California Code of Regulations
Title 9 - Rehabilitative and Developmental Services
Division 1 - Department of Mental Health
Chapter 11 - Medi-Cal Specialty Mental Health Services
Subchapter 1 - General Provisions
Article 3 - Administration
Section 1810.380 - State Oversight

Universal Citation: 9 CA Code of Regs 1810.380

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) The MHPs shall be subject to state oversight, including the following:

(1) Site visits and monitoring of data reports from MHPs and claims processing.

(2) Reviews of program and fiscal operations and the books and records of each MHP to verify that medically necessary services are provided in compliance with this Chapter and the contract between the Department and the MHP.
(A) These books and records shall disclose the quantity of covered services provided under this contract, the quality of those services, the manner and amount of payment made for those services, the beneficiaries eligible to receive covered services, the manner in which the MHP administered its daily business, and the cost thereof.

(B) Such books and records shall include, but shall not be limited to, all physical records originated or prepared pursuant to the performance under the MHP's contract including working papers, reports submitted to the Department, financial records, all medical and treatment records, medical charts and prescription files, and other documentation pertaining to services rendered to beneficiaries.

(C) These books and records shall be maintained for a minimum of three years after the final payment is made and all pending matters closed, or, in the event the MHP has been duly notified that the Department, the U.S. Department of Health and Human Services, or the Comptroller General of the United States, or their duly authorized representatives, have commenced an audit or investigation of the contract, until such time as the matter under audit or investigation has been resolved, whichever is later.

(3) Immediate on-site reviews of MHP program operations whenever the Department obtains information indicating that there is a threat to the health or safety of beneficiaries.

(4) Monitoring compliance with problem resolution process requirements contained in Subchapter 5 and the MHP's Implementation Plan.

(5) Monitoring provider contracts to ensure that the MHP enters into necessary contracts with DSH and Traditional Hospitals and that, pursuant to title 42 CFR section 438.230(a)(1), the MHP is accountable for any functions and responsibilities it has delegated to any subcontractor or another MHP.

(6) Monitoring denials of MHP payment authorizations.

(7) Annual, external, independent reviews of the quality outcomes of, timeliness of, and access to, the services covered by the MHPs as required by Title 42, Code of Federal Regulations, Section 438.204.

(b) If the Department determines that an MHP is out of compliance with State or Federal laws and regulations or the terms of the contract between the MHP and the Department, the Department may take any or all of the following actions:

(1) Require that the MHP develop a plan of correction.

(2) Withhold all or a portion of payments due to the MHP from the Department.

(3) Impose civil penalties pursuant to Section 1810.385.

(4) Terminate the contract with the MHP pursuant to Section 1810.323.

(5) Take other actions deemed necessary to encourage and ensure contract and regulatory compliance.

(c) If the Department determines that an action should be taken pursuant to Subsection (b), the Department shall provide the MHP with a written Notice of Noncompliance. The Notice of Noncompliance shall include:

(1) A description of the violation

(2) A description of any corrective action required by the Department and time limits for compliance.

(3) A description of any and all proposed actions by the Department under this Section or Sections 1810.385 or 1810.323, and any related appeal rights.

(d) Except as provided in Section 1810.325, the MHP may appeal the Notice of Noncompliance to the Department, in writing, within 15 working days after the receipt of the notice, setting forth relevant facts and arguments. The Department shall grant or deny the appeal in whole or in part within 30 calendar days after receipt of the appeal. Except as provided in Section 1810.325, the Department shall suspend any proposed action pursuant to Subsection (c)(3) until the Department has acted on the MHP's appeal.

(e) In consultation with representatives from beneficiaries, their family members, MHPs, and selected other stakeholders, the Department shall develop, and update as appropriate, a comprehensive oversight program. The Department may effect this oversight program through administrative actions; incorporation into regulation as changes to this Section, to Implementation Plan requirements in Section 1810.310 or to other standards in this Chapter; and amendments to the contract between the Department and each MHP.

1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.
4. Editorial correction of HISTORY 3 (Register 98, No. 39).
5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.
6. Editorial correction of HISTORY 5 (Register 2000, No. 42).
7. Editorial correction of HISTORY 5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8. Amendment of subsection (a)(2), new subsections (a)(2)(A)-(C), amendment of subsection (a)(5) and amendment of NOTE filed 10-18-2010; operative 11-17-2010 (Register 2010, No. 43).
9. Change without regulatory effect amending subsection (a)(2)(C) and NOTE filed 8-24-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 35).

Note: Authority cited: Sections 10725, 14680 and 14700, Welfare and Institutions Code. Reference: Sections 14684, 14712, 14714 and 14718, Welfare and Institutions Code; and Title 42, Code of Federal Regulations, Sections 438.204, 438.230 and 438.6.

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