Gila River Regional Behavioral Health Authority Provider Manual

PROVIDER MANUAL

Arizona Department of Health Services

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

NOTE: Viewing the Provider Manual forms and attachments requires Adobe Acrobat Reader.

(Download FREE Adobe Acrobat Reader now)

TABLE OF CONTENTS

1.0		SCOPE
2.0		INTRODUCTION
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		Co-payments
3.5		Third Party Liability and Coordination of Benefits
3.6		Member Handbooks
3.8		Outreach, Engagement, Re-engagement, Closure, and Re-enrollment
3.9		Assessment and Service Planning
3.10		SMI Eligibility Determination
3.11		General and Informed Consent to Treatment
3.12		Advance Directives
3.13		Covered Behavorial Health Services
3.14		Securing Services and Prior Authorization
3.15		Psychotropic Medications: Prescribing and Monitoring
3.16		Medication List
3.17		Transition of Persons
3.18		Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment
3.19		Special Populations
3.20		Credentialing and Recredentialing
3.21		Service Prioritization for Non-Title XIX/XXI Funding
3.22		Out-of-State Placements for Children and Young Adults
3.23		Cultural Competence
3.25		Crisis Intervention Services
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		Disclosure of Behavioral Health Information
4.2		Behavioral Health Medical Record Standards
4.3		Coordination of Care with AHCCCS Health Plans, Primary Care Provider and Medicare Providers
4.4		Coordination of Care with Other Government Entities
4.5		Partnerships with Families and Family-Run Organizations in the Children’s Behavioral Health Systems
5.0		MEMBER RIGHTS AND PROVIDER APPEALS
5.1		Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons
5.2		Member Complaints
5.3		Grievance and Requests for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)
5.4		Special Assistance for Persons Determined to have a Serious Mental Illness
5.5		Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
5.6		Provider Claims Disputes
6.0		DATA AND BILLING REQUIREMENTS
6.1		Submitting Tribal Fee for Service Claims to AHCCCS
7.0		REPORTING REQUIRMENTS
7.1		Fraud and Program Abuse Reporting
7.2		Medical Institution Reporting for Medicare Part D
7.3		Seclusion and Restraint Reporting
7.4		Reporting of Incidents, Accidents and Deaths
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		Encounter Validation Studies
8.2		Independent Case Review
8.3		Behavioral Health Recipient Satisfaction Survey
8.4		Performance Improvement Projects
8.5		Medical Care Evaluation Studies
9.0		TRAINING AND DEVELOPMENT
9.1		Training Requirements
9.2		Peer Support/Recovery Support Training, Certification and Supervision Requirements
10.0		T/RBHA SPECIFIC REQUIREMENTS
11.0		DEFINITIONS
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 3.6 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
		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 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
		PM Attachment 6.0.1 Where Do I Submit My Claim?
		PM Attachment 6.0.2 Billing Instructions Used to Identify Crisis Services
	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		PROVIDER MANUAL INDEX
15.0		ADHS/DBHS Policy and Procedures Manual

Gila River Health Care Corporation address and phone

Enrollment, Disenrollment and Other Data Submissio