BEHAVIORAL HEALTH NETWORK PROVIDER SERVICE DELIVERY REQUIREMENTS

Eligibility status is essential for knowing the types of services a person may be able to access. In Arizona’s public behavioral health system, a person may:

• Be eligible for Title XIX/XXI (Medicaid) or Title XXI covered services;
• Not qualify for Title XIX/XXI services, but be eligible for services as a person determined to have a Serious Mental Illness (SMI);
• Be covered under another health insurance plan or “third party” (including Medicare and plans available via the Federal Health Insurance Marketplace); or
• Be without insurance or entitlement status and asked to pay a percentage of the cost of services.

Determining current eligibility and enrollment status is one of the first things to be completed upon receiving a request for services. For persons who are not Title XIX/XXI eligible, a financial screening and eligibility application must be completed to determine eligibility. Verification of an individual’s identification and citizenship/lawful presence in the United States is completed through the AHCCCS Health-e-Arizona PLUS (HEAPlus) application process. See AHCCCS AMPM Section 650 for additional information. If a member who is determined SMI refuses a financial screening and then requests the screening, they can ask their health home if engaged, or call any health home for a screening. The member may also call the health plan Member Services Line for a list of agencies that provide the screening.

Medicare eligible members, including persons who are dually eligible for Medicare (Title XVIII), Medicaid (Title XIX), and Children’s Health Insurance Program (CHIP) (Title XXI) receive Medicare Part D prescription drug benefits. The benefit also provides for Part D Extra Help for eligible individuals whose income and resources are limited. Dual Eligible individuals are automatically eligible for the Part D Extra Help due to their Medicaid eligibility. See AHCCCS AMPM Section 650 for additional information.

The following information will assist providers of covered services in:

• Accessing and interpreting eligibility and enrollment information;
• Conducting financial screenings and assisting persons with applying for Title XIX/XXI or other benefits; and
• Assessing potential eligibility for Medicare Part D Prescription Drug coverage and the Low Income Subsidy (LIS) program.

Providers must coordinate with AHCCCS Complete Care (ACC), Primary Care Providers (PCP), Arizona Long Term Care System (ALTCS) contractors, service providers and eligible persons to share specific information to determine eligibility for Title XIX/XXI services and behavioral health coverage. In addition, providers must notify AHCCCS and the Health Plan of a member's death, incarceration or relocation out-of-state that may affect a member's eligibility status. Providers are required to have a policy and/or process in place for monitoring AHCCCS Eligibility and conducting timely screenings.

 

13.1.1   Title XIX/XXI Screening and Eligibility Procedures

Providers must screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with Section 13.1 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program.

1. Verify the person’s Title XIX/XXI eligibility for all persons referred for services and at least monthly thereafter;
2. For those persons who are not Title XIX/XXI eligible, screen for potential Title XIX/XXI or other eligibility; and
3. As indicated by the screening tool, assist persons with applications for a Title XIX/XXI or other eligibility determination.

 

13.1.2   Step #1 – Accessing Title XIX/XXI or Other Eligibility Information

Providers who need to verify the eligibility and enrollment of an AHCCCS member can use one of the alternative verification processes 24 hours a day, 7 days a week. These processes include:

• ·AHCCCS Web-based Verification (Customer Support 602-417-4451): This web site allows the providers to verify eligibility and enrollment. To use the web site, providers must create an account before using the applications. To create an account, go to the AZ Website  and follow the prompts. Once providers have an account, they can view eligibility and claim information (claim information is limited to FFS). Batch transactions are also available. There is no charge to providers to create an account or view transactions. For technical web-based issues, contact AHCCCS Customer Support at 602-417-4451 Monday – Friday from 7:00 a.m. To 5:00 p.m.
• AHCCCS Subcontracted Medical Electronic Verification Service (MEVS): the AHCCCS member card can be “swiped” by providers to automatically access the AHCCCS Prepaid Medical Management System (PMMIS) for up-to-date eligibility and enrollment. For information on MEVS, contact the MEVS vendor: Emdeon at 1-800-444-4336.
• Interactive Voice Response (IVR) System: IVR allows unlimited verification information by entering the AHCCCS member’s identification number on a touch-tone telephone. This allows providers access to AHCCCS’s PMMIS system for up-to-date eligibility and enrollment. There is no charge for this service. Providers may call IVR within Maricopa County at 602-417-7200 and all other counties at 1-800-331-5090.
• Medifax: Medifax allows providers to use a PC or terminal to access the AHCCCS PMMIS system for up-to-date eligibility and enrollment information. For information on EVS, contact Emdeon at 1-800-444-4336.
• AHCCCS 270/271 Eligibility Look-up.
• If a person’s eligibility status still cannot be determined using one of the above methods, a provider must:
• Call the Health Plan Customer Service at 866-796-0542 for assistance during normal business hours (8:00 a.m. Through 5:00 p.m. Monday-Friday); or
• Call the AHCCCS Verification Unit, which is open Monday through Friday, from 8:00 a.m. To 5:00 p.m. The Unit is closed Saturdays and Sundays and on state holidays. Callers from outside Maricopa County can call 1-800-962-6690, or 602-417-7000 in Maricopa County, and remain on the line for the next available representative. When calling the AHCCCS Verification Unit, the provider must be prepared to provide the verification unit operator the following information:
  • The provider’s identification number;
  • The member’s name, date of birth, AHCCCS identification number; and social security number (if known); and
  • Dates of service(s).

 

13.1.3   Step #2 – Interpreting Eligibility Information

A provider accesses important pieces of information when using the eligibility verification methods described in Step #1 above: AHCCCS eligibility key codes and/or AHCCCS rate codes. The AHCCCS Codes and Values (CV) 13 Reference System  includes a key code index that may be used by providers to interpret AHCCCS eligibility key codes and/or AHCCCS rate codes. The Health Plan will ensure that providers have access to and are familiar with the codes as they may help indicate provider responsibility for the delivery of Title XIX/XXI covered services.

If eligibility status and provider responsibility is confirmed, the provider must provide any needed covered services in accordance with the Health Plan Provider Manual, the AHCCCS Covered Behavioral Health Services Guide, and the AHCCCS Medical Policy Manual.

There are some circumstances whereby a person may be Title XIX/XXI eligible, but the State behavioral health system is not responsible for providing covered services. This includes persons enrolled as elderly or physically disabled (EPD) under the Arizona Long Term Care System (ALTCS) Program and persons eligible for family planning services only through the Sixth Omnibus Reconciliation Act (SOBRA) Extension Program. Persons who are Title XIX/XXI eligible through ALTCS must be referred to their ALTCS case manager to arrange for provision of Title XIX/XXI services. However, ALTCS-EPD individuals who are determined to have a SMI may also receive Non-Title XIX/XXI SMI services from the Health Plan. ALTCS persons’ services are provided through the AHCCCS behavioral health system.

If the person is not currently Title XIX/XXI eligible, proceed to Step #3 and conduct a screening for Title XIX/XXI or other eligibility.

13.1.4   Step #3 – Screening for Title XIX/XXI Eligibility: When and Who to Screen

The Health Plan Providers are required to screen all Non-Title XIX/XXI persons using the Health-e Arizona PLUS (HEAPlus) online application.

• Upon initial request for services;
• At least annually or during each Federal Health Insurance Marketplace open enrollment period thereafter, if still receiving services; and
• When significant changes occur in the person’s financial status.

Behavioral health providers are required to assist individuals with applying for Federal and Arizona Public Programs (Title XIX/XXI, Federal Health Insurance Marketplace, Medicare Savings Programs, Nutrition Assistance, and Cash Assistance), and Medicare Prescription Drug Program (Medicare Part D), including the Medicare Part D “Extra Help with Medicare Prescription Drug Plan Costs” low income subsidy program prior to receiving Non-Title XIX/XXI covered behavioral health services, at the time of intake for behavioral health services.  A screening is not required at the time an emergency service is delivered but must be initiated within 5 days of the emergency service if the person seeks or is referred for ongoing services.

To conduct a screening for Title XIX/XXI or other eligibility, the provider meets with the person and completes AHCCCS eligibility screening through the Health-e Arizona PLUS online application found at https://www.healthearizonaplus.gov for all Non-Title XIX/XXI persons. Documentation of AHCCCS eligibility screening must be included in a person’s comprehensive clinical record upon completion after initial screening, annual screening and screening conducted when a significant change occurs in a person’s financial status (see Section 11.2 Medical Record Standards). The Health Plan will assist providers with contact information to obtain HEAPlus assistor modules and training from AHCCCS. Once completed, the screening tool will indicate:

• That the person is potentially AHCCCS eligible. Pending the outcome of the Title XIX/XXI or other eligibility determination, the person may be provided services in accordance with Section 8.20 Copayments. Upon the final processing of an application, it is possible that a person may be determined ineligible for AHCCCS health insurance. If the person is determined ineligible for Title XIX/XXI or other benefits, the person may be provided services in accordance with Section 8.20 Copayments.
• That the person does not appear Title XIX/XXI or AHCCCS eligible. If the screening tool indicates that the person does not appear to have Title XIX/XXI or any other AHCCCS eligibility, the person may be provided services in accordance with Section 8.20 Copayments. However, the person may submit the application for review by DES and/or AHCCCS regardless of the initial screening result. Additional information requested and verified by DES/AHCCCS may result in the person receiving AHCCCS eligibility and services after all.

13.1.5   Reporting Requirements for Title XIX/XXI Eligibility Screening

The number of applicant screenings for Title XIX/XXI, SMI, and Federal Health Insurance Marketplace eligibility completed must be documented by providers and reported to the Health Plan on a monthly basis (RF-1011) as outlined in Section 17 Deliverable Requirements. Technical assistance is available by calling the Health Plan Contracts Department.

The reporting is required to include the following elements:

1. Number of applicants to be screened for AHCCCS eligibility;
2. Number of applicant screenings for AHCCCS eligibility completed;
3. Number of applicant screenings for AHCCCS eligibility to be completed;
4. Number of AHCCCS eligible applicants as a result of the screening;
5. Number of applicants to be screened for health coverage via the Federal Health Insurance Marketplace;
6. Number of applicant screenings for health coverage via the Federal Health Insurance Marketplace completed;
7. Number of applicant screenings for health coverage via the Federal Health Insurance Marketplace to be completed; and
8. Number of applicants eligible for health coverage via the Federal Health Insurance Marketplace as a result of the screening.

13.1.6   Medicare Part D Prescription Drug Coverage and Low Income Subsidy (LIS) Eligibility

Persons must report to the Health Plan or the provider if they are eligible or become eligible for Medicare as it is considered third party insurance. See Section 8.22 Third Party Liability and Coordination of Benefits regarding how to coordinate benefits for persons with other insurance including Medicare. If a member is unsure of Medicare eligibility, the Health Plan or providers may verify Medicare eligibility by calling 1-800-MEDICARE (1-800-633-4227), with a member’s permission and needed personal information. Once a person is determined Medicare eligible, the Health Plan providers must offer and provide assistance with Part D enrollment and the LIS application upon a member’s request. The Health Plan providers shall track Part D enrollment and LIS application status of members, and report tracking activities when required by AHCCCS.

13.1.6.1   Enrollment in Part D

All persons eligible for Medicare must be encouraged to and assisted in enrolling in a Medicare Part D plan to access Medicare Part D Prescription Drug coverage. Enrollment must be in a Prescription Drug Plan (PDP), which is fee-for-service Medicare plan or a Medicare Advantage Prescription Drug Plan (MA-PD), which is a managed care Medicare plan. Upon request, providers must assist Medicare eligible persons in selecting a Part D plan. The Centers for Medicare and Medicaid Services (CMS) developed web tools to assist with choosing a Part D plan that best meets the person’s needs. The web tools can be accessed at www.medicare.gov. For additional information regarding Medicare Part D Prescription Drug coverage, call Medicare at 1-800-633-4227 or the Arizona State Division of Aging and Adult Services at 602-542-4446 or toll free at 1-800-432-4040.

13.1.6.2   Applying for the Low Income Subsidy (LIS)

The LIS is a program in which the federal government pays all or a portion of the cost sharing requirements of Medicare Part D on behalf of the person. If the provider determines that a person may be eligible for the LIS (see  the Social Security Administration (SSA) website for income and resource limits), the provider must offer to assist the person in completing an application.  person in completing an application.

Applications can be obtained and submitted through the following means:

• Online at SSA Website ;
• By calling 1-800-772-1213 or TTY 1-800-325-0078, Monday – Friday, 7 AM – 7 PM.
• In person at a SSA local office; or
• By mailing a paper application to the SSA.

13.1.6.3   Federal Health Insurance Marketplace

Providers must educate and encourage Non-Title members with SMI to apply for health coverage from a qualified health plan using the application process located at the Federal Health Insurance Marketplace and offer assistance for those choosing to enroll during open enrollment periods and qualified life events. Members enrolled in a qualified health plan through the Federal Health Insurance Marketplace may continue to be eligible for Non-Title XIX/XXI covered services that are not covered under the Federal Health Insurance Marketplace plan.

13.1.7   Refusal to Participate with Screening and/or Application Process for Title XIX/XXI or Other AHCCCS Eligibility or Enrollment in a Part D Plan

On occasion, a person may decline to participate in the AHCCCS eligibility screening and application process or refuse to enroll in a Medicare Part D plan. In these cases, the provider must actively encourage the person to participate in the process of screening and applying for AHCCCS health insurance coverage or enrolling in a Medicare Part D plan.

Arizona state law provides that persons who refuse to participate in the AHCCCS screening and eligibility application process or to enroll in a Medicare Part D plan are ineligible for state funded services (see A.R.S. § 36-3408). As such, individuals who refuse to participate in the AHCCCS screening and eligibility application or enrollment in Medicare Part D, if eligible, will not be enrolled with the Health Plan during their initial request for services or will be dis-enrolled if the person refuses to participate during an annual screening. The following conditions do not constitute a refusal to participate:

• A person’s inability to obtain documentation required for the eligibility determination;
• Persons incapable of participating as a result of their mental illness and does not have a legal guardian; and/or
• A person who is enrolled in a qualified health plan through the Federal Health Insurance Marketplace and refuses to take part in the AHCCCS screening and application process will not be eligible for Non-Title XIX/XXI SMI funded services.

If a person refuses to participate in the screening and/or application process for Title XIX/XXI or other eligibility, or to enroll in a Part D plan, the provider must ask the person to sign the AHCCCS AMPM Chapter 600 Section 650, Attachment A, Decline to Participate in AHCCCS Screening or Referral Process. If individuals refuse to sign the form, the provider must document their refusal to sign in the comprehensive clinical record (See Section 11.2 Medical Records Standards).

13.1.7.1   Special Considerations for Persons Determined to Have a Serious Mental Illness (SMI)

If a person who is eligible for or requesting services as a person determined to have a SMI is unwilling to complete the eligibility screening or application process for Title XIX/XXI or to enroll in a Part D plan and does not meet the conditions above, the provider must request a clinical consultation by a Behavioral Health Medical Professional. If the person continues to refuse following a clinical consultation, the provider must request that the person sign the AHCCCS AMPM Chapter 600 Section 650, Attachment A, Decline to Participate in AHCCCS Screening or Referral Process. Prior to the termination of services for persons with a SMI who have been receiving behavioral health services and subsequently decline to participate in the screening/referral process, the Health Plan must provide written notification of the intended termination using the Appeal or Serious Mental Illness Grievance Form located in the ACOM Chapter 400, Section 446, Attachment A. Also see Section 9.5 Notice Requirements and Appeal Process (SMI and GMH/SA Non-Title XIX/XXI).

13.1.7.2   Persons Who Refuse to Cooperate with the AHCCCS Eligibility and/or Application Process or Who Do Not Enroll in a Part D Plan

The provider must inform the person who they can contact in the behavioral health system for an appointment if the person chooses to participate in the eligibility and/or application process in the future. Members may call the behavioral health provider, the Health Plan Customer Services at 866-918-4450 8:00 a.m. – 5:00 p.m., Monday – Friday, or the Crisis Call Center at 866-918-4450 for assistance.

It is vital that the State behavioral health system be responsive and accessible to all the persons it serves. It is the expectation of the State that provider response to a person’s identified behavioral health service need is timely and based on clinical need, resulting in the best possible behavioral health outcomes for that person. Provision of services shall not be delayed or pending in order to have all CFT/ART members present for a service planning meeting, or until all are able to sign the Individualized Service Plan (ISP).

Response time is always determined by the acuity of individuals assessed behavioral health condition at the moment they are in contact with the provider. The State has organized responses into two categories: urgent responses and routine responses.

Please note that at the time it is determined that an urgent response is needed, a person’s eligibility and enrollment status may not be known. Providers must respond to all persons in urgent need until the situation is clarified that the provider is not financially responsible. Persons who are determined ineligible for covered services may be referred to applicable community resources.

Per AHCCCS Appointment Availability policy, providers will be monitored for appointment availability standards quarterly through telephonic surveys and reviews of provider schedules during face-to-face site visits. Results of the surveys are reviewed in the Quality Management Performance Improvement Committee Meeting to determine the need for performance improvement projects, corrective actions, or panel closures. Appointment Availability concerns will be addressed in subsequent technical assistance sessions with the assigned provider engagement staff. Appointment Availability performance issues may result in closed panels and overall network trends will be reported out in the monthly Essential Provider Calls.

Providers must develop and implement policies and procedures to monitor the availability and timeliness of appointments for members and providers must disseminate information regarding appointment standards to members, service providers, and out-of-network providers. Providers also must clearly post hours of operation in a location accessible to members. For more information on appointment standards, see the AHCCCS ACOM Policy 417 on Appointment Standards and Timeliness of Services.

