Section
4.3 Coordination of Care with AHCCCS Health Plans and Primary
Care Providers
4.3.1
Introduction
4.3.2 References
4.3.3 Scope
4.3.4 Objectives
4.3.5 Did you know…?
4.3.6 Procedures
4.3.6-A. Suggestions and Guidance for Coordinating Care
4.3.6-B. Sharing information with the PCP
4.3.6-C. Who’s responsible, the Health
Plan or the T/RBHA?
4.3.6-D. PCPs prescribing psychotropic medications
4.3.1
Introduction
In Arizona, the acute care Medicaid program (Title XIX) and the
State Children’s Health Insurance Program (SCHIP/Title XXI)
were developed as behavioral health “carve-outs,” a
model in which eligible persons receive general medical services
through health plans and covered behavioral health services through
behavioral health managed care organizations, also known as Regional
Behavioral Health Authorities and Tribal Regional Behavioral Health
Authorities (T/RBHAs). Because of this separation in responsibilities,
communication and coordination between behavioral health providers
and AHCCCS Health Plan Primary Care Providers (PCPs) is essential
to ensure the well being of persons receiving services from both
systems. Duplicative medication prescribing or contraindicated combinations
of prescriptions and/or incompatible treatment approaches could
be detrimental to the person. For this reason, communication and
coordination of care between behavioral health providers and PCPs
must occur on a regular basis to ensure safety and positive clinical
outcomes for persons receiving care. For T/RBHA enrolled persons
not eligible for Title XIX or Title XXI coverage, coordination and
communication should occur with any known medical care provider.
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4.3.2
References
The following citations can serve as additional resources for this
content area:
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4.3.3
Scope
To whom does this apply?
- All Title
XIX and Title XXI eligible persons; and
- All other
T/RBHA enrolled persons with other health care provider(s).
4.3.4
Objectives
To ensure that timely communication and coordination of
care occurs between the T/RBHAs, subcontracted behavioral health
providers and AHCCCS Health Plan primary care providers (PCPs),
or other health care provider(s), regarding a T/RBHA enrolled person’s
behavioral health and general medical care and treatment.
4.3.5
Did you know?
- Each
AHCCCS Health Plan has a “Behavioral Health Coordinator.”
The Behavioral Health Coordinator can serve as a contact person
and resource for behavioral health providers when problems arise
concerning a person’s medical care or any other health plan
related issue. See
PM
Attachment 4.3.1 for contact information for each
AHCCCS Health Plan.
- When coordinating
care with the person’s PCP, information must be disclosed
in accordance with Section
4.1, Disclosure of Behavioral Health Information.
As a general rule, it is not necessary for behavioral health providers
to obtain a signed authorization form in order to share mental
health related information with the PCP or the person’s
health plan Behavioral Health Coordinator acting on behalf of
the PCP. However, authorization from the person is required when
sharing information regarding Substance Abuse or communicable
diseases, including HIV/AIDS, prior to disclosure.
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4.3.6
Procedures
4.3.6-A.
Suggestions and Guidance for Coordinating Care
The
following procedures will assist behavioral health providers in
coordinating care with AHCCCS Health Plans:
- If the identity
of the person’s primary care provider (PCP) is unknown,
a behavioral health provider can contact the member services department
of the person’s designated health plan to determine the
name of the person’s assigned PCP. See the AHCCCS Contracted
Health Plans,
PM
Attachment 4.3.1 for contact information for each
AHCCCS Health Plan.
- T/RBHA enrolled
persons who have never contacted their PCP prior to entry into
the behavioral health system should be encouraged to seek a baseline
medical evaluation. T/RBHA enrolled persons should also be prompted
to visit their PCP for routine medical examinations annually or
more frequently if necessary.
- Behavioral
health providers may request medical information from the person’s
assigned PCP or the Indian Health Services (IHS) treatment facility
that the individual identifies as their medical home. Examples
include current diagnosis, medications, pertinent laboratory results,
last PCP visit, Early Periodic Screening, Diagnosis and Treatment
screening results and last hospitalization. ADHS/DBHS has developed
a sample request form that may be utilized for this purpose (see
PM Form 4.3.2,
Request for Information from PCP). If the PCP does
not respond to the request, contact the health plan’s Behavioral
Health Coordinator for assistance.
- Behavioral
health providers must address and attempt to resolve coordination
of care issues with AHCCCS Health Plans, PCPs and Indian Health
Services (IHS) medical providers at the lowest possible level.
If problems persist, contact the Gila River RBHA Clinician or
Clinical Manager at the T/RBHA.
