Behavioral health glossary

The Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, is a written notice that providers, physicians, practitioners and suppliers give to Original Medicare beneficiaries when they expect Medicare to deny payment for an item or service. It transfers potential financial liability to the beneficiary. When a provider expects a denial because a service is not reasonable and necessary and gives no valid notice in advance, it cannot shift the cost to the patient if Medicare denies the claim. The notice must be delivered far enough ahead of the service for the patient to consider the options, in person if possible. The ABN is not used for Medicare Advantage or Part D, and providers not enrolled in Medicare cannot issue it.

Also called ABN, CMS-R-131, Form CMS-R-131, advance beneficiary notice

Source: CMS, FFS ABN

In Medicaid managed care, the formal term for a plan's decision to deny or limit a requested service, reduce or end an approved service, or deny payment for a service. Each one triggers the member's right to a written notice and an appeal. The rule carves out one thing: denying payment only because a claim is not a clean claim is not an adverse benefit determination, which is why clearinghouse rejections and data errors are fixed by resubmission rather than appeal. Programs should separate true denials, which need clinical appeals, from rejections and correctable denials, which need corrected claims.

Also called denial, claim denial, adverse benefit determination, ABD

Source: 42 CFR 438.400(b)

A Washington credential that lets a person provide counseling only as an employee or student intern of a recognized agency, such as a licensed behavioral health agency, rather than independently. Chapter 18.19 RCW and WAC 246-810 define three tiers since 2SHB 1724 in 2023: registered, certified and licensed agency affiliated counselors, each with a different scope. The registration is tied to the employer, so it does not travel to private practice. Operators care because the AAC is the usual Department of Health credential for bachelor's-level case managers, care coordinators and mental health staff who are not SUDPs or licensed clinicians, and WAC 246-341 requires every clinical staff member to hold a credential.

Also called agency affiliated counselor, registered agency affiliated counselor, certified AAC, licensed AAC

Source: WAC 246-810-010(2)

Idaho's two substance use disorder counselor certifications, issued by the Idaho Board of Alcohol/Drug Counselor Certification (IBADCC), an IC&RC member board. The ADC, formerly named CADC, is the bachelor's-level credential and practices under an IBADCC-approved clinical supervisor; its scope includes clinical evaluation and diagnostic impression, treatment planning, case management and counseling for SUD and co-occurring disorders. The AADC, formerly ACADC, is the master's-level credential, adds therapy to its scope and can supervise SUDAs and ADCs. Idaho's SUD program standards, now in Idaho Code after IDAPA 16.07.17 was retired in 2025, require clinical staff to hold these or an equivalent license. Operators care because Idaho Medicaid and Magellan contracts tie counselor billing to IBADCC status.

Also called ADC, CADC Idaho, ACADC, Idaho CADC

Source: IBADCC, Alcohol & Drug Counselor

The most a plan will pay for a covered service, also called the eligible expense, payment allowance or negotiated rate. For an in network program the allowed amount is the contracted rate, and the difference between the billed charge and the allowed amount is a contractual write-off. For out of network claims the plan often sets the allowed amount from a usual, customary and reasonable (UCR) figure for the area or a percentage of Medicare. The member's deductible and coinsurance are calculated on the allowed amount, not the charge, which is why the ERA, not the charge master, tells you the true patient balance.

Also called allowable, eligible expense, negotiated rate, payment allowance

Source: HealthCare.gov glossary, Allowed amount

The federal Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b), is a criminal law that prohibits knowingly and willfully offering, paying, soliciting or receiving anything of value to induce or reward referrals of items or services payable by a federal health care program such as Medicare or Medicaid. Remuneration can be cash, free rent, gifts, waived copays or above market pay to a referral source. Regulatory safe harbors protect arrangements that meet every element, such as fair market value personal services contracts. Claims that result from a kickback are also false claims. Behavioral health programs see AKS risk in marketing contracts, sober living relationships, lab deals and patient incentives.

Also called federal anti-kickback statute, 42 U.S.C. 1320a-7b(b), kickback, safe harbor

Source: 42 U.S.C. 1320a-7b(b) Illegal remunerations

California's state recognition for outpatient and other nonresidential alcohol and other drug programs, which are not licensed the way residential facilities are. DHCS certifies these programs under Health and Safety Code chapter 7 (beginning at section 11830.1), and Title 9 CCR chapter 5.5 sets the fee process for programs that are or seek to be certified under that chapter or licensed under chapter 7.5. Since AB 118 took effect on July 10, 2023, any business entity with a physical location in California that provides SUD treatment, recovery, detoxification or medication for addiction treatment services must hold this certification under Health and Safety Code 11832.2 unless exempt, and Drug Medi-Cal and most counties require it as well. Counselors in any AOD program must be registered or certified by a DHCS approved certifying organization under Title 9 CCR chapter 8.

Also called AOD certification, DHCS certification outpatient, alcohol and other drug program certification, California outpatient certification

Source: Cal. Code Regs. tit. 9, section 10700 Purpose of Chapter (licensure and certification fees)

A request that a plan review an adverse benefit determination. Federal managed care rules give the member, or a provider acting with the member's consent, 60 calendar days from the notice to file, require the plan to resolve a standard appeal within 30 days, and allow a state fair hearing after the plan's decision. Oregon CCOs and Washington managed care organizations follow these rules; Idaho's behavioral health plan handles appeals through Magellan. Provider payment disputes with no member denial, such as rate or timely filing disputes, usually run through a separate provider dispute process in the contract. Appeals need the denial letter, the records and a clear medical necessity argument.

Also called appeal, claim appeal, level one appeal, state fair hearing

Source: 42 CFR 438.402(c)(2)(ii)

The brand name for Washington State's Medicaid program and related medical assistance programs, administered by the Health Care Authority (HCA). Apple Health covers mental health and substance use disorder treatment for eligible adults and children. Most members are enrolled in one of five managed care organizations that hold both physical and behavioral health benefits; a smaller group receives coverage without a managed care plan, known as fee for service, and some of those enroll in a Behavioral Health Services Only plan. A program must enroll with HCA in ProviderOne before it can contract with any Apple Health plan or bill fee for service.

Also called Apple Health, Washington Apple Health, Washington Medicaid, WA Medicaid

Source: Washington State Health Care Authority, Apple Health (Medicaid)

Washington's single statewide Apple Health managed care plan for children and youth in foster care, adoption support and extended foster care, plus young adults who aged out of care, administered by Coordinated Care. Eligible children are auto enrolled regardless of county so their coverage does not change when placements do, and families may stay on the plan for up to a year after a dependency ends. AHCC covers physical and behavioral health together and includes care coordination for this population. A youth or family program that serves foster children therefore needs a Coordinated Care contract even if it is otherwise out of network with that plan, and it follows AHCC's own authorization and care coordination contacts.

Also called Apple Health Foster Care, foster care managed care Washington, Core Connections

Source: HCA, Foster Care (Apple Health Core Connections)

The five health plans that HCA pays a monthly capitation to cover Apple Health members: Community Health Plan of Washington (CHPW), Coordinated Care, Molina Healthcare of Washington, UnitedHealthcare Community Plan and Wellpoint Washington. Each plan covers physical health, mental health and substance use treatment together under Integrated Managed Care, and each runs its own provider network, credentialing, prior authorization and claims system. Members can switch plans monthly, so a program that is in network with only one or two plans will lose or turn away patients. Most Washington behavioral health operators pursue contracts with all five plans active in their region, then bill fee for service through ProviderOne only for the few members without a plan.

Also called Apple Health MCO, Washington Medicaid MCOs, Community Health Plan of Washington, CHPW

Source: HCA, Apple Health managed care

Idaho does not issue a general facility license for outpatient substance use disorder programs the way Oregon and Washington do. Instead, the Alcoholism and Intoxication Treatment Act (Idaho Code title 39, chapter 3) designates the Department of Health and Welfare as the state substance abuse authority and has the Board of Health and Welfare set standards a program must meet to be an approved public or private treatment facility. The Department inspects approved facilities periodically, keeps the published list, can require data and records, and may suspend, revoke or restrict an approval after a hearing. Approval matters for the state funded SUD network run through Magellan of Idaho; private pay programs rely on professional licensure, accreditation and payer credentialing.

Also called Idaho program approval, approved public treatment facility, approved private treatment facility, DHW approval

Source: Idaho Code 39-305 Standards for public and private treatment facilities

The 24 hour live in levels of SUD care, ordered by intensity. Level 3.1 is clinically managed low intensity residential, which Washington calls recovery house or long term residential and which pairs housing with at least five treatment hours a week. Level 3.3 is a slower paced residential track Washington uses for special populations such as pregnant and parenting women. Level 3.5 is clinically managed high intensity residential with round the clock structure and daily clinical programming. Level 3.7 is medically monitored intensive inpatient with 24 hour nursing and physician oversight. Oregon defines a residential SUD program as providing twenty four hour observation and monitoring consistent with ASAM Level III and licenses it under OAR chapter 309 division 018.

Also called residential treatment, Level 3, ASAM 3.1, ASAM 3.5

Source: OAR 309-018-0105 (definition 66)

The American Society of Addiction Medicine's framework for deciding which level of substance use disorder care a person needs, when to continue it, and when to step up or down. Clinicians assess six dimensions covering withdrawal risk, medical and mental health conditions, readiness, relapse risk and living environment, then match the result to a level of care along a continuum from outpatient to inpatient. Oregon rules define it as the most current ASAM edition, Washington's WAC 246-341-0200 adopts it for admission, continued service, transfer and discharge decisions, and Idaho Code 39-306 uses it to set the level of care for state funded SUD services. Payers use the same criteria in medical necessity and concurrent reviews.

Also called ASAM, ASAM levels of care, ASAM patient placement criteria, ASAM PPC

Source: ASAM, About The ASAM Criteria

The 2023 revision of The ASAM Criteria that states and payers are now adopting on their own timelines. ASAM released the Fourth Edition in 2023 to replace the Third Edition used since 2013. Oregon requires SUD and co-occurring disorder providers to deliver care aligned with the Fourth Edition by July 1, 2027, and extends existing ASAM levels of care on licenses and certificates through June 30, 2027. Washington's SB 5361 (2025) pushed its adoption date to January 2028 for both the adult and the adolescent and transition age youth criteria. Operators should watch which edition a payer's medical necessity criteria reference, because level names, admission criteria and documentation expectations differ between editions.

Also called ASAM 4th edition, ASAM Fourth Edition, ASAM 4, The ASAM Criteria 4th Edition

Source: OHA, The ASAM Criteria page (Fourth Edition timeline)

The least intensive ASAM level of care: scheduled individual, group and family sessions that total fewer than nine hours of service per week. It fits people who are medically and psychiatrically stable, have a workable living situation and can keep weekly or biweekly appointments. Washington's HCA describes outpatient as under nine hours a week delivered in individual and group settings. In Oregon the program standards for outpatient SUD treatment sit in OAR 309-019-0185, and the program operates under a Certificate of Approval issued under OAR chapter 309 division 008. Most Medicaid payers do not require prior authorization at this level, so it is often the entry point and the step down from IOP.

Also called Level 1, ASAM 1, outpatient SUD treatment, OP

Source: Washington HCA, Adult SUD Services and Continuum of Care fact sheet 82-0687

A structured, nonresidential program for people who need more clinical contact than standard outpatient but do not need daily or residential care. Washington's HCA describes IOP as generally nine to twelve hours of treatment per week for up to 90 days, built mostly on group and individual counseling and SUD education. Medicare's intensive outpatient benefit in 42 CFR 410.44 uses the same floor, a minimum of nine hours per week in the plan of care. Oregon defines intensive outpatient SUD services in OAR 309-019-0105 as care for people who need more therapeutic contacts per week than traditional outpatient. Payers typically bill IOP per diem under H0015 and often require authorization after an initial period.

Also called IOP, Intensive Outpatient, intensive outpatient program, Level 2.1

Source: Washington HCA, Adult SUD Services and Continuum of Care fact sheet 82-0687

A daytime program that delivers near daily clinical care, usually five days a week, to people who need more than IOP but can live at home or in a recovery residence. Medicare's partial hospitalization rule in 42 CFR 410.43 sets the benchmark most payers borrow: a minimum of 20 hours per week of therapeutic services under a physician certified plan of care, with individual and group therapy, occupational therapy, medication management and related services. Programs need access to medical and psychiatric staff and are commonly used as a step down from residential treatment. Nearly every payer requires prior authorization and periodic concurrent review at this level, so documentation of hours and medical necessity matters.

Also called PHP, Partial Hospitalization, partial hospitalization program, Level 2.5

Source: 42 CFR 410.43, Partial hospitalization services

ASPIRE to Excellence is the name CARF gives the framework of business practice and quality improvement standards published in Section 1 of every CARF standards manual. Section 1 standards cover areas such as leadership, strategic planning, input from persons served, financial planning, risk management, health and safety, human resources, technology, rights of persons served, accessibility, and performance measurement and improvement. Section 2 and later sections hold the program specific standards, such as those for intensive outpatient or residential treatment. Survey teams rate conformance to each applicable standard, so a program preparing for CARF works through Section 1 for the whole organization and the program sections for each service it wants accredited.

Also called ASPIRE, Section 1 standards, CARF standards manual, Behavioral Health Standards Manual

Source: CARF International, Our standards

An evidence based, team delivered service for adults with serious and persistent mental illness who have not done well in office based care. A multidisciplinary team including a psychiatric prescriber, nurses, case managers, a peer support specialist and clinical or rehabilitation staff shares a small caseload and provides most services in the person's home and community. Oregon's rules in OAR 309-019-0225 through 0255 require teams to be reachable 24 hours a day, seven days a week, set admission criteria tied to specific diagnoses and functional need, and require providers to pass fidelity reviews scored by the Oregon Center of Excellence for ACT to keep the designation. Washington certifies a similar program and calls it PACT. ACT is usually paid as a monthly case rate.

Also called ACT team, PACT, program of assertive community treatment, assertive community treatment team

Source: OAR 309-019-0105, Definitions (item 7)

Washington's pre-licensure credential for a graduate who is accruing the supervised experience needed for a full counseling, marriage and family therapy or social work license. RCW 18.225.010 defines the associate as a prelicensure candidate with a graduate degree in a mental health field who is gaining required supervision and experience. Full licensure requires a minimum of 3,000 supervised hours over at least two years under an approved supervisor. Since October 1, 2025 an applicant with a complete associate application may practice under supervision for up to 120 days while the Department of Health processes it. Operators care because associates must be supervised, and payers vary on whether they credential associates at all.

Also called LMHCA, mental health counselor associate, LMFTA, LSWAIC

Source: RCW 18.225.010(3)

California's pre-licensure registrations with the Board of Behavioral Sciences for graduates working toward the LMFT, LPCC or LCSW. An applicant cannot accrue supervised experience in California without registering, except under the Board's 90-day rule for recent graduates. Registrations renew annually, the law and ethics exam must be taken each year until passed, and after a set number of renewals the associate must apply for a subsequent registration. Supervised hours are logged on BBS forms and signed by a qualified supervisor. Operators care because associates in a licensed or certified program must be registered before billable work begins, and Medi-Cal and commercial plans differ on whether associate services are reimbursable and under whose enrollment.

Also called AMFT, APCC, ASW, associate marriage and family therapist

Source: BBS, LPCC applicants

The provisional status an Oregon substance use disorder counselor holds while working toward CADC certification. A new hire who provides addiction treatment in a certified program must register with MHACBO within 30 days of starting work, which places the person on the MHACBO registry and binds them to its code of ethics. Candidate status lasts two years and cannot be extended by MHACBO; the person must earn full CADC certification in that window or hold a qualifying health or allied provider license with 60 contact hours of SUD education. Operators care because an unregistered or expired CADC-R is a common finding in OHA certification reviews and can make the person's services unbillable.

Also called CADC-R, CADC Registrant, CADC candidate, registered SUD counselor Oregon

Source: MHACBO, CADC-R registration

DHCS's multi year initiative to improve health outcomes by reforming delivery systems, programs and payment across Medi-Cal. For behavioral health it arrived in stages: streamlined documentation for substance use disorder and specialty mental health services from July 1, 2022, when BHIN 22-019 removed most client plan and treatment plan requirements; No Wrong Door, also July 2022; standardized screening and transition tools between managed care plans and county systems from January 2023; behavioral health payment reform from July 2023, which moved counties from cost based reimbursement to fee schedule payments with CPT coding; and behavioral health administrative integration, scheduled for January 2027. Operators in California track CalAIM because it changes how counties pay and what a note must contain.

Also called CalAIM, Cal AIM, California Advancing and Innovating Medi-Cal, CalAIM behavioral health payment reform

Source: DHCS, CalAIM Behavioral Health Initiative

The license the California Department of Health Care Services requires before anyone operates, or advertises, a facility providing 24-hour nonmedical residential alcoholism or drug abuse recovery or treatment services to adults. The requirement is in Title 9 of the California Code of Regulations, Division 4, Chapter 5 (section 10500 and following), issued under Health and Safety Code chapter 7.5 beginning at section 11834.01. The license names the licensee and the specific building; a program that houses residents in one building and treats them in another may be licensed as a single integral facility only if all buildings are controlled by the same licensee, otherwise each facility needs its own license. DHCS's Licensing and Certification Division administers the program.

Also called DHCS license, California residential license, Title 9 CCR 10505, alcoholism or drug abuse recovery or treatment facility license

Source: Cal. Code Regs. tit. 9, section 10505 Requirement for Licensure

A fixed payment a state makes to a managed care plan for each enrolled member each month, set at an actuarially sound rate, that the plan receives whether or not the member uses services. Under 42 CFR 438.2 this is the defining payment method of Medicaid managed care; Oregon calls the CCO version a global budget. The plan then decides how to pay providers out of that pool, which is why CCOs and Apple Health plans can pay fee for service, case rates or sub capitation and why they manage utilization closely. Some plans also pay behavioral health providers a capitated or per member amount for a defined population, shifting financial risk to the program.

