PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MCUP3127
Policy/Procedure Title: Dispute Resolution Between PHC and MHPs
in Delivery of Behavioral Health Services
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 06/17/2016
Last Review Date: 06/17/2015
Original Date: 01/21/2015
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 06/17/2015
I.
RELATED POLICIES:
A. County specific MOUs
B. PHC Member Grievance System
II.
IMPACTED DEPTS:
A. Health Services
B. Compliance
III.
DEFINITIONS:
A. A Member is a Medi-Cal eligible client who is a member of Partnership HealthPlan of California (PHC).
B. A Potential Dispute Issue (PDI) is defined as a suspected issue impacting continuity of care and/or
delivery of services to members at an appropriate level which requires further investigation to avoid
escalation to a Formal Dispute Resolution Procedure or presents an opportunity to improve current
processes put in place to avoid disputes.
C. A Dispute Resolution (DR) is defined as the formal process specified in MOUs between PHC and MHPs
to resolve disputes between MCPs and MHPs in the delivery of Behavioral Health Services in
accordance with Title 9, CCR, §1850.505 and §1850.525 and in DHCS All Plan Letter 15-007 Dispute
Resolution Process for Mental Health Services
D. A Care Delivery System is defined as an entity that is mandated by the DHCS to deliver specific
behavioral health services to Medi-Cal members. Two Care Delivery Systems are defined in this policy:
1. Partnership HealthPlan of California (PHC) through its Delegated Vendor Beacon Health Strategies
LLC (BHS) providing Managed Care mental health services to clients with mild to moderate
impairment of function who do not qualify for Specialty Mental Health Services
2. County Mental Health Plans (MHPs) providing Specialty Mental Health Services to clients with
serious and persistent psychiatric conditions and significant impairment of function with or without
substance abuse services through County Alcohol and Drug Services Programs (either through
separate departments or through a single Integrated Behavioral Health Department)
E. A Delegated Vendor is an entity contracted and engaged by PHC to deliver Medi-Cal managed care
behavioral health services to PHC Medi-Cal members.
F. The Behavioral Health Screening Tool (BHST), is defined as the tool agreed to by PHC/Beacon and the
MHPs to make appropriate referral decisions per DHCS definitions. Includes versions: Child 0-5, Child
6-17, and Adult. Available at:
http://www.beaconhealthstrategies.com/private/provider/provider_tools.aspx
G. An Initial Screening is defined as the event that takes place when a member seeks or is referred to
behavioral health services and undergoes a brief screening to determine appropriate referral based on
diagnosis and level of functional impairment
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Policy/Procedure Number: MCUP3127
Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and ☒ External Policy
MHPs in Delivery of Behavioral Health Services
☐ Internal Policy
Next Review Date: 06/17/2016
Original Date: 01/21/2015
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
H. A Care Transition is defined as the event that takes place when a member in current treatment under one
Care Delivery System is referred on the basis of level of impairment and/or clinical necessity to another
Care Delivery System
I. A Behavioral Health Service is defined as the diagnosis and/or treatment of behavioral health issues
provided by a credentialed or otherwise approved behavioral health care provider.
J. A Warm Transfer is defined as a direct person-to-person or phone contact used to facilitate referral to a
different Care Delivery System.
IV.
ATTACHMENTS:
A. Behavioral Health Screening Tool: Current versions located at:
http://www.beaconhealthstrategies.com/private/provider/provider_tools.aspx
B. DHCS All Plan Letter 13-021 Medi-Cal MCP Responsibilities
C. DHCS All Plan Letter 13-018 MOU Requirements for MCPs
D. Title 9, CCR, §1850.505 and §1850.525
E. Authorization for Beacon Health Strategies, LLC to Release Confidential Information
F. DHCS All Plan Letter 15-007 Dispute Resolution Process for Mental Health Services
V.
PURPOSE:
To provide a systematic method for the identification, reporting, and processing of Potential Dispute Issues
(PDI) and Dispute Resolutions (DR) and to determine opportunities for improvement in the coordination of
behavioral health services provided by PHC through its delegated vendors and the provision of mental health
services provided by County MHPs, and to direct appropriate actions for improvement based upon outcome,
risk, and member satisfaction.
VI.
