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Fee for Service Providers

This page is utilized by Fee For Service MediCal Providers to obtain documentation related to participation on the MediCal panel and continued authorizations for treatment.

FFS Medi-Cal Documentation Training Link

Applications
1 Instructions and FAQs Credentialing and Contracting (pdf)
Revised 12/31/2020 2020-12-31
2 Credentialing Criteria (pdf)
2020-01-30
3 Credentialing Application Instructions (pdf)
2020-02-19
4 Provider Clinical Application Medi-Cal (docx)
12/28/2020 2020-12-31
5 FFS Specialty Addition App (docx)
12/28/2020 2020-12-31
6 Medi-Cal Documentation Training (pdf)
12/29/2020 2020-12-31
7 Form W-9 (pdf)
2017-11-02

Beneficiary Materials
LimitedEnglishProficiencyPoster_Vietnamese.pdf
Vietnamese 2018-05-25
NoticeofPrivacyPractices_Arabic_12-16-14.pdf
Arabic 2018-05-25
NoticeofPrivacyPractices_English_12-16-14.pdf
English 2018-05-25
NoticeofPrivacyPractices_Spanish_12-16-14.pdf
Spanish 2018-05-25
NoticeofPrivacyPractices_Tagalog_12-16-14.pdf
Tagalog 2018-05-25
NoticeofPrivacyPractices_Vietnamese_12-16-14.pdf
Vietnamese 2018-05-25
Recovery_Brochure_English_8-5-13.pdf
English 2018-05-25
Recovery_Brochure_Spanish_09-11rev.pdf
Spanish 2018-05-25
Grievance_and_Appeal_Form-CCHEA_Advocacy_Spanish_1-15-16.pdf
Spanish 2018-05-25
Grievance_and_Appeal_Form-JFS_Advocacy_English_1-15-16.pdf
English 2018-05-25
Grievance_and_Appeal_Form-JFS_Advocacy_Vietnamese_1-15-16.pdf
Vietnamese 2018-05-25
Grievance_and_Appeal_Form-CCHEA_Advocacy_Tagalog_1-15-16.pdf
Tagalog 2018-05-25
Grievance_and_Appeal_Form-CCHEA_Advocacy_Arabic_1-15-16.pdf
Arabic 2018-05-25
Grievance_and_Appeal_Form-CCHEA_Advocacy_English_1-15-16.pdf
English 2018-05-25
Grievance_and_Appeal_Form-CCHEA_Advocacy_Vietnamese_1-15-16.pdf
Vietnamese 2018-05-25
Grievance_and_Appeal_Form-JFS_Advocacy_Tagalog_1-15-16.pdf
Tagalog 2018-05-25
Grievance_and_Appeal_Form-JFS_Advocacy_Spanish_1-15-16.pdf
Spanish 2018-05-25
Grievance_and_Appeal_Form-JFS_Advocacy_Arabic_1-15-16.pdf
Arabic 2018-05-25
ACL_Poster.pdf
English 2016-10-12
Grievance-Appeal_Brochure_FINAL_Rv_10_17_17_Vietnamese.pdf
Vietnamese 2017-12-13
Grievance-Appeal_Brochure_FINAL_Rv_10_17_17_Tagalog.pdf
Tagalog 2017-12-13
Grievance-Appeal_Brochure_FINAL_Rv_10_17_17_Spanish.pdf
Spanish 2017-12-13
Grievance-Appeal_Brochure_FINAL_Rv_10_17_17_Arabic.pdf
Arabic 2017-12-13
Grievance-Appeal_Brochure_FINAL_Rv_10_17_17_English.pdf
English 2017-12-13
Grievance_and_Appeal_Form_-_CCHEA_Advocacy_12_20_17_FARSI.docx
Farsi 2017-12-22
Grievance_and_Appeal_Form_-_JFS_Advocacy_12-20-17_FARSI.docx
Farsi 2017-12-22
LimitedEnglishProficiencyPoster_Farsi2-1-18.pdf
Farsi 2018-05-18
Full Guide Farsi 2019 (pdf)
Farsi 2018-05-18
Full Guide Spanish 2019 (pdf)
Spanish 2019-05-09
ACL Poster
English 2019-04-26
Advance Directive - Arabic (pdf)
2021-09-17
Advance Directive - English (pdf)
2021-09-17
Advance Directive - Spanish (pdf)
2021-09-17
Advance Directive - Tagalog (pdf)
2021-09-17
Advance Directive - Vietnamese (pdf)
2021-09-17
Advance Directive Farsi (pdf)
2021-09-17
Beneficiary Materials MHP Order Form (pdf)
2020-04-14
Beneficiary Non-Discrimination Notice - ARABIC (doc)
Arabic 2018-08-06
Beneficiary Non-Discrimination Notice - ARABIC (pdf)
Arabic 2018-08-06
Beneficiary Non-Discrimination Notice - ENGLISH (pdf)
