California Code of Regulations › Title 9 - Rehabilitative and Developmental Services › Division 1 - Department of Mental Health › Chapter 11 - Medi-Cal Specialty Mental Health Services › Subchapter 3 - Specialty Mental Health Services Other than Psychiatric Inpatient Hospital Services › Article 2 - Provision of Services › Section 1830.220 - Authorization of Out-of-Plan Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 "Out-of-Plan Services" means specialty mental health services covered by this
					 Subchapter, other than psychiatric nursing facility services, provided to a
					 beneficiary by providers other than the MHP of the beneficiary or a provider
					 contracting with the MHP of the beneficiary.
(b) The MHP shall be required to provide
					 out-of-plan services, when the services are also available through the MHP of the
					 beneficiary or a provider contracting with the MHP of the beneficiary, only under
					 the following circumstances:
(1) When a
					 beneficiary with an emergency psychiatric condition is admitted for psychiatric
					 inpatient hospital services as described in Section
					 1820.225 to the extent provided in
					 Section 1830.230.
(2) When a beneficiary with an emergency
					 psychiatric condition is admitted for psychiatric health facility services under the
					 conditions described in Section
					 1830.245.
(3) When a beneficiary is out of county and
					 develops an urgent condition and there are no providers contracting with the MHP
					 reasonably available to the beneficiary based on the MHP's evaluation of the needs
					 of the beneficiary, especially in terms of timeliness of service.
(4) When there are no providers contracting with
					 the MHP reasonably available to the beneficiary based on the MHP's evaluation of the
					 needs of the beneficiary, the geographic availability of providers, and community
					 standards for availability of providers in the county in which the beneficiary is
					 placed and the beneficiary is placed out of county by:
(A) The Foster Care Program as described in
					 Article 5 (commencing with Section
					 11400), Chapter 2, Part 3, Division 9 of
					 the Welfare and Institutions Code, the Adoption Assistance Program as described in
					 Chapter 2.1 (commencing with Section
					 16115), Part 4, Division 9 of the
					 Welfare and Institutions Code, or other foster care arrangement.
(1) If the beneficiary is a child or youth of
					 either the Foster Care Program, Adoption Assistance Program, or other type of foster
					 care arrangement such as Kin-GAP, and is placed outside his/her county of origin,
					 the MHP of the county of origin must make an authorization decision and notify the
					 host county and the requesting provider, if applicable of that decision within three
					 working days following the date of receipt of the request for service by the MHP of
					 origin. If the MHP of the county of origin documents a need for additional
					 information to evaluate the beneficiary's need for the service, an extension may be
					 granted up to three working days from the date the additional information is
					 received, or 14 calendar days from the receipt of the original Treatment
					 Authorization Request, whichever is less.
(2) Within 30 calendar days of the date of
					 authorization of service, the MHP of the county of origin shall arrange for
					 reimbursement for the service provided to the child or youth through the host county
					 or the requesting provider.
(3) If there
					 is a disagreement between the MHP of the county of origin and the MHP of the host
					 county, the MHPs shall resolve their differences through the arbitration process
					 provided in Section
					 1850.405.
(B) A Lanterman-Petris-Short or Probate
					 Conservator or other legal involuntary placement.