Also called capitation payment, capitated rate, per member per month, PMPM

Source: 42 CFR 438.2, Definitions

The shared online profile that most commercial payers, and many Medicaid managed care plans, pull from when they credential an individual clinician. The clinician, or the practice management staff working for them, enters licenses, education, work history, malpractice coverage and practice locations once, then authorizes each plan to view the record. CAQH now operates as DataSpring and calls the tool the CAQH Provider Data Portal; the ProView name is still widely used. Profiles sit on a 120 day attestation cycle, so a lapsed attestation can stall a credentialing application or a recredentialing cycle. Keeping the profile current is a standing task for any group that bills commercial plans.

Also called CAQH, CAQH Provider Data Portal, DataSpring, CAQH attestation

Source: CAQH Provider Data Portal (caqh.org, now dataspring.com)

The standardized codes on a remittance that explain why a claim or line paid differently than billed, maintained by X12 and used by every HIPAA covered payer. Each CARC is paired with a claim adjustment group code: CO (contractual obligation, the provider absorbs it), PR (patient responsibility), OA (other adjustment) or PI (payer initiated). Behavioral health programs see a handful repeatedly, such as authorization missing, timely filing, non covered service and duplicate claim. Sorting denials by CARC is the fastest way to find the process failure behind them, since each code points to intake, authorization, coding or contracting.

Also called CARC, claim adjustment reason codes, CO 197, PR 1

Source: X12 External Code Lists, Claim Adjustment Reason Codes

A Portland based nonprofit Medicaid health plan, founded in 1993, that holds Oregon Health Authority contracts for two Coordinated Care Organizations, Columbia Pacific CCO on the north coast and Jackson Care Connect in Jackson County, and that administers benefits, including behavioral health, for Health Share of Oregon in the Portland metro area. For a treatment program this means one CareOregon provider contract, credentialing file and claims process can cover members of all three CCOs. CareOregon publishes its own authorization rules, fee schedules and provider manuals, and it is the payer that most Oregon outpatient and residential programs deal with first.

Also called CareOregon Inc, Columbia Pacific CCO, Jackson Care Connect, CareOregon behavioral health

Source: CareOregon, About Us

The CARF survey is the on-site review that ends the accreditation process. A team of peer surveyors observes services, interviews persons served and staff, and reviews documents to decide whether the program conforms to every applicable standard, consulting with staff as they go. CARF then issues an accreditation decision, most commonly a Three-Year Accreditation or a One-Year Accreditation, and sends a written report about six to eight weeks after the survey. The survey fee depends on the number of surveyors and days needed. Operators typically spend a year or more preparing, and the application asks for a two month window in which the survey can occur.

Also called CARF survey, site survey, Three-Year Accreditation, One-Year Accreditation

Source: CARF International, Steps to accreditation

CARF International is an independent, nonprofit accreditor of health and human services, founded in 1966 as the Commission on Accreditation of Rehabilitation Facilities. Its Behavioral Health Standards Manual covers outpatient, intensive outpatient, residential, detoxification and withdrawal management, opioid treatment, and many other program types, and CARF also offers ASAM Level of Care certification for residential addiction programs. Surveyors are industry peers who review conformance to the standards through observation, interviews and document review. Operators pursue CARF because payers, state agencies and SAMHSA (for opioid treatment programs) recognize it, and because Washington grants deemed status to agencies accredited by a recognized national accreditor.

Also called Commission on Accreditation of Rehabilitation Facilities, CARF accreditation, CARF accredited

Source: CARF International, About CARF

The CCBHC prospective payment system (CC PPS) is the cost-based, clinic-specific Medicaid payment method for Certified Community Behavioral Health Clinics in the Section 223 demonstration. States choose one of four methods. CC PPS-1 is a daily rate similar to FQHC payment, with optional quality bonus payments. CC PPS-2 is a monthly rate with required quality bonus and outlier payments. CC PPS-3 and CC PPS-4 are daily and monthly versions that add separate special crisis services rates. States may not pay CCBHCs anything extra for in-scope services beyond the PPS rate, outlier payments and quality bonus payments, and rates are set and rebased using clinic cost reports.

Also called CC PPS, CC PPS-1, CC PPS-2, CC PPS-3

Source: CMS, Section 223 CCBHC Demonstration PPS Guidance, Updated February 2024

A regional organization that contracts with the Oregon Health Authority under ORS 414.572 to deliver Oregon Health Plan benefits, including mental health and substance use treatment, to OHP members in a defined service area for a global budget. CCOs may be local community based groups or statewide organizations with local governance, and they set their own provider networks, credentialing, authorization rules and rates. Current CCOs include Health Share of Oregon, Trillium, PacificSource Community Solutions, AllCare, Jackson Care Connect, Columbia Pacific, Umpqua Health Alliance, Advanced Health, InterCommunity Health Network, Yamhill Community Care and Eastern Oregon CCO. An operator must contract and credential with each CCO whose members it serves; an OHA enrollment alone only covers open card members.

Also called CCO, Coordinated Care Organizations, Oregon CCO, CCO contract

Source: ORS 414.572, Coordinated care organizations; rules

The Oregon Health Authority certificate that lets an organization provide outpatient mental health, substance use disorder or problem gambling treatment under OAR chapter 309 division 008. A current certificate is required for any provider paid through OHA, a CCO or other public funds, and private pay programs may seek one to establish insurance reimbursement eligibility. OHA audits the application, conducts a certification review of each service delivery location and may require a Plan of Correction before issuing. Initial certificates run up to one year and renewals up to three. The certificate lists the service delivery rules the program is approved under, so adding a service or site requires a modification. It is not a substitute for a residential facility license.

Also called Oregon COA, OHA certificate of approval, OHA certificate, behavioral health certificate Oregon

Source: OAR 309-008-0250 Required Certifications for Behavioral Health Treatment Services

A state approval that certain health facilities must obtain before being built, bought or expanded, meant to limit duplication of expensive services. Washington's program under RCW 70.38.105 requires a certificate of need or an exception from the Department of Health before the construction, development or other establishment of a new health care facility as defined in the chapter, the sale or lease of a hospital, and major nursing home capital projects. Oregon's ORS 442.315 applies to any new hospital or new skilled nursing or intermediate care service or facility. Freestanding outpatient and residential behavioral health programs are generally licensed without a CON, but any project with hospital beds or a nursing facility component should confirm CON applicability early.

Also called certificate of need, CON review, Washington certificate of need, Oregon certificate of need

Source: RCW 70.38.105 Health services and facilities requiring certificate of need

The local government sign-offs a treatment site needs before a state license or certificate will issue. A certificate of occupancy is the building department's confirmation that a structure may be used for its intended occupancy class under the building code; licensing agencies ask for it or an equivalent along with zoning and fire approvals. Oregon's residential rule, OAR 309-018-0200, requires programs to keep current documentation that they comply with all applicable local business license, zoning and building codes and fire and safety regulations, and puts the burden on the provider to check with local government. Washington's BHA application requires a statement that the site meets all local and state building and safety requirements.

Also called certificate of occupancy, C of O, occupancy permit, zoning approval licensing

Source: OAR 309-018-0200 Facility Standards for Substance Use Disorders and Problem Gambling Residential Treatment and Recovery Programs

The agency inspection that decides whether a program gets or keeps its certificate or license. Reviewers enter the service delivery location, inspect service records, personnel files, credentials, background checks and medication logs, and interview staff and people served. Oregon distinguishes the Initial Certification Review, the Certification Renewal Review (before expiration and at least every three years) and Discretionary Reviews that may occur without notice after a complaint; OHA may also complete part of a review as a desk review using submitted documents and phone interviews. Washington requires an initial on-site review of every behavioral health agency with entrance and exit conferences, and routine reviews for agencies not deemed through accreditation. Residential facilities also get fire and life safety inspections.

Also called site survey, site review, on-site review, licensure review

Source: OAR 309-008-0700 Types of Reviews

Oregon's substance use disorder counselor certification, issued by MHACBO in three levels. CADC I requires 150 hours of alcohol and drug education, 1,000 hours of supervised counseling experience and a passing score on the IC&RC Alcohol and Drug Counselor exam, with no degree required. CADC II and CADC III add degree and experience requirements and are the levels accepted for clinical supervisor roles. OAR 309-019-0125 requires SUD treatment staff to be certified or licensed by a health or allied provider agency within two years of hire, and MHACBO is the certifying body most Oregon programs use. Operators care because payer enrollment, OHA certification reviews and supervision assignments all turn on CADC level.

Also called CADC, CADC I, CADC II, CADC III

Source: MHACBO, CADC I requirements

A clinic model created by Section 223 of the Protecting Access to Medicare Act of 2014 that must serve anyone who asks for mental health or substance use care regardless of ability to pay, where they live or their age. SAMHSA's 2023 certification criteria set standards in six areas, including staffing, availability, care coordination and a scope of nine required services such as 24 hour crisis services, outpatient mental health and SUD treatment, screening, targeted case management, peer and family support, and primary care screening. Clinics are funded through the Section 223 Medicaid demonstration, which pays a prospective payment system rate, through SAMHSA expansion grants, or through independent state programs. Oregon participates in the demonstration.

Also called CCBHC-E, Section 223 demonstration, Excellence in Mental Health Act clinic

Source: SAMHSA, Certified Community Behavioral Health Clinics

Washington's credential for peer support workers. Historically the Health Care Authority trained and certified peer counselors; chapter 18.420 RCW moved peer support to a Department of Health credential with certified peer support specialist and trainee levels. The law defines peer support services as interventions by a peer in recovery from a mental health condition or substance use disorder, or the parent or guardian of a youth who received behavioral health services, to someone with similar lived experience. Approved supervisors include experienced certified peer support specialists and, until July 1, 2028, other behavioral health providers with two years of relevant experience. Operators care because Apple Health pays for peer support only when the peer is credentialed and supervised as required.

Also called Certified Peer Counselor, CPC, certified peer specialist, CPSS Washington

Source: RCW 18.420.010(5)

Idaho's peer credentials for the Medicaid behavioral health plan administered by Magellan of Idaho. The Certified Peer Support Specialist is an adult with lived experience of mental illness or addiction who supports others in recovery; the Certified Family Support Partner is a parent or caregiver peer who supports other families with children in behavioral health services. BPA Health is the certifying body for both, and CPSSs can add a youth peer support endorsement after extra training. Peer recovery coaches in SUD programs are certified separately by IBADCC. Operators care because Magellan requires certification and a supervisory protocol for peer staff before peer services are billable, and the certifying body differs from the counselor board.

Also called CPSS, Idaho peer support specialist, family support partner, youth peer support Idaho

Source: Magellan of Idaho, Peer Services

MHACBO's certification for addiction peer support workers in Oregon. A CRM must have at least two years of recovery from a substance use disorder, complete an OHA-approved 40-hour addiction peer training and an oral health training, and pass a background check against the ORS 443.004 exclusion list. Recertification runs every two years with 20 hours of continuing education, including 6 hours of ethics. The CRM is separate from the Peer Support Specialist credential that OHA's Traditional Health Worker program issues, though the trainings overlap. Operators care because CRMs can enroll as Oregon Medicaid providers and their services are billed through the certified program that employs them, not by the peer directly.

Also called CRM II, Recovery Mentor, addiction peer Oregon

Source: MHACBO, Certified Recovery Mentor

A private organization the California Department of Health Care Services approves to register and certify alcohol and other drug counselors who work in licensed or certified SUD programs. Title 9 CCR section 13005 defines the certifying organization by reference to the approved list in section 13035, and each program may decide which approved organizations it will recognize when hiring. Approved organizations must hold accreditation, maintain a code of conduct, verify education and experience, test applicants and report counselor status to DHCS. This is the California counterpart of Oregon's MHACBO and Idaho's IBADCC. Operators care because a counselor registered with an organization DHCS no longer approves does not meet the staffing requirement, so verification must go to the organization's live registry.

Also called certifying organization, CCAPP, CADTP, DHCS counselor certification

Source: 9 CCR 13005(3)

Licenses and certificates belong to the specific legal entity and premises named on them and do not follow the business to a buyer. Oregon's OAR 309-008-0300 makes a Certificate of Approval void immediately upon a change in the provider's majority or controlling ownership, and OAR 415-012-0040 states a residential license is not transferable to another person, entity or location, so anyone acquiring a licensed facility must apply for a new license. Oregon applications also require disclosure of every owner with five percent or more ownership and their licensing history. Washington RTF licensees must apply for a license amendment before changing service types, bed count, administrator, structure or address.

Also called CHOW, change of ownership, license transfer, non-transferable license

Source: OAR 309-008-0300 Terms of Certification

A vendor that sits between a provider's EHR or billing system and the payers, converting claims into the HIPAA standard 837 format, running edits (scrubbing) for missing or invalid data, routing each claim to the right payer and returning acknowledgments, rejections, eligibility responses and electronic remittances. CMS describes EDI with Medicare as happening directly or with the assistance of a clearinghouse or billing service. A clearinghouse rejection means the claim never reached the payer and does not start the payer's clock, so rejected claims need daily work. Idaho Medicaid publishes a list of registered billing agencies and clearinghouses on idmedicaid.com.

Also called clearinghouse, EDI clearinghouse, claim scrubber, billing service

Source: CMS, Electronic Billing & EDI Transactions

A claim that a payer can process and pay without asking the provider or anyone else for more information. Federal Medicaid rules define it that way and set payment clocks that start only when a claim is clean, and Oregon's prompt pay statute requires insurers to pay or deny a clean claim within 30 days. For an operator, clean claim rate is the share of claims accepted on first submission, which depends on eligibility verification, authorization numbers, correct codes and modifiers, taxonomy and NPI setup, and complete member data. A low rate means rework, slower cash and more denials to appeal.

Also called clean claim rate, first pass claim, clean claim definition

Source: 42 CFR 447.45(b)

A CLIA Certificate of Waiver (CoW) is the federal certificate for a facility that performs only waived laboratory tests on human specimens to assess health or to diagnose, prevent or treat disease. CLIA certification applies to any such testing site, and laboratories must be properly certified to receive Medicare or Medicaid payment. Drug testing for pre-employment screening is exempt, but testing that guides patient care is not. Applicants file Form CMS-116 with their State Agency, pay the fee and may begin testing once the certificate arrives; New York and Washington follow separate state processes. Certificates are effective for two years. A CoW laboratory must have a laboratory director, with no federal education or experience requirements.

Also called CLIA waiver, Certificate of Waiver, CLIA certificate, CMS-116

Source: CMS, Apply for a CLIA Certificate

Oregon's pre-licensure status for a master's-level social worker who is completing the supervised practice required for the LCSW. The State Board of Licensed Social Workers certifies the CSWA once the applicant shows an accredited MSW and a board-approved plan for completing practice and supervision requirements under ORS 675.537. A CSWA may provide clinical social work only under that plan and the supervisor named in it. Operators care because a CSWA is a QMHP under OAR 309-019-0125 and can deliver billable mental health services inside an OHA-certified program, but many commercial payers will not credential a CSWA directly, so the agency bills under its own enrollment and tracks the associate's plan and supervision hours.

Also called clinical social work associate, Oregon social work associate, LCSW associate Oregon

Source: ORS 675.537

The staff role Oregon requires in every OHA-certified behavioral health program to oversee and evaluate services. OAR 309-019-0125 sets different minimums by program type: in mental health programs the clinical supervisor must meet QMHP requirements and have two years of post-graduate clinical experience; in substance use disorder programs the supervisor must hold an advanced SUD certification or a qualifying health license with 120 hours of SUD education, plus several years of paid counseling experience that varies with degree level. Peer Delivered Services Supervisors must be a certified PSS or PWS with one year of experience. Operators care because the supervisor's qualifications are checked at certification review and drive who can sign off on CADC-R and QMHA-R hours.

Also called clinical supervisor, program clinical supervisor, SUD clinical supervisor, mental health clinical supervisor Oregon

Source: OAR 309-019-0125(3)

The Medicare enrollment applications. The CMS-855I is for an individual practitioner, such as a psychologist, clinical social worker, counselor or marriage and family therapist, and since the CMS-855R was discontinued it also carries reassignment of the clinician's payments to a group. The CMS-855B is for a clinic, group practice or other supplier that bills Medicare under its own Type 2 NPI; its 12/2025 edition also has a section for the group to accept, end or change a clinician's reassignment. Both can be filed on paper or through PECOS, and a new group usually files the 855B and each clinician's 855I together so reassignment takes effect. Each lists the supporting documents required and where to send them.

Also called CMS-855I, CMS-855B, 855I, 855B

Source: CMS-855B, Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (12/2025)

A diagnosis of both a mental health disorder and a substance use disorder (Oregon also counts gambling disorder) in the same person. Washington's WAC 246-341-0200 defines it as the coexistence of a mental health and a substance use disorder. Oregon's OAR 309-019-0145 requires providers serving people with COD to deliver integrated treatment, meaning one assessment and one concurrent service plan covering all diagnoses, and to be approved under OAR chapter 309 division 008 and designated for COD. Oregon pays approved integrated COD providers differently from single track programs, so the designation affects revenue, not just clinical practice. Staff must hold a qualifying mental health or SUD credential and complete COD training.

