Health Plan Coordination of Care Requirements
Persons receiving services in the State system may experience transitions during the course of their care and treatment. Examples of transitions of care include changing service providers, establishing eligibility under Arizona Long Term Care Services (ALTCS), and moving out of The Health Plan geographic service area. During transitions of care, providers must ensure that services are not interrupted and that the person continues to receive needed services. Coordination and continuity of care during transitions are essential in maintaining a person’s stability and avoiding relapse or decompensation in functioning.
For Transition of Enrollment for Persons Turning 18 regardless of the youth’s decision regarding their continued behavioral health enrollment, an updated Arizona Health Care Cost Containment System (AHCCCS) application must be submitted prior to the youth’s 18th birthday and with sufficient time to allow for AHCCCS to process the application (at least 45 days). The application should be completed at least six months prior to the child’s 18th birthday. The provider must assist the member in applying for AHCCCS coverage at the appropriate interval.
Upon turning 18 years of age, if the person is not eligible for services as a person determined to have a Serious Mental Illness or the person has been determined ineligible for Title XIX/XXI services, providers can continue to provide services under block grant funds (as applicable) or per Section 7.22 - Copayments.
When the youth turns 18, the provider must ensure that new consents and release of information documents are signed, reflecting correct diagnosis codes and behavioral health category consistent with Section 6.1 - Enrollment, Disenrollment and other Data Submission. Once the child’s behavioral health category assignment has been changed, ongoing behavioral health service appointments must be provided according to the timeframes for routine appointments in Section 12.2 - Appointment Standards and Timeliness of Services.
13.1.1 Transition Due to a Change of the Behavioral Health Provider or the Behavioral Health Category Assignment
Upon changes of a Member’s provider or behavioral health category assignment, the provider must:
- Review the current individual service plan and, if needed, coordinate the development of a revised individual service plan with the person, clinical team, and the receiving behavioral health provider;
- Ensure the transfer of responsibility for court ordered treatment, if applicable; and
- Coordinate the transfer of any other relevant information between the provider and other provider agencies, if needed.
The Health Plan agency changes are coordinated between The Health Plan agencies.
13.1.2 Transition to ALTCS Program Contractors
Once a person is determined eligible and becomes enrolled with the Arizona Long Term Care Services/Elderly or Physically Disabled (ALTCS/EPD) Program, providers must not submit claims or encounters for Title XIX/XXI covered services to The Health Plan. To determine if a person is ALTCS/EPD eligible, providers shall contact The Health Plan Customer Service for assistance at 888-788-4408. The provider must, however, continue to provide and encounter needed non- Title XIX/XXI covered SMI services (e.g. housing) to persons determined to have a Serious Mental Illness.
Providers who contract as an ALTCS provider must not submit encounters for an ALTCS/EPD enrolled person to The Health Plan after a person transfers to ALTCS, but must submit bills/claims for payment to the ALTCS Program Contractor who in turn submits the encounters to AHCCCS.
Providers must facilitate effective transitions for Members who became eligible for ALTCS services. Providers must complete the following coordination efforts for ALTCS-eligible Members:
- Provide continuity of care between inpatient and outpatient settings, services, and supports;
- Develop and implement transition, discharge, and aftercare plans prior to discontinuation of services in accordance with this Provider Manual;
- Include the Member in transition planning and provide any available information about changes in physician, services, etc.;
- Ensure that the clinical and fiscal responsibility for Title XIX/XXI services shifts to the ALTCS Program Contractor;
- Complete a transfer packet and letter of transition that provides clinical information to the ALTCS Program Contractor regarding the person’s on-going needs for services to assist them in effectively meeting the ongoing health and cultural needs of the Member and ensure continuity of care during the transition period;
- Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving ALTCS provider and/or Health Care Coordinator;
- Transfer responsibility for any court ordered treatment;
- Coordinate the transfer of records to the ALTCS program contractor; and
- Provide information as follows:
- For Title XIX/XXI eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year (October 1 – September 30);
- For all persons, the number of hours of respite received in the contract year (October 1 - September 30); and
- Whether there is a signed authorization for the release of information contained in the comprehensive behavioral health record pursuant to Section 9.6.1 - Disclosure of Health Information.
- Reference ACOM Policy 403 Enrollment in a County with Choice and Change of Contractor: Arizona Long Term Care System Contractors for information regarding changes or transfers between ALTCS contractors.
13.1.3 Transition of Persons Receiving Court Ordered Services
Please see 12.9.5 Court-Ordered Treatment Following Civil Proceedings Under A.R.S. Title 36, Transfers for Members on Court Ordered Treatment
13.1.4 Members Assigned to an Outpatient Provider and become Court Ordered.
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 Outpatient Providers 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 an Outpatient Provider who will assume responsibility for the members Court Ordered Outpatient Treatment Plan. An Outpatient Provider should be designated prior to the member being discharged to the hospital so that a court ordered treatment plan can be submitted to the Court. A transfer/assignment of the member should occur upon discharge from inpatient stay.”
Should this occur, please contact the Health Plan Title 36 Coordinator for additional Technical Assistance”
13.1.5 Transition of Persons Being Discharged from Inpatient Settings
Discharge planning and communication with the Adult Clinical Team or CFT must begin at admission to ensure a smooth transition for Members being discharged from inpatient settings in accordance with the guidelines in Section 3.14 Discharge Planning. Furthermore, re-engagement activities must occur for persons who are discharged from inpatient settings in accordance with Section 12.4 - Outreach, Engagement, Re- engagement and Closure. If a Member will be moving to a different GSA, coordination must occur between RBHA/Health Plans, if applicable, to verify appropriate services/placement and necessary re-engagement activities occur upon discharge and must not occur while member is in an inpatient setting (see Section 13.2 - Inter-RBHA/MCO Coordination of Care).
13.1.6 Transition of Persons Receiving Behavioral Health Services from Indian Health Services
American Indian persons may choose to receive services through a TRBHA/Health Plan, or at an IHS or 638 tribal provider. The Health Plan providers must respond to referrals in accordance with Section 12.3 – Referral and Intake Process, and ensure necessary coordination of care occurs. Contact The Health Plan at 888-788-4408.
13.1.7 Inter-Agency Coordination of Care Transfers (Transferring Member Coordination of Care Responsibility to a Different Agency)
All coordination of care inter-agency transfers between outpatient providers must be completed through the Provider Portal. Each transfer is required to be posted to the portal by the transferring agency and accepted or rejected by the receiving agency within 7 days of the date the transfer was entered into the transfer system.
The Health Plan Network Development Coordinator will monitor inter-agency transfers to ensure the transfer is complete within 7 days from the date the transfer was entered into the system. The transfer is considered timely when the receiving agency accepts or rejects the transfer within 7 days. The following steps must be documented in the medical record to ensure compliance with requirements.
220.127.116.11 Sending Agency Requirements
- Evidence the sending agency staff discussed the transfer with the Member and documented the conversation and Member request in the medical record.
- Documentation that the assigned staff from the sending agency coordinated with the receiving agency within 7 business days of the Member request.
- Evidence the sending agency gathered the required documentation, including the full completion of the Provider Manual Form 4.1.1 Inter-Agency Transfer Checklist; and evidence the sending agency provided the transfer packet to the receiving agency. This form can be obtained from Cutomer Services at 1-866-796-0542 if needed.
- Evidence the Provider Manual Form 4.1.1 Inter-Agency Transfer Checklist and packet were completed by the sending agency and provided to the receiving agency no later than the date of the transfer CFT/ART.
- Evidence the receiving agency documented confirmation of receipt of the transfer packet documents, or a follow up plan for missing documents required as part of the Inter-agency Transfer Checklist. Missing documentation should not delay a transfer from occurring.
- Evidence the sending agency coordinated with the Member/guardian, system partners, and receiving agency to verify a transfer CFT/ART occurred.
- Evidence that once the documentation was provided and the transfer CFT/ART was completed with the receiving agency, the sending agency submitted the transfer through the Provider Portal. The sending agency is required to submit the transfer through the Provider Portal within 2 days following the transfer CFT/ART.
18.104.22.168 Receiving Agency Requirements
- Documentation that the receiving agency coordinated with the sending agency to schedule a transfer Child and Family Team/Adult Recovery Team (CFT/ART) appointment.
