Behavioral Health Services Policies and Procedures

1.04-02 Policy on developing policies and procedures for Behavioral Health Services administrative manual holders and all programs. Also available as a template Word document.

1.04-03 Procedures for the approval of new or revised medical record (or chart) forms for Behavioral Health Services (BHS).

1.04-04 

Policy covering reporting and investigating Quality of Care Concerns that involve program members, guests, staff, and/or facilities within Behavioral Health Services.

1.04-06 Reporting requirements of Electroconvulsive Therapy (ECT) in the City and County of San Francisco.

1.04-07 Policy to promote a work environment within all Behavioral Health Service (BHS) programs (both civil service and contract programs) in which all are treated in a competent and respectful manner.

1.04-08 Issues guidance on the use of MHSA flex funds in Full Service Partnership (FSP) programs.

2.01-02 Outlines how all programs, except inpatient and outpatient hospital services operating under the license of the hospital, must be certified according to the standards of the Short-Doyle/Medi Cal (SD/MC) Manual for Rehabilitation Option and Targeted Case Management in order to bill for Medi-Cal services.

2.01-03 Policy on changes in credentialing criteria for Special Mental Health Services (SMHS) providers in the BHS Mental Health Plan (MHP). 

Refer to the Service Billing Privileges Matrix and the Certification Verification for non-licensed staff form for more information.

2.01-04 Issues requirements for all licensed adult alcohol or other drug recovery or treatment (AOC) facilities to obtain a designation based on the American Society of Addiction Medicine (ASAM) treatment criteria, or equivalent evidence-based standard, as a minimum standard of care.

2.03-08 Process for providers to follow in determining liability for uninsured and underinsured members seeking behavioral health services.

2.03-10 Outlines the manner in which each alcohol and other drug service program must assess fees to participants in their programs.

2.03-11 Patients' chart notes need to accurately reflect the service data entered into the Behavioral Health Billing Information System (BHBIS).

2.03-12 Establishes procedures related to Medi-Cal Share of Cost (SOC).

2.03-18 Guidance to Short-Doyle funded BHS Mental Health (MH) and Substance Use Disorders (SUD) Clinics for handling of payments received at their sites. 

2.03-26 Informs and reinforces regulations regarding physician responsibilities for Medicare and Medi-Cal reimbursement. 

2.03-27 Outlines procedures to ensure compliance with the Department of Health Care Services (DHCS) SDMC Program requirement for services provided to Medi-Cal beneficiaries to be verified.

2.03-28 Policy and procedures for the San Francisco Mental Health Plan (MHP) and for the San Francisco Drug Medi-Cal Organized Delivery System (DMC-ODS) Plan to recover and report overpayments made by these plans to providers per the Federal Medicaid Managed Care Final Rule (Final Rule) and Federal Mental Health and Substance Use Disorder Services Parity Final Rule (Parity Rule) requirements.

2.03-29 Standards for individual provider enrollment, screening, and credentialing activities conducted by BHS Compliance for individual providers.

2.06-16 Standards and guidelines for all BHS Trainee/Internship programs to ensure quality, consistency, and continuity of care of assigned trainees/interns. Substantive Revision. 

2.06-20 Provides guidance on the payment of stipends to clients and family members of clients who are receiving or have received behavioral health services.

2.06-21 Issues guidance on the payment of stipends to awarded applicants of the Multicultural Student Stipend Program (MSSP) who are conducting graduate level traineeships/internships within the BHS systems of care.

2.06-22 Provides guidance to Behavioral Health Services’ civil service employees on the SFDPH Office of Health Equity’s (OHE) addition of the Equity Learning Requirement (ELR) for the annual Performance
Plan and Appraisal Report (PPAR).

2.07-03 Defines user eligibility/requirements and provides guidance for usage of mobile devices, data cards, and/or mobile hotspots issued by BHS to staff when necessary for work-related communications.

3.01-03 Defines eligible criteria for those receiving Behavioral Health Services (BHS) prescription and laboratory services, who is eligible to prescribe such services, and what services are available. 

3.01-04 Guidelines to ensure compliance with state and federal laws on the accessing, ordering, receiving, storage, prescribing, dispensing, administration and safe disposal of medications in clinics that maintain them on site. 

