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INSTRUCTIONS: Use this form to request changes such as a new location, program closures, change in service days/hours, or change in the type of service modalities.Do not use this form to request additional funds. Contractors must receive approval prior to implementing any changes that fall within these categories. Until you receive confirmation of completed site certification, your organization is financially liable for any periods of services lacking site certification, current fire clearance, NPI, or plete the form by checking the boxes below that correspond to your requested change and providing the additional requested information. You may need to submit multiple forms for multiple changes. Please utilize tools at , (under Start-Up of Services at a New MH Program/Site), and (under Medi-Cal Site Certification) to check that your fire clearance and NPI are valid, and that you are only requesting a new NPI when appropriate.Section A: Contact and Program/RU Information/AttachmentsDate of Request FORMTEXT ?????Organization/Legal Entity Name FORMTEXT ?????Organization Contact Person FORMTEXT ?????Organizational Contact Title FORMTEXT ?????Organization Contact Phone FORMTEXT ?????Organization Contact Email FORMTEXT ?????Name(s) of Program(s) that would be impacted by this change FORMTEXT ?????Existing RU(s) that would be impacted by this change (for new RU requests, put N/A) FORMTEXT ?????Contract Type (If submitting requests for both MH and SUD use a separate form for each)? Mental Health (MH)? Substance Use Disorder (SUD)Requested Effective Date* (Must be at least 30-days later than the initial written request to ACBH Contracts around the change. This date is subject to change through finalization process) FORMTEXT ?????Attach valid fire clearance dated within six months of date of intended provision of services? Attached ? N/A only for OUSD school sitesIs your program located within Alameda County??Yes ?No, Please specify which county: FORMTEXT ????? and attach host county site certification For Mental Health programs with specific licensure requirements, attach Community Care Licensing (CCL) letter ? Attached ? Not yet available, anticipated date of completion: FORMTEXT ?????For SUD Programs with specific certification/licensure requirements, attach Department of Health Care Services (DHCS) certification and licensure ? Attached? Not yet available, anticipated date of completion: FORMTEXT ?????Additional notes/rationale for request FORMTEXT ?????* Requested Effective Date cannot be less than 30 days from completing form and/or cannot be before valid fire clearance and/or NPISection B: Requested ChangeWhat is the situation of your requested change (note situation number)? ? #1 Move an existing program/RU to an existing site address ? #2 Add a new program/RU to an existing site address? #3 Move an existing program/RU to a new site address? #4 Add a new program/RU to a new site address? #5 Change program days/hours? #6 Add specific procedure codes (MH Master/SAN only)? #7 Remove specific procedure codes (MH Master/SAN only)? #8 Other, specify belowSection B: Requested Change (continued): Use the areas that correspond to the situation numbers above? #1 Move an existing program/RU to an existing site address, or? #2 Add a new program/RU to an existing site addressCurrent site moving from (put N/A if new site):Site moving to (or new site):Site Address (+ 4 zip) FORMTEXT ?????Site Address (+ 4 zip) FORMTEXT ?????State Provider# / NPI #* FORMTEXT ?????State Provider# / NPI #** FORMTEXT ?????If you are moving a program, are existing clients being moved to the new site? (Note: ACBH Provider Relations will contact you about this transition of clients.) ?Y ?N ?N/A (new site)If you are moving a program, does your organization have other programs/RUs that are staying at the current site address? ?Y (please list programs/RUs that are staying: FORMTEXT ?????) ?N ?N/A (new site)Does your agency have a current Medi-Cal site certification for the new site? (Note: Out-of-County sites need to submit host-County certification)?Y ?N ?N/ADoes the current Medi-Cal site certification have all of the service modalities you need? (Mark any new service modalities later on in Section C. If MH also complete Section D for additional procedure codes. If no, site certification must be done.) ?Y ?N ?N/A (no current site certification or site certification not required per program type)? #3 Move an existing program/RU to a new site address, or? #4 Add a new program/RU to a new site addressCurrent site moving from (put N/A if new site):Site moving to (or new site):Site Address (+ 4 zip) FORMTEXT ?????Site Address (+ 