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Specific Behavioral Health Program Requirements

Urgent Engagement is the process of engaging people into care who have experienced a crisis or have been admitted to an inpatient facility. It is intended to engage persons into care, rather than fulfilling an administrative function. The process includes ensuring effective coordination of care, engagement, discharge planning, a Serious Mental Illness (SMI) screening when appropriate (reference Provider Manual section 12.6), screening for eligibility, referral as appropriate, and prevention of future crises. Once the Behavioral Health Home completes the urgent engagement process, the Behavioral Health Home is the entity that is responsible for coordination of necessary service and discharge planning. Urgent Engagements are required to be started within one hour (at a Community Observation Center) or 24 hours (at a Behavioral Health Inpatient Facility).

14.1.1 Behavioral Health Home Urgent Engagement Responsibility

Behavioral Health Homes must accept referrals and requests for Urgent Engagements 24 hours a day and seven days a week. Providers are required to record, report and track completion of Urgent Engagements.

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.

One Hour Urgent Engagements at a Community Observation Unit (COU)

AzCH-CCP enrolled and State Only (N19/NSMI) inidviduals who receive services at a Community Observation Unit and identify as not engaged with a BH provider must be referred for urgent engagement. The Behavioral Health Home must arrive within one hour of the request. Once a Behavioral Health Home makes contact with the member, they are responsible for discharge planning for that member, including transportation and a follow up appointment. The urgent engagement at a COU should be an abbreviated intake in order to quickly gather the information needed. The engagement process can be completed in a follow up appointment (preferably within the next 24-48 hours).

24-hour Urgent Engagements at a Behavioral Health Inpatient Facility (BHIF)

Every AzCH-Complete Care Plan enrolled or State Only individual who resides in The Health Plan covered service area and meets the requirements (listed below) are eligible for an Urgent Engagement.

  • Member is hospitalized at a Behavioral Health Inpatient Facility
  • Member is not in active care with a Behavioral Health Home
    The selected Behavioral Health Home has 24-hours to arrive at the facility and complete the Urgent Engagement assessment. In the event the individual is sleeping or otherwise unable to participate in the Urgent Engagement process, the Behavioral Health Home shall reschedule the Urgent Engagement assessment within 24-hours and inform The Health Plan of the status.

Behavioral Health Homes activated by the Urgent Engagement process are required to enroll members and non-eligible members refusing services during the COE (Court Ordered Evaluation) process. Once the member is Court Ordered, the Behavioral Health Home is required to proceed with engagement and service delivery; including, an SMI screening.

The Health Home shall transmit the Urgent Engagement Disposition form to AzCHDISPO@azcompletehealth.com within 24-hours of completing assessment.

24-hour Urgent Engagements at a Physical Health Inpatient Facility

Every AzCH-Complete Care Plan enrolled or State Only individual who resides in The Health Plan covered service area and meets the requirements (listed below) are eligible for an Urgent Enagement.

  • Member is hospitalized at a Physical Health Inpatient Facility
  • Member is not in active care with a Behavioral Health Home

Behavioral Health Homes are required to arrive at the facility and complete the urgent engagement assessment within 24 hours of the request. In the event the individual is sleeping or otherwise unable to participate in the urgent engagement process, the Behavioral Health Home shall reschedule the urgent engagement assessment within 24-hours and inform The Health Plan of the status.

24-hour SMI Evaluation at a Behavioral Health Facility (BHIF)

Every AzCH-Complete Care Plan enrolled or State Only individual who resides in the Health Plan covered service area and meets the requirements (listed below) are eligible for an Urgent Engagement.

  • Member is hospitalized at a Behavioral Health Inpatient Facility for psychiatric reasons
  • Member is not in active care with a Behavioral Health Home
  • Member presents with a need for an SMI evaluation, is eligible to be assessed for an SMI diagnosis.

The Behavioral Health Home shall complete the Urgent Engagement assessment within 24-hours and transmit the Urgent Engagement Disposition form to AzCHDISPO@azcompletehealth.com  within 24-hours of completing assessment.

The Behavioral Health Home shall submit the SMI evaluation packet within seven days of the Urgent Engagement assessment to the designated SMI Evaluation provider, Community Response Network (CRN).

SMI Evaluation at the Arizona State Hospital (ASH)

The purpose of the SMI evaluation services, for persons from The Health Plan geographic area admitted to ASH, are for discharge planning.  The Behavioral Health Home has seven calendar days to complete the assessment and submit the Urgent Engagement Disposition form to AzCHDISPO@azcompletehealth.com within 24-hours.

The Behavioral Health Home shall submit the SMI evaluation packet within seven days of the Urgent Engagement assessment to the designated SMI Evaluation provider, Community Response Network (CRN).

14.1.2 Capacity to Travel

Behavioral Health Homes must maintain capacity to travel to locations within Arizona to complete Urgent Engagements.

14.1.3 Computer and Wireless Specifications

Behavioral Health Homes must verify Urgent Engagement staff have access to a laptop, mobile printer and wireless web connectivity to allow access to electronic medical information in the field. The computer and wireless specifications meet or exceed The Health Plan requirements.

14.2.1 72-Hour Rapid Response Requirements for Children

Health Plan contracted Behavioral Health Homes must complete a rapid response assessment within 72 hours of Health Plan activation for all children who are taken into the custody of DCS, regardless of Title XIX/XXI eligibility status.

Within 72-hours of the Health Plan Rapid Response dispatch, the Behavioral Health Home must conduct a face-to-face visit with the child in their placement in order to:

  • Complete an assessment to identify immediate safety needs and presenting problems of the child to stabilize behavioral health crises and to be able to offer immediate services the child may need;
  • Provide behavioral health services to each child with the intention of reducing the stress and anxiety that the child may be experiencing, and offering a coherent explanation to the child about what is happening and what can be expected to happen in the near-term;
  • Provide or arrange needed behavioral health services to each child’s new caregiver, including guidance about how to respond to the child’s immediate needs in adjusting to foster care, behavioral health symptoms to watch for and report, assistance in responding to any behavioral health symptoms the child may exhibit, and identification of a contact within the behavioral health system;
  • Ensure that each child and family is referred for ongoing behavioral health services as indicated by the assessment and service plan and ensure that services start within 21 days of the Rapid Response Assessment.
  • Initiate the development of the Child and Family Team (CFT) for each child (see Child and Family Team Practice Tool (PDF)); and
  • Provide the DCS Specialist with written findings and recommendations for medically necessary covered services within 24 hours of Rapid Response assessment. This information shall be utilized during the initial Preliminary Protective Hearing, which occurs within 5 to 7 days of the child’s removal. (See Provider Manual Section 12.2.4, 72 Hour Urgent Behavioral Health Response for Children taken Into the Department of Child Safety's (DCS) Custody).

Additionally, Behavioral Health Homes are expected to engage the family from which the child was removed within 5 days of the Rapid Response in order to engage them in the assessment process and invite them to participate in the Child and Family Team meeting. The Behavioral Health Home is expected to help the parents identify appropriate services and support them in the enrollment process.

Behavioral Health Homes are required to attend the Pre-Hearing Conference and Preliminary Protective Hearing to present their assessment and recommendations and continue to engage the family.

14.2.1.1 Capacity to Travel

Behavioral Health Homes must maintain capacity to travel to locations within Arizona to complete a 72 Hour Rapid Response assessment.

14.2.1.2 Tracking of Transfers

When applicable following a Rapid Response, Behavioral Health Homes must track the transfer of enrolled Members to other Health Plan contracted Behavioral Health Homes through the Health Plan Provider Portal and continue providing coordination and treatment services until the receiving agency has fully accepted the transfer as indicated in the Provider Portal.

14.2.1.3 Computer and Wireless Specifications

Behavioral Health Homes must verify Rapid Response staff have access to a laptop, mobile printer and wireless web connectivity to allow access to electronic medical information in the field. Computer and wireless specifications must meet or exceed Health Plan requirements.  Ongoing Service Requirements for Comprehensive Medical and Dental Plan (CMDP) Eligible DCS Involved Children. Behavioral Health Homes are expected to provide services for a period of at least six months following the Rapid Response assessment unless the Behavioral Health Home receives a written request from the guardian or the DCS case closes.

14.2.2 Ongoing Service Requirements for CMDP Eligible DCS Involved Children

Behavioral Health Services for DCS involved children must stay open for at least six months following the Rapid Response assessment unless the Behavioral Health Homes receives a written request from the guardian or DCS closes out the member.

DCS Involved Children must receive at least one service, identified on their service plan each calendar month.

Behavioral Health Homes must ensure that services are provided to children within 21 days of the following:

  • Rapid Response Assessment
  • Initial/Intake Assessment
  • Update of the Comprehensive Assessment
  • Agreement of the Child Family Team

Behavioral Health Homes are expected to participate in all court hearings as appropriate for members in their care.

Behavioral Health Homes are required to coordinate care for all CMDP members who become detained in a county detention facility located outside of the Health Plan service area.

Behavioral Health Homes are expected to engage the biological parents, foster parents, kinship parents and adoptive parents throughout the course of treatment. The purpose of this engagement is to engage the parents and caretakers in the assessment process and invite them to participate in the Child and Family Team meeting. The Behavioral Health Home is expected to help the parents identify appropriate services and support them in the enrollment process.

When the DCS Specialist/Legal Guardian is not available, the Behavioral Health Home must recognize the signature of the foster or kinship placement for the purpose of coordinating outpatient behavioral health services. Foster and kinship placements may sign a release of information, consent to treat, the service plan and other necessary documentation. If there is a disagreement between the placement and the DCS Specialist about services, the Legal Guardian/DCS Specialist shall make the final decision.

The DCS Specialist/Legal Guardian must be the one to sign a child in the legal custody of DCS in to a Therapeutic Foster Care (TFC) Home formerly known as Home Care Training for the Home Care Client (HCTC), Behavioral Health Residential Facility (BHRF), Behavioral Health Inpatient Facility (BHIF), Brief Intervention Program (BIP) or a hospital.

14.2.3 Requirements of Jacobs Law/ ACOM Policy 449

14.2.3.1 Requirements of the Foster Care Hotline

AzCH-CCP contracts with the Arizona Crisis Line to maintain a Foster Care Hotline for the specific purpose of answering calls about DCS involved children from Foster, Kinship and Adoptive Parents. The Foster Care Hotline shall be available 365/24/7 to meet the needs of the child and family.

Appropriate calls to the Arizona Crisis Line, Foster Care Hotline, may include but are not limited to:

  • Initiate a Rapid Response at the 73rd hour, not previously initiated by DCS
  • Placement initiated Request for 72 Hour Out of Home Determination due to dangerous or threatening behaviors
  • Request for Crisis Mobile team
  • Request for referral to a Secondary Responder/Placement Stabilization Program

When a foster parent, kinship placement, group home or law enforcement official calls the Foster Care Hotline to initiate a Rapid Response, the Foster Care Hotline staff must immediately email the Health Plan Rapid Response Program at AzCHDCSRR@azcompletehealth.com  and the DCS Child Services liaison.

14.2.3.2 ACOM Policy 449 Requires

The Foster Care Hotline is required to send out a Crisis Mobile Team if a foster, kinship or adoptive parent requests a 72 Hour Higher Level of Care Determination.

The Crisis Mobile Team shall determine if the child needs to go to a hospital, CRC or BIP (for AzCH-CCP members) to ensure the safety of the child while the team meets to determine further clinical needs of the child. If the CMT determines the child is safe to stay in the current environment, a safety plan must be developed prior to leaving the home.

The Crisis Mobile Team shall immediately inform the Behavioral Health Home and The Health Plan CMDP Coordinators at the AzCHDCS@azcompletehealth.com  email of the call and the need for an Emergency CFT.

The Behavioral Health Home is required to have an Emergency CFT to identify the needs of the member and if appropriate follow the Health Plan process for securing the appropriate level of care for the member.

14.2.3.3 Crisis Response for DCS Involved Members and Adopted Children

When the AzCH-CCP Foster Care Hotline is called because the member is in crisis or is showing dangerous or threatening behaviors, a crisis mobile team shall be dispatched.

Crisis Mobile Team providers are required to arrive within 2 hours of dispatch.

Crisis Mobile Teams that do not arrive within 2 hours are expected to call the Foster Care Hotline and report the missed timeframe

AzCH-CCP Foster Care Hotline is required to notify the DCS Child Services Liaison via email of any CMT dispatches that do not meet the 2 hour required response time.

All calls received by the AzCH-CCP Foster Care Hotline must be tracked and reported to The Health Plan using Deliverable EC-301-25 Foster Care Hotline Call Report.

The EC-301.25 Foster Care Hotline Call Report is due the 10th of every month for the previous month. 

14.3.1 Unskilled Respite

Unskilled Respite Care (Respite) is short term behavioral health services or general supervision that provides an interval of rest or relief to a Family member or other individual caring for the member receiving behavioral health services. As of January 1, 2021, the use of Electronic Visit Verification is required for the delivery of respite services as required by AMPM 540. Please reference Provider Manual Section 4.15 Electronic Visit Verification for more information on those requirements.

The availability and use of informal supports and other community resources to meet the caregiver’s respite needs shall be evaluated in addition to formal respite services.

Respite services are limited to 600 hours per year (October 1 through September 30) per person and are inclusive of both behavioral health and ALTCS respite care.

Respite may include a range of activities to meet the social, emotional, and physical needs of the member during the respite period.

These services may be provided on a short-term basis (i.e. few hours during the day) or for longer periods of time involving overnight stays. Respite services can be planned or unplanned. If unplanned respite is needed, the behavioral health provider will assess the situation with the caregiver and recommend the appropriate setting for respite. Community Service Agencies cannot provide respite services.

In accordance with AMPM 310-B, Respite services may be provided in a variety of settings including but not limited to:

  • Habilitation Provider (A.A.C. R6-6-1523),
  • Outpatient Clinic (A.A.C. R9-10-1025),
  • Adult Therapeutic Foster Care – with collaboration health care institution (A.A.C. R9-10-1803),
  • Behavioral Health Respite Homes (A.A.C. R9-10 Article 16), and Behavioral Health Residential Facilities.

A member’s clinical team shall consider the appropriateness of the setting in which the recipient receives respite services,

  • When respite services are provided in a home setting, household routines and preferences shall be respected and maintained when possible. The respite provider shall receive orientation from the Family/caregiver regarding the member’s needs and the Service Plan, and
  • Respite services, including the goals, setting, frequency, duration, and intensity of the service shall be defined in the member’s Service Plan. Respite services are not a substitute for other covered services. Summer day camps, day care, or other ongoing, structured activity programs are not respite unless they meet the definition/criteria of respite services and the provider qualifications.

Parents receiving behavioral health services may receive necessary respite services for their non-enrolled children as indicated in their Service Plan, and

Non-enrolled siblings of a child receiving respite services are not eligible for behavioral health respite benefits.