POLICY / PROCEDURE:
A. GUIDING PRINCIPLES FOR AVOIDING POTENTIAL DISPUTE RESOLUTION ISSUES
1. Emphasis on Local Resolution
a. Every effort should be made to address concerns at the local level with an emphasis of timely
access to the appropriate level of care for the member
b. Initial Screenings and Care Transitions should be made collaboratively as members move
between Care Delivery Systems
c. Effective and timely communication should be established between PHC, its Delegated Vendor
and County MPH units to facilitate collaboration
2. Continuity of Care
a. Referral pathways between PHC and its Delegated Vendors and MHPs should be bidirectional
and employ the agreed-upon Beacon Screening Form
b. Whichever Care Delivery System is first to engage in the member’s care, should continue to
provide necessary care in accordance with the contracted benefits of its plan under the Medi-Cal
program until the Potential Dispute Issue is resolved.
c. Once the issue has been resolved, any necessary transition to a more appropriate level of care
should be made collaboratively, without significant disruption in necessary care.
d. Members should be informed in advance of the transition between systems.
e. The principle of “Honor the service until the dispute is resolved” will be followed.
3. Financial Responsibility while services are in dispute.
a. Assignment of financial responsibility for services when PHC and its Delegated Vendors and
MHPs are engaged in avoiding potential dispute or resolving a formal dispute goes to the Care
Delivery System that is engaged in the member’s care at the time the PDI is identified. Ultimate
financial responsibility is subject to the outcome of any DHCS Dispute Resolution Process.
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Policy/Procedure Number: MCUP3127
Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and ☒ External Policy
MHPs in Delivery of Behavioral Health Services
☐ Internal Policy
Next Review Date: 06/17/2016
Original Date: 01/21/2015
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
B. IDENTIFICATION OF POTENTIAL DISPUTE ISSUES
1. PDI is identified at point of an Initial Screening
a. A PHC provider, Beacon Network Provider, or MHP Access Team member determines the
member’s diagnosis and level of impairment in person or over the phone, preferably using of the
BHST or using another equivalent means of clinical assessment.
b. If the assessment indicates a mild-to-moderate mental health condition, the Member is referred
to Beacon.
1) Results of the BHST and/or clinical assessment are communicated to Beacon by direct
phone contact or fax.
2) Beacon acknowledges acceptance of Member for Beacon services and assigns Member to a
Beacon Provider
c. If the assessment indicates a serious and persistent mental health condition or a substance abuse
problem, the member is referred to the MHP Access Team
1) Results of the BHST and/or clinical assessment are communicated to MHP Access Team by
direct phone contact or fax.
2) MHP acknowledges acceptance of Member for MPH services and assigns Member to
appropriate treatment.
3) County specific methods for receiving new referrals shall be respected as long as continuity
of care is maintained.
d. All referrals need to insure timely access to care and guarantee that all services are received only
within one Care Delivery System.
e. Referring entity is encouraged to follow up with Member to ensure that referral has been
successfully completed and to remain open for further assistance to Member as necessary.
f. A PDI is identified when the receiving entity does not agree that the Member meets criteria for
their services.
2. PDI is identified at point of a Care Transition
a. A treating MHP or Beacon provider determines through clinical assessment that a different level
of care is warranted based on severity of impairment and/or clinical necessity.
b. A new BHST or other pertinent clinical information is transmitted to the potential new Care
Delivery System preferably through clinician to clinician contact.
c. The consent of the Member to the Care Transition must be obtained.
d. Arrangements need to be made to insure that continuity of care is maintained during the Care
Transition and that all services are received only within ONE Care Delivery System.
e. A PDI is identified when the receiving Care Delivery System does NOT agree that the Member
meets their criteria for services and/or the Member does not consent to the Care Transition.
