Skip to Main Content

Quality Management Requirements

An advance directive is a written set of instructions developed by an adult member in the event the member becomes incapable of making decisions regarding their health care. An advance directive instructs others regarding the member’s wishes, if they become incapacitated and can include the appointment of a friend or relative to make health care decisions for the member. An adult member prepares an advance directive when competent and capable of making decisions, and the directive is followed when the member is incapable of making treatment decisions. This section outlines the requirements of providers with regard to advance directives (see 42 CFR 489.102).

10.1.1 Health Care Power of Attorney

A health care power of attorney gives an adult member, not under legal guardianship, the right to designate another adult person to make health care treatment decisions on their behalf. The designee may make health care decisions on behalf of the adult member if/when they are found incapable of making these types of health care decisions. However, the designee must not be a provider directly involved with the health treatment of the adult member at the time the health care power of attorney is executed.

See A.R.S. § 36-3281 for additional information regarding a mental health power of attorney and a member who is “found incapable” of making their own health care decisions.

10.1.2 Power and Duties of Designees

The designee:

  • May act in this capacity until their authority is revoked by the adult member, a legal guardian or by court order;
  • Has the same right as the adult member to receive information and to review the adult member’s medical records regarding proposed health treatment and to receive, review and consent to the disclosure of medical records relating to the adult member’s treatment;
  • Must act consistently with the wishes of the adult member or legal guardian as expressed in the mental health care power of attorney or health care power of attorney. However, if the adult member’s wishes are not expressed in a mental health care power of attorney or health care power of attorney and are not otherwise known by the designee, the designee must act in good faith and consent to treatment that they believe to be in the adult member’s best interest; and
  • May consent to admitting the adult member to an Inpatient Facility licensed by the Arizona Department of Health Services if this authority is expressly stated in the mental health care power of attorney or health care power of attorney.

See A.R.S. § 36-3283 for a complete list of the powers and duties of an agent designated under a mental health care power of attorney.

10.1.3 Information Regarding Advance Directives

At the time of enrollment, all adult members, and when the member is incapacitated or unable to receive information, the member’s family or surrogate as defined in A.R.S. 36-3231, must receive the following information regarding advance directives (see 42 CFR § 422.128 (PDF) and AHCCCS AMPM Policy 640 Advance Directives:

  • The member’s rights, in writing, regarding advance directives under Arizona State law;
  • The organization’s policies respecting the implementation of  those rights, including a statement of any limitations regarding the implementation of advance directives as a matter of conscience;
  • A description of the applicable state law and information regarding the implementation of these rights;
  • The member’s right to file grievances directly with AHCCCS and ADHS Division of Licensing Services; and
  • Written policies including a clear and precise statement of limitations if the provider cannot implement an advance directive as a matter of conscience. This statement, at a minimum, should:
    • Clarify institution-wide conscientious objections and those of individual physicians;
    • Identify state legal authority permitting such objections; and
    • Describe the range of medical conditions or procedures affected by the conscience objection.
  • Changes to State law as soon as possible, but no later than 90 days after the effective date ofhe change [42CFR 438.6(i) (4)].

Written information regarding advance directives shall be provided to members at the time of enrollment with the member handbook.  Refer to The Health Plan Member Handbook and AHCCCS ACOM Policy 404 (Member Information) for member information and AHCCCS ACOM Policy 406 (Member Handbook and Provider Directory) for member handbook requirements.

If an adult member is incapacitated at the time of enrollment, providers may give advance directive information to the member’s family or surrogate in accordance with state law. Providers must also follow up when the member is no longer incapacitated and verify that the information is given to the member directly.

10.1.4 Assistance with Developing and Executing an Advance Directive

Providers must assist adult members or their legal guardians who are interested in developing and executing an advance directive. Providers must maintain written policies that address the rights of adult members to make decisions about medical care, including the right to accept or refuse medical care and the right to execute an advance directive. Members must be provided information about formulating advance directives (see AHCCCS AMPM, Policy 640 Advanced Directives).

For members in an Alternative Home and Community Based setting or a behavioral health residential setting that have completed an advance directive, the document must be kept confidential but be readily available. For example: in a sealed envelope attached to the refrigerator. Staff must have immediate access to executed Advance Directive documents to provide to first responder requests.

Providers shall reference the AHCCCS AMPM Policy 640 (Advance Directives for additional information related to the requirements for providers and what must be disseminated to members upon enrollment and/or as needed.

Additional information regarding advance directives can be obtained by calling The Health Plan Customer Service at 1-866-796-0542.

10.1.5 Other Requirements Regarding Advance Directives

Providers must: (see AHCCCS AMPM, Policy 640)

  • Document in the adult member’s medical record whether or not the adult member was provided the information and whether an advance directive was executed;
  • Not condition provision of care or discriminate against an adult member because of their decision to execute or not execute an advance directive;
  • Provide a copy of a member’s executed advanced directive or documentation of refusal, to the acute care primary care provider (PCP) for inclusion in the member’s medical record; and
  • Provide education to staff on issues concerning advance directives including notification of direct care providers of services, such as home health care, hospice and personal care, of any advance directives executed by member’s to whom they are assigned to provide services.

The provider is not relieved of its obligation to provide the above information to the member once they are no longer incapacitated or unable to receive such information. Follow-up procedures shall be in place to provide the information to the member directly at the appropriate time.

The above information shall also be provided to a member upon each admission to a hospital or nursing facility and each time the individual comes under the care of a home health agency, hospice or personal care provider. (42 U.S.C. § 1396a (w) (2))

10.1.6. Advance Care Planning and End of Life Care Concept

End of Life (EOL) care is is member-centric care that includes Advance Care Planning, and the delivery of appropriate health care services and practical supports. The goals of EOL care focuses on providing treatment, comfort, and quality of life for the duration of the member’s life.

Advance care planning is in relation to the End of Life (EOL) care concept that is an ongoing and in person discussion between a qualified health care professional and the member to (see AHCCCS AMPM Policy 310-HH):

  • Educate the member, legal guardian or designated representatives about the member’s illness and the health care options that are readily available;
  • Develop a written plan of care that identifies the member’s choices for treatment; and
  • Share the member’s wishes with friends, family and providers.

Advance care planning often results in the development of an executed Advance Directive for the member (see AHCCCS AMPM Policy 640).

Advance care planning is initiated by the member’s qualified health care professional (MD, DO, PA, or NP) for any member that is currently or expected to experience declining health or is diagnosed with a chronic, complex or terminal illness.  It is meant to be an ongoing process for the duration of the member’s life.  Providers must perform the following requirements as part of the EOL care concept when providing services to qualifying members:

  • Conduct an in person discussion with the member, legal guardian or designated representative to develop advance care planning;
  • Educate the member, legal guardian or designated representative about the member’s illness and health care options that are available to assist them to make educated decisions;
  • Identify the member’s healthcare, psychological, social and spiritual needs;
  • Develop a member driven care plan that identifies the member’s life goals and choices for care and treatment;
  • Share the member’s wishes with family, friends and providers;
  • Complete an executed Advance Directive;
  • Refer to community resources based on the member’s needs such as pastoral/counseling services and legal services; and
  • Assist the member, legal guardian or designated representative in identifying practical supports to meet the member’s needs.

Practical supports are non-billable services provided by a family member, friend or volunteer to assist or perform functions such as housekeeping, personal care, food preparation, shopping, pet care and non-medical comfort measures.

The Health Plan provides care/case management to qualifying members and coordinates with and supports the member’s provider in meeting the member’s needs.  In addition, the care/case manager assists the member/guardian/designated representative in ensuring practical supports and community referrals are maintained or revised to meet the member’s current needs.

The purpose of this section is to ensure that providers maintain medical records that document medical needs, changes and the delivery of medically necessary services. Medical records must be complete accurate, accessible and permit systematic retrieval of information while maintaining confidentiality. Documentation in the medical record facilitates diagnosis and treatment, coordination of care, supports billing reimbursement information, provides evidence of compliance during periodic medical record reviews and can protect practitioners against potential litigation.

The medical record contains clinical information pertaining to a member’s physical and behavioral health. Maintaining current, accurate, well organized and comprehensive medical records assists providers in successfully treating and supporting member care. A member may have more than one medical record kept by various health care providers that have rendered services to the member.

Providers must maintain legible, signed and dated medical records in paper or electronic format that are written in a detailed and comprehensive manner; conform to good professional practices; permit effective professional review and audit processes; and facilitate an adequate system for follow up treatment. Medical records must contain documentation of referrals to other providers, coordination of care and transfer of care to other providers.

10.2.1 Adequacy and Availability of Documentation

All providers must maintain and store records and data that document and support the services provided to members and the associated encounters/billing for those services. In addition to any records required to comply with providers’ contracts with The Health Plan, there must be adequate documentation to support that all billings or reimbursements are accurate, justified and appropriate.

All providers must prepare, maintain and make available to The Health Plan or AHCCCS, adequate documentation related to services provided and the associated encounters/billings.

Adequate documentation is electronic records and “hard-copy” documentation that can be readily discerned and verified with reasonable certainty. Adequate documentation must establish medical necessity and support all medically necessary services rendered and the amount of reimbursement received (encounter value/billed amount) by a provider; this includes all related clinical, financial, operational and business supporting documentation and electronic records. It also includes clinical records that support and verify that the member’s assessment, diagnosis and Individual Service Plan (ISP) are accurate and appropriate and that all services (including those not directly related to clinical care) are supported by the assessment, diagnosis and ISP.

For monitoring, reviewing and auditing purposes, all documentation and electronic records must be made available at the same site at which the service is rendered. If requested documents and electronic records are not available for review at the time requested, they are considered missing. All missing records are considered inadequate. If documentation is not available due to off-site storage, the provider must submit their applicable policy for off-site storage, demonstrate where the requested documentation is stored and arrange to supply the documentation at the site within twenty-four (24) hours of the original request.

A provider’s failure to prepare, retain and provide to The Health Plan or AHCCCS adequate documentation and electronic records for services encountered or billed, may result in the recovery and/or voiding (not to be resubmitted) of the associated encounter values or payments for those services not adequately documented and/or result in financial sanctions to the provider and The Health Plan.

