Policy and Procedure Manual

​​​​​​​​​​​​​​​​​​​​​This Policy & Procedure Manual provides a record of policy decisions and administrative and clinical procedures to guide the provision of behavioral health services administered by Sacramento County staff and contracted service providers. ​The Behavioral Health Services Director reserves the right to change, modify, or supersede any of the policies and procedures at any time. 
Note: Policies and Procedures created by/for the Division of Behavioral Health Services (BHS) as part of the Department of Health and Human Services are still applicable to ​BHS as a division of the reorganized Department of Health Services.
For additional information regarding policies and procedures, please contact your program coordinator or send an email to bhs-dhs@saccounty.gov.
Enhanced Care Management (ECM​)​
ECM 02 Provider Service Provisions​​

Mental Health (MH) and Mental Health Access (MH Access)

MH 02-01 Contract Advance
MH 02-05 Quarterly Reports
MH 02-08 Definitions of Common Terms Used in the Service Contracts
MH 02-10 Leased Vehicles
MH 02-12 Corrective Action Plan
MH 02-20 Family Advocate/Partner
MH 02-21 Youth Advocate​ ​
​MH 4-02 Multi-Agency Collaboration Agreement
MH 04-03 Subacute Placement Referrals
MH 04-06 Crisis Residential Referral and Admission 
MH 04-07 Enrollment of Youth in the Wraparound Program
     MH 04-07 Attachment A: Wraparound Referral Form
     MH 04-07 Attachment B: Sacramento County Wraparound Program Payment and Termination Notice Form SC123X
     MH 04-07 Attachment C: Wraparound Reimbursement Rate
     MH 04-07 Attachment D: Wraparound Exception Request
MH 04-08 Level of Care Utilization System
MH 04-09 Use of Wraparound Funds (under revision) 
MH 04-10 Child and Family Team
MH 04-11 Prevention Assistance & Re-Housing Services ​
     MH 04-11 Attachment A: Rent Reasonableness Checklist Certification
     MH 04-11 Attac​hment B: Maximum Rental Assistance Calculator
MH 04-12 Therapeutic Behavioral Services​ (under revision)
MH 04-15 Juvenile Justice Competency Remediation
MH 04-19 Level of Intensity Screening Tool
​​MH 05-01 ECT Authorization f​or Adults with forms​​
MH 05-02 ECT Authorization for Children
MH Access 02-01 Mental Health Plan's After Hours Response
MH Access 02-02 Access Team Services
MH Access 02-03 ​Urgent Service Requests
MH Access 02-04 Authorization Requests
MH Access 02-05 Out of County
MH Access 02-06 Notices of Action
MH Access 02-07 Provision of Second Opinions​​ 

Quality Management (QM)

