HomeMy WebLinkAboutMINUTES - 02281995 - 2.3 : BOARD OF SUPERVISORS
FROM: Mark Finucane, Health Services Director Contra
Costa
DATE: February 16, 1995 County
SUBJECT: Approval of Drug/Medi-Cal Contract with the State Department of Alcohol and
Drug Programs for FY 94-95
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Chair, Board of Supervisors, to execute on behalf of the
County, Standard Agreement #29-489 (known as the Drug/Medi-Cal [D/MC] Contract) with
the State Department of Alcohol and Drug Programs, in the amount of $1,972,388, for
the period from July 1, 1994, through June 30, 1995, for provision of Drug/Medi-Cal
Substance Abuse Treatment Services to Medi-Cal beneficiaries.
II. FINANCIAL IMPACT:
This Contract is funded by State General Funds and Federal Medi-Cal Funds, with no
County funds required, in FY 1994-95, as follows:
State Federal
General Funds FFP Funds
DRUG MEDI-CAL SERVICES (D/MC Match) (Medi-Cal) Total
Drug Treatment Services $ 856,246 $ 856,246 $1,712,492
Perinatal Treatment Services 129,948 129,948 259,896
TOTAL FY 94-95 FUNDING $ 986,194 $ 986,194 $1,972,388
If the $986,194 in State General Funds is insufficient to finance needed Drug/Medi-
Cal services and to provide the needed match to Federal Financial Participation
(FFP) .in FY 94-95, then the County must utilize "all available (allocated) State
General Funds for the purposes of D/MC match" as specified in the D/MC Contract's
Fiscal Provisions; State staff interpret this Contract provision to mean that the
County will be required to reduce the State funding in our pre-existing Negotiated
Net Amount (NNA) Contract #NNA07-94 (County #29-488) with the State in order to be
able to fund any needed amendment to the D/MC Contract #29-489, leaving the County
at risk for the cost of NNA Contract services that are financed by State General
Funds which are in jeopardy of being shifted to the D/MC Contract. We currently
expect State Funds to be allocated to Contra Costa County for FY 94-95 as follows:
Pending Current
ALLOCATION OF STATE FUNDS D/MC Contract NNA Contract
TO CONTRA COSTA COUNTY #29-489 #29-488 Total
Current State Funds $ 986,194 $ 612,594 $1,598,788
Pending Contract Amendment -0- 599,195 599,195
TOTAL FY 94-95 STATE FUNDS $ 986,194 $1,211,789 $2,197,983
Total .FY 93-94 State Funds $2,335,194
Current Funding Reduction <$ 137,211>
CONTINUED ON ATTACHMENT: XX YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON KIM 9 R M5 APPROVED AS RECOMMENDED, ✓ OTHER
VOTE OF SUPERVISORS
_ZUNANIMOUS (ABSENT ) 1 HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: _ ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact.: Chuck Deutschman (313-6350) FEB 2 8 1
CC: Health Services (Contracts) ATTESTED
State Dept. of Alcohol and Drug Programs Phil Batchelor, Clerk of the Board of
SupwvWjs aW County Administrator
M382/7-83 BY DEPUTY
u r^v
D/MC Contract
#29-489
Page 2
At present the State has withheld $137,211 from Contra Costa County as part of a
$5.2 Million "Contingency Reserve" which the State has formed by withholding funds
from counties across the State. The State will reportedly use this Contingency
Reserve to finance increases in the costs for Drug/Medi-Cal services (considered to
be a Medi-Cal beneficiary "entitlement" service) . Any unspent amount in the
Contingency Reserve will be redistributed to the contributing counties on the same
basis it was withheld. If Contra Costa County does have a cost increase and the
$986,194 in State General Funds presently allocated in the D/MC Contract is not
sufficient, we will be required somehow by the State, according to State ADP staff,
to shift needed funds from the $1,211,789 in State Funds presently allocated in the
NNA Contract to the D/MC Contract to provide the needed State Matching Funds for
Federal Financial Participation (FFP) . After all of the State General Funds which
are "available" in the NNA Contract have been shifted to the D/MC Contract, then the
County would be "eligible" to apply to the State for additional funding from the
State's $5.2 Million "Contingency Reserve". This will leave the County at risk for
financing the cost of any NNA Contract services which were financed by any State
General Funds that were shifted to the D/MC Contract. Consequently, our previous
report to the Board that the NNA Contract would allow the County to retain the
entire NNA Contract amount of funding, in exchange for providing a specified
"dedicated capacity" or amount of service, appears to no longer remain true,
according to the interpretations of State ADP staff.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
This is a new; first-time Contract for the County and it represents part of the
State's new method for doing business with the counties (abandoning the Allocation
Letter and Annual Plan process of previous fiscal years) . This particular Contract
is unusual with respect to the high level of uncertainty and open-endedness in
provisions which make the County responsible for many circumstances over which the
County has little or no control. For example, this Contract obligates the County:
(1) to be responsible for the cost of all D/MC services, "including amounts paid for
D/MC services by Medi-Cal beneficiaries" , over whom the County has little control;
(2) to comply with the Federal District Court "Order for Permanent Injunction"
issued in Sobky v. Smoley; (3) to contract with all D/MC service providers within
the County service area who are certified by the State now and in the future; (4)
to "maintain continuous availability and accessibility of covered services,
facilities, service sites, and personnel. . . [and such services] shall not be
artificially limited due to budgetary constraints"; (5) to provide covered services
"either directly. . .or through subcontracts with private programs, in the County
service area. . .to Medi-Cal beneficiaries without regard to the beneficiaries' county
of residence"; and (6) to "amend County/subcontractor contracts to provide
sufficient State General Funds to match allowable federal Medicaid reimbursements
for any increase in provider [contractor] D/MC services to Medi-Cal beneficiaries. "
Also noteworthy is the unusually lengthy advance notice requirement for termination.
While the NNA Contract has a standard 30-day advance notice requirement, this D/MC
Contract has a 60-day advance notice requirement and the County's termination can
only take effect "on the last day of the second calendar month following the month
in which the notice was given" . Consequently, if the Board chooses to terminate
this Contract on May 31st, the Board would have to take the action to do so in time
to deliver the notice to the State before March 31st, i.e. , sometime within the next
6 weeks; short of that, the County cannot terminate the Contract prior to the June
30th expiration date. And lastly, the Contract also states that "The State is under
no obligation to renew this contract for any reason" .
Approval of this Contract is necessary in order for the County to continue to
receive this funding. If the County declines to accept this Contract, the State
will revoke the needed State General Funds from the County and will contract
directly with D/MC providers.
The Board Chair should sign eleven copies of the Agreement. Ten copies of the
Agreement and three certified/sealed copies of this Board Order should be returned
to the Contracts and Grants Unit.
VAe Eaw,-4
STPJE OF C_'.LIFORNIA—HEALTH AND WELFARE AGENCY PETE WILSON, Governor
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS 1
1700 K STREET
SACRAMENTO, CA 95814-4037
TTY (916) 445-1942
REC��1995
Chuck Deutschman, MFCC 0% 0 - RECEIVED
Contra Costa County coG BAR 3 1 1 �
Health Services Department APR 21g�5 .
597 Center Ave. , Ste. 320
Martinez, CA 94553-4639
CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
CONTRACT NUMBER: DMCC07-94
1 . Submitted for your signature is one (1) complete copy of the above
referenced contract and eight (8) copies of the contract face sheet.
Please have the individual authorized by your County Board of Supervisors
sign the contract face sheets. Initials or rubber-stamped signatures are
not acceptable. Include authority to sign if other than the Chairman of
the Board signs the contract.
2. The one (1) complete copy of the contract may be retained as a temporary
record of this Agreement. Please return the eight (8) signed copies of
the contract face sheet as soon as possible to:
Margret Davis, Contracts Office
1700 X" Street, 5th Floor
Sacramento, CA 95814-4037
3. Please return, with the signed contract face sheets, a copy of the
resolution, board minutes, order, motion, or ordinance from the County
Board of Supervisors which specifically approves and authorizes execution
of this contract.
4. Inquiries concerning contract services , reporting or payments should be
directed to:
Anita Cabrera , County Analyst, (916) 323-0307
5. Enclosed are the county's copy and the Board of Supervisors ' copy of the
approved contract.
MARGRET DAVIS NOTE: If contract contains pages which are
Contracts Office flagged, these pages include footnotes
(916) 323-5709 where changes have been made to the
proposal.
Enclosures
cc: John Rodriquez, DHS**
Anita Cabrera , County Analyst*
ADP Contracts Office*
ADP Accounting (2)**
ADP County Operations Branch**
J9.6Unty Clerk of the Board**
* Pending and approved contract
**Approved contract only
T— ATTORNEY BY THE
CONTRACT NUMBER
STANWr,AD AGREEMEN
AM.NO.
ATTORNEY GENERAL DMC07-94
STD.2(HpV.4-Yi1.I
TA)(PAYEn FEDERAL EMPLOYER IDENTIFICATION NUM_E=
THIS AGREEMENT,made and entered into this 1st day of July ,19 94 94-6000509
in the State of California,by and between State of California,through its duly elected or appointed,qualified and ac" g
TITLE OF OFFICER ACTING FOR STATE AGENCY — 489
DEPUTY DIRECTOR, DIV. OF ADMIN. HEALTH SERVICES DEPARTMENT
hereafter called the Slate, and
CONTRACTOR'S NAME
COUNTY OF CONTRA COSTA ,hereafter called the Contrac:o
WITNESSETH: That the Contractor for and in consideration of the covenants,conditions,agreements,and stipulations of the State hereinafter expresso.
does hereby agree to furnish to the State services and materials as follows: (Set forth service to be rendered by Contractor,amount to be paid Contractor.
time for performance or completion,and attach plans and specifications,if any.)
Whereas, the Department of Alcohol and Drug Programs (hereinafter referred to as
the State) by authority of an Interagency Agreement with the Department of Health
Services administers the Drug/Medi-Cal Program;
Whereas, such agreements are authorized and provided for by the provision of
Welfare and Institutions Code Section 14021.5(c) ;
Therefore, the State and the above-referenced Contractor enter into the following
Agreement in the amount of $1,972,388 for the 1994-95 fiscal year commencing on
July 1, 1994 and ending on June 30, 1995.
The above-referenced encumbered amount may be increased or decreased by an
amendment to the contract to adjust that amount to actual allowable costs
approved by the Department of Health Services and the State Department of
Finance.
APPROVED
17 1
CONTINUED ON SHEETS, EACH BEARING NAM OF COQ€pAET£JRrAND)CONRA-C�MUMBEA.
The provisions on the reverse side hereof constitute a part Phisagree �WL96t Di vi s i_nx'. IJy =?a Y
IN WITNESS WHEREOF,this agreement has bcen executed by—tfic paru`es`hczerc—upon-the date first-above written.
STATE OF CALIFORNIA CONTRACTOR
AGENCY CONTRACTOR(It other than an individual,state whether a corporation,pannersn'p.etc.)
ALCOHOL & DRUG PR RAMS HEALTH SERVICES COUNTY OF CONTRA COSTA
BBYY(AUTH IGNATURE) Z;� BY(AUT RILED SIGNA E} -
D
PRIAD D NAME OF PERSON SI PRINTED N ME AND TITLE OF PE,7 N SIGNING
CHARD FRANTZ JOHN RODRIGUEZ Chair, Board of Supervisors
TITLE epU y DirectorvDeputy Direct or ADDRESS
Administration Medical Care Services 651 Pine Street, Martinez, California 94553
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY(CODE AND TITLE) FUND TITLE Department of General Services
DOCUMENT Local Assistance Gen/Reimb. Use Only
Q
`p (OPTIONAL USE)
TPRIOR AMOUNT HIS
DFORHIS CONTRACTDrug/Medi -Cal This contract exempt
$ -0- ITEM CHAPTER STATUTE FISCAL YEAR from Dept. of General
TOTAL AMOUNT ENCUMBERED TO 4200-101/102-001 , 139 1994 94/95 Services per Welfare
DATE OBJECT OF EXPENDITURE(CODE AND TITLE) and Institutions Code
$ 1,972,388.00 See attached funding information Section 14087.4
1 hereby certify upon my own personal knowledge that budgeted funds T.B.A.NO. B.R.NO.
are available for the period and p00s of the expenditure stated above.
NATURE OF ACCOUNTWG OFFI pA� �
CONTRACTOR STATE AGENCY DEPT.OF GEN.SER. CONTROLLER
County: Contra Costa Contract No. DMC07-94
Object of Expenditure (Code and Title)
FY 1994-95
$ 856 , 246 7000-59410-705 (SGF Allocation)
$ 0 (SGF Reserve Accessed)
$ 856 , 246 7000-59494-705 (FFP Reimbursement)
$ 129 , 948 7000-59411-705 (Perinatal SGF Allocation)
$ 0 (Perinatal Reserve Accessed)
$ 129 , 948 7000-59495-705 (FFP - PTEP Reimbursement)
$ 1 , 972 , 388 TOTAL AMOUNT
(revised 12-05-94)
" 1
TERMS AND CONDITIONS
STATE GENERAL FUNDS and FEDERAL MEDICAID FUNDS
for
DRUG/MEDT-CAL SUBSTANCE ABUSE TREATMENT SERVICES
ARTICLE I. DEFINITIONS
As used in this contract, the following definition of terms will apply:
A. Administrative costs means the County's indirect costs necessary to sustain the direct
effort involved in administering the Drug/Medi-Cal (hereinafter referred to as D/MC)
program or an activity providing service to the D/MC program. Administrative costs
do not include the cost of treatment or other direct services to the beneficiary.
.Administrative costs may include the cost of training, utilization review, and billing
related services.
B. Beneficiary means any person certified as eligible for Medi-Cal services.
C. County means the county identified in Article 11, Section A.
D. Covered services means outpatient drug free treatment, methadone maintenance, day
care habilitative, Naltrexone, and perinatal residential substance abuse treatment
services.
E. Day means calendar day.
F. Day care habilitative means an outpatient service, of at least three,(3) or more hours,
but less than 24 hours, throughout the day at least three (3) days a week, directed at
stabilization and rehabilitation of Medi-Cal beneficiaries with substance abuse
impairments.
G. Drug/Medi-Cal eligible, beneficiary means any Medi-Cal beneficiary who is not
prohibited from benefits under federal law by virtue of institutionalization, who has a
DSM-111-R and/or a DSM IV diagnosis related to substance abuse, and who meets the
admission criteria for the covered services in this contract.
H. Drug/Medi-Cal Program means the State system wherein eligible beneficiaries receive
covered services from substance abuse treatment programs who are reimbursed for
the services with State General Funds and federal Medicaid funds.
1. Final settlement means the final settlement of actual allowable expenditures based
upon the completion of an audit.
J. Interim payment means the monthly projected payment from the State to the County
for providing and/or arranging for the covered services in this contract.
K. Interim settlement means the temporary settlement based on actual expenditures
reflected in the year-end cost report.
r .
L. Medical necessity means substance abuse treatment services which are reasonable and
necessary to protect life, prevent.significant illness or disability, or alleviate severe
pain through the diagnosis and treatment of a disease, illness or injury.
M. Methadone maintenance means an outpatient service including, but not limited to, the
dispensing of a narcotic drug, directed at stabilization and rehabilitation of Medi-Cal
beneficiaries who are dependent on heroin or other morphine-like drugs.
N. Naltrexone means an outpatient service directed at stabilization and rehabilitation of
Medi-Cal beneficiaries who are narcotic dependent by using the drug Naltrexone to
block the effects.of heroin and other narcotics or opiates.
O. Outpatient drug free means an outpatient service directed at stabilization and
rehabilitation of Medi-Cal beneficiaries with substance abuse impairments.
P. Perinatal residential means treatment services, not including costs associated with
room and board, directed at stabilization and rehabilitation of pregnant, post- partum,
and parenting Medi-Cal beneficiaries with substance abuse impairments who live on
the premises of the facility.
Q. Projected units of service means the number of reimbursable D/MC units of service the
County expects to provide during each month based on historical data.
R. Provider of services means any individual, partnership, clinic, group, association,.
corporation, institution, or public agency which provides direct substance abuse
treatment services and is certified by the State as meeting applicable standards for
participation in the D/MC Program as defined in the Certification Standards for
Substance Abuse Clinics.
S. Service area means the geographical area under the jurisdiction of the County wherein
the eligible beneficiaries will have access to D/MC covered services.
T. State means the State Department of Alcohol and Drug Programs.
U. Subcontractor means an organization who enters directly or through another sub-
contractor into an agreement with the County to furnish any of the administrative
functions related to fulfilling the obligations under the terms of this contract and/or to
provide covered services to eligible beneficiaries.
V. Subcontract means any agreement,between the County and the subcontractor entered
into for the purpose of providing direct services to the beneficiary.
W. Unit of service maximum rate means the maximum.amount paid by D/MC for each
face-to-face service-contact per day per beneficiary. If return visits are necessary,
they shall not be duplicative and they shall be clearly documented in the beneficiary's
record.
X. UtUlzation review means a documented formal process to review quality of care,
medical necessity of treatment, and appropriateness of D/MC reimbursements for
services provided.
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ARTICLE II. PURPOSE OF THE CONTRACT
A. This agreement is entered into by and between the State and County of Contra Costa
for the purpose of identifying and providing for covered D/MC services for substance
abuse treatment in the County service area pursuant to Sections 11987.3 and
1 1987.5(b)and (c) of the Health and Safety Code (hereinafter referred to as HSC) and
consistent with the Interagency Agreement between the Department of Health Services
(hereinafter referred to as DHS) and the State.
B. It is understood and agreed that nothing contained in this agreement shall be construed
to impair the single state agency authority of DHS as set out in Welfare and Institutions
Code Section 14100.1.C.
C. The objective of this contract is to make available substance abuse treatment services
to Medi-Cal beneficiaries through utilization of Title XIX (Social Security Act)
reimbursable covered services offered by certified D/MC service providers, without
abrogating the beneficiary's right to seek substance abuse treatment services from
other qualified non D%MC providers.
ARTICLE III. TERMS OF CONTRACT
A. This contract will cover the cost of all D/MC services to Medi-Cal beneficiaries,
including amounts paid for D/MC services by Medi-Cal beneficiaries, for the period
commencing from July 1, 1994. This contract will continue in full force and effect
through June 30, 1995, subject to the provisions of Section III.E. herein. The State
has funds currently appropriated and available for encumbrance only to cover costs
through June 30, 1995. The State is under no obligation to renew this contract for
any reason.
B. This contract is subject to the review and approval of DHS and the State Department
of Finance.
C. In the event that any provision of this contract is held invalid or unenforceable by any
court of competent jurisdiction, the holding will not invalidate or render unenforceable
any other provision hereof.
D. This contract may be amended at any time by mutual written agreement of the parties.
An amendment proposed by one party shall be forwarded in writing to the other party.
The proposal will include a detailed explanation of the reason and basis for the
proposed change, a complete statement of cost, and the text for the desired
amendment to this contract. A response accepting or rejecting the amendment will be
made by the other party in writing within 30 days. If the proposed amendment is
accepted, the contract will be amended to provide for the change mutually agreed to
by the parties, on the condition that the amendment is approved by DHS and the State
Department of Finance.
E. This contract may be terminated by either party by delivering written notice of
termination to the other party at least sixty (60) days prior to the effective date of
termination. The notice of termination will state the effective date of and reason for
the termination.
3
1. The State may terminate performance of work under this contract in whole, or
in part, whenever for any,reason the State determines that the termination is
in the best interest of the State. If the State determines the health and welfare
of beneficiaries receiving dovered services are jeopardized by continuation of
this contract, the contract will be immediately terminated.
2. The County may terminate this contract at any time by giving written notice to
the State. The termination will become effective on the last day of the second
calendar month following the month in which the notice was given.
.3. In the event the federal Department of Health and Human Services (hereinafter
referred to as DHHS), DHS, or the State determines the County does not meet
the requirements for participation in the D/MC program,the State will terminate
this contract in accordance with this section. The State will not be obligated
to pay the County for any services performed subsequent to the date of
termination of this contract. This payment obligation will cease
notwithstanding the , County's appeal of the termination under any
administrative proceedings or any remedy at law. The County hereby waives
all requests and claims for the continuation of payment pending the outcome
of any and all of these appeals.
4. All obligations to provide covered services under this contract will automatically
terminate on the effective date of any termination of this contract. The County
will be responsible for providing or arranging for covered services to
beneficiaries until the termination or expiration of the contract. The County will
remain liable for processing and paying invoices and statements for covered
services and utilization review requirements prior to the expiration or
termination until all obligations have been met.
ARTICLE IV. PROVISION OF SERVICES
A. Covered Services
1. The County shall establish assessment and referral procedures to arrange,
provide for, or subcontract for, the provision of substance abuse treatment
covered services for eligible Medi-Cal beneficiaries in need of such services in
the County service area in accordance with the terms of the County "Proposal"
which is attached hereto as Exhibit A and incorporated by this reference.
Covered services may include:
a. methadone maintenance;
b. outpatient drug free treatment;
C. day care habilitative;
d. Naltrexone treavyllik and
e. perinatal residential treatment services. _ -
2.1 In the event of a conflict between the description of services defined in Article
I.of this contract and the description of services,in Sections 51341 and 51516
of Title 22 of the California Code of Regulation (hereinafter referred to as CCR),
the provisions of Title 22 shall govern.
4
B. Federal and State Mandates
1. The County, to the extent-applicable, shall comply with Exhibit B "Order for
Permanent Injunction" signed August 19, 1994, in Sobkv v. Smolev, United
States District Court, Eastern District of California, No. Civ. S-92-613 DFL GGH,
consisting of seven (7) pages, attached hereto and incorporated by this
reference.
2. The County shall comply with, and the contract shall be amended to
reflect, any additional legal requirements including any court ordered
requirements enacted subsequent to the execution of this contract.
3. The County shall contract with all existing D/MC certified providers, and
with all newly certified D/MC providers within the County service area
unless the County has a waiver under Section 1915b of the Social Security Act.
4. The County shall maintain continuous availability and accessibility of covered
services, facilities, service sites, and personnel to provide the covered services
in the County service area. Such services shall not be artificially limited due to
budgetary constraints.
a. When a request for covered services is made by an eligible beneficiary,
the County shall require services to be initiated with reasonable
promptness.
i. The. County will have a documented system for monitoring and
evaluating accessibility of care,including a system for addressing
problems that develop regarding waiting times and appointments.
ii. The County shall comply and the County shall require that
subcontractors comply with Exhibits C1 and C2, the "Provider
Waiting List Record" and the "Drug and Alcohol Treatment
Access Report" consisting of two (2) and two (2) page(s)
respectively, samples of which are attached hereto and
incorporated by this reference. Beneficiary specific information
from Exhibit C1 shall be incorporated as aggregate data in Exhibit
C2. Exhibit C2 shall be submitted to the State monthly, by the
tenth of each month following the month for which the data is
collected.
iii. The County shall comply and the County shall require that
subcontractors comply with Exhibits C3, the "California Alcohol
and Drug Data System" (CADDS) ADP 7360 consisting of one
page, and C4, the "California Alcohol and Drug Data System
Provider Summary Report" ADP 7365 consisting of two (2)
pages,samples of which are attached hereto and incorporated by
this reference. Exhibits C3 and C4 shall be submitted in
accordance with the instruction manual which will be provided to
the County by the State.
5
b. The County shall require that treatment programs are accessible to the
disabled.
5. Covered services, provided either directly by the County or through
subcontracts with private programs, in the County service area will be provided
to Medi-Cal beneficiaries without regard to the beneficiaries' county of
residence.
6. In the event the County fails to comply with Subdivision 1 through 5 of this
Section, the State may exercise its rights under Subdivision 12.
7. The County shall obtain State approval prior to reducing the provision of
covered services to be provided in the County service area under this
contract. In addition, a proposal to change the location for the provision
of covered services, or to reduce their availability shall be given to the
State sixty (60) days prior to the proposed effective date.
a. Implementing the proposed changes are prohibited if the State denies
the County's proposal to make changes. ..
8. The County shall report to the State any projected increase in services by
submitting Exhibit D, ADP 7995, "Estimated New Service Provider Costs",
consisting of two (2) pages, attached hereto and incorporated by this reference.
9. The County shall amend County/subcontractor contracts to provide sufficient
State General Funds to match allowable federal Medicaid reimbursements for
.any increase in provider D/MC services to Medi-Cal beneficiaries.
10. The County shall require that providers of D/MC treatment services comply with
the requirements contained in the Perinatal Services Guidelines. The County
shall submit to the State:
a. Exhibit E, "Perinatal Services Monthly Report", consisting of.two (2)
pages, attached hereto and incorporated by this reference. Exhibit E is
to be submitted monthly to the State, no later than 30 days after the
last day of the reporting month.
b. Exhibit F, "ADP Perinatal Services Supplemental Infant Data Form",
consisting of two (2) pages, attached hereto and incorporated by this
reference. Exhibit F is to be completed for all women delivering while
in case management and recovery and treatment services and shall be
submitted monthly to the State no later than 30 days after the last day
of the month following the infant's birth month.
11. The County shall comply and the County shall require that subcontractor(s)
comply with all terms and conditions of this contract and all pertinent State and
federal regulations. The State, DHS,DHHS, Comptroller General of the United
States, or other authorized state agencies and representatives will be allowed'
to inspect or otherwise evaluate the quality, appropriateness, and timeliness of
services performed under this contract. Any and all books, records, and
facilities maintained by the County, and subcontractor(s) related to these
6
services, may be audited at any time during normal business hours.
Unannounced visits may be made by the State at the discretion of the State.
12. Any County failing to provide covered services in accordance with federal or
state statutes and regulations or in accordance with the provisions of this
agreement shall risk forfeiture of the D/MC State General Fund allocation and
surrender its authority to function as the administrator of covered services in
the County service area. Any failure to comply with Section B, Subdivision 3
of this Article will be deemed a breach of this contract sufficient to terminate
this contract in accordance with Article III, Section E.
C. Provider Participation, Certification, Recertification, and Appeals
1. The State shall review and certify the providers to participate in the D/MC
Program. Certification agreements will not be time limited; however, the
providers shall be reviewed for recertification at least every two years.
a. The "Appeal Processes" (later identified as Exhibit M) shall be included
in the County/subcontractor contract to notify the provider of the appeal
process in the event the State disapproves the provider's request for
certification or recertification.
b. The County shall include a provision -in the County/subcontractor
contract notifying the provider that assistance may be sought from the
State in the event of a dispute over the terms and conditions of. the
County/subcontractor contract in accordance with the "Appeal
Processes" which shall be incorporated into the County/subcontractor
contract.
2. The County shall require that the providers of services are licensed, registered,
certified and approved as required by the appropriate agencies. Where
applicable, the County shall require as a condition of County/subcontractor
contracts, that providers comply with:
a. 21 Code of Federal Regulations (CFR) Parts 291 and 1300, et seq. and
California Code of Regulations (CCR), Title 9, Sections 10,000 et seq.
b. Drug/Medi-Cal Certification Standards for Substance Abuse Clinics,
attached as Exhibit G, consisting-of fourteen (14) page(s), attached
hereto and incorporated by this reference.
C. Drug/Medi-Cal Utilization Control Plan,attached as Exhibit H, consisting
of forty-four (44) pages(s), attached hereto incorporated by this
reference.
d. Standards for Drug Treatment Programs, attached as Exhibit J,
consisting of nineteen (19) pages, attached hereto and incorporated by
this reference.
7
i v
3. If at any time the provider's license, registration, certificate, or approval to
operate a substance abuse treatment program is revoked, suspended, modified, ,
or not renewed, the State may amend this agreement as described in Article III,
Section D. herein.
D. Discrimination Prohibition
1. The County will not discriminate and the County shall include within
County/Subcontractor contracts that Subcontractors will not discriminate
against eligible beneficiaries because of race, color, creed, national origin, sex,
age or physical or mental disability as provided by state and federal law and in
accordance with Title VI of the Civil Rights Act of 1964 (42 USC § 2000(d);
the Age Discrimination Act of"1975 (42 USC § 6101); the Rehabilitation Act
of 1973 (29 USC § 794);the Americans with Disabilities Act of 1990 (42 USC
§ 12132); Government Code Section 11.135; Title 9, Division 4, Chapter 6 of
the California Code of Regulations, commencing with Section 10800 and Civil
Code, Section 51 (all types of arbitrary discrimination). For purposes of this
contract, discrimination includes but is not limited to:
a. denying any eligible beneficiary any covered service or availability of a
facility;
b. providing to an eligible beneficiary any covered.service which is different
or is provided in a different manner or at a different time from that
provided to other beneficiaries under this contract, except where
medically indicated;
C. subjecting an eligible beneficiary to segregation or separate treatment in
any manner related to the receipt of any covered service;
d. restricting an eligible beneficiary in any way in the enjoyment of any
advantage or privilege enjoyed by others receiving any covered service;
e. treating an eligible beneficiary differently from others in determining
whether he or she satisfies any admission, enrollment, quota, eligibility,
membership, or other requirement or condition which individuals must
meet in order to be provided any covered service; and
f. assigning times or places for the provision of services to the eligible
beneficiary.
2. The County will comply with Exhibit K,the provisions of the Nondiscrimination
Clause, consisting of one (1) page, attached hereto and incorporated by this
reference.
3. The County shall do a self evaluation to identify facilities accessible to the
disabled within the service area and shall develop a transition plan for
making additional facilities available to the disabled. The self-evaluation
plan may reflect a "core service" concept consistent with requirements at
Title 28, Code of Federal Regulations, Section 35.150 and shall provide
for assessment consistent with the Voluntary Compliance Agreement
8
1 \ '
between the Office of Civil Rights, DHHS, and the .State. The County
shall assure that nonaccessible facilities have in. place appropriate referral
mechanisms for transferring beneficiaries to programs that provide
substantially equivalent services to those requested by the beneficiary,
including procedures for transportation.
4. The County shall establish written procedures wherein beneficiaries are
informed of their appeal rights for alleged violations of their civil rights. The
County shall investigate all grievances alleging discrimination against eligible
beneficiaries and shall forward notice of the grievance, within thirty (30) days
of receipt of the grievance, to the State for review and appropriate action.
5. . The County shall keep records of the procedures referenced in Subdivisions 3
and 4 and copies of the required notice of beneficiary appeal rights, in order for
the State to determine compliance with this Section and with state and federal
legal requirements including the Voluntary Compliance Agreement.
E. Drug Free Work Place
1. By signing this contract, the County certifies under the laws of the State
of California that the County and its Subcontractors will comply with the
requirements of the Drug Free Work Place Act of 1990 (Gov. Code § 8350
et seq.), and will provide a drug free work place by taking the following
actions:
a. Publish a statement notifying employees ' that the unlawful
manufacture, distribution, dispensation, possession, or use of a
controlled substance is prohibited in the person's or organization's
work place and specify the actions that will be taken against
employees for violations of the prohibitions as required by
Government Code Section 8355(a).
b. Establish a drug-free awareness program as required by Government
Code Section 8355(b) to inform employees about all of the
following:
L The dangers of drug abuse in the work place;
ii. The person's or organization's policy of maintaining a drug-free
work place;
iii. Any available drug counseling, .rehabilitation, and employee
assistance programs; and
iv: The penalties that may be imposed upon employees for drug
abuse violations.
C. Provide, as required by Government Code Section 8355(c), that
every employee engaged in the performance of the contract:
L Be given a copy of the County's drug-free policy statement; and
9
ii. As a condition of employment p yment on the contract, agree to abide by
the terms of the statement.
d. Failure to comply with these requirements may result in suspension
of payments under the contract, or termination of the contract, or
both, and the County or its Subcontractors may be ineligible for
future state contracts if the State determines that any of the
following has occurred:
i. The County has made false certification; or
ii. The County has violated the certification by failing to carry out
the requirements as noted above.
F. No Unlawful Use or Unlawful Use Messages Regarding.Drugs
1. The County agrees that information produced through these funds, which
pertains to drug and alcohol-related programs, shall contain a clearly
written statement that there shall be no unlawful use of drugs or alcohol
associated with the program. Additionally, no aspect of a drug or alcohol
related program shall include any message on the. responsible use, if the
use is unlawful, of drugs or alcohol (HSC § 11999). The County agrees
to enforce these requirements by signing this agreement.
ARTICLE V. CONFIDENTIALITY AND RECORDS
A. The County shall conform to and monitor compliance with all state and federal statutes
and regulations regarding confidentiality, including the confidentiality of information
requirements at Part 2, Title 42, Code of Federal Regulations, Welfare and Institutions
Code Section 14100.2, Section 11977, Division 10.5 of the Health and Safety Code;
and Title 22, California Code of Regulations, Section 51009.
B. The County shall ensure that no list of persons receiving services under this contract
is published, disclosed, or used for any purpose except for the direct administration of
this program or other uses authorized by law that are not in conflict with requirements
for confidentiality contained in Welfare and Institutions Code Section 14100.2; Health
and Safety Code Section 11977; Title 22, California Code of Regulations Section
51009; and Title 42, Code of Federal Regulations, Part 2.
C. The County shall retain client records for a minimum of seven (7) years from the date
of service.
D. The County shall retain audit records for three (3) years unless an audit is in process.
If an audit is in process, a County shall retain records until .all audit findings are
resolved.
E. The County shall retain records and minutes of utilization review activities required in
Section VIII herein for a minimum of-four (4) years.
10
ARTICLE VI. FISCAL PROVISIONS
A. To the extent that the County provides the required services in a satisfactory manner,
the State agrees to pay the County D/MC State General Funds and federal Medicaid
Funds according to the procedures delineated in Article VII (Invoice/Claim and Payment
Procedures) of this contract. The County shall be reimbursed federal Medicaid funds
for allowable expenditures as established by the federal government and approved by
DHS, subject to the availability of such funds, for the cost of services rendered to
federally eligible Medi-Cal beneficiaries.
1. Reimbursement for covered services shall be made in accordance with
applicable provisions of Title 22, California Code of Regulations, Section
51516, and all other currently applicable policies and procedures.
2. It is understood and agreed that failure by the County to comply with applicable
federal and state requirements in rendering the covered services under this
contract shall be sufficient cause for the State to deny or recover payments to
the County. If the State, DHS, or DHHS disallows payments made to the
County for any claim submitted by the County, the County shall repay to the
State, federal Medicaid funds and state General Funds for all claims so
disallowed.
a. Before such denial, recoupment, or disallowances are made, the State
shall provide the County with written notice of its proposed action.
Such notice shall include the reason for the proposed action and shall
allow the County thirty (30)days to submit additional information before
the proposed action is taken.
3. If, during the term of this contract,.allowable D/MC services for eligible Medi-
Cal beneficiaries exceed the maximum amount of this contract,the County shall
request to amend the contract to increase contract funding to meet the
requirements of'Article IV. herein.
a. The County may apply to the State for additional State General Funds
to provide allowable services in accordance with the provisions of this
agreement if the following criteria are met:
i. 'The County has utilized all available (allocated) State General
Funds for the purposes of D/MC match; or
ii. A D/MC certified private provider establishes a D/MC treatment
facility in the County service area where such covered service
had not previously existed and the County had not anticipated or
participated in establishing the treatment facility; or
Ill. Additional State General Funds are needed for matching
federal Medicaid funds for provision of perinatal treatment
services.
11
4. If, during the term of this contract, the need for allowable D/MC services for
eligible Medi-Cal beneficiaries is less than the maximum amount of this
contract, the County shall notify the State and obtain approval on expenditure
of the unused State General Funds by proposing a plan for expenditure of the
funds in accordance with Article III., Section D. and Article VI., Section B
herein.
a. Upon approval by the State, the County may reallocate State General
Funds not used for covered services to other treatment service areas .
through an amendment to the County's Negotiated Net Amount
(hereinafter referred to as NNA) Contract with the State.
b. Consistent with this Section, a County may request an amendment
to transfer an unexpended amount of State General Funds to the
County's NNA Contract no sooner _than the end of the second
quarter of this contract's fiscal year. Contract amendments may be
made up until the last day of this contract's fiscal year period.
C. A County shall identify amounts for transfer to the NNA contract
by April 1 of this contract's fiscal year if the County wishes to
retain unspent State General Funds in accordance with Article III,
Section 22, Subdivision b. of the County's NNA contract.
d. The transfer amount shall be determined by subtracting the
maximum D/MC costs from the total of the year-to-date contract
limitation.
e. Along with any amendment request, the County shall submit Page 1 of
the "Report of Expenditures and Revenues Summary" (later identified as
Exhibit 01 and 02) for each D/MC provider that reflects year-to-date
actual cost and revenue data through the end of the month prior to the
date of the amendment.
B. The County assumes total cost of providing covered services listed in Article IV herein
on the basis of the payments delineated in Article VII herein. Any federal Medicaid
funds paid to the County, but not,expended by the County after having fulfilled all
obligations under this contract, will be returned to the State. Any State General Fund
matching funds not expended or obligated by the County after having fulfilled all
obligations under this contract will be returned to the State unless amended to the
NNA contract in accordance with Section A., Subdivision 4, of this Article.
C. It is mutually understood between the parties that this contract may have been written
before ascertaining the availability of congressional appropriation of funds, for the.
mutual benefit of both parties,in order to avoid program and fiscal delays which would
occur if the agreement were executed after that determination.
D. This agreement is valid and enforceable only if sufficient funds are made available to
the State by the United States Government for the Fiscal Year 1994-95 for the
purpose of this program. This agreement is subject to any additional restrictions,
limitations, or conditions enacted by the Congress or any statute enacted by the
12
'F
r 1 .
Congress which may affect the provisions, terms, or funding of this agreement in any
manner.
E. It is mutually agreed that if the Congress does not appropriate sufficient funds for the
program, this agreement shall be amended to reflect any reduction in funds. The State
has the option to void this agreement under the 60-day cancellation clause or to amend
it to reflect any reduction of funds.
F. Exemptions to the provisions in Article VI. Sections C. through E. above may be
granted by the State Department of Finance provided that the Director of DHS certifies
in writing that federal funds are available for the term of the contract.
G. The State and County agree that any payment for covered services rendered in
accordance with this contract shall only be made pursuant to applicable provisions of
Title XIX(Social Security Act);the Welfare and Institutions Code; California's Medicaid
State Plan; and Sections 51132, 51134, 51238, 51341, 51490,and 51516 of Title
22, California Code of Regulations.
1. The County shall be reimbursed by the State on the basis of the County's
actual net reimbursable cost, not to exceed the unit of service maximum rate
or customary charges and any allowable County administrative costs.
H. Allowable costs, as used in Section 51516(c)(2) of CCR Title 22, shall be determined
in accordance with 42 CFR Parts 405 and 413 and HIM-15, "Provider Reimbursement
Manual".
1. Funds allocated under this contract, including perinatal funding for perinatal
services inclusive of case management services, may not be used as match for
targeted case management services (Welf. & Inst. Code, § 14132.44) or Medi-
Cal Administrative Claiming (Welf. & Inst. Code, § 14132.47).
I. As delineated in HSC Section 14021.5, the State shall annually calculate the unit of
service maximum rate allowance contained in Title 22, California Code of Regulations,
Section 51516(c)(3) and submit them to DHS for final determination and approval.
1. The State will recover any D/MC reimbursements in excess of the maximum
allowances described herein unless a rate waiver has been reviewed by the
State and approved by DHS.
2. In accordance with Title 22, CCR, Section 51516(d), the maximum allowance
for covered services may be waived by DHS when application of such
allowances would result in a substantial inability to provide the service.
3. Requests for rate waivers must be reviewed for appropriateness by the State,.
submitted to DHS by the State for final determination, and approved by DHS
prior to the County claiming services at the requested amount. Requests for
rate waivers shall be submitted by the County to the State in a format
prescribed by the State.
13
J. Audits
1. The State, DHS, and the federal government may conduct audits of the County
and/or the subcontractor to make sure that payments are accurate and in
conformance with state and federal laws, regulations, and policies.
2. All funds shall be subject to audit. The purpose of these audits will be to
determine the amount of D/MC reimbursement. Audit procedures will include,
but not be limited to, the determination of actual, allowable costs and charges
and verification of Medi-Cal eligibility, and third-party collection for all persons
receiving D/MC services.
3. Accurate fiscal records and supporting documentation shall be maintained by
the County to support all claims for reimbursement.
4. Audit reports by the State and/or DHS shall reflect any findings,
recommendations, adjustments, and corrective action as appropriate as a result
of its findings in any areas.
a. The County agrees to develop and implement any corrective action plans
in a manner acceptable to the . State'' in order to comply with
recommendations contained in the audit report. Such corrective action
plans shall include time specific objectives to allow for measurement of
progress.
b. If differences cannot be resolved between the State and/or OHS and the
County regarding the terms of the final audit settlements for funds
expended under this contract, the County may request an appeal in
accordance with the appeal process described in Exhibit M, "Appeal
Processes", consisting of five (5) .pages, attached hereto and
incorporated by this reference.
5. The County shall be responsible for any disallowances taken by the federal
government, the State, or DHS as a result of any audit exception which is
related to the County's responsibilities herein.
ARTICLE VII. INVOICE/CLAIM AND PAYMENT PROCEDURES
A. Interim Payments
1. The State shall:
a. Pay the County a monthly interim payment from the state General Fund
for covered services, not to exceed fifty (50) percent of the projected
cost of the projected units of service. In the event the contract is
approved for the State fiscal year period subsequent to July 1,the State
will pay the County an interim payment to pay the provider an amount,
not to exceed fifty (50) percent of the projected cost for D/MC
beneficiary services back to July 1.
14
b. Reimburse the County the federal Medicaid amount upon approval by
the DHS of the monthly claims and reports submitted in accordance
with Section B, Subdivision 1 of this Article.
C. Reimburse federal Medicaid and State General Funds at a rate which is
the lesser of the projected cost or the maximum rate allowance.
2. The County shall submit Exhibit N, ADP Form 7890, "Monthly Interim
Payment Claim Form"; consisting of two (2) page(s), attached hereto and
incorporated by this reference. The invoice projecting units of service shall
be submitted by the' first of each month and shall be used to calculate the
interim payment.
3. Within 30 days from the end of each of the first three quarters of the fiscal
year,the County shall submit Exhibit 01 and 02, ADP Forms 7895 and 7895M,
"Report of Expenditures and Revenues Summary" consisting of four(4).and four
(4) page(s), respectively, attached hereto and incorporated by this reference.
Exhibit 01 and 02 shall be submitted for each D/MC Provider and shall reflect
year-to-date actual cost and revenue data through the end of each quarter.
4. The State shall determine actual costs upon which the rate of reimbursement
should be recalculated from Exhibit 01 and-02.
5. The State will adjust subsequent reimbursements to the County to adjust for
actual "allowable" costs. � Actual allowable costs are federal Medicaid
reimbursements and an equal amount of State General Fund to be used as
matching funds.
6. In the event the County does not submit Exhibit N and Exhibits 01 and 02
within thirty (30) days of the dates required in Subdivision 2 and 3 of this
Section, the State.may discontinue monthly interim payments. If monthly
interim payments are discontinued, the County will be reimbursed federal
Medicaid and State General Funds based on DHS's Approved Services Report.
B. Monthly Claims and Reports
1: In accordance with Title 22, CCR, Section 51490 the County shall submit
ADP-1584 claim forms, entitled "Drug/Medi-Cal Eligibility Work Sheet";
ADP-1592 ,and 1592P forms, entitled 'Monthly Claim for Drug/Medi-Cal
Reimbursement and Monthly Provider Service and Revenue Summary";
and ADP-5035 form, entitled "Report of Drug/Medi-Cal Disallowances by
Provider", to the State within 60 days after the month in which the services
were rendered. Samples of these forms, are included herein as Exhibits P1, P2
a and b, and P3, consisting of a two (2), four (4), and two (2) pages.
respectively, attached hereto and incorporated by this reference.
a. - Except for good cause stated on Exhibit P4("Good Cause Certification"
ADP 6065,consisting of one[1]page,attached hereto and incorporated
by this reference), failure by the County to submit claims within the
stated time frame shall result in the denial of such claims for payment.
15
b. Good cause shall be determined and approved by the State in
accordance with Section 14115 of the Welfare and Institutions Code
and appropriate regulations, policies,-and procedures.
C. Unless federal.exception criteria apply, all claims, whether delayed by
good cause or returned for corrections, shall be submitted to the State
and DHS no later than 19 months following the date of service.
2. The County shall submit, with the monthly claim forms described as Exhibit P,
a listing of all Medi-Cal out-of=county residents receiving'covered services. The
format in which this information shall be reported is included in Exhibit Q,
"Drug/Medi-Cal Services for Out-of-County Residents" consisting of one (1)
page, attached hereto and incorporated by this reference.
3. Monthly claims for reimbursement shall include only those case management
services and administrative charges not claimed pursuant to Welfare and
Institutions Code, Sections 14132.44 and 14132.47.
C. Cost Reports and Year-End Settlements
1. The State will not accept year-end cost reports from subcontractor(s) directly.
The County shall submit to the State Exhibits 01 and 02, and Exhibit R, ADP
Form 7990, "Drug/Medi-Cal Program Cost Summary", consisting of three (3)'
pages, attached hereto and incorporated by this reference. Exhibits 01 and 02
and Exhibit R shall be submitted with the required cost report, required in
accordance with.the State's NNA contract.
ARTICLE Vlll. UTILIZATION REVIEW AND QUALITY OF CARE
A. Section 51159 of CCR Title 22 describes the utilization controls applied to Medi-Cal
services. Service and payment audit controls, which are reviewed for medical
necessity and program coverage after services are rendered and the claim paid, will
apply to covered services provided under this contract.
1. The State may take appropriate steps to recover payments made if subsequent
investigation uncovers evidence that the claim(s) should not have been paid.
B. The State shall periodically monitor the County's compliance with utilization review
requirements. DHS and the federal government may also review the existence and
effectiveness of the County's utilization review system in accordance with federal
requirements.
C. The County shall implement and maintain compliance with the system of review
described in Exhibit H to review the utilization, quality, and appropriateness of covered
services funded by this contract and to ensure that applicable Medi-Cal requirements
are met.
16
D. The State shall periodically monitor the County and the subcontractors)for compliance
with utilization requirements. DHS and DHHS may also review the existence and
effectiveness of the utilization review system in the county service area in accordance
with federal requirements.
