Policy Manual

→ 0-001 MCO Manual Table of Contents

Chapter 1: Corporate Compliance

• • • 1-001 Overview: Compliance Program / Code of Ethics
    • 1-002 Adoption of Macomb County Ethics Ordinance
      • Exhibit A – Macomb County Code of Ethics Ordinance
    • 1-010 Program Integrity Policy
    • 1-015 False Claims Policy

 Chapter 2: Clinical Practice

• • 2-000 Plan for Behavioral Health Services
    • Exhibit A for 2-000
  • 2-001 Person-Centered Planning Practice Guideline
    • 2-001 Exhibit A
  • 2-002 Open Communications with Consumers
  • 2-003 Case Management and Supports Coordination Services
  • 2-004 Residential Placement Services Protocol
  • 2-005 Management of EPSDT Referrals
  • 2-006 Service Provider Appeals
  • 2-007 Self-Determination
    • Technical Requirement
  • 2-008 Consumer Referrals to MCCMH
  • 2-009 Medicaid Grievances and Non-Medicaid Grievances
    • 2-009 Exhibit A – Notice of Receipt of Appeal or Grievance
    • 2-009 Exhibit B – Notice of Grievance Resolution
  • 2-010 Standards for Clinical Services Documentation
    • Compliance Recording of Consumer Contact Time)
    • Compliance Falsification of Consumer Records)
  • 2-011 Integrated Dual-Diagnosis Treatment
  • 2-012 Input from Persons Served
  • 2-013 Access, Eligibility, Admission, Discharge.
    • 2-013 Access, Eligibility, Admission, Discharge.
  • 2-014 Assessment Services
  • 2-015 Psychiatric Evaluation
  • 2-016 Psychiatrists’ Practice in MCCMH
  • 2-017 Abbreviations, Acronyms and Symbols for Record Use
  • 2-018 Correction, Supplementation, or Deletion of Information from EMR
  • 2-019 Community Living Supports (CLS)
    • Adult CLS Decision Tree
    • Child CLS Decision Tree
  • 2-020 Specialized Health Care Services
  • 2-021 Medication / Psychiatric Services
  • 2-022 PMP / Subsidized Laboratory Services
    • Laboratory Tests Order Form (Subsidized Laboratory Services Program)
    • Prior Authorization Form
    • Prior Authorization Request (Subsidized Laboratory Services Program)
    • Laboratory Test(s) Order Form (Prior Authorized)
    • Laboratory Services Utilization Review Request For Clarification
  • 2-023 Electroconvulsive Therapy (ECT)
  • 2-025 Research and Training Policy and Manual
  • 2-026 Jail Diversion
  • 2-030 Trauma Informed Services
  • 2-031 In-Home and Community-Based Services Safety Training
  • 2-032 Person-Centered Process and the Role of Health and Safety Considerations
  • 2-033 Advance Crisis Plan / Advance Directive
    • Advance Directives – Planning for Medical Care in the Event of Loss of Decision-Making Ability (Geller)
    • Advance Directives – Planning for Medical Care in the Event of Loss of Decision-Making Ability (Cheever, Geller, Slocum)
  • 2-034 End of Life Care, Emergency Assistance, Resuscitation
  • 2-035 Crisis Intervention Services
  • 2-040 Olmstead Compliance Policy
  • 2-042 Service Referrals/Recommendations, Coordination of Care, and Follow-Up / Advance Directive
    • Exhibit A: Care Coordination Form
    • Exhibit B: Care Coordination: Assessment Process Flow
  • 2-044 Evidence Based Supported Employment (Individual Placement and Support)
  • 2-048 Telehealth and Telemedicine
    • 2-048 MCCMH Informed Consent for Telehealth Services
  • 2-051 Psychotropic Medication in Community-Based Settings
  • 2-053 Psychotropic Medication For Youth In Foster Care
    • Department of Human Services Informed Consent Bulletin
    • Psychotropic Medication Informed Consent Form
  • 2-060 Professional Treatment/Monitoring
  • 2-070 Medical Alert – Allergies
  • 2-080 Nursing Standards Practice
    • MCCMH Nursing Manual
  • 2-090 Service Authorizations
  • 2-100 Integration Policy

