Behavioral Health Network Provider Service Delivery Requirements
Eligibility status is essential for knowing the types of services a person may be able to access. In Arizona’s public behavioral health system, a person may:
- Be eligible for Title XIX/XXI (Medicaid) or Title XXI covered services;
- Not qualify for Title XIX/XXI services, but be eligible for services as a person determined to have a Serious Mental Illness (SMI);
- Be covered under another health insurance plan or “third party” (including Medicare and plans available via the Federal Health Insurance Marketplace); or
- Be without insurance or entitlement status and asked to pay a percentage of the cost of services.
Determining current eligibility and enrollment status is one of the first things to be completed upon receiving a request for services. For persons who are not Title XIX/XXI eligible, a financial screening and eligibility application must be completed to determine eligibility. Verification of an individual’s identification and citizenship/lawful presence in the United States is completed through the AHCCCS Health-e-Arizona PLUS (HEAPlus) application process. See AHCCCS AMPM Section 650 for additional information.
Medicare eligible Members, including persons who are dually eligible for Medicare (Title XVIII), Medicaid (Title XIX), and Children’s Health Insurance Program (CHIP) (Title XXI) receive Medicare Part D prescription drug benefits. The benefit also provides for Part D Extra Help for eligible individuals whose income and resources are limited. Dual Eligible individuals are automatically eligible for the Part D Extra Help due to their Medicaid eligibility. See AHCCCS AMPM Section 650 for additional information.
The following information will assist providers of covered services in:
- Accessing and interpreting eligibility and enrollment information;
- Conducting financial screenings and assisting persons with applying for Title XIX/XXI or other benefits; and
- Assessing potential eligibility for Medicare Part D Prescription Drug coverage and the Low Income Subsidy (LIS) program.
Providers must coordinate with AHCCCS acute care contractors, Primary Care Providers (PCP), Arizona Long Term Care System (ALTCS) contractors, service providers and eligible persons to share specific information to determine eligibility for Title XIX/XXI services and behavioral health coverage. In addition, providers must notify AHCCCS and The Health Plan of a Member's death, incarceration or relocation out-of-state that may affect a Member's eligibility status. Providers are required to have a policy and/or process in place for monitoring AHCCCS Eligibility and conducting timely screenings.
12.1.1 Title XIX/XXI Screening and Eligibility Procedures
Providers must screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with Section 12.1 - Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program.
- Verify the person’s Title XIX/XXI eligibility for all persons referred for services and at least monthly thereafter;
- For those persons who are not Title XIX/XXI eligible, screen for potential Title XIX/XXI or other eligibility; and
- As indicated by the screening tool, assist persons with applications for a Title XIX/XXI or other eligibility determination.
12.1.2 Step #1 - Accessing Title XIX/XXI or Other Eligibility Information
Providers who need to verify the eligibility and enrollment of an AHCCCS Member can use one of the alternative verification processes 24 hours a day, 7 days a week. These processes include:
- AHCCCS Web-based Verification (Customer Support 602-417-4451): This web site allows the providers to verify eligibility and enrollment. To use the web site, providers must create an account before using the applications. To create an account, go to the AHCCCS login page and follow the prompts. Once providers have an account they can view eligibility and claim information (claim information is limited to FFS). Batch transactions are also available. There is no charge to providers to create an account or view transactions. For technical web based issues, contact AHCCCS Customer Support at 602-417-4451 Monday – Friday from 7:00 a.m. to 5:00 p.m.
- AHCCCS Subcontracted Medical Electronic Verification Service (MEVS): The AHCCCS Member card can be “swiped” by providers to automatically access the AHCCCS Prepaid Medical Management System (PMMIS) for up to date eligibility and enrollment. For information on MEVS, contact the MEVS vendor: Emdeon at 1-800-444-4336.
- Interactive Voice Response (IVR) System: IVR allows unlimited verification information by entering the AHCCCS Member’s identification number on a touch-tone telephone. This allows providers access to AHCCCS’s PMMIS system for up to date eligibility and enrollment. There is no charge for this service. Providers may call IVR within Maricopa County at 602-417-7200 and all other counties at 1-800-331-5090.
- Medifax: Medifax allows providers to use a PC or terminal to access the AHCCCS PMMIS system for up to date eligibility and enrollment information. For information on EVS, contact Emdeon at 1-800-444-4336.
- AHCCCS 270/271 Eligibility Look-up.
If a person’s eligibility status still cannot be determined using one of the above methods, a provider must:
- Call The Health Plan Customer Service at 866-796-0542 for assistance during normal business hours (8:00 a.m. through 5:00 p.m. Monday-Friday); or
- Call the AHCCCS Verification Unit, which is open Monday through Friday, from 8:00 a.m. to 5:00 p.m. The Unit is closed Saturdays and Sundays and on state holidays. Callers from outside Maricopa County can call 1-800-962-6690, or 602-417-7000 in Maricopa County, and remain on the line for the next available representative. When calling the AHCCCS Verification Unit, the provider must be prepared to provide the verification unit operator the following information:
- The provider’s identification number;
- The Member’s name, date of birth, AHCCCS identification number; and social security number (if known); and
- Dates of service(s).
12.1.3 Step #2 - Interpreting Eligibility Information
A provider accesses important pieces of information when using the eligibility verification methods described in Step #1 above: AHCCCS eligibility key codes and/or AHCCCS rate codes. The AHCCCS Codes and Values (CV) 13 Reference System includes a key code index that may be used by providers to interpret AHCCCS eligibility key codes and/or AHCCCS rate codes. The Health Plan will ensure that providers have access to and are familiar with the codes as they may help indicate provider responsibility for the delivery of Title XIX/XXI covered services.
If eligibility status and provider responsibility is confirmed, the provider must provide any needed covered services in accordance with The Health Plan Provider Manual, the AHCCCS Covered Behavioral Health Services Guide, and the AHCCCS Medical Policy Manual.
There are some circumstances whereby a person may be Title XIX/XXI eligible but the State behavioral health system is not responsible for providing covered services. This includes persons enrolled as elderly or physically disabled (EPD) under the Arizona Long Term Care System (ALTCS) Program and persons eligible for family planning services only through the Sixth Omnibus Reconciliation Act (SOBRA) Extension Program. Persons who are Title XIX/XXI eligible through ALTCS must be referred to their ALTCS case manager to arrange for provision of Title XIX/XXI services. However, ALTCS-EPD individuals who are determined to have a SMI may also receive Non-Title XIX/XXI SMI services from The Health Plan. ALTCS-Division of Developmental Disabilities (DDD) persons’ services are provided through the AHCCCS behavioral health system.
If the person is not currently Title XIX/XXI eligible, proceed to Step #3 and conduct a screening for Title XIX/XXI or other eligibility.
12.1.4 Step #3 - Screening for Title XIX/XXI eligibility: When and Who to Screen for Title XIX/XXI or Other Eligibility
The Health Plan Providers are required to screen all Non-Title XIX/XXI persons using the Health-e Arizona PLUS (HEAPlus) online application.
- Upon initial request for services;
- At least annually or during each Federal Health Insurance Marketplace open enrollment period thereafter, if still receiving services; and
- When significant changes occur in the person’s financial status.
Behavioral health providers are required to assist individuals with applying for Federal and Arizona Public Programs (Title XIX/XXI, Federal Health Insurance Marketplace, Medicare Savings Programs, Nutrition Assistance, and Cash Assistance), and Medicare Prescription Drug Program (Medicare Part D), including the Medicare Part D “Extra Help with Medicare Prescription Drug Plan Costs” low income subsidy program prior to receiving Non-Title XIX/XXI covered behavioral health services, at the time of intake for behavioral health services. A screening is not required at the time an emergency service is delivered, but must be initiated within 5 days of the emergency service if the person seeks or is referred for ongoing services.
To conduct a screening for Title XIX/XXI or other eligibility, the provider meets with the person and completes AHCCCS eligibility screening through the Health-e Arizona PLUS online application for all Non-Title XIX/XXI persons. Documentation of AHCCCS eligibility screening must be included in a person’s comprehensive clinical record upon completion after initial screening, annual screening and screening conducted when a significant change occurs in a person’s financial status (see Section 10.2 — Medical Record Standards). The Health Plan will assist providers with contact information to obtain HEAPlus assistor modules and training from AHCCCS. Once completed, the screening tool will indicate:
- That the person is potentially AHCCCS eligible. Pending the outcome of the Title XIX/XXI or other eligibility determination, the person may be provided services in accordance with Section 7.22 — Copayments. Upon the final processing of an application, it is possible that a person may be determined ineligible for AHCCCS health insurance. If the person is determined ineligible for Title XIX/XXI or other benefits, the person may be provided services in accordance with Section 8.11 — Copayments.
- That the person does not appear Title XIX/XXI or AHCCCS eligible. If the screening tool indicates that the person does not appear to have Title XIX/XXI or any other AHCCCS eligibility, the person may be provided services in accordance with Section 7.22 — Copayments. However, the person may submit the application for review by DES and/or AHCCCS regardless of the initial screening result. Additional information requested and verified by DES/AHCCCS may result in the person receiving AHCCCS eligibility and services after all.
12.1.5 Reporting Requirements for Title XIX/XXI Eligibility Screening
The number of applicant screenings for Title XIX/XXI, SMI, and Federal Health Insurance Marketplace eligibility completed must be documented by providers and reported to The Health Plan on a monthly basis (RF-1011) as outlined in Section 16 – Deliverable Requirements. Technical assistance is available by calling The Health Plan Contracts Department.
The reporting is required to include the following elements:
- Number of applicants to be screened for AHCCCS eligibility;
- Number of applicant screenings for AHCCCS eligibility completed;
- Number of applicant screenings for AHCCCS eligibility to be completed;
- Number of AHCCCS eligible applicants as a result of the screening;
- Number of applicants to be screened for health coverage via the Federal Health Insurance Marketplace;
- Number of applicant screenings for health coverage via the Federal Health Insurance Marketplace completed;
- Number of applicant screenings for health coverage via the Federal Health Insurance Marketplace to be completed; and
- Number of applicants eligible for health coverage via the Federal Health Insurance Marketplace as a result of the screening.
12.1.6 Medicare Part D Prescription Drug Coverage and Low Income Subsidy (LIS) Eligibility
Persons must report to The Health Plan or the provider if they are eligible or become eligible for Medicare as it is considered third party insurance. See Section 7.24 — Third Party Liability and Coordination of Benefits regarding how to coordinate benefits for persons with other insurance including Medicare. If a Member is unsure of Medicare eligibility, The Health Plan or providers may verify Medicare eligibility by calling 1-800-MEDICARE (1-800-633-4227), with a Member’s permission and needed personal information. Once a person is determined Medicare eligible, The Health Plan providers must offer and provide assistance with Part D enrollment and the LIS application upon a Member’s request. The Health Plan providers shall track Part D enrollment and LIS application status of Members, and report tracking activities when required by AHCCCS.
22.214.171.124 Enrollment in Part D
All persons eligible for Medicare must be encouraged to and assisted in enrolling in a Medicare Part D plan to access Medicare Part D Prescription Drug coverage. Enrollment must be in a Prescription Drug Plan (PDP), which is fee-for-service Medicare plan or a Medicare Advantage Prescription Drug Plan (MA-PD), which is a managed care Medicare plan. Upon request, providers must assist Medicare eligible persons in selecting a Part D plan. The Centers for Medicare and Medicaid Services (CMS) developed web tools to assist with choosing a Part D plan that best meets the person’s needs. The web tools can be accessed at medicare.gov. For additional information regarding Medicare Part D Prescription Drug coverage, call Medicare at 1-800-633-4227 or the Arizona State Division of Aging and Adult Services at 602-542-4446 or toll free at 1-800-432-4040.
126.96.36.199 Applying for the Low Income Subsidy (LIS)
- The LIS is a program in which the federal government pays all or a portion of the cost sharing requirements of Medicare Part D on behalf of the person. If the provider determines that a person may be eligible for the LIS (see the Social Security Administration (SSA) website at www.ssa.gov for income and resource limits), the provider must offer to assist the person in completing an application.
- Applications can be obtained and submitted through the following means:
- Online at the SSA website
- By calling 1-800-772-1213 or TTY 1-800-325-0078, Monday – Friday, 7 AM – 7 PM.
- In person at a SSA local office; or
- By mailing a paper application to the SSA.
188.8.131.52 Federal Health Insurance Marketplace
Providers must educate and encourage Non-Title Members with SMI to apply for health coverage from a qualified health plan using the application process located at the Federal Health Insurance Marketplace and offer assistance for those choosing to enroll during open enrollment periods and qualified life events. Members enrolled in a qualified health plan through the Federal Health Insurance Marketplace may continue to be eligible for Non-Title XIX/XXI covered services that are not covered under the Federal Health Insurance Marketplace plan.
12.1.7 Refusal to Participate With Screening and/or Application Process for Title XIX/XXI or Other AHCCCS Eligibility or Enrollment in a Part D Plan
On occasion, a person may decline to participate in the AHCCCS eligibility screening and application process or refuse to enroll in a Medicare Part D plan. In these cases, the provider must actively encourage the person to participate in the process of screening and applying for AHCCCS health insurance coverage or enrolling in a Medicare Part D plan.
Arizona state law provides that persons who refuse to participate in the AHCCCS screening and eligibility application process or to enroll in a Medicare Part D plan are ineligible for state funded services (see A.R.S. § 36-3408). As such, individuals who refuse to participate in the AHCCCS screening and eligibility application or enrollment in Medicare Part D, if eligible, will not be enrolled with The Health Plan during their initial request for services or will be dis-enrolled if the person refuses to participate during an annual screening. The following conditions do not constitute a refusal to participate:
- A person’s inability to obtain documentation required for the eligibility determination;
- Persons incapable of participating as a result of their mental illness and does not have a legal guardian; and/or
- A person who is enrolled in a qualified health plan through the Federal Health Insurance Marketplace and refuses to take part in the AHCCCS screening and application process will not be eligible for Non-Title XIX/XXI SMI funded services.
If a person refuses to participate in the screening and/or application process for Title XIX/XXI or other eligibility, or to enroll in a Part D plan, the provider must ask the person to sign the AHCCCS AMPM Chapter 600 Section 650, Attachment A, Decline to Participate in AHCCCS Screening or Referral Process. If individuals refuse to sign the form, the provider must document their refusal to sign in the comprehensive clinical record (See Section 10.2 — Medical Records Standards).
184.108.40.206 Special Considerations for Persons Determined to Have a Serious Mental Illness (SMI)
If a person who is eligible for or requesting services as a person determined to have a SMI is unwilling to complete the eligibility screening or application process for Title XIX/XXI or to enroll in a Part D plan and does not meet the conditions above, the provider must request a clinical consultation by a Behavioral Health Medical Professional. If the person continues to refuse following a clinical consultation, the provider must request that the person sign the AHCCCS AMPM Chapter 600 Section 650, Attachment A, Decline to Participate in AHCCCS Screening or Referral Process. Prior to the termination of services for persons with a SMI who have been receiving behavioral health services and subsequently decline to participate in the screening/referral process, The Health Plan must provide written notification of the intended termination using the Appeal or Serious Mental Illness Grievance Form located in the AHCCCS ACOM Chapter 400, Section 446, Attachment A. Also see Section 8.5 — Notice and Appeal Requirements (SMI and GMH/SA Non-Title XIX/XXI).
220.127.116.11 Persons Who Refuse to Cooperate With the AHCCCS Eligibility and/or Application Process or Who Do Not Enroll in a Part D Plan
The provider must inform the person who they can contact in the behavioral health system for an appointment if the person chooses to participate in the eligibility and/or application process in the future. Members may call the behavioral health provider, The Health Plan Customer Services at 866-918-4450 8:00 a.m. – 5:00 p.m., Monday – Friday, or the Crisis Call Center at 866-918-4450 for assistance.
It is vital that the State behavioral health system be responsive and accessible to all the persons it serves. It is the expectation of the State that provider response to a person’s identified behavioral health service need is timely and based on clinical need, resulting in the best possible behavioral health outcomes for that person.
Response time is always determined by the acuity of individuals assessed behavioral health condition at the moment they are in contact with the provider. The State has organized responses into two categories: urgent responses and routine responses.
Please note that at the time it is determined that an urgent response is needed, a person’s eligibility and enrollment status may not be known. Providers must respond to all persons in urgent need until the situation is clarified that the provider is not financially responsible. Persons who are determined ineligible for covered services may be referred to applicable community resources.
Per AHCCCS Appointment Availability policy, providers will be monitored for appointment availability standards quarterly through telephonic surveys and reviews of provider schedules during face-to-face site visits. Results of the surveys are reviewed in the Quality Management Performance Improvement Committee Meeting to determine the need for performance improvement projects, corrective actions or closing of panels. Appointment Availability concerns will be addressed in subsequent technical assistance sessions with the assigned provider engagement staff. Appointment Availability performance issues may result in closed panels and overall network trends will be reported out in the monthly Essential Provider Calls.
Providers must develop and implement policies and procedures to monitor the availability and timeliness of appointments for Members and providers must disseminate information regarding appointment standards to Members, service providers, and Out-of-Network providers. Providers also must clearly post hours of operation in a location accessible to Members. For more information on appointment standards, see the AHCCCS ACOM Policy 417 on Appointment Standards and Timeliness of Services.
12.2.1 Type of Response by a Behavioral Health Provider (Non- Hospitalized Persons)
For Behavioral Health Provider Appointments:
- Urgent need appointments as expeditiously as the member’s health condition requires but no later than 24 hours from identification of need;
- Routine care appointments:
- Initial assessment within seven (7) calendar days of referral or request for service;
- The first behavioral health service following the initial assessment as expeditiously as the member’s health condition requires but
- for members age 18 years or older, no later than twenty-three (23) calendar days after the initial assessment
- for members under the age of 18 years old, no later than twenty-one (21) days after the initial assessment and
- All subsequent behavioral health services, as expeditiously as the member’s health condition requires but no later than forty-five (45) calendar days from identification of need.
For Psychotropic Medications:
- Assess the urgency of the need immediately; and
- Provide an appointment, if clinically indicated, with a practitioner who can prescribe psychotropic medication within a timeframe that ensures the member a) does not run out of needed medications, or b) does not decline in his/her behavioral health condition prior to starting medication, but no later than 30 calendar days from the identification of need.
For Behavioral Health Appointments for persons in legal custody of the Department of Child Safety (DCS) and adopted children in accordance with A.R.S. §8-512.01:
- Rapid response when a child enters out-of-home placement within the timeframe Iindicated by the behavioral health condition, but no later than seventy-two (72) hours after notification by DCS that a child has been or will be removed from their home,
- Initial assessment within seven calendar days after referral or request for behavioral health services,
- Initial appointment within timeframes indicated, by clinical need, but no later than twenty-one (21) calendar days after the initial assessment; and
- Subsequent Behavioral Health Services within the timeframes according to the needs of the person, but no longer than twenty-one (21) calendar days from the identification of need.
Note: Standards for persons receiving services as part of SABG Grant funding are in Section 12.10 — Special Populations.
12.2.2 Behavioral Health Home Appointment Availability and Scheduling
In accordance with the requirements in this Provider Manual, providers must maintain adequate urgent, and routine outpatient office and in-home appointments to meet the needs of Members in their areas. For more information regarding Appointment Availability Requirements see AHCCCS ACOM Policy 417.
At all clinics open four or more days per week, Behavioral Health Home providers must provide intake and clinical office services during evenings (until at least 7:00 PM and at least two (2) nights per week) and on Saturdays. Behavioral Health Home providers providing routine outpatient services must verify that at least fifteen percent (15%) of a clinic’s scheduled hours of operation are outside of regular business hours (8:00 AM – 5:00 PM, Monday through Friday) in each community served.
Behavioral Health Home providers must maintain daily appointment slots for urgent treatment appointments in each community served. Behavioral Health Home providers also must make available additional urgent psychiatric appointments each week of at least thirty (30) minute duration each and not fill the urgent appointment slots prior to two (2) business days before the date of the urgent appointment.
Behavioral Health Home providers must collaborate with The Health Plan in maintaining a centralized after-hours scheduling system to facilitate after-hours urgent and appointment scheduling. The Behavioral Health Home provider must review and monitor the online centralized schedule at least twice a day to facilitate effective coordination of care. In each community served, a Behavioral Health Home provider must “block” one (1) hour per day of scheduling time in the late afternoon to allow The Behavioral Health Plan and/or its crisis telephone vendor to schedule urgent and emergent psychiatric and intake appointments. If by 8:00 AM on a given day no appointment has been booked in the “blocked” time, the Behavioral Health Home provider may release the “blocked” time for other appointments.
12.2.3 Wait Times
The State has established standards so that persons presenting for scheduled appointments do not have to wait unreasonable amounts of time. Unless a provider is unavailable due to an emergency, a person appearing for an established appointment must not wait for more than one hour. Providers are required to monitor wait times via a daily log to include the time the member arrived, the time of the scheduled appointment and the time the member was taken back to appointment. Providers offering open access or walk-in appointments must carefully monitor wait times and offer Members the opportunity to schedule an appointment if the waiting time is anticipated to exceed two hours.
Providers arranging for, or providing medically necessary non-emergency transportation services for Members must adhere to the following standards:
- Member arrives on time for an appointment, but no sooner than one hour before the appointment;
- Members must not have to wait for more than one hour after the conclusion of their treatment for transporation home.
- Providers must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standard for all subcontracted transportation vendors/brokers and require corrective action if standards are not me.
12.2.4 72-Hour Urgent Behavioral Health Response for Children Taken into the Arizona Department of Children’s Safety (DCS) Custody
An urgent response, known as “Rapid Response” (within 72 hours), is required for all children who are taken into the custody of ADES/DCS regardless of Title XIX/XXI eligibility status.
The purpose for this rapid response service is to identify immediate safety needs and presenting problems of the child, to stabilize behavioral health crises, and to establish services that will lead to family reunification, when appropriate.
More specific details and requirements of the 72-Hour Rapid Response can be found in Provider Manual Section 14.2.1, 72-Hour Rapid Response Requirements for Children Removed by DCS and the Provider Manual Form 6.1.1 Urgent Response Disposition which can be obtained by calling the Provider Service Center at 1-866-796-0542.
12.2.5 Appointments for Psychotropic Medications
For persons who may need to be seen by a Behavioral Health Medical Practitioner (BHMP), it is required that the person’s need for medication be assessed immediately and, if clinically indicated, that the person be scheduled for an appointment within a timeframe that ensures:
- The person does not run out of any needed psychotropic medications; or
- Individuals are evaluated for the need to start medications to verify that the person does not experience a decline in their behavioral health condition, but no later than thirty (30) calendar days from the identification of need.
Response for 387, or Requests for Psychotropic Medications:
|Referral for psychotropic medications||
Assess the urgency of the need immediately.
If clinically indicated, provide an appointment with a BHMP within a timeframe indicated by clinical need, but no later than 30 calendar days from the referral/initial request for services.
Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate.
|All initial assessments and treatment recommendations that indicate a need for psychotropic medications||
The initial assessment and treatment recommendations must be reviewed by a BHMP within a timeframe based on clinical need.
Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate.
12.2.6 Referrals for Hospitalized Persons
Providers must quickly respond to referrals pertaining to eligible persons not yet enrolled in The Health Plan or Title XIX/XXI eligible persons who have not been receiving services prior to being hospitalized for psychiatric reasons and persons previously determined to have a SMI. Upon receipt of such a referral, the following steps must be taken:
- For referrals of Title XIX/XXI eligible persons and persons previously determined to have a SMI, initial face-to-face contact, an assessment and disposition must occur within 24 hours of the referral/request for services.
- For referrals of Non-Title XIX/XXI eligible persons and persons referred for eligibility determination of SMI:
- Initial face-to-face contact and an assessment must occur within 24 hours of the referral/request for services. Determination of SMI eligibility must be made within timeframes consistent with and in accordance with Section 12.6 — SMI Eligibility Determination; and
- Upon the determination that the person is eligible for services and the person is in need of continued behavioral health services, the person must be enrolled and the effective date of enrollment must be no later than the date of first contact.
12.2.7 Other Requirements
All referrals from a person’s primary care provider (PCP) requesting a psychiatric evaluation and/or psychotropic medications must be accepted and acted upon in a timely manner according to the needs of the person, and the response time must help ensure that the person does not experience a lapse in necessary psychotropic medications, as described in Section 12.2.5 — Appointments for Psychotropic Medications.
Title XIX/XXI persons must never be placed on a “wait list” for any Title XIX/XXI covered behavioral health service. If The Health Plan network is unable to provide medically necessary covered services for Title XIX/XXI persons, The Health Plan must ensure timely and adequate coverage of needed services through an alternative provider until a network provider is subcontracted. In this circumstance, The Health Plan must ensure coordination with respect to authorization and payment issues. In the event that a covered behavioral health service is temporarily unavailable to a Title XIX/XXI eligible person, the provider must adhere to the following procedure:
- Maintain the current level of services being provided to the person;
- Identify and provide any supportive services needed by the person while securing the needed service;
- Verify the creation of a service plan and a crisis plan for the Title XIX/XXI Member and verify that the person understands how to access crisis services during this time; and
- Contact The Health Plan’s Utilization Management Department at 1-888-788-4408 to coordinate and track care while securing the service, and to discuss needs for any non-contracted services, including for persons who are in an inpatient or residential facility and are awaiting a referral for outpatient services.
12.2.8 Special Populations
The State receives some funding for services through the Federal Substance Abuse Block Grant (SABG). SABG funds are used to provide substance abuse services for Non-Title XIX/XXI eligible persons. As a condition of receiving this funding, certain populations are identified as priorities for the timely receipt of designated services. Any providers contracted with The Health Plan for SABG funds must follow the requirements found in this Section. For all other providers that do not currently receive these funds, the following expectations do not apply.
18.104.22.168 SABG Block Grant Populations
The following populations are prioritized and covered under the SABG Block Grant:
- First: Pregnant females who use drugs by injection;
- Then: Pregnant females who use substances;
- Then: Other injection drug users;
- Then: Substance-using females with dependent children, including those attempting to regain custody of their child(ren); and
- Finally: All other persons in need of substance abuse treatment.
Response Times for Designated Behavioral Health Services under the SABG Block Grant:
Behavioral health services provided within a timeframe indicated by clinical need, but no later than 48 hours from the referral/initial request for services.
Any needed covered behavioral health service, including admission to a residential program if clinically indicated;
If a residential program is temporarily unavailable, an attempt shall be made to place the person within another provider agency facility, including those in other geographic service areas. If capacity still does not exist, the person shall be placed on an actively managed wait list and interim services must be provided until the individual is admitted. Interim services include: counseling/education about HIV and Tuberculosis (include the risks of transmission), the risks of needle sharing and referral for HIV and TB treatment services if necessary, counseling on the effects of alcohol/drug use on the fetus and referral for prenatal care.
Pregnant individuals/teenagers referred for substance abuse treatment (includes pregnant injection drug users and pregnant substance abusers) and substance-using females with dependent children, including those attempting to regain custody of their child(ren).
Behavioral health services provided within a timeframe indicated by clinical need but no later than 14 days following the initial request for services/referral.
All subsequent services must be provided within timeframes according to the needs of the person.
Includes any needed covered behavioral health services;
Admit to a clinically appropriate substance abuse treatment program (can be residential or outpatient based on the person’s clinical needs); if unavailable, interim services must be offered to the person. Interim services shall minimally include education/interventions with regard to HIV and tuberculosis and the risks of needle sharing and must be offered within 48 hours of the request for treatment.
All other injection drug users
Behavioral health services provided within a timeframe indicated by clinical need but no later than 23 days following the initial assessment.
All subsequent behavioral health services must be provided within timeframes according to the needs of the person.
Includes any needed covered behavioral health services.
All other persons in need of substance abuse treatment
The referral process serves as the principal pathway by which persons are able to gain prompt access to publicly supported services. The intake process serves to collect basic member information in order to enroll members in the AHCCCS system, screen for Title XIX/XXI AHCCCS eligibility and determine the need for any copayments (See Section 7.22 — Copayments). It is critical that both the referral process and intake process are culturally sensitive, efficient, engaging, and welcoming to the member and/or family member seeking services, and leads to the provision of timely and appropriate services based on the urgency of the situation.
A “referral” is any oral, written, faxed or electronic request for services made by the Member or Member’s legal guardian, family member, an AHCCCS Acute Contractor, PCP, hospital, court, Tribe, IHS, school, or other state or community agency.
Providers must not arbitrarily or prematurely reject or disqualify a Member from services/referrals without prior authorization by The Health Plan. Providers must resolve referral disputes promptly, relative to the urgency of the situation. The Health Plan will promptly intervene and resolve any dispute between a provider and a referring source when those parties cannot informally resolve disputes regarding the need for emergency, urgent, or routine appointments. See ACOM Policy 580 Behavioral Health Referral and Intake Process.
The Health Plan providers are responsible for managing referrals and wait lists for Non-Title XIX/XXI persons in accordance with the SABG Block Grant for identified priority populations when services are temporarily unavailable. See AMPM Policy 650 Behavioral Health Provider Reaquiremetns for Assisting Individuals with Eligibility Verification and Screening/Application for Public Health Benefits.
If The Health Plan network is unable to provide medically necessary services to Title XIX/XXI persons, The Health Plan will verify timely and adequate coverage of needed services through an out-of-network provider until a network provider is contracted (See Section 12.2 — Appointment Standards and Timeliness of Service (PDF).
To facilitate a Member’s access to services in a timely manner, providers will maintain an effective process for the referral and intake for services that includes:
- Communicating to potential referral sources the process for making referrals (e.g., centralized intake, identification of providers accepting referrals);
- Collecting enough basic information about the person to determine the urgency of the situation and subsequently scheduling the initial assessment within the required timeframes and with an appropriate provider (See Section 12.2 — Appointment Standards and Timeliness of Service);
- Adopting a welcoming, trauma-informed, and engaging manner with the member and/or member's legal guardian/family member;
- Ensuring that intake interviews are culturally appropriate and delivered by providers who are respectful and responsive to the Member’s cultural needs (see Section 12.14 — Cultural Competence);
- Keeping information or documents gathered in the referral process confidential and protected in accordance with applicable federal and State statutes, regulations and policies;
- Informing, as appropriate, the referral source about the final disposition of the referral; and
- Conducting intake interviews that ensure the accurate collection of all the required information necessary and ensure Members who have difficulty communicating because of a disability or who require language assistance are afforded appropriate accommodations to assist them in fully expressing their needs.
12.3.2 Where to Send Referrals
The Health Plan maintains a provider directory on its website that is available to AHCCCS Health Plans and Department of Economic Security District Program Administrators (DES). A printed copy can be made available upon request. The directory indicates which providers are accepting referrals and conducting initial assessments and intakes. It is important for providers to promptly notify The Health Plan of any changes that would impact the accuracy of the provider directory (e.g., change in telephone or fax number, no longer accepting referrals).
Individuals may access services by directly contacting a Behavioral Health Home. Contracted Behavioral Health Homes are identified on The Health Plan website (www.azcompletehealth.com ) and in The Health Plan Member Handbook. Members may also call The Health Plan Customer Service at 1-866-796-0542, 24 hours a day/7 days a week, and receive a referral to a contracted Health Home. During normal business hours, The Health Plan will transfer callers to an intake provider. After-hour referrals are provided to Health Home providers who are expected to follow up on the referral. The Crisis Call Center staff tracks referrals to verify the caller is appropriately connected with a Health Home. In addition, the Crisis Call Center has access to emergent and urgent psychiatric appointments at intake provider sites and can schedule these appointments on the Member’s behalf.
Providers are required to notify The Health Plan of any changes that would alter or change the information provided through the directory. A 30-day notice is required for changes in telephone number, fax number, email address, service changes, staff changes, service capacity changes or ability to accept new referrals as outlined in Section 16 — Deliverable Requirements.
12.3.3 Choice of Providers
The Health Plan offers Members a choice in selecting providers, and providers are required to provide each Member a choice in selecting a provider of services, provider agency, and direct care staff. Providers are required to allow Members to exercise their right to services from an alternative In-Network provider, and offer each Member access to the most convenient In-Network service location for the service requested by the Member. In addition, providers must make available all Covered Services to all Title XIX/XXI eligible American Indians, whether they live on or off reservation. Eligible American Indian Members may choose to receive services through a RBHA/MCO/Health Plan, Tribal and Regional Behavioral Health Authorities, or through an IHS or 638 tribal provider.
12.3.4 Referral to a Provider for a Second Opinion
Title XIX/XXI Members are entitled to a second opinion and providers are required to provide proof that each Member is informed of the right to a second opinion.
Upon a Title XIX/XXI eligible Member’s request or at the request of the provider’s treating physician, the provider must—at no cost to the Member—make available a second opinion from a qualified health care professional either within the network, or arrange for the Member to obtain a second opinion from a qualified health care professional outside the network (42 CFR 438.206(b)(3)). For purposes of this section, a “qualified health care professional” is (a) an AHCCCS registered provider of covered health services (b) who is a physician, a physician assistant, a nurse practitioner, a psychologist, or an independent Master’s level therapist.
A behavioral health provider can arrange for a second opinion in-network or can contact the Health Plan Customer Service at 1-866-796-0542, 8:00 a.m. – 5:00 p.m. Monday – Friday, for assistance. Out-of-Network requests should be submitted to The Health Plan Medical Management department for review and processing. A provider must maintain a record identifying both (1) the date of service for the second opinion and (2) the name of the provider who provided the second opinion. There must be documentation in the clinical chart of the following:
- Rationale for the use of two medications from the same pharmacological class;
- Rationale for the use of more than three different psychotropic medications in adults; and
- Rationale for the use of more than one psychotropic medication in the child and adolescent population.
12.3.5 Referrals Initiated by Department of Economic Security/ Department of Child Safety (DES/DCS) Pending the Removal of a Child
Upon notification from DES/ Department of Child Safety (DCS) that a child has been, or is at risk of being taken into the custody of DES/Department of Child Safety (DCS), providers are expected to respond in an urgent manner (for additional information, see Section 12.2 — Appointment Standards and Timeliness of Service and AHCCCS Practice Protocol (PDF), Unique Needs of Children, Youth and Families Involved with Child Protective Services).
12.3.6 Accepting Referrals
Providers must establish written procedures for accepting and acting upon referrals, including emergency referrals. Providers must accept referrals for services as identified in the provider’s contract with the Health Plan, unless The Health Plan grants a written waiver or suspension of this requirement. Providers must not arbitrarily or prematurely reject or eject a Member from services/referrals without prior authorization of the Health Plan. Providers must accept referrals, regardless of diagnosis, level of functioning, age, Member’s status in family, or level of service needs. (See 42 CFR 438.210 (a)(3)(iii))
Providers must accept and respond to emergency referrals of Title XIX/XXI eligible Members and Non-Title XIX/XXI Members with SMI twenty-four (24) hours a day, seven (7) days a week. Emergency referrals do not require prior authorization. Emergency referrals include those initiated for Title XIX/XXI eligible and Non-Title XIX/XXI with SMI Members admitted to a hospital or treated in the emergency room. Providers must respond within twenty-four (24) hours upon receipt of an emergency referral.
The following information shall be collected from referral sources:
- Date and time of referral;
- Information about the referral source including name, telephone number, fax number, affiliated agency, and relationship to the person being referred;
- Name of person being referred, address, telephone number, gender, age, date of birth and, when applicable, name and telephone number of parent or legal guardian;
- Whether or not the person, parent, or legal guardian is aware of the referral;
- Transportation and other special needs for assistance due to impaired mobility, blindness/low vision or being deaf or hard of hearing, or developmental or cognitive impairment;
- Accommodations due to cultural uniqueness and/or the need for interpreter services;
- Information regarding payment source (i.e., AHCCCS, private insurance, Medicare or self-pay) including the name of the AHCCCS health plan or insurance company;
- Name, telephone number, and fax number of AHCCCS primary care provider (PCP) or other PCP as applicable;
- Reason for referral including identification of any potential risk factors such as recent hospitalization, evidence of suicidal or homicidal thoughts, pregnancy, and current supply of prescribed psychotropic medications;
- Medications prescribed by the Member’s PCP or other medical professional including the reason why the medication is being prescribed; and
- The names and telephone numbers of individuals the Member, parent, or guardian may wish to invite to the initial appointment with the referred Member.
Providers should act on a referral regardless of how much information they obtained. While the information listed above will facilitate evaluating the urgency and type of practitioner the Member may need to see, timely triage and processing of referrals must not be delayed because of missing or incomplete information.
When psychotropic medications are a part of a member's treatment or have been identified as a need by the referral source, providers must respond as outlined in Section 12 — Appointment Standards and Timeliness of Service.
When individuals seek services, or their family member, legal guardian, or significant other contacts a provider directly about accessing services, provider shall ensure that the protocol used to obtain the necessary information about the person seeking services is engaging and welcoming.
When a SMI eligibility determination is being requested as part of the referral or by the person directly, providers must conduct an eligibility determination for SMI in accordance with Section 12.6 — SMI Eligibility Determination. The SMI assessment and pending determination will not delay behavioral health service delivery to the Member.
12.3.7 Responding to Referrals
Follow-Up: When a request for services is initiated but the Member does not appear for the initial appointment, the provider must attempt to contact the Member and implement engagement activities consistent with Section 12.4 — Outreach, Engagement, Re-engagement and Closure. The provider must also attempt to notify the entity that made the referral.
Final Dispositions: Within 30 days of receiving the initial assessment, or if the person declines services, within 30 days of the initial request for services, the provider must notify the following referral sources of the final disposition:
- AHCCCS health plans;
- AHCCCS PCPs;
- Arizona Department of Economic Security;
- Arizona Department of Child Safety;
- Arizona Department of Economic Security/Division of Developmental Disabilities;
- Arizona Department of Corrections;
- Arizona Department of Juvenile Corrections;
- County Adult and Juvenile Detention Centers;
- Administrative Offices of the Court;
- Arizona Department of Economic Security/Rehabilitation Services Administration; and
- Arizona Department of Education and affiliated school districts.
The final disposition must include 1) the date the Member was seen for the initial assessment; and 2) the name and contact information of the provider who will assume primary responsibility for the Member’s behavioral health care, or 3) if no services will be provided, the reason why. When required, authorization to release information will be obtained prior to communicating the final disposition to the referral sources referenced above. (See Section 10.2.8 — Disclosure of Records).
12.3.8 Documenting and Tracking Referrals
The Health Plan provider shall document and track all referrals for services including, at a minimum, the following information:
- Person’s name and, if available, AHCCCS identification number;
- Name and affiliation of referral source;
- Date of birth;
- Type of referral (immediate, urgent, routine) as defined in Section 12.2 — Appointment Standards and Timeliness of Service;
- Date and time the referral was received;
- If applicable, date and location of first available appointment and, if different, date and location of actual scheduled appointment; and
- Final disposition of the referral.
