1. Fee for Service Outpatient Changes For Psychiatric Services
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

2. Agenda Who is Optum? Medi-Cal Managed Care Plans (MCP)
Title 9 Medical Necessity
Fee for Service (FFS) Outpatient Target Population
Treatment Philosophy
Mental Health Severity Analysis
Authorization Process
Accessing Forms
Partnerships
Resources
Contact Information
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

3. Who is Optum?
Optum is the Administrative Service Organization for the County of San Diego, Behavioral Health Services Division
Contract includes, but is not limited to: Operation of the San Diego County Access and Crisis Line (ACL) and Utilization Management (UM)
Through the ACL, Optum provides 24 hour crisis intervention, suicide prevention and behavioral health referrals. Through UM, Optum provides authorizations for Mental Health and Residential Substance Use Disorders
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

4. MCP- Medi-Cal Background
In January 2014, the Department of Health Care Services (DHCS) for the State of California obligated the Medi-Cal Managed Care Plans (MCPs) to provide mental health services to beneficiaries with mild to moderate impairment of mental, emotional, or behavioral functioning.
Each MCP has its own network of contracted behavioral health providers to serve their beneficiaries. You might also be on one or more of these networks.
The County Mental Health Plan, consisting of County Clinics, Organizational Providers, and the Optum Public Sector FFS Network is targeted to provide services to those individuals with more severe behavioral health impairment.
It should be noted that California Regulation Title 9 is the basis for all Specialty Mental Health Services for Medi-Cal Beneficiaries and in some cases a mild presentation or moderate can meet title 9 medical necessity.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

5. Medi-Cal Managed Care Plans
There are seven Managed Care Plans (MCPs) who provide Health Plan options to San Diego Medi-Cal beneficiaries, you may be contracted with one or more of the MCPs as well.
Aetna Better Health, Care1st, Community Health Group, Health Net, Kaiser, Molina and UnitedHealthcare.
MCPs cover beneficiaries’ medical needs, transportation to Medi-Cal covered services and mild to moderate outpatient behavioral health needs and Applied Behavioral Analysis Treatment.
Beneficiaries may change Managed Care Plans, and in rare circumstances, they may not have a MCP; County will assume responsibility if there is no assigned MCP as long as the clinical presentation meets Title 9 medical necessity.
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

6. Community Health Group
Contact Information for MCP Behavioral Health Services
Health Plan
Medi-Cal Managed Care Plan Behavioral Health Services
Aetna Better Health
(855)
Care1st Health Plan
Care1st.com
Care1st Health Plan (855)
Community Health Group
Chgsd.com
Behavioral Health Services (800)
Health Net
HealthNet.com
Managed Health Network (MHN) (888)
Kaiser Permanente
KP.org
Kaiser Permanente, Department of Psychiatry (877)
Molina Healthcare
MolinaHealthcare.com
(888)
UnitedHealthcare
(866)
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

7. California Code of Regulations- Title 9 Medical Necessity Criteria
Available on DHCS website:
Requires an approved DSM IV primary diagnosis
Requires a significant impairment in an important area of life functioning or for children developmental progress is at risk
The focus of treatment must be on the primary DSM IV diagnosis, exclusions include, Autism, Primary Substance use disorders, Anti-Social Personality Disorder and Mental Health issues due to a known medical condition
The intervention will diminish the impairment, prevent deterioration, and support the child to progress developmentally
The condition would not be responsive to physical health treatment
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

8. Fee for Service (FFS) Population
Adults with serious and persistent psychiatric illness requiring
complex biopsychosocial services to maintain stability
Adults with an approved DSM IV primary diagnosis and focus of treatment must be on the primary DSM IV diagnosis
Adults with a significant impairment in an important area of life functioning and the condition would not be responsive to physical health treatment
Children with a DSM IV diagnosis with behavior inappropriate to the child’s age according to developmental norms and a substantial impairment in two areas of life functioning
Children at risk of removal from home/have been removed from home
OR the impairment has lasted more than six months
Children and adults presenting with clinical risk: psychosis, suicidal ideation, and/or violence
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