- Evidence the receiving agency CFT/ART included the following:
- Attendance by:
- Sending agency staff,
- Receiving agency staff, and
- Other system partners as appropriate.
- Completion of an Inter-agency Transfer Checklist/SBAR (Situation, Background, Assessment, Recommendation) Tool in its entirety.
- Completed Inter-agency Transfer Checklist/SBAR Tool was filed in the medical record within 7 days of completion and is easily accessible.
- Attendance by:
- Evidence that once the transfer CFT/ART was completed and paperwork was confirmed by the receiving agency, the transfer was accepted by the receiving agency on the Provider Portal.
- Evidence Transfer was accepted or rejected by the receiving agency within 5 days following the receipt of request.
- Evidence the intake appointment was completed. The intake appointment may be combined with the transfer CFT/ART.
- Evidence the receiving agency scheduled the next appointment within 7 days following the transfer.
13.1.8 At Risk Member Transitions
The Health Plan Outpatient Providers are recommended to notify The Health Plan Integrated Care Management department immediately anytime a high risk member is scheduled to be transferred between providers, or payers. Outpatient Providers are required to contact The Health Plan Member Transition Coordinators at 1-866-796-0542. Notification is recommended for all at risk members including but not limited to the following members:
- Members with significant medical conditions such as: a high-risk pregnancy or pregnancy within the last trimester; the need for organ or tissue transplantation; chronic illness resulting in hospitalization or nursing facility placement, etc.
- Members who are receiving ongoing services such as dialysis, home health, chemotherapy and/or radiation therapy, or who are hospitalized at the time of transition;
- Members who frequently contact AHCCCS, State and local officials, the Governor’s Office and/or the media;
- Members who have received prior authorization for services such as scheduled surgeries, post-surgical follow-up visits, out-of-area specialty services, or nursing home admission; and Continuing prescriptions, Medical Equipment and Appliances (previously called Durable Medical Equipment) and medically necessary transportation ordered for the transitioning member by the relinquishing Contractor; and
The Health Plan Outpatient Providers are required to fully cooperate with The Health Plan, “receiving and sending providers and health plans” and proactively coordinate care to meet the member’s needs throughout the transition. Outpatient Providers are required to timely release medical records of the transitioning member (the cost, if any, of reproducing and forwarding medical records shall be the responsibility of the provider).
Coordination between Tribal and Regional Behavioral Health Authority /Health Plans must occur in a manner that ensures the provision of continuous covered services that are consistent with the treatment goals and identified needs for persons who:
- Receive services outside of the Geographical Service Area served by their designated T/RBHA/Health Plan (non-enrolled persons),
- Receive services outside of the Geographical Service Area served by their home T/RBHA/Health Plan (enrolled persons), or
- Move to another Geographical Service Area.
13.2.1 Computation of Time
In computing any period of time prescribed or allowed by this policy, the period begins the day after the act, event, or decision occurs and includes all calendar days and the final day of the period. If the final day of the period is a weekend or a legal holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday. If the period of time is not designated as calendar days and is less than 11 days, then intermediate Saturdays, Sundays, and legal holidays must not be included in the computation.
13.2.2 Jurisdictional Responsibilities
For adults (persons 18 years and older), T/RBHA/Health Plan responsibility is determined by the person’s current place of residence. This is applicable regardless of where the adult guardian lives.
Responsibility for service provision, other than crisis services, remains with the home T/RBHA/Health Plan when the enrolled person is visiting or otherwise temporarily residing in a different T/RBHA/Health Plan area but:
- Maintains a place of residence in their previous location with an intent to return, and the anticipated duration of the temporary stay is less than three months.
For children (ages 0-17 years), Health Plan responsibility is determined by the current place of residence of the child’s parent(s) or legal guardian. For children who have been adjudicated as dependent by a court, the location of the child’s court of jurisdiction determines which T/RBHA/Health Plan has responsibility.
The Health Plan may agree to coordinate an Inter-RBHA/Health Plan transfer for individuals unable to live independently on a case-by-case basis. Inter-RBHA/Health Plan transfers must be completed within 30 days of referral by the home T/RBHA/Health Plan. The home T/RBHA/Health Plan must ensure that activities related to arranging for services or transferring a case does not delay a person’s discharge from an inpatient or residential setting.
13.2.3 Out-of-Area Service Provision
22.214.171.124 Crisis Services
Crisis services must be provided without regard to the person’s enrollment status. When a person presents for crisis services, providers must:
- Provide needed crisis services;
- Ascertain the person’s enrollment status with all Health Plans and determine whether the person’s residence in the current area is temporary or permanent;
- If the person is enrolled with another RBHA/Health Plan, the provider is required to notify the home RBHA/Health Plan within 24 hours of the person’s presentation. The home RBHA/Health Plan is fiscally responsible for crisis services and must:
- Make arrangements with the Health Plan at which the person presents to provide needed services, funded by the home RBHA/Health Plan;
- Determine if the person intends to live in the new RHBA/Health Plan’s geographic service area and if so, initiate a transfer. Persons who are unable to live independently but clearly express an intent/desire to permanently relocate to another service area can be transferred.
- If the person is not enrolled with the Health Plan and lives within the service area of the Health Plan at which the person presented for services, providers must notify the Health Plan to initiate enrollment. A person can obtain a referral by calling The Health Plan Customer Service at 888-788-4408.
- If the person is not enrolled with the Health Plan and lives outside of the service area of the Health Plan at which the person presented for crisis services, providers must enroll the person, provide needed crisis services and initiate the Inter-RBHA/Health Plan transfer.
- In the event that The Health Plan or a provider receives a referral regarding a hospitalized person whose residence is located outside the Health Plan’s GSA, the provider must immediately coordinate the referral with the person’s designated Health Plan.
126.96.36.199 Non-Emergency Services
If the person is not enrolled with a RBHA/Health Plan, lives outside of the service area in which they present, and requires services other than a crisis or urgent response to a hospital, the provider must notify the designated RBHA/Health Plan associated with the person’s residence within 24 hours of the person’s presentation. The designated RBHA/Health Plan must proceed with the person’s enrollment if the person is determined eligible for services. The designated RBHA/Health Plan is fiscally responsible for the provision of all medically necessary covered services, including transportation services, for eligible persons.
188.8.131.52 Courtesy Dosing of Methadone
A person receiving methadone administration services who is not a recipient of take-home medication may receive up to two courtesy doses of methadone from the Health Plan while the person is traveling out of the home T/RBHA/Health Plan’s area. All incidents of provision of courtesy dosing must be reported to the home T/RBHA/Health Plan. The home T/RBHA/Health Plan must reimburse the Health Plan providing the courtesy doses upon receipt of properly submitted bills or encounters.
184.108.40.206 Referral to Another T/RBHA/Health Plan for Service Provision
If The Health Plan provider initiates a referral to another T/RBHA/Health Plan or a service provider in another T/RBHA/Health Plan’s area for the purposes of obtaining behavioral health services, The Health Plan provider must:
- Maintain enrollment and financial responsibility for the person during the period of out-of-area behavioral health services,
- Contact the Member Transitions Coordinators at 1-866-796-0542 so that an Out of Service Area Placement Request form (form 520-B) can be completed to maintain member’s enrollment and financial responsibility with current service plan
- Establish contracts with out-of-area service providers and authorize payment for services,
- Maintain the responsibilities of the behavioral health provider, and
- Provide or arrange for all needed services when the person returns to The Health Plan’s area.
13.2.4 Inter-T/RBHA/Health Plan Transfer
A transfer will occur when:
- An adult person voluntarily elects to change their place of residence to an independent living setting from one T/RBHA/Health Plan’s area to another.
- Persons who are unable to live independently but clearly express an intent/desire to permanently relocate to another service area can be transferred. However, the home T/RBHA/Health Plan must make arrangements for housing and consider this a temporary placement for three months. After three months, if the person continues to clearly express an intent/desire to remain in this new service area, the inter-T/RBHA transfer can proceed.
- The parent(s) or legal guardian(s) of a child change their place of residence to another T/RBHA/Health Plan’s area; or
- The court of jurisdiction of a dependent child changes to another T/RBHA/Health Plan’s area.
