Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

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TABLE OF CONTENTS

1.0 
2.0 
3.0
CLINICAL OPERATIONS
3.1 Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance Including Medicare Part D Prescription Drug Coverage and the Limited Income Subsidy Program
3.2
Appointment Standards and Timeliness of Service
3.3
Referral and Intake Process
3.4
3.5
3.6
3.8

3.9

3.10

3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18 Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment
3.19
3.20
3.21
3.22
3.23 Cultural Competence
3.25
3.26 Housing for Individuals determined to have a Serious Mental Illness (SMI)
3.27 Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits
4.0
COMMUNICATION AND CARE COORDINATION
4.1
4.2
4.3
4.4
4.5
5.0
MEMBER RIGHTS AND PROVIDER APPEALS
5.1
5.2
5.3
5.4
5.5
5.6 Provider Claims Disputes
6.0
DATA AND BILLING REQUIREMENTS
6.1
7.0
REPORTING REQUIRMENTS
7.1
7.2
7.3
7.4
7.5 Enrollment, Disenrollment and Other Data Submission
7.6 Duty to Report Abuse, Neglect or Exploitation
7.7 Duty to Warn
7.8 Reporting Discovered Violations of Immigration Status
8.0
PERIODIC AUDITS AND SURVEYS
8.1
8.2
8.3 
8.4
8.5
9.0
TRAINING AND DEVELOPMENT
9.1
9.2
10.0
T/RBHA SPECIFIC REQUIREMENTS
11.0
13.0
FORMS AND ATTACHMENTS
 
Section 3.1 Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance
  PM Form 3.1.1, Tracking of Medicare Part D Enrollment
  PM Form 3.1.2, Tracking of Low Income Subsidy (LIS) Status
  ADHS Policy Form 101.3
  ADHS Policy Form 101.4, Spanish
 
Section 3.3 Referral Process
  PM Form 3.3.1 ADHS/DBHS REFERRAL FOR BEHAVIORAL HEALTH SERVICES
 
Section 3.4 Co-payments
  PM Form 3.4.1 NON-TITLE XIX/XXI CO-PAYMENT ASSESSMENT
  Forma PM 3.4.1 EVALUACION DE PAGO COLATERA/SIN TITULO XIX/XXI
 
Section 3.6 Member Handbooks
  PM Form 3.6.1 MEMBER HANDBOOK RECEIPT
 
Section 3.9 Assessment and Service Planning
  PM Form 3.9.1 ADHS-DBHS BEHAVIORAL HEALTH ASSESSMENT AND SERVICE PLAN CHECKLIST
  PM Form 3.9.2 ADHS-DBHS BEHAVIORAL HEALTH ASSESSMENT: BIRTH – 5 AND SERVICE PLAN CHECKLIST
  PM Attachment 3.9.1, Service Plan Rights Acknowledgement Template
  INSTRUCTION GUIDE FOR THE ASSESSMENT, SERVICE PLAN AND ANNUAL UPDATE
  INSTRUCTION GUIDE FOR THE ASSESSMENT: BIRTH – 5, SERVICE PLAN AND ANNUAL UPDATE
 
Section 3.10 SMI Eligibility Determination
  PM Form 3.10.1 SMI DETERMINIATION
  PM Attachment 3.10.1 SERIOUS MENTAL ILLNESS (SMI) QUALIFYING DIAGNOSIS
  PM Attachment 3.10.2 SUBSTANCE USE/PSYCHIATRIC SYMPTOMATOLOGY TABLE
 
Section 3.11 General and Informed Consent to Treatment
  PM Form 3.11.1
  PM Form 3.11.1 Spanish Version
  PM Form 3.11-GR
  PM Form ADHS MH-103 APPLICATION FOR VOLUNTARY EVALUTION
  Forma PM ADHS MH-103 SOLICITUD DE UNA EVALUACION VOLUNTARIA
 
Section 3.13 Covered Behavioral Health Services
  PM Attachment 3.13.1 COVERED SERVICES MATRIX
 
