial Screenings and Care Transitions should be made collaboratively as members move between Care Delivery Systems.
  6. Effective and timely communication should be established between PHC, its Delegated Vendor and County MPH units to facilitate collaboration.
  7. Continuity of Care
  8. Referral pathways between PHC and its Delegated Vendors and MHPs should be bidirectional and employ the agreed-upon Beacon Screening Form
  9. Whichever Care Delivery System is first to engage in the member’s care, should continue to provide necessary care in accordance with the contracted benefits of its plan under the Medi-Cal program until the Potential Dispute Issue is resolved.
  10. Once the issue has been resolved, any necessary transition to a more appropriate level of care should be made collaboratively, without significant disruption in necessary care.
  11. Members should be informed in advance of the transition between systems.
  12. The principle of “Honor the service until the dispute is resolved” will be followed.
  13. Financial Responsibility while services are in dispute.
  14. Assignment of financial responsibility for services when PHC and its Delegated Vendors and MHPs are engaged in avoiding potential dispute or resolving a formal dispute goes to the Care Delivery System that is engaged in the member’s care at the time the PDI is identified. Ultimate financial responsibility is subject to the outcome of any DHCS Dispute Resolution Process.
  15. IDENTIFICATION OF POTENTIAL DISPUTE ISSUES
  16. PDI is identified at point of an Initial Screening
  17. A PHC provider, Beacon Network Provider, or MHP Access Team member determines the member’s diagnosis and level of impairment in person or over the phone, preferably using of the Behavioral Health Screening Form(Attachment A) or using another equivalent means of clinical assessment.
  18. If the assessment indicates a mild-to-moderate mental health condition, the Member is referred to Beacon.
  19. If the assessment indicates a serious and persistent mental health condition or a use disorder, the member is referred to the MHP Access Team.
  20. All referrals need to insure timely access to care and guarantee that all services are received only within one Care Delivery System.
  21. Referring entity is encouraged to follow up with Member to ensure that referral has been successfully completed and to remain open for further assistance to Member as necessary.
  22. A PDI is identified when the receiving entity does not agree that the Member meets criteria for their services.
  23. PDI is identified at point of a Care Transition
  24. A treating MHP or Beacon provider determines through clinical assessment that a different level of care is warranted based on severity of impairment and/or clinical necessity.
  25. A new Behavioral Health Screening Formor other pertinent clinical information is transmitted to the potential new Care Delivery System preferably through clinician to clinician contact.
  26. The consent of the Member to the Care Transition must be obtained.
  27. Arrangements need to be made to insure that continuity of care is maintained during the Care Transition and that all services are received only within ONE Care Delivery System.
  28. A PDI is identified when the receiving Care Delivery System does NOT agree that the Member meets their criteria for services and/or the Member does not consent to the Care Transition.
  29. APPROPRIATE ACTION PLANS
  30. Actions to be taken upon identifying a PDI:
  31. Within 24-48 hours, parties to PDI will initiate direct person-to-person communication with each other to resolve the PDI.
  32. Member will be kept informed by Care Delivery System that completed the Initial Screening or is providing current care in a manner consistent with standards of appropriate patient care.
  33. Member does not necessarily have to be informed that there is a PDI since this is a systems issue.
  34. Member DOES need to be informed about any anticipated delay in accessing care.
  35. Priority will be given to guaranteeing Member’s access to services while also ensuring that such services are delivered at the appropriate level.
  36. Assessment of risk factors will be given top priority during resolution of the PDI. Emergency action: Either party may determine that a situation exists where immediate action is required to protect the life or well-being of a PHC member or any person, or to reduce substantial and imminent likelihood of significant impairment of the life, health, or safety of the PHC Member or others.
  37. When Beacon, PHC, and the MHP reach agreement and resolve the PDI, a verbal and/or written communication can be directed to the Member to reflect the agreed-upon decision
  38. A Letter of Denial of Services may be deemed necessary by either entity if the Member insists on accessing care from an inappropriate Care Delivery System.
  39. Additional actions to be taken as part of a PDI resolution process:
  40. PDI will be reported to PHC Behavioral Health Administrator by Beacon and/or MHP for tracking purposes within 30 calendar days.
  41. Clinical and/or administrative consultation will be sought by each party within their own Care Delivery System in timely manner if PDI is not resolved at the Initial Screening or Care Transition level.
  42. Potential disputes not resolved within 7 calendar days will be reported to the PHC Behavioral Health Administrator and moved to the Dispute Resolution process defined in the Memorandum of Understanding (MOU) between the MHP and PHC.
  43. Dispute Resolution Process per MOUs agreed upon between County MHPs and PHC
  44. Disagreements and disputes will be brought to a meeting of PHC and MHP liaisons and Medical Directors for resolution.
  45. PHC and MHP staff will make a good faith effort to agree to resolutions that are in the best interest of beneficiaries and are agreeable to all parties involved.
  46. MHP and PHC agree to follow dispute resolution procedures as required in Title 9, CCR,§1850.505
  47. Beneficiaries will continue to receive medically necessary services while the disagreement or dispute is being resolved in accordance with Title 9, CCR,§1850.525(a).
  48. Guidelines should be similar for both systems.
  49. California Department of Health Care Services (DHCS) Dispute Resolution Process (For further details, refer to DHCS All Plan Letter 15-007 Dispute Resolution Process for Mental Health Services)