- In addition to the above, a change in Health Plan outside of the intial enrollment period or the member’s Annual Enrollment Choice will be granted if certain conditions are met in accordance to ACOM Policy 401 Change in Contractor.
Inter-T/RBHA transfers are not to be initiated when a person is under pre-petition screening or court ordered evaluation (see Section 12.9 - Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment).
Please reference Section 13 Behavioral Health Provider’s Responsibilities During an Inter-RBHA/MCO Transfer
The home T/RBHA/Health Plan or its providers must initiate a referral for an Inter-T/RBHA transfer within the following timeframes:
- At least 30 days prior to the date on which the person will move to the new area; or
- If the planned move is in less than 30 days, immediately upon learning of the person’s intent to move.
- If the transfer is the result of medical continuity as defined in ACOM Policy 401 Change of Contractor, the transfer must occur as expeditiously as the member’s health care condition requires or no later than 10 business days.
220.127.116.11 Inter-T/RBHA/Health Plan Transfer Process
An adult person enrolled with The Health Plan, family, guardian, behavioral health provider, state agency staff or other health provider staff is responsible for the initiation of an Inter-T/RBHA transfer. The referral is initiated when the home T/RBHA/Health Plan provides a completed Provider Manual Form 4.2.1 AzCH-CCP Inter-Transfer and Coordination of Services Request Form. This form can be obtained by calling Customer Serviceat 1-866-796-0542. In addition, the following information must be provided to the receiving T/RBHA/Health Plan as quickly as possible:
- The person’s comprehensive clinical record;
- Consents for release of information pursuant to Section 9.6 - Confidentiality;
- For Title XIX/XXI eligible persons between the ages of 21 and 64, the number of days the person has received services in an IMD in the contract year (October 1 – September 30); and
- The number of hours of respite care the person has received in the contract year (October 1 – September 30).
The receiving T/RBHA/Health Plan must not delay the timely processing of an Inter-T/RBHA transfer because of missing or incomplete information.
Upon receipt of the transfer packet, the T/RBHA/Health Plan must:
- Notify the home T/RBHA/Health Plan within seven calendar days of receipt of the referral for Inter-T/RBHA transfer,
- Proceed with making arrangements for the transfer, and
- Notify the home T/RBHA/Health Plan if the information contained in the referral is incomplete.
Within 14 days of receipt of the referral for an Inter-RBHA transfer, the receiving T/RBHA/Health Plan or its providers must:
- Schedule a meeting to establish a transition plan for the person. The meeting must include:
- The person or the person’s guardian or parent, if applicable;
- Representatives from the home T/RBHA/Health Plan;
- Representatives from the Arizona State Hospital (ASH), when applicable;
- The provider and representatives of the CFT/adult clinical team;
- Other involved agencies; and
- Any other relevant Member at the person’s request or with the consent of the person’s guardian.
- Establish a transition plan that includes at least the following:
- The person’s projected moving date and place of residence;
- Treatment and support services needed by the person and the timeframe within which the services are needed;
- A determination of the need to request a change of venue for court ordered treatment and who is responsible for making the request to the court, if applicable;
- Information to be provided to the person regarding how to access services immediately upon relocation;
- The enrollment date, time and place at the receiving RBHA/Health Plan and the formal date of transfer, if different from the enrollment date;
- The date and location of the person’s first service appointment in the receiving T/RBHA/Health Plan’s GSA;
- The individual responsible for coordinating any needed change of health plan enrollment, primary care provider assignment, and medication coverage;
- The person’s provider in the receiving RBHA/Health Plan’s GSA, including information on how to contact the behavioral health provider;
- Identification of the person at the receiving T/RBHA/Health Plan who is responsible for coordination of the transfer, if other than the person’s behavioral health provider;
- Identification of any special authorization required for any recommended service (e.g., non-formulary medications) and the individual who is responsible for obtaining needed authorizations; and,
- If the person is taking medications prescribed for the person’s behavioral health issue, the location and date of the person’s first appointment with a practitioner who can prescribe medications. There must not be a gap in the availability of prescribed medications to the person.
On the official transfer date, the home T/RBHA/Health Plan must enter a closure and disenrollment into CIS. The receiving T/RBHA/Health Plan must enter an intake and enrollment into CIS at the time of transfer. If the person scheduled for transfer is not located or does not show up for their appointment on the date arranged by the T/RBHA/Health Plans to transfer the person, the T/RBHA/Health Plans must collaborate to ensure appropriate re- engagement activities occur (see Section 12.4, Outreach, Engagement, Re- Engagement and Closure) and proceed with the inter-T/RBHA transfer, if appropriate. Each T/RBHA/Health Plan must designate a contact person responsible for the resolution of problems related to enrollment and disenrollment.
When a person presents for crisis services, providers must first deliver needed behavioral health services and then determine eligibility and T/RBHA/Health Plan enrollment status. Persons enrolled after a crisis event may not need or want ongoing behavioral health services through the T/RBHA/Health Plan. Providers must conduct re- engagement efforts as described in Section 12.4, Outreach, Engagement, Re- Engagement and Closure however; persons who no longer want or need ongoing behavioral health services must be dis-enrolled (i.e., closed in the CIS) and an inter-T/RBHA transfer must not be initiated. Persons who will receive ongoing behavioral health services will need to be referred to the appropriate T/RBHA/Health Plan and an inter-T/RBHA transfer initiated, if the person presented for crisis services in a GSA other than where the person resides.
Timeframes specified in 13.1 Transition of Persons cover circumstances when Members inform their provider or T/RBHA/Health Plan prior to moving to another service area. When Members inform their provider or T/RBHA/Health Plan less than 30 days prior to their move or do not inform their provider or T/RBHA/Health Plan of their move, the designated T/RBHA/Health Plan must not wait for all of the documentation from the previous T/RBHA/Health Plan before scheduling services for the Member.
18.104.22.168 Behavioral Health Provider’s Responsibilities During an Inter-RBHA/Health Plan Transfer
- As part of an Inter-RBHA/Health Plan transfer, the provider must (see Provider Manual Section 13.2 Inter-T/RBHA/MCO Coordination of Services:
- Schedule a meeting to establish a transition plan for the person. Include the person in transition planning and provide any available information about changes in physician, services, etc.;
- Provide information regarding the person’s on-going needs for services to verify continuity of care during the transition period;
- Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving provider;
- Transfer responsibility for any court ordered treatment;
- Coordinate the transfer of records to the new behavioral health provider; and
- Provide information as follows:
- For Title XIX/XXI eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year October 1 – September 30;
- For all persons, the number of hours of respite received in the contract year October 1 - September 30; and
- Any signed authorizations for the release of information contained in the person’s comprehensive clinical record pursuant to Section 9.6.1 - Disclosure of Health Information.
For Members who are on court ordered treatment:
- The Behavioral Health Home shall inform the T36 Liaisons at AZCHtitle36@azchcompletehealth.com that must include all court ordered treatment documents along with transfer packet;
- The Receiving Agency shall schedule an Intake appointment and inform the Health Plan Transition Coordinators at AZCHtitle36@azchcompletehealth.com and the Sending Agency the date of the appointment;
- The Receiving Agency must inform the Health Plan Transitions Coordinators and the Sending Agency that intake appointment has been completed ;
- The Receiving Agency must send the Letter of Intent to the Health Plan Transitions Coordinators at AZCHtitle36@azchcompletehealth.com and the Sending Agency;
- Member Transitions and the Sending Agency must acknowledge receipt of the Letter of Intent;
- The Sending Agency shall file the court document to transfer the Court Ordered Treatment from their County to the new County.
13.2.5 Complaint Resolution
A person determined to have a serious mental illness (SMI) that is the subject of a request for out-of-area service provision or Inter-T/RBHA transfer may file an appeal as provided for in Section 8.4 -Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons. Any party involved with a request for out-of-area service provision or Inter-T/RBHA transfer may initiate the grievance procedure. Parties include the home T/RBHA/Health Plan, receiving T/RBHA/Health Plan, person being transferred, or the person’s guardian or parent, if applicable; the Arizona State Hospital (ASH), if applicable, and any other involved agencies.
