Fee for Service Providers

 

Please Read: Provider Services Communications during the COVID-19 Crisis

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.

Applications
1 Instructions and FAQs Credentialing and Contracting (pdf)
Revised 02/12/2020 2020-02-19
2 Credentialing Criteria (pdf)
2020-01-30
3 Credentialing Application Instructions (pdf)
2020-02-19
4 Provider Clinical Application Medi-Cal (docx)
Revised 02/20/2020 2020-02-20
5 FFS Specialty Addition App (pdf)
Revised 05/26/2020 2020-05-28
6 RIHS Account Instructions (pdf)
2019-06-17
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
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)
Arabic 2015-10-09
Advance Directive - English (pdf)
English 2015-10-09
Advance Directive - Spanish (pdf)
Spanish 2015-10-09
Advance Directive - Tagalog (pdf)
Tagalog 2015-10-09
Advance Directive - Vietnamese (pdf)
Vietnamese 2015-10-09
Advance Directive Farsi (pdf)
Farsi 2020-04-10
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 And Appeal Poster - Arabic (pdf)
Arabic 2018-05-25
Grievance And Appeal Poster - English (pdf)
English 2018-05-25
Grievance And Appeal Poster - Tagalog (pdf)
Tagalog 2018-05-25
Grievance And Appeal Poster - Vietnamese (pdf)
Vietnamese 2018-05-25
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 - Farsi (pdf)
Farsi 2020-04-14
Notice of Privacy Practices - Farsi (pdf)
Farsi 2020-04-14
Notice of Privacy Practices Acknowledgement - Arabic (docx)
Arabic 2018-05-25
Notice of Privacy Practices Acknowledgement English 2014 (docx)
English 2018-05-25
Notice of Privacy Practices Acknowledgement Spanish (docx)
Spanish 2018-05-25
Notice of Privacy Practices Acknowledgement Tagalog (docx)
Tagalog 2018-05-25
Notice of Privacy Practices Acknowledgement Vietnamese (docx)
Vietnamese 2018-05-25
Quick Guide to MH Services - Arabic (pdf)
2019-05-16
Quick Guide to MH Services - English (pdf)
2019-05-16
Quick Guide to MH Services - Farsi (pdf)
2019-05-16
Quick Guide to MH Services - Spanish (pdf)
2019-05-16
Quick Guide to MH Services - Tagalog (pdf)
2019-05-16
Quick Guide to MH Services - Vietnamese (pdf)
2019-05-16
SD Grievance-Appeal POSTER - Spanish (pdf)
Spanish 2020-04-14

Claims
LMFT/LCSW/LPCC Codes (pdf)
2019-11-07
MD DO Psychiatrist Codes (pdf)
2019-11-07
PNP Codes (pdf)
2019-11-07
PhD PsyD Psychologist Codes (pdf)
2019-11-07

Communications/Updates
CANS Overview Virtual Training
Live Virtual Training: Thursday, May 21, 2020 2020-05-12
Claims Team OPEN HOUSE - Sept. 14, 2019 (pdf)
Email - 08/15/2019 2019-08-26
Claims Team OPEN HOUSE - Sept. 14, 2019 (pdf)
Flyer - 08/15/2019 2019-08-26
Email - Save the Date - Symposium Alcanzado Nuevos (pdf)
Event - Friday, November 15, 2019 2019-09-16
New Outcome Tools for County of SD Mental Health Plans
2019-04-24
OPTUMIST Newsletter - Winter 2020 (pdf)
2020 2020-02-03
OPTUMIST Newsletter Spring 2019
2019-05-06
OPTUMIST Newsletter Spring 2020 (pdf)
2020-04-30
OPTUMIST Newsletter Summer 2019 (pdf)
2019-08-12
OPTUMIST Newsletter Fall 2019 (pdf)
2019-11-01
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
Training Opportunity: Human (Sex) Trafficking/Commercial Sexual Exploitation of Children 101 (pdf)
Event - Friday - January 24, 2020 2019-11-13
Training Opportunity: Human (Sex) Trafficking/Commercial Sexual Exploitation of Children 101 (pdf)
Event - Friday January 24, 2020 - Flyer 2019-12-12
Upcoming Authorization Process Changes
Effective 01.01.2019 2018-11-02
Updated Outpatient Authorization Request (OAR) Form Info Email
Implementation Date set for JANUARY 1, 2019 2018-12-18
Updated Psychiatry Outpatient Authorization Request (OAR) Form Information
2019-05-23

Forms

TBS Prior Authorization Request & Referral Form-7.26.19.docx
Ancillary Specialty Mental Health Services Request Form (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 (doc)
2018-12-20
BHS Serious Incident Report of Findings (doc)
2018-12-20
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 (pdf)
Vietnamese 2019-03-06
Coordination of Care Form Arabic (doc)
Arabic 2018-05-25
Demographic Form Fill (docx)
Revised 09/12/2019 2019-12-12
Demographic Form Fill - Required Fields (pdf)
Revised 09/12/2019 2019-12-12
Discharge Summary (docx)
Template 2017-04-25
Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
FINAL Coordination of Care Form - Vietnamese (doc)
Vietnamese 2019-03-06
Initial Assessment (docx)
Templates 2017-04-25
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 (docx)
Templates 2017-04-25
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 ECT Authorization Request (doc)
2018-08-24
Outpatient ECT Authorization Request - Form Fill (pdf)
2018-08-24
Outpatient Authorization Request Psychiatry (docx)
Updated 04-11-2019 2019-07-03
Outpatient Authorization Request Psychiatry (pdf)
Updated 04-11-2019 2019-07-03
Progress Note (docx)
Templates 2017-04-25
Psych Testing Request Form (docx)
2019-01-24
Psychotropic Medication Informed Consent Guide (pdf)
2020-05-13
Treatment Plan (docx)
Templates 2017-04-25
Treatment Plan and Informed Consent for Psychotropic Medication (pdf)
Templates 2020-05-13

Manuals

FFS Provider Operations Handbook (pdf)
Revised 01/31/2020 2020-01-30
Inpatient Operations Manual (pdf)
Revised 01/15/2020 2020-02-03

Quick Reference

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

Review - Outpatient
Site Review Tool.pdf
DHCS Reasons for Recoupment FY 18-19 (pdf)
For DOS 7/1/18-6/30/19 2019-03-22
Beneficiary Materials MHP Order Form (pdf)
2020-04-14
DHCS Reasons for Recoupment FY 17-18 (pdf)
For DOS 7/1/17-6/30/18 2017-11-06
DHCS Reasons for Recoupment FY 19-20 (pdf)
2020-05-22
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)
2019-07-08

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

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)
2019-08-02
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 #3 - COVID-19 Guidance Best Practice (pdf)
2020-04-02
BHS Provider Notice 2 - COVID-19 Guidance Best Practice (pdf)
2020-03-25
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 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