Chapter 3: Provider Network Management

• • 3-001 Audit Content and Timetable
  • 3-002 Audit Follow-Up
  • 3-003 Provider Manual
  • 3-004 Network Application / Profiling Process
  • 3-005 Pharmaceutical Company Sales Representatives at MCCMH Provider Sites
    • Compliance Alert For 3-005
  • 3-010 Evaluation and Monitoring of Delegated Functions
  • 3-015 Contract Network Provider Mandatory Training and Workforce Development
    • 3-015 Exhibit A Macomb County Prepaid Inpatient Health Plan Training Requirements Grid
    • 3-015 Exhibit B Training Policy Course Description
    • 3-015 Exhibit C Training Implementation Plan
  • 3-016 FOCUS Access Management – Contract Providers
    • 3-016 FOCUS Access Request Form
  • 3-020 Procurement of Goods and Services
  • 3-030 Procurement of Specialized Residential Facilities
    • 3-030 Exhibit A – Request for Approval
    • 3-030 Exhibit B – Provider Qualification Statement
  • 3-031 Fire Safety in Residential Settings (file is very large)

Chapter 4: Customer Relations/Member Services

• • 4-001 Prevention Services in Macomb County
  • 4-002 Collaborative Community Planning
  • 4-010 Provision and Distribution of Information to Consumers
    • 4-010 Exhibit A – Acknowledgement and Consent
    • 4-010 Exhibit B – Fee Determination Agreement Insurance Authorization
    • 4-010 Exhibit C – Taglines
  • 4-020 Medicaid and Non-Medicaid Notice of Adverse Benefit Determination
    • 4-020 Exhibit A – Notice of Adverse Benefit Determination
    • 4-020 Exhibit B – MDHHS Hearing Request Form
    • 4-020 Exhibit C – MDHHS Request for Withdrawal of Appeal Form
    • 4-020 Exhibit D – Medicaid Adverse Benefit Determination Notice Requirements – Quick Guide
    • 4-020 Exhibit E – Instructions for Completing Advance and Adequate Adverse Benefit Determination Letters
  • 4-030 Medicare Services Decisions and Complaints

 Chapter 5: Administration

• • 5-000 Succession Plan – Replacing Executive Director
  • 5-001 Accessibility
    • 5-001 Exhibit A – Notice of Non-Discrimination and Taglines
  • 5-002 Cultural and Linguistic Competency
    • 5-002 Ex. A Notice of Nondiscrimination and Taglines
  • 5-003 Grievances Alleging Discrimination (Civil Rights Grievances)
    • 5-003 Exhibit A – Notice of Grievance Resolution
  • 5-004 Board Bylaws
  • 5-005 Board Committees
  • 5-006 Mission Statement
  • 5-007 Vision Statement
  • 5-008 Inclement Weather / MCCMH Board Meetings and Board Committee Meetings – Cancellation / Postponement
  • 5-009 Prohibition Against Denial of Services Due to Inability to Pay
  • 5-010 Compliance with Laws and Regulations
  • 5-011 Policy Development, Implementation and Review
  • 5-012 E-Verify
  • 5-013 Board Meetings – State of Emergency

Chapter 6: Confidentiality

• • 6-001 Release of Confidential Information – General
    • 6-001 Ex.A Authorization for Release of Information, (sample)
    • 6-001 Ex. B Documentation for Release of Consumer information Not Requiring Consumer Authorization (sample)
    • 6-001 Ex. C Summary of Section 748 of the Mental Health Code (sample)
  • 6-002 Release of Confidential Information – Alcohol and Drug Abuse
    • 6-002 Exhibit A
    • 6-002 Exhibit B
    • Confidentiality of Alcohol and Drug Abuse Patient Records
  • 6-003 Release of Confidential Consumer Information – Court Orders / Subpoenas
  • 6-004 Facsimile Document Transmission
  • 6-005 Notice of Confidential Information
  • 6-006 Consumer Access to Clinical Records
  • 6-007 Clinical Records Storage and Transport
  • 6-008 Retention and Disposal of Clinical Records
  • 6-100 Notice of Privacy Practices
    • Exhibit A, Notice of Privacy Practices