14.3.2 Behavioral Health Respite Home Requirements

Behavioral Health Respite Home Providers must meet the requirements of AAC R9-10, Article 16.

14.3.2.1 Authorization and Continued Stay Requirements

Behavioral Health Respite Home providers must meet all prior authorization and continued stay requirements for Behavioral Health Supportive Homes as spelled out in this Provider Manual and as directed by the Health Plan.

The Health Plan promotes the service delivery and network capacity for children birth to five by trained specialist (Infant Toddler Mental Health Coalition of Arizona [ITMHCA] standards). Birth to Five providers must identify high needs birth to five populations, provide screening, assessment, service planning, interventions and practices specifically designed to meet the unique needs of children age Birth to Five and their families. Providers are required to utilize the AHCCCS Practice Tools “Working with the Birth to Five Population andPsychiatric and Psychotherapeutic Best Practices for Children Birth Through Five Years of Agefor additional guidance.

Birth to Five providers must demonstrate active participation in state, regional and community sponsored best practices development and committed to working to build community knowledge base and expertise.

Brief Intervention Program providers must maintain an intensive treatment program to deliver services 24 hours a day, 7 days a week, 365 days a year with the purpose of helping persons live successfully in the community. Brief Intervention Program providers must deliver supportive and treatment services necessary to support the Member in the community and must verify access to the services 24 hours a day, 7 days a week, 365 days a year to respond to crises, as appropriate.

14.5.1 Staffing

Brief Intervention Program providers must provide adequate staffing to maintain the safety of the Members and protect them from harm.

14.5.2 Participation Limit

Brief Intervention Program providers must limit participation in the program to ten (10) days per episode.

14.5.3 Coordination with Teams and Family

Brief Intervention Program providers must coordinate with treatment teams and family members, as appropriate, to verify continuity of care. Child and Family Teams/Adult Recovery Teams must be conducted within 72 business hours after admission. Each Brief Intervention Program provider must submit a report as indicated in Section 16 – Deliverable Requirements.

Providers can be considered “Consumer Operated” if they comply with the requirements as outlined in the SAMHSA Consumer Operated Services Evidence-Based Practices Kit. Consumer Operated Providers can hold a behavioral health license from the Arizona Department of Health Services Division of Licensing, or in some situations can be certified as a Community Service Agency per AHCCCS AMPM 965 - COMMUNITY SERVICE AGENCIES. Community Service Agency Application forms can be found on the AHCCCS website.

14.7.1 General Requirements for Crisis Line providers

14.7.1.1 Referrals

Crisis Line providers must comply with the requirements outlined in Provider Manual Section 14.13, Substance Use Disorder Treatment Requirements.

14.7.1.2 After Hours

Crisis Line providers must maintain an administrator–on-call to address any after-hours, weekend or holiday concerns or issues.

14.7.1.3 Services

Services must be individualized to meet the needs of Members and families. Crisis Line 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. Crisis Line providers must provide monitoring, feedback and follow up after crisis based on the changing needs of the individual. The family must be treated as a unit and included in the treatment process, when determined to be clinically appropriate. Crisis Line providers must obtain and document child, family and Member input in treatment decisions.

14.7.1.4 Substance Use Disorders (SUD) Services

Crisis Line providers providing SUD services must develop services that are designed to reduce the intensity, severity and duration of substance use and the number of relapse events, including a focus on life factors that support long-term recovery as appropriate.

14.7.1.5 Coordination of Care

Crisis Line providers must contact the Behavioral Health Home following a member’s utilization of crisis services. Crisis Line providers must verify coordination and continuity within and between service providers and natural supports to resolve initial crisis and to reduce further crisis episodes over time.

14.7.1.6 Community-Based Alternatives

Crisis Line 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, Crisis Line providers must work with the Member to transition back into community-based care settings as rapidly as is clinically feasible and must partner with community provider agencies to develop and offer services that are alternatives to more restrictive institutionally or facility based care.

14.7.1.7 Staff Requirements and Training

All Clinical Supervisors must meet the appropriate Arizona Board of Behavioral Health Examiners requirements to conduct clinical supervision. Crisis Line providers must demonstrate completion of all Arizona Department Health Services Division of Licensing training requirements are met for all direct care staff. All staff Members must complete an annual training in Cultural Competency and annual Fraud & Abuse Training, and providers must maintain documentation verifying completion of the training. In addition, providers must verify that all staff and family of Members who provide Peer Support or Family Support have adequate training to support them in successfully fulfilling the requirements of their position

Crisis Line providers must notify The Health Plan of any staff changes or incidents impacting credentialing involving Behavioral Health Professionals or Behavioral Health Medical Professionals within forty-eight (48) business hours of any additions, terminations or changes.

14.7.1.8 Quality Improvement

Crisis Line providers must participate in clinical quality improvement activities that are designed to improve outcomes for Arizona Members.

14.7.1.9 Electronic Health Record (EHR)

Crisis Line providers are highly encouraged to have in place a fully operational EHR; including, electronic signature, and remote access, as required to meet Federal Medicaid and Medicare requirements. In addition, Crisis Line providers must allow State and The Health Plan staff access to the EHR for the purpose of conducting audits.

14.7.2 Service Requirements

Crisis Line providers must maintain a twenty-four (24) hours per day, seven (7) days per week crisis response system that has a single toll-free crisis telephone number and the discretion to establish a local crisis telephone number. The crisis line must:

  • Be widely publicized within the covered service area and included prominently on The Health Plan website, the Member Handbook, Member newsletters, and as a listing in the resource directory of local telephone books;
  • Be staffed with a sufficient number of staff to manage a telephone crisis response line to comply with the requirements of the Agreement;
  • Be answered within three (3) telephone rings, or within 15 seconds on average, with an average call abandonment rate of less than 3% for the month.
  • Include triage, referral and dispatch of service providers and patch capabilities to and from 911 and other crisis providers as applicable;
  • Offer interpretation or language translation services to persons who do not speak or understand English and for the deaf and hard of hearing; and
  • Provide Nurse On-Call services twenty-four (24) hours per day, seven (7) days per week to answer general healthcare questions from SMI Members receiving physical health care services and to provide them with general health information and self-care instructions.

14.7.2.1 Staff Requirements

Crisis Line providers must follow the requirements below:

  • Establish and maintain the appropriate ADHS Division of Licensing license to provide required services.
  • Maintain appropriate Arizona licensed medical staff, Arizona licensed Behavioral Health Professionals, ADHS Division of Licensing facility licenses, qualified Behavioral Health Technicians and Paraprofessionals, and Peer Support staff to adequately address and triage Member calls and verify the safe and effective resolution of calls.
  • Maintain bilingual (Spanish/English) capability on all shifts and employee interpreter services to facilitate crisis telephone counseling for all callers.
  • Provide consistent clinical supervision to verify services are in compliance with the Arizona Principles and all ADHS Division of Licensing, and State supervision requirements are met.
  • Employ adequate staff to implement the Crisis AfterCare Recovery program.
  • Employ one (1) full-time American Indian Warm-line Program Coordinator and part-time tribal Member employees representing the Tribal Nations served by The Health Plan who have tribal Members living on tribal lands in Arizona.

14.7.2.2 Telephone Call Response Requirements

Crisis Line providers must verify that all calls for Crisis Mobile Teams and Nurse Line are answered within three telephone rings, or within fifteen (15) seconds, as measured by the monthly Average Speed of Answer. All crisis calls and Nurse Line calls must be live answered.

Crisis Line providers must report monthly, quarterly, and annually, all phone access statistics to include: total number of calls received, number and percent abandoned, average speed of answer, and number of calls outside standards. Crisis Line providers must report daily a phone access report that identifies number of calls outside standards, amount of time to answer call for each call outside standards, and number of abandoned calls associated with call outside standards.

14.7.2.3 Crisis Counseling, Triage, Tracking, Mobile Team Dispatch and Resolution

Crisis Line providers must meet the following requirements:

  • Provide crisis counseling, triage and telephonic follow-up 24/7/365. All crisis calls must be live answered. Crisis callers must not receive a prompt, voice mail message, or be placed in a phone queue.
  • Provide crisis counseling and triage services to all persons calling The Health Plan Crisis Line, regardless of the caller's eligibility for Medicaid services.
  • Review Crisis Plans identified in The Health Plan data system to assist with crisis resolution and suggest appropriate interventions.
  • Dispatch mobile team services delivered by provider agencies and must track mobile team intervention resolution in compliance with protocols established or approved by The Health Plan. Crisis Line providers must report on a weekly and monthly basis these dispatches in a format approved by The Health. Daily reports may be required as needed.
  • Assess the safety of a crisis scene prior to mobile team dispatch and track mobile teams to monitor the safety of the mobile team staff.
  • Follow-up with Members, crisis mobile team staff, Integrated Care Managers, and system partners to verify appropriate follow-up and coordination of care.
  • Assess Member dangerousness to self and others and provide appropriate notification to The Health Plan, Behavioral Health Home Health Care Coordinator, and obtain information on Member's consistent use of medications to minimize dangerousness and promote safety to the Member and community.
  • Follow community standards of care and best practice guidelines to warn and protect Members, family members and the community due to threats of violence.
  • Document all interactions and triage assessments to facilitate effective crisis resolution and validate interventions.
  • Conduct a follow-up call within seventy-two (72) hours to make sure the caller has received the necessary services. Verify Members are successfully engaged in treatment before closing out the crisis episode and follow-up to verify system partner and Member satisfaction with the care plan.
  • Support the mobile teams and arrange for transports, ambulance, etc.
  • Dispatch and track requests for 1 hour Urgent Engagements. Dispatch and Track requests for 24 hour Urgent Engagement referrals after hours.
  • Monitor and make best efforts to verify that 1 hour Urgent Engagements are completed within 1 hour of Behavioral Health Home activation.  Provider must document and report any reported response delay reason, monitor and make best efforts to verify that 24 hour Urgent Engagements are completed within twenty-four (24) hours of notification by health plans, hospitals, or detention centers. Provider must document and report any reported response delay reasons.
  • Track all Urgent Engagement requests to verify Members are engaged in follow-up care.
  • Provide reports that track and summarize the requests for, daily pending inpatient report, daily call statistics report, CMT timeliness report, re-entry reports, urgent response report, acute health plan inquiry log, crisis indicator data report, client activity report, second responder tracking and 24 Hour Mobile Urgent Intake requests the disposition of such assessments in a format established or approved by The Health Plan.
  • Make reasonable attempts to verify that the dispositions and intake appointments are completed.
  • Document and report any delay reasons to The Health Plan in real time for all Urgent Response requests.

14.7.3 Customer Service, Member Outreach, Engagement

14.7.3.1 Customer Service

Crisis Line providers must provide customer service functions on behalf of The Health Plan when The Health Plan offices are closed. Crisis Line providers must complete transactions for Customer Service after-hours without referring anyone to call back during regular business hours unless the call is regarding a claim. The Health Plan Customer Service telephone number must be forwarded to The Crisis Call Center whenever The Health Plan offices are closed and occasionally, as arranged in advance, through Work Force Management.

14.7.3.2 Safety Net

Crisis Line providers must serve as a "safety net" to The Health Plan Members by re-engaging Members into treatment, as identified by The Health Plan and per data provided by The Health Plan.

14.7.3.3 Documentation and Monitoring

Crisis Line providers must document and monitor consistent use of crisis services for persons identified as High Need by The Health Plan, provider agencies or by family report. All High Need situations involving dangerousness to self or others must be staffed immediately with an independent licensed supervisor and the supervision must be documented in the record.

14.7.3.4 Grievances and Service Gaps

Crisis Line providers must notify The Health Plan through The Health Plan data systems of any service delivery problems, grievances, service gaps and concerns raised by Members, family members, and system partners.

14.7.3.5 Encounters

Crisis Line providers must encounter and document all services in compliance with the AHCCCS Covered Behavioral Health Service Guide.

14.7.3.6 Quality Improvement

Crisis Line providers must conduct outreach calls, The Health Plan, to facilitate quality improvement initiatives, as determined by The Health Plan, such as but not limited to the timely completion of Service Plans, use of medications, Health Care Coordinator selection and Member satisfaction, consistent use of treatment services, and frequency of treatment team meetings. Crisis Line providers must participate in satisfaction surveys sponsored by the State and The Health Plan as requested and must conduct satisfaction surveys from reports generated by The Health Plan.

14.7.3.7 Coordination of Care

Crisis Line providers must facilitate effective coordination of care with provider agency staff to promote effective recovery for Members. Crisis Line providers must track resolution until Member reports being successfully engaged in care and consistently engages in treatment.

14.7.3.8 Member Assistance and Providing Information

Crisis Line providers must assist Members in getting their prescriptions filled, obtaining services, resolving access to care problems, and obtaining medically-necessary transportation services. Crisis Line providers must also refer Members for outpatient services and warm transfer callers to agencies or service providers whenever possible upon completion of the call. Follow up calls shall be made to verify referred caller made and kept appointment. Crisis Line providers must explain to callers the process to access services, authorization process for Behavioral Health Inpatient and Hospital services and provide names and locations of intake agencies accessible to the caller.

Members must be informed about The Health Plan website, Member rights and grievance and appeal procedures as appropriate. Crisis Line providers must assist Members in addressing third party liability and "payer of last resort" issues related to accessing services including pharmacy services.

Crisis Line providers must assist Members in managing their own care, in better understanding their rights, in identifying and accessing resources and in more effectively directing their care.

14.7.3.9 Member Eligibility

Crisis Line providers must research Member eligibility for services on behalf of providers and Members and make available eligibility information to callers to assist access to care. Crisis Line providers must make available to Members, family members, and provider agencies treatment information about Evidenced Based Practices and shall assist callers in becoming better informed about services and recovery.

14.7.3.10 Peer Outreach and Coordination

Crisis Line providers must successfully coordinate services with PFROs; including, Peer Crisis AfterCare Programs, Peer Warm Lines, Peer Community Reentry Programs, and Peer Hospital Discharge Programs.

14.7.3.11 Crisis

Crisis Line providers must participate in all trainings and crisis coordination meetings required or requested by the State and/or The Health Plan. Crisis Line providers must successfully implement a Crisis AfterCare Recovery Team, employing program staff during peak hours Monday through Friday. The Crisis After-Care Recovery Team must conduct outreach, service coordination and crisis stabilization services to Members following mobile crisis team visits, crisis telephone calls, hospitalization and The Health Plan coordination of care requests. In addition, Crisis Line providers must document coordination efforts in The Health Plan software systems.

14.7.3.12 Certified Health Care Coordinator

Crisis Line providers must support and strengthen the role of the Certified Health Care Coordinator through care facilitation, being careful to not diminish the relationship between the Member and the Health Care Coordinator.

