A. Program monitors must obtain a Medi-Cal provider number through the CBHS Information Systems (IS) office, prior to submitting SD/MC certification forms. (Contact: Retha Pedigo - 255-3787)

B. Program monitors must coordinate with the CBHS Billing Information Systems (IS) office to confirm how billing will occur, and to obtain the necessary information regarding computer hardware requirements, software, and training in a timely manner prior to actual program certification.
(Contact: Retha Pedigo - 255-3787)

C. To obtain SD/MC certification, a program must be in actual operation, providing mental health services as described in the SD/MC Manual (2-10, and 2-11) (Manual may be obtained from Jon Blackner - 255-3771)

It is the responsibility of the Program Monitor to submit the following forms, completed, dated, and signed to the Medi-Cal Provider Certification Coordinator in the Quality Management Section of CBHS for the Director's review and signature. For new providers, these forms must be submitted at the time potential Medi-Cal services begin.

A. SD/MC Provider Certification Application (7-16)
SD/MC Provider Agreement (7-17)
Medi-Cal Provider Data Form (7-18)
Medi-Cal Provider Disclosure Statement
Medi-Cal Point of Service (POS) Network Agreement
(Forms attached - see Attachment 1)

B. Current Fire Clearance Certificate and a documented visit by a local fire official with a Plan of Correction pending, or evidence of compliance. (obtainable from the local Fire Department - SFFD Office of Fire Prevention - 558-3300 ask for the District Inspector for the site address)

Medi-Cal organizational provider recertification reviews may be done every two years based on SFMHP's review schedule. Additional certification reviews may become necessary under circumstances listed below. For recertification, forms (listed in II. A.) must be submitted to Jim Gilday at least 70 days before a significant programatic change takes place that requires recertification. The local mental health director or designee shall be notified by the Program Director or Program Monitor 70 days prior to the changes noted below. The notification must include the effective date, and a description of changes. (use CBHS 100 forms (see Policy 3.07-6))

Additional certification reviews may become necessary if:

A. There is change of legal entity or ownership. This will require a new certification application process.

B. There is change of location. (Involuntary changes of location due to disasters must be reported as soon as possible and are not subject to the 60 day prior notification requirement.) This will require a new fire clearance of the new site, but may not require a full re-submission of certification forms. Programs may expect a certification site visit by State DMH Medi-Cal officials for CBHS programs, or Quality Management Section (QMS) officials for contract programs.

C. The provider makes major staffing changes. All providers must conform to staffing standards as described in Service Definitions for Rehabilitation Option and Targeted Case Management. SD/MC Manual (2-12, and 2-13 and 7-6) The requirement for certification review in this situation is at the State Medi-Cal Field Office or the local mental health director or designee's discretion.

D. The provider makes organizational and/or corporate structure changes
(example: conversion from non-profit status). This will require a new certification application process as would change of ownership.

E. The provider adds Day Treatment or Medication Support services
when Day Treatment or medications were not previously certified to be administered or dispensed from the provider site. This requires notification and may involve a site visit.

F. There are significant changes in the physical plant of the provider site. (some physical plant changes could require a new fire clearance, but may not require a full re-submission of certification forms.)

G. There are complaints regarding the provider. Depending on the gravity of the complaints, it may require a certification review at the SFMHP or State's discretion.

H. There are unusual events, accidents, or injuries requiring medical treatment for clients, staff or members of the community. When persons are injured on a program site, it usually involves a certification review as a matter of course.
(see SD/MC Manual 7-12)

Representatives of the Quality Management Section (QMS) will visit Medi-Cal organizational program sites for the purposes of certification at least every two years based on SFMHP's review schedule. The certification site visits will include a review of items contained in the Medi-Cal certification check list, and program description documents (see attachment II and III).

Upon completion of the necessary documents and after a certification site visit has been completed, the Medi-Cal Certification Coordinator will send a letter of certification citing the date, conditions and term of certification to the Program Monitor, Program Director, BIS office, Budget Manager, and if necessary, to the State Medi-Cal office. All records must be complete to assure a clear audit trail for State Medi-Cal officials or CBHS risks denial of Medi-Cal claims. Subsequent communications to or from the State Medi-Cal office, the State Electronic Data System office, or any external interested party should be copied to the Medi-Cal Certification Coordinator in order to assure a complete record.

As a precondition to SD/MC provider certification, programs providing Adult Residential Treatment Services must be certified as a Social Rehabilitation Program by the Department of Mental Health as either a Transitional Residential Treatment Program or a Long-Term Residential Treatment Program. Facility capacity must be limited to a maximum of 16 beds. Services shall be consistent with Section 532 of Title 9, California Code of Regulations. In addition to the routine forms required for application for SD/MC certification (see II. A.) proof of certification as a Social Rehabilitation Program by the State Department of Mental Health (DMH), Licensing and Certification Unit must accompany the application.

In addition to Social Rehabilitation Program Certification, programs providing Adult Residential Treatment Services must be licensed as a Social Rehabilitation Facility or Community Care Facility by the Department of Social Services or authorized to operate as a mental Health Rehabilitation Center by the Department of Mental Health.

Out of County providers may be certified as SD/MC providers for the SFMHP if the appropriate application forms and fire clearance is submitted, as well as verification of their current SD/MC provider certification status in their home county. If a provider is currently certified in their home county, we may forego the site visit requirement at the discretion of the Medi-Cal Certification Coordinator.

Information obtained during the certification process may be used during subsequent Quality Improvement/Quality Management activities. The information obtained in this process is intended only for the use of the Medi-Cal Certification Coordinator, the , the Director of Mental Health, the State DMH or Medi-Cal officials in the performance of their duties.