 Chapter 7: Financial Procedures

• • 7-001 Determination of Financial Liability
    • Exhibit A, Full Financial Review Income-Expense Analysis-R
    • Exhibit B, Full Financial Review Income-Expense Analysis-NR
    • Exhibit C, Ability to Pay Schedule
  • 7-010 Claims Process Policy
    • Exhibit A, Claim Information and Procedures
    • Exhibit B, Process for New Hospitals
    • Exhibit C, Process for Non-Hospital Providers
    • Exhibit D, Overlapping Service Code Protocol and Time Line
    • Exhibit E, Claim Reconsideration Information & Procedure

 Chapter 8: Quality Improvement

• • 8-001 Quality Improvement Program
  • 8-002 Follow-Up and Satisfication-Customers
  • 8-003 Reporting and Responding to Critical Incidents, Sentinel Events, and Risk Events
    • Root Cause Analysis and Action Plan
    • Report of Death
    • Mortality Review
    • Critical Incidents Chart
    • Sentinel Events Chart
    • Risk Event Determination
    • CRMC Review of RCS / Mortality Review
    • Flowchart of Sentinel Events, RCA, and Mortality Review
  • 8-004 Reporting and Responding to Medication Errors and Adverse Drug Events
  • 8-006 Consumerism
  • 8-007 Record Review Process
  • 8-008 Behavior Treatment Plan Review Committee
    • 8-008 Ex. A Functional Assessment Interview Form
    • 8-008 Ex. B Initial Presentation Worksheet
    • 8-008 Ex. C Ongoing Presentation Worksheet
    • 8-008 Ex.D Behavior Daily Data Tracking Sheet
    • 8-008 Ex. E Behavior Monthly Data Tracking Sheet
    • 8-008 Ex. F Emergency Physical Management Form
    • 8-008 Ex.G BTPRC Action Form
    • 8-008 Ex.H Consent for Behavior Tx Plan
  • 8-010 Organization Credentialing
  • 8-020 Financial Conflict of Interest
  • 8-030 ProAct Policy
    • 8-030 ProAct Policy Exhibit A

 Chapter 9: Recipient Rights

• • 9-100 Applicability of Recipient Rights Policies
  • 9-110 Authorization and Functions
  • 9-120 Rights Functions of the MCCMH Executive Director
  • 9-130 Recipient Rights Director
  • 9-135 Rights Advocacy / Monitoring
  • 9-140 Recipient Rights Training
  • 9-160 Qualifications & Training for Recipients Rights Staff
    • Exhibit A – Technical Requirement for Education
  • 9-170 Local Appeals
  • 9-171 Local Appeal Process (Medicaid)
    • 9-171 Exhibit A – Notice of Receipt of Appeal or Grievance
    • 9-171 Exhibit B – Notice of Appeal Approval
    • 9-171 Exhibit C – Notice of Appeal Denial
  • 9-180 Second Opinion Rights
  • 9-210 Committee Authorization
  • 9-321 Consumer Incident, Accident, Illness, Death, or Arrest Report Monitoring
    • Consumer Incident, Accident, Illness, Death, or Arrest Report
    • User of Physical Management Form
    • Medication Error Form
    • Police Contact Form
    • Emergency Medical Form
    • Recipient Rights Complaint Form
  • 9-405 Recipient Rights Protection Standards
  • 9-510 Recipient Rights Investigation
    • Recipient Rights Complaint Form
  • 9-515 Repeated Rights Events Review Committee
  • 9-520 Recipient Requests to Appeal Findings
  • 9-550 Harassment Following Rights Activity
  • 9-600 Informed Consent for Service
    • Acknowledgment and Consent Form
    • Psychotropic Medication Informed Consent
    • Child Protection Law (Excerpt)
  • 9-601 Informed Consent for Psychotropic Medication
  • 9-604 Release of Oral / Verbal Communications
  • 9-605 Bill of Rights / Bill of Responsibilities
  • 9-606 Dignity / Services Suited to Condition / Humane Environment / Least Restrictive Treatment Environment
  • 9-610 Privileged Communications
  • 9-620 Abortion, Contraception, Sterilization
  • 9-630 Fingerprinting, Photographing, Audio/Videotaping, and 1-Way Glass Viewing
  • 9-640 Choice of Mental Health Professional
  • 9-670 Services for Recipients Affected by Physical Barriers
  • 9-680 Recipient Labor
  • 9-690 Recipient Abuse or Neglect
    • Compliance Falsification of Consumer Records)
  • 9-700 Communication: Telephone, Visiting Rights, Mail
  • 9-710 Freedom of Worship and Religious Belief
  • 9-720 Treatment By Spiritual Means
  • 9-730 Resident’s Right to Media Access
  • 9-750 Comprehensive Examinations
  • 9-760 Change in Type of Treatment
  • 9-780 Personal Property and Funds
  • 9-790 Freedom of Movement
  • 9-795 Physical Management
  • 9-797 Restraint
  • 9-798 Seclusion
  • 9-810 Duty To Warn Third Parties
  • 9-900 Release of Clinical Records to Michigan Protection and Advocacy Services

