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7.5.1
Introduction
The collection and reporting of accurate complete, and timely enrollment,
demographic, clinical and disenrollment data is of vital importance
to the successful operation of the Arizona Department of Health
Services/Division of Behavioral Health Services (ADHS/DBHS) behavioral health service
delivery system. It is necessary for behavioral health providers
to submit specific data on each person who is actively receiving
services from the
behavioral health system. As such, it is important for behavioral
health provider staff (e.g., intake workers, clinicians, data entry
staff) to have a thorough understanding of why it is necessary
to collect the data, how it can be used and how to accurately
label
the data.
Note: This provider manual section describes the overall process, however, it should be noted that Gila River Behavioral Health Services conducts centralized intakes for all Gila River clients. Individuals seeking services from providers should be referred to Gila River Behavioral Health Services for an intake assessment and for an episode of care to be initiated.
This data in
turn is used by ADHS/DBHS to:
- Monitor and
report on outcomes of individuals in an episode of care (e.g., changes in diagnosis
or GAF, employment/educational status, place of residence, substance
use, number of arrests);
- Comply with
federal and state funding and/or grant requirements;
- Assist with
financial-related activities such as budget development, and rate
setting;
- Support
quality management and utilization management activities; and
- Respond
to requests for information.
The intent of
this section is to describe requirements for behavioral health providers
to submit the following data in a timely, complete and accurate
manner:
- Episode of
care transactions; and
- Demographic
and clinical data, including changes in a person’s
behavioral health status.
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7.5.2
References
The following citations can serve as additional resources for this
content area:
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7.5.3
Scope
To whom does this apply?
This applies
to all behavioral health providers who are delivering behavioral
health services to persons who are enrolled in the ADHS/DBHS behavioral
health system. It has particular relevance for those behavioral
health providers that conduct assessments, ongoing service
planning, and annual updates.
As noted above, Gila River Behavioral Health Services conducts all intakes for Gila River clients. Individuals seeking services should be referred to Gila River Behavioral Health Services to begin an episode of care.
7.5.4
Did you know…?
- Arizona Health Care Cost Containment System (AHCCCS) enrolled individuals are considered enrolled with the Tribal/Regional Behavioral Health Authority (T/RBHA) at the onset of their eligibility. They are provided an AHCCCS identification card with the assigned T/RBHA. This assignment is sent daily from ADHS/DBHS to the T/RBHA.
- When the individual contacts a provider for services, the individual should be referred to Gila River Behavioral Health Services to begin an episode of care. The episode of care will remain in effect until the person completes treatment. No separate T/RBHA enrollment is required for AHCCCS enrolled individuals.
- For Non-Title XIX/XXI eligible individuals, a HIPAA 834-enrollment
transaction must be submitted by T/RBHAs to ADHS/DBHS within
14 days of first contact with a behavioral health recipient. Behavioral
health providers may be required to submit 834 transactions to
the T/RBHA within a shorter timeframe (see subsection
7.5.7-A.
for required timeframe).
- Behavioral
health providers are permitted to submit and change single data
fields when necessary, without being required to re-submit every
data field contained in a demographic record transaction.
- Behavioral
health providers delivering services to a Non-Title XIX/XXI
eligible person
are not required to submit fund source changes if the person posts
retroactive Title XIX/XXI eligibility. The ADHS/DBHS system will be
notified by AHCCCS to change the person’s fund source from
Non-Title XIX/XXI eligible to Title XIX/XXI eligible and
requires no action from the behavioral health provider.
- ADHS/DBHS
has developed a flow chart that includes the timeframes for all
data submissions. See
PM
Attachment 7.5.1.
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7.5.5
Definitions
834
Transaction Enrollment/Disenrollment
Annual
Update
Assessment
Behavioral
Health Category Assignment
Change
Client
Information System (CIS)
Closure
Crisis
Episode
Day
Demographics
Edit
Episode of Care
Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
Intake/Enrollment
Outcome Measures
7.5.6
Objectives
To ensure that data elements specified by ADHS/DBHS and
the T/RBHAs are collected and submitted in a timely, complete and
accurate manner for each person in the public behavioral
health system.