English 2018-08-07
Beneficiary Non-Discrimination Notice - FARSI (doc)
Farsi 2018-08-06
Beneficiary Non-Discrimination Notice - FARSI (pdf)
Farsi 2018-08-06
Beneficiary Non-Discrimination Notice - SPANISH (doc)
Spanish 2018-08-06
Beneficiary Non-Discrimination Notice - TAGALOG (docx)
Tagalog 2018-08-06
Beneficiary Non-Discrimination Notice - TAGALOG (pdf)
Tagalog 2018-08-06
Beneficiary Non-Discrimination Notice - VIETNAMESE (doc)
Vietnamese 2018-08-06
Beneficiary Non-Discrimination Notice - VIETNAMESE (pdf)
Vietnamese 2018-08-06
Full Guide - Arabic (pdf)
Arabic 2020-04-10
Full Guide English 2019 (pdf)
English 2019-02-01
Full Guide Tagalog 2019 (pdf)
Tagalog 2019-05-13
Full Guide Vietnamese 2019 (pdf)
Vietnamese 2019-05-13
Grievance-Appeal Brochure Farsi (pdf)
Farsi 2020-04-14
Limited English Proficiency Poster - Arabic (pdf)
Arabic 2018-05-25
Limited English Proficiency Poster - English (pdf)
English 2018-05-25
Limited English Proficiency Poster - Spanish (pdf)
Spanish 2018-05-25
Limited English Proficiency Poster - Tagalog (pdf)
Tagalog 2020-04-14
NOABD Delivery System Notice - ARABIC (doc)
Arabic 2018-08-07
NOABD Delivery System Notice - ENGLISH (doc)
English 2018-08-07
NOABD Delivery System Notice - FARSI (doc)
Farsi 2018-08-07
NOABD Delivery System Notice - SPANISH (doc)
Spanish 2018-08-07
NOABD Delivery System Notice - TAGALOG (doc)
Tagalog 2018-08-07
NOABD Delivery System Notice - VIETNAMESE (doc)
Vietnamese 2018-08-07
NOABD Language Assistance Notice - ENGLISH (pdf)
English 2018-08-07
NOABD Your Rights Notice - ARABIC (pdf)
Arabic 2018-08-07
NOABD Your Rights Notice - ENGLISH (pdf)
English 2018-08-07
NOABD Your Rights Notice - FARSI (pdf)
Farsi 2018-08-07
NOABD Your Rights Notice - SPANISH (pdf)
Spanish 2018-08-07
NOABD Your Rights Notice - TAGALOG (pdf)
Tagalog 2018-08-07
NOABD Your Rights Notice - Vietnamese (pdf)
Vietnamese 2020-04-14
NPP Acknowledgement - Arabic (pdf)
Arabic 2021-09-15
NPP Acknowledgement - English (pdf)
English 2021-09-15
NPP Acknowledgement - Farsi (pdf)
Farsi 2021-09-15
NPP Acknowledgement - Spanish (pdf)
Spanish 2021-09-15
NPP Acknowledgement - Tagalog (pdf)
Tagalog 2021-09-15
NPP Acknowledgement - Vietnamese (pdf)
Vietnamese 2021-09-15
Notice of Privacy Practices - Farsi (pdf)
Farsi 2020-04-14
Quick Guide to MH Services - Arabic (pdf)
2021-09-15
Quick Guide to MH Services - English (pdf)
2021-09-15
Quick Guide to MH Services - Farsi (pdf)
2021-09-15
Quick Guide to MH Services - Spanish (pdf)
2021-09-15
Quick Guide to MH Services - Tagalog (pdf)
2021-09-15
Quick Guide to MH Services - Vietnamese (pdf)
2021-09-15
SD Grievance-Appeal POSTER - Spanish (pdf)
Spanish 2020-04-14
SD Grievance-Appeal POSTER Arabic (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER English (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER English LARGE FONT (pdf)
Revised 03/05/2019 2021-07-14
SD Grievance-Appeal POSTER English LARGE FONT (pdf)
Revised 03/05/2019 2021-07-15
SD Grievance-Appeal POSTER Farsi (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER Spanish (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER Spanish (pdf)
Revised 03/06/2019 2021-07-15
SD Grievance-Appeal POSTER Tagalog (pdf)
Revised 03/06/2019 2021-07-14
SD Grievance-Appeal POSTER Vietnamese (pdf)
Revised 03/06/2019 2021-07-14