 Chapter 10: Directly-Operated Program Management

• • 10-001 Adoption of Macomb County Personnel Policies
    • Ex. A HRLR Policy Manual
  • 10-002 Human Resources Management / Diversity
  • 10-003 Anti-Discrimination and Harassment
  • 10-004 Volunteers and Interns/Trainees
  • 10-005 Criminal Record Checks of Employees/Independent Contractors
  • 10-006 Evaluation of Employees
  • 10-007 Direct Operated Provider & MCCMH Administration Training and Development Program
    • 10-007 Ex. A Macomb County Prepaid Inpatient Health Plan Training Requirements Grid
    • 10-007 Exhibit B MCCMH Course Descriptions
    • 10-007 Exhibit C Training Reciprocity Implementation Plan
  • 10-009 Supplemental Employment
  • 10-010 Conflict of Interest
  • 10-011 Personal Use / Personal Gain
  • 10-012 Access to Administrative Records / Documents
    • 10-012 Exhibit A. Notice of Denial of request for Material Exempted from Public Disclosure by Michigan State Law
    • 10-012 Exhibit B. Fees
    • 10-012 Exhibit C. FOIA Request for Information
    • 10-012 Exhibit D. Waiver
    • 10-012 Exhibit E. FOIA Request Log
  • 10-015 Retention and Disposal of Non-Clinical Records
  • 10-018 Lawsuits
  • 10-020 Compliance with Software Licenses and Laws
  • 10-030 Protection of Electronic Confidential Information
    • 10-030 Ex.A Workforce Confidentiality Agreement
  • 10-031 Expectation of Privacy, Monitoring, Prohibited Content and Use of Electronic and Telephonic Communications
  • 10-032 Acceptable Internet Use
  • 10-033 Use of All Staff Email Messaging
  • 10-034 Social Media Policy
  • 10-040 Conference Attendance / Travel
    • Request for Approval to Attend Conference
    • Mileage Report
  • 10-041 Documentation of Staff Participation in Inservice and Continuing Education Activities
  • 10-050 Emergency Preparedness Plan
  • 10-051 Use and Maintenance of County / Personal Vehicles
  • 10-052 Emergency Procedures – County Vehicles
  • 10-053 First Aid and Safety Equipment – County Vehicles
  • 10-054 Use of Tobacco in MCCMH / County Facilities
  • 10-055 Weapons, Alcohol and Drug-Free Workplace
  • 10-056 Infection Control Plan
    • Incorporated Infection Control Documents
  • 10-060 Determination of Financial Liability
  • 10-061 Standards For Depreciable Assets
  • 10-065 Injection Medication Procedures
  • 10-070 Credentialing and Re-Credentialing
    • Exhibit C – MCCMH Criminal Background Check Form
    • Qualification Requirements
  • 10-200 Service Planning and Review
  • 10-315 Business Associates
  • 10-320 Designated Record Set
  • 10-325 Minimum Necessary HIPAA Privacy
  • 10-330 Right to Restrict Disclosures
  • 10-340 Right to an Accounting of Disclosures
  • 10-345 Confidential Communications
  • 10-350 Privacy Complaint Process
  • 10-355 Privacy Training
  • 10-360 Staff Protected Health Info
  • 10-370 HIPAA Privacy Breach Assessment
  • 10-410 Security Overview
    • 10-410 MCCMH Security Officer Contact Information
  • 10-415 Security Audits
  • 10-420 Periodic Evaluation
  • 10-425 Security Awareness Training
  • 10-430 Security Incident Reporting Process
  • 10-435 Security Investigation / Disciplinary Action
  • 10-440 Access Control
  • 10-442 EPHI Access Management
    • 10-442 FOCUS Access Request Form
  • 10-445 Device Media Control
  • 10-450 EPHI Security
    • 10-450 EPHI Security Exhibit A
  • 10-455 Virus Protection
  • 10-460 Password Management
  • 10-465 Facility Security
  • 10-470 Contingency Plans for EPHI Security
  • 10-510 Reporting Complaints
  • 10-515 Internal Reporting Mechanism
  • 10-520 Investigations / Disciplinary Actions (Compliance)
  • 10-525 Training and Education – Compliance
  • 10-800 Quality Concern Referral
  • 10-805 Mortality-Trauma Debrief

