Certified Community Behavioral 

Health Clinic (CCBHC) 

Criteria Compliance Checklist 

Updated March 2023
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page ii 

Table of Contents

Program Requirement 1: Staffing......................................................................................................... 1 

Criteria 1.A: General Staffing Requirements.......................................................................................... 1 

Criteria 1.B: Licensure and Credentialing of Providers........................................................................... 4 

Criteria 1.C: Cultural Competence and Other Training .......................................................................... 6 

Criteria 1.D: Linguistic Competence ....................................................................................................... 8 

Program Requirement 2: Availability and Accessibility of Services ....................................................... 9 

Criteria 2.A: General Requirements of Access and Availability.............................................................. 9 

Criteria 2.B: General Requirements for Timely Access to Services and Initial and Comprehensive 

Evaluation ...................................................................................................................................... 11

Criteria 2.C: Access to Crisis Management Services............................................................................. 13

Criteria 2.D: No Refusal of Services Due to Inability to Pay ................................................................. 14

Criteria 2.E: Provision of Services Regardless of Residence ................................................................. 15

Program Requirement 3: Care Coordination....................................................................................... 16

Criteria 3.A: General Requirements of Care Coordination................................................................... 16

Criteria 3.B: Care Coordination and Other Health Information Systems............................................. 18

Criteria 3.C: Care Coordination Agreements........................................................................................ 20

Criteria 3.D: Treatment Team, Treatment Planning, and Care Coordination Activities....................... 23

Program Requirement 4: Scope of Services........................................................................................ 24

Criteria 4.A: General Service Provisions............................................................................................... 24

Criteria 4.B: Person-Centered and Family-Centered Care ................................................................... 25

Criteria 4.C: Crisis Behavioral Health Services...................................................................................... 26

Criteria 4.D: Behavioral Health Screening, Assessment, and Diagnosis............................................... 28

Criteria 4.E: Person-Centered and Family-Centered Treatment Planning ........................................... 31

Criteria 4.F: Outpatient Mental Health and Substance Use Services................................................... 33

Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring.............................................. 34

Criteria 4.H: Targeted Case Management Services.............................................................................. 36

Criteria 4.I: Psychiatric Rehabilitation Services.................................................................................... 37

Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports .................................... 38

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces 

and Veterans.................................................................................................................................. 39

Program Requirement 5: Quality and Other Reporting....................................................................... 41

Criteria 5.A: Data Collection, Reporting, and Tracking......................................................................... 41

Criteria 5.B: Continuous Quality Improvement (CQI) Plan................................................................... 43

Program Requirement 6: Organizational Authority, Governance, and Accreditation .......................... 44

Criteria 6.A: General Requirements of Organizational Authority and Finances .................................. 44

Criteria 6.B: Governance ...................................................................................................................... 45
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page iii 

List of Acronyms

CCBHC: Certified Community Behavioral Health Clinic

CEO: Chief operating officer

CQI: Continuous Quality Improvement

DCO: Designated collaborating organizations 

ED: Emergency department

HHS: Health and Human Services

HIPAA: Health Insurance Portability & Accountability Act

LEP: Limited English proficiency 

SUD: Substance use disorder

VHA: Veterans Health Administration
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 1 

CCBHC Criteria Compliance Checklist 2023

This compliance checklist identifies the criteria required for a Certified Community Behavioral Health 

Clinic (CCBHC). 

Program Requirement 1: Staffing

Criteria 1.A: General Staffing Requirements 

1.a.1 Needs Assessment and Staffing Plan 

____ The CCBHC has completed a community needs assessment. The community needs 

assessment includes the following components:

 A description of the physical boundaries and size of the service area, including 

identification of sites where services are delivered by the CCBHC, including through 

DCOs

 Information about the prevalence of mental health and substance use conditions 

and related needs in the service area, such as rates of suicide and overdose

 Economic factors and social determinants of health affecting the population's access 

to health services, such as percentage of the population with incomes below the 

poverty level, access to transportation, nutrition, and stable housing

 Cultures and languages of the populations residing in the service area

 The identification of the underserved population(s) within the service area

 A description of how the staffing plan does and/or will address findings

 Plans to update the community needs assessment every 3 years

 Input with regard to:

• Cultural, linguistic, physical health, and behavioral health treatment needs 

• Evidence-based practices and behavioral health crisis services 

• Access and availability of CCBHC services including days, times, and locations, 

and telehealth options 

• Potential barriers to care such as geographic barriers, transportation challenges, 

economic hardship, lack of culturally responsive services, and workforce 

shortages

 Input gathered from the following entities in the service area: 

• People with lived experience of mental and substance use conditions and 

individuals who have received/are receiving services from the clinic conducting 

the needs assessment 

• Health centers (including FQHCs) 

• Local health departments (Note: these departments also develop community 

needs assessments that may be helpful) 
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• Inpatient psychiatric facilities, inpatient acute care hospitals, and hospital 

outpatient clinics

• One or more Department of Veterans Affairs facilities

• Representatives from local K-12 school systems

• Other community partners 

 Input should also come from other community partners who work with people 

receiving services from the CCBHC and populations that historically are not engaging 

with health services, such as: 

• Organizations operated by people with lived experience of mental health and 

substance use conditions 

• Residential programs 

• Juvenile justice agencies and facilities 

• Criminal justice agencies and facilities 

• Indian Health Service or other tribal programs such as Indian Health Service 

youth regional treatment centers as applicable 

• Child welfare agencies and state licensed and nationally accredited child placing 

agencies for therapeutic foster care service

• Crisis response partners such as hospital emergency departments, crisis 

stabilization settings, crisis call centers and warmlines 

• Specialty providers of medications for treatment of opioid and alcohol use 

disorders

• Peer-run and operated service providers 

• Homeless shelters

• Housing agencies 

• Employment services systems 

• Services for older adults, such as Area Agencies on Aging 

• Aging and Disability Resource Centers

• Other social and human services (e.g., domestic violence centers, pastoral 

services, grief counseling, Affordable Care Act navigators, food and 

transportation programs) 

 Additional state required community needs assessment requirements if any have 

been established by the state.

 The CCBHC has completed a staffing plan that reflects the findings of the needs 

assessment.

 (Recertification) The needs assessment and staffing plan updated in the past 3 years 

or less. 

1.a.2 Staff 

____ The CCBHC staff (both clinical and non-clinical) is appropriate in size and composition, and 

provides services appropriate for the population served.

____ Staffing satisfies the requirements of criteria 4.K for services to veterans. 
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1.a.3 Management Staffing

____ CCBHC management staffing is adequate for the needs of CCBHC, as determined by the 

needs assessment and staffing plan.

____ The Chief Executive Officer (CEO) or equivalent of the CCBHC maintains a fully staffed 

management team appropriate for the needs and size of the clinic, as determined by the 

current needs assessment and staffing plan. 

____ The management team includes a CEO or equivalent/Project Director and a psychiatrist as 

Medical Director.

 For a CCBHC without a psychiatrist, provisions are made for psychiatric consultation 

and a medically trained behavioral health provider with appropriate education and 

licensure to independently prescribe as the Medical Director.

____ The Medical Director provides guidance regarding behavioral health clinical service delivery, 

ensures the quality of the medical component of care, and provides guidance to foster the 

integration and coordination of behavioral health and primary care. 