The following issues may be addressed in the grievance resolution process:
- Any timeframe or procedure contained in this policy,
- Any dispute concerning the level of care needed by the person, and
- Any other issue that delays the person’s discharge from an inpatient or residential setting or completion of an Inter-T/RBHA transfer.
22.214.171.124 Procedure for Non-Emergency Disputes
- A written grievance shall be addressed to:
- The person’s provider at the home T/RBHA/Health Plan, or other individual identified by the T/RBHA/Health Plan, if the issue concerns out-of-area service provision, or
- The identified provider at the receiving T/RBHA/Health Plan, or other individual identified by the T/RBHA/Health Plan, if the issue concerns an Inter-T/RBHA transfer.
- The provider must work with involved parties to resolve the issue within five days of receipt of the grievance.
- If the problem is not resolved, the provider must, on the fifth day after the receipt of the request, forward the grievance to the second level.
- Issues concerning out-of-area service provision must be forwarded to the Chief Executive Officer, or designee, of the home T/RBHA/Health Plan.
- Issues concerning Inter-T/RBHA transfers must be forwarded to the Chief Executive Officer, or designee, of the receiving T/RBHA/Health Plan.
- The Chief Executive Officer must work with the Chief Executive Officer of the other involved T/RBHA/Health Plan to resolve the issue within five days of receipt of the grievance.
- If the problem is unresolved, the Chief Executive Officer must, on the fifth day after the receipt of the request, forward the request to the Deputy Director of the AHCCCS.
- The Deputy Director of the AHCCCS, or designee, will convene a group of financial and/or clinical personnel as appropriate based on the grievance.
- The Deputy Director will issue a final decision within five days of receipt of the request.
126.96.36.199 Procedure for Emergency Disputes
An emergency dispute includes any issue in which the person is at risk of decompensation, loss of residence, or being in violation of a court order. The home T/RBHA/Health Plan must ensure that medically necessary behavioral health services continue pending the resolution of an emergency dispute between T/RBHA/Health Plans.
- Issues concerning out-of-area service provision must be forwarded to the Chief Executive Officer, or designee, of the home T/RBHA/Health Plan.
- Issues concerning Inter-T/RBHA transfers must be forwarded to the Chief Executive Officer, or designee, of the receiving T/RBHA/Health Plan.
- The Chief Executive Officers of the involved T/RBHA/Health Plans must work to resolve the issue within two days of receipt of the grievance.
- If the problem is unresolved, the Chief Executive Officer must, on the second day after the receipt of the request, forward the request to the Deputy Director of AHCCCS.
- The Deputy Director of AHCCCS, or designee, will convene a group of financial and/or clinical personnel as appropriate based on the grievance, to address and resolve the issue.
- The Deputy Director will issue a final decision within two days of receipt of the request.
In Arizona, the acute care Medicaid program (Title XIX) and the State Children’s Health Insurance Program (KidsCare/SCHIP/Title XXI) were developed as behavioral health “carve- outs,” a model in which eligible persons receive general medical services through health plans and covered services through behavioral health managed care organizations, also known as T/RBHA/Health Plans. Because of this separation in responsibilities, communication and coordination between providers, the Arizona Health Care Cost Containment System (AHCCCS), Health Plan Primary Care Providers (PCPs) and Behavioral Health Coordinators is essential to ensure the well-being of persons receiving services from both systems.
Some Members are Medicaid (Title XIX) and Medicare (Title XVIII) eligible and are referred to as “dual eligible” persons. Medicare covers limited inpatient services, outpatient services, and prescription medication coverage. Medicare covered services are provided on either a fee-for-service basis or a managed care basis (through Medicare Advantage Plans). The term Medicare provider refers to both the fee-for-service Medicare providers and the Medicare Advantage Plans. Coordination of care must also occur with Medicare providers to achieve positive health outcomes for Medicare eligible Members.
Holistic treatment requires integration of physical health with behavioral health to improve the overall health of an individual. Members may be receiving care from multiple health care entities. Duplicative medication prescribing, contraindicated combinations of prescriptions and/or incompatible treatment approaches could be detrimental to a person. For this reason, communication and coordination of care between providers, PCPs, and Medicare providers must occur on a regular basis to ensure safety and positive clinical outcomes for persons receiving care. For The Health Plan enrolled persons not eligible for Title XIX/XXI coverage, coordination and communication should occur with any known health care provider(s).
13.3.1 Coordinating Care with AHCCCS Health Plans
The Health Plan employs Transitions Coordinators to manage all coordination with other Health Plans for members who receive their medical services through an AHCCCS health plan and behavioral health services through the RBHA/Health Plan (e.g. ALTCS). Their role is to respond to coordination of care inquiries from AHCCCS Health Plans, primary care providers (PCPs) and other involved clinicians to facilitate clinical coordination of care. When coordinating care with the person’s PCP, Medicare provider or other health care provider, information must be disclosed in accordance with Section 9.6.1 - Disclosure of Health Information.
The following procedures, however, will assist providers in coordinating care with AHCCCS Health Plans:
- If the identity of the person’s primary care provider (PCP) is unknown, a provider must contact the Acute Health Plan and Provider Coordinator(s) for The Health Plan or the Behavioral Health Coordinator of the person’s designated health plan to determine the name of the person’s assigned PCP. See the AMPM AHCCCS Contracted Health Plans for contact information for the Behavioral Health Coordinators for each AHCCCS Health Plan;
- The Health Plan enrolled persons who have never contacted their PCP prior to entry into the behavioral health system should be encouraged to seek a baseline medical evaluation. The Health Plan enrolled persons should also be prompted to visit their PCP for routine medical examinations annually or more frequently if necessary;
- Providers should request medical information from the person’s assigned outpatient provider. Examples include current diagnosis, medications, pertinent laboratory results, last PCP visit, Early Periodic Screening, Diagnosis and Treatment (EPSDT) screening results and last hospitalization. A sample request form that may be utilized for this purpose (see Provider Manual Form 4.3.1, Request for Information from PCP or Medicare Provider which can be obtained by calling Customer Services 1-866-796-0542). If the PCP does not respond to the request, contact the health plan’s Behavioral Health Coordinator for assistance; and
- Providers must address and attempt to resolve coordination of care issues with AHCCCS Health Plans and outpatient providers at the lowest possible level. If problems persist, contact the Health Plan Coordinator by calling 1-866-796-0542 and ask to be connected with the designated The Health Plan Coordinator.
13.3.2 Acute Health Plan and Provider Coordinator
The Health Plan has designated an Acute Health Plan and Provider Coordinator who gathers, reviews, and communicates clinical information requested by PCPs, Acute Care Plan Behavioral Health Coordinators and other treating professionals or involved stakeholders.
The Health Plan maintains a designated and published phone number to contact the Acute Health Plan and Provider Coordinator and has a clearly recognized prompt on an existing phone number that facilitates prompt access to the Acute Health Plan and Provider Coordinator that is staffed during business hours.
The Health Plan Acute Health Plan and Provider Coordinators receive training which includes, at a minimum, the following elements:
- Provider inquiry processing and tracking (including resolution timeframes);
- Health Plan procedures for initiating provider contracts or AHCCCS provider registration;
- Claim submission methods and resources (see Section 7.3 - Submitting Claims and counters to the RBHA/Health Plan);
- Claim dispute and appeal procedures (Section 8.6- Provider Claims Disputes); and
- Identifying and referring quality of care issues.
The Health Plan utilizes the following training modules that providers are required to complete, in order to understand the above listed elements:
- Provider Performance Improvement;
- Claims and Encounters;
- Notice of Action (NOA) and Grievance and Appeals;
- Quality of Care; and
- Overview of RBHA, AHCCCS and The Health Plan.
In addition, The Health Plan meets quarterly with other Health Plans to identify barriers or issues that exist within the delivery of care system for health plan Members and behavioral health enrolled Members.
13.3.3 Sharing Information with PCPs, AHCCCS Health Plans, Other Treating Professionals, and Involved Stakeholders
To support quality medical management and prevent duplication of services, providers are required to disclose relevant behavioral health information pertaining to Title XIX/XXI eligible persons to the assigned Outpatient Provider, AHCCCS Health Plans, other treating professionals and other involved stakeholders within the following required timeframes:
- “Urgent” – Requests for intervention, information, or response within 24 hours; and
- “Routine” – Requests for intervention, information, or response within 10 days.