Attachments: 

• Client Medication Request Log (Via Non-Fax Modality)
• Medication Room Temperature Log - Fahrenheit
• Temperature Log for Refrigerator — Fahrenheit
• Monthly Expired Medication Review
• Drug and Supply Request Form
• Physician’s Supply Medication Log
• Medication Destruction Log
• CBHS Medication Room Compliance Checklist

3.01-05 Guidelines to ensure compliance with state and federal laws and regulations, as well as for general safe practice medications standards to ensure client medication safety in the Mental Health (MH) Residential and Substance Use Disorder (SUD) Residential Treatment Facilities (RTF) setting. 

Substantive revision. Replaces Policy 3.01-5 of November 2, 2022.

Appendix and attachments:

• Centrally Stored Medication and Destruction Record
• Medication Room Temperature Log
• Temperature Log for Refrigerator
• Monthly Expired Medication Review
• Medication Destruction Log
• Residential Care Facility Medication Storage – Compliance Checklist
• High Risk Medication Documentation Form

3.01-06 Provides guidance on and ensures compliance with state and federal laws for laboratory ordering (also referred to as diagnostic testing), review of laboratory results, and documentation of clinical actions related to laboratory results.

3.01-7 Guidelines for Behavioral Health Services (BHS) staff to ensure that forms JV-220-223 are completed and included in the beneficiary's medical record when psychotropic medications are prescribed to court dependent youth.

3.02-09 Guidance for City and County of San Francisco employees on making referrals for clients to services outside the BHS System of Care in ways that are in compliance with State and local laws governing conflicts of interest. Technical Revision. Replaces 3.02-9 of August 2, 2010.

3.02-10 Guidance for BHS contractors on making referrals for clients to services outside the BHS System of Care in ways that are in compliance with State and local laws governing financial conflicts of interest.

3.02-13 Ensures beneficiaries of specialty mental health (SMHS) and substance use disorder services (SUD) experience timely access to care and access to a sufficient number of high-quality, culturally competent and effective service providers that are within reasonable travel distance in accordance with the standards set forth by the California state Department of Health Care Services (DHCS). 

Technical Revision. Replaces 3.02-13 of October 24, 2022

3.02-14 Procedures to ensure that Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and Therapeutic Behavioral Services (TBS) notices are provided to Medi-Cal beneficiaries under 21 years of age and their representatives at the time of placement in certain types of facilities.

3.02-15 Formally designates cultural and linguistic competence as an essential characteristic and defining quality/standard that must be embedded in all aspects of the Behavioral Health Services (BHS) systems of care.

3.02-17 To reduce the possibility of tuberculosis (TB) exposures in the community. 

3.02-19 Guidelines to BHS staff working as members of the Assisted Outpatient Treatment (AOT) Care Team. 

Related documents:

• Adult Behavioral Health Assisted Outpatient Treatment
• Authorization to Release Private Health Information
• Consent for Community Behavioral Health Services Mental Health/Drug and Alcohol Treatment Programs – Assisted Outpatient Treatment
• Legal Rights
• Patients' Rights

3.02-20 Guidelines to BHS staff working as members of the Crisis Intervention Specialist Team supporting the Police Department (SFPD) in situations where a behavioral health need is identified.

3.02-21 Procedures for responding to medical emergencies in ambulatory behavioral health centers. 

3.02-22 Defines the 24/7 coverage responsibilities and requirements for Full Service Partnership (FSP) program providers ensuring availability to provide after-hour intervention. Minor Technical Revision.

3.02-23 Ensures that Behavioral Health Services (BHS) staff can adequately obtain translation services to support client with documentation and educational materials in their preferred language.

3.02-24 Ensures that Behavioral Health Services (BHS) staff can adequately obtain and provide interpretation services for scheduled appointments/meetings as requested by the client and/or the clinician.

3.02-25 Ensures all Medi-Cal beneficiaries and potential beneficiaries are provided with and have timely access to critical beneficiary informing materials regarding specialty mental health services (SMHS) and substance use disorder (SUD) services and to inform providers within the San Francisco Mental Health Plan (MHP) and the Drug Medi-Cal Organized Delivery System (DMCODS) Plan.

Attachment: Form BHRD 84 Acknowledgement of Receipt of Materials (2024)

3.02-26 Establishes the Medication Use Improvement Committee (MUIC) as the oversight body for BHS medication services, providing medication use improvement advisement.

3.02-27 Issues guidance on administering telehealth services for Specialty Mental Health (SMHS) and Drug Medi-Cal Organized Delivery System (DMC ODS) and information for local implementation. 

