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.

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Applications

0 Instructions and FAQs Credentialing and Contracting 6.29.18.docx
2018-07-11
1 Credentialing Application 6.29.18.docx
2018-07-11
2 Provider Clinical Application FFS Medi-Cal 06.29.18.docx
2018-07-11
3 FFS Clincal Speciality Addition App 06.29.18.docx
2018-07-10
Form W-9 (Rev. December 2014)
2017-11-02

Beneficiary Materials

Notice of Privacy Practices Acknowledgement Arabic 2014.docx
2018-05-25
Notice of Privacy Practices Acknowledgement English 2014.docx
2018-05-25
Notice of Privacy Practices Acknowledgement Spanish 2014.docx
2018-05-25
Notice of Privacy Practices Acknowledgement Tagalog 2014.docx
2018-05-25
Notice of Privacy Practices Acknowledgement Vietnamese 2014.docx
2018-05-25
Advance Directive Arabic.pdf
2015-10-09
Advance Directive English.pdf
2015-10-09
Advance Directive Spanish.pdf
2015-10-09
Advance Directive Tagalog.pdf
2015-10-09
Advance Directive Vietnamese.pdf
2015-10-09
FullGuide Arabic 2013.pdf
2016-10-12
FullGuide Spanish 2013.pdf
2016-10-12
FullGuide English.pdf
2016-10-12
FullGuide Tagalog 2013.pdf
2016-06-28
FullGuide Vietnamese 2013.pdf
2016-10-12
GrievanceAndAppealPoster Arabic.pdf
2018-05-25
GrievanceAndAppealPoster English.pdf
2018-05-25
GrievanceAndAppealPoster Tagalog.pdf
2018-05-25
GrievanceAndAppealPoster Vietnamese 04-2012.pdf
2018-05-25
LimitedEnglishProficiencyPoster Arabic 03-17-05.pdf
2018-05-25
LimitedEnglishProficiencyPoster English.pdf
2018-05-25
LimitedEnglishProficiencyPoster Spanish.pdf
2018-05-25
LimitedEnglishProficiencyPoster Vietnamese.pdf
2018-05-25
NoticeofPrivacyPractices Arabic 12-16-14.pdf
2018-05-25
NoticeofPrivacyPractices English 12-16-14.pdf
2018-05-25
NoticeofPrivacyPractices Spanish 12-16-14.pdf
2018-05-25
NoticeofPrivacyPractices Tagalog 12-16-14.pdf
2018-05-25
NoticeofPrivacyPractices Vietnamese 12-16-14.pdf
2018-05-25
Recovery Brochure English 8-5-13.pdf
2018-05-25
Recovery Brochure Spanish 09-11rev.pdf
2018-05-25
Grievance and Appeal Form-CCHEA Advocacy Spanish 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-JFS Advocacy English 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-JFS Advocacy Vietnamese 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-CCHEA Advocacy Tagalog 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-CCHEA Advocacy Arabic 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-CCHEA Advocacy English 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-CCHEA Advocacy Vietnamese 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-JFS Advocacy Tagalog 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-JFS Advocacy Spanish 1-15-16.pdf
2018-05-25
Grievance and Appeal Form-JFS Advocacy Arabic 1-15-16.pdf
2018-05-25
ACL Poster.pdf
2016-10-12
Grievance-Appeal Brochure FINAL Rv 10 17 17 Vietnamese.pdf
2017-12-13
Grievance-Appeal Brochure FINAL Rv 10 17 17 Tagalog.pdf
2017-12-13
Grievance-Appeal Brochure FINAL Rv 10 17 17 Spanish.pdf
2017-12-13
Grievance-Appeal Brochure FINAL Rv 10 17 17 Arabic.pdf
2017-12-13
Grievance-Appeal Brochure FINAL Rv 10 17 17 English.pdf
2017-12-13
Grievance and Appeal Form - CCHEA Advocacy 12 20 17 FARSI.docx
2017-12-22
Grievance and Appeal Form - JFS Advocacy 12-20-17 FARSI.docx
2017-12-22
LimitedEnglishProficiencyPoster Farsi2-1-18.pdf
2018-05-18
FullGuide Farsi rev2018.pdf
2018-05-18