14.7.3.13 American Indian Warm-line Program (aka Tribal Warm Line)

Providers must successfully implement an American Indian Warm-line Program and transfer system that includes (at least) part-time tribal Member employees (aka Tribal Support Partners) from the tribes served by The Health Plan. Tribal Support Partners must conduct calls (inbound/outbound) to facilitate member engagement in treatment, instill hope and promote recovery.

14.7.3.14 Tribal Warm Line (TWL) Service Requirements

  • The TWL must be answered by a Tribal Support Partner Monday through Friday, 9:00 AM to 9:00 PM.
  • Outside of these hours, the TWL must be answered by the crisis line, with a follow-up call by a Tribal Support Partner during the TWL operating hours.
  • Tribal Support Partners must be trained in identifying crisis calls and transferring calls between systems.
  • Tribal Warm Line staff must participate in all trainings and coordination meetings required or requested by the State and/or The Health Plan.

14.7.3.15 24/7 Online Scheduling System

Crisis Line providers must successfully implement a 24/7 online scheduling system to schedule emergent follow-up appointments and urgent intake assessments with an outpatient provider following a crisis episode.

Crisis Mobile Team providers must provide crisis mobile team services in the assigned geographic areas and in accordance to State and The Health Plan requirements.

14.8.1 Supervision by Independently Licensed Behavioral Health Professional

Crisis Mobile Team providers must verify that the Crisis Mobile Team Program is clinically supervised by a The Health Plan Credentialed Independently Licensed Behavioral Health Professional. Crisis Mobile Team providers must verify all Risk Assessments and crisis notes are reviewed and signed off by a The Health Plan Credentialed Independently Licensed Behavioral Health Professional within 24 business hours.

14.8.2 Crisis Mobile Team Provider

Crisis Mobile Team providers must coordinate all services through The Health Plan Crisis Mobile Team provider and follow crisis protocols established by The Health Plan and community stakeholders. Crisis Mobile Team providers must work collaboratively with The Health Plan Crisis Line Provider to receive mobile team dispatches, coordinate all services, and facilitate crisis resolution planning. Crisis Mobile Team providers must report all staffing changes to The Health Plan Network Development Department through the EC-312 deliverable. Crisis mobile team providers are required to carry, and use as required, GPS enabled phones provided by crisis line provider. Crisis Mobile Team Agencies are required to have a super-user available within their agency for technical support. GPS phones will enable one number electronic dispatching from the crisis line provider. GPS phones must be kept with crisis mobile team staff on shift at all times. Crisis Mobile Team staff must be trained in appropriate use of the GPS phones. Crisis Mobile Team providers are required to cover the cost of damaged or lost GPS phones as requested by The Health Plan crisis phone provider. If you are assigned a GPS enabled cellular device, it is a condition precedent that you read and sign your specific User Agreement prior to receiving any such cellular device or devices.

14.8.3 Coordination Calls and Coordination with Outpatient Department

Crisis Mobile Team providers must participate in crisis coordination calls and meetings to facilitate effective working relationships. Crisis Mobile Team providers must verify mobile team services are closely linked to the provider's outpatient department and that coordination of care is occurring with outpatient providers for members who have been in a crisis.  If the crisis occurs during business hour, the expectations is that the coordination occurs in real time.

14.8.4 Staffing and Training

Crisis Mobile Team providers must employ adequate staff to consistently meet the requirements for crisis mobile teams. Crisis mobile teams must have the capacity to serve specialty needs of population served including youth and children, Tribal members, and developmentally disabled. Crisis Mobile Team providers must ensure adequate coverage to maintain full crisis team capacity as a result of staff illnesses and vacations. All direct care crisis staff must be Critical Incident Stress Management (CISM) trained. Crisis Mobile Team providers must participate in training events sponsored by The Health Plan and the State to enhance the performance of the crisis system.

14.8.5 Mobile Crisis Vehicles

A mobile crisis team must be able travel to the place where the individual is experiencing the crisis. Crisis Mobile Team providers must provide and maintain mobile crisis vehicles to facilitate transports and field interventions.

14.8.6 Title 36 Screenings

Crisis Mobile Team providers must ensure Title 36 screenings are conducted by staff other than mobile team staff unless The Health Plan holds a contract with the applicable County, in which case the mobile crisis team should follow the requirements specified in that contract. See Section 12.9 - Pre-Petition Screening.

14.8.7 Telephone and Internet Connectivity

Crisis Mobile Team providers shall be provided GPS enabled cell phones for all crisis staff on duty and must verify effective connectivity. Crisis Mobile Team providers must provide internet and telephone connectivity through cell phone technology to verify staff have the capacity to communicate spontaneously by phone and the internet while in the field. Crisis Mobile Team providers must verify each mobile team has the capability to wirelessly connect and access the electronic medical information in the field as well as email. In addition, Provider must verify the computer and wireless specifications meet or exceed The Health Plan requirements.

14.8.8 Safety

Crisis Mobile Team providers must verify the safety of Members under the care of the Crisis Mobile Team at all times, and verify at-risk Members are monitored and supervised by professional staff in person as long as the person remains at a Danger to Self/Danger to Others (DTS/DTO).

14.8.9 Follow Up Care

Crisis Mobile Team providers must record referrals, dispositions, and overall response time. Crisis Mobile Team providers must verify all Members are effectively engaged in follow up care before terminating crisis services.

14.8.10 Services

Crisis Mobile Team assessment and intervention services in the community are available to any person in the county regardless of insurance or enrollment status. Upon dispatch, Crisis Mobile Team response time expectations are as follows: No Crisis Mobile Team response should be greater than 90 minutes; or if the Crisis Mobile Team is presently located in the same town/city as the law enforcement call, the response time will be no greater than 30 minutes; or if the Crisis Mobile Team is not presently located in the same town/city as the law enforcement call, the response time is no greater than 90 minutes

Crisis Mobile Teams must have the ability to assess and provide immediate crisis intervention and make reasonable efforts to stabilize acute psychiatric or behavioral symptoms, evaluate treatment needs, and develop individualized plans to meet the individual’s needs. Crisis Mobile Team providers must deliver crisis response, crisis assessment and crisis stabilization services that facilitate resolution, not merely triage and transfer. Crisis Mobile Team providers must initiate and maintain collaboration with fire, law enforcement, emergency medical services, hospital emergency departments, AHCCCS Complete Care Health plans and other providers of public health and safety services to inform them of how to use the crisis response system, to coordinate services and to assess and improve the crisis services.

14.8.11 Tracking

Crisis Mobile Teams must maintain adequate licenses to allow each team to utilize and update The Health Plan Risk Management/High Needs Tracking System to effectively coordinate care for Members in crisis.

Crisis Stabilization providers must provide crisis stabilization services in the assigned areas on a 24/7/365 basis and in accordance to State and The Health Plan requirements. Crisis assessment and crisis services must facilitate resolution, not merely triage and transfer. Crisis Living Rooms must be furnished to resemble a home living area, including the following: showers, rest rooms, living room furniture, kitchen, refrigerator, dining table, and microwave oven.

14.9.1 Supervision and Staffing

Crisis Stabilization providers must verify that the Crisis Living Room Program is clinically supervised by a The Health Plan Credentialed Independently Licensed Behavioral Health Professional. Crisis Stabilization providers must verify all Crisis Living Room Assessments are reviewed and signed off by a The Health Plan Credentialed, Independently Licensed Behavioral Health Professional. Crisis Stabilization providers must verify adequate staff capacity to meet variations in the demand for services. Crisis Stabilization providers must verify all direct care crisis staff are CISM trained.

14.9.2 Coordination through Crisis Line Provider

Crisis Stabilization providers must coordinate all services through The Health Crisis Line Provider and follow crisis protocols established by The Health Plan. Crisis Stabilization providers must work collaboratively with The Health Plan Crisis Line Provider to coordinate all services, and facilitate crisis resolution planning.

14.9.3 Outpatient Coordination and Follow Up

Since the Crisis Living Room is an outpatient facility, Crisis Stabilization providers must verify Members are not allowed to remain in the living room for more than 23 hours a day. Crisis Stabilization providers must verify crisis living room services are closely linked to the provider's outpatient department and that coordination of care is occurring with outpatient providers for members who have been in a crisis. Crisis Stabilization providers must verify all Members are effectively engaged in follow-up care before terminating crisis services. This includes coordinating care with the members ACC Health Plan.

14.9.4 Accepting Referrals

Crisis Stabilization providers must embrace a "No Wrong Door" philosophy and accept all voluntary referrals, regardless of ability to pay, clinical presentation, degree of intoxication, or benefit status. Crisis Stabilization providers must accept all referrals from law enforcement and the community.

In a health emergency, Provider is required to verify eligibility for Covered Services in accordance with The Health Plan Provider Manual and with federal, State, and local laws relating to the provision of Emergency Medical Services (including but not limited to A.A.C. R9-22-201 et seq. and 42 CFR 438.114), provided that nothing in this provision shall be deemed to require Provider to violate federal or State law regarding the provision of Emergency Medical Services. Provider is required to notify The Health Plan-designated crisis line provider within twenty-four (24) hours or by the next business day of rendering or learning of the rendering of Emergency Medical Services to a Member.

14.9.5 Transportation

Crisis Stabilization providers must coordinate transportation to facilitate or coordinate care and discharge planning.

14.9.6 Participation in Training and Coordination Calls

Crisis Stabilization providers must participate in training events sponsored by The Health Plan and the State to enhance the performance of the crisis system. Crisis Stabilization providers must participate in crisis coordination calls and meetings to facilitate effective working relationships.

14.9.7 Tracking and Electronic Medical Information

Crisis Stabilization providers must maintain adequate licenses to allow Crisis Living Room staff to utilize The Health Plan Risk Management /High Needs Tracking System to effectively coordinate care for Members in crisis. Crisis Stabilization providers must verify the Crisis Living Room is equipped with a computer, printer and web connectivity to allow access to electronic medical information.

Crisis Transportation providers must provide medically-necessary transportation services in the assigned geographic areas and in accordance to State and the Health Plan requirements. Crisis Transportation providers must establish and maintain appropriate licenses to provide transportation services identified in the Scope of Work.

14.10.1 Coordination

Crisis Transportation providers must coordinate all services through the Health Plan Crisis Line Provider and follow crisis protocols established by the Health Plan. Crisis Transportation providers must participate in crisis coordination calls and meetings to facilitate effective working relationships as requested.

14.10.2 Staff Requirements

Staffing must consistently meet AHCCCS, the State, ADHS Division of Licensing, and The Health Plan requirements. Crisis Transportation providers must verify staff capacity to meet availability requirements as identified in provider’s contract with The Health Plan. Crisis Transportation providers must maintain appropriately trained, supervised, and ADHS Division of Licensing and AHCCCS qualified transportation professionals to conduct transports.

Crisis Transportation providers must provide consistent supervision to verify services are in compliance with the Arizona Principles, and verify all ADHS Division of Licensing regulations and State supervision requirements are met. In addition, all staff transporting Members must maintain DES Fingerprint Clearance cards and maintain copies in Personnel files.

14.10.3 Training

Crisis Transportation providers must participate in training events sponsored by The Health Plan and the State as requested, and verify staff complete all required trainings and document trainings.

14.10.4 Vehicles and Cell Phones

Crisis Transportation providers must provide and maintain safe, clean and updated vehicles to facilitate transportation. Crisis Transportation providers must provide cell phones for all transportation staff on duty to verify effective connectivity and safety.

14.10.5 Billing and Paperwork

Crisis Transportation providers must bill all medically-necessary transportation services utilizing transportation service codes. Crisis Transportation providers must maintain appropriate paperwork in accordance with State and AHCCCS regulations. Crisis Transportation providers must encounter and document all services in compliance with the AHCCCS Covered Behavioral Health Service Guide.

Behavioral Health providers must make available HIV education, screening and counseling services to The Health Plan-enrolled Members.

14.11.1 HIV Risk Assessments

Behavioral Health Providers must make available HIV Risk Assessments to Members which includes pre-test discussions and counseling that assists the client in identifying the behaviors that may have possibly exposed the person to HIV.

14.11.2 Health Education, Health Promotion and Counseling

Health Education and Health Promotion services (including assistance and education about health risk reduction and lifestyle choices) must be provided to Members at substance use, mental health and community facilities in Arizona. Providers must make available to Members information regarding HIV transmission and prevention, and should assist Members in identifying the behaviors that may expose them to HIV.

Behavioral Health providers must make available Pre-Test Counseling to Members to assist in identifying the behaviors that may have possible exposed them to HIV, focusing on the Member's own unique circumstances and risk and helping the Member set and reach an explicit behavior-change goal to reduce the chance of acquiring or transmitting HIV. Provider must make available to Members information regarding HIV transmission and prevention and the meaning of HIV test results. In addition, providers must help the Member to identify the specific behaviors putting them at risk for acquiring or transmitting HIV and commit to steps to reduce their risk.

Providers must make available Post-Test Counseling including summarization of identified risks, review of the Member's risk reduction plan, discussion of next test time or when the confirmation blood draw shall occur if the Member tested positive for HIV, scheduling an appointment for receiving future results, obtaining information on sexual or drug using contacts to enable partner notification process to occur, and providing information and assistance in accessing the HIV Care System.

14.11.3 Prevention Case Management

Providers must provide HIV Prevention Case Management services to any individual requesting assistance from the provider in obtaining resources and accessing needed social services.

14.11.4 Clinical Laboratory Improvement Amendment (CLIA)

Providers of HIV testing services must obtain and retain a Clinical Laboratory Improvement Amendments (CLIA) certificate and verify all HIV Testing is administered in accordance with the CLIA requirements.

14.12.1 Authorization and Continued Stay Requirements

TFC Providers must meet all l licensing and scope of work requirements as outlined by licensing, the Covered Behavioral Health Services Guide, and all prior authorization and continued stay requirements for TFC as listed in Provider Manual Section 10 and as directed by the Health Plan. TFC shall be utilized as an alternative to more restrictive levels of care when clinically indicated.

14.12.2 Children’s Therapeutic Foster Care

TFC (Therapeutic Foster Care) is a covered behavioral health service that provides daily behavioral interventions within a licensed family setting. This service is designed to maximize the member's ability to live and participate in the community and to function independently, including assistance in the self-administration of medication and any ancillary services (such as living skills and health promotion) indicated by the member's ISP as appropriate per Arizona State Plan for Medicaid. The Health Plan provides support and is available to the TFC Family Providers 24 hours per day, seven days per week. Care and services provided in TFC are based on a per diem rate (24-hour day), require prior and continued authorization, and do not include room and board.

TFC service can only be provided for no more than three children in a Professional Foster Home per Arizona State Plan for Medicaid.

AzCH and the TFC Agency/Family Providers shall ensure appropriate notification is sent to the Primary Care Provider (PCP) and Behavioral Health Home or Agency upon intake/admission to, and discharge from TFC.

