INSTRUCTIONS:

1.  Use this form to request changes in program location, closures, service days/hours and type of service modalities (described as (B) in the Process for Provider and Program Changes). BHCS Contractors must receive approval prior to implementation of any changes that fall within these categories.

2.  Complete the form by checking the boxes below that correspond to your requested change and providing the additional requested information. You may need to submit multiple forms for multiple changes.

3.  The blue-shaded boxes should not be completed by requester of changes, and are for the sole use of BHCS Operational Leads and designees (Ops Leads).

4.  Completed forms should be sent to:

·  Assigned Program and Fiscal Contract Managers (PCM and FCM) via email for requested changes to CBO Contracted Programs.

·  Assigned System of Care Director via email for requested changes to County-Run Programs.

Section A: Contact and Program/RU Information
Date of Request* /
Requester Name*
Organization Name*
Organization Contact Person* / Organizational Contact Title*
Organization Contact Phone* / Organization Contact Email*
Contract Type* (If submitting requests for both MH and SUD, please use a separate form for each.) / ☐ Mental Health
☐ Substance Use Disorder (SUD) / Requested Effective Date*
Section B: Requested Change
What is the change you are requesting to make?* (Please provide required follow-up information specified on the next pages for the type of change you are requesting to make) / ☐ 1. Move a program/RU to an “EXISTING” site address (i.e., address already approved/in contracts for this CBO)
☐ 2. Add a new RU to an “EXISTING” site address (i.e., address already approved/in contracts for this CBO)
☐ 3. Move a program/RU to a “NEW” site address for this CBO
☐ 4. Add a new RU to a “NEW” site address for this CBO
☐ 5. Close Program/RU
☐ 6. Change program service delivery days/hours
☐ 7. Add specific procedure codes
☐ 8. Remove specific procedure codes
Section B: Requested Change (Continued)
Complete these fields for these requested changes:
1.  Move a program/RU to an “EXISTING” site address
2.  Add a new RU to an “EXISTING” site address / Program Name(s) / Existing RU#(s)
Current site address moving from* (incl. +4 zip) / Site address moving to
(incl. +4 zip)
State Provider#/ NPI# for current site the program is moving from / State Provider# /NPI# for existing site the program is moving to
1.  Is this an expansion of the current program named above within the existing allocation? (note, this form should not be used to request funding) ☐Y ☐N
2.  Are existing clients in this program/RU being migrated to the site address it’s moving to? (note, BHCS Provider Relations will contact you for more information later if there is a need to migrate clients) ☐Y ☐N
3.  Does your organization have other program/RU(s) at the current site address this program is moving from that will be remaining at this current site address? ☐Y (if yes, please list program(s)/RU(s): ) ☐N
4. Is there a current Medi-Cal Site Certification at the site address the program/RU is moving to, that includes the modalities (includes Modes and Service Function Codes) of services for this program?** ☐Y ☐N
-  If no, what additional modalities of services need to be certified for this site? Please specify by marking the additional modalities of services in Section C below.
Is there a current (effective date within 1 year) fire clearance for site address this program is moving to?*** ☐Y ☐N
-  If yes, attach a copy with this form.
-  If no, provide estimated time frame of fire inspection and/or add additional clarifying information:
5. Complete procedure code table (last page) Section D to identify the services approved for this program.
Complete these fields for these requested changes:
3.  Move a program/RU to a “NEW” site address
4.  Add a new RU to a “NEW” site address / Program Name(s) / Existing RU#(s)
Current site address moving from* (incl. +4 zip) / Site address moving to
(incl. +4 zip)
State Provider#/ NPI# for current site the program is moving from / State Provider# /NPI# for existing site the program is moving to****
1.  Is this an expansion of the current program named above within the existing allocation? (note, this form should not be used to request funding) ☐Y ☐N
2.  Are existing clients in this program/RU being migrated to the site address this program is moving to? ☐Y ☐N
3.  Does your organization have program/RU(s) at the current site address this program is moving from? ☐Y ☐N
4.  Is there a current (effective date within 1 year) fire clearance for site address this program is moving to?*** ☐Y ☐N
-  If yes, attach a copy with this form.
-  If no, provide estimated time frame of fire inspection and/or add additional clarifying information:
5.  Complete procedure code table (last page) Section D to identify the services approved for this program.

** If you have an existing program/RU moving to an existing site address and the current Medi-Cal Site Certification does not include all categories of services a Medi-Cal Site Certification must be conducted as soon as possible. A fire clearance for the new site must be obtained and immediately provided to BHCS (for Mental Health Programs) or to the California Department of Health Care Services (for SUD Programs).

*** If new sites are approved by BHCS for programs that bill to Medi-Cal, a Medi-Cal site certification must be conducted as soon as possible. A fire clearance for the new site must be obtained and immediately provided to BHCS (for Mental Health Programs) or to the California Department of Health Care Services (for SUD Programs).

**** If your organization does not yet have an existing NPI for the site address the program is moving to, apply for a NPI on NPPES website prior to submitting this form at https://nppes.cms.hhs.gov/NPPES/Welcome.do and write ‘Applied for on <date>’ in the next cell.