3.02-28 Ensures that long-acting injectable (LAI) antipsychotics are being appropriately administered within their ordered time frame by nursing staff at all BHS clinics, included contracted agencies. 

3.02-11 Standardizes tuberculosis (TB) screening and testing in substance use disorder residential programs.

3.02-18 Outlines approach to meeting compliance with network adequacy provisions of the Final Rule.

Update COMING SOON

3.01-08 Describes the policy and procedures for safe storage and distribution of intranasal naloxone obtained through the DPH Clearinghouse. 

Substantive Revision. Replaces 3.01-08 of December 8, 2021.

Attachments:

• Policies and Procedures Blank Template
• Staff Naloxone Training Tracker Template
• DPH Clearinghouse Naloxone Distribution FAQ
• Opioid safety and how to use naloxone in English, Spanish, Chinese, Korean, Russian, Tagalog, and Vietnamese
• Fentanyl Test Strips Brochure

3.02-12 Policy standardizes Tuberculosis (TB) Screening and Testing in Mental Health Residential Treatment Programs.

Technical Revision. Replaces policy 3.02-12 of March 14 2019.

3.02-11: Standardizes tuberculosis screening and testing in substance use disorder residential programs.

New Policy

3.03-01 Defines the process regarding the involuntary psychiatric detention, inpatient admission/discharge, and coordination of care for minors. 

3.03-02 Describes and ensures compliance with SB-785 and the delivery of medically necessary specialty mental health services for Medi-Cal eligible children in foster care, Kin-GAP or Aid to Adoptive Parents (AAP) placed outside their county of origin.

NOTE: This policy is in the process of being updated. Please refer to this memo for the latest guidance around presumptive transfer: Presumptive Transfer and Out-of-County Service Request Procedures (February 26, 2024)

3.03-06 Explains residency and/or authorization process for children and youth required in order for individuals to be eligible to receive Behavioral Health Services (BHS) mental health and substance use disorder services.

3.03-14 Declares that Behavioral Health Services (BHS) services are available to San Francisco Health Plan (SFHP) Healthy Workers members when clinically appropriate. Technical Revision. Replaces 3.03-14 of May 11, 2022.

3.03-17 Processes and procedures to ensure nondiscrimination and institutional safeguards for religious providers.

Technical Revision. Replaces 3.03-17 of December 1, 2009.

3.03-18 Establishes requirements for prior authorization of specific outpatient Specialty Mental Health Services, Intensive Home-Based Services (IHBS) and Therapeutic Foster Care (TFC).

3.03-20 Guidance on the provision of comprehensive psychological assessment services throughout Behavioral Health Services (BHS).

3.03-21 Affirms that the SF Mental Health Plan (MHP) is required to operate a utilization management (UM) program that ensures beneficiaries have appropriate access to specialty mental health services (SMHS).

3.03-22 Communicates to the SF Mental Health Plan (MHP) the federal requirements related to the authorization of adult specialty mental health services (SMHS), except for psychiatric inpatient hospital and psychiatric health facility services.

3.03-23 Guidance to Mental Health Plans (MHPs) on standardized, statewide Adult and Youth Screening and Transition of Care Tools to guide referrals of Adult and Youth beneficiaries to the appropriate Medi-Cal mental health delivery system and ensure that beneficiaries requiring transition between delivery systems receive timely coordinated care.

3.03-19 Updated program requirements and standards for the Drug Medi-Cal Organized Delivery System (DMC-ODS) Program for the period of January 2022 through December 2026.

3.04-03 Outlines the procedure for any BHS member or their representative to report and file a complaint in the event that they experience discriminatory practices at a BHS site due to a disability.

3.04-07 Procedural steps for an individual beneficiary or one's legal guardian(s) to request a change in behavioral health provider.

3.04-08 Procedures to ensure a timely and effective response to a beneficiary’s request for a second opinion when a decision has been made by Behavioral Health Services (BHS) or its providers to deny a requested specialty mental health service (SMHS) or Drug Medi-Cal Organized Delivery System (DMC-ODS) service due to not meeting medical necessity criteria. 

3.04-09 Continuity-of-care requirements that county mental health plans have to comply with for Specialty Mental Health Services they provide to Medi-Cal beneficiaries.

3.04-10 Communicates Non-Hospital/Outpatient Specialty Mental Health Services (SMHS) medical necessity definition and criteria for Medi-Cal adult (21 years old and over) and child (under 21 years old) beneficiaries, covered/excluded benefits, and activities.