Inadequate documentation may be determined to be evidence of suspected fraud or program abuse that may result in notification or reporting to the appropriate law enforcement or oversight agency. These requirements continue to be applicable in the event the provider discontinues as an active participating and/or provider as the result of a change of ownership or any other circumstance.

10.2.2 Paper or Electronic Format

Records may be documented in paper or electronic format. A treating provider must sign and date their progress notes after each appointment and/or procedure. A Health Professional must include licensure credentials as part of the signature. Paper medical records and documentation must include:

  • Date and time;
  • Signature and credentials;
  • Legible text written in blue or black ink or typewritten;
  • Corrections with a line drawn through the incorrect information, a notation that the incorrect information was an error, the date when the correction was made and the initials of the person altering the record. Correction fluid or tape is not allowed; and
  • If a rubber-stamp signature is used to authenticate the document or entry, the individual whose signature the stamp represents is accountable for the use of the stamp.

A progress note is documented on the date that an event occurs. Any additional information added to the progress note is identified as a late entry and dated appropriately.

Electronic medical records and documentation must require that:

  • Safeguards are in use to prevent unauthorized access;
  • The date and time of an entry in a medical record is recorded as noted by the computer’s internal clock;
  • The record is recorded only by personnel authorized to make entries using  The Health Plan or its providers’ established policies and procedures;
  • The record indicates the identity of the person making an entry including credentials; and
  • Electronic signatures used to authenticate a document are properly safeguarded and the individual whose signature is represented is accountable for the use of the electronic signature.

Electronic medical records and systems must also:

  • Ensure that the information is not altered inadvertently;
  • Track when, and by whom, revisions to information are made; and
  • Maintain a backup system including initial and revised information.

Providers must meet all federal electronic health record requirements. The federal government may impose penalties on the provider of service in the form of rate reductions for non-compliance.

10.2.3 Comprehensive Clinical Record

The provider of care must verify the development and maintenance of a comprehensive clinical record for each member. The comprehensive clinical record, whether electronic or hard copy, may contain information contributed by several service providers involved with the care and treatment of a member. This section describes categories of information to be included in a member’s comprehensive clinical record: (a) the minimum information; (b) physical health record; (c) the behavioral health record; and (d) information from Community Service Agencies, Home Care Training for the Home Care Client (HCTC) providers and Habilitation providers.

10.2.3.1 Minimum Information

The comprehensive clinical record must include the following to the fullest extent possible:

  • Member identification information on each page of the record (i.e., member’s name and AHCCCS  identification number);
  • Documentation of identifying member information including a member’s name, address, telephone number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin and, if applicable, guardian or authorized representative;
  • Initial history for the member that includes family medical/behavioral health history, social history and laboratory screenings (the initial history of a member under age 21 should also include prenatal care and birth history of the member’s mother while pregnant with the member);
  • Past medical/behavioral health history for all members that includes disabilities and any previous illnesses or injuries, smoking, alcohol/substance abuse, allergies and adverse reactions to medications, hospitalizations, surgeries and emergent/urgent care received;
  • Current presenting concerns;
  • Documentation of review of the Controlled Substances Prescription Monitoring Program (CSPMP) data base prior to prescribing a controlled substance or another medication that is known to adversely interact with controlled substances;
  • Documentation of any review of behavioral health record information by any person or entity (other than members of the clinical team) that includes the name and credentials of the person reviewing the record, the date of the review and the purpose of the review; and
  • Identification of other Stakeholder involvement (DES/DDD, Juvenile Probation Officer/ Department of Corrections(DOC), Department of Child Safety(DCS), DES Adult Protective Services (APS), etc.).

10.2.3.2 Physical Health Record

In addition to the minimum information requirements above, the comprehensive clinical record must include the following physical health information:

  • Initial history for the member as defined in section 10.2.3.1;
  • Past medical history for the member as defined in section 10.2.3.1;
  • Immunization records (required for children; recommended for adult members if available);
  • Dental history, if available, and current dental needs and/or services;
  • Current problem list;
  • Current medications;
  • Current and complete Early and Periodic Screening, Diagnostic and Treatment (EPSDT) forms (required for all members age 0 through 20 years);
  • AHCCCS approved developmental screening tools for children ages 9, 18 and 24 months;
  • Documentation in the comprehensive medical record must be initialed and dated by The Health Plan-contracted PCP, to signify review of:
    • Diagnostic information including:
      • Laboratory tests and screenings;
      • Radiology reports;
      • Physical examination notes;
      • Behavioral health information received from the behavioral health provider; and
      • Other pertinent data.
    • Reports from referrals, consultations and specialists;
    • Emergency and urgent care reports;
    • Hospital discharge summaries;
    • Behavioral health referrals and services provided, if applicable, including notification of behavioral health providers, if known, when a member’s health status changes or new medications are prescribed;
    • Behavioral health history and behavioral health information received from a Regional Behavioral Health Authority/Managed Care Organization or a Health Plan behavioral health provider who is also treating the member.
  • Documentation as to whether or not an adult member has completed advance directives and location of the document;
  • Documentation that the PCP responds to behavioral health provider information requests within 10 business days of receiving the request. The response should include all pertinent information, including, but not limited to, current diagnoses, medications, laboratory results, last provider visit, and recent hospitalizations;
  • Documentation related to requests for release of information and subsequent releases, including retaining consent and authorization for medical records as prescribed in A.R.S. § 12-2297. HIPAA related documents must be retained for a period of six years per 45 CFR 164.530(j)(2);
  • Documentation that reflects that diagnostic, treatment and disposition information related to a specific member was transmitted to other providers, including behavioral health providers, as appropriate to promote continuity of care and quality management of the member’s health care;
  • Obstetric providers complete a standardized, evidence-based risk assessment tool for obstetrics members (i.e. Mutual Insurance Company of Arizona [MICA] Obstetric Risk Assessment Tool or American College of Obstetricians and Gynecologists [ACOG]). Also, lab screenings for members requiring obstetric care must conform to ACOG guidelines;
  • Contact information for the member’s assigned Behavioral Health Home if applicable;
  • Ensure each organizational provider of services (e.g. hospitals, nursing facilities, rehabilitation clinics, transportation) maintains a record of the services provided to members including:
    • Physician or providers orders for the service;
    • Applicable diagnostic or evaluation documentation;
    • A plan of treatment;
    • Periodic summary of the member’s progress towards treatment goals;
    • The date and description of services provided;
    • Signature/initials of the provider for each service.
  • Behavioral health information when received from the behavioral health provider about an assigned member even if the provider has not yet seen the assigned member. In lieu of actually establishing a medical record, such information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established;
  • Consideration for professional and community standards and recognized and accepted evidence-based practice guidelines; and
  • Require documentation in the member’s medical record showing supervision by a licensed professional, who is authorized by the licensing authority to provide supervision, whenever health care assistants or para professionals provide services.

10.2.3.3 Behavioral Health Record

Any information maintained in a behavioral health provider’s record must also be maintained in the comprehensive clinical record. For General Mental Health/ Substance Abuse (GMH/SA) and Integrated Health where the provision of behavioral health services is separate from the provision of physical health services, in addition to the minimum information listed above, the following information must be maintained and forwarded for inclusion in the comprehensive clinical record:

Intake Paperwork documentation that includes:

  • For members receiving substance abuse treatment services under the Substance Abuse Block Grant (SABG), documentation that notice was provided regarding the member’s right to receive services from a provider to whose religious character the member does not object (See Section 12.10 - Special Populations and AMPM Policy 320-T, Exhibit 320-9 for notice requirements);
  • Receipt of the Member Handbook;
  • Receipt of the Notice of Privacy Practice; and
  • Contact information for the member’s primary care provider (PCP), if applicable.

Assessment documentation that includes:

  • Documentation of all information collected in the behavioral health assessment, any applicable addenda and required member information (see Section 12.3 – Referral and Intake Process, Section 12.5 - Assessment and Service Planning, AHCCCS AMPM Policy 580, AHCCCS AMPM Policy 320-O, and AHCCCS Technical Interface Guidelines)
  • Documentation of all information collected in the annual update to the behavioral health assessment including any applicable addenda and updated member information;
  • Diagnostic information including psychiatric, psychological and medical evaluations;
  • Copy of AHCCCS AMPM Policy 320-R, Attachment A Notification of Persons in Need of Special Assistance (see Section 12.11 – Special Assistance for Persons Determined to have a Serious Mental Illness), as applicable;
  • An English version of the assessment and/or service plan if the documents are completed in any language other than English; and
  • For members receiving services via telemedicine, copies of electronically recorded information of direct, consultative or collateral clinical interviews.

Treatment and Service Plan documentation that includes:

  • The member’s treatment and service plan (see Section 12.5 - Assessment and Service Planning and AHCCCS AMPM Policy 320-O);
  • Child and Family Team (CFT) documentation;
  • Adult Recovery Team (ART) documentation; and
  • Progress reports or service plans from all other additional service providers

Progress Note documentation that includes:

  • Documentation of the type of services provided;
  • The diagnosis, including an indicator that clearly identifies whether the progress note is for a new diagnosis or the continuation of a previous diagnosis. After a primary diagnosis is identified, the member may be determined to have co-occurring diagnoses. The service providing clinician will place the diagnosis code in the progress note to indicate which diagnosis is being addressed during the provider session. The addition of the progress note diagnosis code (accurate to all digits of the specific ICD-10/DSM-V code that applies) should be included;
  • The date the service was delivered;
  • The date and time the progress note was signed;
  • The signature and credentials of the staff member that provided the service;
  • Duration of the service (time increments) including the code used for billing the service;
  • A description of what occurred during the provision of the service related to the member’s treatment plan;
  • In the event that more than one provider simultaneously provides the same service to a member, documentation of the need for the involvement of multiple providers including the name and roles of each provider involved in the delivery of services;
  • The member’s response to service; and
  • For members receiving services via telemedicine, electronically recorded information of direct, consultative or collateral clinical interviews.