13.2.1   Type of Response by a Behavioral Health Provider (Non-Hospitalized Persons)

For Behavioral Health Provider Appointments:

1. Urgent need appointments as expeditiously as the member’s health condition requires but no later than 24 hours from identification of need;
2.  Routine care appointments:
   •  Initial assessment within seven (7) calendar days of referral or request for service,
   • The first behavioral health service following the initial assessment as expeditiously as the member’s health condition requires but:
     • For members age 18 years or older, no later than twenty-three (23) calendar days after the initial assessment
     • For members under the age of 18 years old, no later than twenty-one (21) days after the initial assessment and
     • All subsequent behavioral health services, as expeditiously as the member’s health condition requires but no later than forty-five (45) calendar days from identification of need.

For Psychotropic Medications:

1. Assess the urgency of the need immediately.
2.  Provide an appointment, if clinically indicated, with a practitioner who can prescribe psychotropic medication within a timeframe that ensures the member:
   •  does not run out of needed medications, or
   •  does not decline in their behavioral health condition prior to starting     medication, but no later than 30 calendar days from the identification of need.

Note: Standards for persons receiving services as part of SUBG Grant funding are in Section 13.11 Mental Health and Substance Use Disorder Services; Including Federal Grants and State Appropriations Requirements.

13.2.2   Integrated Health Home Appointment Availability and Scheduling

In accordance with the requirements in this Provider Manual, providers must maintain adequate urgent, and routine outpatient office and in-home appointments to meet the needs of members in their areas. For more information regarding Appointment Availability Requirements see AHCCCS ACOM Policy 417.

At all clinics open four or more days per week, Integrated Health Home providers must provide intake and clinical office services during evenings (until at least 7:00 PM and at least two (2) nights per week) and on Saturdays. Integrated Health Home providers providing routine outpatient services must verify that at least fifteen percent (15%) of a clinic’s scheduled hours of operation are outside of regular business hours (8:00 AM – 5:00 PM, Monday through Friday) in each community served.

Integrated Health Home providers must maintain daily appointment slots for urgent treatment appointments in each community served. Integrated Health Home providers also must make available additional urgent psychiatric appointments each week of at least thirty (30) minute duration each and not fill the urgent appointment slots prior to two (2) business days before the date of the urgent appointment.

Integrated Health Home providers must collaborate with the Health Plan in maintaining a centralized after-hours scheduling system to facilitate after-hours urgent and appointment scheduling. The Integrated Health Home provider must review and monitor the online centralized schedule at least twice a day to facilitate effective coordination of care. In each community served, an Integrated Health Home provider must “block” one (1) hour per day of scheduling time in the late afternoon to allow the Behavioral Health Plan and/or its crisis telephone vendor to schedule urgent and emergent psychiatric and intake appointments. If by 8:00 AM on a given day no appointment has been booked in the “blocked” time, the Behavioral Health Home provider may release the “blocked” time for other appointments.

13.2.3   Wait Times

The State (AHCCCS) has established standards so that persons presenting for scheduled appointments do not have to wait unreasonable amounts of time. Unless a provider is unavailable due to an emergency, a person appearing for an established appointment must not wait for more than one hour. Providers are required to monitor wait times via a daily log to include the time the member arrived, the time of the scheduled appointment and the time the member was taken back to appointment. Providers offering open access or walk-in appointments must carefully monitor wait times and offer members the opportunity to schedule an appointment if the waiting time is anticipated to exceed two hours.

Providers arranging for, or providing medically necessary non-emergency transportation services for members must adhere to the following standards:

• Member arrives on time for an appointment, but no sooner than one hour before the appointment;
• Members must not have to wait for more than one hour after the conclusion of their treatment for transportation home, or the time of the will-call return request.
• Providers must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standard for all subcontracted transportation vendors/brokers and require corrective action if standards are not met.

13.2.4   Transportation Timeliness

Providers arranging for, or providing medically necessary non-emergency transportation services for members must adhere to the following standards:

• Member arrives on time for an appointment, but no sooner than one hour before the appointment.
• Members must not have to wait for more than one hour after the conclusion of their treatment for transportation hoe, or the time of the will-call return request.
• Providers must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standard for all subcontracted transportation vendors/brokers and require a corrective action if standards are not met.

13.2.5   Appointments for Psychotropic Medications

For persons who may need to be seen by a Behavioral Health Medical Practitioner (BHMP), it is required that the person’s need for medication be assessed immediately and, if clinically indicated, that the person be scheduled for an appointment within a timeframe that ensures:

• The person does not run out of any needed psychotropic medications; or
• Individuals are evaluated for the need to start medications to verify that the person does not experience a decline in their behavioral health condition, but no later than thirty (30) calendar days from the identification of need.

Response for 387, or Requests for Psychotropic Medications:

	WHEN	WHAT	WHO
Referral for psychotropic medications	Assess the urgency of the need immediately. If clinically indicated, provide an appointment with a BHMP within a timeframe indicated by clinical need, but no later than 30 calendar days from the referral/initial request for services.	Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate.	·   All Title XIX/XXI eligible persons; ·   All Non-Title XIX/XXI persons enrolled with the Health Plan ·   All persons determined to have a SMI; and ·   Any person in an emergency or crisis.
All initial assessments and treatment recommendations that indicate a need for psychotropic medications	The initial assessment and treatment recommendations must be reviewed by a BHMP within a timeframe based on clinical need.	Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate.	·   All Title XIX/XXI eligible persons; ·   All persons determined to have a SMI; and ·   Any person in an emergency or crisis.

 

13.2.6   Referrals for Hospitalized Persons

Providers must quickly respond to referrals pertaining to eligible persons not yet enrolled in the Health Plan or Title XIX/XXI eligible persons who have not been receiving services prior to being hospitalized for psychiatric reasons and persons previously determined to have a SMI. Upon receipt of such a referral, the following steps must be taken:

• For referrals of Title XIX/XXI eligible persons and persons previously determined to have a SMI, initial face-to-face contact, an assessment and disposition must occur within 24 hours of the referral/request for services.
• For referrals of Non-Title XIX/XXI eligible persons and persons referred for eligibility determination of SMI:
  • Initial face-to-face contact and an assessment must occur within 24 hours of the referral/request for services. Determination of SMI eligibility must be made within timeframes consistent with and in accordance with Section 13.7 SMI and SED Eligibility Determination; and
  • Upon the determination that the person is eligible for services and the person is in need of continued behavioral health services, the person must be enrolled and the effective date of enrollment must be no later than the date of first contact.

13.2.7   Other Requirements

All referrals from a person’s primary care provider (PCP) requesting a psychiatric evaluation and/or psychotropic medications must be accepted and acted upon in a timely manner according to the needs of the person, and the response time must help ensure that the person does not experience a lapse in necessary psychotropic medications, as described in Section 13.2.5 Appointments for Psychotropic Medications.

Title XIX/XXI persons must never be placed on a “wait list” for any Title XIX/XXI covered behavioral health service. If the Health Plan network is unable to provide medically necessary covered services for Title XIX/XXI persons, the Health Plan must ensure timely and adequate coverage of needed services through an alternative provider until a network provider is subcontracted. In this circumstance, the Health Plan must ensure coordination with respect to authorization and payment issues. In the event that a covered behavioral health service is temporarily unavailable to a Title XIX/XXI eligible person, the provider must adhere to the following procedure:

1. Maintain the current level of services being provided to the person;
2. Identify and provide any supportive services needed by the person while securing the needed service;
3. Verify the creation of a service plan and a crisis plan for the Title XIX/XXI member and verify that the person understands how to access crisis services during this time; and

Contact the Health Plan’s Utilization Management Department at 1-866-796-0542 to coordinate and track care while securing the service, and to discuss needs for any non-contracted services, including for persons who are in an inpatient or residential facility and are awaiting a referral for outpatient services.

The State receives some funding for services through the Federal Substance Use Prevention, Treatment and Recovery Block Grant (SUBG). SUBG funds are used to provide substance use disorder services for Non-Title XIX/XXI eligible persons. As a condition of receiving this funding, certain populations are identified as priorities for the timely receipt of designated services. Any providers contracted with the Health Plan for SUBG funds must follow the requirements found in this section. For all other providers that do not currently receive these funds, the following expectations do not apply. Please refer to Section 13.11.5 for more information regarding MHBG and State Funding Services.

 

13.3.1   SUBG Block Grant Populations

The following populations are prioritized and covered under the SUBG Block Grant:

• Pregnant women/teenagers who use drugs by injection;
• Pregnant women/teenagers who use substances;
• Other persons who use drugs by injection;
• Substance using women and teenagers with dependent children and their families, including females who are attempting to regain custody of their children and
• All other individuals with a substance use disorder, regardless of gender or route of use, (as funding is available).

 

Response Times for Designated Behavioral Health Services under the SUBG Block Grant:

When	What	Who
Behavioral health services provided within a timeframe indicated by clinical need, but no later than 48 hours from the referral/initial request for services.	Any needed covered behavioral health service, including admission to a residential program if clinically indicated; If a residential program is temporarily unavailable, an attempt shall be made to place the person within another provider agency facility, including those in other geographic service areas. If capacity still does not exist, the person shall be placed on an actively managed wait list and interim services must be provided until the individual is admitted. Interim services include counseling/education about HIV and Tuberculosis (include the risks of transmission), the risks of needle sharing and referral for HIV and TB treatment services if necessary, counseling on the effects of alcohol/drug use on the fetus and referral for prenatal care.	Pregnant individuals/teenagers referred for substance use disorder treatment (includes pregnant injection drug users and pregnant women with substance use disorders) and substance-using females with dependent children, including those attempting to regain custody of their child(ren).
Behavioral health services provided within a timeframe indicated by clinical need but no later than 14 days following the initial request for services/referral. All subsequent services must be provided within timeframes according to the needs of the person.	Includes any needed covered behavioral health services; Admit to a clinically appropriate substance use disorder treatment program (can be residential or outpatient based on the person’s clinical needs); if unavailable, interim services must be offered to the person. Interim services shall minimally include education/interventions with regard to HIV and tuberculosis and the risks of needle sharing and must be offered within 48 hours of the request for treatment.	All other injection drug users
Behavioral health services provided within a timeframe indicated by clinical need but no later than 23 days following the initial assessment. All subsequent behavioral health services must be provided within timeframes according to the needs of the person.	Includes any needed covered behavioral health services.	All other persons in need of substance use disorder treatment.

The referral process serves as the principal pathway by which persons are able to gain prompt access to publicly supported services. The intake process serves to collect basic member information in order to enroll members in the AHCCCS system, screen for Title XIX/XXI AHCCCS eligibility and determine the need for any copayments (See Section 8.20 Copayments). It is critical that both the referral process and intake process are culturally sensitive, efficient, engaging, and welcoming to the member and/or family member seeking services, and leads to the provision of timely and appropriate services based on the urgency of the situation.

A “referral” is any oral, written, faxed or electronic request for services made by the member, the member’s legal guardian or Health Care Decision Maker (HCDM), family member, an AHCCCS Acute Contractor, PCP, Hospital, Treat and Refer Provider, Jail, Court, Probation or Parole Officer, Tribal Entity, his/638 Tribally Operated Facility, School, or other state or community agency.

Providers must not arbitrarily or prematurely reject or disqualify a member from services/referrals without prior authorization by the Health Plan. Providers must resolve referral disputes promptly, relative to the urgency of the situation. The Health Plan will promptly intervene and resolve any dispute between a provider and a referring source when those parties cannot informally resolve disputes regarding the need for emergency, urgent, or routine appointments.

The Health Plan providers are responsible for managing referrals and wait lists for Non-Title XIX/XXI persons in accordance with the SUBG Block Grant for identified priority populations when services are temporarily unavailable. See AMPM Policy 650 Behavioral Health Provider Requirements for Assisting Individuals with Eligibility Verification and Screening/Application for Public Health Benefits.

If the Health Plan network is unable to provide medically necessary services to Title XIX/XXI persons, the Health Plan will verify timely and adequate coverage of needed services through an out-of-network provider until a network provider is contracted (See Section 13.2 Appointment Standards and Timeliness of Service).

13.4.1   Objectives

To facilitate a member’s access to services in a timely manner, providers will maintain an effective process for the referral and intake for services that includes:

• Communicating to potential referral sources the process for making referrals (e.g., centralized intake, identification of providers accepting referrals);
• Collecting enough basic information about the person to determine the urgency of the situation and subsequently scheduling the initial assessment within the required timeframes and with an appropriate provider;
• Adopting a welcoming, trauma-informed, and engaging manner with the member and/or member’s legal guardian/family member;
• Ensuring that intake interviews are culturally appropriate and delivered by providers who are respectful and responsive to the member’s cultural needs (see Section 10.2 Cultural Competence System of Care Requirements and Section 13.15 Cultural Competence for the Behavioral Health System Requirements);
• Keeping information or documents gathered in the referral process confidential and protected in accordance with applicable federal and State statutes, regulations and policies;
• Informing, as appropriate, the referral source about the final disposition of the referral; and
• Conducting intake interviews that ensure the accurate collection of all the required information necessary and ensure members who have difficulty communicating because of a disability or who require language assistance are afforded appropriate accommodations to assist them in fully expressing their needs.

13.4.2   Where to Send Referrals

The Health Plan maintains a provider directory on its website that is available to AHCCCS Health Plans and Department of Economic Security District Program Administrators (DES). A printed copy can be made available upon request. The directory indicates which providers are accepting referrals and conducting initial assessments and intakes. It is important for providers to promptly notify the Health Plan of any changes that would impact the accuracy of the provider directory (e.g., change in telephone or fax number, no longer accepting referrals).

Individuals may access services by directly contacting an Integrated Health Home. Contracted Integrated Health Homes are identified on the Health Plan website and in the Health Plan member Handbook. Members may also call the Health Plan Customer Service at 1-866-796-0542, 24 hours a day/7 days a week, and receive a referral to a contracted Health Home. During normal business hours, the Health Plan will transfer callers to an intake provider. After-hour referrals are provided to Health Home providers who are expected to follow up on the referral. The statewide crisis line staff can track referrals to verify the caller is appropriately connected with a Health Home. In addition, the statewide crisis line has access to emergent and urgent psychiatric appointments at intake provider sites and can schedule these appointments on the member’s behalf.

Providers are required to notify the Health Plan of any changes that would alter or change the information provided through the directory. A 30-day notice is required for changes in telephone number, fax number, email address, service changes, staff changes, service capacity changes or ability to accept new referrals as outlined in Section 17 Deliverable Requirements.

Providers must also notify the Provider Registration Unit of any changes to the information on file at AHCCCS (reference the AHCCCS Fee for Service Provider Manual, Chapter 3.

13.4.3   Choice of Providers

The Health Plan offers members a choice in selecting providers, and providers are required to provide each member a choice in selecting a provider of services, provider agency, and direct care staff. Providers are required to allow members to exercise their right to services from an alternative In-Network provider and offer each member access to the most convenient In-Network service location for the service requested by the member. In addition, providers must make available all Covered Services to all Title XIX/XXI eligible American Indians, whether they live on or off reservation. Eligible American Indian members* may choose to receive services through a RBHA/MCO/Health Plan, Tribal and Regional Behavioral Health Authorities, or through an IHS or 638 tribal provider.

13.4.4   Referral to a Provider for a Second Opinion

Title XIX/XXI members are entitled to a second opinion and providers are required to provide proof that each member is informed of the right to a second opinion.

Upon a Title XIX/XXI eligible member’s request or at the request of the provider’s treating physician, the provider must—at no cost to the member—make available a second opinion from a qualified health care professional either within the network or arrange for the member to obtain a second opinion from a qualified health care professional outside the network (42 CFR 438.206(b)(3)). For purposes of this section, a “qualified health care professional” is (a) an AHCCCS registered provider of covered health services (b) who is a physician, a physician assistant, a nurse practitioner, a psychologist, or an independent Master’s level therapist.

A behavioral health provider can arrange for a second opinion in-network or can contact the Health Plan Customer Service at 1-866-796-0542, 8:00 a.m. – 5:00 p.m. Monday – Friday, for assistance. Out-of-Network requests should be submitted to the Health Plan Medical Management department for review and processing. A provider must maintain a record identifying both (1) the date of service for the second opinion and (2) the name of the provider who provided the second opinion. There must be documentation in the clinical chart of the following:

• Rationale for the use of two medications from the same pharmacological class;
• Rationale for the use of more than three different psychotropic medications in adults; and
• Rationale for the use of more than one psychotropic medication in the child and adolescent population.

13.4.5   Referrals Initiated by Department of Economic Security/Department of Child Safety (DES/DCS) Pending the Removal of a Child

Upon notification from DES/ Department of Child Safety (DCS) that a child has been, or is at risk of being taken into the custody of DES/Department of Child Safety (DCS), providers are expected to respond in an urgent manner (for additional information, see Section 13.2 Appointment Standards and Timeliness of Service and AHCC, CS Policy 585 Unique Needs of Children, Youth and Families Involved with Department of Child Safety.