9. Treatment Philosophy of the Fee for Service Network
The Recovery Model: Clinical improvement and self sufficiency is possible, but challenges during the process may occur along the way
The role of the provider is to stabilize the client by utilizing goal
focused treatment targeting the specific mental health condition
The treatment intervention will diminish the impairment or prevent deterioration
Authorizations-based on Title 9 Medical Necessity regulations
Available on DHCS website:
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

10. The Adult Mental Health Severity Analysis/Screening
The severity index and other information on target population is available at: optumsandiego.com
The County of San Diego and the Medi-Cal MCPs worked together to develop criteria and tools
A shared conceptual framework and a useful guide regarding mild, moderate, and severe criteria to assess with clinical perspective
The Severity Analysis Tool is not applicable to children
Uses four elements: Risk, Clinical Complexity, Life Circumstances, and Benefit of Integrated Care
Use of guide is recommended to ensure assessment alignment across System of Care, all determinations are based on Title 9 Medical Necessity
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

11. Adult Mental Health Severity Analysis – Symptom Examples
FFS and/or other County Providers
Acute risk for SI/harm to others
Psychosis
Cognitive Impairment
Impulsive/Aggressive
Seriously incapacitated in daily activities
Many Mental Health hospitalizations
On conservatorship
Chronic Mental Health conditions
MCP Behavioral Health
Situational issue: loss, break-up, major life change
Disruption in relationships resulting in extreme distress
Excessive truancy or suddenly failing school
Likely to be resolved in 6 mo. or less
Stable on meds for 1 yr. or longer
San Diego County Access and Crisis Line Operates 24 Hours a day, 7 days per week
Provides Suicide Prevention, Crisis Intervention and Referrals
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12. The Process-Referrals and Screening
*The severity analysis is not applicable to children/adolescents
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

13. The Process, Obtaining Initial Authorization
*The severity analysis is not applicable to children/adolescents
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

14. The Process, Obtaining Continuing Authorization
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

15. Accessing Forms Website: www.optumsandiego.com
Select: “County and Staff Providers”
Then, select: “Fee for Service Providers”
Click on “Forms”
Look for Outpatient Authorization Request- Psychiatry
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

16. Forms-Demographic Form (At Auth Request Or If Updates)
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

17. Forms-Outpatient Authorization Request (OAR-Psychiatry)
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

18. The Process-Authorization Increments
Assessments do not require pre-authorization
Follow up sessions will be given at a maximum of 26 sessions per OAR- Psychiatry submission (typically at 2 times per month) and you may request the frequency that is clinically indicated
Team Conferencing & Case Management Sessions are also available upon request
Group sessions are also available, but should focus on the client’s mental health diagnosis or impairment
All Authorizations are based on California Title 9 Medical Necessity for Specialty Mental Health Services
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

19. Forms-Interpreter Services
The MHP covers the cost
Request for Interpreter Services Form is available on our website- County and Staff Providers, Fee For Service Providers, Forms
Must be submitted via fax AT LEAST 2 business days prior to appt., or as soon as appt. is set
Incomplete forms will be sent back and will cause delays in processing
Do not sign the document-Optum is the
entity approving the service
Follow the instructions and fill out ALL highlighted areas (2pages)-complete “form fill” online or print out in color
Submit form to Optum before 1st appt. of new authorization period
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

20. Partnerships Coordination of Care is Essential Managed Care Plans
Primary Care Physicians
Psychiatrists
Case Managers
TBS workers
Protective Service Workers
Probation
Teachers
Therapists
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

21. Contact Information-Optum
Medi-Cal Provider Line
Option 2 Claims
Option 3 Authorizations
Option 3 Provider Clinical Questions
Option 4 Provider Administrative Questions
Option 7 Provider Services
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

22. Wrap up Reminders
We are here to help! Call us! Medi-Cal Provider Line Option 3, Option 3
Mild to Moderate needs can be served by the client’s Managed Care Plan, Severe needs Fee for Service, Clinics or FQHCs
All authorizations are based on California Title 9 Medical Necessity
The role of the provider is to utilize goal-focused treatment targeting
the specific mental health condition
There is an array of Recovery focused organizations in our County,
please refer to all appropriate community supports
Call Access and Crisis Line for additional referrals or resources
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

23. For Questions please call the Provider Line
Thank you!
For Questions please call the Provider Line
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.