 If the CCBHC is unable to hire a psychiatrist and hires another prescriber instead 

psychiatric consultation is obtained regarding behavioral health clinical service 

delivery, quality of the medical component of care, and integration and 

coordination of behavioral health and primary care.

1.a.4 Liability/Malpractice Insurance

____ The CCBHC maintains adequate liability/malpractice insurance.

General Staffing Requirements Notes
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Criteria 1.B: Licensure and Credentialing of Providers 

1.b.1 Appropriate Licensure and Credentialing

____ CCBHC practitioners providing direct services furnish them within their scope of practice in 

accordance with all applicable federal, state, and local laws and regulations, including 

Medicaid billing regulations or policies.

____ Appropriate supervision is provided for CCBHC providers that are working towards licensure.

1.b.2 Required Staffing

____ The CCBHC staffing plan meets requirements of the state behavioral health authority and 

any accreditation or other standards required by the state. 

____ The staffing plan is informed by the community needs assessment and is appropriate to the 

needs of people receiving CCBHC service. 

____ The staffing plan includes clinical, peer, and other staff and core staff comprised of 

employed and as needed, contracted staff. Staffing is appropriate to the needs of people 

receiving services at the CCBHC, reflected in individual treatment plans, and as required to 

meet program requirements of these criteria. 

____ The CCBHC has a medically trained behavioral health care provider, either employed or 

available through formal arrangement, who can prescribe and manage medications 

independently under state law, including buprenorphine and other FDA-approved 

medications used to treat opioid, alcohol, and tobacco use disorders. 

____ If the CCBHC does not have the ability to prescribe methadone for the treatment of opioid 

use disorder directly, it refers to an opioid treatment program (if any exist in the CCBHC 

service area) and provides care coordination to ensure access to methadone.

____ The CCBHC has staff, either employed or under contract, who are licensed or certified 

substance use treatment counselors or specialists. 

____ The Medical Director has experience in the assessment and diagnosis of SUD, substance 

intoxication and withdrawal; pharmacological management of intoxication, withdrawal, and 

SUDs; ambulatory withdrawal management; outpatient addiction treatment; toxicology

testing; and pharmacodynamics of commonly used substances. 

 If the Medical Director is not experienced with the treatment of substance use 

disorders, the CCBHC has experienced addiction medicine physicians or specialists 

on staff, or arrangements that ensure access to consultation on addiction medicine 

for the Medical Director and clinical staff. 

____ The CCBHC has credentialed substance use treatment specialists either employed or under 

contract. 

____ The CCBHC has staff with expertise in addressing trauma and promoting the recovery of 

children and adolescents with serious emotional disturbance and adults with serious mental 

illness. 
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____ The CCBHC supplements its core staff as necessary in order to adhere to program 

requirements 3 and 4 and individual treatment plans, through arrangements with, and 

referrals to, other providers. 

____ The CCBHC has staff disciplines as required (if any) by the certifying state. 

Licensure and Credentialing of Providers Notes
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Criteria 1.C: Cultural Competence and Other Training

1.c.1 Training Plans

____ The CCBHC has a training plan for all employees and contract staff who have direct contact 

with people receiving services or their families.

____ The training plan satisfies and includes requirements of the state behavioral health 

authority and any accreditation standards on training required by the state.

____ At staff orientation and at reasonable intervals, the CCBHC provides training on: 

 Evidence-based practice

 Cultural competency

 Person-centered and family-centered, recovery-oriented planning and services 

 Trauma-informed care 

 The clinic’s policy and a continuity plan for operations/disasters 

 The clinic’s policy and procedures for integration and coordination with primary 

care integrated care of mental health and substance use disorders

____ At orientation and annually thereafter, the CCBHC provides training on: 

 Risk assessment 

 Suicide and overdose prevention and response 

 The roles of families and peer staff

____ Trainings are aligned with the National Standards for Culturally and Linguistically 

Appropriate Services to advance health equity, improve quality of services, and eliminate 

disparities. 

____ Trainings include information related to military culture, to the extent active-duty military or 

veterans are being served.

1.c.2 - 1.c.4 Skills and Competence

____ The CCBHC regularly assesses and has written policies and procedures that describe the 

methods used for assessing skills and competencies of providers and keeps track of training 

provided for each employee. 

____ The CCBHC maintains documentation of completion of training and demonstration of 

competencies within staff personnel records.

____ Individuals providing training to CCBHC staff have the qualifications to do so as evidenced by 

their education, training, and experience.
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Cultural Competence and Other Training Notes
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Criteria 1.D: Linguistic Competence

1.d.1 - 1.d.4 Meaningful Access

____ The CCBHC takes reasonable steps to provide meaningful access to people with Limited 

English Proficiency (LEP) or with language-based disabilities. 

____ Interpretation/translation service(s) are readily available, appropriate and timely for the 

size/needs of the LEP CCBHC consumer population (e.g., bilingual providers, onsite 

interpreters, language video or telephone line). To the extent interpreters are used, such 

translation service providers are trained to function in a medical and, preferably, a 

behavioral health setting.

____ CCBHC auxiliary aids and services are available, ADA compliant, and responsive to the needs 

of people with physical, cognitive, and/or developmental disabilities (e.g., sign language 

interpreters, teletype [TTY] lines) receiving services. 

____ Documents or messages vital to the ability of a person receiving services to access CCBHC 

services (e.g., registration forms, sliding scale fee discount schedule, after-hours coverage, 

signage) are available online and in paper format, in languages commonly spoken within the 

community served, taking account of literacy levels and the need for alternative formats, 

and provided in a timely manner at intake and throughout the time a person is served by 

the CCBHC. 

____ The community needs assessment has informed which languages require language 

assistance.

1.d.5 Meaningful Access and Privacy

____ CCBHC policies have explicit provisions for ensuring that all employees, affiliated providers, 

and interpreters understand and adhere to confidentiality and privacy requirements 

applicable to the service provider, including but not limited to the requirements of the 

Health Insurance Portability and Accountability Act (HIPAA), 42 CFR Part 2 (Confidentiality of 

Alcohol and Drug Abuse Patient Records), patient privacy requirements specific to care for 

minors, and other state and federal laws.

Linguistic Competence Notes
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Program Requirement 2: Availability and Accessibility of 

Services

Criteria 2.A: General Requirements of Access and Availability

2.a.1 - 2.a.8 Access and Availability

____ The CCBHC provides a safe, functional, clean, sanitary, and welcoming environment for 

people receiving services and staff.

____ The CCBHC provides services during times that facilitate accessibility and meet the needs of 

the population served, including some evening and weekend hours as informed by the 

community needs assessment. 

____ The CCBHC provides services at locations that are accessible to and meet the needs of the 

population to be served, such as community settings as informed by the community needs 

assessment. 

____ The CCBHC provides transportation or transportation vouchers for people receiving services 

to the extent possible with relevant funding or programs in order to facilitate access to 

services in alignment with the person-centered and family-centered treatment plan.

____ The CCBHC utilizes telehealth/telemedicine, video conferencing, digital therapeutics, remote 

patient monitoring, asynchronous interventions, and/or other technologies to the extent 

possible in alignment with the preferences of the person receiving services to support 

access to all required services. 

____ The CCBHC conducts outreach, engagement, and retention activities to support inclusion 

and access for underserved individuals and populations as informed by the community 

needs assessment. 