13.4.6   Accepting Referrals

Providers must establish written procedures for accepting and acting upon referrals, including emergency referrals. Providers must accept referrals for services as identified in the provider’s contract with the Health Plan unless the Health Plan grants a written waiver or suspension of this requirement. Providers must not arbitrarily or prematurely reject or eject a member from services/referrals without prior authorization of the Health Plan. Providers must accept referrals, regardless of diagnosis, level of functioning, age, member’s status in family, or level of service needs. (See 42 CFR 438.210 (a)(3)(iii))

The process for making referrals, including self-referrals, is clearly communicated to members and providers.  The process shall ensure the engagement of the member/HCDM or the Designated Representative (DR) to maximize family voice and choice of service providers.  Providers must accept and respond to emergency referrals of Title XIX/XXI eligible members and Non-Title XIX/XXI members with SMI twenty-four (24) hours a day, seven (7) days a week. An acknowledgement of receipt of a referral shall be provided to the referring entity within 72 hours from the date it was received.

Emergency referrals do not require prior authorization. Emergency referrals include those initiated for Title XIX/XXI eligible and Non-Title XIX/XXI with SMI members admitted to a hospital or treated in the emergency room. Providers must respond within twenty-four (24) hours upon receipt of an emergency referral. 

The following information shall be collected from referral sources:

• Date and time of referral;
• Information about the referral source including name, telephone number, fax number, affiliated agency, and relationship to the person being referred;
• Name of person being referred, address, telephone number, gender, age, date of birth and, when applicable, name and telephone number of parent or legal guardian;
• Whether or not the person, parent, or legal guardian is aware of the referral;
• Transportation and other special needs for assistance due to impaired mobility, blindness/low vision or being deaf or hard of hearing, or developmental or cognitive impairment;
• Accommodations due to cultural uniqueness and/or the need for interpreter services;
• Information regarding payment source (i.e., AHCCCS, private insurance, Medicare or self-pay) including the name of the AHCCCS health plan or insurance company;
• Name, telephone number, and fax number of AHCCCS primary care provider (PCP) or other PCP as applicable;
• Reason for referral including identification of any potential risk factors such as recent hospitalization, evidence of suicidal or homicidal thoughts, pregnancy, and current supply of prescribed psychotropic medications;
• Medications prescribed by the member’s PCP or other medical professional including the reason why the medication is being prescribed; and
• The names and telephone numbers of individuals the member, parent, or guardian may wish to invite to the initial appointment with the referred member.

Sufficient information is collected through the referral to:

1. Assess the urgency of the member’s needs,
2. Track and document the disposition of referrals to ensure subsequent initiation of services. The Contractor shall comply with timeliness standards specified in ACOM Policy 417,
3. Ensure members who have difficulty communicating due to a disability, or who require language services, are afforded appropriate accommodations to assist them in fully expressing their needs.
4. Information or documents collected in the referral process are kept confidential and protected in accordance with applicable federal and state statutes, regulations, and policies.
5. Providers offer a range of appointment availability and flexible scheduling options based upon the needs of the member.

Providers should act on a referral regardless of how much information they obtained. While the information listed above will facilitate evaluating the urgency and type of practitioner the member may need to see, timely triage and processing of referrals must not be delayed because of missing or incomplete information.

When psychotropic medications are a part of a member’s treatment or have been identified as a need by the referral source, providers must respond as outlined in Section 13.2 Appointment Standards and Timeliness of Service.

When individuals seek services, or their family member, legal guardian, or significant other contacts a provider directly about accessing services, providers shall ensure that the protocol used to obtain the necessary information about the person seeking services is engaging and welcoming.

When a SMI eligibility determination is being requested as part of the referral or by the person directly, providers must conduct an eligibility determination for SMI in accordance with Section 13.7 SMI and SED Eligibility Determination. The SMI assessment and pending determination will not delay behavioral health service delivery to the member.

13.4.7   Responding to Referrals

Follow-Up: When a request for services is initiated but the member does not appear for the initial appointment, the provider must attempt to contact the member and implement engagement activities consistent with Section 13.5 Outreach, Engagement, Re-engagement and Closure. The provider must also attempt to notify the entity that made the referral.

Final Dispositions: Within 30 days of receiving the initial assessment, or if the person declines services, within 30 days of the initial request for services, the provider must notify the following referral sources of the final disposition:

• AHCCCS health plans;
• AHCCCS PCPs;
• Arizona Department of Economic Security;
• Arizona Department of Child Safety;
• Arizona Department of Economic Security/Division of Developmental Disabilities;
• ·Arizona Department of Corrections;
• Arizona Department of Juvenile Corrections;
• County Adult and Juvenile Detention Centers;
• Administrative Offices of the Court;
• Arizona Department of Economic Security/Rehabilitation Services Administration; and
• Arizona Department of Education and affiliated school districts.

The final disposition must include

1. the date the member was seen for the initial assessment; and
2. the name and contact information of the provider who will assume primary responsibility for the member’s behavioral health care, or
3. if no services will be provided, the reason why. When required, authorization to release information will be obtained prior to communicating the final disposition to the referral sources referenced above. (See Section 11.2.8 Disclosure of Records). 

13.4.8   Documenting and Tracking Referrals

The Health Plan provider shall document and track all referrals for services including, at a minimum, the following information:

• Person’s name and, if available, AHCCCS identification number;
• Name and affiliation of referral source;
• Date of birth;
• Type of referral (immediate, urgent, routine) as defined in Section 13.2 Appointment Standards and Timeliness of Service;
• Date and time the referral was received;
• If applicable, date and location of first available appointment and, if different, date and location of actual scheduled appointment; and
• Date of acknowledgement of receipt.
• The above information must be included in the quarterly Behavioral Health Referral to Intake Deliverable RF-1025.

13.4.9   Eligibility Screening and Supporting Documentation

Persons who are not already AHCCCS eligible must be asked to bring supporting documentation to the screening interview to assist the provider in identifying if the person could be AHCCCS eligible (See Section 13.1 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program). Explain to the person that the supporting documentation will only be used for the purpose of assisting the person in applying for AHCCCS health care benefits. Let the person know that AHCCCS health care benefits may help pay for services, and ask the person to bring the following supporting documentation to the screening interview:

• Verification of gross family income for the last month and current month (e.g., paycheck stubs, social security award letter, retirement pension letter);
• Social security numbers for all family members (social security cards if available);
• For those who have other health insurance, bring the corresponding health insurance card (e.g., Medicare card);
• For all applicants, documentation to prove United States citizenship or immigration status and identity);
• For those who pay for dependent care (e.g., adult or child daycare), proof of the amount paid for the dependent care; and
• Verification of out-of-pocket medical expenses.

13.4.10        Intake Interviews

Providers must conduct intake interviews in an efficient and effective manner that is both “person friendly,” trauma-informed, and verifies the accurate collection of all required information necessary for enrollment into the system or for collection of information for AHCCCS eligible individuals who are already enrolled. The intake process must:

• Be flexible in terms of when and how the intake occurs. For example, in order to best meet the needs of the person seeking services, the intake might be conducted over the telephone prior to the visit, at the initial appointment prior to the assessment and/or as part of the assessment; and
• Make use of readily available information (e.g., referral form, AHCCCS eligibility screens) in order to minimize any duplication in the information solicited from the person and family members.

During the intake, the provider will collect, review, and disseminate certain information to persons seeking services. Examples can include:

• The collection of contact information, insurance information, the reason why the person is seeking services and information on any accommodations the person may require to effectively participate in treatment services (i.e., need for oral interpretation or sign language assistance, consent forms in large font, etc.).
• The collection of required member information and completion of client member information sheet, including the Member’s primary/preferred language (see Section 7.1 Enrollment, Disenrollment and other Data Submission);
• The completion of any applicable authorizations for the release of information to other parties (see Section 11.2.8 Disclosure of Records);
• Advising the member that the Health Plan Member Handbook is available to them (see Section 3 Member Handbook);
• The review and completion of a general consent to treatment (see Section 13.8 General and Informed Consent to Treatment);
• The collection of financial information, including the identification of third party payers and information necessary to screen and apply for AHCCCS health insurance, when necessary (see Section 13 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program and Section 8.22 Third Party Liability and Coordination of Benefits);
• Advising Non-Title XIX/XXI persons determined to have a SMI that they may be assessed a copayment (see Section 8.20 Copayments);
• The review and dissemination of the Health Plan Notice of Privacy Practices and the AHCCCS HIPAA Notice of Privacy Practices in compliance with 45 CFR 164.520 (c)(1)(B); and
• The review of the person’s rights and responsibilities as a member of services, including an explanation of the appeal process.

The person and/or family members may complete some of the paperwork associated with the intake, if acceptable to the person and/or family members.

Providers conducting intakes must be appropriately trained, approach the person and family in an engaging manner, and possess a clear understanding of the information that needs to be collected.

13.4.11        Specialty Behavioral Health Agency Referrals

All Health Plan contracted providers are responsible for ensuring timely and appropriate service delivery as requested by the member and/or as determined necessary to meet the member’s needs. Specialty Behavioral Health Agencies are responsible for determining medical necessity for specialty services and regularly reporting progress to Integrated Health Homes and PCPs as appropriate.

13.4.12        Referrals for Screening and/or Diagnosis of Autism Spectrum Disorders

The Health Plan covers medically necessary behavioral health services for all AHCCCS-eligible children and adults, including the diagnosis and treatment for individuals who may have an Autism Spectrum Disorder (ASD).

AHCCCS-eligible families who are engaged in services within the Health Plan, and who believe an adult or child may have ASD, should schedule an appointment with their psychiatrist or primary care provider.

Children and adults not currently engaged with a behavioral health provider in the Health Plan should first see their primary care provider, who can then refer the child and family to a specialized ASD diagnosing provider.

Completion of an intake at a Health Home or Behavioral Health Provider is not required for families seeking a one-time consultation for diagnosis, or to rule out Autism Spectrum Disorder.

In addition, if there is a diagnosis of Autism, per AMPM 310B families may choose to seek Behavior Analysis services. Behavior Analysts utilize contextual factors, motivating operations, antecedent stimuli, positive reinforcement, and other consequences to help people develop new behaviors, increase, or decrease existing behaviors, and emit behaviors under specific environmental conditions. Refer to AMPM Policy 320-S for more information.

The activities described within this section are an essential element of clinical practice. Outreach to vulnerable populations, establishing an inviting and non-threatening clinical environment, and re-establishing contact with persons who have become temporarily disconnected from services are critical to the success of any therapeutic relationship.

This section addresses five critical activities that providers must incorporate when delivering services within Arizona’s public behavioral health system:

1. Expectations for outreach activities directed to persons who are at risk for the development or emergence of behavioral health disorders;
2. Establish expectations for the engagement of persons seeking or receiving services behavioral health services.
3. Determine procedures to re-engage persons who have withdrawn from participation in the treatment process,
4. Describe conditions necessary to end re-engagement activities for a person in the behavioral health system; and
5. Establish expectations for serving persons who are attempting to re-enter the behavioral health system. (See AMPM 1040, and AMPM 310-B)

13.5.1   Outreach Activities

Integrated Health Home providers must provide outreach activities to inform the public of the benefits and availability of services and how to access them. The Health Plan disseminates and requires providers to disseminate information to the general public, other human service providers, school administrators and teachers, and other interested parties regarding the services that are available to eligible persons.

Outreach activities conducted by the Health Plan and providers may include, but are not limited to:

• Participation in community events, local health fairs, or health promotion activities;
• Involvement with local schools;
• Involvement with outreach activities for military veterans, such as Arizona Veterans Stand Down Coalition events,
• Development of outreach programs and activities for first responders (i.e., police, fire, EMT),
• Routine contact with AHCCCS Health Plan behavioral health coordinators and/or primary care providers;
•  Development of homeless outreach programs;
• Development of outreach programs to persons who are at risk, are identified as a group with high incidence or prevalence of behavioral health issues, or are underserved, or are identified as previously involved or at risk of human trafficking;
• Publication and distribution of informational materials;
• Liaison activities with local, county and tribal jails, prisons, county detention facilities, and local and county Department of Child Safety DCS offices and programs,
• Routine interaction with agencies that have contact with substance abusing pregnant members/teenagers;
• Conduct home visits;
• Development and implementation of outreach programs that identify persons with co-morbid medical and behavioral health disorders and those who have been determined to have a SMI within the Health Plans geographic service area, including persons who reside in jails, homeless shelters, county detention facilities, or other settings;
• Provision of information to behavioral health advocacy organizations; and
• Development and coordination of outreach programs to Native American tribes in Arizona to provide services for tribal members.

In addition to the above outreach activities, the crisis line is familiar with the BH system intake and AHCCCS application process, and can assist members with enrollment and questions. (See AMPM 1040, found at  and AMPM 310-B.

13.5.2   Engagement

Providers must provide services in a culturally competent manner in accordance with the Health Plan Cultural Competency Plan (see Section 10.2 Cultural Competence System of Care Requirements).

Providers are required to:

• Provide a courteous, welcoming environment that provides persons with the opportunity to explore, identify, and achieve their personal goals;
• Engage persons in an empathic, hopeful, and welcoming manner during all contacts;
• Provide culturally relevant care that addresses and respects language, customs, and values and is responsive to the person’s unique family, culture, traditions, strengths, and age, to meet the needs of members with diverse cultural and ethnic backgrounds, including those with limited English Proficiency, disabilities, and regardless of gender, sexual orientation, or gender identity (see Section 10.2 Cultural Competence System of Care Requirements);
• Provide an environment in which consumers from diverse cultural backgrounds feel comfortable discussing their cultural health beliefs and practices in the context of negotiating treatment options;
• Provide care by communicating to members in their preferred language and verifying that they understand all clinical and administrative information (see Section 10.2 Cultural Competence System of Care Requirements);
• Be aware of and seek to gain an understanding of persons with varying disabilities and characteristics;
• Display sensitivity to, and respect for, various cultural influences and backgrounds (e.g., ethnic, racial, gender identity, sexual orientation, and socio-economic class);
• Establish an empathic service relationship in which the person experiences the hope of recovery and is considered to have the potential to achieve recovery while developing hopeful and realistic expectations;
• Demonstrate the ability to welcome the person, and/or the person’s legal guardian, the person’s family members, others involved in the person’s treatment and other service providers as collaborators in the treatment planning and implementation process;
• Demonstrate the desire and ability to include the person’s and/or legal guardian’s viewpoint and to regularly validate the daily courage needed to recover from persistent and relapsing disorders;
• Assist in establishing and maintaining the person’s motivation for recovery; and
• Provide information on available services and assist the person and/or the person’s legal guardian, the person’s family, and the entire clinical team in identifying services that help meet the person’s goals.
• For members with an SMI who are receiving Special Assistance, the person designated to provide Special Assistance per AHCCCS AMPM Policy 320-R.
• The Contractor shall ensure providers engage incarcerated members with high incidence or prevalence of behavioral health issues, or who are underserved as specified in AMPM Policy 1022.

See AMPM Policies:

• 1040
• 310-B
• 1022
• 320-R 

13.5.3   Re-Engagement

Providers must attempt to re-engage persons in treatment who have withdrawn from participation in the treatment process prior to the successful completion of treatment, refused services or failed to appear for a scheduled service. All attempts to re-engage persons who have withdrawn from treatment, refused services, or failed to appear for a scheduled services must be documented in the comprehensive clinical record. The provider must attempt to re-engage the person by:

• Communicating in the person’s preferred language;
• Contacting the person, HCDM or the person’s legal guardian by telephone, at times when the person may reasonably be expected to be available (e.g., after work or school);
• Whenever possible, contacting the person, HCDM or the person’s legal guardian face-to-face, if telephone contact is insufficient to locate the person or determine acuity and risk;
• Sending a letter to the current or most recent address requesting contact, if all attempts at personal contact are unsuccessful, except when a letter is contraindicated due to safety concerns (e.g., domestic violence) or confidentiality issues. The provider will note safety or confidentiality concerns in the progress notes section of the clinical record and include a copy of the letter sent in the comprehensive clinical record; and
• For persons determined to have a Serious Mental Illness who are receiving Special Assistance (see AHCCCS AMPM section 320-R).

If the above activities are unsuccessful, the provider must make further attempts to re-engage persons determined to have an SMI or SED designation, persons under court ordered treatment, children (including children in foster care), pregnant substance abusing members/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others. Further attempts may include contacting the person, HCDM or person’s legal guardian, face-to-face visits, or contacting natural supports who the member has given permission to the provider to contact. If the person appears to meet clinical standards as a danger to self, danger to others, persistently and acutely disabled or gravely disabled, the provider must make attempts as appropriate to engage the person to voluntarily seek inpatient care. If this is not a viable option for the person and the clinical standard is met, the provider must initiate the pre-petition screening or petition for treatment process described in AHCCCS AMPM Section 320-U, https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/320-U.pdf — Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment.

All attempts to re-engage persons designated as SMI, children, pregnant substance abusing members/teenagers, or any person determined to be at risk of relapse, decompensation, deterioration or a potential harm to self or others must be clearly documented in the comprehensive clinical record. Providers are required to have a clearly defined outreach and engagement policy. (See AMPM 1040, and AMPM 310-B.

Re-Engagement for Members on Court Ordered Treatment:

For members who are on Court Ordered Treatment, it is the expectation that providers will re-engage within 24 hours of a missed appointment and continue frequent re-engagement efforts until such a time as the member is re-engaged and adherent with treatment, the court order is amended/revoked with the person placed in a psychiatric facility, or it has been confirmed that the member is now living in a different Regional Behavioral Health Authority/Managed Care Organization/Health Plan area or that the member has permanently moved out of state.