4.3.6-B.
Sharing information with the PCP
Behavioral health providers are required to disclose relevant
behavioral health information pertaining to Title XIX and Title
XXI eligible persons to the assigned PCP as needed to support quality
medical management and prevent duplication of services. However,
the current medical practice within Indian Health Services (IHS)
does not include the identification of an individual medical provider.
IHS patients typically identify a treatment facility as their “PCP”.
Additionally, information regarding hospitalizations, laboratory
values, comprehensive pharmacy information, radiology and other
tests, are made available to all medical practitioners within the
IHS treatment system via an electronic database. At a minimum, for
all behavioral health recipients referred by the PCP or who have
been determined to have a serious mental illness, the following
information must be provided to the person’s assigned PCP:
- The person’s
diagnosis; and
- The person’s
current prescribed medications (including strength and dosage).
T/RBHAs and/or
subcontracted providers must provide the required information annually,
and/or when there is significant change in the person’s diagnosis
and/or prescribed medications.
For all Title
XIX/XXI enrolled persons, behavioral health providers are required
to notify, consult with or disclose the following information with
the person’s PCP:
Upon request
by the PCP, information for any enrolled member must be provided
to the PCP consistent with requirements outlined in Section
4.1, Disclosure of Behavioral Health Information.
When contacting
or sending any of the above referenced information to the person’s
PCP, behavioral health providers need to provide the PCP with an
agency contact name and telephone number in the event the PCP needs
further information.
ADHS/DBHS has
developed a sample communications form (PM
Form 4.3.1) for coordinating care with the AHCCCS Health
Plan PCP. The sample form includes the required elements for coordination
purposes with the PCP. Any other forms developed for use in communicating
with the AHCCCS Health Plan PCP must be submitted through the T/RBHA
for approval by the ADHS/DBHS Medical Director’s Office. For
complex problems, direct provider-to-provider contact is recommended
to support written communications.
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4.3.6-C:
Who’s responsible, the Health Plan or the T/RBHA?
Depending on certain factors, an AHCCCS Health Plan or
the T/RBHA may be responsible for responding to and/or providing
care to Title XIX and Title XXI eligible persons. The following
rules apply:
Emergency
Rooms
- When a Title
XIX or Title XXI eligible person presents in an emergency room
setting, the person’s AHCCCS Health Plan is responsible
for all emergency medical services including triage, physician
assessment and diagnostic tests.
- The T/RBHA,
or when applicable, its designated behavioral health provider,
is responsible for psychiatric and/or psychological consultations
in emergency room settings provided to Title XIX and Title XXI
persons enrolled with a T/RBHA. If a Title XIX or Title XXI person
is not enrolled with the T/RBHA, the AHCCCS Health Plan is responsible
for psychiatric and/or psychological evaluations in emergency
room settings.
Emergency
Services and Psychiatric Hospitalizations
- For Title
XIX and Title XXI eligible persons not enrolled with a T/RBHA,
the AHCCCS Health Plan or AHCCCSA, for persons involved with Indian
Health Services (IHS), is responsible for up to 72 hours of inpatient
behavioral health services per emergency episode (not to exceed
12 days per health plan contract year); however, the T/RBHA or
behavioral health provider must respond to referrals for hospitalized
persons as described in Section
3.2, Appointment Standards and Timeliness of Service.
- If a Title
XIX or Title XXI person is assessed by the T/RBHA or subcontracted
provider prior to admission to an inpatient psychiatric setting,
the T/RBHA is responsible for authorization and payment for the
full inpatient stay.
- The T/RBHA
must not contact the AHCCCS Health Plan to request services authorized
by the T/RBHA after the date of enrollment.
Psychiatric
Evaluations
- When a hospitalized
Title XIX or Title XXI eligible person requires a psychiatric
consultation or evaluation prior to the implementation of a medical
procedure or prior to discharge from a medical facility, the AHCCCS
Health Plan is responsible for the provision of this service for
persons not enrolled with a T/RBHA. If the person is enrolled
with a T/RBHA, the T/RBHA is responsible.
Medical
Treatment for Persons in Behavioral Health Treatment Facilities
- When a Title
XIX or Title XXI eligible person is in a Level II or Level III
residential treatment center and requires medical treatment, the
AHCCCS Health Plan is responsible for the provision of covered
medical services.
