Mental Health and Substance Use and Prevention Treatment service providers (county-operated and contracted) are required to meet client chart documentation standards as established by Medi-Cal and the Division of Behavioral Health Services. Providers are responsible for ensuring that clients meet medical necessity and target population guidelines, understand and apply both billable and non-billable service codes, and how to submit Medi-Cal claims that comply with State and Federal statutory and regulatory requirements. The Division of Behavioral Health Services offers documentation trainings throughout the year.
Below are brief descriptions of the trainings provided as well as a reference list of materials referred to during training.
Documentation Training is offered to provider staff throughout the year (see Training Calendar).
Adult/Child Documentation Day 1:
Target Audience: Direct service staff and clinical supervisors
- Introduction to the Mental Health Plan
- Medical Necessity to the Mental Health Plan
- Cultural Competence
- Review of SUPT services available
- Review Clinical Documentation Requirements/Standards
- SmartCare requirements
- CalAIM Assessment
- Review of CANS, PSC-35, and ANSA
- Care Plan Within Service Notes
- Appropriate for SmartCare users and Providers with their own EHR
Adult/Child Documentation Day 2:
Target Audience: Direct service staff and clinical supervisors
- Review Service Notes and Procedure Codes
- Billable and Non-Billable Procedure Codes
- Procedure Code Break Out Room Group Activity
- Connects Clinical Practice and Documentation
- MHSA/Support Services Procedure Codes (included for applicable programs)
- Programs and Housing Plan
- Appropriate for SmartCare users and Providers with their own EHR
Crisis Programs Documentation:
Target Audience: Direct service staff and clinical supervisors at crisis services programs
- Introduction to the Mental Health Plan
- Medical Necessity
- Cultural Competence
- Diagnosis and Problem List
- Documentation Requirements/Standards
- Care Planning
- Linkage for MH/SUPT Services
- Service Notes
- Classifications and Procedure Codes
- Discharge/Transition Planning
SUPT Treatment Programs Documentation:
Target Audience: Direct service staff and clinical supervisors
- Introduction to the DMC-ODS Plan
- Medical Necessity to the DMC-ODS Plan
- Cultural Competence
- Review of SUPT services available
- Review Clinical Documentation Requirements/Standards
- SmartCare Requirements
- CA ASAM Assessment
- Review of Health Questionaire and Physical Exam Requirements
- Care Plan Within Service Notes and Requirements
- Review Service Notes and Procedure Codes
- Billable and Non-Billable Procedure Codes
- Connects Clinical Practice and Documentation
- Appropriate for SmartCare users and Providers with their own EHR
- Procedure Code Group Activity
See resource materials below related to documentation:
Claiming for Case Consultation
Members' Handbook
Sacramento County Approved Acronyms & Abbreviations
MH Best Practices Assessment Checklist
MH Care Plan-Treatment Plan Checklist
SUPT Best Practices Assessment Checklist
SUPT Care Plan Checklist
Group Attendance Sheet Template
Sacramento County Scanned Document Management Form
Special Populations Definitions
Discharge Options
QM FAQ
For Policies & Procedures (P & P) related to documentation requirements, see our P & P webpage or send an email to QMInformation@saccounty.gov