Also called co-occurring, dual diagnosis, integrated co-occurring disorders, ICD treatment

Source: OAR 309-019-0145, Co-Occurring Mental Health and Substance Use Disorders (COD)

A Community Mental Health Center is a Medicare provider type that participates only to furnish partial hospitalization and intensive outpatient services. Under 42 CFR 410.2, a CMHC provides outpatient services, including specialized services for children, the elderly, people with chronic mental illness and people discharged from inpatient treatment, plus 24 hour emergency care, day treatment or other partial hospitalization, intensive outpatient or psychosocial rehabilitation, and screening for state mental health facility admission. It must meet state CMHC licensing or certification rules and furnish at least 40 percent of its services to people not eligible for Medicare. CMHCs also follow Conditions of Participation at 42 CFR 485.904 through 485.918.

Also called CMHC, Medicare CMHC, CMHC conditions of participation

Source: 42 CFR 410.2, Definitions

A complaint investigation is the regulator's response to a report that a licensed or certified program violated licensing laws or rules. In Washington anyone may report an alleged violation to the Department of Health; if the department decides to investigate, the report becomes a complaint and the agency must give investigators access to the facility, records and staff. Substantiated complaints that require corrective action carry a fee and feed into denial, suspension or revocation decisions under WAC 246-341-0335. In Oregon any individual may complain to the Health Systems Division about a certified provider, which may first require the person to use the provider's grievance process and the Medicaid payer's process. Programs should cooperate, document and correct promptly.

Also called licensing complaint, complaint to the department, regulatory complaint, substantiated complaint

Source: WAC 246-341-0605 Complaint process

The first stage after a licensing application lands at the agency, when staff check that every required document is present and appears to meet the rules before any site visit is scheduled. In Oregon, OAR 309-008-0500 and OAR 415-012-0035 give the Division 60 days to conduct a comprehensive audit of the application materials; a complete application leads to scheduling the certification or licensure review, while an incomplete one triggers a written notice and the applicant has 14 calendar days to submit an amendment. Washington DOH reviews BHA and RTF applications within days of receipt and emails the applicant about missing items. Missing policies, insurance certificates or ownership disclosures at this stage are the most common cause of delay.

Also called completeness check, application audit, incomplete application notice, 60 day application review

Source: OAR 309-008-0500 Response to Application

The payer's review of a course of treatment that is already under way, used to decide whether to keep authorizing days or sessions in residential, withdrawal management, PHP or IOP. The program submits updated clinical information, usually against ASAM Criteria or the plan's own medical necessity criteria, at intervals the payer sets. Under federal claims rules for group health plans, cutting short an approved course of treatment is an adverse benefit determination that the member can appeal. Programs that miss a concurrent review deadline often lose coverage for the days that follow, so tracking due dates matters as much as the clinical write-up.

Also called continued stay review, ongoing utilization review, concurrent care decision

Source: 29 CFR 2560.503-1(f)(2)(ii)

An intermediate enforcement step in which the agency keeps a program licensed but attaches enforceable requirements instead of denying or revoking. Oregon's OAR 309-008-0905 lets OHA place conditions when a program employs staff with substantiated abuse findings or who lack minimum qualifications, substantially fails to comply with the rules, fails to implement a Plan of Correction, or receives substantially similar findings in two consecutive reviews; conditions can include corrective actions with deadlines, enrollment limits and increased oversight, and they are printed on the certificate. Washington's WAC 246-341-0335 allows DOH to place an agency on probation and to revoke if it fails to correct health and safety deficiencies within agreed time frames. CCOs and payers may see conditions.

Also called conditions on a certificate, conditional license, probationary license, license conditions

Source: OAR 309-008-0905 Conditions

Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) are federal health and safety standards in Title 42 of the Code of Federal Regulations that certain provider types must meet to begin and continue participating in Medicare and Medicaid. State survey agencies, working under agreements with HHS, survey providers to see whether each standard is met, and a facility cannot participate in Medicare unless it meets every condition. Behavioral health entities subject to certification include community mental health centers and hospitals, and psychiatric residential treatment facilities participate only in Medicaid. CMS recognized accrediting organizations can deem compliance when their standards meet or exceed the CoPs.

Also called CoPs, Conditions of Participation, Conditions for Coverage, CfCs

Source: CMS, Conditions for Coverage and Conditions of Participation

The training hours a licensed or certified behavioral health worker must complete each renewal cycle to keep the credential active. Requirements are set by the issuing body: in Washington a certified SUDP completes 20 hours every two years, including four hours of ethics and law, with periodic suicide assessment and health equity training. In Oregon, MHACBO requires 20 hours every two years with six hours of ethics for a CRM, and the counselor and social work boards set their own cycles; Idaho boards and IBADCC and California's BBS and certifying organizations do the same. Operators care because the agency, not just the employee, is cited when a staff member's credential lapses, so CE due dates belong in the expirables tracker.

Also called CE, CEU, continuing education, continuing competency

Source: WAC 246-811-240(1)

Federal law sorts controlled substances into five schedules listed in 21 CFR 1308.11 through 1308.15. Schedule II includes methadone, oxycodone, amphetamines and other drugs with accepted medical use and high abuse potential, and requires DEA Form 222 ordering, written or electronic prescriptions with no refills, and strict storage. Schedule III includes buprenorphine products used for opioid use disorder; Schedule IV includes most benzodiazepines; Schedule V includes some cough preparations and pregabalin. A DEA registration states which schedules the registrant may handle, and state rules may add drugs or tighten requirements. Treatment programs need the schedule to set ordering, inventory, security and recordkeeping procedures for each medication.

Also called drug schedules, Schedule II, Schedule III, Schedule IV

Source: 21 CFR 1308.12 Schedule II

A Washington managed care organization, part of Centene, that serves more than 200,000 Apple Health members statewide and administers Apple Health Core Connections, the foster care plan. It also sells Ambetter marketplace coverage. Coordinated Care contracts directly with behavioral health providers, runs its own credentialing and prior authorization, and publishes a provider manual and billing guidance for integrated managed care. For a treatment program it is one of the five Apple Health plans to contract with and the only route to foster care members; its Ambetter line requires a separate commercial agreement.

Also called Coordinated Care of Washington, CCW, Coordinated Care Corporation, Coordinated Care Apple Health

Source: Coordinated Care, About Us

The rules for which plan pays first when a person has more than one source of coverage. Medicaid is the payer of last resort: federal rules require a state to reject a claim and return it to the provider when it knows another payer is probably liable, and both Oregon and Washington require providers to bill known third parties before Medicaid. For a treatment program this means asking about every policy at intake, including a parent's or spouse's plan, billing the primary first, and sending the primary's remittance with the secondary claim. COB errors are a leading cause of Medicaid denials and later recoupments.

Also called COB, coordination of benefits, TPL, third party liability

Source: 42 CFR 433.139(b)(1)

The contract a provider signs with the Washington State Health Care Authority to enroll in Apple Health (Medicaid). HCA enrolls a professional, agency, supplier or contractor only by approving an application for a core provider agreement, a nonbilling provider agreement, or the addition of a servicing provider under one of them. The CPA holder is the billing entity, and clinicians who render services under it enroll as servicing providers. Enrollment runs through the ProviderOne system and must be in place before the first Apple Health claim. Managed care organizations then credential and contract separately, but they require an active CPA first.

Also called core provider agreement, Apple Health provider agreement, Washington Medicaid enrollment, nonbilling provider agreement

Source: WAC 182-502-0005(1)

The county agency, or joint powers group of counties, that holds the DHCS contract to deliver Medi-Cal specialty mental health services in California. Each MHP covers members whose mental health needs are more than mild to moderate, pays for outpatient, crisis, residential and inpatient psychiatric services, and contracts with community providers to deliver them. Medi-Cal managed care health plans handle the mild to moderate tier. A mental health program must therefore become a county MHP network provider, follow that county's authorization, documentation and quality rules, and bill the county rather than DHCS. Many counties run the MHP and the Drug Medi-Cal program out of one behavioral health department.

Also called Mental Health Plan, county MHP, specialty mental health services, SMHS

Source: DHCS, Medi-Cal Specialty Mental Health Services

The CPT code for a psychiatric diagnostic evaluation without medical services, the usual intake assessment billed by a psychologist, clinical social worker, counselor or marriage and family therapist. 90792 is the version with medical services, billed by prescribers. Medicare lists both as covered mental health codes and allows them by telehealth. Most payers pay one 90791 per episode or per year without special justification and expect a full biopsychosocial write-up with diagnosis and treatment plan. Substance use programs billing Medicaid often use H0001 for the SUD assessment instead, so the intake code depends on payer and program type.

Also called 90791, 90792, diagnostic evaluation code, intake assessment code

Source: CMS MLN1986542, Medicare & Mental Health Coverage (March 2026)

The filings Washington state agencies make with the Office of the Code Reviser at each stage of rulemaking. A CR-101, the preproposal statement of inquiry, invites the public to discuss a possible rule before formal notice. Under RCW 34.05.310 it names the statute that authorizes the rule, explains why the rule may be needed and says how interested parties can take part, and it must be published in the Washington State Register at least 30 days before the CR-102. Emergency rules and some others skip it. The CR-102 gives formal notice of a proposed rule, and the CR-103 adopts it; a permanent rule normally takes effect 31 days after the CR-103 is filed.

Also called CR-101, CR-102, CR-103, preproposal statement of inquiry

Source: Washington State Department of Licensing, Definitions for rules

Credentialing is a payer's verification of a clinician's or organization's licenses, education, training, work history, sanctions and malpractice record before it lets them bill as a network provider. Contracting is the separate business step that sets rates and terms; a program can be credentialed and still unpaid until the contract is loaded. Federal rules require each state Medicaid program to set one uniform credentialing and recredentialing policy that covers mental health and substance use providers and to make its managed care plans follow it. Recredentialing repeats the check on a fixed cycle, so expirations, CAQH attestations and ownership changes must be tracked.

Also called credentialing, recredentialing, re-credentialing, credentialing vs contracting

Source: 42 CFR 438.214(b)

Short term care that assesses and treats a person in an acute behavioral health crisis so they do not need a long hospital stay. Washington's RCW 71.05.020 defines a crisis stabilization unit as a licensed or certified short term facility designed to assess, diagnose and treat acute crises or decide whether involuntary commitment is needed, and RCW 71.24.025 adds the 23 hour crisis relief center, open every hour of the year and limited to 23 hours and 59 minutes per visit. Oregon community mental health programs must provide crisis services directly or by linkage under OAR 309-019-0150, with screening within one hour and face to face response within one to three hours by geography. Payment usually runs through the state or BH-ASO rather than a per diem.

Also called crisis stabilization unit, CSU, 23-hour crisis relief center, crisis receiving center

Source: RCW 71.05.020, Definitions (crisis stabilization unit)

A critical incident is a serious or undesirable event involving a person in services, such as a death, serious injury, suicide attempt, abuse or neglect allegation, medication error with harm, or an outbreak of communicable disease. Washington requires each licensed behavioral health agency to have a policy for reporting any critical incident to the Department of Health within 48 hours, including the actions taken, and substantiated critical incident investigations carry a fee. Oregon requires certified providers to maintain incident reporting policies and to report serious incidents to the Oregon Health Authority and, for Medicaid members, to the CCO. Programs should keep an incident log that feeds the QAPI process.

Also called critical incident, incident report, serious incident reporting, WAC 246-341-0420 critical incident

Source: WAC 246-341-0420(12) Agency policies and procedures, Reporting critical incidents

A voluntary, employer paid benefit that gives workers free, confidential assessment, short term counseling and referrals for personal or work problems, including alcohol and drug use, stress and family issues. EAPs are run by vendors or by the behavioral health arms of large insurers, and they typically authorize a small fixed number of sessions, often three to eight, before referring the person to their health plan benefit. For a program, an EAP contract brings referrals and pays a flat per session rate without diagnosis based billing, but the sessions do not carry over to the member's insurance and a separate authorization is needed once EAP sessions are used up.

Also called EAP, Employee Assistance Programs, EAP sessions, EAP referral

Source: U.S. Office of Personnel Management, What is an Employee Assistance Program (EAP)?

EKRA, 18 U.S.C. 220, is a federal criminal law passed in 2018 that makes it a felony to knowingly and willfully pay, offer, solicit or receive remuneration in return for referring a patient to a recovery home, clinical treatment facility or laboratory. Unlike the Anti-Kickback Statute it applies to services covered by any health care benefit program, including commercial insurance and private pay, so cash pay treatment programs are covered. It has its own narrow exceptions, and percentage based or volume based pay for marketers and admissions staff is the most common risk. Penalties reach up to 200,000 dollars and ten years in prison per violation. Compensation plans, marketing agreements and lab arrangements should be reviewed against it.

Also called 18 U.S.C. 220, EKRA compliance, recovery home kickback law

Source: 18 U.S.C. 220 Illegal remunerations for referrals to recovery homes, clinical treatment facilities, and laboratories

An emergency preparedness plan documents how a program keeps people safe and keeps operating during fires, earthquakes, wildfire smoke, floods, power loss, violence and other emergencies. Medicare and Medicaid certified provider types, including community mental health centers and hospitals, must meet the CMS emergency preparedness rule, which requires an all hazards risk assessment, a written plan reviewed and updated at least every two years, policies and procedures, a communication plan, and training and exercises. Washington's licensing rules require every behavioral health agency to document an evacuation plan covering types of emergencies, exit routes, communication with people who have sensory limits, and evacuation of mobility impaired individuals. Accreditors survey the same material.

Also called emergency plan, disaster plan, evacuation plan, CMS emergency preparedness rule

Source: 42 CFR 485.920 Condition of participation: Emergency preparedness (CMHC)

EPSDT is the Medicaid benefit for eligible children and youth under age 21. It requires states to provide periodic screening plus the diagnosis and treatment needed to correct or ameliorate physical and mental illnesses and conditions found through screening, whether or not those services are covered under the State Plan, as long as they fall within the federal list of Medicaid service categories. For behavioral health programs serving youth, EPSDT can be the basis for Medicaid coverage of services a state does not cover for adults, when the service is needed for the individual child. Denials for youth should be checked against this standard before accepting a State Plan limit.

Also called EPSDT, Early and Periodic Screening Diagnostic and Treatment, EPSDT benefit, Medicaid children's benefit

Source: 42 U.S.C. 1396d(r), Section 1905 of the Social Security Act (Cornell LII)

External quality review (EQR) is the annual independent review of each Medicaid managed care plan, including MCOs, PIHPs and PAHPs, performed by a qualified external quality review organization (EQRO) for the state. Mandatory activities include validating performance improvement projects and performance measures, reviewing compliance with federal managed care standards within the previous 3 years, and validating network adequacy. Optional activities include validating encounter data, running consumer or provider surveys, and focused quality studies. The state posts the annual EQR technical report on its website by April 30. For behavioral health providers in managed care networks, EQR findings on access, network adequacy and performance measures often shape what plans ask of their providers.

Also called EQR, EQRO, external quality review organization, EQR technical report

Source: 42 CFR 438.350, External quality review (eCFR via Cornell LII)

General Behavioral Health Integration is a monthly care management service billed under the Medicare Physician Fee Schedule with CPT code 99484 for integration models other than the Psychiatric Collaborative Care Model. It can be used for any mental, behavioral health or psychiatric condition the billing practitioner is treating, including substance use disorders. The practitioner may furnish it alone or with clinical staff working incident to their services, and face to face staff availability is not required. Prior consent is required, and one practitioner cannot report 99484 and the CoCM codes for the same patient in the same month. Physicians of any specialty, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives can report it.

Also called General BHI, BHI, 99484, behavioral health integration code

Source: CMS, Frequently Asked Questions about Billing Medicare for Behavioral Health Integration (BHI) Services

A written estimate of expected charges that providers and facilities must give to uninsured or self pay patients under the No Surprises Act. It must itemize the services and charges, be provided in the patient's preferred form, and be delivered within set timeframes: within one business day when care is scheduled at least three business days out, within three business days when scheduled at least ten business days out, and within three business days of a request. If the final bill exceeds the estimate by 400 dollars or more the patient can use a federal dispute process. Private pay treatment programs must build this into admissions.

Also called GFE, good faith estimate, No Surprises Act, self-pay estimate

Source: 45 CFR 149.610

A grievance is a formal complaint by a person in services, or their representative, about how services were denied or delivered. Oregon's rules let any individual, parent or guardian file a grievance with the provider, with the individual's coordinated care organization, or with the Health Systems Division; the provider must explain the process at entry, help people use it, respond in writing with appeal information, and protect grievants and witnesses from retaliation. Washington requires each agency to protect participant rights and to tell people how to report alleged violations to the Department of Health. Medicaid members also have separate managed care grievance and appeal rights with their plan.

Also called grievance, grievance procedure, client grievance, appeal rights

Source: OAR 309-019-0215 Grievances and Appeals

90853 is group psychotherapy, 90846 is family psychotherapy without the patient present and 90847 is family psychotherapy with the patient present. Medicare covers all three. Washington Apple Health pays group treatment only when it is medically necessary and part of the person's individual service plan, and lists duration and provider type limits for each code. Group notes must show the group's focus, the interventions and the person's response. Substance use programs billing Medicaid often use H0005 or other H codes for group counseling instead, so the choice between CPT and HCPCS codes follows the payer's billing guide.

Also called 90853, 90846, 90847, group therapy code

Source: HCA Mental Health Services Billing Guide, October 2026

The minimum staffing Washington sets for group counseling and group therapy in a licensed behavioral health agency: at least one staff member for every 16 individuals in the session, under WAC 246-341-0515. The same section requires that all clinical staff be appropriately credentialed for the services they provide and receive clinical supervision. In other states, group limits more often come from residential licensing rules, payer contracts and accreditation standards than from a single outpatient rule. Operators care because group size drives IOP and PHP economics, and a group that exceeds the ratio can be cited at licensing review and challenged on audit when billed per participant.