Medical Services Documentation:

  • Physician or providers order for the service;
  • Applicable diagnostic or evaluation documents;
  • A plan of treatment;
  • Periodic summary of the member’s progress towards treatment goals;
  • The date and description of the services provided;
  • Signature and credentials of the provider for each service; and
  • Medication record, when applicable.

Paper or electronic correspondence that includes:

  • Documentation of the provision of diagnostic, treatment and disposition information to the PCP and other providers to promote continuity of care and quality management for the member; and
  • Documentation of any requests for and forwarding of behavioral health record information.

Financial documentation for Non-Title XIX/XXI members receiving behavioral health services that includes:

  • Documentation of the results of a completed Title XIX/XXI screening as required in Section 12.1 – Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Low Income Subsidy Program; and
  • Information regarding establishment of any copayments assessed, if applicable (see Section 7.22- Copayments).

Legal documentation that includes:

  • Documentation related to requests for release of information and subsequent releases;
  • Copies of any advance directives, health care power of attorney or mental health care power of attorney as defined in Section 10.1 - Advance Directives, if applicable including:
    • Documentation that the adult member was provided the information on advance directives and whether an advance directive was executed;
    • Documentation of authorization of any health care power of attorney that appoints a designated person to make health care decisions (not including mental health) on behalf of the member if they are found to be incapable of making these decisions; and
    • Documentation of authorization of any mental health care power of attorney that appoints a designated person to make behavioral health care decisions on behalf of the member if they are found to be incapable of making these decisions.
  • Documentation of general and informed consent to treatment pursuant to Section 12.7 – General and Informed Consent to Treatment and Section 12.8 – Psychotropic Medications: Prescribing and Monitoring;
  • Authorization to disclose information pursuant to Section 9.6 - Confidentiality; and
  • Any extension granted for the processing of an appeal must be documented in the case file, including the Notice regarding the extension sent to the member and their legal guardian or authorized representative if applicable (see Section 8.4 - Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons).

10.2.3.4 Requirements for Community Service Agencies (CSA), Home Care Training to Home Care Client (HCTC) Providers and Habilitation Providers

CSAs, HCTC Provider and Habilitation Provider clinical records must conform to the following standards:

  • Each record entry must be:
    • Dated and signed with credentials noted;
    • Legible text, written in blue or black ink or typewritten; and
    • Factual and correct.
  • If required records are kept in more than one location, the agency/provider shall maintain a list indicating the location of the records.
  • CSAs, HCTC Providers and Habilitation Providers must maintain a record of the services delivered to each behavioral health member. The minimum written requirement for each behavioral health member’s record must include:
    • The service provided and the time increment;
    • Signature and the date the service was provided;
    • The name, title and credentials of the person providing the service;
    • The member’s AHCCCS identification number;
    • The Health Plan ensures that services provided by the agency/provider are reflected in the member’s behavioral health service plan. CSAs, HCTC Providers and Habilitation Providers must keep a copy of each member’s behavioral health 
    • service plan in the member’s record; and
    • Daily documentation of the service(s) provided and monthly summary of progress toward treatment goals.
  • Every thirty (30) days, a summary of the information required in this section must be transmitted from the CSA, HCTC Provider or Habilitation Provider to the member’s clinical team for inclusion in the comprehensive clinical record.

10.2.4 Transportation Service Documentation

For providers that supply transportation services for members using provider employees (i.e. facility vans, drivers, etc.) and providers that use subcontracted transportation services, for non-emergency transport of members, that are not direct employees of the provider (i.e. cab companies, shuttle services, etc.) documentation for the member record must include a summary log of the transportation event received from the transportation provider that includes all elements listed as follows:

  • Complete service provider’s name and address;
  • Signature and credentials of the driver who provided the service;
  • Vehicle identification (car, van, wheelchair van, etc.);
  • Member’s Arizona Health Cost Containment System (AHCCCS) identification number;
  • Complete date of service, including month, day and year;
  • Complete address of pick up site;
  • Complete address of drop off destination;
  • Odometer reading at pick up;
  • Odometer reading at drop off;
  • Type of trip – round trip or one way;
  • Escort (if any) must be identified by name and relationship to the member being transported; and
  • Signature of the member, parent and/or guardian/caregiver, verifying services were rendered. If the member refuses to sign the trip validation form, then the driver should document their refusal to sign and this documentation must be placed into the comprehensive medical record.
  • It is the provider's responsibility to maintain documentation that supports each transport provided. Transportation providers put themselves at risk of recoupment of payment if the required documentation is not maintained or covered services cannot be verified.

10.2.5 PCP Medication Management and Coordination of Care with Behavioral Health Providers

 The Health Plan Primary Care Providers must maintain a medical record that incorporates behavioral health information when received from a behavioral health provider about an assigned member even if the provider has not yet seen the assigned member. In lieu of actually establishing a medical record, such information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established.

In addition to treating physical health conditions, PCPs may treat behavioral health conditions within their scope of practice.  Such treatment shall include but not be limited to substance use disorders, anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD).  For purposes of medication management, it is not required that the PCP be the member’s assigned PCP. PCPs who treat members with these behavioral health conditions may provide medication management services including prescriptions, laboratory and other diagnostic tests necessary for diagnosis, and treatment.  For antipsychotic class of medications, prior authorization may be required. PCPS prescribing medications to treat Opioid Use Disorder (OUD) must refer the member to a behavioral health provider for the psychological and/or behavioral therapy component of the Medication Assisted Treatment (MAT) model and coordinate care with the behavioral health provider.

When a PCP has initiated medical management services for a member to treat a behavioral health disorder, and it is subsequently determined by the PCP and The Health Plan that the member should receive care through the behavioral health system for evaluation and/or continued medication management services, providers will assist the PCP with the coordination of the referral and transfer of care. The PCP will document in the medical record the coordination of care activities and transition of care. The PCP must document the continuity of care (See Section 11.11 – PCP Treatment and Referrals and Section 13.3 - Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers).

10.2.6 Transition of Medical Records

Transfer of a member’s medical records due to transitioning of the member to a new T/RBHA/Health Plan and/or provider (see Section 13.1 - Transition of Persons for additional information on Inter-RBHA/MCO transfers) or due to The Health Plan terminating the provider contract, is important to ensure that there is minimal disruption to the member’s care and provision of services. The medical record must be transferred in a timely manner that ensures continuity of care.

When a member changes their provider, the member’s medical record or copies of it must be forwarded to the new provider within ten (10) business days from receipt of the request for transfer of the medical record.

Federal and State law allow the transfer of medical records from one provider to another, without obtaining the member’s written authorization if it is for treatment purposes (45 C.F.R. § 164.502(b), 45 C.F.R. § 164.514(d) and A.R.S. 12-2294(C)). Generally, the only instance in which a provider must obtain written authorization is for the transfer of alcohol/drug and/or communicable disease treatment information (see Section 9.6. – Confidentiality for other situations that may require written authorization).

The original provider must send that portion of the medical record that is necessary to the continuing treatment of the member. In most cases, this includes all communication that is recorded in any form or medium and that relates to patient examination, evaluation or behavioral or physical health treatment. Records include medical records that are prepared by a health care provider or other providers. Records do not include materials that are prepared in connection with utilization review, peer review or quality assurance activities, including records that a health care provider prepares pursuant to section A.R.S. § 36-441, A.R.S. § 36-445, A.R.S. § 36-2402 or A.R.S. § 36-2917.

Federal privacy law indicates that the Designated Record Set (DRS) is the property of the provider who generates the DRS. Therefore originals of the medical record are retained by the terminating or transitioning provider. The cost of copying and transmitting the medical record to the new provider shall be the responsibility of the transitioning provider (see AHCCCS ACOM, Policy 402).

10.2.7 Medical Record Audits

 The Health Plan will conduct routine medical record audits to assess compliance with established standards and audit tools in accordance with The Health Plan Provider Manual, AMPM, ACOM, Arizona Administrative Code and AHCCCS contract requirements. Medical records may be requested when The Health Plan, AzAHIP or AHCCCS are conducting audits or investigating quality of care issues. Providers must respond to these requests within seven (7) days. Medical records must be made available to AHCCCS for quality review upon request.

The Health Plan utilizes a collaborative and transparent audit approach with providers.  For behavioral health providers, medical record reviews are conducted by The Health Plan on at least an annual basis per AHCCCS AMPM Policy 920 Attachment A. For PCPs, Pediatricians and OB/GYNs medical records are conducted under the Arizona Association of Health Plans (AzAHP). AzAHP serves as an association of contracted AHCCCS health plans.

The following methodologies are utilized:

  • Medical record reviews are conducted using standardized audit tools that have been reviewed and approved by AHCCCS;
  • Medical record reviews are conducted a minimum of every three years;
  • A collaborative approach is utilized  that will result in only one medical record review for each provider;
  • Results of the medical record review are available to all AHCCCS Health Plans who utilize AzAHP for this process and that contract with the audited provider;
  • Deficiencies identified during the reviews are shared with all AzAHP AHCCCS Health Plans contracted with the provider;
  • If quality of care issues are identified during the AzAHP medical review process, all health plans that contract with that provider will be notified promptly (within 24 hours) in order to conduct an independent on-site provider audit;
  • Providers to be included in the AzAHP medical record review process shall include all PCPs that serve children (children defined as under 21 years of age) or that only treat adults and obstetricians/gynecologists. For the review process, see AMPM Policy 940, unless a different methodology is reviewed and approved by AHCCCS:

Behavioral health providers must send copies of any information maintained in their own behavioral health record that must also be maintained in the comprehensive clinical record.

10.2.8 Disclosure of Records

All medical records, data and information obtained, created or collected by the provider related to the member, including confidential information must be made available electronically to The Health Plan, AHCCCS or any government agency upon request.

Per AHCCCS requirement and Arizona Administrative Code (R9-22-512 (E)):

  • A provider shall furnish records requested by AHCCCS, AzAHIP or The Health Plan at no charge. Also if the provider utilizes a copy service, no charge will occur.

