Deliverable Requirements

The following table is a summary of the periodic reporting requirements and is subject to change at any time during the term of the contract. The table is presented for convenience only and should not be construed to limit provider’s responsibilities in any manner. Content for all deliverables is subject to ongoing review. All contractual obligations apply. Reports are to be submitted to AzCHdeliverables@azcompletehealth.com, unless otherwise noted, in the following format: DELIVERABLE #, DUE DATE, PROVIDER NAME -example: ND601_120115_ABCCOUNSELING.

“Days” means calendar days unless otherwise specified. If the due day is a weekend or a State of Arizona holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday

Templates will be provided upon request.

Report #	Deliverable Name	Providers Required to Submit	Due Date
AMPM-1020I –Attachment A	Psychiatric Security Review Board/GEI Conditional Release Monthly Report	Behavioral Providers with Psychiatric Security Review Board (PSRB) Members	2^nd day of the month for the previous months date
CA-905	RSS Inventory Utilization Committee Referral Report – PFRO	Specialty Behavioral Health Providers & CSA Providers that employ Peer and/or Family Supports	5th calendar day after quarter end
CA-906	RSS Inventory Utilization Committee Referral Report - Behavioral Health Home	Behavioral Health Homes	5th calendar day after quarter end
CA-908	Special Assistance Form Deliverable	Behavioral Health Home Providers with active Special Assistance members	5^th day of January, March, May, July, September, & November for the previous 2 months data
CA-910	Monthly Warm Line Report	HOPE, Inc.	5^th calendar day of each month
CD-502	Department of Economic Security - Professional Foster Care Home License	TFC & BH Therapeutic Homes	Within 15 calendar days prior to expiration of each license
CO-115	Justice Services Report	Community Health Associates	5th calendar day of the Month
EC-301-1	Emergency Room Wait Times Report	AzCH-CCP AZ Crisis Line	3rd calendar day of month for previous month’s data
EC-301-1b	Daily Pending Inpatient Placement Report	AzCH-CCP AZ Crisis Line, CBI, CPIH, CHA	Daily by 10am for previous day. Send to Email Distribution List as agreed upon by parties
EC-301-6	Acute Health Plan & Provider Inquiry Log and Detail	AzCH-CCP Nurse Assist Line	20^th calendar day of month for previous month
EC-301-17	Secondary Responder Activation Report	Devereux, La Frontera-EMPACT, HOPE, Inc., Old Pueblo, TLCR, CFSS	10^th of month for previous month
EC-301-19	Report for Pima County-COE detail	CRC	20^th calendar day of month for previous month
EC-301-20	Pima County Crisis Line Report	CRC	20^th calendar day of month for previous month
EC-301-22	Crisis Notifications to Providers	AzCH-CCP AZ Crisis Line	Daily by 10am to individual/applicable providers
EC-301-25	Foster Care Hotline Call Report	AzCH-CCP AZ Crisis Line	10^th calendar day of the month for the previous month
EC-301-26	Tribal Crisis Call Template	AzCH-CCP AZ Crisis Line	7^th calendar day of the month for the previous month
EC-301-99	Crisis Line Dashboard	AzCH-CCP AZ Crisis Line	6^th of every month
EC-301-30	ACC Daily Crisis Notification	AzCH-CCP AZ Crisis Line	Daily
EC-301-31	Crisis Observation (COU) Notification of Admissions	AzCH-CCP AZ Crisis Line	5^th calendar day of the month for previous month
EC-302	COT Title 36 Reporting	Behavioral	2nd Business day of the month. All COT portal entries not yet entered for the current reporting month and all required documents that have not yet been submitted for the current reporting month. When sending report, CC the AZCHtitle36@azcompletehealth.com mailbox
EC-304	Prevention Report	Prevention Providers (except COPE & SAAF)	15th calendar day after month end
EC-305	Annual Prevention Report	Prevention Providers	Submission by September 15, 2018
EC-306	Prevention Program Description/Logic Model	Prevention Providers	Submission by April 1^st