7.5.7
Procedures
7.5.7-A.
Enrollment and disenrollment transactions
General requirements
- For a Non-Title XIX/XXI eligible person to be enrolled, behavioral health providers must submit an 834 enrollment transaction to the T/RBHA. All AHCCCS enrolled individuals with a mental health benefit are considered enrolled with the T/RBHA at the time of their AHCCCS eligibility.
- For a Non-Title XIX/XXI eligible person who receives a covered behavioral health service, he/she must be enrolled effective the date of first contact by a behavioral health provider.
- All persons
who are served through the ADHS/DBHS behavioral health system
must have an active episode of care, even if the person only receives a single service
(e.g., crisis intervention, one time face-to-face consultation).
- An episode of care is the start and end of services for a behavioral health need as documented by transmission of a demographic record. For both AHCCCS enrolled and Non-Title XIX/XXI eligible individuals, the individuals must have an open episode of care starting at the first date of service and ending with the last service.
When is
enrollment information collected?
For Non-Title XIX/XXI-eligible individuals, information necessary to complete an 834 transaction is usually
collected during the intake and assessment process (see
Section
3.9, Intake, Assessment and Service Planning).
PM Attachment 7.5.2, 834 Transaction Data Requirements, contains a list of the data elements necessary to create an 834 enrollment transaction.
For AHCCCS enrolled individuals, the 834 information will be provided to the T/RBHA by ADHS/DBHS daily for the providers to access.
What kind
of data is included in an 834?
The data fields that are included in the 834 transmittals are dictated
by HIPAA and consist of:
- Key client
identifiers used for file matching (e.g., person’s name, address, date of birth) used for file matching;
- Basic demographic
information (e.g., gender, marital status); and
- Information
on third party insurance coverage.
For a specific
list of data elements necessary to create an 834 enrollment and disenrollment, see
PM
Attachment 7.5.2.
What happens
if there is not enough information to complete an enrollment?
Behavioral health providers must actively secure any needed information
to complete the enrollment (834 transaction) for a Non-Title
XIX/XXI eligible individual. An 834 transaction
will not be accepted by the T/RBHA if required data elements are
missing. For Title XIX/XXI eligible individuals, the 834
information will be provided to the T/RBHA by ADHS/DBHS.
What are
the timeframes for submitting enrollment and disenrollment data
for a Non-Title XIX/XXI eligible individual?
The following data submittal timeframes apply to the enrollment/disenrollment
transactions:
The 834-enrollment transaction must be submitted by Gila River
Behavioral Health Services within 14 days of the first
contact with a behavioral health recipient;
The 834 disenrollment transaction must be submitted by Gila River
Behavioral Health Services within 14 days of the person
being disenrolled from the system; and any changes to the
enrollment/disenrollment transaction data fields (e.g., change in
address, insurance coverage) must be submitted 55 days from the date
of identifying the need for the change.
What other events require a submittal of an 834 transaction for a Non-Title XIX/XXI eligible individual?
In addition to submitting an 834 transaction at enrollment and disenrollment, an 834 transaction must also be submitted when any of the following elements of the 834 transaction have changed:
- Name,
- Address,
- Date of birth,
- Gender,
- Marital status, or
- Third party insurance information.
Other considerations
for both Non-Title XIX/XXI eligible and AHCCCS enrolled individuals
- For an
AHCCCS enrolled individual, AHCCCS will notify ADHS/DBHS of
changes to the above information. That information will be
provided from ADHS/DBHS to the T/RBHA on a daily file.
- When a person
in an episode of care permanently re-locates from one T/RBHA’s geographic area to another
T/RBHA’s geographic area, an inter-T/RBHA transfer must occur
(see Section 3.17, Transition of Persons). The steps that are
necessary to facilitate an inter-T/RBHA transfer include the following
data submission requirements:
- The home
T/RBHA must submit an 834 plan change transaction on the
date of transfer and end the episode of care; and
- The receiving
T/RBHA must submit an 834 plan change transaction on the date
of accepting the person for services and start an episode of
care.