____ CCBHC services conform to state or county/municipal court standards for the provision of 

voluntary and court-ordered services.

____ The CCBHC has a continuity of operations/disaster plans in place that: 

 Ensures the CCBHC is able to effectively notify staff, people receiving services, and 

healthcare and community partners when a disaster/emergency occurs or services 

are disrupted

 Identifies alternative locations and methods to sustain service delivery and access to 

behavioral health medications during emergencies and disasters

 Addresses health IT systems security/ransomware protection and backup and access 

to these IT systems, including health records, in case of disaster
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General Requirements of Access and Availability Notes
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Criteria 2.B: General Requirements for Timely Access to Services and Initial and 

Comprehensive Evaluation

2.b.1 Timing of Screening, Evaluation and Provision of Services to People Receiving 

Services New CCBHC

____ All new people requesting or referred for services receive, at the time of first contact, a 

preliminary triage (whether in-person, by telephone, or other remote communication) to 

determine acuity of needs.

 If the triage identifies an emergency/crisis need, appropriate action is taken 

immediately (see 4.c.1 for crisis response timelines and detail about required 

services), including plans to reduce or remove risk of harm and to facilitate any 

necessary subsequent outpatient follow-up. 

 If triage identifies an urgent need, clinical services and initial evaluation are to be 

provided within one (1) business day of the time the request is made.

 If triage identifies routine needs, services are provided, including the initial 

evaluation completed within 10 business days.

____ For those presenting with emergency or urgent needs, if the initial evaluation is conducted 

telephonically, once the emergency is resolved, the person receiving services is seen inperson at the next subsequent encounter and the initial evaluation reviewed.

____ The preliminary triage and risk assessment is followed by: (1) an initial evaluation and (2) a 

comprehensive evaluation, with the components of each specified in program 

requirement 4.

____ All new people receiving services receive a comprehensive evaluation to be completed 

within 60 calendar days of the first request for services. If the state has established 

independent screening and assessment processes for certain child and youth populations or 

other populations, the CCBHC should establish partnerships to incorporate findings and 

avoid duplication of effort. This requirement does not preclude the initiation or completion 

of the comprehensive evaluation, or the provision of treatment during the 60-day period.

2.b.2 Updating Comprehensive Person‐Centered and Family‐Centered Diagnostic 

and Treatment Planning Evaluation

____ CCBHC treatment teams update the person-centered and family-centered diagnostic and 

treatment plan, in agreement with and endorsed by the person receiving services, when 

changes occur with the status of the person receiving services, based on responses to 

treatment, or when there are changes in treatment goals.

____ The treatment plan is reviewed and updated no less frequently than every 6 months unless 

the state, federal, or applicable accreditation standards are more stringent.
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2.b.3 Timing of Services for Established People Who Are Receiving Services

____ Unless state, federal, or applicable accreditation standards are more stringent, 

appointments occur within 10 business days from when the request for appointment is 

made for all people who are already receiving services from the CCBHC and seeking routine 

outpatient clinical service. 

____ If a person receiving services presents with an emergency/crisis need, the CCBHC takes 

appropriate and immediate action that is consistent with the needs of the person receiving 

services. This includes immediate crisis response.

____ If a person already receiving services presents with an urgent, non-emergency need, clinical 

services are generally provided within one business day of the request, or at a later time if 

that is the preference of the person receiving services. 

General Requirements for Timely Access to Services and Initial and Comprehensive Evaluation

Notes
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Criteria 2.C: Access to Crisis Management Services

____ The CCBHC provides crisis management services in accordance with program requirement 

4.c. that are available and accessible 24 hours a day, seven days a week.

____ The CCBHC has policies or procedures in place requiring communication to the public of the 

methods for providing a continuum of crisis prevention, response, and postvention services.

____ The CCBHC educates individuals served by the CCBHC about crisis planning; psychiatric 

advanced directives; how to access crisis services, including the 988 Suicide & Crisis Lifeline 

and other area hotlines and warmlines; and overdose prevention. This includes individuals 

with LEP or disabilities (i.e., CCBHC provides instructions on how to access services in the 

appropriate methods, language(s), and literacy levels in accordance with program 

requirement 1.d).

____ Protocols established for CCBHC staff to address the needs of CCBHC people receiving 

services in psychiatric crisis who come to emergency departments. 

____ Protocols with law enforcement are in place to reduce delays for initiating services during 

and following a behavioral health crisis. 

____ The CCBHC has created, maintained, and followed crisis plans to prevent and de-escalate 

future crisis situations, in conjunction with the person receiving services following a 

psychiatric emergency or crisis. 

Access to Crisis Management Services Notes
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Criteria 2.D: No Refusal of Services Due to Inability to Pay

____ The CCBHC has policies that (1) services cannot be denied because of inability to pay and 

that (2) any fees or payments required by the clinic for such services are reduced or waived 

for those unable to pay. 

____ The CCBHC has published sliding fee discount schedule(s) on the CCBHC website, posted in 

the CCBHC waiting room and that are readily accessible to people receiving services and 

their families. The sliding fee discount schedule is communicated in languages/formats 

appropriate for individuals seeking services who have LEP, literacy barriers, or disabilities.

____ The fee schedule(s) conform to state statutory or administrative requirements or to federal 

statutory or administrative requirements that may be applicable. Absent applicable state or 

federal requirements, the schedule is based on locally prevailing rates or charges and 

includes reasonable costs of operation.

____ The CCBHC has written policies and procedures describing eligibility for and implementation 

of the sliding fee discount schedule and are applied equally to all individuals seeking 

services. 

No Refusal of Services Due to Inability to Pay Notes
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Criteria 2.E: Provision of Services Regardless of Residence

____ The CCBHC has a policy that services cannot be refused due to residence, homelessness, or 

lack of a permanent address.

____ The CCBHC has policies or protocols addressing services for those who do not live close to or 

within the CCBHC service area.

____ The CCBHC provides, at a minimum, crisis response, evaluation, and stabilization services in 

the CCBHC service area regardless of place of residence. 

____ The CCBHC has protocols that address management of the individual’s on-going treatment 

needs beyond crisis services. Protocols may provide for agreements with clinics in other 

localities, allowing the CCBHC to refer and track individuals seeking non-crisis services to the 

CCBHC or other clinics serving the individual’s area of residence. 

Provision of Services Regardless of Residence Notes
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Program Requirement 3: Care Coordination

Criteria 3.A: General Requirements of Care Coordination

____ Care coordination is based on a person-centered and family-centered treatment plan 

aligned with the requirements of Section 2402(a) of the Affordable Care Act and aligned 

with state regulations and consistent with best practices. 

____ The CCBHC coordinates care across the spectrum of health services, including access to 

high-quality physical health (both acute and chronic) and behavioral health care, as well as 

social services, housing, educational systems, and employment opportunities as necessary 

to facilitate wellness and recovery of the whole person. 

____ The CCBHC coordinates with other systems to meet the needs of the people they serve, 

including criminal and juvenile justice and child welfare.

____ The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA, 42 

CFR Part 2, requirements specific to minors, and other privacy and confidentiality 

requirements of state or federal law addressing care coordination and in interactions with 

the DCOs. 

____ The CCBHC obtains necessary consents for sharing information with community partners 

where information is not able to be shared under HIPAA and other federal and state laws 

and regulations. 

 If the CCBHC is unable, after reasonable attempts, to obtain consent for any care 

coordination activity specified in program requirement 3, such attempts are

documented and revisited periodically. 