TFC Family Providers and TFC Agency Providers shall adhere to DCS policies and procedures for children involved with the Arizona Department of Child Safety (DCS).

It is the TFC Agency Providers responsibility to timely obtain necessary authorizations from AzCH for services provided to eligible members.

TFC Providers are required to submit individualized member documentation for admission, continued stay and discharge planning.  AzCH will not accept boiler plate, standardized documentation to substantiate medical necessity.  There should be documentation for the entire 24 hour period the member is present in the TFC and this includes time the member is sleeping and present in the facility. Any time in which the member is receiving care in the TFC and has gone AWOL or is otherwise not present at the TFC it should be documented for care coordination purposes.  Additionally, if the member has been gone from the TFC facility for more than 24 hours it is the TFC’s responsibility to immediately notify AzCH.  Members staying out of a TFC facility for more than 24 hours will be discharged, should the member come back to the TFC after 24 hours it is the facilities responsibility to reinitiate the authorization of services. As a reminder, dates on which the member is inpatient, AWOL or has been discharged are not billable.  Billing should be based on where the member is at 11:59 p.m. Regardless of the time of placement or return to the facility, the day is billable if the member is present at 11:59 p.m. The discharge day is not billable as the member is not there for the full day. This mechanism provides a fair way to bill as there may be days for which you get credit when the member is not there for a full day.

Payment for TFC placements require authorization.  Claims will be denied that do not have formal authorization entered in the AzCH claims payment system. The days billed must coincide with the days authorized to receive appropriate payment.  The cost of Room and Board in a TFC is not an AHCCCS/Medicaid reimbursable service. Additional reimbursement for Room and Board may be available to special populations through the RBHA. Consult the Provider Manual for the appropriate RBHA in which the member resides for details about eligibility for Room and Board reimbursement for special populations. AzCH does not prior-authorize Room and Board.

14.12.3 PROGRAM REQUIREMENTS – TREATMENT PLANNING

The TFC Treatment Plan shall:

  • Be developed in conjunction with the CFT,
  • Describe strategies to address TFC Family Provider needs and successful transition for the member to begin service with TFC Family Provider, including pre-service visits when appropriate as well as respite planning,
  • Complement and not conflict with the ISP and other defined treatments, and include reference to the member’s:
    • Current physical, emotional, behavioral health and developmental needs,
    • Current educational placement and needs,
    • Current medical treatment,
    • Current behavioral treatment through other providers, and
    • Current prescribed medications.
  • Update member’s current Crisis Plan in alignment with TFC setting,
  • Address safety, social, and emotional well-being, discharge criteria, acknowledgement of member’s permanency objectives and post-discharge services,
  • Include short-term, proactive treatment goals that are measurable, time-limited, and in keeping with the ISP,
  • When age and developmentally appropriate, youth and biological, kinship, and adoptive family participation in development of the TFC Treatment Plan is required,
  • Include specific elements that build on the members’ strengths, while also promoting pro-social, adaptive behaviors, interpersonal skills and relationships, community, family and cultural connections, self-care, daily living skills, and educational achievement,
  • Include specifics to coordinate with natural supports and informal networks as a part of treatment,
  • If the TFC Treatment Plan includes co-parenting engagement with the member’s Caregiver(s), specific goals shall be developed to prepare the receiving Caregiver(s) and successfully transition the member to the new placement,
  • Include plans for engagement of the member’s biological family, kinship family, adoptive family, and/or transition foster family and other natural supports that can support the member during TFC placement and after transition,
  • Include respite planning,
  • Be reviewed by:
    • The TFC Family Provider and TFC Agency Provider at every home visit,
    • The TFC Agency Provider and Clinical Supervisor at each staffing, and
    • The TFC Agency Provider, and CFT at each revision or minimum quarterly.
  • Include documentation of the TFC Treatment Plan which shall be kept by the TFC Family Provider and the TFC Agency Provider and shared with the CFT.

For after care planning for DCS involved members, the TFC Family Provider may be the discharge placement. In such cases where the TFC Family Provider is the discharge placement, DCS foster care rates, policies and procedures apply. Licensing agencies shall coordinate these actions through the CFT and DCS as they are not governed by this Policy. Ongoing appropriate and approved relationship and communication with the TFC Family Provider after discharge is encouraged. This is determined with Health Care Decision Maker approval and in the best interest of the member.

 

14.12.4 EXPECTED TREATMENT OUTCOMES:

Treatment outcomes shall align with:

  • The Arizona Vision-12 Principles for Children’s Behavioral Health Service Delivery as specified in AMPM Policy 100, and
  • The member’s individualized physical, behavioral, and developmentally appropriate needs.

Treatment goals for the member’s time in TFC shall be:

  • Specific to the member’s behavioral health condition that warranted treatment,
  • Measurable and achievable,
  • Cannot be met in a less restrictive environment,
  • Based on the member’s unique needs,
  • Include input from the member’s family/healthcare decision-maker and designated representative’s choices where applicable, and
  • Support the member’s improved or sustained functioning and integration into the community.

Active treatment with the services available at this level of care can reasonably be expected to:

  • Improve the member’s condition in order to achieve discharge from the TFC at the earliest possible time, and
  • Facilitate the member’s return to primarily outpatient care in a nontherapeutic/non-licensed setting.

14.12.5 EXCLUSIONARY CRITERIA

Admission to TFC shall not be used as a substitute for the following:

  • An alternative to detention or incarceration.
  • As a means to ensure community safety in an individual exhibiting primarily conduct disordered behaviors.
  • As a means of providing safe housing, shelter, supervision or permanency placement.
  • As an alternative to parents’/Health Care Decision Makers’ or other agencies’ capacity to provide for the member.
  • A behavioral health intervention when other less restrictive alternatives are available and meet the member’s treatment needs, including situations when the member/Health Care Decision Maker is unwilling to participate in the less restrictive alternative, or
  • An intervention for member runaway behaviors unrelated to a behavioral health condition.

14.12.6 CRITERIA FOR ADMISSION

AzCH utilizes InterQual Intensive Community Based Treatment, Child and Adolescent admission criteria for medical necessity, which at a minimum includes the below elements, in accordance with AHCCCS AMPM 320-W.  Admission criteria has been submitted to AHCCCS for approval, as specified in AzCH Contract, and the published approved criteria is posted on the AzCH website.

Criteria for Admission:

  • The recommendation for TFC shall come through the CFT process,
  • Following an Assessment by a licensed BHP, the member has been diagnosed with a behavioral health condition, which reflects the symptoms and behaviors necessary for a request for TFC,
  • As a result of the behavioral health condition, there is evidence that the member has recently (within the past 90 days) had a disturbance of mood, thought or behavior that renders the member incapable of independent or age-appropriate self-care or self-regulation. This moderate functional and/or psychosocial impairment per Assessment by a BHP:
    • Cannot be reasonably expected to improve in response to a less intensive level of care, and
    • Does not require or meet clinical criteria for a higher level of care, or
    • Demonstrates that appropriate treatment in a less restrictive environment has not been successful or is not available, therefore warranting a higher level of care.
  • At time of admission to TFC in participation of Health Care Decision Maker and all stakeholders, there are documented plans for discharge and transition which includes:
    • Tentative disposition/living arrangement identified, and
    • Recommendations for aftercare treatment based upon treatment goals.

 

 

 

14.12.7 CRITERIA FOR CONTINUED STAY

AzCH utilizes InterQual Intensive Community Based Treatment, Child and Adolescent criteria for continued stay which, at a minimum, includes the below elements. AzCH has submitted continued stay criteria to AHCCCS for approval, as specified in the AzCH Contract, and is published on the AzCH website.

All of the following shall be met:

  • The member continues to meet diagnostic threshold for the behavioral health condition that warranted admission to TFC,
  • There is an expectation that continued treatment at the TFC shall improve the member’s condition so that this type of service shall no longer be needed, and
  • The CFT is meeting at least monthly to review progress, and have revised the TFC Treatment Plan and Individualized Service Plan (ISP) to respond to any lack of progress, and for members, the Caregiver to whom the member shall be transitioned after discharge from a TFC has been identified and is actively involved in the member’s care/treatment, if applicable.

All of the following are met:

  • The member continues to demonstrate (within the last 90 days) moderate functional or psychosocial impairment as a result of the behavioral health condition, as identified through disturbances of mood, thought, or behavior, which substantially impairs independent or age appropriate self-care or self-regulation,
  • Active treatment is reducing the severity of disturbances of mood, thought, or behaviors, which were identified as reasons for admission to TFC, and treatment at the TFC is empowering the member to gain skills to successfully function in the community.

 

14.12.8 CRITERIA FOR DISCHARGE

AzCH utilizes InterQual Intensive Community Based Treatment, Child and Adolescent criteria for discharge from a TFC settings which, at a minimum, includes the below elements. Contractors shall AzCH has submitted discharge criteria to AHCCCS for approval, as specified in the AzCH Contract, and it is published on the AzCH website.

  • Sufficient symptom or behavior relief is achieved as evidenced by completion of the TFC treatment goals.
  • The member’s functional capacity is improved and the member can be safely cared for in a less restrictive level of care.
  • The member can participate in needed monitoring and follow-up services or a Caregiver is available to provide monitoring in a less restrictive level of care.
  • Appropriate services, providers, and supports are available to meet the member’s current behavioral health needs at a less restrictive level of care.
  • There is no evidence to indicate that continued treatment in TFC would improve member’s clinical outcome.
  • There is potential risk that continued stay in TFC may precipitate regression or decompensation of member’s condition.
  • A current clinical Assessment of the member’s symptoms, behaviors, and treatment needs has been reviewed by the CFT and has established that continued care in TFC is setting no longer adequate to provide for the safety and treatment. The CFT will then discuss if a higher level of care is necessary.

14.12.9 PROGRAM REQUIREMENTS - DISCHARGE PLANNING

Discharge planning details shall be included in the TFC Treatment Plan and be updated monthly. Discharge plans shall be completed using the approved standardized criteria across all providers. The CFT shall review and approve the plans as their support is required to successfully implement the details:

  • Discharge planning is considered the successful completion of treatment goals such that sustainable transition into a less restrictive setting is possible:
  • Discharge planning shall be developed as part of the TFC Treatment Plan and shall be in alignment with the ISP,
  • The Discharge Plan shall include identification of and consistent work with Health Care Decision Maker(s), and
  • The TFC team shall continue to plan for discharge from the TFC Family Provider as soon as an appropriate lower level of community-based care is identified.

Successful discharge planning for TFC shall include engagement of receiving Caregiver(s) to participate in transitionary visits. It is important to understand the needs of the receiving Caregiver(s), and to provide them the appropriate coaching and mentorship, and

c. In the event that the member has not been successful in TFC and the decision is made to move the member to a higher level of care, the TFC Family Provider and TFC Agency Provider in collaboration with the CFT will work to make this transition as seamless as possible.

 

Planned Admissions

Providers are required to obtain Prior Authorization for all admissions to TFC.   The Child Recovery Team (CFT) shall submit an updated treatment plan (completed within the prior 90 days) indicating the specific treatment goals for the TFC to address with the member.  The goals MUST be focused on the signs and symptoms of a disturbance of mood, though or behavior that renders the member incapable of independent or age-appropriate self-care or self-regulation.  An active treatment plan should aim to overcome the member’s symptoms and promote stabilization, and successfully return the member to the community as early as possible.  Individualized member documentation MUST include a tentative discharge plan, a recent assessment by a licensed BHP that reflects current concerning behaviors, functioning and diagnoses, and a CFT team note indicating the team’s recommendations must accompany the submitted treatment plan and prior authorization form. All documentation MUST be individualized to the specific member needs, pre-printed script will not be accepted.

There MUST be evidence that the Health Care Decision Maker and all stakeholders has agreed to and is willing to participate in treatment.

Prior Authorization requests not containing the mandated documents will be considered invalid and returned to the provider.

AzCH will review the prior authorization request within 72 hours of receipt of the request.

If the prior authorization is being approved for a future placement, the AzCH PA will be valid for only 45 days.  In cases where placement has not occurred within the 45 day authorized window the PA will be voided and resubmission with updated clinicals will be required.

Timelines for approval - Initial authorization

If approved, the initial authorization period will be:

Children – 90 days, then continued stay process would be followed

 

Continued Stay

Seven (7) days prior to the LCD (last covered day) the TFC provider and treatment team are required to provide documentation for continued stay.  The TFC provider receives a “Notice of Coverage” letter indicating the LCD (last covered day), it is the responsibility of the TFC provider to submit all required documentation to AzCH prior to the LCD. Failure to submit required documentation by the LCD may result in continued stay denial.   Once the continued stay denial has been issued the TFC provider will need to formally appeal the denial action.

Continued stay requests MUST include the following documentation:

  • CFT note indicating monthly meetings to review progress, and documentation that continued TFC shall improve the member’s condition. 
  • Documentation of Treatment Plan and Individualized Service Plan (ISP) revision in response to any lack of progress
  • Member specific documentation of that member continues to demonstrate moderate functional or psychosocial impairment as a result of their behavioral health condition.
  • Medication Sheets
  • Goals to discharge plan, including barrier for transition to outpatient services or less restrictive level of care.  Identification of the Caregiver to whom the member will be transitioned and their active involvement in the member’s care/treatment.

Approved continued stay authorizations will be issued for:

Children - 90 days, providers must continue to follow the above guidance for any continued stay requests.