4 zip) FORMTEXT ?????State Provider# / NPI # FORMTEXT ?????State Provider# / NPI # FORMTEXT ?????If you are moving a program, are existing clients being moved to the new site? (Note: ACBH Provider Relations will contact you about this transition of clients.) ?Y ?N ?N/A (new site)If you are moving a program, does your organization have other programs or RUs that are staying at the current site address??Y (please list programs/RUs that are staying: FORMTEXT ?????) ?N ?N/A (New Site)Note: Please fill in the service modalities in Section C. If MH also complete Section D.? #5 Change program days/hoursProgram Name(s) FORMTEXT ?????Existing RU#(s) FORMTEXT ?????Current program days/hours FORMTEXT ?????New program days/hours FORMTEXT ?????? #6 Add PCs (procedure codes), or? #7 Remove PCsNote: Requests to add and remove procedure codes are only permitted for MH programs. Please fill in both the service modalities in Section C and revised procedure codes in Section D. If adding, are the new procedure codes in a different service modality than are in your current site certification and contract? (This change may require a revised site certification.)# 8 OtherPlease specify other changes not otherwise captured: FORMTEXT ?????** Apply for an NPI number for a new site at , and indicate “applied for [date]” in box SecSection C: Service Modalities (use this section if you were referred here by Section B, check all that apply)Mental Health: Outpatient? Mental Health Services ? Case Management/Brokerage ? Crisis Intervention ? Therapeutic Behavioral Services (TBS)? Medication Support (specify: ? Prescribing Only or ? Prescribing, Dispensing, and Storing)Mental Health: Day Services, see Section E for attachment requirements? Crisis Stabilization ? Day Treatment (please specify: ? Intensive or ? Rehabilitation) AND (please specify: ? Full Day or ? Half Day) Mental Health: 24-Hour Services, see Section E for attachment requirements? Residential ? Crisis Residential ? Other (Please specify:) FORMTEXT ?????Substance Use Disorder: Program Code see Section E for attachment requirements ? Non-Perinatal Services ? Perinatal Services Substance Use Disorder: Service Modalities, see Section E for attachment requirements? Outpatient Services (OS)? Intensive Outpatient Services (IOS) ? Opioid Treatment Program (OTP)/Narcotic Treatment Program (NTP) ? Clinically Managed 3.1 Low-Intensity Residential Services? Clinically Managed Population-Specific 3.3 High-Intensity Residential Services? Clinically Managed Population-Specific 3.5 High-Intensity Residential Services ? Recovery Residence? Clinically Managed Residential Withdrawal Management ? Portal? Transition to Treatment ? Prevention ? Other, Please specify: FORMTEXT ????? Section D: Procedure Codes for Mental Health Only (check all that apply)Clinician’s Gateway/Data Entry (Mode 00)Case Management/Brokerage (CM) FORMCHECKBOX Clinician’s Gateway (CG)* PC: 197 FORMCHECKBOX BrokerageSFC: 01 - PC: 571 FORMCHECKBOX CG FSP Data EntryPC: 198 FORMCHECKBOX Katie A. ICC for Child/TAY TreatmentSFC: 07 - PCs: 577Outpatient Services (Mode 15) FORMCHECKBOX Katie A. ICC for Child Family TeamSFC: 07 - PCs: 578Mental Health Services (MHS)Crisis Intervention FORMCHECKBOX Assessment/Plan Dev./ Eval.SFC: 30 - PCs: 323-326, 581 FORMCHECKBOX Crisis InterventionSFC: 70 - PCs: 377-378 FORMCHECKBOX CollateralSFC: 10 - PCs: 310, 311, 317, 614Medication Support (MS)* FORMCHECKBOX Individual TherapySFC: 40 - PCs: 413, 441-443, 449 FORMCHECKBOX Medication Support: Evaluation and Management/PsychotherapySFC: 60 - PCs: 367, 369, 465, 467, 468, 545-549, 565, 641, 643-646 FORMCHECKBOX Individual RehabilitationSFC: 40 - PC: 381 FORMCHECKBOX Group TherapySFC: 50 - PCs: 455-456 FORMCHECKBOX Med. Support in SNFSFC: 60 - PCs: 650, 653-658 FORMCHECKBOX Group RehabilitationSFC: 50 - PC: 391 FORMCHECKBOX Interactive ComplexitySFC: 30, PC: 491 FORMCHECKBOX Katie A. IHBSSFC: 57 - PC: 557 FORMCHECKBOX TBSSFC: 58 - PC: 498 FORMCHECKBOX Psych Testing (limited service)SFC: 30 - PCs: 415, 417, 491, 535Section D: Procedure Codes for Mental Health only (continued, check all that apply)Outreach/Support (Modes 45, 55 and 65)24 Hour Services (Mode 5) FORMCHECKBOX Mental Health PromotionSFC: 10 - PC: 401 FORMCHECKBOX Child Residential DaySFCs: 60 - PC: 180 FORMCHECKBOX Consultation to OrganizationsSFC: 10 - PC: 404 FORMCHECKBOX Adult Residential DaySFCs: 65-79 - PC: 165 FORMCHECKBOX Community Service OtherSFC: 10 - PC: 405 FORMCHECKBOX Crisis Residential DaySFCs: 40-49 - PC: 141 FORMCHECKBOX Onsite Outreach/SupportSFC: 20 - PC: 402 FORMCHECKBOX IMD DaySFCs: 36 - PC: 131 FORMCHECKBOX Offsite Outreach/SupportSFC: 20 - PC: 403 FORMCHECKBOX IMD Non-Contract Day*SFCs: 