Section 3.14 Securing Services and Prior Authorization
  PM Attachment 3.14.1 ADMISSION TO PSYCHIATRIC ACUTE HOSPITAL AND SUB-ACUTE FACILITIES AUTHORIZATION CRITERIA
  PM Attachment 3.14.2 CONTINUED PSYCHIATRIC ACUTE HOSPITAL OR SUB-ACUTE FACILITY
AUTHORIZATION CRITERIA
  PM Attachment 3.14.3 ADMISSION TO RESIDENTIAL TREATMENT CENTER AUTHORIZATION CRITERIA
  PM Attachment 3.14.4 ADHS/DBHS CONTINUED RESIDENTIAL TREATMENT CENTER STAY
AUTHORIZATION CRITERIA
  PM Form 3.14.1 CERTIFICATION OF NEED (CON) FOR LEVEL I FACILITIES
  PM Form 3.14.2 RE-CERTIFICATION OF NEED (RON) FOR LEVEL I FACILITIES
  PM Form 3.14.3 TRBHA PRIOR AUTHORIZATION REQUEST FORM
 
Section 3.15 Psychotropic Medications: Prescribing and Monitoring
  PM Form 3.15.1 INFORMED CONSENT FOR PSYCHOTROPIC MEDICATION TREATMENT
  Forma PM 3.15.1 CONSENTIMIENTO INFORMADO PARA TRATAMIENTO CON MIDICAMENTOS PSICOTROPICOS
 
Section 3.16 Medication List
  PM Attachment 3.16.1 PRIOR AUTHORIZATION INSTRUCTIONS FOR MEDICATIONS
 
Section 3.19 Special Populations
  PM Attachment 3.19.1 NOTICE TO INDIVIDUALS RECEIVING SUBSTANCE ABUSE SERVICES
  PM Attachment 3.19.2 ARIZONA PATH PROGRAM-ADMINISTRATORS CONTACT LIST
  Documento Adjunto PM 3.19.1 NOTIFICACION A INDIVIDUOUS QUIENES RECIBEN SERVICIOS PARA EL ABUSO DE ESTUPERFACIENTES
  PM Form 3.19.1 QUARTERLY PATH REPORT
 
Section 3.20 Credentialing and Privileging
  PM Attachment 3.20.1 EXAMPLES OF COLLEGE CLASSES RELATED TO BEHAVIORAL HEALTH
  PM Form 3.20.1 ATTESTATION OF COMPETENCIES FOR CLINICAL LIAISONS PERFORMING INITIAL ASSESSMENTS
  PM Form 3.20.2 BEHAVIORAL HEALTH TECHNICIAN CASE SUPERVISION REPORT
  Section 3.22 Out-of-State Placements for Children and Young Adults
  PM Form 3.22.1 Out-of-State Placement Initial Notice
  PM Form 3.22.2 Out-of-State Placement 90-Day Update
 
Section 3.27
Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits
  PM Attachment 3.27.1, Documents Accepted by AHCCCS To Verify Citizenship and Identity
  PM Attachment 3.27.2, Non-Citizen/Lawful Presence Verification Documents
  PM Attachment 3.27.3, Persons Who Are Exempt From Verification of Citizenship During the Prescreening and Application Process
  PM Attachment 3.27.4, Flowchart for the Citizenship/Lawful Presence Verification Process Through Health-e-Arizona
 
Section 4.2 Behavioral Health Medical Record Standards
  PM Form 4.2.1 CLINICAL RECORD DOCUMENTATION FORM
 
Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs
  PM Attachment 4.3.1 AHCCCS CONTRACTED HEALTH PLANS CONTACT INFORMATION
  DBHS Policy Form 902.1, Communication Document
  PM Form 4.3.2 REQUEST FOR INFORMATION FROM PCP
 
Section 4.4 Coordination of Care with Other Government Entities
  PM Attachment 4.4.1 DCYF CHILD WELFARE TIMEFRAMES
  PM Attachment 4.4.2 ARIZONA FAMILIES F.I.R.S.T. (AFF) PROGRAM MODEL & REFERRAL PROCESS
 
Section 5.1 Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons
  PM Form 5.1.1 NOTICE OF OUR INTENDED ACTION REGARDING TITLE XIX/XXI COVERED SERVICES
  Forma PM 5.1.1 AVISO DE ACCION
  PM Form 5.1.2 NOTICE OF EXTENSION OF TIMEFRAME FOR SERVICE AUTHORIZATION DECISION REGARDING TITLE XIX/XXI BEHAVIORAL HEALTH SERVICES
  Forma PM 5.1.2 AVISO DE EXTENSION DE PLAZO PARA AUTORIZACION DE DECISIÓN PARA SERVICIOS DE SALUD MENTAL TITULO XIX/XXI
 