Claims

Communications

JV-220 Updated Information.pdf
2018-05-25
Federal and State False Claims Act - HHSA (pdf)
2016-05-11
JV-220 Application For Psychotropic Medication
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
New Outcome Tools for County of SD Mental Health Plans (pdf)
2019-04-24
OPTUMIST Newsletter Fall 2018 (pdf)
2018-11-02
OPTUMIST Newsletter Spring 2018 (pdf)
2018-05-01
OPTUMIST Newsletter Summer 2018 (pdf)
2018-08-13
OPTUMIST Newsletter Winter 2019 (pdf)
2019-02-06
Upcoming Authorization Process Changes Effective 01.01.2019 (pdf)
2018-11-02
Updated Outpatient Authorization Request (OAR) Form Info Email (pdf)
Implementation Date set for JANUARY 1, 2019 2018-12-18

Forms

Advance Health Care Directives.pdf
2018-05-25
Coordination of Care Release Form San Diego.doc
2015-10-09
FINAL Coordination of Care Form English.pdf
- 2019-03-06
FINAL Coordination of Care Form Spanish.doc
- 2019-03-06
FINAL Coordination of Care Form Spanish.pdf
- 2019-03-06
FINAL Coordination of Care Form Tagalog.doc
- 2019-03-06
FINAL Coordination of Care Form Tagalog.pdf
- 2019-03-06
FINAL Coordination of Care Form Viet.doc
- 2019-03-06
FINAL Coordination of Care Form Viet.pdf
- 2019-03-06
Medi-Cal Behavioral Health Transition of Care Form.doc
- 2019-03-06
MediCal Grievance and Appeal Forms.pdf
- 2015-10-09
Sample - Discharge Summary.docx
2017-04-25
Sample - Initial Assessment.docx
2017-04-25
Sample - Med Management Progress Note.docx
2017-04-25
Sample - Progress Note.docx
2017-04-25
Sample - Treatment Plan.docx
2017-04-25
Sample Psych Testing Request Form 012016.pdf
2016-02-24
Psych Testing Guidelines.pdf
2016-02-24
Authorization To Use or Disclosed PHI Form.doc
2016-11-01
NOABD Delivery System Notice - TAGALOG.docx
- 2018-08-07
NOABD Delivery System Notice - SPANISH.doc
- 2018-08-07
NOABD Delivery System Notice - ARABIC.doc
- 2018-08-07
NOABD Delivery System Notice - VIETNAMESE.doc
- 2018-08-07
NOABD Delivery System Notice - ENGLISH.doc
- 2018-08-07
NOABD Delivery System Notice - FARSI.doc
- 2018-08-07
NOABD Your Rights Notice - ARABIC.pdf
- 2018-08-07
NOABD Your Rights Notice - VIETNAMESE.pdf
- 2018-08-07
NOABD Your Rights Notice - FARSI.pdf
- 2018-08-07
NOABD Your Rights Notice - SPANISH.pdf
- 2018-08-07
NOABD Your Rights Notice - TAGALOG.pdf
- 2018-08-07
NOABD Your Rights Notice - ENGLISH.pdf
- 2018-08-07
Outpatient Authorization Request Psychiatry 11-1-18.docx
2019-02-25
Outpatient Authorization Request Psychiatry 11-1-18.pdf
2019-02-25
Interpreter Services Auth Form Update 2019.pdf
BHS Serious Incident Report (doc)
2018-12-20
BHS Serious Incident Report of Findings (doc)
2018-12-20
Beneficiary Materials MHP Order Form (docx)
2019-03-08
Beneficiary Non-Discrimination Notice - ARABIC (doc)
2018-08-06
Beneficiary Non-Discrimination Notice - ARABIC (pdf)
2018-08-06
Beneficiary Non-Discrimination Notice - FARSI (doc)
2018-08-06
Beneficiary Non-Discrimination Notice - FARSI (pdf)
2018-08-06
Beneficiary Non-Discrimination Notice - SPANISH (doc)
2018-08-06
Beneficiary Non-Discrimination Notice - TAGALOG (docx)
2018-08-06
Beneficiary Non-Discrimination Notice - TAGALOG (pdf)
2018-08-06
Beneficiary Non-Discrimination Notice - VIETNAMESE (doc)
2018-08-06
Beneficiary Non-Discrimination Notice - VIETNAMESE (pdf)
2018-08-06
CARE PLAN INFORMED CONSENT PSYCHOTROPIC MEDICATION.pdf
2018-02-01
Demographic Form Fill - Required Fields (pdf)
2018-12-06
Demographic Form Fill (docx)
2018-12-06
Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
FINAL Coordination of Care Form Arabic (doc)
- 2018-05-25
FINAL Coordination of Care Form Arabic (pdf)
- 2019-01-23
FINAL Coordination of Care Form English (doc)
- 2019-01-23
MFT Eligibility Verification Form (pdf)
2019-03-06
Medi-Cal Psych Testing Request Form (docx)
2019-01-24
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