36 - PC: 130 FORMCHECKBOX Program Support: HousingSFC: 78 - PC: 423 FORMCHECKBOX IMD Bed Day Hold*SFCs: 36 - PC: 133 FORMCHECKBOX Program Support: Voc.SFC: 78 - PC: 424 FORMCHECKBOX SNF Intensive DaySFCs: 30 - PC: 135 FORMCHECKBOX Program Support: Ed.SFC: 78 - PC: 425 FORMCHECKBOX SNF Intensive Non-Contract Day*SFCs: 30 - PC: 134 FORMCHECKBOX Client Support: HousingSFC: 78 - PC: 623 FORMCHECKBOX SNF Intensive Bed Day Hold*SFCs: 30 - PC: 136 FORMCHECKBOX Client Support: Voc.SFC: 78 - PC: 624 FORMCHECKBOX PHF DaySFCs: 20-29 - PC: 121 FORMCHECKBOX Client Support: Ed.SFC: 78 - PC: 625 FORMCHECKBOX PHF Non-Contract Day*SFCs: 20-29 - PC: 120 FORMCHECKBOX CBO MAA CodesSFC: 10 – PCs: 502, 504, 505-506, 508, 519, 524, 528, 537-538, 674, 680, 693, 695-696, 699 FORMCHECKBOX Local Inpatient DaySFC: 10 - PC: 111 FORMCHECKBOX Local Inpatient Admin Day*SFC: 19 - PC: 113Program-Specific Services: CalWORKsDay Services (Mode 10) FORMCHECKBOX CalWORKs MH Services (MHS Rate)SFC: 30 - PC:33 6; SFC: 40 - PC: 346; SFC: 50 - PC: 356 FORMCHECKBOX Crisis Stabilization EmergencySFCs: 20-24 - PC: 221 FORMCHECKBOX Crisis Stabilization UrgentSFCs: 25-29 - PC: 221 FORMCHECKBOX CalWORKs CM/Brokerage (CM Rate)SFC: 01 - PC: 576 FORMCHECKBOX Intensive Half DaySFCs: 81-84 - PC: 281 FORMCHECKBOX CalWORKs Med. Support (MS Rate)SFC: 60 - PC: 366 FORMCHECKBOX Intensive Full DaySFCs: 85-89 - PC: 285 FORMCHECKBOX CalWORKs MH Services (MHS Rate)SFC: 30 - PC: 336; SFC: 40 - PC: 346; SFC: 50 - PC: 356 FORMCHECKBOX Rehabilitation Half DaySFC: 91 - PC: 291 FORMCHECKBOX Rehabilitation Full DaySFC: 95 - PC: 295Other Procedure Codes, Please Specify: FORMTEXT ?????Section E: CBO AuthorizationBy signing this document and checking boxes below, you are verifying that you are responsible for the submission of needed documentation to support your program change request AND understand that your organization may be financially liable for any period of services at a new or moved service delivery site: ? If lacking valid fire clearance, NPI, licensure, and/or approval in principle from ACBH; and/or ? If this request (with the submission of documents and/or requested effective date) did not abide by the 30 day-notice needed prior to any move of any program location or change of contracted hours of operation (as referenced in Exhibit A-1).Name of Organizational Contact Signatory FORMTEXT ?????Signature FORMTEXT ?????Date: FORMTEXT ?????Section F: ACBH Use Only – Ops Lead and/or Finance Director Approval in PrincipleBy signing this document, you are verifying that you have reviewed the program change request and documenting your approval in principle or denial of the request. Approval of Change in Principle ? Approved in Principle ? Partially Approved in Principle (Describe in Notes Below) ? Denied Notes FORMTEXT ?????Operational Lead Name FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ?????Finance Director Name (Removal of MAA Codes only) FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ?????Section G: ACBH Use Only – Contracts Unit ReceiptBy signing this document, you are verifying that you have confirmed to the best of your ability that the needed documentation has been submitted and is attached to support the completion of the program change request. You are also taking responsibility for completing next steps assigned to Contracts Unit as outlined below according to established Contracts Unit Processes:PCM/FCM: Submission of completed and signed form to Administrative Point Person (Contracts Unit)Administrative Point Person: Distribution of the signed form to Notification Distribution List as well as the provider contact personAdditional steps may include: site certification (Quality Assurance), RU changes (Contracts Unit/Billing & Benefits Unit [formerly known as Provider Relations]) and/or contract changes (Contracts Unit)Contracts Unit Confirmation for Implementation of ChangeVerification: Valid NPI ? Y ? N ? N/A Verification: Fire Clearance Attached ? Y ? N ? N/ABoard Approval Received (if applicable)? Date: _________ ? N/A Confirmation: Effective date 30-days out from initial CBO request? Y (Contract Managers to update if needed)Next steps needed in any of these areas ? Site Certification ? New Provider # ? New RU(s) ? Edit current RU(s) ? New Legal Entity (SUD ONLY) # of RUs: FORMTEXT ?????Comments/Other: FORMTEXT ?????Program Contract Manager Name FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ?????Fiscal Contract Manager Name FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ?????Administrative Point Person Name (Contracts Unit) FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ?????++ ................
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