 Chapter 11: Substance Abuse

• • 11-001 Substance Abuse Provider Manual

 Chapter 12: Utilization and Access Management

• • 12-001 Access Management Manual
  • 12-002 Utilization Management
  • 12-003 CMHSP General Fund Waiting List

Signed Policy Reviews

2014 Signed Policy Review
2015 Signed Policy Review
2016 Signed Policy Review
2017 Signed Policy Review
2018 Signed Policy Review
2019 Signed Policy Review

Executive Directives

Executive Directives Index

• 2021
  • Executive Directive 1/2021 – General Fund Benefit Plan

•  2020
  • Executive Directive 7/2020
  • Executive Directive 6/2020
  • Executive Directive 5/2020
  • General Fund (March 20th, 2020)
  • COVID-19 Executive Directive Updates #2 (March 17th, 2020)
  • COVID-19 Executive Directive (March 13th, 2020)
  • Executive Directive 1-2020

•  2019
  • Executive Directive 2-2019
  • Executive Directive 1-2019

•  2018
  • GF Phase 4 Implementation Guide
  • Executive Directive 1-2018
  • Executive Directive 2-2018

•  2015
  • Request for Second Opinion Form 0415
  • MCCMH Contractors of Inpatient Psychiatric Services MCCMH Access Center

•  2014
  • Limited Benefit Plan – Phase Three
  • Dual-Eligible (Medicare/Medicaid) Contract Providers
  • Deletion of MCO Policy (10-075) — 06/04/2014
  • Immediate Implementation of Modified GF Benefit Plan of Services — 01/30/2014

•  2013
  • Deletion of MCO Policies (2-052, 8-004, 5-003) — 7/3/2013
  • Implementation of Modified GF Benefit Plan of Services — 5/23/2013
  • Notification of Critical Laboratory Results and Values — 2/4/2013

•  2012
  • Deletion of MCO Policy (2-004) — 11/28/12

•  2011
  • Deletion of Administrative Policies (3-02-010, 7-04-010) — 4/28/11
  • Deletion of Administrative Policy (3-02-050) — 3/28/2011
  • Deletion of Administrative Policies (3-02-010, 7-04-010) — 4/28/11
  • Deletion of Administrative Policy (3-02-050) — 3/28/2011
  • Supervisory Expectations of Program Supervisors / Therapist IIIs — 1/21/2011

•  2010
  • Moratorium on Use of Experimental Treatment Modalities — 12/2/2010
  • Deletion of Administrative Policy (5 / 2010) — 7/30/2010
  • Deletion of Administrative Policy (4 / 2010) — 6/7/2010
  • Deletion of MCO Policy (3 / 2010) — 4/14/2010
  • Deletion of MCO Policy (2 / 2010) — 4/1/2010
  • Deletion of MCO Policy (1 / 2010) — 2/26/2010

•  2009
  • Deletion of Administrative Policies — 11/03/2009
  • Deletion of Administrative Policies — 4/14/2009
  • Authorization of Services (General Fund) — 3/04/2009
  • Medicaid Minors / CLS — 2/25/2009

•  2008
  • Deletion of Administrative Policy (2-08-010) — 12/17/2008
  • Deletion of Administrative Policy (2-11-012) — 11/12/2008
  • Deletion of Administrative Policy (3-01-040) — 6/11/2008
  • Deletion of Administrative Policy (7-02-040) — 5/23/2008
  • Authorization Revisions — 5/22/2008
  • Deletion of Administrative Policy (7-01-010) — 5/21/2008
  • Deletion of Administrative Policies (2-07-012, 2-07-040) — 5/15/2008
  • Deletion of Administrative Policy (8-01-010) — 4/18/2008
  • Deletion of Administrative Policy (7-02-060) — 1/03/2008