Health records must be maintained as confidential and must only be disclosed according to the following provisions:

  • When requested by a member’s behavioral health provider, primary care provider or the member’s DES/DDD/ALTCS support coordinator, the member’s health record or copies of health record information must be forwarded within ten (10) business days of the request. The response should include all pertinent information, including, but not limited to, current diagnoses, medications, laboratory results, last provider visit and recent hospitalizations (see Section 13.3 – Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers and AHCCCS AMPM, Policy 940 for more information).
  • Providers must obtain consent and authorization to disclose protected health information in accordance with 42 CFR 431, 42 CFR part 2, 45 CFR parts 160 and 164 and A.R.S. § 36-509. Unless otherwise prescribed in federal regulations or statute, it is not necessary to obtain a signed release in order to share health related information with the member‘s parent/legal guardian, behavioral health provider, primary care provider (PCP), The Health Plan Health Coordinator acting on behalf of the PCP or authorized state social service agency.

AHCCCS or its designee may inspect Title XIX/XXI medical records at any time during regular business hours at the offices of AHCCCS, The Health Plan or its providers. The Department of Economic Security, Division of Developmental Disabilities (DES/DDD) or its designee may inspect the medical records of their enrolled Title XIX, Title XXI, and DES/DDD Arizona Long Term Care Services (ALTCS) members at any time during regular business hours at the offices of AHCCCS, The Health Plan or its providers.                  

The Health Plan has the discretion to obtain a copy of a member’s medical records without written approval by the member if the reason for such request is directly related to the administration of service delivery. Furthermore,  The Health Plan has the discretion to release information related to fraud and abuse so long as protected HIV-related information is not disclosed (see A.R.S. § 36-664) and substance abuse information is only disclosed consistent with federal and state law, including but not limited to 42 CFR 2.1, et seq.

Additionally, providers must provide each member who makes a request one copy of their medical record free of charge annually.

Upon request, providers must allow members to view and amend their medical record as specified in 45 C.F.R. § 164.524, 45 C.F.R. § 164.526 and A.R.S. § 12-2293 and must have policies in place indicative of such.

10.2.9 Medical Record Maintenance

All providers must retain the original or copies of a member’s medical records as follows:

  • For an adult, for at least six (6) years after the last date the adult member received medical or health care services from The Health Plan or a provider; and
  • For a child, either for at least three (3) years after the child’s eighteenth (18th) birthday or for at least six (6) years after the last date the child received medical or health care services from The Health Plan or a provider, whichever occurs later.

The maintenance and access to the member’s medical record shall survive the termination of a provider’s contract with The Health Plan, regardless of the cause of the termination.

In addition, the provider shall comply with the record retention periods specified in HIPAA laws and regulations, including, but not limited to, 45 CFR 164.530(j) (2).

This policy is intended for contracted providers that deliver covered services to eligible persons. The information collected from the surveys is used to design quality improvement activities

10.3.1 Member Satisfaction Survey

As requested by the Health Plan, providers shall participate in member satisfaction surveys in accordance with the Statewide Consumer Survey protocol [42 CFR §438.10] and [A.A.C R9-22-522 (B) (1) and (5)]. For these surveys:

The Health Plan may conduct surveys or authorize a third party to conduct surveys of a representative sample of the membership and providers.

  • The Health Plan may provide the survey tool or require the providers to develop the survey tool, which shall be approved in advance.
  • The results of the surveys will become public information and available to all interested parties on the Health Plan website. Providers may be required to participate in workgroups and efforts that are initiated as a result of the survey results.
  • Providers shall participate in additional surveys requested by the Health Plan

10.3.2 Additional Member Surveys

In addition to the Member Satisfaction Survey addressed above, providers shall perform annual, general or focused member surveys. For these surveys:

  • The Health Plan may conduct surveys of a representative sample of the membership and providers.
  • The Health Plan may provide the survey tool or require the providers to develop the survey tool, which shall be approved in advance.
  • A scope of work and a timeline for the survey project is submitted if the survey is not initiated by The Health Plan. The Health may require inclusion of certain questions.
  • Data, results and the analysis of the results is submitted to The Health Plan within 45 days of the completion of the project.
  • Providers shall bear all costs associated with the survey.
  • Note that surveys may include Home and Community Based Services Member experience surveys, Health Effectiveness Data and Information Set (HEDIS) Experience of Care Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.
  • Survey findings may result in the provider being required to develop a corrective action plan (CAP) to improve any areas noted by the survey or a requirement to participate in workgroups and efforts as a result of the survey results. Failure of the provider to develop a Corrective Action Plan (CAP) and improve the area may result in regulatory action.

10.4.1 Purpose

The Health Plan is committed to establishing high quality services. One method for achieving this is through adherence to the standards and guidelines set by the Centers for Medicare and Medicaid Services (CMS) and AHCCCS, which includes implementation of performance improvement projects (PIP) specific to member needs and data identified through internal/external surveillance of trends (42 CFR 438.240; AM/PM Section 980). PIP methodologies are developed according to CMS and AHCCCS requirements. This policy provides information regarding the responsibilities of The Health Plan and providers in implementing and reporting PIPs as required by CMS or AHCCCS, or The Health Plan topics approved by AHCCCS.

10.4.2 General Information about Performance Improvement Projects

A Performance Improvement Project (PIP) is a systematic, standardized process designed to identify, plan and implement system interventions through ongoing measurement and intervention to:

  • Improve the quality of care and services provided to members;
  • Evaluate and monitor the effectiveness of system interventions and data on an ongoing basis; and
  • Result in significant performance improvement sustained over time.

PIPs are designed to achieve two primary goals. The first goal is to demonstrate achievement and sustainment of improvement for significant aspects of clinical care and non-clinical services, with the expectation of improved health outcomes and member satisfaction. A second goal is to correct significant systemic issues.

A clinical study topic would be one for which outcome indicators measure a change in behavioral or physical health acute or chronic conditions, health status or functional status; high risk services; or continuity and coordination of care. A non-clinical or administrative study topic would be one for which indicators measure changes in availability, accessibility and adequacy of the service delivery system, cultural competency of service, inter-personal aspects of care, and appeals, grievances or complaints.

PIP topics may come to the attention of AHCCCS in part through data from the AHCCCS functional areas (e.g.: network, medical director’s office); statewide contractor performance data and contract monitoring activities; tracking and trending of grievance and appeal data and quality of care concerns; provider credentialing and profiling as well as other oversight activities, such as chart reviews; Quality Management/Medical Management data analysis and reporting; and member and/or provider satisfaction surveys and feedback.

The Health Plan providers play an integral role in the implementation of AHCCCS PIPs. When applicable, contracted providers are expected to collaborate with The Health Plan, other providers, stakeholders, and community members to identify, plan and implement recommended improvement strategies that are developed as a result of an identified performance improvement project.

Specific information concerning current PIPs can be found in the AHCCCS and The Health Plan Quality Management Plans and AHCCCS Utilization Management Plans. The process for carrying out a PIP is documented in the AHCCCS Medical Policy Manual (AMPM), Section 980.  The Health Plan and its providers will utilize a Plan-Do-Study-Act (PDSA) cycle, to test changes (interventions) quickly and refine them as necessary. It is expected that this process will be implemented in as short a time frame as practical based on the PIP topic. The process for carrying out a PIP is documented in the AHCCCS AMPM, Section 980, Exhibit 980-1, Protocol for Conducting Performance Improvement Projects (PIP), including steps:

  1. Plan: Plan the change(s) or intervention(s), including a plan for collecting data. State the objective(s) of the intervention(s).
  2. Do: Try out the intervention(s) and document any problems or unexpected results.
  3. Study: Analyze the data and study the results. Compare the data to predictions and summarize what was learned.
  4. Act: Refine the change(s)/intervention(s), based on what was learned, and prepare a plan for retesting the intervention(s).
  5. Repeat: Continue the cycle as new data becomes available until improvement is achieved.

All Performance Improvement Projects conducted by The Health Plan and its providers must use the Performance Improvement Project reporting templates included in the AHCCCS AMPM, Section 980-2.

Evidenced Based Practices are interventions recognized as effective in treating a specific health-related condition based on scientific research; the skill and judgment of care health professionals; and the unique needs, concerns and preferences of the person receiving services (AHCCCS Contract General Requirements Exhibit 1-Definitions). Clinical practice guidelines are systematically developed statements to assist practitioners and member decisions about appropriate health care for specific circumstances.

Providers must ensure they coordinate and provide member access to quality health care services, regardless of type, amount, duration, scope, service delivery method and population served, that are informed and supported by evidence-based practice guidelines; will reasonably prevent injury and result in improved health outcomes; and are cost effective (AHCCCS Contract General Requirements 4.2.1 & 10.1.2.2). The delivery of services should be consistent with values, principles and goals of effective, innovation promoting, evidence-based practices. (AHCCCS Contract System Values and Guiding Principles 1.2). Providers should complete member service plans with written descriptions of all covered health services and other informal supports which reflect applicable evidence-based practice guidelines (AHCCCS Contract System Values and Guiding Principles 1.2).

10.5.1 Evidenced Based Practices and Protocols

The Health Plan and providers must ensure the following:

  • Monitor, at a clinical and system level,  each individual’s health status and service utilization to determine use of evidence-based care and ensure all services to members are consistent with acuity, and evidenced-based outcome expectations (AHCCCS Contract Care Management 5.1);
  • Review Clinical Practice Guidelines annually to determine that they remain applicable and reflect the best practice standards, 42 CFR 438.236 (b) (AHCCCS Contract Practice Guidelines 8.9);
  • Ensure PCP providers treating members with anxiety, depression and Attention Deficit Hyperactivity Disorder (ADHD) are aware of clinical tool kits available in the AHCCCS AMPM and/or are utilizing other recognized, clinical tools/ evidenced-based guidelines. Also have a monitoring process in place to ensure that evidence-based guidelines/recognized clinical tools are used when prescribing medications to treat depression, anxiety, and ADHD (AHCCCS Contract 4.13.2).
  • Behavioral health providers should receive training on the AHCCCS National Practice Guidelines and Clinical Guidance Documents with required elements before providing services, but must receive training within six months of the staff person's hire date (protocol training is only required if pertinent to populations served) (https://www.azahcccs.gov/; AHCCCS AMPM Policy 1060).