____ Consistent with requirements of privacy, confidentiality, and the preferences and needs of 

people receiving services, the CCBHC assists people receiving services and the families of 

children and youth referred to external providers or resources in obtaining an appointment 

and tracking participation in services to ensure coordination and receipt of supports. 

____ The CCBHC coordinates care in keeping with the preferences of the person receiving 

services and their care needs. 

____ The CCBHC develops a crisis plan with each person receiving services. Crisis plans may 

support the development of a Psychiatric Advanced Directive, if desired by the person 

receiving services. Psychiatric Advance Directives are entered in the electronic health record 

of the person receiving services so that the information is available to providers in 

emergency care settings. 
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____ The CCBHC has procedures to coordinate care in collaboration with the family/caregiver of 

the person receiving services. The CCBHC develops a crisis plan with each person receiving 

services to identify the preferences of the person in the event of psychiatric or substance 

use crisis. 

 At minimum, people receiving services should be counseled about the use of the 

National Suicide & Crisis Lifeline, local hotlines, warmlines, mobile crisis, and 

stabilization services should a crisis arise when providers are not in their office. 

____ The CCBHC has procedures to coordinate care for medication reconciliation with other 

providers.

____ CCBHC agreements for care coordination do not limit the freedom of a person receiving 

services to choose their provider within the CCBHC, its DCOs, or any other provider.

____ The CCBHC assists people receiving services and families to access benefits, including 

Medicaid, and enroll in programs or supports that may be beneficial to them. 

General Requirements of Care Coordination Notes
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Criteria 3.B: Care Coordination and Other Health Information Systems

____ The CCBHC has a health information technology system in place that includes electronic 

health records. 

____ The CCBHC uses its secure health IT system and related technology tools to conduct 

activities such as population health management, quality improvement, quality 

measurement and reporting, disparity reduction, outreach, and research. 

____ The CCBHC (CCBHCs are not required to have all these capabilities in place when certified or 

when submitting their attestation) uses technology that has been certified to current criteria 

under the ONC Health IT Certification Program for the following required core set of 

certified health IT capabilities that align with key clinical practice and care delivery 

requirements for CCBHCs:

 Capture health information, including demographic information such as race, 

ethnicity, preferred language, sexual and gender identity, and disability status (as 

feasible) 

 At a minimum, support care coordination by sending and receiving summary of care 

records

 Provide people receiving services with timely electronic access to view, download, 

or transmit their health information or to access their health information via an API 

using a personal health app of their choice

 Provide evidence-based clinical decision support

 Conduct electronic prescribing

____ The CCBHC works with DCOs to ensure all steps are taken, including obtaining consent from 

people receiving services, to comply with privacy and confidentiality requirements. These 

include, but are not limited to, those of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 

42 CFR Part 2, and other federal and state laws, including patient privacy requirements 

specific to the care of minors. 

____ Within two years from CCBHC certification or submission of attestation the CCBHC produces 

a plan to focus on ways to improve care coordination between the CCBHC and all DCOs 

using a health IT system. This plan includes: 

 Information on how the CCBHC can support electronic health information exchange 

to improve care transition to and from the CCBHC using the health IT system they 

have in place or are implementing for transitions of care

 Integrating clinically relevant treatment records (evaluation planning, treatment, 

and care coordination) generated by the DCO for people receiving CCBHC services 

and incorporating them into the CCBHC health record 

 All clinically relevant treatment records maintained by the CCBHC are available to 

DCOs within the confines of federal and/or state laws governing sharing of health 

records
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Care Coordination and Other Health Information Systems Notes
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Criteria 3.C: Care Coordination Agreements

____ The CCBHC has a partnership1 establishing care coordination with Federally Qualified Health 

Centers and, where relevant, Rural Health Clinics, unless health care services are provided 

by the CCBHC. 

____ For people receiving services who are served by other primary care providers, including but 

not limited to FQHC Look-Alikes and Community Health Centers, the CCBHC has established 

protocols to ensure adequate care coordination.

____ The CCBHC has partnerships1 that establish care coordination expectations with programs 

that can provide inpatient psychiatric treatment, OTP services, medical withdrawal 

management facilities and ambulatory medical withdrawal management providers for 

substance use disorders, and residential substance use disorder treatment programs (if any 

exist within the CCBHC service area). These include tribally operated mental health and 

substance use services including crisis services that are in the service area. The CCBHC tracks 

when people receiving services are admitted to and discharged from these facilities (unless 

there is a formal transfer of care to a non-CCBC entity).

____ The CCBHC has established protocols and procedures for transitioning individuals from EDs, 

inpatient psychiatric programs, medically monitored withdrawal management services, and 

residential or inpatient facilities that serve children and youth such as Psychiatric Residential 

Treatment Facilities and other residential treatment facilities, to a safe community setting. 

This includes transfer of health records of services received (e.g., prescriptions), active 

follow-up after discharge, and, as appropriate, a plan for suicide prevention and safety, 

overdose prevention, and provision for peer services.

____ The CCBHC has partnerships2

 (with a variety of community or regional services, supports, 

and providers. CCBHCs are required to develop partnerships with the following 

organizations operating within the service area: 

 Schools 

 Child welfare agencies 

 Juvenile and criminal justice agencies and facilities, including drug, mental health, 

veterans and other specialty courts

 Indian Health Service youth regional treatment centers 

1 These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the 

partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop 

unsigned joint protocols that describe procedures for working together and roles in care coordination. At a 

minimum, the CCBHC has developed written protocols for supporting coordinated care undertaken by the CCBHC 

and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be 

developed. All partnership activities should be documented to support partnerships independent of any staff 

turnover.

2 These partnerships should be supported by a formal, signed agreement detailing the roles of each party or 

unsigned joint protocols that describe procedures for working together and roles in care coordination. At a 

minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and 

efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be 

developed. All partnership activities should be documented to support partnerships independent of any staff 

turnover.
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 State licensed and nationally accredited child placing agencies for therapeutic foster 

care service

 The 988 Suicide & Crisis Lifeline call center serving the area in which the CCBHC is 

located

 Additional partners as required by certifying states 

 CCBHCs may develop partnerships based on the population served, the needs and 

preferences of people receiving services, and/or needs identified in the community 

needs assessment (see 3.c.3 for examples) 

____ The CCBHC has partnerships1 in place with the nearest Department of Veterans Affairs' 

medical center, independent clinic, drop-in center, or other facility of the Department.

____ The CCBHC has care coordination partnerships1 establishing expectations with inpatient

acute-care hospitals in the area served by the CCBHC and their associated services/facilities 

including emergency departments, hospital outpatient clinics, urgent care centers, and 

residential crisis settings. 