Also called staffing ratio, group ratio, 1:16 ratio, staff to client ratio

Source: WAC 246-341-0515(3)

Idaho's managed behavioral health program, administered by Magellan Healthcare under contract with the Department of Health and Welfare. The IBHP coordinates mental health, substance use disorder and youth behavioral health benefits for Idaho Medicaid members and also covers some state funded services for residents who are not on Medicaid. Nearly all outpatient, residential and crisis behavioral health claims for Idaho Medicaid members flow through the IBHP rather than the state's fee for service system, so a program must join Magellan's network, follow its authorization rules and bill Magellan to be paid. The IBHP replaced the earlier Optum Idaho contract.

Also called IBHP, Idaho Behavioral Health Plan, Idaho BH plan, Magellan IBHP

Source: Magellan of Idaho, Idaho Behavioral Health Plan home page

Idaho pays for most Medicaid outpatient, inpatient, residential and crisis behavioral health services through a single managed care contract, the Idaho Behavioral Health Plan, run by Magellan Healthcare. A program must be enrolled with Idaho Medicaid and then join Magellan's network, which means credentialing (verifying licenses, certifications and history) and contracting (agreeing to rates and terms) before claims will pay. Magellan processes claims through Availity and rejects claims without a valid taxonomy code. The plan also covers some non Medicaid members and the Department of Juvenile Corrections network, and members may choose any in network provider.

Also called IBHP, Magellan credentialing, Magellan contracting, Idaho behavioral health managed care

Source: Idaho DHW, Behavioral Health managed care (IBHP)

Idaho's Section 1115 Medicaid demonstration, approved by CMS in April 2020, that lets Idaho Medicaid pay for mental health and substance use treatment for adults age 21 through 64 in facilities with more than sixteen beds, known as institutions for mental diseases, which standard Medicaid rules exclude. It also commits the state to building out a community based continuum of care. The waiver matters to residential operators because it decides whether adult Medicaid patients in larger residential or inpatient psychiatric settings can be billed to Medicaid. CMS has granted temporary extensions while it reviews Idaho's March 12, 2025 renewal request; the CMS demonstration record shows the waiver authorized through March 31, 2027 under the extension approved August 28, 2026.

Also called Idaho 1115 waiver, Idaho IMD waiver, Behavioral Health Transformation demonstration, Idaho SMI SUD waiver

Source: Idaho Department of Health and Welfare, Idaho Behavioral Health Transformation Waiver

Idaho's umbrella health and human services agency. DHW houses the Division of Medicaid, which runs Idaho Medicaid, and the Division of Behavioral Health, which holds the Magellan contract for the Idaho Behavioral Health Plan and distributes state and federal block grant funds for mental health and substance use treatment. DHW also handles facility licensing and certification functions that affect behavioral health programs. For an operator, DHW is both the regulator that approves a program to operate and the agency whose Medicaid dollars flow through Magellan to pay for care.

Also called IDHW, Idaho DHW, Idaho Health and Welfare, Division of Behavioral Health Idaho

Source: Idaho Department of Health and Welfare, About DHW

The Idaho agency that houses the state's professional licensing boards, including the Board of Counselors and Marriage and Family Therapists, the Board of Social Work Examiners and the Board of Psychologist Examiners, and that handles license applications, renewals and discipline for them. DOPL describes itself as regulating more than 250,000 licensees across 42 boards and commissions. For a behavioral health operator, DOPL is where clinical staff licenses are verified and renewed and where complaints against individual practitioners go. It does not approve or license SUD treatment programs; program approval and the state funded SUD network run through the Department of Health and Welfare, and addiction counselor certification runs through IBADCC.

Also called Board of Professional Counselors and Marriage and Family Therapists, Idaho Board of Social Work Examiners, Idaho Division of Occupational and Professional Licenses, Idaho DOPL

Source: Idaho DOPL, About DOPL

Idaho's Medicaid program, run by the Division of Medicaid within the Department of Health and Welfare. It covers low income children, pregnant women, adults in the expansion group, older adults and people with disabilities. Physical health is mostly paid fee for service through the Health PAS OnLine system operated by Gainwell at idmedicaid.com, while mental health and substance use benefits are carved out to the Idaho Behavioral Health Plan managed by Magellan. A behavioral health program therefore enrolls with Idaho Medicaid for a provider number and then contracts with Magellan to be paid for most treatment services.

Also called Idaho Medicaid program, Division of Medicaid Idaho, Idaho Medicaid Health PAS OnLine, idmedicaid.com

Source: Idaho Department of Health and Welfare, Medicaid and Health

Enrolling as an Idaho Medicaid provider through the state's fiscal agent, Gainwell Technologies, at idmedicaid.com. The provider registers a Trading Partner Account, completes the online enrollment application, and uploads a signed Medicaid Provider Enrollment Agreement, a W-9 and the other attachments for its provider type. The Department of Health and Welfare treats the enrollment effective date as the day a complete and acceptable application is received. For behavioral health this is step one; most behavioral health services are then paid through the Idaho Behavioral Health Plan, which requires separate credentialing and contracting with Magellan. The same site hosts fee schedules, handbooks and the clearinghouse list.

Also called Idaho Medicaid enrollment, idmedicaid.com, Gainwell, Trading Partner Account

Source: Idaho DHW, Provider Enrollment

Idaho's statutory condition for residential substance use disorder providers that contract with the Department of Health and Welfare. Idaho Code 39-306B, added by SB 1024 in 2025, requires any contractor providing residential treatment under the Alcoholism and Intoxication Treatment Act to be nationally accredited by CARF and to hold an ASAM level of care certification verifying the program can deliver level III (3.x residential) care. In practice this makes CARF accreditation and the ASAM certification the de facto residential license for the publicly funded network, since Idaho has no separate state residential SUD facility license; Oregon and Washington, by contrast, license residential programs directly and treat accreditation as optional or as a path to deemed status.

Also called Idaho CARF requirement, 39-306B, Idaho residential treatment accreditation, ASAM level of care certification Idaho

Source: Idaho Code 39-306B Residential treatment services

In 2025 the Idaho Legislature passed Senate Bill 1024, which moved the state's substance use disorder program requirements out of administrative rule and into statute. The bill declared the rules in IDAPA 16.07.17 (Substance Use Disorders Services), 16.07.33 (Adult Mental Health Services) and 16.07.37 (Children's Mental Health Services) null and void on and after July 1, 2025, and added new sections to Idaho Code chapter 39-3 covering qualified SUD personnel (39-305A), SUD professional trainees (39-305B), background check waivers (39-305C), eligibility screening and ASAM based level of care (39-306), provider choice (39-306A) and residential accreditation (39-306B). Operators should cite the Idaho Code sections, not 16.07.17, in policies and contracts.

Also called SB 1024, Senate Bill 1024 Idaho, IDAPA 16.07.17 repeal, Idaho substance use disorder services rule

Source: Idaho Senate Bill 1024 (2025), Section 15

The numbering system and official compilation for Idaho agency rules, maintained by the Office of the Administrative Rules Coordinator in the Division of Financial Management under the Governor. Rules are cited by agency, title and chapter, for example IDAPA 16.05.06 for the Department of Health and Welfare's criminal history and background check rule (agency 16, title 05, chapter 06). Idaho rules must be reauthorized by the Legislature each year, and the Legislature can retire whole chapters, which is how the SUD services rule 16.07.17 disappeared in 2025. Operators should check the current rules index at adminrules.idaho.gov rather than rely on older PDFs, and should expect behavioral health requirements to sit in Idaho Code as often as in IDAPA.

Also called IDAPA, Idaho administrative rules, Idaho Administrative Procedure Act rules, IDAPA 16

Source: Idaho Office of the Administrative Rules Coordinator

Under 42 CFR 438.6(e), a state may make a monthly capitation payment to an MCO or PIHP for an enrollee aged 21 to 64 receiving inpatient treatment in an institution for mental diseases (IMD) when the facility is a hospital providing mental health or substance use disorder inpatient care, or a sub-acute facility providing crisis residential services, and the stay lasts no more than 15 days during that month. The care must meet the in lieu of service conditions. The rule is separate from Section 1115 IMD demonstrations. For larger residential and inpatient programs, tracking length of stay against the 15 day limit determines whether a managed care plan can pay.

Also called 438.6(e), 15 day IMD rule, IMD in lieu of service, managed care IMD stay

Source: 42 CFR 438.6, Special contract provisions related to payment (eCFR via Cornell LII)

An in lieu of service or setting (ILOS) is a service or setting a Medicaid managed care plan offers as a substitute for one covered under the State Plan, when the state finds it medically appropriate and cost effective. Enrollees cannot be required to use an ILOS and keep the right to the State Plan service. Each ILOS must be approvable through a 1915(c) waiver or a State Plan Amendment, must be named in the plan contract, and must carry state-specific codes in encounter data. ILOS costs, apart from short IMD stays, cannot exceed 5 percent of the program's total managed care payments. Short IMD stays under 42 CFR 438.6(e) must meet the same ILOS conditions.

Also called ILOS, in lieu of services, in lieu of service, in lieu of setting

Source: 42 CFR 438.2, Definitions (eCFR via Cornell LII)

A payer's network is the set of facilities and clinicians it has contracted with. An in network program has agreed to the plan's rates and rules and generally may not balance bill members; an out of network program has no contract, is paid at the plan's out of network allowance if the member has that benefit, and may bill the member for the rest unless a law or single case agreement says otherwise. Members usually pay more out of network, which affects collections. Medicaid plans generally pay out of network only by agreement, so getting in network is the practical goal.

Also called network, in-network, out-of-network, OON

Source: HealthCare.gov glossary, Network

Incident to billing lets a physician or other practitioner bill Medicare Part B for services furnished by auxiliary personnel as an integral, though incidental, part of their professional services in a noninstitutional setting, meaning anywhere other than a hospital or skilled nursing facility. Most incident to services require direct supervision, which since January 1, 2026 can include real-time audio and video presence. Behavioral health services are an exception and can be furnished under general supervision, meaning the practitioner directs the service but need not be present. Auxiliary personnel must meet state licensure rules, must not be excluded by the OIG and must not have revoked Medicare enrollment. Only the supervising practitioner may bill the service.

Also called incident to, incident-to services, auxiliary personnel, general supervision

Source: 42 CFR 410.26, Services and supplies incident to a physician's professional services: Conditions

State licensing rules require behavioral health programs to protect a defined set of rights for every person in services and to give each person a written rights statement at intake. Washington's WAC 246-341-0600 lists rights such as receiving services without discrimination, reasonable accommodation, respect, dignity and privacy, confidentiality, review of the service record, refusing treatment, and freedom from abuse, with the list posted and given in a language the person understands. Oregon's OAR 309-019-0115 and 309-018-0115 include informed consent, choice of least restrictive services, access to records, freedom from seclusion and restraint, and the right to grieve without retaliation. Surveyors check the posted statement, the signed acknowledgment and staff knowledge.

Also called client rights, patient rights, participant rights, individual rights statement

Source: WAC 246-341-0600 Individual rights

Informed consent means the person, and guardian where applicable, has had the service options, risks and benefits explained in a way they understand and has agreed to services on or before the first date of service. Oregon requires written informed consent before services start except in a medical emergency, and allows minors to consent on their own when married, emancipated at 16 or older, or 14 or older for outpatient services. Washington requires the individual service record to document informed consent to treatment unless treatment is court ordered. Consent to treatment is separate from HIPAA and 42 CFR Part 2 consent to disclose records, and programs should keep the forms distinct.

Also called informed consent, consent to treatment, consent for services, minor consent

Source: OAR 309-019-0105 Definitions, Informed Consent for Services

The Inpatient Psychiatric Facility Prospective Payment System is how Medicare pays for inpatient psychiatric services in psychiatric hospitals and in psychiatric units of acute care and critical access hospitals. It pays a standardized federal per diem rate, adjusted at the patient level for age, specified MS-DRGs and selected comorbidities, and at the facility level for wage index, rural location, teaching status, a qualifying emergency department and cost of living in Alaska and Hawaii. It also includes outlier payments, an interrupted stay policy and an additional payment for each electroconvulsive therapy treatment. Facilities that fail to report required data to the IPF Quality Reporting Program lose 2.0 percentage points from their annual payment update.

Also called IPF PPS, inpatient psychiatric facility, IPF, IPFQR

Source: CMS, Inpatient Psychiatric Facility PPS

A federal Medicaid rule that bars federal matching funds for care of adults age 21 through 64 while they are patients in an institution for mental diseases. Regulations in 42 CFR 435.1010 define an IMD as a hospital, nursing facility or other institution of more than 16 beds primarily engaged in diagnosis, treatment or care of people with mental diseases, and CMS counts substance use disorders as mental diseases for this purpose. A residential SUD or psychiatric program with 17 or more beds therefore cannot bill Medicaid for adult stays unless the state has a Section 1115 demonstration or another exception. Oregon, Washington and Idaho each hold such waivers, which is why bed count is a first question in any residential project.

Also called IMD, IMD exclusion, 16 bed rule, 16-bed limit

Source: 42 CFR 435.1010, Definitions relating to institutional status

Washington's model for Apple Health in which one managed care plan holds a member's physical health, mental health and substance use disorder benefits instead of splitting behavioral health out to a regional organization. HCA rolled it out by region starting with Southwest Washington in April 2016 and finished statewide on January 1, 2020. The ten regions are Southwest, North Central, Greater Columbia, King, Pierce, Spokane, North Sound, Great Rivers, Salish and Thurston-Mason; each has its own mix of plans and its own BH-ASO for crisis and non Medicaid services. An operator checks which plans serve its region before contracting, since not every plan is in every region.

Also called Fully Integrated Managed Care, FIMC, integrated managed care regions, Washington IMC region

Source: HCA, Integrated Managed Care: Changes coming to Apple Health (Medicaid) in January 2020 FAQ (PDF)

An Oregon program for children and young people from birth through age 20 whose behavioral health needs would otherwise push them toward residential or psychiatric hospital care. OAR 309-019-0167 requires a combination of community based services and supports delivered to the child and family: child psychiatric services, skills training, individual and family therapy, 24 hour in home proactive support and crisis response, case management and peer delivered services. Staffing must include licensed medical professionals, QMHPs, QMHAs and peer support specialists sufficient to meet each family's needs. The Oregon Health Plan pays IIBHT under OAR 410-172-0695, and CCOs authorize it as an intensive outpatient level of care for youth.

Also called IIHBT, intensive in-home, in-home behavioral health treatment for children

Source: OAR 309-019-0167, Intensive In-Home Behavioral Health Treatment (IIBHT) for Children

The managed behavioral health organization that administers the Idaho Behavioral Health Plan for the Department of Health and Welfare. Magellan credentials and contracts providers, issues prior authorizations, pays claims and publishes the provider handbook, fee schedule and level of care rules for Idaho Medicaid behavioral health. It also handles state funded services for people without Medicaid in the same system. For an Idaho program, Magellan is effectively the Medicaid payer: enrollment with Idaho Medicaid gets a provider number, but no treatment claim pays until Magellan has accepted the program into its network.

Also called Magellan Healthcare Idaho, Magellan Idaho, Magellan, Magellan provider enrollment

Source: Magellan of Idaho, Idaho Behavioral Health Plan home page

Mandatory reporting laws require named professionals, and in some states everyone working for an organization, to report suspected child abuse or neglect, and in most states abuse of vulnerable adults, to child welfare or law enforcement. Oregon makes public and private officials, including health care and treatment staff, report immediately when they have reasonable cause to believe a child has been abused (ORS 419B.010). Washington lists practitioners, counselors and others who must report to law enforcement or DCYF (RCW 26.44.030). Idaho requires a report within 24 hours (Idaho Code 16-1605). Reports are permitted disclosures under HIPAA and 42 CFR Part 2. Programs train all staff and document each report in the record.

Also called mandatory reporter, mandated reporter, child abuse reporting, vulnerable adult reporting

Source: ORS 419B.010 Duty of officials to report child abuse

The federal rule that new and renewing DEA registrants who prescribe Schedule II to V controlled medications must attest, starting June 27, 2023, to at least eight hours of training on opioid or other substance use disorders, or hold board certification in addiction medicine or addiction psychiatry, or meet another listed exemption. The requirement comes from section 1263 of the Consolidated Appropriations Act, 2023, the same law that removed the X-waiver. It is a one-time attestation at registration, not a recurring CE cycle. Operators care because every physician, nurse practitioner and physician assistant who prescribes for the program needs documentation of the training in the credentialing file, and a lapsed DEA registration stops prescribing and OTP dosing orders.

Also called MATE Act, eight-hour DEA training, 8 hour SUD training, DEA registration training requirement

Source: SAMHSA, Waiver Elimination (MAT Act), section 1263

A clinical practice of giving clients standardized symptom and functioning measures at regular intervals, reviewing the scores with them, and using the trend to adjust treatment. SAMHSA defines it as a clinical process that uses standardized measurements to track a client's progress over time and inform shared treatment planning. Common tools are the PHQ-9 for depression, GAD-7 for anxiety and brief SUD and functioning scales. MBC matters to operators because payers and accreditors increasingly expect it: CCBHC criteria require quality measure reporting, Oregon's IIBHT rule requires an OHA approved outcome tool at entry and discharge, and value based contracts often tie payment to measured improvement. SAMHSA's 2024 guide covers how to finance it.

Also called measurement based care, outcome measures, PHQ-9, GAD-7

Source: SAMHSA, Financing Measurement-Based Care in Community Behavioral Health Settings (PEP24-01-007)

California's Medicaid program, administered by the Department of Health Care Services (DHCS). Medi-Cal covers low income children and adults, and it splits behavioral health into three delivery systems: Medi-Cal managed care plans cover mild to moderate mental health, county Mental Health Plans cover specialty mental health, and county Drug Medi-Cal programs cover substance use disorder treatment. A behavioral health operator in California therefore usually contracts with a county rather than with DHCS or a health plan, and the county sets the rates, authorization rules and documentation standards within DHCS guidance. CalAIM is the current statewide effort to standardize these systems.