• If a member misses a Behavioral Health Medical Provider (BHMP) appointment, whether it is because the member canceled, no-showed, or the provider canceled the appointment, Re-engagement attempts should immediately be started to reschedule the missed BHMP appointment. The appointment should be rescheduled so that the requirement of a monthly appointment is met.
• BHMP emergency appointment slots should be utilized to accommodate this appointment.
• Missed appointments and non-adherence to the treatment plan should prompt the treatment team to re-evaluate the treatment plan to ensure that it is meeting the member’s needs and goals. A member’s input into the plan, with attention to achieving their goals as much as possible, will help with engagement. Any barriers to attending appointments should be assertively and creatively addressed, for example a member’s difficulties with communication, transportation, competing commitments, childcare, managing schedules, etc. The treatment plan should be as flexible and personalized as possible to facilitate each member’s adherence.
• If maximal effort to re-engage a member into outpatient treatment fails, the treatment team should file a revocation so that the member may be assessed in a crisis setting. This is especially important if the member has missed an injection as a result of missing their outpatient appointment. Whether or not the member is hospitalized as a result of the revocation, revocations are another opportunity to re-engage the member and amend the treatment plan with the member’s input.
• If a provider does not reschedule the missed appointment within two business days, the provider should not revoke the member for this reason alone. Instead, the provider must make arrangements to reschedule the member as soon as possible. Providers should not revoke a member due to a provider administrative or coordination issue.

13.5.3.1   Follow Up After Missed Appointments

Providers are required to contact all persons who miss scheduled appointments without rescheduling. Providers must contact the person following a missed appointment or as soon as possible but no later than two workdays after the missed appointment. Documentation of all attempts to reach the person shall be documented in the person’s medical record. At least three attempts shall be made to reschedule a missed appointment and shall include contacts made by certified mail and telephone. Face-to-face outreach shall be required for all persons receiving medication services, all individuals identified to be at risk, or to persons who have reported danger to self/danger to others thoughts in the last year. All outreach attempts shall be completed within thirty days of a missed appointment.

13.5.3.2   Follow Up After Significant and/or Critical Events

Providers must also document activities in the clinical record and conduct follow-up activities to maintain engagement within the following timeframes:

• Discharged from inpatient services in accordance with the discharge plan and within 7 days of the person’s release to ensure client stabilization, medication adherence, and to avoid re-hospitalization,
• Involved in a behavioral health crisis within timeframes based upon the person’s clinical needs, but no later than seven days, and
• Refusing prescribed psychotropic medications within timeframes based upon the person’s clinical needs and individual history; and
• Released from local and county jails and detention facilities based on the needs of the member but no later than 7 days.

Additionally, for persons released from jail or hospital settings, outpatient providers must help establish priority prescribing clinician appointments based on the needs of the member but no later than 7 days of the person’s release to ensure client stabilization, medication adherence, and to avoid re-hospitalization.

13.5.3.3   Provider Requirements to Notify the Statewide Crisis Line of At-Risk Situations

Providers are required to notify the statewide crisis line by telephone call within 2 hours of any enrolled persons determined to be a danger to self or others and supply an updated crisis plan (AHCCCS Crisis Plan reference. Providers are also required to notify the statewide crisis line by telephone call and report a member who has withdrawn from treatment and presents a potential risk to self, others, or the community; including, all persons with a SMI, all children at risk, all pregnant substance abusing members/teenagers, and any person determined to be at risk of relapse. The statewide crisis line will assist with telephonic engagement activities, assist providers in developing appropriate intervention strategies, and coordinate with the Health Plan to bring additional resources to assist effective engagement in treatment.

13.5.4   Ending Treatment for a Person in the Behavioral Health System

Providers may not end a member’s treatment because of an adverse change in the member’s health status or because of the member’s utilization of medical services, diminished capacity, or uncooperative or disruptive behavior. Providers must not arbitrarily or prematurely reject or eject a member from services without prior authorization of the Health Plan. However, under certain circumstances, it may be appropriate or necessary to close a person’s chart for administrative reasons, or after re-engagement efforts described above have been expended.

13.5.4.1   Children Held at County Detention Facilities

Providers must check the AHCCCS Pre-paid Medical Management Information System (PMMIS) to determine eligibility for treatment services prior to the delivery of each behavioral health service to a child who is held in a county detention facility.

Contact the Health Plan for assistance when a child loses their Title XIX/XXI eligibility while in detention. Children who lose their eligibility or have their eligibility suspended while temporarily in detention may be eligible for Mental Health Block Grant (MHBG) funded services, depending on availability of funds and prior approval of AHCCCS. Funding availability may vary from year to year based on the availability of applicable Non-Title XIX/XXI funds. Funding for services for Adolescents in detention must be approved by AHCCCS based on an approved Health Plan comprehensive work plan (Reference AMPM 320 T1 for additional information and requirements).

Even when funding is not available, Integrated Health Homes are required to maintain contact with children in detention and during the 30-day period prior to release to facilitate appropriate release planning.

13.5.4.2   Inmates of Public Institutions

AHCCCS has implemented an electronic inmate of public institution notification system developed by the AHCCCS Division of Member Services (DMS). If a member is eligible for AHCCCS covered services during the service delivery period. The Health Plan is obligated to cover the services regardless of the perception of the members’ legal status.

In order for AHCCCS to monitor any change in a member’s legal status, and to determine eligibility, the Health Plan providers are required to notify the Health Plan and AHCCCS via e-mail, and if they become aware that an AHCCCS eligible member is incarcerated. AHCCCS has established an email address for this purpose. Notifications shall be sent via email to the following email address: MCDUJustice@azahcccs.gov. Notifications must include the following member information:

• AHCCCS ID;
• Name;
• Date of Birth;
• Incarceration date; and
• Where incarcerated.

Integrated Health Homes are required to maintain contact with persons in detention and during the 30-day period prior to release to facilitate appropriate release planning. These coordination of care services are funded through state funds and block grant funds.

AHCCCS supports a model for assessment, service planning, and service delivery that is strength-based, person-centered, family friendly, culturally, and linguistically appropriate, Trauma Informed, and clinically sound and supervised. The model is based on four equally important components:

• Input from the person regarding individual needs, strengths, and preferences;
• Input from other persons involved in the person’s care who have integral relationships with the person;
• Development of a therapeutic alliance between the person and provider that fosters an ongoing partnership built on mutual respect and equality; and
• Clinical expertise.

The model incorporates the concept of a “team,” established for each person receiving services in accordance with the Arizona Vision and 12 Principles and the 9 Guiding Principles for recovery oriented adult behavioral health services. For children, this team is the Child and Family Team (CFT) and for adults the Adult Recovery Team (ART). At a minimum, the functions of the CFT and ART include:

• Ongoing engagement of the person, family, and others who are significant in meeting the behavioral health needs of the person, including their active participation in the decision-making process and involvement in treatment;
• An assessment process is conducted to:
  • Elicit information on the strengths, needs, and goals of the individual person and family members/guardians/Health Care Decision Maker;
  • Identify the need for further or specialty evaluations; and
  • Support the development and updating of a service plan which effectively meets the person’s/family’s needs and results in improved health outcomes.
• Continuous evaluation of the effectiveness of treatment through the CFT and ART process, the ongoing assessment of the person, and input from the person and their team resulting in modification to the service plan, if necessary;
• Provision of all covered services as identified on the service plan, including assistance in accessing community resources, as appropriate and, for children, services which are provided consistent with the, and for adults, services which are provided consistent with the 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems;
  • These covered services include Behavioral Health (BH) Services to Family Members: BH services may be provided to the member’s family members, regardless of the family member’s Title XIX/XXI entitlement status, as long as the member’s Service Plan (ISP) reflects that the provision of these services are aimed at AHCCCS MEDICAL POLICY MANUAL SECTION 310 – COVERED SERVICES 310-B (pp. 5), accomplishing the member’s ISP goals (i.e. they show a direct, positive effect on the member). The member does not have to be present when the services are being provided to family members.
• Indirect Contact with the member includes email or phone communication (excluding leaving voice mails), specific to a member’s services including; obtaining collateral information, and/or picking up and delivering medications. Refer to the AHCCCS Fee-For-Service Provider Manual (Chapter 19) and the AHCCCS IHS/Tribal Provider Manual (Chapter 12 for IHS/638 providers) for additional guidance.
• Ongoing collaboration, including the communication of appropriate clinical information, with other individuals and/or entities with whom delivery and coordination of services is important to achieving positive outcomes (e.g., primary care providers, school, child welfare, juvenile or adult probation, other involved service providers);
• Oversight to ensure continuity of care by taking the necessary steps (e.g., clinical oversight, development of facility discharge plans, or after-care plans, transfer of relevant documents) to assist persons who are transitioning to a different treatment program, (e.g., inpatient to outpatient setting), changing providers and/or transferring to another service delivery system (e.g., out-of-area, out-of-state or ); and
• Development and implementation of transition plans prior to discontinuation or modification of services.
•  (See AMPM 1040,  and AMPM 310-B).
• Assessment, Evaluation, and Screening Services, and Behavioral Health Counseling and Therapy shall be provided by individuals who are qualified BHPs or BHTs supervised by BHPs when clinically appropriate. For additional information regarding Behavioral Health Assessment and Treatment/Service Planning for AHCCCS members, refer to AMPM Policy 320-O. Psychophysiological Therapy and Biofeedback shall be provided by qualified BHPs.

 

13.6.1   Assessments

All persons being served in the public behavioral health system must have a behavioral health assessment upon an initial request for services. For persons who continue to receive services, updates to the assessment must occur at least annually. Behavioral health assessments must be utilized to collect necessary information that will inform providers of how to plan for effective care and treatment of the individual.

AHCCCS does not mandate that a specific assessment tool or format be used but requires certain minimum elements. Providers must collect and submit all required member information in accordance with the criteria outlined in the AHCCCS Demographic and Outcome Data Set User Guide (DUG).

The initial and annual assessment must be completed by a behavioral health professional (BHP) or behavioral health technician (BHT) under the clinical oversight of a BHP, trained on the minimum elements of a behavioral health assessment and who meets requirements in Section 6 Credentialing and Re-credentialing Requirements and Section 16 Training and Workforce Development.

 

13.6.1.1   Minimum Elements of the Behavioral Health Assessment

AHCCCS has established the following minimum elements that must be included in a comprehensive behavioral health assessment and documented in the comprehensive clinical record, in accordance with AHCCCS AMPM Section 320-O, Behavioral Health Assessment and Treatment Service Planning Providers are required to have policies in place to monitor accuracy and completion of the behavioral health assessment.

For persons referred for or identified as needing ongoing psychotropic medications for a behavioral health condition, the assessor must establish an appointment with a licensed medical practitioner with prescribing privileges, in accordance with Section 13.2 Appointment Standards and Timeliness of Service. If the assessor is unsure regarding a person’s need for psychotropic medications, then the assessor must review the initial assessment and treatment recommendations with their clinical supervisor or a licensed medical practitioner with prescribing privileges.

If an assessment was completed by another provider or prior to outpatient treatment, the provider must review, update and document member’s assessment information per A.A.C. R9-10-1011

All providers shall maintain an immediately accessible copy of the member’s assessment (see AMPM Policy 940).

The Health Plan promotes a network of Trauma Informed Care (TIC)-certified therapists. The Health Plan will analyze the network sufficiency of TIC-certified therapists. Integrated Health Homes must provide trauma screenings for all individuals receiving treatment. Behavioral Health Providers must ensure the provision of Trauma Informed Care Services, including routine trauma screenings and ensuring sufficient capacity of TIC certified therapists.

 

13.6.1.2   Social Determinants of Health and Specific Integrated Health Home Housing Screening and Service Requirements

AHCCCS and the Health Plan collect and track member outcomes related to Social Determinants of Health. The use of specific International Classification of Diseases, 10^th Edition, Clinical Modification (ICD-10-CM) diagnostic codes representing Social Determinants of Health are a valuable source of information related to member health.

The Social Determinants of Health codes identify conditions in which people are born, grow, live, work, and age. They are often responsible, in part, to health inequities. They include factors such as

• Education
• Employment
• Physical environment
• Socioeconomic status, and
• Social support networks.

As appropriate and within a scope of practice, providers should be routinely screening for, and documenting, the presence of social determinants. Any identified social determinant diagnosis codes should be provided on all claims for AHCCCS members in order to comply with state and federal coding requirements.

Reference Section 12.6 of the Provider Manual for a listing of the current Social Determinants of Health ICD-10-CM diagnosis codes. Note that Social Determinants of Health codes may be added or updated on a quarterly basis. Providers are required to remain current in their thorough utilization of these codes.

Integrated Health Homes are required to coordinate with the AHCCCS Housing Administrator to secure a Housing Management Information System (HMIS) license in order to ensure that members are entered into the AzCH-Complete Care Plan Coordinated Entry.  The Health Plan requires that providers complete a homeless assessment using the Vulnerability Index Service Prioritization Decision Assistance Tool (VI SPDAT) for all members experiencing homelessness, at risk of homelessness, or request assistance with housing.

The Integrated Health Home must then enter the VI SPDAT assessment for each member into the Continuum of Care (CoC) AzCH-Complete Care Plan Coordinated Entry through the Homeless Management Information System (HMIS) database referring the member to the Health Plan Coordinated Entry Housing list. Members meeting the HUD definition of homelessness will also be entered into the CoC Coordinated Entry List. This step will open housing opportunities beyond the AHCCCS housing programs for members experiencing homelessness, assist providers in maintaining contact with those members, and ensure heightened coordination and collaboration with the full network of homeless and housing services available in local communities.

 Integrated Health Homes serving adults are required to identify and screen members; including members with an SMI designation that satisfy Section 8 criteria and refer prospective tenant to the appropriate contracted Public Housing Authority.  Providers are required to participate with the individual's treatment team in order to identify available housing units and to place the individual in an affordable appropriate living environment upon discharge from an institutional setting.

 

13.6.2   Service Planning

All persons being served in the public behavioral health system must have a written plan for services upon an initial request for services and periodic updates to the plan to meet the changing behavioral health needs for persons who continue to receive behavioral health services. AHCCCS does not mandate a specific service planning tool or format. Service plans must be utilized to document services and supports that will be provided to the individual, based on behavioral health service needs identified through the person’s behavioral health assessment. Provider Manual Attachment 3.5.1 Service Plan Rights Acknowledgment Template is available to use. Providers are directed to call Customer Service  at 1-866-796-0542 to obtain a copy of this attachment, if needed.

Service planning shall encompass a description of all covered health services that are deemed as medically necessary and based on member voice and choice. The service plan shall be a uniform, single plan that is developed and administered by the health home, FFS provider or the ALTCS Case Manager, and includes all treatment plans and additional relevant documents from other service providers or entities involved in the members’ care (i.e., education, probation, etc.)

At a minimum, the member, guardian (if applicable), HCDM (if applicable) advocates (if assigned), and a qualified behavioral health representative must be included in the development of the service plan. In addition, family members, designated representatives, agency representatives, and other involved parties, as applicable, may be invited to participate in the development of the service plan. Providers must coordinate with the person’s health plan, PCP, or others involved in the care or treatment of the individual, as applicable, regarding service planning recommendations (see Section 14.3 Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers).

 

13.6.2.1   Minimum Elements of the Service Plan for Title XIX/XXI Members

Service plans must be completed (see AHCCCS AMPM Section 320), Behavioral Health Assessment and Treatment Service Planning and the AHCCCS BQI Specifications Manual found on the AHCCCS Resources website. The Service Plan is included in the medical record in accordance with AMPM Policy 940.

Providers must have policies in place to monitor the timely completion of service plans.

Members must be provided with a copy of their Plan. Questions regarding service plans or member rights should be directed to the Health Plan customer service line at 1-866-796-0542.

The health home provider serves as the primary responsible entity for coordination of all primary, physical and/or behavioral health services and supports to deliver and/or arrange whole person care.

 

13.6.2.2   Optional Elements that Can Be Included in the Service Plan

A Functional Behavioral Assessment (FBA) can be requested by any member of the treatment team and included in the member’s Individualized Service Plan. The purpose of an FBA is to ascertain the purpose or reason behind problem behaviors that a family, care giver or team may be unable to identify. An FBA allows teams to determine the why, how, where, when and what of a member’s behavior. FBA’s use a variety of techniques to understand and change behaviors. An FBA can be completed for the member at any time with updates being made as needed after completion of the assessment. Provider Manual Attachment 3.5.8 Functional Behavioral Assessment Guidance Document is included in the attachments. Providers are directed to call Customer Service at 1-866-796-0542 to obtain a copy of this attachment, if needed.

 

13.6.2.3   Appeals or Service Plan Disagreements

Every effort should be taken to ensure that the service planning process is collaborative, solicits and considers input from each team member, and results in consensus regarding the type, mix, and intensity of services to be offered. In the event that a person and/or legal or designated representative disagree with any aspect of the service plan, including the inclusion or omission of services, the team should take reasonable attempts to resolve the differences and actively address the person’s and/or legal or designated representative’s concerns.

Despite a behavioral health provider’s best effort, it may not be possible to achieve consensus when developing the service plan. In cases that the person and/or legal or designated representative disagree with some or all of the Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given the opportunity to obtain a second opinion from an in-network provider or, if necessary, an out-of-network provider at no cost.

In cases that a person designated as SMI and/or legal or designated representative disagree with some or all of the Non-Title XIX/XXI covered services included in the service plan, the person and/or legal or designated representative must be given a copy of the Appeal or Serious Mental Illness Grievance Form located in the AHCCCS ACOM Chapter 400, Section 446, Attachment A by the behavioral health representative on the team.

In either case, the person and/or legal or designated representative may file an appeal within 60 days of the action.