Section 5.2 Member Complaints
  PM Form 5.2.1 ADHS/DBHS APPEAL OR SMI GRIEVANCE FORM
 
Section 5.3 Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)
  PM Form 5.3.1 ADHS/DBHS APPEAL OR SMI GRIEVANCE FORM
  Forma PM 5.3.1 FORMA DE APELACION ADHS/DBHS O QUEJA SMI
 
Section 5.4 Special Assistance for SMI Members
  PM Form 5.4.1 REQUEST FOR SPECIAL ASSISTANCE
  Forma PM 5.4.1 SOLICITUD DE ASISTENCIA ESPECIAL
 
Section 5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
  PM Attachment 5.5.1 NOTICE OF SMI GRIEVANCE AND APPEAL PROCEDURE
  Documento Adjunto PM 5.5.1 AVISO DE QUEJA Y APELACION FORMAL DE SMI DE ADHS/DBHS
  PM Form 5.5.1 NOTICE OF DECISION AND RIGHT TO APPEAL
  Forma PM 5.5.1 AVISO DE DECISION Y DERECHO DE APELACION
  PM Form ADHS MH-209 NOTICE OF DISCRIMINATION PROHIBITED
  PM Form ADHS MH-211 NOTICE OF LEGAL RIGHTS FOR PERSONS WITH SERIOUS MENTAL ILLNESS
  Forma PM MH DE ADHS-211 AVISO DE LOS DERECHOS LEGALES PARA PERSONAS CON UNA ENFEREDAD MENTAL GRAVE
 
Section 5.6 Provider Claims Disputes
  PM Attachment 5.6.1 PROVIDER CLAIMS DISPUTES CONTACT LIST
  PM Attachment 5.6.2 PROCESS FOR PROVIDER CLAIMS DISPUTES
 
Section 6.1 Submitting Claims and Encounters
  DBHS Policy Attachment 501.1, Billing Instructions Used to Identify Crisis Services
  DBHS Policy Attachment 501.2 Where to Submit Claims and Encounters
 
Section 7.1
Section 7.1 Fraud and Abuse Reporting
  PM Form 7.1.1 SUSPECTED FRAUD OR ABUSE REPORT
 
Section 7.2 Institutions for Mental Disease (IMD) Reporting
  PM Form 7.2-GR TITLE XIX INSTITUTION FOR MENTAL DISEASE ADMISSION/DISCHARGE NOTIFICATION FORM
 
Section 7.3 Seclusion and Restraint Reporting for Level I Facilities
  PM Attachment 7.3.1 SECLUSION AND RESTRAINT MONITORING REQUIREMENTS
  PM Form 7.3.1 SECLUSION AND RESTRAINT REPORTING
  PM Form 7.3-GR GILA RIVER RBHA SECLUSION AND RESTRAINT SUMMARY REPORT
 
Section 7.4 Reporting of Incidents, Accidents and Deaths
  PM Form 7.4.1 INCIDENT/ACCIDENT/DEATH REPORT FORM
 
Section 7.5 Enrollment, Disenrollment, and Other Data Submission
  PM Attachment 7.5.1 TIMEFRAMES FOR DATA COLLECTION AND SUBMISSION
  PM Attachment 7.5.2 834 TRANSACTION DATA REQUIREMENTS
  PM Attachment 7.5.3 SMI AND SED QUALIFYING DIAGNOSES TABLE
  PM Attachment 7.5.4 SUBSTANCE ABUSE DISORDERS QUALIFYING DIAGNOSES TABLE
 
Section 8.5 Medical Care Evaluation Studies
  PM Attachment 8.5.1 INSTRUCTIONS FOR THE COMPLETION OF MEDICAL CARE EVALUATION STUDY FORMS
  PM Form 8.5.1 MCE STUDY REQUEST FOR REGISTRATION AND EVALUATION METHODOLOGY
  PM Form 8.5.2 MEDICAL CARE EVALUATION – PROVIDER AND T/RBHA REVIEW OF FINAL RESULTS
 
Section 9.1 Training Requirements
  PM Form 9.1.1 Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation
  PM Attachment 9.1.1 Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation User’s Guide
 
Section 9.2 Peer Support/Recovery Support Training, Certification and Supervision Requirements
  PM Attachment 9.2.1 Suggested Curriculum Development References
14.0
15.0 ADHS/DBHS Policy and Procedures Manual
Gila River Health Care Corporation address and phone
Enrollment, Disenrollment and Other Data Submissio