Providers are required to also verify all services are performed in accordance and in compliance with State Clinical and Recovery Practice Protocols and any revisions or additions to the State Clinical and Recovery Practice Protocols.

Providers must adopt and implement the following practices as appropriate:

10.5.2 Dissemination of Evidenced Based Practices and Protocols

The Health Plan and providers  shall disseminate to members and potential members upon request, Clinical Practice Guidelines based on valid and reliable clinical evidence or a consensus of health care professionals in the field that considers member needs, 42 CFR 438.236 (c) (AHCCCS Contract Practice Guidelines 8.9). Providers must be able to provide a basis for consistent decisions for utilization management, member education, coverage of services and other areas to which the guidelines apply, 42 CFR 438.236 (d) (AHCCCS Contract Practice Guidelines 8.9; AHCCCS Contract Drug Utilization Review  8.15).

10.5.3 Monitoring for Effectiveness

The effectiveness of AHCCCS Clinical Practice Protocols and Evidenced Based Practices are monitored by The Health Plan and contracted providers in the following ways:

  • Monitor required service expectations selected by AHCCCS for targeted implementation annually using The Health Plan approved tools and methodologies as requested;
  • Identify new or enhanced interventions that will be implemented in order to bring performance up to at least minimum level established by AHCCCS including evidence-based practices that will be effective in the same/similar populations (AHCCCS AMPM Policy 970.2.ii);
  • Participate in the monitoring of the effectiveness of other Evidenced Based Practices using monitoring processes and methodologies approved by The Health Plan and AHCCCS and developed in collaboration with The Health Plan and AHCCCS;
  • Implement interventions to improve performance, based on an evaluation of barriers to care/use of services and evidence-based approaches to improving performance (AHCCCS AMPM Policy 980).

Peer Review Committee (PRC) scope includes member treatment concerns where there is evidence that a provider has not met standard of care, or there was omission of care or services by a participating or non-participating health care professional or provider whether delivered in or out of state. The Chief Medical Officer may, at their discretion, refer other cases and/or practitioner reviews to the PRC for evaluation and corrective action recommendation. All Peer Review proceedings are protected by statute from discovery in any legal proceeding. Any correspondence pertaining to a peer review is labeled “Privileged and Confidential, Peer Review” thus maintaining the protection under applicable State and Federal laws. Adverse actions taken as a result of the Peer Review Committee must be reported to AHCCCS within 24 hours of an adverse decision being made.  The Health Plan also must implement recommendations made by the AHCCCS Peer Review Committee. Some AHCCCS Peer Review recommendations may be appealable agency actions under State law. A The Health Plan provider may appeal such a decision through the administrative process described in A.R.S. § 41-1092, et seq.

Matters appropriate for peer review may include, but are not limited to:

  • Questionable clinical decisions;
  • Lack of care and/or substandard care;
  • Inappropriate interpersonal interactions or unethical behavior;
  • Trends of over or under utilization of services;
  • Information from fraud and abuse investigations by AHCCCS;
  • Physical, psychological, verbal, or sexual abuse by provider staff;
  • Allegations of criminal or felonious actions related to practice;
  • Issues that immediately impact the Member and that are life threatening or dangerous;
  • Unanticipated death of a Member;
  • Issues that have the potential for adverse outcome; or
  • Allegations from any source that bring into question the standard of practice.

The Peer Review Committee, using their clinical judgment, is responsible for making recommendations to the Chief Medical Officer. The assigned lead reviewer for each case gives a clinical summation of the case and highlights any points of concern or discussion to the committee. The peer review process ensures that providers of the same or similar specialty participate in the review. If the PRC requires additional information prior to making a determination, the case is pended and information is obtained for review at a future PRC.  The Peer Review Committee must determine appropriate action and next steps. The Chief Medical Officer is responsible for implementing all peer review actions.

Within 15 calendar days of the PRC meeting, the reviewed provider will receive a written notification informing them of the outcome of the review including corrective action and timeframes for completion if applicable. This letter will also notify provider of the procedure for provider appeals and hearings related to peer review committee.  Providers are informed in the written notification that any appeal must be received within 30 days of receipt of the notification.  The provider is entitled to an opportunity for a hearing in the event the PRC recommends corrective action(s) for reasons relating to the competence or professional conduct of the provider, or in the event the provider is entitled by law to an opportunity for a hearing.  The Procedure for Provider appeals and hearings related to Peer Review corrective actions is the same as that outlined in the Credentialing Practitioner Appeal Hearing Process. Upon completion of the corrective actions and satisfactory behavioral changes by the provider, the provider is notified of completion in writing. If the Peer Review Committee review results in a recommendation for termination of a provider, the recommendation is presented to the Credentialing Committee for final determination. Reviews resulting in the reduction, suspension, or termination of a provider’s participation are reported to appropriate boards, regulatory agencies and the National Practitioner’s Data Back.

The Quality Management department responds to quality of care concerns received from Members and providers or issues identified during routine clinical review of Members’ care, or received from anywhere within The Health Plan or from anywhere in the community. If substantiated as a true quality of care issue, the concern will be tracked and trended or may be forwarded to the Peer Review Committee. Summary information on quality of care reviews is furnished to the Credentialing Committee at the time of the providers’ re-credentialing. All of these activities concerning provider information may be used for future Performance Improvement Projects.

10.7.1 Documentation Related to Quality of Care Concerns

Quality of Care (QOC) concerns may be referred by State agencies, internal AHCCCS sources (e.g., Customer Service, the Office of the Deputy Director), and external sources (e.g., Members; providers; other stakeholders; Incident, Accident, and Death reports).

Upon receipt of a QOC concern, The Health Plan follows the procedures below.

First, The Health Plan documents each issue raised, when and from whom it was received, and the projected time frame for resolution. The Health Plan then promptly determines whether the issue is to be resolved through one or more of the following operational areas: Quality of Care; Customer Service; Grievance and Appeal process; and/or Fraud, waste, and program abuse.

The Health Plan then acknowledges receipt of the issue and explains to the Member or provider the process that will be followed to resolve the issue through written correspondence. If the issue is being addressed as other than a QOC investigation, The Health Plan explains to the Member or provider the process that will be followed to resolve their issue using written correspondence. QOC related concerns remain with the Quality Management department due to state and federal regulations: 42 U.S.C. 1320c-9, 42 U.S.C. 11101 et seq., A.R.S. §36-2401, A.R.S. §36-2402, A.R.S. §36-2403, A.R.S. §36-2404, A.R.S. §36-2917.

The Health Plan assist the Member or provider as needed to complete forms or take other necessary actions to obtain resolution of the issue. The Health Plan ensures the confidentiality of all Member information and informs the Member or provider of all applicable mechanisms for resolving the issue.

The Health Plan documents all processes (including detailed steps used during the investigation and resolution stages) implemented to verify complete resolution of each issue, including but not limited to the following:

  • Corrective action plan(s) or action(s) taken to resolve the concern;
  • Documentation that education/training was completed (including but not limited to in-service training objectives and attendance sheets, and
  • New policies and/or procedures.

Finally The Health Plan documents all follow-up with the Member that includes, but is not limited to: assistance as needed to verify that the immediate health care needs are met, and a closure/resolution letter that provides sufficient detail to verify all covered, medically necessary care needs are met and a contact name/telephone number to call for assistance or to express any unresolved concerns.

10.7.2 Process of Evaluation and Resolution of Quality of Care Concerns

The quality of care concern process at The Health Plan includes documentation of identification, research, evaluation, intervention, resolution, and trending of Member and provider issues. Resolution must include both Member and system interventions when appropriate. The quality of care process must be a standalone process and shall not be combined with other agency meetings or processes.

The Health Plan completes the following actions in the QOC process:

  • Identification of the quality of care issues;
  • Initial assessment of the severity of the quality of care issue;
  • Prioritization of action(s) needed to resolve immediate care needs when appropriate;
  • Review of trend reports to determine possible trends related to the provider(s) involved in the allegation(s) including: type(s) of allegation(s), severity and substantiation, etc.;
  • Research, including, but not limited to: a review of the log of events, documentation of conversations, and medical records review, mortality review, etc.; and
  • Quantitative and qualitative analysis of the research, which may include root cause analysis.
  • For substantiated QOC allegations it is expected that some form of action is taken, for example:
    • Developing an action plan to reduce/eliminate the likelihood of the issue reoccurring;
    • Determining, implementing, and documenting appropriate interventions;
    • Monitoring and documenting the success of the interventions;
    • Incorporating interventions into the organization’s Quality Management (QM) program if appropriate, or
    • Implementing new interventions/approaches, when necessary.

Each issue/allegation must be resolved; Member and system resolutions may occur independently from one another. The following determinations should be used for each allegation in a QOC concern:

  • Substantiated – The alleged complaint (allegation) or reported incident was verified or proven to have happened based on evidence and had a direct effect on the quality of the Members health care. Substantiated allegations require a level of intervention such as a corrective action plan of steps to be taken to improve the quality of care or service delivery and/or to verify the situation will not likely happen again.
  • Unable to Substantiate – There was not enough evidence at the time of the investigation to show whether a QOC allegation did occur or did not occur. The evidence was not sufficient to prove or disprove the allegation. No intervention or corrective action is needed or implemented.
  • Unsubstantiated – There was enough credible evidence (preponderance of evidence) at the time of the investigation to show that a QOC allegation did not occur. The allegation is based on evidence, verified or proven, to have not occurred. No intervention or corrective action is needed or implemented.