 

13.6.3   Updates to the Assessment and Service Plan

Providers must complete an annual assessment update with input from the member and family, if applicable, that records a historical description of the significant events in the person’s life and how the person/family responded to the services/treatment provided during the past year. Following this updated assessment, the service plan should then be updated as necessary. While the assessment and service plan must be updated at least annually, the assessment and service plan may require more frequent updates to meet the needs and goals of the member and their family. Providers must have a policy in place to monitor timely updates of both assessments and services plans.

A critical component of the service delivery system is the effective and efficient identification of persons who have special behavioral health needs due to the severity of their behavioral health disorder.   The health plan follows the standardized AHCCCS established process to proactively identify individuals who may have a Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED). Without receipt of the appropriate care, these persons are at high risk for further deterioration of their physical and mental condition, increased hospitalizations, and potential homelessness and incarceration. For this reason, the Health Plan contracted Integrated Health Homes are required to provide a SMI or SED screening/assessment to any person requesting a SMI or SED determination at no cost to the requesting person.

In order to ensure that persons with a SMI or SED are promptly identified and enrolled for services, AHCCCS has developed a standardized process for the referral, evaluation, and determination for SMI and SED eligibility. The requirements associated with the referral for a SMI or SED evaluation and eligibility determination are set forth in AHCCCS 320P Eligibility Determinations for Individuals with Serious Emotional Disturbance and Serious Mental Illness. Additionally, review the SMI and SED Determination Forms.

 

13.7.1   Criteria for SMI and SED Eligibility

All individuals from birth to 18 years of age should be evaluated for SED eligibility by a qualified clinician and have an SED eligibility determination made by the determining entity if the individual or their Health Care Decision Maker (HCDM) makes such a request.

All individuals 17.5 or older must be evaluated for SMI eligibility by a qualified clinician, as defined in A.A.C R9-21-101(B) and have an SMI eligibility determination made by the determining entity if:

• The individual makes such a request.
• A HCDM makes a request on behalf of the individual.
• An Arizona Superior Court issues an order instructing that an individual is to undergo a SMI evaluation/ determination.
• Clinically indicated by the presence of a qualifying diagnosis.
• There is reason to believe that the assessment may indicate the presence of a qualifying diagnosis and functional impairment.

The determination of SMI or SED requires both a qualifying diagnosis and functional impairment as a result of the qualifying diagnosis (see AHCCCS AMPM, 320-P2 for a list of qualifying diagnostic categories).

 

13.7.2   Functional Criteria for SED Eligibility

The final determination of SED requires both a qualifying SED diagnosis and functional impairment because of the qualifying diagnosis. Refer to Prepaid Medical Management Information System (PMMIS) screen RF260 and the Medical Coding Page on the AHCCCS website for a list of qualifying diagnoses.

To meet the functional criteria for SED, an individual shall have, because of a qualifying SED diagnosis, dysfunction in at least one of the following four domains, as specified below, for most of the past six months, or for most of the past three months with an expected continued duration of at least three months:

Seriously disruptive to family and/or community. Pervasively or imminently dangerous to self or others’ bodily safety. Regularly engages in assaultive behavior. Has been arrested, incarcerated, hospitalized or is at risk of confinement because of dangerous behavior. Persistently neglectful or abusive towards others.

 

Severe disruption of daily life due to frequent thoughts of death, suicide, or self-harm, often with behavioral intent and/or plan. Affective disruption causes significant damage to the individual’s education or personal relationships.

 

Dysfunction in role performance. Frequently disruptive or in trouble at home or at school. Frequently suspended/expelled from school. Major disruption of role functioning. Requires structured or supervised school setting. Performance significantly below expectation for cognitive/developmental level. Unable to attend school or meet other developmentally appropriate responsibilities.

• Child and Adolescent Level of Care Utilization System (CALOCUS) recommended level of care 4, 5, or 6;
• Risk of deterioration;
• A qualifying diagnosis with probable chronic, relapsing, and remitting course,
• Co-morbidities (e.g., developmental/intellectual disability, Substance Use Disorder (SUD), personality disorders),
• Persistent or chronic factors such as social isolation, poverty, extreme chronic stressors (e.g., life-threatening or debilitating medical illnesses, victimization), or
• Other (e.g., past psychiatric history, gains in functioning have not solidified or are a result of current compliance only, court-committed, care is complicated and requires multiple providers).

An inability to obtain existing records or information, or lack of a face-to-face psychiatric or psychological evaluation shall not be sufficient in and of themselves for denial of SED eligibility.

 

13.7.3   Functional Criteria for SMI Eligibility

To meet the functional criteria for SMI status, a person must have, as a result of a qualifying SMI diagnosis, dysfunction in at least one of the following four domains, as described below, for most of the past twelve (12) months or for most of the past six (6) months with an expected continued duration of at least six (6) months:

• Inability to live in an independent or family setting without supervision: Neglect or disruption of ability to attend to basic needs. Needs assistance in caring for self. Unable to care for self in safe or sanitary manner. Housing, food, and clothing must be provided or arranged for by others. Unable to attend to the majority of basic needs of hygiene, grooming, nutrition, medical and dental care. Unwilling to seek prenatal care or necessary medical/dental care for serious medical or dental conditions. Refuses treatment for life threatening illnesses because of behavioral health disorder.
• A risk of serious harm to self or others: Seriously disruptive to family and/or community. Pervasively or imminently dangerous to self or others’ bodily safety. Regularly engages in assaultive behavior. Has been arrested, incarcerated, hospitalized or at risk of confinement because of dangerous behavior. Persistently neglectful or abusive toward others in the person’s care. Severe disruption of daily life due to frequent thoughts of death, suicide, or self-harm, often with behavioral intent and/or plan. Affective disruption causes significant damage to the person’s education, livelihood, career, or personal relationships.
• Dysfunction in role performance: Frequently disruptive or in trouble at work or at school. Frequently terminated from work or suspended/expelled from school. Major disruption of role functioning. Requires structured or supervised work or school setting. Performance significantly below expectation for cognitive/ developmental level. Unable to work, attend school, or meet other developmentally appropriate responsibilities; or
• Risk of Deterioration: A qualifying diagnosis with probable chronic, relapsing and remitting course. Co-morbidities (like cognitive difficulties, substance dependence, personality disorders, etc.). Persistent or chronic factors such as social isolation, poverty, extreme chronic stressors (life-threatening or debilitating medical illnesses, victimization, etc.). Other (past psychiatric history; gains in functioning have not solidified or are a result of current compliance only; court-committed; care is complicated and requires multiple providers; etc.).

The following reasons shall not be sufficient in and of themselves for denial of SMI eligibility:

• An inability to obtain existing records or information; or
• Lack of a face-to-face psychiatric or psychological evaluation.

 

13.7.4   Considerations for Persons with Co-Occurring Substance Use Disorder

For persons who have a qualifying SMI diagnosis and co-occurring substance use, for purposes of SMI determination, presumption of functional impairment is as follows:

For psychotic diagnoses (bipolar I disorder with psychotic features, delusional disorder, major depression, recurrent, severe, with psychotic features, schizophrenia, schizoaffective disorder, and psychotic disorder not due to a substance or known psychological condition) functional impairment is presumed to be due to the qualifying psychiatric diagnosis.

For other major mental disorders (bipolar disorders, major depression, and obsessive-compulsive disorder), functional impairment is presumed to be due to the psychiatric diagnosis, unless:

1. The severity, frequency, duration, or characteristics of symptoms contributing to the functional impairment cannot be attributed to the qualifying mental health diagnosis, or
2. The assessor can demonstrate, based on a historical or prospective period of treatment, that the functional impairment is present only when the person is abusing substances or experiencing symptoms of withdrawal from substances.

For all other mental disorders not covered above, functional impairment is presumed to be due to the co-occurring substance use unless:

1. The symptoms contributing to the functional impairment cannot be attributed to the substance use disorder, or
2. The functional impairment is present during a period of cessation of the co-occurring substance use of at least 30 days, or
3. The functional impairment is present during a period of at least 90 days of reduced use and is unlikely to cause the symptoms or level of dysfunction.

 

13.7.5   Completion Process of Final SMI or SED Determination

A licensed psychiatrist, psychologist, or psychiatric nurse practitioner designated by the AHCCCS contracted Evaluation Agency must make a final determination as to whether the person meets the eligibility requirements for SMI status based on:

• A face-to-face assessment or reviewing a face-to-face assessment by a qualified assessor; and
•  A review of current and historical information, if any, obtained orally or in writing by the assessor from collateral sources, and/or present or previous treating clinicians.

The following must occur if the designated reviewing psychiatrist, psychologist, or psychiatric nurse practitioner has not conducted a face-to-face assessment and has a disagreement with the qualified assessor and/or the treating Behavioral Health Professional that cannot be resolved by oral or written communication:

• Disagreement Regarding Diagnosis: Determination that the person does not meet eligibility requirements for SMI status must be based on a face-to-face diagnostic evaluation conducted by a designated psychiatrist, psychologist, or nurse practitioner. The resolution of (specific reasons for) the disagreement shall be documented in the person’s comprehensive clinical record.
• Disagreement Regarding Functional Impairment: Determination that the person does not meet eligibility requirements must be based upon a face-to-face functional evaluation conducted by a designated psychiatrist, psychologist, or nurse practitioner. The psychiatrist, psychologist, or nurse practitioner shall document the specific reason(s) for the disagreement in the person’s comprehensive clinical record.

If there is sufficient information to determine SMI or SED eligibility, the person shall be provided written notice of the eligibility determination within three (3) business days of the initial meeting with the qualified assessor in accordance with the next section of this policy.

 

13.7.6   Issues Preventing Timely Completion of SMI or SED Eligibility Determination

The time to initiate or complete the SMI or SED eligibility determination may be extended no more than 20 days if the person agrees to the extension and:

• There is substantial difficulty in scheduling a meeting at which all necessary participants can attend;
• The person fails to keep an appointment for assessment, evaluation, or any other necessary meeting (see Section 13.5 Outreach, Engagement, Re-Engagement, and Closure);
• The person is capable of but temporarily refuses to cooperate in the preparation of the completion of an assessment or evaluation;
• The person or the person’s guardian and/or designated representative requests an extension of time;
• Additional documentation has been requested, but has not yet been received; or
  • There is insufficient functional or diagnostic information to determine SMI or SED eligibility within the required time periods.
  • Insufficient diagnostic information shall be understood to mean that the information available to the reviewer is suggestive of two or more equally likely working diagnoses, only one of which qualifies as SMI or SED, and an additional piece of existing historical information or a face-to-face psychiatric evaluation is likely to support one diagnosis more than the other(s).

The AHCCCS contracted SMI and SED Evaluation Agency (Solari Crisis & Human Services) must:

• Document the reasons for the delay in the person’s eligibility determination record when there is an administrative or other emergency that will delay the determination of SMI or SED status; and
• Not use the delay as a waiting period before determining SMI or SED status or as a reason for determining that the person does not meet the criteria for eligibility (because the determination was not made within the time standards).

In situations in which the extension is due to insufficient information:

• The AHCCCS contracted Evaluation Agency (Solari Crisis & Human Services) shall request and obtain the additional documentation needed (e.g., current and/or past medical records) and/or perform or obtain any necessary psychiatric or psychological evaluations;
• The designated reviewing psychiatrist, psychologist, or nurse practitioner must communicate with the person’s current treating clinician, if any, prior to the determination of SMI or SED, if there is insufficient information to determine the person’s level of functioning; and
• SMI or SED eligibility must be determined within three (3) days of obtaining sufficient information, but no later than the end date of the extension.

If the person refuses to grant an extension, eligibility must be determined based on the available information. If eligibility is denied, applicants shall be notified of their appeal rights and the option to reapply (see the next section of this policy).

If the evaluation or information cannot be obtained within the required time period because of the need for a period of observation or abstinence from substance use in order to establish a qualifying mental health diagnosis, the person shall be notified that the determination may, with the agreement of the person, be extended for up to 90 (calendar) days.

• This extension may be considered a technical re-application to verify compliance with the intent of Rule. However, the person does not need to actually reapply. Alternatively, the determination process may be suspended and a new application initiated upon receipt of necessary information.

 

13.7.7   Notification of SMI or SED Eligibility Determination

If the eligibility determination results in approval of SMI or SED status, the SMI or SED status must be reported to the person in writing, including notice of the right to appeal the decision (see Section 9.4 Notice Requirements and Appeal Process (Title XIX/XXI).

If the eligibility determination results in a denial of SMI or SED status, the AHCCCS contracted  Evaluation Agency (Solari Crisis & Human Services) shall include in the notice above:

• The reason for denial of SMI or SED eligibility (see AHCCCS AMPM 320-P SMI and SED Determination);
• The right to appeal (see Section 9.4 Notice Requirements and Appeal Process (Title XIX/XXI) and Section 9.5 Notice Requirements and Appeal Process (SMI and GMH/SA /Non-Title XIX/XXI); and
• The statement that Title XIX/XXI eligible persons will continue to receive needed Title XIX/XXI covered services.

 

13.7.8   Review of SMI and SED Eligibility

A review of SMI or SED eligibility made by the Health Plan for individuals currently enrolled as a person with a SMI or SED may be initiated by the Health Plan or their contracted behavioral health providers:

•  As part of an instituted, periodic review of all persons determined to have a SMI or SED;
•  When there has been a clinical assessment that supports that the person no longer meets the functional and/or diagnostic criteria; or
•  As requested by an individual currently enrolled as a person with a SMI or SED, or their legally authorized representative.

A review of the determination may not be requested by the Health Plan or their contracted behavioral health providers within six (6) months from the date an individual has been determined SMI or SED eligible.

If, as a result of a review, the person is determined to no longer meet the diagnosis and functional requirements for SMI or SED status, the Health Plan must ensure that:

• Services are continued depending on eligibility, the Health Plan service priorities and any other requirements as described in Section 2 Covered Services and Related Program Requirements and Section 14.2 Inter-RBHA/MCO Coordination of Care and Section 13.11 Mental Health and Substance Use Disorder Services; Including Federal Grant and State Appropriation Requirements
• Written notice of the determination made on review with the right to appeal is provided to the affected person with an effective date of thirty (30) days after the date the written notice is issued.

 

13.7.9   SMI and SED Decertification

There are two established methods for removing a SMI or SED designation, one clinical and the other an administrative option, as follows:

A member who has a SMI or SED designation or an individual from the member’s clinical team may request a SMI or SED Clinical Decertification. A Clinical Decertification is a determination that a member who has a SMI or SED designation no longer meets criteria. If, as a result of a review, the person is determined to no longer meet the diagnostic and/or functional requirements for SMI or SED status:

1. The Determining Entity (Solari Crisis & Human Services) shall ensure that written notice of the determination and the right to appeal is provided to the affected person with an effective date of 30 days after the date the written notice is issued,
2. Services are continued in the event an appeal is timely filed, and services are appropriately transitioned as part of the discharge planning process.

A member who has a SMI or SED designation may request an Administrative Decertification from SOLARI if the member has not received behavioral health services for a period of six months.

1. Upon receipt of a request for Administrative Decertification, SOLARI shall notify the Health Plan to request a review of behavioral health service utilization over the last 6 months for the member.
2. The Health Plan will provide the summary of behavioral health service utilized over the last 6 months to SOLARI representatives. Based upon the review, the following will occur:
   • In the event there are no behavioral health services utilized over the last 6 months, SOLARI will proceed with decertification for the members SMI status and notify the member.
   • In the event the review finds that the member has received behavioral health services within the six month period, the member will be notified by SOLARI that they may seek decertification of their SMI status through the Clinical Decertification process with SOLARI.

Providers are highly encouraged to use SMI and SED forms located on the Solari Crisis & Human Services and  Solari Crisis and Human Services portal 

Each member has the right to participate in decisions regarding behavioral health care, including the right to refuse treatment (42 CFR 438.100(b)(2)(iv)). It is important for persons seeking services to agree to those services and be made aware of the service options and alternatives available to them as well as specific risks and benefits associated with these services.

AHCCCS recognizes two primary types of consent: general consent and informed consent 

General consent is a one-time agreement to receive services that are usually obtained from a person during the intake process at the initial appointment and is always obtained prior to the provision of any services. General consent must be verified by a member’s or legal guardian’s signature.

Informed consent must be obtained before the provision of a specific treatment that has associated risks and benefits. Informed consent is required prior to the provision of the following services and procedures:

• ·         Complementary and Alternative Medicine (CAM);
• Psychotropic medications;
• Electro-convulsive therapy (ECT);
• Use of telemedicine;
• Application for a voluntary evaluation;
• Research;
•  Admission for medical detoxification, an inpatient facility or a residential program (for persons with a SMI); and
• Procedures or services with known substantial risks or side effects.

Prior to obtaining informed consent, an appropriate behavioral health representative, as identified in R9-21-206.01(c), must present the facts necessary for a person to make an informed decision regarding whether to agree to the specific treatment and/or procedures. Documentation that the required information was given and that the person agrees or does not agree to the specific treatment must be included in the comprehensive clinical record, as well as the person’s/guardian’s signature when required.

Active Parent Consent

In addition to general and informed consent for treatment, state statute (A.R.S. § 15-104) requires written consent from a child’s parent or legal guardian for any behavioral health survey, analysis, or evaluation conducted in reference to a school-based prevention program.

Completion of Substance Abuse Prevention Program and Evaluation Consent applies solely to consent for a survey, analysis, or evaluation only, and does not constitute consent for participation in the program itself.

The intent of this section is to describe the requirements for reviewing and obtaining general and informed consent, for persons receiving services within the public behavioral health system, as well as consent for any behavioral health survey or evaluation in connection with an AHCCCS school-based prevention program.

