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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 January, March, May, July, September, & November for the previous 2 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 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

20th calendar day of month for previous month

EC-301-17

Secondary Responder Activation Report

Devereux, La Frontera-EMPACT, HOPE, Inc., Old Pueblo, TLCR, CFSS

10th of month for previous month

EC-301-19

Report for Pima County-COE detail

CRC

20th calendar day of month for previous month

EC-301-20

Pima County Crisis Line Report

CRC

20th 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

10th  calendar day of the month for the previous month

EC-301-26

Tribal Crisis Call Template

AzCH-CCP AZ Crisis Line

7th calendar day of the month for the previous month

EC-301-99

Crisis Line Dashboard

AzCH-CCP AZ Crisis Line

6th 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

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. 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 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 or with any staff changes

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

CBI, CHA, CPIH, 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 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 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

Denga Medical Transport

5th calendar day after quarter end

OI-218

Tribal Warm Line Outreach Report

AzCH-CCP AZ Crisis 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, CPI-H, Devereux, ICHD

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