Facility/Organizational Providers Approval Signatures: Available Upon Request

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Section: II Number: N206.VOC

Keywords: Programs, Malpractice, Insurance, Accreditation

Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

Page 1 of 20 Original Date of Issue: 11/12/2001

Functional Area: VOC Network Operations Date(s) Revised: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

Operating Unit: ValueOptions of California, Inc.

Subject: Credentialing Criteria for Facility/Organizational Providers Approval Signatures:

Available Upon Request

______________________________________________________________________________________ Tara S. Bender Harold Levine, D.O.

VOC Network Operations Liaison Interim VOC Medical Director

I. Purpose:

A. To ensure facility/organizational provider applicants meet ValueOptions of California (VOC) credentialing criteria.

B. This policy replaces ValueOptions, Inc. (VOI) policy N206.

II. Departments and Committee(s) Affected: A. VOC Credentialing Committee

B. VOC Quality Management Committee and Sub-committees C. VOC Network Operations

D. VOC Provider Relations E. VOI Network Operations

F. VOI Company Quality Council (CQC) and Sub-committees III. Policy:

It is the policy of ValueOptions of California that facility/organizational provider applicants must meet, at a minimum, the established credentialing criteria for network participation. In addition, applicants must demonstrate compliance with applicable licensure statutes and regulations.

IV. Procedures:

A. The following criteria apply to all facility/organizational providers serving the VOC network:

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

2. Possess professional liability coverage at a minimum level of $1,000,000 per episode and $3,000,000 aggregate. Submit a copy of current face sheet indicating the applicant as the insured, policy period, and coverage amounts.

3. Must meet acceptable criteria for malpractice claims history for the past five years – if applicable. When a judgment/settlement includes a confidentiality agreement or is pending, the applicant must provide a brief statement detailing the facts of the claim, the allegation, and the response of the applicant. The applicant must submit a corrective action plan that details areas of deficiency, action steps implemented, and relevant prevention initiatives. Refer to VOC Policy N404.VOC –

Practitioner/Provider Malpractice Insurance Coverage Status: Acceptable Malpractice History Criteria.

4. Accreditation from one of the following accrediting bodies: National Committee for Quality Assurance (NCQA), Joint Commission on Accreditation of Health Organizations (JCAHO); The Rehabilitation Accreditation Commission (CARF); Council on Accreditation (COA); American Osteopathic Association (AOA); or Accreditation Association for Ambulatory Health Care (AAAHC); or Community Health Accreditation Program (CHAP). When not accredited, a site visit review must be completed prior to the credentialing decision being made. Refer to VOC Policy N406B.VOC – Facility/Organization Site Visit.

5. Certification from Medicare or Medicaid, if applicable.

6. Drug Enforcement Administration (DEA) certification, if applicable. B. The following items must be submitted by all facility/organizational providers in

order to apply to or maintain participation in the VOC network:

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

2. A current malpractice insurance face sheet indicating the facility/organizational provider applicant as the insured, policy period, and coverage amounts.

3. Copies of all valid and applicable licensures, certifications, and accreditations.

4. A staff roster for non-accredited outpatient mental health and/or substance abuse clinics.

5. A copy of the Patient Bill of Rights and policies and procedures for handling patient complaints.

C. Program Specific Criteria:

All facility/organizational providers must meet the following criteria in order to participate in the VOC network, as applicable. Refer to VOC Policy N605.VOC – Exceptions to VOC Credentialing Criteria.

1. Inpatient Psychiatric

a. Must provide 24 hour/7 days per week skilled nursing staff. b. Must accept admissions 24 hours/7 days per week.

c. Must have written admission and discharge criteria.

d. Must provide medical diagnostic services on-site or by contract. e. Must provide a full range of treatment programming 7 days per

week.

f. Must provide individualized treatment plans.

g. Must provide emergency psychiatric/medical services on-site or by contract.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

VOC Network Operations Liaison Interim VOC Medical Director 2. Inpatient Detoxification

a. Must provide 24 hour/7 days per week skilled nursing staff. b. Must accept admissions 24 hours/7 days per week.

week.

h. Must require and/or encourage family involvement in treatment. i. Must provide structured recovery support groups.

j. Must have an Addictionologist either on staff or contracted or Medical Director must have three (3) years experience treating substance abuse patients as evidenced in resume.

k. Must receive oversight from a Medical Director. 3. Inpatient Substance Abuse Rehabilitation

a. Must provide 24 hour/7 days per week coverage by licensed staff. b. Must accept admissions 24 hours/7 days per week.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