12.3.9 Eligibility Screening and Supporting Documentation
Persons who are not already AHCCCS eligible must be asked to bring supporting documentation to the screening interview to assist the provider in identifying if the person could be AHCCCS eligible (See Section 12.1 — Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program (PDF). Explain to the person that the supporting documentation will only be used for the purpose of assisting the person in applying for AHCCCS health care benefits. Let the person know that AHCCCS health care benefits may help pay for services, and ask the person to bring the following supporting documentation to the screening interview:
- Verification of gross family income for the last month and current month (e.g., pay check stubs, social security award letter, retirement pension letter);
- Social security numbers for all family members (social security cards if available);
- For those who have other health insurance, bring the corresponding health insurance card (e.g., Medicare card);
- For all applicants, documentation to prove United States citizenship or immigration status and identity);
- For those who pay for dependent care (e.g., adult or child daycare), proof of the amount paid for the dependent care; and
- Verification of out-of pocket medical expenses.
12.3.10 Intake Interviews
Providers must conduct intake interviews in an efficient and effective manner that is both “person friendly,” trauma-informed, and verifies the accurate collection of all required information necessary for enrollment into the system or for collection of information for AHCCCS eligible individuals who are already enrolled. The intake process must:
- Be flexible in terms of when and how the intake occurs. For example, in order to best meet the needs of the person seeking services, the intake might be conducted over the telephone prior to the visit, at the initial appointment prior to the assessment and/or as part of the assessment; and
- Make use of readily available information (e.g., referral form, AHCCCS eligibility screens) in order to minimize any duplication in the information solicited from the person and family members.
During the intake, the provider will collect, review, and disseminate certain information to persons seeking services. Examples can include:
- The collection of contact information, insurance information, the reason why the person is seeking services and information on any accommodations the person may require to effectively participate in treatment services (i.e., need for oral interpretation or sign language assistance, consent forms in large font, etc.).
- The collection of required member information and completion of client member information sheet, including the Member’s primary/preferred language (see Section 6.1 - Enrollment, Disenrollment and other Data Submission);
- The completion of any applicable authorizations for the release of information to other parties (see Section 10.2.8 — Disclosure of Records);
- Advising the member that The Health Plan Member Handbook is available to them (see Section 3 — The Health Plan Member Handbook);
- The review and completion of a general consent to treatment (see Section 12.7 — General and Informed Consent to Treatment);
- The collection of financial information, including the identification of third party payers and information necessary to screen and apply for AHCCCS health insurance, when necessary (see Section 12.1 — Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program and 7.24 — Third Party Liability and Coordination of Benefits);
- Advising Non-Title XIX/XXI persons determined to have a SMI that they may be assessed a copayment (see Section 7.22 — Copayments);
- The review and dissemination of The Health Plan Notice of Privacy Practices and the AHCCCS HIPAA Notice of Privacy Practices in compliance with 45 CFR 164.520 (c)(1)(B) (PDF); and
- The review of the person’s rights and responsibilities as a Member of services, including an explanation of the appeal process.
The person and/or family members may complete some of the paperwork associated with the intake, if acceptable to the person and/or family members.
Providers conducting intakes must be appropriately trained, approach the person and family in an engaging manner, and possess a clear understanding of the information that needs to be collected.
12.3.11 Specialty Behavioral Health Agency Referrals
All Health Plan contracted providers are responsible for ensuring timely and appropriate service delivery as requested by the member and/or as determined necessary to meet the member’s needs. Specialty Behavioral Health Agencies are responsible for determining medical necessity for specialty services and regularly reporting progress to Behavioral Health Homes and PCPs as appropriate.
12.3.12 Referrals for Screening and/or Diagnosis of Autism Spectrum Disorders
The Health Plan covers medically necessary behavioral health services for all AHCCCS-eligible children and adults, including the diagnosis and treatment for individuals who may have an Autism Spectrum Disorder (ASD).
AHCCCS-eligible families who are engaged in services within the Health Plan, and who believe an adult or child may have ASD, should schedule an appointment with their psychiatrist or primary care provider.
Children and adults not currently engaged with a behavioral health provider in the Health Plan should first see their primary care provider, who can then refer the child and family to a specialized ASD diagnosing provider.
Completion of an intake at a Health Home or Behavioral Health Provider is not required for families seeking a one-time consultation for diagnosis, or to rule out Autism Spectrum Disorder.
The activities described within this section are an essential element of clinical practice. Outreach to vulnerable populations, establishing an inviting and non-threatening clinical environment, and re-establishing contact with persons who have become temporarily disconnected from services are critical to the success of any therapeutic relationship.
This section addresses five critical activities that providers must incorporate when delivering services within Arizona’s public behavioral health system:
- Expectations for outreach activities directed to persons who are at risk for the development or emergence of behavioral health disorders;
- Establish expectations for the engagement of persons seeking or receiving services behavioral health services.
- Determine procedures to re-engage persons who have withdrawn from participation in the treatment process,
- Describe conditions necessary to end re-engagement activities for a person in the behavioral health system; and
- Establish expectations for serving persons who are attempting to re-enter the behavioral health system. See AMPM 1040 (PDF) and AMPM 310-B (PDF).
12.4.1 Outreach Activities
Behavioral Health Home providers must provide outreach activities to inform the public of the benefits and availability of services and how to access them. The Health Plan disseminates and requires providers to disseminate information to the general public, other human service providers, school administrators and teachers, and other interested parties regarding the services that are available to eligible persons.
Outreach activities conducted by The Health Plan and providers may include, but are not limited to:
- Participation in community events, local health fairs, or health promotion activities;
- Involvement with local schools;
- Involvement with outreach activities for military veterans, such as Arizona Veterans Stand Down Coalition events,
- Development of outreach programs and activities for first responders (i.e. police, fire, EMT),
- Routine contact with AHCCCS Health Plan behavioral health coordinators and/or primary care providers;
- Development of homeless outreach programs;
- Development of outreach programs to persons who are at risk, are identified as a group with high incidence or prevalence of behavioral health issues, or are underserved;
- Publication and distribution of informational materials;
- Liaison activities with local, county and tribal jails, prisons, county detention facilities, and local and county Department of Child Safety DCS offices and programs,
- Routine interaction with agencies that have contact with substance abusing pregnant members/teenagers;
- Conduct home visits;
- Development and implementation of outreach programs that identify persons with co-morbid medical and behavioral health disorders and those who have been determined to have a SMI within The Health Plans geographic service area, including persons who reside in jails, homeless shelters, county detention facilities, or other settings;
- Provision of information to behavioral health advocacy organizations; and
- Development and coordination of outreach programs to Native American tribes in Arizona to provide services for tribal members.
In addition to the above outreach activities, the Crisis Call Center telephonically conducts outreach to new AHCCCS enrollees to educate them about the availability of behavioral health services and how to access services, and to assist in removing stigma associated with obtaining services.
Providers must provide services in a culturally competent manner in accordance with The Health Plan Cultural Competency Plan (see Section 9.2 — Cultural Competence).
Providers are required to:
- Provide a courteous, welcoming environment that provides persons with the opportunity to explore, identify, and achieve their personal goals;
- Engage persons in an empathic, hopeful, and welcoming manner during all contacts;
- Provide culturally relevant care that addresses and respects language, customs, and values and is responsive to the person’s unique family, culture, traditions, strengths, and age, to meet the needs of members with diverse cultural and ethnic backgrounds, including those with limited English Proficiency, disabilities, and regardless of gender, sexual orientation or gender identity (see Section 3.15 — Cultural Competence);
- Provide an environment in which consumers from diverse cultural backgrounds feel comfortable discussing their cultural health beliefs and practices in the context of negotiating treatment options;
- Provide care by communicating to Members in their preferred language and verifying that they understand all clinical and administrative information (see Section 9.2 — Cultural Competence);
- Be aware of and seek to gain an understanding of persons with varying disabilities and characteristics;
- Display sensitivity to, and respect for, various cultural influences and backgrounds (e.g. ethnic, racial, gender identity, sexual orientation, and socio-economic class);
- Establish an empathic service relationship in which the person experiences the hope of recovery and is considered to have the potential to achieve recovery while developing hopeful and realistic expectations;
- Demonstrate the ability to welcome the person, and/or the person’s legal guardian, the person’s family members, others involved in the person’s treatment and other service providers as collaborators in the treatment planning and implementation process;
- Demonstrate the desire and ability to include the person’s and/or legal guardian’s viewpoint and to regularly validate the daily courage needed to recover from persistent and relapsing disorders;
- Assist in establishing and maintaining the person’s motivation for recovery; and
- Provide information on available services and assist the person and/or the person’s legal guardian, the person’s family, and the entire clinical team in identifying services that help meet the person’s goals.
Providers must attempt to re-engage persons in treatment who have withdrawn from participation in the treatment process prior to the successful completion of treatment, refused services or failed to appear for a scheduled services. All attempts to re-engage persons who have withdrawn from treatment, refused services, or failed to appear for scheduled services must be documented in the comprehensive clinical record. The provider must attempt to re-engage the person by:
- Communicating in the person’s preferred language;
- Contacting the person or the person’s legal guardian by telephone, at times when the person may reasonably be expected to be available (e.g., after work or school);
- Whenever possible, contacting the person or the person’s legal guardian face-to-face, if telephone contact is insufficient to locate the person or determine acuity and risk;
- Sending a letter to the current or most recent address requesting contact, if all attempts at personal contact are unsuccessful, except when a letter is contraindicated due to safety concerns (e.g., domestic violence) or confidentiality issues. The provider will note safety or confidentiality concerns in the progress notes section of the clinical record and include a copy of the letter sent in the comprehensive clinical record; and
- For persons determined to have a Serious Mental Illness who are receiving Special Assistance (see AHCCCS AMPM section 320-R)
If the above activities are unsuccessful, the provider must make further attempts to re-engage persons determined to have a SMI, persons under court ordered treatment, children (including children in foster care), pregnant substance abusing members/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others. Further attempts may include contacting the person or person’s legal guardian, face-to-face visits, or contacting natural supports who the Member has given permission to the provider to contact. If the person appears to meet clinical standards as a danger to self, danger to others, persistently and acutely disabled or gravely disabled, the provider must make attempts as appropriate to engage the person to voluntarily seek inpatient care. If this is not a viable option for the person and the clinical standard is met, the provider must initiate the pre-petition screening or petition for treatment process described in AHCCCS AMPM Section 320-U, 320-U (PDF) — Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment.
All attempts to re-engage persons determined to have a SMI, children, pregnant substance abusing members/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others must be clearly documented in the comprehensive clinical record. Providers are required to have a clearly defined outreach and engagement policy.
Re-Engagement for Members on Court Ordered Treatment:
“For members who are on Court Ordered Treatment, it is the expectation that providers will re-engage within 24 hours of a missed appointment and continue frequent re-engagement efforts until such a time as the member is re-engaged and adherent with treatment, the court order is amended/revoked with the person placed in a psychiatric facility, or it has been confirmed that the member is now living in a different Regional Behavioral Health Authority/Managed Care Organization/Health Plan area or that the member has permanently moved out of state”.
- If a member misses a Behavioral Health Medical Provider (BHMP) appointment, whether it is because the member canceled, no-showed, or the provider canceled the appointment, Re-engagement attempts should immediately be started to reschedule the missed BHMP appointment. The appointment should be rescheduled so that the requirement of a monthly appointment is met.
- BHMP emergency appointment slots should be utilized to accommodate this appointment.
- Missed appointments and non-adherence to the treatment plan should prompt the treatment team to re-evaluate the treatment plan to ensure that it is meeting the member’s needs and goals. A member’s input into the plan, with attention to achieving their goals as much as possible, will help with engagement. Any barriers to attending appointments should be assertively and creatively addressed, for example a member’s difficulties with communication, transportation, competing commitments, childcare, managing schedules, etc. The treatment plan should be as flexible and personalized as possible to facilitate each member’s adherence.
- If maximal effort to re-engage a member into outpatient treatment fails, the treatment team should file a revocation so that the member may be assessed in a crisis setting. This is especially important if the member has missed an injection as a result of missing their outpatient appointment. Whether or not the member is hospitalized as a result of the revocation, revocations are another opportunity to re-engage the member and amend the treatment plan with the member’s input.
- If a provider does not reschedule the missed appointment within two business days, the provider should not revoke the member for this reason alone. Instead, the provider must make arrangements to reschedule the member as soon as possible. Providers should not revoke a member due to a provider administrative or coordination issue.
22.214.171.124 Follow-Up After Missed Appointments
Providers are required to contact all persons who miss scheduled appointments without rescheduling. Providers must contact the person following a missed appointment or as soon as possible but no later than two work days after the missed appointment. Documentation of all attempts to reach the person shall be documented in the person’s medical record. At least three attempts shall be made to reschedule a missed appointment and shall include contacts made by certified mail and telephone. Face-to-face outreach shall be required for all persons receiving medication services, all individuals identified to be at risk, or to persons who have reported danger to self/danger to others thoughts in the last year. All outreach attempts shall be completed within thirty days of a missed appointment.
126.96.36.199 Follow-Up After Significant and/or Critical Events
Providers must also document activities in the clinical record and conduct follow-up activities to maintain engagement within the following timeframes:
- Discharged from inpatient services in accordance with the discharge plan and within 7 days of the person’s release to ensure client stabilization, medication adherence, and to avoid re-hospitalization,
- Involved in a behavioral health crisis within timeframes based upon the person’s clinical needs, but no later than seven days, and
- Refusing prescribed psychotropic medications within timeframes based upon the person’s clinical needs and individual history; and
- Released from local and county jails and detention facilities based on the needs of the member but no later than 7 days.
Additionally, for persons released from jail or hospital settings, outpatient providers must help establish priority prescribing clinician appointments based on the needs of the member but no later than 7 days of the person’s release to ensure client stabilization, medication adherence, and to avoid re-hospitalization.
188.8.131.52 Provider Requirements to Notify the Crisis Call Center of At-Risk Situations
Providers are required to notify the Crisis Call Center by telephone call within 2 hours of any enrolled persons determined to be a danger to self or others and supply an updated crisis plan (AHCCCS Crisis Plan reference (PDF)). Providers are also required to notify the Crisis Call Center by telephone call and report a Member who has withdrawn from treatment and presents a potential risk to self, others, or the community; including, all persons with a SMI, all children at risk, all pregnant substance abusing members/teenagers, and any person determined to be at risk of relapse. The Crisis Call Center will assist with telephonic engagement activities, assist providers in developing appropriate intervention strategies, and coordinate with The Health Plan to bring additional resources to assist effective engagement in treatment.
12.4.4 Ending Treatment for a Person in the Behavioral Health System
Providers may not end a member’s treatment because of an adverse change in the member’s health status or because of the member’s utilization of medical services, diminished capacity, or uncooperative or disruptive behavior. Providers must not arbitrarily or prematurely reject or eject a Member from services without prior authorization of The Health Plan. However, under certain circumstances, it may be appropriate or necessary to close a person’s chart for administrative reasons, or after re-engagement efforts described above have been expended.
184.108.40.206 Children Held at County Detention Facilities
Providers must check the AHCCCS Pre-paid Medical Management Information System (PMMIS) to determine eligibility for treatment services prior to the delivery of each behavioral health service to a child who is held in a county detention facility.
Contact The Health Plan for assistance when a child loses their Title XIX/XXI eligibility while in detention. Children who lose their eligibility or have their eligibility suspended while temporarily in detention may be eligible for Mental Health Block Grant (MHBG) funded services, depending on availability of funds. Behavioral Health Homes are required to maintain contact with children in detention and during the 30-day period prior to release to facilitate appropriate release planning. These coordination of care services are funded through state funds and block grant funds.
220.127.116.11 Inmates of Public Institutions
AHCCCS has implemented an electronic inmate of public institution notification system developed by the AHCCCS Division of Member Services (DMS). If a Member is eligible for AHCCCS covered services during the service delivery period. The Health Plan is obligated to cover the services regardless of the perception of the Members’ legal status.
In order for AHCCCS to monitor any change in a Members’ legal status, and to determine eligibility, The Health Plan providers are required to notify The Health Plan and AHCCCS via e-mail, and if they become aware that an AHCCCS eligible Member is incarcerated. AHCCCS has established an email addresses for this purpose as well. Please note that there are two separate AHCCCS e-mail addresses based on the Members’ age. For children less than 18 years of age, please use DMSJUVENILEincarceration@azahcccs.gov. For adults age 18 years and older, please use DMSADULTIncarceration@azahcccs.gov. Notifications must include the following Member information:
- AHCCCS ID;
- Date of Birth;
- Incarceration date; and
- Name of public institution where incarcerated.
Please note that providers do not need to report Members incarcerated with the Arizona Department of Corrections.
Behavioral Health Homes are required to maintain contact with persons in detention and during the 30-day period prior to release to facilitate appropriate release planning. These coordination of care services are funded through state funds and block grant funds.
AHCCCS supports a model for assessment, service planning, and service delivery that is strength-based, person-centered, family friendly, culturally and linguistically appropriate, and clinically sound and supervised. The model is based on four equally important components:
- Input from the person regarding individual needs, strengths, and preferences;
- Input from other persons involved in the person’s care who have integral relationships with the person;
- Development of a therapeutic alliance between the person and provider that fosters an ongoing partnership built on mutual respect and equality; and
- Clinical expertise.
The model incorporates the concept of a “team,” established for each person receiving services in accordance with the Arizona Vision and 12 Principles and the 9 Guiding Principles for recovery oriented adult behavioral health services. For children, this team is the Child and Family Team (CFT) and for adults the Adult Recovery Team (ART). At a minimum, the functions of the CFT and ART include:
- Ongoing engagement of the person, family, and others who are significant in meeting the behavioral health needs of the person, including their active participation in the decision-making process and involvement in treatment;
- An assessment process is conducted to:
- Elicit information on the strengths, needs, and goals of the individual person and family members/guardians;
- Identify the need for further or specialty evaluations; and
- Support the development and updating of a service plan which effectively meets the person’s/family’s needs and results in improved health outcomes.
- Continuous evaluation of the effectiveness of treatment through the CFT and ART process, the ongoing assessment of the person, and input from the person and their team resulting in modification to the service plan, if necessary;
- Provision of all covered services as identified on the service plan, including assistance in accessing community resources, as appropriate and, for children, services which are provided consistent with the Arizona Vision and Principles, and for adults, services which are provided consistent with the 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems;
- Ongoing collaboration, including the communication of appropriate clinical information, with other individuals and/or entities with whom delivery and coordination of services is important to achieving positive outcomes (e.g., primary care providers, school, child welfare, juvenile or adult probation, other involved service providers);
- Oversight to ensure continuity of care by taking the necessary steps (e.g., clinical oversight, development of facility discharge plans, or after-care plans, transfer of relevant documents) to assist persons who are transitioning to a different treatment program, (e.g., inpatient to outpatient setting), changing providers and/or transferring to another service delivery system (e.g., out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) Contractor); and
- Development and implementation of transition plans prior to discontinuation or modification of services.
All persons being served in the public behavioral health system must have a behavioral health assessment upon an initial request for services. For persons who continue to receive services, updates to the assessment must occur at least annually. Behavioral health assessments must be utilized to collect necessary information that will inform providers of how to plan for effective care and treatment of the individual.
AHCCCS does not mandate that a specific assessment tool or format be used but requires certain minimum elements. Providers must collect and submit all required member information in accordance with the criteria outlined in the AHCCCS Demographic and Outcome Data Set User Guide (DUG).
The initial and annual assessment must be completed by a behavioral health professional (BHP) or behavioral health technician (BHT) under the clinical oversight of a BHP, trained on the minimum elements of a behavioral health assessment and who meets requirements in Section 5 — Credentialing and Re-credentialing and Section 15— Training Requirements.
18.104.22.168 Minimum Elements of the Behavioral Health Assessment
AHCCCS has established the following minimum elements that must be included in a comprehensive behavioral health assessment and documented in the comprehensive clinical record, in accordance with AHCCCS AMPM Section 320-O, Behavioral Health Assessment and Treatment Service Planning Providers are required to have policies in place to monitor accuracy and completion of the behavioral health assessment.
For persons referred for or identified as needing ongoing psychotropic medications for a behavioral health condition, the assessor must establish an appointment with a licensed medical practitioner with prescribing privileges, in accordance with Section 12.2 — Appointment Standards and Timeliness of Service. If the assessor is unsure regarding a person’s need for psychotropic medications, then the assessor must review the initial assessment and treatment recommendations with their clinical supervisor or a licensed medical practitioner with prescribing privileges.
The Health Plan promotes a network of Trauma Informed Care (TIC)-certified therapists. The Health Plan will analyze the network sufficiency of TIC-certified therapists. Behavioral Health Homes must provide trauma screenings for youth and families. Behavioral Health Providers must ensure the provision of Trauma Informed Care Services, including routine trauma screenings and ensuring sufficient capacity of TIC certified therapists.
22.214.171.124 Social Determinants of Health and Specific Behavioral Health Home Housing Screening and Service Requirements
AHCCCS and the Health Plan collect and track member outcomes related to Social Determinants of Health. The use of specific International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) diagnostic codes representing Social Determinants of Health are a valuable source of information related to member health.
The Social Determinants of Health codes identify conditions in which people are born, grow, live, work, and age. They are often responsible, in part, to health inequities. They include factors such as
- Physical environment
- Socioeconomic status, and
- Social support networks.
As appropriate and within a scope of practice, providers should be routinely screening for, and documenting, the presence of social determinants. Any identified social determinant diagnosis codes should be provided on all claims for AHCCCS members in order to comply with state and federal coding requirements.
Reference Section 11.7 of the Provider Manual for a listing of the current Social Determinants of Health ICD-10-CM diagnosis codesNote that Social Determinants of Health codes may be added or updated on a quarterly basis. Providers are required to remain current in their thorough utilization of these codes.
Behavioral Health Homes are required to coordinate with the Health Plan to secure a Housing Management Information System (HMIS) license in order to ensure that members are entered into the AzCH-Complete Care Plan Coordinated Entry. The Health Plan requires that providers complete a homeless assessment using the Vulnerability Index Service Prioritization Decision Assistance Tool (VI SPDAT) for all members experiencing homelessness, at risk of homelessness, or request assistance with housing.
The Behavioral Health Home must then enter the VI SPDAT assessment for each member into the Continuum of Care (CoC) AzCH-Complete Care Plan Coordinated Entry through the Homeless Management Information System (HMIS) database referring the member to the Health Plan Coordinated Entry Housing list. Members meeting the HUD definition of homelessness will also be entered into the CoC Coordinated Entry List. This step will open housing opportunities beyond the Health Plan housing programs for members experiencing homelessness, assist providers in maintaining contact with those members, and ensure heightened coordination and collaboration with the full network of homeless and housing services available in local communities.
Behavioral Health Homes serving adults are required to identify and screen members; including members with SMI that satisfy Section 8 criteria and refer prospective tenant to the appropriate contracted Public Housing Authority. Providers are required to participate with the individual's treatment team in order to identify available housing units and to place the individual in an affordable appropriate living environment upon discharge from an institutional setting.
12.5.2 Service Planning
All persons being served in the public behavioral health system must have a written plan for services upon an initial request for services and periodic updates to the plan to meet the changing behavioral health needs for persons who continue to receive behavioral health services. AHCCCS does not mandate a specific service planning tool or format. Service plans must be utilized to document services and supports that will be provided to the individual, based on behavioral health service needs identified through the person’s behavioral health assessment. Provider Manual Attachment 3.5.1 Service Plan Rights Acknowledgment Template is available to use. Providers are directed to call the Provider Services Call Center at 866-796-0542 to obtain a copy of this attachment, if needed.
If a person is in immediate or urgent need of services (see Section 12.2 — Appointment Standards and Timeliness of Service), an interim service plan may need to be developed to document services until a complete service plan is developed. A complete service plan, however, must be completed no later than 90 days after the initial appointment.
At a minimum, the Member, guardian (if applicable), advocates (if assigned), and a qualified behavioral health representative must be included in the development of the service plan. In addition, family members, designated representatives, agency representatives, and other involved parties, as applicable, may be invited to participate in the development of the service plan. Providers must coordinate with the person’s health plan, PCP, or others involved in the care or treatment of the individual, as applicable, regarding service planning recommendations (see Section 4.3 — Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers).
126.96.36.199 Minimum Elements of the Service Plan for Title XIX/XXI Members
Service plans must be completed (see AHCCCS AMPM Section 320), Behavioral Health Assessment and Treatment Service Planning and the AHCCCS BQI Specifications Manual found on the AHCCCS Resources website. Providers must have policies in place to monitor the timely completion of service plans.
Members must be provided with a copy of their Plan. Questions regarding service plans or Member rights should be directed to The Health Plan customer service line at 1-866-796-0542.
188.8.131.52 Optional element that can be included in the Service Plan
A Functional Behavioral Assessment (FBA) can be requested by any member of the treatment team and included in the member’s Individualized Service Plan. The purpose of an FBA is to ascertain the purpose or reason behind problem behaviors that a family, care giver or team may be unable to identify. An FBA allows teams to determine the why, how, where, when and what of a member's behavior. FBA's use a variety of techniques to understand and change behavior. An FBA can be completed for the member at any time with updates being made as needed after completion of the assessment. Provider Manual Attachment 3.5.8 Functional Behavioral Assessment Guidance Document is included in the attachments. Providers are directed to call the Provider Services Call Center at 866-796-0542 to obtain a copy of this attachment, if needed.
184.108.40.206 Minimum Elements of the Service Plan for Non-Title XIX/XXI Persons Determined to Have a SMI That Do Not Have an Assigned Health Care Coordinator
Service plans for Non-Title XIX/XXI persons determined to have a SMI who do not have an assigned Health Care Coordinator can be incorporated into the psychiatric progress notes completed by the Behavioral Health Professional as long as the treatment goals reflect the needs identified on the assessment, are clearly documented, and summarize the progress made. The BHP must document when a clinical goal has been achieved and when a new goal has been added.
Non-Title XIX/XXI persons determined to have a SMI, who do not have an assigned Health Care Coordinator shall have the option of accessing peer support services to assist them in developing a Peer-Driven, Self-Developed Proposed Service Plans (PDSDPSPs) to be shared with their BHMP for approval, adoption, and implementation. PDSDPSPs are not required to contain all minimum elements as outlined above for those that have assigned Health Care Coordinators; however, they should consider the Member-specific needs for and expected benefits from community-based support services including, but not limited to supported employment, peer support, family support, permanent supportive housing, living skills training, health promotion, personal assistance, and respite care. PDSDPSPs should also address natural supports that can be leveraged and strengthened as well as outline crisis prevention approaches (e.g. warm line availability) and how the emergence of a potential crisis will be addressed. These services should be incorporated into the PDSDPSPs as appropriate.
It is recommended that a standardized process be used to develop Peer-Driven, Self-Developed Proposed Service Plans (PDSDPSPs ). Providers serving Non-Title XIX/XXI Adults with SMI must ensure all services outlined on PDSDPSPs are reviewed and Member wishes identified on the PDSDSPs are included on individualized service plans.
Additionally, the PDSDPSPs must be reviewed with and approved by the behavioral health medical practitioner and maintained in the medical record. Progress and outcomes related to the approved PDSDPSPs must be tracked and documented by the behavioral health medical practitioner.
220.127.116.11 Appeals or Service Plan Disagreements
Every effort should be taken to ensure that the service planning process is collaborative, solicits and considers input from each team member, and results in consensus regarding the type, mix, and intensity of services to be offered. In the event that a person and/or legal or designated representative disagree with any aspect of the service plan, including the inclusion or omission of services, the team should take reasonable attempts to resolve the differences and actively address the person’s and/or legal or designated representative’s concerns.
Despite a behavioral health provider’s best effort, it may not be possible to achieve consensus when developing the service plan. In cases that the person and/or legal or designated representative disagree with some or all of the Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given the opportunity to obtain a second-opinion from an in-network provider or, if necessary, an out-of-network provider at no cost.
In cases that a person determined to have a SMI and/or legal or designated representative disagree with some or all of the Non-Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given a copy of the Appeal or Serious Mental Illness Grievance Form located in the AHCCCS ACOM Chapter 400, Section 446, Attachment A by the behavioral health representative on the team.
In either case, the person and/or legal or designated representative may file an appeal within 60 days of the action.
18.104.22.168 Updates to the Assessment and Service Plan
Providers must complete an annual assessment update with input from the Member and family, if applicable, that records a historical description of the significant events in the person’s life and how the person/family responded to the services/treatment provided during the past year. Following this updated assessment, the service plan should then be updated as necessary. While the assessment and service plan must be updated at least annually, the assessment and service plan may require more frequent updates to meet the needs and goals of the Member and their family. Providers must have a policy in place to monitor timely updates of both assessments and services plans.
A critical component of the service delivery system is the effective and efficient identification of persons who have special behavioral health needs due to the severity of their behavioral health disorder. One such group is persons with Serious Mental Illness (SMI). Without receipt of the appropriate care, these persons are at high risk for further deterioration of their physical and mental condition, increased hospitalizations, and potential homelessness and incarceration. For this reason, The Health Plan contracted Behavioral Health Homes are required to provide a SMI screening/assessment to any person requesting a SMI determination at no cost to the requesting person.
In order to ensure that persons with a SMI are promptly identified and enrolled for services, AHCCCS has developed a standardized process for the referral, evaluation, and determination for SMI eligibility. The requirements associated with the referral for a SMI evaluation and SMI eligibility determination are set forth in AHCCCS AMPM Policy 320-P, SMI Eligibility Determination. Additionally, the SMI Determination Form found at the Crisis Response Network website.
12.6.1 Criteria for SMI Eligibility
The determination of SMI requires both a qualifying SMI diagnosis and functional impairment as a result of the qualifying diagnosis (see AHCCCS AMPM, 320-P2 for a list of qualifying diagnostic categories).
22.214.171.124 Functional Criteria for SMI Eligibility
To meet the functional criteria for SMI status, a person must have, as a result of a qualifying SMI diagnosis, dysfunction in at least one of the following four domains, as described below, for most of the past twelve (12) months or for most of the past six (6) months with an expected continued duration of at least six (6) months:
- Inability to live in an independent or family setting without supervision: Neglect or disruption of ability to attend to basic needs. Needs assistance in caring for self. Unable to care for self in safe or sanitary manner. Housing, food, and clothing must be provided or arranged for by others. Unable to attend to the majority of basic needs of hygiene, grooming, nutrition, medical and dental care. Unwilling to seek prenatal care or necessary medical/dental care for serious medical or dental conditions. Refuses treatment for life threatening illnesses because of behavioral health disorder.
- A risk of serious harm to self or others: Seriously disruptive to family and/or community. Pervasively or imminently dangerous to self or others’ bodily safety. Regularly engages in assaultive behavior. Has been arrested, incarcerated, hospitalized or at risk of confinement because of dangerous behavior. Persistently neglectful or abusive towards others in the person’s care. Severe disruption of daily life due to frequent thoughts of death, suicide, or self-harm, often with behavioral intent and/or plan. Affective disruption causes significant damage to the person’s education, livelihood, career, or personal relationships.
- Dysfunction in role performance: Frequently disruptive or in trouble at work or at school. Frequently terminated from work or suspended/expelled from school. Major disruption of role functioning. Requires structured or supervised work or school setting. Performance significantly below expectation for cognitive/ developmental level. Unable to work, attend school, or meet other developmentally appropriate responsibilities; or
- Risk of Deterioration: A qualifying diagnosis with probable chronic, relapsing and remitting course. Co-morbidities (like cognitive difficulties, substance dependence, personality disorders, etc.). Persistent or chronic factors such as social isolation, poverty, extreme chronic stressors (life-threatening or debilitating medical illnesses, victimization, etc.). Other (past psychiatric history; gains in functioning have not solidified or are a result of current compliance only; court-committed; care is complicated and requires multiple providers; etc.).
The following reasons shall not be sufficient in and of themselves for denial of SMI eligibility:
- An inability to obtain existing records or information; or
- Lack of a face-to-face psychiatric or psychological evaluation.
126.96.36.199 Considerations for Person with Co-occurring Substance Use Disorder
For persons who have a qualifying SMI diagnosis and co-occurring substance use, for purposes of SMI determination, presumption of functional impairment is as follows:
For psychotic diagnoses (bipolar I disorder with psychotic features, delusional disorder, major depression, recurrent, severe, with psychotic features, schizophrenia, schizoaffective disorder and psychotic disorder not due to a substance or known psychological condition) functional impairment is presumed to be due to the qualifying psychiatric diagnosis.
For other major mental disorders (bipolar disorders, major depression, and obsessive-compulsive disorder), functional impairment is presumed to be due to the psychiatric diagnosis, unless:
- The severity, frequency, duration or characteristics of symptoms contributing to the functional impairment cannot be attributed to the qualifying mental health diagnosis, or
- The assessor can demonstrate, based on a historical or prospective period of treatment, that the functional impairment is present only when the person is abusing substances or experiencing symptoms of withdrawal from substances.
For all other mental disorders not covered above, functional impairment is presumed to be due to the co-occurring substance use unless:
- The symptoms contributing to the functional impairment cannot be attributed to the substance use disorder, or
- The functional impairment is present during a period of cessation of the co-occurring substance use of at least 30 days, or
- The functional impairment is present during a period of at least 90 days of reduced use and is unlikely to cause the symptoms or level of dysfunction.
12.6.2 Completion Process of Final SMI Determination
A licensed psychiatrist, psychologist, or psychiatric nurse practitioner designated by the AHCCCS contracted SMI Evaluation Agency must make a final determination as to whether the person meets the eligibility requirements for SMI status based on:
- A face-to-face assessment or reviewing a face-to-face assessment by a qualified assessor; and
- A review of current and historical information, if any, obtained orally or in writing by the assessor from collateral sources, and/or present or previous treating clinicians.
The following must occur if the designated reviewing psychiatrist, psychologist, or psychiatric nurse practitioner has not conducted a face-to-face assessment and has a disagreement with the qualified assessor and/or the treating Behavioral Health Professional that cannot be resolved by oral or written communication:
- Disagreement Regarding Diagnosis: Determination that the person does not meet eligibility requirements for SMI status must be based on a face-to-face diagnostic evaluation conducted by a designated psychiatrist, psychologist, or nurse practitioner. The resolution of (specific reasons for) the disagreement shall be documented in the person’s comprehensive clinical record.
- Disagreement Regarding Functional Impairment: Determination that the person does not meet eligibility requirements must be based upon a face-to-face functional evaluation conducted by a designated psychiatrist, psychologist, or nurse practitioner. The psychiatrist, psychologist, or nurse practitioner shall document the specific reason(s) for the disagreement in the person’s comprehensive clinical record.
If there is sufficient information to determine SMI eligibility, the person shall be provided written notice of the SMI eligibility determination within three (3) business days of the initial meeting with the qualified assessor in accordance with the next section of this policy.
12.6.3 Issues preventing timely completion of SMI eligibility determination
The time to initiate or complete the SMI eligibility determination may be extended no more than 20 days if the person agrees to the extension and:
- There is substantial difficulty in scheduling a meeting at which all necessary participants can attend;
- The person fails to keep an appointment for assessment, evaluation, or any other necessary meeting (see Section 12.4 — Outreach, Engagement, Re-Engagement, and Closure);
- The person is capable of but temporarily refuses to cooperate in the preparation of the completion of an assessment or evaluation;
- The person or the person’s guardian and/or designated representative requests an extension of time;
- Additional documentation has been requested, but has not yet been received; or
- There is insufficient functional or diagnostic information to determine SMI eligibility within the required time periods.
The AHCCCS contracted SMI Evaluation Agency (Crisis Response Network (CRN)) must:
- Document the reasons for the delay in the person’s eligibility determination record when there is an administrative or other emergency that will delay the determination of SMI status; and
- Not use the delay as a waiting period before determining SMI status or as a reason for determining that the person does not meet the criteria for SMI eligibility (because the determination was not made within the time standards).
In situations in which the extension is due to insufficient information:
- The AHCCCS contracted SMI Evaluation Agency (CRN)shall request and obtain the additional documentation needed (e.g., current and/or past medical records) and/or perform or obtain any necessary psychiatric or psychological evaluations;
- The designated reviewing psychiatrist, psychologist, or nurse practitioner must communicate with the person’s current treating clinician, if any, prior to the determination of SMI, if there is insufficient information to determine the person’s level of functioning; and
- SMI eligibility must be determined within three (3) days of obtaining sufficient information, but no later than the end date of the extension.
If the person refuses to grant an extension, SMI eligibility must be determined based on the available information. If SMI eligibility is denied, applicants shall be notified of their appeal rights and the option to reapply (see the next section of this policy).
If the evaluation or information cannot be obtained within the required time period because of the need for a period of observation or abstinence from substance use in order to establish a qualifying mental health diagnosis, the person shall be notified that the determination may, with the agreement of the person, be extended for up to 90 (calendar) days.
 Insufficient diagnostic information shall be understood to mean that the information available to the reviewer is suggestive of two or more equally likely working diagnoses, only one of which qualifies as SMI, and an additional piece of existing historical information or a face-to-face psychiatric evaluation is likely to support one diagnosis more than the other(s).
 This extension may be considered a technical re-application to verify compliance with the intent of Rule. However, the person does not need to actually reapply. Alternatively, the determination process may be suspended and a new application initiated upon receipt of necessary information.
12.6.4 Notification of SMI Eligibility Determination
If the eligibility determination results in approval of SMI status, the SMI status must be reported to the person in writing, including notice of the right to appeal the decision (see Section 8.4 — Notice Requirements and Appeal Process (SMI and Non-SMI/Non-Title XIX).
If the eligibility determination results in a denial of SMI status, the AHCCCS contracted SMI Evaluation Agency (CRN) shall include in the notice above:
- The reason for denial of SMI eligibility (see AHCCCS AMPM 320-P SMI Determination);
- The right to appeal (see Section 8.4 — Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and Section 8.5 — Notice Requirements and Appeal Process (SMI and Non-SMI/Non-Title XIX); and
- The statement that Title XIX/XXI eligible persons will continue to receive needed Title XIX/XXI covered services.
12.6.5 Review of SMI Eligibility
A review of SMI eligibility made by The Health Plan for individuals currently enrolled as a person with a SMI may be initiated by The Health Plan or our contracted behavioral health providers:
- As part of an instituted, periodic review of all persons determined to have a SMI;
- When there has been a clinical assessment that supports that the person no longer meets the functional and/or diagnostic criteria; or
- As requested by an individual currently enrolled as a person with a SMI, or their legally authorized representative.
A review of the determination may not be requested by The Health or their contracted behavioral health providers within six (6) months from the date an individual has been determined SMI eligible.
