- Participating Physician Groups (PPG)
Health Net Medi-Cal members obtain the following mental health services through MHN, Health Net's behavioral health subsidiary:
- Individual and group mental health evaluation and treatment (psychotherapy)
- Psychological testing to evaluate a mental health condition
- Outpatient services that include laboratory work, medications and supplies
- Outpatient services for the purposes of monitoring medication therapy
- Psychiatric consultations
Members do not need to contact their primary care physician (PCP), participating physician group (PPG) or attending physician to request a referral for mental health care services. Health Net members may obtain these services directly through MHN's extensive behavioral health network by calling the member services telephone number listed on their identification card (ID). Participating providers may also contact MHN for assistance with mental health services referrals.
Prior authorization is not required for initial assessment for outpatient behavioral health services.
PCPs may refer members to MHN marriage and family therapists, social workers, professional counselors, psychologists, and psychiatrists for services, as follows:
- Marriage and family therapists, social workers, professional counselors, and psychologists can:
- Diagnose, treat and consult for the management of mild to moderate emotional problems for which the PCP or member feels the need for consultation.
- Evaluate cases for which a member would benefit from psychotherapy in addition to psychotherapeutic medication.
- Conduct psychological testing for clarification of diagnosis to establish a treatment plan (psychologists).
- Psychiatrists can:
- Diagnose, treat and recommend a medication regimen in difficult or complex cases, including cases of depression that do not respond to a 60-day trial of selective serotonin re-uptake inhibitor (SSRI) medications or other antidepressants.
- Evaluate cases in which members report feeling suicidal or homicidal, severe anxiety states, clear somatoform disorders, schizophrenic disorders where Clozaril® or risperidone is being considered, and bipolar disorder where lithium, carbamazepine or valproic acid may be needed.
PCPs are responsible for coordinating referrals for members requiring specialty or inpatient mental health services to county mental health plans (CMHPs) in Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, San Diego, San Joaquin, Stanislaus, Tulare. PCPs retain responsibility for coordination of ongoing care for co-existing medical and mental health needs and provision of medically necessary medications.
The Mental Health Services Division (MHSD) oversees CMHPs and each county is required to provide access to specialty mental health services for Medi-Cal members. Refer to the MHSD Medical Necessity Criteria document for additional information about criteria for specialty mental health services.
Refer to the Medi-Cal Rx program for psychotherapeutic medications excluded. These medications are covered through the Medi-Cal fee-for-service (FFS) or Medi-Cal Rx program. Providers must bill the state directly for these medications.
Health Net is responsible to:
- Monitor appropriate referral of members by primary care physicians (PCPs) through audits (specific services may be considered Early and Periodic Screening, Diagnosis and Treatment (EPSDT) supplemental services for members under age 21).
- Monitor the availability of coordination of care services when indicated and requested by the PCP or mental health care provider.
- Provide medically necessary emergency room (ER) professional services and medical transportation services for emergency medical conditions. This includes facility charges for ER visits that do not result in a psychiatric admission and all laboratory and radiology services necessary for the diagnosis, monitoring or treatment of a member's mental health condition.
- Transportation for non-emergency conditions is not covered unless prior authorized. ER services for non-emergency medical conditions, services after stabilization, or an emergency medical condition require authorization.
The following Mental Health Services Division (MHSD) medical necessity criteria for specialty mental health services are the responsibility of the county mental health plan (CMHP).
Diagnosis - The member must have one of the following DSM IV-included diagnoses, which indicates the focus of the intervention provided:
|Included diagnosis||Excluded diagnosis*|
*A beneficiary may receive services for an included diagnosis even if an excluded diagnosis is present.
**Early and Periodic Screening, Diagnosis and Treatment (EPSDT) beneficiaries with an included diagnosis and a substance-related disorder may receive specialty mental health services directed at the substance use component. The intervention must be consistent with, and necessary to the attainment of, the specialty mental health treatment goals.