Claims
LMFT/LCSW/LPCC Billing Codes (pdf)
09/01/2021 2021-09-07
MD/DO Billing Codes (pdf)
09/01/2021 2021-09-07
PNP/PA Billing Codes (pdf)
09/01/2021 2021-09-07
PhD/PsyD Billing Codes (pdf)
09/01/2021 2021-09-07

Communications/Updates
OPTUMIST Newsletter Fall 2020 (pdf)
2020-11-04
OPTUMIST Newsletter Spring 2021 (pdf)
2021-05-03
OPTUMIST Newsletter Summer 2021 (pdf)
07/31/2021 2021-09-08
OPTUMIST Newsletter Winter 2021 (pdf)
2021-01-29
Optum Response to Presumptive Transfer Inquiries in SD
2018-03-14
Therapeutic Behavioral Services Prior Authorization Request & Referral Process (pdf)
Memo - August 9, 2019 2019-08-09

Forms

Ancillary Specialty Mental Health Services Request (docx)
Revised 01/01/20 2019-12-31
Authorization to Use of Disclose PHI - ARABIC (pdf)
Arabic 2017-02-17
Authorization to Use or Disclose PHI - CHILD (dot)
2017-02-17
Authorization to Use or Disclose PHI - ENGLISH (pdf)
English 2017-02-17
Authorization to Use or Disclose PHI - SPANISH (pdf)
Spanish 2017-02-17
Authorization to Use or Disclose PHI - TAGALOG (pdf)
Tagalog 2017-02-17
Authorization to Use or Disclose PHI - VIETNAMESE (pdf)
Vietnamese 2017-02-17
BHS Serious Incident Report (docx)
2021-02-17
BHS Serious Incident Report of Findings (docx)
2021-02-17
Coordination of Care Form - Arabic (doc)
Arabic 2018-05-25
Coordination of Care Form - Arabic (pdf)
Arabic 2019-01-23
Coordination of Care Form - English (doc)
English 2019-01-23
Coordination of Care Form - English (pdf)
English 2019-03-06
Coordination of Care Form - Spanish (doc)
Spanish 2019-03-06
Coordination of Care Form - Spanish (pdf)
Spanish 2019-03-06
Coordination of Care Form - Tagalog (doc)
Tagalog 2019-03-06
Coordination of Care Form - Tagalog (pdf)
Tagalog 2019-03-06
Coordination of Care Form - Vietnamese (doc)
Vietnamese 2019-03-06
Coordination of Care Form - Vietnamese (pdf)
Vietnamese 2019-03-06
Demographic Form Fill (docx)
Revised 06/21/2021 2021-07-29
Discharge Summary (pdf)
2021-08-12
ECT Authorization Request Form (pdf)
Revised 10/16/2020 2020-10-22
Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
Initial Assessment (docx)
2021-08-19
Initial Assessment (pdf)
2021-08-12
Interpreter Services Request Form (pdf)
2019-07-29
JV-220 Application For Psychotropic Medication (pdf)
2016-07-01
JV-220(A) Physician's Statement—Attachment (pdf)
2018-03-01
JV-220(B) Physician's Request to Continue Medication—Attachment (pdf)
2018-03-01
MFT Eligibility Verification Form (pdf)
2019-03-06
Med Management Progress Note (pdf)
2021-08-12
Med Management-Psychotherapy Note (pdf)
2021-08-12
Medi-Cal Behavioral Health Transition of Care Form (doc)
2019-03-06
NOABD Your Rights Notice - VIETNAMESE (pdf)
Vietnamese 2018-08-07
Outpatient Authorization Request Form - Therapists (doc)
2018-12-03
Outpatient Authorization Request Form - Therapists (pdf)
2018-12-03
Outpatient Authorization Request Form Therapists - Required Fields (pdf)
2018-12-13
Outpatient_Authorization_Request_Psychiatry (docx)
2021-04-21
Outpatient_Authorization_Request_Psychiatry (pdf)
2021-04-21
Progress Note (docx)
2021-08-16
Progress Note (pdf)
2021-08-12
Psych Testing Request Form (docx)
2019-01-24
Psychotropic Medication Informed Consent Guide (pdf)
2020-05-13
Serious Incident Report - Explanation (pdf)
2020-10-08
Serious Incident Report of Findings Explanation (pdf)
2020-11-05
TBS Prior Authorization Request and Referral Form (docx)
Revised 07/26/2019 2020-07-07
Treatment Plan (docx)
Templates 2017-04-25
Treatment Plan and Informed Consent for Psychotropic Medication (pdf)
Templates 2020-05-13

Manuals

FFS Operations Handbook (pdf)
Revised 01/31/2021 2021-01-13
Inpatient Operations Manual (pdf)
Revised 01/15/2020 2020-02-03