Also called California Medicaid, Medi-Cal program, MediCal, Medi-Cal managed care

Source: California Department of Health Care Services, About Us

Clinic services are a Medicaid benefit for preventive, diagnostic, therapeutic, rehabilitative or palliative outpatient services furnished by a facility that is not part of a hospital, with services generally furnished at the clinic by or under the direction of a physician. This location limit is often called the four walls requirement. A 2024 federal rule added an optional exception that lets states cover services furnished outside a clinic primarily organized for outpatients with behavioral health disorders, including mental health and substance use disorders, by clinic personnel under the direction of a physician. Behavioral health clinics should confirm their state adopted the option before billing home or community visits under this benefit.

Also called clinic services, clinic option, four walls requirement, four walls rule

Source: 42 CFR 440.90, Clinic services (eCFR via Cornell LII)

A Medicaid rule (section 1902(xx)) States must start by January 1, 2027 unless granted a good faith effort exemption. It covers adults 19 to 64 in the expansion adult group or similar section 1115 coverage who are not pregnant or on Medicare. For 1 or more State-set months, they must show 80 hours of work, community service or a work program, at least half-time school, or monthly income of at least the federal minimum wage times 80. Exclusions include people whose substance use disorder (unless in recovery 5 or more years) or disabling mental disorder significantly impairs their ability to comply, and anyone in drug or alcohol treatment. Anyone not verified gets a notice and 30 days to respond.

Also called community engagement requirement, Medicaid work requirements, work requirements, section 1902(xx)

Source: Federal Register, CMS-2454-IFC, Medicaid Program; Community Engagement Requirement for Certain Individuals (June 3, 2026)

Federal rules list when a state Medicaid agency must deny or terminate a provider's enrollment. Grounds include an owner with a 5 percent or greater interest convicted of a Medicare, Medicaid or CHIP related offense in the last 10 years, termination by Medicare or by another state's Medicaid or CHIP program, failure to submit fingerprints within 30 days of a request, refusal to allow site visits, and failure to submit timely and accurate information. For several grounds the state may keep the provider if it documents that termination is not in the program's best interest. A termination in one program can therefore follow a behavioral health organization into every state where it bills Medicaid.

Also called Medicaid termination, enrollment denial, for cause termination, terminated provider

Source: 42 CFR 455.416, Termination or denial of enrollment (eCFR via Cornell LII)

A Medicaid Fraud Control Unit (MFCU) is a state unit, usually part of the state attorney general's office, that investigates and prosecutes Medicaid provider fraud and the abuse or neglect of residents in health care facilities and board and care facilities and of Medicaid enrollees in other settings. MFCUs operate in all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands, must be separate from the state Medicaid agency, and are recertified each year by the HHS Office of Inspector General. When a state suspends payments for a credible allegation of fraud, it refers the case to the MFCU. Residential programs can face MFCU review for abuse or neglect as well as billing.

Also called MFCU, Medicaid Fraud Control Units, state Medicaid fraud unit, attorney general Medicaid fraud unit

Source: HHS Office of Inspector General, Medicaid Fraud Control Units

A Medicaid Health Home is an optional State Plan benefit under Section 1945 of the Social Security Act that pays a designated provider or care team to coordinate care for enrollees with chronic conditions. Eligible people have at least two chronic conditions, one condition and risk of a second, or one serious and persistent mental health condition, and the listed conditions include mental health conditions and substance use disorder. Services include comprehensive care management, care coordination, transitional care, patient and family support, and referral to community supports. States get a 90 percent federal match for the first 8 quarters, and can request 2 more quarters for SUD-focused programs approved on or after October 1, 2018.

Also called health home, Section 1945 health home, SUD health home, health home services

Source: 42 U.S.C. 1396w-4, Section 1945 of the Social Security Act (Cornell LII)

The two ways a state Medicaid program pays for care. Under fee for service the state pays the provider directly for each covered service at the state fee schedule. Under managed care the state pays a health plan a fixed monthly amount per member (capitation) and the plan pays providers under its own contracts and rules, as set out in 42 CFR Part 438. Oregon's CCOs, Washington's Apple Health plans and California's county plans are managed care; Oregon's open card members and Idaho's physical health benefit are fee for service. A program needs the state enrollment for fee for service and separate plan contracts for managed care; rates, authorization rules and appeals differ between them.

Also called managed care, fee for service, FFS, open card

Source: Medicaid.gov, Managed Care

Recoupment is how a Medicaid agency or managed care plan takes back money it decides it should not have paid. Oregon's rule treats every claim as the provider's certification that it is true, accurate and complete, lets the Health Authority deny or recover payments when a review or audit finds the service was not provided according to rule or contract, and requires providers who discover their own overpayment to submit an adjustment and refund it. Washington and Idaho Medicaid and their managed care plans have similar audit and recovery provisions, and the federal False Claims Act makes knowingly keeping an identified overpayment beyond 60 days a false claim. Documentation that supports each billed unit is the main defense.

Also called recoupment, overpayment, Medicaid recovery, audit recoupment

Source: OAR 410-120-1397 Recovery of Overpayments to Providers, Recoupments and Refunds

Federal Medicaid rules require providers to accept the amount the state or its managed care plan pays, plus any copay the plan assigns to the member, as payment in full. The difference between the program's charge and that payment is a contractual write-off, recorded as an adjustment when the remittance posts. Write-off discipline means posting only adjustments the remittance supports, coding each write-off to a reason (contractual, timely filing, authorization, bad debt) and reviewing avoidable write-offs monthly, since a timely filing write-off is a process failure and a contractual one is not. Clean reason codes make the denial trend visible.

Also called write-off, contractual adjustment, write off discipline, payment in full

Source: 42 CFR 447.15

A state Medicaid agency must suspend all Medicaid payments to a provider once it determines there is a credible allegation of fraud with an investigation pending, unless it finds good cause not to suspend or to suspend only in part. The state may act without advance notice, must generally send notice within 5 days, and must refer the matter in writing to the Medicaid Fraud Control Unit by the next business day. The suspension is temporary but can continue while law enforcement investigates and any proceedings finish. The provider may submit written evidence asking the state to lift it. For behavioral health programs that rely on Medicaid, a suspension can halt most revenue.

Also called payment suspension, credible allegation of fraud, CAF, 42 CFR 455.23

Source: 42 CFR 455.23, Suspension of payments in cases of fraud (eCFR via Cornell LII)

Revalidation is the periodic re-screening a state Medicaid agency must complete for every enrolled provider, regardless of provider type, at least every 5 years. States screen revalidations at the provider's categorical risk level, the same as new applications, and may request updated ownership and control disclosures during the process. A state must terminate or deny enrollment when a provider or certain owners or managing employees fail to submit timely and accurate information, unless it documents that termination is not in the program's best interest. Behavioral health organizations should track the revalidation date for the agency and each enrolled clinician so billing is not interrupted.

Also called revalidation, Medicaid revalidation, Medicaid re-enrollment, 42 CFR 455.414

Source: 42 CFR 455.414, Revalidation of enrollment (eCFR via Cornell LII)

Federal rules require each state Medicaid agency to screen new applications, new practice locations, re-enrollments and revalidations at a categorical risk level of limited, moderate or high, using the highest level that fits. Limited screening covers license verification and database checks before and after enrollment. Moderate adds site visits before and after enrollment. High adds a criminal background check and fingerprints for the provider and anyone with a 5 percent or greater ownership interest, due within 30 days of a request. The state must raise a provider to high after events such as a payment suspension for a credible allegation of fraud or an existing Medicaid overpayment. Programs should learn their category before applying.

Also called categorical risk level, limited risk screening, moderate risk screening, high risk screening

Source: 42 CFR 455.450, Screening levels for Medicaid providers (eCFR via Cornell LII)

Medicaid retroactive eligibility lets coverage reach back before the month a person applies, so services delivered then can be billed if the person would have been eligible at the time. Federal law has required coverage back to the third month before the application month. Public Law 119-21 changed this for applications made on or after the first day of the first quarter beginning after December 31, 2026, which is January 1, 2027. For those applications, coverage reaches back one month for the adult expansion group and two months for everyone else. Programs that help uninsured clients apply should file quickly and record application dates.

Also called retroactive coverage, retro eligibility, retroactive Medicaid, Medicaid retroactive coverage period

Source: 42 U.S.C. 1396a(a)(34), Section 1902 of the Social Security Act (Cornell LII)

The Medicaid State Plan is the comprehensive written statement a state Medicaid agency submits to CMS describing the nature and scope of its Medicaid program, and it is the basis for federal matching funds. A State Plan Amendment (SPA) changes the plan, and states must amend it to reflect changes in federal law and material changes in state law, policy or operations. A plan or amendment is considered approved unless CMS disapproves it or asks for more information within 90 days of receipt. For behavioral health programs, the plan and its SPAs set which services Medicaid covers and how payment methods work, so a new benefit or rate method usually begins with a SPA.

Also called State Plan Amendment, SPA, Medicaid state plan, Title XIX state plan

Source: 42 CFR 430.10, The State plan (eCFR via Cornell LII)

Federal rules require state Medicaid agencies to pay 90 percent of clean claims from practitioners in individual or group practice or shared health facilities within 30 days of receipt, and 99 percent within 90 days. Providers must submit claims no later than 12 months from the date of service, and the agency must pay all other claims within 12 months of receipt, with listed exceptions. A clean claim can be processed without more information from the provider or a third party, and claims from providers under fraud or abuse investigation or under medical necessity review do not count as clean. Billing staff can cite these standards when escalating aged fee-for-service Medicaid claims.

Also called 447.45, Medicaid prompt pay rule, Medicaid clean claim payment standard, 90 percent in 30 days rule

Source: 42 CFR 447.45, Timely claims payment (eCFR via Cornell LII)

The standard a payer applies to decide whether a service is covered for a particular person. Washington's Medicaid rules define a medically necessary service as one reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of a condition that endangers life, causes suffering or pain, or threatens disability, with no equally effective and less costly alternative. Oregon uses the term medically appropriate in OHP rules. Behavioral health payers usually apply the ASAM Criteria for substance use and their own or LOCUS style criteria for mental health. Every authorization request, concurrent review and appeal is an argument that the documentation meets this definition.

Also called medically necessary, medical necessity criteria, medically appropriate, level of care criteria

Source: WAC 182-500-0070

Medically Unlikely Edits are part of the National Correct Coding Initiative and are used by Medicare Administrative Contractors to reduce improper payments on Part B claims. An MUE is the maximum units of service reported for a HCPCS or CPT code on the vast majority of appropriately reported claims by the same provider for the same beneficiary on the same date of service. Not every code has an MUE, and some MUE values are confidential. CMS publishes tables for practitioner services, outpatient hospital services and DME suppliers and posts changes quarterly. Billers check MUE values before submitting codes billed in multiple units, because the edits exist to stop payment when units of service are reported incorrectly.

Also called MUE, MUEs, medically unlikely edit, units of service edit

Source: CMS, Medicare NCCI Medically Unlikely Edits (MUEs)

The federal health program for people 65 and older and for younger people with qualifying disabilities. Part A covers inpatient hospital, skilled nursing, hospice and home health care, including inpatient psychiatric stays. Part B covers outpatient services, and for behavioral health that includes therapy, psychiatric evaluation, medication management, partial hospitalization and intensive outpatient programs, and mental health care delivered as part of substance use treatment. Part D covers prescription drugs through separate plans. Part C, Medicare Advantage, bundles these through private plans. A program bills Original Medicare through its regional contractor and must enroll in PECOS first; it cannot bill Medicare for services from staff types Medicare does not recognize.

Also called Medicare, Original Medicare, Medicare Part A, Medicare Part B

Source: Medicare.gov, Parts of Medicare

A Medicare Administrative Contractor is a private health care insurer that CMS has awarded a geographic jurisdiction to process Medicare Part A and Part B claims, or durable medical equipment claims, for Original Medicare beneficiaries. The MAC is the main operational contact between Medicare and enrolled providers. It processes and pays claims, enrolls providers, audits institutional cost reports, handles redeterminations (the first level of appeal), answers provider inquiries, educates providers on billing requirements, reviews medical records for selected claims and establishes Local Coverage Determinations. For a behavioral health program, the MAC for its region decides its enrollment application, publishes the billing guidance it must follow and is the first stop in any claim dispute.

Also called MAC, A/B MAC, Medicare contractor, Part A and Part B contractor

Source: CMS, What's a MAC

Private health plans approved by Medicare that bundle Part A, Part B and usually Part D into one plan as an alternative to Original Medicare. Insurers such as Regence, Providence Health Assurance, Moda, PacificSource, Kaiser and UnitedHealthcare sell them in the Northwest. Medicare Advantage plans may limit members to a network and require prior authorization for services such as partial hospitalization or residential care, and they pay under their own contracts rather than the Medicare fee schedule. A program that is enrolled with Medicare is not automatically in network with Medicare Advantage plans; each plan needs its own contract and credentialing, and claims go to the plan, not the Medicare contractor.

Also called Medicare Advantage, MA plan, Part C, Medicare HMO

Source: Medicare.gov, Parts of Medicare (Medicare Advantage section)

Accepting assignment means a provider agrees to take the Medicare-approved amount as payment in full, collecting only the patient's deductible and coinsurance, and must submit the claim directly to Medicare. A provider that accepts assignment does so for all Medicare covered Part A and Part B services. For outpatient mental health visits, the patient generally pays 20 percent of the Medicare-approved amount after the Part B deductible. Non-participating providers may accept assignment case by case, and when they do not, they can charge more, in many cases no more than 15 percent above the approved amount, called the limiting charge. Medicare pays nothing to providers who have opted out, except in emergencies.

Also called accept assignment, accepting assignment, Medicare non-participating provider, limiting charge

Source: Medicare.gov, Does your provider accept Medicare as full payment?

A Medicare Part B benefit that began January 1, 2024, paying for intensive outpatient services furnished by hospitals, critical access hospitals, community mental health centers, federally qualified health centers, rural health clinics and opioid treatment programs. The regulation defines IOP patients as those who need a minimum of 9 hours per week of therapeutic services under a plan of care, can benefit from a coordinated program rather than isolated sessions, do not need 24 hour care and have adequate support. Payment is a per diem on institutional claims, not the S9480 code, so a freestanding agency needs an eligible provider type to bill it.

Also called Medicare IOP, IOP benefit 2024, 42 CFR 410.44, Medicare intensive outpatient

Source: 42 CFR 410.44(c)

Medicare permanently allows behavioral health telehealth, including substance use disorder services, to patients in their homes with no geographic restriction, and two-way audio-only technology is permitted. The statute also requires an in-person, non-telehealth visit within 6 months before the first mental health telehealth service, effective after December 31, 2027, and then an in-person service within 12 months of each telehealth service, with limited exceptions. CMS says patients who began home mental health telehealth on or before December 31, 2027 are established and need at least one in-person visit every 12 months after that date. Another practitioner of the same specialty in the same group can perform the visit when the treating practitioner is unavailable.

Also called in-person visit requirement, six month in-person visit, Medicare mental health telehealth, home originating site

Source: CMS, Telehealth FAQ (updated 2/26/26)

Opting out lets an eligible physician or practitioner leave Medicare and treat Medicare beneficiaries under private contracts instead of submitting claims. The clinician files an affidavit with each Medicare Administrative Contractor they would otherwise bill. The initial opt-out period lasts two years and starts on the date the affidavit is signed, if it is filed within 10 days after the first private contract with a beneficiary. Affidavits signed on or after June 16, 2015 renew automatically every two years unless canceled in writing at least 30 days before the next period. Medicare pays nothing for an opted-out clinician's services except in emergencies. Eligible practitioners include clinical psychologists, clinical social workers and nurse practitioners.

Also called Medicare opt-out, opt-out affidavit, Medicare private contract, opting out of Medicare

Source: 42 CFR 405.410, Conditions for properly opting-out of Medicare

Medicare Part B pays for outpatient behavioral health from physicians, clinical psychologists, clinical social workers, nurse practitioners and physician assistants, and, since January 1, 2024, from marriage and family therapists and mental health counselors enrolling and billing independently. The regulations define each practitioner type by degree, two years or 3,000 hours of supervised post degree experience, and state licensure; CMS treats licensed professional counselors and certified alcohol and drug counselors who meet the definition as mental health counselors. Enrollment runs through PECOS with the CMS-855I. Part B also covers IOP, PHP, OTP bundles and office based OUD bundles.

Also called Medicare Part B behavioral health, MFT Medicare enrollment, MHC Medicare enrollment, LPC Medicare

Source: 42 CFR 410.54; 42 CFR 410.53

Medicare's partial hospitalization benefit covers an intensive, structured outpatient program offered as an alternative to psychiatric hospitalization, paid per diem in hospital outpatient departments and Community Mental Health Centers. Under 42 CFR 410.43, patients must require at least 20 hours per week of therapeutic services in their plan of care, have a mental health or substance use disorder diagnosis, not need 24 hour care and not be judged dangerous to self or others. Services must follow a physician certification and plan of care and can include individual and group therapy, occupational therapy, family counseling, patient education and diagnostic services. Physician and qualified psychologist services are covered separately and are not paid as part of the PHP per diem.