14.12.10 TFC REQUIREMENTS A. ROLES/RESPONSIBILITIES/QUALIFICATIONS

  • The TFC Family Provider will be licensed through the DCS and will not require AHCCCS credentialing.
  • The TFC Agency Provider will require credentialing with the MCOs.
  • The TFC Agency Provider plays a critical role in providing clinical supports to the TFC Family Provider as they meet the daily needs of the member. This is in addition to fulfilling the administrative requirements of the AzCH as the Medicaid entity, the State, and Tribal licensing authority. These services include but are not limited to:
    • Ensuring TFC Family Provider(s) comply with all state and local licensing requirements including application, training, life safety inspections, and administrative requirements,
    • Submission of deliverables,
    • During initial six weeks of placement, the TFC Agency Provider shall conduct one home visit per week; these visits may occur in-person or via telemedicine (i.e. interactive audio/video communications). For continued stay beyond the initial six weeks, the TFC Agency Provider shall conduct a minimum of two home visits per month, (or more frequently as needed) with supporting documentation of each visit, including:
      • Review of the TFC Treatment Plan with TFC Family Provider,
      • Review case files and required documentation, and
      • Check medical records and medication logs.
    • Complete all AHCCCS required group biller requiements,
    • Conduct TFC Family Provider recruitment to maintain and increase number of providers that can meet the needs of members placed in TFC services, and
    • Conduct ongoing training per state Licensing rule that develops the skills TFC Family Providers to enable them to meet the needs of members.
  • The TFC Agency Provider shall:
    • Have staff to operate resource teams to support the TFC Family Provider as follows:
      • Beginning at the level of the Agency Worker, extending to the Clinical Supervisor,
      • Provide oversight by one or more independently licensed BHPs,
      • Work in concert, applying their specialized skills and knowledge for:
        • Service planning,
        • Training, and
        • Support of direct service providers, as well as to the CFT.
      • Each member of the team shall have in-depth familiarity with the strengths and needs of the TFC Family Provider, in order to be effective resources to them in the provision of:
        • Care,
        • Developing training plans, and
        • Assisting in matching members to service environments.
    • Have a documented agency crisis response policy. This shall include:
      • Supervisor’s availability and the use of crisis response provider to augment hours of availability,
      • The TFC Agency Provider fulfilling the role of first line support for TFC Family Provider and member during times of crisis,
      • Access to a TFC Agency Provider and/or appropriate agency staff shall be on a 24/7 basis, and
      • Ensuring that escalation to appropriate TFC Agency Provider clinical leadership is available at all times.
    • Coordinate the TFC Treatment Plan with the ISP and incorporate TFC Family Provider participation in CFT meetings,
    • Support the TFC Family Provider(s) through clinical supervision available upon request and/or as TFC Agency Worker that identifies needs including but not limited to:
      • Provide training and specific skill building to enhance family’s ability to stabilize behaviors and intervene as challenges arise,
      • Facilitate respite,
      • Attend all CFT, Court, and professional meetings with or on behalf of the family, and
      • Contact between TFC Family Provider and other Caregiver(s) in preparation for discharge.
    • Ensure documentation, Assessments, and records are updated and available including but not limited to the member’s:
      • Current TFC Treatment Plan,
      • Current ISP,
      • Crisis Plan,
      • Discharge Plan,
      • Social history information,
      • Previous and current (within a year of referral date) behavioral health annual Assessments, psychiatric evaluations, psychological evaluations,
      • School and educational information,
      • Medical information,
      • Previous placement history and outcomes, and
      • Member and family strengths and needs, including skills, interests, talents, and other assists.
  • The TFC Agency Worker shall:
    • Be qualified at minimum, at the level of Behavioral Health Technician with a minimum of one year experience in a human services field,
    • Be supervised by staff that possess a Master’s degree in a behavioral health field, and licensed in the state of Arizona, with a minimum of two years’ experience in a human services field,
    • Be the primary agency representative at the CFT, who shall:
      • Be present to review the ISP,
      • Document progress to those plans,
      • Support the CFT,
      • Support the TFC Family Provider(s), and
      • Participate in the CFT meetings.
    • Lead the development of the TFC Treatment Plan with the TFC Family Provider and obtain clinical supervisor review,
    • Ensure TFC Family Provider(s) complete full and accurate clinical documentation of interventions on the TFC Treatment Plan to demonstrate progress toward meeting treatment needs is captured to ensure full and accurate record of case progress,
    • Ensure the TFC Treatment Plan be shared with the Behavioral Health Agency, other treating providers, and stakeholders as part of the member’s ISP to assure care coordination,
    • Monitor Client Load (client is identified as the TFC member placed in the TFC placement)
      • The preferred maximum number of members that may be assigned to a single Agency Worker is 10, and
      • The client load shall be adjusted downward if evaluation by the Supervisor deems additional time is needed for one or more assigned families/members for oversight and support.
    • Shall have contact with the TFC member and TFC Family Provider minimum of once a week for the first six weeks of placement; these visits may occur in-person or via telemedicine (i.e. interactive audio/video communications),
    • Shall have contact with the TFC member and TFC Family Provider every other week or as needed for the remainder of the treatment, with one visit per month with the TFC member to assess physical, emotional and behavioral health needs are being met; these visits may occur in-person or via telemedicine (i.e. interactive audio/video communications), and
    • Encourage coordination/collaboration/advocacy with the Educational System to support the TFC Family Provider and member in meeting treatment and educational goals.
  • The TFC Agency Provider – Supervisor Requirements:
    • Clinical Supervision requires Behavioral Professional or higher with a graduate degree in a human services field, and be licensed with a minimum two years of experience:
      • Clinical supervision of TFC Agency staff that directly supports TFC Family Providers shall be completed by a qualified clinical professional through regular direct clinical supervision. An agency may employ a shared supervision model where administrative supervision is conducted by a nonclinical professional.
    • Administrative Supervision requires a master’s degree in a human service field and a minimum of two years of experience,
    • Treatment planning for all TFC Family Providers shall be overseen by a qualified clinical professional as specified below:
      • The TFC Agency Provider shall define and document minimum frequency of TFC Treatment Plan reviews, which shall occur no less than once per quarter,
      • The clinical supervisor shall have direct contact with the TFC Family Provider minimum once per month; these visits may occur in-person or via telemedicine (i.e. interactive audio/video communications), and
      • The clinical supervisor is part of the treatment team and as such shall be active in the case review and not solely an independent reviewing of the TFC Treatment Plan. The Supervisor shall participate in the CFT on an as needed basis depending on the progress of the TFC Treatment Plan.
  • The TFC Family Provider shall:
    • Have the following qualifications:
      • Minimum one year of experience as an active licensed foster home working directly with members, or professional experience working directly with members that have behavioral health and/or developmental challenges,
      • Shall adhere to the AHCCCS requirements of registration and assure they meet the requirements as an AHCCCS registered provider, and
      • Complete all required trainings and evaluations in preparation to effectively and safely provide TFC services to members and their families, as well as ongoing training as identified/required by agencies in collaboration the CFT.
    • TFC Family Providers have the following responsibilities:
      • Abide by all licensing regulations as outlined in current and relevant state and federal statutes for Family Foster Parent Licensing Requirements, therapeutic level of licensure,
      • Provide basic parenting functions (e.g. food, clothing, shelter, educational support, meet medical needs, provide transportation, teach daily living skills, social skills, the development of community activities, and support cultural, spiritual/religious beliefs),
      • Provide behavioral interventions (e.g. anger management, crisis de-escalation, psychosocial rehabilitation, living skills training and behavioral intervention) that shall aid the member in making progress on TFC Treatment Plan goals,
      • Provide a family environment that includes opportunities for:
        • Familial and social interactions and activities,
        • Use of behavioral interventions,
        • Development of age appropriate living and self-sufficiency skills, and
        • Integration into a family and community-based setting.
      • Meet the individualized needs of the member in their home as defined in the member’s TFC Treatment Plan,
      • Be available to care for the member 24 hours per day, seven days a week for the entire duration that the member is receiving out of home treatment services including times the member is with respite Caregivers,
      • Ensure that the member’s needs are met when member is in respite care with other TFC Family Providers,
      • Participate in planning processes such as CFTs, TFC discharge planning, Individualized Education Programs (IEPs),
      • Keep documentation, per expectations of the TFC Agency Provider including:
        • Record behavioral health symptoms,
        • Incident reports,
        • Interventions utilized,
        • Progress toward the TFC Treatment Plan goals, and
        • Discharge plan.
      • Assist the member in maintaining contact with their family and natural supports,
      • Assist in meeting the member’s permanency planning or TFC discharge planning goals,
      • Advocate for the member in order to achieve TFC Treatment Plan goals and to ensure timely access to educational, vocational, medical, or other indicated services,
      • Provide medication management is consistent with AHCCCS guidelines for members in out of home care,
      • Report allegations of misconduct toward members shall be managed according to all state and federal regulations,
      • Maintain confidentiality according to statutory, HIPAA and AHCCCS requirements,
      • Any request to move a member from placement prior to successful completion of TFC Treatment Plan shall be made through the CFT and written notice shall be provided and following contractual time frames with the only exception being immediate jeopardy. TFC Family Providers shall follow the Crisis Plan and work to preserve the placement to the best of their ability, including consultation with the CFT for consideration of additional in-home supports and services as appropriate, and necessary to support the member and family, and
      • TFC Family Provider(s) shall utilize the Crisis Plan and accept Agency Worker and Supervisor support, including the use of respite to maintain the placement until an emergency CFT is convened, services implemented, and the placement is preserved. In the event the TFC placement cannot be preserved, the TFC Agency Provider shall support the member and TFC Family Provider(s) until a proper transition is identified.

 

Providers are required to provide culturally-competent, evidence-based substance use treatment to a person who is experiencing acute and severe behavioral health and/or substance use symptoms, which may include emergency reception and assessment; crisis intervention and stabilization; individual, group and family counseling; outpatient detoxification and referral. Services provided to each member must be individualized to meet the member’s unique treatment needs.

Substance use disorders may include a range of conditions that vary in severity over time, from problematic, short-term use of substances, to severe and chronic disorders requiring long-term and sustained treatment and recovery management.

All substance use treatment programs delivered by any provider within AzCH-CCP system of care must:

  • Provide for:
    • Member and family education and involvement;
    • Brief intervention;
    • Acute stabilization and treatment;
    • Assessment of other needs including housing and vocational interests and goals;
    • A focus on life factors that support long-term recovery to facilitate reduction of the intensity, severity and duration of substance use and the number of relapse events; and
    • A return of the member to the workplace or school, as appropriate.
  • Monitor member retention in treatment, provide engagement efforts and outcomes of treatment, modify treatment approaches as needed;
  • Provide physician oversight of medical treatment including methadone, medication and detoxification services, as clinically appropriate;
  • Provide or make available Tuberculosis (TB), HIV, and Hepatitis B and C education, screenings and treatment services at the time of intake,
    • In the case of an individual in need of such treatment who is denied admission to the program on the basis of the lack of the capacity of the program to admit the individual, will refer the individual to another provider of tuberculosis services, and will implement infection control procedures designed to prevent the transmission of tuberculosis, including the following:
      • Screening of patients,
      • Identification of those individuals who are at high risk of becoming infected,
      • Meeting all State reporting requirements while adhering to Federal and State confidentiality requirements, including [42 CFR part 2], and
      • Will conduct case management activities to ensure that individuals receive such services;
  • Coordinate continuity of care between service providers and other agencies;
  • Utilize the American Society of Addiction Medicine (ASAM) in assessing persons with substance use disorders. In addition, the provider must screen all persons with substance use disorders for the need for residential treatment services and document the screening. All Members seeking treatment for Substance Use Disorders must receive an ASAM assessment at intake and at least every six months during treatment;
  • Promote the use of Motivational Interviewing Principles in substance use treatment; verify access to new treatment alternatives targeted to the needs of specific high-risk populations, such as Members with co-occurring substance use and mental illness, according to the Arizona Principles for behavioral health care;
  • Demonstrate which evidence based practice is utilized, how training is conducted and how fidelity is monitored;
  • Document in each member record which evidence based practice is being utilized during treatment of the member, and;
  • Be provided by clinicians who are overseen by a Behavioral Health Professional (BHP) with experience in substance use disorders and treatment.

Providers must maintain the capacity to conduct drug screening/testing on members, as defined by AHCCCS Covered Behavioral Health Services Guide and as deemed clinically appropriate by the member’s treatment team.

While not required, AzCH-CCP supports the use of drug screening during the substance use screening, assessment and treatment process.

14.13.1 Psychosocial Outpatient Services

Substance use treatment providers must make individualized outpatient services available to assist the client in reducing or eliminating substance use/abuse. A continuum of services including therapy (individual, group, family), case management, peer support, vocational services and any other service identified in the AHCCCS Covered Behavioral Health Services Guide must be available and must utilize and maintain fidelity to evidence-based methods.

14.13.2 Intensive Outpatient Services

Substance use treatment providers that offer intensive outpatient programming must ensure that operates at least three (3) hours per day and at least three (3) times per week, as required by AHCCCS Covered Behavioral Health Services Guide. Intensive Outpatient Services are limited to Mediciad enrolled members and persons with substance use disorders receiving substance use treatment.

14.13.3 Residential Services Treatment

Residential Substance Use Treatment services are available to adults and adolescents who are TXIX eligible and to individuals who are Non-TitleXIX, but eligible for Substance Abuse Block Grant (SABG) funds, as described in Provider Manual 12.10, Substance Use Disorder Services, Federal Grants and State Appropriations Fund Requirements, and who are screened using the ASAM as needing this level of care.

Behavioral health residential facilities (BHRFs) providing substance use treatment must ensure length of stay is consistent with member’s needs and meets medical necessity. Treatment must remain individualized for each member, dependent upon ASAM placement criteria and treatment needs.

All residential treatment facilities are subject to Utilization Management review as per Provider Manual Section 10.

14.13.4 Substance Abuse Transitional Facilities

Substance Abuse Transitional Facility Providers must provide SUD treatment services through a licensed Substance Abuse Transitional Facility on a 24/7/365 basis. See R9-10-1401 et seq. Substance Abuse Transitional Facility Providers must verify appropriate clinical supervision to safely administer treatment services and verify availability of medical staff to provide appropriate medical consultation and supervision. To verify Members receive appropriate follow up care, providers must verify coordination of care. Substance Abuse Transitional Facility Providers must utilize Peer Support staff to maximize opportunities for Members to understand and embrace recovery. Immediate and ongoing detoxification and psychiatric crisis stabilization services must be provided in the least restrictive setting, consistent with individual and family need and community safety.

14.13.5 Continuing Care, Discharge Planning, Aftercare Planning

Designated staff at the treatment provider engages the member, family/guardian and natural supports to actively participate in discharge planning. Discharge planning begins at the time of admission and continues to be an active part of the treatment/service planning process. It is recommended that agencies create an individualized, medically and clinically comprehensive crisis plan as part of discharge planning.

At a minimum the discharge plan must:

Include realistic/quantifiable/measurable goals and objectives to inform when the member is discharge ready;

  • Identify specific skills and supports the member needs in order to be successful upon discharge from a specific level of care;
  • Include referrals to community resources, including 12–step programs and/or SMART Recovery;
  • Reflects active coordination of care with providers and all involved agencies; and
  • Include arrangements for therapy and other applicable psychiatric services provided in a timely manner.

14.13.6 Developing a Relapse Prevention Plan

At a minimum the relapse prevention plan:

  • Includes the member’s identification of what relapse would look like;
  • Identifies possible stressful events and triggers;
  • Describes signs and symptoms that a relapse is imminent;
  • Describes recommended interventions and the persons responsible;
  • Identifies resources or supports to contact if in crisis, including phone numbers;
  • Identifies interventions to avoid; and
  • Assesses for potential safety issues.

14.13.7 Program Requirements for Providers of IV Drug and Opioid Treatment Services

Providers must fully educate the Member about all treatment options and strategies to promote recovery from opiate use; including, health risks, relapse risks, and alternative treatments.