188.8.131.52 Coordination of Care for Members with a Serious Mental Illness
For all Members referred by the Outpatient Provider and determined to have a Serious Mental Illness and/or a diagnosis of a chronic medical condition on Axis III, the following information must be provided to the person’s assigned Outpatient Provider:
- The Member’s diagnosis;
- Critical lab results as defined by the laboratory and prescribed medications; and
- Changes in class of medications.
Providers with the assistance of The Health Plan must provide the required information annually, and/or when there is a significant change in the person’s diagnosis and/or prescribed medications.
Providers are required to pro-actively coordinate behavioral health and medical care for Members with a Serious Mental Illness and/or a diagnosis of a chronic medical condition on Axis III. This includes helping Members identify their health and wellness goals, include those goals in the Members’ Individualized Service Plans, and coordinating with medical professionals to help Members achieve those goals.
184.108.40.206 Coordination of Care for Title XIX/XXI Members
For all Title XIX/XXI enrolled persons, providers are required to:
- Notify the assigned Outpatient Provider of the results of PCP initiated behavioral health referrals;
- Provide a final disposition to the health plan Behavioral Health Coordinator in response to PCP initiated behavioral health referrals, (for more information on the referral process, see Section 12.3 – Referral and Intake Process);
- Coordinate the placement of persons in out-of-state treatment settings as described in Section 12.13 - Out-of State Placement for Children and Young Adults;
- Notify, consult with, or disclose information to the assigned PCP regarding persons with Pervasive Developmental Disorders and Developmental Disabilities, such as the initial assessment and treatment plan and care and consultation between specialists;
- Provide a copy to the PCP of any executed advance directive, or documentation of refusal to sign an advance directive, for inclusion in the Member’s medical record; and
- Notify, consult with, or disclose other events requiring medical consultation with the person’s PCP.
Upon request by the PCP or Member, information for any enrolled Member must be provided to the PCP consistent with requirements outlined in Section 9.6.1 - Disclosure of Health Information.
When contacting or sending any of the above referenced information to the person’s PCP, providers must provide the PCP with an agency contact name and telephone number in the event the PCP needs further information.
Provider Manual Form 4.3.2, Communications Document can be used for coordinating care with the AHCCCS Health Plan PCP or Behavioral Health Coordinator. The form includes the required elements for coordination purposes and must be completed in full for coordination of care to be considered to occur. For complex problems, direct provider-to-provider contact is recommended to support written communications. This form can be obtained by calling Customer Services at 1-866-796-0542.
Provider Manual Form 4.3.2, Communications Document will not have to be used if there is a properly documented progress note. To be considered properly documented the progress note must:
- Include a header that states “Coordination of Care”;
- Be legible; and
- Include all of the required elements contained in Provider Manual Form 4.3.2, Communications Document.
13.3.4 Responsibility for Fee-for-Service Persons
The Health Plan provides fee-for-service services to Title XIX/XXI eligible persons not enrolled with an AHCCCS Health Plan. The Health Plan provides all inpatient emergency services for fee-for-service persons with psychiatric or substance abuse diagnoses. The Health Plan provides services to tribal Title XIX/XXI eligible persons referred by an Indian Health Services (IHS) or tribal facility for emergency services rendered at non-IHS facilities.
13.3.5 Responsibility for Persons Enrolled in an AHCCCS Health Plan
Services which may have been covered by the AHCCCS Health Plan Contractor for Prior Period Coverage will now be the responsibility of The Health Plan. This is limited to the services only after the individual has been medically cleared. The Health Plan Contractor is still obligated to provide all necessary medical services.
The rules below apply for other areas of coverage.
220.127.116.11 Pre-Petition Screenings and Court Ordered Evaluations
The Health Plan works closely with each county to collaborate regarding pre-petition screenings and court ordered evaluations. Payment for pre-petition screenings and court ordered evaluations are the responsibility of the county except for Pima County. The Health Plan facilitates and pays for pre-petition screenings in Pima County. The Health Plan develops protocols with each county to effectively coordinate crisis services. The Health Plan contracted providers are required to adhere to the county crisis protocols and facilitate constructive collaboration to meet the needs of members in each county. The county protocols can be located on The Health Plan website www.azcompletehealth.com
18.104.22.168 Emergency Behavioral Health Services
When a Title XIX/XXI eligible person presents in an emergency room setting, the person’s AHCCCS Health Plan is responsible for all emergency medical services including triage, physician assessment, and diagnostic tests.
The Health Plan, or when applicable, its designated behavioral health provider, is responsible for psychiatric and/or psychological evaluations in emergency room settings provided to all Title XIX/XXI persons enrolled with The Health Plan.
The Health Plan is responsible for providing all non-inpatient emergency services to Title XIX/XXI eligible persons. Examples of non-inpatient emergency services include assessment, psychiatric evaluation, mobile crisis, peer support and counseling.
The Health Plan is responsible for providing all inpatient emergency services to persons with psychiatric or substance abuse diagnoses for all Title XIX/XXI eligible persons.
Emergency transportation of a Title XIX/XXI eligible person to the emergency room (ER) when the person has been directed by The Health Plan or a The Health Plan provider to present to this setting in order to resolve a behavioral health crisis is the responsibility of The Health Plan. The Health Plan or its provider directing the person to present to the ER must notify the emergency transportation provider of The Health Plan and fiscal responsibility for the service.
Emergency transportation of a Title XIX/XXI eligible person required to manage an acute medical condition, which includes transportation to the same or higher level of care for immediate medically necessary treatment, is the responsibility of the person’s AHCCCS Health Plan.
For information on emergency services for Non-Title XIX/XXI persons see Section 2.8, Crisis Intervention Services.
 Note: in inpatient settings, these services would be included in the per diem rate.
22.214.171.124 Non-Emergency Behavioral Health Services
For Title XIX/XXI eligible persons, The Health Plan is responsible for the provision of all non-emergency services.
If a Title XIX/XXI eligible person is assessed as needing inpatient psychiatric services by The Health Plan or its provider prior to admission to an inpatient psychiatric setting, The Health Plan is responsible for authorization and payment for the full inpatient stay, as per Section 4.1 - Securing Services and Prior Authorization.
When a medical team or health plan requests a behavioral health or psychiatric evaluation prior to the implementation of a surgery, medical procedure, or medical therapy to determine if there are any behavioral health contraindications, The Health Plan is responsible for the provision of this service. Surgeries, procedures, or therapies can include gastric bypass, interferon therapy or other procedures for which behavioral health support for a patient is indicated.
126.96.36.199 Non-Emergency Transportation
Transportation of a Title XIX/XXI eligible person to an initial behavioral health intake appointment is the responsibility of The Health Plan.
188.8.131.52 Medical Treatment for Persons in Behavioral Health Treatment Facilities
When a Title XIX/XXI eligible person is in a behavioral health residential treatment center and requires medical treatment, the AHCCCS Health Plan is responsible for the provision of covered medical services.
If a Title XIX/XXI eligible person is in a behavioral health inpatient facility and requires medical treatment, those services are included in the per diem rate for the treatment facility. If the person requires inpatient medical services that are not available at the behavioral health inpatient facility, the person must be discharged from the psychiatric facility and admitted to a medical facility. The AHCCCS Health Plan is responsible for medically necessary services received at the medical facility, even if the person is enrolled with The Health Plan.
13.3.6 Primary Care Providers (PCPs) Prescribing Psychotropic Medications
Within their scope of practice and comfort level, an AHCCCS Health Plan PCP may elect to treat select behavioral health disorders. The select behavioral health disorders that AHCCCS Health Plan PCPs can treat are:
- Attention-Deficit/Hyperactivity Disorder;
- Uncomplicated depressive disorders; and
- Anxiety disorders.
184.108.40.206 The “Agreed Conditions”
Certain requirements and guiding principles regarding medications for psychiatric disorders have been established for persons under the care of both a health plan PCP and behavioral health provider simultaneously. The following conditions apply:
- Title XIX/XXI eligible persons must not receive medications for psychiatric disorders from the health plan PCP and provider simultaneously. If a person is identified to be simultaneously receiving medications from the health plan PCP and behavioral health provider, the provider must immediately contact the PCP to coordinate care and agree on who will continue to medically manage the person’s behavioral health condition.
