Fee for Service Providers

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)	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-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
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)	Revised 07/01/2020	2020-07-06
MD/DO Billing Codes (pdf)	Revised 07/01/2020	2020-07-06
PNP Billing Codes (pdf)	Revised 07/01/2020	2020-07-06
PhD/PsyD Billing Codes (pdf)	Revised 07/01/2020	2020-07-06

Communications/Updates


OPTUMIST Newsletter Fall 2020		2020-11-04
OPTUMIST Newsletter Spring 2021 (pdf)		2021-05-03
OPTUMIST Newsletter Summer 2019 (pdf)		2019-08-12
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 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
ECT Authorization Request Form (pdf)	Revised 10/16/2020	2020-10-22
Example - Outpatient Authorization Request - Therapists (docx)		2018-12-11
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_Authorization_Request_Psychiatry (docx)		2021-04-21
Outpatient_Authorization_Request_Psychiatry (pdf)		2021-04-21
Progress Note (docx)	Templates	2017-04-25
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
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
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