C. APPROPRIATE ACTION PLANS
1. Actions to be taken upon identifying a PDI:
a. Within 24-48 hours, parties to PDI will initiate direct person-to-person communication with
each other to resolve the PDI
b. Member will be kept informed by Care Delivery System that completed the Initial Screening or
is providing current care in a manner consistent with standards of appropriate patient care
c. Member does not necessarily have to be informed that there is a PDI since this is a system’s
issue.
d. Member DOES need to be informed about any anticipated delay in accessing care
e. Priority will be given to guaranteeing Member’s access to services while also ensuring that such
services are delivered at the appropriate level.
f. Assessment of risk factors will be given top priority during resolution of the PDI. Emergency
action: Either party may determine that a situation exists where immediate action is required to
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Policy/Procedure Number: MCUP3127
Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and ☒ External Policy
MHPs in Delivery of Behavioral Health Services
☐ Internal Policy
Next Review Date: 06/17/2016
Original Date: 01/21/2015
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
protect the life or well-being of a PHC member or any person, or to reduce substantial and
imminent likelihood of significant impairment of the life, health, or safety of the PHC Member
or others.
g. When Beacon, PHC, and the MHP reach agreement and resolve the PDI, a verbal and/or written
communication can be directed to the Member to reflect the agreed-upon decision
h. A Letter of Denial of Services may be deemed necessary by either entity if the Member insists
on accessing care from an inappropriate Care Delivery System.
2. Additional actions to be taken as part of a PDI resolution process:
a. PDI will be reported to PHC Mental Health Clinical Director by Beacon and/or MHP for
tracking purposes within 30 calendar days.
b. Clinical and/or administrative consultation will be sought by each party within their own Care
Delivery System in timely manner if PDI is not resolved at the Initial Screening or Care
Transition level.
c. Potential disputes not resolved within 7 calendar days will be reported to the PHC Mental
Health Clinical Director and moved to the Dispute Resolution process defined in the
Memorandum of Understanding (MOU) between the MHP and PHC.
3. Dispute Resolution Process per MOUs agreed upon between County MHPs and PHC
a. Disagreements and disputes will be brought to a meeting of PHC and MHP liaisons and Medical
Directors for resolution.
b. PHC and MHP staff will make a good faith effort to agree to resolutions that are in the best
interest of beneficiaries and are agreeable to all parties involved.
c. MHP and PHC agree to follow dispute resolution procedures as required in Title 9, CCR,
§1850.505
d. Beneficiaries will continue to receive medically necessary services while the disagreement or
dispute is being resolved in accordance with Title 9, CCR, §1850.525(a).
e. Guidelines should be similar for both systems.
4. DHCS Dispute Resolution Process (For further details, refer to DHCS All Plan Letter 15-007
Dispute Resolution Process for Mental Health Services)
a. PHC is required to enter into a memorandum of understanding (MOU) with the MHP in each of
the counties which PHC serves
b. Whether or not MCP and PHC have an executed MOU, the parties are required to document
attempts to resolve the disputed issue(s) (Title 9, CCR, §1850.505 (d) (2))
c. If PHC is unable to resolve a dispute with a MPH, PHC may submit a written Request for
Resolution signed by the PHC’s CEO or his or her designee to DHCS. If PHC has a MOU with
the MHP, the Request for Resolution must be submitted within 15 calendar days of the
completion of the dispute resolution process described in the MOU. If there is no MOU, a
Request for Resolution must be submitted within 30 days following the disrupted event. A
Request for Resolution should be submitted via secure email to Sarah Brooks, Chief, MCQMD,
at sarah.brooks@dhcs.ca.gov
d. DHCS will review disputes involving the following:
1) The obligations of PHC and MHP under their contracts with DHCS;
2) State Medi-Cal laws and regulations; and/or
3) The MCP-MHP MOU as described in Title 9, CCR, §1810.370
e. A Request for Resolution submitted to DHCS must contain all of the following:
1) Summary of disputed issue(s) and a statement of the desired remedies, including any
disputed services that have been or are expected to be delivered to the beneficiary by either
party;
2) History of attempts to resolve the issue with the MHP;
3) Justification for the MCP’s desired remedy: and
Page 4 of 6
Policy/Procedure Number: MCUP3127
Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and ☒ External Policy
MHPs in Delivery of Behavioral Health Services
☐ Internal Policy
Next Review Date: 06/17/2016
Original Date: 01/21/2015
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
4) If applicable, any additional documentation that the MCP deems relevant to resolve the
disputed issue(s)
f. Within seven calendar days after DHCS’ receipt of a Request for Resolution from PHC, a copy
of the Request for Resolution will be forwarded to the Director of the affiliated MHP via secure
email (“Notification”). The MHP will have 21calendar days to submit a response and any
relevant documents to support the MHP position (“MPH Documentation”) (Title 9, CCR,
§1850.505 (e) and (f)). If the MHP fails to respond, DHCS will decide on the disputed issue(s)
based solely on the documentation submitted by PHC.
