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-1020-1 |
Psychiatric Security Review Board/GEI Conditional Release Monthly Report |
Behavioral Providers with Psychiatric Security Review Board (PSRB) Members |
2nd 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-907 |
Persons Receiving Special Assistance |
Behavioral |
28th day of each month via secure email |
CA-908 |
Special Assistance Form Deliverable |
Behavioral Health Home Providers with active Special Assistance members |
5th day of the month for the previous months data |
CA-910 |
Monthly Warm Line Report |
HOPE, Inc. |
5th calendar day of each month |
CD-502 |
Department of Economic Security - Professional Foster Care Home License |
HCTC & 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 Nurse Assist Line |
3rd calendar day of month for previous month’s data |
EC-301-1b |
Daily Pending Inpatient Placement Report |
AzCH-CCP Nurse Assist 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 |
20th calendar day of month for previous month |
EC-301-17 |
Secondary Responder Activation Report |
Deveroux, La Frontera, EMPACT, HOPE, Inc., Old Pueblo, TLCR |
10th of month for previous month |
EC-301-19 |
Report for Pima County-COE detail |
AzCH-CCP Nurse Assist Line |
20th calendar day of month for previous month |
EC-301-20 |
Pima County Crisis Line Report |
AzCH-CCP Nurse Assist Line |
20th calendar day of month for previous month |
EC-301-22 |
Crisis Notifications to Providers |
AzCH-CCP Nurse Assist Line |
Daily by 10am to individual/applicable providers |
EC-301-25 |
Foster Care Hotline Call Report |
AzCH-CCP Nurse Assist Line |
10th calendar day of the month for the previous month |
EC-301-26 |
Tribal Crisis Call Template |
AzCH-CCP Nurse Assist Line |
7th calendar day of the month for the previous month |
EC-301-99 |
Crisis Line Dashboard |
AzCH-CCP Nurse Assist Line |
6th of every month |
EC-301-30 |
ACC Daily Crisis Notification |
AzCH-CCP Nurse Assist Line |
Daily |
EC-301-31 |
Crisis Observation (COU) Notification of Admissions |
AzCH-CCP Nurse Assist Line |
5th 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.
|
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 1st |
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 1st and August 1st |
EC-313 |
Coalition Detailed Implementation Plan |
Prevention Providers |
September 15th or 30 days after approved program changes |
EC-314 |
HIV Early Intervention Monthly Report |
HIV Early Intervention Providers COPE SAAF |
5th calendar day after month end
|
EC-319 |
Evidence Based Prevention Assessment |
Prevention Providers |
15th of July |
EC-320 |
Urgent Transportation Report |
AMT, Saguaro, & TLC-R |
10th calendar day after month end |
EC-321 |
T36 Pre-Petition Data |
CBI |
Last day of the month for previous month’s data |
EC-322 |
Scorecard |
CRC, HHW, CBI |
29th calendar day after month end |
EC-323 |
Crisis Mobile Team Activity Log |
ACTS, CBI, CHA, HHW |
5th calendar day after month end |
EC-325 |
Living Room Center Admission Report |
CHA |
10th 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 Nurse Assist 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 received over $750,000 federal grant funds for their agency
(SABG and MHBG funds 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 |
SABG and MHBG Policies |
Providers receiving SABG and MHBG Block Grant Funds – Fee for Service or Block Payment or Block Purchase |
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 PSA Art Awakenings Intermountain Centers for Human Development, Horizon Health & Wellness Community Bridges Community Health Associates Native American Advancement Foundation |
5th calendar day after quarter end |
OI-218 |
Tribal Warm Line Outreach Report |
AzCH-CCP Nurse Assist Line |
5th calendar day after month end |
OI-230 |
Monthly CCCT/CCI Program Report |
Casa De Los Niños, CPES, Intermountain & Pathways |
5th calendar day after month end |
OI-235 |
Employment Services Monthly Report |
All Behavioral Health Homes and Employment Specialty Providers
|
5th calendar day of the month following |
OI–236 |
MAT Census Report |
CBI, La Frontera, COPE , CODAC, CMS, HHW, New Hope BH, Wellbeing |
5th calendar day after month end |
RF-101 |
Weekly BIP Report |
CBI, Cope, CODAC, CPCC, Devereux, ICHD & Park Place |
Every Friday |
RF-1002 |
Engagement Specialist Tracking Log |
PPEP, CCS, Old Pueblo |
5th calendar day after month end |
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 |
10th calendar day of the month |
TR-001 |
Call Stats - Service Level |
Transportation Provider - Veyo |
15th of the month for previous month |
TR-002 |
Complaints & Grievances |
Transportation Provider - Veyo |
15th of the month for previous month |
TR-003 |
Executive Summary |
Transportation Provider - Veyo |
15th of the month for previous month |
TR-004 |
Detail and Summary Trip Report |
Transportation Provider - Veyo |
15th of the month for previous month |
TR-005 |
Quarterly Executive Summary |
Transportation Provider - Veyo |
15th of the month following quarter end for previous quarter |