- Medications prescribed by providers within The Health Plan system must be filled by The Health Plan subcontracted pharmacies under The Health Plan pharmacy benefit (see exceptions to this requirement for dual eligible persons in Section 13.3.7 - Coordination of Care with Medicare Providers). This is particularly important when the pharmacy filling the prescription is part of the subcontracted pharmacy network for both the prescribing provider and the person’s AHCCCS Health Plan. The Health Plan and its providers must take active steps to ensure that prescriptions written by providers within The Health Plan system are not charged to the person’s AHCCCS Health Plan.
220.127.116.11 One-Time Face-to-Face Psychiatric Evaluations
Providers must be available to conduct a face-to-face evaluation with a Title XIX/XXI eligible person upon the PCPs request in accordance with Section 12.2 - Appointment Standards and Timeliness of Service.
A one-time face-to-face evaluation is used to answer PCPs specific questions and provide clarification and evaluation regarding a person’s diagnosis, recommendations for treatment, need for behavioral health care, and/or ongoing behavioral health care or medication management provided by the PCP.
The PCP must have seen the person prior to requesting a one-time face-to-face psychiatric evaluation with the behavioral health provider.
AHCCCS Health Plan PCPs must be provided current information about how to access psychiatric consultation services. The Health Plan Customer Care Department maintains all current information on how to access psychiatric consultation services in The Health Plan geographic service area. Customer Care can be contacted by calling 888-788-4408. The Health Plan is obligated to offer general consultations and one-time face-to-face psychiatric evaluations and must provide direct and timely access to behavioral health medical practitioners (physicians, nurse practitioners and physician assistants) or other behavioral health practitioners if requested by the PCP.
For additional information on how to obtain a one-time consultation for the evaluation and diagnosis of Autism Spectrum Disorder, please reference Provider Manual Section 12.3.13.
13.3.7 Coordination of Care with Medicare Providers
18.104.22.168 Medicare Advantage Plans
Medicare health plans, also known as Medicare Advantage (MA) plans, are managed care entities that have a Medicare contract with the Centers for Medicare and Medicaid Services (CMS) to provide services to Medicare beneficiaries. MA plans provide the full array of Medicare benefits, including Medicare Part A, hospital insurance, and Medicare Part B, medical insurance. As of January 1, 2006, MA plans also included Medicare Part D, prescription drug coverage.
Many of the AHCCCS Contracted Health Plans are MA plans. These plans provide Medicare Part A, Part B and Part D benefits in addition to Medicaid services for dual eligible persons and are referred to as Medicare Advantage- Prescription Drug/Special Needs Plans.
The Health Plan offers a Medicare Advantage Dual Eligible Special Needs Plan through the Allwell Dual Medicare (HMO-DSNP) from Arizona Complete Health.
22.214.171.124 Medicare Fee-for-Service Program
Instead of enrolling in a Medicare Advantage plan, Medicare eligible Members may elect to receive all Medicare services (Parts A, B and/or D) through any provider authorized to deliver Medicare services. Therefore, Members in the Medicare Fee-for-Service program may receive services from Medicare registered providers in The Health Plan provider network.
126.96.36.199 Inpatient Psychiatric Services
Medicare has a lifetime benefit maximum for inpatient psychiatric services. The Health Plan’s cost sharing responsibilities and billing for inpatient psychiatric services must be in accordance with Section 7.23 - Third Party Liability and Coordination of Benefits, and Section 7.3 - Submitting Claims and Encounters to The Health Plan.
The Health Plan requires all contracted providers to bill all third parties prior to billing The Health Plan. The Health Plan is the payer of last resort. When a member has primary insurance through another Health Plan and The Health Plan has been notified of the member’s admission to the hospital, The Health Plan will coordinate with that other Health Plan. The Health Plan will coordinate with the hospital staff to ensure that member’s needs upon discharge are coordinated and meet their needs.
188.8.131.52 Outpatient Behavioral Health Services
Medicare provides some outpatient services that are also State covered services. The Health Plan cost sharing responsibilities and billing for outpatient services must be in accordance with Section 7.22 - Third Party Liability and Coordination of Benefits and Section 7.3 - Submitting Claims and Encounters to The Health Plan.
The Health Plan requires all contracted providers to bill all third parties prior to billing The Health Plan. The Health Plan is the payer of last resort.
184.108.40.206 Prescription Medication Services
Medicare eligible Members must enroll in a Medicare Part D Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD) to receive the Part D benefit. PDPs only provide the Part D benefit and any Medicare registered provider may prescribe medications to Members enrolled in PDPs. Some MA-PDs may contract with RBHA/Health Plans or their providers to provide the Part D benefit to Medicare eligible Members.
While PDPs and MA-PDs are responsible for verifying prescription drug coverage to Members enrolled in their plans, there are some prescription medications that are not included on plan formularies (non-covered) or are excluded Part D drugs. The RBHA/Health Plan is responsible for covering non-covered or excluded Part D behavioral health prescription medications listed on the RBHA/Health Plan formulary, in addition to Part D cost sharing, in accordance with Section 7.23 - Third Party Liability and Coordination of Benefits.
Effective communication and coordination of services are fundamental objectives for providers when serving Members involved with other government entities. When providers coordinate care efficiently, the following positive outcomes can occur:
- Duplicative and redundant activities, such as assessments, service plans, and agency meetings are minimized;
- Continuity and consistency of care are achieved;
- Clear lines of responsibility, communication, and accountability across service providers in meeting the needs of the Member and family are established and communicated; and
- Limited resources are effectively utilized.
The Health Plan recognizes the importance of a responsive behavioral health system, especially when the needs of vulnerable Members have been identified by other government entities. For example, the State strongly supports the timely response and coordination of services for children who have been, or imminently will be, removed from their homes by the Arizona Department of Child Safety (see Section 12.2 - Appointment Standards and Timeliness of Service). The State expects all providers to collaborate and provide any necessary assistance when DCS initiates requests for covered services or supports.
The intent of this Section is to communicate The Health Plan’s expectations for providers who must cooperate and actively work with other agencies serving Members. The Health Plan expects any system partner involved with a member to be invited to Child and Family Team (CFT)/Interdisciplinary Care Team (ICT) meetings.
AHCCCS has Intergovernmental Agreements (IGAs), Interagency Service Agreements (ISAs), and Memorandums of Understanding (MOUs) with several State, county, tribal, and local agencies to collaborate while serving Members involved with multiple systems. The Health Plan and The Health Plan contracted providers are required to adhere to the applicable provisions of the IGAs, ISAs and MOUs.
In addition, providers are required to adhere to collaborative protocols established between The Health Plan, the community and the state stakeholders. These protocols can be accessed at www.azahcccs.gov
13.4.1 Department of Child Safety (DCS)
When a child Member receiving services is also receiving services from DCS, the provider must work toward effective coordination of services with the DCS Specialist.
ADES Arizona Families F.I.R.S.T. (Families in Recovery Succeeding Together) Program Providers must ensure coordination for parents/families referred through the Arizona Families F.I.R.S.T (AFF) program (see Provider Manual Attachment 4.4.1 Arizona Families F.I.R.S.T. Program Model and Referral Process).
The AFF program provides expedited access to substance abuse treatment for parents and caregivers referred by Department of Child Safety and the ADES/ Family Assistance Administration (FAA) Jobs Program. AHCCCS participates in statewide implementation of the program with ADES (see A.R.S. § 8-881). The Health Plan providers who are contracted with AFF are required to:
Accept referrals for Title XIX/XXI eligible and enrolled Members and families referred through AFF;
- Accept referrals for Non-Title XIX and Non-Title XXI persons and families referred through AFF and provide services, if eligible;
- Ensure that services made available to persons who are Non-Title XIX and Non-Title XXI eligible are provided by maximizing available federal funds before expending State funding as required in the Governor’s Executive Order 2008 -01;
- Collaborate with ADES/DCS, the ADES Family Assistance Administration (FAA) Jobs Program and Substance Use Treatment providers to minimize duplication of assessments and achieve positive outcomes for families; and
- Develop procedures for collaboration in the referral process to verify effective service delivery through The Health Plan. Appropriate authorizations to release information must be obtained prior to releasing information.