ARTICLE IX. GENERAL PROVISIONS
A. This contract is subject to the examination and audit of the State Auditor for a period
of three (3) years after final payment (Government Code Section 10532).
B. The County agrees that the State will, have the right to review, obtain, and copy all
records pertaining to the performance of this contract. The County agrees to provide
the State with any relevant information requested and shall permit the State access
to its premises, upon reasonable notice, during normal business hours for the purpose
of interviewing employees and inspecting and copying such books, records, accounts,
and other material that may be relevant to a matter under investigation for the purpose
of determining compliance with this contract.
C. The County agrees to comply with the additional provisions delineated in Exhibit A(F),
entitled "State of California Department of Health Services Additional Provisions (For
Federally Funded Subvention Aid/Local Assistance Cost Reimbursement
Contracts/Grants)" consisting of twenty seven (27) pages, attached hereto and
incorporated by this reference.
D. The County shall have liability insurance sufficient to cover hazardous activities
pursuant to Section 1254 of the State Administrative Manual. To the extent that the
County subcontracts for the provision of transportation services, the County is liable
to determine that the subcontractor has sufficient liability insurance to meet the
requirements of Section 1254 of the State Administrative Manual.
17
LISTING OF EXHIBITS
A County Proposal ,
AM Department of Health Services Additional Provisions (for Federally Funded Subvention
Aid/Local Assistance Cost Reimbursement Contracts/Grants)
B Sobky v. Smolev Order for Permanent Injunction
C 1 Provider Waiting List Record
C 2 Drug and Alcohol Treatment Access Report (DATAR)
C 3 California Alcohol and Drug Data System (CADDS) - ADP 7360
C 4 CADDS Provider Summary Report - ADP 7365
D Estimated New Service Provider Costs - ADP 7995
E Perinatal Services Monthly Report
F ADP Perinatal Services Supplemental Infant Data Form
G Drug/Medi-Cal Certification Standards for Substance Abuse Clinics
H Drug/Medi-Cal Utilization Control Plan
J Standards for Drug Treatment Programs
K Nondiscrimination Clause
M Appeal Processes
N Monthly Interim Payment Claim Form for D/MC State General Funds - ADP 7890
01 Report of Expenditures and Revenues Summary - ADP 7695
02 Report of Expenditures and Revenues Summary - ADP 7895M
P 1 Drug/Medi-Cal Eligibility Worksheet- ADP 1584
P 2a Monthly Claim for D/MC Reimbursement and Monthly Provider Service and Revenue
Summary - ADP 1592
P 2b Monthly Claim for D/MC Reimbursement and Monthly Provider Service and Revenue
Summary - Program 25 Perinatal Services -ADP 1592P
P 3 Report of D/MC Disallowances by Provider - ADP 5035B
P 4 Good Cause Certification - ADP 6065
Q Drug/Medi-Cal Services for Out-of-County Residents
R Drug/Medi-Cal Program Cost Summary - ADP 7990
EXHIBIT A
COUNTY PROPOSAL
EXHIBIT A
-L Health Services Department
E
-'' COMMUNITY SUBSTANCE ABUSE
Ar. SERVICES DIVISION
1 - 1
'4 Administrative Offices
597 Center Avenue, Suite 320
%o Martinez, CA 94553-4639
oosrA-co"dn'� c3�'
(510) 313-6300
November 4, 1994
Andrew Mecca, Dr. P.H., Director
State of California
Department of Alcohol and Drug Programs
1700 K Street
Sacramento, California 95814-4037
Dear Dr. Mecca:
The following "Drug/Medi-Cal Services Contract Proposal" is in response to the
Department of Alcohol and Drug Programs (DADP) Memorandum D/MC #194-07 and
numerous other directives which have been issued by DADP over the past 30 days.
The manner in which Contra Costa County administers the Drug/Medi-Cal Program is
in "compliance with federal Medicaid regulations, decisions from Sobky v. Smoley,
State budget requirements, and the DHS/ADP interagency agreement" and various
other regulations and statutes not mentioned in D/MC #94-07. The following
"proposal" is structured in a manner which is directly responsive to the questions
posed by DADP in memo D/MC .#94-07. The "proposal" describes various aspects of
how D/MC services are provided and claimed for in Contra Costa County and does
not presuppose that this County has established a separate D/MC system to mirror the
questions raised in D/MC #94-07. Finally, this plan has not been formally reviewed
and approved by the County Board of Supervisors and precludes any assumptions
regarding managed care and the impact it may have on the various services levels.
A. Quality Management Plan
1. The staff person responsible for coordinating all aspects of the D/MC
program at this time is the Substance Abuse Program Administrator, Chuck
Deutschman, MFCC, MBA.
2. Attachment A contains an organizational matrix which delineates "service
tracks" and the Community Substance Abuse Services (CSAS) supervisor responsible
A-371-A (5/94) Contra Costa County
• Drug/Medi-Cal Services Contract Proposal EXHIBIT A
November 4, 1994
Page 2
for oversight of these programmatic areas. Contract management, monitoring, billing,
utilization review, data reporting, and budgets for D/MC requirements are the responsibility
of these various supervisors. These supervisors are knowledgeable regarding all DADP
directives and actively ensure that compliance is achieved on all aspects contained in D/MC
#94-07. In addition, programmatic and fiscal decisions and compliance are constantly
monitored and reviewed by the Substance Abuse Program Director, Chuck Deutschman, and
the Health Services Department (HSD) Fiscal Officer, George Khoury.
3. Methods, frequency and time frames for:
a. At the present time all certified (DADP) Medi-Cal providers have
D/MC contracts or are County-operated programs. If new DADP Medi-Cal providers come
on line, D/MC contracts will be developed as per directives from DADP. Limitations for
development of contracts will only be limited by such factors as staff necessary for the
development of monitoring of the contracts and inadequate site for services and not due to
budget limitations resulting from lack of State general funds (SGF). While the State
certification process is estimated to be about 200 days, the County, at the same time, may
require an equal amount of time for new providers depending on the increase in providers. It
is anticipated that all perinatal providers will be processed expeditiously because planning for
this D/MC conversion began over one year ago.
b. It is the responsibility of the Substance Abuse Program Director to
ensure that the appropriate level of services are provided to eligible beneficiaries. The
Contra Costa County Utilization Control Plan (UCP) is being updated to more clearly identify
the role of the utilization review committee in determining progress in treatment and
appropriateness of care.
C. At the present time D/MC providers are reimbursed on a monthly basis
from the County. Reimbursement from DADP is running over 60 days, so the County is
advancing D/MC reimbursement based on the monthly utilization statistics which are
submitted by the provider.
4. The monitoring of expenditures is routinely completed by the HSD Fiscal
Officer and the CSAS Director. Federal maintenance of effort requirements are monitored
regularly and SGF funds will only be budgeted to non-D/MC services when funds are
remaining due to non-use of D/MC services by beneficiaries.
5. Weekly meetings and as-needed training are held to ensure that all
supervisory staff are knowledgeable and competent in the areas described in the
various DADP directives. Supervisory staff are also provided copies of all DADP
correspondence which pertains to D/MC #94-07 and other directives. All providers,
Drug/Medi-Cal Services Contract Proposal ExxisiT A
Nbvember 4, 1994
Page 3
both D/MC and non-D/MC certified, are kept abreast of recent directives issued by
DADP. This knowledge dissemination and monitoring processes includes, but is not
limited to, the following topics: Sobky vs. Smoley; CADDS; DATAR; D/MC
billings; UCP; and UCR. Supervisory staff and applicable providers are also given
information regarding Perinatal Services Guidelines. Monitoring of these guidelines is
routinely done with the recognition that these are standard of care guidelines and not
regulations per se.
6. All contracts which are funded through CSAS are monitored at least
semi-annually. During this monitoring supervisors pay particular attention to
utilization issues; access for the disabled; DATAR compliance issues; and a host of
other pressing issues which impact on the quality of care which is provided in our
county-operated and contract facilities. Supervisors are in constant contact with the
various program directors to provide technical assistance and to be proactive in the
management of problems which may arise. With respect to the monitoring of D/MC
utilization rates, this information is reviewed at least quarterly (and monthly during
some conversion or start-up phases) by the HSD Fiscal Officer and the CSAS
Director.
B. A list of providers, services offered and number of participants is contained in
Attachment B. For the convenience of DADP staff, a sum total of this information is
provided on the last page of Attachment B.
C. The projected expansion of the D/MC is difficult to accurately project at this
time. The vagaries and uncertainties of the health care field make projections
difficult. With these factors in mind, Appendix C presents descriptions of providers,
services and participants which might result from the expansion of services.
Contra Costa County has an excellent system for ensuring that services for the
prevention and treatment of alcohol and drug problems are provided in a manner
which ensures quality of care and cost effectiveness. This service delivery system
attempts to serve as many citizens as possible while recognizing that many clients have
unique needs--whether they be priority access due to HIV status or priority access due
to payor source, i.e. Drug/Medi-Cal. Keeping these disparate needs in balance is a
complex and demanding challenge for all staff. As the system becomes more complex
without increasing funding, services are further eroded and the public becomes ever
more confused about why some people have preferred access to care and others do
not. In the coming years, perhaps we can streamline and simplify administration of
these programs and perhaps we can institute a system which determines access to care
based on medical status and not only based on payor source. While residential
services for adults are not Drug/Medi-Cal reimbursable, many times these adults are
the parents of children who desperately need their fathers and mothers. Clearly, the
Drug/Medi-Cal Services Contract Proposal EXHIBIT A
November 4, 1994
Page 4
suffering of the alcoholic/addict who chooses recovery in a residential program is no
less than the suffering of an addict in a methadone program. For the sake of the
children, both parents should be afforded an opportunity to recover.
Sincerely,
Chuck Deutschman, Director
Community Substance Abuse Services Division
Attachments
Copy to: Mark Finucane .
Substance Abuse Advisory Board
CSAS Management Team
George Khoury
Gloria Merk
Anita Cabrera-Bruno
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EXHIBIT A
ADDENDUM TO MEDI-CAL PROPOSAL
=age 1 of 1
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
DRUG MEDI—CAL FISCAL DETAIL
ESTIMATED NEW SERVICE PROVIDER COSTS
.:OUNTY CONTRA COSTA
CONTRACT PERIOD 1
DATE PREPARED 11/10/94
Col.1 Col.2 Col.3 Col.4 I col.5 Col.6 Col.7 1 Col.8 1 Col.a I CaI. 10
Actual I YTD Estimate
Medi—Cal ! Total Maximum/4 Maxirnurn Ma-dmum
Provider Tmt I Total Total I Cost Per Medi—Cal Waivered I Payment I Medi—Cal
Provider Number Com . costs Units Unit Unite Hate Rate Costs
1 INIA I I NIA I I NIA I NIA IN AIN1 A
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EXHIBIT A
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EXHIBIT A
Health Services Department
'.� COMMUNITY SUBSTANCE ABUSE
SERVICES DIVISION
Administrative Offices
..... a e a .. 597 Center Avenue, Suite 320
Martinez, CA 94553-4639
(510) 313-6300
Co
Anita Caberra-Bruno
Alcohol and Drug Program Analyst
Department of Alcohol & Drug Programs
1700 K Street
Sacramento, Ca. 95814
November 23, 1994
Dear Anita:
It was a pleasure talking with you on yesterday. This letter will respond to the concerns you
had regarding Contra Costa County's Drug Medi-Cal Proposal.
The attached "Addendum" to Item #6 of Chuck Deutschman's original letter dated November
4, 1994, has been expanded to include information germane to management of the Waiting List.
Should you require additional information/clarification, do not hesitate to contact me at (510)
313-6388.
ce ,
Adanna E. Henry, CSA upervisor
A-371-A ,5,94, Contra Costa County
EXHIBIT A
Drug/Medi-Cal Services Contract Proposal
November 4, 1994
Page 4
ADDENDUM
6. All contracts which are funded through CSAS are monitored at least
semi-annually. During this monitoring-supervisors pay particular
attention to utilization issues; access for the disabled; DATAR
compliance issues; and a host of other pressing issues which impact on
the quality of care which is provided in our county-operated and contract
facilities. Supervisors are in constant contact with the various program
directors to provide technical assistance and to be proactive in the
management of problems which may arise. With respect to the
monitoring of D/MC utilization rates, this information is reviewed at
least quarterly (and monthly during some conversion or start-up phases)
by the HSD Fiscal Officer and the CSAS Director.
The Waiting List will be managed by CSAS Program Supervisors in
compliance with Sobsky vs Smoley litigation, e.g., no client will be
placed on a Waiting List unless all publically funded slots are filled,
All possibilities will be exhausted prior to placing a client on a
Waiting List. to include referring clients to treatment programs
outside of Contra Costa County.
EXHIBIT A
Page 1 of 3
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (OMM1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
COUNTY-WIDE SUMMARY
COUNTY CONTRA COSTA
CONTRACT PERIOD 7/1/94-6/30/95
DATE PREPARED December 12 1994
TYPE OF PROGRAM OMM (Specify as OMM,ODF,DCH,NAL,RES)
A B C D E
TOTAL PRIVATE NNA/PUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI-CAL FUNDED NNA/PUBUC
GROSS COSTS
A. PROGRAM(TREATMENT) 2,052,000 540,000 1,512,000 0 1,512,000
B. COUNTY ADMINISTRATION 80,000 0 80,000 0 80,000
C. TOTAL GROSS COSTS 2132000 540 000 1 592 000 0 1 592 000
REVENUES
D. PARTICIPANT FEES 540,000 540,000 0 0 0
E. INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 0 0 0 0
F. CONTRACTS&GRANTS(SPECIFY) � . .-.
F1. COUNTY-FEDERAL ALCOHOL&DRUG 0 0 0 0 0
F2. COUNTY-STATE ALCOHOL&DRUG 0 0 0 0 0
F3. COUNTY-COUNTY(ALCOHOL&DRUG) 0 0 0 0 0
F4. COUNTY-FEDERAL PERINATAL) 0 0 0 0 0
F5. COUNTY-STATE PTEP)(PERINATAL) 0 0 0 0 0
F6. COUNTY-COUNTY(PERINATAL) 0 0 0 0 0
F7. COUNTY/STATE-FEDERAL MEDI-CAL(ALCOHOL&DRUG) 796,000 0 796,000 0 796,000
F8. COUNTY/STATE-STATE MEDI-CAL ALCOHOL&DRUG) 796,000 0 796,000 0 796,000
F9. COUNTY/STATE-FEDERAL MEDI-CAL PERINATAL 0 0 0 0 0
Flo.COUNTY/STATE-STATE MEDI-CAL(PERINATAL) 0 0 0 0 0
Fl 1.FEDERAL/STATE-DIRECT CONTRACT 0 0 0 0 0
F12: 0 0 0 0 0
F13. 0 0 0 0 0
F14. 0 0 0 0 0
G. OTHER(SPECIFY)TCM/MAC(AB2377)(FEDERAL SHARE) 0 0 0 0 0
Gi. 0 0 0 0 0
G2. 0 0 0 0 0
G3. 0 0 0 0 0
TOTAL REVENUES 2,132,000 540,000 1,592,000 0 1,592,000
NET COSTS GROSS COSTS LESS LINES D E G 1 592 000 0 11592,000 0 1.592.000
H. UNITS OF SERVICE
H1. FACE TO FACE VISITS INDIVIDUAL,GROUP,ETC. 0 0 0 0 0
H2. FACE TO FACE VISITS DOSES 142,70336,144 106,559 0 106,559
H3. DAY CARE HABIUTATIVE DAY 0 0 0 0 0
H4. RESIDENTIAL DAY 0 0 0 0 0
H5. OTHER(SPECIFY) 0 0 0 0 0
H6. 0 0 0 0 0
H7. 0 ol 0 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H7) 142,703 36,144 106,559 0 106,559
I. STAFF HOURS DIRECT SVCS-COUNSEUNG,MEDICAL,ETC. 92,642 24,380 68,262 0 68,262
J. METHADONE SLOTS(OMM onl 760 200 560 0 560
K. COST PER UNIT OF SERVICE UNITS GROSS COSTS/UNE H8 14.94 14.94 14.94 ERR 14.94
L COST PER STAFF HOUR GROSS COSTS/UNE Q 23.01 22.15 23.32 ERR 23.32
M. COST PER SLOT GROSS COSTS INE 2805.26 2700.00 2842.86 ERR 2842.86
TOTAL STATE GENERAL FUND(ADD LINES F2,F8 796,000 0 796,000 0 796,000
ADP FORM 7895B (8/94)
Page 2 of 3
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS EXHIBIT A (OMM1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER 24-469
CONTRACTOR BAART PITTSBURG
CONTRACT PERIOD 7/1/94-6/30/95 MEDT-CAL PROV. NO. 0709
DATE PREPARED December 12, 1994 CADDS PROVIDER NO.
TYPE OF PROGRAM OMM (Specify as OMM,ODF, DCH, NAL, RES)
A B C D E
TOTAL PRIVATE NNA/PUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI-CAL FUNDED NNA/PUBUC
GROSS COSTS 3`
A. PROGRAM(TREATMENT) 810,000 270,000 540,000 540,000
B. COUNTY ADMINISTRATION 28,560 28,560 28,560
C. TOTAL GROSS COSTS 838,560. 270,0D0 568.560 0 568,560
REVENUES ;':
D. PARTICIPANT FEES 270,000 270,000 0
E. INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 0
F. CONTRACTS&GRANTS(SPECIFY)
F1. COUNTY-FEDERAL ALCOHOL&DRUG 0 0
F2. COUNTY-STATE ALCOHOL&DRUG 0 0
F3. COUNTY-COUNTY ALCOHOL&DRUG) 0 0
F4. COUNTY-FEDERAL(PERINATAL) 0 0
F5. COUNTY-STATE(PTEP)(PERINATAL) 0 0
F6. COUNTY-COUNTY(PERINATAL) 0 0 i
F7. COUNTY/STATE-FEDERAL MEDI-CAL(ALCOHOL&DRUG) 284,280 284,280 284,280
F8. COUNTY/STATE-STATE MEDI-CAL(ALCOHOL&DRUG) 284,280 284,280 284,280
F9. COUNTY/STATE-FEDERAL MEDI-CAL(PERINATAL) 0 0
F10.COUNTY/STATE-STATE MEDT-CAL(PERINATAL) 0 0
F11.FEDERALISTATE-DIRECT CONTRACT 0 0
F12. 0 0
F13. 0 0
F14. 0 0
G. OTHER(SPECIFY)TCM/MAC(AB2377)(FEDERAL SHARE) 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 838,560 270,000 568,560 0 568,560
NET COSTS GROSS COSTS LESS LINES D E G 568 560 0 568,560 0 568.560
H. UNITS OF SERVICE
H1. FACE TO FACE VISITS INDIVIDUAL,GROUP,ETC.) 0 0
H2. FACE TO FACE VISITS DOSES 56,128 18,072 38,056 38,056
H3. DAY CARE HABILITATIVE DAY 0 .0
H4. RESIDENTIAL DAY 0 0
H5. OTHER(SPECIFY) 0 0
H6. 0 0
H7. 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H 56,128 18,072 38,056 0 38,056
I. STAFF HOURS(DIRECT SVCS-COUNSELING,MEDICAL,ETC.) 36,569 12,190 24,379 24,379
J. METHADONE SLOTS OMM on 300 100 200 200
K COST PER UNIT OF SERVICE NITS GROSS COSTS/UNE H8 14.94 14.94 14.94 ERR 14.94
L COST PER STAFF HOUR GROSS COSTS/UNE 9 22.93 22.15 23.32 ERR 23.32
M. COST PER SLOT GROSS COSTS/LINEh 2795.20 . 2700.00 2842.80 . ERR 2842.80
TOTAL STATE GENERAL FUND ADD LINES F2,F8 284,280 7 284,280 ol 284,280
ADP FORM 7895B (8/94)
EXHIBIT A
Page 3 of 3
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (OMM1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER 24-469
CONTRACTOR BAART RICHMOND
CONTRACT PERIOD 7/1/94-6/30/95 MEDI-CAL PROV. NO. 0708
DATE PREPARED December 12, 1994 CADDS PROVIDER NO.
TYPE OF PROGRAM OMM (Specify as OMM, ODF, DCH, NAL, RES)
A B C D E
TOTAL PRIVATE NNA/PUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI-CAL FUNDED NNA/PUBUC
GROSS COSTS
A. PROGRAM(TREATMENT) 1,242,000 270,000 972,000 972,000
B. COUNTY ADMINISTRATION 51,440 51,440 51,440
C. TOTAL GROSS COSTS 1.293.440 . 270 000 1.023,440 0 1 023 440
REVENUES az
D. PARTICIPANT FEES 270,000 270,000 0
E. INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 0
F. CONTRACTS&GRANTS(SPECIFY)
Fl. COUNTY-FEDERAL ALCOHOL&DRUG) 0 0
F2. COUNTY-STATE ALCOHOL&DRUG 0 0
F3. COUNTY-COUNTY ALCOHOL&DRUG 0 0-
F4. COUNTY-FEDERAL(PERINATAW 0 0
F5. COUNTY-STATE PTEP (PERINATAL) 0 0
F6. COUNTY-COUNTY(PERINATAL) 0 0
F7. COUNTY/STATE-FEDERAL MEDI-CAL(ALCOHOL&DRUG) 511,720 511,720 511,720
F8. COUNTY/STATE-STATE MEDT-CAL ALCOHOL&DRUG 511,720 511,720 511,720
F9. COUNTY/STATE-FEDERAL MEDI-CAL(PERINATAL) 0 0
Flo.COUNTY/STATE-STATE MEDI-CAL(PERINATAL) 0 0
F11.FEDERAL/STATE-DIRECT CONTRACT 0 0
F12. 0 0
F13. 0 0
F14. 0 0
G. OTHER(SPECIFY)TCM/MAC(AB23 FEDERAL SHARE) 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 1,293,440 270,000 1,023,440 0 1,023,440
NET COSTS GROSS COSTS LESS LINES D E G 1.023.440 0 1,023.440 0 1.023.440
H. UNITS OF SERVICE
H1. FACE TO FACE VISITS(INDIVIDUAL,GROUP,ETC. 0 0
H2. FACE TO FACE VISITS DOSES 86,575 18,072 68,503 68,503
H3. DAY CARE HABILITATIVE DAY 0 0
H4. RESIDENTIAL DAY 0 0
H5. OTHER SPECT 0 0
H6. 0 0
H7. 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H 86,575 18,072 68,503 0 68,503
I. STAFF HOURS DIRECT SVCS-COUNSELING,MEDICAL,ETC. 56,073 12,190 43,883 43,883
J. METHADONE SLOTS OMM on 460 100 360 360
K. COST PER UNIT OF SERVICE NITS GROSS OOSTS/LINE H8 14.94 14.94 14.94 ERR 14.94
L COST PER STAFF HOUR GROSS COSTS/LINE Q 23.07 22.15 23.32 ERR 23.32
M. COST PER SLOT GROSS OOSTS/UNEQ 2811.83 2700.00 2842.89 ERR 2842.89
TOTAL STATE GENERAL FUND ADD ONES F2,F8 511,7201 ol 511,720 0 511,720
ADP FORM 7895B (8/94)
EXHIBIT A
Page 1 of 6
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDI—CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
COUNTY—WIDE SUMMARY
COUNTY CONTRA COSTA
CONTRACT PERIOD 7/1/94-6/30/95
DATE PREPARED 11/01/94
TYPE OF PROGRAM ODF (Specify as OMM, ODF, DCH,NAL, RES)
A B C D E
TOTAL PRIVATE NNA/PUBUC TOTAL MC/
CATEGORIES PROGRAM PAY MEDT-CAL FUNDED NNA/PUBUC
GROSS COSTS
A PROGRAM(TREATMENT) 665,8921 6,4181 380.388 279,086 659.474
B. COUNTY ADMINISTRATION 0 0 01 0 0
C. TOTAL GROSS COSTS 665,892 6,418 380,388 279,086 659,474
REVENUES
D. PARTICIPANT FEES 6,418 6.418 0 0 0
E. INSURANCE,MEDICARE,&OTHER THiRD PART 0 0 0 0 0
F. CONTRA TS&G
C RANT (SPECIFY)
F1. COUNTY—FEDERAL ALCOHOL&DRUG 73,463 0 01 73,463 73,463
F2. COUNTY—STATE ALCOHOL&DRUG 45,033 0 0 45,033 45,033
F3. COUNTY—COUNTY ALCOHOL&DRUG 160,590 0 0 160,590 160,590
F4. COUNTY—FEDERALPERINATA 0 0 0 0 0
F5. COUNTY—STATE PTE (PERINATAL) 0 0 0 0 0
F6. COUNTY—COUNT(PERINATAL) 0 01 0 0 0
F7. COUNTY/STATE—FEDERAL MEDI—CAL(ALCOHOL&DRUG) 60,246 01 60,246 0 60,246
F8. COUNTY/STATE—STATE MEDT—CAL(ALCOHOL&DRUG) 60,246 0 60.246 0 60.246
F9. COUNTY/STATE—FEDERAL MEDT—CAL(PERINATAL). 129,948 01 129.948 0 129,948
F10.COUNTY/STATE—STATE MEDI—CAL(PERINATAL) 129.948 01 129,948 0 129,948
F11.FEDERAL/STATE—DIRECT CONTRACT 0 0 0 0 0
F12. 0 0 0 0 0
F13. 01 0 0 0 0
F14. 0 0 0 0 0
G. OTHER SPECT TCM/MAC(AB2377)(FEDERAL SHARE) 0 0 0 0 0
G1. 0 0 0 0 0
G2 0 01 0 0 0
G3. 0 01 0 0 0
TOTAL REVENUES 665,8921 6,4181 380.388 279,086 659,474
NET COSTS GROSS COSTS LESS LINES 0 E G 659,4741 01 380,388 279.086 659 474
H. UNITS OF SERVICE
H1. FACE TO FACE VISITS INDIVIDUAL,GROUP,ETC. 9,818 133 5,663 4,022 9,685
H2. FACE TO FACE VISITS DOSES 0 0 0 0 0
H3. DAY CARE HABILITATIVE DAY 0 0 0 0 0
H4. RESIDENTIAL DAY 0 0 0 0 0
H5. OTHER(SPECIFY) 0 0 0 0 0
H6. 0 0 0 0 0
H7. 0 0 0 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES HI THROUGH H 9,818 133 5.663 4.022 9,685
I. STAFF HOURS DIRECT SVCS—COUNSELING,MEDICAL.ETC. 17,144 217 9,390 7.537 16.927
J. METHADONE SLOTS(OMM only) 0 0 1 0 0 0
K COST PER UNIT OF SERVICE UNITS GROSS COSTS/UNE HB 67.821 48.261 67.171 69.39 68.09
L COST PER STAFF HOUR GROSS COSTS/UNE I 38.841 29.581 40.511 37.031 38.96
M. COST PER SLOT GROSS COSTSJUNEQ I ERRI ERRI ERRI ERRI ERR
TOTAL STATE GENERAL FUND(ADD LINES F2,F8) 1 105,2791 01 60,2461 45.033 105.279
ADP FORM 7895B (8/94)
EXEM*=f AL
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDT-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER
CONTRACTOR AIRS EAST
CONTRACT PERIOD 7/1/94-6/30/95 MEDT-CAL PROV. NO. 07AA
DATE PREPARED 11/1/94 CADDS PROVIDER NO.
TYPE OF PROGRAM ODF (Specify as OMM, ODF, DCH,NAL, RES)
A
TOTAL PRIVATE NNA/PUSUC TOTAL MC/
CATEGORIESPROGRAM PAY MEDI-CAL FUNDED NNA/PUBLIC
GROSS COSTS
TS
A PROGRAM EATMEN 105,530 5.312 36,480 63,738 100,218
S. COUNTY ADMINISTRATION 0 0
C. TOTAL GROSS COSTS 1 105.530 5,312 36.480 63,738 100,218
REVENUES
E
S
D. PARTICIPANT FEES 5,3121 5,312 0
E INSURANCE,MEDICARE.&OTHER THIRD PARTY 0 0
FCONTRACT
S&GRANTS
(SPECIFY)
F1. COUNTY-FEDERAL ALCOHOL&DRUG 28,355 28,355 28,355
F2. COUNTY-STATE ALCOHOL&DRUG 17,3821 17,382 17.382
F3. COUNTY-COUNTY ALCOHOL&DRUG 18,001 ol 18,001 18,001
F4. COUNTY- FEDERAL(PERINATAL) 0 0
F5. COUNTY-STATE PTE (PERINATAL) 0 0
F6. COUNTY-COUNTY(PERINATAL) 0 0
F7. COUNTY/STATE-FEDERAL MEDT-CAL(ALCOHOL&DRUG) 18,240 18,2401 18.240
F8. COUNTY/STATE-STATE MEDI-CAL ALCOHOL&DRUG 18,240 18.2401 18,240
F9. COUNTYISTATE-FEDERAL MEDI-CAL(PERINATAL) ol 1 0
F10.COUNTY/STATE-STATE MEDI-CAL(PERINATAL) ol 10
F11.FEDERAUSTATE- DIRECT CONTRACT ol 0
F12. 0 0
F13. ol 0
F14. ol 0
G. OTHER(SPECIFY)TCM/MAC A8237 FEDERAL SHARE) 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 105,530 5,312 36,480 63,738 100.218
NET COSTS GROSS COSTS LESS LINES D E G 100.218 0 36.480 63.738 100,218.
F R
H.
UNIT SE S 0 SERVICE
H1. FACE TO FACE VISITS INDIVIDUAL.GROUP,ETC. 2,204 111 762 1,331 2,093
H2. FACE TO FACE VISITS DOSES 0 0
H3. DAY CARE HABILITATIVE DAY 0 0
H4. RESIDENTIAL DAY 0 0
H5. OTHER(SPECIM 0 0
H6. 0 0
H7. 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H7 2.204 1111 7621 1,331 2.093
1. STAFF HOURS DIRECT SVCS-COUNSELING,MEDICAL,ETC. 3:685 1851 1,274 2,226 3,500
J. METHADONE SLOTS(OMM only) of I 1 0
K COST PER UNIT OF SERVICE(UNITS)(GROSS COSTS/UNE H8) 47.88 47.86 47.87 47.89 47.88
i COST PER STAFF HOUR GROSS COSTS/I.:NE 1 28.64 28.71 28.631 28.63 28.63
N. COST PER SLOT(GROSS COSTSIUNE ERRI ERR ERRI ERR ERR
TOTAL STATE GENERAL FUND ADD LINES F2,F8 35,6221 ol 18,2401 17,382 35,622
ADP FORM 7895B (8/94)
E J:5'of4
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUN4MARY
COUNTY CONTRA COSTA CONTRACT NUMBER
CONTRACTOR BORN FREE CENTRAL
CONTRACT PERIOD 7/1/94-6/39/95 MEDI-CAL PROV. NO. 0770
DATE PREPARED 11/1/94 CADDS PROVIDER NO.
TYPE OF PROGRAM ODF (Specify as OMM,ODF, DCH,NAL, RES)
A B C D E
TOTAL PRIVATE NNA/PUBUC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI-CAL FUNDED NNA/PUSUC
R
G OSS COSTS
A. PROGRAM(TREATMENT) 156.5171 99,590 56,927 156,517
B. COUNTY ADMINISTRATION 01 0
C. TOTAL GROSS COSTS 156,5171 0. 99.590 56,927 156,517
R UES
ES
D. PARTICIPANT FEES p:l 0..
E INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 I 0
F. CONTRA T RANTS
C S&G (SPECIFY)
..
F1. COUNTY-FEDERAL ALCOHOL&DRUG o.............................................................................0........ .....................0.
F2. COUNTY-STATE ALCOHOL&DRUG ol 0
F3. COUNTY-COUNTY ALCOHOL&DRUG 56,927 4 56,927 56.927
F4. COUNTY-FEDERAL(PERINATAL) ol 1 0 0
F5. COUNTY-STATE(PTEP)(PERINATA 0 I 0
F6. COUNTY-COUNTY(PERINATAL) 0 I 0
F7. COUNTY/STATE- FEDERAL MEIN-CAL(ALCOHOL&DRUG) ol 0
=8. COUNTY/STATE-STATE MEDI-CAL(ALCOHOL&DRUG) O l 0
=9. COUNTY/STATE-FEDERAL MEDI-CAL PERINATAL I 49,795; 49,795 49,795
F10.COUNTY/STATE-STATE MEDI-CAL(PERINATAL) 49,795' 49,795 49,795
F11.FEDERAUSTATE-DIRECT CONTRACT
0! ! 0
F12. 0 t 0
F13. 01 0
F14. 0i 0
G. OTHER SPECT TCM/MAC(AB237 FEDERAL SHARE) 0 0
G7. 61 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 156,517 0 99,590 56,927 156,517
NETCOSTS GROSS COSTS LESS LINES DEG 156517 0 99 590 56.927 156.517
H. UNITS F SERVICE --
E
H1. FACE TO FACE VISITS INDIVIDUAL GROUP,ETC. 1,532 1,212..::: 320..::. 1,532:
H2. FACE TO FACE VISITS DOSES ol 0
H3. DAY CARE HABILITATIVE DAY 0; 0
H4. RESIDENTIAL DAY ol 0
H5. OTHER SPECI 0 0
H6. 0 0
H7. 'o 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H 1,532 0 1,212 320 1,532
!. STAFF HOURS DIRECT SVCS-COUNSELING,MEDICAL,ETC. 2,780 1,769 1,011 2,780
J. METHADONE SLOTS(OMM only) 0 0
< COST PER UNIT OF SERVICE UNITS GROSS COSTS/LINE HB 102.17 ERR 82.17 177.90 102.17
_ COST PER STAFF HOUR(GROSS COSTS/UNE 1) 56.301 ERR I 56.30 56.31 56.30
J. COST PER SLOT(GROSS COSTS/UNE J) I ERRI ERRI ERRI ERRI ERR
TOTAL STATE GENERAL FUND(ADD LINES F2,F8) 0 l 01 O I O I 0
;DP FORM 78968 (8/94)
EXHA@XVofa
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDT-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER
CONTRACTOR BORN FREE WEST
CONTRACT PERIOD 7/1/94-6/30/95 MEDI-CAL PROV. NO. 0773
DATE PREPARED 11/01/94 CADDS PROVIDER NO.
TYPE OF PROGRAM ODF (Specify as OMM, ODF, DCH, NAL, RES)
A B C D E
TOTALPRNATE NNA/PUSUC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI—CAL FUNDED NNA(PUBUC
GROSS CO
SS
PROGRAM(TREATMENT) 119,776 104,760 15,016 119,776
B. COUNTY ADMINISTRATION 0 0
C. TOTAL GROSS COSTS 1197761 0 104,760 15,016 119 776
REVENUES
D. PARTICIPANT FEES 0 0
E. INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 0
T
F. CON S&GRAN P
TRAC TS S ECI
F1. COUNTY—FEDERAL ALCOHOL&DRUG 0 0 0
F2. COUNTY—STATE ALCOHOL&DRUG 0 0
F3. COUNTY—COUNTY ALCOHOL&DRUG 15,016 15,016 15.016
F4. COUNTY—FEDERAL(PERINATAL) 0 0 0
F5. COUNTY—STATE(PTEP)(PERINATA ol 0
F6. COUNTY—COUNTY(PERINATAW 0 I 0
F7. COUNTY/STATE—FEDERAL MEDI—CAL ALCOHOL&DRUG ol 0
F8. COUNTY/STATE—STATE MEDT—CAL(ALCOHOL&DRUG) 0 I 0
F9. COUNTY/STATE—FEDERAL MEDI—CAL(PERINATAL) 52,380 52.380 52.380
F10.COUNTY/STATE—STATE MEDT—CAL(PERINATAL) 52.380 52.380 52.380
F11.FEDERAUSTATE—DIRECT CONTRACT ol 0
F12. ol 0
F13. ol 0
F14, ol 0
G. OTHER SPECT TCM/MAC(AB2377)(FEDERALSHAR 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 119.776 0 104,760 15.016 119,776
NET COSTS GROSS COSTS LESS LINES D E f-A 119.776 0 104,760 15.016 119.776
H. UNITS OF SERVICE
C
E
H1, FACE TO FACE VISITS INDIVIDUAL,GROUP,ETC. 1,532 1,340 192 1,532
42. FACE TO FACE VISITS DOSES 0 0
13. DAY CARE HABILITATIVE DAY 0 0
14. RESIDENTIAL DAY 0 0
45. OTHER SPECT 0 0
H6. 0 0
47. 0 0
J8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H 1,532 ol 1,340 192 1,532
. STAFF HOURS DIRECT SVCS—COUNSELING,MEDICAL,ETC. 2.928 2.561 367 2,928
I. METHADONE SLOTS(OMM only) 0 0
C COST PER UNIT OF SERVICE UNITS GROSS COSTS/UNE HB 78.181 ERRI 78.181 78.211 78.18
COST PER STAFF HOUR GROSS COSTS/UNE 1 40.911 ERR 40.911 40.921 40.91
A. COST PER SLOT GROSS COSTS/UNE ERRI ERRI ERRI ERRI ERR
TOTAL STATE GENERAL FUND ADD LINES F2,F8 ol ol ol ol 0
+DP FORM 78958 (8/94)
EXEKROoftl
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER
CONTRACTOR BORN FREE EAST
CONTRACT PERIOD 7/1/94-6/30/95 MEDI-CAL PROV. NO. 0774
DATE PREPARED, 11/1/94 CADDS PROVIDER NO.
TYPE OF PROGRAM ODF (Specify as OMM,ODF, DCH,NAL, RES)
A B C 0 E
TOTAL PRIVATE NNA/PUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDT-CAL FUNDED NNA/PUBUC
GROSS COSTS STS
A PROGRAM(TREATMENT) 97,555 55,546 42,009 97,555
B. COUNTY ADMINISTRATION 0 0
C. TOTAL GROSS COSTS 97,555 0 55,546 42.009 97,555
REVENUES
D. PARTICIPANT FEES 0 0
E,INSURANCE,MEDICARE,&OTHER THIRD PARTY 0 0
»:
F TS&GRANTS(SPECIFY)
F. CONTAAC
F1. COUNTY-FEDERAL ALCOHOL&DRUG 0 0 0
F2. COUNTY-STATE ALCOHOL&DRUG 0 0
F3. COUNTY-COUNTY ALCOHOL&DRUG 42,009 42,009 42,009
F4. COUNTY-FEDERAL(PERINATAQ 0 0 0
F5. COUNTY-STATE(PTEP)(PERINATA 0 0
F6. COUNTY-COUNTY(PERINATAL) 0 0
F7. COUNTY/STATE-FEDERAL MEDI-CAL ALCOHOL&DRUG ol 0
F8. COUNTY/STATE-STATE MEDI-CAL ALCOHOL&DRUG) ol 0
F9. COUNTY/STATE-FEDERAL MEDI-CAL(PERINATAL) 27,773 27,773 27,773
F10.COUNTY/STATE-STATE MEDT-CAL(PERINATAL) 27,773 27,773 27,773
F11.FEDERAUSTATE— DIRECT CONTRACT 0 0
F12. 0 0
F13. 0 0
F14. 0 I 0
G. OTHER SPECT TCM/MAC(AB2377)(FEDERAL SHARE) 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 97,555 0 55,546 42,009 97,555
NET COSTS GROSS COSTS LESS LINES D E G 97.555 0 55,5461 42.009 97 555
t
H. UNITS OF SERVICE
E
H1. FACE TO FACE VISITS INDIVIDUAL GROUP,ETC. 836 676 160 836
H2. FACE TO FACE VISITS DOSES 0 0
H3. DAY CARE HABIUTATIVE DAY 0 0
H4. RESIDENTIAL DAY 0 0
H5. OTHER SPECT 0 0
H6. 0 0
H7. 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES H1 THROUGH H 836 0 676 160 836
I. STAFF HOURS DIRECT SVCS—COUNSELING,MEDICAL ETC. 2,349 1,338 1,011 2,349
J. METHADONE SLOTS(OMM only 0 0
K COST PER UNIT OF SERVICE NITS GROSS COSTS/UNE H8 116.691 ERRI 82.171 262.561 116.69
L COST PER STAFF HOUR GROSS COSTS/UNE I 41.53 I ERRI 41.511 41.551 41.53
M. COST PER SLOT GROSS COSTS/UNE ERRI ERRI ERRI ERRI ERR
TOTAL STATE GENERAL FUND ADD UNES F2,F8 ol ol ol 0 0
4DP FORM 7895B (8/94)
EXK&#XjWofs
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS (ODF1)
DRUG MEDI-CAL FISCAL DETAIL
BUDGET OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRA COSTA CONTRACT NUMBER
CONTRACTOR SOJOURNE
CONTRACT PERIOD 7/1/94-6/30/95 MEDI-CAL PROV. NO. 0761
DATE PREPARED 11/1/94 CAODS PROVIDER NO.
TYPE OF PROGRAM ODF (Specify as OMM,OOF, DCH,NAL, RES)
A B C D E
TOTAL PRIVATE NNA/PUBUC TOTAL MC/
CATEGORIES PROGRAM PAY MEDT-CAL FUNDED NNA/PUBUC
GROSS COSTS
T
A PROGRAM EATMEN 186,514 1,106 84,012 101;396 185,408
B. COUNTY ADMINISTRATION 0 0
C. TOTAL GROSS COSTS 186,5141 1 106 84,012 101,396 185,408
REVENUES
D. PARTICIPANT FEES 1,106 1,106 0
E INSURANCE.MEDICARE.&OTHER THIRD PARTY ol 0
. CONTRACTS RANTS(SPECIFY) ........................::.....:.......::....:.:.............................:...........:.....:..........:................................. .....
F1. COUNTY-FEDERAL ALCOHOL&DRUG 45,108 45,108 45,108
F2. COUNTY-STATE ALCOHOL&DRUG 27,651 27,651 27,651
F3. COUNTY-COUNTY ALCOHOL&DRUG 28,637 28,637 28,637
F4. COUNTY-FEDERAL(PERINATAL) 0 0
F5. COUNTY-STATE PTE (PERINATAL) 0 0
F6. COUNTY-COUNTY(PERINATAL) ol 0
F7. COUNTY/STATE-FEDERAL MEDI-CAL ALCOHOL&DRUG 42,006 I 42.006 1 42,006
F8. COUNTY/STATE-STATE MEDI-CAL(ALCOHOL&DRUG) 42.0061 42,006 42,006
F9. COUNTY/STATE-FEDERAL MEDT-CAL(PERINATAL) 0 0
F10.COUNTY/STATE-STATE MEDI-CAL(PERINATAL) 0 I ( 0
F11.FEDERALISTATE-DIRECT CONTRACT 0! 0
F12. 0 j 0
F13. 0 0
F14. 0 0
G. OTHER SPECT TCM/MAC(AB2377)(FEDERAL SHARE) 0 0
G1. 0 0
G2. 0 0
G3. 0 0
TOTAL REVENUES 186,514 1,1061 84,012 101,396 185,408
NET COSTS GROSS COSTS LESS LINES D E G 185,408 ol 84,012 101.396 185.408
H. UNITSOF SERVICE
CE `iiriiiii><.i<::? >i :'•> >». .... .. .. -
H1. FACE TO FACE VISITS ONDIVIDUAL GROUP,ETC. 3,714 22 1,673 2,019 3,692
H2. FACE TO FACE VISITS DOSES 0 0
H3. DAY CARE HABIUTATIVE DAY 0 0
H4. RESIDENTIAL DAY 0 0
H5. OTHER SPECT 0 0
H6. 0 0
H7. 0 0
H8.TOTAL UNITS OF SERVICE ADD LINES Ht THROUGH H 3,714 22 1,673 2.019 3,692
1. STAFF HOURS DIRECT SVCS-COUNSELING,MEDICAL ETC. 5,402 32 2.448 2,922 5,370
J. METHADONE SLOTS(OMM onl ol 0
K COST PER UNIT OF SERVICE UNITS GROSS COSTS/UNE HB 50.221 50.27 50.221 50.221 50.22
L COST PER STAFF HOUR GROSS COSTS/UNE I 34.53 34.561 34.32 34.70 34.53
M. COST PER SLOT GROSS COSTS/UNE ERRI ERRI EARI ERRI ERR
TOTAL STATE GENERAL FUND(ADD LINES F2.F8) 69,657 0 l 42,0061 27,651 1 69,657
ADP FORM 78958 (8/94)
EXHIBIT A(F)
Page 1 of 27
STAT OF CAMORMA '
DEPARTMENT OF HEALTH SERVICES
ADDITIONAL PROVISIONS
(FOR FEDERALLY FUNDED SUBVENTION AID/LOCAL ASSISTANCE
COST REIMBURSEMENT CONTRACTS/GRANTS)
1. sauai apporttmity Clause
a. The Contractor will not discriminate against any employee or applicant for
employment because of race. color, religion, sex, national origin, physical or mental
handicap, or age. The Contractor will take affirmative action to ensure that qualified
applicants are employed, and that employees are treated during employment
without regard to their race, color religion, sex, national origin, physical or mental
handicap, or age. Such action shall include, but not be limited to. the following:
employment, upgrading, demotion or transfer recruitment or recruitment advertising;
layoff or termination; rates of pay or other forms of compensation; and career
development opportunities and selection for training,,including apprenticeship. The
Contractor agrees to post in conspicuous places, available to employees and
applicants for employment,notices to be provided by the Federal Government or the
State, setting forth the provisions of the Equal Opportunity clause and the
Rehabilitation Act of 1973. Such notices shall state the Contractor's obligation under
the law to take affirmative action to employ and advance in employment qualified
applicants without discrimination based on their race, color, religion, sex, nationol
origin, physical or mental handicap, or age, and the rights of applicants and
employees.
b. The Contractor will,in all solicitations or advertisements for employees placed by or on
behalf of the Contractor, state that all qualified applicants will receive consideration
for employment without regard to race. color, religion,sex, national origin, physical or
mental handicap,or age.
c. The Contractor will send to each labor union or representative of workers with which
he or she has a collective bargaining agreement or other contract or understanding a
notice, to be provided by the Federal Government or the State, advising the labor
union or worker's representative of the Contractor's commitments under this Equal
Opportunity clause and shall post copies of the notice In conspicuous places
available to employees and applicants for employment.
d. The Contractor will comply with an provisions of the Rehabilitation Act of 1979 and of
the Federal Executive Order No. 11246.as amended,and of the rules,regulations, and
relevant orders of the Secretary of Labor.
e. The Contractor will furnish as information and reports required by Federal Executive
Order No. 11246 as amended and the Rehabilitation Act of 1973, and by the rules.
regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit
access to his books, records, and accounts by the contracting agency and the
Secretary of Labor for purposes of investigation to ascertain compliance with such
rules.regulations and orders.
