Additional Coverage Requirements and Clarifications. 18.5.1 The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Cal, reside in Marin County, and meet the criteria for DMC-ODS services as per established requirements above.
18.5.2 Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when:
18.5.2.1 Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis.
18.5.2.1.1 Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- ODS services provided are reimbursable.
18.5.2.1.2 All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”.
18.5.2.2 Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan.
18.5.2.3 While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 23-068, treatment plans continue to be required for some services in accordance with federal law. Treatment plans are required by federal law for: Narcotic Treatment Programs (NTPs) and Peer Support Services.
18.5.2.4 Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.
Additional Coverage Requirements and Clarifications. The target population for DMC-ODS SUD services includes members who are enrolled in Medi-Cal, reside in Placer County, and meet the criteria for DMC-ODS services as per established requirements above.
