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 Process
3.4
3.5
3.6
3.7
3.8

3.9

3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.19
3.20
3.21
3.22
3.23 Cultural Competence
4.0
COMMUNICATION AND CARE COORDINATION
4.1
4.2
4.3
4.4
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
8.0
PERIODIC AUDITS AND SURVEYS
8.2
8.3 
8.4
8.5
9.0
TRAINING AND DEVELOPMENT
9.1
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 Attachment 3.1.1 AHCCCS TITLE XIX/XXI BEHAVIORAL HEALTH ELIGIBILITY KEY CODE INDEX
  PM Attachment 3.1.2 AHCCCS RATE CODE DESCRIPTIONS
  PM Attachment 3.1.3 AHCCCS RATE CODES
  PM Form ADHS AE-01 AHCCCS TITLE XIX/XXI ELIGIBILITY SCREENING
  PM Form ADHS AE-08 DECLINE TO PARTICIPATE IN THE SCREENING AND/OR REFERRAL PROCESS FOR AHCCCS (TITLE XIX/XXI) HEALTH INSURANCE
  Forma PM ADHS AE-08 NEGACION A PARICIPAR EN LA EVALUACION Y/O EN EL PROCESO DE REMISION AL SEGURO DE SALUD DE AHCCCS
 
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 3.9 Intake, 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
  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 SERIOUS MENTAL ILLNESS (SMI) QUALIFYING DIAGNOSIS
  PM Form 3.10.2 SUBSTANCE USE/PSYCHIATRIC SYMPTOMATOLOGY TABLE
  PM Form 3.10.3 SMI DETERMINATION
 
Section 3.11 General and Informed Consent to Treatment
  PM Form 3.11-GR
  PM Form ADHS MH-103 APPLICATION FOR VOLUNTARY EVALUTION
  Forma PM ADHS MH-103 SOICIDTUD 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 3.19 Special Populations
  PM Attachment 3.19.1 NOTICE TO INDIVIDUALS RECEIVING SUBSTANCE ABUSE SERVICES
  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 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
  PM Form 4.3.1 PCP 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 ACYF CHILD WELFARE TIMEFRAMES
 
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 PROVIDED CLAIMS DISPUTES CONTACT LIST
  PM Attachment 5.6.2 PROCESS FOR PROVIDER CLAIMS DISPUTES
 
Section 6.1 Submitting Claims and Encounters
  PM Form 6.1.1 CMS 1500 FORM
  PM Form 6.1.2 UB 92 CLAIM FORM
 
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 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 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 MEDICAL CARE EVALUATION (MCE) STUDY REQUEST FOR REGISTRATION
  PM Form 8.5.2 SUMMARY OF MEDICAL CARE EVALUATION METHODOLOGY
  PM Form 8.5-GR GILA RIVER RBHA MEDICAL CARE EVALUATION (MCE) FINAL REPORT
 
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
14.0
15.0 ADHS/DBHS Policy and Procedures Manual
Gila River Health Care Corporation address and phone