EC-310	Annual Heat Plan Update	Behavioral Health Home Providers	April 15th
EC-312	Crisis Mobile Team Readiness Review	Providers with Crisis Mobile Teams (CPIH, CBI, CHA, HHW)	February 1^st and August 1^st or with any staff changes
EC-313	Coalition Detailed Implementation Plan	Prevention Providers	September 15^th or 30 days after approved program changes
EC-314	HIV Early Intervention Monthly Report	HIV Early Intervention Providers COPE SAAF	5^th calendar day after month end
EC-319	Evidence Based Prevention Assessment	Prevention Providers	15^th of July
EC-321	T36 Pre-Petition Data	CBI	Last day of the month for previous month’s data
EC-322	Scorecard	CRC, HHW, CBI	29^th calendar day after month end
EC-323	Crisis Mobile Team Activity Log	CBI, CHA, CPIH, HHW	5^th calendar day after month end
EC-325	Living Room Center Admission Report	CHA	10^th day of the month for previous month
EC-326	Quarterly SABG Prevention Activity Report	Prevention Providers (except COPE & SAAF)	45-days after quarter end
EC-327	Prevention Performance Measure Tables 31 & 32	Prevention Providers (except COPE & SAAF)	45-days after quarter end
EC-328	ACC Real Time Crisis Activity (Trigger Triage)	AzCH-CCP AZ Crisis Line	Real Time notification
FN-101	Month End Financial Statements (including Year to Date Income Statement, Balance Sheet, Statement of Cash Flow and financial ratios)	Behavioral Health Home Providers on Case Rate payment method or Fee for Service Payment or Block Payment	30th calendar day after month end
FN-401	Quarterly Financial Statements (including Year to Date income statement, Balance Sheet, Statement of Cash Flow and financial rations)	-All Specialty Providers paid via Block Payment. -All Crisis Providers paid via Block Purchase -Excludes specialty, non-crisis providers that are ONLY paid Block Purchase	30th calendar day after quarter end
FN-402	Final Audited Financial Statements Final Audited Financial Statements for All Related Parties Earning Revenue under this Contract Final to the Audited Financial Statements including Income Statement, Balance Sheet, Statement of Cash Flow Liquidity Ratios and Profit Percentage calculations per terms of the contract	All RHBA providers submitting the FN-101 and FN-401 and all RBHA FFS providers receiving $3,000,000 or more in annual revenue from The Health Plan, or as requested by the Health Plan.	Includes Behavioral Health Home Crisis Providers Specialty Block Payment Specialty FFS Behavioral Health Home / FFS Hospitals FFS Transportation FFS Due 120 days after provider’s fiscal year end
FN-403	Non-Title Funding Expenditure Report	Providers that received Supported Housing funds, SABG, MHBG, NT SMI – Fee for Service or Block	30th calendar day after quarter end
FN-405	OMB Single Audit	Providers that expended over $750,000 federal grant funds for their agency (SABG, MHBG, MAT-PDOA, STR and SOR and other federal grants as noted are sub-awards and included in providers Schedule of Federal Awards)	150 days after provider’s fiscal year end Banner Healthcare Only - 210 days after provider’s fiscal year end
FN-408	Federal grant Policies	Providers receiving federal grants including SABG and MHBG Block Grant Funds, MAT-PDOA, STR or SOR and any other future grant awards – Fee for Service or Block Payment or Block Purchase or Contractor Expenditure Report	By November 1 of each contract year
IT-702	7 Day Access to Care	Behavioral Health Home Providers	as requested
OI-201	Child Dedicated Health Care Coordinator Inventory	Behavioral Health Home Providers (except Banner, CBI, COPE, CRM, Desert Senita, & El Rio)	2nd calendar day of the Month
OI-206	Housing Roster Report	Achieve, Horizon Health and Wellness, SEABHS, Marana Health , CODAC, COPE, La Frontera, Community Partners Integrated Healthcare, Old Pueblo Community Services, CBI, Wellness Connections, TLCR, Pinal Hispanic Council	5th calendar day of the Month