If, as a result of a review, the person is determined to no longer meet the diagnosis and functional requirements for SMI status, The Health Plan must ensure that:
- Services are continued depending on eligibility, The Health Plan service priorities and any other requirements as described in Section 2 — Covered Services and Related Program Requirements and Section 13.2 — Inter-RBHA/MCO Coordination of Care and Section 12.10 — Special Assistance for Members Determined to Have a Serious Mental Illness
- Written notice of the determination made on review with the right to appeal is provided to the affected person with an effective date of thirty (30) days after the date the written notice is issued.
12.6.6 SMI Decertification
There are two established methods for removing a SMI designation, one clinical and the other an administrative option, as follows:
A member who has a SMI designation or an individual from the member’s clinical team may request a SMI Clinical Decertification. A SMI Clinical Decertification is a determination that a member who has a SMI designation no longer meets SMI criteria. If, as a result of a review, the person is determined to no longer meet the diagnostic and/or functional requirements for SMI status:
- The Determining Entity (CRN) shall ensure that written notice of the determination and the right to appeal is provided to the affected person with an effective date of 30 days after the date the written notice is issued,
- Services are continued in the event an appeal is timely filed, and services are appropriately transitioned as part of the discharge planning process.
A member who has a SMI designation may request a SMI Administrative Decertification if the member has not received behavioral health services for a period of two or more years.
- Upon receipt of a request for Administrative Decertification, the Contractor shall direct the member to contact AHCCCS Division of Health Care Management (DHCM) Customer Service,
- AHCCCS will evaluate the member’s request and review data sources to determine the last date the member received a behavioral health service. AHCCCS will inform the member of changes that may result with the removal of the member’s SMI designation. Based upon review, the following will occur:
- In the event the member has not received a behavioral health service within the previous two years, the member will be provided with AHCCCS AMPM Exhibit 320-P-3. This form must be completed by the member and returned to AHCCCS,
- In the event the review finds that the member has received behavioral health services within the prior two year period, the member will be notified that they may seek decertification of their SMI status through the Clinical Decertification process.
Providers are highly encouraged to use SMI forms located on the CRN website
Each Member has the right to participate in decisions regarding behavioral health care, including the right to refuse treatment (42 CFR 438.100(b)(2)(iv)). It is important for persons seeking services to agree to those services and be made aware of the service options and alternatives available to them as well as specific risks and benefits associated with these services.
AHCCCS recognizes two primary types of consent: general consent and informed consent (AHCCCS AMPM 320-Q)
General consent is a one-time agreement to receive services that is usually obtained from a person during the intake process at the initial appointment and is always obtained prior to the provision of any services. General consent must be verified by a Member’s or legal guardian’s signature.
Informed consent must be obtained before the provision of a specific treatment that has associated risks and benefits. Informed consent is required prior to the provision of the following services and procedures:
- Complementary and Alternative Medicine (CAM);
- Psychotropic medications;
- Electro-convulsive therapy (ECT);
- Use of telemedicine;
- Application for a voluntary evaluation;
- Admission for medical detoxification, an inpatient facility or a residential program (for persons with a SMI); and
- Procedures or services with known substantial risks or side effects.
Prior to obtaining informed consent, an appropriate behavioral health representative, as identified in R9-21-206.01(c) (PDF), must present the facts necessary for a person to make an informed decision regarding whether to agree to the specific treatment and/or procedures. Documentation that the required information was given and that the person agrees or does not agree to the specific treatment must be included in the comprehensive clinical record, as well as the person’s/guardian’s signature when required.
Active Parent Consent
In addition to general and informed consent for treatment, state statute (A.R.S. § 15-104) requires written consent from a child’s parent or legal guardian for any behavioral health survey, analysis, or evaluation conducted in reference to a school based prevention program.
Completion of Substance Abuse Prevention Program and Evaluation Consent applies solely to consent for a survey, analysis, or evaluation only, and does not constitute consent for participation in the program itself
The intent of this section is to describe the requirements for reviewing and obtaining general and informed consent, for persons receiving services within the public behavioral health system, as well as consent for any behavioral health survey or evaluation in connection with an AHCCCS school-based prevention program.
12.7.1 General Requirements
Any person, aged 18 years and older, in need of services must give voluntary general consent to treatment, demonstrated by the person’s or legal guardian’s signature on a general consent form, before receiving services.
For persons under the age of 18, the parent, legal guardian, or a lawfully authorized custodial agency must give general consent to treatment, demonstrated by the parent, legal guardian, or lawfully authorized custodial agency representative’s signature on a general consent form prior to the delivery of services.
Any person aged 18 years and older or the person’s legal guardian, or in the case of persons under the age of 18, the parent, legal guardian or a lawfully authorized custodial agency, after being fully informed of the consequences, benefits and risks of treatment, has the right not to consent to receive services.
Any person aged 18 years and older or the person’s legal guardian, or in the case of persons under the age of 18, the parent, legal guardian or a lawfully authorized custodial agency has the right to refuse medications unless specifically required by a court order or in an emergency situation.
Providers treating persons in an emergency situation are not required to obtain general consent prior to the provision of emergency services. Providers treating persons pursuant to court order must obtain consent, as applicable, in accordance with A.R.S. Title 36, Chapter 5.
All evidence of informed consent and general consent to treatment must be documented in the comprehensive clinical record per Section 10.2 — Medical Record Standards.
In initiating general care for The Health Plan Members, providers are required to use informed consent forms that include all the elements identified in the Provider Manual Form 3.7.1, General Consent to Treatment. The form can be obtained by calling the Provider Services Call Center at 866-796-0542.
Providers prescribing psychotropic medications for The Health Plan Members are required to use informed consent forms that include all the elements identified in AHCCCS AMPM Section 310-V, Attachment A.
12.7.2 General Consent
Administrative functions associated with a Member’s enrollment do not require consent, but before any services are provided, general consent must be obtained. General consent is usually obtained during the intake process and represents a person’s, or if under the age of 18, the person’s parent, legal guardian or lawfully authorized custodial agency representative’s, written agreement to participate in and to receive non-specified (general) services. Providers are required to use Provider Manual Form 3.7.1, General Consent to Treatment which can be obtained by calling the Provider Services Call Center at 866-796-0542, and to have a policy in place to monitor completion of general consents.
12.7.3 Informed Consent
188.8.131.52 What Information Must Be Provided to Obtain Informed Consent?
In all cases where informed consent is required by this section, informed consent must include, at a minimum, the following:
- Member’s right to participate in decisions regarding health care, including the right to refuse treatment, and to express preferences about future treatment decisions;
- Information about the person’s diagnosis and the proposed treatment, including the intended outcome, nature and all available procedures involved in the proposed treatment;
- The risks, including any side effects, of the proposed treatment, as well as the risks of not proceeding;
- The alternatives to the proposed treatment, particularly alternatives offering less risk or other adverse effects;
- That any consent given may be withheld or withdrawn in writing or orally at any time. When this occurs the provider must document the person’s choice in the medical record;
- The potential consequences of revoking the informed consent to treatment; and
- A description of any clinical indications that might require suspension or termination of the proposed treatment.
184.108.40.206 Who Can Give Informed Consent, and How Is It Documented?
Persons, or if applicable the client’s parent, guardian or custodian shall give informed consent for treatment by signing and dating an acknowledgment that they have received the information and gives informed consent to the proposed treatment.
When informed consent is given by a third party, the identity of the third party and the legal capability to provide consent on behalf of the person, must be established. If the informed consent is for psychotropic medication or telemedicine and the person or the person’s guardian (if applicable) refuses to sign an acknowledgment and gives verbal informed consent, the medical practitioner shall document in the person’s record that the information was given, the client refused to sign an acknowledgment, and that the client gives informed consent to use psychotropic medication or telemedicine.
220.127.116.11 Who Can Provide Informed Consent and How Is It Communicated?
When providing information that forms the basis of an informed consent decision for the circumstances identified above, the information must be:
- Presented in a manner that is understandable and culturally appropriate to the person, parent, legal guardian or an appropriate court; and
- Presented by a credentialed behavioral health medical practitioner or a registered nurse with at least one year of behavioral health experience. It is preferred that the prescribing clinician provide information forming the basis of an informed consent decision. In a specific situation in which that is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience.
18.104.22.168 Psychotropic Medications, Complementary and Alternative Treatment and Telemedicine
Unless treatments and procedures are court ordered, providers must obtain written informed consent, and if written consent is not obtainable, providers must obtain oral informed consent. If oral informed consent is obtained instead of written consent from the person, parent, or legal guardian, it must be documented in written fashion. Informed consent is required in the following circumstances:
- Prior to the initiation of any psychotropic medication or initiation of Complementary and Alternative Treatment (CAM) (see Section 12.8 — Psychotropic Medication: Prescribing and Monitoring). The use of Provider Manual Form 3.7.1, General Consent to Treatment (AHCCCS AMPM Section 310-V, Attachment A) is recommended as a tool to review and document informed consent for psychotropic medications which can be obtained by calling he Provider Services Call Center at 866-796-0542; and
- Prior to the delivery of services through telemedicine.
Informed Consent for Telemedicine:
- Before a health care provider delivers health care via telemedicine, verbal or written informed consent from the member or their health care decision maker must be obtained. Refer to AMPM Policy 320-I,
- Informed consent may be provided by the behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience. When providing informed consent it must be communicated in a manner that the member and/or legal guardian can understand and comprehend.
- Exceptions to this consent requirement include:
- If the telemedicine interaction does not take place in the physical presence of the member,
- In an emergency situation in which the member or the member’s health care decision maker is unable to give informed consent, or
- To the transmission of diagnostic images to a health care provider serving as a consultant or the reporting of diagnostic test results by that consultant.
22.214.171.124 Electro-Convulsive Therapy (ECT), Research Activities, Voluntary Evaluation and Procedures or Services with Known Substantial Risks or Side Effects
Written informed consent must be obtained from the person, parent, or legal guardian, unless treatments and procedures are under court order, in the following circumstances:
- Before the provision of (ECT);
- Prior to the involvement of the person in research activities;
- Prior to the provision of a voluntary evaluation for a person. The use of AMPM Exhibit 320-Q-1, Application for Voluntary Evaluation is required for persons with SMI and is recommended as a tool to review and document informed consent for voluntary evaluation of all other populations; and
- Prior to the delivery of any other procedure or service with known substantial risks or side effects.
126.96.36.199 Additional Provisions
Written informed consent must be obtained from the person, legal guardian, or an appropriate court prior to the person’s admission to any medical detoxification, inpatient facility, or residential program operated by a behavioral health provider.
188.8.131.52 Revocation of Informed Consent
If informed consent is revoked, treatment must be promptly discontinued, except in cases in which abrupt discontinuation of treatment may pose an imminent risk to the person. In such cases, treatment may be phased out to avoid any harmful effects.
12.7.4 Special Requirements for Children Related to Consents
In accordance with A.R.S. § 36-2272, except as otherwise provided by law or a court order, no person, corporation, association, organization or state-supported institution, or any individual employed by any of these entities, may procure, solicit to perform, arrange for the performance of or perform mental health screening in a nonclinical setting or mental health treatment on a minor without first obtaining consent of a parent or a legal custodian of the minor child. If the parental consent is given through telemedicine, the health professional must verify the parent's identity at the site where the consent is given. This section does not apply when an emergency exists that requires a person to perform mental health screening or provide mental health treatment to prevent serious injury to or save the life of a minor child.
184.108.40.206 Non-Emergency Situations
In cases where the parent is unavailable to provide general or informed consent and the child is being supervised by a caregiver who is not the child’s legal guardian (e.g., grandparent) and does not have power of attorney, general and informed consent must be obtained from one of the following:
- Lawfully authorized legal guardian;
- Foster parent, group home staff, or other person with whom the Department of Economic Security/Department of Child Safety (DES/DCS) has placed the child; or
- Government agency authorized by the court.
If someone other than the child’s parent intends to provide general and, when applicable, informed consent to treatment, the following documentation must be obtained and filed in the child’s comprehensive clinical record:
Copy of court order assigning custody
Copy of power of attorney document
Copy of court order assigning custody
DES/DCS Placements (for children removed from the home by DES/DCS), such as:
 If providers doubt whether the individual bringing the child in for services is a person/agency representative in whose care DES/DCS has placed the child, the provider may ask to review verification, such as documentation given to the individual by DES indicating that the individual is an authorized DES/DCS placement. If the individual does not have this documentation, then the provider may also contact the child’s DES/DCS caseworker to verify the individual’s identity.
For any child who has been removed from the home by DCS, the foster parent, group home staff, foster home staff, relative, or other person or agency in whose care the child is currently placed may give consent for the following services:
- Evaluation and treatment for emergency conditions that are not life threatening; and
- Routine medical and dental treatment and procedures, including early periodic screening, diagnosis and treatment services, and services by health care providers to relieve pain or treat symptoms of common childhood illnesses or conditions (including behavioral health services and psychotropic medications).
Any minor who has entered into a lawful contract of marriage, whether or not that marriage has been dissolved subsequently, emancipated youth, or any homeless minor may provide general and, when applicable, informed consent to treatment without parental consent (A.R.S. § 44-132).
220.127.116.11 Emergency Situations
In emergency situations involving a child in need of immediate hospitalization or medical attention, general and, when applicable, informed consent to treatment is not required.
Any child, 12 years of age or older, who is determined upon diagnosis of a licensed physician, to be under the influence of a dangerous drug or narcotic, not including alcohol, may be considered an emergency situation and can receive behavioral health care as needed for the treatment of the condition without general and, when applicable, informed consent to treatment.
12.7.5 Informed Consent During Involuntary Treatment
At times, involuntary treatment can be necessary to protect safety and meet needs when a person, due to mental disorder, is unwilling or unable to consent to necessary treatment. In this case, a court order may serve as the legal basis to proceed with treatment. However, capacity to give informed consent is situational, not global, as an individual may be willing and able to give informed consent for aspects of treatment even when not able to give general consent. Individuals should be assessed for capacity to give informed consent for specific treatment and such consent obtained if the individual is willing and able, even though the individual remains under court order.
12.7.6 Consent for Behavioral Health Survey or Evaluation for School-Based Prevention Programs
Written consent must be obtained from a child’s parent or legal guardian for any behavioral health survey, analysis, or evaluation conducted in reference to a school-based prevention program administered by The Health Plan Provider.
AHCCCS AMPM Section 320-Q-2 Substance Abuse Prevention Program Evaluation Form must be used to gain parental consent for evaluation of school based prevention programs. Providers may use an alternative consent form only with the prior written approval of AHCCCS. The consent must satisfy all of the following requirements:
- Contain language that clearly explains the nature of the screening program and when and where the screening will take place;
- Be signed by the child’s parent or legal guardian; and
- Provide notice that a copy of the actual survey, analysis, or evaluation questions to be asked of the student is available for inspection upon request by the parent or legal guardian.
Completion of AHCCCS AMPM Section 320-Q-2 Substance Abuse Prevention Program Evaluation Form applies solely to consent for a survey, analysis, or evaluation only, and does not constitute consent for participation in the program itself.
AHCCCS has developed guidelines and minimum requirements designed to guide the Health Plans in developing appropriate psychotropic medication use policies and procedures to:
- Promote the safety of persons taking psychotropic medications;
- Reduce or prevent the occurrence of adverse side effects;
- Promote positive clinical outcomes for behavioral health recipients who are taking psychotropic medications;
- Monitor the use of psychotropic medications to foster safe and effective use; and
- To clarify that medication will not be used for the convenience of the staff, in a punitive manner or as a substitute for other services and shall be given in the least amount medically necessary with particular emphasis placed on minimizing side effects which otherwise would interfere with aspects of treatment, as stated in R9-21-207(C) (PDF).
See Provider Manual Attachment 3.8.5 – Minimum Laboratory Monitoring for Psychotropic Medications. Providers are directed to call the Provider Services Call Center at 866-796-0542 to obtain a copy of this attachment, if needed. It is also available in our Pharmacy section of our website.
12.8.1 Basic Requirements
Medications may only be prescribed by The Health Plan credentialed and licensed physicians, licensed physician assistants, or licensed nurse practitioners. See Section 5 — Credentialing and Re-Credentialing Requirements for more information regarding credentialing requirements.
Psychotropic medication will be prescribed by a licensed psychiatrist, psychiatric nurse practitioner, physician assistant, or other physician trained or experienced in the use of psychotropic medication. The prescribing clinician must have seen the Member and is familiar with the Member’s medical history or, in an emergency, the prescribing clinician is at least familiar with the Member’s medical history.
When a Member on psychotropic medication receives a yearly physical examination, the results of the examination will be reviewed by the physician prescribing the medication. The physician will note any adverse effects of the continued use of the prescribed psychotropic medication in the Member’s record (see Section 10.2 — Medical Record Standards).
Whenever a prescription for medication is written or changed, a notation of the medication, dosage, frequency or administration, and the reason why the medication was ordered or changed will be entered in the Member’s record (see Section 10.2 — Medical Record Standards).
Reasonable clinical judgment, supported by available assessment information, must guide the prescribing of psychotropic medications. To the extent possible, candidates for psychotropic medication use must be assessed prior to prescribing and providing psychotropic medications. Psychotropic medication assessments must be documented in the person’s comprehensive clinical record per Section 10.2 — Medical Record Standards and must be scheduled in a timely manner consistent with Section 12.2 — Appointment Standards and Timeliness of Service. Behavioral Health Professionals (BHPs) can use assessment information that has already been collected by other sources and are not required to document existing assessment information that is part of the person’s comprehensive clinical record. At a minimum, assessments for psychotropic medications must include:
- An adequately detailed medical and behavioral health history;
- A mental status examination;
- A diagnosis;
- Target symptoms;
- A review of possible medication allergies;
- A review of previously and currently prescribed psychotropic or other medications including any reported side effects and/or potential drug-drug interactions and all medications (including medications prescribed by the PCP and medical specialists, OTC medications, and supplements) currently being taken for the appropriateness of the combination of the medications;
- For sexually active females of childbearing age, a review of reproductive status (pregnancy);
- For post-partum females, a review of breastfeeding status; and
- A review of the recipients profile in the Arizona State Board of Pharmacy Controlled Substance Prescription Monitoring Program (CSPMP) database when initiating a controlled substance (i.e. amphetamines, opiates, benzodiazepines, etc.) that will be used on a regular basis or for short term addition of agents when the client is known to be receiving opioid pain medications or another controlled substance from a secondary prescriber.
Reassessments require the prescribing clinician of psychotropic medication notes in the Member’s record the following (see Section 10.2 — Medical Record Standards):
- The reason for and the effectiveness of the medication;
- The clinical appropriateness of the current dosage;
- All medication (including medications prescribed by the PCP and medical specialists, over the counter medications, and supplements) being taken and the appropriateness of the combination of the medications;
- Any side effects such as weight gain and/or abnormal/involuntary movements if treated with an anti-psychotic medication; and
- Minimum requirements as per Section 12.8 — Psychotropic Medication: Prescribing and Monitoring;
- Rationale for the use of two medications from the same pharmacological class and
- Rationale for the use of more than three different psychotropic medications in adults, and
- Rationale for the use of more than one psychotropic medication in the child and adolescent population.
12.8.3 Informed Consent
Informed consent must be obtained from the person and/or legal guardian for each psychotropic medication prescribed. When obtaining informed consent, the BMHP must communicate in a manner that the person and/or legal guardian can easily understand. It is preferred that the prescribing clinician provide information forming the basis of an informed consent decision. In specific situations in which this is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or a registered nurse.
The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 10.2 — Medical Record Standards). Essential elements for obtaining informed consent for medication are contained within AHCCCS AMPM Section 310-V, Attachment A: Informed Consent for Psychotropic Medication Treatment. AHCCCS AMPM Section 310-V, Attachment A is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record in an alternative fashion (see Section 10.2 — Medical Record Standards).
For more information regarding informed consent, see Section 12.7 — General and Informed Consent to Treatment.
12.8.4 Youth and Psychotropic Medications
- Youth under the age of 18 are to be educated on options, allowed to provide input, and encouraged to assent to medication(s) being prescribed. Information is discussed with the youth in a clear and age-appropriate manner consistent with the developmental needs of the youth.
- The information to be shared should be consistent with the information shared in obtaining informed consent from adults.
- Discussion of the youth’s ability to give consent for medications at the age of 18 years old is begun no later than age 17 ½ years old, especially for youth who are not in the custody of their parents.
- There should be special attention to the effect of medications on the reproductive status and pregnancy, as well as long term effects on weight, abnormal involuntary movements and other health parameters.
- Evidence of the youth’s consent to continue medications after reaching age 18 may be documented through use of AHCCCS Policy Form 108.1, Informed Consent/Assent for Psychotropic Medication Treatment, a recommended tool to review and document informed consent for psychotropic medications.
12.8.5 Psychotropic Medication Monitoring
Per national guidelines and to address the monitoring of psychotropic medications and metabolic parameters, the provider must establish policies and procedures for monitoring of lithium, valproic acid, carbamazepine, renal function, liver function, thyroid function, glucose metabolism, as well as screening for metabolic syndrome and movement disorders. See Provider Manual Attachment 3.8.5 Minimum Laboratory Monitoring for Psychotropic Medication. Providers are directed to call the Provider Services Call Center at 866-796-0542 to obtain a copy of this attachment, if needed.
Medications prescribed for Youth (members less than 18 years old) must be monitored for efficacy, side effects and adverse events at each visit with a registered nurse, physician assistant, psychiatric nurse practitioner, or physician.
12.8.6 Reporting Requirements
The Health Plan has established the AHCCCS system requirements for monitoring the following:
- Adverse drug reactions;
- Adverse drug event; and
- Medication errors.
The above referenced events must be identified, reported, tracked, reviewed and analyzed by The Health Plan.
An incident report must be completed for any medication error, adverse drug event and/or adverse drug reaction that results in harm and/or emergency medical intervention (See Section 10.10 — Reporting of Incidents, Accidents and Deaths for more information).
12.8.7 Complementary and Alternative Medicine (CAM)
Complementary and alternative medicine (CAM) is not AHCCCS reimbursable.
When a Behavioral Health Professional uses Complementary and Alternative Medicine (CAM), (See Arizona Medical Board’s Guidelines For Physicians Who Incorporate Or Use Complementary Or Alternative Medicine In Their Practice found at http://azmd.gov/Files/Guidelines/AlternativeMedicineInPhysicianPractice.pdf (PDF)) informed consent must be obtained from the person or guardian, when applicable, for each CAM prescribed (See Section 4.13.9 — The Health Plan’s Preferred Drug List). When obtaining informed consent, behavioral health medical practitioners must communicate in a manner that the person and/or legal guardian can easily understand. The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 10.2 — Medical Record Standards).
Essential elements for obtaining informed consent for medication are contained within AHCCCS AMPM Section 310-V, Attachment A, Informed Consent for Psychotropic Medication Treatment.
If AHCCCS AMPM Section 310-V, Attachment A is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record in an alternative fashion (see Section 10.2 — Medical Record Standards).
At times, it may be necessary to initiate civil commitment proceedings to ensure the safety of a person, or the safety of other persons, due to a person’s mental disorder when that person is unable or unwilling to participate in treatment. In Arizona, State law permits any responsible person to submit an application for pre-petition screening when another person may be, as a result of a mental disorder:
- A danger to self (DTS);
- A danger to others (DTO);
- Persistently or acutely disabled (PAD); or
- Gravely disabled (GD).
If the person who is the subject of a court ordered commitment proceeding is subject to the jurisdiction of an Indian Tribe rather than the State, the laws of that Tribe, rather than State law, will govern the commitment process. Information about the tribal court process and the procedures under State law for recognizing and enforcing a tribal court order are found in Section 12.9.10 — Court-Ordered Treatment for American Indian Tribal Members in Arizona.
Pre-petition screening includes an examination of the person’s mental status and/or other relevant circumstances by a designated screening agency. Upon review of the application, examination of the person and review of other pertinent information, a licensed screening agency’s medical director or designee will determine if the person meets criteria for DTS, DTO, PAD, or GD as a result of a mental disorder.
If the pre-petition screening indicates that the person may be DTS, DTO, PAD, or GD, the screening agency will file an application for a court-ordered evaluation. Based on the immediate safety of the person or others, an emergency admission for evaluation may be necessary. Otherwise, an evaluation will be arranged for the person by a designated evaluation agency within timeframes specified by State law.
Based on the court-ordered evaluation, the evaluating agency may petition for court-ordered treatment on behalf of the person. A hearing, with the person and legal representative and the physician(s) treating the person, will be conducted to determine whether the person will be released and/or whether the agency will petition the court for court-ordered treatment. For the court to order ongoing treatment, the person must be determined, as a result of the evaluation, to be DTS, DTO, PAD, or GD. Court-ordered treatment may include a combination of inpatient and outpatient treatment. Inpatient treatment days are limited contingent on the person’s designation as DTS, DTO, PAD, or GD. Persons identified as:
- DTS may be ordered up to 90 inpatient days per year;
- DTO and PAD may be ordered up to 180 inpatient days per year; and
- GD may be ordered up to 365 inpatient days per year.
If the court orders a combination of inpatient and outpatient treatment, a mental health agency may be identified by the court to supervise the person’s outpatient treatment. In some cases, the mental health agency may be a Regional Behavioral Health Authority/Managed Care Organization /Health Plan; however, before the court can order a mental health agency to supervise the person’s outpatient treatment, the agency medical director must agree and accept responsibility by submitting a written treatment plan to the court.
At every stage of the pre-petition screening, court-ordered evaluation, and court-ordered treatment process, a person will be provided an opportunity to change status to voluntary. Under voluntary status, the person is no longer considered to be at risk for DTS/DTO and agrees in writing to receive a voluntary evaluation.
County agencies and Regional Behavioral Health Authority/ Health Plan subcontracted agencies responsible for pre-petition screening and court-ordered evaluations must use the following forms prescribed in AAC R9-21, Article 5 (PDF) for persons determined to have a Serious Mental Illness.
The following forms can be obtained by going to the AHCCCS government Medical Policy Manual website.
- Application for Involuntary Evaluation (AHCCCS AMPM Chapter 300, Section 320-U-1)
- Application for Emergency Admission for Evaluation (AHCCCS AMPM Chapter 300, Section 320-U-2)
- Petition for Court-Ordered Evaluation (AHCCCS AMPM Chapter 300, Section 320-U3)
- Petition for Court-Ordered Treatment Gravely Disabled Person (AHCCCS AMPM Chapter 300, Section 320-U-4)
- Affidavit (AHCCCS AMPM Chapter 300, Section 320-U-5)
*For the Pima County: forms referenced in this section, Behavioral Health Home Title 36 Liaisons should reach out to the Pima County Attorney to obtain copies. For other forms referenced, the Behavioral Health Home Title 36 Liaison may contact AzCHTitle36@AZCompleteHealth.com
Agencies may also use these forms for all other populations. In addition to court-ordered treatment as a result of civil action, an individual may be ordered by a court for evaluation and/or treatment upon: 1) conviction of a domestic violence offense; or 2) upon being charged with a crime when it is determined that the individual is court-ordered to treatment, or programs, as a result of being charged with a crime and appears to be an individual with a possible substance abuse disorder. The responsibilities of The Health Plan and its providers for the provision and coverage of those services is described in Section 12.9.7 — Court-Ordered Treatment for Persons Charged with or Convicted of a Crime.
The intent of this section is to provide a broad overview of the pre-petition screening, court-ordered evaluation, and court-ordered treatment process. Depending on a provider’s designation as a screening, evaluation, or court-ordered treatment agency, the extent of involvement with persons receiving pre-petition screening, court-ordered evaluation, and court-ordered treatment services will vary.
12.9.1 Licensing Requirements
Providers who are licensed by the Arizona Department of Health Services/Division of Licensing Services as a court-ordered evaluation or court-ordered treatment agency must adhere to ADHS Licensing requirements.
12.9.2 Pre-Petition Screening
Arizona counties are responsible for managing, providing, and paying for pre-petition screening and court-ordered evaluations and are required to coordinate provision of services with the State system. Some counties contract with Regional Behavioral Health Authority/Managed Care Organization/Health Plans to process pre-petition screenings and petitions for court-ordered evaluations.
All applicants calling The Health Plan for court-ordered evaluations are referred to the Crisis Call Center at 866-495-6735 to assist callers in identifying the correct pre-petition screening agency and answering any questions they may have about the process.
When a county does not contract with The Health Plan for pre-petition screening services, the Crisis Call Center will answer any questions the caller may have about the process and warm-transfer the caller to the appropriate county-contracted prepetition screening agency.
When a county contracts with The Health Plan for pre-petition screening and petitioning for court-ordered evaluation, the Crisis Call Center will dispatch a designated pre-petition screening agency.
The pre-petition screening agency must conduct the following procedures:
- Provide pre-petition screening within forty-eight hours of the request excluding weekends and holidays;
- Prepare a report of the clinical assessment, professional opinions and conclusions. If pre-petition screening was not possible, the screening agency must report reasons why the screening was not possible, including opinions and conclusions of staff members who attempted to conduct the pre-petition screening;
- Request the screening agency’s medical director or designee review the report if it indicates that there is no reasonable cause to believe the allegations of the applicant for the court-ordered evaluation;
- Prepare a petition for court-ordered evaluation and file the petition if the screening agency’s Medical Director determines that the person, due to a mental disorder, including a primary diagnosis of dementia and other cognitive disorders, is a Danger to Self (DTS), Danger to Others (DTO), Persistently or Acutely Disabled (PAD), or Gravely Disabled (GD). Refer to the Petition for Court-Ordered Evaluation form for pertinent information for court-ordered evaluation;
- If the screening agency determines that there is reasonable cause to believe that the person, without immediate hospitalization, is likely to harm themselves or others, the screening agency will verify completion of the Application for Emergency Admission for Evaluation form, and take all reasonable steps to procure hospitalization on an emergency basis; and
- Contact the county attorney prior to filing a petition if it alleges that a person is a Danger to Others.
12.9.3 Court-Ordered Evaluation
If the pre-petition screening indicates that the person may be DTS, DTO, PAD, or GD, the screening agency will file an application for a court-ordered evaluation. The procedures for court-ordered evaluations are outlined below.
If a county should subcontract with The Health Plan to provide court-ordered evaluations, The Health Plan or its provider must follow these procedures:
- A person being evaluated on an inpatient basis must be released within seventy-two hours if further evaluation is not appropriate, unless the person makes application for further care and treatment on a voluntary basis;
- A person who is determined to be DTO, DTS, PAD, or GD as a result of a mental disorder must have a petition for court-ordered treatment prepared, signed, and filed by the RBHA/MCO/Health Plan medical director or designee; and
- Title XIX/XXI funds must not be used to reimburse court-ordered evaluation services.
Regional Behavioral Health Authority/ /Health Plans are not responsible for the costs associated with court-ordered evaluation outside of the limited “medication only” benefit package available for Non-Title XIX/XXI persons determined to have a SMI, unless other prior payment arrangements have been made with another entity (e.g. county, hospital, provider).
12.9.4 Voluntary Evaluation
Any Health Plan provider that receives an application for voluntary evaluation must immediately refer the person to the facility responsible for voluntary evaluations. Providers are to contact the Crisis Call Center at 1-866-495-6735 for assistance.
The Health Plan providers must follow these procedures:
- The evaluation agency must obtain the individual’s informed consent prior to the evaluation (see AHCCCS Section 320-U-7, Application for Voluntary Evaluation) and provide evaluation at a scheduled time and place within five days of the notice that the person will voluntarily receive an evaluation; and
- For inpatient evaluations, the evaluation agency must complete evaluations in less than seventy-two hours of receiving notice that the person will voluntarily receive an evaluation.
If a provider conducts a voluntary evaluation service as described in this section, the comprehensive clinical record (see Section 10.2 — Medical Record Standards) must include:
- A copy of the application for voluntary evaluation, use AHCCCS AMPM Section 320-U-7 Application for Voluntary Evaluation;
- A completed informed consent form (see Section 12.7 — General and Informed Consent to Treatment); and
- A written statement of the person’s present medical condition.
12.9.5 Court-Ordered Treatment Following Civil Proceedings Under A.R.S. Title 36
Based on the court-ordered evaluation, the evaluating agency may petition for court-ordered treatment. The provider must follow these procedures:
- Upon determination that an individual is DTS, DTO, GD, or PAD, and if no alternatives to court-ordered treatment exist, the medical director of the agency that provided the court-ordered evaluation must file a petition for court-ordered treatment (see Petition for Court-Ordered Treatment Gravely Disabled Person form);
- Any provider filing a petition for court-ordered treatment must do so in consultation with the person’s clinical team prior to filing the petition;
- The petition must be accompanied by the affidavits of the two physicians who conducted the examinations during the evaluation period and by the affidavit of the applicant for the evaluation (see Affidavit form);
- A copy of the petition, in cases of grave disability, must be mailed to the public fiduciary in the county of the patient’s residence, or the county in which the patient was found before evaluation, and to any person nominated as guardian or conservator; and
- A copy of all petitions must be mailed to the superintendent of the Arizona State Hospital.
Per Arizona Revised Statutes 36-545.06-County Services: “Each County shall provide directly, or by contract the services of a screening Provider and an evaluation Provider.”
Each County must have a process in place for:
- Involuntary mental health treatment requests and evaluations
- Court proceedings to satisfy the statutory requirements under Title 36 for individuals under court-ordered evaluation and court-ordered treatment
Every County in Arizona manages this responsibility differently based on their interpretation of the state statutes and the resources in that County. The Court Ordered Treatment/Court Ordered Evaluation (COT/COE) Coordinator and Liaison are required to work with the County Attorney’s Office to ensure proper execution of its procedures.
The Health Plan is responsible for treatment of an eligible person* once placed under a Title 36 civil commitment or court-ordered treatment (COT). Per Arizona Administrative Code (R9-21-504) the RBHA/MCO/Health Plan “shall provide, either directly or by contract all treatment required by A.R.S. Title 36, Chapter 5, Article 5.”
* Populations eligible for RBHA/MCO/Health Plan services per The Health Plan Provider Manual Section 2.1.1-2:
- Title XIX/XXI enrolled individuals;
- Persons determined to have a Serious Mental Illness;
- Special populations, including individuals receiving services through the Substance Abuse Block Grant(SABG)
Each Behavioral Health Home per The Health Plan contract scope of service is required to designate a staff person to serve as COT/COE Coordinator and Liaison for Title 36 and Court-Ordered services.
A Provider coordinates the provision of clinically appropriate covered services to individuals requiring court ordered treatment and serves as the Supervising Provider for court-ordered outpatient treatment plans.
In all cases, the Provider Medical Director** or physician designee has primary responsibility for oversight of an individual’s court-ordered treatment and is responsible for reviewing and signing all documents filed with Court, including the initial court-ordered treatment plan.
** Per ARS 36-501 (24) Definitions - Medical Director of a mental health treatment Provider" means a psychiatrist, or other licensed physician experienced in psychiatric matters, who is designated in writing by the governing body of the Provider as the person in charge of the medical services of the Provider for the purposes of this chapter and includes the chief medical officer of the state hospital.”
Individuals on court ordered treatment (COT) are one of the most at-risk populations served. These Individuals will need to receive services with a Behavioral Health Provider who can submit the Outpatient treatment Plan to the Courts.
- Individuals on COT must be seen at least monthly by the Medical Director or designee (must be a Prescriber)
- Outreach and engagement with these individuals should be assertive and follow the re-engagement processes within The Health Plan Provider Manual (Section 3.4). The goal is to avoid re-hospitalization and improve the quality of life for the individual.
- A solid crisis plan must be developed that includes what works and does not work for this individual, supports that can help, and types of outreach that should be attempted if the individual has an increase in symptoms or disengages from treatment.
- The Health Plan has developed crisis protocols for every County served that include detailed descriptions about the way the crisis system works in each respective County. There are extensive sections on involuntary treatment that should be referenced for details on how each County facilitates the COT process. The protocols are located on The Health Plan website at www.azcompletehealth.com
- Providers must closely monitor COT expiration dates. Pursuant to A.R.S 36-540 (D), a court order cannot exceed 365 days, but some counties may order fewer days. Providers must ensure they understand the County’s interpretation of the COT expiration date. Providers must monitor expiration dates to schedule annual reviews to determine if the individual’s COT should continue for another year. Additionally, it gives Providers enough time to file a Petition for Continued Treatment with Court for individuals who were found Persistently or Acutely Disable or Gravely Disabled.
- The Health Plan will monitor and audit COT requirements and will issue Corrective Action Letters and/or Sanctions for failure to follow the requirements.
Each Provider is responsible for maintaining a current list of individuals who are receiving court-ordered treatment.
PIMA COUNTY: Providers are responsible for establishing a group generic email box to receive minute entries from the Court. An example is MinuteEntries@[provider name].com.
Urgent Engagement, SMI Evaluations and AHCCCS Screening for Member in COE/COT Process
The Health Plan enrolled and State Only (N19/NSMI) individuals who are identified as not engaged with a behavioral health provider must be referred for urgent engagement and “for persons who are not yet enrolled in Medicaid, Block Grant programs, or the Marketplace, Behavioral Health Homes are required to continue to pursue coverage for the person”. (See Section 14.1.1 Behavioral Health Home UE Responsibility)
For individuals going through Court Ordered Evaluation to be Court Ordered for Treatment, all avenues are explored to determine eligibility for services offered by The Health Plan. Therefore, when an agency in any county is activated for an Urgent Engagement for an individual who is NT19 and GMH and being evaluated for Court Ordered Treatment, an SMI evaluation/assessment should be completed. In general the SMI determination should be expedited by checking the 3-day turnaround time frame. The Behavioral Health Home should also conduct financial screenings and assist the individual in applying for Title 19 benefits.
Should the member refuse services during the Court Ordered Evaluation process; the Behavioral Health Home activated due to an urgent engagement shall retain the member until the member is Court Ordered for Treatment and then proceed to engage the member so that eligibility with AHCCCS and an SMI determination can be completed. Please contact the Title 36 Coordinator at The Health Plan for additional Technical Assistance.
Behavioral Health Homes are required to enroll and engage Title XIX members who refuse services during the COE process upon the member being Court Ordered.
Provider Participation in Hearings
The Individual’s assigned Health Care Coordinator must attend all COT hearings, including the original hearing for court-ordered treatment, judicial reviews, and Petitions for Continued Treatment of Gravely Disabled (GD) or Persistently or Acutely Disabled (PAD). It is expected the Health Care Coordinator follows courtroom rules of decorum. The Health Care Coordinator should be prepared to provide information/clarification to Court regarding facts relevant to the hearing and the proposed outpatient treatment plan. The Health Care Coordinator must be present to receive orders set forth by the Judge/Commissioner and specific orders regarding the submitted outpatient treatment plan. In Pinal County, this also includes the dates COT status reports are to be submitted to the Court.