 

13.8.1   General Requirements

Any person aged 18 years and older, in need of services must give voluntary general consent to treatment, demonstrated by the person’s or legal guardian’s signature on a general consent form, before receiving services.

For persons under the age of 18, the parent, legal guardian, or a lawfully authorized custodial agency must give general consent to treatment, demonstrated by the parent, legal guardian, or lawfully authorized custodial agency representative’s signature on a general consent form prior to the delivery of services.

Any person aged 18 years and older or the person’s legal guardian, or in the case of persons under the age of 18, the parent, legal guardian, or a lawfully authorized custodial agency, after being fully informed of the consequences, benefits, and risks of treatment, has the right not to consent to receive services.

Any person aged 18 years and older or the person’s legal guardian, or in the case of persons under the age of 18, the parent, legal guardian or a lawfully authorized custodial agency has the right to refuse medications unless specifically required by a court order or in an emergency situation.

Providers treating persons in an emergency situation are not required to obtain general consent prior to the provision of emergency services. Providers treating persons pursuant to court order must obtain consent, as applicable, in accordance with A.R.S. Title 36, Chapter 5.

All evidence of informed consent and general consent to treatment must be documented in the comprehensive clinical record per Section 11.2 Medical Record Standards.

In initiating general care for the Health Plan members, providers are required to use informed consent forms that include all the elements identified in the Provider Manual Form 3.7.1, General Consent to Treatment. The form can be obtained by calling Customer Service at 1-866-796-0542.

Providers prescribing psychotropic medications for the Health Plan members are required to use informed consent forms that include all the elements identified in AHCCCS Medical Policy 

 

13.8.2   General Consent

Administrative functions associated with a member’s enrollment do not require consent, but before any services are provided, general consent must be obtained. General consent is usually obtained during the intake process and represents a person’s, or if under the age of 18, the person’s parent, legal guardian or lawfully authorized custodial agency representative’s, written agreement to participate in and to receive non-specified (general) services. Providers are required to use Provider Manual Form 3.7.1, General Consent to Treatment which can be obtained by calling Customer Service at 1-866-796-0542, and to have a policy in place to monitor completion of general consents.

13.8.3   Informed Consent

 

13.8.3.1   What Information Must Be Provided to Obtain Informed Consent?

In all cases where informed consent is required by this section, informed consent must include, at a minimum, the following:

• Member’s right to participate in decisions regarding health care, including the right to refuse treatment, and to express preferences about future treatment decisions;
• Information about the person’s diagnosis and the proposed treatment, including the intended outcome, nature and all available procedures involved in the proposed treatment;
• The risks, including any side effects, of the proposed treatment, as well as the risks of not proceeding;
• The alternatives to the proposed treatment, particularly alternatives offering less risk or other adverse effects;
• That any consent given may be withheld or withdrawn in writing or orally at any time. When this occurs, the provider must document the person’s choice in the medical record;
• The potential consequences of revoking the informed consent to treatment; and
• A description of any clinical indications that might require suspension or termination of the proposed treatment.

 

13.1.3.2   Who Can Give Informed Consent and How Is It Documented?

Persons, or if applicable, the client’s parent, guardian or custodian shall give informed consent for treatment by signing and dating an acknowledgment that they have received the information and gives informed consent to the proposed treatment.

When informed consent is given by a third party, the identity of the third party and the legal capability to provide consent on behalf of the person, must be established. If the informed consent is for psychotropic medication or telemedicine and the person or the person’s guardian (if applicable) refuses to sign an acknowledgment and gives verbal informed consent, the medical practitioner shall document in the person’s record that the information was given, the client refused to sign an acknowledgment, and that the client gives informed consent to use psychotropic medication or telemedicine.

 

13.8.3.3   Who Can Provide Informed Consent and How Is It Communicated?

When providing information that forms the basis of an informed consent decision for the circumstances identified above, the information must be:

• Presented in a manner that is understandable and culturally appropriate to the person, parent, legal guardian or an appropriate court; and
• Presented by a credentialed behavioral health medical practitioner or a registered nurse with at least one year of behavioral health experience. It is preferred that the prescribing clinician provide information forming the basis of an informed consent decision. In a specific situation in which that is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience.

 

13.8.3.4   Psychotropic Medications, Complementary and Alternative Treatment and Telemedicine

Unless treatments and procedures are court ordered, providers must obtain written informed consent, and if written consent is not obtainable, providers must obtain oral informed consent. If oral informed consent is obtained instead of written consent from the person, parent, or legal guardian, it must be documented in written fashion. Informed consent is required in the following circumstances:

• Prior to the initiation of any psychotropic medication or initiation of Complementary and Alternative Treatment (CAM) (see Section 13.9 Psychotropic Medication: Prescribing and Monitoring). The use of Provider Manual Form 3.7.1, General Consent to Treatment AHCCCS AMPM Section 310-V, Attachment A (https://www.azahcccs.gov/shared/MedicalPolicyManual/) is recommended as a tool to review and document informed consent for psychotropic medications which can be obtained by calling Customer Service at 1-866-796-0542 for ACC and ACC-RBHA, or
• Prior to the delivery of services through telemedicine.

Informed Consent for Telemedicine:

• Before a health care provider delivers health care via telemedicine, verbal or written informed consent from the member or their health care decision maker must be obtained. Refer to AMPM Policy 320-I,
• Informed consent may be provided by the behavioral health medical practitioner or registered nurse with at least one year of behavioral health experience. When providing informed consent, it must be communicated in a manner that the member and/or legal guardian can understand and comprehend.
  • Exceptions to this consent requirement include:
  • If the telemedicine interaction does not take place in the physical presence of the member,
  • In an emergency situation in which the member or the member’s health care decision maker is unable to give informed consent, or
  • To the transmission of diagnostic images to a health care provider serving as a consultant or the reporting of diagnostic test results by that consultant.

 

13.8.3.5   Electro-Convulsive Therapy (ECT), Research Activities, Voluntary Evaluation, and Procedures or Services with Known Substantial Risks or Side Effects

Written informed consent must be obtained from the person, parent, or legal guardian, unless treatments and procedures are under court order, in the following circumstances:

• Before the provision of (ECT);
• Prior to the involvement of the person in research activities;
• Prior to the provision of a voluntary evaluation for a person. The use of AMPM Exhibit 320-Q-1, Application for Voluntary Evaluation is required for persons with SMI and is recommended as a tool to review and document informed consent for voluntary evaluation of all other populations; and
• Prior to the delivery of any other procedure or service with known substantial risks or side effects.

 

13.8.3.6   Additional Provisions

Written informed consent must be obtained from the person, legal guardian, or an appropriate court prior to the person’s admission to any medical detoxification, inpatient facility, or residential program operated by a behavioral health provider.

 

13.8.3.7   Revocation of Informed Consent

If informed consent is revoked, treatment must be promptly discontinued, except in cases in which abrupt discontinuation of treatment may pose an imminent risk to the person. In such cases, treatment may be phased out to avoid any harmful effects.

 

13.8.4   Special Requirements for Children Related to Consents

In accordance with A.R.S. § 36-2272, except as otherwise provided by law or a court order, no person, corporation, association, organization or state-supported institution, or any individual employed by any of these entities, may procure, solicit to perform, arrange for the performance of or perform mental health screening in a nonclinical setting or mental health treatment on a minor without first obtaining consent of a parent or a legal custodian of the minor child. If the parental consent is given through telemedicine, the health professional must verify the parent's identity at the site where the consent is given. This section does not apply when an emergency exists that requires a person to perform mental health screening or provide mental health treatment to prevent serious injury to or save the life of a minor child.

 

 

 

 

13.8.4.1   Non-Emergency Situations

In cases where the parent is unavailable to provide general or informed consent and the child is being supervised by a caregiver who is not the child’s legal guardian (e.g., grandparent) and does not have power of attorney, general and informed consent must be obtained from one of the following:

• Lawfully authorized legal guardian;
• Foster parent, group home staff, or other person with whom the Department of Economic Security/Department of Child Safety (DES/DCS) has placed the child; or
• Government agency authorized by the court.

If someone other than the child’s parent intends to provide general and, when applicable, informed consent to treatment, the following documentation must be obtained and filed in the child’s comprehensive clinical record:

Individual/Entity	Documentation
Legal guardian	Copy of court order assigning custody
Relatives	Copy of power of attorney document
Other person/agency	Copy of court order assigning custody
DES/DCS Placements (for children removed from the home by DES/DCS), such as: ·         Foster parents ·         Group home staff ·         Foster home staff ·         Relatives ·         Other person/agency in whose care DES/DCS has placed the child	None required*

* If providers doubt whether the individual bringing the child in for services is a person/agency representative in whose care DES/DCS has placed the child, the provider may ask to review verification, such as documentation given to the individual by DES indicating that the individual is an authorized DES/DCS placement. If the individual does not have this documentation, then the provider may also contact the child’s DES/DCS caseworker to verify the individual’s identity.

 

For any child who has been removed from the home by DCS, the foster parent, group home staff, foster home staff, relative, or other person or agency in whose care the child is currently placed may give consent for the following services:

• ·Evaluation and treatment for emergency conditions that are not life threatening; and
• Routine medical and dental treatment and procedures, including early periodic screening, diagnosis and treatment services, and services by health care providers to relieve pain or treat symptoms of common childhood illnesses or conditions (including behavioral health services and psychotropic medications).

Any minor who has entered into a lawful contract of marriage, whether or not that marriage has been dissolved subsequently, emancipated youth, or any homeless minor may provide general and, when applicable, informed consent to treatment without parental consent (A.R.S. § 44-132).

 

13.8.4.2   Emergency Situations

In emergency situations involving a child in need of immediate hospitalization or medical attention, general and, when applicable, informed consent to treatment is not required.

Any child, 12 years of age or older, who is determined upon diagnosis of a licensed physician, to be under the influence of a dangerous drug or narcotic, not including alcohol, may be considered an emergency situation and can receive behavioral health care as needed for the treatment of the condition without general and, when applicable, informed consent to treatment.

AHCCCS has developed guidelines and minimum requirements designed to guide the Health Plans in developing appropriate psychotropic medication use policies and procedures to:

• ·Promote the safety of persons taking psychotropic medications;
• Reduce or prevent the occurrence of adverse side effects;
• Promote positive clinical outcomes for behavioral health recipients who are taking psychotropic medications;
• Monitor the use of psychotropic medications to foster safe and effective use; and
• To clarify that medication will not be used for the convenience of the staff, in a punitive manner or as a substitute for other services and shall be given in the least amount medically necessary with particular emphasis placed on minimizing side effects which otherwise would interfere with aspects of treatment, as stated in R9-21-207(C).

See Provider Manual Attachment 3.8.5 – Monitoring Parameters for Psychotropic Medications. Providers are directed to call Customer Service at 1-866-796-0542 for ACC and ACC-RBHA to obtain a copy of this attachment, if needed. It is also available on our website.

 

13.9.1   Basic Requirements

Medications may only be prescribed by the Health Plan credentialed and licensed physicians, licensed physician assistants, or licensed nurse practitioners. See Section 6 Credentialing and Re-Credentialing Requirements for more information regarding credentialing requirements.

Psychotropic medication will be prescribed by a licensed psychiatrist, psychiatric nurse practitioner, physician assistant, or other physician trained or experienced in the use of psychotropic medication. The prescribing clinician must have seen the member and is familiar with the member’s medical history or, in an emergency, the prescribing clinician is at least familiar with the member’s medical history.

When a member on psychotropic medication receives a yearly physical examination, the results of the examination will be reviewed by the physician prescribing the medication. The physician will note any adverse effects of the continued use of the prescribed psychotropic medication in the member’s record (see Section 11.2 Medical Record Standards).

Whenever a prescription for medication is written or changed, a notation of the medication, dosage, frequency or administration, and the reason why the medication was ordered or changed will be entered in the member’s record (see Section 11.2 Medical Record Standards).

13.9.2   Assessments

Reasonable clinical judgment, supported by available assessment information, must guide the prescribing of psychotropic medications. To the extent possible, candidates for psychotropic medication use must be assessed prior to prescribing and providing psychotropic medications. Psychotropic medication assessments must be documented in the person’s comprehensive clinical record per Section 11.2 Medical Record Standards and must be scheduled in a timely manner consistent with Section 13.2 Appointment Standards and Timeliness of Service. Behavioral Health Professionals (BHPs) can use assessment information that has already been collected by other sources and are not required to document existing assessment information that is part of the person’s comprehensive clinical record. At a minimum, assessments for psychotropic medications must include:

• An adequately detailed medical and behavioral health history;
• A mental status examination;
• A diagnosis;
• Target symptoms;
•  A review of possible medication allergies;
• A review of previously and currently prescribed psychotropic or other medications including any reported side effects and/or potential drug-drug interactions and all medications (including medications prescribed by the PCP and medical specialists, OTC medications, and supplements) currently being taken for the appropriateness of the combination of the medications;
• For sexually active females of childbearing age, a review of reproductive status (pregnancy);
• For post-partum females, a review of breastfeeding status; and
• A review of the recipient’s profile in the Arizona State Board of Pharmacy Controlled Substance Prescription Monitoring Program (CSPMP) database when initiating a controlled substance (i.e., amphetamines, opiates, benzodiazepines, etc.) that will be used on a regular basis or for short term addition of agents when the client is known to be receiving opioid pain medications or another controlled substance from a secondary prescriber.

Reassessments require the prescribing clinician of psychotropic medication notes in the member’s record the following (see Section 11.2 Medical Record Standards):

• The reason for and the effectiveness of the medication;
• The clinical appropriateness of the current dosage;
• All medication (including medications prescribed by the PCP and medical specialists, over the counter medications, and supplements) being taken and the appropriateness of the combination of the medications;
• ·ny side effects such as weight gain and/or abnormal/involuntary movements if treated with an anti-psychotic medication; and
• Minimum requirements as per Section 13.9 Psychotropic Medication: Prescribing and Monitoring;
• Rationale for the use of two medications from the same pharmacological class and
• Rationale for the use of more than three different psychotropic medications in adults, and
• Rationale for the use of more than one psychotropic medication in the child and adolescent population.

 

13.9.3   Informed Consent

Informed consent must be obtained from the person and/or legal guardian for each psychotropic medication prescribed. When obtaining informed consent, the BMHP must communicate in a manner that the person and/or legal guardian can easily understand. It is preferred that the prescribing clinician provide information forming the basis of an informed consent decision. In specific situations in which this is not possible or practicable, information may be provided by another credentialed behavioral health medical practitioner or a registered nurse.

The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 11.2 Medical Record Standards). Essential elements for obtaining informed consent for medication are contained within AHCCCS AMPM Section 310-V, Attachment A  Informed Consent for Psychotropic Medication Treatment. AHCCCS AMPM Section 310-V, Attachment A  is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record in an alternative fashion (see Section 11.2 Medical Record Standards).

For more information regarding informed consent, see Section 13.8 General and Informed Consent to Treatment.

 

 

13.9.4   Youth and Psychotropic Medications

• Youth under the age of 18 are to be educated on options, allowed to provide input, and encouraged to assent to medication(s) being prescribed. Information is discussed with the youth in a clear and age-appropriate manner consistent with the developmental needs of the youth.
• The information to be shared should be consistent with the information shared in obtaining informed consent from adults.
• Discussion of the youth’s ability to give consent for medications at the age of 18 years old is begun no later than age 17 ½ years old, especially for youth who are not in the custody of their parents.
• There should be special attention to the effect of medications on the reproductive status and pregnancy, as well as long term effects on weight, abnormal involuntary movements, and other health parameters.
• Evidence of the youth’s consent to continue medications after reaching age 18 may be documented through use of AHCCCS Policy Form 108.1, Informed Consent/Assent for Psychotropic Medication Treatment, a recommended tool to review and document informed consent for psychotropic medications.

 

13.9.5   Psychotropic Medication Monitoring

Per national guidelines and to address the monitoring of psychotropic medications and metabolic parameters, the provider must establish policies and procedures for monitoring of lithium, valproic acid, carbamazepine, renal function, liver function, thyroid function, glucose metabolism, as well as screening for metabolic syndrome and movement disorders. See Provider Manual Attachment 3.8.5 Monitoring Parameters for Psychotropic Medication. Providers are directed to call Customer Service at 1-866-796-0542 to obtain a copy of this attachment, if needed.

Medications prescribed for Youth (members less than 18 years old) must be monitored for efficacy, side effects and adverse events at each visit with a registered nurse, physician assistant, psychiatric nurse practitioner, or physician.

 

13.9.6   Reporting Requirements

The Health Plan has established the AHCCCS system requirements for monitoring the following:

• Adverse drug reactions;
• Adverse drug event; and
• Medication errors.

The above referenced events must be identified, reported, tracked, reviewed, and analyzed by the Health Plan.

An incident report must be completed for any medication error, adverse drug event and/or adverse drug reaction that results in harm and/or emergency medical intervention (See Section 11.10 Reporting of Incidents, Accidents and Deaths for more information).

 

13.9.7   Complementary and Alternative Medicine (CAM)

Complementary and alternative medicine (CAM) is not AHCCCS reimbursable.

When a Behavioral Health Professional uses Complementary and Alternative Medicine (CAM), (See Arizona Medical Board’s Guidelines For Physicians Who Incorporate Or Use Complementary Or Alternative Medicine In their Practice informed consent must be obtained from the person or guardian, when applicable, for each CAM prescribed (See Section 4.13.4 The Health Plan Preferred Drug List). When obtaining informed consent, behavioral health medical practitioners must communicate in a manner that the person and/or legal guardian can easily understand. The comprehensive clinical record must include documentation of the essential elements for obtaining informed consent (see Section 11.2 Medical Record Standards).