Quick Reference

Adult MediCal Mental Health Severity Analysis Tool (pdf)
2016-08-30
Children, Youth and Families (CYF) Behavioral Health Services Provider Resource Manual (pdf)
01/01/2017 2017-03-09
Demographic Form Fill - Required Fields (pdf)
Revised 10/23/2018 2018-12-06
Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
MediCal Behavioral Health Quick Guide (pdf)
2016-08-10
MediCal Quick Reference Guides (pdf)
2015-10-09
Mild-Moderate-Severe FAQs (pdf)
Effective 09/01/2016 2016-10-24
Outpatient Authorization Request - Psychiatry Tip Sheet (doc)
Revised 09/10/2020 2020-09-14
Outpatient Authorization Request Form - Psychiatry – Required Fields (pdf)
Revised 11/01/2018 2019-02-08
Outpatient Authorization Request Form - Therapists (docx)
Revised 12/01/2018 2018-12-03
Outpatient Authorization Request Form - Therapists (pdf)
Revised 12/01/2018 2018-12-03
Outpatient Authorization Request Form - Therapists - Required Fields (pdf)
Revised 12/01/2018 2018-12-13
Timely Access to Care (pdf)
2018-04-30

Review - Outpatient
Site_Review_Tool.pdf
Beneficiary Materials MHP Order Form (pdf)
2020-04-14
DHCS Reasons for Recoupment FY 19-20 (pdf)
2020-05-22
DHCS Reasons for Recoupment FY 20-21 (pdf)
2021-03-19
Documentation Tip Sheet (pdf)
Revised 04/13/2020 2020-04-13
Initial Client Checklist (pdf)
Revised 04/2020 2020-04-09
Pre-Credentialing_Site_Review_Tool_(pdf)
2019-10-30
Reasons for Recoupment Quick Guide FY 18-19 (pdf)
2019-02-01
Record Keeping and Treatment Record Requirements (pdf)
2017-08-07
Treatment Record Review Tool (pdf)
Revised 07/07/2021 2021-07-07

Review - Inpatient
Inpatient Professional Service Documentation Guide (pdf)
2018-07-12
Inpatient Review Tool (pdf)
2017-08-07

Review - Medication Quality Assurance
Optum Adult Medication QA Tool (pdf)
2021-03-26
Optum Child Adolescent Medication QA Tool (pdf)
2021-03-26

QI Corner
Best Practices Series- Record Keeping Requirements (pdf)
2021-04-13

Training
Optum San Diego Website Provider Registration Instructions (pdf)
Updated 08/19/2019 2019-08-19
Federal and State False Claims Act - Contractor Roles and Responsibilities (pdf)
PowerPoint Presentation 2020-04-03
Fee for Service Outpatient Changes For Psychiatric Services (pptx)
PowerPoint Presentation 2018-11-16
Privacy and Security Training (pdf)
Presentation 2019-08-14
Provider Orientation Presentation (pdf)
2018-11-16
Quick Guide to Provider Orientation (pdf)
2019-02-13

CANS/PSC
CANS Instructions and Process (pdf)
Updated 08/01/2019 2019-08-05
CANS User Guide (pdf)
v1.0 July 2019 2019-09-16
CANS-PSC Completion Tip Sheet with link to Tools (pdf)
Updated 08/01/2019 2019-08-05
CYF mHOMS Client Information Sheet (pdf)
Revised 07/01/2020 2020-08-06
Electronic CANS & PSC Resources (pdf)
04/02/2020 2020-04-02
Electronic CANS Form (pdf)
04/02/2020 2020-04-02
Electronic CANS Form – Early Childhood Version (pdf)
2020-04-22
Electronic PSC - Parent Form (pdf)
04/02/2020 2020-04-02
Electronic PSC - Parent Form - Spanish (pdf)
04/02/2020 2020-04-02
Electronic PSC - Youth Form (pdf)
04/02/2020 2020-04-02
Electronic PSC - Youth Form - Spanish (pdf)
04/02/2020 2020-04-02

COVID-19
BHS Provider Notice #2 - COVID-19 Guidance Best Practice (pdf)
2020-03-25
BHS Provider Notice #3 - COVID-19 Guidance Best Practice (pdf)
2020-04-02
Outpatient Authorizations for Continuing Services during COVID-19 (pdf)
04/01/2020 2020-04-01
Telephone Telehealth Approved Notification (pdf)
2020-03-25
Working Remotely Business as Usual (pdf)
2020-03-25

Provider Services Info

Change of Practice Forms
Change From a Group to a Private Practice (pdf)
05/01/2020 2020-05-05
Change of Address, Phone, Demographics Form (pdf)
05/01/2020 2020-05-05

 

Telehealth Attestation/Standards
Standards of Practice for Telehealth
12/28/2020 2020-12-29
Telemental Health Attestation (pdf)
04/13/2021 2021-04-22