Read frequently asked questions on Medical Necessity related to CalAIM (Non-Hospital/Outpatient SMHS).

3.04-11 Stipulates that Medi-Cal beneficiaries shall receive timely mental health services without delay regardless of the delivery system where they seek care and are able to maintain treatment relationships with trusted providers without interruption.

Read frequently asked questions on CalAIM No Wrong Door.

3.06-17 BHS' policy on the implementation of Application Programming Interfaces (APIs).

3.04-12 Defines priority populations for Substance Use Disorder (SUD) programs, the extent to which they receive priority in admissions and presents the procedure for offering interim services when they are needed. New Policy.

3.04-09 County mental health plans must give Medi-Cal beneficiaries the option to continue treatment for up to 12 months with an out-of-network Medi-Cal provider (organizational provider, provider group, or individual practitioner) with whom the beneficiary has a pre-existing provider relationship, upon the beneficiary's request for such continuity-of-care.

3.05-01 Describes the consent form and corresponding provider's duty to inform the individual or their legal representative about the recommended care and conditions of treatment.

3.05-03 Guidance on consent for behavioral health care (mental health and substance abuse) treatment services for minor (under 18 years of age) clients.

3.05-06 Provides updated instructions regarding informed consent of psychiatric/psychotropic medication(s) for voluntary specialty mental health clients in ambulatory care (outpatient and day treatment programs).

• Consent form for psychiatric medication(s) for adults/older adults and Consent form for psychiatric medication(s) for children will be available on Epic.

3.06-01 Guidance to staff on how to protect the confidentiality of protected health information of Behavioral Health Services members and clients. 

3.06-04 Provides guidance to staff for the processing of subpoenas and court orders for records that include mental health, substance abuse, and HIV test results.

3.06-05 Guidance regarding limitation of creation, use, and the subsequent maintenance of notes separate and apart from the medical record, and describing proper means to destroy notes that include any protected health information (PHI).

3.06-09 Guidance to staff of SF Behavioral Health Services (BHS) regarding the psychotherapist's duty to warn and protect a reasonably identifiable victim(s) of a BHS member's serious threat of physical violence communicated by a member or the member's family . Last amended May 15, 2024.

There is also an updated Quality of Care Reporting Form.

3.06-11 Delineates the requirements of the Child Abuse and Neglect Reporting Act (CANRA) and ensures that Behavioral Health Services (SF BHS) staff understand their role as mandated reporters and meet the statutory reporting requirements.

3.06-12 Guidance to staff for sealing a member's medical records, usually pertaining to juvenile records. 

3.06-13 Guidelines and responsibilities for any mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that causes reasonable suspicion of abuse of an elder or dependent adult, must report the known or suspected abuse. 

3.06-16 Assists providers with issues related to responding to a family's grief at the loss of a loved one and related risk management, member privacy, and medical record release concerns.  

Technical Update. Replaces Policy 3.06-16 of March 1, 2019.

3.07-02 Provides guidelines for establishing authority for involuntary detention for up to 72-hour evaluation and treatment and to ensure compliance with state law, regulations, and county procedures.

3.07-04 Ensures all providers contracted with the Private Provider Network (PPN) have and maintain their professional credentials, in accordance with San Francisco Mental Health Plan (SFMHP) standards for individual providers.

3.07-5 Defines the role of pharmacists in the provision of medication management services in Behavioral Health Services (BHS) to support the wellness and recovery of clients and maximize the effectiveness of the medical-clinical team.

3.07-5.1 Role of pharmacists in the provision of medication management services in Behavioral Health Services to support the wellness and recovery of clients and maximize the effectiveness of the medical-clinical team.

3.07-06 Recognizes role of the Psychiatric-Mental Health Nurse Practitioner (PMHNP) in the provision of services in Behavioral Health Services (BHS) and to fully utilize their skill set to support the wellness and recovery of clients, and to maximize effectiveness of the medical-clinical team.

3.07-07 The obligations of providers, Mental Health Plans (MHPs) and Drug Medi-Cal/Organized Delivery System (DMC/ODS) to obtain, report and monitor disclosures as part of Medicaid’s and Medicare’s provider enrollment and screening program integrity standards.

3.09-02 Provides instructions to staff on how to respond to clients who have been victims of sexual assault/battery.

3.09-03 Guidance for staff on responding to violence related to clients in the program and/or clinic setting.