VOC Network Operations Liaison Interim VOC Medical Director f. Must provide individualized treatment plans.

h. Must require and/or encourage family involvement in treatment. i. Must provide structured recovery support groups and aftercare. j. Must have an Addictionologist either on staff or contracted or

Medical Director must have three (3) years experience treating substance abuse patients as evidenced in resume.

k. Must receive oversight from a Medical Director. 4. Residential (Psych or CD)

a. Must provide 24 hour/7 days per week California licensed supervision of all residents.

b. Must provide a multi-disciplinary California licensed staff (i.e. social worker, counselors, nurses, etc.)

d. Must provide a full range of social and recreational therapies. e. Must provide individualized treatment plans.

f. Must provide a full range of treatment programming 7 days per week.

g. Must require and/or encourage family involvement in treatment. h. Must provide emergency psychiatric/medical services on-site or by

contract.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

VOC Network Operations Liaison Interim VOC Medical Director 5. Partial Hospitalization (Psych or CD)

a. Must be under the supervision of a California licensed physician. b. Must have written admission and discharge criteria.

c. Must provide physician medication management.

d. Staffing must include California licensed psychiatry, nursing, psychology, and social work.

e. Must provide chemical dependency education and treatment. (CD only)

g. Must provide a full program schedule to include individual and group therapy.

h. Must operate at least 3 – 5 days per week and at least a minimum of 6 hours per day.

i. Must receive oversight from a Medical Director. 6. 23 Hour Observation/Holding Bed

a. Must have a California licensed physician available 24 hours/7 days per week.

b. A California licensed physician on all admissions must conduct medical histories and physicals.

c. Must accept admissions 24 hours/7 days per week.

d. Must provide 24 hour/7 days per week skilled nursing staff. e. Must have a 24 hour emergency on-call staff.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

VOC Network Operations Liaison Interim VOC Medical Director 7. Ambulatory Detoxification

a. Must have written admission and discharge criteria. b. Must provide individualized treatment plans.

c. Must provide drug and/or blood alcohol level screens on-site or by a state licensed or certified lab.

d. Must have the ability to refer to a Medical Doctor for any health problem that may interfere with this service.

e. Must have emergency services available, if needed.

f. Must provide and/or encourage education and counseling for family members/significant others.

g. Must provide or make available any structured recovery support groups.

h. Must receive oversight from a Medical Director. 8. Intensive Outpatient (Psych or CD)

a. Must have a written program narrative. b. Must provide individualized treatment plans.

c. Must have written procedures for handling medical/psychiatric emergencies.

d. Must provide or make available any structured recovery support groups.

e. Must have the supervision of a California licensed behavioral health clinician.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

h. Must provide services at least 3 hours per day, 2 to 4 days per week.

9. Day Treatment (Psych or CD)

a. Must have written admission and discharge criteria.

b. Must have the supervision of a California licensed behavioral health clinician.

c. Must provide individualized treatment plans.

d. Must have a full program schedule to provide psychotherapy every day.

e. Must provide chemical dependency education and treatment (CD only).

f. Staffing must include California licensed nursing, psychology and social work.

g. Must provide services at least 4 hours per day, 5 days per week. 10. Halfway House

a. Must provide 24 hour/7 days per week supervision of residents. b. Must be compliant with after-care/continuing care.

c. Must provide or have access to a full range of educational, social and recreational therapies.

d. Must conduct criminal background checks on all staff. e. Must provide activities of daily living.

f. Must monitor for potential/suspected substance abuse via random urine drug screens.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

h. Must have emergency psychiatric/medical services available either on site or by agreement.

i. Must have oversight by a director who is a California licensed clinician.

11. Methadone Maintenance Program

a. Must have oversight by a California licensed physician.

b. Staff must include California licensed clinicians with diagnostic skills to identify co-existing psychiatric disorders and implement appropriate treatment plans.

c. Must have access to California licensed psychologist, social workers and nurses when needed.

d. Staff must have at least one year of experience working with opioid abusing population.

e. Must have on-site medical services or the availability of immediate referrals.

f. Program must include the following components: i. medical history and physical exams ii. psychosocial assessment

iii. counseling and education programs iv. relapse prevention element

v. random urine toxicology testing

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

h. Must provide treatment at least one time per week based on consumer need.