OI-214	Quarterly Rehab Progress Report	All Behavioral Health Homes and Employment Specialty Providers	2nd calendar day after quarter end
OI-217	Tohono O’odham Nation Quarterly Report	Community Partnership Integrated Health Care Intermountain Centers for Human Development, Horizon Health & Wellness Community Bridges Community Health Associates Native American Advancement Foundation	5^th calendar day after quarter end
OI-218	Tribal Warm Line Outreach Report	AzCH-CCP AZ Crisis Line	5^th calendar day after month end
OI-230	Monthly CCCT/CCI Program Report	Casa De Los Niños, CPES, Intermountain & Pathways	5^th calendar day after month end
OI-235	Employment Services Monthly Report	All Behavioral Health Homes and Employment Specialty Providers	5^th calendar day of the month following
OI–236	MAT Census Report	CBI, La Frontera, COPE , CODAC, CMS, HHW, New Hope BH, Wellbeing	5^th calendar day after month end
RF-101	Weekly BIP Report	CBI, Cope, CODAC, CPI-H, Devereux, ICHD	Every Friday
RF-1005	Incidents, Accidents, and Death Report	All Providers	Within (2) two business days of the incident and the IAD must be entered into the AHCCCS QMS Portal https://qmportal.azahcccs.gov/WF_Public_Default.aspx
RF-1008	Notification of Persons in Need of Special Assistance	Behavioral Health Home Providers	Due to OHR within (5) five business days of identifying need for special assistance, copy to The Health Plan
RF-1009	Notification of Persons No Longer in Need of Special Assistance	Behavioral Health Home Providers	Due to OHR within (10) days of identifying individual is no longer in need of special assistance, copy to The Health Plan via secure email
RF-1010	Complaint Resolution Confirmation Response	All Providers	Within two (2) business days of the request
RF-1013	PASRR Level II Evaluations completed by a Psychiatrist	Behavioral Health Home Providers	When requested by AHCCCS or The Health Plan, complete evaluation within (3) three business days for hospitalized individuals and within 5 business days for all others.
RF-1015	Notification by email or letter of an unexpected material facility change that could impact the Provider Network	All Providers	Within one (1) business day of becoming aware of the unexpected change.
RF-1016	Notification of Change Form	All Providers	At least (90) ninety calendar days prior to the anticipated change that could impact the Provider Network.
RF-1018	Ad Hoc Reports not listed	All Providers	as requested
RF-1021	System of Care Practice Review (SOCPR) Practice Improvement Plan Updates	Children’s Health Home Providers participating in annual practice review process	Initial Plan due: upon request. Plan Updates due upon request
RF-1022	Medicare Advantage D-SNP Member Pre-Service Appeals Report	Banner	10^th calendar day of the month
RF-1023	Total number of incidents of the use of S&R involving AHCCCS members in the prior month	All Level 1 facilities	5^th of the month for previous month
RF-1024	DME Service Delivery Reporting	DME providers of customized hospital beds, customized wheelchairs and augmentative communication devices	5^th calendar day after quarter end
RT-11715	ABA Monitoring Report- RBHA Members	All Health Homes & Specialty Providers who provide ABA	Due quarterly by the 3^rd of the month, starting in April 2020
RT-11711	ABA Monitoring Report-ACC Members	All Health Homes & Specialty Providers who provide ABA	Due quarterly by the 3^rd of the month, starting in April 2020
TR-001	Call Stats - Service Level	Transportation Provider - Veyo	15^th of the month for previous month
TR-002	Complaints & Grievances	Transportation Provider - Veyo	15^th of the month for previous month
TR-003	Executive Summary	Transportation Provider - Veyo	15^th of the month for previous month
TR-004	Detail and Summary Trip Report	Transportation Provider - Veyo	15^th of the month for previous month
TR-005	Quarterly Executive Summary	Transportation Provider - Veyo	15^th of the month following quarter end for previous quarter