- If a Title
XIX or Title XXI eligible person is in a Level I psychiatric facility
and requires medical treatment, those services are included in
the per diem rate for the treatment facility. If the person requires
inpatient medical services that are not available at the Level
I psychiatric facility, the person must be discharged from the
psychiatric facility and admitted to a medical facility. The AHCCCS
Health Plan is responsible for medically necessary services received
at the medical facility, even if the person is enrolled with a
T/RBHA.
Transportation
- Emergency
transportation of a Title XIX or Title XXI eligible person to
the emergency room when the person has been directed by the T/RBHA
or provider to present to this setting to resolve a behavioral
health crisis is the responsibility of the T/RBHA. The T/RBHA
or subcontracted provider directing the person to present to the
ER must notify the emergency transportation provider of its fiscal
responsibility for the service.
- Emergency
transportation of a Title XIX or Title XXI eligible person required
to manage an acute medical condition and which includes transportation
to the same or higher level of care for immediate medically necessary
treatment is the responsibility of the person’s AHCCCS Health
Plan.
- Transportation
to an initial behavioral health intake appointment for a non-T/RBHA
enrolled person is the responsibility of the AHCCCS Health Plan.
Transportation to all ongoing behavioral health services is the
responsibility of the T/RBHA.
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4.3.6-D:
PCPs prescribing psychotropic medications
Within their scope of practice and comfort level, an AHCCCS
Health Plan PCP may elect to treat select behavioral health disorders.
The select behavioral health disorders that AHCCCS Health Plan PCPs
can treat are:
- Attention-Deficit/Hyperactivity
Disorder;
- Uncomplicated
depressive disorders; and
- Anxiety
disorders.
The “Rules”
Certain requirements and guiding principles have been established
under the Psychotropic Medication Initiative. The following conditions
apply:
- Title XIX
and Title XXI eligible persons must not receive medications for
psychiatric disorders from the health plan PCP and behavioral
health provider simultaneously. If a person is identified to be
simultaneously receiving medications from the health plan PCP
and behavioral health provider, the behavioral health provider
must immediately contact the PCP to coordinate care and agree
on who will continue to medically manage the person’s behavioral
health condition. Medications prescribed by providers within the
T/RBHA behavioral health system must be filled by T/RBHA contracted
pharmacies under the T/RBHA pharmacy benefit. This is particularly
important when the pharmacy filling the prescription is part of
the contracted pharmacy network for both the prescribing T/RBHA
and the person’s AHCCCS Health Plan. The T/RBHA and contracted
providers must take active steps to ensure that prescriptions
written by providers within the T/RBHA system are not charged
to the person’s AHCCCS Health Plan.
- Title XIX
and Title XXI eligible persons who are being treated by the behavioral
health provider for the above listed disorders and are clinically
stable may be referred to the PCP for ongoing care following:
- Consultation
with the person’s PCP; and
- Acceptance
by the person’s PCP and AHCCCS Health Plan; and
- Approval
by the person.
- If a Title
XIX or Title XXI eligible person is receiving medication management
services through the PCP, other behavioral health services, such
as counseling, can be provided by the behavioral health provider
with the expectation that close coordination of care and communication
between the PCP and behavioral health provider occurs.
Psychiatric
Consultations
There are two (2) types of psychiatric consultations available under
the Psychotropic Medication Initiative:
- General Psychiatric
Consultations; and
- Face-to-Face
Psychiatric Consultations
RBHAs must make
available general and/or one-time face-to-face psychiatric consultations
upon request to AHCCCS Health Plan PCPs. AHCCCS Health Plan PCPs
must be provided current information about how to access RBHA psychiatric
consultation services. RBHAs are obligated to offer psychiatric
consultation services and must provide direct and timely access
to behavioral health medical practitioners (physicians, nurse practitioners
and physician assistants) or other behavioral health practitioners
if requested by the PCP.
General
Psychiatric Consultations
- Behavioral
health medical practitioners must be available to AHCCCS Health
Plan PCPs to answer diagnostic and treatment questions of a general
nature;
- Are not
person specific; and
- Are usually
conducted over the telephone between the PCP and the behavioral
health medical practitioner.
Face-to-Face
Psychiatric Consultations
- Must be
available upon request by the person’s PCP in accordance
with Section 3.2, Appointment Standards and Timeliness of Service;
- Are used
to clarify a person’s diagnosis and/or make recommendations
for treatment with the expectation that the PCP will continue
to manage a person’s medications if appropriate; and
- The PCP must
have seen the person prior to requesting a face-to-face psychiatric
consultation with the behavioral health provider.
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4.3
Coordination of
Care with AHCCCS Health Plans and Primary Care Providers
Last Revised: 07/19/2007
Effective Date: 12/01/2007 |