The Health Plan and the Department of Child Safety (DCS) Central, Southeast and Southwest Districts have combined efforts to establish a mutually agreed upon protocol to verify effective and efficient delivery of behavioral health services. “Collaborative Protocol between The Health Plan, Behavioral Health of Arizona and the Department of Child Safety (DCS)” defines the respective roles and responsibilities of each party.
The goal of the AFF Program is to promote permanency for children, stability for families, protect the health and safety of abused and/or neglected children and promote economic security for families. Substance abuse treatment for families involved with DCS must be family centered, provide for sufficient support services and must be provided in a timely manner (see Section 12.2 – Appointment Standards and Timeliness of Service and Section 12.10 - Special Populations).
13.4.2 Arizona Department of Education (ADE), Schools, or Other Local Educational Authorities
AHCCCS has delegated the functions and responsibilities as a State Placing Agency to The Health Plan for Members in The Health Plan’s Geographic Service Areas. The Health Plan works in collaboration with the ADE for the placement of children with behavioral health service providers.
Providers serving children can gain valuable insight into an important and substantial element of a child’s life by soliciting input from school staff and teachers. Providers can collaborate with schools and help a child achieve success in school by:
- Working in collaboration with the school and sharing information to the extent permitted by law and authorized by the child’s parent or legal guardian (see Section 9.6.1 - Disclosure of Health Information);
- For children receiving special education services, actively consider information and recommendations contained in the Individual Education Plan (IEP) during the ongoing assessment and service planning process (see Section 12.6, Assessment and Service Planning);
- For children receiving special education services, ensuring that the provider or designee participates with the school in developing the child’s IEP and share the behavior treatment plan interventions, if applicable;
- Inviting teachers and other school staff to participate in the CFT if agreed to by the child and legal guardian;
- Having a clear understanding of the Individualized Education Plan (IEP) requirements as described in the Individuals with Disabilities Education Act (IDEA) of 2004;
- Ensuring that students with disabilities who qualify for accommodations under 504 of the Rehabilitation Act of 1973 are provided adjustments in the academic requirements and expectations to accommodate their needs and enable them to participate in the general education program; and
- Ensuring that transitional planning occurs prior to and after discharge of an enrolled child from any out-of-home placement.
13.4.3 Department of Economic Security/Arizona Early Intervention Program (ADES/AzEIP).
Providers can work toward effective coordination of care for children identified as having, or likely having, disabilities or developmental delays by:
- Ensuring that children birth to three years of age are referred to AzEIP in a timely manner when information obtained in their behavioral health assessment reflects developmental concerns;
- Ensuring that children found to require services as part of the AzEIP evaluation process receive appropriate and timely service delivery (see Section 12.2 – Appointment Standards and Timeliness of Service);
- Ensuring that, if an AzEIP team has been formed for the child, the provider will coordinate team functions so as to avoid duplicative processes between systems;
13.4.4 Courts and Corrections
The Health Plan and its providers are expected to collaborate and coordinate care for Members involved with:
- The Arizona Department of Corrections, Rehabilitation and Reentry (ADCRR),
- Arizona Department of Juvenile Corrections (ADJC),
- Administrative Offices of the Court (AOC),
- Federal, state, county, municipal, tribal, and private jails/prisons/detention facilities, and
- Probation/Pretrial Service agencies (Adult and Juvenile)
When a Member receiving services is also involved with a court or correctional agency, providers work towards effective coordination of services by:
- Working in collaboration with the appropriate staff involved with the Member;
- Inviting probation or parole members to participate in the development of the ISP and all subsequent planning meetings as members of the Member’s clinical team with Member’s approval;
- Actively considering information and recommendations contained in probation or parole case plans when developing the ISP; and
- Ensuring that the provider evaluates and participates in transition planning prior to the release of eligible Members and arranges and coordinates care upon the person’s release (see Section 12.3 – Referral and Intake Process). For a copy of the Criminal Justice Release of Information Form, see Form 4.4.6 Authorization for Use or Disclosure of Protected Health Information – Criminal Justice System Referral.
Criminal Justice Reach-In Care Coordination Program and the Arizona Department of Corrections:
- The Health Plan staff will receive a notification when a member meeting Reach-In criteria is identified as nearing release. An Intake and Assessment appointment via MyHealthDirect (The Health Plan’s provider office scheduling vendor) to occur within seven days post-release with the member’s chosen provider.
- The provider shall conduct the Intake and Assessment appointment. During the Intake and Assessment appointment will be scheduled for adult members via MyHealthDirect (The Health Plan’s provider office scheduling vendor) to occur within seven days post-release with the member’s chosen provider.
- The provider shall conduct the Intake and Assessment appointment. During the Intake and Assessment appointment, the provider must educate the member and/or Health Care Decision Maker (HCDM) on the benefits of peer and/or family support and submit an automatic referral for peer support services through a Behavioral Health Home or Specialty Provider, if the member consents.
- The provider shall schedule an ART or CFT meeting to occur within 10 days post-release. With authorization from the member or HCDM, the provider must make every attempt to include The Health Plan’s Care Coordinator, probation/parole officer and other partners the provider identifies as supports to participate in the ART or CFT meeting.
- If transportation assistance is required for the member and/or HDCM to attend any of the appointments, the provider must coordinate and provide for the transportation. The provider must provide coordination and services for both behavioral and physical health.
- If the member does not appear for a scheduled appointment/service, the provider must attempt to contact the member and/or HDCM no fewer than three times. Attempts must be assertive and not simply a phone call, but documented in-person attempts and other avenues utilized for communication. For those members identified as not attending the required 7-day appointment, the provider must coordinate with the Health Plan’s Justice Team to identify and document the reason for the missed appointment.
- The provider must continue to engage the member and provide services identified on the Individualized Service Plan (ISP).
Criminal Justice Reach-In Care Coordination Program and the County Detention Centers:
- The Health Plan’s contracted Jail Liaisons will serve as the hub for Reach-In coordination and receive a weekly list of all eligible Reach-In members. Jail Liaisons will be notified weekly when a member meeting Reach-In criteria is identified as nearing release from a detention center. Notification will include members in active care and members not currently in an active status (inactive). The Health Plan’s contracted Jail Liaisons will meet with each adult member in person, when permissible by the detention center, within five business days of notification that a member is nearing release. If an in-person meeting is not permissible by the detention center, the Jail Liaisons must meet with the member via video visitation and within five business days.
- During the in-person or video visitation meeting, the Jail Liaisons will work diligently to engage the member into services to include: Provide education regarding behavioral health services; discuss the importance of physical health services; discuss services available such as peer support, housing, employment and other resources available; provide appointment scheduling and health plan information, if applicable; and education on the importance of obtaining medications or prescriptions and discharge plan from the detention center’s treating provider. An Assessment appointment will be scheduled for adult members MyHealthDirect to occur within seven days post-release with the member’s chosen provider.
- The provider shall conduct the Intake and Assessment appointment. During the Intake and Assessment appointment, the provider must educate the member and/or HDCM on the benefits of peer and/or family support and submit an automatic referral for peer support services through a Behavioral Health Home or Specialty Provider, if the member consents.
- The provider shall schedule an ART or CFT meeting to occur within 10 days post-release. With authorization from the member or HDCM, the provider must make every attempt to include The Health Plan’s Care Coordinator, probation/parole officer and other partners the provider identifies as supports to participate in the ART or CFT meeting.
- If transportation assistance is required for the member and/or HDCM to attend any of the appointments, the provider must coordinate and provide for the transportation. The provider must provide coordination and services for both behavioral and physical health.
- If the member does not appear for a scheduled appointment/service, the provider must attempt to contact the member no fewer than three times. Attempts must be assertive and not simply a phone call, but documented in-person attempts and other avenues utilized for communication. For those members identified as not attending the required 7-day appointment, the provider must coordinate with The Health Plan’s Justice Team to identify and document the reason for the missed appointment.
- The provider must continue to engage the member and provide services identified on the Individualized Service Plan.