The Health Plan, as an active participant in this process, will use the following to determine the level of severity of the quality of care issue:

  • Level 0 (Track and Trend Only) – An issue no longer has an immediate impact and has little possibility of causing, and did not cause, harm to the recipient and/or other recipients, an allegation that is unsubstantiated or unable to be substantiated when the QOC is closed.
  • Level 1 – Concern that MAY potentially impact the Member and/or other Members if not resolved.
  • Level 2 – Concern that WILL LIKELY impact the Member and/or other Members if not resolved promptly.
  • Level 3 – Concern that IMMEDIATELY impacts the Member and/or other Members and is considered potentially life threatening or dangerous.
  • Level 4 – Concern that NO LONGER impacts the Member. Death or an issue no longer has an immediate impact on the Member, an allegation that is substantiated when the QOC is closed.

 The Health Plan, as an active participant in the process, will report issues to the appropriate regulatory agency including Adult Protective Services, AHCCCS, Department of Child Safety, the Attorney General’s Office, or law enforcement for further research/review or action. Initial reporting may be made verbally, but must be followed by a written report within one business day.

Cases are referred to the Peer Review Committee when appropriate. Referral to the Peer Review Committee shall not be a substitute for implementing interventions. (See Section 10.6, Peer Review)

The Health Plan, as an active participant in the process, must notify AHCCCS of any adverse action taken against a provider.

Upon receiving notification that a health care professional’s organizational provider or other provider’s affiliation with their network is suspended or terminated as a result of a quality of care The Health Plan, as an active participant in the process, is required to notify AHCCCS of the same.

The Health Plan, as an active participant in the process, is expected to submit a closing letter to AHCCCS. These letters will include the following:

  • A description of the issues/allegations, including new issues/allegations identified during the investigation/review process,
  • A substantiation determination and severity level for each allegation
  • An overall substantiation determination and level of severity for the case.
  • Written response from or summary of the documents received from referrals made to outside agencies such as accrediting bodies, or medical examiner.

10.7.3 Tracking/Trending of Quality of Care Issues

The Health Plan uses data pulled from the QOC database to monitor the effectiveness of QOC-related activities to include grievances and allegations received from Members and providers, as well as from outside referral sources.  The Health Plan, as an active participant in the QOC process, also tracks and trends QOC data and reports trends and potential systemic problems to AHCCCS.

The data from the QOC database will be analyzed and evaluated to determine any trends related to the quality of care or service in The Health Plan’s service delivery system or provider network, and aggregated for AHCCCS. When problematic trends are identified through this process, The Health Plan will incorporate the findings in determining systemic interventions for quality improvement. The Health Plan, as an active participant in the QOC process, also incorporates trended data into systemic interventions.

As evaluated trended data is available, The Health Plan will prepare and present analysis of the QOC tracking and trending information for review and consideration of action by the Quality Management Committee and Chief Medical Officer, as Chairperson of the Quality Management Committee.

Quality tracking and trending information from all closed quality of care issues within the reporting quarter will be submitted to AHCCCS/Division of Health Care Management/Clinical Quality Management (AHCCCS/DHCM/CQM) utilizing the Quarterly Quality Management Report. The report will be submitted within 45 days after the end of each quarter and will include the following reporting elements:

  • Types and numbers/percentages of substantiated quality of care issues
  • Interventions implemented to resolve and prevent similar incidences, and
  • Resolution status of “substantiated”, “unsubstantiated” and “unable to substantiate” QOC issues.

If a significant negative trend is found, The Health Plan may choose to consider it for a performance improvement activity to improve the issue resolution process itself, and/or to make improvements that address other system issues raised during the resolution process.

The Health Plan will submit to AHCCCS Clinical Quality Management all pertinent information regarding an incident of abuse, neglect, exploitation, serious incident (including suicide attempts) and unexpected death (including all unexpected transplant deaths) as soon as The Health Plan becomes aware of the incident, and no later than 24 hours. Pertinent information must not be limited to autopsy results only, but must include a broad review of all issues and possible areas of concern. Delays in the receipt of autopsy results shall not result in a delay in the investigation of a quality of care concern by The Health Plan. As The Health Plan receives delayed autopsy results, it will use them to confirm the resolution of the QOC concern. If the cause and manner of death gives reason to change the findings of the QOC concern, The Health Plan will notify AHCCCS and resubmit a revised resolution report. The Health Plan will also revise closing letters to AHCCCS if the cause and manner of death changes the findings of a QOC investigation.

The Health Plan, as an active participant in the QOC process, must verify that Member health records are available and accessible to authorized staff of their organization and to appropriate State and federal authorities, or their delegates, involved in assessing quality of care or investigating Member or provider quality of care concerns, grievance and appeals, allegations of abuse, neglect, exploitation grievances and Healthcare Acquired Conditions (HCAC). Member record availability and accessibility must be in compliance with federal and State confidentiality laws, including, but not limited to, Health Insurance Portability and Accountability Act (HIPAA) and 42 C.F.R. 431.300 et seq.

10.7.4 Provider-Preventable Conditions

If a Health Care Acquired Condition (HCAC) or Other Provider-Preventable Condition (OPPC) is identified, The Health Plan will conduct a quality of care investigation and report the occurrence and results of the investigation to the AHCCCS Clinical Quality Management Unit.

All Health Care Acquired Conditions and Other Provider-Preventable Conditions are reported to the AHCCCS Quality Management Team on a quarterly basis.

Medicare eligible Members, including persons who are dually eligible for Medicare (Title XVIII) and Medicaid (Title XIX) receive Medicare Part D prescription drug benefits through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA- PDs). Medicare Part D coverage includes copayment and coinsurance requirements. However, Medicare Part D copayments are waived when a dual eligible person enters a Medicaid funded medical institution for at least a full calendar month. The facility must notify the Arizona Health Care Cost Containment System (AHCCCS) when a dual eligible person is expected to be in the medical institution for at least a full calendar month to verify copayments for Part D are waived. See AHCCCS ACOM Policy 201, Attachment A Notification to Waive Medicare Part D Co-Payments for Members in a Medicaid Funded Medical Institution. The waiver of copayments applies for the remainder of the calendar year, regardless of whether the person continues to reside in a medical institution. Given the limited resources of many dual eligible persons and to prevent the unnecessary burden of additional copay costs, it is imperative that these individuals are identified as soon as possible.

The objective of this policy is to inform providers designated as medical institutions of reporting and tracking requirements for dual eligible persons to verify Medicare Part D copays are waived.

10.8.1 Reporting Requirements

To verify that dual eligible persons’ Medicare Part D copayments are waived when it is expected that dual eligible persons will be in a medical institution, funded by Medicaid, for at least a full calendar month, the facility must notify AHCCCS immediately upon admittance.

Reporting must be done using AHCCCS ACOM Policy 201, Attachment A, AHCCCS Notification to Waive Medicare Part D Copayment for members in a medical institution that is funded by Medicaid. Providers must not wait until the person has been discharged from the medical institution to submit the form. Reporting must be done on behalf of the following:

  • Persons who have Medicare Part “D” only;
  • Persons who have Medicare Part “B” only;
  • Persons who have used their Medicare Part “A” lifetime inpatient benefit; and
  • Persons who are in continuous placement in a single medical institution or any combination of continuous placements that are identified below.

Medical institutions include the following providers:

  • Acute Hospital
  • Psychiatric Hospital – Non-Institute of Mental Disease
  • Psychiatric Hospital – Institute of Mental Disease
  • Residential Treatment Center – Institute of Mental Disease
  • Residential Treatment Center – Non- Institute of Mental Disease
  • Skilled Nursing Facility

Additional information regarding Medicare cost sharing for members covered by Medicare and Medicaid can be found in AHCCCS ACOM, Policy 201.

Seclusion and restraint are high-risk interventions that must be used to address emergency safety situations only when less restrictive interventions have been determined to be ineffective, in order to protect Members, staff members or others from harm. All persons have the right to be free from seclusion and restraint, in any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Seclusion or restraint may only be imposed to ensure the immediate physical safety of the person, a staff member or others and must involve the least restrictive intervention, and be discontinued at the earliest possible time (42 CFR §482.13).

This section includes seclusion and restraint reporting requirements for contracted behavioral health inpatient facilities (42 CFR §482.13) (A.A.C. R9-21) and behavioral health inpatient facilities serving persons under the age of 21 (42 CFR §483 Subpart E).

10.9.1 Additional Information

  • Trauma associated with seclusion and restraint can trigger Post Traumatic Stress Disorder;
  • Each state has a designated protection and advocacy system. In Arizona, the Arizona Center for Disability Law serves as the designated protection and advocacy agency;
  • R9-21-204 require that all staff members and medical professionals involved in ordering, providing, monitoring or evaluating seclusion or restraint complete and document education and training to include: understanding behavioral and environmental risk factors, nonphysical interventions, the safe use of seclusion or restraint and responding to emergency situations;
  • In 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) published the Roadmap to Seclusion and Restraint Free Mental Health Services. Developed by administrations, experts and Members, the training is a resource for mental health service direct care staff, administrators, and Members on alternatives to the use of seclusion or restraint, as well as a tool for mental health system transformation;
  • A staff member employing any method that results in a person either being precluded from exiting an area in fact or left with the reasonable belief of being prohibited from being able to exit freely (for example – a staff member’s use of their body to block an individual’s exit from a specified area) constitutes seclusion, R9-21-101.B.56;
  • A.R.S. § 36-513 and A.R.S. § 36-528 require that a person under emergency detention or court ordered evaluation may not be treated without consent, except that pharmacological restraint may be used to protect the safety of that person and others in an emergency. Therefore, psychiatric medications given involuntarily to persons under emergency detention or court ordered evaluation must be considered chemical restraint and documented as such;
  • 42 CFR 482.13 clarifies that a drug or medication used as a restraint is not a standard treatment or dosage for a Member’s condition. Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN); and
  • The Health Plan is also required to collect certain aggregate data that compiles total seclusion and restraints for the reporting period, and forward that data to the State.

10.9.2 Reporting to The Health Plan

Contracted behavioral health inpatient facilities shall follow local, state and federal regulations and requirements related to seclusion and restraint.