Treatment Plan Development and Filing
Prior to the date of the hearing, the Health Care Coordinator is responsible for coordinating an Adult Recovery Team (ART) meeting for enrolled individual to develop discharge plans and ensure that those plans are included in the individual’s Individual Service Plan (ISP). The ISP must be discussed/reviewed with the Provider Medical Director or physician designee. The individual’s inpatient team must be involved in and agree to discharge decisions.
The COT outpatient treatment plan must be signed by Provider staff that reviewed the plan with the individual and the outpatient team. The individual is not required to sign the COT outpatient treatment plan and individual signature is optional. If the individual does not sign the plan, the individual signature line is to be left blank. Information regarding why the individual did not sign the plan is not to be written on the plan.
The COT outpatient treatment plan must have the individual’s correct address/zip code and phone number and the type of residence (home, family, friend, BHRF, jail, etc.). If the individual is to reside with family, friends, etc., Provider staff must confirm this arrangement with family, friends, etc.
If a COT outpatient treatment plan has not been completed, the Health Care Coordinator is to inform Court why the plan has not been completed and the projected date of completion.
PIMA COUNTY: For individuals who are TXIX/TXXI eligible, the Health Care Coordinator develops a COT outpatient treatment plan using PIMA County-COT Plan Ind. Receiving AHCCCS Benefits or the PIMA County-COT Plan Ind. NOT Receiving AHCCCS Benefits form. In the event Persons who are Non-Title XIX/XXI eligible but are determined to have a Serious Mental Illness (SMI), the Health Care Coordinator develops a COT outpatient treatment plan using PIMA County-COT Plan Ind. Receiving AHCCCS Benefits form or the PIMA County-COT Plan Ind. NOT Receiving AHCCCS Benefits. The Health Care Coordinator is to be submit to Court the original COT outpatient treatment plan to the Judge/Commissioner for signature, with 5 copies 1) County Attorney, 2) Defense Attorney, 3) Hospital T-36 Liaison, 4) Individual, 5) The Health Plan, totaling six treatment plans.
Amendments/Revocations (see the County Crisis Protocols or County specific sections of this guide for a detailed description of the process) Refer to ARS 36-540 depending on the County process.
The provider can amend/revoke an individual’s court order and place the individual in an inpatient setting if the individual is not following the terms of the court order. It is important to note that only the Medical Director or physician designee can request an amendment/revocation of the outpatient treatment plan. Note: Medical Directors are required to be available after hours if needed in order to facilitate the revocation/amendment of a court order.
- It is important the provider track the numbers of days a member has spent in an inpatient setting, because there are a limited amount of inpatient days the court may order pursuant to A.R.S. 36-540:
- DTS up to 90 days
- DTO & PAD up to 180 days
- GD up to 365 days
- If there are no more inpatient days available, the Medical Director must determine if the individual requires continued court-ordered treatment. If the individual is DTO/DTS the provider can follow the process for an Emergency Application for Evaluation for Admission. If the individual is PAD/GD the provider can initiate the Annual Review process or follow the Pre-Petition Screening process.
- Amended outpatient treatment orders do not increase the total period of commitment originally ordered by Court.
Emergent Amendment/Revocation A.R.S. 36-540 (E)(5)
If the individual is presenting with DTO/DTS behaviors and requires immediate hospitalization, the provider can verbally amend the outpatient treatment plan without an order from Court. The Medical Director or physician designee must contact an inpatient psychiatrist, discuss and agree that the individual requires immediate inpatient treatment. The Medical Director or physician designee may authorize a peace officer to transport the individual to the inpatient treatment facility.
The Medical Director of the outpatient treatment facility must file a motion for an amended court order requesting inpatient treatment no later than the next working day following the individual being taken to the inpatient facility. If this paperwork is not filed in this timeframe, the individual may be detained and treated for no more than 48 hours, excluding weekends and holidays.
When an individual is hospitalized pursuant to an amended order, the provider must inform the individual of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546.
PIMA COUNTY: Use the PIMA County-Emergent Amendment form
PIMA COUNTY: Verbal Revocation Process
When a member is in crisis at their placement, the following steps shall be taken: 1) The Out of Home (OOH) Placement shall assess if the Behavioral Health Home is able to become involved. 2) If the Behavioral Health Home can respond, they will follow their process for determining what steps need to be taken next. 3) If the Behavioral Health Home cannot be involved, the OOH placement shall call AzCH Nurse Assist Line, who shall triage the situation and dispatch the Crisis Mobile Team.
If Crisis Mobile Team is dispatched, the Crisis Mobile Team shall assess if the member can be stabilized at the OOH placement. If member cannot be stabilized at the placement, the CMT shall consult on revocation recommendations with the Behavioral Health Home doc on call. If the Behavioral Health Home doctor does not recommend revocation, the Crisis Mobile Team shall determine next steps needed.
If the Behavioral Health Home doctor does recommend revocation, the Crisis Mobile Team shall call the Crisis Response Center Intake Coordinator and staff member’s care. The Crisis Response Center shall complete their internal paperwork to document the verbal revocation. The Crisis Response Center shall contact law enforcement to request Verbal Revocation Transport. Law Enforcement shall verify name, date of birth, and authorizing doctor and Behavioral Health Home with the Crisis Mobile Team. Law Enforcement shall transport the member to the Crisis Response Center.
The Behavioral Health Home shall be responsible the next business day for completing and filing with the courts the amendment in order to complete the verbal revocation process.
Non-Emergent Amendment/Revocation A.R.S. 36-540 (E)(4)
If the provider determines that the individual is not complying with the terms of the order or that the outpatient treatment plan is no longer appropriate, the Medical Director or physician designee can petition the court to amend/revoke the outpatient treatment plan to inpatient treatment. Court, without a hearing and based on the court record, the patient's medical record, the affidavits and recommendations of the Medical Director (must be notarized) , and the advice of staff and physicians or the psychiatric and mental health nurse practitioner familiar with the treatment of the patient, may enter an order amending its original order.
If the individual refuses to comply with an amended order for inpatient treatment, the court may authorize and direct a peace officer, on the request of the Medical Director, to take the individual into protective custody and transport the individual for inpatient treatment.
When an individual is hospitalized pursuant to an amended order, the provider must inform the individual of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546.
PIMA COUNTY: For non-emergent amendments use the PIMA County-Non-Emergent Amendment form. The request for amendment to outpatient treatment plan must be signed by the outpatient psychiatrist and notarized. The provider submits the notarized form to The Health Plan approved law firm. Court requires specific information/facts regarding the individual’s lack of compliance with the outpatient treatment plan. The preparer of the amended request should avoid using conclusions such as “delusional,” “non-compliant,” “AWOL (Absence without Leave),” “disruptive,” “inappropriate,” etc. The request should contain information regarding outreach attempts, attempts to engage the individual in treatment, or to offer hospitalization on a voluntary basis.
PIMA COUNTY: If Provider staff obtains updated information as to the individual’s location after the amendment to the outpatient treatment plan has been filed with Court, the Provider should contact Pima County Mental Health Support Team (MHST) to provide updated information. When providing updated location information, staff should inform the MHST officer that an amendment to the outpatient treatment plan has been filed with Court. The MHST officer may request a copy of the amendment, which is permissible.
Quash a Court’s Order for Law Enforcement to Transport for a Non-emergent Amendment
If Court has entered an order for law enforcement to transport the individual to an inpatient treatment facility and the provider believes this level of care is no longer required, the Provider can motion the court to quash the order to transport by law enforcement. This ensures the individual is not unnecessarily transported to an inpatient facility.
PIMA COUNTY: If 90 days has expired since the last amendment, the Provider is required to submit a written statement to The Health Plan approved law firm requesting to quash the previous amended and transport order. At this time the Provider may file a new amendment with the court for another 90 days. . If an individual becomes incarcerated at Pima County Adult Detention Center (PCADC) during the timeframe of the amended outpatient treatment plan, a court order to quash the transport is not required if the current amendment does not indicate the address of PCADC. The Provider is responsible for notifying Pima County’s MHST of the change in location of the individual. The Provider must email the amended pleading to MHST and PCADC records.
Tolling a Court Ordered Treatment
Per Statute 36.544; a member’s Court Ordered Treatment is tolled during the unauthorized absence of the patient and resumes running only on the patient's voluntary or involuntary return to the treatment agency.
As defined by the Statute, an unauthorized absence is the following:
- if a member is no longer living in a placement or residence specified by the treatment plan without authorization OR
- leaving or failing to return to the county or state without authorization
- Absent from an inpatient treatment facility without authorization
The Statute indicates within five (5) days after a patient's unauthorized absence, the Behavioral Health Homes shall file a motion with the Court to request a Toll of the Court Ordered Treatment.
Behavioral Health Home Title 36 Liaisons will be responsible for Filing Toll requests with the Courts, monitoring the number of days of the Toll and ensuring Status Reports for re-engagement efforts are filed every 60 days up to 180-Tolled Days. Tolled Orders will be reported to the The Health Plan Title 36 Coordinators.
Should the member not be re-engaged voluntarily or involuntarily, the Behavioral Health Home has the option to ask the Court to terminate the Court Ordered Treatment after 180 days on Toll.
Tolling a Court Order will move forward the expiration date of the current Order based upon the number of days the member was absent.
Judicial Reviews A.R.S. 36-546
Providers must inform the individual of the right to Judicial Review every 60 days and must document this in the clinical record. Judicial Reviews are to be calendared and offered every 60 days from the date of the original court order. The days from the court order are as follows: 60, 120, 180, 240,300, and 360. It is the responsibility of the Provider to track the Judicial Review dates and ensure a Judicial Review is offered to an individual under Court-Ordered Treatment (COT) every 60 days. If an individual is hospitalized pursuant to an amendment to the outpatient treatment plan the Provider must inform the individual of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546. This Judicial Review does not change the count of the 60 days set from the date of the court order. It is considered an exception per statute and is permitted before the 60 days.
A Judicial Review must also be offered to the member should the member be absent for 60 or more days,returns and is re-engaged in treatment. The due dates of the offers may need to be adjusted upon return.
If the individual requests Judicial Review, the Health Care Coordinator completes the Judicial Review-right to Speak to Legal Counsel Form. The form includes the following information:
- The individual being treated and the treating Provider.
- The individual to whom the request for release was made.
- The individual making the request for release, indicating whether the individual is the individual being treated or someone acting on the individual’s behalf.
The individual reports current address and signs the form. The Health Care Coordinator must schedule an appointment for the individual to be evaluated by the Provider’s Behavioral Health Medical Provider. The appointment cannot be scheduled with a Nurse Practitioner or Physician’s Assistant. The completed PM form and psychiatric report must be completed and submitted to the County Attorney within 72 hours of the request and by the filing deadline.
For PIMA County, the completed form and psychiatric report is submitted to the law firm within 72 hours of the request and by the filing deadline.
For Greenlee, Graham, LaPaz, Santa Cruz and Yuma Counties; “The Treatment Team Recommendation for Judicial Review for COT” form, should be completed and submitted along with the following documents:
- Letter from Medical Director;
- The Right to Notification of Judicial Review form;
- The last progress note from the Behavioral Health Medical Provider proving the Judicial review was discussed with Member and reporting recommendations.
For PINAL County, the following documents should be completed and submitted:
- The Right to Notification of Judicial Review form;
- The last 30-day Behavioral Health Medical Provider appointment that provides a psychiatric exam of the member. This is counted as the current “psychiatric exam”.
As a reminder, the Court could request additional documentation.
For Cochise County; the form “The Psychiatric Reports RE: Request for Judicial Review” must be completed and filed with the clerk of court along with the following documents:
- The Psychiatric Report RE: Request for Judicial Review (The medical director’s letter);
- The Right to Notification and Legal Counsel of Judicial Review form;
- The last psychiatric evaluation that was completed.
For Maricopa County, providers follow the protocols already established by the Maricopa Court.
The Behavioral Health Medical Provider appointment should be scheduled no later than 48 hours from request, so the Judicial Review form is received by the County Attorney or law firm the next day, to meet the 72 hour timeframe.
If the individual declines a Judicial Review, the Health Care Coordinator completes the same form - Judicial Review-right to Speak to Legal Counsel, and the individual signs this form. The individual provides a current address and location. The Provider maintains this form in the clinical record. If the individual is unavailable at the time the Judicial Review is due, the Health Care Coordinator completes the same form- Judicial Review-right to speak to Legal Counsel. The Health Care Coordinator must provide reasons why the individual was not available for the Judicial Review and include outreach and re-engagement attempts made. The Provider maintains this form in the clinical record. It should match the progress notes regarding outreach.
Court requires the psychiatric report to contain sufficient clinical information to render a decision regarding whether the individual needs continued court-ordered treatment or not. This psychiatric report can be in the form of a progress note. At a minimum the Judicial Review must include information regarding the individual’s insight regarding mental illness and information regarding adherence to court-ordered treatment plan. If the individual does not attend the Judicial Review appointment, all attempts should be made to reschedule the appointment. If the member does not attend, the health care coordinator should then confirm with the member that they have changed their mind and are no longer requesting a judicial review hearing. If an individual is hospitalized pursuant to an amended outpatient treatment plan and requests a Judicial Review, merely stating the individual is involuntarily hospitalized is not enough factual information for Court to render a decision. The BHMP should attempt to contact the inpatient Behavioral Health Medical Provider to gather information for the Judicial Review. Failure to provide sufficient evidence of need for continued treatment could result in Court requesting a hearing on the matter. A hearing can be set by the Judge/Commissioner or if requested by the defense attorney.
At the original hearing for court order, the Judge/Commissioner may direct the provider to submit status reports to Court. The Judge/Commissioner will set the dates when the reports are to be submitted.
- Pinal County court requires status reports due to the court at 30, 90, 180, 270 days. If the Provider fails to complete the status report to the court, the judge can order the person to appear and provide an in person status report regarding the treatment and process of the consumer.
- As this time, the following counties do not require a status report: Cochise, Graham, Greenlee, Yuma, La Paz and Pima.
Annual Review A.R.S. 36-543
Within 90 days of the expiration of the court order, the provider must conduct an annual review of an individual who was court-ordered to treatment as Gravely Disabled or Persistently or Acutely Disabled (GD & PAD) to determine if continuation of COT is appropriate and assess the needs of the individual for guardianship or conservatorship or both. The annual review includes a review of the mental health treatment and clinical records contained in the individual’s treatment file.
If the Medical Director believes that continuation of the court-ordered treatment is appropriate, the Medical Director appoints one or more psychiatrists (depending on the County) to carry out a psychiatric examination of the individual. Each psychiatrist participating in the psychiatric examination must submit a report to the Medical Director that includes the following:
- The psychiatrist’s opinions as to whether the individual continues to have a grave disability or persistent or acute disability as a result of a mental disorder and is in need of continued COT;
- A statement as to whether suitable alternatives to COT are available;
- A statement as to whether voluntary treatment would be appropriate;
- Review of the individual’s need for a guardian or conservator or both;
- Whether the individual has a guardian with mental health powers that would not require continued COT;
- The result of any physical examination that is relevant to the psychiatric condition of the individual.
Additionally, the individual’s clinical team shall hold a service planning meeting, not less than 45 days prior to the expiration of the court-ordered treatment to determine if the court order should continue. The following information must be indicated and written in the BHMP progress notes of the service planning meeting for the annual review that you submit:
- That this appointment is for the 45/90 day face to face annual review appointment;
- That the recommendation is either to roll/continue the members COT or to allow the COT expire;
- That the recommendation was discussed with the member; and
- Note: In Maricopa County, if the Medical Director has determined that the member’s court order can expire, providers only submit a final status report to the Court. AzCH will not require a face to face annual review appointment in Maricopa County for these members; but there should be progress notes to indicate that the member was informed the Court Order would be allowed to expire. Copies of those progress notes along with the Final Status Report should be submitted to AzCH.
If the Medical Director believes after reviewing the annual review that continued COT is appropriate, the Medical Director files with Court, no later than forty-five days before the expiration of the court order for treatment, an application for continued court-ordered treatment and the psychiatric examination conducted as part of the annual review. If the individual is under guardianship, the Medical Director must mail a copy of the application to the individual’s guardian.
The annual exam must have current contact information for the individual. This includes full address, zip code, and telephone number. If the individual’s location and/or other contact information changes, provider staff must contact the individual’s attorney with this new information
Annual Review of Incarcerated Members or Missed Annual Review Appointments
For the Annual Review requirement, please ensure that the Psychiatrist/Behavioral Health Medical Provider does the following within the allotted time frame (45-90 days) of the Annual Review dates:
- For Incarcerated members:
Write a note in the chart that consists of the following information:
- This is an annual review;
- Circumstances as to why the member was not present;
- Indicate the date the member was booked to jail and that the member is still incarcerated;
- Indicate whether their recommendation is to roll the order or to allow it to expire. If the recommendation is to roll based on the member’s clinical record and you are not able to file a Petition for Continued Treatment with the Court, indicate that due to lack of coordination from the jail, this is not possible;
- Indicate the date when you attempted to reach out to the jail psychiatrist to discuss member’s annual review;
- File in the Member’s medical Record;
- Send a copy to the Title 36 Coordinator indicating this is an annual review for an incarcerated member.
- For members who have missed scheduled annual review appointments within the required time frame, prior to the 45th day of the COT expiring, a chart review may be necessary.
Write a note in the chart that consists of the following information
- This is a chart review for the required annual review;
- Dates of previous annual review appointments scheduled and missed
- Circumstances as to why the member was not present,
- Date a revocation was filed with the Court when appropriate
- Indicate whether their recommendation is to roll the order or to allow it to expire. If recommendation would be to roll, indicate that due to lack of contact with the member, this is not possible;
- Indicate that re-engagement protocols have been attempted to locate the member (A request for progress notes to review re-engagement attempts may be asked for);
- File in the Member’s medical record;
- Send a copy to the Title 36 Coordinator indicating this is an annual review for a missing member.
If your agency uses a psychiatric annual review examination form, please use that document and include the above information.
NOTE: You should still enter these reviews as the annual review for the member
A hearing is conducted if requested by the individual’s attorney on behalf of the request of the individual or otherwise ordered by Court.
For individuals determined DTS and/or DTO the provider must initiate the pre-petition screening process pursuant to Arizona Administrative Code.
For individuals whose Court Order is currently being tolled, the annual review will not be required until the member is re-engaged into services.
Progress notes for the annual review can be emailed as soon as the annual review has been completed, but no later than the 2nd business day of the following month the annual review must have been completed.
PIMA COUNTY: For continued treatment examinations for individuals found to be GD, utilize PIMA County Psych Exam for Annual Review for GD Persons form. For continued treatment examinations for individuals found to be PAD, utilize the PIMA County Psych Exam for Annual Review for PAD Persons. The Health Plan law firm will forward to the provider the conformed copy of the petition and order. The provider is required to give the paperwork to the individual and obtain a signature using the Confirmation of Receipt form. This form provides evidence to Court and defense counsel the individual is aware of the petition and the right to speak to an attorney. This original signed form must submit The Health Plan law firm within five (5) business days of receipt. If set for hearing, the Provider’s Behavioral Health Medical Provider who completed the Annual Exam must testify at the hearing. The COT/COE Liaison is responsible for coordinating the hearing with The Health Plan law firm, provider staff and the Behavioral Health Medical Provider. The Health Care Coordinator must inform the individual of the hearing and arrange for transportation to the hearing. The Health Care Coordinator may be called as a witness.
Termination/Release from Court Ordered Treatment A.R.S. 36-541.01
Upon written request of the individual’s Behavioral Health Medical Provider, a Court may order an individual to be released from court-ordered treatment prior to the expiration of the court-ordered period.
Specifically, the Title 36 Statute states “A patient who is ordered to undergo treatment pursuant to this article may be released from treatment before the expiration of the period ordered by the court if, in the opinion of the medical director of the mental health treatment agency, the patient no longer is, as a result of a mental disorder, a danger to others or a danger to self or no longer has a persistent or acute disability or a grave disability. A person who is ordered to undergo treatment as a danger to others may not be released or discharged from treatment before the expiration of the period for treatment ordered by the court unless the medical director first gives notice of intention to do so as provided by this section.”
Termination from Reporting a member who is on Court Ordered Treatment
There are certain circumstances when a Behavioral Health Home may no longer be required to report to The Health Plan a member who is on Court Ordered Treatment. These conditions would be as follows: 1) a member has been sentenced to the Department of Corrections, 2) a member has died, 3) the member has lost AHCCCS benefits and is NOT Severely Mentally Ill (SMI) and does not meet SMI criteria, 5) the member’s Court Order has been Tolled for 180 days and the Court approves the Behavioral Health Home’s request to terminate the Court Order, 6) the Order is dismissed during a Judicial Review hearing, and 7) the member has agreed to become voluntary.
Suspension of Outpatient Treatment Plan
In Pima County and occasionally in Maricopa County, if a member moves out of state and the Behavioral Health Home can no longer provide services; the Behavioral Health Home may petition the court to suspend the outpatient treatment section of the member’s court ordered treatment. This relieves the Behavioral Health Home of the responsibility of services specifically for the court ordered treatment.
For Court Orders issued from Yuma, Pinal, Cochise, Santa Cruz, Graham and Greenlee Counties, no formal process has been established for suspending the outpatient treatment portion of the court order. Behavioral Health Homes Title 36 Liaison are advised to contact The Health Plan Title 36 Coordinator for direction.
Termination of a Court Order that has been Tolled
Per Revised ARS Title 36 Statute 36-544, if a member’s Court Order has been tolled for 180 days, the Behavioral Health Home may petition the court to terminate the member’s Court Ordered Treatment. The Court may or may not approve of the request.
Members Currently Being Served by a Behavioral Health Home.
A Provider serving as a Behavioral Health Home is required to provide all services including outpatient treatment plan services for members on Court Ordered Treatment.
However, there are some Intake Agencies who cannot typically provide the services required by the Outpatient Treatment Plan for Court Ordered Treatment. If the member is currently receiving services from one of these providers, the member may need to be transferred/assigned to a Behavioral Health Home who will assume responsibility for the members Court Ordered Outpatient Treatment Plan. Should this occur, please contact The Health Plan Title 36 Coordinator for additional Technical Assistance.
Agency Transfers for Members on Court Ordered Treatment.
This Section pertains to court ordered treatment under A.R.S. § 36, Chapter 5 and the Arizona Administrative Code R9-21-507.
Note: The following are general guidelines-each County has the right to request additional or different documentation. When the specific County process is known, it shall be included in this guide.
A person ordered by the court to undergo treatment and who is without a guardian may be transferred from one provider to another provider, as long as the medical director of the provider initiating the transfer has established that:
- The member’s Court Ordered Treatment is not expiring within 90 days of the transfer;
- There is no reason to believe that the person will suffer more serious physical harm or serious illness as a result of the transfer;
- The person is being transitioned to a level and type of treatment that is more appropriate to the person’s treatment needs; and
- The medical director of the receiving provider has accepted the person for transition.
The medical director of the provider requesting the transition must have been the provider that the court committed the person to for treatment or have obtained the court’s consent to transition the person to another provider as necessary.
The medical director of the provider requesting the transition must provide notification to the receiving provider allowing sufficient time (but no less than 3 days) for the transition to be coordinated between the providers. Notification of the request to transition must include:
- A summary of the person’s needs;
- A statement that, in the medical director’s judgment, the receiving provider can adequately meet the person’s treatment needs;
- A modification to the individual service plan, if applicable;
- Documentation of the court’s consent, if applicable;
- A written compilation of the person’s treatment needs and suggestions for future treatment by the medical director of the transitioning provider to the medical director of the receiving provider. The medical director of the receiving provider must accept this compilation before the transition can occur; and
This is best accomplished by sending an email to the provider the member has requested to be transferred to and requesting a “Letter of Intent to Treat”.
The receiving Provider’s Title 36 liaison should be cc’d on any emails when a member on court ordered treatment is going to be transferred.
The Letter of Intent can be a letter from the Medical Director of the receiving Behavioral Health Clinic that includes:
- Name and DOB of the individual on COT
- COT start and end date
- The standard under which the person is court ordered (DTO; /DTS; PAD; GD)
- Printed name and signature of the receiving Provider’s Medical Director
- Effective transfer date (date of intake)
- The letter can read simply: “This letter is to verify that Dr. X and Provider Y has agreed to provide court ordered treatment to member Z”
- The Behavioral Health Clinic must keep a copy of the letter in the clinical record.
The Medical Director of the receiving Provider notifies Court in writing that there has been a change in oversight of the individuals COT. It is recommended that an official document from the court be requested that reflects the current treatment Provider/Medical Director as the responsible party overseeing the court ordered treatment
Transportation from the sending provider to the receiving provider is the responsibility of the sending behavioral health provider.
If transferring to another Health plan, you must also follow guidelines in this section: 18.104.22.168 Inter-RBHA Process
NOTE: Inter-T/RBHA transfers are not to be initiated when a person is under pre-petition screening or court ordered evaluation
Arizona State Hospital (AzSH)
AzSH PSRB GEI-If a person is being released from AzSH after serving a sentence under the guilty except insane (GEI) standard, the release of this person is generally reviewed by the Psychiatric Security Review Board. (PSRB) The PSRB will make recommendations for the individuals release into the community. This will often include a referral to the Regional Behavioral Health Authority/Managed Care Organization /Health Plan where the individual plans to reside upon release and often consideration for court ordered treatment. In these situations, the local County Attorney’s office is notified by AzSH to initiate the court ordered evaluation process.
PIMA COUNTY: A transfer hearing must be set if a COT individual objects to the transfer to ASH.
Change of Venue – Counties other than Pima
When a client transfers from one County to another, the receiving provider must agree to accept the individual on COT through an LOI and, once transferred, must request the change of venue from the County in which the COT originated. Although, Change of Venue is a Court jurisdiction process, the receiving provider must follow-up with Court to ensure the change of venue is completed to ensure there is an accurate record of COT individuals by provider.
Change of venue from Pima County to another County
Change of venue should be requested by the outpatient provider at the time of the initial Court Ordered Treatment hearing. The provider should appear in court with an outpatient treatment plan and request the judge to change the venue to the receiving County. If a change of venue needs to occur after the initial Court Ordered Treatment hearing, the outpatient provider must submit: 1) Motion for approval of court-ordered outpatient treatment plan, accompanied by a Court Ordered Treatment Plan, 2) Motion to Change Venue, Order to Change Venue, accompanied by a Letter of Intent. The documents must be mailed to The Health Plan approved law firm to file with the Court.
Per AHCCCS, monthly reporting is required for all persons on court ordered treatment. All providers must identify and track treatment engagement of Court Ordered Treatment (COT) individuals.
- Provider can complete/submit updates at any time during the reporting month, but all updates (updates include portal data entry and required documentation) must be completed and submitted no later than the 2nd business day of the next month.
- Provider must submit initial or continuing COTs as soon as they are received from Court
- It is highly recommended that each Provider designate a backup designee for the COT/COE Coordinator and Liaison to manage report submission and any questions from The Health Plan T-36 Coordinator if the Provider’s COT/COE Coordinator and Liaison not be available.
- It is recommended that the COT/COE Coordinator, the Liaison and their backup designee be responsible to submit the data the manual speadsheet
- There can be multiple updates per member per month depending on the number of events occurring in the reporting month
- The EC-302 COT Title 36 Reporting Monthly Deliverable due on the 2nd business day of the next month, as outlined in Section 16 – Deliverable Requirements is to ensure that updates and documents are entered/submitted no later than this date.
12.9.6 Persons Who Are Title XIX/XXI Eligible or Non-Title XIX/XXI and/or Determined to Have a Serious Mental Illness (SMI).
When a person referred for court-ordered treatment is Title XIX/XXI or non-Title XIX/XXI eligible and/or determined or suspected to have SMI, the provider must:
- Conduct an evaluation to determine if the person has a Serious Mental Illness in accordance with Section 12.6 — SMI Eligibility Determination, and conduct a behavioral health assessment to identify the person’s service needs in conjunction with the person’s clinical team, as described in Section 12.5 — Assessment and Service Planning;
- Provide necessary court-ordered treatment and other covered services in accordance with the person’s needs, as determined by the person’s clinical team, the Member, family Members, and other involved parties (see Section 12.5 — Assessment and Service Planning); and
- Perform, either directly or by contract, all treatment required by ARS Title 36, Chapter 5, Article 5 and 9 AAC 21, Article 5.
12.9.7 Court-Ordered Treatment For Persons Charged with or Convicted of a Crime
The Health Plan or providers may be responsible for providing evaluation and/or treatment services when an individual has been ordered by a court due to: conviction of a domestic violence offense; or upon being charged with a crime when it is determined that the individual is court ordered to treatment, or programs, as a result of being charged with a crime and appears to be an “alcoholic.”
12.9.8 Domestic Violence Offender Treatment
Domestic violence offender treatment may be ordered by a court when an individual is convicted of a misdemeanor domestic violence offense. Although the order may indicate that the domestic violence (DV) offender treatment is the financial responsibility of the
offender under A.R.S. § 13-3601.01 The Health Plan will cover Domestic Violence services with Title XIX/XXI funds when the person is Title XIX/XXI eligible, the service is medically necessary, required prior authorization is obtained if necessary, and the service is provided by an in-network provider. For Non-TXIX/XXI eligible person’s court ordered for DV treatment, the individual can be billed for the DV services.
12.9.9 Court-Ordered DUI Services
Substance abuse evaluation and/or treatment (i.e., DUI services) ordered by a court under A.R.S. § 36-2027 is the financial responsibility of the county, city, town, or charter city whose court issued the order for evaluation and/or treatment. Accordingly, if AHCCCS or The Health Plan receives a claim for such services, the claim will be denied with instructions to the provider to bill the responsible county, city, or town.
12.9.10 Court-Ordered Treatment for American Indian Tribal Members in Arizona
Arizona Tribes are sovereign nations, and tribal courts have jurisdiction over their members residing on reservation. Tribal court jurisdiction, however, does not extend to tribal members residing off the reservation or to State court-ordered evaluation or treatment ordered because of a behavioral health crisis occurring off reservation.
Although some Arizona Tribes have adopted procedures in their tribal codes that are similar to Arizona law for court-ordered evaluation and treatment, each Tribe has its own laws which must be followed for the tribal court process. Tribal court ordered treatment for American Indian tribal members in Arizona is initiated by tribal behavioral health staff, the tribal prosecutor, or other person authorized under tribal laws. In accordance with tribal codes, tribal members who may be a danger to themselves or others and in need of treatment due to a mental health disorder are evaluated and recommendations are provided to the tribal judge for a determination of whether court ordered treatment is necessary. Tribal court orders specify the type of treatment needed.
Additional information on the history of the tribal court process, legal documents, and forms as well as contact information for the tribes The Health Plan liaisons, and tribal court representatives can be found on the AHCCCS web page titled, Tribal Court Procedures for Involuntary Commitment - Information Center.
Since many Tribes do not have treatment facilities on reservation to provide the treatment ordered by the tribal court, tribes may need to secure treatment off reservation for tribal members. To secure court ordered treatment off reservation, the court order must be “recognized” or transferred to the jurisdiction of the State.
The process for establishing a tribal court order for treatment under the jurisdiction of the State is a process of recognition, or “domestication” of the tribal court order (see A.R.S. § 12-136). Once this process occurs, the State recognized tribal court order is enforceable off reservation. The State recognition process is not a rehearing of the facts or findings of the tribal court. Treatment facilities, including the Arizona State Hospital, must provide treatment, as identified by the tribe and recognized by the (A.R.S. § 12-136 Recognition and Enforcement of Tribal Court Involuntary Commitment Orders in the Arizona Superior Courts (PDF).
The Health Plan providers must comply with State recognized tribal court orders for Title XIX/XXI and Non-Title XIX/XXI SMI persons. When tribal providers are also involved in the care and treatment of court-ordered tribal members, The Health Plan and providers must involve tribal providers to verify the coordination and continuity of care of the Members for the duration of court ordered treatment and when Members are transitioned to services on the reservation, as applicable.
This process must run concurrently with the tribal staff’s initiation of the tribal court ordered process in an effort to communicate and ensure clinical coordination with the appropriate RBHA/MCO/Health Plan. This clinical communication and coordination with the RBHA/MCO/Health Plan is necessary to assure continuity of care and to avoid delays in admission to an appropriate facility for treatment upon State/county court recognition of the tribal court order. The Arizona State Hospital should be the last placement alternative considered and used in this process
A.R.S. § 36-540(B) states, “The Court shall consider all available and appropriate alternatives for the treatment and care of the patient. The Court shall order the least restrictive treatment alternative available.” RBHA/MCO/Health Plans are expected to partner with American Indian Tribes and tribal courts in their geographic service areas to collaborate in finding appropriate treatment settings for American Indians in need of services.
Due to the options American Indians have regarding their health care, including services, payment of services for AHCCCS eligible American Indians may be covered through a TRBHA, RBHA/MCO/Health Plan or Indian Health Services/638 provider (see Behavioral Health Services Payment Responsibilities on the AHCCCS Tribal Court Procedures for Involuntary Commitment web page).
12.9.10 Mental Health and Substance Use Disorder Services; Including, Federal Grant and State Appropriations Requirements
AHCCCS receives Federal grants and State appropriations to provide services to Non-Title XIX/XXI eligible populations in addition to Federal Medicaid (Title XIX) and the State Children’s Health Insurance Program (Title XXI) funding. The federal grants are awarded by a Federal agency, typically by the Substance Abuse and Mental Health Services Administration (SAMHSA), and made available to the State. The Arizona State legislature annually issues appropriations targeting specific needs in the State. The grants and State appropriations may vary significantly from year to year. AHCCCS disburses the grant and State appropriations funding throughout Arizona for the delivery of covered services in accordance with the requirements of the fund source.
The Substance Abuse Block Grant (SABG), the Mental Health Block Grant (MHBG) are annual formula grants authorized by the United States Congress. The Substance Abuse and Mental Health Services Administration (SAMHSA) facilitates these grant awards to states in support of a national system of mental health and substance use disorder prevention and treatment services.
Federal grant funds can be used to provide behavioral health and substance use services to the Non-Title XIX/XXI parent/guardian/custodian of a Title XIX/XXI, Non-Title XIX/XXI, or Title XIX/XXI child/children who is/are at risk of being removed from their home by the Department of Child Safety (DCS) and is/are eligible under the Block Grant SED or SUD eligibility criteria. The grant-funded provider is required to ensure the Non-Title XIX/XXI parents, guardians, or custodians of a child who is at risk of being removed from the family receive the services and supports needed to preserve the family unit and enable the child with SED or SUD to remain in the home. These services should include, but are not limited to, life skills training such as parenting classes, skill building, and anger management. The provider shall adhere to eligibility requirements as specified in the Section of this Provider Manual for eligibility criteria for the MHBG/SABG Grants.
Federal Grant and State Appropriation funding shall not be used to supplant other funding sources; if funds from the Indian Health Services and/or Tribal owned/or operated facilities are available, the IHS/638 funds shall be treated as the payor of last resort.
All the requirements of the SABG and MHBG provisions outlined in The Health Plan Provider Manual apply to SABG and MHBG funded-providers. Many of the service provisions in this section are Best Practices for the delivery of SUD and MHD services and apply to all providers delivering SUD and MHD services to Title XIX/XXI and Non-Title XIX/XXI members, including those providers who do not receive Block Grant or State Appropriation funds.
Non-Title XIX/XXI Contracted Provider Requirements (Federal Block Grant and State Appropriation Funds)
Providers receiving Federal Block Grant funds and/or State Appropriation funds are required to use funds for authorized purposes as directed by The Health Plan, account for funds in a manner that permits separate reporting by fund source and track and report expenditures, including unexpended funds. Unexpended or inappropriately used funds are subject to recoupment.
Providers receiving grant and/or State Appropriation funding are required to ensure all members receiving Federal Grant and/or State Appropriation funded services are screened for Title XIX/XXI eligibility at intake and annually, documenting the eligibility screening in the medical record. Providers shall enroll the individual in Non-Title XIX/XXI funded services immediately, while continuing to assist the individual with the processes to determine Title XIX/XXI eligibility. If the individual is deemed eligible for Title XIX/XXI funding, the Member can choose a Contractor and American Indian Members may choose either a Contractor, or AIHP, or a TRBHA if one is available in their area, and receive covered services through that Contractor or AIHP or a TRBHA.
The provider shall work with the Care Coordination teams of all involved Contractors or payers to ensure each Member’s continuity of care. Members designated as SMI are enrolled with a RBHA. American Indian Members designated as SMI have the choice to enroll with a TRBHA for their behavioral health assignment if one is available in their area. If a Title XIX/XXI Member loses Title XIX/XXI eligibility while receiving behavioral health services, the provider shall attempt to prevent an interruption in services. The provider shall work with the care coordinators of the Contractor or RBHA in the GSA where the Member is receiving services, or Contractor enrolled or AIHP enrolled Members, or the assigned TRBHA, to determine whether the Member is eligible to continue services through available Non-Title XIX/XXI funding. If the provider does not receive Non-Title XIX/XXI funding, the provider and Member shall work, together to determine where the Member can receive services from a provider that does receive Non-Title XIX/XXI funding. The provider shall then facilitate a transfer of the Member to the identified provider and work with the Care Coordination teams of all involved Contractors or payors.
Providers will be paid for treating Members while payment details between entities are determined. If a Title XIX/XXI Member, whether Contractor or AIHP enrolled, requires Non-Title XIX/XXI services, the provider shall work with the RBHA in the GSA where the Member is receiving services, or the assigned TRBHA, to coordinate the Non-Title XIX/XXI services. Behavioral health providers are required to assist individuals with applying for Arizona Public Programs (Title XIX/XXI, Medicare Savings Programs, Nutrition Assistance, and Cash Assistance), and Medicare Prescription Drug Program (Medicare Part D), including the Medicare Part D “Extra Help with Medicare Prescription Drug Plan Costs” low income subsidy program prior to receiving Non-Title XIX/XXI covered behavioral health services, at the time of intake for behavioral health services.
An individual who is found not eligible for Title XIX/XXI covered services may still be eligible for Non-Title XIX/XXI services. An individual may also be covered under another health insurance plan, including Medicare. Individuals who refuse to participate in the AHCCCS screening/application process are ineligible for state funded behavioral health services. Refer to A.R.S. §36-3408 and AMPM Policy 650. The following conditions do not constitute an individual’s refusal to participate:
- An individual’s inability to obtain documentation required for the eligibility determination[MRL1] , and/or;
- An individual is incapable of participating as a result of their mental illness and does not have a legal guardian. Pursuant to the U.S. Attorney General’s Order No. 2049–96 (61 Federal Register 45985, August 30, 1996), individuals presenting for and receiving crisis, mental health or SUD treatment services are not required to verify U.S. citizenship/ lawful presence prior to or in order to receive crisis services.