____ Care coordination partnerships with these entities include: 

 Procedures and services, such as peer recovery specialist/coaches, to help 

individuals successfully transition from ED or hospital to CCBHC and community care 

to ensure continuity of services and to minimize the time between discharge and 

follow up 

 Tracking when people receiving CCBHC services are admitted to facilities providing 

the services listed above, as well as when they are discharged 

 The transfer of health records of services received (e.g., prescriptions) and active 

follow-up after discharge 

 For all people receiving CCBHC services being discharged from such facilities who 

are at risk for suicide or overdose, a requirement to coordinate consent and followup services with the person receiving services within 24 hours of discharge and that 

continues until the individual is linked to services or assessed to be no longer at risk 

 The CCBHC requests that notification be provided through the Admission-DischargeTransfer (ADT) system of relevant inpatient and outpatient facilities, for people 

receiving CCBHC services 

____ The CCBHC makes and documents reasonable attempts to contact all people receiving 

CCBHC services who are discharged from these settings within 24 hours of discharge. 
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 22

Care Coordination Agreements Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 23

Criteria 3.D: Treatment Team, Treatment Planning, and Care Coordination 

Activities

____ CCBHC treatment teams include the person receiving CCBHC services, their 

family/caregivers to the extent the person receiving CCBHC services chooses, and any other 

people the person receiving CCBHC services desires to be involved in their care. All CCBHC 

treatment planning and care coordination are person-centered and family-centered and 

align with the requirements of Section 2402(a) of the Affordable Care Act.

____ All treatment planning and care coordination activities comply with HIPAA (Pub. L. No. 104-

191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including 

patient privacy requirements specific to the care of minors. 

____ The CCBHC designates interdisciplinary treatment teams that is responsible, with the person 

receiving services and their family/caregivers/legal guardians, to the extent the person 

receiving services desires their involvement for directing, coordinating, and managing care 

and services. 

____ The interdisciplinary team is composed of individuals who work together to coordinate the 

medical, psychiatric, psychosocial, emotional, therapeutic, and recovery support needs of 

people receiving services traditional approaches to care for people receiving services who 

are American Indian or Alaska Native or from other cultural and ethnic groups.

____ The CCBHC coordinates care and services provided by DCOs in accordance with the current 

treatment plan. 

Treatment Team, Treatment Planning, and Care Coordination Activities Notes
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Program Requirement 4: Scope of Services

Criteria 4.A: General Service Provisions

____ Whether delivered directly or through a DCO agreement, the CCBHC is responsible for 

ensuring access to all care specified in the Protecting Access to Medicare Act. This includes 

the following required services: crisis services; screening, assessment, and diagnosis; 

person-centered and family-centered treatment planning; outpatient behavioral health 

services; outpatient primary care screening and monitoring; targeted case management; 

psychiatric rehabilitation; peer and family supports; and intensive community-based 

outpatient behavioral health care for members of the U.S. Armed Forces and veterans.

____ The CCBHC organization directly delivers the majority (51% or more) of encounters across 

the required services (excluding Crisis Services) rather than through DCOs. 

____ All CCBHC services, if not available directly through the CCBHC, are provided through a DCO. 

____ The CCBHC or DCO make outside referrals if a needed specialty service is unavailable 

through the CCBHC or DCO entities.

____ People receiving CCBHC services have freedom to choose providers within the CCBHC and its 

DCOs.

____ People receiving CCBHC services will be informed of and have access to CCBHC grievance 

procedures, including for CCBHC services provided by a DCO.

____ With regard to CCBHC or DCO services, the grievance process satisfies the minimum 

requirements of Medicaid and other grievance requirements such as those that may be 

mandated by relevant accrediting entities.

____ CCBHC services provided by DCOs meet the same quality standards as those required of the 

CCBHC.

General Service Provisions Notes
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Criteria 4.B: Person-Centered and Family-Centered Care

____ The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided in 

a manner aligned with the requirements of Section 2402(a) of the Affordable Care Act. The 

CCBHC and its DCOs provide services that reflect person-centered and family-centered and 

recovery oriented, being respectful of the needs, preferences, and values of the person 

receiving CCBHC services, and ensuring both involvement of the person receiving CCBHC 

services and self-direction of services received.

____ The services that the CCBHC and its DCOs provide for children and adolescents are familycentered, youth-guided, and developmentally appropriate.

____ CCBHC services are responsive to the race, ethnicity, sexual orientation, and gender identity 

of the person receiving CCBHC services and are culturally and ethically appropriate, as 

indicated in the needs assessment, including services for people who are American Indian or 

Alaska Native. 

Person-Centered and Family-Centered Care Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 26

Criteria 4.C: Crisis Behavioral Health Services

____ The CCBHC provides crisis services directly or through a DCO agreement with existing statesanctioned, certified, or licensed system or network for the provision of crisis behavioral 

health services as identified in these criteria. 

 The CCBHC has received approval from HHS to have a DCO relationship with a statesanctioned crisis system that operates under less stringent standards than those 

identified in these criteria. 

 The certifying state has received approval from HHS to certify CCBHCs in its state

that has or seeks to have a DCO relationship with a state-sanctioned crisis system 

with less stringent standards than those included in these criteria.

____ The CCBHC provides or coordinates with telephonic, text, and chat crisis intervention call 

centers that meet 988 Suicide & Crisis Lifeline standards for risk assessment and 

engagement of individuals at imminent risk of suicide. 

____ Protocols have been established to track referrals made from the call center to the CCBHC 

or its DCO crisis care provider to ensure the timely delivery of mobile crisis team response, 

crisis stabilization, and post crisis follow-up care.

____ The CCBHC provides community-based behavioral health crisis intervention services using 

mobile crisis teams twenty-four hours per day, seven days per week to adults, children, 

youth, and families anywhere within the service area including at home, work, or anywhere 

else where the crisis is experienced. 

____ Mobile crisis teams arrive in-person within one hour (2 hours in rural and frontier settings) 

from the time that they are dispatched, with response time not to exceed 3 hours.

Telehealth/telemedicine may be used to connect individuals in crisis to qualified mental 

health providers during the interim travel time. Technologies also may be used to provide 

crisis care to individuals when remote travel distances make the 2-hour response time 

unachievable 

 The ability to provide an in-person response is available when it is necessary to 

assure safety.

____ The CCBHC provides crisis receiving/stabilization services that includes at minimum, urgent 

care/walk-in mental health and substance use disorder services for voluntary individuals. 

____ Urgent care/walk-in services identify the individual’s immediate needs, de-escalate the 

crisis, and connect them to a safe and least-restrictive setting for ongoing care. 

____ Walk-in hours are informed by the community needs assessment and include evening hours 

that are publicly posted. 

____ Services are available to individuals of any level of acuity, whether individuals present on 

their own, with a concerned individual, such as a family member, or with a human service 

worker and/or law enforcement in accordance with state and local laws. 
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 27

____ Crisis services include suicide prevention and intervention and services capable of 

addressing crises related to substance use including the risk of drug and alcohol related 

overdose and support following a non-fatal overdose after the individual is medically stable. 

____ Overdose prevention activities include the availability of naloxone for overdose reversal to 

individuals who are at risk of opioid overdose, and as appropriate, to their family members. 

____ The CCBHC has an established protocol specifying the role of law enforcement during the 

provision of crisis services. 

____ As a part of the requirement to provide training related to trauma-informed care, the 

CCBHC specifically focuses on the application of trauma-informed approaches during crises.

Crisis Behavioral Health Services Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 28

Criteria 4.D: Behavioral Health Screening, Assessment, and Diagnosis

____ The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, 

including risk assessment for behavioral health conditions. In the event specialized services 

outside the expertise of the CCBHC are required for purposes of screening, assessment, or 

diagnosis, the CCBHC refers the person to an appropriate provider. 

____ Screening, assessment, and diagnosis are conducted in a timeframe responsive to the needs 

and preferences of the person receiving services and are of sufficient scope to assess the 

need for all services required to be provided by the CCBHC.