Contracted behavioral health inpatient facilities authorized to use seclusion and restraint shall report the following to The Health Plan:

  • Each occurrence of seclusion and restraint to The Health Plan within five (5) calendar days of the occurrence, via email AzCHQualityManagement@azcompletehealth.com, attention Quality Management. Failure to submit seclusion and restraint reports timely may result in a financial sanction for late submission of a contract deliverable.
  • Reports of seclusion and restraint are to be submitted using Provider Manual Form 9.9.1 Seclusion and Restraint Reporting Form which can be obtained from the Provider Services Call Center at 866-796-0542.
  • The Provider Manual Form 9.9.1, Seclusion and Restraint Reporting Form must be completed in its entirety and include the required information detailed on AHCCCS Policy Attachment 1702A.
  • In the event that a use of seclusion or restraint requires face-to-face monitoring, a report detailing face-to-face monitoring must be completed using the Provider Manual Form 9.9.1, Seclusion and Restraint Reporting Form or attached to the reporting form. The face-to-face monitoring form must include the requirements as per 42 CFR 482.13, 42 CFR § 483 Subpart 12, and R9-21-204.
  • The Health Plan may also request copies of provider agency Policies and Procedures pertaining to the use of seclusion and restraint, evidence of staff trainings, and any corrective actions taken to reduce the frequency of usage.
  • Each behavioral health inpatient facility or Mental Health Agency shall report the total number of incidents of the use of S&R involving AHCCCS members in the prior month to the Health Plan by the fifth calendar day of the month. If there were no incidents of Seclusion or restraint during the reporting period, the report should so indicate.

Providers are directed to call the Provider Service Center to obtain a copy of these forms, if needed, at 1-866-796-0542.

10.9.3 Reporting a Serious Occurrence or Death

Because of the high-risk nature of seclusion and restraint interventions, it is possible that a person may be injured or that a serious occurrence may occur during a seclusion and restraint event.

Contracted behavioral health inpatient facilities authorized to use seclusion and restraint shall report any occurrence of injury or serious occurrence during a seclusion and restraint following the guidelines in Section 10.10 - Reporting of Incidents, Accidents and Deaths.

Behavioral health inpatient facilities must be aware of what constitutes an event that requires reporting to the following entities:

The Health Plan

Behavioral health inpatient facilities must report any incident, accident or death that pertain to the following, of an enrolled Member to The Health Plan within 2 business days, following the guidelines in Section 10.10 – Reporting Of Incidents, Accidents and Deaths.

AHCCCS

Licensed behavioral health inpatient facilities are required to report a serious occurrence, including a death, following a seclusion and/or restraint event, to AHCCCS no later than one working day following the serious occurrence. Staff must document in the person’s record and in the incident/accident report log that the serious occurrence was reported to AHCCCS, and include the names of the individuals who received the report. For reporting of serious occurrences:

  • AHCCCS: fax number 602-417-4162 Attention DHCM Senior Clinical and Quality Consultant.

ADHS Division of Licensing

Licensed behavioral health inpatient facilities must notify the ADHS Division of Licensing within one working day of discovering a serious occurrence that requires medical services, or death that occurs as a result of a seclusion and/or restraint. This notification must be followed up by a written ADHS Division of Licensing report within five days of initial notification. Reporting to ADHS Licensing would not utilize the QMS Portal or the AHCCCS Incident, Accident, Death report form.

Arizona Center for Disability Law (ACDL)

Licensed behavioral health inpatient facilities are required to report a serious occurrence, including a death, following a seclusion and/or restraint event, to The ACDL no later than one working day following the serious occurrence. Staff must document in the person’s record and in the incident/accident report log that the serious occurrence was reported to The ACDL, and include the names of the individuals who received the report. For reporting of serious occurrences:

  • The Arizona Center for Disability Law: fax number 602-274-6779 Attention Mental Health Team

Centers for Medicare and Medicaid Services (CMS)

In the case of a person’s death, the information must be reported to the Center for Medicare and Medicaid Services (CMS) Regional Office. The program must report:

  • Each death that occurs while a resident is in restraint or seclusion;
  • Each death that occurs within 24 hours after the resident has been removed from restraint or seclusion; and
  • Each death known to the facility that occurs within one week after the restraint or seclusion where it is reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to a resident’s death. “Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or deaths related to chest compression, restriction of breathing or asphyxiation.

Each death must be reported to CMS by telephone within one working day following knowledge of the resident’s death. All staff must document the death in the program’s incident/accident log. Staff must document in the member’s medical record the date and time the death was reported to CMS, and the names of the individuals who received the report.

  • CMS Regional Office (to report a death only): Division of Survey & Certification phone: 415-744-3501.

Licensed behavioral health inpatient facilities must know what information is to be reported, including any applicable forms and/or reports; where the requisite information must be sent within the agencies identified above and the reporting timeframes.

Significant events, such as accidents, injuries, allegations of abuse, human rights violations, and deaths require careful examination and review to ensure the protection of Members. AHCCCS, as well as other federal and State agencies, require the prompt reporting of significant events involving persons receiving services within the public health system. The reporting of significant events to the State, such as incidents, accidents, and deaths, serves the following purposes:

  • The collection of relevant information facilitates a comprehensive review and investigation when indicated;
  • Compliance with notification requirements to the Centers for Medicare and Medicaid Services (CMS), Arizona Health Care Cost Containment System (AHCCCS), the Arizona Center for Disability Law, and ADHS Division of Licensing as applicable; and
  • The trending and analysis of significant events can identify opportunities for behavioral health system improvements.

The intent of this section is to identify reporting requirements for providers following an incident, accident, or death involving a Member. In addition, The Health Plan may require providers to submit a written summary of their review of deaths of adult Non-Seriously Mentally Ill Members.

Providers must be aware of what constitutes an event that requires reporting to:

  • CMS;
  • AHCCCS;
  • The Arizona Center for Disability Law; or
  • ADHS Division of Licensing
  • Division of Developmental Disabilities (DDD)

Providers must know what information is to be reported, including any applicable forms and/or reports; and where the requisite information must be sent within the agencies identified above.

10.10.1 Additional Information

  • All deaths, regardless of whether the enrolled Member is a child, adult with SMI or adult without SMI, are reviewed by the State Medical Director or designee, and selected cases are reviewed for potential action, in accordance with the State’s established quality assurance process;
  • ADHS Division of Licensing Behavioral Health Inpatient Facilities are required to report any serious occurrence that occurs as a result of a seclusion and restraint event, in accordance with Section 10.9 - Seclusion and Restraint Reporting;
  • Upon recognition of abuse, neglect or exploitation of an incapacitated person, providers must immediately report the allegation to the appropriate authorities (i.e., police or protective services worker) in accordance with A.R.S. § 46-454. The oral reports must be followed up by a written report within 48 hours. See Section 9.4 - Duty to Report Abuse, Neglect or Exploitation; and
  • Each state has a designated protection and advocacy system. In Arizona, the Arizona Center for Disability Law serves as the designated protection and advocacy agency.

10.10.2 Reporting Incidents, Accidents and Deaths to The Health Plan Behavioral Health Providers must report any incident, accident or death that pertain to the following, of an enrolled Member to The Health Plan within 48 hours:

  • Deaths;
  • Medication error(s);
  • Opioid related concerns;
  • High profile incidents;
  • Abuse or neglect allegation made about staff member(s);
  • Suicide attempt;
  • Self-inflicted injury;
  • Injury requiring emergency treatment;
  • Physical injury that occurs as the result of personal, chemical or mechanical restraint;
  • Unauthorized absence from a licensed behavioral health facility, group home or HCTC of children or recipients under court order for treatment;
  • Suspected or alleged criminal activity;
  • Discovery that a client, staff member, or employee has a communicable disease as listed in R9-6-202 (A) or (B);
  • Incidents or allegations of violations of the rights as described in A.A.C. R9-20-203 (PDF) or in A.A.C. R9-21, Article 2 (PDF);
  • Discrimination;
  • Exploitation;
  • Coercion;
  • Manipulation;
  • Retaliation for submitting grievances to authorities;
  • Threat of discharge/transfer for punishment;
  • Treatment involving denial of food;
  • Treatment involving denial of opportunity to sleep;
  • Treatment involving denial of opportunity to use toilet;
  • Use of restraint or seclusion as retaliation; and/or
  • Health Care-Acquired and Provider Preventable Conditions as described in the AHCCCS AMPM Chapter 900.

Additionally, providers must submit incident, accident, or death reports involving “sentinel events” within 6 hours of the occurrence. A “sentinel event” is defined as any of the following:

  • Suicide or significant suicide attempt by a Member;
  • Homicide committed by a Member;
  • Unauthorized absence of a Member from a locked behavioral health inpatient facility;
  • Sexual assault while a Member is a resident of a locked behavioral health inpatient facility; or
  • Death while a Member is a resident of a Behavioral Health Inpatient Facility or other psychiatric hospital or other inpatient institution.

Providers are responsible for reporting incidents, accidents, and deaths of behavioral health Members through the QMS Portal. The QMS Portal is intended for the use of providers reporting IADs to The Health Plan. This system is administered by AHCCCS. Access to the QMS Portal is at: https://qmportal.azahcccs.gov/WF_Public_Default.aspx

The QMS Portal has links for: Registration Guide, Quick Start-Creating an IAD (Incident, Accident, Death Reports), Current Build Release Notes and Technical Assistance.

10.10.3 Reporting Incidents, Accidents and Deaths During Prevention Activities

Providers are required to report to The Health Plan any incident, accident or death of a Member participating in the health plan provider sponsored prevention activity, as defined in this section, regardless of their enrollment status with The Health Plan, within 48 hours.

10.10.4 Reporting to Office of Human Rights

The Health Plan submits all behavioral health incident reports involving enrolled children and adults to the Office of Human Rights upon review of the incident report. The Health Plan removes all information that personally identifies the members, in accordance with federal and state confidentiality laws.

10.10.5 Reporting Deaths and Serious Occurrences in ADHS Division of Licensing Behavioral Health Inpatient Facilities

This subsection is applicable to Title XIX/XXI certified ADHS Division of Licensing Behavioral Health Inpatient Facilities that provide inpatient psychiatric services to persons under the age of 21.