Members can be served through Non-Title XIX funding while awaiting a determination of Title XIX/XXI eligibility. However, upon Title XIX eligibility determination the covered services billed to Non-Title XIX, that are Title XIX covered, will be reversed by the Contractor and charged to Title XIX funding for the retro covered dates of Title XIX eligibility. This does not apply to Title XXI Members, as there is no Prior Period Coverage for these Members.
If there are any barriers to care, the provider shall work with the Care Coordination teams of all involved health plans or payers. If the provider is unable to resolve the issues in a timely manner to ensure the health and safety of the Member, the provider shall contact AHCCCS/DHCM, Clinical Resolutions Unit (CRU). If the provider believes that there are systemic problems, rather than an isolated concern, the provider shall notify AHCCCS/DHCM, CRU of the potential barrier v. AHCCCS will conduct research and work with the Contractors and responsible entities to address or remove the potential barriers.
Providers receiving Non-Title XIX/XXI funds (Federal Block Grant and/or State Appropriation Funds) are required to meet the following additional service delivery and reporting requirements:
- Develop and maintain internal policies and procedures related to the type of funds received. The policies and procedures must meet grant and funding guidelines and be approved by The Health Plan. The policies and procedures are subject to audits by the Health Plan at least annually;
- Ensure grant and state appropriation funds are expended in conformance with grant and/or state appropriation rules;
- Employ and document strategies and monitoring of targeted interventions to improve health outcomes including, but not limited to Social Determinants of Health (SDOH) and National Outcome Measures (NOMS);
- Employ and document the use of and expansion of Evidence Based Practices and Programs (EBPPs) and demonstrate ongoing fidelity;
- Deliver evidence-based services to special populations requiring substance use interventions and supports; including, homeless individuals, individuals with sight limitations, who are deaf or hard of hearing, persons with criminal justice involvement and persons with co-occurring mental health disorders;
- Provide specialized, evidence-based treatment and recovery support services for all populations as contracted;
- Providers of treatment services that include clinical care to those with a SUD shall also be designed to have the capacity and staff expertise to utilize FDA approved medications for the treatment of SUD/OUD and/or have collaborative relationships with other providers for service provision;
- Specific requirements regarding preferential access to services and the timeliness of responding to a Member’s identified needs;
- Report program descriptions, service utilization, outreach activities, total enrolled members and similar data upon request to AzCH to effectively identify programs available in the community, measure capacity, unmet needs and respond to requests from AHCCCS;
- Treat the family as a unit, admitting women and their children into treatment as appropriate;
- Arrange and coordinate primary medical care for women who are receiving SUD services, including prenatal care;
- Arrange for gender-specific SUD treatment and other therapeutic interventions for women that address issues of relationships, sexual abuse, physical abuse, parenting and child care while women are receiving services;
- Arrange for child care while women receive SUD services to facilitate access to care;
- Make available and document continuing education in the delivery of grant or State appropriation funded services or activities (or both, as the case may be) to employees of the facility who provide the services or activities;
- Submit specific data elements and record limited information in the AHCCCS DUGless Portal Guide (Reference: AHCCCS DUGless Portal Gide for requirements).
- Providers are required to comply with AHCCCS demographic requirements, submitting demographic data to AHCCCS through the AHCCCS DUGLess portal. The AHCCCS Demographic & Outcomes Data Set User Guide and describes the minimum required data elements that comprise the demographic data set, in part.
Mental Health Room and Board Funded Through Grants and State Appropriation Funds
Mental Health Room and Board is not a Medicaid reimbursable service. Specialized populations may be eligible to receive Federal grant or State appropriation funding to cover the cost of Mental Health Room and Board. Room and Board includes the provision of lodging and meals to an individual residing in a residential facility or supported independent living setting which may include but is not limited to:
- Housing costs;
- Services such as food and food preparation;
- Personal laundry; and
For providers who own the properties, room and board comprises real estate costs (debt service, maintenance, utilities, and taxes) and food and food preparation, personal laundry, and housekeeping. Room and Board may also be used to report bed hold/home pass days in Behavioral Health Residential facilities.
Room and Board services do not require prior-authorization for payment. Contracted providers are required to verify member eligibility and maintain accurate accounting of expenses and utilization. For room and board services (H0046 SE), the following billing limitations apply:
- All other fund sources (e.g. Arizona Department of Child Safety (DCS) funds for foster care children, SSI) shall be exhausted prior to billing this service; and
- Room and Board services funded by the SABG are limited to children/adolescents with a Substance Use Disorder (SUD), and adult priority population Members (pregnant females, females with dependent child(ren), and people who use drugs by injection with a Substance Use Disorder) to the extent in which funding is available. Room and Board services may be available for a Member’s dependent child(ren) as a support service for the Member when they are receiving medically necessary residential treatment services for a SUD. The Room and Board would apply to a Member with dependent children, when the child(ren) reside with the Member at the Behavioral Health Residential Facility. The use of this service is limited to: Members receiving residential services for SUD treatment where the family is being treated as a whole, but the child is not an enrolled Member receiving billable services from the provider.
- Room and Board Services funded by the MHBG are limited to youth with SED qualifying diagnoses.
- Room and Board Services funded through State Appropriation Funds are limited to members meeting eligibility requirements for State Appropriation Funds and requires prior approval by The Health Plan.
Federal Block Grant Specific Requirements
Providers receiving MHBG and/or SABG funds are required to obtain and maintain an Inventory of Behavioral Health Services (I-BHS) number through SAMHSA. Grant funded providers may not discriminate against members receiving services on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. If a member objects to the religious nature or religious practice of a provider organization, the provider must give the member the right to a referral to another provider of substance use disorder treatment that provides a service of at least equal value and facilitate the receipt of services from the other provider within seven (7) days of the request or earlier based on the member’s condition (see AMPM Policy 320-T1, Attachment A.)
Providers receiving Federal Block Grant funds are required to meet all the applicable requirements outlined in the AHCCCS Policy Manual, AMPM 320 T1-Block Grants and Discretionary Grants and 2 CFR Part 200 ; including demonstrating full knowledge and adherence to the following:
- Member eligibility criteria to receive services through these funding sources;
- Prioritization of funding;
- Federal grant requirements and notifications;
- Prohibited use of the funds;
- Separate reporting, single audit requirements, subaward information; and
- Available services through each funding source.
Grant funded providers are required to ensure expenditures are in accordance with 2 CFR Part 200, Grants and Agreements, and ensure compliance with approved indirect cost agreements and/or use of a de minimis rate (Reference: 2 CFR 200.414). The policies and procedures must be comprehensive regarding SABG, MHBG, and other federal grants that include, but are not limited to, a listing of prohibited expenditures, references to the SABG and MHBG FAQs, AMPM 320-T, Exhibits 300-2b, monitoring and separately reporting of funds by SABG, MHBG and other federal grant funding categories. Provider grant recipients are required to utilize the AHCCCS Federal Grant FAQs document to educate staff about the grants (Reference document: AHCCCS FAQs- Substance Abuse Block Grant (SABG) and Mental Health Block Grant (MHBG).
12.10.1 Substance Abuse Block Grant (SABG) Specific Requirements
SABG Services and Prioritization
The SABG supports primary prevention services, early intervention services and treatment services for persons with substance use disorders. SABG treatment services shall be designed to support the long-term treatment and substance-free recovery needs of eligible Members. The funds are used to plan, implement, and evaluate activities to prevent and treat substance use disorders. Grant funds are also used to provide referral and early intervention services for HIV, tuberculosis disease, hepatitis C and other communicable diseases in high-risk substance users.
The Goals of the SABG include, but are not limited to the following:
- To ensure access to a comprehensive system of care, including employment, housing services, case management, rehabilitation, dental services, and health services, as well as SUD services and supports;
- To promote and increase access to evidence-based practices for treatment to effectively provide information and alternatives to youth and other at-risk populations to prevent the onset of substance use or misuse;
- To ensure specialized, gender-specific, treatment as specified by AHCCCS and recovery support services for females who are pregnant or have dependent children and their families in outpatient/residential treatment settings;
- To ensure access for underserved populations, including youth, residents of rural areas, veterans, Pregnant Women, Women with Dependent Children , People Who Inject Drugs (PWID) and older adults, e. to promote recovery and reduce risks of communicable diseases; and
- To increase accountability through uniform reporting on access, quality, and outcomes of services.
Substance use treatment services shall be available to all eligible Members with a SUD based upon medical necessity and the availability of funds; including youth and adults with Opioid Use Disorders. SABG funds are used to ensure access to treatment and long-term supportive services for the following populations (in order of priority):
- Pregnant individuals/teenagers who use drugs by injection,
- Pregnant individuals/teenagers with a SUD;
- Other persons who use drugs by injection;
- Individuals and teenagers with a SUD, with dependent children and their families, including individuals who are attempting to regain custody of their children; and
- All other individuals with a SUD, regardless of gender or route of use, (as funding is available).
Families involved with DCS who are in need of substance use disorder treatment and are not Title XXI/XXI eligible, can receive services paid for with SABG funds as long as funds are available.
All Members receiving SABG-funded services are required to have a Title XIX/XXI eligibility screening and application completed and documented in the medical record at the time of intake and annually thereafter. Members shall be required to indicate active substance use within the previous 12-months to be eligible for SABG treatment services. This includes individuals who were incarcerated and reported using while incarcerated. The 12-month standard may be waived for individuals on medically necessary methadone maintenance upon assessment for continued necessity, and/or incarcerated for longer than 12 months that indicate opioid use in the 12 months prior to incarceration.
Choice of SABG Substance Use Disorder Providers (Charitable Choice)
Members receiving SUD treatment services under the SABG have the right to receive services from a provider to whose religious character they do not object. Behavioral health providers providing SUD treatment services under the SABG shall notify Members at the time of intake of this right as required in AHCCCS AMPM Policy 320-T1 Attachment A. Providers shall document that the Member has received notice in the Member’s medical record. If a Member objects to the religious character of a behavioral health provider, the provider shall refer the Member to an alternate provider within seven days, or earlier when clinically indicated, after the date of the objection. Upon making such a referral, providers shall notify the RBHAs, of the referral and ensure that the Member makes contact with the alternative provider.
Intake Providers must utilize the Health Plan web-based Member transfer system to facilitate all transfers between provider agencies, including transfers associated with religious considerations (see Section 13.1 — Transition of Persons).
Substance Use Disorder Services and Provider Program Requirements
Substance Use Disorder treatment services must be designed to support the long-term recovery needs of eligible persons and meet the applicable requirements set forth in the Health Plan Provider Manual. Specific requirements apply regarding preferential access to services and the timeliness of responding to a person’s identified needs (see Section 12.2 — Appointment Standards and Timeliness of Service).
Substance Use Disorder treatment programs must include the following minimum core components: outreach, screening, referral, early intervention, case management, relapse prevention, child care services and continuity of addiction treatment. These are critical components for treatment programs targeting substance-using individuals. In addition, medical providers must be included in the treatment planning process from the initial contact for services to verify continuity and coordination of care. The overall goal in a continuum of comprehensive addiction treatment is improved life functioning and wellbeing, as measured by: an increase in medical wellness and improved psychosocial, spiritual, social and family relationships.
- Additional non-Medicaid reimbursable services available to Title XIX/XXI and Non-Title XIX/XXI members through SABG funding include:
Auricular acupuncture to the pinna, lobe or auditory meatus to treat alcoholism, substance use disorders or chemical dependency by a certified acupuncturist practitioner pursuant to A.R.S. 32-3922
- Mental Health Services (Traditional Healing Services) for mental health or substance use provided by qualified traditional healers. These services include the use of routine or advanced techniques aimed to relieve the emotional distress evident by disruption to the person’s functional ability.
- Childcare Services (also referred to as child sitting services): Childcare supportive services are covered when providing medically necessary Medicated Assisted Treatment or outpatient (non-residential) SUD treatment or other supportive services for SUD to Members with dependent children, when the family is being treated as a whole. The following limitations apply:
- The amount of Childcare services and duration shall not exceed the duration of MAT or Outpatient (non-residential) treatment or support services for SUD being provided to the Member whose child(ren) is present with the Member at the time of receiving services;
- Childcare services shall ensure the safety and well-being of the child while the Member is receiving services that prevent the child(ren) from being under the direct care or supervision of Member;
- The child is not an enrolled Member receiving billable services from the provider; and
- Other means of support for childcare for the children are not readily available or appropriate.
- Supported housing services provided by behavioral health professionals, behavioral health technicians, or behavioral health paraprofessionals, to assist individuals or families to obtain and maintain housing in an independent community setting including the individual’s own home or apartments and homes owned or leased by a provider;
- Mental Health Services, Room and Board;
- Other Non-Title XIX/XXI Behavioral Health Services: For Non-Title XIX/XXI eligible populations, most behavioral health services that are covered through Title XIX/XXI funding are also covered through Non-Title XIX/XXI funding including but not limited to: services provided in a residential setting, counseling, case management, and supportive services, but Non-Title XIX/XXI funded services may be restricted to certain Members as described in The Health Plan Provider Manual and as specified in AMPM Exhibit 300-2B, and are not an entitlement.
Services provided through Non-Title XIX/XXI funding are limited by the availability of funds.
Additional SABG Contracted Provider Requirements
The following SABG contracted provider requirements are applicable to all SABG contracted SUD treatment providers:
- Ensure preference is given to pregnant women who are seeking SUD treatment;
- Notify the AzCH Behavioral Health and Specialty Services department immediately when the provider has reached capacity and can no longer accept more pregnant women into the program;
- Arrange interim services within 48 hours of a pregnant woman not being able to be accepted into the program;
- Clearly indicate on program materials that pregnant women are the first priority for referral into the program;
- SABG funded providers are required to maintain service utilization, attendance and capacity records and report the information utilizing the AHCCCS SABG Capacity Management Report template (AMPM 320-T1, Attachment J) as required by AHCCCS;
- Provide HIV Activity Reports, training materials and Ad hoc reports as requested;
- Participate in the annual AHCCCS Independent Case Review process; providing treatment and documentation in compliance with the AHCCCS Substance Abuse Block Grant (SABG) Case File Review Tool
- SABG treatment providers are required to train and educate provider staff and audit staff performance related to the most recent Case File Review Tool standards; correcting deficiencies to promote ongoing performance improvement. (Reference: AHCCCS Substance Abuse Prevention Case File Review Findings).
- SABG treatment providers are required to respond timely to record requests to facilitate the annual audit.
Waitlist and Interim Services for Pregnant and Parenting Women/Teenagers and People Who Use Drugs By Injection (Non-Title XIX/XXI only)
BHRF providers serving members with substance use disorders and receiving SABG funding are required to promptly submit information for Priority Population Members (i.e. Pregnant Women/Teenagers, Women/Teenagers with Dependent Children, and People Who Use Drugs by Injection who are waiting for placement in a Behavioral Health Residential Facility (BHRF), to the AHCCCS online Residential Waitlist System. Title XIX/XXI Members may not be added to the Residential Waitlist. Priority Population Members who are not pregnant, parenting women/teenagers, or People Who Use Drugs by Injection shall be added to the Residential Waitlist if the provider is not able to place the Member in a BHRF within the Response Timeframes for Designated Behavioral Health Services as outlined herein. For women/teenagers who are pregnant, the requirement is within 48 hours, for women with dependent children the requirement is within 5 calendar days and for individuals who use drugs by injection the requirement is within 14 calendar day.
The purpose of interim services is to reduce the adverse health effects of substance use disorders, promote the health of the individual, and reduce the risk of transmission of disease. Interim services must be made available for Non-Title XIX/XXI priority populations who are maintained on an actively managed wait list. Provision of interim services must be documented in the Member’s chart as well as reported to the State through the State SABG Waitlist System. The minimum required interim services include education that covers the following:
- Prevention of and types of behaviors which increase the risk of contracting HIV, Hepatitis C, and other sexually transmitted diseases;
- Effects of substance use on fetal development;
- Risk assessment/screening;
- Referrals for HIV, Hepatitis C, and tuberculosis screening and services; and
- Referrals for primary and prenatal medical care.
Provider Program Requirements Related to Gender-Specific Services and SABG Priority Populations and Parents with Children
SABG funded providers are required to disseminate information about Priority Population eligibility by posting and advertising at community provider locations and through strategic methods; including, but not limited to street outreach programs, posters placed in targeted community areas and other locations where pregnant women, women with dependent children, persons who inject drugs, and uninsured or underinsured people with SUD who do not meet eligibility for Title XIX/XXI are likely to attend, in accordance with the specifications in 45 CFR 96.131(a)(1-4). SABG providers shall publicize admission preferences by frequently disseminating information about treatment availability to community-based organizations, healthcare providers, and social services agencies.
Providers shall publicize the availability of gender-based substance use disorder treatment services for pregnant women or women who have dependent children. Publication must include, at minimum, the posting of fliers at each SABG service delivery site notifying pregnant women or women with dependent children of the availability and right to receive substance use disorder treatment services at no cost.
SUD treatment providers serving parents with dependent children shall:
- Deliver the following services as needed: referral for primary medical care for women and primary pediatric care for children; gender-specific substance use treatment; therapeutic interventions for children; and case management and medically-necessary transportation to access medical and pediatric care.
- Eliminate barriers to access treatment through incorporation of child care, case management and medically-necessary transportation to medical and pediatric care and treatment services.
- Prioritize services available for substance use disorder treatment services for pregnant women pursuant to A.R.S. § 36-141.
Specific goals of women-focused treatment include reducing fetal exposure to alcohol/drugs, verifying a healthy birth outcome as an immediate priority, and addressing issues relevant to women; such as, domestic abuse and violence, demands of child-rearing, vocational and employment skills.
- SUD treatment providers are required to ensure that Case Management, Child Care and Transportation do not pose barriers to access to obtaining substance use disorder treatment. Contracted providers with approved funding may bill “Childcare T1009 - for Dependent Children” to provide child care support services for a member who meets the criteria for SABG funding as defined in the Health Plan Provider Manual and the AMPM 320-T1.
SABG contracted treatment providers must comply with Program Requirements for Pregnant Women and Women with Dependent Children in accordance with this Provider Manual as follows:
- Engage, retain, and treat pregnant women and women with dependent children who request and are in need of substance use disorder treatment.
- Deliver outreach, specialized evidence-based treatment, and recovery support services for pregnant women, women with dependent children or women attempting to regain custody of children.
- Deliver services to the family as a unit and for residential treatment programs, admit both women and their children into treatment.
- Deliver medically necessary covered services to each pregnant individual who requests and is in need of substance use disorder treatment within forty-eight (48) hours of the request.
- Deliver medically necessary covered services for women with dependent children within five (5) days.
SABG Funded Child Care Supportive Services (Amount, Duration, and Scope of SABG Funded Child Care Support Services)
- The amount of services and duration is dependent upon the BHRF or Outpatient (non-residential) treatment or recovery support services for SUD being provided to the member and whose child is present with the member at the time of the treatment. Childcare supportive services are covered when providing medical necessary BHRF or outpatient (non-residential) treatment or other supportive services for SUD to Members with dependent children, when the family is being treated as a whole, the following limitations apply:
- The amount of Childcare services and duration shall not exceed the duration of BHRF or Outpatient (non-residential) treatment or support services for SUD being provided to the Member whose child(ren) is present with the Member at the time of receiving services;
- Childcare services shall ensure the safety and well-being of the child while the Member is receiving services, which prevent the child(ren) from being under the direct care or supervision of Member;
- The child is not an enrolled Member receiving billable services from the provider, and;
- Other means of support for childcare for the children are not readily available or appropriate.
- The scope of the Child Care Recovery Support Services should be what is necessary to ensure the safety and well-being of the child while the member is in treatment services, which prevent the child(ren) from being under the direct care or supervision of the member.
- The service is to be billed in 15 minute increments not to exceed the amount of time the enrolled member received services.
The use of SABG Funded Child Care Support Services is limited to:
- Enrolled members receiving BHRF or Outpatient (non-residential) treatment or recovery support services for SUD treatment where the family is being treated as a whole, but the child is not an enrolled member receiving billable services from the provider.
- Where other means of supports for childcare for the child are not readily available or appropriate.
- Only Provider Types that provide BHRF or Outpatient (non-residential) SUD treatment or recovery support services are eligible for this service.
Each Provider providing SUD treatment services to parents with Dependent Children shall have policies and procedures that address: informed consent, case management, transportation, facilities, staffing, supervision, monitoring, documentation, service description, safety measures, ages accepted, and schooling/service accessibility to the children. The content of the policies and procedures must be included in the informed consent documentation that must be reviewed and signed by the member acknowledging the potential benefits and risks associated with receiving the Child Care Recovery Support Service as a part of the member’s treatment.
Program Requirements for Persons Involved with Injection Drug Use
Providers must engage in evidence-based best practice outreach activities to encourage individuals in need of services to undergo treatment and deliver medically necessary covered services to persons involved with injection drug use who request and are in need of substance use disorder treatment. SABG contracted providers must ensure that each individual who requests, and is in need of treatment for intravenous drug abuse is admitted to a program of such treatment not later than 14 days after making the request for admission to such a program; or 120 days after the date of such request, if no such program has the capacity to admit the individual on the date of such request and if interim services, including referral for prenatal care, are made available to the individual not later than 48 hours after such request. MAT providers must notify the Health Plan when an intravenous drug use program has reached ninety percent (90%) of its capacity. Providers are prohibited from using SABG funds to supply individuals with hypodermic needles or syringes to use illegal drugs.
Human Immunodeficiency Virus (HIV) , Tuberculosis (TB), Hepatitis C and Other Communicable Diseases (Referral, Screening and Early Intervention Services)
SUD treatment providers must refer persons with substance use disorders for HIV, tuberculosis, hepatitis C and other communicable disease screening. In addition, providers must deliver services to persons with HIV in accordance to requirements in this Provider Manual.
Because individuals with substance use disorders are considered at high risk for contracting HIV-related illness, the SABG requires the use of HIV intervention services to reduce the risk of transmission of this disease. SABG funded HIV Early Intervention services are available exclusively to Members receiving substance use disorder treatment. SABG funded HIV services may not be provided to incarcerated populations per 45 CFR 96.135.2.
SUD treatment providers are required to establish linkages with a comprehensive community resource network of related health and social services organizations to ensure a wide-based knowledge of the availability of these services and must provide locations and specified times for Members to access HIV Early Intervention services. Providers shall inform Members of the opportunity to receive HIV education, screenings and early intervention services and facilitate Members’ access to the services. Substance use treatment providers must make their facilities available for HIV Early Intervention providers contracted with the Health Plan and verify Members have access to HIV Early intervention services. Providers may contact AzCH customer service for assistance in locating and obtaining access to HIV Early Intervention Services.
Requirements for Providers Offering HIV Early Intervention Services
HIV early intervention service providers who accept funding under the SABG must provide HIV testing services. Providers must administer HIV testing services in accordance with the Clinical Laboratory Improvement Amendments (CLIA) requirements, which requires that any agency that performs HIV testing must register with Centers for Medicare and Medicaid (CMS) to obtain CLIA certification. However, agencies may apply for a CLIA Certificate of Waiver, which exempts them from regulatory oversight if they meet certain federal statutory requirements.
Many of the Rapid HIV tests are waived. For a complete list of waived Rapid HIV tests please see (http://www.fda.gov/cdrh/clia/cliawaived.html). Waived rapid HIV tests can be used at many clinical and non-clinical testing sites, including community and outreach settings. Any agency that is performing waived rapid HIV tests is considered a clinical laboratory. Any provider planning to perform waived rapid HIV tests must develop a quality assurance plan, designed to verify any HIV testing will be performed accurately. (See Centers for Disease Control Quality Assurance Guidelines).
HIV early intervention service providers cannot provide HIV testing until they receive a written HIV test order from a licensed medical doctor, in accordance with A.R.S. § 36-470. HIV rapid testing kits must be obtained from the ADHS Office of HIV Prevention.
HIV early intervention providers are required to collect and report early intervention activities to the Health Plan utilizing the AHCCCS SABG HIV Activity Report (AMPM Policy 320-T, Attachment E). In addition, HIV early intervention providers are required to regularly provide education and training to members and staff at SUD treatment facilities; collecting and reporting education and training site visits utilizing the AHCCCS SABG HIV site visit Report (AMPM Policy 320-T, Attachment F).
Contracted HIV early intervention providers are required to administer a minimum of one test per $600 in HIV funding.
HIV Education and Pre/Post-Test Counseling
The HIV Prevention Counseling training provided through Arizona Department of Health Services must be completed by all the Health Plan HIV Coordinators, provider staff and provider supervisors whose duties are relevant to HIV services. Staff must successfully complete the training with a passing grade prior to performing HIV testing. HIV education and pre/post-test counseling. The Health Plan HIV Coordinators and provider staff delivering HIV Early Intervention Services for the SABG also must attend an HIV Early Intervention Services Webinar issued by the State on an annual basis, or as indicated by the State. The Webinar will be recorded and made available by the State. New staff assigned to duties pertaining to HIV services must view the Webinar as part of their required training prior to delivering any HIV Early Intervention Services reimbursed by the SABG. HIV early intervention service providers are required to actively participate in regional community planning groups to verify coordination of HIV services.
Reporting Requirements for HIV Early Intervention Services
For every occurrence in which an oral swab rapid test provides a reactive result, a confirmatory blood test must be conducted and the blood sample sent to the Arizona State Lab for confirmatory testing. Therefore, each provider who conducts rapid testing must have capacity to collect blood for confirmatory testing whenever rapid testing is conducted.
The number of the confirmatory lab slip shall be retained and recorded by the provider. This same number will be used for reporting in the Luther data base as required by the CDC. The HIV Early Intervention service provider must establish a Memorandum of Understanding (MOU) with their local County Health Department to define how data and information will be shared. Providers must use the Luther database to submit HIV testing data after each test administered.
Monitoring Requirements for HIV Early Intervention Services
HIV early intervention services providers are required to submit monthly progress reports to the Health Plan. The Health Plan will conduct bi-annual site visits to providers offering HIV Early Intervention Services. The State HIV Coordinator, the Health Plan HIV Coordinator, provider staff, and supervisors relevant to HIV services must be in attendance during site visits. As part of the site visit, provider must make available a budget review and a description/justification for use of the SABG funding.
Oxford House Program Requirements
Providers contracted to provide Oxford House services are required to employ evidence based practices and abide by all approved program description requirements and applicable grant requirements as outlined in The Health Plan Provide Manual and by AHCCCS. Providers are required to maintain processes to demonstrate continuing fidelity to the model. Oxford House providers are required to collect, analyze and report service utilization, outcomes, financial and program data as requested by The Health Plan and AHCCCS; including completing the Oxford House Model Report (AMPM 320-T1, Attachment H) and the Oxford House Financial Report (AMPM 320-T1, Attachment F-1).
SABG Program and Financial Management Policies
SABG contracted providers must establish program and financial management policies and procedures for services funded by the SABG to meet all requirements in the provider agreement, the Provider Manual and the requirements of the Children's Health Act of 2000, P.L. 106-310 Part B of Title XIX of the Public Health Service Act (42 USC 300 et seq.) and 45 CFR Part 96 as amended. The policies and procedures should include, but are not limited to, a listing of prohibited expenditures, references to the SABG FAQs, monitoring and reporting of funds by priority populations and funding category.
All providers who receive SABG funding are required to submit their SABG Policy and Procedure to AzCH-Complete Care Plan annually, each November. As applicable, Procedures should include reporting and monitoring requirements to track encountering of SABG funds and to verify that treatment services are delivered at a level commensurate with funding under the SABG. Providers must submit SABG related program reports. These reports must be submitted in a format prescribed by the Health Plan.
The Health Plan must submit an annual plan regarding outreach activities and coordination efforts with local substance use disorder coalitions. Providers receiving SABG funds are required to provide the Health Plan with requested information to complete the report.
Grant funding is the payor of last resort for Title XIX/XXI behavioral health covered services which have been exhausted (e.g. respite), Non-Title XIX/XXI covered services, and for Non-Title XIX/XXI eligible Members for any services. Grant funding shall not be used to supplant other funding sources, if funds from the Indian Health Services and/or Tribal owned/or operated facilities are available, the IHS/638 funds shall be treated as the payor of last resort. Copayments, or any other fee, are prohibited for the provision of services funded by SABG Block Grants.
Restrictions on the Use of SABG Grant Funds
Providers may not expend SABG funds on the following activities:
- Inpatient hospital services,
- Physical health care services including payment of copays, unless otherwise specified for Priority Populations,
- Cash payments to intended recipients of health services,
- Purchase or improvement of land, purchase, construct, or permanently improve any building or facility except for minor remodeling with written approval from AHCCCS,
- Purchase of major medical equipment,
- To satisfy any requirement for the expenditure of non-federal funds as a condition for the receipt of federal funds,
- Provision of financial assistance (grants) to any entity other than a public or nonprofit private entity,
- Provision of hypodermic needles or syringes for illegal drug use, unless the Surgeon General of the Public Health Service determines that a demonstration needle exchange program would be effective in reducing drug use and the risk that the public will become infected with the etiologic agent for Acquired Immune Deficiency Syndrome (AIDS),
- Payment of salary of an individual through a grant or other extramural mechanism at a rate in excess of Level I of the Executive Salary Schedule for the award year, see https://grants.nih.gov/grants/policy/salcap_summary.htm,
- Purchase of treatment services in penal or correctional institutions in the State of Arizona,
- Flex funds purchases, or
- Sponsorship for events and conferences.
12.10.2 Additional Mental Health Block Grant (MHBG) Contracted Provider Requirements
The MHBG provides funds to establish or expand an organized community-based system of care for providing Non-Title XIX/XXI mental health services to children with serious emotional disturbances (SED), youth and young adults experiencing First Episode Psychosis (FEP) and adults with a Serious Mental Illness (SMI). MHBG funding may be used to provide Non-Title XIX/XXI services for Title XIX/XXI members meeting the above criteria. The MHBG Block Grant funds are used to: (1) carry out the State plan contained in the federal grant application; (2) evaluate programs and services; and (3) conduct planning, administration, and educational activities related to the provision of services. The goals of the MHBG include, but are not limited to the following:
- Ensuring access to a comprehensive system of care, including employment, housing services, case management, rehabilitation, dental services, and health services, as well as mental health services and supports;
- Promoting participation by consumer/survivors and their families in planning and implementing services and programs, as well as in evaluating State mental health systems;
- Ensuring access for underserved populations, including people who are homeless, residents of rural areas, and older adults;
- Promoting recovery and community integration for adults with SMI and children with SED; and
- Increasing accountability through uniform reporting on access, quality, and outcomes of services.
The MHBG Block Grant requires AHCCCS to maintain a statewide planning council with representation by Members, family members, State employees and providers.
Populations Covered and Prioritization
To be eligible for services under MHBG, Members shall be determined to have an SMI, an SED, or ESMI/FEP. Screenings/assessments may be covered for Non-Title XIX/XXI eligible Members when they are conducted to determine SMI or SED eligibility, for block grant funding regardless of the assessment’s determination. Providers are required to verify and document that members indicate active mental health symptoms in the previous 12-months to be eligible for MHBG federal block services.
Other funding sources, such as the State General Fund appropriations for SMI shall be utilized before block grant funding to ensure block grants are the payor of last resort. Refer to AMPM 320-O for additional information on behavioral health assessments and treatment/service planning.
In serving children with SED, youth and young adults experiencing FEP, and adults with SMI, MHBG funds may be used for the following:
- To ensure access to a comprehensive system of care, including employment, housing, case management, rehabilitation, dental, and health services, as well as mental health services and supports;
- To promote participation by Member/survivors and their families in planning and implementing services and programs, as well as in evaluating State mental health systems;
- To verify access for underserved populations, including people who are homeless, residents of rural areas, and older adults;
- To promote recovery and community integration for adults with a SMI youth and young adults experiencing FEP, and children with SED;
- To provide for a system of integrated services to include:
- Social services;
- Educational services;
- Juvenile justice services;
- Substance use disorder services; and
- Health and services.
- To provide for training of providers of emergency health services regarding behavioral health.
MHBG Specific Provider Requirements
- MHBG funded providers are required to ensure members receiving services under the MHBG are given access to comprehensive system of care services offered through the AzCH provider network or community; including, employment, housing services, case management, rehabilitation, dental, health services as well as mental health services;
- MHBG funded providers must account for funds separately; and ensure staff resources are appropriately allocated and employed according to grant requirements; including:
- Ensuring MHBG funded positions or interventions are not used to fulfill the requirement of other contracts; including Title XIX/XXI contract requirements;
- Ensuring MHBG funded positions do not simultaneously bill for services, unless specified in AzCH award letter.
First Episode Psychosis (FEP) Programs
Providers delivering FEP programs funded through MHBG and Title XIX/XXI funding are required to develop an annual Program Description and Operating Plan and obtain approval of the Plan from the Health Plan and AHCCCS. Once approved the provider must implement the Plan as written and document adherence and performance of the Plan; including, conducting outreach as outlined in the Plan and serving the required number of members outlined in the Plan. The provider must collect, analyze and timely report all data required in the Plan. All FEP programs must be based on Evidence Based Practices approved by AHCCCS. FEP providers must develop, implement and demonstrate a process to verify ongoing fidelity to the model. FEP providers are required to develop and execute an Annual Community Education and Marketing Plan to educate families, high schools, and institutions of higher learning, first responders and communities about the early signs and symptoms of FEP. The provider is required to document and report educational and marketing efforts; including dates, venues, attendees or recipients training and education. In addition, the FEP provider is required to collect, analyze and report data required in the First Episode Psychosis Program Status Report (See AMPM 320-T1, Attachments C and C-1).
The following are diagnoses that qualify under ESMI/FEP. These are not intended to include conditions that are attributable to the physiologic effects of an SUD, are attributable to an intellectual/developmental disorder, or are attributable to another medical condition:
- Delusional Disorder;
- Brief Psychotic Disorder;
- Schizophreniform Disorder;
- Schizoaffective Disorder;
- Other specified Schizophrenia Spectrum and Other Psychotic Disorder;
- Unspecified Schizophrenia Spectrum and Other Psychotic Disorder;
- Bipolar and Related Disorders, with psychotic features; and
- Depressive Disorders, with psychotic features.
Members do not have to be or designated as SMI or SED to be eligible for FEP services. Individuals who are accessing FEP MHBG services can be GMH at the beginning, or throughout their FEP episode of care.
Adolescents in Detention
Most adjudicated youth from secure detention do not have community follow-up or supervision, therefore, risk factors remain unaddressed. Youth in juvenile justice systems often display a variety of high-risk characteristics that include inadequate family support, school failure, negative peer associations, and insufficient use of community-based services. MHBG services to adolescents in detention is contingent upon funding availability, and Health Plan and AHCCCS approval.
MHBG funded providers may deliver services to Adolescents with SED in detention in accordance to the following requirements:
- Services may only be provided in juvenile detention facilities meeting the description provided by the OJJDP;
- Juvenile detention facilities are used only for temporary and safe custody, are not punitive, and are not correctional or penal institutions.
Services shall be provided:
- Only to voluntary members with SED;
- By qualified BHPs/BHTs/BHPPs;
- Based upon assessed need for SED services;
- Utilizing EBPPs;
- Following an individualized service plan;
- For a therapeutically indicated amount of duration and frequency; and
- With a transition plan completed prior to transfer to a community based provider.
Non-Encounterable MHBG Activities or Positions
Contracted MHBG SED services for outreach activities or positions that are non-encounterable can be an allowable expense, but they shall be tracked, activities monitored, and outcomes collected on how the outreach is getting access to care for those Members with SED.
The use of MHBG SED funds in schools is allowable as long as the following requirements are met:
- Funded positions or interventions cannot be used to fulfill the requirement for the same populations as the funds for Behavioral Health Services for School-Aged Children listed in the Title XIX/XXI Contract;
- Funded positions cannot bill for services provided;
- Funded positions or interventions need to focus on identifying those with SED and getting those who do not qualify for Title XIX/XXI engaged in services through the MHBG; and
- This funding shall be utilized for intervention, not Prevention, meaning that Members who are displaying behaviors that could be signs of SED can be assisted, but MHBG funding shall not be used for general Prevention efforts to children who are not showing any risks of having SED.
Provider Management of MHBG Funds
Providers must comply with all terms, conditions, and requirements of the MHBG including the Children's Health Act of 2000, P.L. 106-310 Part B of Title XIX of the Public Health Service Act (42 U.S.C. 300 et seq.) and 45 CFR Part 96 as amended. Providers must retain documentation of compliance with Federal requirements, and produce upon the Health Plan request, financial, performance, and program data that is subject to audit. These services will be available based upon medical necessity and the availability of funds.
Providers must report MHBG and SABG funds and services separately and report or produce information related to block grant expenditures to the Health Plan upon request. Providers must manage the MHBG funds during each fiscal year to make funds available for obligation and expenditure until the end of the fiscal year for which the funds were paid.
Providers must have internal MHBG policies and procedures that should include, but are not limited to, a listing of prohibited expenditures, references to the MHBG FAQs, monitoring and reporting of funds by priority populations and funding category. All providers who receive MHBG funding are required to submit their MHBG Policy and Procedure to AzCH-Complete Care Plan annually, each November. Copayments, or any other fee, are prohibited for the provision of services funded by MHBG Block Grants.
Restrictions on the Use of MHBG Block Grant Funds
Providers must ensure that MHBG Block Grant funds are not expended on the following activities:
- Inpatient services,
- Physical health care services including payment of copays,
- General Prevention efforts,
- To make cash payments to intended recipients of health services, Purchase or improvement of land, purchase, construct, or permanently improve (other than minor remodeling) any building or other facility, or purchase major medical equipment,
- To satisfy any requirement for the expenditure of non-Federal funds as a condition or the receipt of Federal funds,
- Provision of financial assistance to any entity other than a public or nonprofit private entity,
- Provision of hypodermic needles or syringes so for illegal drug use, unless the Surgeon General of the Public Health Service determines that a demonstration needle exchange program would be effective in reducing drug use and the risk that the public will become infected with the etiologic agent for AIDS,
- Payment of salary of an individual through a grant or other extramural mechanism at a rate in excess of Level I of the Executive Salary Schedule for the award year (see National Institutes of Health (NIH) Grants & Funding Salary Cap Summary),
- Purchase of treatment services in penal or correctional institutions of the State of Arizona,
- Flex fund purchases,
- Sponsorship for events and conferences, or
- Childcare Services.
For Non-TXIX/XXI eligible persons court ordered for DV treatment, the individual can be billed for the DV services (ACOM Policy 423).
