Behavioral Health

CenCal HEALTH members have access to services addressing mental health and substance use.  Coverage and provision of these services are shared between CenCal Health, County Behavioral Health Services and State FFS.  CenCal Health Behavioral Health Department is responsible for Mental Health Benefits for those who are determined to be mild to moderate in impairment of functioning: additionally, The Behavioral Health Department reviews authorization requests for ABA treatment.  

Outpatient Services

CenCal Health Primary Care Physicians (PCP) are responsible to provide alcohol screening, brief depression screenings, and referrals for treatment.  CenCal Health Mental Health Benefits includes; psychotherapy, psychological testing, monitoring of drug therapy, outpatient lab services and psychiatric consultation. Members can start mental health services (psychotherapy or medication management) by a contracted the Behavioral Health Department for assistance in locating a provider.  Members and Primary Care Physicians (PCP) can find a list of providers by location and specialty on the CenCal Health Provider Directory.

Please call the Behavioral Health Provider Line at (805) 562-1600 for questions related to outpatient mental health services or Behavioral Health Treatment (ABA) services.  CenCal Health Members can contact The Behavioral Health Department directly through Member Services at (877) 814-1861.

Mental Health Provider

CenCal covers limited substance use screening and treatment services provided at primary healthcare locations.  

Covered Benefits:
Screening, providing brief behavioral counseling interventions (“SBIRT”) and professional fees associated with visits when a provider, within the scope of his or her practice, prescribes medications to reduce symptoms of withdrawal.

Carved Out Benefit: 
The County Department of Behavioral Health provides treatment for Members with Substance Use Disorders.
Members must be referred and contact the Santa Barbara County ACCESS line 1 (888) 321-2843 or the San Luis Obispo County ACCESS line 1 (800) 838-1381 to be screened. 

Screening Tools:

Resources: 

Counties of Santa Barbara and San Luis Obispo

Frequently Asked Questions:

Q: Do I need to fax the above Level of Care screening Tool to CenCal Health?

A: No, please ensure that all members have the screening in their medical records.

Q: Are there limitations to how often I can see a member? 

A: CenCal Health provides Mental Health Benefits to  members with mild to moderate impairment of functioning. The frequency of services are required to be consistent with the treatment of a mild to moderate impairment

Q: My Patient needs a higher level of care, what do I do?

A:  Mental Health providers recommending members for a higher level of care should discuss these recommendations with the member and contact the Behavioral Health Care Coordination Center Provider line at (805) 562-1600 for assistance in transitioning the member to the appropriate level of service. You should continue to provide services to the member until they are engaged with a County level provider. 

Behavioral Health Treatment (ABA) Provider

Behavioral Health Treatment (BHT) are behavioral interventions and include modalities services such as Applied Behavior Analysis (ABA).  

CenCal Health provides coverage of all medically necessary BHT services for eligible beneficiaries under 21 years of age for which a licensed physician, surgeon, or psychologist deems that BHT services are medically necessary.

Resources:

Frequently Asked Questions:

Q: When is the BHT Social Skills Assessment Report required? 

A: Please submit the document when submitting a TAR (50-1 Form) for social skills group services only.  This can be managed via the Provider Portal Authorization module or via a paper authorization form.

Q: Are ABA providers required to use CenCal Health Templates? 

A: Yes, you must complete all templates as required and upload it with the TAR 50-1 authorization request. 

 

 

Primary Care Provider (PCP) Screening Tools

CenCal Health covers screening members for alcohol use and providing brief behavioral interventions at primary healthcare.  Members with primary Medi-Cal Insurance who meet DSM V criteria for substance use disorder must be referred to County Alcohol and Drug Services for appropriate out-patient and residential treatment services.  Members with primary Medicare Insurance who meet DSM V criteria for substance use disorders must be referred to appropriate resources that accept Medicare.

Tools and Resources: 

Services for Alcohol and Other Drug Use:

Frequently Asked Questions:

Q: The patient scored positive on the mental health substance use screening tool. How do I refer them to services? 

A: For Substance Use Services please refer the member to the Santa Barbara County ACCESS Line 1 (888) 321-2843 or San Luis Obispo County ACCESS Line 1 (800) 838-1381.  The member can also contact the Behavioral Health Care Coordination Center for further assistance 1 (877) 814-1861.



Authorizations

Authorizations are required for all case managed CenCal Health members; however, there are a number of exceptions to this rule such as Psychotherapy and Medication Management as referrals (RAF) and TARs are not required for these services.  For authorization requirements, please reference Section E6 & E7 of the Provider Manual.

Please reference the scenarios below when submitting authorizations via the Provider Portal or submitting by paper authorization requests.  If submitting via the paper authorization, please include the Behavioral Health Department Fax Cover Sheet and fax all of your details to (805) 681-3070.  For additional resources, please reference the Authorization Section of our website.