•  2007
  • Deletion of Administrative Policies (Ch. 9 and 11) — 12/06/2007
  • REISSUED (11/29/07) With New Title – PMP Medication for Indigent Consumers — 11/29/2007
  • Deletion of MCO Policy (9-361) — 11/20/2007
  • Deletion of Administrative Policies (2-07-010, 2-07-030, 2-07-050) — 10/19/2007
  • Deletion of Administrative Policy (2-11-011) — 9/19/2007
  • Case Manager / Supports Cooridinator Continuity — 9/18/2007
  • Distribution of Advance Directive Materials to Adult Consumers — 8/06/2007
  • Health / Nursing Assessment Signitures — 8/06/2007

•  2006
  • Deletion of MCO Policies (8-004, 8-005) — 11/01/2006
  • Guiding Principles of Integrated IDDT-COD-EBP — 10/19/2006
  • View Compliance Alert related to this Directive
  • Deletion of Administrative Policies — 10/19/2006
  • Use of Electronic Medical Record — 9/14/2006
  • Staff Privileges for Provisions of Children’s Services – Compliance with DCH Training Requirement — 8/31/2006
  • Deletion of Administrative Policy — 8/25/2006
  • Deletion of Executive Directive 7/2003 — 6/06/2006
  • Medication Procedures — 6/06/2006
  • Provision and Distribution of Information to Consumers — 6/06/2006
  • Deletion of Administrative Policy — 5/25/2006
  • Respite Services — 3/30/2006

•  2005
  • Deletion of Administrative Policy — 12/15/2005
  • Deletion of Administrative Policy — 9/30/2005
  • Deletion of Administrative Policy — 8/18/2005
  • Deletion of Administrative Policy — 3/11/2005
  • HAB Waiver Services — 2/02/2005

•  2004
  • Deletion of Administrative Policy — 12/10/2004
  • Deletion of Administrative Policy — 5/03/2004
  • Authority to Speak on Behalf of MCCMH — 3/26/2004

•  2003
  • Deletion of Administrative Policy — 12/09/2003
  • Name Stamps — 11/06/2003
  • View Compliance Alert related to this Directive
  • Prohibition of Instant Messaging and Third-party Email account access — 9/29/2003
  • Assessment Summary – Fifth Edition Revised — 9/04/2003
  • Reporting of Consumer Service Time — 6/30/2003
  • View Compliance Alert related to this Directive
  • MCCMH Staff Medical / Personal Health Information — 4/14/2003
  • Media Contact / Public Information — 4/10/2003
  • Provisional Credentials and Privileges — 4/02/2003
  • Deletion from Administrative Manual — 1/16/2003

•  2002
  • Deletions from Administrative Manual — 11/01/2002
  • Deletions from Administrative Manual — 9/13/2002
  • Deletions from Administrative Manual — 8/08/2002
  • Extension of Temporary Credentials and Privileges — 4/30/2002

•  2001
  • Person – Centered Planning Training Requirement — 10/03/2001
  • Use of MCCMH #289, Acknowledgment and Consents — 5/16/2001

•  2000
  • SAL Codes — 9/25/2000
  • Deletion from Administrative Manual — 8/14/2000
  • Process for Requesting Continued Service Authorization — 4/10/2000
  • Medication Review Form — 1/26/2000
  • Deletions from Administrative Manual — 1/24/2000

•  1999
  • Deletions from Administrative Manual — 12/27/1999
  • Charges for Services to EARLY-ON Recipients — 11/19/1999
  • Collection of Fees for Copies of Clinical Records Information — 9/17/1999

•  1998
  • Consent for Mental Health Services — 12/21/1998
  • MCCMH Policy 6-01-020, “Privileging” — 7/06/1998
  • MCCMH Policy 9-06-130, “Refusal of emergency Basic Life Support” — 6/05/1998

•  1997
  • Financial Liability Rules for Mental Health Services — 4/15/1997

•  1996
  • Crisis Counseling Privileges — 11/21/1996
  • Requests for payment for Medical Information from PSPs / PCPs — 10/01/1996
  • Deletion of Administrative Policies — 1/31/1996

•  1995
  • QA Transition Plan; QA By-Laws Suspension — 4/06/1995

•  1994
  • Modification of Psychiatric Evaluation Process — 10/05/1994