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. An example is 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	Behavioral Health Providers employing Peer Supports	5th calendar day after quarter end. Submit within the AHCCCS QM Portal https://qmportal.azahcccs.gov/
CA-906	Credentialed P/FSS Inventory	Any BH Provider that employ Credentialed Parent/Family Support Specialists	5th calendar day after quarter end. Submit within the AHCCCS QM Portal https://qmportal.azahcccs.gov/
CA-909	Member and Family Advocacy Council Deliverable	Integrated Health Homes	15^th day of each month
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-301-1b	Daily Pending Inpatient Placement Report	CBI, CHA, Spectrum, Terros	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-Complete Care Plan 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-301-22	Crisis Notifications to Providers	AzCH–CCP Statewide Crisis Line	Daily by 11am to individual/applicable providers
ECS301-25	Foster Care Hotline Report	AzCH-Complete Care Plan Statewide Crisis Line	10^th of every month
ECS301-26	Tribal Crisis Call Template	AzCH-Complete Care Plan Statewide Crisis Line	Quarterly beginning January
ECS301-99	Crisis Line Dashboard	AzCH-Complete Care Plan Statewide Crisis Line	10^th of every month
AZ-400 & AZ-401	ACC Daily Crisis Notification	AzCH-Complete Care Plan Statewide Crisis Line	Daily by 11am
EC590A	Crisis Line Overall Data Report	AzCH-Complete Care Plan Statewide Crisis Line	10^th of every month for each region
ECS158	Outreach Report	AzCH-Compete Care Plan Statewide Crisis Line	10^th of every month
EC-159	911 TFN Raw Date	AzCH-Complete Care Plan Statewide Crisis Line	10^th of every month
EC-301-31	Crisis Observation (COU) Notification of Admissions	CBI, CRC, Southwest, The Guidance Center, ChangePoint	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-310	Annual Heat Plan Update	Integrated Health Home Providers	April 15th
EC-311	Children's Behavioral Health Services Report	Casa De Los Ninos,	5^th calendar day after month end

		COPE,

		La Frontera, Intermountain Center, Clarvida,

		Mohave Mental Health,

		The Guidance Center,

		Southwest Behavioral Health
EC-312	Crisis Mobile Team Readiness Review	Providers with Crisis Mobile Teams (CBI, CHA, Spectrum, Terros)	5th of the month for the previous month
EC-314	HIV Early Intervention Monthly Report	HIV Early Intervention Providers	5^th calendar day after month end

		COPE, North Country HealthCare
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-325	Living Room Center Admission Report	CHA	10^th day of the month for previous month
EC-326	Quarterly SUBG Prevention Activity Report	Prevention Providers (except COPE & SAAF)	45-days after quarter end
FN-101 (South GSA)	Year to Date (YTD) Financial Statements (including YTD Income Statement, Balance Sheet, Statement of Cash Flow, and financial ratios)	Integrated Health Home	30th calendar day after quarter end.
FN-501 (North GSA)		Includes RBHA Integrated Health Homes on Case Rate payment method, Fee for Service Payment, Block Payment, or receiving RBHA Integrated Health Home assignments.	Quarter ending:

			3/31/20XX

			6/30/20XX

			9/30/20XX

			12/31/20XX
FN-401 (Formerly FN-501 for the North GSA)	Year to Date (YTD) Financial Statements (including YTD income statement, Balance Sheet, Statement of Cash Flow, and financial ratios)	-All RBHA behavioral health providers paid via Block Payment.	30th calendar day after quarter end

		-All Crisis Providers paid via Block Purchase	Quarter ending:

		-Excludes specialty, non-crisis providers that are ONLY paid Block Purchase	3/31/20XX

			6/30/20XX

			9/30/20XX

			12/31/20XX
FN-402 (South GSA)	Final Audited Financial Statements Final Audited Financial Statements for All Related Parties Earning Revenue under this Contract *Final Audited Financial Statements including Income Statement, Balance Sheet, Statement of Cash Flow	All RHBA providers submitting the FN-101 and FN-401 and all RBHA FFS or as requested by the Health Plan.	Includes
	*Liquidity Ratios and Profit Percentage calculations per terms of the contract	All providers considered Sub-Recipients of Federal grant funds that are required to complete a Uniform Guidance Audit (see FN-405).	- Integrated Health Home
FN-502 (North GSA)
			-Crisis Providers
			-RBHA behavioral health Block Payment
			-RBHA behavioral health FFS providers receiving Non-Title XIX/XXI funds
			Due 120 days after provider’s fiscal year end
FN-403	Non-Title Funding Expenditure Report	Providers that receive funding (Fee for Service or Block) in the following categories: SUBG, MHBG, NTXIX SMI (excluding supported housing), NTXIX Crisis, NTXIX Substance Use Disorder Services (SUD), NTXIX Children’s Behavioral Health Services Funds (CBHSF), Pima County IGA	Bi-annually 45 calendar days after quarter end