Section B: Requested Change (Continued)
Complete these fields for requests to:
5.  Close Program/RU / Program Name(s) / Existing RU#(s)
Existing site address
1.  Does your organization have additional program/RU(s) at this site address? ☐Y ☐N
Complete these for requests to:
6.  Change program service delivery days/hours / Program Name(s) / Existing RU#(s)
Existing service delivery days/hours / Requested service delivery days/hours
Complete these for requests to:
7.  Add specific procedure codes (specify from attached table) / Program Name(s) / Existing RU#(s)
1.  Are the procedure codes requested in a different modality of services (i.e. modality) from what the program is currently contracted and/or Medi-Cal certified for? ** ☐Y ☐N
-  If yes, please specify by marking the additional modalities of services in Sections C below.
Is there a current (effective date within 1 year) fire clearance for the site address this program is moving to? *** ☐Y ☐N
-  If yes, attach a copy with this form.
-  If no, provide estimated time frame of fire inspection and/or add additional clarifying information:
Complete these for requests to:
8.  Request to remove specific procedure codes (specify from attached table) / Program Name(s) / Existing RU#(s)
Section C: New Service Modalities Requiring Medi-Cal Site Certification (Complete if you were referred here in Section B)
Mental Health
Outpatient Services ☐ Mental Health Services ☐ Case Management/Brokerage ☐ Crisis Intervention
☐ Medication Support (please specify: ☐Prescribing Only or ☐Prescribing, Dispensing and Storing)
Day Service ☐ Crisis Stabilization ☐ Day Treatment (please specify: ☐ Intensive or ☐ Rehabilitation, and ☐Full Day or ☐ Half Day)
24-Hour Services ☐Residential ☐Crisis Residential ☐Other (please specify: )
Substance Use Disorder
Non-Perinatal: ☐ Outpatient Treatment (ODF) ☐ Intensive Outpatient Treatment (IOT) ☐ NTP-Methadone Maintenance
Perinatal: ☐ Outpatient Treatment (ODF) ☐ Intensive Outpatient Treatment (IOT) ☐ Residential ☐ NTP-Methadone Maintenance
Section D: Procedure Code Tables (Complete if you were referred here in Section B)
Mental Health /
Clinician’s Gateway/Data Entry (Mode 00) / PCs / / Program-Specific Services: CalWORKS / SFC - PCs
☐Clinician’s Gateway (CG) / PC: 197 / / ☐ CalWORKS MH Services (MHS Rate) / SFC: 30 - PC: 336; SFC: 40 - PC: 346; SFC: 50 - PC: 356
☐CG FSP Data Entry / PC: 198 / / ☐ CalWORKS CM/Brokerage (CM Rate) / SFC: 01 - PC: 576
Outpatient Services (Mode 15) / SFC - PCs / / ☐ CalWORKS Med. Support (MS Rate) / SFC: 60 - PC: 366
Mental Health Services (MHS) / / ☐ CalWORKS Fees / SFC: 30 - PCs: 796, 797, 798
☐ Assessment/Plan Dev./ Eval. / SFC: 30 - PCs: 323-326, 581 / / 24 Hour Services (Mode 5) / SFC - PCs
☐ Collateral / SFC: 10 - PCs: 310, 311, 317, 614 / / ☐ Child Residential Day / SFCs: 60 - PC: 180
☐ Individual Therapy / SFC: 40 - PCs: 413, 441-443, 449 / / ☐ Adult Residential Day / SFCs: 65-79 - PC: 165
☐ Individual Rehabilitation / SFC: 40 - PC: 381 / / ☐ Crisis Residential Day / SFCs: 40-49 - PC: 141
☐ Group Therapy / SFC: 50 - PCs: 455-456 / / ☐ IMD Day / SFCs: 36 - PC: 131
☐ Group Rehabilitation / SFC: 50 - PC: 391 / / ☐ IMD Non-Contract Day / SFCs: 36 - PC: 130
☐ Interactive Complexity / SFC: 30, PC: 491 / / ☐ IMD Bed Day Hold / SFCs: 36 - PC: 133
☐ Katie A. IHBS / SFC: 57 - PC: 557 / / ☐ SNF Intensive Day / SFCs: 30 - PC: 135
☐ CSOC TBS / SFC: 58 - PC: 498 / / ☐ SNF Intensive Non-Contract Day / SFCs: 30 - PC: 134
☐ Psych Testing (limited service) / SFC: 30 - PCs: 415, 417, 491, 535 / / ☐ SNF Intensive Bed Day Hold / SFCs: 30 - PC: 136
Case Management/Brokerage (CM) / / ☐ PHF Day / SFCs: 20-29 - PC: 121
☐ Brokerage / SFC: 01 - PC: 571 / / ☐ PHF Non-Contract Day / SFCs: 20-29 - PC: 120
☐ Katie A. ICC for Child/TAY Treatment / SFC: 07 - PCs: 577 / / ☐ Local Inpatient Day / SFC: 10 - PC: 111