12.10.3 Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA) Criminal Justice Project – CFDA 93.243
The purpose of this program is to expand/enhance access to medication assisted treatment (MAT) services for persons with criminal justice involvement that have an opioid disorder and are seeking or receiving MAT. Key project outcomes include an increase in the number of individuals with criminal justice involvement being admitted to MAT, an increase in the number of individuals receiving integrated care/treatment, a decrease in illicit opioid drug use at 6-month follow-up, and a decrease in the use of prescription opioids in a non-prescribed manner at 6-month follow-up.
Providers must have internal policies and procedures for federal grant tracking, including the MAT-PDOA grant, which should include, but are not limited to, a listing of prohibited expenditures, monitoring and reporting of funds. All providers who receive MAT-PDOA funding are required to submit their MAT-PDOA Policy and Procedure to AzCH-Complete Care Plan annually, each November.
Restrictions on the Use of MAT-PDOA Grant Funds
- Pay for any lease beyond the project period.
- Provide services to incarcerated populations (defined as those persons in jail, prison, detention facilities, or in custody where they are not free to move about in the community).
- Pay for the purchase or construction of any building or structure to house any part of the program.
- Pay for housing other than residential mental health and/or substance use disorder treatment.
- Provide residential or outpatient treatment services when the facility has not yet been acquired, sited, approved, and met all requirements for human habitation and service provision.
- Provide inpatient treatment or hospital-based detoxification services. Residential services are not considered to be inpatient or hospital based services.
- Only allowable costs associated with the use of federal funds are permitted to fund evidence-based practices (EBPs).
- Make direct payments to individuals to induce them to enter prevention or treatment services. However, SAMHSA discretionary grant funds may be used for non-clinical support services, limited to bus tokens and child care, designed to improve access to and retention in prevention and treatment programs.
- Make direct payments to individuals to encourage attendance and/or attainment of prevention or treatment goals.
- Funds may not be used to distribute sterile needles or syringes for the hypodermic injection of any illegal drug.
- Pay for pharmacologies for HIV antiretroviral therapy, sexually transmitted diseases (STD)/sexually transmitted illness (STI), TB, and hepatitis B and C or for psychotropic drugs.
- Outside individuals or companies that prepare or participate in the preparation of grant applications may not be contractors on those grants per 45 CFR 75.328, which addresses full and open competition.
12.10.4 State Opioid Response Grant (SOR)
The SOR program aims to address the opioid crisis by increasing access to medication assisted treatment using the three FDA-approved medications including: methadone, buprenorphine products, including single-entity buprenorphine products, buprenorphine/naloxone tablets, films, buccal preparations, long-acting injectable buprenorphine products, buprenorphine implants, and injectable extended-release naltrexone for the treatment of Opioid Use Disorder (OUD). The overarching goal of the SOR project is to increase access to MAT treatment, coordinated and integrated care, opioid use disorder (OUD)/stimulant use disorder recovery support services and prevention activities to reduce the prevalence of OUDs, stimulant use disorder and opioid-related overdose deaths. The grant provides for the provision of prevention, treatment and recovery activities for OUD (including illicit use of prescription opioids, heroin, and fentanyl and fentanyl analogs). This program also supports evidence-based prevention, treatment, and recovery support services to address stimulant misuse and use disorders, including for cocaine and methamphetamine.
Eligible populations are individuals with OUD, stimulant use disorder, and populations at risk for developing either and related behavioral health consequences.
SOR Grant funded providers are require to:
- Implement evidence-based treatments, practices, and interventions for OUD and make available FDA-approved MAT to those diagnosed with OUD
- Implement and maintain a robust peer support program and support sustained recovery
- Coordinate with AzCH and correctional facilities to sustain and identify early MAT eligible individuals re-entering the community
- Coordinate care with hospitals and emergency departments to facilitate warm handoffs and entry into treatment
- Provide street-based outreach
- Provide or coordinate access to supportive housing services
- Implement FDA-approved MAT for OUD. Medical withdrawal (detoxification) is not the standard of care for OUD, is associated with a very high relapse rate, and significantly increases an individual’s risk for opioid overdose and death if opioid use is resumed. Therefore, medical withdrawal (detoxification) when done in isolation is not an evidence-based practice for OUD. If medical withdrawal (detoxification) is performed, it shall be accompanied by injectable extended-release naltrexone to protect such individuals from opioid overdose in relapse and improve treatment outcomes
- Employ effective prevention and recovery support services to ensure that individuals are receiving a comprehensive array of services across the spectrum of prevention, treatment, and recovery
- Implement evidence-based prevention, treatment, and recovery support services to address stimulant misuse and use disorders
- Collect and report outreach activities and treatment data as requested by AzCH and/or AHCCCS
- Develop and maintain internal policies and procedures for federal grant tracking, including the SOR grant, which should include, but are not limited to, a listing of prohibited expenditures, monitoring and reporting of funds. All providers who receive SOR funding are required to submit their SOR Policy and Procedure to AzCH-Complete Care Plan annually, each November.
Restrictions on the Use of SOR Grant Funds
- Pay the salary of an individual at a rate in excess of Executive Level II. The Executive Level II salary can be found in SAMHSA’s standard terms and conditions for all awards at https://www.samhsa.gov/grants/grants-management/notice-award-noa/standard-terms-conditions. This amount reflects an individual’s base salary exclusive of fringe and any income that an individual may be permitted to earn outside of the duties to the applicant organization.
- Pay for any lease beyond the project period.
- Pay for the purchase or construction of any building or structure to house any part of the program.
- Provide residential or outpatient treatment services when the facility has not yet been acquired, sited, approved, and met all requirements for human habitation and service provision. (Expansion or enhancement of existing residential services is permissible.)
- Provide detoxification services unless it is part of the transition to MAT with extended release naltrexone
- Make direct payments to individuals to enter treatment or continue to participate in prevention or treatment services. Note: A recipient or treatment or prevention provider may provide up to $20 non-cash incentive to individuals to participate in required data collection follow-up. This amount may be paid for participation in each required follow up interview.
- Meals are generally unallowable unless they are an integral part of a conference grant or specifically stated as an allowable expense in the FOA. Grant funds may be used for light snacks, not to exceed $3.00 per person.
- Support non-evidence-based treatment.
22.214.171.124 Emergency Grants Mental Health and Substance Use Disorders during COVID-19 (Emergency COVID-19)
The purpose of the COVID-19 program is to provide crisis intervention services, mental and substance use disorder treatment, and other related recovery supports for children and adults impacted by the COVID-19 pandemic, including staff.
COVID-19 Grant Restrictions
Emergency COVID-19 Grants funds shall not be used to:
- Directly or indirectly, purchase, prescribe, or provide marijuana or treatment using marijuana. Treatment in this context includes the treatment of opioid use disorder;
- Grant funds also cannot be provided to any individual who or organization that provides or permits marijuana use for the purposes of treating substance use or mental disorders. Refer to 45 CFR 75.300(a) (requiring HHS to “ensure that Federal funding is expended in full accordance with U.S. statutory requirements.”), 21 U.S.C. §§ 812(c)(10) and 841 (prohibiting the possession, manufacture, sale, purchase or distribution of marijuana). This prohibition does not apply to those providing such treatment in the context of clinical research permitted by the DEA and under an FDA-approved investigational new drug application where the article being evaluated is marijuana or a constituent thereof that is otherwise a banned controlled substance under federal law;
- Pay for promotional items including, but not limited to, clothing and commemorative items such as pens, mugs/cups, folders/folios, lanyards, and conference bags;
- Pay for the purchase or construction of any building or structure to house any part of the program;
- Provide residential or outpatient treatment services when the facility has not yet been acquired, sited, approved, and met all requirements for human habitation and services provision;
- Provide inpatient treatment or hospital-based detoxification services. Residential services are not considered to be inpatient or hospital-based services;
- Make direct payments to individuals to enter treatment or continue to participate in prevention or treatment services;
- Provide meals unless they are an integral part of a conference grant or specifically stated as an allowable expense. Grant funds may be used for light snacks, not to exceed $3.00 per individual per day;
- Purchase sterile needles or syringes for the hypodermic injection of any illegal drug. Provided, That such limitation does not apply to the use of funds for elements of a program other than making such purchases if the relevant State or local health department, in consultation with the Centers for Disease Control and Prevention, determines that the State or local jurisdiction, as applicable, is experiencing, or is at risk for, a significant increase in hepatitis infections or an HIV outbreak due to injection drug use, and such program is operating in accordance with state and local law;
- Purchase of personal protective equipment (PPE) except for use by staff charged to the grant. Purchase of PPE for other employees or clients is not an allowable use of these funds; or
- Purchase equipment or supplies (e.g. pre-paid minutes, cell phones, Hot spots, iPad, and tablets) for clients.
Emergency Grants Mental Health and Substance Use Disorders during COVID-19 (Emergency COVID-19)
The purpose of this program is specifically to address the needs of individuals with Serious Mental Illness. Additionally, the program will also focus on meeting the needs of individuals with mental disorders that are less severe than serious mental illness, including those in the healthcare profession. Eligible Populations include:
- Individuals diagnosed with a SM;
- Individuals diagnosed with SUDs;
- Individuals with a co-occurring (SMI/SUD); and
- Individuals with mental disorders that are less severe than SMI.
Contracted providers shall use grant funds primarily to provide direct services and to the extent possible and use SAMHSA grant funds only for services to individuals who are not covered by public or commercial health insurance programs, individuals for whom coverage has been formally determined to be unaffordable, or for services that are not sufficiently covered by an individual’s health insurance plan. Contracted providers shall facilitate the health insurance application and enrollment process for eligible uninsured clients and shall consider other systems from which a potential member may be eligible for services (e.g. the Veterans Health Administration or senior services), if appropriate for, and desired by, that individual to meet their needs. Contracted providers shall ensure other sources of funding are utilized before Emergency COVID-19 Grants funds are used when other funding sources are available for that individual.
Contracted providers receiving this funding are required to:
- Implement evidence-based mental and/or substance use disorder treatment services for individuals impacted by the COVID-19 pandemic;
- Ensure that service provision may occur in a telehealth context including the use of telephone;
- Screen and assess clients for the presence of mental and substance use disorders and/or co-occurring disorders, and use the information obtained from the screening and assessment to develop appropriate treatment approaches;
- Provide evidence-based and population appropriate treatment services;
- Provide recovery support services (e.g. linkages to nutrition/food services, individual support services, childcare, vocational, educational, linkages to housing services, and transportation services) which will improve access to, and retention in services;
- Provide services virtually where needed;
- Provide or coordinate access to Crisis mental health services;
- Complete a Government Performance and Results Modernization Act (GPRA) for each unduplicated client at baseline, every 6-months thereafter while in treatment, and at discharge;
- Collect and report outreach activities and treatment data as requested by AzCH and/or AHCCCS.
COVID19 Emergency Response for Suicide Prevention Grant
The overarching goal of the Emergency Suicide Prevention project is to decrease the number of uninsured/underinsured individuals age 25 and older who die by suicide in Pima County, and to increase access to both related behavioral health and domestic violence services. The project approach includes partnering with local level collaborations and service enhancements to implement suicide and domestic violence screening best practices, and to create new referrals paths to care. Such behavioral health services may include treatment of anxiety, depression, or other general mental health issues.
Contracted providers receiving this funding are required to:
- Rapidly follow-up with adults who have attempted suicide or experienced a suicidal crisis after discharge from emergency departments and inpatient psychiatric facilities;
- Provide community recovery/support/resources/referrals to assist individuals who have attempted or are at risk of attempting suicide, including supports to impacted household members;
- Rapid assessment of members needs and effective coordination of services from the inpatient facilities into community based and outpatient services, including treatment for general mental health if necessary;
- Establish follow-up and care transition protocols that address individual safety, especially among high risk adults in health or behavioral health care settings, who have attempted suicide or experienced a suicidal crisis. The protocols shall include discharge plans and the coordination of care into the community to include assessment and referral; including those persons diagnosed with a serious mental illness and/or those challenged by a substance use disorder(s) and those with general mental health challenges;
- Provide community recovery supports/resources/referrals to assist individuals who have attempted or are at risk for attempting suicide and includes supports for impacted household members;
- Screen for suicide and domestic violence risk and provide appropriate clinical treatment services and referrals as a result of the assessment. Referrals and coordination of care shall be conducted with outpatient providers, intensive outpatient providers, residential facilities (when indicated), referrals for individual and group counseling and family service settings;
- Employ evidence-based practices related to suicide and suicide prevention;
- Collect and report outreach activities and treatment data as requested by AzCH and/or AHCCCS.
126.96.36.199 State Targeted Response to the Opioid Crisis Grant (STR) - CFDA 93.788
The purpose of the STR project is to increase opioid use disorder (OUD) treatment, coordinated and integrated care, recovery support services and prevention activities to reduce the prevalence of OUD and opioid-related overdose deaths. The project approach includes developing and supporting state, regional, and local level collaborations and service enhancements to develop and implement best practices to comprehensively address the full continuum of care related to opioid misuse, above and dependency.
Providers must have internal policies and procedures for federal grant tracking, including the STR grant, which should include, but are not limited to, a listing of prohibited expenditures, monitoring and reporting of funds. All providers who receive STR funding are required to submit their STR Policy and Procedure to AzCH-Complete Care Plan annually, each November
Restrictions on the Use of STR Grant Funds
- Pay for any lease beyond the project period.
- Provide services to incarcerated populations (defined as those persons in jail, prison, detention facilities, or in custody where they are not free to move about in the community).
- Pay for the purchase or construction of any building or structure to house any part of the program. (Applicants may request up to $75,000 for renovations and alterations of existing facilities, if necessary and appropriate to the project.)
- Pay for housing other than residential mental health and/or substance use disorder treatment.
- Provide residential or outpatient treatment services when the facility has not yet been acquired, sited, approved, and met all requirements for human habitation and services provision. (Expansion or enhancement of existing residential services is permissible).
- Only allowable costs associated with the use of federal funds are permitted to fund evidence-based practices (EBPs). Other sources of funds may be used for unallowable costs (e.g. meals, sporting events, entertainment). Other support is defined as funds or resources, whether federal, non-federal or institutional, in direct support of activities through fellowships, gifts, prizes or in-kind contributions.
- Make direct payments to individuals to induce them to enter prevention or treatment services. However, SAMHSA grant funds may be used for non-clinical support services (e.g., bus tokens, child care) designed to improve access to and retention in prevention and treatment programs.
- Make direct payments to individuals to encourage attendance and/or attainment of prevention or treatment goals. Meals are generally unallowable unless they are an integral part of a conference grant or specifically stated as an allowable expense in the FOA. Grant funds may be used for light snacks, not to exceed $3.00 per person.
188.8.131.52 Non-Title XIX/XXI Services and Funding (Excluding Block Grant and Discretionary Grants)
AHCCCS receives specific appropriations of the general fund for Non-Title XIX/XXI behavioral health services from the Arizona State Legislature. The goals of the funding are:
To ensure access to a comprehensive system of care for children and adults; including
- Housing services;
- Case management;
- Mental health and substance abuse services and support.
Non-Title XIX/XXI eligible populations include:
- Non-Title XIX/XXI Persons with SMI;
- Non-Title XIX/XXI individuals in the GMH behavioral health category;
- Non-Title XIX/XXI individuals in the SUD behavioral health category.
AHCCCS covers Non-Title XIX/XXI behavioral health services (mental health and/or substance use) within certain limits for Title XIX/XXI and Non-Title XIX/XXI Members when medically necessary. Payment for behavioral health services covered under Non-Title XIX/XXI Funds (excluding federal grants) are limited to providers contracted to deliver the services and subject to availability of funds and the approval of The Health Plan.
- Auricular Acupuncture Services is the application b of auricular acupuncture needles to the pinna, lobe, or auditory meatus to treat mental health, alcoholism, substance use or chemical dependency by a certified acupuncturist practitioner as specified in A.R.S. §32-3922. 2;
- Mental Health Services (Traditional Healing Services) Treatment services for mental health or substance use problems provided by traditional healers;
- Supported Housing services provided by behavioral health professionals, behavioral health technicians, or behavioral health paraprofessionals, to assist individuals or families to obtain and maintain housing in an independent community setting including the individual’s own home or apartments and homes owned or leased by a subcontracted provider;
- Mental Health Services, Room and Board;
- Other Non-Title XIX/XXI Behavioral Health Services For Title XIX/XXI Eligible Populations;
- Crisis Services; and
- Assessments for Non-Title XIX/XXI Members when they are conducted to determine SMI eligibility. Non-Title XIX/XXI SMI General Funds may be used for the assessment, regardless of whether the individual is found to have a SMI and includes individuals who are assessed at 17.5 years old and older.
Restrictions on the Use of Non-Title XIX/XXI State Appropriation Funds
Non-Title XIX/XXI Funding may not be utilized for the following:
- Cash payments to members receiving or intending to receive health services;
- Purchase or improvement of land, purchase, construct, or permanently improve any building or facility except for minor remodeling with written approval from AHCCCS;
- Purchase of major medical equipment;
- Flex funds purchases of non-medically necessary services and supports that are not reimbursable or covered under Title XIX/XXI or Non-Title XIX/XXI;
- Sponsorship for events and conferences; or
- Childcare Services.
Behavioral Health Homes and contracted BH Inpatient Facilities must identify and report to the AHCCCS Office of Human Rights (OHR) on members determined to have a Serious Mental Illness (SMI) who meet the criteria for Special Assistance. If the person’s Special Assistance needs appear to be met by an involved family member, friend, designated representative or guardian providers must still submit a notification to the OHR. Behavioral Health Homes, contracted BH Inpatient Facilities and the Behavioral Health Office of Grievances and Appeals (BHOGA) must ensure that the person designated to provide Special Assistance is involved at key stages.
Behavioral Health Homes and contracted BH Inpatient Facilities are expected to follow the policies and procedures outlined in AMPM Policy 320-R, all other applicable AHCCCS policies and state policies outlined in Arizona Revised Statutes and Arizona Administrative Code.
12.10.1 General Requirements
Criteria to deem a member to be in need of Special Assistance:
A member determined to have a Serious Mental Illness (SMI) is in need of Special Assistance if the member is unable to do any of the following:
- Communicate preferences for services;
- Participate effectively in Individual Service Planning (ISP) or Inpatient Treatment Discharge Planning (ITDP);
- Participate effectively in the appeal, grievance or investigation processes.
The member’s limitations described above must also be due to any of the following:
- Cognitive ability/intellectual capacity (i.e. cognitive impairment, borderline intellectual functioning, or diminished intellectual capacity);
- Language barrier (an inability to communicate, other than a need for an interpreter/translator); and/or
- Medical condition (including, but not limited to traumatic brain injury, dementia, or severe psychiatric symptoms).
A member who is subject to general guardianship has been found to be incapacitated under A.R.S. § 14-5304, and therefore automatically satisfies the criteria for Special Assistance.
For a member determined to have a SMI, the existence of any of the following circumstances may warrant the Behavioral Health Home to more closely review whether the member is in need of Special Assistance:
- Developmental disability involving cognitive ability;
- Residence in a 24 hour setting;
- Limited guardianship, or The Health Plan or the Behavioral Health Home is recommending the establishment of a limited guardianship; or
- Existence of a serious medical condition, that affects intellectual and/or cognitive functioning (such as, dementia or traumatic brain injury).
12.10.2 Persons Qualified to Make a Special Assistance Determination
Specific staff and agencies are qualified to screen for Special Assistance and determine whether a member qualifies for Special Assistance (See AHCCCS AMPM Policy 320-R for specific requirements).
12.10.3 Screening for Special Assistance
Behavioral Health Homes and contracted Behavioral Health (BH) Inpatient Facilities perform screenings to assess whether members determined to have a SMI are in need of Special Assistance, in accordance with the criteria set out in AHCCCS AMPM Policy 320-R. Provider Manual Attachment 3.11.1 Special Assistance Guidance Document is available to assist Behavioral Health Homes and contracted BH Inpatient Facilities screen for Special Assistance by calling the Provider Services Call Center at 866-796-0542 to obtain a copy of this attachment, if needed.
Special Assistance documentation and record keeping policies and procedures are referenced in AMPM Policy 320 Special Assistance for Members Determined to Have a Serious Mental Illness.
If a member is currently identified as a member in need of Special Assistance, a notation of “Special Assistance” and a completed AHCCCS AMPM 320-R, Attachment A, Notification of Member in Need of Special Assistance should already exist in the clinical record. However, if it is unclear, Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities can contact The Health Plan Independent Oversight Committee Liaison (email@example.com ) to inquire about current status. The Behavioral Health Plan maintains a database on members in need of Special Assistance and shares data with Health Homes and contracted Behavioral Health Inpatient Facilities on a regular basis.
12.10.5 Notification Requirements to the Office of Human Rights
Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities are expected to follow the policies and procedures for notifying the Office of Human Rights as outlined in AMPM Policy 320-R.
Behavioral Health Homes and contracted Behavioral Health inpatient Facilities must use the current electronic Special Assistance Notification Form found on the AHCCCS QM Portal.
12.10.6 Members No Longer in Need of Special Assistance
Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities are expected to follow the policies and procedures for notifying the Office of Human Rights when a member no longer meets Special Assistance criteria, as outlined in AHCCCS AMPM Policy 320-R.
12.10.7 Requirement to Help Ensure the Provision of Special Assistance
Behavioral Health Homes and contracted BH Inpatient Facilities collaborate with and involve the member (guardian, family member, friend, Office of Human Rights advocate, etc.) meeting Special Assistance needs in all relevant Behavioral Health planning and processes. Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities are expected to follow the policies and procedures within AHCCCS AMPM Policy 320-R.
12.10.8 Behavioral Health Home Reporting Requirements
Behavioral Health Homes and contracted BH Inpatient Facilities are expected to follow all reporting requirements listed within the AHCCCS AMPM Policy 320-R.
To support The Health Plan and OHR in maintaining accurate and up-to-date information on members in need of Special Assistance, Behavioral Health Homes are required to report involvement of the person meeting Special Assistance needs bimonthly as outlined in Provider Manual Section 16. Behavioral Health Homes are also required to update the QM portal with any relevant changes within 5 business days of the change taking place as outlined in AHCCCS AMPM 320-R.
Behavioral Health Homes with repetitive occurrences of not meeting /succeeding the Special Assistance MPS of 85% will be required to attend a live Special Assistance training facilitated by The Health Plan. Identified Behavioral Health Home staff are required to attend the live training within 2 months of the notification.
12.10.9 Confidentiality Requirements
Behavioral Health Homes shall grant access to clinical records of members in need of Special Assistance to the Office of Human Rights in accordance with federal and state confidentiality laws (AHCCCS AMPM Policy 550).
Independent Oversight Committees receive confidential information related to Special Assistance members and are expected to safeguard the information in accordance with the requirements set out in AHCCCS ACOM, Policy 447.
12.10.10 Other Procedures
Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities must follow the training requirements related to Special Assistance, as outlined in AHCCCS AMPM, Policy 320-R and AHCCCS AMPM Policy 1060.
Behavioral Health Homes and contracted Behavioral Health Inpatient Facilities must assign one staff member to act as the Special Assistance Single Point of Contact. The Single Point of Contact must be proficient in all Special Assistance policies and procedures as outlined in AHCCCS AMPM, Policy 320-R and all other applicable Special Assistance policy.
The Single Point of Contact verifies AHCCCS Office of Human Rights requests for further information and/or ensures timely submission of documents. The Single Point of Contact is responsible to review all information provided on AHCCCS AMPM 320-R Attachment A, Notification of Member in Need of Special Assistance, prior to submission to AHCCCS Office of Human Rights to ensure member meets criteria.
Behavioral Health Home Single Point of Contact staff are required to attend the Special Assistance Single Point of Contact Monthly Conference Call. Behavioral Health Homes should notify The Health Plan Independent Oversight Committee Liaison of any changes in Single Point of Contact staff.
12.10.11 Transfer of a Special Assistance Member
Notice of a request to transfer, for all Special Assistance members, must be shared with The Health Plan prior to initiating the transfer through the Provider Portal and submitting the transfer packet. All changes and updates to a Special Assistance member’s services, including transfers, requires collaboration with the person assigned to meet Special Assistance needs.
AzSH is a Level I facility currently licensed under applicable State and local law, is accredited by The Joint Commission and certified by the Centers for Medicare and Medicaid Services (CMS). AzSH is a long-term inpatient psychiatric hospital that provides the most restrictive setting for care in the state. Coordination between AzSH and The Health Plan must occur in a manner that ensures persons being admitted meet medical necessity criteria. Pursuant to A.R.S. § 36-201 through 36-217, AzSH provides inpatient care and treatment to patients with mental disorders, personality disorders or emotional conditions. The level of care provided at AzSH must be the most appropriate and least restrictive treatment option for the person (A.R.S. § 36‑501(21)). The provision of appropriate, medically necessary covered behavioral health services must be consistent with treatment goals outlined on the admission application and individual needs identified in the course of treatment of individuals admitted to AzSH.
The goal of all hospitalizations of persons at AzSH is to provide comprehensive evaluation, treatment, and rehabilitation services to assist each behavioral health recipient in their own recovery, and to achieve successful placement into a less restrictive community-based treatment option.
To ensure that individuals are treated in the least restrictive and most appropriate environment that can address their individual treatment and support their needs, the criteria for clinically appropriate admissions to AzSH are as follows:
- The Member must not require acute medical care beyond the scope of medical care available at AzSH.
- The referral source must make reasonable good-faith efforts to address the individual’s target symptoms and behaviors in an inpatient setting(s).
- The referral source must complete Utilization Review of the potential admission referral and it recommend admission to the AzSH as necessary and appropriate, and as the least restrictive option available for the person based on clinical status.
- When a community provider agency or other referral source believes that a civilly committed or voluntarily admitted adult is a candidate to be transferred from another inpatient facility for treatment at AzSH, the agency will contact The Health Plan to discuss the recommendation for admission to AzSH. The Health Plan must be in agreement with the referral source that a referral for admission to AzSH is necessary and appropriate. If the candidate is not Health Plan enrolled, the Member will be referred for SMI determination and the enrollment process prior to application or at the latest within twenty-four (24) hours of admission pursuant to Section 12.2 — Appointment Standards and Timeliness of Service to AzSH. The enrollment date is effective the first date of contact by a The Health Plan contracted Behavioral Health Home. The Health Plan Behavioral Health Home is required to also complete a Title XIX/XXI application once enrollment is completed. For all non- T/RBHA enrolled Tribal behavioral health recipients, upon admission to AzSH, the hospital will enroll the person, if eligible in the AHCCCS Indian Health Program.
- For T/RBHA (Tribal RBHA only) enrolled Members, AHCCCS must also be in agreement with the referring agency that admission to AzSH is necessary and appropriate, and AHCCCS must prior authorize the person’s admission (see Section 4.1 — Securing Services and Prior Authorization/Retrospective Authorization).
- The Health Plan and/or other referral sources must contact the AzSH Admissions Office and forward a completed packet of information regarding the referral to the Admissions Office, and if determined to be SMI and previously assessed as requiring Special Assistance, then the existing Special Assistance form should be included in the package. If the form has not been completed, please refer to Section 12.11 — Special Assistance for Persons Determined to have a Serious Mental Illness for further instructions.
- The Admissions Office confirms receipt of the complete packet and notifies the referral source of missing or inadequate documentation within two business days of receipt. AzSH cannot accept any person for admission without copies of the necessary legal documents.
- For TXIX enrolled persons, The Health Plan needs to generate a Letter of Authorization (LOA) or issue a denial. Once the member is accepted, the Certification of Need (CON) and Letter of Authorization (LOA) are provided to AZSH just prior to admit with other documents as outlined in the AZSH Admission Workflow; an AzSH document. See AHCCCS Prior Authorization Forms: Certification of Need.
- The Health Plan is responsible for notifying AzSH’s Admissions Office of any previous court ordered treatment days utilized by the Member. Members referred for admission must have a minimum of forty-five (45) inpatient court-ordered treatment days remaining to qualify for admission. The Member’s AHCCCS eligibility will be submitted by The Health Planthe Health Plan to the AzSH Admissions Office with the admission application and verified during the admission review by the AzSH Admissions Office. The AzSH Admissions Office will notify (AHCCCS) Member Services of the behavioral health recipient’s admission to AzSH and any change in health plan selection, or if any other information is needed.
- The Chief Medical Officer or Acting Designee will review the information within 14 calendar days after receipt of the completed packet and determine whether the information supports admission and whether AzSH can meet the Member’s treatment and care needs.
- If the AzSH Chief Medical Officer or Acting Designee determines that the Member does not meet criteria for admission, the Chief Medical Officer or Acting Designee will provide a denial letter.
- If the admission is approved, the Admissions Office will send the acceptance statement from the Chief Medical Officer or Acting Designee to the referral source.
- A Court Order for transfer is not required by AzSH when the proposed Member is already under a Court Order for treatment with forty-five (45) remaining inpatient days. However, in those jurisdictions in which the court requires a court order for transfer be issued, the referring agency will obtain a court order for transfer to AzSH.
- If a Court Order for transfer is not required, the AzSH Admissions Office will set a date and time for admission. It is the responsibility of the referring agency to make the appropriate arrangements for transportation to AzSH.
- When AzSH is unable to admit the accepted behavioral health recipient immediately, AzSH shall establish a pending list for admission. If the behavioral health recipient’s admission is pending for more than 15 days, the referral agency must provide AzSH a clinical update in writing, including if any alternative placements have been explored while pending, and if the need for placement at AzSH is still necessary.
12.11.2 Adult Members Under Civil Commitment
The Member must have a primary diagnosis of Mental Disorder (other than Cognitive Disability, Substance Abuse, Paraphilia-Related Disorder, or Antisocial Personality Disorder) as defined in A.R.S. § 36-501, which correlates with the symptoms and behaviors precipitating the request for admission, and be determined to meet DTO, DTS, GD, or PAD criteria as the result of the mental disorder.
The Member is expected to benefit from proposed treatment at AzSH (A.R.S. § 36-202). The Member must have completed 25 days of mandatory treatment in a local mental health treatment agency under T-36 COT, unless waived by the court as per A.R.S. § 36-541 or, if PAD, waived by the Chief Medical Officer of AzSH.
AzSH must be the least restrictive alternative available for treatment of the person (A.R.S. § 36-501) and the less restrictive long-term level of care available elsewhere in the State of Arizona to meet the identified behavioral health needs of the Member.
The Member must not suffer more serious harm from proposed care and treatment at AzSH. (AAC R9-21-507(B)(1) (PDF)).
Hospitalization at AzSH must be the most appropriate level of care to meet the person’s treatment needs, and the person must be accepted by the Chief Medical Officer for transfer and admission (AAC R9-21-507(B)(2) (PDF)).
12.11.3 Treatment and Community Placement Planning
AzSH will begin treatment and community placement planning immediately upon admission, utilizing the Adult Clinical Team model. All treatment is patient-centered and is provided in accordance with AHCCCS-established five principles of person-centered treatment for adult Members determined to have SMI.
Members shall remain assigned to their original clinic/outpatient treatment team throughout their admission, unless the Member initiates a request to transfer to a new clinic site or treatment team.
- Consideration of comprehensive information regarding previous treatment approaches, outcomes and recommendations/input from The Health Plan and other outpatient community treatment providers is vital.
- Representative(s) from the outpatient treatment team are expected to participate in treatment planning throughout the admission in order to facilitate enhanced coordination of care and successful discharge planning.
- Treatment goals and recommended assessment/treatment interventions must be carefully developed and coordinated with the outpatient providers (including The Health Plan, ALTCS Health Plan, other providers/other state agencies as appropriate), the Member’s legal guardian, family members, significant others as authorized by the Member and advocate/designated representative whenever possible.
- The first Inpatient Treatment and Discharge Plan (ITDP) meeting, which is held within 10 days of the Member´s admission, should address specifically what symptoms or skill deficits are preventing the Member from participating in treatment in the community and the specific goals/objectives of treatment at AzSH. This information should be used to establish the treatment plan.
- The first ITDP meeting should also address the discharge plan for reintegration into the community. The Member’s specific needs for treatment and placement in the community, including potential barriers to community placement and successful return to the community, should be identified and discussed.
- All required medical services for enrolled members residing at AzSH that are not provided by AzSH will be provided by Valleywise Health Medical Center. The Health Plan will provide payment to MIHS for all medically necessary services provided to enrolled T19/21 persons with a Serious Mental Illness (SMI) as described in the AHCCCS ACOM – Policy 432- Benefit
Coordination and Fiscal Responsibility for Behavioral Health Services and Physical Health Services, Section III –B, titled Specific Circumstances Regarding Payment for Behavioral Health Services.
AzSH will provide all treatment plans to the responsible agency. The responsible agency should indicate review of an agreement/disagreement with the treatment plan on the document. Any disagreements should be discussed as soon as possible and resolved as outlined in AAC 9R-21 (PDF).
Treatment plans are reviewed and revised collaboratively with the Adult Clinical Team at least monthly.
Any noted difficulties in collaboration with the outpatient provider treatment teams will be brought to the attention of The Health Plan to be addressed. The Health Plan Hospital Liaison will monitor the participation of the outpatient team and assist when necessary.
Through the Adult Clinical Team, AzSH will actively address the identified symptoms and behaviors which led to the admission, and link them to the community rehabilitation and recovery goals whenever possible. AzSH will actively seek to engage the Member and all involved parties to establish understandable, realistic, achievable and practical treatment, discharge goals and interventions.
While in AzSH and depending upon the Member’s individualized treatment needs, a comprehensive array of evaluation and treatment services are available and will be utilized as appropriate and as directed by the Member’s treatment plan and as ordered by the Member’s treating psychiatrist.
12.11.4 Recertification of Need (RON)
The AzSH Utilization Manager is responsible for the recertification process, when recertification is required, for all Title XIX/XXI eligible persons and is the contact for AzSH for all The Health Plan continued stay reviews.
The AzSH Utilization Manager will work directly with the Member’s attending physician to complete the Provider Manual Form 10.1.2, Recertification of Need (RON) which can be obtained by calling the Provider Services Call Center at 866-796-0542 For members 65 and over, the RONs cover up to a 60 day span, for members under 21 the RONs cover a 30 day span and are submitted accordingly. The RON will be sent to The Health Plan within five (5) days of expiration of the current CON/ RON. If required by The Health Plan, the AzSH Utilization Manager will send to The Health Plan Utilization Review staff additional information/documentation needed for review to determine continued stay. The Health Plan pays the first 30 days following admission to the AzSH for T19 members; following this period, a 1-day authorization is created for all members regardless of age, and then denies.
All Health Plan decisions with regard to the approval or denial for continued stay will be rendered prior to the expiration date of the previous authorization and upon receipt of the RON for those Members. The Health Plan authorization decisions are based on review of chart documentation supporting the stay and application of the AHCCCS Level Continued Stay criteria. If continued stay is approved, The Health Plan sends a Letter of Approval (LOA) to the AzSH Utilization Management Department with the completed RON and updated standard nomenclature diagnosis codes (if applicable). Denials will be issued upon completion of the denial process described in Section 4.1 — Securing Services and Prior Authorization.
12.12.5 Transition to Community Placement Setting
The Member is considered to be ready for community placement and is placed on the Discharge Pending List when the following criteria are met:
- The agreed upon discharge goals set at the time of admission with The Health Plan have been met by the Member.
- The Member presents no imminent danger to self or others due to psychiatric disorder. Some Members, however, may continue to exhibit occasional problematic behaviors. These behaviors must be considered on a case-by-case basis and do not necessarily prohibit the person from being placed on the Discharge Pending List. If the Member is psychiatrically stable and has met all treatment goals but continues to have medical needs, the Member remains eligible for discharge/community placement.
- All legal requirements have been met.
Once a Member is placed on the Discharge Pending List, The Health Plan must immediately take steps necessary to transition the Member into community-based treatment as soon as possible. The Health Plan has up to thirty (30) days to transition the Member out of AzSH. The Health Plan outpatient treatment team should identify and plan for community services and supports with the Member’s inpatient clinical team 60 – 90 days out from the Member’s discharge date. This will allow sufficient time to identify appropriate community covered behavioral health services.
When the Member has not been placed in a community placement setting within 30 days, a quality of care concern will be initiated by the Health Plan or AHCCCS, if an agreement has not been made between AzSH and the outpatient treatment team that the discharge will take place after 30 days.
For T19/21 persons with a Serious Mental Illness and insulin-dependent diabetes, Health Plan will provide at discharge the same brand and model glucose monitoring device as used competently at AzSH. Care must be coordinated with the AzSH prior to discharge to ensure that all supplies are authorized and available to the member upon discharge.
AzSH Conditional Release Requirements
- The Health Plan has processes in place to provide high touch care management and/or other behavioral health and related services to members on Conditional Release from the Arizona State Hospital (AzSH) that are consistent with the Conditional Release Plan (CRP) issued by the Psychiatric Security Review Board (PSRB) per AHCCCS AMPM Policy 1020- I: Contractor Care Management. This includes but is not limited to assignment to a contractor care manager, which may be the assigned AzSH liaison or another team care manager working in conjunction with the AzSH liaison. Care management functions may not delegate these functions to a subcontracted provider.
- The Health Plan Care Manager is responsible to provide, at a minimum, the following:
- Discharge planning coordination with AzSH;
- Participation in developing and implementing Conditional Release Plans;
- Participation in the modification of an existing Individual Service Plan (ISP) or the modification of an existing ISP that complies with the Conditional Release Plan (CRP);
- Member outreach and engagement to help the PSRB evaluate compliance with CRP;
- Attendance in outpatient staffing at least once per month;
- Coordination of care with member’s treatment team, TRBHA, and physical and behavioral health providers to implement the ISP and CRP;
- Routine delivery of comprehensive status reporting to the PSRB;
- Attendance in a monthly conference call with AHCCCS Medical Management (MM)
- In the event that a member violates any term of their CRP, the Health Plan shall immediately notify the PSRB and provide a copy of the notification to AHCCCS and AzSH;
- The Health Plan agrees and understands that is will follow all obligations, including those stated above, applicable to it as set forth in A.R.S. §13-3994.
- Any violation of the Conditional Release, psychiatric decompensation or the use of alcohol, illegal substances or prescription medications not prescribed to the member shall be reported to the PSRB and the AzSH immediately.
The Health Plan shall submit a monthly comprehensive status report for members on Conditional Release to the PSRB and AHCCCS Medical Management, as specified in Contract utilizing AHCCCS AMPM Attachment 1020-1. The Health plan shall provide additional documentation at the request of AHCCCS Medical Management. In the event that a member’s mental status renders them incapable or unwilling to manage their medical condition and the member has a skilled medical need, the Health Plan must arrange ongoing medically necessary nursing services in a timely manner.
