The Alameda County Behavioral Health (ACBH) Policies & Procedures (P&P) Manual is a compilation of all the policies and procedures that apply to ACBH staff and contractors. The purpose of the P&P Manual is to ensure that everyone associated with ACBH operations is aware of and consistently implements the requirements under federal, state, and local laws and regulations.

ACBH P&Ps are developed through a procedure outlined in Policy 000-1-1, “Development, Approval, Dissemination, and Revision of Alameda County Behavioral Health Policies and Procedures.”

The ACBH P&P Manual is organized by category, and the Table of Contents is available below.

TABLE OF CONTENTS

• 000-1 POLICY ON POLICIES
  • 000-1-1 “Development, Approval, Dissemination, and Revision of Alameda County Behavioral Health Policies & Procedures” (8/28/24)

• 100-1 ACCESS TO MH SERVICES
  • 100-2-5 “Adult and Older Adult System of Care Coordination of Medi-Cal Specialty Mental Health Services” (6/23/26)
  • 100-2-6 “Adult and Older Adult Specialty Mental Health Member Care Transitions Within the Mental Health Plan” (12/1/2025)
• 100-2 ACCESS TO MH & SUD SERVICES
  • 100-2-1 “Out of Network Access and Continuity of Care for Specialty Mental Health Services and Substance Use Disorder Services” (1/24/20)
  • 100-2-2 “24/7 Language Assistance to Members” (3/27/26)
  • 100-2-3 “Timely Access to Service Standards, and Tracking and Monitoring Requirements” (9/25/2025)
  • 100-2-4 “Accessibility of Services” (12/16/19)
  • 100-2-7 “Telehealth Policy” (10/01/2025)
  • 100-2-8 “Network Adequacy Standard Requirements, Data Collection, Monitoring, and Reporting for MHP and DMC-ODS” (6/24/25)

• 100-3 CALAIM
  • 100-3-1 “Criteria for Beneficiary Access to SMHS” (5/13/22)
  • 100-3-2 “No Wrong Door for Mental Health Services” (1/29/26)
  • 100-3-3 “Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services” (01/11/23)

• 150-1 ACCESS TO SUD SERVICES
  • 150-1-1 “Interim Services Management for SUD Treatment Programs” (10/24/16)
  • 150-1-2 “Charitable Choice” (4/28/21)
  • 150-1-3 “Drug Medi-Cal Organized Delivery System (DMC-ODS) Care Coordination, Continuity of Care, and Transition of Care of Medi-Cal Specialty Mental Health, Substance Use Disorder, and Primary Care Services” (12/16/19)
  • 150-1-4 “Expanding Access to Medications for Addiction Treatment (MAT)” (4/1/25)
  • 150-1-5 “Naloxone Distribution Program (NDP)” (7/15/2025)
• 150-2 CALAIM
  • 150-2-1 “Drug Medi-Cal Organized Delivery System (DMC-ODS) Requirements for the Period of 2022 – 2026” (5/13/22)

• 200-1 “Psychological Testing Requirements” (1/30/26)
• 200-2 “Authorization of Specialty Mental Health Services” (1/18/24)
• 200-3 “Prior Authorizations for Day Rehabilitation and Day Treatment Intensive” (10/22/22)

• 300-1 CONSUMER GRIEVANCE AND APPEAL PROCESSES
• 300-1-1 “Consumer Grievance and Appeal System”(6/24/2025)
• 300-1-1 Appendix - Consumer Grievance and Appeal Procedure Manual (7/29/25)
• 300-1-2 “Notices of Adverse Benefit Determination for Medi-Cal Beneficiaries” (9/24/2025)

• 350-2 CONSUMER SAFETY AND WELL-BEING
  • 350-2-1 “Protection of Trafficking Victims” (8/3/23)
  • 350-2-2 “Medication Monitoring for Drug Medi-Cal Organized Delivery System” (6/1/21)
• 350-3-1 CONFIDENTIALITY
  • 350-3-1 “Privacy Security and Confidentiality Statement of Client Services Records and Information" (5/10/24)

• 400-1-1 “24/7 Coverage Requirement for Children, TAY, Adult, and Older Adults Full Service Partnerships” (6/19/20)
• 401 SERVICE DEFINITIONS
  • 401-1 “Adult/Older Adult Outpatient Levels of Care Determination” (7/06/21)
  • 401-2 “Full Service Partnership Implementation" (5/16/2024)
  • 401-3 “Therapeutic Behavioral Services Implementation” (6/1/2021)
• 403 CYASOC, INCLUDING TAY
  • 403-2-1 “Obtaining Authorization for Prescribing Psychotropic Medication to Youth in Out of Home Placement Under the Protection of the Juvenile Court” (7/22/25)
  • 403-3-1 “Implementing Behavioral Health Child and Family Teams” (8/7/26)
  • 403-4-1 “Provisions, Protocols, and Criteria for Identifying and Providing Intensive Services to Children/Youth in the Katie A. Subclass” (12/16/19)
  • 403-5-1 “AB1051 and Revision of AB1299 Presumptive Transfer for Foster Youth Placed Out of County” (1/30/26)
  • 403-6-1 “Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Notification” (1/30/26)
  • 403-7-1 “Families First Prevention Services Act, Qualified Individual Assessment Process” (10/26/22)
  • 403-8-1 “Criteria for Therapeutic Foster Care Services” (10/26/22)
  • 403-9-1 “Implementing Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS)” (10/31/22)
  • 403-10-1 “Child, Adolescent, and Young Adult System of Care (CYASOC) Level of Care Transfer” (10/31/22)
  • 403-11-1 “Mental Health Referral Process for Alameda County Children and Youth (ACL 24-35)” (5/4/26)
  • 403-11-2 “Mental Health Program Approval of Short-Term Residential Therapeutic Program (STRTP)” (6/23/26)
• 404 CRISIS SERVICES
  • 404-1-1 “Mobile Crisis Team Services Policy and Procedure” (12/16/19)
• 406 CLIENT CARE
  • 406-1-1 Eating Disorders (12/16/19)
• 407 Adult Forensic Behavioral Health (AFBH)
• 408 Families, Peers and Volunteers
  • 408-1-1 Community Altruist Compensation Policy (10/01/2025)
• 409 ACBHD Peer Support Services
  • 409-1 ACBHD Peer Support Services(APSS) (3/27/2026)