IV Drug and Opioid Treatment Providers (OTPs) must maintain current policies and procedures designed to verify adherence to The Health Plan Provider Manual, 42 CFR Par 8, SAMHSA - Treatment Improvement Protocol 49, AHCCCS Practice Protocol - Buprenorphine Guidance, the American Psychiatric Association Practice Guideline - Treatment of Patients with Substance Use Disorders, the Drug Enforcement Administration (DEA) and any applicable accreditation requirements.

IV Drug and Opioid Treatment Providers must also ensure Members have access to any medically necessary lab or physical health screening as referenced in the SAMHSA Treatment Improvement Protocol 49.

All Opioid Treatment Providers must have in place written policies and procedures describing their agency’s Diversion Control Program.

All OTPs must have information on the Dangers of Street Drugs posted in their clinic lobbies.

14.13.8 Promotion of Recovery

Treatment must promote recovery, minimizing the impact of substances on the Member's life and assisting the Member in reaching the maximum level of functioning in life appropriate for the Member.

Assessment and treatment for adolescents who act out sexually must be supervised by qualified clinicians using acceptable treatment modalities based on Evidenced Based Practices for the treatment of adolescents who act out sexually, and in accordance with State and Federal laws. Treatment teams must include licensed clinicians, health care coordinators, and in-home family support staff. Providers of services to adolescents who act out sexually must verify Treatment and Discharge Planning is developed through Child and Family Team Practice.

Service Providers to adolescents who act out sexually must develop an effective Safety Plan that safeguards the community br preventing the Member from re-offending. When group treatment is prescribed by the treatment provider, service providers to adolescents who act out sexually must place the adolescent in a treatment program with adolescents of similar age and developmental maturity.

Providers of services to adolescents who act out sexually must comply with the professional Code of Ethics of the Association for the Treatment of Sexual Abusers. Reference: www.atsa.com.

Providers of services to adults who act out sexually must provide treatment services geared toward preventing further offenses and safeguarding the community from harm. Services must include assessments related to inappropriate sexual behavior, treatment planning, family support services, address family reunification and visitation (as appropriate), collaborate with probation/parole or other supervision  or multidisciplinary professionals, engage community supports, and include transition services and continuity of care.

Treatment must be supervised by qualified clinicians using acceptable treatment modalities based on Evidenced Based Practices for the treatment of adults who act out sexually and in accordance with State and Federal laws. Providers of services to adults who act out sexually must verify treatment teams include licensed clinicians, health care coordinators, and in home family support staff. Treatment and discharge planning must be provided through Adult Recovery Team Meetings.

Providers of services to adults who act out sexually must develop an effective Safety Plan that addresses risk management and safeguards the Member and community from re-offending. Providers of services to adults who act out sexually must place the adult in a treatment program with adults of similar age and developmental maturity level, when group treatment is prescribed by the treatment provider.

14.16.1 Purpose Of Program

To provide crisis intervention services to a person for the purpose of stabilizing or preventing a sudden, unanticipated, or potentially dangerous behavioral health condition, episode, or behavior. These intensive and time limited services are designed to prevent, reduce, or eliminate a crisis situation and are provided 24 hours a day, 7 days a week, 365 days a year.

14.16.2 Services To Be Provided

14.16.2.1 Health, Risk and Acuity Assessments for Triage

All individuals entering the facility (based on Arizona Division of Licensing approval to accept members) shall have a basic health, risk and acuity screening completed by a qualified behavioral health staff member as defined by ACC R9-10-114. Triage assessments shall be completed within fifteen (15) minutes of an individual’s entrance into the facility. Any individual demonstrating an elevated health risk shall be seen by appropriate staff to meet the member’s needs.

14.16.2.2 Comprehensive Screening and Assessment

Comprehensive screenings and assessments shall be completed on all individuals presenting at the facility to determine the individual’s behavioral health needs and immediate medical needs. Assessments are required to be completed by a qualified behavioral health professional as defined by ARS Title 32 and ACC R9-10-101. Screening and assessment services may result in a referral to community services, enrollment in The Health Plan system of care, admittance to crisis stabilization services, or admittance to inpatient services. At minimum, a psychiatric and psychosocial evaluation, diagnosis and treatment for the immediate behavioral crisis shall be provided. Breathalyzer analysis of Blood Alcohol Level and/or specimen collections for suspected drug use may be provided as clinically appropriate.

14.16.2.3 Crisis Intervention Services

Crisis intervention services (stabilization) is an immediate and unscheduled behavioral health service provided in response to an individual’s behavioral health issue, to prevent imminent harm, to stabilize, or resolve an acute behavioral health issue. Crisis stabilization services are able to be provided for a maximum of 23 hours and designed to restore an individual’s level of functioning so that the individual might be returned to the community with coordinated follow up services. Services provided include assessment, counseling, intake and enrollment, medical services, nursing services, medication and medication monitoring, and the development of a treatment plan. Discharge planning and coordination of care shall begin immediately upon admission and shall be developed through coordination with the Behavioral Health Home, and the Adult Recovery Team (ART) or Child and Family Team (CFT) as appropriate.

14.16.2.4 Provider Title 36 Emergency Petition

If licensed to provide court ordered evaluation and treatment, the provider shall verify that services and examinations necessary to fulfill the requirements of ARS §36-524 through ARS §36-528 for emergency applications for admission for involuntary evaluation are provided in the least restrictive setting available and possible with the opportunity for the individual to participate in evaluation and treatment on a voluntary basis. Prior to seeking an individual’s admission to a Behavioral Health Inpatient facility for Court Ordered Evaluation (COE) Provider shall make all reasonable attempts to engage the individual in voluntary treatment and discontinue the use of the involuntary evaluation process.

Provider shall verify that staff members are available to provide testimony at Title 36 hearings upon the request of County courts.

14.16.3 Reporting Requirements

Provider shall submit all documents, reports and data in accordance with the Deliverable Schedule in Section 16 – Deliverable Requirements. All deliverables shall be submitted in the format prescribed by The Health Plan and within the time frames specified. Provider is required to submit any additional documents and/or ad hoc reports as requested by The Health Plan.

14.16.4 Community Observation Unit Capacity Requirements

14.16.4.1 Pima County Banner UMC Crisis Response Center Community Observation Unit Capacity

Provider shall have a capacity of 34 (chairs) for adults, 18 years or older, and eight (8) chairs for children, to provide accommodations for overnight stay as mandated by ADHS Division of Licensing Services in accordance with AAC Title 9, Chapter 10. Provider shall have capacity to provide facility-based 23-hour crisis observation/stabilization services for at least 34 adults and at least eight (8) children at any one time.

14.16.4.2 Pima County CBI Center Community Observation Unit Capacity

Provider shall have a capacity of forty (40) chairs for adults, 18 years or older, to provide accommodations for overnight stay as mandated by ADHS Division of Licensing Services in accordance with AAC Title 9, Chapter 10. Provider shall have capacity to provide facility-based. 23-hour crisis observation/stabilization services for at least forty (40) adults at any one time.

14.16.4.3 Yuma County Horizon Health and Wellness Community Observation Unit Capacity

Provider shall have a capacity of 14 (chairs) and one patient bedroom for adults, 18 years or older, to provide accommodations for overnight stay as mandated by ADHS Division of Licensing Services in accordance with AAC Title 9, Chapter 10. Provider shall have capacity to provide facility-based. 23-hour crisis observation/stabilization services for at least 15 adults at any one time.

14.16.4.4 Pinal County Horizon Health and Wellness Community Observation Unit Capacity

Provider shall have a capacity of 24 (chairs) and two patient bedrooms for adults, 18 years or older, to provide accommodations for overnight stay as mandated by ADHS Division of Licensing Services in accordance with AAC Title 9, Chapter 10. Provider shall have capacity to provide facility-based. 23-hour crisis observation/stabilization services for at least 26 adults at any one time.

14.16.4.5  Pinal County Community Bridges, Inc. Facility Capacity

Provider shall have a capacity of 16 sub acute beds with the ability to covert for 23 hours chairs and law enforcement drop offs for adults,18 years or older, to provide accommodations for overnight stay as mandated by ADHS Division of Licensing Services in accordance with AAC Title 9, Chapter 10.

14.17.1 Program Requirements

Providers delivering ACT Team services are required to establish ACT teams that comply with the requirements outlined in the SAMHSA Assertive Community Treatment (ACT) Evidence-Based Practices Kit, https://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345, in communities approved by the Health Plan.

14.17.2 Fidelity to the Model

Providers delivering ACT Team services shall participate in SAMSHA EBP fidelity audits coordinated with the Health Plan on an annual basis at minimum.

14.17.3 Reporting Requirements

Provider shall submit all documents, reports and data in accordance with the Deliverable Schedule as indicated in Section 16 – Deliverable Requirements. All deliverables shall be submitted in the format prescribed by the Health Plan and within the time frames specified. Provider is required to submit any additional documents and/or ad hoc reports as requested by the Health Plan.

14.17.4 Other Requirements

ACT Team providers must participate in all trainings and meetings required or requested by AHCCCS and/or The Health Plan n. ACT Team providers must coordinate for continuity of care between provider, member’s Behavioral Health Home, stakeholders (Adult Protective Services, Probation Officer, Department of Corrections, and other agencies), and other Specialty Providers (both physical and behavioral health) involved with the member.

Adult Behavioral Health Therapeutic Home (ABHTH) is a residential setting in the community that provides daily behavioral interventions within a licensed family setting.  This service is designed to maximize the member’s ability to live and participate in the community and to function independently, including assistance in the self-administration of medication and any ancillary services, such as living skills and health promotion, indicated by the member’s Service Plan and/or Treatment Plan as appropriate.

14.18.1 ADULT BEHAVIORAL HEALTH THERAPEUTIC HOMES TREATMENT PLANNING

The ABHTH Treatment Plan shall be developed by the Collaborating Health Care Institute (CHI) in collaboration with the ABHTH Provider and the ART within the first 30 days of placement:

The Treatment Plan shall:

  • Describe strategies to address ABHTH Provider needs and successful transition for the member to begin service with ABHTH Provider, including pre-service visits when appropriate,
  • Compliment and not conflict with the ART Service Plan and other defined treatments, and shall also include reference to the member’s:
    • Current physical, emotional, behavioral health and developmental needs,
    • Current educational placement and needs,
    • Current medical treatment,
    • Current behavioral health treatment through other Providers, and
    • Current prescribed medications.
  • Address safety, social, and emotional well-being, discharge criteria, acknowledgement of member’s permanency objectives and post-discharge services,
  • Include short-term, proactive treatment goals that are measurable, time-limited, and in keeping with the ART Service Plan,
  • Clearly identify responsible individuals from treatment team to implement each aspect of the ABHTH Treatment Plan and the timing of completion. The CHI has the responsibility to ensure the treatment team is implementing the ABHTH Treatment Plan,
  • Include specific elements that build on the members’ strengths while also promoting pro-social, adaptive behaviors, interpersonal skills and relationships, community, family and cultural connections, self-care, daily living skills, and educational achievement,
  • Include specifics to coordinate with natural supports and informal networks as a part of treatment,
  • Include plans for engagement of the member’s family of choice and other natural supports that can support the member during ABHTH placement and after transition,
  • Be reviewed by the ABHTH Provider and CHI at every home visit,
  • Be reviewed by the CHI Clinical Supervisor at each staffing,
  • Be revised as appropriate or quarterly at minimum, and
  • Include documentation of the ABHTH Treatment Plan which shall be kept by the ABHTH Provider and CHI.

Contractors and providers shall ensure that members/Health Care Decision Maker and designated representatives receive a copy of the treatment plan and any updated treatment plans.

 

14.18.2 EXPECTED TREATMENT OUTCOMES

Treatment outcomes shall align with:

  • The Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems as specified in AMPM Policy 100, and
  • The member’s individualized physical, behavioral, and developmentally appropriate needs.

Treatment goals for members placed in an ABHTH shall be:

  • Specific to the member’s behavioral health condition that warranted treatment,
  • Measurable and achievable,
  • Unable to be met in a less restrictive environment,
  • Based on the member’s unique needs,
  • Inclusive of input from the member’s family/Health Care Decision-Maker and Designated Representative’s choices where applicable, and
  • Supportive of the member’s improved or sustained functioning and integration into the community.

Active treatment with the services available at this level of care can reasonably be expected to:

  • Improve the member’s condition in order to achieve discharge from the ABHTH at the earliest possible time, and
  • Facilitate the member’s return to primarily outpatient care in a nontherapeutic/non-licensed setting.

 

14.18.3 EXCLUSIONARY CRITERIA             

Admission to an ABHTH shall not be used as a substitute for the following:

  • An alternative to detention or incarceration.
  • As a means to ensure community safety in an individual exhibiting primarily conduct disordered behaviors.
  • As a means of providing safe housing, shelter, supervision or permanent placement.
  • A behavioral health intervention when other less restrictive alternatives are available and meet the member’s treatment needs, including situations when the member/Health Care Decision Maker is unwilling to participate in the less restrictive alternative.

 

14.18.4 CRITERIA FOR ADMISSION

AzCH utilizes InterQual Supervised Living, Adult and Geriatric criteria for medical necessity, which at a minimum includes the below elements, in accordance with AHCCCS AMPM 320-X.  Admission criteria has been submitted to AHCCCS for approval, as specified in AzCH Contract, and the published approved criteria is posted on the AzCH website.

  • Criteria for Admission:
    • The recommendation for ABHTH shall come through the ART process,
    • Following an Assessment by a licensed BHP, the member has been diagnosed with a behavioral health condition which reflects the symptoms and behaviors necessary for a request for ABHTH,
    • As a result of the behavioral health condition, there is evidence that the member has recently (within the past 90 days) had a disturbance of mood, thought, or behavior which renders the member incapable of independent or age-appropriate self-care or self-regulation. This moderate functional and/or psychosocial impairment per Assessment by a BHP:
      • Cannot be reasonably expected to improve in response to a less intensive level of care, and
      • Does not require or meet clinical criteria for a higher level of care, or
      • Demonstrates that appropriate treatment in a less restrictive environment has not been successful or is not available, therefore warranting a higher level of care.
    • At time of admission to an ABHTH, in participation with the Health Care Decision Maker and all relevant stakeholders, there is a documented plan for discharge which includes:
    • Tentative disposition/living arrangement identified, and
    • Recommendations for aftercare treatment based upon treatment goals.

 

14.18.5 CRITERIA FOR CONTINUED STAY

AzCH utilizes InterQual Supervised Living, Adult and Geriatric criteria for medical necessity, which at a minimum includes the below elements.  Continued stay criteria has been submitted to AHCCCS for approval, as specified in AzCH Contract, and the published approved criteria is posted on the AzCH website.