At times, it may be necessary to consider an out-of-state placement for a child or young adult to meet the person’s unique circumstances or clinical needs, as outlined in the AHCCCS AMPM Policy 450, Out of State Placements for Children or Young Adults for Behavioral Health Treatment.
12.12.1 Initial Notification to AHCCCS Office of Medical Management
All Provider Manual Forms and Attachments can be obtained by calling the Provider Services Call Center at 866-796-0542, if needed.
Providers are required to assist The Health Plan in gathering the required information to notify the AHCCCS Office of Medical Management prior to a referral for out-of-state placement using Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30 Day Update Prior authorization must be obtained prior to making a referral for out-of-state placement, in accordance with the Health Plan criteria (See Section 4.1 — Securing Services and Prior Authorization).
184.108.40.206 Process for Providing Initial Notification to the State
For providers subcontracted with The Health Plan, the provider notifies The Health Plan of the intent to make a referral for out-of-state placement on Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update.
Prior to placing the child or young adult the Behavioral Health Home provider must complete Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update and submit it to the Health Plan The Health Plan. The Health Plan will review the documentation and forward it to AHCCCS Office of Medical Management for approval of the out-of-state placement request. The Health Plan will also submit an electronic copy to AHCCCS Office of Medical Management, via secure e-mail, for approval of planned out-of-state placements.
12.12.2 Periodic Updates to AHCCCS Office of Medical Management
In addition to providing initial notification, the provider is required to submit updates to the Health Plan for review. The updates will be forwarded to the AHCCCS Office of Medical Management regarding the person’s progress in meeting the identified criteria for discharge from the out-of-state placement every 30 days. To adhere to this requirement, providers must use Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update.
Once completed, the Behavioral Health Home must submit the form to The Health Plan Medical Management department every 30 days the person continues to remain in out-of-state placement. The 30 day update timelines will be based upon the date of approval by AHCCCS of the out-of-state placement. The Health Plan will review the form and forward it to the AHCCCS Office of Medical Management.
12.12.3 Required Reporting of an Out-of-State Provider
All out-of-state providers are required to meet the reporting requirements of all incidences of injury/accidents, abuse, neglect, exploitation, healthcare acquired conditions, and/or injuries from seclusion/restraint implementations
See Section 9.2 Cultural Competence System of Care Requirements
In addition, behavioral health providers report appropriately for Language Assistance - T1013, Interpretation.
- T1013 must be reported when providing language assistance delivered by certified bilingual staff or provided by a language vendor or any qualified interpreter. This code is used to track language assistance that is being provided at any time (languages other than English, including ASL). T1013 does not require a modifier.
- Interpretation must be reported in conjunction with another service that cannot be delivered effectively without the availability of sign language or interpreter assistance, never a standalone code.
12.14.1 Business Continuity/Recovery Plans
In order to effectively manage unexpected events that may negatively and significantly impact the ability to deliver services to members, all Administrative Service Subcontractors and all of the following provider types must develop, maintain and annually test a Business Continuity/Disaster Recovery and Emergency Response Plan.
Provider Type (provider type licensing code number)
Level 1 Hospitals (02)
Level 1 Psych Hospitals (71)
Behavioral Health Outpatient Clinics (77)
Integrated Clinics (77)
Level 1 Residential Treatment Center Secure (non-IMD) (78)
Community Service Agency (A3)
Rural Substance Abuse Transitional Agency (A6)
Level 1 Residential Treatment Center Secure (IMD) (B1)
Level 1 Residential Treatment Center Non-Secure (non-IMD) (B2)
Level 1 Residential Treatment Center Non-Secure (IMD) (B3)
Level 1 Subacute Facility (IMD) (B6)
Crisis Service Provider (B7)
Federally Qualified Health Center (FQHC) (C2)
Community/Rural Health Center (RHC) (29)
12.14.2 Business Continuity and Emergency Response Plan Provisions
These provider types listed in Section 12.15.1 must develop, maintain, and annually test a Business Continuity/Recovery and Emergency Response Plan to manage unexpected events that may negatively and significantly impact its ability to deliver services to Members. Providers must develop a process to train key personnel and organizational staff to be familiar with and implement the Business Continuity/Recovery Plan and Emergency Response when necessary.
The Business Continuity and Emergency Response Plan must specify, at a minimum, strategies to address the following:
- Indicate that the Plan is reviewed annually and updated
- The Plan contains staff training requirements including how often training is conducted.
- The Plan is specific to the Contractor’s operations in Arizona and references local resources.
- The Plan contains planning and training for:
- Electronic/telephonic failure at the Contractor’s main place of business and any satellite offices in or out of State;
- Complete loss of use of the main site and any satellite offices out of State’
- Loss of primary computer system/records;
- Extreme weather conditions;
- How the Contractor will communicate with The Health during a business disruption;
- Directing the Contractor staff to contact AHCCCS Security at 602-417-4888 in the event of a disruption outside of normal business hours;
- Provisions for periodic testing, at least annually. Results of the tests are documented.
- The Plan must address key customer priorities and key factors that could cause disruption, including access to the following key customer priorities:
- Member Services;
- Clinic and/or Physician Visits;
- Transportation Services;
- Prior Authorization;
- Outpatient or Inpatient Procedures;
- Utilization Review/ Concurrent Review;
- Provider Services/Claims/ Provider Payments;
- Grievance/Appeals and Quality of Care Concerns;
- Any other critical services identified by the Contractor;
- The Plan addresses emergency plan provisions for facilities and hospitals in the event members are displaced in an emergency;
- The Plan includes timelines for resumption of services including percentages of recovery; and
- The Contractor has designated a Business Continuity Planning Coordinator and includes contact information in the Plan.
(See the adjacent link for details; refer to AHCCCS ACOM Policy 104, Attachment A for additional template.
In the event of a pandemic, as declared the Governor of Arizona, U.S. Government or the World Health Organization, which makes performance of any term outlined in the AHCCCS Contract with The Health Plan impossible or impracticable, the State shall have the following rights:
- After the official declaration of a pandemic, the State or The Health Plan may temporarily void the provider agreement in whole or specific sections, if the provider cannot perform to the standards agreed upon in the initial terms
- The State and The Health Plan shall not incur any liability if a pandemic is declared and emergency procurements are authorized by the Director as per A.R.S. 41-2537 of the Arizona Procurement Code.
- Once the pandemic is officially declared over and/or the provider can demonstrate the ability to perform, the State or The Health Plan, at their sole discretion, may reinstate the temporarily voided provider agreement.
- The State or The Health Plan, at any time, may request to see a copy of the written plan from the provider. The provider shall produce the written plan within seventy-two (72) hours of the request.
12.14.4 Emergency Preparedness
Under the direction of The Health Plan or the State, the provider must participate in health emergency response planning, preparation, and deployment in case of a Presidential, State, or locally-declared disaster. The preparedness action must include:
- Participation in development of a comprehensive disaster response plan, including specific measures for:
- Member management and transportation,
- Plans for access to medications for displaced Members, and
- Provision of critical incident interventions for Members exposed to a disaster.
- Collaboration with local hospitals, emergency rooms, fire, and police to provide emergency mental health supports for first responders.
- Coordination with other providers to assist in a disaster in Maricopa County or in the event of a disaster in another region of the State.
12.14.5 Heat Plan Requirements
Behavioral Health Home Provider must have a Heat Plan in place to mitigate the effects of extreme heat on members. This plan must be reviewed and updated on an annual basis. The Heat Plan must include, at a minimum:
- Address the Behavioral Health Home process to ensure that medically-necessary routine transportation is available for individuals who are at increased risk, and unable to access public transportation.
- Address a process to ensure that heat advisory messages and public health information on extreme heat protection are communicated to members.
- Address a process of identifying and outreaching members who are at risk to extreme heat complications due to their living conditions.
The Health Plan is responsible to ensure members have adequate access to a broad array of behavioral health services and programs. As such, The Health Plan requires that Behavioral Health providers give The Health Plan written notice by certified mail of intent to eliminate a behavioral health program, add a behavioral health program or discontinue being designated as a Behavioral Health Home, not less than ninety (90) days prior to the change. Contracted Behavioral Health Home providers are required to meet all The Health Plan Provider Manual requirements and can not elect to discontinue specific programs or services that are required in The Health Plan Provider Manual and remain a designated Behavioral Health Home.
The Health Plan requires contracted Behavioral Health Home providers to meet additional service delivery requirements as outlined below, in addition to all behavioral health requirements outlined in The Health Plan Provider Manual. These include recovery support, access to care, outreach and engagement, enrollment, staffing, and system partner coordination of care. Members can select a Behavioral Health Home to receive their services. Members with chronic behavioral health care conditions are encounraged to receive their coordination of care services through a contracted Behavioral Health Home. The following contracted Behavioral Health Homes are required to meet the requirements identified in this section in addition to all behavioral health requirments identified in the Health Plan Provider Manual.
The Behavioral Health Homes serving children required to meet these requirements include: Arizona Children’s Association, Casa de los Ninos, CODAC, Community Health Associates, Community Partners Integrated Health, COPE Community Services, Easter Seals Blake Foundation, El Rio Health Center, Horizon Health and Wellness, Intermountain Health Care, Jewish Family & Children’s Service , LaFrontera Center, LaFrontera EMPACT, Marana Health Care, Pathways Behavioral Health, Pinal Hispanic Council, Rural Center for Border Health, SEABHS-Southeastern Arizona Behavioral Health Services, , Southwest Behavioral & Health Services, Touchstone Behavioral Health, and Valle Del Sol Inc.
The Behavioral Health Homes serving adults required to meet these requirements include: Banner U of A Healthcare, CODAC, Community Bridges, Inc., Community Health Associates, Community Partners Integrated Health, COPE Community Services, El Rio Health Center, Horizon Health and Wellness, Intermountain Health Care, Jewish Family and Children’s Services, LaFrontera Center, LaFrontera EMPACT, Marana Health Care, Pathways Behavioral Health, Pinal Hispanic Council, Rural Center for Border Health, SEABHS-Southeastern Arizona Behavioral Health Services, Southwest Behavioral & Health Services, and Valle Del Sol Inc.
12.16.1 Screening and Serving Members with Complex Needs
Members with Complex Needs will be identified by The Health Plan utilizing the Integrated and Non-Integrated Risk Rosters. The risk rosters will be uploaded to the provider FTP sites monthly. Providers must review the uploaded documents to determine if any members have been added or removed to the rosters.
All children must be screened for High Needs at the time of the initial comprehensive assessment and annually thereafter, per the AHCCCS AMPM 320-O, a high needs assessment (using the AHCCCS identified tool when available), for children ages 6-17.
Providers must place a copy of the children’s High Needs screening tool in the Member’s Electronic Health Record. A progress note is required following each screening, describing the actions taken as a result of the screening.
Providers must develop and implement service plans for Members with High/Complex Needs that include strategies to address a crisis and deliver all appropriate services to help the Member remain at home, minimize placement disruptions, and avoid the inappropriate use of the police and the criminal justice system
220.127.116.11 Declination of Intensive Services
Providers are required to follow evidenced based practices and must ensure Members with High Needs receive appropriate services and take action to address risk management concerns when Members decline against medical advice to receive services. Permitted actions include: 1) notifying Members, guardians and families in writing of the risks associated with declining to accept more intensive treatment, 2) seek a court order for treatment when the adult Member/guardian declines more intensive treatment and the Member is a risk to themselves or others, or 3) with sufficient notice to the Member, decline to continue to provide treatment services which are ineffective in meeting the Member's needs.
18.104.22.168 Dedicated Health Care Coordinators (DHCCs)
Behavioral Health Homes providing services to children are responsible for ensuring that the ratio of DHCC’s to Children with High Needs does not exceed 1:25. A ratio of 1:15 is preferred.
Behavioral Health Homes providing services to adults are expected to employ an adequate number of Health Care Coordinators to maintain low member to staff ratios and meet the needs of Adult High Needs members.
The providers are responsible for ensuring the integrity of the role of the Dedicated Health Care Coordinator by empowering the DHCC to facilitate the delivery of behavioral health services; enhance treatment goals and treatment effectiveness; and coordinate services for Members with High Needs.
22.214.171.124 Requirements for Behavioral Health Homes in Meeting the Needs of Members with High/Complex Needs
Behavioral Health Homes are expected to:
- Provide 24/7/365 services as clinically appropriate when planned in advance.
- Maintain low Dedicated Health Care Coordinator to member ratios. The AHCCCS “Meet Me Where I Am Initiative” (MMWIA) requires Behavioral Health Homes that serve children with High Needs to ensure that the ratio of DHCC’s to Children with High Needs does not exceed 1:25. A ratio of 1:15 is preferred.
- Provide Intensive Community Based Support that improves member outcomes and reduces the number of members in Out Of Home placements, reduces Emergency Department visits, and reduces Inpatient stays by providing appropriate support in the member’s community and home.
- Maintain an adequate number of Direct Support Staff to meet the needs of adult High Needs members.
126.96.36.199 Transition to Adulthood
Children turning 18 years of age may choose to remain with their current Behavioral Health Home, transfer to another Behavioral Health Home as desired or clinically indicated, or close out of the behavioral health system entirely.
12.16.2 Behavioral Health Home Access to Care Requirements
Providers must adhere to the following access to care requirements.
Providers must perform various screening and assessment services:
- Providers must apply for AHCCCS coverage on behalf of Members through Health-e Arizona and assist Members in renewing their AHCCCS enrollment by completing applications on their behalf through Health-e Arizona and not refer persons to DES offices.
- Offer in-person screenings and assessments for Medicaid, SMI, SABG and MHBG eligibility at no cost to Members or persons requesting the screening/assessment.
- Provide intake, assessment and coordination services in the community, hospitals, nursing homes, state agency offices, detention, jail and prison facilities, specialty provider offices and Member's homes.
- Providers must screen all children age 8 to 18, and adults for substance use disorders utilizing a standardized screening tool, at minimum:
- At intake;
- Bi-annually for children and annually for adults; and
- Within 7 days of reported or suspected problematic use.
If a screening yields positive results, members must receive a more comprehensive assessment to include substance use history, current use, and trauma, in accordance with Section 12.5 – Assessments, AHCCCS Clinical Guidance Document, Comprehensive Assessment and Treatment of Adults with Substance Use Disorders and AHCCCS Clinical Guidance Document, Comprehensive Assessment and Treatment for Substance Use Disorders in Children and Adolescents.
- Ensure that all Comprehensive Assessments, Individualized Service Plans, and Assessment Updates are signed by a The Health Plan -Credentialed, Licensed Behavioral Health Professional or Behavioral Health Medical Professional within 72 hours after the member received the assessment.
- Establish written criteria and procedures for accepting and acting upon referrals, including emergency referrals. The written criteria must include the definition of a referral for health services as described by the State.
- When a Member requests to access Covered Services, there shall be no wrong door. The Health Plan and Provider are required to respond when a Member requests Covered Services and follow through to ensure the Member receives appropriate services. Provider is required to assist any Member with obtaining Covered Services for which the Member is eligible, from the Participating Health Care Providers best suited to deliver effective services to Member.
- Behavioral Health Home providers must accept all referrals for intakes and services for populations identified provider’s contract with The Health Plan, unless The Health Plan grants a written waiver or suspension of this requirement.
- Accept all referrals regardless of diagnosis, level of functioning, age, Member's status in family or level of service needs.
- Providers serving non-Title XIX/XXI must accept and respond to emergency referrals twenty-four (24) hours a day, seven (7) days a week.
- Make appropriate referrals to and schedule appointments with In-Network Specialty Providers to meet Members' treatment needs and effectively coordinate care.
- Have a process to verify all Network options have been explored and exhausted before completing a request for out-of-Network services. Provider must notify The Health Plan of all Out-of-Network requests.
- Provider understands that all community residents, including visitors are eligible to receive crisis services and provider must assist anyone experiencing a crisis in obtaining crisis services through a The Health Plan contracted crisis provider by calling the Crisis Call Center.
188.8.131.52 Outpatient Services
Providers must offer outpatient services identified in the provider’s agreement with The Health Plan, including intakes, comprehensive assessments, service planning, coordination of care and outpatient services to all populations specified in the provider’s agreement with The Health Plan.
Behavioral Health Homes are required to ensure members have transportation to medically necessary services including pharmacy. Providers may contract with a transportation vendor, provide transportation through their own fleet of vehicles, distribute bus passes or arrange transportation through the Health Plan contracted transportation vendor. Providers must complete and submit to AHCCCS an AHCCCS Group Billing Packet located at https://www.azahcccs.gov/PlansProviders/NewProviders/packet.html in order to bill for subcontracted transportation services. The subcontracted transportation provider is required to be credentialed with The Health Plan. When billing for the transportation services, the rendering provider field must include the NPI of the subcontracted transportation provider.
Providers shall maintain all records in compliance with the noted specifications for record keeping related to transportation services. It is the responsibility of the provider to maintain documentation that supports each transport provided. As outlined in AHCCCS AMPM Policy 310-BB, Transportation, non-emergency transportation services are covered to transport a member to one of the following local community-based support programs and are identified in the member’s service plan:
- Alcoholics Anonymous (AA)
- Narcotics Anonymous (NA) Cocaine Anonymous
- Crystal Meth Anonymous
- Dual Recovery Anonymous
- Heroin Anonymous
- Marijuana Anonymous
- Self-Management and Recovery Training (SMART Recovery)
- National Alliance on Mental Illness (NAMI) Family Support
- Living Well with a Disability and Working Well with a Disability Program
184.108.40.206 Answering Service
Providers must maintain an answering service and telephone prompts appropriate to direct Members to verify access to services 24/7. Include language on telephone prompts, voicemail, answering services and advertisements that identifies the provider as Member of The Health Plan’s Network of Providers and informs Members what to do in case of an emergency.
12.16.3 Behavioral Health Home Outreach, Engagement, Re-Engagement and Closure Requirements
In addition to the requirements of Section 12.4 – Outreach, Engagement, Re-Engagement, and Closure, Providers must cooperate with the State and The Health Plan outreach and marketing initiatives, and conduct outreach, engagement, re-engagement and closure as described in this Provider Manual. Providers funded to employ dedicated outreach staff must work closely with all community system partners and residents, including incarcerated community members to educate them about services and help them get enrolled in Medicaid and/ or the Health Exchange. Providers must offer outreach and engagement services to persons who are homeless, involved in the criminal justice system, experiencing co-occurring mental health disorders and at risk populations. Providers must offer regular contact with Members residing in detention centers a minimum of once every (30) days up to the time the member is released from detention. Upon request, providers must provide outreach and dissemination of information to the general public, other human service providers, county and state governments, school administrators and teachers and other interested parties regarding available services.
Providers may be notified when a member has been booked into a detention center. For those members who are active, the provider must hold an emergency Integrated Team Meeting within one (1) business day of notification of release. For those members who are inactive, the provider must outreach the individual upon notification of booking and schedule an intake to be held within seven (7) days of release.
Providers must facilitate and document in the Member's clinical record effective engagement, including obtaining and maintaining accurate support system names and contact information, up-to-date member information with contact information, following up after missed appointments, and engaging peers and support systems to facilitate effective engagement.
220.127.116.11 Marketing Limitations
Providers must comply with various outreach and marketing limitations. Any outreach or incentive item given to its Members shall not exceed $50.00. Any marketing item given away by the provider shall not exceed $10.00. The total cost of all marketing and outreach/incentive items given to each Member, at each event, may not exceed $50.00 per Member. All marketing materials shall identify the provider as a The Health Plan, AHCCCS and the State provider.
In addition, all marketing materials produced by the provider that refer to the services defined in the agreement must specify that the services are funded through the provider agreement with The Health Plan. Provider is also required to list The Health Plan and the State as the funding source on all brochures, flyers, and other promotional materials that involve services funded by The Health Plan and the State. Provider must include The Health Plan logo on these promotional documents.
12.16.4 Behavioral Health Home Enrollment, Demographic, Connectivity, Software, Web and Electronic Health Record Requirements
18.104.22.168 Enrollment and Demographics
Providers must meet all enrollment requirements as outlined by the State and The Health Plan, verifying the integrity and reliability of the data. At a minimum, providers must:
- Submit all enrollment (834) electronically. The Health Plan shall have the right to reject any claims without a current enrollment on record.
- Complete and submit the Enrollment (834) transaction for all non-Medicaid Members within two (2) calendar days of the completion of a clinical intake. Provider must submit a Closure (834) transaction within two (2) calendar days after the end of treatment at the agency, unless the Member is being transferred to another agency or otherwise remains eligible for services in The Health Plan Geographical Service Area (GSA).
22.214.171.124 Electronic Health Record (EHR) and Health Information Exchange (HIE) Requirements
Providers must meet various requirements regarding paper and electronic records. Providers must:
- Have a fully operational EHR; including, electronic signature, and remote access. In addition, allow the State and The Health Plan staff remote read-only access to the EHR for the purpose of conducting audits.
- Ensure all paper files are fully archived and the provider is no longer dependent on paper files to conduct or document treatment services.
- Ensure provider is EHR is certified to fully meet the Federal "Meaningful Use Requirements".
- Establish and maintain membership with, and bi-directional data connectivity to, the state Health Information Exchange, “The Network/AZHeC”.
Providers must meet various requirements regarding equipment and licenses. Providers must:
- Ensure each outpatient clinic location licensed by the ADHS Division of Licensing has access to video equipment to facilitate treatment and treatment team meetings for persons with health, or disability limitations and special circumstances that prevent them from traveling to an office. Provider must maintain availability of telemedicine and video equipment to meet this requirement.
- Ensure Members have access to specialty services and consultation services through telemedicine, portable telemedicine, or video equipment and not be required to travel more than thirty miles to receive specialty services (except when required by state or federal law). In addition, utilize clinical expertise through consultants when appropriate to provide treatment services in the community, prevent out-of-home placements and allow Members to remain in their communities.
- Ensure that each outpatient clinic location licensed by the ADHS Division of Licensing is equipped with at least one (1) fully functional Polycom Speaker Phone system with (2) two microphones to facilitate effective communication during treatment team meetings to allow access to system partners and family members who desire to attend treatment team meetings telephonically.
126.96.36.199 Access to Web and Website
Providers must make available to the Benefits Coordinator and Members at least one computer with internet access at each outpatient facility licensed by the ADHS Division of Licensing. The computers must be available during hours of operation to conduct eligibility screening activities through Health-e Arizona. Providers must make available easy access of information by Members, family members, providers, system partners, and the general public in compliance with the American with Disabilities Act (ADA).
In addition, providers must develop and maintain a website and include the following information on its website that is easy to find, understand and navigate:
- Identify The Health Plan as a MCO/Health Plan for your service area and provide a link to The Health Plan website.
- Toll-free customer service telephone number and a Telecommunications Device for the Deaf telephone number.
- General customer service information, including information on community resources, how to file a grievance or grievance, and interpreter services.
- Crisis phone numbers and how to access the crisis services.
- Identify site locations and services provided to Members.
188.8.131.52 Management Information System (MIS) and Performance Criteria
Providers must meet the following MIS and performance criteria:
- Use a The Health Plan approved MIS to collect, analyze, integrate, and report data.
- Utilize electronic transactions in conformance with requirements.
- Prior to implementation, notify The Health Plan of planned MIS changes, the estimated impact upon the interface process, and test with The Health Plan, if the provider plans to make any modifications that may affect any of the data interfaces. Provider shall not implement the proposed change until The Health Plan evaluates and approves such.
- Verify that changing or making upgrades to or implementing new systems that are or are related to the core MIS, claims processing, or any other business component, will be accompanied by a plan which includes a timeline, milestones, and adequate testing before implementation date, the Provider must provide the system change plan to The Health Plan for review and comment.
- Notify The Health Plan in advance of the exact implementation date of all changes and cooperate with The Health Plan if The Health Plan elects to monitor MIS changes for operability and sustainability.
184.108.40.206 Compliance with Health Information Portability and Accountability Act (HIPAA)
Providers must comply with all federal HIPAA requirements, verifying the safety of all Member information.
220.127.116.11 Notice of Changes
The Health Plan shall provide provider with at least ninety (90) days' notice before implementing a change to its MIS system unless The Health determines that the system change must be implemented sooner, and in that instance, provide provider with as much notice as possible under the circumstances.
12.16.5 Behavioral Health Home Staffing Requirements
Behavioral Health Homes are required to have organizational, management, and administrative systems capable of meeting all contract requirements with clearly defined lines of responsibility, authority, communication, and coordination within and between departments, units, or functional areas of operation. Behavioral Health Home’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with contract requirements, including the requirement to provide culturally competent services. Provider is required to have sufficient staff and utilize appropriate resources to comply with contract requirements. Provider must require all staff, whether employed or under contract, to have the training, education, experience, orientation, and credentialing, as applicable, to perform assigned job duties.
18.104.22.168 Certified Health Care Coordinators
Providers must maintain a sufficient number of Certified Health Care Coordinators who are able to coordinate services for Members. Providers must verify the Professional job responsibilities associated with the role of Certified Health Care Coordinator are clearly defined and include:
- A clear understanding of how to help facilitate an effective treatment team meeting.
- The empowerment of Members to direct their own care.
- Monitoring of treatment to verify services are identified and performed in accordance to the wishes of Members and clinical Evidenced Based Practices.
- Verify the availability of direct supports including support and rehabilitation services to optimize opportunities for recovery and increased resiliency.
- Verify appropriate coordination among providers of care and Stakeholders.
- Verify adult persons are encouraged to obtain employment, engage in meaningful activities and demonstrate altruism.
- Verify children have the resources and services to progress to be successful adults.
22.214.171.124 Behavioral Health Professionals
Providers must assign credentialed Behavioral Health Professionals to provide clinical oversight in the Member's care and monitor progress towards meeting goals in the Service Plan, coordinate and communicate with other systems where clinical knowledge of the Member's care is important (42 CFR 438 208(b) (1));and verify that all services provided to the Member, including Transportation meet medical necessity.
Providers must verify Behavioral Health Medical Professionals, Behavioral Health Professionals, Behavioral Health Technicians and Behavioral Health paraprofessionals meet all of the requirements as identified by the ADHS Division of Licensing. Verify all persons hired into these roles meet the requirements as defined by state regulation.
Providers must employ an adequate number of The Health Plan -Credentialed, Independently Licensed Behavioral Health Professionals to verify all Members are seen by a The Health Credentialed, Independently Licensed Professional within 7 and 23 days following referral.
126.96.36.199 Child and Family Team & Adult Recovery Team Facilitators
Providers must verify an adequate number of staff are trained and certified as Child and Family Team (CFT) Facilitators, and/or Adult Recovery Team (ART) Facilitators.
188.8.131.52 Administrator on Call
Providers must maintain an administrator–on-call to address any after-hours, weekend or holiday concerns or issues related to coordination of care or the health and/or safety of Members. The Administrator-on-call must respond to all requests, including requests from The Health Plan contracted Crisis Line Provider, within one (1) hour of being called.
184.108.40.206 Independently Licensed Staff
Provider must verify the availability of The Health credentialed independently licensed staff to determine medical necessity, provide adequate oversight and supervision of service delivery.
220.127.116.11 Clinical Supervisors
Providers must verify all Clinical Supervisors meet the requirements of the appropriate Arizona Licensing Board to conduct Clinical Supervision.
18.104.22.168 Medical Director
Providers must employ a Medical Director to oversee prescribing practices at the provider’s facilities, process Court Ordered Treatment (COT) documents, provide clinical consultation and serve as the collaborating physician for Nurse Practitioners in the agency. Medical Directors, or their designee, need to be available after hours for revocations of outpatient court ordered treatment under Title 36. A.R.S. § 36-540. Providers must verify the Medical Director Attends the regular Medical Director Meetings with The Health Plan.
22.214.171.124 COT/COE Coordinator
Providers must designate a staff person to serve as COT/COE Coordinator and Liaison for Title 36 and Court Ordered services.
126.96.36.199 Information Liaison of the Day/Point of Contact
Providers must designate one person to serve as the Information Liaison of the Day (point-of-contact) for system partners, foster families seeking services, and specialty providers to call to obtain information about services, referrals, updated Comprehensive Assessments, Individualized Service Plans and monthly reports. They must provide the name and contact number for the Information Liaison of the Day monthly to The Health Plan as part of the key contact list. The phone number for the Information Liaison of the Day must be live answered. All calls to the Information Liaison of the Day must be addressed and resolved within one (1) business hour of the call. Callers must be warm line transferred to the Information Liaison of the Day and callers are not to be told to call another number.
188.8.131.52 Peer Support
Behavioral Health Homes are required to educate members about the role of Peer Support / Recovery Support Specialists and are required to make Peer Support / Recovery Support Specialists available to all members receiving services and to ensure members are introduced to Peer and Family Run Organizations.
In addition, providers must demonstrate that Peer Support Specialists and Family Support Specialists meet minimum training requirements. Providers must empower Members and family members to take "personal ownership" of their Individualized Service Plans, Crisis and WRAP Plans, treatment services, recovery strategies, and advocate for themselves.
184.108.40.206 Parent/Family Support Partners
Behavioral Health Homes are required to educate members about the role of Parent/Family Support Partners and are required to make Parent/Family Support Partners available to all families of members receiving services. Adult members’ families are defined as “families of choice”, determined by the adult member.
220.127.116.11 Substance Use Treatment Staff
Providers serving adults and youth with substance use disorders must train 100% of all Assessors, and Behavioral Health Professionals in the Best Practice of ASAM through a training program approved by The Health Plan. In addition, providers providing substance use treatment services must verify that services are delivered by staff competent to assess and treat substance use disorders in individuals and families. Providers serving adults must employ or make available an adequate number of registered/wavered Buprenorphine Prescribers to meet the needs of Members with substance use disorders under the Provider’s care.
18.104.22.168 Nursing Staff
Providers must employ or make available adequate nursing staff to administer injectable psychotropic medications at all Outpatient Treatment Centers.
Providers must employ a sufficient number of BHMPs to meet member access to care standards.
Providers delivering telemedicine services must ensure adequately and appropriately trained staff are available prior to the provision of the telemedicine service to conduct any required vitals.
Providers delivering telemedicine services must adhere to confidentiality expectations of the telehealth session by ensuring no other person, other than those agreed to by the member receiving services, will observe or monitor the service either electronically or from “off camera. For more information regarding confidentiality during a telemedicine session. Please see AHCCCS AMPM Policy 320-I and AHCCCS AMPM Policy 550 for more information regarding confidentiality safeguards
The provider must however, offer the member the option of having a telepresenter present during the telehealth session. A telepresenter is defined as a designated individual who is familiar with the member‘s case and has been asked to present the member‘s case at the time of telehealth service delivery if the member‘s originating site provider is not present. The telepresenter must be familiar, but not necessarily a medical expert with the member‘s medical condition, in order to present the case accurately. The telepresenter also is required to assist the member after the telehealth session in scheduling any required follow-up appointments and/or getting prescriptions filled.
In addition, providers must verify that BHMPs and BHPs providing eighteen or more hours a week of telemedicine services on behalf of the provider must host semi-annual one-day “meet and greet” events “in person” in the communities where the telemedicine services are provided to give Members and system partners the opportunity to meet telemedicine BHMPs and BHPs in person. Exceptions to this requirement must be approved in writing by The Health Plan.
22.214.171.124 Discharge Planners/Hospital Liaison Role Definition and Responsibilities
In addition to the requirements of Section 4.12 – Discharge Planning, the Behavioral Health Home discharge planner/hospital liaison is also responsible for the following:
- Behavioral Health Home Discharge Planner/hospital liaison serves as the lead for coordination of care for members for the duration of hospitalization upon notification of admission.
- Behavioral Health Home discharge planner/hospital liaison is responsible to notify the Health Care Coordinator of member’s inpatient status.
- Behavioral Health Home discharge planner/hospital liaison is responsible to send the clinical packet of information to inpatient facility. Documents include:
- Most recent psychiatric evaluation,
- History & Physical from Primary Care Provider, if available,
- Medications list from Behavioral Health Medical Provider & PCP,
- Most recent BHMP note,
- List of current diagnoses,
- Current Individualized Service Plan & Crisis Plan,
- Allergies or past poor reactions to medications,
- Anticipated target level of functioning upon discharge from hospital services,
- Tentative Discharge Plan
- Behavioral discharge planner/hospital liaison is required to make contact with members within 48 hours of admission date/time. This can be via phone if admission occurs out of county or state, preferred method is a face to face visit.
- Health Home discharge planner/hospital liaison is required to document discharge planning efforts in the Member’s medical record.
- Behavioral Health Home discharge planner/hospital liaison is required to connect with The Health Plan Discharge Integrated Care Managers to provide an update on the initial discharge plan at 72 hours from date and time of admission, and to communicate updated discharge plans prior to discharge. The Behavioral Health Home Discharge Planner/hospital liaison is required to communicate any barriers to discharge to The Health Plan Discharge Integrated Care Managers. If the Health Home discharge planner/hospital liaison encounters barriers related to the discharge plan and resources, The Health Plan Discharge Integrated Care Managers will outreach the Utilization Management Reviewer and/or the Integrated Care Managers/Care Coordinator for assistance.
- Behavioral Health Home discharge planner/hospital liaison schedules an Adult Recovery Team Meeting (ART) /Child & Family Team (CFT) meeting to take place at the inpatient facility, for every behavioral health admission and as clinically needed for physical health admissions. Attendees required to attend for both behavioral and physical health and behavioral health ART/CFT Meetings, should include the following at a minimum:
- Representation from inpatient facility such as hospital social worker/discharge planner/Health Care Coordinator (with updates on member status, medication changes, doctor recommendations, estimated discharge date),
- Behavioral Health Home Discharge Planner/Hospital Liaison, Behavioral Health Home Health Care Coordinator, & Member, (Guardian if under 18, POA, Public Fiduciary or Title 14.)
- The Behavioral Health Home Discharge Planner/hospital liaison facilitates ART/CFT. Other attendees may include, therapist, peer support, member’s natural support, and inpatient facility unit charge nurse.
- Behavioral Health Home discharge planner/hospital liaison is required to facilitate scheduling a conversation between the Behavioral Health Home BHMP and Attending Psychiatrist, PCP and attending physician, as requested or if the team is unable to agree on a safe disposition plan. Behavioral Health Home medical director and The Health Plan medical director may take part in these discussions, as appropriate.
- Behavioral Health Home discharge planner/hospital liaison is required to create a new Individualized Service Plan and Crisis Plan that provides additional resources and supports to decrease chance of member readmission in addition to updating the annual assessment.
- Behavioral Health Home discharge planner/hospital liaison is required to work closely with Behavioral Health Home Utilization Management Point of Contact and The Health Plan Utilization Management Reviewer regarding authorizations related to step down from the hospital to another level of care. Requests, which may come from the Behavioral Health Home or the inpatient or out-of-home facility, are required to be submitted via Provider Portal or via fax according to instruction. Any questions related to receipt of authorization requests, status updates, or general questions related to authorization procedure or required documents should go to The Health Utilization Management PA #: 866-796-0542.
- Modification for type of authorization: It is the responsibility of the Behavioral Health Home discharge planner/hospital liaison to submit the request for authorization for Behavioral Health placement, and other behavioral health needs on the ISP;
- It is the responsibility of the Hospital Social Worker/Discharge planner/Health Care Coordinator to submit authorization request for physical health placement, Durable Medical Equipment, Home Health-IC Inpatient Utilization Management reviewer to follow up with The Health Plan outpatient reviewer on status of authorizations related to discharge plan, such as placement, medical equipment, etc.
- Behavioral Health Home discharge planner/hospital liaison must provide the member with the following appointments:
- For Behavioral Health Admission: behavioral health medical Provider within 7 calendar days of member’s discharge from facility.
- For Physical Health Admission: primary care provider within 7 calendar days of member’s discharge unless medically indicated to see provider sooner.
- Behavioral Health Home discharge planner/hospital liaison is required to complete a verbal and written handoff to the ongoing RC upon member discharge, including review of the discharge summary from the hospital.
- Ongoing, the Health Care Coordinator is required to outreach the member to ensure follow through with aftercare plan including but not limited to placement, behavioral health services, pharmacy issues, outpatient appointments, and medical equipment.
- Ongoing, the Health Care Coordinator is required to outreach The Health Plan Integrated Care Managers/Care Coordinators with a status update on the member’s discharge and aftercare within 14 business days from date of discharge.
126.96.36.199 Behavioral Health Home Requirements Related to the Discharge Planner/Hospital Liaison Role
- Discharge planning begins at the time of notification of admission to any inpatient facility for Physical and Behavioral Health needs.
- All Behavioral Health Home discharge planners/hospital liaisons are required to have a dedicated phone number with voicemail and email address to communicate with the inpatient facility and The Health Plan Utilization Management Reviewer and The Health Plan Integrated Health Care Coordinator.
- The Behavioral Health Home discharge planner/hospital liaison must be a Behavioral Health Technician or Behavioral Health Professional; complete the Discharge Planning Curriculum in Relias Learning Management System and pass post‐test with at least 80% accuracy. If the position is filled by a Behavioral Health Technician, all clinical forms related to the discharge planning process must be reviewed and signed by a Behavioral Health Professional at the Behavioral Health Home. This includes but is not limited to: Individualized Service Plan, Crisis Plan and Updated Annual Assessment.
12.16.6 Behavioral Health Home Requirements Related to Member and Family Involvement
Providers must verify that Members, their family members, and peers provide input and assist with decision making.
188.8.131.52 Member and Family Involvement
Providers must develop a process for Members to have regular and ongoing input to assist in decision making, program development, and enhancement of customer service at each provider site where Case Management services are delivered.
Providers must also collaborate with families, children and Members as partners, including Family-Run Organizations to facilitate child and family involvement in all aspects of the assessment process, service planning, service delivery, and the evaluation of services and the system.
Providers must verify that the following member-involvement activities are performed as part of the service delivery process:
- Ongoing engagement of the Member, family and others who are significant in meeting the needs of the Member, including active participation in decision-making process.
- Develop and implement service plans that address likely events in a Member's life including transitions to different stages of life, new relationships, new schools, new placements, and transitions to other service delivery systems.
- For Members referred for or identified as needing ongoing psychotropic medications for a health condition, verify the review of the initial assessment and treatment recommendations by a licensed medical practitioner with prescribing privileges.
- Members on psychotropic medications receive an updated annual psychiatric evaluation before the twelve (12) month anniversary of the date of last evaluation;
- Continuous evaluation of the effectiveness of treatment through the ongoing assessment of the Member and input from the Member and other relevant persons resulting in modification to the Treatment Plan, if necessary.
- Child and Family Team/Adult Recovery Team Meetings are scheduled within three (3) business days for all Members placed in Brief Intervention Programs or the Assessment Intervention Center.
- Transfers out-of-area, or to an ALTCS Contractor, as applicable.
- Development and implementation of transition discharge, and aftercare plans prior to discontinuation of services.