CAG fon c"M DAVI n"a 02 01191)
EXHIBIT A(F)
Page 2 of 27
f. -in the event of the Contractors noncornplionce with the requirements of this Equal
Opportunity clause or with any federal rules. regulations. or. orders which are
referenced in this clause, this contract may be canceled. terminated. or suspended in
w!;ole or in part and the Contractor may be declared ineligible for further federal or
state contracts in accordance with procedures authorized. in Federal Executive Order
No. 11246 as amended and such other sanctions may be imposed and remedies
invoked as provided in Federal Executive Order No. 11246 as amended, or by rule,
regulation, or order of the Secretary of Labor, or as otherwise provided by law.
g. The Contractor will include the provisions of paragraphs (a] through "(gl in every
subcontract or purchase order unless exempted by rules. regulations, or orders of the
Secretary of Labor issued pursuant to Federal Executive Order No. 11246 as amended,
or Section 503 of the rehabilitation Act of 1973. so that such provisions will be binding
upon each subcontractor or vendor. The Contractor will take such action with
respect to any subcontract or purchase order as the Director of the Office of Federal
Contract Compliance Programs or the State may direct as a means of enforcing such
provisions Including sanctions for noncompliance-provided, however, that in the event
the Contractor becomes involved In, or is threatened with, litigation with a
subcontractor or vendor as a result of such direction by the State, the Contractor may
request in writing to the State, who, in turn, may request the United States to enter Into
such litigation to protect the interests of the State and of the United States.
2. Trigival einel Par Diem
Any reimbursement for necessary traveling and per diem shall be at rates not to exceed
those amounts paid to the State's represented employees under collective bargaining
agreements currently In effect. No travel outside the State of Calif omia sholl be reimbursed
unless prior written authorization is obtained from the State.
3. Prncuramant Raeuiramant
a. Prior authorization In writing by the State will be required before the Contractor will be
reimbursed for any purchase order or subcontract exceeding $2.500 for any articles.
supplies. equipment, or services or for any fee, or other payment, for consultation of
three hundred fifty dollars ($350) or more per day. The Contractor must provide in Its
request for authorization all particulars necessary for evaluation of the necessity or
desirability of Incurring such cost, and as to the reasonableness of the price or cost.
For purchases of any sold articles, supplies, equipment, services, or for consultant fees
exceeding such minimum amount, three competitive quotations must be submitted
with the request, or the absence of bidding must be adequately justified.
b. If other than the lowest bidder or a sole-source provider is selected, all documents
used in contractor selection must be presented in writing to the State for prior
approval before awarding any contract, and maintained for possible future oudit as
specified in paragraph 7 below.
c. The terms 'purchase order and 'subcontract as used in the above paragraph 3a
only, excludes: (a) purchase orders not exceeding $2.500, and (b) subcontracts or
purchase orders for public utility services at rates established for uniform applicability
to the general pubic.
-2.
EXHIBIT AM
Page 3 of 27
4. Sjendards of Work
The Contractor agrees that the performance of work and services pursuant to the
requirements of this contract shall confirm to high professional standards.
5. f=ltlng of IMperty by the State or Purchase of Property with State or Federal Funds
o. (1) All equipment. material, supplies, or property of any kind purchased from funds
advanced or reimbursed or furnished by the State under the terms of this
contract and not fully consumed in the performance of the contract shall be the
property of the State and shall be subject to the provisions of this paragraph (a).
as well as paragraphs( ),(c),and(d)below.
If the Equipment Line Item in the budget or in any other paragraph of this
contract,exceeds$11 0=or more.the provisions of subparagraph b shall apply.
CZ Inventory and Disposition
(a) Contractor shall, at the request of the State, submit an inventory of
equipment furnished or purchased under the terns of this contract. Such
inventory will be required not more frequently than annually.
(b) At the termination of this contract, the Contractor shall provide a final
inventory to the State and shall at that time query the State as to the State's
requirements. Including the manner and method, in returning said
equipment to the State.- Fnal disposition of such equipment shall be at state
expense In accordance with instructions from the State to be issued
immediately after receipt of the final inventory.
(3) Motor Vehicles
(a) If, under the provisions of paragraph C2) above,any part of such property Is
motor vehicles, the State Office of Procurement shall purchase said motor
vehicles for and on behalf of the Contractorr The provisions of clause (5b)
below are applicable to this paragraph concerning motor vehicles.
(b) If, under the provisions of paragraphs (2) or (3) above, any part of such
property Is motor vehicles, the State authorizes the Contractor to use said
motor vehicles under the terms and conditions of this contract for purposes
of this contract only, and in accordance with the provisions of
subparogrophs (c)through (f) below.
(c) It is mutually understood that the State of California shall be the legal owner
of said vehicles and the Contractor shall be the registered owner.
(d) Upon return of such motor vehicles to the State, Contractor shall deliver to
State all necessary documents of title to enable proper transfer of
marketable title to the State.
(e) Contractor agrees that all operators of motor vehicles"listed in said
agreement shop Fold a valid State of California driver's license. In the event
12 or more passengers are to be carried in any one vehicle listed in said
agreement,a Class 2 driver's license will also be required.
(n Contractor shall furnish to the State a certificate of insurance stating that
there is liability insurance presently in effect for the Contractor of not less
than S500MO per occurrence for bodily injury and property damage liability
combined.
-3-
• _ EXHIBIT A(F)
Page 4 . of 27
The certificate of insuronpe must include provisions (0 and 00.stating'that:�'
(j) The insurer will not cancel the insured's coverage without 30 days prior
written notice to the State.
f7 The State of California,its officers. agents,employees,and servants are
Included as additional insureds. but only insofar as the operations
under this contract are concerned.
Contractor agrees that the bodily injury liability insurance herein provided
for shall be in effect at all times during the term of this contract. In the event
said insurance coverage expires at any time or times during the term of this
contract, Contractor agrees to provide at least thirty (30) days prior to said
expiration date a new certificate of insurance evidencing insurance
coverage as provided for herein for not less than the remainder of the term
of the contract, or for a period of not less than one (1) year. New
certificates of insurance are subject to the approval of said Department of
General Services. and Contractor agrees that no worts or services shall be
performed prior to the giving of such approval. In the event Contractor fails
to keep in effect at all times Insurance coverage as herein provided. State
may. In addition to any other remedies it may have,terminate this contract
upon the occurrence of such event.
b. if the Equipment line item budget in this contract is $10= or more, the State shall
purchase said equipment through its Office of Procurement. The cost of the
procurement of equipment will be deducted from the contract amount. Contractor
shall submit to the State a separate list of the equipment specifications. State will pay
vendor directly for equipment purchases and title to the equipment will remain with
the State. The equipment will be delivered either to the Contractor's address as
stated in the contract unless notified by the Contractor In writing.
C. (1) Title to state property shall not be affected by the incorporation or attachment
thereof to any property not owned by the State,nor shall such state properly, or
any part thereof, be or become a fixture or lose Its identity as personality by
reason of affixation to any realty.
(Z Unless otherwise provided herein. the State shall not be under any duty or
obligation to restore or rehabilitate, or pay the cost of the restoration or
rehabilitation of the Contractor's facility or any portion thereof which is affected
by removal of any state property.
C3) The Contractor shop maintain and administer.in accordance with sound business
practice, a program for the utilization, maintenance. repair, protection, and
preservation of state property so to assure its full availability and usefulness for the
performance of this contract. The Contractor shalt take all reasonable steps to
comply with all appropriate directions and instructions which the State may
prescribe as reasonably necessary for the protection of state property.
d. for equipment only. Before equipment purchases made by the Contractor are
reimbursed by the State.the Contractor must submit paid vendor receipts identifying
the purchase price, description of .the Item, serial number, model number, and
location where equipment will be used during the term of this agreement. Said paid
. receipts will be attached to Contractors invoices submitted to the State.
-4-
EXHIBIT AM
Page S of 27
6. rneerrme Restrieions
The Contractor agrees that any refunds, rebates, credits. or other amounts (including any
interest thereon) accruing to or received by the Contractor under this contract shall be
paid by the Contractor to the State, to the extent that they are properly allocable to costs
for which the Contractor has been reimbursed by the State under this contract.
7. F rorninatien of Aecounts. Audit_ Records_ end Subeentract lone.Lege_
a. The Contractor shall maintain books, records, documents, and other evidence,
accounting procedures, and practices, sufficient to reflect properly all direct and
indirect costs of whatever nature claimed to have been Incurred in the performance
of this contract, including any matching costs and expenses. The foregoing
constitutes'recordr for the purpose of this clause.
b. The Contractor's facility or office or such part thereof as may be engaged in the
performance of this contract and his records shall be subject-at all reasonable times
to inspection, audit, and reproduction by the State or any of Its duly authorized
representatives. Including the Comptroller General of the United States.
C.- The Contractor shall preserve and make available his records (i) for a period of three
years from the date Of final payment under this contract, and (ii) for such longer
period, If any, as is required by applicable statute, by any other clause of this contract,
or by subparagraphs (1) or (2) below.
(1) If this.contract is completely or partially terminated, the records relating to the
work terminated shall be preserved and mode available for a period of three
years from the date of any resulting final settlement.
(2) If any litigation, claim, negotiation, audit, or other action involving the records
has been started before the expiration of the three-year period, the records shop
be retained until completion of the action and resolution of all issues which arise
from ft, or until the end of the regular three-year period, whichever is later.
d. The Contractor further agrees to Include In oil his subcontracts hereunder a written
agreement with sold subcontractor or vendor,the following clause:
'(Nome of Vendor or Subcontractor) agrees to maintain and preserve, until three
years after termination of(Contractors name) agreement or contract with the State
of California, and to permit the State or any of its duly authorized representatives.
Including the Comptroller General of the United States, to have access to and
examine and audit any pertinent books, documents, papers, and records of(name of
subcontractor or vendor) related to this(purchase order or subcontract).•
8. Covenant Against Centinaent Fees
The Contractor warrants that no person or seeing agency has been employed or retained
to sodClt or secure this contract upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee..excepting bona fide employees or bona fide
established commercial or selling agencies maintained by the Contractor for the purpose
of securing business. For breach or violation of this warranty, the State shop have the right
to annul this contract without Robility or in its discretion to deduct from the contract price or
Consideration, Or otherwise recover, the tuft amount of such Commission, percentage,
brokerage, or contingent fee.
.5-
EXHIBIT A(F)
Page 6 of 27
The State, through any outhorited representatives. hos the right at all reasonable`times to
inspect or otherwise evaluate the work performed or being performed hereunder including
subcontract supported activities and the premises in which it.is being performed. If any
inspection or evaluation is made by the State of the premises of the Contractor or a
subcontractor, the Contractor shall provide and shall require his subcontractors to provide
all reasonable facilities and assistance for the safety and convenience of the state
representatives in the performance of their duties. All inspections and evaluations shall be
performed in such a manner as will not unduly delay the work.
10. Nondiscrimination in Servlces_ Benefits_ and Facilities
a. The Contractor will not discriminate in the provision of services because of race, color,
creed, national origin, sex, age. or physical or mental handicap as provided by state
and federal law.
b. For the purpose of this contract, distinctions on the grounds of race, color, creed,
national origin, sex, age, or physical or mental handicap include, but are not limited
to, the following: denying a participant any service or providing a benefit to a
participant which is different, or is provided'In a different manner or at a different time
from that provided to other participants under this contract; subjecting a participant
to segregation or sepprote treatment in any matter related to his receipt of any
service: restricting a participant in any way in the enjoyment of any advantage or
privilege enjoyed by others receiving any service or benefit; treating a participant
differently from others In determining whether he satisfied any admission, enrollment
quota, eligibility, membership, or other requirement or condition which individuals must
meet In order to be provided any service or benefit; the assignment of times or places
for the provision of services on the basis of the race, color, creed, or national origin of
the participants to be served.
c. The Contractor will take affirmative action to ensure that intended beneficiaries are
provided services without regard to race, color creed, national origin, sex, age. or
physical or mental handicap.
d. The Contractor agrees that Complaints alleging discrimination In the delivery of
services by the Contractor or his or her subcontractor because of race, color, national
origin, creed, sex, age, or physical or mental handicap will be resolved by the State
through the Department of Health Services' -Affirmative Action/Discrimination
Compliant Process.
e. The Contractor shop, subject to the approval of the Department of Health Services.
establish procedures under which service participants are informed of their rights to file
a complaint alleging discrimination or a violation of their civil rights with the
Department of Health Services.-
L The Contractor shall operate the program or activity In such a manner that It Is readily
accessible to and usable by mentally or physicapy handicapped persons pursuant to
45 Code of Federal Regulations. Parts 84,Sections 84.21 and 84.22.
g. The Contractor shall keep records, submit required compliance reports, and permit
state access to records in order that the State con determine compliance with the
nondiscrimination requirements pursuant to 45 Code of Federal regulations, Parts 80-
84. and 90. Sections 80.6, 84.61, and 90.42.
.6.
EXHIBIT A(F)
` Page 7 of 27
11. Finel Inveiee—Final RennR—Retention of Funds
It a final report is required by this contract, 10 percent of the face amount of the contract
or 50 percent of the final invoice, whichever is the larger amount, but not to exceed 53.000.
shall be withheld until atter receipt by the State of a report satisfactory to the State.
14, AfBeias Net to 9eneftt
No member of or delegate to Congress or the State Legislature shalt be admitted to any
shore or part of this contract, or to any benefit that may arise therefrom; but this provision
shall not be construed to extend to this contract if made with a corporation for Its general
benefit.
13. Bightsi� n Date
a. Subject Data. As used In this clause, the term 'Subject Data' means writings, sound
recordings, pictorial reproductions, drawings, designs or graphic representations,
procedural manuals;forms, diagrams, work flow charts, equipment descriptions, data
files and data processing or computer programs, and works of any similar nature
(whether or not copyrighted or copyrightable) which are first produced or developed
under this contract. The term does not include financial reports, cost analyses, and
similar information-incidental to contract administration.
b. Federal Government and State Rights. Subject only to the provisions of 'c'.below, the
Federal Government and State may use, duplicate. or disclose In any manner and for
any purpose whatsoever, and hove or permit others to do so, all Subject Data
delivered under this contract.
c. License to Copyrighted Data. In addition to the Federal Government and State rights
as provided in (bj above, with respect to any subject data which may be
copyrighted, the Contractor agrees to and does hereby grant to the Federal
Government and State a royalty-free. nonexclusive and irrevocable license
throughout the world to use, duplicate, or dispose of such data in any manner for
State or Federal Government purposes and to have or permit others to do so.
Provided, however, that such license shall be only to the extent that Contractor now
has, or prior to completion or final settlement Of this contract may acquire, the right to
grant such license without becoming liable to pay compensation to others solely
because of such grant.
Cl. Relation to Patents. The State reserves a license on patent rights 4n any contract
involving research or developmental, experimental, or demonstration work with
respect to any discovery or Invention which arises under this contract.
e. Marking and Identification. The Contractor shall mark all Subject Data with the
number of this contract and the name and address of the contractor or
subcontractor who generated the data. The Contractor shag not affix any restrictive
markings upon any Subject Data, and If such markings are affixed, the Federal
Government or State shag have the fight at any time to modify, remove, obliterate. or
ignore any such markings.
t Subcontractor Data. Whenever any Subject Data is to be obtained from a
subcontractor .under this contract, the Contractor.shall use this some clause in
subcontract without alteration, and no other clause shall be used to enlarge or
diminish the Federal Government's or State's rights in the subcontractor Subject Data.
-7-
EXHIBIT A(F)
Page 8. of 27
g. -Deterred Ordering and Deiiverl of Dorc. The Federal Government or State shall have
the rignt to order, at any time during the performance of this contract, or within two
years from either acceptance of all items (other than data) to be delivered under this
contract or termination of this contract, whichever is later, any Subject Data and any
data not called for in the schedule of this contract but generated in performance of
the contract, and the Contractor shall promptly prepare and deliver such data as is
ordered. If the principal investigator is no longer associated with the Contractor, the
Contractor shall exercise Its best efforts to prepare and deliver such data as is ordered.
The Federal Government's or State's right to use data delivered pursuant to this
paragraph (g) shall be the some as the rights in Subject Data as provided in 'b'
above. The Contractor shall be relieved of obligation to furnish data pertaining to on
item obtained from a subcontractor upon the expiration of two years from the date
he accepts such items. When data, other than Subject Data, is delivered'oursuant to
this paragraph (g), payment shall be made. by equitable adjustment or otherwise, for
converting the data into the prescribed form, reproducing it or preporing It for
delivery. The terms of such payment shall be agreed upon in writing by the
Contractor and the State and/or Federal Government, whichever ordered the
production of the data.
14. Disabled Veterans end Veterans of the Vietnam Era
a. The Contractor will not discriminate against any employee or applicant for-
employment because he or she is a disabled veteran or veteran of the Vietnam era In
regard to any position for which the employee or applicant for employment is
Qualified. The Contractor agrees to take affirmative action to employ, advance in
employment, and otherwise treat qualified disabled veterans and veterans of the
Vietnam era without discrimination based upon their disability or veterans status in all
employment practices such as the following: employment upgrading, demotion or
transfer, recruitment, advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training. Including apprenticeship.
b. The Contractor agrees that all suitable employment openings of the Contractor which
exist at the time of the execution of this contract and those which occur during the
performance of this contract. Including those not generated by this contract and
including those occurring at an establishment of the Contractor other than the one
wherein the contract Is being performed but excluding those of Independently
operated corporate affiliates,shall be listed at an appropriate local office of the state
employment service system wherein the opening occurs. The Contractor further
agrees to provide such reports to such local office regarding employment openings
and hires as may be required.
State and local government agencies holding federal contracts.of $10.000 or more
shall also list all their suitable openings with the appropriate office of the state
employment service, but are not required to provide those reports set forth in
paragraphs'd' and'e'.
c. Listing of employment openings with the employment service system pursuant to this
clause shall be made at least concurrently with the use of any other recruitment
source or effort and shall Involve the normal obligations which attach to the placing
of bona fide job order. Including the acceptance of referrals of veterans and
nonveterans. The listing of employment openings does not require the hiring of any
particular job applicant or from any particular group of job applicants, and nothing
herein is intended to relieve the Contractor from any requirements in Executive Orders
or regulations regarding nondiscrimination in employment.
-8-
EXHIBIT A(F)
Page. 9 of 27
The reports required by parograpli 'b- of this clause shall include. but not be limited to.
periodic reports which shall be filed at least quarterly with the appropriate local office
or, where the Contractor has more than one hiring location in a State, with the central
- office of that state employment service. Such reports shall indicate for each hiring
location (1) the number of individuals hired during the reporting period, (2) the
number of nondisabled veterans of the Vietnam era hired, (3) the number of disabled
veterans of the Vietnam era hired, end (4) the total number of disabled veterans
hired. The reports should include covered veterans hired for the on-the-job training
under 39 U.S.C. 1787. The Contractor shall submit a report within 30 days after the end
of each reporting period wherein any performance is made on this contract
identifying data for each hiring location, The Contractor shall maintain at each hiring
location copies of the reports submitted until the expiration of one year after final
payment under the contract, during which time these reports and related
documentation shall be made'available, upon request, for examination by any
authorized representatives of the Federal Contracting Officer, the State, or the
Secretary of Labor. Documentation would include personnel records respecting job
openings, recruitment, and placement.
e. Whenever the Contractor becomes contractually bound to the listing provisions of this
clause, it shall advise the employment service system in each state where It hos
establishments of the name and location of each hiring location in the state. As long
as the Contractor is contractually bound to these provisions and has so advised the
state system, there is no need to advise the state system of subsequent contracts. The
Contractor may advise the state system when It is no longer bound by this contract
clause.
f. This clause does not apply to the listing of employment openings which occur and are
filled outside the 50 states, the District of Columbia. Puerto Rico, Guam, and the
Virgin Wands.
g. -The provisions of paragraphs 'b', 'c', 'd', and 'e' of this clause do not apply to
openings which the Contractor proposes to fill from within his own organization or to fM
pursuant to a customary and traditional employer-union hiring arrangement. This
exclusion does not apply to a particular,opening once an employer decides to
consider applicants Outside of his own organization Or employer-union arrangement
for that opening.
h. As used In this clause:
(1) •AII suitable employment openings' includes, but is not limited to, openings which
occur in the following job categories: production and nonproduction: plant and
office; laborers and mechanics: supervisory and nonsupervisory: technical and
executive, administrative, and professional openings that ore compensated on a
salary basis Of less than $25.000 per year. This term includes full-time employment,
temporary employment of more than three days' duration, and part-time
employment. It does not include openings which the Contractor proposes to fZ
from within his own organization or to fill pursuant to a customary and traditional
employer-union hiring arrangement not openings in an educational institution
which are restricted to students of that institution. Under the most compelling
circumstances. an employment,opening may not be suitable for listing. Including
such situations where the needs of the Federal Government cannot reasonably
be otherwise supplied. where listing would be contrary to national security, or
where the requirement of listing would otherwise not be for the best interest of
the Federal Government.
• EXHIBIT A(F)
Page 19 of 27
(2) -Appropriate office of the state employment service system" means the local
office of the federal/state national system of public employment offices with
assigned responsibility for serving the area where the employment Opening is to
be filled, including the District of Columbia. Guam, Puerto Rico, and the
Virgin Islands. '
(3) 'Openings which the Contractor proposes to fill from within his own organization'
means employment openings for which no consideration will be given to persons
outside the Contractors organization (including any affiliates, subsidiaries. and
the parent companies) and includes any openings which the Contractor
proposes to fill from regularly established 'recall'lists.
(4) *Openings which the Contractor proposes to fill pursuant to a customary and
traditional employer-union hiring arrangement' means employment openings
which the contractor proposes to fill from union halls which is part of the
customary and traditional hiring relationship which exists between the Contractor
and representatives of his employees.
I. The Contractor agrees to comply with the.rules, regulations. and relevant orders of the
Federal Secretary of Labor issued pursuant to the Act.
J. In the event of the Contractors noncompliance with the requirements of this clause.
actions for noncompliance may be taken in accordance with the rules, regulations.
and relevant orders of the Federal Secretary of Labor issued pursuant to the Act.
It. The Contractor agrees to post in conspicuous places available to employees and
applicants for employment notices in a form to be prescribed by the Director of the
Office of Federal Contract Compliance Programs, provided by or through the
contracting Officers Or State. Such notices shall state the Contractors obligation
under the law to take affirmative action to employ and advance In employment
Qualified disabled veterans and veterans of the Vietnam era for employment, and the
rights of applicants and employees.
I. The Contractor will notify each labor union or representative of workers with which R
has a collective bargaining agreement or other contract understanding that the
Contractor is bound by terms of the Vietnam Era Veteran's Readjustment Assistance
Act and is committed to take affirmative action to employ and advance in
employment qualified disabled veterans and veterans of the Vietnam era.
m. The Contractor will include the provisions of this clause,in every subcontract or
purchase order of $10.000 or more unless exempted by rules. regulations. or orders of
the Federal Secretary of Labor issued pursuant to the Act, so that such provisions will
be binding upon each subcontractor or vendor. The Contractor will take such action
with respect to any subcontract or purchase order as the Director of the Office of
Federal Contract Compliance Programs may direct to enforce such provisions,
including action for noncompliance.
15. Clan Ah and Water
a. (Applicable Only If the contract is not with a sole source vendor of products or
services. or If It exceeds$5.000.)
The Contractor agrees under penalty of perjury (it.he.she) is not in violation of any
order or resolution which is not subject to review promulgated by the State Air
Resources Board Or an air pollution district.
- EXHIBIT A(F)
Page 11 of 27
The Contractor agrees under penalty or perjury (it, he. she) is not subject to cease and
desist order which is not subject to review issued pursuant to Section 13301 of the
Water Code for violation of waste discharge requirements or discharge prohibitions, or
is not finally determined to be in violation of provisions of tederal law relating to air or
water pollution.
b. (Applicable only If the contract or subcontract exceeds $100,000 or the contract is not
otherwise exempt under 40 CFR 15.5.)
The Contractor agrees as follows:
(1) To comply with all the requirements of Section 114 of the Clean Air act as
amended (42 U.S.C. 7401 et seq., as amended by Public Law 95.95), and section
308 of the Federal Water,Pollution Control Act (33 U.S.C. 1251 et seq., as
amended by Public Law 92-500).respectively, relating to inspection, monitoring,
entry, reports, and information, as well as all other requirements specified in
Section 114 and Section 308 of the Air Act and the Water Act, respectively, and
all regulations and guidelines issued to implement,those Acts before the award of
this contract.
(2) That no portion of the work required by this contract will be performed In a facility
listed on the Environmental Protection Agency List of Violating Facilities on the
date when this contract was awarded unless and until the Environmental
Protection Agency eliminates the name of such facility or facilities from such
listing.
(3) To use his best efforts to comply with clean air standards and clean water
standards at the facility in which the contract Is being performed. The terms used
in this paragraph have the following meanings:
(a) The term 'clean air standards' means any enforceable rules, regulations,
guidelines standards. limitations, orders, controls, or prohibitions or other
requirements which are contained in, issued under, or adopted pursuant to
the Clean Air Act.
(b) The term'ciean water standards'means any enforceable Imitation, control,
condition, prohibition, standard. or another requirement which is
promulgated pursuant to the Clean Water Act or contained in a permit
issued to a discharger by EPA or by the State under on approved program
as authorized by Section 402 of the Clean Water Act (33 U.S.C. 1342). or by
a local government to ensure compliance with pretreatment regulations as
required by Section 307 of the Clean Water Act (33 U.S.C. 1317), and
regulations Issued pursuant thereto.
(c) In addition to compliance with clean air and water standards, the term
compliance shall also mean compliance with a schedule or plan ordered or
approved by a court of competent jurisdiction, the Environmental Protection
Agency, or an air or water pollution control agency In accordance with the
requirements of the Clean Air Act and the Federal Water Pollution Control
Act.
(4) As a condition for the award of a contract the applicant or contractor shall notify
the State of the receipt of any communication from the Assistant Administrator
for Enforcement. U.S. EPA indicating that a facility to be utilized for the contract is
under consideration to be listed on the EPA list of Violating Facilities. Prompt
notification shall be required prior to contract award.
• _ EXHIBIT A(F)
Page 12 of 21
(5) To report violations to the State and to the Assistant Administrator for
Enforcement.
(6) To insert the substance of the provisions of paragraph (b) into any nonexempt
subcontract, including this paragraph (b6]. and to take such action os the
Federal Government may direct as a means of enforcing such provisions.
16. Utilization of Small Business and Minority and Women Owned Business Enterprise
a. It is a federal policy to award a fair share of contracts to small, minority, and women
owned business firms. The State Legislature has declared that a fair proportion of the
total purchases and contracts or subcontracts for property and services for the State
be placed with small minority and women owned business enterprises.
b. A firm shall quality as a small business if it meets the requirements specified in
Government Code Section 14837.
C. The Contractor hereby agrees to carry out this policy in the awarding of subcontracts
to the fullest extent consistent with efficient contract performance. As used in this
contract, the term 'minorlty business enterprise'means a business concern (1) which Is
at least 51 percent owned by one or more minortty group members or women, or in
the case of publicly owned business. at least 51 percent of the stock of which Is
owned by one or more minority group members or women; and .(2) whose
management and daily business operations are controlled by one or more such
Individuals. A minority group member is a person who is Black, Asian, Hispanic, Filipino,
Polynesian, American Indian, or Alaskan Native.'Control,• as used In this clause, means
exercising the power to make policy decisions.
d. Contractors acting 'In good faith may rely On written representations by.their
subcontractors regarding their status as minority business enterprises In lieu of an
Independent investigotlon.
17. ping
If Printing or other reproduction work of more than an incidental and minor dollar amount Is
a reimbursable Item In this contract.It shall be printed or produced by the State Printer. The
State Printer may, at his sole option. elect to forego said work and delegate the work to the
private sector. If the State Printer prints or produces said work, or the State obtains the
printing or other work through the Office of State Procurement, the cost will be deducted
from said contract amount. This requirement does not apply to normal in-house copying
necessary for routine business matters of the Contractor.
113. trlMr AnnmyC Mt TrMinrng Saminen Werk2hees Of COnferenQes
Contractor shag obtain prior state approval over the location, costs. dates. agenda, instructors,
i alluCtbnal RlateflC.4 and attendees at arty fehtxAabie training seminot workshop or conference.
and over any renih ilrsable publicity or educational materials to be made available for dsteoution.
The Contractor shall acknowledge the support of the State whenever pubicwng the work under the
Cal all in any media. This paragraph does not apply to necessary staff meetirgs to conduct routine
business matters.
-12-
EXHIBIT A(F)
Page 13 of 27
19. �'^nIlfv et Inferrr_±eiien .
a. The Contractor and his or her employees agents, or subcontractors shall protect from
unauthorized disclosure names and other identifying information concerning persons
either receiving services pursuant to this contract or persons whose names or
identifying information become available or are disclosed to the Contractor, his/her
employees. agents, or subcontractors as a result of services performed under this
Contract, except for statistical information not identifying any such person.
b. The Contractor, his/her employees, agents, or subcontractors shall not use such
identifying information for any purpose other than carrying out the Contractor's
obligations under this contract.
c. The Contractor, his/her employees, agents, or subcontractors shall promptly transmit
to the State all requests for disclosure of such identifying Information not emanating
from the client or person. -
d. The Contractor shall not disclose, except as otherwise specifically permitted by this
contract or authorized by the client, any such identifying information to anyone other
than the State without prior written authorization from the State.
e. For purposes of this paragraph, Identity shall Include, but not be limited to, name,
Identifying number, symbol, or other identifying particular assigned to the Individual,
such as finger or voice print or a photograph.
20. National leder Rele lens 9card CertHleetien
(not applicable if Contractor is a public entity.)
Contractor, by signing this agreement, does swear under penalty of penury that no more
than one final unappealable finding of contempt of court by a federal court has been
Issued against Contractor within the immediately preceding two-year period because of
the Contractor's failure to comply with an order of a federal court which orders the
Contractor to comply with an order of the National labor Relations Board.
21, Documents and Wrttten Ree'j
Any document or written report prepared as a requirement of this agreement shall contain,
In a separate section preceding the main body of the document, the number and dollar
amounts of all contracts and subcontracts relating to the preparation of such document or
report, If the total cost for work by nonemployees of the State exceeds$5.,000.
22, $esnlutinn of Direct Service Centreet Di�nLttee
a. If the Contractor believes there Is a dispute or grievance between the Contractor and
the State. the procedures set forth in Chapter 2.1, Sections 20201 through 20205, of
Title 22. of the California Code of Regulations.shad be followed.
b. If the Contractor wishes to appeal the decision of the Deputy Director for Public
Health or his/her designee, the Contractor shall follow the procedures set forth in
Division 25.1 (commencing with Section 38050) of the Health and Safety Code and
the regulations adopted thereunder. (Title 1, Subchapter 2.5 commencing with
Section 251, California Code of Regulations.)
-13.
EXHIBIT A(F)
Page 14. of 27
c. Disputes arising out of an audit or examination of a contract not covered by subdivision
(a) of Section 20204. of Chapter 2.1. Title 22. of the California Code of Regulations. and
for which no procedures for appeal are provided in statute. regulation or the contract
shall be handled in accordance with the procedures identified in Sections 51016
through 51047.Title 22.California Code of Regulations.
23. financial and Comollance Audit of Noneroflt Entitles
(Applicable only If Contractor is a private,nonprofit entity)
a. Definitions within this paragraph are defined in Section 38040 of the Health and Safety
Code,which,by this reference,is made a part hereof.
b. Contractor agrees to obtain an annual single, organization wide, financial and
compliance audit. The audit shall be conducted in accordance with the requirements
specified in the Federal Office of Management and the Budget (OMB) Circular A-133,
'Audits of Institutions of Higher Education and Other Nonprofit Organizations.'
c. References to 'Federar In OMB Circular A=133 shall be considered to man 'Federal
and/or State' in contracts where State funds are present either alone or in conjunction
with Federal funds.
d: The audit shall be completed by the 15th day of the fifth month following the end of the
Contractors fiscal year. Two copies of the oudlt report shall be delivered to the State.
program funding this contract. The report shall be due within 30 days after the
completion of the audit.
e. If the contractor receives less than $254100 per year from the State. the audit shall be
conducted biennially, unless there Is evidence of froud or other violation of state low in
connection with this contract. This requirement takes precedence over the OMB A 133
section which exempts from Federal audit requirements any nonprofit Institution
receiving less than$254100 per year.
f. The cost. of such audit may be Included in the funding for this contract up to the
proportionate amount this contract represents of the Contractor's total revenue.
g. The State, or its authorized designee Including the Auditor-General, is responsible for
conducting contract performance audits which are not financial and compliance
audits.
h. Nothing in this contract limits the State's responsiibility or authority to enforce State low or
regulations,procedures,or reporting requirements arising pursuant thereto.
L Nothing in this paragraph limits the authority of the State to make audits of this contract.
provided however, that If independent audits arranged for by Contractor meet
generally accepted governmental auditing standards, the State shall rely on those
audits and any additional audit work shall build upon the work already done.
j. The State may, at Its option, direct Its own auditors to perform the single audit described
In OMB Circular A-133. The State's auditors shall meet the independence standards
specified in Government Auditing Standards. The audit shall be conducted in
accordance with OMB Circular 41133 so as to satisfy all State and Federal requirements
for a single organization wide audit.
24. Contract Amendmeft
a. This contract may be amended by mutual agreement between the parties and. If
required by Government Code. Section 11010.5. or Public Contract Code. Section
10355,the amendment shall be subject to the approval of the Deportment of General
Services.unless otherwise exempted.
-14-
EXHIBIT A(F)
Page 15 of 27
b. If any amendment to this contract has the effect of increasing the monetary amount
of the contract or an agreem6nt by the State to indemnify or save harmless the
Contractor, his agents or employees, the amendment shall be approved by the
Department of General Services. unless otherwise exempted.
25; lion of Centraeters
The Contractor's performance under this contract shall be evaluated at the conclusion of
the term of this contract. The evaluation shall include, but not be limited to:
a. Whether the contracted work or services were completed as specified in the contract
and reasons for and amount of any cost overruns.
b. Whether the contracted work or services met the quality standards specified in the
contract,
C. Whether the Contractor fulfilled all requirements of the contract.
d. Factors outside the control of the Contractor which caused difficulties in Contractor
performance. The evaluation of the Contractor shall not be a public record.
26. Certtliet of Interest—Current end Former State Fmcloyees
a. Current State Officers and Employees
(1) Contractor shall not utilize in the performance of this contract any state officer or
employee in the state civil service or other appointed state official unless the
employment, activity, or enterprise is required as a condition of the officer or
employee's regular state employment. Employee in the state civil service is
defined to be any person legally holding a permanent or intermittent position In
the state civil service.
(2) If any state officer of employee Is utilized or employed in the performance of this
contract. Contractor shall first obtain written verification from the State that the
employment, activity, or enterprise 1s required as a condition of the officet's,
employee's, or official's regular state employment and shall keep sold verification
on file for three years atter the termination of this contract.
(3) Contractor may not accept occasional work from any currently employed state
officer,employee,or official.
(4) If Contractor accepts volunteer work from any currently employed State officer,
employee, or. Official. Contractor may not reimburse, or otherwise pay or
compensate. such person for expenses incurred, including, without limitation.
travel expenses. per diem, or the like, in connection with volunteer work on
behalf of contractor.
(5) Contractor shall not employ any state officers, employees, or officials who are on
paid or unpaid leave of absence from their regular state employment.
(6) Contractor or anyone having a financial Interest In this contract may not
become a state officer, employee, or official during the term of this contract.
Contractor shall notify each of Its employees, and any other person having a
financial Interest in this contract that it unlawful under Public Contract Code,
Section 10410 for such person to become a state officer, employee, or official
during the term of this contract unless any relationship with the Contractor giving
rise to a financial interest, as an employee or otherwise..is first terminated.
=15-
EXHIBIT A(F)
Page 16 of 2 ,
47) Occasional or one-time reimbursement of a state employee's travel expenses Is
not acceptable.
(Citation: Public Contract Code. Section 104 10)
b. Former State Officers and Employees
(1) Contractor shall not utilize In the performance of this contract any formerly
employed person of any state agency or department that was employed under
the state civil service. or otherwise appointed to serve in the State Government. If
that person was engaged in any negotiations, transactions, planning,
arrangement, or any part of the decision-making process relevant to the
contract while employed in any capacity by any state agency or department.
This prohibition shall apply for a two-year period beginning on the date the
person left state employment.
(2) Contractor shall not utilize within 12 months from the date of separation of
services, a former employee of the contracting state agency or department if
that former employee was employed in a policy making position in the some
general subject area as the proposed contract .within the 12-month period prior
to the employee leaving state service.
(Citation: Public Contract Code,Section 10411)
C. Failure to Comply with Subparts'a'or•b'
(1) If Contractor violates any provision of Subparts 'a' or 'b' above, such action by
Contractor shall render this contract void. tjnlecs the violation is technicnl nr
nonsuhstantive_
(Citation: Public Contract Code,Section 10420)
27, single Audit set of 1994 (applicable only if Contractor Is a governmental entity)
In accordance with Public law 98-502 and OMB Circular A-128. It is stipulated between the
parties hereto that:
a. The cost of the single audit will be charged to the federal assistance program
providing funds for this agreement on a 'Fair Share' basis. The amount chargeable to
federal assistance programs for the cost of the single audit is calculated based on the
ratio of federal expenditures to total expenditures of the Contractor. The State's share
of the single audit cost under this contract is based upon the ratio of federal funds
received under this agreement to total federal funds received by the Contractor
each fiscal year.
b. The Contractor shall include a clause In any contract the Contractor enters Into with
the audit firm doing the single audit to provide access by the State or Federal
Government to the working papers of the independent auditor who prepares the
single audit for the Contractor.
c. Federal or State auditors shall have 'expanded scope auditing* authority to conduct
specific program audits during the some period in which a single audit is being
performed, but the audit report has not been issued. The federal or state auditors
shall review and have access to the current audit work being conducted and will not
apply any testing or review procedures-which have not been satisfied by previous
audit work that has been completed.
-16-
- _ EXHIBIT A(F)
Page 17 of 27
The term 'expanded scope oudting' is applied and defined in the U.S. General
-Accounting Office (GAO) issued Standards for Audit of Govemmental Organizations,
Programs,Activities and Funchors,better known as the 'yellow book.'
28. Conti Cfor Nome Chance
Contractor shall provide written notice to the State at least 30 days prior to any changes to
the Contractors current legal name.
29. flan
If the Contractor proposes any novation agreement,the State shall act upon the proposal
within.60 days after receipt of the written'proposal. The State may review and consider the
proposal,consult and negotiate with the Contractor,and accept or reject all or part of the
proposal. Acceptance or rejection may be made orally within the 60 day period. and
confirmed in writing within five days.
30. Drug-Free workplace
Contractor certifies to the State that it will provide a drug-free workplace by doing all of
the following:
a. Publishing a statement notifying employees that the unlawful manufacture:
distribution, dispensation, possession, or use of a controlled substance Is prohibited In
the person's or organization's workplace and specifying the actions that will be taken
against employees for violations of the prohibition.
b. Establishing a drug-free awareness program to Inform employees.about all of the
following:
(1) The dangers of drug abuse in the workplace.
CZ) The person's or organization's policy of maintaining a drug-free workplace.
C3) Any available drug counseling, rehabilitation, and employee assistance
programs.
(4) The penotties that may be imposed upon employees for drug abuse violations.
c. Requiring that each employee engaged in the performance of the contract or grant
be given a copy of the statement required by subdvision(a) and that,as a condition
of employment on the contract or grant,the employee agrees to abide by the terns
of the statement.
d. Contractor agrees this contract may be subject to suspension of payments or
termination of this contract,or both,and the contractor may be subject to debarment,
in accordance with the requirements of the Government Code Section 8350.et seq.:if
Ve Department determines that any of the following has occurred:
Cl) The contractor or grantee has made a false certification.
CZ) The contractor violates the certification by failing to Carry out the requirements of
subdivisions(a)through(C)above.
-17-
EXHIBIT A(F)
31. Da nt and 5161202091100 Reaulrements Page 18 of .27
Contractor agrees to comply with the debarment and suspension requirements as found in
7 Code of Federal Regulations.Part 3017,or as amended. '
32. LIMRATIONS ON PAYMENTS TO INFLUENCE
QRTAIN FEDERAL ACTIONS AND RELATED DISCLOSURES
(a) Definitions. As used in this Exhibit.
'Agency.' as defined in 5 U.S.C. 552M. includes Federal executive departments and
agencies as well as independent regulatory commissions and Government
corporations,as defined in 31 U.S.C.9101(1).
'Covered Federal action'means any of the following Federal actions:
(1) The awarding of any Federal contract.
C2) The making of any Federal grant.
(3) The making of any Federal loan;
(4) The entering into of any cooperative agreement; and
(5) The extension, continuation, renewal, amendment, or modification of any
Federal contract.grant,loan,or cooperative agreement.
Covered Federal action does not include receiving from an agency a commitment
providing for the United States to insure of guarantee.a loan.
Indian tribe' and 'tribal organization' have the meaning provided in section 4 of the
Indian Self-Determination and Education Assistance Act (25 U.S.C. 4508). Alaskan
Natives are included under the definitions of Indian tribes In the Act.
'Influencing or attempting to influence' means making, with the Intent to Influence,
any communication to or appearance before an officer or employee of any agency,
a Member of Congress, an officer or employee of Congress. or an employee of a
Member of Congress.In connection with any covered Federal action.
'Local governmentmeans a unit of government in a State and. If chartered.
established.or otherwise recognized by a State for the performance of a government
duty, including a local public authority. a special district, an Intrastate district, a
council of governments, a sponsor group representative organization, and any other
instrumentality of a local government.
'Officer or employee of an agency' Includes the following Individuals who are
employed by an agency:
Cl) An Individual who Is appointed to a position in the Government under title 5.
U. S. Code.Including a position under a temporary appointment;
C2) A member of the uniformed services as defined in section 101(3). title 37,
U. S. Code;
(3) A special government employee as defined In section 202. title 18. U. S. Code.
and
(4) An individual who h a member of a Federal advisory committee, as defined by
the Federal Advisory Committee Act,title 5.U.S. Code.Appendix 2.
•18-
EXHIBIT A(F)
Page 19 of 27
'Person' means on individual, corporation, company, association. authority, firm,
partnership,society. State. and local government, regardless of whether such entity is
operated for profit or not for profit. This term excludes an Indian tribe. tribal
-organization, or any other Indian organization with respect to expenditures specifically
permitted by other Federal law.
'Reasonable compensation' means. with respect to a regularly employeed officer or
employee of any person, compensation that is consistent with the normal
compensation for-such officer or employee for work that is not furnished to, not
funded by,or not furnished in cooperation with the Federal Government.
'Reasonable poyment* means. with respect to professional and other technical
services,a payment in an amount that is consistent with the amount normally paid for
such services in the private sector.
'Recipient' includes the Contractor or Grantee,and all subcontractors or subgrontees
at any tier in connection with a Federal contract, grant, or other Federally funded
activity. The term excludes an Indian tribe, tribal or gon¢ation, or any other Indian
organization with respect to expenditures specifically permitted by other Federal law.
'Regularly employed''means, with respect to an officer or employee of a person
requesting or receiving a Federal contract, an officer or employee who is employed
by such person for at least 130 working days within 1 year immediately preceding the
date of the submission that initiates agency consideration of such person for receipt of
such contract. An officer or employee who Is employed by such person for less than
130 working days within 1 year immediately preceding the date of the submission that
initiates agency consideration of such person shall be considered to be regularly
employed as soon as he or she is employed by such person for 130 working days..
'State' means a State of the United States. the District of Columbia, the
Commonwealth of Puerto Rico, a territory or possession of the United States, an
agency or Instrumentality of a State. and a multi-State, regional, or interstate entity
having governmental duties and powers.
b Prohibition.
(1) Section 1352 of title 31, U. S. Code provides in part that no appropriated funds
may be expended by the recipient of a Federal contract, grant, loan, or
cooperative agreement to pay any person for influencing or attempting to
Influence on-officer or employee of any agency, a Member of Congress. an
officer or employee of Congress, or an employee of a Member of Congress in
connection with any of the following covered Federal actions: The awarding of
any Federal contract, the making of any Federal grant, the making of any
Federal loan, entering Into of any cooperative,agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant,bean,or cooperative agreement.
CZE The prohibition does not appy as follows:
(D . Agency and aegislative iaison by Own Employees.
(A) The prohibition on the use of appropriated funds. in paragraph (b)(1).
does not apply in the case of a payment of reasonable compensation
made to an officer or employee of a person requesting or receiving a
Federal contract If the payment is for agency and legislative liaison
activities not directly related to a covered Federal action.
-19-
EXHIBIT A(F)
Page 20, of 27
(13) For purposes of paragraph (b)(2)(7(A). providing any information
specifically requested by an agency or Congress is allowable at any
time.
(C) For purposes of paragraph (b)(2)(1)(A) of this section, the following
agency and legislative liaison activities are allowable at any time only
where they are not related to a specific solicitation for any covered
Federal action:
01 Discussing with any agency (including individual demonstrations)
the qualities and characteristics of the person's products or
services,conditions or terms of sale,and service capabilities; and,
u Technical discussions and other activities regarding the
application or adaptation of the person's products or services for
an agency's use.
(D) For purposes of paragraph (b)(2)(1)(A) of this section, the following
agency and legislative liaison activities.are allowable only where they
are prior to formal solicitation of any covered federal action:
(0 Providing any information not specifically requested but necessary.
for an agency to make an informed decision about Initiation of a
covered Federal action;
(7 Technical discussions regarding the preparation of an unsolicited
proposal prior to its official submission; and.