g. At its discretion, DHCS may allow both the PHC and MHP representatives the opportunity to
present oral arguments.
h. MMCD and MHSUDS will make a joint recommendation to the DHCS Director based on their
review of the submitted documentation and applicable statutory, regulatory, and contractual
obligations of PHC and the MHP, and any oral arguments presented.
i. Within 30 calendar days from: (1) DHCS’ receipt of the MHP documentation; or (2) 21 calendar
days after the Notification date, whichever is earlier, the final decision will be communicated
via secure email to both the PHC CEO and the MHP Director. DHCS’s decision will state the
reasons for the decision, the determination of rates of payment (if rates of payment were
disputed), and any actions PHC and the MHP are required to take to implement the decision
(Title 9, CCR, §1850.520(b))
j. If DHCS’ dispute resolution determination includes a finding that the unsuccessful party has a
financial liability to the other party for services rendered by the successful party, the PHC or the
MHP is required to follow the financial liability criteria set forth in Title 9, CCR § 1850.530,
which specify the provisions regarding financial liability rates and proof of reimbursement. If
necessary, DHCS shall enforce the decision, including with-holding funds to meet any financial
liability established pursuant to Title 9, CCR, §1850.530 (Title 9, CCR, §1850.520(c)).
k. The provision of medically necessary specialty and other mental health services, physical health
care services, or related prescription drugs and laboratory, radiological, or radioscope services to
beneficiaries shall not be delayed during the pendency of a dispute between PHC and the MHP
(Title 9, CCR, §1850.525(a)). See DHCS APL 15-007 for further details.
5. Member rights
a. Members who are denied services can file a Member Grievance or State Fair Hearing against
either Care Delivery System using the appropriate member appeal process.
D. REPORTING PROCEDURES
1. Beacon will maintain a monthly report on the number referrals to MHP from Beacon and to Beacon
from MHP, as reported in each County served by PHC.
2. All MHP and MCP providers and assessors will be encouraged to use the BHST or an agreed-upon
alternative method for all Initial Screenings and Care Transitions to facilitate accurate record
keeping
3. PDIs reported by any source will be documented on a PDI Tracking Spreadsheet monitored by a
designated employee of PHC’s Health Services Department to include:
a. Date of origination
b. Nature of PDI
c. Care Delivery Systems involved (including specific providers or assessment personnel)
d. Specifics regarding of continuity of care for Member
e. Specifics regarding communication with the Member
f. Date and nature of resolution
Page 5 of 6
Policy/Procedure Number: MCUP3127
Lead Department: Health Services
Policy/Procedure Title: Dispute Resolution Between PHC and ☒ External Policy
MHPs in Delivery of Behavioral Health Services
☐ Internal Policy
Next Review Date: 06/17/2016
Original Date: 01/21/2015
Last Review Date: 06/17/2015
☐ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
4. All Formal Dispute Resolution Procedures will be fully documented to include:
a. Date of origination
b. MHP and PHC and/or Beacon parties involved
c. Nature of disagreement or dispute
d. Specifics regarding of continuity of care for Member
e. Specifics regarding communication with the Member
f. Date and nature of resolution.
E. CONFIDENTIALITY AND EXCHANGE OF INFORMATION
1. Communication between Beacon, PHC, and MHPs will maintain proper standards in the exchange
of Protected Health Information (PHI) per HIPAA standards and adherence to Federal Regulation
CFR Part 2 regarding alcohol or drug abuse information
2. An Authorized Release of Information shall be used as deemed necessary and appropriate.
3. Existing policies or those developed in the future by DHCS for the exchange of information between
MCPs and MHPs in the delivery of behavioral health services shall be adhered to.
VII.
REFERENCES:
A. N/A
VIII.
DISTRIBUTION:
A. Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Mental Health Clinical Director
X.
REVISION DATES: 01/21/15; 06/17/15
PREVIOUSLY APPLIED TO:
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