____ The CCBHC’s initial evaluation of people receiving CCBHC services includes the following: 

 Preliminary diagnoses 

 Source of referral 

 Reason for seeking care, as stated by the person receiving CCBHC services or other 

individuals who are significantly involved 

 Identification of the immediate clinical care needs related to the diagnoses for 

mental and substance use disorders of the person receiving services

 A list of current prescriptions and over-the-counter medications, herbal remedies 

and dietary supplements and the indication for any medication

 A summary of previous mental health and substance use disorder treatments with a 

focus on which treatments helped and were not helpful

 The use of any alcohol and/or other drugs the person receiving services may be 

taking

 An assessment of whether the person receiving services is a risk to self or to others, 

including suicide risk factors

 An assessment of whether the person receiving services has other concerns for their 

safety, such as intimate partner violence 

 An assessment of need for medical care (with referral and follow-up as required) 

 A determination of whether the person presently is or ever has been a member of 

the U.S. Armed Services

 for children and youth, whether they have system involvement (such as child 

welfare and juvenile justice) 

____ All people receiving CCBHC services receive a comprehensive evaluation. 

____ The comprehensive evaluation should gather the amount of information that is 

commensurate with the complexity of their specific needs and prioritize preferences of 

people receiving services with respect to the depth of evaluation and their treatment goals. 

____ The comprehensive evaluation include: 

 Reasons for seeking services at the CCBHC, including information regarding onset of 

symptoms, severity of symptoms, and circumstances leading to the presentation to 

the CCBHC of the person receiving services
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 29

 An overview of relevant social supports; social determinants of health and healthrelated social needs such as housing, vocational, and educational status; 

family/caregiver and social support; legal issues; and insurance status 

 A description of cultural and environmental factors that may affect the treatment 

plan of the person receiving services, including the need for linguistic services or 

supports for people with LEP

 Pregnancy and/or parenting status

 Behavioral health history, including trauma history and previous therapeutic 

interventions and hospitalizations with a focus on what was helpful and what was 

not helpful in past treatments

 Relevant medical history and major health conditions that impact current 

psychological status

 A medication list including prescriptions, over-the counter medications, herbal 

remedies, dietary supplements, and other treatments or medications of the person 

receiving services. Include those identified in a Prescription Drug Monitoring 

Program (PDMP) that could affect their clinical presentation and/or 

pharmacotherapy, as well as information on allergies including medication allergies

 An exam that includes current mental status, mental health (including depression 

screening, and other tools that may be used in ongoing measurement-based care) 

and substance use disorders (including tobacco, alcohol, and other drugs)

 Basic cognitive screening for cognitive impairment

 Assessment of imminent risk, including suicide risk, withdrawal and overdose risk, 

danger to self or others, urgent or critical medical conditions, and other immediate 

risks including threats from another person

 The strengths, goals, preferences, and other factors to be considered in treatment 

and recovery planning of the person receiving services

 Assessment of the need for other services required by the statute (i.e., peer and 

family/caregiver support services, targeted case management, psychiatric 

rehabilitation services)

 Assessment of any relevant social service needs of the person receiving services, 

with necessary referrals made to social services. For children and youth receiving 

services, assessment of systems involvement such as child welfare and juvenile 

justice and referral to child welfare agencies as appropriate

 An assessment of need for a physical exam or further evaluation by appropriate 

health care professionals, including the primary care provider (with appropriate 

referral and follow-up) of the person receiving services

 The preferences of the person receiving services regarding the use technologies 

such as telehealth/telemedicine, video conferencing, digital therapeutics, remote 

patient monitoring, and asynchronous interventions 

____ Screening and assessment conducted by the CCBHC related to behavioral health include 

those for which the CCBHC is accountable pursuant to program requirement 5 and Appendix 

B of the criteria.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 30

____ Other screening and monitoring required (if any) by the certifying state.

____ The CCBHC uses standardized and validated and developmentally appropriate screening and 

assessment tools appropriate for the person and, where warranted, brief motivational 

interviewing techniques to facilitate engagement. 

____ The CCBHC uses culturally and linguistically appropriate screening tools and approaches that 

accommodate all literacy levels and disabilities (e.g., hearing disability, cognitive 

limitations), when appropriate. 

____ If screening identifies unsafe substance use, including problematic alcohol or other 

substance use, the CCBHC conducts a brief intervention and the person receiving services is 

provided a full assessment and treatment, if appropriate within the level of care of the 

CCBHC, or referred to a more appropriate level of care. If the screening identifies more 

immediate threats to the safety of the person receiving services, the CCBHC takes 

appropriate action as described in 2.b.1.

Behavioral Health Screening, Assessment, and Diagnosis Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 31

Criteria 4.E: Person-Centered and Family-Centered Treatment Planning3

____ The CCBHC directly, or through a DCO, provides person-centered and family-centered 

treatment planning including but not limited to, risk assessment and crisis planning.

____ The CCBHC develops an individualized treatment plan based on information obtained 

through comprehensive evaluation and the person receiving services’ goals and preferences. 

____ The plan addresses the person’s prevention, medical, and behavioral health needs and is 

developed in collaboration with and be endorsed by the person receiving services, their 

family (if the person receiving services so wishes), and family/caregivers/legal guardians of 

youth and children. 

____ The treatment plan development is coordinated with staff or programs necessary to carry 

out the plan and supports care in the least restrictive setting possible.

____ All necessary releases of information are obtained and included in the health record as a 

part of the development of the initial treatment plan. 

____ The CCBHC uses the initial and comprehensive evaluations and ongoing screening 

assessments of the person receiving services to inform the treatment plan and services 

provided. 

____ Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in 

a manner capturing the words or ideas of the person receiving services or their family if 

appropriate. 

____ The treatment plan is comprehensive, addressing all services required, including recovery 

supports, with provision for monitoring of progress towards goals and built upon a shared 

decision-making approach.

____ The CCBHC seeks consultation where appropriate during treatment planning (e.g., eating 

disorders, traumatic brain injury, intellectual and developmental disabilities (I/DD), 

interpersonal violence and human trafficking. 

____ The person’s health record documents any advance directives related to treatment and 

crisis planning. If the person receiving services does not wish to share their preferences, that 

decision is documented. Please see 3.a.4., requiring the development of a crisis plan with 

each person receiving services.

____ Other aspects of person-centered and family-centered treatment planning required (if any)

by the certifying states. 

3 For more information related to person-centered treatment planning see eCFR :: 42 CFR Part 485 Subpart J --

Conditions of Participation: Community Mental Health Centers (CMHCs) and eCFR :: 42 CFR Part 441 Subpart M --

State Plan Home and Community-Based Services for the Elderly and Individuals with Disabilities.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 32

Person-Centered and Family-Centered Treatment Planning Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 33

Criteria 4.F: Outpatient Mental Health and Substance Use Services

____ The CCBHC directly, or through a DCO, provides outpatient behavioral health care including 

psychopharmacological treatment that are evidence-based services using best practices for 

treating mental health and substance use disorders across the lifespan with tailored 

approaches for adults, children, and families. 

____ SUD treatment and services are provided as described in the American Society for Addiction 

Medicine Levels 1 and 2.1 and include treatment of tobacco use disorders. 