12. Treatment Group Home

a. Must provide 24 hour/7 days per week supervision of residents. b. A California licensed mental health practitioner must supervise all

staff.

c. Must provide or have access to a full range of educational, social and recreational therapies.

d. Must conduct criminal background check on all staff.

e. Must provide or have access to a full range of treatment programming 7 days per week.

g. Must require and/or encourage family involvement in treatment. h. Must have emergency psychiatric/medical services on-site or by

contract.

i. Must receive oversight from a Medical Director. 13. Treatment/Therapeutic Foster Care

a. Must be licensed as a child placement agency.

b. Must perform criminal background checks on staff and treatment parents.

c. Must use specially trained staff to implement treatment model. d. Must have a written policy explaining the procedures and criteria

for treatment parent selection.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

f. Must have written policies and procedures for handling psychiatric and/or medical emergencies.

g. Must require family involvement in treatment.

h. Must provide 24 hour on-call crisis intervention services. i. Must receive oversight from a licensed Program Director. 14. Home Health

a. Must provide individualized treatment plans.

b. Must have crisis intervention available 24 hours/7 days per week. c. Must have specially trained home health workers providing care. d. Must conduct criminal background checks on all in-home staff. e. Must have a written narrative of services.

f. Must have medical/nursing supervision.

g. Must receive oversight from a Medical Director. 15. Respite Care

a. Must have written policies explaining the procedures and criteria for

1. respite provider training and selection.

b. Must have specially trained staff to implement treatment plans. c. Must provide medical consultation 24 hours/7 days per week. d. Must provide 24 hour/7 days per week supervision of residents. e. Must have written procedures for handling psychiatric/medical

emergencies.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

g. Must receive oversight from a California licensed clinician. 16. Outpatient Mental Health and/or Substance Abuse Clinic

a. Must have a governing body and an organized professional staff. b. Must have or have a formal contract with a multi-disciplinary staff

that includes at least one California licensed psychiatrist, one California licensed psychologist (psychologist must also be licensed to perform psychological testing) and at least one California licensed masters or doctoral level mental health clinician.

c. Must have written credentialing criteria for all clinical staff. d. Must have criteria for admissions, screening and referral. e. Must provide comprehensive individualized treatment plans. f. Must provide 24 hour/7 days per week coverage for crisis

assessment/intervention.

g. All non-licensed staff must have direct clinical supervision by California licensed staff; non-licensed staff may not provide the predominant portion of any major intervention modality, other than educational services.

h. Must have written quality improvement program.

i. Must receive oversight from a California licensed behavioral health professional.

j. All billing must be under the clinic’s name and tax identification number.

k. Must have centralized intake and billing.

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

VOC Network Operations Liaison Interim VOC Medical Director 17. Eating Disorders

NOTE: Services can be provided at different levels of intensity, including inpatient, structured outpatient, or partial hospital, depending on the clinical needs of the patient.

a. Must provide the following program components: i. Initial medical evaluation and follow-up

ii. Initial psychiatric evaluation and follow-up, when indicated iii. Psycho education program and self-growth activities

iv. Family educational program v. Nutritionist consultation

vi. Individual, group, family therapy for eating disorders vii. Self-help programs, if appropriate

viii. Psychological testing, if indicated ix. Aftercare program

x. Individualized treatment programs.

b. Must offer separate treatment programs for adult and adolescent patients.

c. Program must be sufficient length (1-12 months) with graded levels of intensity to address relevant medical/psychiatric issues. d. Must have or have a formal contract with a multi-disciplinary staff

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

e. A California licensed professional, who has training and expertise in the treatment of eating disorders, including 3 years of experience in the field, must supervise the program.

f. Program must have a California licensed non-psychiatric physician on staff, or by formal contract, who provides adequate medical coverage to meet patient care requirements.

g. Must have emergency medical services available, either on site or by contract with a JCAHO facility.

h. Must receive oversight from a Medical Director. 18. Dual Diagnosis

NOTE: Services can be provided at different levels of intensity, including inpatient, structured outpatient, partial hospital, residential, day treatment, or outpatient, depending on the clinical needs of the patient.

a. Must be under Medical Director supervision. b. Must provide the following program components:

i. Access to individual, group and family therapy

ii. Access to full education program for children and adolescents, if applicable

iii. History and physical within 24 hours of admission iv. Focus on individualized treatment vs. fixed programs v. Discharge planning

vi. Disease model based CD education and self-growth activities

vii. Medication Management

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

ix. Regular plan for blood and/or urine screens, as clinically indicated

x. Access to family program (education and therapy)

xi. Aftercare program, a minimum of one year, including monthly random urine drug screens

c. Program staff must include or have a formal contract with California licensed psychologists, social workers, counselors, marriage and family therapist, and Board certified psychiatrists. d. Must have 24 hour on-site nursing coverage (inpatient only)

e. The following requirement applies to inpatient services only. If the facility provides disposition services (i.e. a dispositional bed contracted to allow for a patient with decreased symptom acuity to remain at the facility for continued, brief observation until they are transitioned to another level of care), then there must be 24-hour on-site nursing coverage. “Dispositional beds” are required to meet all of the above criteria.