  50. PHC is required to enter into a memorandum of understanding (MOU) with the MHP in each of the counties which PHC serves.
  51. Whether or not MCP and PHChave an executed MOU, the parties are required to document attempts to resolve the disputed issue(s) (Title 9, CCR, §1850.505 (d) (2))
  52. If PHC is unable to resolve a dispute with a MPH, PHCmay submit a written Request for Resolutionsigned by the PHC’s CEO or his or her designee to DHCS. If PHC has a MOU with the MHP, the Request for Resolution must be submitted within 15 calendar days of the completion of the dispute resolution process described in the MOU. If there is no MOU, a Request for Resolution must be submitted within 30 days followingthe disrupted event. A Request for Resolution should be submitted via secure email to Sarah Brooks, Chief, MCQMD, at
  53. DHCS will review disputes involving the following:
  54. A Request for Resolution submitted to DHCS must contain all of the following:
  55. Within seven calendar days after DHCS’ receipt of a Request for Resolution from PHC,a copy of the Request for Resolution will be forwarded to the Director of the affiliatedMHP via secure email (“Notification”). The MHP will have 21calendar days to submit a response and any relevant documents to support the MHP position (“MPH Documentation”) (Title 9, CCR, §1850.505 (e) and (f)). If the MHP fails to respond, DHCS will decide on the disputed issue(s) based solely on the documentation submitted by PHC.
  56. At its discretion, DHCS may allow both the PHCand MHP representatives the opportunity to present oral arguments.
  57. Medi-Cal Managed Care Division (MMCD) and Mental Health & Substance Use Disorder Services (MHSUDS) will make a joint recommendation to the DHCS Director based on their review of the submitted documentation and applicable statutory, regulatory, and contractual obligations of PHC and the MHP, and any oral arguments presented.
  58. Within 30 calendar days from:
  59. If DHCS’ dispute resolution determination includes a finding that the unsuccessful party has a financial liability to the other party for services rendered by the successful party, the PHC or the MHPis required to follow the financial liability criteria set forth in Title 9, CCR § 1850.530, which specify the provisions regarding financial liability rates and proof of reimbursement. If necessary, DHCS shall enforce the decision, including with-holding funds to meet any financial liability established pursuant to Title 9, CCR, §1850.530 (Title 9, CCR, §1850.520(c)).
  60. The provision of medically necessary specialty and other mental health services, physical health care services, or related prescription drugsand laboratory, radiological, or radioscope services to beneficiaries shall not be delayed during the pendency of a dispute between PHC and the MHP (Title 9, CCR, §1850.525(a)). See DHCS APL 15-007 for further details.
  61. Member rights
  62. Members who are denied services can file a Member Grievance or State Fair Hearing against either Care Delivery System using the appropriate member appeal process.
  63. REPORTING PROCEDURES
  64. Beacon will maintain a monthly report on the number of referrals to MHP from Beacon and to Beacon from MHP, as reported in each County served by PHC.
  65. All MHP and MCP providers and assessors will be encouraged to use the Behavioral Health Screening Formor an agreed-upon alternative method for all Initial Screenings and Care Transitions to facilitate accurate record keeping.
  66. PDIs reported by any source will be documented on a PDI Tracking Spreadsheet monitored by a designated employee of PHC’s Health Services Department to include:
  67. Date of origination
  68. Nature of PDI
  69. Care Delivery Systems involved (including specific providers or assessment personnel)
  70. Specifics regarding continuity of care for Member
  71. Specifics regarding communication with the Member
  72. Date and nature of resolution
  73. All Formal Dispute Resolution Procedures will be fully documented to include:
  74. Date of origination
  75. MHP and PHC and/or Beacon parties involved
  76. Nature of disagreement or dispute
  77. Specifics regarding continuity of care for Member
  78. Specifics regarding communication with the Member
  79. Date and nature of resolution.
  80. CONFIDENTIALITY AND EXCHANGE OF INFORMATION
  81. Communication between Beacon, PHC, and MHPs will maintain proper standards in the exchange of Protected Health Information (PHI) per HIPAA standards and adherence to Federal Regulation CFR Part 2 regarding alcohol or substance use disorder information
  82. An Authorized Release of Information shall be used as deemed necessary and appropriate.
  83. Existing policies or those developed in the future by DHCS for the exchange of information between MCPs and MHPs in the delivery of behavioral health services shall be adhered to.
  1. REFERENCES:
  2. Title 9,California Code of Regulations (CCR) Sections §1810.370, §1850.505, §1850.520, §1850.525, and §1850.530
  3. DHCS All Plan Letter 15-007 Dispute Resolution Process for Mental Health Services
  4. DHCS All Plan Letter 17-018 Medi-Cal Managed Care Health Plan Responsibilities for Outpatient Mental Health Services
  5. DHCS All Plan Letter 13-018 MOU Requirements for MCPs
  6. HIPAA standards
  7. Title 42 Code of Federal Regulations(CFR) Part 2 regarding alcohol or substance use disorder information
  1. DISTRIBUTION:
  2. PHC Provider Manual
  3. PHC Department Directors
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Behavioral Health Administrator
  1. REVISION DATES:01/21/15;06/17/15; 04/20/16; 04/19/17; *06/13/18

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

PREVIOUSLY APPLIED TO:N/A

*********************************

Inaccordance with theCalifornia Healthand SafetyCode,Section 1363.5,this policywasdevelopedwith involvement from activelypracticinghealth care providersandmeetstheseprovisions:

  • Consistentwith sound clinicalprinciplesand processes
  • Evaluatedand updated atleast annually
  • Ifusedas thebasis ofadecision to modify, delayordenyservices ina specific case, thecriteria will be disclosedto the provider and/orenrollee upon request

The materials provided areguidelinesusedbyPHC to authorize, modifyor denyservices forpersonswithsimilar illnesses or conditions.Specific care andtreatment mayvarydependingonindividualneedand the benefitscovered underPHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.

Page 1 of 7