Referral Authorization Form (RAF) Scenarios 

Scenario #1: I am a Primary Care Physician (PCP) and I am wanting to refer a patient for therapy, how do I do this?

OPTIONS: 
1. PCP office can submit a Care Coordination request to the BH Department for member outreach.
2. PCP can direct Member to call the Behavioral Health Care Coordination Center for assistance in identifying a Mental Health provider (Call Member Services Line for access).
3. Member can be directed to locate a provider through the CenCal Health Contracted Provider Directory search tool on CenCal Health website and directly schedule with Mental Health provider. 


Scenario #2: I am a Primary Care Physician (PCP) and my patient has been identified as developmentally delayed and showing signs of ASD.  The parent is requesting ABA, how do I refer? 

OPTIONS:
1. PCP can submit RAF for psychological testing to clarify diagnosis and determine medical eligibility for ABA. 
2. PCP can submit a developmental assessment that was completed in the past two years by a qualifying provider (developmental pediatrician/clinical psychologist/pediatric neurologist/TCRC evaluation) with a RAF for ABA.  

Treatment Authorization Requests (TAR) 50-1 Form Scenarios 

Scenario #1: I am a clinical psychologist and I received a RAF to complete psychological testing for a member to clarify ASD diagnosis. How do I proceed? 

PROCEED: Once you received an approved referral from the member's PCP and CenCal Health, please determine initial psychological testing units. Complete a TAR (50-1) with requesting units for testing through the Provider Portal or via fax. You must await for approval prior to commencing with assessment for all CenCal Health eligible members. 

Scenario #2: I am a ABA provider and my client is nearing the end of the 6 months authorization for ABA services. 

PROCEED: Submit a TAR (50-1) via the Provider Portal or via fax and upload a copy of CenCal Health's 6 Month Progress Report and the signed ABA Service Hour Log. To ensure a timely re-authorization please submit the TAR at least 30 calendar days prior to the expiration of the existing TAR.

 

Services for Children diagnosed with Autism Spectrum Disorder

CenCal Health covers many services for the medical and behavioral health needs of children diagnosed with ASD. 

Applied Behavior Analysis (ABA) therapy is based on science and learning. The goal is to increase helpful and appropriate behaviors (such as greeting others and responding to directions).

ABA therapy can help to improve:

  • Language
  • Communication
  • Attention
  • Memory
  • Social skills

ABA services can be provided by:

  • Board-certified behavior analysts (BCBA)
  • Registered Behavior Technicians

ABA services offered through insurance do not replace ABA services your child may be receiving at school or a regional center.

Physical Therapy (PT) is provided by a licensed physical therapist. Physical therapy focuses on:

  • Developing gross motor skills
  • Improving balance and coordination
  • Improving confidence in social situations
  • Other specific goals (like increasing ankle mobility for those that walk on their toes).

Occupational Therapy (OT) is provided by a licensed occupational therapist. Occupational therapy focuses on improving skills to support independent learning, such as:

  • Independently dressing and eating
  • Fine motor skills
  • Using the restroom
  • Eating and swallowing

Speech Therapy is provided by a licensed speech therapist. Speech therapy focuses on:

  • Improving language
  • Improving verbal, nonverbal and social communication
  • Enunciation (making clearer sounds)
  • Strengthening muscles used to speak
  • Modulating tone of voice
  • Understanding nonverbal social cues (like body language and facial expressions)

Mental Health Services address co-occurring symptoms and conditions such as ADHD, anxiety, and mood disorders.  Mental Health services may include:

  • Medication management with a Psychiatrist or Psychiatric Nurse Practitioner 
  • Individual or family therapy

Please talk to your child’s pediatrician for to learn more about these services. 

Frequently Asked Questions

CenCal Health is listening. Please take a moment to review some recent questions and answers that we received during the January 1, 2022 transition.

Q: We currently receive a new client via email from The Holman Group, and the email usually includes the demographics, and FBA authorization. So my question is if we would be getting these same email from CenCal Health? 

A: Members who need psychotherapy are able to go directly to the provider to start services; Psychotherapy and Medication Management providers will not receive a referral.  ABA providers will receive referrals via right fax or secure email, depending on the office information provided to Provider Services. ABA providers will receive a standard authorization form that includes member name, member number, member contact information, as well as the authorized services. CenCal Health will authorize initial units to complete the FBA. Provider will complete FBA within 60 days and submit for treatment units by using the Provider Portal Treatment Authorization Request (TAR) 50-1 form.

Q: What are ABA Providers?
A:  ABA Providers refers to the providers that are authorized to provide Applied Behavioral Analysis.  These providers vary by scope and degree but all meet DHCS standards in APL14-001 as a qualified provider. For further questions regarding ABA services and what is a covered benefit, please refer to APL 19-014.