() Capability presentations by persons seeking awards from an
agency pursuant to the provisions of the Small Business Act, as
amended by Public Law 95-507 and other subsequent
amendments.
M Only those activities expressly authorized by paragraph (b)(2)(1) are
allowable under paragraph(b)(2)(D.
(i7 Professional and technical services by Own Employees.
(A) The prohibition on the use of appropriated funds, in paragraph (b)(1),
does not apply in the case of any reasonable payment of reasonable
compensation made to an officer or employee of a persom requesting
or receiving a Federal contract or an extension,continuation, renewal,
amendment, or modification of a Federal contract If payment is for
professional or technical services rendered directly in the preparation.
submission or negotiation of any bid. proposal. or application for that
Federal contract or for meeting requirements imposed by or pursuant
to law as a condition for receiving that Federal contract.
_2D-
EXHIBIT A(F)
Page 21 of 27
(g) For purposes of paragraph (b)(2)(i7(A), 'professional and technical
services' shall be.limited to advice an analysis directly applying any
professional or technical discipline. For example, drafting of a legal
document accompanying a bid or proposal by a lawyer is allowable.
Similarly, technical advice provided by an engineer on the
performance or operational capability of a piece of equipment
rendered directly in the negotiation of a contract is allowable.
However, communications with the intent to influence made by o
professional (such as a licensed lawyer) or a technical person (such as
a licensed accountant)are not allowable under this section unless they
provide advice and analysis directly applying their professional or
technical expertise and unless the advice or analysis is rendered
directly and solely in the preparation, submission or negotiation of a
covered Federal action. thus, for example, communications with the
intent to influence made by a lawyer that do not provide legal advice
and analysis directly and solely related to the legal aspects of his or her
client's proposal, but generally advocate one proposal over another
are not allowable under this section because the lawyer is not
providing professional legal services. Similarly,communications with the
intent to influence made by an engineer providing an engineering
analysis prior to the preparation or submission of a bid or proposal ore
not allowable under this section since the engineer is providing
technical services but not directly in the preparation, submission or
negotiation of a covered Federal action.
(C) Requirements imposed by or pursuant to law as a condition for
receiving a covered Federal award include those required by law or
regulation,or reasonably expected to be required by law or regulation,
and any other requirements In the actual award documents.
CD) Only those services expressly authorized by paragraph (b)(2)(ii) are
allowable under paragraph(b)(2)(il).
nReporting for Own Employees.
No reporting Is required with respect to payments of reasonable
compensation made to regularly employed officers or employees of a
person.
(iv) Professional and technical services by Other than Own Employees.
(A) The prohibition on the use of appropriated funds, in paragraph (b)(1),
does not apply in the case of any reasonable payment to a person,
other than an officer or employee of a person requesting or receiving a
covered Federal action, It the payment Is for professional or technical
services rendered directly In fhe preparation,submission,or negotiation
of any bid, proposal, or application for that Federal contract or for
meeting requirements imposed by or pursuant to low as a condition for
receiving that Federal contract.
-21-
EXHIBIT AM
Page '22 of 2
(B) For purposes of paragraph Cb)C2)Clv)(A)..'professional and technical
services' shalt be limited to advice and analysis directly applying any
professional or technicol discipline. For example. drafting of a legal
document accompanying a bid or proposal by a lawyer is allowable.
Similarly, technical advice provided by an engineer on the
performance or operational capability of a piece of equipment
rendered directly in the negotiation of a contract is allowable.
However, communications with the intent to influence made by a
professional (such as a licensed lawyer) or a technical person (such as
a licensed accountant)are not allowable under this section unless they
provide advice and analysis directly applying their professional or
technical expertise and unless the advice or analysis is rendered
directly and solely in the preparation, submission or negotiation of a
covered Federal action. Thus. for example, communications with the
intent to influence mode by a lawyer that do not provide legal advice
or analysis directly and solely related to the legal aspects of his or her
client's .proposal. but generally advocate one proposal over another
are not allowable under this section because the lawyer is not
providing professional legal services. Similarly,communications with the
intent to influence mode by an engineer providing an engineering
analysis prior to the preparation or submission of a bid or proposal are
not allowable under this section since the engineer is providing
technical services but not directly In the preparation, submission or.
negotiation of a covered Federal action
(C:) Requirements imposed by or pursuant to low as a condition for
receiving a covered Federal award include'those required by law or
regulation,or reasonably expected to be required by law or regulation.
and any other requirements In the actual award documents.
(D) Persons other than officers or employees of a person requesting or
receiving a covered Federal action include consultants and trade
associations.-
(E) Only those services expressly authorized by paragraph Cb)C2X'rv) of this
section are allowable under paragraph WXZQv).
(v) The prohibition on use of Federal appropriated funds does not apply to
Influencing activities not in connection with a specific covered Federal
action, These activities Include those related to legislation and regulations
for a program versus a specific covered Federal action
C55 Fed. Reg. 24542 (June 13. 1990).)
(c) Certification and Disclosure.
(1) Each person (or recipient) who requests or receives a contract, subcontract.
grant,or wbgrant,which Is subject to section 1352 of title 31.United States Code.
and which exceeds S100D00 at any tier,shall file a certification Cin the form set
forth in Attachment 1, consisting of one page, entitled 'Certification Regarding
Lobbing-) that the recipient has not made. and will not make, any payment
prohibited by paragraph Cb)of this Exhibit.
.22.
EXHIBIT A(F)
- _ .Page 23 of 27
(2) Each recipient shall file c disclosure (in the form set forth in Attachment 2
consisting of three pages, entitled 'Standard Form-LLL'Disclosure of Lobbying
Activities') if such recipient has made or has agreed to make any payment using
nonappropriated funds (to include profits from any covered Federal action) in
connection with a contract or grant or any extension or amendment of that
contract or grant, which would be prohibited under paragraph (b) of this Exhibit
if paid for with appropriated funds.
(3) Each recipient shall file a disclosure form at the end of each calendar quarter in
which there occurs any event that requires disclosure or that materially affects
the accuracy of the information contained in any disclosure form previously tiled
by such person under paragraph (c)C2). An event that materially affects the
accuracy of the information reported includes:
(i) A cumulative increase of S25A00 or more in the amount paid or expected
to be paid for influencing or attempting to influence a covered Federal
action;or
(1) A change in the person(s) or Individuals) influencing or attempting to
influence a covered Federal action; or,
Gu A change in the officer(s), employee(s), or Member(s) contacted for the
purpose.of influencing or attempting to influence a covered Federal action
(4) Each person (or recipient) who requests or receives from a person referred to in
paragraph (c)(1) of this section a contract, subcontract, grant, or subgrant
exceeding $100A00 at,any tier under a contract or grant shall file a certification,
and a disclosure form.If required,to the next tier above.
(5) AD disclosure forms(but not certifications)shalt be forwarded from tier to tier until
received by the person referred to in paragraph (1) of this section. That person
shall forward all disclosure forms to the State agency.
(d) Agreement. In accepting any contract,grant,subcontract or subgrant subject to this
Exhlbtt,the recipient (and any person submitting an offer for such a contract or grant)
agrees not to make any payment prohibited by law or this Exhibit.
(e) Penalties.
(1) Any person who makes an expenditure prohibited under paragraph (b) of this
Exhibit shall be subject to a civil penalty of not less than S 10A00 and not more
than S 100A00 for each such expenditure.
C2) Any person who fats to file or amend the disclosure form to be filed or amended
if required by this Exhibit,shall be subject to a civil penalty of not less than S 10A00
and not more than$I 00=for each such failure.
(3) Recipients may rely without liability on the representations made by their
subcontractors or subgrantees in the certification and disclosure form.
(f) Cost allowability. Nothing In this Exhibit is to be Interpreted to make allowable or
reasonable any costs which would be unallowable or unreasonable in accordance
with Part 31 of the Federal Acquisition Regulation. Conversely.costs made specifically
unallowable by the requirements in this Exhibit will not be made allowable under any
of the provisions of Part 31 of the Federal Acquisition Regulation
-23-
Page 24 of 27
Att=hrrwnt 1
STATE OF CALIFORNIA
' DEPARTMENT OF HEALTH SERVICES
CERTIFICATION REGARDING LOBBYING
The undersigned certifies,to the best of his or her knowledge and belief,that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the
undersigned,-to any person for Influencing or attempting to influence an officer or employee of an agency
of the United States Government, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress In connection with the making, awarding or entering into of this
Federal contract, Federal grant, or cooperative agreement, and the extension, continuation, renewal,
amendment,or modification of this Federal contract.grant,or cooperative.agreement.
Q)If any funds other than,Federal appropriated funds have been paid or will be paid to any person
for Influencing or attempting to Influence an officer or employee of any agency of the United States
Government,a Member of Congress,an officer or employee of Congress,or an employee of a Member of
Congress In connection with this Federal contract,grant,or cooperative agreement,the undersigned shag
complete and submit Standard Form LLL. 'Disclosure. of Lobbying Activities' in accordance with Its
Instructions.
(3) The undersgned shalt require that the language of this certification be Included in the award
documents for all subawards at all tiers (Including subcontractors,subgrants,and contracts under grants
and cooperative agreements) of S100,000 or more,and that all subreciplents shall certify and disclose
accordingly.
This certification bb material representation of fact upon which reliance was placed when this transaction
was made or entered Into. Submission of this certification Is a prerequisite for making or entering into this
transaction Imposed by Section 1352.Title 31, U. S. Code. any person who falls to file the required
certification shall be subject to a civil penalty of not less than S10,000 and not more than S100=for each
such failure.
CotinOCt/'Grv1ll�aiba lq�so d Ibe�n 9�q/p eeriQefar
coo lIr
After a amd1on by or on Behalf of Conboetor,please return toe
Departrnsnt Of FlsOtth Services
(Name of the M program providing the fu W
P.O.Boot 942732
714 P Street
Sacramento.CA 94234-7320
cis t+eue.om&"2n ka a noon •24-
txrilbl-1 A(F)
- Page 25 of 27
AttaChment 2
DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying actiyttfes Pursuant to 31 U.S.C. 1352
(See reverse for pubic:burden d sc!osure)
I.,Type of Federal Acton. 2. Status of Federal Action: 3. Report Type:
a. contract ❑ a. bid/offer/application Q a. inittdi rtGng
b. grant b. initial award b. material change
Material Change c. cooperative agreement C. post-awdrd For g orvy:
a. Joan
e. ban guarantee Year quarter
f, loan Inurance date Of idst report
A. Name and Address of Reporting Entity: 5. If Reporting Entity in No.4 is Subawardee.Enter Name
and Address of Rime:
❑ Rime ❑ S7u�bawardee
Toy y����
il-.I M )wn:
Conoressional District It known: Con ressionol District.If known:
6. Federal Department/Agency: 7. Federal Program Name/Description:
CFDA Number.If dpdicable:
G. Federal Action Number.it known: 9. Award Amount.It known:
10. a. Name and Address of Lobbying Entity b. Name and Address of Lobbying Entity
(If Individual.last name.first name.MD: (If individual.last name.first name.MI):
(attach Continuatlon Sheet(s)SKU-A.If necessary)
11. Amount of Payment(check oil that appty): 13. Type of Payment(Check all Mat apply):
S O actual O panned O a. retainer
12. Forth of Payment(check all that apply): O b. one-time fee
O a. cash O c. comrnwon
O b. inddnd.specfy: Nature O d contingent tee
O e. deferred
Value O t other.speciy
14. Shot Description of Services Performed or to be Platformed and Date(s)of Service.including Ofter(s).Employee(s)
or Member(s)Contacted.for Payment Indicated In from 11:
(Attach Continuation Sheet(s)SKU-A.if necessary)
15. Continuation ShaetW SF-LLL-^Attochod: O v es O No
16. Infornotbn requested ftougn the tarn Is authordsd by Tifie 31.
U.S.C..Section 1352 This aedou"of IDIA109 p oeti--is a
material representation of fact upon whish reliance was �f°ees
placed by the tier Cb"when to tWN10=1101 was mode or
entered into. 1Ns disclosure it required pumx3nt to Title 31. ret rbw�
U.S.C..Section 1= TM irMamotion will be reported to the
Congress semiannuolly and will be ovallable for public 1
inspeetlm Any pown%#o.fob to tie fie regkiwd didosue
ural be;subject to o cIA penally of not Jess than S10=and
not more an S lm=for each such foiue. � Cos:
.:..::;tea.. ,....,., .:.
X...;;>....:...... . . ...,.....::`: 'i:P:.,}.3: •• Autrtie
hDd for thOr1 10
sMh}y. •wC•. :..\Y;Fv'v'ti}{•:2•.•y'v.:.4\•:.:.• iiS-�nY,�::•,v,:,i:)NS'{.�.�::�`.J.;'.^,'. �{ �•.
•::...n... �.•;hii::.::v.!Ar.. •}:ii;r'4i.y.•'w :.i.N.^}vW:�;ri-n:;a`
��:��.�IfY +i�'v •%O h .ry f'r.::d0�:•r}:;::i;h::'viti?:::.{v.' ar {::Fi4 i 4 { Y
-..•:•-.::i;•:,..•,.. .L::. •;yid::. •. F
..,.;:.4.•:ov::;::ca+:::.::r,':..v.,•.:'.S.yv.:+:w>•r.<;.;;,:.a,}P.':-,:.;....:,;}.•�i`:;."...`"'?�42... ?%r9':,'.-Fs�::'.r.+.o'::::: .i;;.•:::.:e„
MAS.rtinobua.+rhas aOCR%) -25-
VA41 u1♦ Ak J /
INSTRUCTIONS FOR COMPLETION OF SFALL DISCLOSURE OF LOBBYING ACTiVMES Page 26 of 2
this agwo"o !arm Inas be compieted by the reporting entity. whether amc warcee or prime Feaerct'recci,6/rot. at rrti
, mriatlon or receipt or a covered Feaerc i action, or a enoteriat cnonge to a previo&a riling, purs=mt to Tate 31. U.S.C..
Sec?ian J=, '.fill fill ng or CL form b reCwed rot earn payment a< agreement to mice payment to cnv tocowng entity for
.nWencing or attempting to influence an officer or employee or any agency. a Member or congress, an officer or
employee or congress. or on employee of a Member cqf Congress in connection with a covereCt Federal action. Use the
SF-LLL-A Continuation Sheet for additional informdticn it the space on the form is inadequate. Complete all items that
=ply for both the initial filing and mctenal change report. Refer to the implementing guidance publimed by the Office of
Mancgement and Budget for ademanol information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to Influence the
outcome of a covered Federal action.
2. Identify the status at the covered Federal ocflan
3. Identify the appropriate classification of this report. If this is o follow UP report cooed by a material change to the
Information previously reported.enter the yea and quarter in which the change occurred. Enter the date of the lost
previously MAyMed report by this reporting entity for this covered Federal Action.
A. Enter the full name,addles,city,state and zip code of the reporting entity. Indwe Congressional District,it known
Check the appropriate classification of the reporting entity Mot designates if it is. Or expects to be. a prime or
subowcrd recipient. Identify the tier of the subowardee. e.g..the fust subawordee of the prime is the 1st Net.
Subawotds include but are not limited to subcontracts,stzgrants and contract awards under grants.
S. If the orgo lizafian filing the report in hem 4 checks'SiAx wordee!then enter the full name,address,city,state and W
code of the prime Federal recipient. Include Congresional District.If known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organlmtiond
ksvel below agency name.It known For e:omple.Department of Transportation.United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known. enter the full
Catalog of Federal Domestic Assistance (CFDA) number for grants. cooperative agreements. loons. and loan*
commttmerds.
B. Enter the most appropriate Federal Identifying number available for the Federal action Identified In Item 1
(e.g..Request for Proposal(RFI) number;Invitation for Bid(IFB)number, grant on nouncement number.the contract.
grant. or kaon award number. the applicallon/proposol control number csigned by the Federal agency). Include
Prefixes.e.g.'RFROE-9=1
9. For a covered Federal action where there hos been on award or loan commitment by the Federal agency,enter the
Federal amount of the aword/loan comnlMywit for the prime entity Identified in hem 4 or&
10. (a) Enter the full name,address.city,state and zip code of the lobbying entity engaged by the reproting enftty
Identified In hem 4 to Influence the covered Federal action '
(b) Enter the full names of the i ndivlduaKs)perform- services,and Include fun address If different from 10.(o). Enter
kit name.first name.and middle Initial(MQ.
11. Enter the amount of compenwhan paid Or reasonobty expected to be paid by the reporting entity (stem'4)to the
lobbying entity(hem 10). NO=*whetter the payment has boon mode(octud)or will be mode(ptarVeM. Cheek
all boxes that apply. If this is a material cinange repo11 1.enter thio cumulative amount of payment made or plonnsd to
tie made.
12. Check the appropriate box(ea). Check all boozes that apply. If payment is made through an kwdnd contribution.
specify the nature and value of the Inddnd payment.
13. Chock the approprinto box(osl Cheek oil boxes)shot apply. a other.specify nature.
14. Provide c specific and detailed description of fife services that the lobbyist has performed, or will be expected to
perform,and the dateW of any services rendered. Include as preparatory and related activity,not Just time spent In
actual contact with Federal officials Identify the Federal offldal(s) or employee(s) contacted or the officer(s).
employeeW,or MermborW of Congress that were contacted.
1S Check wether or not o SFdLL-A cotIftiohon III*@=6 alta hied.
ld Tl»certlfyinp official shalt spin and date the form.forint hsRne►name,flue.and telephone rLrmbw.
Pt colic repomg b6TWn for this collection of information is e0moted to average 30 mmWes per response.
Irteluolrtg time for reviewing hOrLCUOM searehitng exi:»ng data spaces,gathennp and maintairong the
dots needed.and completing and reviewing me collection of infor mahm Send comments regording
the burden es timate or any ottwr aspect of this collection of information,including suggestions for
reducing this burden. to the Office of Management and Budget. 'Paperwork Reduction Project
(0348,41113A6).Washington.D.C..20503.
-26-
EXHIBIT A(F)
Page 27 of 27
DISCLOSURE OF LOBBYING ACTIVITIES
VITI
CONTINUATION SHEET
Aacrw.a ey OMB
• - -sa8mae
+D Eiblllc PcQ9 of
AJleow 1s Lwa A.voe+e.o+
CM WOMONWO a Wh Pft 14(1001) -27- sranaesa fanr►{t►r►
_ EXHIBIT B
Page 1 of 7
1 DANIEL E. LUNGREN, Attorr.ey General FILED
of the State of California
2 DENNIS ECKHART, Supervising
�d Deputy Attorney General AUG 22 IM
3 JOSEPH 0. EGAN, State Bar No. 53469
Deputy Attorney General CLERK.U.S.DISTRict cuuat
A P.O. Box 944255 ay EASTERN DISTRICT OFCAufo4NI
Sacramento, California 94244-2550
5 Telephone: (916) 323-87890 -?-'Ty"�
rneys. Ior -Defendants
L
� me, , .N. , Andrew M. Mecca
J.Dra
e S. Belsh4
J
1
r8 9
9 UNITED STATES DISTRICT COURT
JACX EAS N CLE Ul DISiRICT000kTOR THE EASTERN DISTRICT OF CALIFORNIA
6Y OISTRICi OF CALGORN !
12 REDA Z. SOBKY, M.D. , PhD. , ) No. CIV S-92-613 DFL GGH
HUMANISTIC ALTERNATIVES TO )
13 ADDICTION RESEARCH AND _ ) ORDER FOR
TREATMENT, INC. , JANE DOE, ) PERMANENT INJUNCTION
14 FRANCES FOE, and HENRY HOE, on) RE: 42 D.S.C. SECTION
behalf of themselves and all ) 1396a(a) (8) AND (a) (101
15 others similarly situated, )
16 Plaintiffs, )
17 V. )
)
18 SANDRA SMOLEY, R.N. , in her )
official capacity as Secretary)
19 of the California Health and )
Welfare Agency, ANDREW M. )
20 MECCA, in his official )
capacity as Director, )
21 California Department of )
Alcohol and Drug Programs, )
22 KIMBERLY BELSH9, in her )
official capacity as Director, )
23 California Department of )
Health Services, )
24 )
Defendants. )
25 )
26
27 ///
EXHIBIT B
Page 2 of 7
1 The Court having considered the evidence and argument
2 of counsel, and pursuant to the Court's order filed June 14 ,
3 1994, setting forth its reasons for granting plaintiffs' motion
4 for summary judgment, and it appearing to the Court that
5 plaintiffs are entitled to a permanent injunction, the following
6 permanent injunction shall issue:
7 IT IS HEREBY ORDERED that defendants and their
8 successors, agents, officers, servants, employees., attorneys and
9 representatives, and all persons in active concert or
10 participating with them are hereby enjoined as follows:
11 1 . From violating Title 42 United States Code section
12 . 1396a(8) in the provision of methadone maintenance services under
13 the Medi-Cal program. _
14 2. From violating Title 42 United States Code section
15 1396a(10) (B) in the provision of methadone maintenance services
16 under the Medi-Cal program.
17 3. To expeditiously take all practicable steps to
18 assure that, pursuant to (1) contracts between counties and the
19 Department of Alcohol and Drug Programs pursuant to California
20 law, or (2) direct contracts between certified Medi-Cal methadone
21 maintenance providers and the defendants, all Medi-Cal eligible,
22 categorically needy individuals, meeting licensing, Medi-Cal
23 certification and utilization requirements, lawful contractual
24 standards for drug treatment programs, and lawful conditions
25 established by the provider for participation in a methadone
26 maintenance program, receive methadone maintenance treatment
27 services that are equal in amount, duration, and scope; that all
EXHIBIT B
Page 3 of 7
1 Medi-Cal eligible categorically needy persons meeting licensing,
2 Medi-Cal certification and utilization requirements, lawful
3 contractual standards for drug treatment programs, and lawful
4 conditions established by the provider for participation in a
5 methadone maintenance program, receive methadone maintenance
6 treatment services , that are at least equal in amount, duration,
7 and scope to services provided to Medi-Cal eligible, medically
8 needy persons; meeting licensing, Medi-Cal certification and
• 9 utilization requirements, lawful contractual standards for drug
10 treatment programs, and lawful conditions established by the
11 provider for participation in a methadone maintenance program;
12 that Medi-Cal funded methadone maintenance treatment services
13 shall be furnished with reasonable promptness; and that no
14 persons eligible for Medi-Cal funded methadone maintenance
15 treatment services will be placed on waiting lists for such
16 services due to budgetary constraints.
17 4 . To provide written notice to all methadone
18 maintenance programs licensed by the Department of Alcohol and
19 Drug Programs, directing each such program to post prominently,
20 for a period of 90 days, the Medi-Cal Notice of Availability of
21 State Hearing, attached hereto as Exhibit A, and for each such
22 program and the Department of. Alcohol and Drug Programs to `
23 distribute the Hearing Request form attached hereto as Exhibit B
24 to any person requesting the form.
25 IT IS FURTHER ORDERED that for purposes of this
26 injunction the term "agents" includes the counties of California.
27
3 .
EXHIBIT B
Page 4 of 7
1 IT IS FURTHER ORDERED that within 30 days of the filing
2 of this order, defendants shall submit to counsel for plaintiffs
3 a detailed plan setting forth defendants ' proposed method for
4 implementing paragraph 3 above, that within 15 days after service
5 of defendants' proposed plan, plaintiffs shall serve upon
6 defendants their objections, if any, to the plan, that. within 10
7 days of service of said objections, the parties shall meet and
8 confer to resolve plaintiffs' objections, if any, that within 21
9 days after said meeting, plaintiffs shall serve upon defendants
10 and file with the Court their objections, if any, to defendants'
11 proposed plan, and that defendants shall implement forthwith all
12 portions of the proposed plan to which plaintiffs have filed no
13 objection and which may practicably be implemented pending
14 resolution of plaintiffs' objections by the court..
15 The proposed plan implementing paragraph 3 above shall
16 include provisions. for:
17 (1) written notice of this injunction to all methadone
18 maintenance programs licensed by the Department of Alcohol and
19 Drug Programs;
20 (2) written notice of this injunction to each Drug
21 Program Administrator for each county of the State;
22 (3) written notice to all methadone maintenance
23 programs licensed by the Department of Alcohol and Drug Programs,
24 directing each such program to prominently post a notice
25 informing methadone patients and persons seeking methadone
26 maintenance of the availability of methadone maintenance under
27 Medi-Cal as set forth in this injunction and the means of
4 .
E%IBIT B
Page 5 of 7
1 applying for methadone maintenance under Medi. Cal, if the person
2 is otherwise eligible for Medi-Cal services;
3 (4 ) the method(s ) for the distribution of funds,
4 including the role of counties in budgeting for methadone
5 maintenance services, the methods by which defendants will
6 monitor waiting lists due to budgetary constraints in those
7 counties where there are licensed and Medi-Cal certified
8 methadone maintenance programs, and the means of increasing
. 9 budget allocations if necessary to assure that no persons
10 eligible for Medi-Cal funded methadone maintenance treatment
11 services are placed on waiting lists for such services due to
12 budgetary constraints;
13 (5) the amount of funds allocated;
14 (6) forwarding to the court and plaintiffs, no less
15 than quarterly, beginning with the quarter ending December 31,
16 1994, through the quarter ending December 31, 1997, a written
17 report (each report shall be submitted within 30 days of the end
18 of the preceding quarter) describing the number of persons
19 receiving methadone maintenance under Medi-Cal from each
20 certified provider, the number of treatment slots available to
21 Medi-Cal beneficiaries as determined by each provider, the number
22 of Medi-Cal beneficiaries, if any, on a waiting list, and the
23 earliest date on the list;
24 (7) the means by which defendants will expeditiously
25 resolve any disputes between counties and providers with respect
26 to the adequacy of budget allocations to assure that Medi-Cal
27 beneficiaries are not placed on waiting lists;
5.
EZIBIT B
Page 6 Of 7
1 (8) provisions for. Medi-Cal payments , based on Medi-
. _ -
2 Cal rates in effect at the time services were provided to (A)
3 Medi-Cal beneficiaries, eligible for methadone maintenance
4 services, who paid a Medi-Cal certified provider for such
5 services on or after July .1, 1994, as a result. of placement on a
6 waiting list due to budgetary constraints, or (B) Medi-Cal
7 certified providers who provided methadone maintenance services
8 to Medi-Cal beneficiaries, eligible for such services, on or
9 after July 1, 1994, as a result of placement on a waiting list
10 due to budgetary constraints, provided that such services were
11 provided consistent with Medicaid laws and regulations and that
12 the provider has not been paid by the beneficiary.
13 In the event plaintiffs file objections to the proposed
14 plan, the Court may hold a hearing to resolve the dispute and
15 decide whether further relief is necessary. Should the Court
16 sustain any of plaintiffs' objections, or otherwise grant further
17 relief, it shall issue an order thereon. After resolution of
18 plaintiffs' objections by the Court, defendants and their
19 successors, agents, officers, servants, employees, attorneys and
20 representatives, and all persons in active concert or
21 participating with them shall comply with the plan.
. 22 IT IS FURTHER ORDERED that nothing herein: (1) shall
23 be deemed to require defendants to assure that a licensed
24 methadone maintenance program exists in every county in the
25 state, or (2) preclude placement of persons eligible for Medi-
26 Cal funded methadone maintenance treatment services on waiting
27 lists for such services due to non-budgetary constraints.
6 .
EXHIBIT B
Page 7 of 7
1 IT IS FURTHER ORDERED that this order,. and the Exhibits
2 thereto, are subject to modification, upon stipulation of the
3 parties, or upon further order of the court, and that nothing
4 herein shall be deemed to preclude plaintiffs or defendants from
5 seeking court approval to amend this injunction or the plan,
6 provided they give reasonable prior written notice of any
7 proposed amendment.
8 DATED: u k r 1994
9
to e7 •
DAVID F. LEVI
11 UNITED STATES DISTRICT JUDGE
12 APPROVED AS TO FORM: _ I
13
14 AMITAI SCHWARTZ
Attorney for Plaintiffs
15
16 j 47OVED AS TO FORM:
'
17
JO&EPH 0. EGAN
18' Deputy Attorney General
19
20
21
22
23
24
25
26
27
7 .
.EXHIBIT C
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rnu v w9n vvwi I SN%a ua i REGURG (WLR)
Completion Instructions
Column 1 Applicant Name: Enter the names land, optionally, the phone numbers) of applicants who
cannot be admitted to treatment services because program capacity is full, and who are waiting
for a treatment slot to become available. If they are waiting for a publicly funded slot, place a
check in the 'Pub Fund' box (refer to,the Capacity Manaaement User Manual for a definition of
public funds as well as detailed instructions for the entire form). NOTE: Identifying information
on applicants is protected by Federal confidentiality regulations (45CFR, Part 2).
Note: If a person is waiting for a publicly funded slot while in a paid treatment slot, he/she
should be reported on DATAR.
Column 2 Uniaue ID: Enter the initials of the applicant in order of last name, then first name, the gender
0 for male or 2 for female), and the date of birth (using 2 digits each for month, day and year
of birth). For example, Mary Jones who was born on May 12, 1950, would be coded:
JM2051250.
Column 3 Status: Check all that apply.
IDU: Place a check in this column if the applicant uses drugs by injecting them.
PW: Place a check in this column if the applicant is pregnant at the time her name
is entered to the waiting list.
Medi-Cal: Place a check in this column if the applicant has a Medi-Cal card or sticker,
which would enable a Medi-Cal provider to immediately bill for covered
services.
SSI RMA: Place a check in this column if the applicant is a SSI/SSP recipient AND was
referred to the program by a field case manager contracting with the
MAXIMUS Referral and Monitoring Agency (RMA).
Column 4 Service Requested: Enter the code number for the type of service requested by the applicant or
to which the applicant was referred:
1 = Nonresidential Treatment/Recovery 5 = Residential Detoxification, Non-Hospital
(ODF) IRDX) ,
2 = Nonresidential Treatment/Recovery 6 = Residential Treatment/Recovery
with Methadone (OMM) (RDF)
3 - Nonresidential Detoxification with 7 = Nonresidential Day Treatment/Recovery;
Methadone (OMD) Intensive Outpatient (DCDF)
4 - Nonresidential Detoxification (ODX) 8-- Other le.g., hospital
(without Methadone) detoxification, jail, etc.)
Column 5 Date Entered On Waitino List: Enter the date the applicant was placed on the waiting list.
t
Column 6 Date Removed From Waiting Ust: Enter the date the applicant was taken off the waiting list for
any reason, and note the reason in column 9 (see column 9, below).
Column 7 Days on Welting List: Calculate the number of days between the dates entered in columns 5
and 6 and post the result here.
Column 8 Referred To Interim Services: If the applicant was referred to interim services, post the date of
referral here. If the applicant was referred to tuberculosis services, place a check mark in the
TS column. If the applicant is already in treatment but is waiting for an alternate treatment slot
to become available, post'in tx' in this column instead of a referral date.
Column 9 Beason Removed From Waiting Ust: Enter the code number for the reason the applicant was
removed from the waiting Set:
1 = Admitted to this program 4 - applicant failed to contact
2 = Admitted to another program to indicate continuing
program interest in admission
3 = Applicant refused services 5 = Program attempted to contact
applicant, no response
6 - Other (specify in column 9)
EXHIBIT C-2
Stata•or Ca4to •Hesbh and Walter*Agency DRUG AND ALCOHOL TREATMENT ACCESS REPORT(DATAR)_. tieavtnem or A cer,d ane on,�egrar
rrpe
Section A: General Provider Information (Please TYAe)
Program Name Report Month and Year
Street Address CADDS PROVIDER NUMBER
City Zip County
Contact Person I Telephone ( )
Please rotor to Completion Instructions
Section 6: Capacity Report 1 2 :-:3 4 5 6 7 g
NRTIR NRT/R " NROX NRDX ROX, RT/R NR OTHER
METH METH NON DAY
(ODF7 (OMM) ' (OMD) (ODX) HOSP (RDF) (DCDF)
IRDX)
1. Total treatment capacity:. . . . .. . .. .. ..... .. . .. . . . . .
2. Public treatment capacity:
i
i
a) Total . . . . . ... .. . . . . . .. . . . .. . .... .. . . .. . . . .
b) Available treatment openings at end of month . . . . . . .
3. Number of days the pregran's censuslenrollment exceeded I I I I I I
90 percent of public capacirf during the nonth . . . . . . . . . li
Aa res:craas below ae:ty orgy tc a:a-carhs sws-t.ng gutt2y lanced s:ehs
Section C: Statistical Reper. I I ( ( I
4. Applicants on the waiting Its:a:any time during the month
(include applicants.carried ever frer.;prier nerwt s. aeerg Ni:.h
applicants placed on w rer..c.ed Item the waiting lis:during
the reper,month):
Tc-al number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S. Number of acolicants en waiting Int on las•da of reecr.
n
cn:h . . . . . . . . . . . . . . . . . . . .'. . . . . '. . . . . . . . . . . . .
E: Applicants admtreC tc trernent from the waiting Its:eunng
t'e revcr.month freascn cede 1 or 2 in Column n Cl the
WLR):
a) Number of applicants admitted to treatment . .. . . . . . .
b) Total number of days tney spent on waiting list Isum of I I I I I I
WLRcolumn 7) . . . . . . . . . . . . ... . ... ... . .. . . . . ..
7. Of total applicants in 4,how many were:
(NOTE: An applicant may be counted more than once.)
al Injecting Drug User(IOU) ... . .... . .............
b) Pregnant women(PW) .......... ..... I I
c) Pregnant=s ..............................
d) Medi-Cal beneficiaries ........................ I
e) SSUSSP refefred by RMA ...................... I
t
Type of Service codes:
NRTfR • he - sidentiat troattsenw•recavery; NRTIK Iuf M.Nmrtisideraisl treatnemrocavery.with nrethado s as a prosenbed moetcamoK NR:X.METH. Norvasdentut
detoailicatgn,with metMdone as a proscribed medication; NROX•Norrasidentsal lets ilteaten(without metredonel; ROX,NON F.CSP . res eennsi doto■il.cstwn an a no►hospitai
setting: RT/R . Flasidentiai tro+tnnenttroCovery NR,DAY. Nonresidential dey troantrnurscavery,intensive WAostem: OTHER . Ctmer than tM above sartetgs imeudes hoso.tal
detositrcatrom 04 seems.etc. OOP . outpatient Orap Free; OMM . Wastent Atetlfeere Mttatenvnee: OMp . tl rtpat.ne MatSseero Dotal; CDX • ovtcatent Doto■heft
meth; ROX • Rssdetel dotes; OCOF. Day Cafe Drug Free
Program Direc:cr Signature Date
DATAR forms are due to the State by the 10th of each month. Please refer to User Manual Ice nailing address.
DRUG AND ALCOHOL TREATMENT ACCESS REPORT(DATAR)
COMPLETION INSTRUCTIONS -
(Refer to Capacity/Waiting List Management Program User Manual for detailed instructions)
Section A: Enter the program name, service location address,telephone number, contact person,the month and year to which the data submitted in V
report applies (i.e.the 'report month'), CADDS provider number, and county name.
Section B: Enterthe appropriate information on each line in each applicable column.
LINE 1 REFERS TO TOTAL TREATMENT CAPACITY. ALL OTHER ITEMS IN SECTION 6 AND C APPLY TO PUBLIC TREATMENT CAPACITY ONLY.TF
CAPACITY MANAGEMENT USER MANUAL DEFINES TOTAL AND PUBLIC TREATMENT CAPACITY,SLOTS, AND PUBLIC FUNDS.
Lina t: Enter the total treatment caoacity at this location by type of service. Entries for programs with two or more types of service must reflect t
number of slots which can be filled for each service type at any given time. (See definition in manual.)
Line 2a: Enter the public treatment capacity at this location by type of service. Entries for programs with two or more types of service must reflect t
number of slots which can be filled for each service type at any given time. (See definition in manual.)
Line 2b: Enter the unused public treatment capacity at this location as of the last day of the month(i.e. how many publicly funded slots were empty).
Line 3: Enter the number of days during the month that the program's enrollment exceeded 90 percent of its public treatment capacity.
Section C: Enter the appropriate information on each line in each applicable column. This section shows the number of individuals that request
admission to a vestment program but were denied due to lack of publicly funded capacity. It includes individuals who were already
the waiting list at the beginning of the month, as well as those who were added during the report month.
Line 4: Enter the number of applicants that were on the waiting list at any time during the month.
Data source: All Waiting List Record (WLR) entries having an entry in column 1 'Pub Fund' box, and either a blank or a date within the rept
report month in WLR column 6.
Line 5: Enter the number of applicants active on the waiting list as of the last day of the report month.
Data source: All Waiting list Record (WLR) entries having an entry in column 1 'Pub Fund' box, and a blank in WLR column 6 on the last d:
of the report month.
Line 6a: Enter the number of clients removed from the waiting list during the report month because they were admitted to treatment either at this progra
or another program.
Data source: All unduplicated WLR entries from WLR column 2 with an entry in'Pub_Fund'box;AND the date entered in column 6 is within#
report month: AND code 1 or code 2 in column 9.
One 6b: Enter the total number of days the clients were active on the_waiting fist.
Data source: Sum of WLR column 7 for all applicants counted in 6a,above.
Line 7s: Enter the number of iniecting drug user UDU) applicants that were on the waiting fist at any time during the month. An IDU is defined as anyol
who has injected drugs in the past year.
Data source: All WLR envies having an entry in column 1 'Pub Fund'box:ANDA check in column 3'IDU'box;AND either a blank or a date with
the report month posted in column 6 .
Line 7b: Enter the number of applicants on the waiting list at any time during the month that were Preanant.
Data source: All WLR entries having an entry in eolurnn i 'Pub Fund'bolt;AND a check in column 3'PW'box;AND either a blank or a date with
the report month posted in column 6.
Line 7c: Of the number of pregnant women in 7b,enter the number that were also Irjecdng Drug Users.
Data source: Same as 7b.but ltntited to those who"column 3 stews also contains an entry On the'IDU' (injeeentg drug user)box.
Line 7d: Enter the number of Medi-Cal beneficiaries on the waidrtg fist at any time during the report month.
Dm source: An WLR enures having an entry in cokwo 1 `Pub Fund'box;AND a check in column 3'MediCer box:AND either a blank or a da
within the report month posted in column S.
Late 7e: Enter the Miter of SSI/SSP beneficiaries on the waiting fist at any time during the report north that were referred to the program by a field ca
manager contracting with the MAXIMUS Referral and Monitoring Agency(RMAI.
Data source: AN WLR entries having an entry in coktmrf t 'Pub Fund';AND an entry in column 3'SSI RMA'box: AND either a blank or a da
within the report month posted in column 6.
daterl.ins 15/27/94)
HEALTH AND WELFARE AGENCY DEPT. OF ALCOHOL AND DRUG PROGRAMS EXHIBIT C-3
CALIFORNIA ALCOHOL AND DRUG DATA SYSTEM (CADDS) PARTICIPANT RECORD (PR
(USE BALL POINT PEN.-PRESS HARD)
r2.
. PRO1ImER D 14. DATE OF ADMISSION................... EII-El�
ProprorR �Coyn Y Facility Iq (F•vat iaee•fo•faa bsiftwM/,&cowry cervi&) Month Day Year
FORM StcRtAL NUMBER A 4 3 �J]Initial& Sex Date of Birth 15. TRANSACTION TYPE ......I-Initsl Admission; 2•Transterorchangesservice
. UNIQUE ® 1:1
PARTICIPANTJ EIDZI:�=
ID 16. TYPE OF SERVICE......................................................... ❑
Leat-First 14Aalo Month Day Year Non-residential/Outpatient: Residential:
2-Female
4. PROVMS PARTICIPANT ID 1. Treatment/ncowry 4. Detoxification(hospital)
2. Day prognm-Intontkre 6. D&toxification(non-hospital)
(Opapoq 3. DetoAation 6. Treatment/recovery(30 days or Moa)
7. Treatment/recovery(31 days or mora)
S. CODEPENDENT/SIGNIFICANT OTHER.........................(1-Yes 2•No) ❑ STOP HERE it Codependent(tem 5)ill Yes(1).
(ltYes.complete Gens1-10;saw yes 0neei.irgsw&uhecnneof --------------------------- --
mown else's ateoh ol/drug problem)
S. RACE........................... 17. MEDICATION PRESCRIBED ..............1.None 2.Methadone 3.Other..................................... L�
O1. White 08• Filipino 18. NUMBER OF PRIOR EPISODES M ANY ALCOHOL OR DRUG
02. AmerBlacican
Indian riean 09. Guam man 15. Vietnamese
03. American Indian _ 10. Hewa6an TREATMENT/RECOVERY PROGRAM...........................(ENTER t?-9)
04. Alaskan Native it. Japanese 16. Other Asian
17
05 Awn Indian 12 Korean . Other Race CODES: (PLACE ANSWERS IN MATRIX BELOW FOR QUESTIONS 19-20
00. Chinese 11. Samoan 13. Laotian
07. Chinese 14. PROBLEM Mate code In Question 19 below"00"s not a"lid response.)
7. ETFPACITY ........... ❑ 01. Heroin 11. Other Hallucinogens
..................... ... ........... . .............. 02. Alcohol 12. Tranqu0aers(Benzodiazepine)
I. Not Hispanic 4. Puerto Rican 03. Barbiturates 13. Other Tranquilizers
2. Mexican/Mexican American 6. Other Hispanic/Latino 04. Other Sedatives or Hypnotic$ 14. Non-Prescription Methadone
3• Cuban 05. Methamphetamine 15. Other Opiates and Synthetics
S. EMPLOYMENT STATUS... 06. Other Amphetamines 16. Inhalants
. .... . . ......... ... .. .. . ... ... . ... ❑ 07. Other Stimulants 17. Over-The-Counter
1. Employed Fug Time(35 or mora hours/week) 08. Cocaine/Crack 21. Other(specify).
2. Employed Part Time(leu than 35 hours/week) 09• Marquana/Hashish
3. Unemployed(looking for work) 10. PCP 22. NOME
4. Not in the labor fora(not seeking employment)
9. HIGHEST SCHOOL GRADE COMPLETED..............(00.20.GED-12) USUAL ROUTE OF ADMINISTRATION(Enter code in Question 20 below)
/0. PRINCIPAL SOURCE OF REFERRAL............ •••••-•••-•, ❑ 1.Orel 2.Smoking 3.Inhalation 4.bgection(IV or intramuscular) S.Other
................
1: Individual(Includes self-referral) 5. Employer/EAP FREQUENCY OF USE(Enter code in Question 21 below)
2. Alcohol/Drug Abuse Care Program 6. Court/Criminal Justice 1.No past month use 3. 1-2 times per week 5.Daily
3. Other Health Care Provider 7. 12 Slop mutual aid(AA.AI•Ardn etc) 2. 1-3 times in pest month 4.3-6 limes per week
4. School(Educational) S. Other Community Referral
11. IS THIS PERSON CURRENTLY PREGNANT?..................(1-Yes 2-No) 1:1Oue&tlon a Primary Secondary Tertiary
Am-for ALL participants.M this participant.whether tl.&anant or not.Is in a 19. ALCOHOL/DRUG I I 1
PNOUI Treatment Expansion Program.pease*alar•'P"in box 15 sod"X-in bus PROBLEM
10 of Codd RentarkaT
12. LEGAL STATUS............... 20. USUAL ROUTE OF
. ••-••••••••••••�•••••••••�.•••..•.•..❑ ADMINISTRATION d*t.trtttt■-
1. Not applicable 4. On, bort from any
lederel,
'2. Under parol supervision.by CDC state or local oisdiction 21. FREQUENCY OF USE tut%w■•rd.
3. On parol from any other 5. Admitted ender diversion from any court •e Uund"urs/
juriadieti0n
S. bearcareted I 1 .118"SSeccon
•0 participating in a apodal Parch*Sarvias Nowak project,please enter the 22. AGE OF FIRST USE/ I 1 a■,tt.rrmwict.a.d
participant's CDC attmtber in boxes 1-4 of Codd RemekL ALCOHOL INTOXICATION do titre
13. DISABILITY IMPAIRMENT la
(Einer the CNN for cap to three kttpsirsaft Y oro Imcalo
pai se t. r"1".) Z3. HAS TNS PARTICIPANT PASTTWELVE USED NEEDLES
2nd DURING THE PAST MONTHS?.......................(1•Yes 2-No)
1. NONE 4. Speech 7. DevelopmeMally Disabled
2. Visual (5. Mobility 6. Dow 3rd 24. SPECIAL SERVICES/CONiRACf: ..........
_:
3. !Maung 6. Mortal Lem bleak unless sa abr s as&iord by ADPJ = -
GENERAL INSTRUCTIONS: Refor to thekatrse-m Manuel when Completing thls r OPTIONAL DATA ITEMS
Participant Record Form 25. HAS THIS PARTICIPANT EVER BEEN DIAGNOSED AS ALSO
HAVING CHRONIC MENTAL LLNESS7
A Participant Record(PR)loom mast be competed for each individual who receives direct
trestm.nt er recovery aemvieao for an akbltol a drop4eeMd problem from IM provider
26. IS THIS PARTICIPANT HOMELESS?...........................(1-Yes 2-No)
MalaR looms stay also y. Pbe Competed for adopesdetts/oipnifiada others or Mmiy
members whe oceive disc,aarvipes;eosstdt your p onrem director or=vaty administrator
for quidaaeo car poli codpeddetah teal oUtsr data 27. !P CSE OF PARI (PANTS CURIIENT RESMICE....
TM whits admission spy of Ute PR lora,ahold to ped cut and faw0114 tr data army
pocass mg ssa a pamcipaM is Wvi*odsitted for amiss.Submit a PR lois only degr CO 0 REMARI(S:BOXES 1-23 FOR STATE USE;BOXES 24-6 FOR LOCAL USE
a9 stake and admission procedures we tmatploted.sad It lou base dstornined that the K9c 01 l►tVl
individual moats the ptv** adhroasion atetia.said a Who"or Ment No lou base / 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
opartod.A copy of the PR tam mold be kept In the participant tecord or cb M pe.