• 501 PHARMACY SERVICES OFFICE
  • 501-1-1 “Clinical Psychiatric Pharmacist Scope of Practice for Medication Therapy Management” (7/22/2025)
• 502 Nursing Policies and Standardized Procedures
  • 502-1-1 Standardized Procedure: Refill of Medications in Adult, Child, and Adolescent Community Support Centers by RN (9/2/26)
  • 502-1-2 Standardized Procedures and Protocols for Psychiatric Nurse Practitioners (PNPs) (9/2/26)
• 503 Designation & Reporting
  • 503-1-1 “Designation for Mental Health Professionals to Initiate 5150/5585 Holds” (12/16/19)
  • 503-1-2 “Reporting Disorders Characterized by Lapses of Consciousness” (6/9/26)

• 1302 NETWORK OFFICE
  • 1302-1 CONTRACT MONITORING
    • 1302-1-1 “Contract Compliance and Sanctions for BHCS-Contracted Providers” (12/14/22)
• 1303 PROVIDER CONCERNS
• 1303-1 “Provider Problem Resolution and Appeals” (12/16/19)

• 1350-1 FINANCE OFFICE
• 1350-1-4 Identifying, Reporting, and Recovering Overpayments (7/17/23)
• 1350-1-5 Identifying, Reporting and Expending SUBG Funds P&P (8/13/24)

• 1601 QUALITY IMPROVEMENT OFFICE
  • 1601-1 BENEFICIARY CARE AND OUTCOME
    • 1601-1-1 “CANS (Child and Adolescent Needs and Strengths), ANSA (Adult Needs and Strengths Assessment), and Pediatric Symptom Checklist (PSC-35) Implementation” (rev. 6/19/20)
• 1602 CULTURAL COMPETENCE OFFICE
  • 1602-1 CULTURAL COMPETENCE WITH CLIENTS
    • 1602-1-1 “Integration of Spiritual Interests in Recovery and Wellness” (1/30/26)
• 1603 QUALITY ASSURANCE OFFICE
  • 1603-1 CALAIM:DOCUMENTATION
    • 1603-1-3 “Documentation Requirements for all Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services” (6/28/22)
  • 1603-2 CHART REVIEW
    • 1603-2-1 “‘Audit of Clinical Records for Services Funded by Medi-Cal and Other Sources” (5/4/26)
  • 1603-3 CREDENTIALING AND SCOPE OF PRACTICE
    • 1603-3-1 “Mental Health Professional Licensure Waiver” (6/24/25)
    • 1603-3-2 “Credentialing & Re-Credentialing Verification for ACBH Mental Health & Substance Use Service Providers” (rev. 10/25/22)
    • 1603-3-3 “ACBHD Clinical Trainee Policy” (8/28/24)
  • 1603-4 UNSUAL OCCURRENCE/DEATH REPORTING
  • 1603-4-1 “Unusual Occurrence and Death Reporting” (4/25/22)
  • 1603-5 MEDI-CAL SITE CERTIFICATION
    • 1603-5-1 “Medi-Cal Site Certification for Providers of Mental Health Services” (8/15/2022)
  • 1603-6 CONCURRENT REVIEW
    • 1603-6 “Concurrent Review of Crisis Residential Treatment Services and Adult Residential Treatment Services” (10/07/22)
  • 1603-7 ACBHD PROVIDER TRAINING REQUIREMENTS
    • 1603-7 “ACBHD Provider Training Requirements ” (1/30/25)

• 1702
  • 1702-1 “Record and Data Retention and Destruction of Protected Health Information” (6/11/21)

• 1702-2 “Community Based Organization Program Closures” (10/01/2025)

• 1703 PROGRAM INTEGRITY
  • 1703-1 SERVICE VERIFICATION
    • 1703-1-1 “Service Verification for Medi-Cal Reimbursed Services” (5/16/24)
  • OCS.C.001 EXCLUSION SCREENING
    • OCS.C.001 "EXCLUSION SCREENING" (09/01/21)
  • 1703-3 FRAUD, WASTE, AND ABUSE
    • 1703-3-1 “Whistleblower Program for Fraud, Waste, and Abuse” (8/13/24)
• 1704 PRIVACY AND SECURITY
  • 1704-1 BREACHES
    • 1704-1-1 “Privacy and Security Incident Reporting” (7/6/18)

• 2101 EXECUTIVE ADMINISTRATION
  • 2101-2 EMERGENCY RESPONSE
    • 2101-2-1 “BHCS Internal Critical Incident Response Policy” (10/21/16)