Also called Medicare PHP, Medicare partial hospitalization, PHP benefit, 42 CFR 410.43

Source: 42 CFR 410.43, Partial hospitalization services: Conditions and exclusions

The Medicare Physician Fee Schedule is the primary method Medicare uses to pay enrolled health care providers for professional services. Medicare uses it to pay for the professional services of physicians and other practitioners in private practice, services furnished incident to a physician's services, diagnostic tests other than clinical laboratory tests, and radiology. Rates are built from relative value units and a conversion factor, and CMS updates the schedule each calendar year through a final rule that can also change telehealth, supervision and behavioral health policy. For behavioral health programs, the PFS sets what Medicare pays practitioners for services such as behavioral health integration, collaborative care and digital mental health treatment billed on professional claims.

Also called PFS, MPFS, physician fee schedule, PFS final rule

Source: CMS, Physician Fee Schedule

A redetermination is the first level of appeal for an Original Medicare claim decision, a review by Medicare Administrative Contractor staff who were not involved in the initial determination. Any dissatisfied party, including the provider, can request it in writing on Form CMS-20027 or in a letter naming the beneficiary, Medicare number, services, dates of service and the reason for disagreeing, with supporting documentation. The request is due within 120 days of receiving the initial determination, which is presumed received 5 calendar days after the notice date. No minimum dollar amount applies. The MAC generally sends its decision within 60 days. Minor errors and omissions are corrected through a reopening, not an appeal.

Also called redetermination, Medicare redetermination, CMS-20027, first level of appeal

Source: CMS, First Level of Appeal: Redetermination by a Medicare Contractor

Medicare Secondary Payer describes situations where another entity must pay before Medicare. Congress began making Medicare secondary to certain primary plans in 1980. Every entity that bills Medicare must determine whether Medicare is the primary payer for the service. Common examples: a beneficiary 65 or older covered by an employer group health plan through their own or a spouse's current employment at an employer with 20 or more employees, where the group plan pays first, and a disabled beneficiary covered through current employment at an employer with 100 or more employees. For behavioral health programs, intake must capture all other coverage so claims go to the correct payer first.

Also called MSP, Medicare secondary payer rules, working aged, Medicare as secondary payer

Source: CMS, Medicare Secondary Payer

An opioid treatment program (OTP) site that is separate from the program's main location. Under 42 CFR 8.2 it can be a brick and mortar location or a mobile unit, and OTP practitioners or contractors, or community pharmacists, may dispense or administer medication for opioid use disorder and provide other OTP services there. A fixed-site unit needs its own DEA registration because medication can be stored there; a mobile unit is a vehicle that shares the main OTP's DEA registration, returning there each day. Washington allows both under chapter 246-341 WAC, and each needs a Pharmacy Quality Assurance Commission registration, a DOH notification form and SAMHSA form SMA-162. A unit may offer only services the OTP is certified for.

Also called medication unit, fixed-site medication unit, mobile medication unit, OTP mobile unit

Source: Washington State Department of Health, Opioid Treatment Program Fixed-Site Medication Units

The use of FDA approved medications together with counseling and behavioral therapy to treat substance use disorders. SAMHSA describes it as a whole patient approach in which medications are clinically driven and tailored to each patient. For opioid use disorder the medications are buprenorphine, methadone and naltrexone; for alcohol use disorder they include naltrexone, acamprosate and disulfiram. Many agencies and payers now prefer the terms medications for opioid use disorder (MOUD) or medications for alcohol use disorder (MAUD) because the medication is the treatment, not an assist. Operators see MAT in payer policies, in state rules that bar programs from refusing or forcing tapers of prescribed medications, and in Oregon and Washington residential rules that require on site access or referral.

Also called medication assisted treatment, medications for addiction treatment, pharmacotherapy for SUD

Source: SAMHSA, Medications for Substance Use Disorders

The three FDA approved medications used to treat opioid use disorder and the services around them. Buprenorphine is a partial agonist available as daily films or tablets and as monthly injections, prescribed by any practitioner with Schedule III DEA authority. Methadone is a full agonist that can be dispensed for OUD only through a certified Opioid Treatment Program. Naltrexone is an antagonist available as a daily tablet or monthly injection and carries no misuse risk. SAMHSA describes these medications as normalizing brain chemistry, relieving cravings and restoring normal body function. Oregon Health Plan, Apple Health and Idaho Medicaid all cover MOUD; Washington residential and inpatient SUD agencies must offer it on site or arrange off site access.

Also called medications for OUD, buprenorphine, Suboxone, methadone

Source: SAMHSA, Medications for Substance Use Disorders

Oregon's licensed 24-hour residential settings for adults with a qualifying mental illness, distinct from residential SUD programs. OHA licenses three types under OAR chapter 309 division 035: Residential Treatment Homes (RTH) for up to five residents, and Residential Treatment Facilities (RTF) and Secure Residential Treatment Facilities (SRTF) for six to 16 residents, with a few contracted facilities serving more. The statutory basis is ORS 443.410, which requires an OHA license to operate a residential treatment facility or home. Most placements come from the Oregon State Hospital and acute care through the local Community Mental Health Program, so these programs depend on county and OHA contracts. Washington uses RTF for a different license covering both mental health and SUD facilities.

Also called RTF Oregon, RTH, SRTF, secure residential treatment facility

Source: OHA, Licensing and Certification: Residential Mental Health Treatment Facilities

The Merit-based Incentive Payment System is the Medicare program required by section 1848(q) of the Social Security Act that scores eligible clinicians on performance categories and applies a payment adjustment to their Medicare Part B payments in a later payment year. Each clinician gets a final score on a 0 to 100 scale and is identified by a billing TIN and NPI combination. Eligible clinician types include physicians, nurse practitioners, physician assistants, clinical psychologists and, from the 2024 payment year, clinical social workers. Clinicians or groups at or below the low-volume threshold, $90,000 in allowed charges, 200 Part B patients or 200 covered services, are excluded. Behavioral health groups check eligibility each year to plan reporting.

Also called MIPS, Quality Payment Program, QPP, MIPS eligible clinician

Source: 42 CFR 414.1305, Definitions (Quality Payment Program)

The private certification board that credentials Oregon's non-licensed behavioral health workforce. Founded in 1977 as ACCBO, MHACBO issues the CADC levels, CADC-R registration, QMHA and QMHP registration and certification, the Certified Recovery Mentor and gambling counselor credentials, using competency reviews and national psychometric exams from IC&RC, NAADAC and CES. It maintains a public registry, investigates ethics complaints and runs its applications through the Certemy platform. OAR 309-019-0125 names certification by a health or allied provider agency as the path for SUD treatment staff, and MHACBO is the body nearly every Oregon program uses. Operators care because hiring, supervision and audit readiness all depend on MHACBO status being current.

Also called MHACBO, ACCBO, Mental Health and Addiction Certification Board of Oregon, Oregon certification board

Source: MHACBO, About

The 2008 federal law that bars most group health plans and insurers from applying stricter limits to mental health and substance use disorder benefits than to medical and surgical benefits. Parity covers dollar limits, copays and visit limits, and also non quantitative treatment limits such as prior authorization, concurrent review, medical necessity criteria and network admission standards. It does not force a plan to cover behavioral health, but the Affordable Care Act requires it in individual and small group plans, and CMS applies parity to Medicaid managed care. For an operator, parity is the basis for appealing a residential or IOP denial when the plan would not apply the same review to a comparable medical service.

Also called MHPAEA, parity, mental health parity, Parity Act

Source: CMS, The Mental Health Parity and Addiction Equity Act (MHPAEA)

The minimum necessary standard in 45 CFR 164.502(b) requires a covered entity or business associate to make reasonable efforts to limit protected health information to the minimum needed to accomplish the purpose of a use, disclosure or request. It does not apply to disclosures to a provider for treatment, to the patient, or to disclosures made under a valid authorization or required by law. For a treatment program it shapes role based EHR access, what goes on a claim or prior authorization request, what is faxed to a payer during utilization review, and what staff may discuss with family. Policies should identify which workforce roles need which categories of PHI.

Also called minimum necessary, minimum necessary rule, 164.502(b)

Source: 45 CFR 164.502(b) Standard: Minimum necessary

A team that goes to wherever a behavioral health crisis is happening, in the community rather than an office or emergency department, to de-escalate, assess, stabilize and connect the person to follow up care. Section 1947 of the Social Security Act, added by the American Rescue Plan, lets state Medicaid programs cover qualifying community based mobile crisis intervention services furnished by a multidisciplinary team that includes at least one behavioral health professional able to assess the person, with an 85 percent federal match for the first twelve quarters between April 2022 and March 2027. Oregon defines mobile crisis services in OAR 309-019-0105 as crisis care delivered onsite in the community; Washington calls the team a mobile rapid response crisis team in RCW 71.24.025.

Also called mobile crisis services, mobile crisis team, mobile rapid response crisis team, MRSS

Source: 42 U.S.C. 1396w-6, State option to provide qualifying community-based mobile crisis intervention services

A rehearsal of a licensing or accreditation survey run by the program itself or an outside reviewer before the real one. The team pulls sample records, interviews staff and checks each standard the way a surveyor would, then fixes what it finds. CARF builds this into its recommended timeline, telling organizations to use the survey preparation workbook about nine months out to conduct a presurvey that identifies areas of weakness or nonconformance, then act on the results. The same method works for a state certification review: Oregon and Washington surveyors review policies, service records, personnel files and facility safety and interview staff and clients, so a mock survey against OAR 309 or WAC 246-341 surfaces deficiencies early.

Also called presurvey, readiness review, mock audit, internal survey

Source: CARF International, Survey preparation for accreditation

A Portland based health insurer, part of Moda Companies, selling commercial, individual and Medicare plans in Oregon, Alaska, Idaho and Texas. Moda also administers Eastern Oregon Coordinated Care Organization (EOCCO), the Oregon Health Plan CCO for twelve rural eastern counties, so a program east of the Cascades deals with Moda for both commercial and Medicaid members. Moda runs its own provider contracting and behavioral health authorization process. Operators treat it as one of the four or five commercial carriers worth a direct contract in Oregon.

Also called Moda, ODS Health, Moda Health Plan, Eastern Oregon CCO

Source: Moda Health, Our Story

The approval a licensed program must get before changing what or where it is approved to deliver. In Oregon, OAR 309-008-1000 requires a certified provider to submit a written request at least 60 days before opening a new service delivery location, relocating one or adding treatment services under different service delivery rules, and OHA aims to decide within 45 days; a new program director also needs Division approval. Washington RTFs must notify DOH, file an amendment application and pay the fee before changing service types, bed count, room use, structure, administrator or address, and BHAs add certifications or branch sites through WAC 246-341-0300. Billing at an address not yet on the certificate is a licensing violation and a claims problem.

Also called certificate modification, license amendment, scope of services change, adding a location

Source: OAR 309-008-1000 Modification to Certification

The body of rules Oregon agencies adopt to carry out state statutes, published by the Secretary of State and organized by chapter and division. Behavioral health programs live mostly in chapter 309 (Oregon Health Authority behavioral health) and chapter 415 (substance use disorder services). The divisions operators meet most often are 309-008 (certification procedure for the Certificate of Approval), 309-019 (outpatient service delivery standards), 309-018 (residential SUD and problem gambling service standards), 415-012 (residential licensure procedure), 415-050 (withdrawal management standards) and 415-020 (opioid treatment programs). OHA site reviews check compliance against these rules, so the cited division numbers appear on certificates, deficiency statements and Plans of Correction.

Also called OAR, Oregon Administrative Rules, OAR chapter 309, OAR 309

Source: OAR 309-008-0100 Purpose and Scope

The office inside the Washington Department of Health that inspects and investigates state licensed health care facilities and agencies, including behavioral health agencies, residential treatment facilities, hospitals and psychiatric and alcohol treatment hospitals. It sits within Health Systems Quality Assurance, the DOH division that took over behavioral health licensing and certification from DSHS in 2018. OHSO conducts the initial and routine on-site reviews, writes the statement of deficiencies, approves plans of correction and, when needed, initiates enforcement. For an operator it is the team that shows up for the survey and the office to call about facility and agency credentialing questions.

Also called DOH Office of Health Systems Oversight, Health Systems Quality Assurance, HSQA, Washington DOH facilities licensing

Source: Washington DOH, Office of Health Systems Oversight (OHSO)

Treatment of opioid use disorder with buprenorphine or naltrexone prescribed from an ordinary medical office, clinic or telehealth practice rather than dispensed at an OTP. Until 2023 prescribers needed a special DATA 2000 waiver, often called the X waiver, with training and patient caps. Section 1262 of the Consolidated Appropriations Act, 2023 removed that requirement. Any practitioner with a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for OUD if state law allows, and the DATA waiver number is no longer needed on prescriptions. Methadone for OUD still cannot be prescribed this way. Operators adding OBOT should check state prescribing rules, DEA registration at each location and payer rules for medication management visits.

Also called office-based buprenorphine, X-waiver, DATA waiver, DATA 2000 waiver

Source: SAMHSA, Removal of DATA Waiver (X-Waiver) Requirement

HCPCS codes Medicare uses for office based treatment of opioid use disorder outside an opioid treatment program. G2086 covers the first calendar month, including development of the treatment plan, care coordination and individual and group therapy; G2087 covers each later month; G2088 is an add-on for additional time. A clinic prescribing buprenorphine in an outpatient setting bills these monthly bundles instead of billing each counseling session, while the medication itself is billed to the pharmacy benefit. These are not the OTP weekly codes (G2067 to G2080), which only SAMHSA certified OTPs may bill. Commercial and Medicaid payers vary on whether they accept them.

Also called G2086, G2087, G2088, office based opioid treatment bundle

Source: CMS MLN1986542, Medicare & Mental Health Coverage (March 2026)

The Oregon state agency that runs the Oregon Health Plan (Medicaid), oversees coordinated care organizations and regulates behavioral health programs. Its Behavioral Health Division licenses and certifies residential and outpatient mental health, substance use disorder, withdrawal management and problem gambling programs, adult foster homes, sobering facilities and community based structured housing. OHA conducts the certification and licensure site reviews, issues Certificates of Approval and residential licenses, and investigates complaints. For an operator, OHA is both the regulator and, through OHP and CCO contracts, a major payer, but holding an OHA license or certificate does not by itself enroll a program as an OHP provider.

Also called OHA, Oregon Health Authority, Oregon health authority behavioral health division

Source: OHA, Licensing and Certification - Residential and Outpatient Behavioral Health Programs

The OHA office that reviews applications and conducts site reviews for Oregon behavioral health programs. Each program type has a compliance specialist who approves programs for licensing or certification. The unit certifies outpatient programs for up to three years, licenses most residential programs every two years and adult foster homes annually, and may schedule additional inspections with or without notice to confirm continued compliance with the OARs and ORS. Its program pages list the certification rule (309-008), the service delivery rules (309-019, 309-018, 415-050) and the licensure rules (415-012) that apply to each program type, which is the quickest way to confirm which rules a new program must meet.

Also called OHA Licensing and Certification, L&C, OHA compliance specialist, Behavioral Health Division licensing

Source: OHA, Licensing and Certification: Requirements for Residential and Outpatient Programs

The part of the Oregon Health Authority that, under the current rules, issues behavioral health certificates and residential licenses. OAR 309-008 and OAR 415-012 both define the Division as the Health Systems Division of the Oregon Health Authority or its designee, so when a rule says the Division shall inspect, issue a certificate or require a Plan of Correction, it means this office and its licensing and certification staff. HSD also held Medicaid policy and CCO oversight. OHA has said that as of April 1, 2024 the Health Systems Division began transitioning back into separate Medicaid and Behavioral Health divisions, so correspondence may now come from the Behavioral Health Division while the rules still say HSD.

Also called Health Systems Division, OHA HSD, the Division (OAR 309-008)

Source: OHA, Health Systems Division

Oregon's Medicaid program, run by the Oregon Health Authority (OHA). It pays for mental health and substance use disorder treatment alongside physical and dental care for Oregonians who qualify by income or category. Most members are enrolled in a regional Coordinated Care Organization (CCO) that holds their behavioral health benefit; the rest are open card members whom OHA pays directly at the published fee schedule rate. An operator bills OHP either through a CCO contract or through an OHA fee for service enrollment, and OHA's Prioritized List and administrative rules decide which services are covered. Oregon Medicaid and DMAP are older names for the same program.

Also called OHP, Oregon Health Plan, Oregon Medicaid, OHP open card

Source: Oregon Health Authority, Oregon Health Plan (Oregon Medicaid)

Oregon Health Plan members are either enrolled in a coordinated care organization or served fee-for-service, which providers call open card. OHA rules define a fee-for-service provider as one not paid under an OHA contract with a CCO or prepaid health plan, and note that a CCO provider is a fee-for-service provider when treating a member who is not in a CCO. The distinction decides who you bill, whose authorization rules apply and what rate you get: OHA's billing page tells providers to bill the CCO when the member has one. Eligibility checks show the enrollment, and it can change month to month.

Also called open card, OHP fee-for-service, fee-for-service provider, CCO member

Source: OAR 410-120-0000(96)

The HHS Office of Inspector General excludes individuals and entities from federal health care programs for reasons such as program related convictions, patient abuse or license revocation, and lists them in the List of Excluded Individuals/Entities (LEIE). No federal program payment may be made for items or services an excluded person furnishes, orders or prescribes, and an employer that bills for an excluded employee's work can face civil monetary penalties. Providers therefore screen new hires, current staff, contractors and vendors against the LEIE at hire and routinely thereafter; state Medicaid agencies must check the LEIE at least monthly under 42 CFR 455.436, and state provider agreements and managed care contracts commonly require enrolled providers to screen their own staff on the same schedule.