(South GSA)
			Quarter ending:

FN-503 (North GSA)			3/31/20XX due 5/15/20XX

			9/30/20XX due 11/14/20XX

			Submissions that need corrections and/or do not align with AZCH-CCP records may need to be submitted quarterly on a case by case review.
FN-405	Uniform Guidance Audit/ Single Audit	Providers that expend $750,000 or more in federal funds for period ending 9/30/2024 or $1M in federal funds beginning 10/1/2024 (provider fiscal year), or as threshold is updated in 2 C.F.R. Part 200 from time to time.	150 days after provider’s fiscal year end

(South GSA)		(Including, but not limited to SUBG (CFDA# 93.959), MHBG (CFDA# 93.958), SOR (CFDA# 93.788), COVID19 Emergency (CFDA# 93.665), or PPW-PLT (CFDA# 93.243), and other federal grants as applicable for subawards
			Banner Healthcare Only - 210 days after provider’s fiscal year end
FN-505 (North GSA)
FN-408	Federal Grant Policies	Providers receiving federal grants including SUBG and MHBG Block Grant Funds, SOR, COVID-19 Emergency, PPW-PLT, and any other future grant subawards. Includes Fee for Service or Block Payment or Block Purchase or Contractor Expenditure Report	By November 1 of each contract year and within 30-days of a new subaward.

(South GSA)


FN-508 (North GSA)
OI-201	Child Dedicated Health Care Coordinator Inventory	All Integrated Health Home Providers and Specialty providers who have HNCM	5th calendar day after quarter end.
OI-202	Adult Dedicated Health Care Coordinator Inventory	All Integrated Health Home Providers	5^th calendar day after quarter end.
OI-206	Housing Roster Report	Achieve, Horizon Health and Wellness, SEABHS, Marana Health, CODAC, COPE, Community Partners Integrated Healthcare, Old Pueblo Community Services, CBI, Pinal Hispanic Council	2nd calendar day of the Month
OI-217	Tohono O’odham Nation Quarterly Report	Intermountain Centers for Human Development. Community Bridges, Community Health Associates, Spectrum Healthcare	5^th calendar day after quarter end
OI-235	Employment Services Monthly Report	All Integrated Health Homes and Employment Specialty Providers	2nd 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
OI-237	Support & Rehabilitative Services (SRS) Capacity Report (AMPM 582)	ALL Providers with an SRS Program	Biweekly on Mondays
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	Integrated 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	Integrated 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	Contracted/	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.

		Approved PASRR Providers
RF-1015	Notification of Change 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 – for expected material facility changes that could impact the Provider Network	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-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 (Provider Type 30)	5^th calendar day after quarter end
RF-1025	BH Referral to Intake	Integrated Health Homes	25^th calendar day after quarter end
RF-1026	Annual Behavioral Health Trauma Informed Care Services Deliverable	Integrated Health Homes	Annually on March 10th
RF-1028	TFC 320W Deliverable	All Child Therapeutic Foster Care agencies	Due Semi Annual on June 5th and December 5th

			and within 30 days of a significant staffing change
RF-1029	Therapist Grid	Integrated Health Homes and any Behavioral Health Specialty Provider Agency	June 1^st and December 1^st
RF-1031	Key Provider Contacts Project	Behavioral Health Providers	Due February 1^st and August 1st
RF-1032	BHRF Smartsheet	Behavioral Health Residential Facilities	Due July 15th and January 15^th
RF-1033	IOP Smartsheet	Intensive Outpatient Providers	Due August 1^st and February 1^st
RF-1034	SDOH Smartsheet	Behavioral Health Providers	Due March 1^st and September 1st
RF-1035	ASD Diagnosing Providers and Support Services Attestation	ASD diagnosing providers and ABA providers	15^th calendar day following quarter end
TR-001	Call Stats - Service Level	Transportation Broker/Provider	15^th of the month for previous month
TR-002	Complaints & Grievances	Transportation Broker/Provider	15^th of the month for previous month
TR-003	Executive Summary	Transportation Broker/Provider	15^th of the month for previous month
TR-004	Detail and Summary Trip Report	Transportation Broker/Provider	15^th of the month for previous month
TR-005	Quarterly Executive Summary	Transportation Broker/Provider	15^th of the month following quarter end for previous quarter
TR-006	Blank Grievance Report by LOB	Transportation Broker/Provider	15^th of the month for previous month
TR-007	On Time Performance (ACOM 417)	Transportation Broker/Provider	5^th of the month following quarter end for previous quarter