____ In the event specialized or more intensive services outside the expertise of the CCBHC or 

DCO are required for purposes of outpatient mental and substance use disorder treatment 

the CCBHC makes them available through referral or other formal arrangement with other 

providers or, where necessary and appropriate, through use of telehealth/telemedicine, in 

alignment with state and federal laws and regulations. 

____ The CCBHC provides or makes available through a formal arrangement traditional 

practices/treatment as appropriate for the people receiving services served in the CCBHC 

area. 

____ The CCBHC delivers the evidence-based practices as required by certifying states. 

____ Treatments are provided that are appropriate for the phase of life and development of the 

person receiving services and delivered by staff with specific training in treating the segment 

of the population being served.

 When treating children and adolescents, CCBHCs provide evidenced-based services 

that are developmentally appropriate, youth-guided, and family/caregiver-driven. 

 When treating older adults, the desires and functioning of the individual person 

receiving services are considered, and appropriate evidence-based treatments are 

provided. 

 When treating individuals with developmental or other cognitive disabilities, level of 

functioning is considered, and appropriate evidence-based treatments are provided. 

____ Supports for children and adolescents comprehensively address family/caregiver, school, 

medical, mental health, substance use, psychosocial, and environmental issues.

Outpatient Mental Health and Substance Use Services Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 34

Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring

____ The CCBHC monitors key health indicators and health risks, and coordinates care in a timely 

fashion. The Medical Director has established protocols that conform to screening 

recommendations with scores of A and B of the United States Preventive Services Task Force 

Recommendations for the following conditions:

 HIV and viral hepatitis 

 Primary care screening pursuant to CCBHC Program Requirement 5 Quality and 

Other Reporting and Appendix B

 Other clinically indicated primary care key health indicators of children, adults, and 

older adults receiving services, as determined by the CCBHC Medical Director and 

based on environmental factors, social determinants of health, and common 

physical health conditions experienced by the CCBHC person receiving services 

population. 

____ The Medical Director developed organizational protocols to ensure screening for common 

physical health conditions experienced by CCBHC populations across the lifespan. Protocols 

include: 

 Identifying people receiving services with chronic diseases 

 Ensuring that people receiving services are asked about physical health symptoms

 Establishing systems for collection and analysis of laboratory samples, fulfilling the 

requirements of 4.g.

____ The CCBHC should have the ability to collect biologic samples directly, through DCO, or 

through a formal agreement. Laboratory analyses can be done directly or through another 

arrangement with an organization separate from the CCBHC.

____ The CCBHC provides ongoing primary care monitoring of health conditions as identified in 

4.g.1 and 4.g.2., and as clinically indicated for the individual. Monitoring includes the 

following: 

 Ensuring individuals have access to primary care services 

 Ensuring ongoing periodic laboratory testing and physical measurement of health 

status indicators and changes in the status of chronic health conditions 

 Coordinating care with primary care and specialty health providers including 

tracking attendance at needed physical health care appointments; and promoting a 

healthy lifestyle
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 35

Outpatient Clinic Primary Care Screening and Monitoring Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 36

Criteria 4.H: Targeted Case Management Services

____ The CCBHC provides directly, or through a DCO, targeted case management services that 

assists people receiving services in sustaining recovery, and gaining access to needed 

medical, social, legal, educational, housing, vocational, and other services and supports. 

CCBHC targeted case management should include supports for people deemed at high risk 

of suicide or overdose, particularly during times of transitions; individual with complex or 

serious mental health or substance use conditions and for individuals who have a short-term 

need for support in a critical period.

____ The CCBHC provides the scope of targeted case management services to the specific 

populations for which they are intended as specified (if any) by certifying states/ 

Targeted Case Management Services Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 37

Criteria 4.I: Psychiatric Rehabilitation Services

____ The CCBHC or through a DCO provides evidence-based rehabilitation services for both 

mental health and substance use disorders. Psychiatric rehabilitation services include: 

 Supported employment programs designed to provide those receiving services with 

on-going support to obtain and maintain competitive, integrated employment (e.g., 

evidence-based supported employment, customized employment programs, or 

employment supports that are run in coordination with Vocational Rehabilitation or 

Career One-Stop services)

 Services that help people to participate in supported education and other 

educational services; achieve social inclusion and community connectedness; 

participate in medication education, self-management, and/or individual and 

family/caregiver psychoeducation; and find and maintain safe and stable housing 

____ Evidence-based and other psychiatric rehabilitation services above the minimum 

requirements described in 4.i as required (if any) by certifying states. 

Psychiatric Rehabilitation Services Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 38

Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports

____ The CCBHC or through a DCO provides peer supports, including peer specialist and recovery 

coaches, peer counseling, and family/caregiver supports. 

____ The CCBHC or through a DCO provides the scope of peer and family services specified (if 

any) by certifying states. 

Peer Supports, Peer Counseling, and Family/Caregiver Supports Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 39

Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of 

the Armed Forces and Veterans

____ The CCBHC provides directly, or through a DCO, intensive, community-based behavioral 

health care for certain members of the U.S. Armed Forces and veterans, particularly those 

Armed Forces members located 50 miles or more (or one hour’s drive time) from a Military 

Treatment Facility and veterans living 40 miles or more (driving distance) from a VA medical 

facility, or as otherwise required by federal law. The CCBHC has demonstrated efforts to 

facilitate the provision of intensive community-based behavioral health services to veterans 

and active-duty military personnel.

____ With all individuals inquiring about services, the CCBHC documents whether they have ever 

served in the U.S. military. For those affirming current or former service in the U.S. military, 

CCBHCs either directs them to care or provides care through the CCBHC as required by 

criterion 4.k.2.

____ The CCBHC offers assistance with enrollment in the VHA for the delivery of health and 

behavioral health services to persons affirming former military service.

____ The CCBHC ensures coordination for the care of substance use disorders and other mental 

health conditions for veterans and active-duty military personnel who experience both, to

the extent those services are appropriately provided by the CCBHC in accordance with 

criteria 4.k.1 and 4.k.2.

____ The CCBHC provides for integration and coordination of care for behavioral health 

conditions and other components of health care for all veterans and active-duty military 

personnel who experience both, to the extent those services are appropriately provided by 

the CCBHC in accordance with criteria 4.k.1 and 4.k.2.

____ The CCBHC assigns a Principal Behavioral Health Provider to every veteran seen, unless the 

VHA has already assigned a Principal Behavioral Health Provider. When veterans are seeing 

more than one behavioral health provider and when they are involved in more than one 

program, the identity of the Principal Behavioral Health Provider is made clear to the 

veteran and identified in the health record. The Principal Behavioral Health Provider fulfills 

requirements in accordance with accordance with criteria 4.k.4.

____ The CCBHC provides behavioral health services for veterans that are recovery-oriented and 

adhere to the guiding principles of recovery (outlined in criteria 4.k.5), VHA recovery, and 

other VHA guidelines.

____ CCBHC staff who work with people receiving CCBHC services who are military or veterans 

are trained in cultural competence, and specifically military and veterans’ culture.

____ The CCBHC develops a behavioral health treatment plan for all veterans receiving behavioral 

health services compliant with provisions of Criteria 4.K.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 40

Intensive, Community-Based Mental Health Care for Members of the Armed Forces and Veterans 

Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 41

Program Requirement 5: Quality and Other Reporting

Criteria 5.A: Data Collection, Reporting, and Tracking

____ The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality 

data, including, but not limited to, data capturing of: 

 Characteristics of people receiving services 

 Staffing

 Access to services 

 Use of services 

 Screening, prevention, and treatment 

 Care coordination 

 Other processes of care 

 Costs 

 Outcomes of people receiving services

____ The CCBHC collects and reports the Clinic-Collected quality measures identified as required 

in Appendix B for all people receiving CCBHC services. CCBHCs report quality measures nine 

(9) months after the end of the measurement year as that term is defined in the technical 

specifications. 