Individuals who aro weaned and pieced as awaiting NIM.or who tmeeive vias abrvenfim
referral, or eduatio"I genie"only.are not Consider"portidpeMa for Ute purpose of pgprGy
l droeecting data on the aIata 17 18 19 20 21 22 23 24 25 26 27 26 29 30
Who a participant leavea Ute programor tdtomges aatvica type►(see Nem 16 above).enter
the Discharge Information Gtomo 28.32)an to yellow an of the PR harm.N a parbcipsnt
s re•admated or changes service type.a caw admission PR tons must be competed. 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Data collection by the CaU mica Alcohol and Dreg Data System Is attlhormed by the
Caflomin Health and Safety Code.Section 11756 I I I 1 11 1 1 1 1 1 1 ET-]--,)
• dire■ ■.��►.�.• �i►r+n.i
EXHIBIT C-4
'Heal�h and Welfare Agency Department of Alcohol and Drug Programs
CALIFORNIA ALCOHOL AND DRUG DATA SYSTEM . PROVIDER SUMMARY REPORT (PSR) j
Name of Provider:
1. PROVIDER ID F m
Program County Facility
2. REPORT MONTE m--
Month Year Provider Location Address:
Check box if this is to correct a
previously submitted PSR.
3. METHADONE CENSUS - Enter the number
of participants actively enrolled
in methadone treatment on the last Name of Provider Liaison:
day of the Report Month. (These
participants should also be counted
in the Participant Census below) .
Telephone Number:
Detoxification Maintenance ( )
4. PARTICIPANT CENSUS - In the matrix
.below, enter the number of partici- Director:
pants actively enrolled in this
facility. The census should be Please check this box
reported as of the last day of the if above are changes.
Report Month by type of service under
the appropriate funding column. 5. PARTICIPANT RECORDS
SUBMITTED FOR THIS REPORT
Active Participants MONTH
TYPE OF SERVICE by Type of Funding
Total admissions
NON-RESIDENTIAL/ Alcohol Drug (include codependents)
OUTPATIENT Funds Funds TOTAL
Total discharges
1) Treatment/Recovery
2) Day Prog/Intensive PARTICIPANT CENSUS
VERIFICATION
3) Detoxification
I have reviewed this report
RESIDENTIAL and verify that it contains
complete and accurate
4) Detox/Hospital information.
5) Detox/Non-hospital
16) Treatment/Recovery Director's signature/date
(30 days or less) FOR STATE USE ONLY
7) Treatment/Recovery Date postmarked
(31 days or more)
Date received
All Codependents/
Significant Others Date Entered
t
INSTRUCTIONS FOR COMPLETING THE PROVIDER SUMMARY REPORT (PSR)
The Provider Summary Report (PSR) serves"as a cover sheet for submitting each month's
batch of Participant Record (PR) forms. The PSR also provides data on the number of
participants receiving services in each facility at the end of the month. A hardcopy PSR
form must be submitted each month by every provider participating in the California
Alcohol and Drug Data System (CADDS), even if there are no PR .forms submitted that month.
THE PROGRAM DIRECTOR IS RESPONSIBLE FOR VERIFYING AND SIGNING THE PSR FORM TO ENSURE THE
ACCURACY OF THE DATA IT CONTAINS. The procedures used to verify the accuracy of the
participant census reported on the CADDS PSR form should be documented and maintained at
the facility.
ITEM 1 - PROVIDER ID: The Provider ID consists of three parts: Program, County, and .
Facility ID. Enter the Provider ID assigned to this facility by ADP. This must be the
same as the Provider ID entered on the CADDS PR forms.
ITEM 2 - REPORT MONTH: Enter two digits for the month and year in which the data were
collected. CADDS data are submitted the month after the Report Month.
ITEM 2a - CORRECTION TO PRIOR PSR: If the Participant Census reported on a previous
month's PSR is found to be incorrect, a corrected copy of the PSR should be made and
submitted with the next batch of CADDS forms. To make a corrected copy of a PSR:
Using a new form, check the box and fill in item 1 (Provider ID) ; in item 2, enter the
Report Month of the PSR you wish to correct; complete the entire Participant Census
(item 4) with the corrected figures; complete item 3 (Methadone Census) if applicable;
and have the program director sign the form. The rest of the form should be left blank.
ITEM 3 - METHADONE CENSUS: Enter the number ofparticipants actively enrolled in
methadone detoxification and maintenance treatment .on the last day of the Report Month.,
The participants counted here should also be included in item 4 (Participant Census).
ITEM 4 PARTICIPANT CENSUS: Facilities should conduct a census .of active participants on
the last day of each wont . A participant should be counted only if he/she meets the
criteria for inclusion in CADDS (see CADDS Instruction Manual, pages 3, 12., 13, and 21).
Enter the actual number of participants actively enrolled in the facility as of the last
day of the Report Month. This count is reported by type of service under the appropriate
funding column. "Funding" refers to the county's alcohol program and drug program
budgets. A facility receiving only alcohol funds would enter all of its participants
under the Alcohol Funds column. Facilities receiving only drug funds and private
methadone clinics enter all active participants under the Drug funds column. Facilities
receiving both alcohol and drug funds must apportion their active participants between the
two program budgets. Add across each row and write the sum in the Total column for each
service type.
If a participant has received -more than one type of service in this facility during the
Report Month, that participant will be counted in the type of service he/she was receiving
on the last day of the Report Month. Codependents/Significant Others are entered on a
separate line, not by service category.
PROVIDER INFORMATION: Enter the provider information. Please print legibly or type. The
provider's CADS liaison is the staff member who is responsible for correcting errors and
responding to inquires concerning CADDS reporting. .
ITEM 5 - PARTICIPANT RECORDS ADMISSION DISCHARGE ACTIVITY: Enter the number of admission
PR forms (including codependent significant other) and discharge PR forms (if applicable)
submitted with this PSR.
•
Col.2
������
INSTRUCTIONS FOR DRUG MEDI-CAL FISCAL DETAIL
ESTIMATED NEW SERVICE PROVIDER COSTS
ADP FORM #7995
COLUMN AND LINE INSTRUCTIONS:
COLUMN 01: Enter Medi-Cal contract provider name.
COLUMN 02: Leave blank.
COLUMN 03: Enter Treatment Component (i.e. Methadone Maintenance (OMM), Out Patient Drug Free (ODF),
etc.) If a.provider offers more than one type of treatment, enter each on a separate line.
COLUMN 04: Enter total projected program costs per treatment component to include both Medi-Cal and
nonMedi-Cal services. The projected costs should be for the portion of the year the provider is
expected to provide Medi-Cal services. (Example: A provider is expected to provide services
beginning in January, the projected costs should be for the six (6) month period covering January
through June).
COLUMN 05: Enter total projected units per treatment program to include.both Medi-Cal and nonMedi-Cal
services. The projected units should be for the portion of the year the provider is expected to
provide Medi-Cal services.
COLUMN 06: Determine cost per unit by dividing column 04 by column 05.
COLUMN 07: Enter total projected Medi-Cal units for the portion of the year the provider is expected to provide
Medi-Cal services.
COLUMN 08: Enter established Maximum/Waivered Rate applicable to each type of treatment.
COLUMN 09: Enter the lower of the maximum/waivered rate (column 08) or the Cost Per Unit (column 06).
COLUMN 10: Multiply Maximum Payment Rate (column 10) by the Total projected Medi-Cal units (column 07).
_ EXHIBIT E
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INSTRUCTIONS FOR THE PERINATAL SERVICES MONTHLY REPORT
1. Provider name and California Alcohol and Drug Data System (CADDS) number as reported in the annual
County Plan. Use a separate line for each service code, include program name if applicable. Indicate
programs that are new this month with an asterisk (°).
2. Service Codes. Use the definitions in the County Plan Guidelines.
Outreach -22 Short Term Residential -57 Primary Medical Care - 69
Day Care Habilitative -30 . Transitional Living _ -S6 Pediatric Medical Can -70
Outpatient Drug Free -31 Alcohol/Drug Free Housing (start up cost only) -57
Methadone Maintenance -40 Interim Services - 67
Long Term Residential -51 Case Management - 68
3. List total number of women served this month.
4. List the total number of children served this month.
S. Of the total number of women served this month enter the number that are pregnant.
6. Total number of births for the month. If a toxicology screen was performed, place number in the positive or
negative box.
7. Static capacity: the number of women that can be served at any one time given the available resources
(facility, staffing, licensed capacity, etc.). In a larger facility, this means only the number of perinatal
slotstbeds that have been specifically contracted for or funded. Do not include slots for children.
S. Units of service availab) and used per month. For each perinatal service, a 'unit of service' is defined as:
Residential: the static capacity for women available per month multiplied by the days in month. (Includes
Transitional hiving Centers and Alcohol and Drug Free Living Centers.)
Day Care Habilitative: the static capacity multiplied by the total number of days program services were
available during the month.
Outpatient: the total number of hours available for person.to person contacts during the month that result in
a record of therapeutic experience in the client's chart.
Case Management: the total number of hours available for person to person contacts during the month.
Outmch: the total number of hours available for group presentations and person to person contact during
the month.
Primary Medical Cate: In the •UNITS OF SERVICE-USED' column only, place the number of
medical visits paid with perinatal funds. Programs providing medical care with perinatal funding must
document that alternative funding is not available. (Refer to Perinatal Guidelines).
Pediatric Medical Care: In the "UNITS OF SERVICE-USED"column only,place the number of
pediatric medical visits paid with perinatal funds. Programs providing pediatric medial care with
perinatal funding must document that alternative funding is not available. (Refer to Perinatal Guidelines).
Interim Services: In the "UNITS OF SERVICE-USED" column only,plan the number of referrals givers
to pregnant women listed in column S, Service Code 67. Liu agencies to whom referrals were made in the
comments section. For the definition of interim services, refer to the Perinatal Guidelines.
- EXHIBIT F
ADP PERINATAL SERVICES SUPPLEMENTAL INFANT DATA FORM
To be completed afterbirth of participant's infant., Please see instructions on back.
I Provider ID . . . . . . . . . . . . C
Program ' County Facility M
2 Unique Participant ID
2
Last First 1=Male M M D D Y Y
2=Female
3 What is woman's frequency of substance use at time of delivery? . . .
I. Abstinent
2. Significant decrease from admission
3. No change
4. Worse from admission
9. Unknown
4 Infant's Date of Birth . . . . . .
M M D D Y Y
5 Infant Birth Weight (grams) . . . . . . . . . . . .
6 Infant Toxicology Screen at Birth . . . . . . . . . . . . . . . . :. . . . . . . . . . . . .�
1. Positive
2. Negative
9. Unkno%m
7 Infant's Living Arrangement after Birth . . . . . . . . . . . . . . . . . . . . . . . .Q
i. Both parents
I Mother only
3. Father only
4. Other relatives
S. Foster care
6. Other arrangemtetts
9. Unknown
ADP Perinatal Services Supplemental Infant. Data Form
INSTRUCTIONS.
Please complete this form about the patticipatit and infant as soon after the bitch as
possible,for those women who entered the program during pregnancy. Infant Data Forms
should be submitted to the county's ADP perinatal liaison. Please see Perinatal Services
Guidelines,Fall 1993,page 26 for more information.
Item l--Provider 1D
Program Precoded response to identify the type of statelfederal funding
received by the provider as listed below:
C= Both Alcohol and Drug funds
County Identify the county in which the provider is physically located (2
digits).
Facility ID This 4-digit number is assigned by ADP to each location where
services are provided.
Item 2--Unique Particinont ID
Initials: Last/First Enter the first letter of the participating woman's
last/first name. Use the proper name and write in capital letters.
Sex Use the preeoded '2'on the form to identify the gender of the
participating woman.
Binh Date Enter the participating woman's date of birth,using two digits each
for the month, day. and year.
Item 1--Frcnuencv of Substance Use at Binh
Use one of the codes on the form to select the most appropriate
status.
'Item 4--Inf2nt's Date of Binh
Enter the infant's date of birth of the participating woman using two
digits each for the month,day,and year.
Item 5=lnfant Weight_t Binh
Enter the weight at birth,in grams,of participating woman's infant.
If the-birthweight is recorded in pounds,convert it to grams. Code
9999 for unknown.
Item Cr-lnfant Texicologyv Schen at Birth
Use one of the codes on the form to select the toxicological screen
result.
Item 7--Infant's Living Arrangement after Binh
Use one of the codes on the form to select the most approptiatt
living arrangement after discharge from the hospital after birth.
EXHIBIT G
DRUGMEDI-CAL CERTIFICATION STANDARDS
FOR SUBSTANCE ABUSE CLINICS
Effective October 1, 1994
EXHIBIT G
TABLE OF CONTENTS
Page _
I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
A. Substance Abuse Clinic . . . . . . . . . . . . . . . . . 1
B. Satellite Clinic . . . . . . . . . . . . . . . . . . . . 1
C. Perinatal Residential Program . . .. . . . . . . . . 2
D. Employed Staff . . . . . . . . . . . . . . . . . . . . . . 2
E. Certification . . . . . . . . . . . . . . . . . . . . . . . . 2
F. Recertification . . . . . . . . . . . . . . . . . . . . . . . 2
G. Under the Direction of a Physician . . . . . . . . . . 3
M. GENERAL REQUIREMENTS . . . . . . . . . . . . . . . . . . 3
A. Fire Safety . . . . . . . . . . . . . . . . . . . . . . . . . 3
B. Use Permits . . . . . . . . . . . . . . . . . . . . . . . . . 3
C. Clinic Director . . . . . . . . . . . . . . . . . . . . . . . 3
D. Medical Director . . . . . . . . . . . . . . . . . . . . .. 4
E. Availability of Service . . . . . . . . . . . . . . . . . . 5
F. Integration of Staff Services . . . . . . . . . . . . . . . 5
G. Minimum Clinic Staff . . . . . . . . . . . . . . . . . . 5
H. Physical Plant . . . . . . . . . . . . . . . . . . . . . . . 5
I. Utilization Review . . . . . . . . . . . . . . . . . . . . 5
J. Patient Health Records . . . . . . . . . . . . . . . . . . 5
K. Administrative Policies . . . . . . . . . . . . . . . . . . 6
L. Health Records . . . . . . . . . . . . . . . . . . . . . . 7
M. Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
N. Basic Services . . . . . . . . . . . . . . . . . . . . . . . 8
O. -Optional Services . . . . . . . . . . . . . . . . . . . . . 8
IV. STAFF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
A. Clinic Head/Chief/Director . . . . . ... . . . . . . . . 8
B. Minimum Staff Requirements . . . . . . . . . . . . . 10
V. CERTIFICATION REQUIREMENTS . . . . . . . . . . . . 11
VI. PHARMACEUTICAL SERVICE REQUIREMENTS . . . 11
A. Orders for Drugs . . . . . . . . . . . . . . . . . . . . 11
B. Labeling and Storage . . . . . . . . . . . . . . . . . . 11
C. Disposal of Drugs . . . . . . . . . . . . . . . . . . . . 12
D. Dispensing of Drugs . . . . . . . . . . . . . . . . . . 12
_ EXHIBIT G
1
I. INTRODUCTION
Substance abuse clinics wishing to receive Drug/Medi-Cal (D/MCj reimbursement will require
an on-site survey by the Department of Alcohol and Drug Programs (ADP). Intermittent clinics
may require an on-site inspection for certification at the determination of ADP.
Ii. DEFINITIONS
A. "Substance abuse clinic"means a clinic or a parent cliq}ic which provides direct substance
abuse treatment services,including evaluation,treatment,and referral for individuals who
remain less than 24 hours. In addition,such clinics may provide methadone maintenance
services, drug-free services, day care habilitative, medication, psychotherapy and
counseling, and other medically necessary services.
B. "Satellite clinic" means a clinic which is operated on separate premises from the parent
clinic and is under the administrative and professional supervision of the parent clinic.
The parent clinic must exercise administrative and professional supervision of the satellite
clinic. A director or substance abuse professional from the parent clinic must be on-site
at the satellite clinic a minimum of four hours a week.
There are two categories of satellite clinics:
1. "Branch clinic" is a satellite clinic which is open 20 hours a.week or more.
Branch clinics shall:
a. Have a provider number separate from their parent clinics;
b. Claim reimbursement by submitting completed Alcohol and Drug
Program (ADP) 1584s, Drug/Medi-Cal Eligibility Work Sheets,
identifying the type of services rendered.
ADP 1584s must be submitted utilizing individual provider numbers,not
the parent clinics' provider number.
2. "Intermittent clinic" is a satellite clinic which is open for less than 20 hours a
week.
Intermittent clinics shall not be required to have a provider number separate from
their parent clinics. The services rendered by intermittent clinics shall be
included on the parent clinic's claim form. However, the services provided by
the intermittent clinic must be clearly identified on the parent clinic's billing
claims. A separate billing claim.for each intermittent clinic is required. A clear
audit trail must be maintained.
EXHIBIT G .
2
The parent clinic shall assure:
a. The intermittent clinic can provide only those services provided by the
parent clinic.
b. The intermittent clinic has been issued a fire clearance by the state Fire
Marshal or fire authority having jurisdiction in accordance with Section
M.A., Fire Safety.
C. The intermittent clinic is in compliance with pertinent and governing
laws, regulations, policies, and health and safety standards.
C. "Perinatal Residential Program"means a 24-hour freestanding residential program which
is licensed for 16 beds or less for the women in treatment. Beds may be occupied by
children who stay in the facility with their mothers; however, these beds are not counted
in the 16-bed limit. Services are limited to pregnant, postpartum, and parenting women
with substance abuse impairments. Services include substance abuse counseling and
rehabilitative services within a residential setting.
D. "Employed Staff", for the purpose of these certification standards, shall mean either
employed by the organization operating the clinic or contracted by the organization
operating the clinic to perform specific duties. The contract must at least specify duties,
hours, period of time and reimbursement for the contracted employee.
E. "Certification" shall mean an on-site inspection of the facility to establish eligibility to
participate in the D/MC Program. The on-site facility inspection shall be conducted by
ADP surveyors who ascertain whether the provider is in compliance with certification
standards.
F. "Recertification" shall mean the completion of the same process as for "certification" to
be conducted at least every two years. Recertification surveys for D/MC will be
conducted by ADP. On-site inspections may occur at anytime. Variance from the survey
schedule may be brought about by the following:
1. The.provider sustains major staffing changes.
2. The provider has organizational and/or corporate structure changes including:
a. Conversion from non-profit to for-profit status.
b. Conversion from intermittent clinic to branch clinic.
c. Change of ownership.
3. The provider changes the scope of services.
4. The provider has major changes in physical plant, i.e., eneesive remodeling.
EXHIBIT G
3
S. The provider changes address and/or location. A 6O-day notification is required.
Services provided at the new location shall not be D/MC reimbursable until
certification of the new site has been completed by ADP. This requires at a
minimum a fire clearance.
6. Investigation of a complaint. ADP may investigate a complaint registered against
the provider.
It is the responsibility of the provider to promptly notify ADP of any occurrence of the
items listed in 1 through 6 above. Failure to do so may result in decertification.
On site inspection surveys are not limited to purposes of recertification.
G. "Under the direction of a nhysician" means a physician formulation of, approval of, or
involvement in each D/MC patient's plan of care within 30 calendar days from the date
of initial services. Such direction may take one of several forms, such as development
or review/approval of the treatment plan of care, clinical consultation on the patient's
case medication evaluation, or involvement in the patient's case conference. Evidence
of the physician's direction must be documented by the physician's notations and
signature in the patient's health record and treatment plan.
III. GENERAL REQUIREMENTS
Participation in the D/MC Program is contingent upon compliance with the following
requirements.
A. Fire Safety
Each clinic shall conform with the rules and-regulations adopted by the state Fire
Marshal. Each clinic shall have a fire clearance from the state Fire Marshal or fire
authority having jurisdiction. The clinic is required to meet all local fire. safety
requirements. Fire clearances are requested by ADP personnel unless, subject to ADP
approval, an acceptable local fire clearance is submitted by the applicant.
B. Use Permits
Approval, as necessary, shall be secured by the local agency authorized to provide a
building use permit, or right to occupy/lease.
C. Clinic Director
A substance abuse elm c direr=must be a person who has completed four years work
experience in mental health/substanee abuse programs and can demonstrate progressive
respaffiI t' y in the areas of counseling, supervision, and program administration; and
possesses an Associate of Arts degree. Up to four years of college or university
education may be substi=d for up to two years of work experience.
' EXHIBIT G
4
1. The clinic staff, professional and nonprofessional,shall be under the direction of
the clinic director.
2. The clinical director shall be of one of the following disciplines:
a. A psychiatrist as defined in Section N.A.1.
b. A physician as defined in Section IV.A.8.
c. A psychologist as defined in Section IV.A.2.
d. . A social worker as defined in Section N.A:3.
C. A registered nurse as defined in Section IV.A.4.
f. A licensed vocational nurse as defined in Section IV.A.5.
g. A psychiatric technician as defined in Section N.A.&
h. A mental health rehabilitation specialist as defined in Section IV.A.7.
L A substance abuse professional as defined in Section IV.A.9.
D. Medical Director
1. Each substance abuse clinic shall have a licensed physician designated as the
medical director. The medical director shall direct medical services, either by
acting alone or through an organized medical staff.
2. The medical director's responsibilities, acting alone or through an organized
medical staff, shall include:
a. Establishing,reviewing,and maintaining medical policies and standards,
which shall be reviewed at least annually and revised as necessary.
b. Assuring the quality of medical services given to all patients treated by
the clinic.
C. Reviewing and approving all protocols in the clinic.
d. Assuring that at least one physician practicing at the clinic shall have
admitting privileges to a general acute care hospital or a plan, as
approved by ADP, for ®sluing naded hospital services. (California
Code of Regulations [CCR], Methadone Regulations, Title 9, Section
10340.)
EXHIBIT G
5
C. Assuring that a physician has assumed medical responsibility for all
patients treated by the clinic. (CCR, Title 9, Methadone Regulations,
Section 10110.)
E. Availability of Service
Services shall be reasonably available and accessible.
F. Integration of Staff Services
The services of the various professional disciplines shall be integrated through regular
staff meetings and other conferences for joint planning and evaluation of treatment. This
shall be documented in the form of minutes.
G. Minimum Clinic Staff
The minimum clinic staff shall include qualified substance abuse professionals. The staff
may also include other qualified professionals and counselors which may include
psychiatric technicians,registered nurses, licensed vocational nurses, nurse practitioners,
physician's assistants, or other nonphysician practitioners. Each clinic shall retain a
qualified medical director to ensure quality of medical services provided.. DHS in
consultation with ADP may authorize modification of staffing of a substance abuse clinic.
One person may serve, if qualified,in all three positions,medical director, clinic director
or qualified substance abuse professional. Methadone clinics shall be staffed by a
licensed nurse or other individuals lawfully authorised to administer medication(Title 9,
Methadone Regulations, Section 10100).
H. Physical Plant
The clinic shall be clean, sanitary, and in good repair at all times. Maintenance shall
include provisions and surveillance of maintenance services and procedures for the safety
and well-being of patients, personnel, and visitors (Health and Safety Code, Sections
208(a) and 1275).
I. Utilization Review aW
The clinic shall establish, implement, and maintain UR procedures in accordance with
the State UR Plan. A copy of the approved Utilization Control Plan (UCP) shall be
maintained at the clinic. Any changes to the UCP after its original submission must
receive ADP's approval. If changes are not made to the UCP,a letter indicating that fact
shall be submitted to ADP on an annual basis.
J. Patient Health Records
1. Eacb clinic shall establish and maintain a patient health record on every patient
admitted for care at the clinic(State of California, Standards For Drug Treatment
Programs, Section II.C.I.a., and State UCP Section II.P.).
EXHIBIT G.
6
2. Health records shall be permanent. All health records of discharged patients
shall be completed and filed within 30 days after discharge, and such records
shall be kept for a minimum of 7 years, except for minors, whose records shall
be kept at least 1 year after the minor has reached the age of 18, but in no case
less than 7 years.
3. Information contained' in health records shall be confidential and shall be
disclosed only to authorized persons in accordance with federal, state, and local
laws. (CCR, Title 9, Methadone Regulations, Section 10155).
K. Administrative Policies
Written administrative policies shall be implemented, maintained, reviewed annually and
revised as necessary. The policies shall include:
1. Policies and procedures governing patient health records annually reviewed and
signed by the medical director.
2. Management and personnel policies shall be established and maintained which:
a. Are written and revised as needed and are approved by governing body;
b. Are applicable to all employees and are available to and reviewed with
new employees;
C. Comply with applicable local, state, and federal employment practice
laws; and
d. Contain information about the following:
Recruitment, hiring process, evaluation,promotion, disciplinary
action and termination;
Equal-employment opportunity, discrimination, and affirmative
action policies as applicable;
- Employee benefits (vacation, sick leave), training and
development, grievance procedures;
salary schedule,merit adjustment,severance pay,employee rules
and conduct;
Employee safety and injuries; and
Physical health status as required.
' EXHIBIT G
7
3. Personnel Files
Personnel files shall be maintained on all employees and shall contain:
a. Application for employment and/or resume;
b.' Employment confirmation statement;
C. Salaryschedule and salary adjustment information;
d. .Employee's evaluations;
e. Health records as required; and
f. Other personnel actions(e.g., commendations, discipline,status change,
employment incidents and/or injuries).
4. Procedures shall be established for access to and confidentiality of personnel
records.
5. Job descriptions shall be developed, revised as needed, and approved annually
by the governing body. The job descriptions shall include:
a. Position title and classification;
b. Duties and responsibilities;
C. Lines of supervision, (if applicable);
d. Education,training,work experience and other qualifications for
the position.
6. A written code of conduct for employees and volunteers shall be established
which addresses at least the following:
a. Use of drags and/or alcohol;
b. Prohibition of sexual contact with clients; and
C. Conflict of interest.
L. Health Records
Health screening and health records shall be maintained of persons working in the clinic.
1. All persons working in the clinic, including volunteers, shall have a health
screening within six months prior to employment or within 15 days after
employment.
EXHIBIT 'G
8
_ 2. The clinic shall maintain'a health record of each employee which includes reports
of all employment related health examinations. These records shall be kept for
a minimum of three years following termination of employment.
3. All persons working in the clinic shall be screened and those who are known to
r have symptoms of infectious disease shall be removed from contact with patients.
M. Drugs
If the clinic maintains, administers, or dispenses drugs, the drug distribution service shall
be in conformance with all appropriate state and federal pharmacy laws (see Section VI.
below).
N. Basic Services
The following basic services shall be provided by all D/MC substance abuse clinics:
1. A DSM-III or DSM-IV diagnosis and evaluation,toward formulation of a
continuing treatment plan.
2. A medication maintenance program, if appropriate.
3. Individual and/or group therapy.
O. Optional Services
1. The following optional services also qualify for Drug/Medi-Cal reimbursement
when provided by a certified clinic:
a. -Body fluid testing to determine client drug use (required for methadone
maintenance).
b. Collateral Services.
C. Prenatal and postpartum substance abuse information.
d. AIDS education services.
C. Crisis Intervention.
IV. STAFF
A. Clinic Head/Chief/Diry=
a
Pending the possession of the qualifications defined in Section M.C., the following
personnel may serve as the head/chief of a particular service or the director of the clinic.
EXHIBIT G
9
1. Psychiatrist
A psychiatrist shall have a license as a physician and surgeon in the state and
show evidence of having completed three years graduate training in psychiatry
in a program approved by the American Medical Association or the American
Osteopathic Association.
2. Psychologist
A psychologist shall have obtained or have been declared board eligible by the
Psychology Examining Committee for a California license by the Medical Board
of California, and within one year, shall have been granted a California license
by the Medical Board of California, and shall have two years of postdoctoral
experience in a mental health and/or substance abuse programs.
3. Social Worker
A social worker shall have a license as a clinical social worker granted by the
California Board of Behavioral Science Examiners and have, at a minimum, two
years'experience in substance abuse/mental health programs and can demonstrate
progressive responsibility in the areas of counseling, supervision, and program
administration.
4. Registered Nurse
A registered nurse shall be licensed to practice as a registered nurse by the
California Board of Registered Nursing and two years of nursing experience in
mental health/substance abuse programs.
5. Licensed Vocational Nurse
A licensed vocational nurse shall have a license to practice vocational nursing
issued by the California Board of Vocational Nurse and Psychiatric Technician
Examiners and six years of postlicense experience in mental health/substance
abuse programs. Up to four years of college or university education may be
substituted for the required experience on a year-to-year basis.
6. Psychiatric Technician
A psychiatric technician shall have a current license to practice as a psychiatric
technician issued by the California Board of Vocational Nurse and Psychiatric
_Technician E=miners and six years of postlicense experience in mental
healtb/snbstantx abuse programs. Up m four years of college or university
e&=Won may be substituted for the required eaperience on a year-to-year basis.
E%iiIBIT G
10
7. Mental Health Rehabilitation Specialist
A mental health rehabilitation specialist shall be an individual who has a
baccalaureate degree and four years of experience in a mental health setting as
a specialist in the field of physical restoration, social adjustment, or vocational
adjustment. Up to two years of graduate professional education may be
substituted for the experience requirement on a year-to-year basis; up to two
years of post-Associate Arts clinical experience may be substituted for the
required educational experience in addition to the requirement of four years'
experience in a mental health setting.
8. Physician
Physician means a person licensed as a physician and surgeon by the Medical
Board of California.
9. Substance Abuse Professional
A substance abuse professional is defined to mean a person who has completed
an Associate of Arts degree and one year of experience, or has three years
experience in a mental health or substance abuse setting. Experience in a mental
health or substance abuse field may be substituted for degree requirement on a
year-for-year basis provided that the experience includes clinical evaluation,
treatment planning, and individual and group counseling.
B. Minimum Staff Requirements
1. Medical Responsibility
All medical services provided by the substance abuse clinic shall be under the
direction of a physician, who must be available on a regularly scheduled basis
and otherwise on call. A physician shall assume medical responsibility for all
patients.
Documentation of assumption of medical responsibility shall include, but not be
limited to, written approval of the treatment plan within the 30th calendar day
from the date of initial service. Treatment plans for ongoing clients shall be
updated and approved by a physician at least every 90 calendar days.
2. Clinic Personnel
IL Clinic staff d II fiunish the services prescctbed for patients admitted.
registered. or accepted for care by the clinic.
b. The clinic staff shall be qualified in accordance with current legal,
professional, and technical standards and appropriately licensed,
registered, or certified where required.
,t
EXHIBIT G
11
V. CERTIFICATION REQUIREMENTS
A. Initial and continued certifications shall be based upon full compliance with the standards
above.
I. Noncompliance means: a deficiency in any of the standards cited above.
2. Statement of deficiencies means: a written statement of all deficiencies noted by
ADP at the time of the on-site survey.
3. Plan of correction means: a written response by the program, submitted to ADP
within 30 days of receipt of the statement of deficiencies, and including:
a. A description of how and when deficiencies will be corrected.
b. A description of the method of monitoring to prevent recurrence and
ensure ongoing compliance.
VI. PHARMACEUTICAL SERVICE REQUIREMENTS
If the clinic maintains, administers, or dispenses drugs, the drug distribution service shall be in
conformance with all appropriate state and federal pharmacy laws.
A. Orders for Drugs
No drugs shall be administered except upon the order of a person lawfully authorized to
prescribe for and treat human illness. All such orders shall be in writing and signed by
the person giving the order. The name, quantity or duration of therapy,dosage, and time
of administration of the drug, the route of administration if other than oral, and the site
of injection when indicated shall be specified. Telephone orders may be given to a
licensed pharmacist, licensed nurse, registered nurse, or licensed psychiatric technician
and shall be immediately recorded in the patient's health record, and shall be signed by
the prescriber within 72 hours. The signing of orders shall be by signature or a personal
computer key.
B. Labeling and Storage
Labeling and storage of drugs shall comply with the following:
1. . Containers which are cracked, soiled, or without secure closures shall not be
used. Drugs labels shall be legible.
2. All drugs obtained by prescription shall.be labeled in compliance with state and
federal laws governing prescription dispeosmg. No person other than a
pharmacist or a physician shall alter any prescription label.
3. Nonlegend drugs shall be labeled in.conformance with state and federal food and
drug laws.
EXHIBIT G
12
4. Test reagent, germicides, disinfectants, and other household substances shall be
stored separately from drugs.
5. External use drugs in liquid, tablet, capsule, or powder form shall be stored
separately from drugs for internal use.
6. Drugs shall be stored at appropriate temperatures. Drugs required to be stored
at room temperature shall be stored at a temperature between 15 c (59 F) and 30
c (86 F). Drugs requiring refrigeration shall be stored in a refrigerator between
2 c (36 F) and 8 c (46 F). When drugs are stored in the same refrigerator with
food, the drugs shall be kept in a closed properly labeled container clearly
labeled "DRUGS".
7. Drugs shall be stored in an orderly manner in cabinets, drawers, or carts of
sufficient size to prevent crowding.
B. Drugs shall be accessible only to personnel designated in writing by the facility.
9. Drugs shall not be kept in stock after the expiration date on the labels, and no
contaminated or deteriorated drugs shall be available for use.
10. The drugs of each patient shall be kept and stored in their original individual
received containers. No drug shall be transferred between containers, with the
exception of take-home bottles.
C. Disposal of Drugs
Disposition of drugs shall meet all applicable state and federal requirements.
D. Dispensing of Drugs
Drugs shall only be dispensed by a physician, pharmacist, or those persons lawfully
authorized to dispense and shall be in compliance with all applicable laws and
regulations.
1. Drugs shall be administered as prescribed and shall be recorded in the patient's
health record.
2. Drugs shall be administered only by those persons lawfully authorized to
administer.
_ EXHIBIT H
STATE OF CALIFORNIA
DEPARTMENT OF ALCOHOL AND DRUG.. PROGRAMS
1700 K STREET
SACRAMENTO, CALIFORNIA 95814-4037
DRUG/MEDI-CAL UTILIZATION CONTROL PLAN
EFFECTIVE January 1, 1995
orcaovrsnwou®arc�►L ucr�.�s
TABLE OF CONTENTS
Page
I• INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . 1
A. Purpose and Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . 1
B. Medical Necessity . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . 1
C. Reimbursements Specific to D/MC Benefits and Service Functions . . . . . . . . . . . 2
D. Clinic Services Utilization Control Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
II. UTILIZATION REVIEW COM 7TTEE COMPOSITION, RESPONSIBILITY AND
AUTHORITY AND AmNry UM SERVICE REQLMZEMENTS . . . . . . . . . . . . . . . . 5
A. Committee Representation and Frequency of Meetings . . . . . . . . . . . . . . . 5
B. Committee Location . . . . . . . . . . . . . . 6
C. Recordkeeping ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
D. Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
E. Utilization Review Committee Documentation . . . . . . . . . . . . . . . . . . . . . 6
F. URC Action 7
G. No Fees Charged . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 7
H. Discharge Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
I. URC Phase-In Period for New Programs . . . . ... . . . . . . . . . . . . . . . . .. . . . . 8
J. Client Fair Hearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
K. Audit Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
L. Drug/Medi-Cal Administrative Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
M. Local Utilization Control Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
N Physician Direction . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . 12
O. Treatment Plans for All Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
P. Treatment Termination_ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Q. Client Record Requirements and Availability for Inspection . . . . . . . . 13
R. Client Attendance Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
'S. Retroactive URC Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
T. Naltrexone(Trexan) . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .1. . 0 . . . . 14
U. Services for Pregnant and Puating Wong . . . . . . . . . . . . . . . . . . . . . . . . 14
V. Follow W Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
III. OUTPATIENT METHADONE MAPnWgANCE SERVICES . . . . . . . . . . . . . . . 15
A. Objectives of Otttpatieat Methadone MaWwnam Services . . . . . . . . . . . . . . . 15 .
B. Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
C. Required Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
D. Ammon Criteria . . . . . . . . . . . . . . . . . . . . . . „ . . . . . . . . . . . . 16
E. Pregnant Clients: Additional Regttirementa . . . . . . . . . . . . . . . . . . . . . . . . 17
F. Exceptions to bfinimm Admission Criteria . . . . . . . . . . e e . . . . . . . . . . . . 17
G. Temporary Exceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
EXHIBIT H
TABLE OF CONTENTS
(CONT DMM)
Page
H. Initial Treatment Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
I. Stay Review and Supporting Documentation . . . . . . . . . . . . . . . . . . . . . . . . 17
J. Initial Utilization Review and Utilization Review for
Extended Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
K. Naltrexone . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
IV. OUTPATIENT DRUG-FREE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
A. Objectives of Outpatient Drug-Free Services . . . . . . . . . . . . . . . . . . . . . . . . 19
B. Staff . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
C. Required Services . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 20
D. Physician Direction . . . . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . . . . . . 20
E. Urine Surveillance . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 20
F. Admission Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
G. Initial Utilization Review . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 21
H. Utilization Review for Extended Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 21
I. Stay Review and Supporting Documentation . . . . . . . . . . . . . . . . . . . . . . . . 21
J. Physician Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
K. Medication Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
L. Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
M. Emergency Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
N. Naltrexone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
O. Follow-up Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
V. DAY CARE HABILITATIVE SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
A. Objectives of Day Care Habilitative Services . . . . . . . . . . . . . . . . . . . . . . . . 23
B. Staff . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
C. Required Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
D. Physician Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
E. Urine Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
'F. Admission Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
G. Initial Utilization Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
H. Utilization Review for Extended Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 26
I. Stay Review and Supporting Doarmenta . . . . . . . . . . . . . . . . . . . . . . . . . 26
J. on : . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 26
K. Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 "
L. Nahrexone . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
M. Follow-W Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
TABLE OF CONTENTS
(CONTINUED)
Page
VI. PERINATAL RFSIDENTTAL SUBSTANCE ABUSE SERVICES . . . . . . . . . . . . . 27
A. Objectives of Perinatal Residential Substance Abuse Services . . . . . . . . . . . . . . 28
B. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
C. Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
D. Required Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
E. Program Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
F. Physician Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 .
G. Urine Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
H. Admission Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 30
I. Initial Utilization Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
J. Utilization Review for Extended Treatment . . . . . . . .. . . . . . . . . . . . . 31
K. Stay Review and Documentation . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . 31
L. Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
M. Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . 32
N. Follow-up Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
VII. ATTACHMENTS
D/MC #92-03 - Submission of D/MC Disallowances By Provider . . . . . . . . . . . . . . . 33
D/MC #93-10- Methadone Maintenance Services of Medi-Cal Recipients . . . . .. . . . . . 36
D/MC#94-04 - Reporting Drug/Medi-Cal Disallowances . . . . . . . ... . . . . . . . . . . . . 37
DDP #94-15 - Capacity/Waiting List Management Program . . . . . . . . . . . . . . . . . . 39
EXHIBIT H
I. INTRODUCTION
A. Purpose and Authorization
The Utilization Control Plan (UCP) is a document meant to provide certain safeguards
against unnecessary services in substance abuse programs receiving Drug/Medi-Cal
(D/MC)monies. It is intended as an aid to maintaining high quality client care and
becomes part of a quality assurance program. On July 20, 1979, a Department of
Health Services (DHS) letter to the Department of Alcohol and Drug Programs'
(ADP) Director stated that "all programs being funded with Medi-Cal dollars through
the 05 Short-Doyle (now Lancaster AB 3873) process will be subject to a form of
utilization control." The UCP takes effect under the authority of Federal Medicaid
law (SSA Section 1902 (a) 30-33) and Federal Medicaid Regulations 456.2 through
456.6 inclusive. Further, State law and regulations apply utilization control to
Medi-Cal services in California. The organization and arrangement of the county
UCP's shall be based upon the form established in this document.
All D/MC providers must have a written utilization review (UR) plan in effect for all
D/MC clients. The UR plan must specify a program that meets the requirements
listed herein. The purpose of the program is to review the medical necessity,
appropriateness, and quality of substance abuse treatment services.
Substance abuse programs which have D/MC funding and space available cannot deny
program access to non-county residents which are D/MC beneficiaries (see attached
D/MC #93-10). In addition, no persons who are D/MC eligible should be placed on
waiting lists for services due to budgetary constraints (see attached DDP//9415,
Capacity/Waiting List Management).
B. Medical Necessity
Medical necessity is defined as health care services which are reasonable and
necessary to protect life, to prevent significant illness or significant disability, or to
alleviate severe pain through the diagnosis or treatment of a disease, illness or injury
(California Code of Regulations, Section 51303 of Title 22).
All D/MC providers must implement a continuous UR program for all D/MC clients
necessitating initial and extended visits. The UR program must provide for review of
each client's needs and suitable services.
In addition, the UR program must:
1, Verify cacti Medi-Cal cheat's zeed for care;
2. Vaify that a treatment play exists for each Medi-Cal client;
3. Identify pertinent information required for UR;
1
.4. Set forth the UR plans and procedures to be used by the clinic;
5. Conduct UR as required; and
6. Make disallowances of billings to D/MC as required for:
a. Untimely initial Utilization Review Committee (URC) review;
b. Untimely annual URC review for methadone maintenance services;
C. Untimely extended URC reviews for day care habilitative, drug free,
and residential services;
d. Untimely treatment plans;
e. Untimely physician review of treatment plans;
f. Untimely justification for continued treatment for methadone
maintenance; and
g. Previously submitted incorrect billings (recoupment actions).
C. Reimbursements Specific to D/MC Benefits and Service Functions
Drug/Medi-Cal service functions are billed under an all-inclusive rate method, i.e. all
costs associated with providing substance abuse treatment (counseling, urinalysis,
medication, physical examinations and laboratory tests, utilization review activities,
etc.) are combined to identify a specific rate for each unit of service provided. The
services related to outpatient methadone maintenance, outpatient drug free, naltrexone,
day care habilitative, and perinatal residential treatment are not reimbursable benefits.
under the Medi-Cal fee-for-services (FFS)program. Such services, which are subject
to utilization review and which must be billed under a substance abuse diagnosis to
D/MC, include:
L Methadone Maintenance-services include intake, assessment and diagnosis;
all medical supervision; urine drug screenings; physician and nursing services
related to substance abuse; individual and group counseling; admission
physical examinations and laboratory tests; the provision of methadone as
prescribed by a physician to alleviate the symptoms of withdrawal from
narcotics; and other required/
appropriate activities and services.
2. Outpatient Drug Free-services include intake; assessment; diagnosis;
evaluation; extensive counseling; medical supervision; medically necessary
drug urine screens; and other appropriate activities and services.
3. Day Care Habilhative-services include, but are not limited to, intake;
assessment; diagnosis; evaluation; individual and group counseling; medically
necessary drug screens; and other appropriate activities and services.
.4. Perinatal Residential-aervices include intake; assessment; medical direction;
counseling services; medically necessary mine drug screens; and other
appropriate activities and services.
2
EXHIBIT H
5. Naltrexone - services ipclude medication; medical direction; medically
necessary urine drug screens; counseling; and other appropriate activities and
services.
Treatment Services are defined as:
1. Individual Counseling - person-to-person contacts between a client and a
therapist or counselor. These must be face-to-face contacts provided at the
certified program facility. Telephone contacts, home visits and hospital visits
are not billable units of service.
2. Group Counseling - contacts in which one or more counselors treat two or
more identified clients at the same time, focusing on the needs of the
individuals served.
3 Medication- any services provided to prescribe or administer medication or
to assess the side effects and/or results of medication.
4. Assessment - the evaluation or analysis of the cause or nature of mental,
emotional,'psychological, behavioral, and substance abuse disorders including
intake physical examination, evaluation of treatment needs, and laboratory_
testing, such as urinalysis, necessary for substance abuse treatment and
evaluation.
5. Collateral Services - face-to-face sessions with significant persons in the life
of an identified client, focusing on the needs of the identified client.
6. Crisis Intervention- person-to-person contact between a qualified professional
and an identified client in crisis. Interviews are designed to alleviate
problems which present an imminent threat to the health of the client.
Drug/Medi-Cal shall be billed on a per visit basis. If return visits are necessary, they
shall not be a duplicate service and shall be clearly documented in the client's record
in order to be billed as an additional visit on the same day. They should not,
however, create a hardship on the Medi-Cal beneficiary, and every effort should be
made to provide all needed services during one visit.
Service function codes are assigned to each category of substance abuse treatment.
The reporting of service functions is needed so ADP and DHS can obtain information
on the types of service provided and their charges. This data is also used to assist
ADP and DHS in the development of anpnal service function rates. Federal
reimbursement is limited to certain function codes. The following codes are federally
reimbursable for D/MC program services provided to federally linked Medi-Cal
recipients:
3
Service Function Service Function Codes
Methadone Maintenance 20 - 29
Day Care Habilitative 30 - 39
Perinatal Residential 40 -49
Naltrexone 50- 59
Outpatient Drug Free 80- 89 ,
D. Clinic Services Utilization Control Plan
County and contract providers.must have a current, formalized Utilization Control
Plan (UCP) approved by the County Alcohol/Drug Program Administrator and ADP.
Plans must comply with the requirements noted herein. If contract providers intend to
follow the County Plan, then the County Plan shall indicate the names of the contract
providers accordingly.
The County Alcohol/Drug Program Administrator has the responsibility to ensure the
organization and continued operation of the utilization review program. The original
plan, all subsequent plans, and any changes to the UCP must be submitted in writing
and approved by ADP. A copy of the approved county UCP must be at each
provider.location.
The UCP, for review and control of appropriate services, must specify:
1. The composition, organization, authority, and functions of the URC,
including the names of all providers which it serves;
2. The location and frequency of the URC meetings;
3. The policies and procedures for documenting and reporting of URC meeting
minutes, records, activities, determinations, results and recommendations;
4. Procedures for performing UR functions;
5. Reviewer restrictions and appeal procedures of URC decisions by the
program staff, client, or family of the client;
6. Written procedures.between the URC, the billing persons) or department of
the agency or County, and the contract provider staff to ensure that only
initially approved and corded services authorized by the URC are billed to
D/MC;
7. Provisions for ensuring confidentiality among clients, program staff;and
reviewers with respect to URC activities. detecmiaatioffi, results. and/or
recommendations; and
8. The record storage locations and the We of the records clerk and mtodian.
4
EXHIBIT H
II. UTILIZATION REVIEw COMMITTEE COMPOSITION, RESPONSIBILITY AND
ALrMORITY, AND MP433T M SERVICE REQUIREMENTS
A local URC shall be established as an integral part of all UCPs. Their composition,
location, objectives, functions and recordkeeping are described in the following sections, as is
the mechanism for provider appeals against URC decisions and the state audit process. URC
functions apply to all D/MC funded substance abuse programs.