19. Pathological Gambling

NOTE: Services can be provided at different levels of intensity, including inpatient, structured outpatient, partial hospital or outpatient, depending on the clinical needs of the patient.

a. Must be under Medical Director supervision. b. Must provide the following program components:

i. Focus on individualized treatment vs. fixed programs ii. Active family involvement

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

iv. Education program (Disease Model) and self-growth activities

v. Family Program (educational and therapy) vi. Individual, group and family therapy vii. Continuing care (aftercare) program viii. Relapse program

ix. Structured recovery support groups x. Restitution program

xi. Financial planning

c. Must have a designated Program Director who has completed one year of full time equivalent work experience in the treatment of pathological gambling.

d. Staff must include California licensed psychologist, counselors, social workers and nurses.

e. Program must meet at least 3 times per week in the intensive phase, for a minimum of 9 hours per week.

20. Crisis Intervention

a. Program is part of a facility accredited by JCAHO as a hospital or as a health care organization that provides psychiatric services to adults or children/adolescents, or

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

Program is licensed or holds a certificate of compliance from California, and meets all applicable federal, state, and local laws and regulations.

b. Must provide 24-hour accessibility/availability, 7 days a week, 365 days a year.

c. Services may be provided through emergency inpatient admission, emergency shelters, hot lines, walk-in intervention, crisis

residential services and mobile crisis teams.

d. Must attest to a formal written agreement with a provider of inpatient services, 23 or 24-hour observation/residential services for emergency medical and psychiatric care.

e. Service operates without restrictions to sex, race, religion, creed, or national origin.

f. Service is part of a program that has an organized quality monitoring/improvement program.

g. Program must provide the following: i. Crisis evaluation

ii. Crisis intervention and management

iii. Coordination of care with other known providers of care to individual enrollees

iv. Disposition and referral to appropriate treatment-setting including “bed finding”.

v. Emergency medication management or referral

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

i. California licensed nursing staff and other California licensed mental health professionals (minimum of one in a supervisory role).

j. Combination of mental health workers and other appropriately trained staff (e.g., paraprofessional, psychiatric technicians). 21. Crisis Stabilization Unit

a. Program must be part of a JCAHO accredited hospital or health care organization that provides psychiatric services, or

Program is part of a facility accredited by AOA, TRICARE, or CARF or COA accredits the program itself, as an

observation/holding bed program that provides psychiatric services.

b. Program must meet California state licensure/certification and Medicaid requirements (as applicable).

c. Program must meet all applicable federal, state and local laws and regulations.

d. Program must attest to a formal written agreement with JCAHO accredited provider for emergency psychiatric, substance abuse, and/or medical care if such care is not available on site.

e. Program has a written quality monitoring/improvement program. f. Program operates without restrictions to sex, race, religion, creed,

or national origin.

g. Program must provide the following: i. Safe, secure environmental setting

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

iii. Ability to recognize need for psychiatric or substance abuse screening or evaluation as needed.

iv. Emergency medication management

v. Access to a California licensed psychiatrist 24-hours per day, 7 days per week.

vi. Initial assessment and treatment plan focused on stabilizing and resolving the crisis situation.

vii. Discharge/disposition planning including the development of a crisis relapse plan.

h. Access to a board certified California licensed psychiatrist 24-hours per day, 7 days per week.

i. Combination of California licensed mental health professional, mental health workers and other appropriate paraprofessional staff. 22. Psychiatric Residency Training Programs

a. The training program must provide the accreditation number given by the Accreditation Council of Graduate Medical Education to confirm accreditation.

b. The organization agrees to accept the standard fee schedule for outpatient therapy.

c. Patients must be informed of their psychiatrist’s status as trainees. This will be documented in the case file.

23. EAP Services

a. Must have a governing body and organized professional staff b. Must have a multi-disciplinary staff that includes at least one

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Last Review Date: 11/10/2003, 10/11/2004, 6/6/2005, 8/1/2005, 1/30/2006, 6/19/2006, 12/04/2006, 7/2/2007, 8/13/2007

c. All outpatient professional services provided must be billed under the organization’s name and tax identification number.

d. Must provide the following program components: i. Written credentialing criteria for all clinical staff ii. Written criteria for admissions, screening, and referrals iii. 24 hour/7 day coverage for crisis assessment/intervention iv. Centralized intake and billing