3.10-02 Affirms that BHS staff will document services provided to clients in an accurate and timely manner, including all BHS policies and procedures pertaining to client confidentiality, data security, and integrity of behavioral health records.

3.10-05 Provides guidelines on how BHS staff process case closures in the electronic health record (and paper documents) in the event that the client either terminates treatment with the program, is referred to other programs or is deceased.

3.10-07 Guidelines for the security and retention of Behavioral Health Services (BHS) medical records.

Replaces Policy 3.10-07 of July 17, 2018.

3.10-10 Guidance for providers within Behavioral Health Services (BHS) for situations which necessitate the creation of two or more additional volumes for a BHS client’s medical record.

3.10-12 Ensures uniform definition and standard practice of tracking client no-shows.

MEMO: No-show Data Submission for Uploaders (2024-05-20)

3.10-13 Establishes documentation requirements for Children, Youth, and Families System of Care (CYFSOC) civil service and contracted providers who complete a comprehensive mental health assessment prior of the start of planned specialty mental health services to children and youth ages 0 - 20.

3.10-14 Streamlines clinical documentation requirements for all Specialty Mental Health Services (SMHS) and Drug Medi-Cal Organized Delivery System (DMC-ODS) services. Attachments:

• Requirements That Remain in Effect
• Superseded Regulations
• AOA CalAIM Updates At-A-Glance
• CYF CalAIM Updates At-A-Glance
• Adult SUD CalAIM Updates At-A-Glance
• CYF SUD CalAIM Updates At-A-Glance
• FAQ CalAIM Documentation Requirements

3.11-01 Defines the grievance and appeal system for BHS members, describes the processes for handling grievances and appeals of adverse benefit determinations, and identifies the respective roles and responsibilities of BHS, providers, and members through its informing materials and documentation requirements. 

3.11-02 Defines the role of SF Mental Health Clients' Rights Advocates (SFMHCRA) and the expectation of cooperation of BHS providers, as required or permitted by law, in the event of a requested monitoring or investigation.

3.11-04 Defines an adverse benefit determination to ensure that the rights of Medi-Cal members are protected and to describe the situations that warrant a Notice of Adverse Benefit Determination (NOABD) and the process through which a NOABD is issued.

3.12-01 Provides guidance on resolving problems and responding to appeals brought to San Francisco Behavioral Health Services (BHS) by any of its contracted organization, group, and individual providers.

3.13-01 Provides adult Medi-Cal beneficiaries served by BHS with information concerning their rights regarding Advance Medical Directives.

3.15-01 Ensure that BHS members with disabilities have equal access to behavioral health services and benefits at all BHS facilities, including sites operated by providers with whom there is an established contract with the Department of Public Health BHS.

5.00-02 Ensures that members of the public with physical and/or mental impairments are able to participate in all BHS public meetings and hearings.

5.00-03 Addresses the relationship between BHS and the pharmaceutical industry and is intended to prevent conflicts of interest and ensure that selection of medications for BHS clients is based upon objective clinical and scientific evidence.

6.00-01 Defines electronic staff signature and their use within Behavioral Health Services (BHS). Technical Revision. Replaces Policy 6.00-01 of June 23, 2010.

6.00-02 Ensures the proper use and application of the Behavioral Health Services (BHS) electronic prescribing system. 

6.00-03 Defines security and retention of electronic records within Behavioral Health Services (BHS). Replaces 6.00-03 of December 2, 2010.

6.00-04 Defines the minimum data elements that must be entered into the Behavioral Health Systems (BHS) Electronic Health Record (EHR) for the purposes of submitting claims, fulfilling mandated State and local reporting requirements, and complying with BHS Electronic Prescribing Policy. Replaces Policy 6.00-04 of December 2, 2010.

6.00-05 Addresses all DPH electronic health record audit requirements and ensures compliance with Center for Medi-Care and Medi-Caid Services (CMS) audit requirements for electronically signed records.

6.00-06 Establishes standards and guidelines related to requesting, maintaining, and closing Behavioral Health Services (BHS) Electronic Health Record (EHR) User Accounts in order to maintaining security of electronic Protected Health Information (PHI). Replaces Policy 6.00-06 of January 25, 2011.

6.00-07 Guidelines related to installing and maintaining anti-virus software for Behavioral Health Services (BHS) Contracted Providers. 

6.00-08 Guidance on the use of electronic signatures in order to maintain the accuracy and integrity of the full electronic health record (EHR) for Behavioral Health Services (BHS).