1. (a) A Quality Improvement Program responsible for reviewing the quality of specialty mental health services provided to beneficiaries by the MHP that:

   1. (1) Is accountable to the director of the MHP.

   2. (2) Has active involvement in planning, design and execution from:

      1. (A) Providers;
      2. (B) Beneficiaries who have accessed specialty mental health services through the MHP; and
      3. (C) Parents, spouses, relatives, legal representatives, or other persons similarly involved with beneficiaries who have accessed specialty mental health services.
   3. (3) Ensures that the persons participating in the Quality Improvement Program under Subsection (a)(2) shall not be subject to discrimination or any other penalty in their other relationships with the MHP as a result of their role in representing themselves and their constituencies in the Quality Improvement Program.
   4. (4) Includes substantial involvement of a licensed mental health professional.
   5. (5) Conducts monitoring activities including but not limited to review of beneficiary grievances, appeals, expedited appeals, fair hearings, expedited fair hearings, provider appeals, and clinical records review.
   6. (6) Is reviewed by the MHP and revised as appropriate annually.

2. (b) A Utilization Management Program responsible for assuring that beneficiaries have appropriate access to specialty mental health services from the MHP that:

   1. (1) Assures that the access and authorization criteria established in this Chapter are met.
   2. (2) Conducts monitoring activities to ensure that the MHP meets the established standards for authorization decision making and takes action to improve performance if necessary.
   3. (3) Is reviewed by the MHP and revised as appropriate annually.

3. (c) A beneficiary documentation and medical records system that meets the requirements of the contract between the MHP and the Department and requirements of State and federal law and regulation governing beneficiary documentation and medical records systems, including the following:

   1. (1) Client plans signed (or electronic equivalent) by:

      1. (A) The person providing the service(s), or
      2. (B) A person representing a team or program providing services, or
      3. (C) A person representing the MHP providing services.

   2. (2) Documentation of the beneficiaries' participation in and agreement with their client plans. Documentation of participation in and agreement with the client plan may include, but is not limited to reference in the client plan to the beneficiary's participation in and agreement with the client plan, the beneficiary's signature on the client plan, or a description in the medical record of the beneficiary's participation and agreement with the client plan, except as follows:

      1. (A) The MHP shall obtain the beneficiary's signature or the signature of the beneficiary's legal representative on the client plan when:

         1. 1. The beneficiary is expected to be in long term treatment as determined by the MHP and
         2. 2. The client plan provides that the beneficiary will be receiving more than one type of specialty mental health service.
      2. (B) When the beneficiary's signature or the signature of the beneficiary's legal representative is required on the client plan under Subsection (d)(1) and the beneficiary refuses to sign the client plan or is unavailable for signature, the client plan shall include a written explanation of the refusal or unavailability.

The MHP shall establish a Quality Management Program in accordance with the terms of the contract between the MHP and the Department that includes at least the following elements:

Note: Authority cited: Section 14680, Welfare and Institutions Code. Reference: Sections 5777, 14683 and 14684, Welfare and Institutions Code.

History

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).