Manuals

FFS Provider Operations Handbook (pdf)
Revised 10/31/2018 2018-10-30
Inpatient Operations Handbook (pdf)
Revised 05/16/2017 2018-09-24

Quick Reference

Adult MediCal Mental Health Severity Analysis Tool.pdf
2016-08-30
April CWS Unit Roster (docx)
2019-04-09
Children, Youth and Families (CYF) Behavioral Health Services Provider Resource Manual (pdf)
2017-03-09
Demographic Form Fill (docx)
2018-12-06
Demographic Form Fill (pdf)
2018-12-06
Example - Outpatient Authorization Request - Therapists (docx)
2018-12-11
FFS LMFT/LCSW/LPCC Codes and Rates (pdf)
2019-02-01
FFS MD DO Psychiatrist Codes and Rates (pdf)
2019-02-01
FFS PNP Codes and Rates (pdf)
2019-02-01
FFS PhD PsyD Psychologist Codes and Rates (pdf)
2019-02-01
Fee for Service Outpatient Changes For Psychiatric Services - PowerPoint Presentation (pptx)
2018-11-16
MediCal Behavioral Health Quick Guide (pdf)
2016-08-10
Mild-Moderate-Severe Process FAQs.pdf
2016-10-24
Optum Response to Presumptive Transfer Inquiries in SD - 3.9.18 (pdf)
2018-03-14
Optum San Diego Website Provider Registration Instructions (pdf)
2018-05-01
Outpatient Authorization Request Form - Therapists (doc)
2018-12-03
Outpatient Authorization Request Form - Therapists (pdf)
2018-12-03
Outpatient Authorization Request Form Psychiatry – Required Fields (pdf)
2019-02-08
Outpatient Authorization Request Form Therapists - Required Fields (pdf)
2018-12-13
Outpatient Authorization Request Psychiatry Tip Sheet (pdf)
2019-04-10
Provider Orientation Presentation (pdf)
2018-11-16
Timely Access to Care (pdf)
2018-04-30
Title 42 Training for Providers - Presentation (pdf)
2018-10-02
You Can Get Help Resolving A Problem
2015-10-09

Review - Outpatient

DHCS Reasons for Recoupment FY 18-19 (pdf)
For DOS 7/1/18-6/30/19 2019-03-22
Beneficiary Materials MHP Order Form (docx)
2019-03-08
DHCS Reasons for Recoupment FY 17-18 (pdf)
For DOS 7/1/17-6/30/18 2017-11-06
Documentation Tip Sheet (pdf)
2016-09-15
Initial Client Checklist (pdf)
2019-02-11
Quick Guide to Provider Orientation (pdf)
2019-02-13
Reasons for Recoupment Quick Guide FY 18-19 (pdf)
2019-02-01
Record Keeping and Treatment Record Requirements (pdf)
2017-08-07
Site Review Tool (pdf)
2018-02-22
Treatment Record Review Tool (pdf)
2017-05-10

Review - Inpatient

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

Training