All of the following shall be met:

  • The member continues to meet diagnostic threshold for the behavioral health condition that warranted admission to ABHTH,
  • The member continues to demonstrate (within the last 90 days) moderate functional or psychosocial impairment as a result of the behavioral health condition, as identified through disturbances of mood, thought, or behavior, which substantially impairs independent or appropriate self-care or self-regulation,
  • Active treatment is reducing the severity of disturbances of mood, thought, or behaviors, which were identified as reasons for admission to ABHTH, and treatment at the ABHTH is empowering the member to gain skills to successfully function in the community,
  • There is an expectation that continued treatment at the ABHTH shall improve the member’s condition so that this type of service shall no longer be needed, and
  • The ART is meeting at least monthly to review progress, and have revised the Treatment Plan and/or Service Plan to respond to any lack of progress.

 

14.18.6 ADULT BEHAVIORAL HEALTH THERAPEUTIC HOMES DISCHARGE PLANNING

A comprehensive discharge plan shall be created during the development of the initial Treatment Plan and shall be reviewed and/or updated at each review thereafter. The discharge plan shall document the following:

  • Clinical status for discharge.
  • Follow-up treatment, crisis, and safety plan.
  • Coordination of care and transition planning are in process when appropriate.

 

14.18.7 CRITERIA FOR DISCHARGE

AzCH utilizes InterQual Supervised Living, Adult and Geriatric criteria for medical necessity, which at a minimum includes the below elements.  Discharge criteria has been submitted to AHCCCS for approval, as specified in AzCH Contract, and the published approved criteria is posted on the AzCH website.

  • Sufficient symptom or behavior relief is achieved as evidenced by completion of the ABHTH treatment goals.
  • The member’s functional capacity is improved and the member can be safely cared for in a less restrictive level of care.
  • The member can participate in needed monitoring and follow-up services or a Provider is available to provide monitoring in a less restrictive level of care.
  • Appropriate services, Providers, and supports are available to meet the member’s current behavioral health needs at a less restrictive level of care.
  • There is no evidence to indicate that continued treatment in an ABHTH would improve member’s clinical outcome.
  • There is potential risk that continued stay in an ABHTH may precipitate regression or decompensation of member’s condition.

 

14.18.8 Planned Admissions

Providers are required to obtain Prior Authorization for all admissions to ABHTH.   The Adult Recovery Team (ART) shall submit an updated treatment plan (completed within the prior 90 days) indicating the specific treatment goals for the ABHTH to address with the member.  The goals MUST be focused on the signs and symptoms of a disturbance of mood, though or behavior that renders the member incapable of independent or age-appropriate self-care or self-regulation.  An active treatment plan should aim to overcome the member’s symptoms and promote stabilization, and successfully return the member to the community as early as possible.  Individualized member documentation MUST include a tentative discharge plan, a recent assessment (past 90 days) by a licensed BHP that reflects current concerning behaviors, functioning and diagnoses, and a ART team note indicating the team’s recommendations must accompany the submitted treatment plan and prior authorization form. All documentation MUST be individualized to the specific member needs, pre-printed script will not be accepted.

There MUST be evidence that the Health Care Decision Maker and all stakeholders has agreed to and is willing to participate in treatment.

Prior Authorization requests not containing the mandated documents will be considered invalid and returned to the provider.

AzCH will review the prior authorization request within 72 hours of receipt of the request.

If the prior authorization is being approved for a future placement, the AzCH PA will be valid for only 45 days.  In cases where placement has not occurred within the 45 day authorized window the PA will be voided and resubmission with updated clinicals will be required.

Timelines for approval - Initial authorization

If approved, the initial authorization period will be:

  • Adult – 90 days, then continued stay process would be followed

Continued Stay

Seven (7) days prior to the LCD (last covered day) the ABHTH provider and treatment team are required to provide documentation for continued stay. The ABHTH provider receives a “Notice of Coverage” letter indicating the LCD (last covered day), it is the responsibility of the ABHTH provider to submit all required documentation to AzCH prior to the LCD. Failure to submit required documentation by the LCD may result in continued stay denial. Once the continued stay denial has been issued the ABHTH provider will need to formally appeal the denial action.

Continued stay requests MUST include the following documentation:

  • ART note indicating monthly meetings to review progress, and documentation that continued ABHTH shall improve the member’s condition. Documentation of Treatment Plan and revisions in response to any lack of progress
  • Member specific documentation of that member continues to demonstrate moderate functional or psychosocial impairment as a result of their behavioral health condition.
  • Medication Sheets
  • Goals to discharge plan, including barrier for transition to outpatient services or less restrictive level of care.  Identification of the Caregiver to whom the member will be transitioned and their active involvement in the member’s care/treatment.

Approved continued stay authorizations will be issued for:

  • Adult - 90 days, providers must continue to follow the above guidance for any continued stay

14.19.1  Administrative Requirements

As specified in A.A.C. R9-10-101, a Behavioral Health Residential Facility (BHRF) is a health care institution that provides treatment to an individual experiencing a behavioral health issue that limits the individual’s ability to be independent or causes the individual to require treatment to maintain or enhance independence.  A BHRF is defined as a 24-hour therapeutic living environment.

Under the 24-hour therapeutic treatment umbrella it is required that members receive counseling, groups, or other therapeutic activities. These services are included in the contracted daily rate.  An exception to this requirement may occur if the member has special health care treatment needs that require the services of a specialist not employed by the BHRF agency.  In such circumstance, the provider should receive approval from the Health Plan UM reviewer; however, an authorization for the specialty outpatient behavioral health services is not required (see details below).

Members should not be simply present, they should be receiving active treatment and the member should be engaged in the therapeutic environment.  Per AHCCCS AMPM 320 V, the following services are required to be made available and provided by the BHRF:

  • Counseling and therapy (group and individual)
  • Skills training and development
  • Behavioral health prevention/promotion and medication training
  • Behavioral health support services

BHRF Providers shall comply with all applicable Medicaid laws, regulations, including applicable sub-regulatory guidance and Contract provisions. [42 CFR 457.1201(i), 42 CFR 438.230(c)(2), 42 CFR 438.3 (k).  Additionally, the BHRF Provider shall cooperate with all AzCH Program and Quality Management requirements and comply with the utilization control and review procedures specified in 42 CFR 456, and the AHCCCS AMPM Chapters 900 and 1000.  It is the BHRF Provider responsibility to timely obtain any necessary authorizations from AzCH for services provided to eligible and/or enrolled members.

BHRF Providers shall ensure appropriate notification is sent to the member’s Primary Care Physician (PCP) and Behavioral Health Provider/Agency/Health Plan upon intake to and discharge from the BHRF.  When a member is not assigned to an outpatient Behavioral Health Home, outpatient Behavioral Health Provider or Agency it is the responsibility of the BHRF to facilitate an intake with the appropriate Behavioral Health Provider or Agency and coordinate care to ensure continuity of services.

BHRF Providers are required to submit individualized member documentation for admission, continued stay and discharge planning.  AzCH will not accept boiler plate, standardized documentation to substantiate medical necessity.  There should be documentation for the entire 24 hour period the member is present in the BHRF and this includes time the member is sleeping and present in the facility. Any time in which the member is receiving care in the BHRF and has gone AWOL or is otherwise not present at the BHRF it should be documented for care coordination purposes.  Additionally, if the member has been gone from the BHRF facility for more than 24 hours it is the BHRF’s responsibility to immediately notify AzCH.  Members staying out of a BHRF facility for more than 24 hours will be discharged, should the member come back to the BHRF after 24 hours it is the facilities responsibility to reinitiate the authorization of services. As a reminder, dates on which the member is inpatient, AWOL or has been discharged are not billable.  Billing should be based on where the member is at 11:59 p.m. Regardless of the time of placement or return to the facility, the day is billable if the member is present at 11:59 p.m. The discharge day is not billable as the member is not there for the full day. This mechanism provides a fair way to bill as there may be days for which you get credit when the member is not there for a full day.

Payment for BHRF placements require authorization.  Claims will be denied that do not have formal authorization entered in the Health Plan claims payment system. The days billed must coincide with the days authorized to receive appropriate payment.  The cost of Room and Board in a BHRF is not an AHCCCS/Medicaid reimbursable service. Additional reimbursement for Room and Board may be available to special populations through the RBHA. Consult the Provider Manual for the appropriate RBHA in which the member resides for details about eligibility for Room and Board reimbursement for special populations. AzCH does not prior-authorize Room and Board.

14.19.2 BHRF Provider required documentation for Admission/Assessment/Treatment/Discharge Planning

BHRF Providers rendering services to AzCH members shall follow the guidance outlined below for admission, assessment, treatment and discharge planning requirements, as required in AHCCCS AMPM 320-V.

  • A behavioral health assessment for a member shall be completed before treatment is initiated and within 48 hours of admission
  • The CFT/ART/Health Plan shall be included in the development of the Treatment Plan within 48 hours of admission for member enrolled with AzCH.
  • All BHRFs serving Health Plan members shall coordinate care with the Health Plan throughout the admission, assessment, treatment and discharge process.
  • The Treatment Plan shall connect back to the member’s comprehensive Service Plan for members enrolled with AzCH.
  • A comprehensive discharge plan shall be created during the development of the initial Treatment Plan and shall be reviewed and/or updated at each review thereafter.  The discharge plan shall document the following:
    • Clinical status for discharge,
    • Member/health care decision maker and designated representative and CFT/ART/Health Plan understands follow-up treatment, crisis and safety plan, and
    • Coordination of care and transition planning are in process (reconciliation of medications, applications for lower level of care submitted, follow-up appointments made, identification of wrap services/supports and potential providers).
  • The BHRF staff and the CFT/ART/Health Plan shall meet to review and modify the Treatment Plan at least once a month, if not more frequently.
  • A Treatment Plan may be completed by a BHP, or by a BHT that has oversight and signature by a BHP within 24 hours, this may not be rubber stamped, it must be signed on paper or electronically in a EHR by the BHP.  The BHRF must implement a system to report the timeliness of BHP signature/review when the Treatment Plan is completed by the BHT.
  • A process to actively engage family/health care decision maker and designated representative in the treatment planning process as appropriate.
  • Clinical practices, as applicable to services offered and population served, shall demonstrate adherence to best practices for treating specialized service needs, including but not limited to:
    • Cognitive/intellectual disability
    • Cognitive disability with comorbid behavioral health condition(s)
    • Older adults, and co-occurring disorders (substance use and behavioral health conditions)
    • Comorbid physical and behavioral health conditions
  • Services deemed medically necessary through the assessment and/or CFT/ART/Health Plan which are not offered at the BHRF, shall be documented in the Service Plan and documentation will include a description of the need, identified goals and identification of provider meeting the need for the member.  The BHRF provider shall make the following services available to AzCH members, these services cannot be billed separately unless otherwise approved:
    • Counseling and Therapy (group and individual) – Group Behavioral Health Counseling and Therapy may not be billed on the same day as BHRF services unless specialized group behavioral health counseling and therapy have been identified in the Service Plan as a specific member need that cannot otherwise be met as required within the BHRF setting.
    • Skills Training and Development
      • Independent Living Skills (self-care, household management, budgeting, avoidance of exploitation, safety education and awareness)
      • Community Reintegration Skill building (use of public transportation system, understanding community resources and how to use them)
      • Social Communication Skills (conflict and anger management, same/opposite different sex gender friendships, development of social support networks, recreation)
    • Behavioral Health Prevention/Promotion Education and Medication Training and Support Services including but not limited to :
      • Symptom management (including identification of early warning signs and crisis planning/use of crisis plan)
      • Health and Wellness education (benefits of routine medical check-ups, preventative care, communication with their PCP and other health practitioners)
      • Medication education and self-administration skills
      • Relapse prevention
      • Psychoeducation Services and On-going support to maintain employment work/vocational skills, educational needs assessment and skill building
      • Treatment for Substance Use Disorder (substance use counseling, groups)
      • Personal Care Services (if BHRF provider meets additional licensing requirements in A.A.C. R9-10-702, R9-10-715, R9-10-814)

 

14.19.3 Requirements for Expected Treatment Outcomes

Treatment outcomes shall align with:

  • The Arizona Vision-12 Principles for Children’s Behavioral Health Service Delivery as directed in AHCCCS AMPM Policy 430.
  • The 9 Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems as outlined in contract
  • The member’s individualized basic physical, behavioral, and developmentally appropriate needs.

Treatment goals shall be developed in accordance with the following:

  • Specific to the member’s Behavioral Health Condition(s)
  • Measurable and Achievable
  • Cannot be met in a less restrictive environment
  • Based on the member’s unique needs and tailored to the member and the family’s/health care decision maker and designated representative’s choices where possible
  • Support the member’s improved or sustained functioning and integration into the community.

 

14.19.4 Criteria for Admission

Providers are required to utilize AzCH contracted facilities for BHRF treatment. Non-contracted treatment centers should ONLY be utilized as a last resort and MUST have prior approval of AzCH.  If a non-contracted facility is being requested, AzCH requires documentation that contracted facilities have refused the member, at a minimum 3 contracted facilities MUST be contacted with documentation of the time/date and facilities reason for refusal.  Failure to obtain prior authorization for a non-contracted treatment center will result in denial of payment.

The Health Plan utilizes INTERQUAL and ASAM criteria guidelines in conjunction with the below medical necessity guidance from AHCCCS, AMPM 320 V.

  • Member has a diagnosed Behavioral Health Condition which reflects the symptoms and behaviors necessary for a request for residential treatment.  The Behavioral Health Condition causing the significant functional and/or psychosocial impairment shall be evidenced in the assessment by the following:
    • At least one are of significant risk of harm documented within the past three months as a result of:
      • Suicidal/aggressive/self-harm/homicidal thoughts or behaviors without current plan or intent,
      • Impulsivity with poor judgement/insight
      • Maladaptive physical or sexual behavior
      • Inability to remain safe within environment, despite environmental supports
      • Medication side effects due to toxicity or contraindications
    • At least one are of serious functional impairment as evidenced by:
      • Inability to complete developmentally appropriate self-care or self-regulation due to their Behavioral Health Condition
      • Neglect or disruption of ability to attend to majority of their basic needs, such as personal safety, hygiene, nutrition or medical care
      • Frequent inpatient psychiatric admissions, or legal involvement due to lack of insight or judgment associated with psychotic or affective mood symptoms or major psychiatric disorders
      • Frequent withdrawal management services, which can include but are not limited to, detox facilities, MAT, and ambulatory detox
      • Inability to independently self-administer medically necessary psychotropic medications despite interventions such as education, regimen simplification, daily outpatient dispensing, and long-acting injectable medications
      • Impairments persisting in the absence of situational stressors that delay recovery from the presenting problem
    • A need for 24 hour behavioral health care and supervision to develop adequate and effective coping skills that will allow the member to live safely in the community
    • Anticipated stabilization cannot be achieved in a less restrictive setting
    • Evidence that appropriate treatment in a less restrictive environment has not been successful or is not available, therefore warranting a high level of care
    • Member agrees to participate in treatment.  In the case of those who have a health care decision maker, including minors, the health care decision maker also agrees to, and participates as of, the treatment team.