Q: Can I continue to do telehealth from home when seeing CenCal Health members when this is carved in with CenCal Health on January 1, 2022?
A:  DHCS has authorized telehealth policy during Public Health Emergency. Providers are responsible for determining when clinically appropriate and using the appropriate modifiers for telehealth and telephonic services.  
 
Q: I don't have access to the CenCal Health Provider Portal Restricted site, how to I get it?
A:  Once you become contracted with CenCal Health your Provider Services Representative will provide you with your username and temporary password.  Within the restricted site you will have access to check a members individual eligibility status, create a Batch Eligibility File (a list of members eligibility status), submit authorizations (RAF, 50-1 TAR), and submit claims.  Please reference our Provider Portal User Guide for step-by-step instructions on how to utilize these online tools!

Q: Since we are transitioning away from The Holman Group to CenCal Health, is CenCal Health providing clinical forms (assessments, progress notes, RTA's) or can we use our own forms?
A:  Mental Health Providers will utilize a level of care screening with their assessment tools to ensure all members are appropriate for mild to moderate outpatient care. This level of care screening will be available on the provider webpage for download. Providers will be responsible to ensure each medical chart has a level of care screening.  For members who are screened as moderate to severe, providers will coordinate with the Behavioral Health Care Coordination call center to transition members to Specialty Mental Health Services at the County Department of Behavioral Health. This process as well as documentation standards are outlined in the Provider Manual for further reference.

ABA Providers will be required to utilize the following CenCal Health templates: FBA, Progress Report, Social Skills, and Service Logs. 

Q: Will Speech and OT service for children with ASD work similar to ABA services?
A: Speech and Occupational Services should be requested on a separate Referral Authorization Forms (RAF), and submitted to through the Provide Portal. The Behavioral Health Department will not be reviewing these authorizations; Medical Management will determine medical necessity and review all authorizations for Speech and Occupational therapies. 

Q: With The Holman Group, clients get approved for 52 weeks of mental health services. Will it be the same with CenCal Health?
A: Prior authorization is not required for psychotherapy or medication management. Please refer to the Provider Manual for further guidance on billing codes and limitations for claims.

Q: Do you have to check a members eligibility status the first of every month and prior to the appointment?
A:  Providers should check a members eligibility status at every visit or utilize the Batch Eligibility tool  via the Provider Portal so you know whether the member is eligible for CenCal Health benefits prior to every visit.  Please reference our Eligibility section of our website for more resources.

 

Claims & Billing

Claims with past Date of Service (DOS) up to 12/31/2021 need to be submitted to The Holman Group. Claims with Date of Service (DOS) on or after 01/01/2022, will now be submitted to CenCal Health for payment for eligible members and services.

You can bill CenCal Health three ways:

  1. CenCal Health Provider Portal, click here to watch the Mental Health & BHT CMS-1500 Claims Entry Portal video tutorial 
  2. Electronic EDI system, please email edi@cencalhealth.org for more details
  3. Mail your paper CMS-1500 claim form to CenCal Health PO Box 948, Goleta CA 93116-0948. 

Providers can use the procedure codes and modifiers outlined within the CenCal Health Provider Manual (Section E7 for Mental Health Providers & Section E6 Behavioral Health Providers).

Helpful Tips:

  • When submitting your claim via the Provider Portal CMS-1500 Professional form, please choose either MH/BHT or Medi-Medi in the 'Claim Type' field
  • Behavioral Health Treatment can be claimed with Direct supervision a the rate of 2 hours for every 10 hours of direct 1:1 treatment
  • Behavioral Health Treatment can bill H0031 at the initiation of service by new provider.  If a member's treatment is disrupted for 4 or more months, another FBA will be authorized. 
  • When billing for psychotherapy services rendered by an AMFT, ACSW, APCC, Assistant Psychologist, please bill with the supervising clinician's NPI in the Rendering NPI field within the CMS-1500 form, and add modifier HO to the line for the procedures performed by the associate. If you would like to submit the associate's NPI, please enter their NPI in the Remarks box (Box 19) so CenCal Health can reimburse at the appropriate rate.

  •  When billing for BHT (ABA) services rendered by an assistant BCBA or Behavioral Technician.  Please bill with the supervising clinician's NPI (who must be a board certified Behavioral Analyst), and use modifier HO for Assistant Behavioral Analysts, and modifier HM for Behavioral Technicians. If the assistant behavior analyst or behavior technician have an NPI, you may record that in the Remarks box (box 19). If the service is performed by a certified Behavior Analysts, do not bill with modifiers HO or HM.

For additional resources please reference the Claims Section of the CenCal Health website.