Essential elements for obtaining informed consent for medication are contained within AHCCCS AMPM Section 310-V, Attachment A, https://www.azahcccs.gov/shared/MedicalPolicyManual/ Informed Consent for Psychotropic Medication Treatment.

If AHCCCS AMPM Section 310-V, Attachment A  is not used to document informed consent, the essential elements for obtaining informed consent must be documented in the person’s individual comprehensive clinical record in an alternative fashion (see Section 11.2 Medical Record Standards).

At times, it may be necessary to initiate civil commitment proceedings to ensure the safety of a person, or the safety of other persons, due to a person’s mental disorder when that person is unable or unwilling to participate in treatment. In Arizona, State law permits any responsible person to submit an application for pre-petition screening when another person may be, as a result of a mental disorder:

• A danger to self (DTS);
• A danger to others (DTO);
• Persistently or acutely disabled (PAD); or
• Gravely disabled (GD).

If the person who is the subject of a court ordered commitment proceeding is subject to the jurisdiction of an Indian Tribe rather than the State, the laws of that Tribe, rather than State law, will govern the commitment process. Information about the tribal court process and the procedures under State law for recognizing and enforcing a tribal court order are found in Section 13.10.10 Court-Ordered Treatment for American Indian Tribal members in Arizona.

Pre-petition screening includes an examination of the person’s mental status and/or other relevant circumstances by a designated screening agency. Upon review of the application, examination of the person and review of other pertinent information, a licensed screening agency’s medical director or designee will determine if the person meets criteria for DTS, DTO, PAD, or GD as a result of a mental disorder.

If the pre-petition screening indicates that the person may be DTS, DTO, PAD, or GD, the screening agency will file an application for a court-ordered evaluation. Based on the immediate safety of the person or others, an emergency admission for evaluation may be necessary. Otherwise, an evaluation will be arranged for the person by a designated evaluation agency within timeframes specified by State law.

Based on the court-ordered evaluation, the evaluating agency may petition for court-ordered treatment on behalf of the person. A hearing, with the person and legal representative and the physician(s) treating the person, will be conducted to determine whether the person will be released and/or whether the agency will petition the court for court-ordered treatment. For the court to order ongoing treatment, the person must be determined, as a result of the evaluation, to be DTS, DTO, PAD, or GD. Court-ordered treatment may include a combination of inpatient and outpatient treatment. Inpatient treatment days are limited contingent on the person’s designation as DTS, DTO, PAD, or GD. Persons identified as:

• DTS may be ordered up to 90 inpatient days per year;
•  DTO and PAD may be ordered up to 180 inpatient days per year; and
• GD may be ordered up to 365 inpatient days per year.

If the court orders a combination of inpatient and outpatient treatment, a mental health agency may be identified by the court to supervise the person’s outpatient treatment. In some cases, the mental health agency may be a Regional Behavioral Health Authority/Managed Care Organization /Health Plan; however, before the court can order a mental health agency to supervise the person’s outpatient treatment, the agency medical director must agree and accept responsibility by submitting a written treatment plan to the court.

At every stage of the pre-petition screening, court-ordered evaluation, and court-ordered treatment process, a person will be provided an opportunity to change status to voluntary. Under voluntary status, the person is no longer considered to be at risk for DTS/DTO and agrees in writing to receive a voluntary evaluation.

Entities responsible for COE shall ensure the use of the forms as specified in 9 A.A.C. 21, Article 5 for individuals with a Serious Mental Illness (SMI) designation, though they may also use these forms for individuals who do not have an SMI designation, as applicable.

*For the Pima County: forms referenced in this section, Integrated Health Home Title 36 Liaisons should reach out to the Pima County Attorney to obtain copies. For other forms referenced, the Integrated Health Home Title 36 Liaison may contact AzCHTitle36@AZCompleteHealth.com.

Agencies may also use these forms for all other populations. In addition to court-ordered treatment as a result of civil action, an individual may be ordered by a court for evaluation and/or treatment upon 1) conviction of a domestic violence offense; or 2) upon being charged with a crime when it is determined that the individual is court-ordered to treatment, or programs, as a result of being charged with a crime and appears to be an individual with a possible substance use disorder. The responsibilities of the Health Plan and its providers for the provision and coverage of those services is described in Section 13.10.7 Court-Ordered Treatment for Persons Charged with or Convicted of a Crime.

The intent of this section is to provide a broad overview of the pre-petition screening, court-ordered evaluation, and court-ordered treatment process. Depending on a provider’s designation as a screening, evaluation, or court-ordered treatment agency, the extent of involvement with persons receiving pre-petition screening, court-ordered evaluation, and court-ordered treatment services will vary.

 

13.10.1   Licensing Requirements

Providers who are licensed by the Arizona Department of Health Services/Division of Licensing Services as a court-ordered evaluation or court-ordered treatment agency must adhere to ADHS Licensing requirements.

 

13.10.2   Pre-Petition Screening

Unless otherwise indicated in an intergovernmental agreement (IGA), Arizona counties are responsible for managing, providing, and paying for pre-petition screening and court-ordered evaluations and are required to coordinate provision of behavioral health services  with the member’s contractor or the FFS program that is responsible for the provision of behavioral health services. Some counties contract with Regional Behavioral Health Authority/Managed Care Organization/Health Plans to process pre-petition screenings and petitions for court-ordered evaluations.

All applicants calling the Health Plan for court-ordered evaluations are referred to the statewide crisis line at 844-534-4673 to assist callers in identifying the correct pre-petition screening agency and answering any questions they may have about the process.

When a county does not contract with the Health Plan for pre-petition screening services, the statewide crisis line will answer any questions the caller may have about the process and warm-transfer the caller to the appropriate county-contracted prepetition screening agency.

When a county contracts with the Health Plan for pre-petition screening and petitioning for court-ordered evaluation, the statewide crisis line will dispatch a designated pre-petition screening agency.

During the pre-petition screening, the designated agency shall offer assistance to the applicant, if needed, requested by the member, member’s representative, or identified as a need by the member’s clinical team, in the preparation of the application for involuntary COE. Any behavioral health provider that receives an application for COE shall immediately refer the application for pre-petition screening and petitioning for COE to the Contractor designated pre-petition screening agency or county facility.

The pre-petition screening agency must conduct the following procedures:

• Provide pre-petition screening within forty-eight hours of the request excluding weekends and holidays;
• Prepare a report of the clinical assessment, professional opinions and conclusions. If pre-petition screening was not possible, the screening agency must report reasons why the screening was not possible, including opinions and conclusions of staff members who attempted to conduct the pre-petition screening;
• Request the screening agency’s medical director or designee review the report if it indicates that there is no reasonable cause to believe the allegations of the applicant for the court-ordered evaluation;
• Prepare a petition for court-ordered evaluation and file the petition if the screening agency’s Medical Director determines that the person, due to a mental disorder, including a primary diagnosis of dementia and other cognitive disorders, is a Danger to Self (DTS), Danger to Others (DTO), Persistently or Acutely Disabled (PAD), or Gravely Disabled (GD). Refer to the Petition for Court-Ordered Evaluation form for pertinent information for court-ordered evaluation;
• If the screening agency determines that there is reasonable cause to believe that the person, without immediate hospitalization, is likely to harm themselves or others, the screening agency will verify completion of the Application for Emergency Admission for Evaluation form, and take all reasonable steps to procure hospitalization on an emergency basis; and
• Contact the county attorney prior to filing a petition if it alleges that a person is a Danger to Others.

 

13.10.2.1   Emergent/Crisis Petition Filing Process

When it is determined that there is reasonable cause to believe that the individual being screened is in a condition that without immediate hospitalization is likely to harm themselves or others, an emergent application shall be filed. The petition shall be filed at the appropriate agency as determined by the Contractor. As specified in A.R.S. § 36-501 et. Seq, when considering the emergent petition process, the following shall apply:

1. Applications indicating DTS, DTO, PAD, and GD can be filed on an emergent basis.
2. The applicant shall have knowledge of the behavior(s) displayed by the individual that is a danger to self or others consistent with requirements as specified in A.R.S. § 36-524.
3. The applicant shall complete application for Emergency Admission for Evaluation, as specified in A.R.S. § 36.524.
4. The applicant and all witnesses identified in the application as direct observers of the dangerous behavior(s) may be called to testify in court if the application results in a petition for COE.
5. Immediately upon receipt of an application for Emergency Admission for Evaluation, as specified in A.R.S. § 36-524, and all corroborating documentation necessary to successfully complete a determination, the admitting physician will determine if enough evidence exists for an emergency admission for evaluation. If there is enough evidence to support the emergency admission for evaluation, the appropriate facility is not currently operating at or above its allowable member capacity, and the individual does not require medical care, then, facility staff will immediately coordinate with local law enforcement or other transportation service contracted by the county for the detention of the individual and transportation to the appropriate facility.
6. If the individual requires a medical facility, or if appropriate placement cannot be arranged within the 48-hour timeframe identified above relating to the application for Emergency Admission for Evaluation, as specified in A.R.S. § 36-524, the Medical Director of the Contractor, or for FFS members, the FFS Provider’s Medical Director, shall be consulted to arrange for a review of the case.
7. The application for Emergency Admission for Evaluation, as specified in A.R.S. § 36-524 may be discussed by telephone with the facility admitting physician, the referring physician, and a peace officer to facilitate transportation of the individual to be evaluated.
8. An individual proposed for emergency admission for evaluation may be apprehended and transported to the facility under the authority of a peace officer or authorized transportation entity contracted by the county using the application for Emergency Admission for Evaluation, as specified in A.R.S. § 36-524, A.R.S § 36-524(D) and A.R.S § 36-525(A), which outlines criteria for a peace officer or other county contracted transportation provider to apprehend and transport an individual based upon either a telephonic or written application for emergency admission.
9. An emergency admission for evaluation begins at the time the individual is detained involuntarily by the admitting physician who determines if there is reasonable cause to believe that the individual, as a result of a mental disorder, is DTS, DTO, PAD, or GD, and that during the time necessary to complete pre-screening procedures the individual is likely, without immediate hospitalization, to suffer harm or cause harm to others.
10. During the emergency admission period of up to 23 hours the following occurs:
    • The individual’s ability to consent to voluntary treatment is assessed,
    • The individual shall be offered and receive treatment to which they may consent; otherwise, the only treatment administered involuntarily will be for the safety of the individual or others, i.e., seclusion/restraint or pharmacological restraint as specified in A.R.S. § 36-513, and
    • When applicable, the psychiatrist will complete the Voluntary Evaluation within 24 hours of determination that the individual no longer requires an involuntary evaluation.

 

13.10.3   Court-Ordered Evaluation

If, after review of the petition for evaluation, the individual is reasonably believed to be DTS, DTO, PAD, or GD as a result of a mental disorder, the court can issue an order directing the individual to submit to an evaluation at a designated time and place. The order shall specify whether the evaluation will take place on an inpatient or an outpatient basis.

The court may also order that, if the individual does not or cannot submit, the individual be taken into custody by a peace officer or other county contracted transportation provider and delivered to an evaluation agency. For further requirements surrounding COEs on an inpatient basis, refer to A.R.S. § 36-529.

 If the pre-petition screening indicates that the individual may be DTS, DTO, PAD, or GD, the screening agency will file a petition for COE. When, through an IGA with a county, the Contractor is contracted to provide COE, they shall adhere to the following requirements when conducting COEs:

1. An individual who is reasonably believed to be DTS, DTO, PAD, or GD as a result of a mental disorder shall have a petition for COE prepared, signed and filed by the Medical Director of the agency or designee,
2. An individual admitted to an evaluation agency shall receive an evaluation as soon as possible, and receive care and treatment as required by their condition for the full period they are hospitalized,
3. A clinical record shall be kept for each individual which details all medical and psychiatric evaluations and all care and treatment received by the individual,
4. An individual being evaluated on an inpatient basis shall be released within 72 hours (not including weekends and court holidays) if further evaluation is not appropriate, unless the individual makes application for further care and treatment on a voluntary basis, or unless an application for COT has been filed, and
5. On a daily basis at minimum, an evaluation shall be conducted throughout the COE process for the purposes of determining if an individual desires to be switched to a voluntary status or qualifies for discharge.

 For information on individuals being released from COE, and on COE dispositions, refer to A.R.S. § 36-531.

 

13.10.4   Voluntary Evaluation

Any Health Plan provider that receives an application for voluntary evaluation must immediately refer the person to the facility responsible for voluntary evaluations. Providers are to contact the statewide crisis line at 844-534-7673 for assistance.

The Health Plan providers must follow these procedures:

• The evaluation agency must obtain the individual’s informed consent prior to the evaluation (see AHCCCS Section 320-U-7, Application for Voluntary Evaluation) and provide evaluation at a scheduled time and place within five days of the notice that the person will voluntarily receive an evaluation; and
• For inpatient evaluations, the evaluation agency must complete evaluations in less than seventy-two hours of receiving notice that the person will voluntarily receive an evaluation.

If a provider conducts a voluntary evaluation service as described in this section, the comprehensive clinical record (see Section 11.2 Medical Record Standards) must include:

• A copy of the application for voluntary evaluation, use AHCCCS AMPM Section 320-U-7 Application for Voluntary Evaluation; 
• A completed informed consent form (see Section 13.8 General and Informed Consent to Treatment); and
• ·A written statement of the person’s present medical condition.

 

 

 

13.10.5   Court-Ordered Treatment Following Civil Proceedings Under A.R.S. Title 36

Based on the court-ordered evaluation, the evaluating agency may petition for court-ordered treatment. The provider must follow these procedures:

• Upon determination that an individual is DTS, DTO, GD, or PAD, and if no alternatives to court-ordered treatment exist, the medical director of the agency that provided the court-ordered evaluation must file a petition for court-ordered treatment;
• Any provider filing a petition for court-ordered treatment must do so in consultation with the person’s clinical team prior to filing the petition;
• The petition must be accompanied by the affidavits of the two physicians who conducted the examinations during the evaluation period and by the affidavit of the applicant for the evaluation (see Affidavit form);
• A copy of the petition, in cases of DTS, DTO, PAD, and/or GD, must be mailed to the public fiduciary in the county of the patient’s residence, or the county in which the patient was found before evaluation, and to any person nominated as guardian or conservator; and
•  A copy of all petitions must be mailed to the superintendent of the Arizona State Hospital.
• For information regarding court options for treatment, release, discharge, annual reviews, or COT violations, refer to A.R.S. § 36-540 et seq. For requirements relating to Judicial Review, refer to A.R.S. § 36-546 and A.R.S. § 36-546.01.
• For COT Relating to DUI-Domestic Violence or other Criminal Offenses, refer to ACOM Policy 423.

 

13.10.5.1   Background

Per Arizona Revised Statutes 36-545.06-County Services: “Each County shall provide directly, or by contract the services of a screening Provider and an evaluation Provider.”

Each County must have a process in place for:

• Involuntary mental health treatment requests and evaluations
• Court proceedings to satisfy the statutory requirements under Title 36 for individuals under court-ordered evaluation and court-ordered treatment.

 

Every County in Arizona manages this responsibility differently based on their interpretation of the state statutes and the resources in that County. The Court Ordered Treatment/Court Ordered Evaluation (COT/COE) Coordinator and Liaison are required to work with the County Attorney’s Office to ensure proper execution of its procedures.

The Health Plan is responsible for treatment of an eligible person* once placed under a Title 36 civil commitment or court-ordered treatment (COT). Per Arizona Administrative Code (R9-21-504) the RBHA/MCO/Health Plan “shall provide, either directly or by contract all treatment required by A.R.S. Title 36, Chapter 5, Article 5.”

Populations eligible for RBHA/MCO/Health Plan services per Provider Manual Section 2.1.1:

• Title XIX/XXI enrolled individuals;
• Persons determined to have a Serious Mental Illness;
• Special populations, including individuals receiving services through the Substance Use Prevention, Treatment and Recovery Block Grant (SUBG).

 

13.10.5.2   Overview

Each Integrated Health Home per the Health Plan contract scope of service is required to designate a staff person to serve as COT/COE Coordinator and Liaison for Title 36 and Court-Ordered services. Each provider should also designate back up staff for the Coordinator/Liaison if they become unavailable.

A Provider coordinates the provision of clinically appropriate covered services to individuals requiring court ordered treatment and serves as the Supervising Provider for court-ordered outpatient treatment plans.

In all cases, the Provider Medical Director** or physician designee has primary responsibility for oversight of an individual’s court-ordered treatment and is responsible for reviewing and signing all documents filed with Court, including the initial court-ordered treatment plan.

** Per ARS 36-501 (24) Definitions - Medical Director of a mental health treatment Provider" means a psychiatrist, or other licensed physician experienced in psychiatric matters, who is designated in writing by the governing body of the Provider as the person in charge of the medical services of the Provider for the purposes of this chapter and includes the chief medical officer of the state hospital.”

Individuals on court ordered treatment (COT) are one of the most at-risk populations served.  These individuals will need to receive services with a Behavioral Health Provider who can submit the Outpatient treatment Plan to the Courts.