10.10.5.1 Reporting Serious Occurrences Of Members:

Title XIX/XXI certified/ADHS Division of Licensing Behavioral Health Inpatient Facilities that provide inpatient psychiatric services to persons under the age of 21 are required to report any serious occurrences involving a Member to:

  • AHCCCS;
  • The Arizona Center for Disability Law; and
  • CMS Regional Office (for deaths only).

10.10.5.2 Timeframes

Any serious occurrence involving a Member in a Behavioral Health Inpatient Facility must be reported to AHCCCS, the Arizona Center for Disability Law, and the CMS Regional Office (for deaths only) no later than close of business of the next business day following the serious occurrence.

10.10.5.3 Where to Send the Report

For serious occurrence reporting, send information to:

  • AHCCCS: fax number 602-417-4162 Attention DHCM Behavioral Health Administrator;
  • The Arizona Center for Disability Law: fax number 602-274-6779 Attention Investigator; and
  • CMS Regional Office (to report a death only): fax number 415-744-2692 Attention Survey & Certification Coordinator.

10.10.5.4 Other Considerations

Specific documentation requirements apply to ADHS Division of Licensing licensed provider records. Please see Section 10.2 - Medical Record Standards.

In the case of a minor (person under the age of 18), the behavioral health inpatient facility must also notify the person’s parent(s) or legal guardian(s) as soon as possible, but no later than 24 hours from the serious occurrence.

Note that these reporting requirements pertain only to serious occurrences (see definition). Reports of non-serious occurrences and other events are not made to AHCCCS, the Arizona Center for Disability Law, or CMS.

10.10.6 Minimum Performance Standard

Behavioral Health Home providers must meet each Minimum Performance Standard (MPS) for both the Integrated and Non-Integrated Plans as identified below.

RHBA Performance Measures for Contract Year 2019

Behavioral Health Performance Measures – GMH/SU Population

Measure

Source

MPS

Follow-Up After Hospitalization for Mental Illness, 7 Days

CMS

60%

Follow-Up After Hospitalization for Mental Illness, 30Days

CMS

85%

Mental Health Utilization

HEDIS

TBD

Use of Multiple Concurrent Antipsychotics in Children and Adolescents

CMS

<2%

Use of Opioids at High Dosage in Persons Without Cancer

CMS

TBD

Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug (7 & 30 Day)

CMS

TBD

Access to Behavioral Health Professional Services, 7 days

AHCCCS

Tabled

Access to Behavioral Health Professional Services, 30 days

AHCCCS

Tabled

Metabolic Monitoring for Children and Adolescents on Antipsychotics

HEDIS

TBD

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

CMS

TBD

 

Integrated Performance Measures – SMI Integrated Population

Measure

Source

MPS

Inpatient Utilization (IPU)

HEDIS

<350

Ambulatory Care (AMB)-ED Utilization

HEDIS

<150

Hospital Readmission within 30 Days of Discharge (PCR)

CMS

<23%

Follow-Up After Hospitalization for Mental Illness, 7 Days

CMS

60%

Follow-Up After Hospitalization for Mental Illness, 30 Days

CMS

85%

Adult’s Access to Preventive Services

HEDIS

85%

Breast Cancer Screening (BCS)

CMS

55%

Cervical Cancer Screening (CCS)

CMS

53%

Chlamydia Screening in Women (CHL)

CMS

57%

Colorectal Cancer Screening (COL)

HEDIS

65%

CDC-HbA1c Testing

CMS

86%

CDC-HbA1c Poor Control (>9.0%) 

CMS

<43%

CDC-Eye Exam

HEDIS

55%

Asthma Medication Ratio (AMR) Ages 19-64

CMS

TBD

Timeliness of Prenatal Care: Prenatal Care Visit in the First Trimester or Within 42 Days of Enrollment (PPC)

CMS

80%

Timeliness of Postpartum Care: Postpartum Care Rate (PPC)

CMS

64%

Contraceptive Care (CCP) – Post-Partum Women Ages: 18-20 Years, 21-44 Years

CMS

TBD

Mental Health Utilization (MPT)

HEDIS

TBD

Use of Opioids at High Dosage in Persons Without Cancer

CMS

TBD

Concurrent Use of Opioids and Benzodiazepines (COB)

CMS

TBD

Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug Dependence (FUA-AD) 7 & 30 Day

CMS

TBD

Access to Behavioral Health Professional Services, 7 days

AHCCCS

Tabled

Access to Behavioral Health Professional Services, 30 days

AHCCCS

Tabled

Diabetes Admissions, Short-Term Complications (PQI-01)

CMS

<40

Flu Vaccinations for Adults, Ages 18-64 (FVA)

CMS

50%

Flu Vaccinations for Adults, Ages 65+ (FVA)

CMS

75%

Annual Monitoring for Patients on Persistent Medications, Combo Rate (MPM)

CMS

87%

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI-05)

CMS

<90

Asthma in Younger Adults Admissions (PQI-15)

CMS

<20

Heart Failure Admission Rate (PQI-08)

CMS

<32

EPSDT Participation, members aged 18-21

CMS

68%

Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications

CMS

80%

 

Complete Care Plan 2019 Performance Measures

Performance Measures - Childhood and Adolescent

Source

MPS

Children's Access to PCPs: 12-24 months

CMS

95%

Children's Access to PCPs: 25 months to 6 years

CMS

87%

Children's Access to PCPs:  7-11 years

CMS

90%

Adolescents' Access to PCPs:  12-19 years

CMS

89%

Well-Child Visits:  15 Months (6 or more)

CMS

62%

Well-Child Visits:  3-6 Years

CMS

66%

Adolescent Well-Care Visits: Age 12-21

CMS

41%

CRS-Identified Member Initial Visit (within 30 days)

AHCCCS

75%

Developmental Screening in the First Three Years of Life (DEV)

CMS

55%

Metabolic Monitoring for Children and Adolescents on Antipsychotics

HEDIS

Baseline

Use of Multiple Concurrent Antipsychotics in Children and Adolescents

CMS

<2%

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics

CMS

Baseline

Annual Dental Visits (ages 2-20 years)

HEDIS

60%

Percent of Eligibles with Preventive Dental Svc

CMS

46%

Dental Sealants Children 6-9 Yrs. @ Risk of Caries

CMS

Baseline

EPSDT Participation

CMS

68%

DTaP

CMS

76%

IPV

CMS

88%

MMR

CMS

89%

Hib

CMS

88%

HBV

CMS

88%

VZV

CMS

88%

PCV

CMS

77%

Hep A

CMS

85%

Influenza

CMS

45%

Rotavirus

CMS

65%

Combination 3

CMS

68%

Combination 7

CMS

50%

Combination 10

CMS

25%

Adolescent Meningococcal

CMS

85%

Adolescent Tdap/Td

CMS

85%

Adolescent Combo 1

CMS

85%

Adolescent Combo 2

CMS

21%

Human Papillomavirus Vaccine

CMS

25%

Body Mass Index (BMI) Assessment for Children/Adolescents

CMS

55%

Performance Measures - Adult

 

MPS

Inpatient Utilization (days/1,000 member months)

HEDIS

33

ED Utilization (visits/1,000 member months)

HEDIS

58

Plan All-Cause Readmissions

CMS

14%

Asthma in Young Adults Admission Rate (per 100,000 member months)

CMS

9

Comprehensive Diabetes Care - HbA1c Tests

CMS

86%

Comprehensive Diabetes Care - Eye Exams

HEDIS

55%

Diabetes, Short Term Complications Admission Rate (per 100,000 member months)

CMS

16

Heart Failure Admission Rate (per 100,000 member months)

CMS

23

COPD/Asthma in Older Adults Admission Rate (per 100,000 member months)

    CMS

55

Timeliness of Prenatal Care

CMS

80%

Postpartum Care

CMS

64%

Contraceptive Care (CCP) – Post-Partum Women Ages 15-20 years, 21-44 years

CMS

TBD

Adult Access to Preventive Care

HEDIS

75%

Chlamydia Screening

CMS

57%

Flu shots Ages 18-64

CMS

50%

Flu shots Ages 65 & older

CMS

75%

Breast Cancer Screening

CMS

55%

Cervical Cancer Screening

CMS

53%

Colorectal Cancer Screening

HEDIS

65%

Comprehensive Diabetes Care - Poor Control (HbA1c > 9.0%)

CMS

43%

Mental Health Utilization

HEDIS

Baseline

Use of Opioids in High Dosage

CMS

Baseline

Concurrent Use of Opioids and Benzodiazepines (COB)

CMS

Baseline

Asthma Medication Ratio (AMR) – Ages: 5-18 years, 19-64 years

CMS

Baseline

Annual Monitoring for Patients on Persistent Medications (MPM)

CMS

87%

Follow-Up After Hospitalization for Mental Illness, 7 Days

CMS

60%

Follow-Up After Hospitalization for Mental Illness, 30 Days

CMS

85%

Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug 7 & 30 Days

CMS

TBD

Access to Behavioral Health Professional Services, 7 days

AHCCCS

Tabled

Access to Behavioral Health Professional Services, 30 days

AHCCCS

Tabled

10.10.7 Improvement Activities

Behavioral Health Home providers must participate in The Health Plan or State process improvement projects as requested and engage in Practice Improvement Processes to generate positive improvement in provider practices. Providers must participate in clinical quality improvement activities that are designed to improve outcomes for Arizona Members. Providers are also required to participate in the Children's System of Care Practice Reviews; including, at a minimum, participation in family interviews, chart reviews, team observation, providing accurate contact information, and participating in Feedback Meetings, as requested.

10.10.8 Corrective Action and Audits

Behavioral Health Home providers must respond to all Corrective Action Letters as requested and develop effective Corrective Action Plans, utilizing PM Form 9.11.4 Corrective Action Plan Template, to overcome the identified problems. Providers must cover the cost of a second The Health Plan audit resulting from provider’s failure to pass the minimum performance standards associated with a The Health Plan audit, and must cover the travel costs associated with the repeat/second audit which may include hotel, meals, car rental and gasoline.