Also called LEIE, List of Excluded Individuals/Entities, exclusion screening, OIG exclusion

Source: HHS OIG, Exclusions Program

A program certified by SAMHSA under 42 CFR Part 8 and registered with the DEA to dispense methadone and other FDA approved medications for opioid use disorder, together with counseling, medical and other services. It is the only setting where methadone can be dispensed for OUD. Federal standards in 42 CFR 8.12 cover admission, dosing, take home doses and required services, and an OTP must also hold accreditation from a SAMHSA approved body. Oregon approves OTPs through the Health Systems Division under OAR chapter 415 division 020. Washington defines and certifies OTPs under RCW 71.24.590, which adds local consultation and public notice steps before a new site opens. Each state Medicaid program sets its own OTP bundled rates.

Also called methadone clinic, narcotic treatment program, NTP, 42 CFR Part 8 program

Source: 42 CFR Part 8, section 8.12 Federal opioid treatment standards

Federal rules require state Medicaid agencies to make every physician or other professional who orders or refers services under the State Plan or a waiver enroll as a participating Medicaid provider. The rule applies even when that practitioner never submits a claim, because the state must be able to screen everyone whose orders or referrals lead to Medicaid payment. States may rely on screening already done by Medicare contractors or another state's Medicaid or CHIP program. For behavioral health programs, claims can depend on the enrollment status of prescribers, physicians and other professionals who order labs, medications or admissions, so their Medicaid enrollment should be confirmed during onboarding.

Also called ORP, ordering and referring enrollment, ordering, referring and prescribing, 42 CFR 455.410(b)

Source: 42 CFR 455.410, Enrollment and screening of providers (eCFR via Cornell LII)

The unit inside the Oregon Department of Human Services that runs criminal history and abuse record checks for ODHS and Oregon Health Authority programs, including OHA-certified and licensed behavioral health providers. Checks are requested through the ORCHARDS system by qualified entities, and the rules in OAR chapter 407 division 007 define mandatory exclusions, potentially disqualifying conditions and the fitness determination process. Peer workers and CRMs are also screened against the ORS 443.004 crime list. Operators care because every employee, contractor and volunteer with direct access must be cleared before unsupervised work, and an incomplete BCU file is a frequent finding in OHA site reviews.

Also called Background Check Unit, ODHS background check, ORCHARDS, Oregon abuse check

Source: ODHS, Background Checks

The federal agreement under Section 1115 of the Social Security Act that lets Oregon run the Oregon Health Plan differently from standard Medicaid rules. The current demonstration runs 2022 through 2027 and added continuous eligibility (two full years of OHP coverage for people age six and older, effective July 1, 2023), full EPSDT coverage for children regardless of the Prioritized List, and health-related social needs benefits such as housing and nutrition supports. OHA also maintains a separate SUD 1115 waiver for substance use disorder treatment. OHA has posted a 2026 to 2031 renewal application. Operators watch the waiver because it shapes CCO budgets, member churn and which services CCOs can pay for.

Also called Oregon 1115 waiver, OHP 1115 waiver, 2022-2027 waiver, Oregon SUD 1115 waiver

Source: Oregon Health Authority, 2022-2027 Medicaid 1115 Demonstration Waiver

The license the Oregon Health Authority issues to operate a residential substance use disorder or problem gambling treatment program. The procedure is in OAR chapter 415 division 012, which defines the license as one issued to applicants in substantial compliance with the rules and renewable every two years; the clinical and facility standards are in OAR chapter 309 division 018. The license attaches to both the program and the premises, is not transferable to a new owner or location and may carry restrictions on capacity, age or gender served. A provisional license of one year or less may be issued when compliance is incomplete. A residential provider that also offers outpatient services must also hold a Certificate of Approval.

Also called residential license Oregon, OAR 415-012, OAR 309-018, residential treatment license

Source: OAR 415-012-0010 Definitions

The Oregon statute that sets the framework for the Certificate of Approval. It defines an assessment as an on-site quality assessment of an organizational provider that is not accredited by a national organization OHA accepts, conducted by OHA or a contractor for the purpose of issuing the certificate. It requires OHA to adopt assessment criteria by rule with an advisory committee that includes CCOs, providers and insurers, and it tells CCOs to rely on the OHA assessment instead of running their own quality review unless no assessment has occurred in 36 months. The practical effect for operators is that the COA review doubles as the credentialing site assessment CCOs would otherwise demand.

Also called ORS 430.637, Oregon organizational provider assessment, certificate of approval criteria statute

Source: ORS 430.637

The physician responsible for all medical and behavioral health services in an opioid treatment program. Under 42 CFR 8.2 the medical director must be licensed to practice medicine in the state where the OTP sits. The 2024 revision of 42 CFR Part 8 lets the medical director delegate specific duties to program physicians and to appropriately licensed non-physician practitioners with prescriptive authority, such as nurse practitioners and physician assistants where state law allows, without giving up responsibility. The program sponsor need not be a physician but must keep a licensed physician in the role. Operators care because the role is a condition of SAMHSA certification and is checked at survey.

Also called medical director, program physician, addiction medicine physician, methadone clinic medical director

Source: 42 CFR 8.2 (2024 edition)

Medicare pays opioid treatment programs through weekly bundled payments rather than per service. Codes G2067 through G2073 each describe a seven day episode of care that includes a specific medication (methadone, oral buprenorphine, injectable or implantable buprenorphine, naltrexone) plus dispensing, counseling, therapy and toxicology testing; G2074 is the weekly bundle without medication and G2075 the bundle with a medication not otherwise specified. G2076 through G2080 are add-on codes for intake, periodic assessment, take home supplies and additional counseling time. A program bills one bundle per patient per seven day period and must not bill separate drug or counseling claims that overlap it. State Medicaid programs may use the same codes or their own.

Also called G2067, G2068, G2069, G2070

Source: CMS Opioid Treatment Program Billing & Payment

The Hospital Outpatient Prospective Payment System is the Medicare payment system for hospital outpatient services, and it also sets the per diem rates for partial hospitalization and intensive outpatient programs in hospital outpatient departments and Community Mental Health Centers. Codes are assigned to Ambulatory Payment Classifications (APCs). For PHP and IOP, CMS keeps two APCs for each provider type, one for days with three services and one for days with four or more services. For CY 2026, CMHC costs are calculated at 40 percent of hospital based costs. CMS updates OPPS every calendar year by final rule. Because of the three versus four or more service split, the services documented each program day affect payment.

Also called OPPS, Hospital Outpatient Prospective Payment System, APC, Ambulatory Payment Classification

Source: CMS, Calendar Year 2026 Hospital OPPS and ASC Final Rule (CMS-1834-FC) fact sheet

A payment a provider received that it was not entitled to, whether from a billing error, a duplicate payment, a service that was not documented or a credentialing lapse. Under federal law a Medicare or Medicaid provider that identifies an overpayment must report and return it within 60 days of identifying it, or by the date a cost report is due if later; keeping it past that point can become a False Claims Act liability. Payers also recover overpayments through recoupment against future remittances. Programs should have a written process for investigating credit balances and audit findings and for issuing refunds on time.

Also called overpayment, recoupment, refund, 60-day rule

Source: 42 CFR 401.305(b)

Medicaid providers must disclose to the state agency the name, address and identifying information of every person or corporation with an ownership or control interest, family relationships among owners, other Medicaid entities those owners hold interests in, and the name and identifying information of each managing employee. Disclosures are due with the enrollment application, when the provider agreement is signed, on request during revalidation, and within 35 days after any change in ownership. Federal matching funds are not available for payments to a provider that fails to disclose. For behavioral health operators, an acquisition or new investor should prompt a disclosure filing within that 35 day window.

Also called disclosure of ownership, ownership and control interest, managing employee disclosure, 42 CFR 455.104

Source: 42 CFR 455.104, Disclosure of ownership and control (eCFR via Cornell LII)

Oregon's staff designation for non-clinician mental health workers who deliver skills training, case management, rehabilitation and support services under a person-centered treatment plan in an OHA-certified program. OAR 309-019-0125 requires a bachelor's degree in a behavioral science field, or a combination of at least three years of relevant work, education, training or experience, plus demonstrated competencies. QMHAs cannot complete assessments or diagnoses; those belong to a QMHP. MHACBO administers registration (QMHA-R) and certification (QMHA-I and QMHA-II) and requires 1,000 supervised hours before testing. Operators care because QMHA status determines which Medicaid rehabilitative services a staff member can bill and how the person must be supervised.

Also called QMHA-I, QMHA-II, QMHA-R, Qualified Mental Health Associate

Source: OAR 309-019-0125(9)

Oregon's staff designation for the clinician who can assess, diagnose, write and supervise treatment plans, and provide therapy in an OHA-certified mental health program. OAR 309-019-0125 sets the minimum qualifications, which include a graduate degree in a behavioral science field, or a bachelor's degree in nursing or occupational therapy with an Oregon license, plus demonstrated competencies. Licensed clinicians such as LPCs, LCSWs and psychologists already meet the definition. Unlicensed master's-level staff register with MHACBO as QMHP-R and certify as QMHP-C after 1,000 supervised hours. Operators care because Medicaid billing for assessment and therapy in certified programs depends on QMHP status, and clinical supervisors must themselves meet QMHP requirements.

Also called QMHP-C, QMHP-R, Qualified Mental Health Professional

Source: OAR 309-019-0125(10)

A written agreement that lets a 42 CFR Part 2 substance use disorder program share patient records with an outside organization that serves it, without the patient's written consent. A qualified service organization provides services such as data processing, bill collecting, laboratory analyses, legal, accounting or medical staffing work, and agrees in writing that it is fully bound by Part 2 when handling the program's records and, if necessary, will resist in judicial proceedings any effort to get patient identifying information except as Part 2 permits. Under 42 CFR 2.12(c)(4), Part 2's limits do not apply to sharing what it needs for those services. A HIPAA business associate of a program that is also a covered entity can qualify.

Also called QSOA, QSO, qualified service organization, QSO agreement

Source: 42 CFR 2.11, Definitions (eCFR via Cornell LII)

The minimum clinical staffing rule for Idaho behavioral health programs that provide substance use disorder services, now in Idaho Code 39-305A. Each program must employ enough staff to deliver its services as a multidisciplinary team and at least one qualified substance use disorders professional at every program location. The statute defines that person as an IBADCC certified alcohol/drug counselor or advanced alcohol/drug counselor, a master addictions counselor certified by NBCC or NCCAP, or a licensed professional. Trainees are addressed in 39-305B. Because this came from the retired IDAPA 16.07.17 rule, programs that wrote their staffing plans against the old rule should update the citation and confirm each site has a qualifying clinician.

Also called Idaho Code 39-305A, qualified SUD professional, IBADCC certified counselor requirement, Idaho SUD staffing

Source: Idaho Code 39-305A Qualified substance use disorders personnel

QAPI is the structured, ongoing process a program uses to measure, monitor and improve the quality and effectiveness of its services. Oregon's outpatient behavioral health rules (OAR 309-019-0210) require every certified provider to develop and implement one, and residential rules carry a parallel requirement. Washington requires each licensed agency to maintain a written internal quality management plan that monitors rule compliance and continuously improves care, including in response to critical incidents and substantiated complaints (WAC 246-341-0410). Accreditors review the same thing under performance measurement and improvement standards. A working QAPI plan names indicators, data sources, review frequency, who is responsible, and how findings become corrective actions.

Also called QAPI plan, quality improvement plan, performance improvement, quality management plan

Source: OAR 309-019-0210 Quality Assessment and Performance Improvement

The Quality Improvement Plan is the written response a CARF accredited organization owes after its survey. Within 90 days of being told the accreditation decision, the organization submits a QIP describing what it has done or will do about each area for improvement listed in the survey report. Accredited programs then file an Annual Conformance to Quality Report (ACQR) each year to keep the accreditation in good standing. SAMHSA certified opioid treatment programs also send CARF a SAMHSA Implementation Report within 180 days of the decision. For an operator, the QIP is the document that turns survey findings into assigned tasks and deadlines.

Also called CARF QIP, Annual Conformance to Quality Report, ACQR, areas for improvement

Source: CARF International, Steps to accreditation (step 8)

The HCPCS code for intensive outpatient psychiatric services, billed once per day the person attends. It is the usual code for a mental health IOP, while substance use IOP is normally billed with H0015. Washington's mental health billing guide has behavioral health agencies bill S9480 with HK as the primary modifier under the 251S00000X taxonomy, and sends hospitals to the outpatient hospital guide. S codes are not payable by Medicare, which pays IOP through its own 2024 benefit on institutional claims, so a program serving Medicare members needs a different billing path for them.

Also called S9480, intensive outpatient psychiatric services per diem, mental health IOP code

Source: HCA Mental Health Services Billing Guide, October 2026

To dispense methadone or other medications for opioid use disorder as an opioid treatment program, a provider must be certified by SAMHSA under 42 CFR 8.11, in addition to holding a DEA narcotic treatment program registration and state approval. The application is Form SMA-162, filed through the SAMHSA OTP extranet with the program's accreditation status, state authority approval and supporting documents. A new program that has applied to a SAMHSA approved accreditation body such as CARF or The Joint Commission can receive provisional certification for up to one year while it completes accreditation. Certification is renewed annually or every three years to match the accreditation term, and SAMHSA must be notified of program changes.

Also called SMA-162, OTP certification, SAMHSA certification, provisional certification

Source: 42 CFR 8.11 Opioid Treatment Program certification

Seclusion is involuntary confinement of a person alone in a room they cannot leave; restraint is any manual, mechanical or chemical method that restricts movement. Oregon's outpatient and residential behavioral health rules list freedom from seclusion and restraint as an individual right, so community programs may not use them. Hospitals and hospital based psychiatric units follow the Medicare condition of participation at 42 CFR 482.13(e), which allows restraint or seclusion only to protect immediate physical safety, using the least restrictive effective method, under an order and with specific monitoring, training and death reporting. Washington's chapter 246-341 addresses seclusion and restraint only for competency restoration services. Any use must be documented and reviewed through incident reporting.

Also called restraint, seclusion, physical restraint, restraint and seclusion rules

Source: OAR 309-019-0115(1)(m) Individual Rights

A Section 1115 reentry demonstration lets a state claim federal Medicaid matching funds for certain health services delivered to eligible people in prisons, jails or youth correctional facilities shortly before release, which the inmate payment exclusion would otherwise block. Under CMS guidance from April 2023, CMS expects a state's pre-release package to include at least case management, medication-assisted treatment for all types of substance use disorder with counseling, and a 30 day supply of prescribed medications at release. The 2023 guidance allowed up to 90 days of pre-release coverage, while a September 2026 approval for Maine limited jails and prisons to 60 days. Community providers may deliver in-reach services and continue care after release.

Also called reentry waiver, reentry 1115, pre-release Medicaid services, Reentry Section 1115 Demonstration Opportunity

Source: CMS State Medicaid Director Letter SMD 23-003, Reentry Section 1115 Demonstration Opportunity

A CMS approved demonstration that lets a state Medicaid program pay for short term residential and inpatient SUD treatment in facilities with more than 16 beds despite the IMD exclusion, in exchange for building out the full ASAM continuum and meeting reporting and quality terms. Oregon's SUD 1115 demonstration was approved April 8, 2021, began paying for residential care in larger facilities January 1, 2022, ran through March 31, 2026 and was temporarily extended to September 30, 2026 while OHA seeks a five year renewal. Idaho's Behavioral Health Transformation waiver, approved April 2020, covers SUD and serious mental illness in IMDs and was also extended to September 30, 2026 pending its renewal. Washington's approved waiver requires an independent outpatient ASAM assessment before Medicaid residential admission.

Also called 1115 waiver, SUD 1115 waiver, IMD waiver, SUD IMD demonstration

Source: OHA, Substance Use Disorder 1115 Demonstration Waiver

A Section 1915(b) waiver lets CMS waive most Medicaid State Plan requirements under Section 1902 of the Social Security Act, most often freedom of choice of provider, when the state shows the change is cost effective, efficient and consistent with Medicaid's objectives. States use these waivers for primary care case management, specialty physician systems, local enrollment brokers, sharing cost savings with enrollees, and restricting enrollees to providers that meet state reimbursement, quality and utilization standards. Restrictions cannot apply in emergencies or to family planning services. A waiver is granted for up to 2 years unless the state requests a continuation. For a behavioral health program, a 1915(b) waiver can explain why only network providers are paid for certain enrollees.

Also called 1915(b) waiver, freedom of choice waiver, Medicaid managed care waiver, selective contracting waiver

Source: 42 CFR 431.55, Waiver of other Medicaid requirements (eCFR via Cornell LII)

A Section 1915(c) waiver lets a state cover home and community based services for people who, without those services, would need the level of care of a hospital, nursing facility or intermediate care facility. Services are delivered under a written plan of care, room and board are excluded, and the statute allows services such as case management, habilitation, respite care, and day treatment or other partial hospitalization, psychosocial rehabilitation and clinic services for people with chronic mental illness. States can waive statewideness and comparability, so a waiver may cover only certain areas or groups. An initial waiver runs 3 years and renewals run 5 years. Behavioral health providers deliver these services only for enrolled waiver participants.

Also called 1915(c) waiver, HCBS waiver, home and community based services waiver, Medicaid HCBS waiver

Source: 42 U.S.C. 1396n, Section 1915 of the Social Security Act (Cornell LII)

Section 1915(i) lets a state add home and community based services to its Medicaid State Plan through a State Plan Amendment, without first finding that a person would otherwise need hospital or nursing facility care. Eligibility rests on needs-based criteria the state sets, which must be less stringent than its institutional criteria, and a diagnosis alone is not enough. The core group covers people with income up to 150 percent of the poverty line. An independent evaluation determines eligibility and is repeated at least every 12 months. Room and board are excluded, and services must be delivered in home and community based settings, which exclude institutions for mental diseases. For behavioral health programs, eligibility turns on assessed need, not diagnosis.