A. Committee Representation and Frequency of Meetings
The URC shall consist of a multi-disciplinary team. URC members shall be appointed
by the functioning County Alcohol/Drug Program Administrator for the county in
which the program is located. The URC shall include, and its decisions shall be made
by, not less than three persons as follows:
1. One M.D. or other qualified substance abuse professional not directly
providing treatment of the program's clients;
2. One substance abuse counselor; and
3. . One other person.
At no time shall a staff person participate in the review of his/her clients' charts. To
assure that the County Alcohol/Drug Program Administrator's Office has full
knowledge of URC activity and effectiveness, those counties with D/MC contract
providers must have at least one member of the URC who is a county
representative.
The URC shall meet at least once a month to review new clients and requests for
extended treatment. -If-no case requires a review or follow-up, it should be so noted
in the signed and dated monthly URC minutes. For the months that do not indicate a
URC meeting was held, ADP will verify that no charts required review for that
period. No less than a quorum (at least a majority) of the committee shall make URC
determinations.
The full URC shall have the full authority to make decisions related to medical
necessity, appropriateness of continuing treatment, focus of care, and level and
fiupency of services. These decisions must be based on adequate documentation in
the clinical record of each client. The functions and responsibilities of the URC must
be consistent with ensuri ig timely processing of cases for consideration of timely
authori�tion, reporting activities relevant to these decisions, and documenting all
aspects of the UR process.
If the URC serves more than one substance abuse program, ADP suggests that the
Committee be comprised, where feasible, of representatives from a cross-section of
those programs served.
5
B. Committee Location
Each substance abuse program using DIMC funds shall be served by a URC. The
URC shall be located at the discretion of the County Alcohol/Drug Program
Administrator as follows:
1. At each provider location;
2. At one facility and function as URC for several providers; or
3. At one facility to serve all providers.
Accordingly, the UR Plan must specify the location and frequency of all URC
meetings. In those instances where URC is conducted off site of the provider
premises, provisions for transporting client files to and from the URC shall be
delineated to ensure compliance with record security and confidentiality regulations.
C. Recordkeeping
Minutes and records of each URC meeting shall be maintained for.four years and be
made available for inspections by ADP and DHS. Such documentation shall be
maintained in a separate file from that housing the client's clinical records. The UCP
shall indicate where minutes and records will be filed and the discipline responsible
for their maintenance.
D. Confidentiality
Each URC shall keep confidential their minutes and records, and their disclosure must
be in accordance with applicable state and federal laws. Information and data will be
maintained as required to assure confidentiality and compliance with all applicable
regulations.
E. Utilization Review Committee Documentation
Each URC shall document its activities, determinations, rtc:ommendationss, and actions
aw malas such doaurentation available upon request to the facility's administrative
staff, the County AleoholIDrug Program Administrator and his/her staff, ADP and
DHS. Such documentation, in the form of minuues and other written records and
reports, shall include, at miniauum, the following:
i. The name and location of the URC;
2. The date and duration of each Wig;
3. The name of the URC members in strendance;
6
EXHIBIT H
4. A description of the URC's activities;
5. The number of cases screened and reviewed by the URC;
6. The case number, client admission date and URC review date by case. After
each case number, a brief narrative to include the progress in treatment,
medical problems and the URC's decision regarding the necessity for
continued treatment, including the basis for each determination. For
methadone maintenance client records; narratives shall include comments
pertaining to step level and attempts to down dose;
7. Action taken for each case not approved or requiring corrective action, an
explanation as to why the disallowance or correction should occur, and
specified time lines for compliance; and
8. Notice of adverse decision resulting in disallowance of visits claimed under
D/MC sent to the responsible staff person and billing personnel or
department.
The minutes shall be signed by members or the chairperson of the URC.
Any disallowances identified by the URC must be listed in the minutes with an
explanation as to why the disallowance occurred. A copy of ADP 5035, Report of
Drug/Medi-Cal Disallowances by Provider form, shall also be included in the
minutes.
F. URC Action
The URC has the authority to request additional information or call for corrective
action while reviewing client charts. A provider shall not bill D/MC for
reimbursement without required documentation and appropriate authorization by the
URC. The expiration date of the URC approval shall be clearly noted in the client's
record. The URC must document its disallowances in accordance with the attached
ADP information letter D/MC#92-03 dated April 1, 1992 and D/MC# 94-05 dated
May 20, 1994.
G. No Fees Charged
The URC shall assure that no fees are charged by providers for D/MC services.
Proof of eligibility shall be accepted as payment in full for D/MC services, except
where co-payment requires are noted on the monthly Medi-Cal identification
card.
7
H. Discharge Review ,
Because all services billed to D/MC must be approved by the URC, the committee
must review all required areas and assure that all requirements were met at the time of
discharge. This must be documented in the URC minutes within 60 days of.the
discharge date.
I. URC Phase-In Period for New Programs
As new substance'abuse treatment providers are certified and approved by ADP to
participate in the D/MC program, it is understood that Medi-Cal beneficiaries may
already be enrolled and receiving treatment by these providers. To alleviate the
problem of new providers having to perform a substantial number of initial URC
reviews at one time. D/MC beneficiaries already receiving services from the date of
certification will be allowed to be phased in within three months. Those D/MC
clients who are admitted to treatment on or after the program's effective date of
certification shall be reviewed within the time frames specified for each reimbursable
service.
J. Client Fair Hearings
Each Medi-Cal beneficiary has the right to a fair hearing related to denial, termination
or reduction in D/MC services. Procedures outlined in Title 22, California Code of
Regulations, Sections 50951, 50953 and 51014.1; Welfare and Institutions Code,
Sections 10950 through 10965; and Department of Social Services (DSS) Manual of
Policy and Procedures, Chapter 22 will be followed by the provider, the URC and the
beneficiary.
The provider must first submit details of the intended action to the URC. The URC
shall, upon notification that a beneficiary has filed for a fair hearing, write a position
paper to the Office of the Chief Referee, DSS, summarizing the facts of the case and
setting forth the regulatory justification for the action. The provider or authorized
county representative must be present at the fair hearing to present the position paper.
As part of the fair hearing process, the provider must inform the beneficiary in
writing at least ten days before the effective date of the intended action to
terminate/reduioe services tinder D/MC. The provider's notice to the beneficiary shall
include:
1. A statement of action that the provider intends to t9m;
2. The reason for the intended action;
3. A citation of the specific regulations) supporting the intended action(s);
8
EXHIBIT H
4. An explanation of the bpneficiary's right to request a fair hearing for the
purpose of appealing the provider's decision.
5. An explanation of the procedure for the beneficiary to request a fair hearing.
The beneficiary requests a hearing by submitting a request to:
Office of the Chief Referee
Department of Social Services
744 P Street, Room 1750
Sacramento, CA 95814
Telephone: (916) 322-9700
6. An explanation of the circumstances under which the service and D/MC
payment for the service shall be continued if a hearing is requested.
The findings and decision of the DSS hearing officer shall be submitted,to the
Director, DHS, for review in accordance with Title 22; Section 50953(x). As part of
its review, DHS shall seek input from ADP. DHS retains sole authority for decision
making on Medi-Cal issues.
Drug/Medi-Cal recipients have the right to a fair hearing under both Title 22,
California Code of Regulations (CCR), and Title 9, CCR. A fair hearing under Title
22 is specific to the client's rights as a Medi-Cal beneficiary; a fair hearing under
Title 9 is specific to the client's rights as a recipient of substance services
administered by ADP.
The URC has no authority to terminate D/MC payment for services because of client
violation of Title 9 requirements. The URC may approve or disapprove D/MC
services on the basis of Title 22 requirements, in which case the client would have the
right to a fair hearing under Title 22 procedures. The program may terminate
services to a D/MC client for cause (such as client noncompliance with program rules
and instructions) pursuant to Title 9 regulations, in which case the client would have
the right to a fair hearing under Title 9 procedures.
K. Audit Process
Recommendations of the program staff, decisions of the provider's URC, and
compliance with the local program's URC plan will be periodically reviewed by both
DHS and ADP staffs. Audit exceptions with fiscal adjustments may be taken after
notification by ADP. If ADP does not make the adjustments, the provider will be
instructed to take appropriate action.
9
L. Drug/Medi-Cal Administrative Appeals
Drug/Medi-Cal providers who wish to appeal dispositions made by ADP or DHS
concerning recoupment of specific Medi-Cal claims must.follow procedures included
under Section 51015, Title 22, CCR, and in accordance with the DHS and ADP
Interagency Agreement. This section applies to D/MC claims processing.
First-level grievances and complaints will be managed as follows:
1. The provider and/or county shall initiate action by submitting their grievance
or complaint in writing to ADP identifying the claims involved and
specifically describing the disputed action or inaction' regarding such claims.
2. The appeal shall be submitted to ADP within 30 calendar days from the date
the provider and/or county receives written notification of theAecision to
disallow claims.
3. ADP shall acknowledge the written grievance or complaint within 15 calendar
days of its receipt.
4. ADP shall act on the appeal and inform the provider and/or county of ADP's
decision and the basis therefore within 15 calendar days after ADP's
acknowledgement notification.
5. ADP shall have the option of extending the decision response time if
additional information is required from the provider and/or county. The
provider and/or county will be notified if ADP extends the response time
limit.
Grievances shall be submitted in the form of a letter signed by the provider and/or
county and should specify that a grievance is being submitted in accordance with
Section 51015, Title 22, CCR.
Grievances should be on the official stationery of the provider and/or county and
signed by an appropriate representative.
All grievances should be directed to the:
Deputy Director
Office of Treatment and Recovery
Department of Alcohol and Drug Programs
1700 K Street
Sacramento, CA 95814.4037
Sewnd-level grievances and complaints will be managed as follows:
10
EXHIBIT H
A provider and/or county may refer their grievance or complaint to DHS only after
complying with first-level grievances and complaints procedures and only in the
following circumstances:
1. ADP has failed to acknowledge the grievance or complaint within 15 days of
its receipt.
2. The provider and/or county are dissatisfied with the action taken by ADP
where the conclusion is based on its own evaluation of the merits of the
grievance or complaint.
3. The second-level appeal shall be submitted to DHS within 30 calendar days
from the date ADP failed to acknowledge the first-level appeal or from the
date of the ADP first-level appeal decision.
In referring a grievance or complaint to DHS, the provider and/or county shall
include a copy of the original written grievance or complaint sent to ADP, a copy of
ADP's report of such grievance or complaint, and the specific finding(s) or
conclusion(s) of ADP with which the provider is dissatisfied.
DHS shall review the written documents submitted in the grievance or complaint; may
ask for additional information; may hold an informal meeting with the involved
parties; and shall send a written report of its conclusions and reasons to the provider
and/or county and ADP within 60 dayk of receipt of the referral. DHS shall have the
option of extending the decision response time if additional information is required
from the provider and/or-county. The provider and/or county will be notified if DHS
extends the response time limit.
All second-level appeals made in accordance with this section shall be directed to:
Chief
Field Services Branch
Department of Health Services
714 P Street, Room 1516
Sacramento, CA 95814
These appeal procedures should only be used after direct communications with the
State's D/MC program analyst assigned to the area or inquiries submitted to ADP
through normal channels have not resulted in a satisfactory resolution of the case.
M. Local Utilization Control Plans
Every substance abuse treanneot program using D/MC funding shall be subject to a
local UCP. Such a plan for the review and control of appropriate substance abuse
nounent services must be formalized and submitted to ADP.
11
Any changes to the plan.after its original submission must receive ADP's approval. If
changes are not made to the UCP, a letter indicating that fact shall be submitted to
ADP on an annual basis.
N. Physician Direction
Drug/Medi-Cal covered services (outpatient methadone maintenance, outpatient drug
free, day care habilitative, perinatal residential, and naltrexone treatment) rendered to
DIMC clients must be provided by or under the direction of a physician. Physician
direction shall include physician formulation of, approval of, or involvement in each
D/MC client's plan of care within specified time limits.
O. Treatment Plans for All Services
Each client shall have an individualized written treatment plan which is based upon
the information obtained in the intake and assessment processes. The treatment plan
shall be developed within 30 days from the client's date of admission. There shall be
periodic review and update of the treatment plan every 90 days.
Treatment plans are to be reviewed,.signed and dated by the program physician within
15 days of the date the plan was developed. A licensed psychologist may review and
sign the treatment plans for clients with no medications prescribed. The treatment
plan shall include the following:
1. Statement of problems to be addressed in treatment;
2. Time-limited goals to be reached which address the problem;
3. Action steps which will be taken by program and/or client to accomplish
gam;
4. Target dazes for accomplishment of action steps and goals, and when
possible, dates of resolution;
S. A description of the type of counseling services to be provided and the
frequency thereof; and
6. The assignment of a primary counselor.
P. Treatment Termination
There are two caegories of dam who Wm mte their treanneot. The fust is
comprised of those
who ooampleoe the intaloe process but iail to remora to the program
for nuanent. The second category involves the client whose termination occurs after
nuatment has begun.
EXHIBIT H
There are four instances in which termination might occur after treatment has begun:
1. Transfer to another program;
2. Completed treatment;
3. Voluntary dropout; or
4. Suspension.
Discharge summaries should be written immediately upon determining a client's status
in relationship to the above four instances.
Q. Client Record Requirements and Availability for Inspection
The URC shall assure that adequate client records are being kept and that the records
are available for inspection upon demand. Title 22 and ADP program standards
require that adequate client records be maintained on each D/MC client for at least
seven years. All such records shall be kept confidential in accordance with applicable
state and federal regulations. Specific requirements for client records mandated by
federal rules and regulations for all substance abuse treatment programs funded
entirely or in part from a federal source are available from ADP upon request.
R. Client Attendance Requirements
The URC shall determine that each substance abuse program has established client
attendance requirements appropriate both to the individual client and the particular
service being rendered. Such attendance shall be noted in the client's record
whenever the client receives service.
S. Retroactive URC Reviews
Retroactive review by the URC may occur when:
1. Certification of the Medi-Cal beneficiaries eligibility by the County welfare
Department is delayed; i.e., when a beneficiary receives retroactive coverage.
2. "Other coverage" (e.g., Medicate or other health insurance programs) denied
payment of a claim for services.
3. Clients-do not identify themselves to a provider as a Medi-Cal beneficiary by
deliberate concealment or because of physical or mental incapacity to so
identify themselves. .
4. Emergency or "crisis" visits fall outside the approved visits (see Section
N.L.)
13
Retroactive authorization shall be documented in the URC minutes identifying one of
the four statements noted above.
Any fees collected from the client shall be refunded to the client if D/MC is
retroactively billed. Retroactive billing to D/MC may occur within one year after the
month in which service was rendered.
T. Naltrexone (Trexan)
Substance abuse treatment programs that bill for either methadone maintenance, drug
free, day care habilitative, or residential services may be reimbursed for treating
narcotic-free Medi-Cal beneficiaries with naltrexone through the D/MC system on a
per-visit basis. Physician documentation of the medical necessity for naltrexone
treatment is required.
U. . Services for Pregnant and Parenting Women
In addition to the basic requirements delineated in each treatment service area,
programs focused on pregnant and parenting women shall include the following:
1. program staff who are sensitive to and reflective of the target population,
gender, and cultural diversity;
2. on-site child care for clients' children who are between birth and 36 months
of age and provisions and/or arrangements for child care for children 37
months to 12 years of age;
3. provide or arrange for transportation to and from treatment, primary medical
care, and ancillary services for women who do not have their own
transportation;
4. education on the impact of substance abuse during pregnancy and breast
feeding;
S. parenting dells, training, and education on child development;
6. coordination and accommodation for obstetrical, gynecological, pediatric,
social service and other community services;
7. access to edttcationaltvocational training;
8. education on IUV/AIDS transmission and access to HIV tm*g;
9. provide or arrange for tubereWasis services;
10. provide or arrange for primary medical care and prenatal cart;
14
EXHIBIT H
11. collect and submit client and service data at required intervals to ADP.
Perinatal D/MC providers must meet all requirements delineated in the Perinatal
Services Guidelines; however, D/MC will reimburse only those allowable cost
identified in Section I.C. above.
V. Follow-up Requirements
All substance abuse programs are required to develop a follow-up procedure. The
URC shall assure that an adequate follow-up procedure has,been established for the
clients of a particular program. Whenever clients discontinue treatment for any
reason, a follow-up procedure should go into effect.
III. OUTPATIENT MMUDONE MAUgTENANCE SERVICES
Outpatient methadone maintenance programs serve addicts meeting certain eligibility criteria
by giving daily dosages of methadone which relieves the "drug craving". In the State of
California, methadone maintenance is the treatment classification for all clients who receive
methadone for more than 21 consecutive days. California Code of Regulations, Title 9
requirements apply to all methadone programs licensed and certified to provide D/MC
services.
A. Objectives of Outpatient Methadone Maintenance Services
The objectives of outpatient methadone maintenance services are to:
1. Eliminate all dependency on drugs as rapidly as is practical; and
2. Aid clients in altering their lifestyles.
B. Staff
Staff selection is a critical arra and must consider each of three individual staff units,
administrative, medical, and counseling. The principal considerations in designing a
staffing pattern are:
1. Number of clients to be served in the program;
2. Total number of direct, in-house servicrs offered;
3. Number of staff responsible for each of these semces; and
4. Number of individuals directly reporting to the administrator.
15
Usually, the medical and counseling units constitute the two major components, with a
recommended counselor/client iatio of 1-30 where possible, although differences may
occur depending on the number of stable clients.
C. Required Services
Current federal methadone regulations require counseling, vocational and educational
counseling, legal services, and adjunctive medical services. Since both medical and
psychosocial factors are considered elements of addiction, medical and counseling
efforts are viewed as equal components of methadone maintenance. State Standards
for Drug Treatment Programs require that all clients shall receive two counseling
sessions per 30-day period or be subject to discharge.
Exceptions to the frequency of services may be made for individual clients where it is
determined by the program staff that fewer contacts are clinically appropriate and that
progress toward treatment goals is being maintained. .Such exceptions shall be noted
in the treatment plan that shall be reviewed, signed and dated by the program
physician.
D. Admission Criteria
The following minimum criteria are required in the selection of each maintenance
client and shall be documented in the client's chart or medical record:
1. Confirmed documented history of at least two years of addiction. The
methods to be used to make confirmations shall be stated. Documents
maintained in clients' charts should include records of arrests, treatment
failures, and any other pertinent data or records. Statements of personal
friends or family shall not be sufficient alone to establish a history of
addiction,
2. Confirmed history of two or more failures of withdrawal treatment with
subsequent relapse to regular narcotic use. The methods used to make
confirmations and types of records to be maintained in clients' charts shall be
indicated;
3. A minimum age of IS years;
4. Certification of fitness for methadone treatment by a physician based upon
physical eaatnination, medical history and indicated laboratory findings.
Plana for correction of existing medical problems should be indicated; and
S. Evidence of cutimt narcodc dependence. Such evidence shall include the
early signs of withdrawal. The results of an initial urinalysis shall be used to
aid in determining current use and shall be noted in the client's record.
16
EXHIBIT H
E. Pregnant Clients: Additional Requirements
A program shall not admit as a client any person who is pregnant, nor shall any
program continue to treat any client who becomes pregnant, unless and until the
program physician first determines and records in the client's record that:
1. The client is medically able to participate in the program; and
2. The client shall be in the care of a qualified physician (trained in obstetrics
and/or gynecology) for her pregnancy, and the physician is informed of the
client's participation in the program.
F. Exceptions to Minimum Admission Criteria
1. Pregnant women may be admitted without a documented two-year history of
addiction or two withdrawal failures. Clients admitted pursuant to this
subsection shall be reevaluated by the program physician not later than 60
days following termination of the pregnancy in'order to determine whether
continued methadone maintenance is appropriate.
2. With prior department approval, if the program physician determines that
withholding treatment constitutes a life- or health-endangering situation and
the program physician documents this with appropriate entries in the client's
chart, the client may be admitted to treatment (Title 9, Section 10270(b)(1).
G. Temporary Exceptions
Section 10425, Title 9, California Code of Regulations, provides for ADP to grant
temporary exceptions for methadone treatment providers, if such action would
improve treatment services or afford greater protection to the health, welfare, and
safety of clients, the community, or the general public.
H. Initial Treatment Plans
Treatment plans shall be developed within four weeks of a client's admission to
treatment and documented over a program physician's dated signature within 15 days
from the date the plan was developed.
I. Stay Review and Supporting Doaaaentation
mmem shall be discondaved within two eontianous years after such
treatment is begun unless, based upon the clinical judgment of the program physician
and staff which shall be recorded in the client's clinical seem by the program
physician, the client's status indicates that such treatment should be continued for a
17
longer period of time because discontinuance from treatment would lead to a return to
opiate dependency.
A client's status relative to continued maintenance treatment shall be reevaluated at
least annually after two continuous years of maintenance treatment and documented in
the client's record by a program physician or maintenance treatment shall be
terminated.
J.. Initial Utilization Review and Utilization Review for Extended Treatment
Within 45 days from admission, the URC shall review the initial treatment plan and
all admission criteria required by Title 9, data collection and reporting requirements
and county requirements for assessing ability to pay. Clients identified as Medi-Cal
beneficiaries shall not pay fees, except where co-payment requirements are noted on
the monthly Medi-Cal identification card.
Within the first year of treatment and annually thereafter, a review of the client's
progress and a review of all Title 9 requirements shall be conducted. This shall
include step-level justifications, continued treatment justifications, admission exception
requests, take-home exceptions and client birth reports.
If the URC finds that the program is out of compliance with any Title 9 regulation
(such as program response to dirty urines, dosage change without physician orders,
etc.), corrective action shall be required before approving billing to D/MC. The
resume or clinical chart submitted to the URC for review and approval must include
adequate documentation as follows:
1. Principal diagnosis and significant associated diagnoses;
2. Evidence that all the minimum criteria for admission,have been met;
3. Description of the client's progress; and
4. Trearment plan for the client which should include the medication schedule.
If after two years of treatment the program staff is of the opinion that further
treatment will be required for a client, an additional year of treatment may be
approved by the URC. The justification must include:
1. Client's progress in treatment during the past year;
'2. Consequences of disoozmnuing treatment;
3. What can be expected to be achieved dmigg the next year of treatment;
4. Whether any detox efforts have been attempted or planned;
18
EXHIBIT H
5. Target date for client to be off methadone; and
6. Medical and/or psychological reason to continue treatment.
K. Naltrexone
Individuals for whom naltrexone treatment is considered the treatment of choice,
following a completed course of outpatient methadone maintenance treatment, the
client's record must have an annual UR, annual physician justification for continued
treatment, an initial naltrexone treatment plan within 30 days of admission to
naltrexone treatment, and 90-day treatment updates approved by the program
physician. These components must be documented consistent with utilization control
requirements outlined in this section pertaining to active maintenance treatment.
IV. OUTPATIENT DRUG-FREE SERVICES
Outpatient drug-free services provide a therapeutic setting where clients are seen by
appointment. While group counseling is available, the focus is on individualized counseling
where short-term personal, family, job/school, and other problems can be discussed in
relation to substance abuse or a return to substance abuse. For deeper, more complicated
problems, outpatient counseling serves as a referral resource and advocate. With the
counselor's assistance, the client is encouraged to take advantage of public and mental health
services, legal aid, vocation counseling, and any other community resources which pertain to
the client's particular problem.
A. Objectives of Outpatient Drug-Free Services
The objectives of outpatient drug-free services are to:
1. Provide clients with therapeutic setting for analysis of substance abuse
problems; and
2. Redirect a client's life through couaseliug and related services.
B. Staff
Each program shall be staffed to ensure adequate delivery of required and provided
services as approved in the program protocol. Typical staffing consists of an
administrator, medical director, supervising counselor, counselors and a
Iary/clerk typist In selecting staff, the program should strive for a mix that will
reflect client needs.
19
1
1 1
C. Required Services
Each program provides consultation with the medical director for those clients
receiving prescription medication through the program or from a private physician.
This consultation will be provided, at a minimum, once every four weeks or more
frequently depending upon the needs of the client.
Each client should be seen weekly or more often, depending on his/her needs and
treatment plan. At minimum, all clients shall receive two,counseling sessions per
30-day period or be subject to discharge.
A complete medical and substance abuse history shall be taken. The program shall
take reasonable steps to protect the clients from spread of infectious disease(s). An
assessment of the physical condition of the client shall be made within 30 days from
admission and documented in the client record in one of the following ways:
1. A physical examination by a physician, registered nurse practitioner or
physician's assistant according to procedures prescribed by state law; or
2. Upon the review of the medical.history and other appropriate material, a
determination must be made by a licensed physician of the need for physical
and laboratory examinations. A waiver shall be completed by a licensed
physician if it is determined that a physical examination and laboratory
examination is not necessary.
D. Physician Direction
Physician direction shall include physician formulation of, approvalof, or
involvement in each D/MC client's plan of care within 30 calendar days from the date
of initial service. Evidence of the physician's direction must be documented by the
physician's signed and dated approval of the treatment plan or signed and dated
notation indicating concurrence with the plan of treatment in the client's clinical
record. This must reoccur:
1. Whenever there is a significant change on the uu=ent plan (i.e., change in
mode or modality) of service, problem identification, or focus of treatment);
or
2. At least once within every 90 days (prior to the start of a new 9D day
period), whichever comes first.
E. Urine Surveillance
For those situations where substance abuse screwing by urinalysis is domed
appropriate and necessary by the program director or supervising Pbysician+ the .
program shall:
20
EXHIBIT H
1. • -Establish procedures which protect against the falsification and/or
contamination of any urine sample; and
2. Document urinalysis results in the client's file.
F. Admission Criteria
Each substance abuse program must develop criteria for the admission of clients and
the termination of services to them. The primary substance of abuse shall be clearly
recorded in each client's record. Procedures must be established under which a
complete personal, medical and drug history for each client will be secured upon the
client's entry into the program and shall be maintained and kept up to date throughout
the client's treatment.
It is important to conduct this intake process as rapidly as possible so that clients are
not discouraged from pursuing treatment. The purpose of making a medical and drug
history is to immediately identify the client experiencing flashbacks, psychotic
manifestations, and severe physical illness requiring immediate psychiatric or medical
care. Only when this information is collected and reviewed can the program be
reasonably assured of preparing the best possible treatment plan for the client. It is in
this context that a complete personal, medical, and substance abuse history is essential
for all treatment modalities.
G. Initial Utilization Review
Initial treatment shall be determined by the client and program staff within the county
D/MC client care policy. Within this treatment plan, the client may receive 15
outpatient units of service in any 90-day period without prior approval by the URC.
H. Utilization Review for Extended Treatment
After the initial 90-day period and every 90 days thereafter, the treatment plan and
additional visits shall be approved by the URC. The approvals shall be required
whenever the 15 units of service have been received or a 90-day period of time has
elapsed, whichever domes first.
I. Stay Review and Supporting Doc unwntation
After the first year of treatment, a review of the client's progress shall be conducted.
If after one year of tree nM the program staff is of the opinion that further
neaunm will be required, the program physician must evaluate and determine if it is
medically necessary that the client continue bawneaL The justification to continue
treatment must include:
21
1. Clients progress in treatment during the past.year;
2. Medical/psychological reasons to continue treatment;
3. Consequences of discontinuing treatment;
4. Target date for client to complete treatment; and
.5. What can be expected to be achieved during the continued time in treatment.
J. Physician Approval
The program physician must sign and date all treatment plans within 15 days from the
date the plan was developed.
K. Medication Visits
Medication visits are services of 30 minutes or less provided by staff licensed to
prescribe, administer, or dispense medications. These visits shall include evaluation
of side effects and/or results of medication. They also must be appropriately
documented. Medication visits are exempt from utilization controls in terms of the
15-visit count in any 90-day period. Medication visits shall be reviewed on a regular .
basis as part of the UR. This also applies in instances where the client provides a
urine sample, under surveillance of clinic staff, absent of any other service during the
visit.
L. Documentation
The resum6 or clinical chart submitted to the URC must include adequate clinical
documentation as.follows:
1. The principal diagnosis and significant associated diagnoses;
2. Adequate clinical description of the present symptomatology and behavior
which would justify the diagnosis and additional visits; .
3. Prognosis and estimated frequency and duration of treatment; and
4. Drug regimen. This should include specific medications with dosages
indicated. If none is used, that should be stated.
22
s
EXHIBIT H
M. Emergency Visits
Emergency or "crisis" services shall be considered as one or more of the initial 15 or
the ongoing approved additional visits. Should these services be provided but fall
outside the initial 15, retroactive approval may be granted by the URC.
N. Naltrexone
Individuals provided naltrexone treatment services by an outpatient drug free provider
are subject to the same requirements, i.e., treatment plans, 90-day updates, physician
reviews, etc., which apply to all other D/MC outpatient drug free clients.
O. Follow-up Requirements
Weekly telephone calls for several weeks after discontinuation of treatment and
periodic requests for a counseling contact at the program or in the client's home
reinforce the counselor's commitment to the client's rehabilitation and let the client
know that the program is always available to him/her. Again, programs with the staff
resources should follow up clients for evaluation purposes as well so that progress can
be made based on long-term successes and failures.
V. DAY CARE HABU ITAI"M SERVICES
Day care habilitative programs provide counseling and rehabilitation services to Medi-Cal
beneficiaries with substance abuse impairments. Clients shall participate in programs three or
more hours, but less than 24 hours, throughout the day at least three days a week. Clients
may live independently, semi-independently or in a supervised residential facility which does
not provide this service.
Day care differs from outpatient care in that clients participate according to a minimum
attendance schedule and have regularly assigned, supervised work functions. The
effectiveness of counseling can be tested on a daily basis, and reconciliation and improved
client/family relationships can be emphasized.
A. Objectives of Day Care Habilitative Services
The objectives of day can habilitative services are to:
1. Restore or maintain personal independence in cheats with substance abuse
2. Provide a viable alternative to 24-hour residential care; and
23
3. Provide needed services to clients requiring more than weekly individual or
group counseling provided at outpatient drug free programs.
B. Staff
Staffing selections for day care programs are critical. Staffing will vary depending on
the anticipated program size, treatment philosophy, and the availability of ancillary
community resources. Principal considerations for designing staffing patterns include:
1. The number of direct services that will be offered at the program;
2. The number of staff responsible for each service (the need to provide
ten-hour coverage six days per week should be considered);
3. The number of clients planned to be served in the program; and
4. The number of individuals reporting directly to the program administrator.
C. Required Services
A complete medical and substance abuse history shall be recorded for each client
admitted to treatment. The program shall'take reasonable steps to protect the clients
from spread of infectious disease(s). An assessment of the physical conditions of the
client shall be made within 30 days from admission and documented in the client
record in one of the following ways:
1. A physical examination by a physician, registered nurse practitioner or
physician's assistant according to procedures prescribed by state law; or
2. Upon the review of the medical history and other appropriate material, a
determination must be made by a licensed physician of the need for physical
and laboratory examinations. A waiver shall be completed by a licensed
physician if it is determined that a physical examination and laboratory
examination are not necessary.
Day care habilitative services qualifying for D/MC reimbursement must include, but
are not limited to: intake, assessment, diagnosis, evaluation, individual and group
counseling, and other appropriate activities and services. A minimum of nine hours
per week of scheduled, formalized services (e.g., a work program, treatment
techniques, urine surveillance, creative recreational activities, and ancillary services)
shall be available for each client.
All DCH services provided to the client must occur within the regularly scheduled
array of activities. As such, only one trait of service may be claimed per day.
Exceptions may include emergency and crisis visits aid must be documented as such
in the client record.
24
EXHIBIT H
D. Physician Direction
Physician direction shall include physician formulation of, approval of, or
involvement in each D/MC client's plan of care within 30 calendar days from the date
of initial service. Evidence of the physician's direction must be documented by the
physician's signed and dated approval of the treatment plan or signed and dated
notation indicating concurrence with the plan in the client's clinical record. This must
occur:
1. Within 15 days of the date the plan was developed;
2. Whenever there is a significant change on the treatment plan (i.e., change in
mode or modality) of service, problem identification, or focus of treatment);
or
3. At least once within every 90-day period (prior to the start of a new 90-day
period), whichever comes first.
When a medication regimen is a part of the treatment plan, such plan must also be
approved by the physician.
E. Urine Surveillance
For those situations where substance abuse screening by urinalysis is deemed
appropriate and necessary by the program director or supervising physician, the
program shall:
1. Establish procedures which protect against the falsification and/or
contamination of any urine sample; and
2. Document urinalysis results in the client's file.
F. Admission Criteria
Each substance abuse program must develop criteria for the admission of clients and
the termination of services to them. The primary substance of abuse shall be clearly
recorded in each client's record. Procedures must be established under which a
complete personal, medical and substance abuse history for each client will be secured
upon the client's entry into the program and shall be maintained and kept up to date
throughout the dicer's treatment.
25
G. Initial Utilization Review
Initial treatment shall be determined by the client and program staff within the county
DIMC client care policy. Within 45 days from admission, the URC shall review the
initial treatment plan and all admission criteria.
Local programs may set shorter review requirements within their own systems at their
own discretion.
H. Utilization Review for Extended Treatment
The URC may approve additional visits provided that, prior to each 90-day period, a
treatment plan and progress notes addressing clinical needs has been presented to the
URC for review.
If treatment is required beyond the initial 30 days sof treatment, the URC may
authorize extended treatment in increments not to exceed 90 calendar days. Treatment
plans are due every 90 days. The program physician must sign and date all treatment
plans within 15 days after the date of completion.
I. Stay Review and Supporting Documentation
After the first six months of treatment, a review of the client's progress shall be
conducted. If after six months of treatment, the program staff is of the opinion that
further treatment will be required, the program physician must evaluate and determine
if it is medically necessary that the client continue treatment. The justification to
continue treatment must include:
1. Clients progress in treatment during the past year;
2. Medicallpsychological reasons to continue treatment;
3. Consequences of discontinuing treatment;
4. Target date for client to complete treatment; and
5. What can be expected to be achieved during the continued time in treatment.
J. Documentation
The r&=d or clinical chart submitted to the URC must include adequate clinical
docatmeatadon as follows:
1. The principal diagnosis and significant associated diagnoses;
26
- EXHIBIT H
2. Adequate clinical description of the present symptomatology and behavior
which would justify the diagnosis and additional visits;
3. Prognosis and estimated frequency and duration of treatment; and
4. Drug regimen. This should include specific medications with dosages
indicated. If none is used, that should be stated.
K. Progress Notes
Weekly individual narrative summary notes shall be recorded for each client'.
Progress on individual treatment plan problems, goals, objectives and ancillary
services shall be included, and client attendance shall be noted.
The beginning and ending time of each client's participation shall be clearly recorded.
Daily client sign-in sheets shall be maintained to track the schedule of services
delivered to each client.
L. Naltrexone
Individuals provided naltrexone treatment services by a day care provider are subject
to the same requirements which apply to all other D/MC outpatient services.
M. Follow-up Requirements
All day care habilitative services are required to develop a follow-up procedure. The
URC should assure itself that an adequate follow-up procedure has been established
for the clients of a particular program. Whenever clients discontinue treatment for
any reason, a follow-up procedure should go into effect.
VI. PERINATAL RESIDENTIAL SUBSTANCE ABUSE SERVICES
Perinatal rehabilitation services are provided in a non-institutional residential setting where
individuals are supported in their efforts to restore, maintain and apply interpersonal and
independent living skills. and access community support systems. Programs shall provide a
range of activities and services.for individuals who would be at risk of hospitalization or
other institutional placement if they were not in the residential treatment program. This is a
structured program with services available day and night, seven days a week.
27
A. Objectives of Perinatal Residential Substance Abuse Services
1. Provide a 24-hour structured environment for treatment of substance abuse
impairment;
2. Restore, maintain and support long-term functional competency, personal
independence and alcohol/drug-free lifestyle; and
3. Provide needed services to clients requiring more than day care habilitative
treatment to achieve a sober and drug-free status.
B. Limitations
Services are limited to women who are:
1. Pregnant substance using; or
2. Parenting, with an identified impairment in her ability to care for a child,
ages birth through 17, due to substance use.
Parenting includes:
• A woman with a dependent child ages birth - 17 years.
• A woman who is attempting to regain legal custody of a child.
• A woman who voluntarily left a child with a caretaker and is attempting to
reasstune parenting responsibilities.
Services must be provided in a residential facility with a licensed treatment bed
capacity of 16 or less beds. Beds occupied by children do not have to be counted
towards the 16-bed limit.
Residential facility is defined as an institution that furnishes (in single or multiple
facilities) food, shelter and treatment services for four or more persons unrelated to
the proprietor. Further, the residential program must be operated as a single,
5astanding institution.
C. Staff
Staffing selections for residential programs are'critical. Staffing will vary depending
on the anticipated program sine, treannew philosopby, and availability of ancillary
U n n m<miq resolucxa. Principal considerations for designing staffing patterns include:
1. The number and level of direct services offered at the program;
28
EXHIBIT H
2. The number and qualifications of staff responsible for each service;
3. The number, cultural background, and needs of clients served in the
program;
4. The number of staff reporting directly to the program administrator;
5.. Sufficient staffing to provide 24-hour supervision of clients seven days per
week.
D. Required Services
Residential programs qualifying for D/MC reimbursement must include the following
services at minimum: intake, assessment, diagnosis, evaluation, individual and group
counseling. Each client shall participate in scheduled, therapeutic activities. In
addition to counseling, these activities should include, but are not limited to:
educational sessions, HN counseling, self-help and peer support groups, a work
program, urine surveillance, and ancillary services.
Complete medical, psychosocial and substance abuse histories shall be taken. The
client's physical condition shall be assessed within 30 days from admission and
documented in the client record in one of the following ways:
1. A physical examination by a physician, registered nurse practitioner or
physician's assistant according to procedures prescribed by state law; or
2. Upon review of the medical history and other appropriate material, a licensed
physician will determine the need for physical and laboratory examinations.
A waiver shall be completed by a licensed physician if a physical examination
and laboratory tests are determined not to be necessary.
The program shall take reasonable steps to protect clients, their children, and
staff on the premises from the spread of infectious disease(s).
Each program shall provide consultation with the medical director for clients
receiving prescription medication through the program or from a private
physician. This consultation will be provided, at a minimum, once every
four weeks or more firequently depending upon the needs of the client.
E. Program Protocol
The program protocol shall identify the days and hours of scheduled services, types of
services provided, staffing pattern for 24-hour coverage, description of residence
accommodations including capacity and floor plan, procedures for meal preparation,
house ndes, and other services provided onsite or by referral.
29
Copies of the protocol must be maintained at the program and be made available on
request to ADP or DHS staff.
F. Physician Direction
Physician direction shall include physician formulation of, approval of, or
involvement in each D/MC client's plan of care within 30 calendar days from the date
of initial service. Evidence of the physician's direction must be documented by the
physician's signed and dated approval of the treatment plan or signed and dated
notation showing concurrence with the plan in the client's clinical record. This must
occur:
1. Within 15 days of the date the plan was developed;
2. Whenever there is a significant change of service, problem identification, or
treatment focus in the treatment plan (i.e., change in mode or modality); or
3. At least once within every 90-day period (before the start of a new 90-day
period);whichever comes first.
When a drug regimen is a part of the treatment plan, such plan must also be approved
by the physician.
G. Urine Surveillance
For those situations where alcohol and drug screening by urinalysis is deemed
appropriate and necessary by the program director or supervising physician, the
program shall:
1. Establish procedures which protect against the falsification and/or
contamination of any urine sample; and
2. Document urinalysis results in the client's file.
H. Admission Criteria
Each residential substance abuse program must develop criteria for the admission of
clients and termination of services to clients. Such admission criteria apply only to
cheats with a diagnosis of alcohol and/or drug abuse. Procedures must be established
for securing complete medical, psychosocial and substance abuse histories for each
client upon entry into the program and for maintaining and updating these histories
timmo act the client's tteumem
This Moe process should be conducted as rapidly as possible so that clients are not
disooutaged from pursuing treatincut. The purpose of taking these histories is to
30
EXHIBIT H
immediately identify the client experiencing flashbacks, psychotic manifestations and
severe physical illness requiring immediate psychiatric or medical care or crisis
intervention. Only when this information is collected and reviewed can the program
be reasonably assured of preparing the best possible treatment plan for the client and
her family.
I. Initial Utilization Review
The initial treatment plan shall be determined by the client and program staff
according to the county D/MC client care policy. The URC must conduct an initial
review and approval of the treatment plan and other admission criteria within 30 days
of the date services were first provided and every 90 days thereafter.
J. Utilization Review for Extended Treatment
The URC may, after review and approval, authorize extension of residential services
in increments not to exceed 90 days. The program physician must sign and date all
treatment plan updates within 15 days after the date the plans are developed.
K. Stay Review and Documentation
Residential services shall be discontinued within six months after such treatment is
begun unless, based on the clinical judgment of the program physician and staff, the
client's status indicates that such treatment should be continued for a longer period of
time because discontinuance from treatment would lead to a return to substance abuse.
Justification for extended treatment shall be recorded in the client's clinical record by
the program physician. The justification to continue treatment must include:
1. Clients progress in treatment during the past year;
2. Medical/psychological reasons to continue treatment;
3. Consequences of discontinuing treatment;
4. Target date for client to complete treatment; and
5. What can be expected to be achieved during the continued time in treatment.
L. Documentation
The resume or clinical chart submitted to the URC murst include adequate clinical
dowmamtation as follows:
1. Chemical dependency diagnosis and significant associated diagnoses;
31
2. Adequate clinical description of the present symptomatology and behavior
that would justify the diagnosis and residential treatment;
3. Prognosis and estimated duration of treatment; and
4. Drug regimen which states specific medications with dosages (if applicable).
If no drugs are prescribed, that should be stated.
M. Progress Notes
Weekly individual narrative summary notes shall be recorded for each client.
Progress on individual treatment plan problems, goals and objectives shall be
included, and client attendance at scheduled activities shall be noted.
N. Follow-up Requirements
All residential substance abuse providers are required to develop a follow-up
procedure. The URC should assure that an adequate follow-up procedure has been
established for all clients. Whenever clients discontinue treatment for any reason, a
follow-up procedure should go into effect.
i
32
STATE OF-GUFORNtA—MEAtfl1 AND WELFARE AGENCY PETE VAMON. Gewmw
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
1700 K STREET EXHIBIT H
SACRAMENTO, CA 93614.6077
)4
'(?i% Y2R3873' ,
April 1, 1992
TO: COUNTY ALCOHOL AND DRUG PROGRAM ADMINISTRATORS
SUBJECT: REPORTING DRUG/MEDI-CAL DISALLOWANCES' D/MC 092-03
Enclosed are revised Drug/Medi-Cal (D/MC) Disallowance by Provider forms
(ADP 5035)-. These forms were revised in response to a 1991 audit of the
D/MC program by the Office of the Auditor General. That review revealed
that providers and/or counties were not reporting or completely adjusting
disallowances as. required. This letter, therefore, replaces DDP 088-51
dated December 21. 1988.
As you can see, the new forms are printed on three-part NCR paper. In
addition to continuing to submit these reports on a monthly basis. the
Utilization Review Committee (URC) shall submit the white original to the
county for processing with monthly D/MC Eligibility Worksheets (ADP 1584) .
The pink copy shall be submitted to the Department of Alcohol and Drug
Programs (ADP) , Drug/Medi-Cal Section at the time the form is completed,
and the, yellow copy shall be retained and filed with the URC minutes. The
ADP staff will be monitoring providers during regular on-site reviews for
compliance with these instructions.
.This change takes effect immediately. If you have questions about this
process or need additional forms, please feel free to call Rowena Jeffery
at (916) 323-2055. Thank you for working with us to ensure D/MC
reimbursements are appropriately managed.
RICHA�tD PEZ
Deputy Director
Office for Treatment and Recovery
Enclosure
cc:' D/MC Providers
County Fiscal Staff
33
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COMPLE77ON INSTRUCTIONS FOR DISALLOIT ANCES BY PROVIDER ADP 5035 B
GENERAL '
The ADP Disallowance by Provider form is used by a Drug/Medi--Cal Provider to report disallowable units of_service identified by the
County/Provider Utilization Review Committee(URC)
Report only one 6;cal year(FY)en a page
Report disallowances for only one provider and one service function code per page
Submit only one month per line `
HEADING INSTRV.0 Los
j a. URC MINUTES DATED—enter tie data of the monthly URC meeting when the disallowances were identified.
b.!FISCAL YEAR—enter the FY that disallowances are for • -
! c. COUNTY—enter the county name in which the provider is located
I d. PROVIDER NAME—enter the name of the program submitting the disallowances
i e. PROVIDER NUMBER—enter the four—digit provider number assigned to the program by the Department of Alcohol and Drug
Programs(ADP)
f. SERVICE FUrlCTION CODE (SFC)—enter the two—digit SFC for.2D—Methadone Maintenance:30—Day Care Habilitative:
50—Naltrexone:or 80—Outpatient Drug Free _
g. PROGRAM CODE—enter one of the following two—digit codes to indicate the program coos: _
10—Alcohol Services 20—Drug Services 25—Perinatal Services
h. PAGE—enter mis page number and the total number of pages being submitted per provider. FYI and smrvice function code
COLUMN INSTRUCTIONS
a. CLIENT NAME--enter the then:name:last name.first initial
b. CHART NUMBER—enter the client chart number
c. REFERENCE CLAIM I.D.NUMBER—enter the number preceded by a'D'•located in the upper right comer of the Drug/Medi—Cal
Eligibility Worafteet ADP 1584 aid the line number where the claim appears. For tape submissions use the number on the first
column of the fa-.simile ADP 1584 that is preceded by an'A'(the last two digits'are the line number)
d. DISALLOWA14CE DATES—entor the beginning and ending dates of the disallowance
e: DISALLOWANCE REASON—enter the reason for the disallowance using the codes from the lower front of this form
I. CLAIM FOR•1610/YR—enter the four—digit code that indicates the month/year(mo/yr)from the header of the ADP 1592 in which
the servic es•were billed
g. UNITS OF SERVICE(U/S)—enter the number of units(visits)to be disallowed for each month of service..