Impairment - Member must have one of the following as a result of an included mental disorder:
- A significant impairment in an important area of life functioning
- A probability of significant deterioration in an important area of life functioning
Children also qualify if there is a probability the child will not progress developmentally as individually appropriate. Children covered under EPSDT qualify if they have a mental disorder that can be corrected or ameliorated.
Intervention related - All three of the following must apply:
- The focus of proposed intervention is to address the condition identified in the impairment criteria identified above.
- It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning, or for children, it is probable the child will progress developmentally as individually appropriate (or if covered by EPSDT can be corrected or ameliorated).
- The condition would not be responsive to physical health care-based treatment.
Primary care physicians (PCPs) provide outpatient mental health services within the scope of their practice. The PCP is responsible for identifying and treating, or making a specialty medical referral for, the member's general medical conditions that cause or exacerbate psychological symptoms.
If members require mental health services for mild to moderate conditions, PCPs may refer members to MHN for assessment and referral to a mental health provider. PCPs must continue to:
- Make available all necessary medical records and documentation relating to the diagnosis and care of the mental health condition that resulted in a referral.
- Ensure the appropriate documentation is included in the member's medical record.
- Respond to requests to coordinate non-specialty mental health conditions and services with specialists.
Examples of mental health services generally considered appropriate to be provided by the PCP are:
- Complete physical and mental status examinations and extended psychosocial and developmental histories when indicated by psychiatric or somatic presentations (fatigue, anorexia, overeating, headaches, pains, digestive problems, altered sleep problems, and acquired sexual problems).
- Diagnosis of physical disorders with behavioral manifestation.
- Maintenance medication management after stabilization by a psychiatrist or, if longer-term psychotherapy continues, with a non-physician therapist.
- Diagnosis and case management of child, elder and dependent adult abuse and domestic violence victims.
- Coordination of psychological assessments to rule out:
- General medical conditions as a cause of psychological symptoms.
- Mental or substance-related disorders caused by a general medical condition.
Participating physician groups (PPGs) are responsible for providing the initial health history and physical assessment of members admitted to the psychiatric ward of a general acute care hospital or to a freestanding licensed psychiatric inpatient hospital.
Health Net's public programs administrators resolve disputes that arise between the county mental health plan (CMHP) and Health Net or the primary care physician (PCP). During the dispute period, the Health Net Medi-Cal Health Services Department and the PCP or specialty provider continue to coordinate the care of the member until the matter is resolved.
The need for referral for specialty mental health services is determined by the primary care physician's (PCP's) evaluation of the member's medical history, psychosocial history, current state of health, and any request for such services from either the member or the member's family. Once the determination has been made to refer the member for specialty mental health services, PCPs may do one of the following based on the member's level of mental health impairment:
- For members with mild to moderate impairment, providers may contact MHN for assistance.
- For Health Net members assigned to Molina with mild to moderate impairment, refer to the Molina Behavioral Health Services Line.
- For all Medi-Cal members with a severe level of impairment, refer to the county mental health plan (CMHP) for specialty mental health services (SMHS). Providers may also refer directly to the CMHP.
Refer to the Mental Health Services Division (MHSD) Medical Necessity Criteria in the section above for included and excluded diagnoses and information on when to refer to the CMHP.
Members may self-refer to MHN by calling the member services telephone number listed on their identification card (ID). The member services representative transfers the member's call to MHN on behalf of the member. Health Net members assigned to Molina may also self-refer by calling the member services telephone number listed on their ID card.
Specialty mental health services covered by county mental health plans (CMHPs) include:
- Outpatient services
- Mental health services, including assessments, plan development, therapy and rehabilitation
- Medication support
- Day treatment services and day rehabilitation
- Crisis intervention and stabilization
- Targeted case management
- Therapeutic behavior services
- Residential services
- Adult residential treatment services
- Crisis residential treatment services
- Inpatient services
- Acute psychiatric inpatient hospital services
- Psychiatric inpatient hospital professional services
- Psychiatric health facility services
Refer to the Mental Health Services Division (MHSD) Medical Necessity Criteria discussion above for additional information.