____ CCBHCs participating in Section 223 Demonstration report the data to their states. 

____ CCBHC-Es that are required to report quality measure data, report it directly to SAMHSA.

____ The CCBHC collects and reports any of the optional Clinic-Collected measures identified in 

Appendix B as required (if any) by certifying states. 

____ CCBHCs participating in the Section 223 Demonstration have arrangements with DCOs for 

access to quality measures data for CCBHC services delivered by DCOs as legally permissible. 

____ CCBHCs participating in the Section 223 Demonstration program participate in discussions 

with the national evaluation team and other evaluation-related data collection activities if 

requested.

____ CCBHCs participating in the Section 223 Demonstration program annually submit a cost 

report with supporting data within six months after the end of each Section 223 

Demonstration year to the state.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 42

Data Collection, Reporting, and Tracking Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 43

Criteria 5.B: Continuous Quality Improvement (CQI) Plan

____ The CCBHC develops, implements, and maintains an effective, CCBHC-wide continuous 

quality improvement (CQI) plan for the services provided. 

____ The CCBHC establishes a critical review process to review CQI outcomes and implement 

changes to staffing, services, and availability that improves the quality and timeliness of 

services. 

____ The CQI plan focuses on indicators related to improved behavioral and physical health 

outcomes and takes actions to demonstrate improvement in CCBHC performance.

____ The Medical Director is involved in the aspects of the CQI plan that apply to the quality of 

the medical components of care, including coordination and integration with primary care.

____ The CQI plan addresses how the CCBHC reviews known significant events including, at a

minimum: 

 Deaths by suicide or suicide attempts of people receiving services 

 Fatal and non-fatal overdoses

 All-cause mortality among people receiving CCBHC services 

 30-day hospital readmissions for psychiatric or substance use reasons 

 Such other events the state or applicable accreditation bodies may deem 

appropriate for examination and remediation as part of a CQI plan

____ The CQI plan is data-driven and the CCBHC considers the use of quantitative and qualitative 

data in their CQI activities. 

____ CCBHCs participating in the Section 223 Demonstration address the data resulting from the 

CCBHC-collected and, as applicable for the, State-Collected, quality measures that may be 

required as part of the Demonstration.

____ The CQI plan includes an explicit focus on populations experiencing health disparities 

(including racial and ethnic groups and sexual and gender minorities) and addresses how the 

CCBHC uses disaggregated data from the quality measures and, as available, other data to 

track and improve outcomes for populations facing health disparities.

Continuous Quality Improvement (CQI) Plan Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 44

Program Requirement 6: Organizational Authority, 

Governance, and Accreditation

Criteria 6.A: General Requirements of Organizational Authority and Finances

____ The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the 

following statutorily established criteria: 

 Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United 

States Internal Revenue Code

 Is part of a local government behavioral health authority

 Is operated under the authority of the Indian Health Service, an Indian tribe, or 

tribal organization pursuant to a contract, grant, cooperative agreement, or 

compact with the Indian Health Service pursuant to the Indian Self-Determination 

Act (25 U.S.C. 450 et seq.)

 Is an urban Indian organization pursuant to a grant or contract with the Indian 

Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 

1601 et seq.)

____ To the extent CCBHCs are not operated under the authority of the Indian Health Service, an 

Indian tribe, or tribal or urban Indian organization, CCBHCs has reached out to such entities 

within their geographic service area and enter into arrangements with those entities to 

assist in the provision of services to tribal members and to inform the provision of services 

to tribal members. To the extent the CCBHC and such entities jointly provide services, the

CCBHC and those collaborating entities, as a whole, satisfy the requirements of these 

criteria. 

____ An independent financial audit is performed annually for the duration that the clinic is 

designated as a CCBHC in accordance with federal audit requirements, and, where 

indicated, a corrective action plan is submitted addressing all findings, questioned costs, 

reportable conditions, and material weakness cited in the Audit Report. 

General Requirements of Organizational Authority and Finances Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 45

Criteria 6.B: Governance

____ The CCBHC has identified how to integrate meaningful participation in leadership and 

decision-making positions within their governance by individuals with lived experience of 

mental and/or substance use disorders and their families, including youth. 

 Option 1. At least fifty-one percent of the CCBHC governing board is comprised of 

individuals with lived experience of mental and/or substance use disorders and 

families. 

OR

 Option 2. Individuals with lived experience of mental and/or substance use 

disorders and family members of people receiving services have representation in 

governance that assures input into Identifying community needs and goals and 

objectives of the CCBHC; service development, quality improvement, and the 

activities of the CCBHC; fiscal and budgetary decisions; and governance (human 

resource planning, leadership recruitment and selection, etc.). 

• The governing board must establish protocols for incorporating input from 

individuals with lived experience and family members 

• Board meeting summaries are shared with those participating in the 

alternate arrangement and recommendations from the alternate 

arrangement are entered into the formal board record 

• A member or members of the arrangement must be invited to board 

meetings; and

• Representatives of the alternate arrangement must have the opportunity to 

regularly address the board directly, share recommendations directly with 

the board, and have their comments and recommendations recorded in the 

board minutes

• The CCBHC provides staff support for posting an annual summary of the 

recommendations from the alternate arrangement under option 2 on the 

CCBHC website

• Opportunity to share recommendations directly with the board. 

– The CCBHC provides staff support for posting an annual summary of the 

recommendations from the alternate arrangement on the CCBHC 

website. 

For Option 2, the certifying state or the federal grant funding agency determined 

that the approach to achieve meaningful participation is acceptable.

• If not acceptable, the CCBHC has made satisfactory progress in the process 

of implementing additional mechanisms as required by the certifying state 

or federal grant funding agency to fulfill this requirement. CCBHC makes 

available the results of its efforts in terms of outcomes and resulting 

changes.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 46

Note: See criteria 6.b.3 for CCBHC that are comprised of a governmental or tribal 

organization, subsidiary, or part of a larger corporate organization that cannot meet these 

requirements for board membership. Members of the governing or advisory boards are 

representative of the communities in which the CCBHC's service area is located and are

selected for their expertise in health services, community affairs, local government, finance 

and accounting, legal affairs, trade unions, faith communities, commercial and industrial 

concerns, or social service agencies within the communities served. No more than one half 

(50 percent) of the governing board members may derive more than 10 percent of their 

annual income from the health care industry.

Governance Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist Page 47

Criteria 6.C: Accreditation

____ The CCBHC is enrolled as a Medicaid provider and licensed, certified, or accredited provider 

of both mental health and substance use disorder services including developmentally 

appropriate services to children, youth, and their families, unless there is a state or federal 

administrative, statutory, or regulatory framework that substantially prevents the CCBHC 

organization provider type from obtaining the necessary licensure, certification, or 

accreditation to provide these services. 

____ The CCBHC adheres to any applicable state accreditation, certification, and/or licensing 

requirements. 

____ The CCBHC participates in SAMHSA Behavioral Health Treatment Locator.

Accreditation Notes