DOLLARS DISALLOWED _
a. TOTAL—enter the dollar amount.including cents•to be disallowed for each fine.
PAGE TOTALS
a..Tabulate.the total for the UIS column and enter the total at the bottom of the column
s b. Tabulate'ths total for dollars,including cents.disallowed and enter at the bottom of the page _
GRAND TOTALS
If more than one page per provider and FY,enter grand totals at the bottom of the last page.
o Enter URC ChairpersorJURC inembers signature and date •:
C: -
= PROGRAM SUBMISSION INSTRUCTIONS
Upon identifying a disallowable unit(&).the URC Shat complete this form.forward the white original and the blue county copy
to the county Ascal office.pink copy to ADP.and attach yellow copy to the signed.dated minutes
COUNTY SUBMISSION INSTRUCTIONS_.
e The county fiscal office shall process the ADP 5035 8 by deducting the grand total amount from the held monthly
dabn tD be submitted to ADP and attach the original and two copies of the ADP 5035 B to the nronthiy claim'
C N the disallowance is for a prior yew,the county shah(onward the original and two copies of the ADP SMS f3 t0 ADP.
;.� SIL TO: ; Department of Alcohol and Drug Programs
_
Drug/Med—CSI Section
r 1700 K Street
Sacramento,CA 95614-4037dd—
' _• _
'REVISED 04
L./ ,
EXHIBIT H
STATE OF CALIFORNIA-4MALTM AND V*WARE AGENCY PM WILSON. c-„e„mm"
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
1700 K STREET
SACRAWWO, CA 9M 14-40V
M (916) 445.1942
(916) 327-7226
December 30, 1993
D/MC #93-10
TO: COUNTY ALCOHOL AND DRUG PROGRAM ADMINISTRATORS
SUBJECT: METHADONE MAINTENANCE SERVICES FOR MEDI-CAL RECIPIENTS
On December 1, 1993, the United States District Court issued
an order for preliminary injunctive relief in the case of Sobkv
v. Gould. The order requires the Department of Alcohol and Drug
Programs (ADP) to ensure that Drug/Medi-Cal (D/MC) methadone
maintenance services, provided either directly by the county or
through contracts with private methadone programs, are provided "
to Medi-Cal recipients without regard to the recipients' county
of residence. Any policy or contract provision to the contrary
is invalid and must be immediately eliminated.
Methadone treatment programs which have D/MC funding and
space available cannot deny access to treatment to noncounty
residents who are Medi-Cal recipients. This policy was
previously communicated by ADP to all county administrators in
May 1990 through D/MC 190-04 policy letter.
The Department will be closely monitoring all methadone
treatment providers certified to participate in the D/MC program
to assure compliance with this directive. Information will be
submitted to the court on a quarterly basis reporting progress on
this issue and any violations to the order.
Questions on this policy may be directed to Venus Little at
(916) 323-2057. Thank you for immediately implementing the
mandates of the federal court.
PAUL. D. WYATT, Ed.D.
Deputy Director
Office of Treatment and Recovery
cc: Methadone Treatment Programs
36
EXHIBIT H
STATE OF CALIMMMA--HEALTH AND WELFARE AGENCY PETE WILSON, Gow mom
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS -
17W K STREET
SACRAMENTO, CA 93814.4037
TTY (916) 443-1942
(916)323-2QS7
May 20, 1994
D/MC #94-04
TO : COUNTY ALCOHOL AND DRUG PROGRAM ADMINISTRATORS
DRUG/MEDI-CAL PROVIDERS
SUBJECT: Reporting Drug/Medi-Cal Disallowances
Drug/Medi-Cal (D/MC) letter #92-03 outlined D/MC disallowance reporting
procedures which were established in response to an audit of the D/MC program by the
Office of the Auditor General. It has come to our attention that Report of Drug/Medi-Cal
Disallowances by Provider forms (ADP 5035B) are not being submitted as required.
Disallowances shall be reported as follows:
• The Utilization Review Committee (URC) shall, at the time the disallowance is
identified, complete the Report of Drug/Medi-Cal Disallowances by Provider
form (ADP 5035B) and submit the pink copy to the Department of Alcohol
and Drug Programs (ADP), Drug/Medi-Cal Services Branch to the attention of
Sandra Pina.
• The URC shall submit the white original disallowance form to the county.
The county shall report the disallowances on the Monthly Claim for
Drug/Medi-Cal Reimbursement and Monthly Provider Service and Revenue
Summary form (ADP 1592) in the Disallowance column with the next monthly
claim. NOTE: If the program currently has a direct contract with ADP,
submit the white original form to ADP with the Monthly Claim for
Drug/Medi-Cal Reimbursement and Monthly Provider Service and Revenue
Summary form (ADP 1592).
• 7lie yellow copy of the disallowance form shall be retained by the program
and filed with the URC minutes.
• Disallowance forms must be separated by fiscal year.
37
2- ,.
Disallowances must be adjusted during each billing month. If the disallowances
are not offset by the program/county, ADP will adjust the disallowances on the next monthly
claim submitted by the program/county.
If you have questions about the disallowance reporting process, please feel free to
call Sandra Pina at (916) 323-2047.
VENUS LlITI7rE, Manager
Drug/Medi-Cal Services Branch
Office of Treatment and Recovery
38
EXHIBIT H
STATE OF CALIFORYIA-1(FALTR AID WELFARE A6EMCY PETE WILSOM, Governor
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
1700 Y STREET
SACRAI(EMTO, CA 95814-4037 _
TOO (916) 445.1942 w
(916) 323-2061
May 27, 1994
To: County Alcohol Program Administrators DDPr 94-15
County Drug Program Administrators
Subject: Capacity/Waiting List Management Program
In a letter to the Alcohol and Drug Program Administrators dated
March 8, 1994, the Department of Alcohol and Drug Programs (ADP) described the
activity it was undertaking to meet the Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration regulations which
require the states to establish a Capacity Management Program and a Waiting List
Management Program (45 CFR 96, Section 96.126).
The letter described and requested field review and comment on a plan
which: 1) creates a Waiting List Record (WLR) to be completed and retained by
treatment providers, and 2) revises the current Drug Abuse Treatment,Access
Report (DATAR), which providers would complete and forward to ADP on a
monthly basis. The new Waiting List Record incorporates the IDU, TB and
Pregnant Women data capture required by 45 CFR 96. While those regulations
apply to IDU and pregnant women treatment applicants, the State has broadened
the data base to gain information on the capacity to serve all applicants for
treatment services. The use of these two instruments was preliminarily discussed
with the Planning Committee of the County Administrator's Association. Two
counties, San Joaquin and Tulare, volunteered to pilot test the new instruments.
That test began in December 1993 and is now completed.
All treatment providers who use public funds, whether targeting alcohol,
drug or a combination of clients, plus all methadone treatment providers are to
complete the DATAR report on a monthly basis. ADP would expect to receive the
provider reports either directly from the provider or via the county, depending on
a county's wishes. ADP will join in negotiations with any county that wishes to
report DATAR data on electronic media rather than paper. If any county wishes to
capture more waiting list or capacity data than the minimum prescribed, ADP
concurs as long as DATAR is reported to ADP in the prescribed statewide
standardized paper or electronic media formats.
39
County Alcohol and Drug - 2 - May 27, 1994
Program Administrators '
Enclosed are the final DATAR reporting system forms which emerged from
the pilot test and the field review/comment period. Effective July 1, 1994, the
new system will replace the existing DATAR system. The last reporting month for
which data should be submitted on the current DATAR report is June 1994. The
Department is printing a supply of forms for the new system, which will be mailed
to the County Administrators by mid-June for distribution to their providers. A
user manual will also be distributed by mid-June.
The Waiting List Record is a minimum data set to assure standardized
statewide capture of the elements necessary for responding to 45 CFR 96. It is
the essential data source which providers must consult when preparing the DATAR
report. ADP will rely upon the DATAR report to monitor conformity with
45 CFR 96. In addition, the counties are expected to install whatever additional
monitoring/waiting list information sharing measures they deem appropriate to their
local circumstances. Counties are expected to put into place the processes
necessary to refer clients/participants from providers who have no unused capacity
to those that do.
Please direct your comments or questions concerning DATAR reporting
protocols to Karen Redman of my staff at (916) 323-7836, or Jack Colbert at
(916) 327-7623.
Sincerely,
eC�H�AD L. F R A N T Z
Deputy Director
Division of Administration
Enclosure
40 -
- . - EXHIBIT J
t
STATE OF CALIFORNIA
STANDARDS FOR DRUG TREATMENT PROGRAMS
REVISED SEPTEMBER 1482
r
TA= OF CoNTZNT8 _
3330DVCTS0N. . • . . . . . •. . . . • . . . . • o • • • • . . . . . . . . . . . . .'. . . . . • . . . . . 1
Z. 2
A. Governing Body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
B. Chief Executive Officer; . . . . . . . . . . . . . . . . . . . . . . . . . . 2
C. Personnel Policies... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
D. Fiscal Management. . . . . . 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 4
E. volunteer Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
II. PROGRAM lAGEBENT. . . • . . . . • . • . . . • . • • . . . ••. . o • :000000000 * 5
A. Admission or Readmission. . . . . . . . . . . . . . . . . . . . . . . . . . 5
1. Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Intake. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. Medical Assessment. . . o . . . . . . . . . . . . . . . . . . . . . . . 6
B. Services• • . •. . . . . • . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 6
1. Staffing. 6
2. Hours of Operation.. . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Counseling and other Therapeutic Services. . . . 7
.
4. Referral`al Services. . . . . O • • • . • • . • • • . • • • • • • o • . . . 8
5. Medical Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
C. Case Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1. Establishment and Control of Records. . . . . . . . . 8
2. Contents of Records. . . . . . . . . . . . . . . . . . . . . o . . . . 9
D. Quality Assurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1. Continuity of Care. . . . . . . . . . . . . . . . . . . . . . . . • . . 11
2. Case Review and Treatment Plan Revision. . . . . . 12
3. Program Evaluation. . . . . . . . . . . . . . . ... . . . . . . . . . . 12
4. Follow-up. . . . . . . . . . . . . . . . . • . • • . . . . . . . h . • . . • . . 12
S. 'Staff Development. . . . . • . . . • • • • • . • • . • . . . . • . • • • 13
'6. Utilization Review. . . . . . . . . . . . . . . . . . . . . . . . . . . 13
7. 'Facility Management. . • . . . . . . . . . . . . . . . . . . . . . . . 13
E. Client Rights. . . . . .. . . . . • . o . . . . . • . • . • . . . . . . . . . . . . . 13
1. Document. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2. Confidentiality. . . . . •. oO . . . . . • • . . . . . • • . . . • . . • 24
3. Consent to Treatment. . . o . . . . . . . . . . . . . . . . . . . . . 14
4. Consent
��to Follow-up. . . . . • . . . . . . . . . . . . . . . . . . • 14
5. Research. . . . . . . . . . . • • . . • . • • • . • . • We • . . • . • • . • • • 14
F. Discharge. 600000 . . . 0 . 0 . 00 • 00 • . . . . . . . . . . . . . . . . . . . . . 14
1. Criteria. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2• Summary• o • • • . • • • • • . • • • . • • • • • o • • • s • • • • • • • • • • • • 14
==t. cZNZRRL PROVXBIMBO...•..... .•.... . .•.... . .. .. •h. . ... . . 15
l►. Protocol. • ••• • ••.•:••. ..:..• •.....• .h. . . o .•• . . . o• • . 15
$• Exceptions• • • • • •••• • . • .. .. ... . . •. ..• . ..o . . . . • • • • • • 15
�� DEF IT♦ONS• • • • .• • • • . •• • • • • • • • • • • • • • . • • . • • • • o • • • . • . • • • • 16
EXHIBIT J
IMODVCTIOX
The Standards included in this document identify minimal
requirements for Drug.Treatment Programs with the State of
California. They apply to all programs designated as treatment
services in each County Plan and funded wholly or in part through
the Department of Alcohol and Drug Programs (ADP) . only those
policies and procedures considered absolutely essential are
specifically identified in these minimal standards.
Requirements identified elsewhere - such as Confidentiality
Regulations (42 CFR Part 2) , Methadone Regulations (Title 9) ,
"Proposed Short-Doyle Medi-Cal Certification Standards," and
Short-Doyle Community Services Systems Manual are not repeated in
this document. in case of conflicts the most restrictive
requirement shall apply.
• The funding source(s) decide whether these standards apply
when it first approves a program protocol.
1
Z. GENERAL MMAGEMENT
A; Governiac Body
Each program shall have a governing body .which has full
legal authority for operating the program. The
governing body- shall most at least quarterly. Yinutes
of all meetings shall be kept and be available to the
public.
Names and addresses of all governing board members
shall be available.
The bylaws, and rules of the program shall follow
applicable legal requirements.
Public organizations shall provide an organization
chart which reflects the program's placement within a
government agency. Private organizations shall provide
documentation of the legal authority for the formation
of the agency.
B. Chief Executive Officer
For private organizations providing drug abuse
services, the governing body shall appoint a chief
officer(s) . The major duties, authority, and
qualifications of the officer(s) shall be defined in
the organization's bylaws or rules.
Here is a suggested list of duties for chief officer(s)
to be included in the bylaws or rules. A chief officer
should:
a) plan activities;
b) report programs operations;
c) report program,,s finances, including developing
the annual operation budget; and
d) develop program*s rules, including- personnel
policies.
C. Personnel Policies
1.' Personnel policies shall be established and
maintained which:
a. are written and revised as needed and are
approved by the governing body;
2
EXHIBIT J
b. are applicable to all employees and are
available .'to and reviewed with new employees;
C. comply with applicable local, state, and
federal employment practice laws; and ,
d. contain information about the following:'
• recruitment, hiring process, evaluation,
promotion, disciplinary action and
termination;
• equal employment opportunity,
nondiscrimination, and affirmative
action policies as applicable;
• employee benefits, (vacation, sick
leave) , training and development,
grievance procedures;
• salary schedule, merit adjustment,
severance pay, employee rules of
conduct;
• employee safety and injuries; and
• physical health status as required.
2. Personnel files shall be maintained on all
employees and shall contain:
a. application for employment and resume;
b. employment confirmation statement;
c. salary schedule and salary adjustment
information; ,
d. employee's evaluations;
es health records as required; and
- 30 Procedures shall be established for access to and
confidentiality of personnel records.
4. Job descriptions shall be developed, revised as
needed, and approved by the governing body. The
job descriptions shall include:
a. position title and classification;
b. duties and responsibilities;
• 3
c. lines of supervision; and
d. education, training, work experience and
other qualifications for• the position.
S. A written code of conduct for employees and
volunteers shall be established which addresses at
least the following:
a. use of drug and/or alcohol;
b. relationship between staff-client;
C* prohibition of sexual contact with clients;
and
d. conflict 'of interest.
D. Fiscal Manacement
1. Each program shall have an annual written budget
which includes expected income and expenses, and
that:
a. lists all income by source; and
bo lists all expenses by program component or
type of service.
2. Each program shall use the Uniform Method of .
Determining Ability to Pay (VMDAP) as the fee
schedule for collecting fees.
3. Each program shall develop a reporting mechanism
which indicates the relation of the budget to
actual income and expenses to date.
4. Each program shall maintain written policies and
procedures that govern the fiscal management
system (e.g. , purchasing. authority, accounts
receivable, cash, billings and cost allocation) .
S. Program -personnel responsible for signing checks
and performing other accounting activities shall
be bonded.
G. The fiscal management system shall. provide for an
audit of the financial operations of the program
at least every two years, either by a public
accountant who is not a staff nor Board member or
by the funding agency.
4
t,hr♦
EXHIBIT J
g. volunteer services
If a program utilizes the services of (volunteers, it
should develop and implement policies ,and procedures
which addresses volunteers:
a. recruitment;
b. screening;
C* selection;
d. training and orientation;
e* duties and assignments;
fe supervision;
g. evaluation; and
h." protection of client confidentiality.
II. . PROGRAM MANAGEMENT
A. Admission or Readmission
1. criteria
Each program shall include in its protocol written
admission and readmission criteria for determining
clients' eligibility and suitability for
treatment. These criteria shall include, at
minimum: '
a. identification of drugs of abuse;
b. documentation of social, psychological,
physical and/or behavioral problems related
to drug abuse; and
c. statement of nondiscrimination.
2. Intake
a. An initial interview shall determine whether
or not a client meets the admission criteria.
b. If a potential client does not meet -the
admission criteria, the client shall be
referred elsewhere for treatment.
C. All clients admitted shall meet the admission
criteria and this shall be documented in the
client's record.
5
1
d. If a client is appropriate .for treatment, the
following information shall be gathered at
minimum:
• social, .eccnomic and family background;
• education;
• vocational achievements;.
• criminal history, legal status;
• medical history; and .
• previous treatment.
e. Only upon completion of this process and the
signing of the consent form, shall the client
be .admitted to treatment.
3. Medical Assessment
A complete medical and drug history shall be
taken. The program shall take reasonable steps to
protect the clients from spread of infectious .
disease(s) . An assessment of the physical
conditions of the client shall be made within 30
days from admission and documented in the client
record in one of the following gays:
a. A physical examination by a physician,, -
registered nurse practitioner or physician's
-
assistant according to procedures prescribed
by State Law.
b. Upon the review of the medical history and
other appropriate material, a determination
must be made by a licensed physician of the
need for physical and laboratory
examinations. Any recommended examination
• must be made available either directly by the
program or by referral.
B. services
1. Staffing
Each program shall be staffed to ensure adequate
delivery of required and provided services as
approved in the program protocol.
6
EXHIBIT J
2. Hours of Operation
Each program should provide sufficient scheduled
hours .of service to meet the needs of the clients.
The hours shall be so distributed that clients can
utilize the services without undue inconvenience.
When not open, the program should provide
information concerning the availability of short-
term emergency counseling or referral services,
including, but not limited to, emergency telephone
services.
3. Counseling and Other Therapeutic Services
a. Frequency of Services
• outiatient - Each client should be seen
weekly or more often, depending on
his/her need and treatment plan. At
minimum, all clients shall receive two
counseling sessions per 30 day period or
be subject to discharge.
• Residential - A minimum of twenty hours
per week' of counseling and/or structured
therapeutic activities shall be provided
for each client.
• Dav Treatment - A minimum of ten hours
per week of counseling and/or structured
therapeutic activities shall be provided
for each client.
Exceptions to the above frequency of services may
be made for individual clients where it is
determined by program staff that fewer contacts
are clinically appropriate and that progress
toward treatment goals is being maintained. Such
exceptions shall be noted in the case file.
b. Type of Services
The need for the following minimum services
must be assessed and, when needed, shall be
provided directly or by referral to an
ancillary services. These services include,
but are not limited to:
• education opportunity;
• vocational counseling and training;
• job referral and placement;
7
• legal services;
• medical services, dental services;
• social/recreational services; and
• individual counseling and group
counseling 'for clients, spouses, parents
and other significant people.
To the maximum extent possible, programs
shall provide and utilize community resources
and document referrals in client records.
4. Referral services
if during the course of treatment it is judged
that a client is not appropriate, for treatment, or
is in need of other services, the program shall
provide the client with a referral to appropriate
alternative services.
Program policies and procedures shall identify the
conditions under which referrals are made, the
procedures for making and following-up the
referrals, and the agencies to which referrals may
be made.
S. Medical Services
a. Emercenev - Each program shall make
provisions for emergency medical services for
its clients.
b. Consulting - Each program shall have
available, either directly or by referral, a
qualified medical consultant to ensure
quality of medical services.
c. Medical Detoxification - When deemed
appropriate, each program shall provide or
refer a client for medical detoxification.
C. Case Management
1. Establishment, Control and Location of Records
a. A case file (client record) must be
established for each client admitted to the
program-
' 8
EXHIBIT J
b. All client records are to be maintained and
information released only in accordance with
42 CFR, Part 2.
2.' Contents of Records
All records must contain the following,' at
minimum:
a. Demographic and Identifying Data:
• client identifier (i.e. name, number,
etc. ) ;
• date of birth;
• SeX;
• race/ethnic background; -.
• address;
• telephone number;
• next of kin, or emergency contact
(include phone number) ;
• consent to treatment;
• referral source and reason for referral;
date of admission; and
• type of admission (i.e. , new, etc. ) .
b. Intake Data
All data gathered during intake (see Section
II.A.2.) shall appear in the client's record.
c. Treatment Plan
Each client shall have as individual written
treatment plan which is based upon the
information obtained in the intake and
assessment processes. The treatment plan
shall be developed within 30 days from the
client's admission. There shall be periodic
review and update of the treatment plan at
least every 90 days. At minimum, the
treatment plan shall include the following:
9
• statement of problems to be addressed in
treatment;
• • statement of goal (s) to be reached which
address the problem(s) . .
• action steps which will ,be taken by
program and/or client to accomplish
goals; and
• • target date(s) for accomplishment of
action step(s) , goal (s) and when
possible, resolution of problem(s) .
d. Urine Surveillance
For those situations where drug screening by
urinalysis is deemed appropriate and
• necessary by the program director, or
supervising physician, the program shall:
• establish procedures which protect
against the falsification and/or
contamination of any urine sample; and .
• document urinalysis results in the
client's files.
e. Other Information Required
• The documentation of all services- which
show the relationship of services to
treatment plans (see Section II.8.3. )
• ,The documentation of quality assurance
•procedures (see Section II.D. ) .
• The documentation of required discharge
information (see Section II.F. ) .
• Progress notes which state clients'
progress toward reaching goals.
f. Other Requirements
• Client records shall be written legibly
in ink or typewritten. .
• All entries shall be signed and dated.
EXHIBIT J
• All significant information pertaining
to i 'client shall be included in the
• - client's record. A standard format
shall be used for all records. These
records shall be easily accessible to
staff providing services to the clients.
g. Disposal and Maintenance of Records
• Closed Programs = In the case of a
program closing, all client records
shall 'be stored in an appropriate
confidential manner by the County Drug
Program Administrator for not less than
four years.
• Closed Cases — There shall be a written
policy in. all programs regarding the
-maintenance and disposal of client
records. All records shall be stored in
an appropriate confidential manner for
not less than four years from the date
they are officially closed.
D. Quality Assu;ance
Each program shall maintain written policies and
procedures for quality assurance. The procedures must
include the following:
1. Continuity of Care
The program shall provide for a staff person ( or
persons) responsible for the client's continuity
of care and assurance that, at least, the
following -activities take place:
as a treatment plan is developed at the earliest
practical time after admission, not to exceed
30 days;
b. the services required are provided and
documented in the client record;
co failure of the client to keep scheduled
appointments is discussed with the client and
other action taken as appropriate;
d. progress in achieving the goals and
objectives identified in the treatment plan
assessed and documented on a continuous
basis;
11 '
e. the treatment plan is periodically reviewed
and updated, at least, every 90 days;
f. the clients record contains all required
documents (e.g. , correspondence,
authorization to release information, consent
for treatment, etc. . . ) ; and
g. if feasible, the client is followed-up after.
treatment as scheduled in the discharge
summary.
2. Case Review and Treatment Plan Revision
a. ' Case Reviews
At minimum, case reviews shall occur at
intake, when treatment plan revision is
appropriate, and at discharge. The purpose
of the documented case review is to ensure
that:
• the treatment plan is relevant to the
stated problem(s)
• the services delivered are relevant to
the treatment plan; and
• . recordkeeping is adequate.
b. Treatment Plan Review
The treatment plan review shall:
• assess progress to date;
• •reassess needs and services; and
• identify additional problem areas and
• formulate new goals, when appropriate.
3. Program Evaluation
Each program shall have written self-evaluation
procedures for management decision-making, which
shall be included in the program protocol.
a. Follow-up
Each program should have follow-up procedures for
clients who remain in the community atter
discharge.
12
• EXHIBIT J
5. staff Developmaent
Each program shall have a written plan for
training needs of staff. All training events
shall be documented.
6. utilization Review'
.Each program shall have written procedures for
utilization review.
7. Facility Management
Each program's facility shall comply with all
applicable local, state and federal laws and
regulations. 'Procedures shall be developed to
ensure that the facility will be maintained in a .
clean, safe, sanitary, and drug free condition.
E. Client Ricbts
1. A document shall be prepared which shall include
the following:
a. a statement of nondiscrimination by race,
religion, sex, ethnicity, age, disability,
sexual preference, and ability to pay;
b. client rights;
C. grievance procedures;
d. appeal process for discharge;
ISO program rules and regulations;.
f. client fees; and
g. access to treatment files in accordance with
Executive Order #B-22/76.
A copy of the document shall be provided to each
client upon admission or posted in a prominent
place, accessible to clients.
2. confidentiality - All programs shall comply with
42 CFR, Part 2 and Article 7 (commencing with
Section 53250 of Subchapter 2, Part 1 of Division
5 of the Welfare' .and Institution Code. In
addition, all methadone programs shall comply with
Sections 11875-11882 of the Health and Safety
Code.
13
3. Consant to TreatmeZ11 - Each program shall develop
a consent to treatment (or admission agreement)
form, -which shall be read and signed by client
upon admission. This from shall advise clients of
his/her obligations as wall as those of the
program.
4. consent for Fo11ov-sem - The follow-up after
discharge cannot occur without a written consent
from the client.
5. Research - Any program conducting research using
clients as subjects shall comply with all.
standards of the California Research Advisory
Panel and the federal regulations for protection
of human subjects (4 5 CFR 46) .
F. Discbarca
Each program shall have written procedures regarding
client discharge. These procedures shall contain the
following:
1. written criteria for discharge defining:
a. successful completion of program;
b. unsuccessful discharge;
ce involuntary discharge; and
d. transfers and referrals.
2. A discharge summary which includes:
a. description of treatment episode;
b. current drug usage;
C. vocational/educational achievements;
d. cziminal activity;
a. - reason for discharge;
f. clients' discharge pian; and
g. referrals.
14
EXHIBIT J
III. GLIUMJLL PRO S:ZC i8
A-. Each program shall develop a written protocol
indicating compliance with all of the standards
contained herein which shall be approved by the
appropriate funding source(s) .
S. Request for exceptions to the standards shall be
submitted to the appropriate funding source(s) with a
full explanation and justification.
These exceptions shall be granted only if the quality
of treatment is not significantly reduced or when
application of these standards makes the program cost
ineffective.
•
15
pLlZNZT20ll�
Action Stems - specific iime. limited, verifiable actions of
client and/or services, which leads to the
accomplishment of treatment plan goals.
Admission - At this point, the program determines that
the client meets the admission criteria and
the client signs a consent to treatment form.
Appeal Process - A written procedure by which client may
appeal discharge.
Assessment The process of evaluating a client's
problems, needs, strengths, and weaknesses,
so that a treatment plan may be developed or
revised.
-Client/patient - An individual who has a drug abuse problem,
for whom intake procedures have been
completed, and has been admitted to the
program. However, for confidentiality
reasons, a person becomes a client upon
applying for treatment.
-Client Record - The file established for each client upon
admission to a program which contains the
required information.
Counsel * - A process based on a face-to-face
client/counselor contact or group/family
counselor interaction for the purpose of
identifying client's problems related
directly or indirectly to substance abuse.
Counselor - An individual who, by virtue of education,
training, and/or experience, provide services
which may include advice, opinion, or
instruction. to an individual or group to
allow clients an opportunity to explore
problems related directly or indirectly to
substance abuse.
pav Treatment - A ten-hour, five-day, non residential,
structured, supervised environment to further
an individual's ability to live and work in
the community. .
Documentation written evidence of compliance.
Drug=se - The use of drugs, licit, or illicit, which
results in an individual's physical, mental,
emotional, and/or social impairment.
16
EXHIBIT J
Follow-uu - Process for determining the status of an
individual who has been discharged from a
program.
gunding s_,ource - The County (Drug Program Administrator) for
programs operated through contract, with the
County, and the State for programs operated
by the County or by private organizations
directly funded by the State.
Governing Body - In a government operated program it is
defined, for example, as Board of
Supervisors, City Council; and in a private
operated program it is defined as Board of
Directors.
-Grievance Procedure A written procedure by which a client may
protest alleged violation rights.
Intake - The process of collecting and evaluating
information to determine the appropriateness
of a prospective client for the .drug abuse
program.
MAY - Reflects an acceptable method that is
.recognized but not necessarily preferred or
mandatory.
outpatient Modality A nonresidential program offering treatment
services.
Program - An organized service system which addresses
treatment needs of clients.
Program Evaluation A documented process by which a program
periodically assesses the quality of -
treatment services using measurable criteria.
Protocol - A document which describes the program's
procedures for compliance with these
standards as well as other applicable laws
and regulations.'
Oualified Medical A licensed physician or a nurse practitioner
Consultant or a physician assistant operating under the
supervision of a licensed physician.
17
EXHIBIT M
Page 1 of S
APPEAL PROCESSES
1. FINANCIAL AUDIT APPEALS
The Department of General Services, Office of Administrative Hearings (OAH), provides an
administrative hearing process for the Department of Alcohol and Drug Programs (ADP).
This process is used only for appeals of financial disallowances of alcohol and/or drug
program audits.
An appeal may be filed with ADP if the Contractor disagrees with any financial finding. The
appeal process consists of two parts, a prehearing conference and a formal hearing. The
prehearing conference is scheduled for the purpose of resolving disagreements by exploring
possibilities of settlement. If ADP and the Contractor agree to settle all of the audit appeal
issues, OAH will prepare and transmit a stipulation for ADP and the Contractor to sign.
If the appeal cannot be resolved at the prehearing conference, OAH will immediately confer
with the ADP and the Contractor to set a formal hearing date and location. At the formal
hearing, an Administrative Law Judge will review all legal issues through oral and written
testimony and issue a proposed decision to the Director of ADP for consideration.
A. The following process is required for requesting a prehearing conference:
1. The Contractor shall prepare and submit a written statement, a Notice of
Defense (which is a statement of disputed issues), to ADP specifying any
objections to the financial findings.
a. The Notice must be received by ADP within sixty (60) calendar clays
from receipt of the Audit Report.
b. The Notice must include the signature and mailing address of an
individual with the authority to represent the Contractor.
C. The Notice must be submitted to:
Audit Appeals Coordinator
Department of Alcohol and Drug Programs
1700 K Street
Sacramento, CA 95614
2. The individual representing the Contractor at the prehearing conference must
have the authority to agree to a binding decision.
3. ADP will notify the Contractor regarding further arrangements after receipt of
the Notice.
1
I1. ADMINISTRATIVE APPEALS
If the Contractor wishes to appeal dispositions made by ADP or the Department of Health
Services (DHS) concerning recoupment of specific Medi-Cal claims,the procedures included
in California Code of Regulations (CCR) Title 22 Section 51015 must be followed. This
section applies to Drug/Medi-Cal (D/MC) claims processing. The Contractor may also appeal
disapprovals by ADP for (re)certification requests.
A. The following process will apply to first-level grievances/complaints:
1. The Contractor shall initiate the action by submitting the grievance/complaint
in writing to ADP.
a. The grievance/complaint shall be submitted in the form of a letter on
the official stationery of the Contractor and signed by an authorized
representative of the Contractor.
b. The document shall state that it is being submitted in accordance with
CCR Title 22 Section 51015.
C. The document shall identify the specific claims) involved and describe
the disputed (in)action regarding the claims.
2. The appeal shall be submitted to ADP within 30 calendar days from the date
the Contractor receives written notification of the decision to disallow claims.
a. Grievances/complaints shall be directed to:
Deputy Director
Office of Treatment and Recovery
Department of Alcohol_and Drug Programs
1700 K Street
Sacramento, CA 95814
3.. ADP shall acknowledge the grievance/complaint within fifteen (15) calendar
days of its receipt.
4. ADP shall act on the appeal and inform the Contractor of ADP's decision, and
the basis therefore, within fifteen (15) calendar days after ADP's notice of
acknowledgement.
a. ADP shall have the option of extending the decision response time if
additional information is required from the Contractor. The Contractor
shall be notified if ADP extends the response time limit.
B. The Contractor may initiate a second-level grievance/complaint for claims processing
only. The grievance/complaint shall be directed to DHS. The second-level process
may be pursued only after complying with the first-level grievance/complaint process
and only under the following circumstances:
2
EXHIBIT M
1. ADP failed to acknowledge the grievance/complaint within fifteen (15) days
of its receipt.
2. The Contractor is dissatisfied with the action taken by ADP where the
conclusion is based on ADP's own evaluation of the merits of the
grievance/complaint.
3. The second-level appeal is submitted to DHS within thirty (30) calendar days
from the date ADP failed to acknowledge the first-level appeal or from the
date of the first-level appeal decision by ADP.
C. The following process will apply to second-level grievances/complaints:
1. The Contractor shall refer the grievance/complaint to DHS to the attention of:
Chief
Field Services Branch
Department of Health Services
714 P Street, Room 1516
Sacramento, CA 95814
2. The following information shall be submitted:
a. a copy of the original written grievance/complaint that was sent to
ADP;
b. a copy of ADP's report to which the grievance/complaint applies; and
C. a copy of ADP's response, specific finding(s), and conclusion(s)
regarding the grievance/complaint with which the Contractor is
dissatisfied.
3. DHS shall review the written documents submitted in the grievance/complaint
and send a written report of its conclusions and reasons to the Contractor and
ADP within sixty (60) days of receipt of the referral. DHS may request
additional information and/or hold an informal meeting with the involved
parties before rendering a decision.
a. DHS shall have the option of extending the decision response time if
additional information is required from the Contractor. The Contractor
and ADP will be notified if DHS extends the response time limit.
III. CLIENT RIGHT TO ADMINISTRATIVE DUE PROCESS
Each Medi-Cal beneficiary has the right to an administrative hearing regarding any action
taken to deny, terminate, or reduce a beneficiary's receipt of D/MC benefits under CCR Title
22 and methadone treatment services under CCR Title 9. Procedures outlined in CCR Title
-22 Sections 50951, 50953, and 51014.1; Welfare and Institutions Code Sections 10950
through 10965; and the Department of Social Services (DSS) Manual of Policy and
3
Procedures, Chapter 22 will be followed by the Contractor,the Utilization Review Committee
(URC) and the beneficiary for D/MC benefits.
If an administrative hearing is requested, an explanation of the circumstances under which
the D/MC service and payment shall be continued must be explained to the beneficiary. In
preparation for a hearing, these steps must be followed:
-A. The Contractor must inform the beneficiary in writing at least ten (10) days before
the effective date of the intended action to terminate/reduce services under D/MC.
The notice to the beneficiary shall include:
1. a statement of the action the Contractor intends to take;
2. the reason for the intended action;
3. citation of the specific regulation(s) supporting the intended action(s);
4. an explanation of the beneficiary's right to request an administrative hearing
due to the Contractor's decision; and
5. an explanation of the procedure for the beneficiary to request a hearing. The
beneficiary must submit the request to:
Office of the Chief Referee
Department of Social Services
744 P Street, Room 1750
Sacramento, CA 95614
B. The Contractor must submit the details of the intended action to the URC.
C. Upon notification that a beneficiary has filed for an administrative hearing, the URC
shall write a position paper to the Office of the Chief Referee at DSS. The position
paper must summarize the facts of the case and set forth the regulatory justification
for the action.
1. The URC does not have the authority to terminate D/MC payment for services
because of client violation of CCR Title 9 requirements. If the beneficiary
does not comply with program rules and requirements according to Title 9,the
Contractor may terminate services and the beneficiary would have the right
to a fair hearing under Title 9 procedures.
D. The findings and decision of the DSS hearing officer shall be submitted to the
Director, DHS, for review in accordance with Title 22 Section 50953(a). As part of
its review, DHS shall seek input from ADP; however, DHS retains sole authority for
decision-making regarding Medi-Cal issues.
4
EXHIBIT K
NONDISCRIMINATION CLAUSE (OCP-1)
1 . During the performance of this contract, contractor and its
subcontractors shall not unlawfully discriminate, harass or allow
harassment, against any employee or applicant for employment
because of sex, race, color, ancestry, religious creed, national
.origin, physical disability (including HIV and AIDS) , mental
disability, medical condition (cancer) , age (over 40) , marital
status, and denial of family care leave. Contractors and
subcontractors shall insure that the evaluation and treatment of
their employees and applicants for employment are free from such
discrimination and harassment. Contractor and subcontractors
shall comply with the provisions of the Fair Employment and
Housing Act (Government Code, Section 12900 et seq. ) and the
applicable regulations promulgated thereunder (California Code of
Regulations, Title 2, Section 7285.0 et seg. ) . The applicable
regulations of the Fair Employment and Housing Commission
implementing Government Code, Section 12990 (a-f) , set forth -in
Chapter 5 of Division 4 of Title 2 of the California Code of
Regulations are incorporated into this contract by reference and
made a part hereof as if set forth in full. Contractor and its
subcontractors shall give written notice of their obligations
under this clause to labor organizations with which they have a
collective bargaining or other agreement.
2. This contractor shall include the nondiscrimination and compliance
provisions of this clause in all subcontractors to perform work
under the contract.
EXHIBIT h
IV. APPEALS TO THE STATE FROM PROVIDERS REGARDING COUNTY/SUBCONTRACTOR
CONTRACTS
A provider may appeal to ADP in accordance with the plan developed in response to the
Sobkv v. Smolev "Order for Permanent Injunction, United States District Court, Eastern
.District of California, No. Civ. S-92-613 DFL GGH", and in accordance with Article IV,
Section C, Subdivision 1.b. of the State/county D/MC contract.
A. Issues that may be appealed to ADP as violating the terms and conditions of the
county/subcontractor contract and the court ordered plan are:
1. Insufficient funding in the county/subcontractor contract to support the level
-of D/MC services the provider is interested in and capable of providing to
Medi-Cal beneficiaries.
B. The issue that may be appealed to ADP as violating the court ordered plan is:
1. Refusal of the county to contract with the provider after D/MC certification
has been granted by ADP.
C. Appeals shall be submitted in writing to ADP and shall include documentation of the
appealable issue in accordance with Section II.A.1.a. and c. above.
D. Appeals shall be forwarded to:
Deputy Director
Office of Treatment and Recovery
Department of Alcohol and Drug Programs
1700 K Street
Sacramento, CA 95814
E. When ADP receives an appeal in accordance with Section IV.C. above, ADP will
investigate the appeal and resolve the matter within forty-five (45) days from the
date the complaint is received.
F. To the extent that ADP determines that the county violated one or more of the
appealable issues as specified in Sections IV.A. and B. above, ADP may redirect the
counties' State General Funds and/or terminate the State/county contract. In the
case of contract termination, ADP may contract directly with the provider or through
a broker/intermediary.
5
COMPLETION INSTRUCTIONS FOR
ADP 7890 (8/94)
GENERAL:
The ADP 7890 - MONTHLY INTERIM PAYMENT CLAIM FORM FOR DRUG/MEDI-CAL
STATE GENERAL FUNDS is used for requesting projected Drug/Medi-Cal
units of service and total dollar amount claimed.
HEADING INSTRUCTIONS:
a. Page/of - enter, each page number and total of pages (i.e. ,
page 1 of 9) .
b. Date - enter the date this form was completed.
C. Program Code - check the appropriate box for Combined Services
(20-101) or Perinatal (25-102) .
d. County Name - enter name of county submitting claim.
e. ADP Contract Number - enter contract number which authorizes
the interim payment.
f. County Code - enter the two digit county code.
g. Claim for Mo/Yr ; - enter month/year of projected service.
h. Fiscal Year - enter fiscal year of projected service.
COLUMNAR INSTRUCTIONS:
a. Projected Units of Service - determine. and enter the units of
projected services by treatment component (OMM, NAL, ODF, DCH
and RES) for the claim month.
b. Amount Claimed for 'Interim - enter the rate per unit utilized
to project costs for each treatment component.
C. Net Claim - determine the total dollars and cents claimed.
d. . Total — enter the total amount of all net claims.
e. Total State General Fund - enter the State General Fund amount
of total net claims (Divide total by 2) .
COUNTY FISCAL REPRESENTATIVE:
a. The signature and date of the responsible county
representative for contact purposes shall be entered on this
line.
SUBMISSION INSTRUCTIONS:
a. The original Interim Payment Claim Form (ADP 7890) and two
copies shall be mailed to:
Department of Alcohol and Drug Programs
Drug/Medi-Cal Section
1700 x Street
Sacramento, CA 95814
EXHIBIT N
F11EAATE OF CALIFORNIA DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
L7W AND WELFARE AGENCY PAGE OF
MONTHLY INTERIM PAYMENT CLAIM FORM
FOR DRUG/MEDT—CAL STATE GENERAL FUNDS
DATE: PROGRAM CODE: (Check One)
( ) 20-101 Combined Services
( ) 25-102 Perinatal Services
COUNTY NAME: (ADP CONTRACT'NUMBER:I COUNTY CODE CLAIM FOR MO/YR I FISCAL YEAR
PROJECTED AMOUNT
TYPE OF SERVICE UNITS OF CLAIMED FOR NET CLAIM
SERVICE IN7ERIM
OUIPATIENT MMADONE MAINTENANCE—OMM
NALTREXONE—NAL
OU7PATIENT DRUG FREE—ODF
DAYCARE HABILITATIVE—DCH
RESIDENTIAL.—RES
TOTAL
TOTAL STATE GENERAL FUND
SIGNATURE OF COUNTY FISCAL REPRESENTATIVE: DATE:
ADP PROGRAM CERTIFICATION
I hereby certify that the within request is in accordance with the clisting contract and approve for payment,this
interim payment
SIGNATURE OF ADP ANALYST: DATE.-
ADP
ATEADP FORM 7890 (9/94)
EXHIBIT 0-1
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 1 of 4
DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
SUMMARY
COUNT CONTRACT NUMBER
CONTRACTOR ,
CONTRACT PERIOD MEDI—CAL PROV.NO.
DATE PREPARED CADDS PROVIDER NO..
TYPE OF PROGRAM (Specify as ODF,DCH,RES)
A B C D E
TOTAL PRIVATE NNAJPUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI—CAL FUNDED NNAJPUBLIC
A. PERSONNEL SERVICES
B. DIRECT SERVICES
C. EQUIPMENT MATERIALS b SUPPLIES
D. OTHER OPERATING EXPENSES
_. PROFESSIONAL d SPECIAL SERVICES
TRANSPORTATION
3. INDIRECT COSTS
G1.COUNTY ADMINISTRATION
TOTAL GROSS COSTS
REVENUES ;;? >: ;. .w.vr`' xy>: :<... s ;>•:`•
-1. PARTICIPANT FEES
INSURANCE,MEDICARE,A OTHER THIRD PARTY
J. CONTRACTS&GRANTS(SPEC"
A. COUNTY—FEDERAL/STATE/COUNTY(NON—PERI
12. COUNTY—FEDERALISTATE/COUNTY(PERINATAL)
J3. COUNTY/STATE—FEDISTATE MEDI—CAL(NON—PERI
J4. COUNTYISTATE—FED/STATE MEDI—CAL(PERINATAL)
Z. FEDERAVSTATE—DIRECT CONTRACT
�6.
7.
8.
OTHER(SPEC
:1. TCM/MAC(FEDERAL SHARE)(AS 2377)
C2.
:3.
TOTAL REVENUES
NET COSTS(GROSS COSTS LESS LINES HAIQ .
UNITS OF SERVICE w
INDIVIDUAL FACE TO FACE VISITS
1. GROUP FACE TO FACE VISITS
:. OTHER(SPEC"
�t.
2.
TOTAL LINKS OF SERVICE
STAFF HOURS(DMCT SVCS—COUNSELING,MEDICAL:ETC.)
COST PER UNIT OF SERVICE(UNITS)(GROSS COSTS/UNE O)
COST PER STAFF HOUR(GROSS COSTS/LINE P)
DP FORM 7895(8/94)
%HIBIT O-1
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 2 of 4
DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
-*OUNTY CONTRACT NUMBER
-ONTRACTOR
:ONTRACT PERIOD MEDI—CAL PROV.NO.
)ATE PREPARED CARDS PROVIDER NO.
YPE OF PROGRAM (Specify as ODF,DCH,RES)
TOTAL PRIVATE NNAIPUBLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDT—CAL FUNDED NNA/PUSLIC
'ERSONNEL SERVICES
SakWo A wages
Employee Serntib
TOTAL PERSONNEL SERVICES
tRECT SERVICES
A Personal Supplies
=ood
-aundry Services A Supplies
°harnummuca;
"or MPaIM
SUBTOTAL DIRECT SERVICES
WIPMENT,MATERIALS&SUPPLIES
)eprocislim—Equipment
Aainbrwme—Equipment
Aedical,DenW,and Labrat"Suppies
Aembemlilp Dues
:eats A Looses Equipmod
map Tools 8 Instruments
.fig
ther(S
USTOTAL EQUIPMENT.MATERIALS d SUPPLIES
HER OPERATING EXPENSES
2nnnunicafbns
spreciaion—Stuckwas&ImprwAmenb
xmhoid Esperms
suusu
sngt
asad Makdormnoe.8bu lura Ir nprovunerds A grounds
w nbru noe—Sbu hm,Improvonwft A Grounds
soeisneo m Expense
fico aporw
P FORM 7895 WN)
EXHIBIT 0-1
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 3 of 4
DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
COUNTY CONTRACT NUMBER
CONTRACTOR
CONTRACT PERIOD MEDI—CAL PROV.NO.
DATE PREPARED CADDS PROVIDER NO.
TYPE OF PROGRAM (Specify as ODF,DCH,RES)
TOTAL PRIVATE NNA/PUSUC TOTAL MG
CATEGORIES PROGRAM PAY MEDT—CAL FUNDED NNAIPUBLIC\\
:)THER OPERATING EXPENSES(Conten :k
PubUcatons and Legal Nooses
Raub a Leaves—Land,Strwwma a tmprowrnenb
Tames d Wonses
Drug Scrmur fts a Oliver Testing
Um"s
O"r(Specify)
SUBTOTAL OTHER OPERATING EXPENSES
ROFESSIONAL&SPECIAL SERVICES
AANSPORTATION
imaymportallon
i ravel
!as.OU,S Mak1enanoa—Val'm
aerMs 8 Loasas—Votiabs
lepncMdian—Vafrialas
,UBTOTAL TRANSPORTATION
tOTAL NONPERSONNEL
id"d Costs
VERALL TOTAL
P FORM 7895 MW)
COMPLETION INSTRUCTIONS FOR
ADP 7890 (8/94)
GENERAL:
The ADP 7890 - MONTHLY INTERIM PAYMENT CLAIM FORM FOR DRUG/MEDI-CAL
STATE GENERAL FUNDS is used for requesting projected Drug/Medi-Cal
units of service and total dollar amount claimed.