Also called 1915(i), 1915(i) benefit, state plan HCBS, 1915(i) state plan option

Source: 42 CFR 441.715, Needs-based criteria and evaluation (eCFR via Cornell LII)

A Washington service that provides withdrawal management and medical stabilization to people detained or committed involuntarily for a substance use disorder under the Involuntary Treatment Act, chapters 71.05 and 71.34 RCW, as well as voluntary patients. A designated crisis responder must find the person gravely disabled or a likelihood of serious harm because of the SUD. Facilities are certified by the Department of Health under WAC 246-341-1135 at the ASAM 3.7-WM level, must keep a substance use disorder professional and a physician, physician assistant or nurse practitioner available 24 hours a day for consultation, and must be able to hold patients securely. HCA pays for SWMS through managed care and fee for service, and only agencies holding this specific certification may bill it.

Also called secure detox, secure withdrawal management, involuntary withdrawal management, Ricky's Law facility

Source: WAC 246-341-1135, Secure withdrawal management and stabilization services, service standards

A security risk analysis is the required first administrative safeguard under 45 CFR 164.308(a)(1). The organization identifies where electronic protected health information lives, then assesses threats, vulnerabilities and the likelihood and impact of each, and documents the result. The companion risk management requirement then calls for security measures that reduce those risks to a reasonable and appropriate level. HHS treats a missing or outdated risk analysis as one of the most common findings in investigations and settlements, so programs should repeat it on a schedule and whenever systems change, such as adopting a new EHR or telehealth tool, and keep the documentation for six years.

Also called HIPAA risk analysis, security risk assessment, SRA, risk management plan

Source: 45 CFR 164.308(a)(1)(ii)(A) Risk analysis

A health plan in which the employer itself takes on the responsibility of paying the medical claims of employees and their dependents; the employer may hire a third party administrator for enrollment, claims processing and provider networks. ERISA, the federal Employee Retirement Income Security Act of 1974, governs plans set up by employers engaged in commerce, with exceptions that include government plans and church plans that have not elected coverage, and supersedes state laws that relate to them. State laws that regulate insurance still apply, but ERISA says a covered plan is not deemed an insurer under them, so state insurance rules generally reach insured coverage and not a self-funded plan. Check which kind of plan it is at verification.

Also called self-funded plan, self-insured plan, ERISA, Employee Retirement Income Security Act

Source: 29 U.S.C. 1144, ERISA preemption (Cornell LII)

SAMHSA's terms for adults and children with a mental disorder that substantially interferes with functioning. Serious mental illness (SMI) means someone over 18 who has had, within the past year, a diagnosable mental, behavioral or emotional disorder that substantially interferes with their life and ability to function; examples include bipolar disorder, major depressive disorder and schizophrenia. Serious emotional disturbance (SED) is the parallel term for someone under 18 whose diagnosable disorder within the past year caused functional impairment that substantially interferes with or limits the child's role or functioning in family, school or community activities. SAMHSA's 2023 National Survey on Drug Use and Health found 14.6 million adults, or 5.7%, reported SMI in the past year.

Also called SMI, SED, serious mental illness, serious emotional disturbance

Source: SAMHSA, Serious Mental Illness and Serious Emotional Disturbances

The licensing terms for where services may legally be delivered. Oregon issues one Certificate of Approval per provider, with an accompanying letter listing every approved service delivery location, defined as the office, facility or other physical premises where treatment is provided; opening or relocating a site requires Division approval at least 60 days ahead. Washington licenses a main site and adds branch sites, each a physically separate licensed site under the same parent organization, through an abbreviated application, while off-site services in schools, residences or shelters and mobile units can operate under the existing license with notice and a written safety protocol. Seeing clients at an unapproved address is a common deficiency.

Also called service delivery location, branch site, off-site location, satellite site

Source: WAC 246-341-0342 Agency licensure and certification, Off-site locations

A one time contract between a payer and a provider that is not in its network, covering one member for a defined service and period at an agreed rate. Washington's enrollment rule authorizes the Medicaid agency to enter into a single case agreement or other written agreement with a provider, and commercial plans and CCOs use them when no in network program can meet the member's need, for example a specialized residential program. The SCA should state the codes, rate, dates, authorization requirements and billing instructions. Programs that rely on SCAs carry more administrative load per admission than contracted programs.

Also called single case agreement, letter of agreement, LOA, out of network agreement

Source: WAC 182-502-0005(2)

The Stark Law, 42 U.S.C. 1395nn, prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician or an immediate family member has a financial relationship, and prohibits that entity from billing for the referred service, unless an exception applies. It is a strict liability civil law, so intent does not matter. Designated health services include clinical laboratory services, outpatient prescription drugs, inpatient and outpatient hospital services and several therapy and imaging categories, but not counseling or most outpatient behavioral health services. It becomes relevant to behavioral health when a physician owner refers to an affiliated lab, pharmacy or hospital based program.

Also called Stark, Stark Law, physician self-referral law, 42 U.S.C. 1395nn

Source: 42 U.S.C. 1395nn Limitation on certain physician referrals

A federal mechanism that lets a state require its Medicaid managed care plans to pay providers in a particular way, such as a minimum fee schedule, a uniform percentage increase or a value based arrangement, instead of leaving rates entirely to plan and provider negotiation. CMS must approve each directed payment under 42 CFR 438.6(c), usually for one rating period at a time, and the state must show it advances a quality goal. Oregon's Behavioral Health Directed Payment, which sets minimum CCO rates for qualifying behavioral health providers, is the example Northwest operators encounter most. Without an approved directed payment, a state Medicaid agency cannot dictate what a plan pays a provider.

Also called state directed payment, SDP, directed payment, 438.6(c)

Source: 42 CFR 438.6, Special contract provisions related to payment

The State Opioid Treatment Authority is the agency, or official, designated by a state's governor to govern treatment of opioid use disorder with medications in opioid treatment programs within that state. Federal rules in 42 CFR Part 8 route several approvals through the SOTA: a new OTP needs SOTA sign off as part of SAMHSA certification, exception requests such as take home dose changes are submitted through the SOTA, and programs must notify the SOTA about interim treatment admissions. In Oregon the SOTA sits in the Oregon Health Authority, in Washington in the Health Care Authority, and in Idaho in the Department of Health and Welfare; SAMHSA keeps the current contact list.

Also called state methadone authority, state opioid treatment authority, SOTA approval

Source: 42 CFR 8.2 Definitions (State Opioid Treatment Authority)

The written report a licensing agency issues after a site review listing each rule the program failed to meet and what must be corrected. In Oregon, OAR 309-008-0800 requires the Division to issue a report within 30 days of an initial or renewal certification review with a statement of any deficiency, the findings and the required corrective actions; the Plan of Correction clock starts when the provider receives it. Washington DOH sends a statement of deficiencies report after a behavioral health agency on-site review with instructions and time frames for the plan of correction, and for residential treatment facilities issues a notice of correction under WAC 246-337-021 that cites the rule, states what compliance requires and sets a deadline.

Also called deficiency notice, statement of deficiency, notice of correction, deficiency report

Source: WAC 246-341-0320 On-site reviews and plans of correction

The diagnostic term for a pattern of alcohol or drug use that continues despite significant problems it causes. DSM-5 grades it mild, moderate or severe by symptom count, and ICD-10 F10 through F19 codes carry the diagnosis on claims. Regulators in all three states use the term in place of older labels such as chemical dependency and alcohol and drug treatment. Washington defines it in WAC 182-538D-0200 as a cluster of cognitive, behavioral and physiological symptoms, Oregon's OAR 309-019-0105 covers disorders related to drugs of abuse including alcohol, and Idaho Code 39-306 requires a DSM-5 substance related diagnosis for state funded services. SUD treatment records carry extra federal confidentiality protection under 42 CFR Part 2.

Also called substance use disorder, addiction, chemical dependency, alcohol and drug

Source: WAC 182-538D-0200, Definitions

IBADCC's entry-level Idaho credential for a person working in substance use disorder treatment before qualifying for the ADC. A SUDA can only practice under the supervision of an IBADCC-approved clinical supervisor, and the scope is limited to screening, brief intervention and referral, diagnostic impression, service coordination and SUD education with individuals and groups; it does not include independent assessment or counseling. The role functions like Oregon's CADC-R and Washington's SUDP trainee, giving programs a compliant way to employ staff who are still accruing education and hours. Operators care because SUDA services bill only under the supervising counselor's oversight and the supervisor's own IBADCC approval must be current.

Also called Idaho SUD associate, IBADCC associate, counselor in training Idaho

Source: IBADCC, Substance Use Disorder Associate

Washington's state certification for substance use disorder counselors, issued by the Department of Health under chapter 18.205 RCW and WAC 246-811. The credential was formerly titled Chemical Dependency Professional (CDP). Applicants need an associate's degree or higher in a human services field, or equivalent college credits or a registered apprenticeship, plus supervised experience hours and a passing exam. Certified SUDPs complete 20 hours of continuing education every two years. Operators care because WAC 246-341 requires every staff member providing SUD clinical services in a licensed behavioral health agency to hold the right DOH credential, and SUDP status determines who can assess, diagnose and sign treatment plans for Apple Health billing.

Also called Substance Use Disorder Professional, CDP, Chemical Dependency Professional, Washington SUD counselor

Source: WAC 246-811-010(24)

The legal threshold a program must meet to receive or keep a license or certificate; it does not mean zero deficiencies. Oregon's OAR 309-008-0200 defines substantial compliance as a level of adherence to the rules, statutes and regulations that, even if one or more requirements is not met, does not constitute a danger to the health, welfare or safety of any individual or the public and is not a willful, negligent or ongoing violation. OHA issues initial certificates and renewals to applicants that demonstrate substantial compliance, and the Plan of Correction process exists to bring a program with findings back to that level. The same term anchors the Oregon residential license definition in OAR 415-012-0010.

Also called substantial compliance standard, in substantial compliance, licensing compliance threshold

Source: OAR 309-008-0200 Definitions

Washington's credential for a person working toward SUDP certification while gaining education and supervised experience. The trainee must work under an approved supervisor, a certified SUDP with at least one year (2,000 hours) of post-certification experience and 28 hours of clinical supervisor training; the supervisor reviews and signs all of the trainee's clinical documentation and is responsible for the trainee's patients. Trainees renew annually and must show progress toward certification. Operators care because trainee time is billable only within the supervisor's oversight, supervisor qualifications must be documented before training begins, and the trainee-to-supervisor relationship is a standard item in DOH behavioral health agency reviews.

Also called SUDPT, SUDP trainee, Substance Use Disorder Professional Trainee, CDPT

Source: WAC 246-811-049(2)

An evidence based service that helps adults with serious mental illness find and keep competitive jobs, integrated with their mental health treatment rather than run as a separate vocational program. Oregon's OAR 309-019-0275 describes the Individual Placement and Support model: anyone who wants to work is eligible regardless of symptoms or substance use, job search starts quickly, services honor the person's preferences, employment specialists build relationships with employers, benefits planning is offered, and job supports continue as long as the worker wants them. Providers must meet fidelity requirements under OAR 309-019-0280 through 0295. Supported employment is a billable Oregon Health Plan service for community mental health programs and often appears in CCO contracts.

Also called Individual Placement and Support, IPS supported employment, evidence-based supported employment, employment specialist

Source: OAR 309-019-0275, Individual Placement and Support (IPS) Supported Employment Overview

A Unified Program Integrity Contractor (UPIC) is a CMS contractor responsible for preventing, detecting and deterring fraud, waste and abuse in both Medicare and Medicaid. UPICs look for program vulnerabilities, investigate allegations from beneficiaries, providers, CMS, the OIG and other sources, and work with state Medicaid agencies, state program integrity units and Medicaid Fraud Control Units. Where there is reliable evidence of fraud they can start administrative actions, including payment suspensions and revocations, and refer cases to the OIG for possible civil or criminal action. Because a UPIC inquiry can end in suspension, revocation or referral, behavioral health programs should treat it as a compliance matter, not a routine claim question.

Also called UPIC, Unified Program Integrity Contractors, program integrity contractor, UPIC audit

Source: CMS Medicare Program Integrity Manual, Chapter 4 (Pub. 100-08)

UnitedHealthcare's Medicaid plan in Washington and one of the five Apple Health managed care organizations. It covers physical and behavioral health together under integrated managed care and supports the Collaborative Care model in primary care. Behavioral health contracting, credentialing and authorizations for UnitedHealthcare members generally run through its Optum behavioral health network rather than the medical contracting team, so a program may hold an Optum agreement that covers UnitedHealthcare commercial, Medicare Advantage and Community Plan members at different rates. Claims and prior authorizations are submitted through the UnitedHealthcare Provider Portal.

Also called UHC Community Plan, UnitedHealthcare Community Plan, UHC Apple Health, United Healthcare Medicaid Washington

Source: UHCprovider.com, UnitedHealthcare Community Plan of Washington

The set of techniques a payer, or a company it delegates to, uses to decide whether care is medically necessary, appropriate and efficient. It covers prior authorization before care, concurrent review during care and retrospective review after a claim is paid. Oregon statute defines the term for commercial insurers and requires that denials cite clinical review criteria and offer a timely appeal. For a treatment program, UR is usually a staff function: a person who gathers documentation, speaks with payer reviewers, tracks authorization end dates and files appeals. Good UR work is built on clear assessments and progress notes tied to ASAM dimensions or the payer's criteria.

Also called utilization review, utilization management, UM

Source: ORS 743B.001

The chapter of the Washington Administrative Code that sets the state minimum standards for licensed behavioral health agencies. It covers the licensure process (WAC 246-341-0300 through 0370), deeming, on-site reviews and plans of correction, agency policies and procedures, personnel records, individual service records, and the certification standards for each service type such as outpatient intervention, assessment and treatment, withdrawal management, residential and inpatient treatment, opioid treatment programs and crisis services. DOH adopted the chapter in 2019 when licensing moved from DSHS and rewrote it effective July 1, 2021, so older section numbers in templates and consultant checklists may no longer exist. The chapter does not apply to state psychiatric hospitals or federal facilities.

Also called WAC 246-341, chapter 246-341 WAC, Washington behavioral health agency licensing rules, BHA WAC

Source: WAC 246-341-0100 Behavioral health, Purpose and scope

The official publication of rule-making activity by Washington state agencies, issued twice a month by the Office of the Code Reviser. Every proposed, emergency and permanent rule filing receives a WSR number in the form year-issue-sequence (for example 21-12-042), and that number appears in the history note at the bottom of each WAC section. For operators it is the way to see what DOH or the Health Care Authority is changing in WAC 246-341 or 246-337 before it takes effect, to find the effective date of a rule change cited in a survey, and to comment on proposed rules. The WAC/WSR table lets you look up every filing that touched a given section.

Also called Washington State Register, WSR filing number, rule-making notice Washington

Source: Washington State Legislature, Washington State Register

One of the five Apple Health managed care organizations, offering Medicaid coverage that combines physical and mental health in one plan and a Behavioral Health Services Only product for members with other primary coverage. Wellpoint is the current name of the plan that operated in Washington as Amerigroup, so older contracts, ProviderOne screens and member cards may still show Amerigroup. Wellpoint contracts directly with outpatient and residential behavioral health programs, runs its own authorization process and provider portal, and participates in the IMC regions it serves. An operator with a legacy Amerigroup contract should confirm it has been assigned to Wellpoint and that its directory listing has moved.

Also called Wellpoint, Wellpoint Apple Health, Amerigroup Washington, Amerigroup

Source: Wellpoint, Washington Apple Health (Medicaid)

The current term for detox: supervised care that helps a person get through the physical effects of stopping alcohol or drugs safely. ASAM grades it in its own WM levels. Ambulatory withdrawal management (1-WM and 2-WM) happens in outpatient settings. Level 3.2-WM is clinically managed residential withdrawal management, which Washington treats as sub acute, with counselors monitoring and medications usually self administered. Level 3.7-WM is medically monitored, with nurses on site and physicians on call around the clock. Level 4-WM is hospital based, medically managed care. Oregon licenses withdrawal management programs separately from outpatient certification, Washington's DOH licenses the facility and certifies the service under WAC 246-341-1100 and following, and Idaho now sets standards in Idaho Code after SB 1024.

Also called detox, detoxification, 1-WM, 2-WM

Source: Washington HCA, Substance Use Disorder Billing Guide (July 1, 2026)

OHA's approval for a residential or inpatient program that provides detoxification services for people with substance use disorders. OHA approves programs for one or more ASAM levels: adult clinically managed residential withdrawal management (3.2-WM), adult medically monitored inpatient withdrawal management (3.7-WM) and adolescent medically monitored inpatient withdrawal management (3.7-WM). The service standards are in OAR chapter 415 division 050, and the approval itself is issued through the residential licensure process in OAR 415-012; the rule describes a Letter of Approval effective for two years with an inspection at least every two years. Washington handles the same service as a withdrawal management certification under WAC 246-341-1100 held by a licensed behavioral health agency operating in a licensed facility.

Also called detox license Oregon, withdrawal management license, OAR 415-050, Letter of Approval detox

Source: OAR 415-050-0010 Program Approval

A team based care coordination process for children and youth with complex behavioral health needs and their families. A facilitator convenes the family, natural supports and involved agencies into one team that builds a single plan and meets regularly, following National Wraparound Initiative values and principles. Oregon's OAR 309-019-0105 defines wraparound as a high fidelity model of team based intensive care coordination, with program rules in OAR 309-019-0324 and 0326. Washington's version is Wraparound with Intensive Services (WISe) for Apple Health enrollees age 20 or younger with complex needs who meet medical necessity. Both states pay for wraparound through Medicaid, often as a monthly rate, and both require fidelity and outcome reporting.

Also called wraparound services, youth wraparound, WISe, Wraparound with Intensive Services

Source: OAR 309-019-0105, Definitions (item 127)