- Documentation of the above is maintained in the Member's health record by the point of contact.
- Assist Members locate and obtain permanent housing.
- Providers must accept all transfer following a 24 hour mobile crisis intervention and engage member into services within seven (7) days.
Additional provider requirements include:
- Demonstrate documentary evidence to show participation of at least one peer or family member in the interview process when hiring all direct service staff positions. Maintain interview sign-in sheets and produce the sign-in sheets to document compliance with this expectation.
- Verify that every TXIS (T19) adult has a Peer Support Specialist available to be involved with the Member’s Adult Recovery Team.
- Verify that Members, families and youth have a voice in their individual treatment decisions and a voice in the operations of the delivery system.
- Obtain and document in the Member's record, Member and family input in treatment decisions.
- Providers providing substance use treatment must involve peer support staff in all aspects of the treatment process; including outreach, engagement, assessing readiness for treatment, maintaining sobriety and re-engagement.
- Assess the Member's perspective on treatment progress, in order to verify that the Member and family's perspectives are honored and they are effectively engaged in treatment planning and in the process of care.
184.108.40.206 Councils and Meetings
Behavioral Health Homes are required to:
- Establish Member and Family Advisory Councils with representatives from each community served by the Behavioral Health Home, to provide direction, feedback and meaningful influence to their senior management team.
- Demonstrate documentary evidence (agenda, sign in sheets, minutes) to show that Member and Family Advisory Councils are being held at least monthly.
- Maintain a written Plan that includes a method to verify Members and families attend regular meetings with clinical leadership and are authorized to make recommendations.
- Recruit leaders from provider’s Member and Family Advisory Councils to regularly attend The Health Plan monthly regional Member and Family Advisory Councils
- Facilitate regular attendance of these provider Member and Family Advisory Council leaders to The Health Plan monthly regional Member and Family Advisory Councils.
Providers must collaborate with Peer-Run and Family-Run Organizations, involving them in program development activities, peer support and family support training, staff trainings, committee meetings and strategic planning.
- Behavioral Health Homes that serve youth are required to have a Youth Advisory Council (YAC). Members no younger than 14 and no older than 17 are eligible to participate in the Behavioral Health Home’s Youth Advisory Council. All youth that meet this criteria at the Behavioral Health Home are encouraged to participate.
- Behavioral Health Home Youth Advisory Council must meet at a minimum of one time per month, but may meet as often as determined by the Youth Advisory Council.
- Each Behavioral Health Home must have a sufficient amount of facilitators to assure safety and growth of the Youth Advisory Council.
Providers are expected to assist members to attend provider and The Health Plan committee meetings, provider Member and Family Advisory Councils, and The Health Plan Member and Family Advisory Councils and Boards.
12.16.7 Behavioral Health Home Requirements Related to System Partner Coordination of Care
Providers are encouraged to seek out and facilitate opportunities to co-locate with state agencies (The Department of Child Safety, Juvenile Probation, and Adult Probation), first responder settings (police, fire, emergency service) or other community settings that facilitate coordination of care between and among systems of care for Members receiving services through multiple systems.
220.127.116.11 Contract with Arizona Department of Economic Security (ADES)/Rehabilitation Services Agency (RSA)
Behavioral Health Homes must have systems in place to ensure effective collaboration with system partners in accordance with Provider Manual Section 13.4, Coordination of Care with Other Governmental Agencies, by communicating appropriate clinical information, to individuals or entities that are involved in the Member's care including primary care providers, schools, child welfare, juvenile or adult probations, ADES/Division of Developmental Disabilities (DDD), Arizona Department of Corrections (ADOC), Arizona Department of Juvenile Corrections (ADJC), ADES/RSA, ADES/Department of Child Safety (DCS) and other service providers.
12.16.8 Behavioral Health Home Requirements Related to Delivery of Care
18.104.22.168 Medically Necessary Covered Services
Providers must provide all Members with medically necessary covered services that are:
- In accordance with the this Provider Manual;
- In accordance with the State System Principles in this Provider Manual;
- Identified in collaboration with the Member and other persons identified by the Member that (a) determine strengths, needs and goals of the Member and (b) identify the need for further evaluations necessary for Service Plan development;
- Identified with clinical involvement by a credentialed and trained clinician who is either a Behavioral Health Professional or a Behavioral Health Technician under the supervision of a BHP (42 CFR 438 208 (2) and (3)); and
- Strengths-based and include an emphasis on goals to increase Members quality of life and involvement in meaningful community activities, including goals related to living, learning, working, and social connectedness. Goals must reflect the Member's hopes, dreams, and recovery vision.
22.214.171.124 Service Plans
Providers must verify Service Plans meet State, AHCCCS and The Health Plan requirements as outlined in Provider Manual Section 12.5, Assessment and Service Planning.
Providers must provide medically-necessary transportation services to Members receiving services as appropriate to facilitate access to care, including evenings and weekends as necessary.
Providers must assess all Members for the need for specialty services and ensure the provision and monitoring of the quality and reliability of specialty services. Providers must also ensure that Members are assessed for co-occurring mental health conditions and physical disability/disease and these co-occurring issues are addressed.
126.96.36.199 Psychiatric Care for Persons with Developmental Disabilities
Providers must verify that all children and adults with Developmental Disabilities who are on psychotropic medications or need to be screened for the need for psychotropic medications receive treatment services from a psychiatrist trained specifically to work with children or adults (appropriate to the Member’s age) and with persons with Developmental Disabilities.
188.8.131.52 Alternatives to Out-of-Home Care
Providers must promote community-based alternatives to out-of-home care. In situations where a more restrictive level of care is temporarily necessary, providers must work with the Member to transition back into community-based care settings as rapidly as is clinically feasible and partner with community provider agencies to develop and offer services that are alternatives to more restrictive institutionally based care.
Providers must deliver services to the extent possible, in the Member's home and community in order to minimize out-of-home placements and facilitate a rapid return to the home and community when a Member is in an out-of-home placement. Providers must notify The Health Plan Utilization Management (UM) department within 1 business days of placing a The Health Plan Member into an out-of-home placement.
12.16.9 Behavioral Health Home Requirements Related to Medical Integration
Providers must provide the following services related to medical integration:
- Encourage all adult Members to receive a full physical examination with labs at least once per year, facilitate, and coordinate access to PCP's to reach this goal and monitor Member compliance with this expectation.
- Develop and maintain a list of Members with chronic conditions including obesity, cardiac conditions, pulmonary conditions, and diabetes.
- Identify reasonable target dates for achieving medical integration goals and maintain acceptable progress toward reaching those goals.
- Collect and maintain vital signs for all adults including blood pressure, pulse and BMI.
- Collect and monitor lab results specific to any chronic condition including HbA1c (Hemoglobin A1c), Cholesterol, Low-Density Lipoprotein (LDL), High-Density Lipoprotein (HDL), and Triglyceride.
- Incorporate the eight dimensions of wellness into each Title XIX/XXI adult Member's Comprehensive Assessment and Individualized Service Plan.
- Collaborate with The Health Plan to reduce the use of emergency rooms for non-life threatening behavioral or medical reasons.
- Collect and submit outcome data as outlined by The Health Plan.
- Become a primary care provider or work with community health clinics to coordinate behavioral health and physical health services and provide integrated behavioral health and physical health care to Members.
- Maintain wellness programs and wellness equipment to serve Members in each community in which the Provider has an outpatient clinic licensed by the ADHS Division of Licensing.
- Ensure Health Care Coordinators are skilled in promoting wellness and coordinating health and wellness Treatment Plans, and are able to accompany Members to PCP appointments, arrange for other health care as needed and monitor health outcomes.
12.16.10 Behavioral Health Home Training and Information Dissemination Requirements
Providers must utilize The Health Plan approved web-based "e-learning" training program to verify compliance with The Health Plan training requirements and the training requirements outlined in this Provider Manual. New employees have ninety (90) days from the date of hire to complete the assigned competencies to their user profiles. Existing employees have ninety (90) days from the date that new training curriculums have been assigned to their profiles to complete the training modules. All provider required trainings must be registered through The Health Plan web-based e-learning training software program.
Providers must demonstrate evidence of employee orientation and training, which may include the number of Members, Member list, training calendars and sign-in sheets. Providers must also demonstrate evidence of all training to personnel, service providers and Members which may include the number of Members, Member list, training calendars and sign-in sheets. Providers must run quarterly compliance reports to monitor staff compliance with training competencies and meet a compliance standard of ninety percent (90%).
184.108.40.206 Annual Training Plan
Providers must develop, and maintain an annual training plan that incorporates all The Health Plan and State training requirements including involvement of Members and family members in the development and delivery of trainings. Providers must maintain a Train-the-Trainer program to verify adequate capacity to provide training, orient new staff and verify all staff Members have the skills to perform the requirements outlined in the Agreement.
220.127.116.11 Practice Protocols
Providers must train staff and implement the identified service expectations on the Clinical and Recovery Practice Protocols as appropriate and relevant to services provided. All staff must receive training on all Practice Protocols within six (6) months of hire date. Providers must review the appropriate Practice Protocols annually. Additionally, providers must verify existing staff review new Practice Protocols within six (6) months of a new Practice Protocol being published. Providers must track initial training and annual review of the Practice Protocols by using the "e-learning" training program.
18.104.22.168 Verify Attendance and Completion
Providers must verify attendance at all required trainings and trainings for which staff have enrolled. Providers must also verify all staff complete an annual Fraud & Abuse Training and maintain documentation verifying completion of the training.
Providers must maintain at least one current American Society of Addiction Medicine (ASAM) manual at each clinic location.
12.16.11 Behavioral Health Home Requirements Related to Hospital Admissions
Providers must comply with all UM and Out-of-Home Provider requirements, per this Provider Manual.
22.214.171.124 Information Upon Admission
Providers must provide the following clinical information to the Licensed Hospital, or BH Inpatient Facility and unit staff for all Members admitted into the facility on the day of notification of the admission:
- Most recent psychiatric evaluation;
- History and Physical from the Primary Care Provider (PCP), if available;
- Current psychotropic medications to include dosages and frequencies from the Behavioral Health Medical Provider and current physical health medications from the PCP;
- Most recent BHMP note;
- List of current diagnoses;
- Current Individualized Service Plan (ISP) and Crisis Plan;
- Allergies or past poor reactions to medications;
- Anticipated target level of functioning upon discharge from Hospital services; and
- Initial, tentative Discharge Plan.
126.96.36.199 Performance Requirements
Providers must meet the following performance requirements:
- Demonstrate that 50% of Members that discharge from a Hospital facility keep a follow-up appointment within seven (7) days of that discharge;
- Provide a Member a minimum of two (2) appointments within eight (8) to thirty (30) days of discharge from a Hospital Facility;
- Demonstrate that 70% of Members that discharge from a Hospital Facility keep follow-up appointments within eight (8) to thirty (30) days of that discharge; and
- Demonstrate that readmissions within thirty (30) days do not exceed 12.5% of all Hospital admissions for provider members.
12.16.12 Behavioral Health Home Requirements Related to Facilities (Licensed Hospital Facility, Behavioral Health Inpatient Facility, Behavioral Health Residential Facility, Behavioral Health Supportive Homes, and TFC Admissions
Providers must submit the Out Of Home (OOH) request packet to The Health Plan within two work days following a treatment team request for out-of-home placements, and receive prior authorization for Behavioral Health Inpatient Facilities (formerly RTC), Licensed Hospital Facilities (formerly Level I Inpatient), Behavioral Health Inpatient Facility (formerly Level I Sub-Acute Facilities), Behavioral Health Residential, Behavioral Health Supportive Home and Therapuetic Foster Care (TFC) services before admitting a Member, unless exemption in writing to this requirement is provided by The Health Plan. See Provider Manual Form 10.1.6, Concurrent Review which can be obtained by calling the Provider Services Call Center at 866-796-0542.
Providers must verify all Child and Family Team (CFT) meetings and Adult Recovery Team (ART) meetings are coordinating regularly with the facility. In addition, providers must verify that all CFT/ART meetings involving persons admitted into out-of-home care include, at a minimum: Member and legal guardian, collateral parties, such as Juvenile Probation Officer (JPO), Division of Developmental Disabilities (DDD), or out-of-home facility staff, and provider agency staff who have clinical knowledge and a relationship with the Member. The Member's family/natural supports must be included in out-of-home treatment services once the Member is admitted.
In addition, providers must verify that an agency representative with clinical knowledge and a relationship with the Member attend all scheduled juvenile/adult court hearings in which participation of provider staff would be beneficial to the Courts.
188.8.131.52 Discharge Plans/Outpatient Follow Up
Providers must identify and develop discharge aftercare plans prior to admission to an out-of-home placement and must provide outpatient clinical services within seven (7) days of a Member's discharge from a facility.
184.108.40.206 Performance Requirements
Providers must meet the following performance requirements:
- Demonstrate that at least 50% of Members that discharge from a facility keep a follow-up appointment within seven (7) days of that discharge;
- Provide a Member a minimum of two (2) appointments within eight (8) to thirty (30) days of discharge from a facility;
- Demonstrate that at least 70% of Members that discharge from a facility keep follow-up appointments within thirty (30) days of that discharge.
12.16.13 Integrated Health Care Service Delivery for Behavioral Health Homes
Providers must incorporate several elements into its Integrated Health Care service delivery system approach. This includes effective use of a comprehensive Care Management Program. There must be a Treatment Team with an identified single point of contact. The team must include a Psychiatrist or equivalent Behavioral Health Medical Professional and an assigned Primary Care Provider. Care must be whole person oriented and encompass Member and family voice and choice, plus use of peer and family delivered support services. There must be an emphasis on quality and safety, accessible care, coordination of care, health education and health promotion services, referrals to appropriate community and social support services, use of health information technology to link services, and improved whole health outcomes of Members.
220.127.116.11 Health Education and Health Promotion
Providers must provide assistance and education for appropriate use of health care services; health risk-reduction and health lifestyle choices including tobacco cessation and screening for tobacco use with the Ask, Advise, and Refer model and refer to the Arizona Smokers Helpline utilizing the proactive referral process; to Adults with SMI to access The Health Plan Crisis Line Provider; for self-care and management of health conditions including wellness coaching; EPSDT services for Members including identifying providers that are trained and use AHCCCS approved developmental screening tools; about maternity care programs and services for pregnant members; and self-help programs or other community resources that are designed to improve health and wellness.
12.16.14 Additional Behavioral Health Home Referral Requirements
18.104.22.168 Written Procedures for Referrals to Physical Health Specialists
Providers must establish and implement written procedures for referrals to specialists or other services, to include, at a minimum, the following:
- Referrals to Specialty Physician Services must be from a PCP, except that members have direct access to in-network OB/GYN providers, including Physicians, Physician Assistants and Nurse Practitioners within the scope of their practice, without a referral for preventive and routine services (42 CFR 438.206(b)(2)).
- Adults with SMI that need a specialized course of treatment or regular care monitoring have a mechanism for direct access to a Specialist (for example through a standing referral or an approved number of visits) as appropriate for the Member's condition and identified needs. Any waiver of this requirement by The Health Plan is required be approved in advance by The Health Plan.
- A process for the Member's PCP to receive all Specialist and Consulting reports and a process for the PCP to follow-up on all referrals. A process to refer any Member who requests information or is about to lose AHCCCS eligibility or other benefits to options for low-cost or no-cost health care services.
22.214.171.124 Notification of Change
Provider shall notify The Health Plan before making any material change in the size, scope, or configuration of Provider’s services. Provider is required to notify The Health Plan in writing within one (1) day of knowledge of or anticipation of the following: (i) any unexpected material change or deficiency; (ii) any material change to Provider’s license, certification or registration; (iii) any condition which terminates, suspends or limits Provider from effectively participating in the network, including the necessity for transition of Members to a different provider; (iv) any situation which develops involving Provider when notice of that situation must be given to any regulatory body with authority over Provider; or (v) when a change in Provider’s license to operate is affected, or may reasonably be affected, as a result of any investigation conducted by, or complaint filed with, the official body with regulatory authority over Provider.
Providers of behavioral health services shall submit notification to The Health Plan 90 days prior to the effective date of change via the Notification of Change deliverable (RF-1016) for any material change to (i) the Provider’s license, certification or registration; (ii) a change in programming or population served; (iii) a site move, closure, or opening of a new site; or (iv) the addition or closure of a program. See Section 16 – Deliverable Requirements.
All providers must update credentialing or other personnel information filed with The Health Plan within 15 days of new hires or terminations by the provider agency. Providers are responsible for the maintaining the accuracy of their staff and facility information, so that the provider listings made available to members by The Health Plan is current and relevant.
Laboratory services must be provided by a Participating laboratory provider. Services provided by a non-participating provider or facility must be authorized by The Health Plan prior to the services being provided or the member is responsible for payment. Medically necessary diagnostic testing and screening are covered services.
Participating providers may offer laboratory work in their offices; however, some services are considered bundled charges and are not paid in addition to an office visit fee.
12.17.1 Clinical Laboratory Improvement Amendments (CLIA) Certificate
Providers must have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver or a certificate of registration along with a CLIA Identification number. In addition, providers must meet all the requirements of 42 CFR § 493, Subpart A. Providers must provide verification of CLIA Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in termination of the Agreement and denial of laboratory claims.
Pass-through billing or other similar activities with the intent to avoid the requirements listed above is prohibited. Laboratories with certificates of waiver are limited to providing only the types of tests permitted under the terms of their waiver. Laboratories with certificates of registration are allowed to perform a full range of laboratory tests. Providers must manage and oversee the administration of all laboratory services in accordance with all state and federal laws.
Medical tests ordered for diagnosis, screening or monitoring of a condition will be paid by The Health Plan as defined and limited in the AHCCCS Covered Behavioral Health Services Guide and in accordance with the fee schedule in provider’s agreement with The Health Plan.
12.17.3 Service Standards/Provider Qualifications
Laboratory and medical imaging services may be prescribed by a licensed physician, nurse practitioner, or physician assistant within the scope of their practice. With the exception of specimen collections in a medical practitioner's office, laboratory services must be provided in CLIA approved hospitals, medical laboratories and other health care facilities that meet state licensure requirements as specified in A.R.S. Title 36, Chapter 4, Federal Clinical Laboratory Improvement Amendments in AAC R9-14-101 (PDF) and the Federal Code of Regulations 42 CFR 493, Subpart A.
12.17.4 Billing/Coding Specific Information
Current Procedural Terminology (CPT) codes are restricted to independent practitioners with specialized training and licenses as outlined in the AHCCCS B-2 Allowable Procedure Code Matrix.
12.18.1 Specialty Providers
126.96.36.199 Staffing Requirements
Specialty Agencies are required to have organizational, management, and administrative systems capable of meeting all contract requirements with clearly defined lines of responsibility, authority, communication, and coordination within and between departments, units, or functional areas of operation. Specialty Agency’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with the requirements of this section, including the requirement to provide culturally competent services. The provider is required to have sufficient staff and utilize appropriate resources to comply with this Provider Manual. Providers must require all staff, whether employed or under contract, to have the training, education, experience, orientation, and credentialing, as applicable, to perform assigned job duties.
Providers must accept all referrals for specialty services that are consistent with its program admission criteria, licensure status, and level of care.
Specialty Providers are responsible for ensuring their agency’s compliance with medical records standards mandated by licensure and/or certification authorities at all times. Crisis providers must obtain appropriate documentation to effectively provide and bill for Crisis Services.
188.8.131.52 Refusal/Termination of Services
Specialty providers are not allowed to refuse to serve a referred person except for good cause related to inability of the provider to meet the person's needs safely and professionally, or due to inability to serve the member due to capacity restrictions. Providers may not refuse or terminate services to a The Health Plan enrolled Member or discharge a The Health Plan enrolled Member without first coordinating and arranging interim, follow-up or alternative services.
184.108.40.206 After-Hours Services
Specialty providers must provide after-hours clinical on-call services to address Member concerns and facilitate treatment services as needed. Providers must maintain an administrator–on-call to address any after-hours, weekend or holiday concerns or issues related to coordination of care or the health and/or safety of Members.
220.127.116.11 Individualized Service Plan
Specialty providers must ensure services identified on the Individualized Service Plan are provided in the timeframe, frequency, and duration as identified on the Service Plan.
18.104.22.168 Child and Family Team & Integrated Treatment Team Participation
Specialty providers must participate in person or telephonically in Child and Family Team or Integrated Treatment Team meetings pertaining to Members receiving services from the provider as clinically appropriate.
22.214.171.124 Treatment Updates
Specialty providers must provide the PCP and Behavioral Health Home (if the member has a Behavioral Health Home) with regular treatment updates related to services rendered to Members as clinically appropriate.
126.96.36.199 Diagnosis on Claims
Specialty providers must ensure claims submitted for services contain a diagnosis identified on either the Behavioral Health Homes Comprehensive Assessment or the Specialty Agency Assessment at the time of the date of service. Failure to meet this requirement can result in recoupment of payment. Crisis providers must maintain appropriate documentation to effectively bill for Crisis Services.
188.8.131.52 Community-Based Alternatives
Specialty providers must promote community-based alternatives instead of treatments that remove the Members from their family and community. In situations where a more restrictive level of care is temporarily necessary, providers must work with the Member to transition back into community-based care settings as rapidly as is clinically feasible and will partner with community provider agencies to develop and offer services that are alternatives to more restrictive institutionally based care.
184.108.40.206 Continuity of Care
Specialty providers must ensure coordination and continuity within and between service providers and natural supports to reduce premature discharge/disenrollment and support continuity of care over time.
220.127.116.11 Individualized Services and Member Involvement
Specialty providers must ensure services are individualized to meet the needs of Members and families. In addition, providers must assess the Member's perspective on treatment progress, in order to verify that the Member's perspectives are honored and they are effectively engaged in treatment planning and in the process of care. Providers must obtain and document ongoing engagement of the Member, family and others who are significant in meeting the needs of the Member, including active participation in treatment decisions which may result in modifications to the Member’s service plan.
18.104.22.168 HIV Education and Screening
Specialty providers must provide or make available HIV education and screening services to all persons receiving Substance Use Disorder (SUD) treatment services. Providers must work with The Health Plan’s contracted providers of HIV education and screening services to verify all persons have access to the services.
22.214.171.124 SUD Treatment Services
Specialty Providers offering SUD treatment services must ensure adherence to the Health Plan’s Provider Manual Section 14.13, Substance Use Disorder Treatment Requirements.
126.96.36.199 Quality Improvement Activities
Providers must participate in clinical quality improvement activities that are designed to improve outcomes for Arizona Members.
188.8.131.52 Notification of Change
Providers shall notify the Health Plan before making any material change in the size, scope, or configuration of Provider’s services. The Provider is required to notify The Health Plan in writing within one (1) day of knowledge of or anticipation of the following: (i) any unexpected material change or deficiency; (ii) any material change to Provider’s license, certification or registration; (iii) any condition which terminates, suspends or limits the Provider from effectively participating in the network, including the necessity for transition of Members to a different provider; (iv) any situation which develops involving the Provider when notice of that situation must be given to any regulatory body with authority over Provider; or (v) when a change in Provider’s license to operate is affected, or may reasonably be affected, as a result of any investigation conducted by, or complaint filed with, the official body with regulatory authority over the Provider.
184.108.40.206 Electronic Health Record/Electronic Medical Record
Providers are encouraged to have in place a fully operational Electronic Health Record (EHR); including, electronic signature, and remote access, as required to meet Federal Medicaid and Medicare requirements. In addition, providers must allow AHCCCS and The Health Plan staff access to the EHR for the purpose of conducting audits. Providers are required to establish and maintain membership with, and bi-directional data connectivity to, the state Health Information Exchange, “The Network/AZHeC”.
220.127.116.11 Peer Support Training
Providers must verify that all staff and family of Members who provide Peer Support or Family Support have the required training to support them in successfully fulfilling the requirements of their position.
12.18.2 Behavioral Health Inpatient Facilities and Licensed Hospitals
Providers must comply with The Health Plan’s quality improvement programs and the utilization control and review procedures specified in 42 CFR, Parts 441 and 456, as implemented by AHCCCS and the State. Providers must participate in periodic Quality Management audits and respond to Corrective Action Letters (CALs) related to trends in average length of stay and Member satisfaction, polypharmacy, timeliness of staffings, discharge planning and quality care. Providers must not arbitrarily or prematurely reject or eject a Member from services without prior authorization The Health Plan from the Health Plan.
Providers must comply with all Utilization Management and facility requirements as outlined in this Provider Manual. This includes the following:
- Timeliness for submission of the Certification of Need (CON) and Re-Certification of Need (RON).
- Required contact with The Health Plan UM Department to discuss clinical rationale for emergent admissions.
- Appropriate documentation of the need for emergent services, including admitting psychiatric evaluation and other clinical data.
- Documentation required within seventy-two (72) hours of the admission date.
18.104.22.168 Inpatient Care Assessments
Providers delivering inpatient care (AHCCCS provider types 2, 71, B1, B2, B3, B5 and B6) must provide a comprehensive assessment and treatment plan involving close daily (including holidays and weekends) psychiatric and/or medical supervision based upon provider type and reason for admission. Failure to provide a daily psychiatric and/or medical claim or encounter verifying daily contact with the physician or nurse practitioner will result in a denial of payment.
22.214.171.124 Lab Work
All lab work for Members must be conducted within industry standards for completeness and timeliness. For example, therapeutic blood levels must be reported within thirty-six to forty-eight (36-48) hours.
126.96.36.199 Discharge Planning
In addition to the requirements of Section 4.12 – Discharge Planning, providers must demonstrate that discharge planning is started at the time of admission for emergent admissions. Provider must submit the discharge plan to The Health within forty-eight (48) hours of discharge from the facility.
188.8.131.52 Medical Care Evaluation Study Methodology and Study Results
Providers must submit the Medical Care Evaluation Study Methodology and Study Results in accordance with this Provider Manual, State Policy and Procedures, AHCCCS Quality Management/Utilization management Plan as requested by The Health Plan.
12.18.3 Licensed Hospitals – Specific Requirements
Providers must meet the requirements of 42 CFR 440.10 and Part 482 and be licensed pursuant to A.R.S. 36, Chapter 4, Articles 1 and 2; or,
- For adults age twenty-one (21) or over, certified as a provider under Title XVIII of the Social Security Act; or,
- For adults age twenty-one (21) or over, currently determined by ADHS Assurance and Licensure to meet such requirements.
Providers must be licensed as a Hospital by the ADHS Division of Licensing if providing emergency inpatient services beyond seventy-two (72) hours. If providers maintain a freestanding psychiatric facility, providers must meet the specific requirements of the ADHS Division of Licensing (i.e., provision of psychiatric acute care). If seclusion and restraint is provided, the facility must meet the requirements set forth by the ADHS Division of Licensing.
Providers must abide by the billing limitations as outlined in the AHCCCS Covered Behavioral Health Services Guide; including the following limitations:
- Medical supplies provided to a person while in a hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
- Laboratory, Radiology and Medical Imaging provided by the hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
- Medication provided/dispensed by the hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
- The hospital/psychiatric hospital cannot bill for therapeutic leave/bed hold
- No more than 30% of an individual’ gross monthly household income be sued for the purposes of room and board. This limitation applies only to beneficiaries enrolled with the RBHA, determined to have a serious Mental Illness and residing in a Behavioral Health Residential Facility.
Case management, medical services, family support and peer support services may be billed on the same day as H0018 as long as they are billed through an Outpatient Clinic (77) and not excluded on the AHCCCS B-5 matrix (billing limitations). Providers must accept the Medicaid payment as “payment in full” for all Medicaid enrolled Members receiving residential services and cannot bill the Member for any ancillary costs.
184.108.40.206 Medical Clearance
Providers must maintain capacity to provide basic medical clearance, including vitals, medical history and review of symptoms. Providers must not require Members to obtain a medical clearance prior to accepting the Member unless there is an obvious identifiable present or past medical concerns warranting formal medical evaluation or medical tests.
12.18.4 Behavioral Health Hospital Facilities – Specific Requirements
Providers must provide continuous treatment to a person who is experiencing acute and severe behavioral health and/or substance use symptoms. Crisis services may include: emergency reception and assessment; crisis intervention and stabilization; individual, group and family counseling; detoxification and referral.
220.127.116.11 Accreditation and Licensing
Providers must ensure all Behavioral Health inpatient facilities are accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"), Commission on Accreditation of Rehabilitation (CARF), or a similar agency and licensed by the ADHS Division of Licensing as a Behavioral Health Inpatient Facility. Providers must meet the requirements set forth by the ADHS Division of Licensing in accordance with 42 CFR 441 and 483 for seclusion and restraint, if the facility has been authorized by ADHS Division of Licensing to provide seclusion and restraint. Crisis intervention services may be provided in a setting licensed as a Behavioral Health Inpatient Facility, but which does not require the Member to be admitted to the facility.
18.104.22.168 Laboratory Services
Providers must complete routine lab services and not refer to emergency rooms to complete routine labs. Laboratory and medical imaging services may be prescribed by a licensed physician, nurse practitioner, or physician assistant within the scope of their practice. With the exception of specimen collections in a medical practitioner's office, provider must verify laboratory services are provided in CLIA approved hospitals, medical laboratories and other health care facilities that meet state licensure requirements as specified in A.R.S. Title 36, Chapter 4, Clinical Laboratory Improvement Amendments in AAC R9-14-101 (PDF) and the federal code of regulations 42 CFR 493, Subpart A.
22.214.171.124 Medical Clearance Exams
Providers must maintain capacity to provide basic medical clearance, including vitals, medical history and review of symptoms. Providers must not require Members to obtain a medical clearance prior to accepting the Member unless there are obvious identifiable present or past medical concerns warranting formal medical evaluation or medical tests. Providers must conduct uncomplicated medical clearance examinations and refer to emergency rooms for medical clearance only when medical complications warrant such a referral.
126.96.36.199 Weekend and Holiday Discharges
Providers must facilitate weekend and holiday discharges from Behavioral Health Inpatient Facilities, and coordinating discharges through The Health Plan Crisis Line provider and the Member's affiliated Behavioral Health Home.
12.18.5 Behavioral Health Inpatient Facilities – Specific Requirements
Providers must provide an integrated residential inpatient program of therapies, activities, and experiences provided to Members who are under twenty-one (21) years of age and have severe or acute behavioral health symptoms.
188.8.131.52 Notification of Placement
Providers must notify The Health Plan UM department within 2 business days of accepting placement of a The Health Plan Member into provider’s facility.
184.108.40.206 Accreditation and Licensing
Provider Behavioral Health inpatient facilities must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or by the Commission on Accreditation of Rehabilitation (CARF) and licensed by the ADHS Division of Licensing as a Behavioral Health Inpatient Facility meeting the specific requirements of the ADHS Division of Licensing. Behavioral Health Inpatient Facilities must meet the requirements set forth by the ADHS Division of Licensing, and in accordance with 42 CFR 441 and 483 for seclusion and restraint, if the facility has been authorized by the ADHS Division of Licensing to provide seclusion and restraint.
220.127.116.11 Bed Holds
Providers must reserve a Member's bed (bed hold) in the Behavioral Health Inpatient Facility while the Member is on an authorized/planned overnight leave. Payment for bed holds is limited to:
- Therapeutic leave to enhance psychosocial interaction or as a trial basis for discharge planning, or
- Admittance to a hospital for a short stay.
Payment for bed hold leave days is limited to up to twenty-one (21) days per year (July 1st through June 30th) per Member. In addition, Providers must manage bed hold days so as to verify billed bed hold days do not exceed twenty-one (21) days per year.
18.104.22.168 Coordination with Health Care Coordinators
Providers must create opportunities for Behavioral Health Home Health Care Coordinators to provide face-to-face contact at least once a month with all Members placed in out-of-home care.
22.214.171.124 Involvement of Family and Other Parties
Providers make reasonable efforts to verify that all Child and Family Team meetings involving children placed in Behavioral Health Licensed Facilities include, at a minimum: Member and legal guardian, collateral parties, such as Juvenile Probation Officer, Division of Developmental Disabilities, or out-of-home facility staff, and provider agency staff who has clinical knowledge and a relationship with the child. Providers must make reasonable efforts to verify that at least one facility staff Member who has clinical knowledge and a relationship with the Member attends all scheduled court hearings. Providers must make reasonable efforts to verify that the child's family/natural supports are included in out-of-home treatment services while the child is in placement.
126.96.36.199 Discharge Plans
Providers must assist in the development of discharge aftercare plans prior to accepting a referral. Providers must make reasonable efforts to provide continuity of care services for children who are placed in detention and assist with discharge and transitional planning to an alternative setting if they are not able to treat the Member upon discharge from the detention facility.
12.18.6 Residential Facilities – Specific Requirements
Behavioral Health Residential Facility (BHRF) providers must provide an integrated residential program of therapies, activities, and experiences to Members in compliance with all relevant provisions in A.R.S § 36-1201.
Providers must collaborate with community system partners, State agency partners, federal agencies and other entities to identify, educate, and inform on Brief Intervention Programs, Behavioral Health Residential Facility, and Assessment Intervention Center programs, in accordance with the frequency and deadlines as established by the contractor.
188.8.131.52 Behavioral Health Residential Facility Services
Behavioral Health Residential Facilities are contracted as an all-inclusive daily rate that includes all program and treatment services (including standard assessments, counseling, peer support and transportation) provided by the BHRF provider. Specialty assessments, counseling, peer and family support, non-program transportation may be provided and billed by third party providers as clinically appropriate but not billed by the BHRF provider. Providers must assist Members in preparing for employment as appropriate and in accordance with AHCCCS protocols. In addition, providers must verify educational resources are available and accessible based upon the individual needs of the Member. Provider must provide tutoring at the facility Monday through Friday, as appropriate, to meet the Members' educational needs. Providers must verify that treatment is provided to all Members while in the facility including daily life skills training, behavioral management training, emotional regulation training, vocational/academic preparation and support, and social skills training. All members must receive regular medical (PCP) examinations and treatment, as appropriate.
184.108.40.206 Room and Board Parameters
For Medicaid purposes, room and board comprises real estate costs (debt service, maintenance, utilities, and taxes) and raw food. Members shall be billed a maximum of 30% of income not to exceed calculation based upon 300% of SSI benefit level (e.g. SSI income). Members with incomes of $0 to $500 per month shall pay zero toward Room and Board.
Providers may not arbitrarily or prematurely reject or eject a Member from services without prior approval The Health Plan from the Health Plan. Providers must notify The Health Plan’s UM department within 1 business days of accepting placement of a The Health Plan Member into a facility. Providers must immediately notify The Health Plan Crisis Line provider whenever a Member leaves a facility against medical advice (or AMA), is hospitalized or arrested.
220.127.116.11 Prior Authorization and Continued Stay Requirements
Providers must meet all prior authorization and continued stay requirements for residential services as spelled out in this Provider Manual, unless granted an exception to this requirement in writing from The Health Plan. Only prior authorized services are eligible for payment by The Health Plan. Respite services provided in a Residential facility do not require prior authorization.
18.104.22.168 Treatment Setting and Supervision
Providers must provide residential services that provide a structured treatment setting with twenty-four (24) hour supervision and counseling or other therapeutic activities for persons who do not require on-site medical services, under the supervision of an on-site or on-call Behavioral Health Professional.
22.214.171.124 Licensing and Staffing
Residential facilities must be licensed by the ADHS Division of Licensing as a BH Residential Facility. Providers must provide appropriate staffing (including one-on-one staff as needed) to accommodate all referrals who do not require a higher level of care.
126.96.36.199 Program Outcomes
Providers must promote and demonstrate the following program outcomes:
- Improved self-regulation;
- Development of appropriate social skills;
- Expeditious return to less restrictive environment;
- Minimal readmission rate;
- Increase in Member self-sufficiency;
- Development of health leisure activities;
- Engagement in ongoing services;
- Decreased risk factors (less runaway behavior, self-harm, aggressive behavior);
- Increased community connections and readiness for employment.
Per the Memorandum of Agreement between the Tohono O’odham Nation and The Health Plan, any provider wishing to deliver services within the exterior boundaries of the Tohono O’odham Nation will need prior approval from The Health Plan and the Tohono O’odham Nation.
12.20.1 Approved Providers
A listing of providers approved by The Health Plan and the Tohono O’odham Nation to provide services within the boundaries of the Nation can be located on The Health Plan’s website at https://www.azcompletehealth.com.
12.20.2 Quarterly Reporting
All approved providers, located and/or delivering services within the exterior boundaries of the Nation, must submit a quarterly service report OI-217 Tohono O’odham Nation Quarterly Report using the designated template outlined in Provider Manual Section 16 – Deliverable Requirements.
12.20.3 Requesting Approval
Any provider that would like to request approval to deliver services on the Nation should contact The Health Plan’s Tribal Program Development team to initiate the process.
All contracted behavioral health providers and integrated health care providers are required to deliver or assist members in obtaining employment and rehabilitation services. Provider Organizations delivering and billing employment and rehabilitation related activities shall employ at least one fully dedicated Employment Specialist. Provider Organizations delivering and billing for employment and rehabilitation services are required to employ an adequate number of fully dedicated Employment Specialists to meet the needs of the members served in each clinic. It may be permissible for the employment/rehabilitation staff to cover more than one clinical team or split time with other duties, based on staffing, availability, regional locations and enrollment numbers.
Provider Organizations delivering employment and rehabilitation services are required to:
- Monitor employment service utilization including job placement data and ensure accurate and reliable employment status within the Supplemental Member Data Provider Portal.
- Implement Supported Employment and meet SAMHSA Supported Employment fidelity.
- Fulfill the requirements listed in all employment Technical Assistance Documents and provide annual training to all clinical staff on the Technical Assistance Documents.
- Provide benefits planning utilizing Disability Benefits 101 (DB101).
- Adhere to the guidelines within the Interagency Service Agreement (ISA) between AHCCCS and ADES/RSA.
- Provider Organizations serving adults determined Seriously Mentally Ill (SMI) are responsible for ensuring at least a 7% of members with SMI determinations are engaged with RSA/VR services versus the providers’ overall enrollment of members with SMI determinations.
- Make all reasonable efforts to become mutually contracted with ADES/RSA.
- Adhere to AHCCCS ACOM 447 - Employment (PDF)
Employment Specialists must:
- Obtain certification from Arizona Complete Health as an Employment Specialist.
- Connect members to sustainable employment resources in the community including RSA/VR, AZ@Work, Linkages of Arizona, etc.
- Provide individualized supports to assist members in obtaining and maintaining competitive employment.
- Fulfill responsibilities listed in the ISA/Collaborative Protocol with ADES/RSA and refer all adults interested in employment services to the RSA VR Program.
- Participate in Health Plan sponsored meetings/events and Bi-Annual Coordination meetings with AHCCCS and ADES/RSA.