BHRF Providers are expected to establish policies and procedures to ensure members on MAT are not excluded from admission and are able to receive MAT to ensure compliance with Arizona Opioid Epidemic Act SB 1001, Laws 2018, First Special Session.  BHRF providers are subject to periodic Health Plan audits and expected to demonstrate compliance with these requirements.

14.19.5 Criteria for Continued Stay

The Health Plan utilizes INTERQUAL and ASAM criteria guidelines in conjunction with the below medical necessity guidance from AHCCCS, AMPM 320 V.

Continued stay shall be assessed by the BHRF staff AND the CFT/ART/Health Plan during Treatment plan review and update.  Progress towards the treatment goals and continued display of risk and functional impairment shall also be assessed.  Treatment interventions, frequency, crisis/safety planning, and targeted discharge shall be adjusted accordingly to support the need for continued stay.  The following criteria shall be considered when determining continued stay:

  • The member continues to demonstrate significant risk of harm and/or functional impairment as a result of their Behavioral Health Condition
  • Providers and supports are available to meet current behavioral and physical health needs at a less restrictive lower level of care.

 

14.19.6 Criteria for Discharge Readiness

The Health Plan utilizes INTERQUAL and ASAM criteria guidelines in conjunction with the below medical necessity guidance from AHCCCS, AMPM 320 V.

Discharge planning shall begin at the time of admission.  Discharge readiness shall be assessed by the BHRF staff and the CFT/ART/Health Plan during each Treatment Plan review and update.  The following criteria shall be considered when determining discharge readiness:

  • Symptom or behavior relief is reduced as evidenced by completion of the Treatment Plan goals
  • Functional capacity is improved, essential functions such as eating or hydrating necessary to sustain life has significantly improved or is able to be cared for in a less restrictive level of care
  • Member can participate in needed monitoring or a caregiver is available to provide monitoring in a less restrictive level of care
  • Providers and supports are available to meet current behavioral and physical health needs at a less restrictive level of care.

It is not expected that all behavioral health or psychological difficulties will be resolved by the time of discharge from the facility.  Members should have a detailed outpatient plan outlined to facilitate coordination of care.

 

14.19.7 Exclusionary Criteria

Admission to a BHRF shall not be used as a substitute for the following:

  • An alternative to detention or incarceration
  • As a means to ensure community safety in circumstances where a member is exhibiting primarily conduct disorder behavior without the presence of risk or functional impairment
  • A means of providing safe housing, shelter, supervision, or permanency placement
  • A behavioral health intervention when other less restrictive alternatives are available and meet the member’s treatment needs, including situations when the member/health care decision maker are unwilling to participate in the less restrictive alternative
  • As an intervention for runaway behaviors unrelated to a Behavioral Health Condition

ALL BEHAVIORAL HEALTH RESIDENTIAL FACILITY PRIOR AUTHORIZATION REQUESTS WILL BE PROCESSED WITHIN 72 HOURS OF DOCUMENTED RECEIPT OF THE REQUEST.

Prior Authorization is not a guarantee of payment, member must be eligible to receive benefits on the dates of service and billing must be submitted correctly.

 

14.19.8 BEHAVIORAL HEALTH RESIDENTIAL FACILITIES

Planned Admissions (Members not requiring urgent admission)

Providers serving members who are NOT in need of urgent admission to Behavioral Health Residential Facilities are required to obtain Prior Authorization for admission.   The Adult Recovery Team (ART) or Child Recovery Team (CFT) shall submit an updated treatment plan (completed within the prior 90 days) indicating the specific treatment goals for the Behavioral Health Residential Facility to address with the member.  The goals MUST be focused on the signs and symptoms of the mental health or substance use disorders that resulted in the member being unable to successfully achieve treatment goals in an outpatient setting and successfully continue to live in the community.  An active treatment plan should aim to overcome the member’s symptoms and promote recovery, and successfully return the member to the community as early as possible.  Individualized member documentation MUST include a tentative discharge plan, a recent psychiatric evaluation that reflects current concerning behaviors, functioning and diagnoses, and an ART/CFT team note indicating the team’s recommendations must accompany the submitted treatment plan and prior authorization form. All documentation MUST be individualized to the specific member needs, pre-printed script will not be accepted.

There MUST be evidence that the member has agreed to and is willing to participate in treatment, the Member or the Health Care Decision maker has signed an informed consent acknowledging the residential treatment is a time limited placement for active treatment.

Prior Authorization requests not containing the mandated documents will be considered invalid and returned to the provider.

AzCH will review the prior authorization request within 72 hours of receipt of the request.

If the prior authorization is being approved for a future placement, the AzCH PA will be valid for only 45 days.  In cases where placement has not occurred within the 45 day authorized window the PA will be voided and resubmission with updated clinicals will be required.

Timelines for approval - Initial authorization

If approved, the initial authorization period will be:

  • Adults – up to 30 days, then continued stay process would be followed
  • Children – 30 days, then continued stay process would be followed

Continued Stay

Seven (7) days prior to the LCD (last covered day) the BHRF provider and treatment team are required to provide documentation for continued stay.  The BHRF provider receives a “Notice of Coverage” letter indicating the LCD (last covered day), it is the responsibility of the BHRF provider to submit all required documentation to AzCH prior to the LCD. Failure to submit required documentation by the LCD may result in continued stay denial. Once the continued stay denial has been issued the BHRF provider will need to formally appeal the denial action.

Continued stay requests MUST include the following documentation:

  • CFT/ART note or progress note indicating continued need for this level of care (CFT/ART required monthly)
  • Rendering service providers documentation (current progress notes/reports, facility treatment plan noting progress)
  • Member specific documentation of current symptoms/behaviors/functioning that justify the need for continued stay at the current level of care
  • Current medication sheets
  • Goals to discharge plan, including barrier for transition to outpatient services or less restrictive level of care

Approved continued stay authorizations will be issued for:

  • Adults - up to 30 days, providers must continue to follow the above guidance for any continued stay requests. 
  • Children - 30 days, providers must continue to follow the above guidance for any continued stay requests.
  • Urgent admissions from an Inpatient Setting (BHIF)/Detox Center, a Crisis facility, or preadmission evaluation indicates the member needs an immediate placement.

Prior Authorization is not required for urgent admissions to AzCH contracted BHRF facilities

The BHRF is responsible for assessing the member’s needs, determining and documenting the reasons for an urgent admission and ensuring member meets the criteria standards for admission.  The BHRF shall submit the Behavioral Health Residential Facility Admission Notification Form to AzCH. The Health Plan will authorize up to the initial 5 days for this admission. The BHRF Admission Notification Form must be received within 2 calendar days after the member is admitted to the facility for treatment.  All required documentation MUST be received within the initial 5 days to receive continued authorization beyond the initial 5 days.  Failure to submit notification and provide documentation may result in the denial of the initial 5 days.  Urgent admissions are subject to retrospective review, admissions not meeting medical necessity criteria will be denied and any payments recouped.

The BHRF will submit a current treatment plan indicating the specific treatment goals for the Behavioral Health Residential Facility to address with the member.  The goals MUST be focused on the signs and symptoms of the mental health or substance use disorders that resulted in the member being unable to successfully achieve treatment goals in an outpatient setting and successfully continue to live in the community.  An active treatment plan should aim to overcome the member’s symptoms and promote recovery, and successfully return the member to the community as early as possible.

Individualized member documentation MUST include:

  • BHRF Admission Notification Form
  • Individualized treatment plan
  • A tentative discharge plan,
  • Recent psychiatric evaluation that reflects current concerning behaviors, functioning and diagnoses,
  • BHRF team admission/progress notes indicating the recommendations.

All documentation MUST be individualized to the specific member needs, pre-printed script will not be accepted.

There MUST be evidence that the member has agreed to and is willing to participate in treatment, the Member or the Health Care Decision maker has signed an informed consent acknowledging the residential treatment is a time limited placement for active treatment.

Prior Authorization requests not containing the mandated documents will be considered invalid and returned to the provider.

The Health Plan will review the admission notification within 72 hours of receipt of the request.

Timelines for approval after Initial authorization period of 5 days

  • Adults – up to 30 days, then continued stay process would be followed
  • Children – 30 days, then continued stay process would be followed

Continued Stay

Seven (7) days prior to the LCD (last covered day) the BHRF provider and treatment team are required to provide documentation for continued stay.  The BHRF provider receives a “Notice of Coverage” letter indicating the LCD (last covered day), it is the responsibility of the BHRF provider to submit all required documentation to AzCH prior to the LCD. Failure to submit required documentation by the LCD may result in continued stay denial.   Once the continued stay denial has been issued the BHRF provider will need to formally appeal the denial action.

Continued stay requests MUST include the following documentation:

  • CFT/ART note or progress note indicating continued need for this level of care (CFT/ART required monthly)
  • Rendering service providers documentation (current progress notes/reports, facility treatment plan noting progress)
  • Member specific documentation of current symptoms/behaviors/functioning that justify the need for continued stay at the current level of care
  • Current medication sheets
  • Goals to discharge plan, including barrier for transition to outpatient services or less restrictive level of care

Approved continued stay authorizations will be issued:

  • SUD BHRF Adults - up to 14 days, providers must continue to follow the above guidance for any continued stay requests.
  • General BHRF Adults - up to 30 days, providers must continue to follow the above guidance for any continued stay requests.
  • Children - 30 days, providers must continue to follow the above guidance for any continued stay requests.

 

14.19.9 OUT OF STATE PLACEMENT (Child and Young Adult)

It is considered in the best interest of the child and family to treat the member in a setting as close to the member’s home as possible. All instate treatment alternatives, including higher levels of care shall be exhausted before requesting an out-of-state placement for a child or young adult to meet the member’s unique circumstances or clinical needs. Prior authorization and approval from AHCCCS is required for all out-of-state placements. The following circumstances must exist in order to consider an out-of-state placement for a member:

  • The CFT or ART shall explore all applicable and available in-state services and placement options and,
    • Determine that all In-state facilities do not adequately meet the specific needs of the member, or
    • All In-state facilities decline to accept the member.
  • The member’s family/guardian is in agreement with the out-of-state placement (for minors and members between 18 and under 21 years of age under guardianship),
  • The out-of-state placement is registered as an AHCCCS provider,
  • Prior to placement, ensure the member has access to non-emergent medical needs by an AHCCCS registered provider,
  • The out-of-state placement meets the Arizona Department of Education Academic Standards, and
  • A plan for the provision of non-emergency medical care must be established.

No Bed Availability

In the event a covered behavioral health service is temporarily unavailable for persons in an inpatient or residential facility who are discharge-ready and require covered, post-discharge behavioral health services, AzCH will coordinate with the provider to:

  • Allow the member to remain in the facility under an administrative rate or a negotiated rate based on the member’s discharge plan and level of care.
  • Offer intensive outpatient services.
  • Collaborative case management with the facility and the health plan
  • Appropriate peer services while waiting for the covered behavioral health service.

BHRF with Personal Care Services

BHRF Providers who are licensed to provide Personal Care Services shall offer those services in accordance with A.A.C. R9-10-702 and A.A.C. R9-10-715.  BHRF Providers shall ensure that all identified needs can be met in accordance with A.A.C. R9-10-814(A)(C)(D) and (E).  BHRF Providers MUST submit documentation of these services when seeking initial review, concurrent review and as part of the member’s discharge planning.

The following is a list of examples of services that may be provided:

  • Blood sugar monitoring, Accu-Check diabetic care
  • Administration of oxygen
  • Application and care of orthotic devices
  • Application and care of prosthetic devices
  • Application of bandages and medical supports, including high elastic stockings
  • ACE wraps, arm and leg braces, etc
  • Application of topical medications
  • Assistance with ambulation
  • Assistance with correct use of cane/crutches/walker
  • Bed baths
  • Care of hearing aids
  • Radial pulse monitoring
  • Respiration monitoring
  • Denture care and brushing teeth
  • Dressing member
  • Supervising self-feeding of members with swallowing deficiencies
  • Hair care, including shampooing
  • Incontinence support, including assistance with bed pans/bedside commodes/bathroom support
  • Measuring and recording blood pressure
  • Non-sterile dressing change and wound care
  • Passive range of motion exercises
  • Use of pad lifts
  • Shaving
  • Shower assistance using shower chair
  • Skin maintenance to prevent and treat bruises, injuries, pressure sores.  Members with stage 3 or 4 pressure sores ARE NOT to be admitted to a BHRF, per A.A.C. R9-10-715(3), and infections
  • Use of chair lifts
  • Skin and foot care
  • Measuring and giving insulin, glucagon injections
  • Gastrostomy tube (G-tube) care
  • Ostomy and surrounding skin care
  • Catheter care

Personal care services involve the provision of support activities to assist an individual in carrying out activities of daily living such as bathing, shopping, dressing and other activities essential for living in a community.

  • Personal care services may be provided in an unlicensed setting such as a member’s own home or community setting,
  • Parents (including natural parent, adoptive parent and stepparent) may be eligible to provide personal care services if the member receiving services is 21 years or older and the parent is not the member’s legal guardian,
  • Personal Care Services provided by a member’s spouse is not covered, and
  • More than one provider agency may bill for personal care services provided to a member at the same time if indicated by the member’s clinical needs as identified through their Service Plan.

The following is a list of examples of services that may be provided:

  • Blood sugar monitoring, Accu-Check diabetic care
  • Administration of oxygen
  • Application and care of orthotic devices
  • Application and care of prosthetic devices
  • Application of bandages and medical supports, including high elastic stockings
  • ACE wraps, arm and leg braces, etc
  • Application of topical medications
  • Assistance with ambulation
  • Assistance with correct use of cane/crutches/walker
  • Bed baths
  • Care of hearing aids
  • Radial pulse monitoring
  • Respiration monitoring
  • Denture care and brushing teeth
  • Dressing member
  • Supervising self-feeding of members with swallowing deficiencies
  • Hair care, including shampooing
  • Incontinence support, including assistance with bed pans/bedside commodes/bathroom support
  • Measuring and recording blood pressure
  • Non-sterile dressing change and wound care
  • Passive range of motion exercises
  • Use of pad lifts
  • Shaving
  • Shower assistance using shower chair
  • Skin maintenance to prevent and treat bruises, injuries, pressure sores.  Members with stage 3 or 4 pressure sores ARE NOT to be admitted to a BHRF, per A.A.C. R9-10-715(3), and infections
  • Use of chair lifts
  • Skin and foot care
  • Measuring and giving insulin, glucagon injections
  • Gastrostomy tube (G-tube) care
  • Ostomy and surrounding skin care
  • Catheter care