HEADING INSTRUCTIONS:
a. Page/of - enter each page number and total of pages (i .e. ,
page 1 of 9) .
b. Date - enter the date this form was completed.
C. Program Code - check the appropriate box for Combined Services
(20-101) or Perinatal (25-102) .
d. County Name - enter name of county submitting claim.
e. ADP Contract Number - enter contract number which authorizes
the interim payment.
f. County Code - enter the two digit county code.
g. Claim for Mo/Yr - enter month/year of projected service.
h. Fiscal Year - enter fiscal year of projected service.
COLUMNAR INSTRUCTIONS:
a. Projected Units of Service - determine and enter the units of
projected services by treatment component (OMM, NAL, ODF, DCH
and RES) for the claim month.
b. Amount Claimed for 'Interim - enter the rate per unit utilized
to project costs for each treatment component.
C. Net Claim - determine the total dollars and cents claimed.
d. Total - enter the total amount of all net claims.
e. Total State General Fund - enter the State General Fund amount
of total net claims (Divide total by 2) .
COUNTY FISCAL REPRESENTATIVE:
a. The signature and date of the responsible county
representative for contact purposes shall. be entered on this
line.
SUBMISSION INSTRUCTIONS:
a. The original Interim Payment Claim Form (ADP 7890) and two
copies shall be mailed to:
Department of Alcohol and Drug Programs
Drug/Medi-Cal Section
1700 x street
Sacramento, CA 95814
EXHIBIT N
STATE OF CALIFORNIA DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS
IIEALTN AND WELFARE AGENCY PAGE OF
MONTHLY INTERIM PAYMENT CLAIM FORM
FOR DRUG/MEDI-CAL STATE GENERAL FUNDS
DAZE: PROGRAM CODE: (Cheek One)
( } 20-101 Combined Services
( ) 25—IM Perinatal Services
COUNTY NAME: (ADP CONTRACT NUMBER:I COUNTY CODE I CLAIM FOR MO/YR FISCAL YEAR
PROJECTED AMOUNT
TYPE OF SERVICE UNIZS OF CLAIMED FOR NET CLAIM
SERVICE INTERIM
OUTPATIENT METHADONE MAINRBNANCE—OMM
NALZREXONE—NAL
OUTPATIENT DRUG FREE—ODF
DAYCARE HABILTTAZIVE—DCH
RESIDENTIAL—RES
TOTAL
TOTAL STATE GENERAL FUND
SIGNATURE OF COUNTY FISCAL REPRESENTATIVE: DATE:
ADP PROGRAM CERTIFICATION
I hereby certify that the within request is in accordance with the dating contract and approve for payment,this
interim payment.
SIGNATURE OF ADP ANAJLYST: DATE--
ADP
ATEADP FORM 7890 (9/94)
❑ Valley Memorial Hospital E] ValleyCare Medical Center
N/VALLEvCARE Pleasanton, CA 94588
H E Livermore, cn 94550
Phone (510)447-7000
SYSTEM
I.R.S. 94-1429628 I.R.S. 94-3097094
PATIENT NAME ACCOUNT NO., '-' ROOM NO. ADM.DATE - - DISC.DATE PAGE
VERGA, HENRY C .. . 73.92194 0000— 8/06/94 8/06/94 1
INSURANCE NAME BILLING DATE
VERGA, HENRY C 171318 NO INSURANCE COVER 8/31/94
2520 RYAN RD #43
CONCORD CA 945180000 GROUPNO. TYPE F►NCL POLICY NO.
02 ER 00
RE—BILL
SATE CHARGE DESCRIPTION, SERVICE-CODE: STANDARD PRICE ESTIMATED - ESTIMATED ESTIMATED PATIENT
3F INS.COVERAGE INS.COVERAGE INS.COVERAGE CHARGE
SERVICE _ .. _---.-_ CPT4 CODE RVS# REF LAB
***2.50 PHARMACY
8/06 DIP—TET TOX—ADULT 2132525 1 45.05
UB82 TOTAL ## 45.05
***270 MEDICAL SURGICAL SUP
8/06 CLAVICLE STRAP LG 4050652 1 74.0It)
8/06 SLING ARM LG 4051210 1 34.2.5
8/06 CLAVICLE STRAP LG 40506.52 1 74.00c
## UB82 TOTAL ## 34.25
*##320 RADIOLOGY — DIAG. IM
8/06 CLAVICLE 3073060 1 73000 73000 222.75
UB82 TOTAL #* 222.7.5
**#450 EMERGENCY ROOM
8/06 LEVEL CHARGE 6 .7010035 1 123.00
8/06 INJECTION 7030114 1 22.00
8/06 WOUND PREP MINOR 7030144 1 12001 22.00
,8/06 ORTHO APPLICATION 7030064 2 44.00
8/06 WOUND PREP MINOR 7030144 1 12001 22.00C
*#
UB82 TOTAL *# 189.00
_.
Please Note: The total above is the amount due the hospital. If you have insurance coverage your CONTINUE
insurance company will be billed as a courtesy to you. However, the responsibility for payment of this
statement rests with the guarantor. You will be advised of any payments,charges or credits not presently
in the business office by subsequent statements.
This statement does not include fees for your physician,anesthesiologist or private duty nurse. _
FORM 04095(10/91)
PATIENT COPY PLEASE PAY THIS AMOUNT
EXHIBIT 0-1
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 1 of 4
DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRACT NUMBER
CONTRACTOR .
CONTRACT PERIOD MEDT-CAL PROV.NO.
DATE PREPARED CADDS PROVIDER NO.
TYPE OF PROGRAM (Specify as ODF,DCH,RES)
A B C D E
TOTAL PRIVATE NNA/PUSLIC TOTAL MC/
CATEGORIES PROGRAM PAY MEDI-CAL FUNDED NNA/PUBLIC
A. PERSONNEL SERVICES
B. DIRECT SERVICES
C. EQUIPMENT MATERIALS 3 SUPPLIES
D. OTHER OPERATING EXPENSES
_. PROFESSIONALS SPECIAL SERVICES
=. TRANSPORTATION
3. INDIRECT COSTS
G1.COUNTY ADMINISTRATION
TOTAL GROSS COSTS
REVENUES >... <• `{^ {:\ .Yk' ;o?S :v.'• .`•Ysii{ k.
i. PARTICIPANT FEES
INSURANCE,MEDICARE,S OTHER THIRD PARTY
J. CONTRACTS S GRANTS(SPECIFY)
A. COUNTY-FEDERAL/STATE/COUNTY(NON-PERO
J2. COUNTY-FEDERAL/STATE/COUNTY(PERINATAL)
J3. COUNTYISTATE-FED/STATE MEDI-CAL(NON-PERO
J4. COUNTY/STATE-FED/STATE MEDT-CAL(PERINATAL)
JS. FEDERAIATATE-DIRECT CONTRACT
6.
7.
8 '
OTHER(SPECIFY)
:1. TCM/MAC(FEDERAL SHARE)(AS 2577)
:2.
:3.
TOTAL REVENUES
NET COSTS(GROSS COSTS LESS LINES(H.I.IQ .
UNITS OF SERVICE OEM
INDIVIDUAL FACE TO FACE VISITS
1. GROUP FACE TO FACE VISITS
OTTER(SPECIFY) 77
It.
2.
TOTAL UNITS OF SERVICE
STAFF MOORS(DiECT sVCS-COUNSELING.MEDICAL:ETC).
COST PER UNIT OF SERVICE(UNITS)(GROSS COSTSA INE O)
COST PER STAFF HOUR(GROSS COST'S/LINE P)
DP FORM 7895(8/94)
_ EXHIBIT 0-1
t
Page 4 of 4
INSTRUCTIONS FOR DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
ADP FORM #789510DF, DCH, RES)
This form will be completed for each provider of Medi-Cal services by type of treatment program (ODF, DCH, RES). If a provider
operates more than one type of treatment program (ie: ODF and DCH, etc.), a separate report form must be completed for each
treatment program. For County operated programs, prepare this form for each program.
HEADING: Enter the county name, contractor, contract number, contract period, Medi-Cal and CADDS Provider Numbers, type of
program, and ditto prepared.
COLUMN INSTRUCTIONS:
COLUMN A: Enter total costs, revenues, and units of service of Columns B, C, D for all lines.
COLUMN B: Enter total costs for each category from pages 2 and 3. Revenues and units of service should be obtained from the
Provider's records.
COLUMN C: Enter total costs for each category from pages 2 and 3. Revenues and units of service should be obtained from the.
Provider's records.
ZOLUMN D: Enter total costs for each category from pages 2 and 3. Revenues and units of service should be obtained from the
Provider's records.
�OLUMN E: Enter total of costs, revenues, and units of service of Columns C, D for`all lines.
Note: The information in Column E should also be entered in the appropriate column of ADP Forth 7225E-G.
LINE INSTRUCTIONS:
_INE 09: For contract and county-operated programs, the county will enter allowable county administration. Allowable
county administration costs pertaining to this Line are only the costs associated with utilization review, billing.
and training. (See Page 3 instructions below for reporting of other county administrative costs).
DOTAL GROSS COSTS: Enter total amounts applicable to each of Columns B, C, D, and E.
_INE H: Enter total amounts applicable to each cost center.
_INE I: Enter total amounts applicable to each cost center.
-INE J: Enter totals of the funding sources listed for each cost center. For county-operated programs, enter all
funding sources in the appropriate line.
_INE K: Enter tonal amounts applicable to each cost center.
TOTAL REVENUES: Enter total amounts of all revenues (Lines H through K).
JET COSTS: Subtract Total Gross Costs by Lines H,I,K for each cost center.
.INES L,M,N: Enter the total amounts applicable to each cost center.
INE O: Enter total amounts of all units (Lines L through N).
INE P: Enter the total direct service staff hours (counseling, medical, etc.) applicable .to each cost center.
INE Q: Compute the cost per unit of service by dividing Total Gross Costs by Line O (Total Units of Service).
INE R: Compute the cost per staff hour by dividing Total Gross Costs by Line P (Staff Hours).
AGES 2 6 3: These costs provide a recording of the trial balance expense accounts from the provider's accounting books
and records under the major categories listed.
Enter the costs, by line item, for each cost center. Column A will be the total amount of Columns B,C,D.
Column E will be the.total of Columns,C, D. Enter Subtotals for each category in the appropriate Lines.
age 3: bndrrect (Admirdswa4iw and Program) Costs:
For non-county providers, this Line.includes all administrative and program indirect costs.
For county-operated programs, this Line ineludes indreat program (treatment) costs and other indirect administrative
costs such es, County A-87 overhead, Health and/or Mental Health Department, and Alcohol and Dnp Programs
administrative costs. The allowable administrative casts for utilisation w4ow,billing, and training must be reported in
Line G1 on Page I.
Note: Sir= ODF aervicos consist of individual and group activities, costs must be allocated using 'Staff Hours' as
the basis.
EXHIBIT 0-2
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 1 of 4.
DRUG MEDI-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
SUMMARY
COUNTY CONTRACT NUMBER
CONTRACTOR
CONTRACT PERIOD MEDI—CAL PROV.NUMBER
DATE PREPARED CADDS PROVIDER NUMBER
PROGRAM CHEMICALLY ASSISTED
A B C D E F G
MAINTENANCE
TOTAL PRIVATE NNA/PUSUC TOTAL MC/ TOTAL
CATEGORIES METHADONE DETOX PAY MEDI-CAL FUNDED NNA/PUSUC MAINTENANCE
4. PERSONNEL SERVICES
3. DIRECT SERVICES
:. EQUIPMENT MATERIALS 3 SUPPLIES
). OTHER OPERATING EXPENSES
:. PROFESSIONAL d SPECIAL SERVICES
TRANSPORTATION
i. INDIRECT COSTS
11.COUNTY ADMINISTRATION
TOTAL GROSS COSTS
REVENUES :. . . :..:• ...: . .
..•
. PARTICIPANT FEES
INSURANCE.MEDICARE.Q OTHER THIRD PARTY
CONTRACTS&GRANTS(SPECS .
i.COUNTY-FEDERAL/STATE/COUNTY(NON-PERI
2.COUNTY-FEDERAWSTATE/COUNTY(PERINATAL)
3.COUNTY/STATE-FED/STATE MEDI-CAL(NON-PERQ
4.COUNTY/STATE-FED/STATE MEDI-CAL(PERS
s.FEDERALISTATE-DIRECT CONTRACT
0.
OTHER(SPECIFY)
TCM/MAC MERAL SHARE) AS WM
TOTAL REVENUES
ET COSTS(GROSS COSTS LESS LINES KM
ITS OF SERVICE
FACE TO FACE VISITS
TAKE HOME DOSE$
COLLA ESY/.NL DOSES 177,
LICENSED SLOTS C
COST PER UNIT OF SERVICE(Chow ODsWLkw U
P#78g5M (W)
EXHIBIT 0-2
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS Page 2 of 4
DRUG MEDT-CAL FISCAL DETAIL
REPORT OF EXPENDITURES AND REVENUES
i
COUNTY CONTRACT NUMBER
CONTRACTOR
CONTRACT PERIOD MEDT—CAL PROV.NUMBER
DATE PREPARED CADDS PROVIDER NUMBER
MAINTENANCE
TOTAL PRIVATE NNA/PUBLIC TOTAL MC TOTAL
CATEGORIES METHADONE DETOX PAY MEDT—CAL FUNDED NNA/PUBLIC MAINENANCE
.r.::•.;;,•• ::• .,.S ::,n ';c:n: '••: .,;' `•'...v..'..::r:.•kxit :eat>>:` ',..a,:ti• r ♦k•::•<�•{•�:�••�•.�••:
DERSONNEL SERVICES "<> .' 3f •z.�:;uti: •3:i,.E
Sslariss 3 Wages
Ernplayse Berwft
TOTAL PERSONNEL SERVICES
31RECT SERVICES ; ; •• ::„<`::;
00thinp A Personal Supplies
Food
Laundry Services&Supplies_
Pharmaceutical
Other(SpeclM
SUBTOTAL DIRECT SERVICES
OUIPMENT,MATERIALS A SUPPLIES k ^`
Deprscislim—E uFpment
Maknsnarm—Equipment
Medical,Dental,and UMratory Supplies
Membom4p Dues
Pleats 6 Leases Equipment
3ma0 Tools A kabunenls
rrao*v
)M1er(Speclly)
1BTOTAL EQUIPMENT,MATERIALS,A SUPPLIES
TIER OPERATING EXPENSES
4mmudcatlons
epreciatiOn—Str11Ct1aes A knprovenNnis
ounhoid Expwms
suranoo
ee►eet Eperm
wed Property Mak tananoe.ftucOses
,provemend tGroude
ak rune—ssbuotues,tyamenwft S Grouds
i.oegansa■E�ense
.Nos
Ni ftm and Leet NoWn
P#7895M(8/94)
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS EXHIBIT 2
DRUG MEDI—CAL FISCAL DETAIL page 3 o f f 4
REPORT OF EXPENDITURES AND REVENUES
COUNTY CONTRACT NUMBER
CONTRACTOR
CONTRACT PERIOD MEDI—CAL PROV. NUMBER
DATE PREPARED CARDS PROVIDER NUMBER
MAINTENANCE
TOTAL PRIVATE NNA/PUBLIC TOTAL MC/ TOTAL
CATEGORIES METHADONE DETOX PAY MEDI—CAL FUNDED NNA/PUBLIC MAINENANCE
OTHER OPERATING EXPENSES(Conrd)
Rsrds&Leasss-land,Strucims S tmprovernnts
Taxes A Lbenses
Drug Scresninps b OM»r TswN
Ufilfbes
Olher(Spec
SUBTOTAL OTHER OPERATING EXPENSES
°ROFESSIONAL A SPECIAL SERVICES
TRANSPORTATION
Transporbtion
Trawl
Gas,ON,A Malyder ante—.VehicNs
Rent 6 Leases—Vehicles
Depreciation—Vehicbs
2USTOTAL TRANSPORTATION
TOTAL NONPERSONNEL
lndheet Cosb
TOTAL GROSS COSTS
j3P#E78" (W)
EXHIBIT 0-2
INSTRUCTIONS FOR DRUG MEDI-CAL FISCAL DETAIL Page 4 of 4
DRUG/MEDI-CAL PROGRAM
REPORT OF EXPENDITURES AND REVENUES
ADP FORM #r7895M (OMM, NAL)
This form will be completed for each provider of Medi-Cal services by type of treatment program (OMM, NAL). If a provider
operates more than one type of treatment program (is: OMM and NAL), a separate report form must be completed for each
treatment program. For County operated programs, prepare this form for each program.
HEADING: Enter the county name,contractor,contract number,contract period, Medi-Cal and CADDS Provider Numbers,and date
prepared.
COLUMN INSTRUCTIONS:
COLUMN A: Enter total of costs, revenues,:and units of service of Columns B, C, D, E for all lines.
COLUMN B: Enter total costs; for each category from pages 2 and 3. Revenues and units of service should be obtained from.
the Provider's records.
COLUMN C: Enter total costs; for each category from pages 2 and 3. Revenues and units of service should be obtained from
the Provider's records.
COLUMN D: Enter total costs for each category from pages 2 and 3. Revenues and units of service should be obtained from
the Provider's records.
COLUMN E: Enter total costs for each category from pages 2 and 3. Revenues and units of service should be obtained from
the Provider's records.
COLUMN F: Enter total of costs, revenues, and units of service of Columns D, E for all lines.
COLUMN G: Enter total of costs, revenues, and units of service of Columns C, F for all lines.
Note: The information in Column F should also be entered in the appropriate column of ADP Form 7225E-G.
UNE INSTRUCTIONS:
LINE G1: For contract and county-operated programs, the county will enter allowable county administration.
Allowable county administration costs pertaining to this Line are only the costs associated with utilization
review, billing, and training. (See Page 3 instructions below for reporting of other county administrative
costs).
TOTAL GROSS COSTS: Enter total amounts applicable to each of Columns B, C, D, E, F, and G.
LINE H: Enter total amounts applicable to each cost center.
LINE 1: Enter total amounts applicable to each cost center.
LINE J: Enter totals of the funding sources listed for each cost center. For county-operated programs, enter all
funding sources in the appropriate fines.
LINE K: Enter tectal amounts applicable to each cost center.
TOTAL REVENUES: Enter total amounts of all revenues (Lines H through K).
NET COSTS: Subtract. Total Gross Costs by Lines H,I,K for each cost center.
LINES L,M,N: Enter the total amounts applicable to each cost center.
LINE 0: Enter licensed slots applicable to each cost center.
LINE P: Compute the cost per unit of service by dividing Total Gross Costs by Line L(Face to Face Volts).
PAGES 2& 3: These costs provide a recording of the trial balance expense accounts from the provider's accounting books
and records under the major categories fisted.
Enter the costs, by line item,for each cost center. Column A will be the total amount of Columns B,C,D,E.
Column F will be the total of Columns ME. Column G will be the total of Columns C.F. Enter Subtotals for
each category in the appropriate Una*.
Page 3: Indirect IAdmiroistretiwI and Program)Costs:
For nongmunty providence, this Line includes all administrative and program kxarwt crests
For coarty-opmew programs, this Line includes indirect program (treatment) crests and either indirect administrative
costs such as, County A-87 overhead. Health and/or Mental Health Department, and Alcohol and Drug Programs
administrative costs. The allowable cdmiristrative costs for utilization review, billing, and trainirug must be reported
in Linn 61 on Page 1.
EXHIBIT P-1
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COMPLETION INSTRUCTIONS
DRLjG/NIEDI-CAL ELICIBILITI' WORKSHEET-IEE1 ADI' 1554
(FOR SUBMISSION OF FEDERAL DRUG/MEDT-CAL CLAIMS ONLY)
REPLACES;.DRUG/MEDT-CAL ELIGIBILITY WORKSHEET-ADP 1584 (REV. 6/92)
HEADING INSTRUCTIONS > Treatment Dates (continued).
METHADONE MAINTENANCE-Enter a two-digit code in the"first"
A. Enter the provider name(do not mix providers on one worksheet). field.Multiple(consecutive)days of service MUST be claimed on one
Bre.(i•e..April 1.1993 through April t5.•1993•MUST be claimed as
S. 'Enter the tour-digit provider code assigned by the Department of 0115).if there is a break in service,a new fine MUST be used with
'•Alcohol and Drug Programs. the same date format.
G. 1 Enter the month and year the worksheet is submitted for as a tour- J. Enter a 1 it"client was discharged during this month of service.
-droit numerical code(i.e..May, 1993-0593) otherwise leave blank.
D. Enter.one of the following two'digit Codes to indicate the program code- K. "Service Function Code(SFC)-Enter one of the following two•dmpil
20-Alcohol/Drug Services 25-Perinatal Services Service Function Code numbers:
Methadone Maintenance 20-29
E. Enter`one,of the lobowing two-digit codes to indicate Mode of Service - Day Care Hablfitative 30-39
provipad: ;- i - Na
h►exons 50-59
I 12!Outpatient Hospital Services Outpatient Drug Frac 80-89
17 Clinic,Services
F. Enter,page cumber and total papas submitted by provider NOTE: 00 NOT INTERMINGLE DIFFERENT SFCs ON THE SAME
ADP 15841
by program Code.by service lunation code.
t
LINE INSTRUCTIONS L. • units of Service-Enter units of service.One unit o1 service for each
visit for each client with acceptable federal aid codes.A separate visit
e may be claimed if a Client leaves the facility and returns for a second
i A- In alphabetical order enter the surname of the eligible Drug/ visit on the same day.
Medi-Cal client first:then enter only the initial of the first name.
1 i = M. Total Amount-Enter the total cost for each client including cents.
B. Enter'the client's record number(char)a st'program).
1 N. Good Cause Code-4f applicable.enter the alpha code to Indicate the
C.' Enter the Welfare identification number in its complete form as shown on "Good Cause"for any claim lines qualifying for exemption to the
i the Medi-Cal card. For Title XIX•beneficiaries with Welfare i submission deadlines.Refer to the instructions regarding-Good
Identification Numbers listed as(99-60-1234567890),the number is• Cause•'in ADP letter to Drug/Medi•Csl County Program Administrators
to beim the following format. i _ dated 8.5.86.
County Code i'' Aid Code Case Number FBU Pers.No. O. Duplicate Override-Enter the alpha code."Y"it this is s duplicate
29 1`60 '• 1 1234567 8 90
service.Include a Multiple Billing Override Certification lam ADP 77W
with the claim.
1 or:enter the Client's Social Sewrhy Number(SSN)saing
onty tM fust Dina fields sing the following format:
+ _ P. Total the cofimns for units of service and dollars Claimed for this page
County Code Aid Code Case Number : . and enter the totals it the appropriate spaces at the bottom of each
i
29 so 12345 pM last two boldest the Case eolumm
nunmw fields.FOU.t Pers.W are left blank)
+ S - - i Q.. On the Iasi page Of each provider's set of worksheets.enter the grand
D. Enter as a Muse dglt'coda,th fclient'a year of birth(a.g.'. ` tolab for Units of Serine and Total Dollars,Claimed.
1949,-949.;
R. The signature,phone cumber•end data is required as each page of
E. ;Enter the appropriate letter code to denote the client's sax: ° each mode of service and/or service function code.
sh
M-Ma �. F-Ferlsls . U_Unknown
._ ._
SUBMISSION INSTRUCTIONS .:
F. Enter this appropriate twmeric-code to denote the client's ace/atluriclty '` _
1-White 4-Awn/PacKlc 7-Filipino : A Retain the last gape(pink gimpy)for you records and submit tM original
1 2-Hispanic. - S-American Indiatl a "8" OIMr ' ' and fust two(white and yellow)eoplas to the county fiscal office for
i3-Bleep ' Alaskan Native processing.
0. Enter1M client's diaomostic code.Rom to this ArteriCam Pavel tric S. The County Mental Health fiscal offids shall forward:
Diaoro@M Sar}oa Matwal M for the preps).diagnoatie codas.
1 1.ADP 1884-Ose eri*01 and one copy(whits).and
FL 'Mo/yr of Sallee-4W9r"a bdrclpit code.the month and year that L ADP 1592-Oct original with original signatures and 3 copies
aervk*W tlraprovided UAL.Jansry 4911113-4119M. -.. •r- e. . ....
NOTE 00 NOT.REPORT SERVICES PROW XD N PRIOR FISCAL YEARS. NOTE..All proMdus
ea mt Ira NOW on the sans ADP 1592_
, _I
L Trestm.ni pates r t ± Department of Alcohol and Drug Programs
Complete the first and(sat trostmant date for all c6sats. Drug/Medi•Cal Section
_.:�. _ ..:.. .. .. .: 1700 K Street
Clients neaivklg CUfPATibff 0RLO PREF a DAY CARE MANNA7M—: Sacramento.CA OW 14.4037 .
adrvidoa coo aha Iolloadn8 tttrmst . r. I
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i day w o INO'spit Gods tier ata Oesl dwom es"tooalwd , ! .
ttratreaat frost atiaplorittar,,.. .......». ....- «.:.�:,•.o•.�•: _,..: ..•.....�. ..
f Last day-Eater s.......dipp Coda d{imp 1111 tlatse day Y aatalad M
l ant a���.sift r r.• t .. a .w.
The"fla!"sad~IatIC'traalmMt Clan mit ahray M IIN same CI a
Jima/0�10101."".•. .. . - • .. .. � _, - -. ,,... . ..
EXHIBIT P-2a
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COUNTY CERTIFICATION
�ITfiFYurdlerprna/fy of p ryriy friar/sm tri+oflaW respc =V@*w fire adrnitisfnrfon of DnW Program saviors In and*w said Beim int
of/lsrw rrat bickard ny of fie p wv idons ofSeesonus IWO lnou¢x 1OW 01016 Cv0v* mwrr Codi:frrrf frfr gnnrsrt!a►which
�r�ursenrent es alarmed herein is n aoeordenor wfM f?aplrr 3,Drisiarr 3 of lJer Wr/lar+r ar:d InslIIrOorss Cody:and trtri fail trig bait of my
70wledVi and belief tries algin is h al respras true,tomrct and in aco rdwor**')#If low.
IGNATI E GAZE E)XCU`IED AT .CA
17HUG PFnGRAM ADMINISTRATOR
> R/1Fyfarderperdy ofperjwy tlsrrt IBM tee defy gtd/bed amdafR=kvd ofldal of VW him W i dainsrrtnsspanslbfe fir ra axarnisrfton
ad pfliarraarr!olacmcrrfr.
iGNATUFE DATE EMCUTED AT ,CA
TLE (example: Conray Auditor—Controler.City Finance Officer,oft.)
NOTE ! ! ! -Signatures are required on each page of original ADP,1SM.
wgmietion frfstuf 6=for ACP 1582(revised M
GENERAL
The ADP 1562 MONTHLY CLAM FOR DRUG/MEDI—CAL FEMBUFWMENT AND MONTHLY PROVIDER SERVICE AND
FEVENUE SUMMARY is used tar reporing trW Drug/Medi—Cal units of service,tial dollar amount daimed,toal revenue
cdlecsed/repoted by source,claim disallowances and the net claim amount by provider.
HEADING INSTRUCTIONS
a. County—oftbr norm of coumty submitting claim
b. County Code —enter the two digit county code
C. Claim far Mo/Yr—ensu manih/year of service being b01sd
d. Program Code—ehodc the approprintm box for Alcohol Services(10)or Drug Sersces aq
a. Fiscal Year— enter!soil year of service
L Gars— enter fie date this form was oormpW d
Q. Page/of—wftr each page number and total of pages(i.e..payer 1 of 9)
COLUMNAR INSTRUCTIONS
a. Provider Name—ornar name of program pnoviding services
b. Provider Number—ensu the tour digit provider member assigned by the Department of Alcohol and Drug Programs
e. Service Fu nebon Code(SFC) —order the two digit SFC:20-29=Methadone Monwunce.30—WaDayears Hal:ilrsr-t e,
W-56=Nal:"exane,GO—®=0itpin rent Drug Fres
d. Units of Service—tar each mods of serviom,determine and emir the unfits N sewioa rendered or re by each provider for
to ubim month
e. Amours Claimed—for eadt mode of service,determine the teal dollars and carts inarred or reported by provider for the eisim month.
NOTEII ALL INCURFED OR REPORTED DOLLARS BILLED MUST BE SUPPORnED BY THE ADP 1584 DRUG/MEDI—CAL
ELIGIBILITY WORKSHF—M
t A*wVnwM to to Cocas Chir: FEVENLIE—for each mode of service and each provider,determine and order the wal
revenue adlecied or reported during the dais mordh by revenue source. FEVENLE SOUFivES NOT LISTED ON FRONTMAY E
REPORTED UNDER THE%7D ER COLUMN AND i AMOUNTENTERED. Those revenues not listed on tont are:Pzbern
kmfrance.Share of Coat and Grants. DISALLOWANCES—enter disallowanoes by provider.(orgy deduet Its FY disallowances)
p. Teal Rlevenue/Gaalonpncas—wrier tool of both revenue and dstalowanoss.
h.'Not Claim—net claim equals a- ow claimed.ninus total revenue and/or disalowaneec
t. Page Tatds—enter oakum foals for urtia of service.amount rimmed.%AM rovwwe and/or dsellcue noes and not Clalr.
1. Gland Toads—on the iast pave of rho non"Invoice.crag!a grand a tda of amount curried.tctl reverse and/or
ds dkwmn=s and net dim.
County Aepresefttafive Conaf:t—the td pftre and phone mintbar andudng the was code)at*u respcnsibie .
caurtly spraaonalive to c- act purposes shol be entered on tM bottom of Zhu page.
SUBMISSION INSTRUMONS: IWWL TO: Department at Alcohol and Drug Programs
1. The original Eigix V Werksheat(ACP 1504)and are oap1. DruglMod—Cal Socdc n
!. Original Dirallowunm by Provider torn(ADP=15)wfth 1700 IC Steet
original sign eares.and lino Copies Of seljustrt wft aro made Saosmento.CA RW14-47
In fAis nrorO s da'i m).
rti;.;...r u"ne,ty t^s.'nn M Orua/Msd—Cal Reimmhcrsarmrermt
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COUNTY CERTIFICATION
/C EffnPYsesdwPwwW alPwjury asst l am aw maid rrsaooU&M br aw ad nMrssadan of Ds p Prapam s nims band far add dwnwit
asst/Asre rot r iadfedanr a!f'„prcamiiarrc dSeamiars
107 t"=V h tlW d aw C>jorerrrrrwrr!Gbdr;Ars!aw armour!far which
rrrrs'xrrswrrsrrtAt di&Wwdharabr b h amoA*nw w1Eh darperr a DfWslon 3 claw WNbns and uncut om Cade;and a■ft to aw brat of ey
frrawf wW and brAisf lois a Wn Ar b d iegprasr Vw,aareatad v ewwdraor alar he Asa:
SIONATUNE WE EIECUTED AT .CA
MM PROGRAM ADMINSTRIATOR
10ER1TPYofdwPauftofPwAsysunlamOvsd*qLwwsdatsdmwxwAmdolfaWoffthwrh@W unttaspar-0k bowawnbsaar
aid asawrorrt a�Iie�sarrrsa.
SI WNATURE DIVE DECUTED AT .CA
TITLE (crumple: County Auditor-ConvWer.City Fireuoe Otiose,ale).
NOTE I 1 I Signatufm are mqulrld on each page of oTlginal ADP ISM.
Cwq*ban*WLVtl'arar bADP 11th¢evaed4W)
L GENERAL
Thr ADP 15M-MONTHLY CLAM FOR DM M1EDI-CAL.REIMBURSEMENT AND MONTHLY PROVIDER SEWCE AND REVENUE
BUMMMW Is used for repardng WW Drug4Ud-Owl unit of telae,tart ddler amount dwnwd.WW revoun wlected/reponed by scutes.
aloin dhalbwanOn and ft not chin wrount by pr&Adw.
It. HEADING INSTRUCTIONS
a. County-serer nacos of oounly submiffing abn
b. County Cods-entre the tyro dgft ocunty code
o. Clain for Mo/Vr-snrr rrcrth/ w of service bang biied
d. F'fOWwn Cods-the program cods 25 is pre-pri led an this form for pwi aW seniors
s. Raw Year-trete than year of wenioe
t Dot•-enter the dols this form utas campletd
g. Pags/d-enter each pope nu ba and WW of pages(.s..pope 1 of til
Ill. COLUMNAR INSTRUCTIONS
a. Provider Name-wmr matte of popam pnouidmnp eerviwss
b. PravWer Number-enrr the bur digitprovider ru ba assigned by the DepwVrw t of Abel-and Drug Propanes
c. Service Fu w an Code(SPC)-snrr the* and digit 8FC; 2D-29=Matwdone Msir lomwe.310-ai w Dsymae Hiabnrtive,
30-39-Nslremo w.e0-®•Oupabrrtt Drug Fres.
• d. Unft of 6rrAno -for each mode of service.deowmirs and enter the unit of renviar renired or repQtd by eaah provider for
ton ohim marilh
e. An oust Chirsd-br each crumb of servos,down w"tort dolars and ornt owned or reported by prwAdw br the aielm rnanh.
NOTEII ALL INGJRRED OR REPORTED DOLLARS BILLED MUST BE 6UPPOW110,6Y THE ADP 1394 DRUG)MOI-GAL
ELIGIBLTTY WORWHEEM
t A*n&nwrrr far the Grass CWnc FEVENUE-br each node atssnvha and esoh povidw,Mwnaiw and entr the tort
w e eolirobd or nperled darNrg to dsir mach by reveres wares. REVENUE 80UROE8 NOT LEM ON PRONE MAY E
IEPOATED LENDER THE 90T1ER!COLUMN AND$AMOUNT ENTERED. Thorn rwwnwr not fisted on Ucntam:Paden
Meawanoe.81wra of Castsmd GrwlL DMAl10WANCES-enter dmlommm by pwalder.(only de*otl*FY dmnwm noes)
9. Tahl ibvaree/Dissloura u-trete toll of bolls revenue and dealowanoss.
IL Nat Cham-nat elelm equeh wnwAt shined.mires tort revenue arrgEar tladoasarroaa.
L Pale Tarts=ante 01101M teras tor,welt of esMoa.enrarmd ahbrrs'Low wveue amlar dmloaaroas acrd ret dsbrL
j Grand Tart-an 1M Asst gels ditto nwrArAr tfawiss.enter tlta tT�d 9orh d arrrsaft ahlnrad.furl route usriMar
dl■loaanous and nut ddnL
CuwW apnsar60, OsrM■o1-to dpsrae cord phorrs im dm *stmng the anus some)alt o raepardbie
sorsa* P br adam pr+pmm;dtul d•earned Mtn' I d tlrr papa. .
SUMOWN OWN INMtlCi10N8: YAILM
1. Thu EipbiTiq►Walnlreat(ADp 13r�and ane Dopy
2. crow aisaloe.rros by P-a"ar ow exim vft DepafMwd of Alcohol and Drug Pfogrwra
anig. dpulurw wul Sw wpm P a4wWwft We mob Dnj~l—Qd Section
twtlrls cerarlrti ort 1700 W Strout
S Cdghrl IWlw ly chinbr 0ugrMedi-OW Rrinmbvrearnent Saammonlo,CA 05814-4037
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COMPLE7710NINSTRUCTIONS FOR DISALLOWANCES BYPROVIDER ADP 5035 B ,
• GENER
The ADP Disallowance by Provider form is used by a Drug/Medi—Cat Provider to report disallowable units of service identified by the
County/Provider Utilization Review Committee(URC) -
Report only one fiscal year(FY)on a page
Report disall6wances for only one provider and one service function code per page
Submit only.one month per fine _
: HgADING 1NSfRUgMONS
a. URC MINUTES DATED—enter the date of the monthly URC meeting when the disallowances were identified.
b. FISCAL YEAR—enter the FY that disallowances are for
c. COUNTY—enter the county name in which the provider Is located
d. PROVIDER NAME—enter the name of the program submitting the disallowances
e. PROVIDER NUMBER—enter the four—digit provider number assigned to the program by the Department of Alcohol and,Drug
Programs(ADP)
1. SERVICE FUNCTION CODE(SFC)—enter the two—digit SFC for.20--Methadone Maintenance;30—Day Care Habilhative;
S( —Naltrexone;or 60—Outpatient Drug Free
g PROGRAM CODE—enter one of the following two—digit codes to Indicate the program code:
10—Alcohol Services 20—Drug Services 25—Perinatal Services
li. PAGE—enter this page number and the total number of pages being submitted per provider.FY,andsenrice function code
COLUMN INSTRUCTIONS
a. CLIENT NAME—enter the client name:last name,first initial
b. CHART NUMBER—enter the client chart number
c REFERENCE CLAIM I.D.NUMBER—enter the number preceded by a'D',located in the upper right comer of the Drug/Medi—Cal
Eligibility Worksheet ADP 1584 and the line number where the claim appears. For tape submissions use the number on the first
column of the facsimile ADP 1584 that is preceded by an*A'(the last two digits are the line number)
u. DISALLOWANCE DATES—enter the beginning and ending dates of the disallowance
e. DISALLO:VANCE REAS014—enter the reason for the disallowance using the codes from the lower front of this form
f. CLAIM FOR MO/YR—enter the four—digit code that indicates the monthlyear(mo/yr)from the header of the ADP 1592 in which
the services were billed
6 Ur.ITS 3F SERVICE(U/S)—enter the number of units(visits)to be disallowed for each month of service
DOLLARS DISALLOWED
a TOTAL—enter the dollar amount.including cents.to be disallowed for each fine
PAGE TOTALS
a. Tabulate the total for the U/S column and enter the total at the bottom of the column
b. Tabulate the total for dollars.including cents.disallowed and enter at the bottom of the page
GRAND TOTALS .
If more than one page per provider and FY.enter grand totals at the bottom of the last page.
En:er URC Chsitperson/URC member's signature and date
PROGRAM SUBMISSION INSTRUCTIONS
Upon idemilying a disallowable unit(s).the URC shall complete this fort,forward the while original and the blue county copy
to the county fiscal office,pink copy to ADP,and attach yellow copy to the signed.dated minutes
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COUNTY SUBMISSION INSTRUCTIONS _
c The county fiscal office shall process the ADP 5035 B by deducting the grand total amount from Ow next monthly
claim to be submitted to ADP and attach the original and two copies of tate ADP 5035 8 to the monthly claim
If the d!sallowanee is for a prior year,the county shall forward the original and two copies of the ADP 5035 B to ADP
MAIL To: Department of Alcohol and Drug Programs
Drug/Medi—Cal Section
1700 K Street
Sacramento, CA 95814.4037
RcVISED W4
.EXHIBIT P-4
11irrAm oP GALrowm-NES TH AND WELFARE Ammy DEPARTMENT OF ALCOHOL AND DRUG PROD" Ma
GOOD CAUSE CERTIFICATION
=May USE ONLY
County requests a waWr of the two Month DruglMedi-Cal billing
Imitations for the We clelm ontrin on the attached:
[ )ADP 1584 forms [ J Error Correction Reports for the run date of .
Enter the seven digit claim LD.d(the number preceded by the letter W for manual claims or W for tape
submissions)and the line#of the claim to be affixed with a good cause code in the spaoes below
CLAIM I.D. No. LINE No. CLAIM FOR MO/YR CLAIM I.D. No. LINE No CLAIM FOR MO/YR
The boxes checked below(with corresponding alphabetical letter written In the GOOD CAUSE COLUMN
of ADP 1584)are the applicable good cause reason(s)as specified in Title 22, Section 51008, for each late claim.
L ] A. Patient or l ega1 reprelmadve's failure to present Medi-Cal identification
[ ] B. Billing involving other coveraM including/not limited to Medi-Caw, Kaiser. Ross-Loos. or Cbanq=
[ ] C. Circumstaaaes beyond ft eomtral of the county/provider regarding delay or error in the caurimtion
of Medi-Ctrl elilpibility of the benefuaary by the ante or county
[ ]
E. Special that came a b0iag delay such as a court de=an or far hearing demon
[ J F. Iai<iatioa of legal prooeedings to obtain payment of a liable third party pursuant to Section 14115 of
the Welfare and InairWon Code
6"ture of Count'Reprawntative Phone Number Date
t 1
ATE USE act' •`�, _-
r
j D. Cu+atmeaaaoes beyond the control of ft ootmt11fprovider:e0nding delays caused by=mnd dfsaaer
and wrglfol sots by an amplic e,delays is prvHda oartafuad m, or other circtaataoes that have
boon nVotted to the appropdW bw eaiosoemeat os fire agency when applicable
HAVE CHECKED BOX'O'ABOVE AND HEREBY APPROVE THE ATTACHED COUNTYIPROVIOER'S SUBSTANTIATING
DOCUMENTATION FOR 0000 CAUSE REASON 0
Signature—Fiscal Unit Date
W 61765(Rev.
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EMBIT R
DEPARTMENT OF ALCOHOL AND DRUG PROGRAMS - Page 1 of 3
DRUG/MEDI-CAL FISCAL DETAIL
DRUG/MEDI-CAL PROGRAM COST SUMMARY
COUNTY CONTRACT NUMBER
CONTRACTOR
CONTRACT PERIOD MEDI-CAL PROV.NUMBER
DATE PREPARED CADDS PROVIDER NUMBER
TYPE OF PROGRAM (Specify as OMM,NAL,ODF,DCH,RES)
ADJUSTMENT OF TOTAL COST
1 2
LESS
TOTAL UNALLOWABLE PROGRAM
CATEGORY PROVIDER COSTS COSTS ADJUSTED COST
A. PERSONNEL SERVICES
8. DIRECT SERVICES
C. EQUIPMENT,MATERIAL,d SUPPLIES
D. OTHER OPERATION EXPENSES
E. PROFESSIONAL A SPECIAL SERVICES
F. TRANSPORTATION
G. INDIRECT COSTS
MEDI—CAL PROVIDER COST CALCULATION
PROGRAM COUNTY
ADJUSTED COST ADMINISTRATION TOTAL
01 TOTAL SERVICE COSTS 01
02 TOTAL SERVICE UNITS 02
00 COST PER UNIT OF SERVICE 03
04 MAXIMUM ALLOWABLE UNIT RATE 04
RUG MEDI-CAL UNITS OF SERVICE
0S I TOTAL UNITS OF SERVICE 0S
OST OF DRUG EDI-CAL UNITS OF SERVICE
00 COST Wm a X Lkw 5) 00
10 MAXIMUM ALLOWED 4 X Lka 10
11 DRUG/MEDI-CAL ALLOWED 22=of Lkw 00 or 1 11
=VENUE FROM DRUGIM®I-CAL UNITS OF SERVICE
11 1 REVENUE 14
DRUB CAL OOSTd
17 NET COST C.Im 11 w*m Ling 1 17
20 I ES8: AMOUNT RECEIVED m
21 BALANCE DUE PROVIDER 21
)P#7990(W)
EXHIBIT R
INSTRUCTIONS FOR DRUG MEDT-CAL FISCAL DETAIL - Page 2 of 3
DRUG/MEDI-CAL PROGRAM COST SUMMARY
ADP FORM 47990(OMM, NAL) '
This form replaces ADP 7410/741 OP and ADP 741117411 P and must be completed for each provider of Medi-Cal services and
in conjunction with ADP Form 741517415P.
ADJUSTMENT OF TOTAL COST
HEADING: Enter the county name, contractor, contract number, contract period, Medi-Cal and CADDS Provider Numbers, and
date prepared.
Note: For County operated programs, prepare this form for each program.
COLUMN INSTRUCTIONS:'
COLUMN 1: Enter total provider costs for each cost category from Page 1, Column F (Total MC/NNA/Public) of ADP Form
7895M.
COLUMN 2: Less Unallowable Costs - Enter total unallowable costs for each category. Unallowable costs are those costs
that are not reimbursable by Drug/Medi-Cal-
COLUMN 3: Enter the total of Column A mim s Column S.
MEDT-CAL PROVIDER COST CALCULATION
COLUMN AND UNE INSTRUCTIONS:
UNE 01: Enter Total Program Adjusted Cost from Column C above (Total of Lines A through G) in Column 1 and the amount
of County Administration in Column 2 and the sum of Columns 1 and 2 in Column 3.
COUNTY ADMINISTRATION:
For contract providers, county administration will consist of County Utilization Control Review, training and billing
costs.
For county-operated programs, county administration includes indirect administrative costs such as, County A-87
overhead, Heath and/or Mantel Health Department and Alcohol and Drug Programs administrative costs, and the
costs associated with utilization review, billing, and training.
UNE 02: Enter the total service units from Page 1, Coluam F. Line L of ADP Form 7895M in Columns 1 and 3.
UNE 03: Enter the cost per unit of service by dividing Lina 01 by Line 02 for Columns 1 and 3.
UNE 04: Enter the maximum allowable unit rats in Columns 1 and 3.
UNE 05: Enter the Dnp/Medi-Cal service units from Page 1, Column D, Line L of ADP Form 7895M in Columns 1 and 3.
UNE 09: Enter the cost of Dnq/Miedi-Cal units of service, Line 03 multiplied by Una 05, in Columns 1 and 3.
UNE 10: Enter the maximum allowed cost of Drug/Madi-Cal units of service, Line 04 multiplied by Lina 05, in Columns 1 and
3.
UNE 11: Enter the amount of allowable Dnrg/Medi-Cal, for Columns 1 and 3. Enter the lesser of Line 09 or Line 10. (The
dollar amount should equal those shown in Column 4 of Actual Costs of ADP Form 7415.)
JNE 14: Enter the revenue attributed to Federal DnplMedii-Cal units of service Inquired co-payments) for Columns 1 and 3.
JNE 17: Enter the Net Drug/Modi-Cal costs, Una 11 minus Line 14,for Columns 1 and 3.
JNE 20: Enter the amount of reimbursement received from the county in Column 1.
JNE 21: Enter the balance due the courtly or provider. Lina 17 minus Line 20,in Column I. .
Note: Do not complete Liras 20,21 for corsnty-operated programs.