- AHCCCS will
notify ADHS/DBHS when a T/RBHA
enrolled person is determined eligible for the Arizona Long Term
Care System (ALTCS) Elderly and Physically Disabled (EPD) Program.
This information will be passed to the T/RBHA on a daily file.
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7.5.7-B.
Demographic and clinical data
When is demographic and clinical data collected?
Demographic and clinical data will be collected starting at the
first date of service. For Non-Title XIX/XXI eligible individuals,
an 834 must be completed. For both AHCCCS enrolled and Non-Title
XIX/XXI eligible individuals, a demographic record must be collected
within 45 days of the first service and submitted to ADHS/DBHS
within 55 days . Additional clinical data may
be collected at subsequent assessment and service planning meetings
with the person (e.g., education, vocation) as well as
during periodic and annual updates. Demographic and clinical data
recorded in the person's behavioral health medical record must match
the demographic file on record with ADHS/DBHS.
What are
the specific data elements?
The
ADHS/DBHS Demographic Data Set User Guide describes the
data elements that comprise the demographic data set and timeframe
requirements for submitting the demographic data set. T/RBHAs must
ensure that providers collect required demographic data set elements
in accordance with the
ADHS/DBHS Demographic Data Set User Guide.
When ADHS/DBHS issues updates to the demographic data set, T/RBHAs
are responsible for communicating changes to their providers.
What are
the timeframes for submitting demographic and clinical data?
The following timeframes apply to demographic and clinical data
submissions (see the
ADHS/DBHS Demographic Data Set User Guide):
- All
required demographic data submitted by Gila River Behavioral
Health Services within 55 days of the initial intake for all enrolled
persons.
- Outcome measures, for children birth through age 17, submitted by Gila River Behavioral Health Services within the 6 month anniversary date of the last demographic submission (See Section 3.9, Intake, Assessment and Service Planning). For outcome measures submission dates that do not coincide with the annual update, the reason for submission will be indicated as a “change” (see specific instructions in the
ADHS/DBHS Demographic Data Set User Guide).
- All required demographic data submitted by Gila River Behavioral Health Services on the annual update (see
Section 3.9, Intake, Assessment and Service Planning).
- All required demographic data submitted by Gila River Behavioral Health Services within 55 days of a recorded change in the person’s demographic data record. Behavioral health providers must ensure that the person’s behavioral health medical record matches the demographic data set on file with ADHS/DBHS.
- All
required data elements submitted by Gila River Behavioral Health
services within 14 days of the end of the episode of care. The required data elements
include the reason for the person’s disenrollment. See the
ADHS/DBHS Demographic Data Set User Guide to determine the specific data elements that must accompany a demographic disenrollment transaction.
Determining
a behavioral health recipient’s behavioral health category
assignment
Behavioral health providers must designate a person’s behavioral
health category assignment during the assessment process
as well as at any other times that necessitate changes to the person’s
assignment (e.g., transition to adulthood). Behavioral health categories
include:
Behavioral health
providers must initially assign and update, as necessary, behavioral
health category assignments as follows (see the
ADHS/DBHS Demographic Data Set User Guide for more detailed instructions on assignment of behavioral health categories):
- For a child
who is non-SED, enter “C”;
- For a
child who is SED, enter "Z";
- For a person
determined to have a Serious Mental Illness in accordance with
Section 3.10, SMI Eligibility Determination, enter “S”,
then enter "a" or "b";
- For an adult
non-SMI person with a general mental health need (who does not
have a substance abuse problem) enter “M”; and
- For an adult
non-SMI person with a reported substance abuse problem enter “G”.
How can
demographic and clinical data be used?
Behavioral health providers are encouraged to utilize demographic
and clinical data to improve operational efficiency and gain information
about the persons who receive behavioral health services. Behavioral
health providers may consider:
- Utilizing
and integrating collected demographic data into the person’s
assessments;
- Monitoring
the nature of the provider’s behavioral health recipient
population; and
- Evaluating
the effectiveness of the provider’s behavioral health services
towards improving the clinical outcomes of persons enrolled in
the ADHS/DBHS system.
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7.5
Enrollment, Disenrollment and Other Data Submission
Last Revised: 12/22/2010
Effective Date: 02/01/2011
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