Crisis Intervention / / ☐ Local Inpatient Admin Day / SFC: 19 - PC: 113
☐ Crisis Intervention / SFC: 70 - PCs: 377-378 / / Day Services (Mode 10) / SFC - PCs
Medication Support (MS) / / ☐ Crisis Stabilization Emergency / SFCs: 20-24 - PC: 221
☐ Med. Support: Evaluation and Management/Psychotherapy / SFC: 60 - PCs: 367, 369, 465, 467, 468, 545-549, 565, 641, 643-646 / / ☐ Crisis Stabilization Urgent / SFCs: 25-29 - PC: 221
☐ Med. Support in SNF / SFC: 60 - PCs: 650, 653-658 / / ☐ Intensive Half Day / SFCs: 81-84 - PC: 281
Outreach/Support (Modes 45, 55 and 65) / SFC - PCs / / ☐ Intensive Full Day / SFCs: 85-89 - PC: 285
☐ Mental Health Promotion / SFC: 10 - PC: 401 / / ☐ Rehabilitation Half Day / SFC: 91 - PC: 291
☐ Consultation to Organizations / SFC: 10 - PC: 405 / / ☐ Rehabilitation Full Day / SFC: 95 - PC: 295
☐ Community Service Other / SFC: 10 - PC: 405 / / Other Procedure Codes / SFC - PCs
☐ Onsite Outreach/Support / SFC: 20 - PC: 402 / / ☐
☐ Offsite Outreach/Support / SFC: 20 - PC: 403 / / ☐
☐ Program Support: Housing / SFC: 78 - PC: 423 / / ☐
☐ Program Support: Voc. / SFC: 78 - PC: 424 / / ☐
☐ Program Support: Ed. / SFC: 78 - PC: 425 / / ☐
☐ Client Support: Housing / SFC: 78 - PC: 623 / / ☐
☐ Client Support: Voc. / SFC: 78 - PC: 624 / / ☐
☐ Client Support: Ed. / SFC: 78 - PC: 625 / / ☐
☐ CBO MAA Codes / SFC: 10 – PCs: 502, 504, 505-506, 508, 528, 537-538, 639, 674, 680, 693, 695-696, 699 / / ☐
☐ County MAA Codes / SFC: 10 – PCs: 502, 504, 505-506, 508, 514-517, 527-528, 601, 607-609, 639, 670, 674, 680, 684, 693, 695-699 / / ☐
Section D: Procedure Code Tables (Continued)
Substance Use Disorder /
Clinician’s Gateway/Data Entry / PCs / / SUD Program-Specific Codes / PCs
☐ Clinician’s Gateway (CG) / PC: 197 / / ☐ Cherry Hill – Sobering Station Visit / PC: 770
SUD Outpatient Treatment / PCs / / ☐ Cherry Hill – Residential Day Detox / PC: 773
☐ DMC Individual Visit / PC: 701 / / NTP – Methadone Maintenance / PCs
☐ DMC Group Visit / PC: 709 / / ☐ NTP Daily Dosing / PC: 704
☐ Individual Visit (outside of DMC) / PCs: 311, 341, 343, 353, 355, 356, 371, 555 / / ☐ NTP Individual Counseling / PC: 791
☐ Group Visit (outside of DMC) / PCs: 351, 354 / / ☐ NTP Group Counseling / PC: 799
☐ General Non-Billable / 331, 571 / / NTP – Methadone Detox / PCs
☐ Adolescent Non-Billable / PCs: 410, 411, 441, 451 / / ☐ Detox Re-Exam / PC: 706
SUD Intensive Outpatient Treatment / PCs / / ☐ 1st-7th Day Detox / PC: 707
☐ IOT Day / PC: 702 / / ☐ 8th-21st Day Detox / PC: 708
SUD Residential Treatment / PCs / / ☐ 22nd-close Day Detox / PC: 746
☐ Residential Day / PC: 703 / / Other Codes / PCs
☐ Perinatal Child Bed Day / PC: 303 / / ☐
SUD Recovery Residence / PCs / / ☐
☐ Transitional Bed Day / PC: 783 / / ☐
SUD Fees / PCs / / ☐
☐ Probation Report Fees* / 792 / / ☐
☐ CalWORKS Fees* / 796, 797, 798 / / ☐
Section E: For BHCS Use Only
Ops Lead Approval of Change / ☐Approved ☐Partially Approved (Describe below) ☐Denied
Ops Lead Notes (for any special circumstances)
Ops Lead Name /
Signature
/
Date
I have received this completed form, signed by the Operational Lead, and take responsibility for next steps to be completed according to established Network Office procedures. Next steps include:
·  Confirmation of receipt to provider and submitting signed form to Administrative Point Person (Shahneka) - FCM/PCM
·  Scanning and distribution of the signed form to Network Office Notification Distribution List - Administrative Point Person
·  Report back to the provider around approval of their request – FCM/PCM
May also include additional steps such as site certification, RU changes and/or contract changes
Program Contract Manager Name
/
Signature
/
Date
Fiscal Contract Manager Name /
Signature
/
Date
Administrative Point Person Name /
Signature
/
Date

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