13.4.5 Arizona Detention Facilities
When someone detained in jail is believed by jail personnel to have a behavioral health diagnosis, jail personnel may request the assistance of The Health Plan’s contracted providers to coordinate care as outlined below. In addition, The Health Plan’s Behavioral Health Home Providers are required to proactively assist persons detained who are determined to have, or perceived to have, a Serious Mental Illness (see Section 4.6.4 - SMI Eligibility Determination). Behavioral Health Home Providers are required to accept all requests for Community Re-Entry, Coordination of Care assistance and SMI Evaluations for Inviduals in county jails and perform the following duties:
- Timely and proactively collaborate with the appropriate jail and court staff involved with the Member;
- Proactively ensure that screening, assessment, and coordination of care services are provided;
- Upon receiving notification of a member being detained (through a phone call, a data feed or other communication), Behavioral Health Homes are required to provide the list of prescribed medications to the respective Detention Center Health Care Provider within 24 hours of notification; provide consultation services to advise jail staff related to diagnosis, medications, and the provision of other behavioral health services to detained Members upon request;
- Verify that the Member has a viable release plan, that includes access to medications, peer support services, counseling, transportation, and housing;
- Facilitate continuity of care if the Member is discharged or detained in another correctional institution;
- Share pertinent information with all staff involved with the Member’s care or incarceration with Member approval and in accordance with Section 9.6.1 - Disclosure of Health Information. For a copy of the Criminal Justice Release of Information Form, see Form 4.4.6 Authorization for Use or Disclosure of Protected Health Information – Criminal Justice System Referral.;
- Provide assistance in the determination of whether the Member is eligible for Mental Health Court or a Jail Diversion Program.; and
- Assure systems and processes are designed for discussion with detention and detention healthcare staff of services and resources needed for individuals to safely transition into the community upon release from detention if those individuals are designated as seriously mentally ill (SMI), or designated as seriously emotionaly disturbed (SED), or are categorized as General Mental Health (GMH),or substance abuse, or have any behavioral health or physical health care condition.
For additional information or assistance regarding providing coordination services to incarcerated Members, contact the Health Plan’s Customer Services at 1-866-796-0542.
13.4.6 Arizona Department of Economic Security/Rehabilitation Services Administration (ADES/RSA)
The purpose of RSA is to work with individuals with disabilities to achieve increased independence or gainful employment through the provision of comprehensive rehabilitative and employment support services.
Supportive employment services available through the AHCCCS system are distinct from vocational services available through RSA. Please refer to the AHCCCS Covered Behavioral Health Services Guide for more details.
When a Member determined to have a Serious Mental Illness is receiving services and is concurrently receiving services from RSA, the provider ensures effective coordination of care by:
- Working in collaboration with the vocational rehabilitation (VR) counselors or employment specialists in the development and monitoring of the Member’s employment goals;
- Ensuring that all related vocational activities are documented in the comprehensive clinical record (see Section 9.2 - Medical Record Standards);
- Inviting RSA staff to be involved in planning for day programming to ensure that there is coordination and consistency with the delivery of vocational services;
- Participating and cooperating with RSA in the development and implementation of a Regional Vocational Service Plan; and
- Allocating space and other resources for Vocational Rehabilitation (VR) counselors or employment specialists working with enrolled Members who have been determined to have a Serious Mental Illness.
13.4.7 Arizona Department of Health Services/Office of Assisted Living Licensing
When a Member receiving services is residing in an assisted living facility, providers must coordinate with the Office of Assisted Living Licensing to ensure that the facility is licensed and that there are no existing violations or legal orders. Providers must also determine and verify that the Member living in an assisted living facility is at the appropriate level of care. The provider can coordinate with the Office of Assisted Living Licensing to determine the level of care that a particular assisted living facility is licensed to provide.
13.4.8 First Responders and Community Agencies
The Health Plan and its providers proactively collaborate with municipal first responders: police, fire, Emergency Medical Services (EMS) and community agencies, such as: acute AHCCCS health plans and hospital emergency departments. Providers are expected to develop strong, effective relationships with first responders and community agencies in the communities they serve. Further information and assistance in engaging with first responders and community agencies may be obtained by contacting The Health Plan’s Justice System and System Partner Relations Department at 866-495-6738.
13.4.9 Veterans Administration
The Veteran’s Administration (VA) is a federally funded health system that provides benefits to qualified persons who served in the active military, naval, or air service, and who were discharged or released under conditions other than dishonorable (Congressional Research Center, 2012). The Health Plan’s Members with Veterans benefits can receive services from The Health Plan’s contracted providers. Veterans who are eligible for VA services have a choice from whom they receive services. Veterans can receive mental and/or physical health benefits through The Health Plan’s network or they may receive mental and/or physical health services through the VA, or medication only from one or the other, or any combination thereof. The Health Plan and its contracted providers are responsible to work collaboratively with the VA to share information and coordinate care.
13.4.10 Indian Health Services
Indian Health Services (IHS) is an agency within the Department of Health and Human Services and is responsible for providing federal health services to American Indians and Alaskan Natives. Individuals who are eligible for IHS benefits through an IHS provider or 638 licensed facility and are eligible to received services from The Health Plan’s contracted providers have a choice in whom they prefer to receive services. American Indian and Alaskan Natives can receive mental health benefits through The Health Plan’s network and physical health services through the IHS, or medication only from one or the other, or any combination thereof. The Health Plan and its contracted providers are responsible to work collaboratively with IHS to share information and coordinate care. See Section 13.1 - Transition of Persons for more information.
Arizona promotes various family roles and partnerships with families and family-run organizations within the children and adultbehavioral health system. The involvement of families is credited as making a significant contribution in improving the service system.
Partnership between individuals, staff, and family members/natural supports allow for shared decision making with a foundation of trust. Treatment decisions are made through a collaborative partnership with the member who is the driving force in their treatment. Compassion-based alliances with a focus on recovery optimization bolster self-confidence, expands understanding and empathy, and leads to the creation of optimum protocols and outcomes.
Parents/caregivers and youth are treated as full partners in the planning, delivery and evaluation of services and supports. Parents/caregivers and youth are equal partners in the local, regional, tribal and state representing the family perspective as participants in systems transformation. Arizona Complete Health Complete Care providers must:
- Ensure that families have access to information and have the opportunity to fully participate in all aspects of service planning and delivery.
- Approach services and view the enrolled child in the context of the family rather than isolated in the context of treatment.
- Recognize that families are the primary decision-makers in service planning and delivery.
- Provide culturally and linguistically relevant services that appropriately respond to a family’s unique needs.
- Assess the family’s need for a family support partner and make family support available when requested.
- Provide information to families on how they can contact staff at all levels of the service system
- Work with Arizona Complete Health Complete Care Plan to develop training in family engagement and participation, roles and partnerships for provider staff, parents/caregivers, youth and young adults
Also, please reference the AHCCCS Practice Protocol, Family and Youth Involvement in the Children’s Behavioral Health System (PDF) found on the AHCCCS website.
A Warm Line is a peer-run support line designed to help members manage life stressors. Warm lines are required to provide support through listening and offer resources to support members in the development of natural supports and independence, as appropriate.
13.6.1 Service Requirements
Warm line providers must follow these requirements:
- Be widely publicized within the covered service area;
- Be staffed with a sufficient number of peers to manage the Warm Line call volume and comply with the requirements of The Health Plan contract;
- Be answered within three (3) telephone rings, or within 15 seconds on average; and an average call abandonment rate of less than 3% each month;
- Be answered by a certified Peer Support staff person at a minimum Monday through Friday, 8:00 AM to 10:00 PM;
- Include the ability to triage calls, make referrals to appropriate resources, dispatch service providers and patch capabilities to and from 911 and crisis line providers as applicable;
- Offer interpretation or language translation services to members, including the deaf and hard of hearing;
- Warm Line staff must participate in all trainings and coordination meetings required or requested by the AHCCCS and/or AzCH-CCP;
- Warm Line staff must be trained in identifying crisis calls and transferring calls between systems.
13.6.2 Staff Requirements
Warm Line providers must follow these staffing requirements:
- Maintain adequate Peer Support staff to answer calls in a timely manner and document the resolution of calls;
- Maintain bilingual (Spanish/English) capability on all shifts and be able to effectively utilize interpreter services to facilitate Warm Line telephone peer support for all callers;
Provide consistent clinical supervision to ensure services are in compliance with the Arizona Principles and all State supervision requirements.