QM 00-01 Uniform Method of Determining Ability to Pay (UMDAP)
QM 00-03 EHR Account Management and Password Protection
QM 00-04 Use of AVATAR Billable and Non-Billable Codes
QM 00-05 Pharmaceutical Company Representatives
QM 00-06 Medication Support Staff Electronic Documentation Requirements
QM 00-07 AVATAR Document Management for Clinical Records
QM 00-08 Deletion of Open & Closed Charges
QM 00-09 Client and Family Billing​
QM 00-10 Division of Behavioral Health - Telepsychiatry
QM 01-03 Interpretation Services by Family Members
QM-01-07 Determination for Medical Necessity & Access to Specialty Mental Health Services​​
QM 01-08 Inpatient Hospitalization Treatment Authorization Requests
QM 02-01 Notice of Adverse Benefit Determination 
QM 02-04 Presumptive Transfer (Assembly Bill 1299)
QM 03-01 Problem Resolution
QM 03-04 Nurse Practitioner
QM 03-05 Advance Medical Directive
QM 03-06 Licensure Waiver and Monitoring of Accrued Supervised Hours
QM 03-07 Staff Registration and Credentialing (Click here for Staff Registration and Credentialing Forms)
QM 03-08 Problem Resolution Forms and Brochures Distribution
QM 03-09 Physician Assistant
QM 03-10 Conlan vs. Bonta Claims
QM 03-11 Video and Audio Recordings of Consumers
QM 03-12 Incident Reporting and Breach Notification of Protected Health Information
QM 03-13 License Differential
QM 04-01 Site Certification of Provider Physical Plant
QM 05-01 Credentialing Policy for Network Providers
QM 05-02 Credentialing Policy for Organizational Providers and County Mental Health Programs
QM 05-03 5150 Welfare & Institutions Code Certification & Designation
QM 05-04 Day Program Requirements
QM 07-02 Medication Monitoring
QM 07-03 Dispensing “Sample” Medications
QM 07-05 Vital Sign Training for Unlicensed Staff
QM 08-01 Clinical Pathways​​​
QM 08-02 Continuity of Care
QM 09-01 Adverse Incident Reports
QM 09-02 Quality Assessment and Performance Improvement Program
QM 09-03 Continuing Education Requirements
QM 09-05 Electronic Utilization Review/Quality Assurance Activities
QM 10-23 Out of County Authorization, Documentation and Billing Procedure 
QM 10-25 Health Questionnaire
QM 10-26 Core Assessment
QM 10-27 Client Plan​ 
QM 10-28 Discharge Process 
QM 10-29 Mental Status Exam
QM 10-30 Progress Notes (Mental Health) 
QM 10-31 Child and Adolescent Needs and Strengths (CANS) Assessment Standards
QM 10-32 Informed Consent for Psychotropic Medication
QM 10-33 Pediatric Symptom Checklist (PSC-35) Standards
QM 10-34 Adult Needs and Strengths Assessment (ANSA) Standards
QM 14-01 Review Process for Implementation of New Clinical Practices
QM 20-01 DHS Claims Certification and Program Integrity
QM 20-03 Deficit Reduction Act False Claims Recovery
QM 20-05 Timely Access
     Attachment A - MH Non-Psychiatric SMHS Timeliness Record​
     Attachment B - MH Psychiatric SMHS Timeliness Record
​     Attachment C - SUPT Outpatient Timeliness Record
     Attachment D - SUPT Opioid Timeliness Record
QM 41-01 Division of Behavioral Health Services Compliance Program
QM 41-03 Division of Behavioral Health Services Code of Conduct
QM 42-01 Division of Behavioral Health Services Compliance Officer
QM 42-02 Division of Behavioral Health Services Compliance Committee
QM 44-01 Division of Behavioral Health Services Issue Reporting 
Substance Use Prevention and Treatment (SUPT)
SUPT 01-01 SUPT Overview
SUPT 02-08 Provider Reimbursements
SUPT 02-09 Provider Overpayment​
SUPT 02-10 Victims of Trafficking and Violence Protection Act of 2000
SUPT 03-01 DMC-O​DS Overview
SUPT 03-02 Distribution of Informing Materials
SUPT 03-03 Timeliness to Services
SUPT 03-08 California Assembly Bill 2760 Anti-Overdose
SUPT 03-09 DMC-ODS Medication Monitoring
SUPT 03-10 DMC-ODS Over and Underutilization
SUPT 03-11 Coordination and Continuity of Care
SUPT 03-12 Scope of Practice​
SUPT 03-13 DMC-ODS After-Hours Response
SUPT 03-14 Naloxone-Distribution-Project
​​SUPT 03-15 DMC-ODS Out of Network Single Case Agreements​​​
SUPT 04-01 Prevention Services Overview
SUPT 09-02 Non-Religious Alternatives to 12-Step Programs
SUPT 10-01 Confidentiality and Release of Client Information
SUPT 11-01 Maintenance of Provider Directories
SUPT 11-02 Electronic Health Record and Documentation ​
SUPT 11-03 Data Reporting