·         Individuals on COT must be seen at least monthly by the Medical Director or designee (must be a Prescriber)

• Outreach and engagement with these individuals should be assertive and follow the re-engagement processes within the Health Plan Provider Manual. The goal is to avoid re-hospitalization and improve the quality of life for the individual.
• A solid service plan must be developed that includes what works and does not work for this individual, supports that can help, and types of outreach that should be attempted if the individual has an increase in symptoms or disengages from treatment.
• The Health Plan has developed crisis protocols for every County served that include detailed descriptions about the way the crisis system works in each respective County. There are extensive sections on involuntary treatment that should be referenced for details on how each County facilitates the COT process. The protocols can be requested by any Arizona Complete Health – Complete Care Plan Justice or Crisis team member.
• Providers must closely monitor COT expiration dates. Pursuant to A.R.S 36-540 (D), a court order cannot exceed 365 days, but some counties may order fewer days. Providers must ensure they understand the County’s interpretation of the COT expiration date. Providers must monitor expiration dates to schedule annual reviews to determine if the individual’s COT should continue for another year. Additionally, it gives Providers enough time to file a Petition for Continued Treatment with Court for individuals who were found Persistently or Acutely Disable or Gravely Disabled.
• The Health Plan will monitor and audit COT requirements and may issue Corrective Action Letters, Sanctions, and/or submit Quality of Care Concerns for failure to follow the requirements.

 

13.10.5.3   Requirements

Each Provider is responsible for maintaining a current list of individuals who are receiving court-ordered treatment.

 

Pima County: Providers are responsible for establishing a group generic email box to receive minute entries from the Court. An example is MinuteEntries@[provider name].com.

 

13.10.5.4   Urgent Engagements, SMI Evaluations, and AHCCCS Screening for Members in COE/COT Process

The Health Plan enrolled and State Only (N19/NSMI) individuals who are identified as not engaged with a behavioral health provider must be referred for urgent engagement and “for persons who are not yet enrolled in Medicaid, Block Grant programs, or the Marketplace, Integrated Health Homes are required to continue to pursue coverage for the person”. (See Section 13.10.6 Persons who are Title XIX-XXI Eligible or Non-Title XIX/XXI and/or Determined to Have a Serious Mental Illness (SMI) and Section 15.1.1 Integrated Health Home Urgent Engagement Responsibility.)

For individuals going through Court Ordered Evaluation to be Court Ordered for Treatment, all avenues are to be explored to determine eligibility for services offered by the Health Plan. Therefore, when an agency in any county is activated for an Urgent Engagement for an individual who is NT19 and GMH and being evaluated for Court Ordered Treatment, an SMI evaluation/assessment should be completed. In general, the SMI determination should be expedited by checking the 3-day turnaround time frame. The Integrated Health Home should also conduct financial screenings and assist the individual in applying for Title 19 benefits.

Should the member refuse services during the Court Ordered Evaluation process; the Integrated Health Home activated due to an urgent engagement shall retain the member until the member is Court Ordered for Treatment and then proceed to engage the member so that eligibility with AHCCCS and an SMI determination can be completed. Please contact the Title 36 Coordinator at the Health Plan for additional Technical Assistance.

Integrated Health Homes are required to enroll and engage Title XIX members who refuse services during the COE process upon the member being Court Ordered.

 

13.10.5.5   Provider Participation in Hearings

The assigned Health Home must ensure a representative with knowledge of the member attend all COT hearings, including the original hearing for court-ordered treatment, judicial reviews, and Petitions for Continued Treatment of Gravely Disabled (GD) or Persistently or Acutely Disabled (PAD). It is expected that the representative follows courtroom rules of decorum. The representative should be prepared to provide information/clarification to Court regarding facts relevant to the hearing and the proposed outpatient treatment plan. The representative must be present to receive orders set forth by the Judge/Commissioner and specific orders regarding the submitted outpatient treatment plan. In Pinal and Maricopa Counties, this also includes the dates COT status reports are to be submitted to the Court.

 

13.10.5.6   Treatment Plan Development and Filing

Prior to the date of the hearing, the Integrated Health Home representative is responsible for coordinating an Adult Recovery Team (ART) meeting for enrolled individual to develop discharge plans and ensure that those plans are included in the individual’s Individual Service Plan (ISP). The ISP must be discussed/reviewed with the Agency Medical Director or physician designee. The individual’s inpatient team must be involved in and agree to discharge decisions.

The COT outpatient treatment plan must be signed by the Agency Medical Director or physician designee and appropriate staff that reviewed the plan with the individual and the outpatient team. The individual is not required to sign the COT outpatient treatment plan and individual signature is optional. If the individual does not sign the plan, the individual signature line is to be left blank. Information regarding why the individual did not sign the plan is not to be written on the plan.

The COT outpatient treatment plan should have the individual’s correct address/zip code and phone number and the type of residence (home, family, friend, BHRF, jail, etc.). If the individual is to reside with family, friends, etc., Provider staff must confirm this arrangement with family, friends, etc.

If a COT outpatient treatment plan has not been completed, the Agency representative is to inform Court why the plan has not been completed and the projected date of completion.

Pima County: For individuals who are TXIX/TXXI eligible, the Health Care Coordinator develops a COT outpatient treatment plan using PIMA County-COT Plan Ind. Receiving AHCCCS Benefits or the PIMA County-COT Plan Ind. NOT Receiving AHCCCS Benefits form. In the event Persons who are Non-Title XIX/XXI eligible but are determined to have a Serious Mental Illness (SMI), the Health Care Coordinator develops a COT outpatient treatment plan using PIMA County-COT Plan Ind. Receiving AHCCCS Benefits form or the PIMA County-COT Plan Ind. NOT Receiving AHCCCS Benefits. The Health Care Coordinator is to submit to Court the original COT outpatient treatment plan to the Judge/Commissioner for signature, with 5 copies 1) County Attorney, 2) Defense Attorney, 3) Hospital T-36 Liaison, 4) Individual, 5) the Health Plan, totaling six treatment plans.

Maricopa County: For individuals being petitioned in Maricopa County at ValleyWise behavioral hospital, the legal staff will provide a generic outpatient treatment plan on behalf of the agency to the Court.

Amendments/Revocations (see the County Crisis Protocols or County specific sections of this guide for a detailed description of the process) Refer to ARS 36-540 depending on the County process.

13.10.5.7   Amendments/Revocations

(See the County Crisis Protocols or County specific sections of this guide for a detailed description of the process.) Refer to ARS 36-540 depending on the County process.

The provider can amend and/or revoke a member’s court order and place the individual in an inpatient setting if the member is not following the terms of the court order. It is important to note that only the Medical Director or physician designee can request an amendment/revocation of the outpatient treatment plan. Note: Medical Directors are required to be available after hours if needed in order to facilitate the revocation/amendment of a court order.

• ·         It is important the provider track the numbers of days a member has spent in an inpatient setting, because there are a limited amount of inpatient days the court may order pursuant to A.R.S. 36-540:
  • DTS up to 90 days
  • DTO & PAD up to 180 days
  • GD up to 365 days
• If there are no more inpatient days available, the Medical Director must determine if the individual requires continued court-ordered treatment. If the individual is DTO/DTS the provider can follow the process for an Emergency Application for Evaluation for Admission. If the individual is PAD/GD, the provider can initiate the Annual Review process or follow the Pre-Petition Screening process.
• Amended outpatient treatment orders do not increase the total period of commitment originally ordered by Court.

 

13.10.5.8   Emergent Amendment/Revocation A.R.S. 36-540 (E)(5)

If a member currently on Court Ordered Treatment (COT) is presenting with DTO/DTS behaviors and requires immediate hospitalization, the Health Home provider can amend the outpatient treatment plan without first obtaining an order from the Court. The Crisis System, which includes the statewide crisis line and Crisis Mobile Teams (CMTs),  are available to assist with emergent amendment/revocation needs. The Health Home Medical Director or physician designee must contact either a 23-hr Observation Unit or a Behavioral Health Inpatient Facility (BHIF) psychiatrist to discuss and coordinate the member’s immediate inpatient treatment needs. The Health Home medical director or physician designee can then authorize a peace officer (including but not limited to law enforcement officers) to transport the member to a screening agency, either the 23-hr Observation Unit or the BHIF. Either the Health Home or the 23-hr Observation Unit can contact law enforcement to request the transport. In some counties, a faxed or emailed “pick up order” or “transport order” may be required prior to contacting law enforcement to complete the transport (please refer to the County-specific Crisis Protocol for details).

To effectively request a peace officer to locate and transport the member to either the 23-hr Observation Unit or the BHIF, the Health Home Medical Director or physician designee or 23-hr Observation Unit staff should contact the law enforcement agency with jurisdiction over the member’s current location. 9-1-1 should only be used when there is an imminent safety or medical concern requiring an emergency response. In all other circumstances, contact the law enforcement communication center’s non-emergency phone number and request a “Law Enforcement Transport for an Emergent Revocation of Court Ordered Treatment”. Required information includes providing the law enforcement communication center with the member’s full name, date of birth, location address, Health Home authorizing doctor, and any specific safety concerns. (Examples of safety concerns may include weapons on scene, impairment, etc.)

The Health Home Medical Director must file a motion for an amended court order requesting inpatient treatment no later than the next working day following the individual being transported to either the 23-hour Observation Unit or the BHIF. If this paperwork is not filed within this timeframe, the member may be detained and treated for no more than 48 hours, excluding weekends and holidays.

When a member is hospitalized pursuant to an amended order, the Health Home Medical Director must inform the individual of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546.

 

Pima County: Verbal Revocation Process

Pima County allows for a verbal revocation/amendment of COT process. If a member on COT is in an Out of Home (OOH) Placement and is in crisis, the OOH Placement should first attempt to contact the member’s Health Home provider. If the Health Home can respond, they will assess and determine if the member’s COT should be revoked. If the Health Home cannot respond, the OOH Placement should contact the Statewide Crisis Line at 844-534-4673 who will triage the situation and dispatch a CMT.

If a CMT is dispatched, the CMT will assess if the member can be stabilized at the OOH Placement. If the member cannot be stabilized at the OOH placement, the CMT will consult on revocation recommendations with the Health Home Medical Director or physician designee on call. If the Health Home Medical Director or physician designee does not recommend revocation, the CMT will complete the crisis assessment and safety plan then advise the OOH Placement and the member will remain at OOH Placement.

If the Health Home Medical Director or physician designee does recommend revocation, the CMT will call the Crisis Response Center (CRC) and provide staffing to include the authorizing Health Home doctor’s name, member’s name, member’s date of birth and member’s current location. The CRC will complete their internal paperwork to document the verbal revocation. The CRC will contact the law enforcement agency with jurisdiction over the member’s location by calling the law enforcement communication center’s non-emergency dispatch number and request a “Law Enforcement Transport for a Verbal Revocation of Court Ordered Treatment”. Once on scene, law enforcement will speak with the CMT and verify the member’s name, date of birth, and the Health Home authorizing doctor’s name. Law enforcement will transport the member to the CRC.

The Health Home will be responsible for completing and filing the COT amendment with the Courts within the next business day in order to complete the verbal revocation process.

 

13.10.5.9   Non-Emergent Amendment/Revocation A.R.S. 36-540 (E)(4)

If the Health Home provider determines that a member is not complying with the terms of their COT or that the outpatient treatment plan is no longer appropriate, the Health Home Medical Director or physician designee can petition the Court to amend/revoke the outpatient treatment plan to inpatient treatment. The Court may enter an order amending the outpatient treatment plan based on the court record, the member’s/patient's medical record, the affidavits, and recommendations of the Medical Director (which must be notarized), and the advice of staff and physicians or the psychiatric and mental health nurse practitioner familiar with the treatment of the member.

If a member refuses to comply with an amended order for inpatient treatment, at the request of the Health Home Medical Director, the Court may authorize an Order to Transport to direct a peace officer (law enforcement officer) to take the member into custody and transport them to the designated 23-hour Observation Unit or BHIF for inpatient treatment.

When a member is hospitalized pursuant to an amended COT order, the Health Home Medical Director must inform the member of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546.

 

Pima County: The request for amendment/revocation of a COT outpatient treatment plan must be signed by the Health Home Medical Director or physician designee and notarized. The Health Home provider will submit the notarized form to the Health Plan-approved law firm. The Court requires specific information/facts regarding the member’s lack of compliance with the outpatient treatment plan. The preparer of the amended request should avoid using conclusions such as “delusional,” “non-compliant,” “AWOL (Absent without Leave),” “disruptive,” “inappropriate,” etc. The request should contain information regarding Health Home provider outreach attempts, attempts to engage the member in treatment, missed appointments, lack of medication compliance, and/or Health Home provider’s attempts to offer voluntary hospitalization.

If the Health Home provider obtains updated information as to the individual’s location after the amendment to the outpatient treatment plan has been filed with the Court, the Health Home provider should contact the appropriate law enforcement agency designated to locate the member and serve the amendment/revocation.  Either the Tucson Police Department Mental Health Support Team (MHST) or the Pima County Sheriff’s Department MHST should be contacted to confirm receipt of the Order and to coordinate service. When providing updated location information, the Health Home provider should inform the MHST officer/deputy that an amendment to the outpatient treatment plan has been filed with the Court.

 

13.10.5.10                Quash a Court’s Order for Law Enforcement to Transport for a Non-Emergent Amendment

If the Court has entered an order for law enforcement to transport the member to an inpatient treatment facility and the provider believes this level of care is no longer required, the Health Home provider can notify the Health Plan-approved law firm to petition the Court to quash the law enforcement order to transport. This ensures the member is not unnecessarily transported to an inpatient facility.  A quash can neither be granted telephonically nor verbally.

 

Pima County: If 90 days has expired since the last COT amendment, the Health Home provider is required to submit a written statement to the Health Plan-approved law firm requesting to quash the previous amendment and transport order. At this time, the Health Home provider may file a new amendment with the Court for another 90 days. If the member becomes incarcerated at the Pima County Adult Detention Center (PCADC) during the timeframe of the amended outpatient treatment plan, a court order to quash the transport is not required if the current amendment does not indicate the address of PCADC. The Provider is responsible for immediately notifying the Pima County Sheriff’s Department MHST Supervisor of the member’s location so that the Order may be served. The Provider must email the amended pleading to the Pima County Sheriff’s Department MHST and PCADC records.

 

13.10.5.11                Tolling a Court Ordered Treatment

Per Statute 36.544; a member’s Court Ordered Treatment is tolled during the unauthorized absence of the patient and resumes running only on the patient's voluntary or involuntary return to the treatment agency.

As defined by the Statute, an unauthorized absence is the following:

• If a member is no longer living in a placement or residence specified by the treatment plan without authorization OR
• Leaving or failing to return to the county or state without authorization OR
• Absent from an inpatient treatment facility without authorization.

The Statute indicates within five (5) days after a patient's unauthorized absence, the Integrated Health Homes shall file a motion with the Court to request a Toll of the Court Ordered Treatment.

Maricopa County: Per the County Attorney, Maricopa County interprets the Toll Statute differently than most other counties. In order for a Toll to be placed on a member’s COT in Maricopa County, there must be two confirmations from reliable sources that indicate the member has left the County or state.  A member’s self-report is not enough to Toll a COT order.

Integrated Health Home Title 36 Liaisons will be responsible for Filing Toll requests with the Courts, monitoring the number of days of the Toll and ensuring Status Reports for re-engagement efforts are filed every 60 days up to 180-Tolled Days. Tolled Orders will be reported to the Health Plan Title 36 Coordinators.

Should the member not be re-engaged voluntarily or involuntarily, the Integrated Health Home has the option to ask the Court to terminate the Court Ordered Treatment after 180 days on Toll.

Tolling a Court Order will move forward the expiration date of the current Order based upon the number of days the member was absent.

 

13.10.5.12         Judicial Reviews A.R.S. 36-546

Providers must inform the individual of the right to Judicial Review every 60 days and must document this in the clinical record. Judicial Reviews are to be calendared and offered every 60 days from the date of the original court order. The days from the court order are as follows: 60, 120, 180, 240,300, and 360. It is the responsibility of the Provider to track the Judicial Review dates and ensure a Judicial Review is offered to an individual under Court-Ordered Treatment (COT) every 60 days. The provider, upon request, will submit documentation showing evidence they are in compliance with the statute regarding judicial review notifications (i.e., progress/prescriber notes, established judicial review form, and Court Filing, if applicable). If an individual is hospitalized pursuant to an amendment to the outpatient treatment plan the Provider must inform the individual of the right to judicial review and the right to consult with counsel pursuant to A.R.S. 36-546. This Judicial Review does not change the count of the 60 days set from the date of the court order. It is considered an exception per statute and is permitted before the 60 days.

A Judicial Review must also be offered to the member should the member be absent for 60 or more days on a Toll, returns to treatment and is re-engaged in treatment. The due dates of the offers may need to be adjusted upon return. The form can be completed via telephone, with the Health Care Coordinator indicating the member as offered the review by phone call noted on the signature line.

If the individual requests Judicial Review, the Health Care Coordinator completes the Judicial Review-right to Speak to Legal Counsel Form. The form includes the following information:

1. The individual being treated and the treating Provider.
2. The individual to whom the request for release was made.
3. The individual making the request for release, indicating whether the individual is the individual being treated or someone acting on the individual’s behalf.

The individual reports current address and signs the form (or the Health Care Coordinator marks the form indicating the offer was given telephonically). The Health Care Coordinator must schedule an appointment for the individual to be evaluated by a Behavioral Health Medical Professional (BHMP) of the Provider.

The completed PM form and psychiatric report must be completed and submitted to the County Attorney within 72 hours of the request and by the filing deadline.

Pima County: The completed form and psychiatric report is submitted to the law firm within 72 hours of the request and by the filing deadline.

For all other counties, please follow the local crisis protocol which references the following; “The Treatment Team Recommendation for Judicial Review for COT” form, should be completed and submitted along with the following documents:

1. Letter from Medical Director;
2. The Right to Notification of Judicial Review form;
3. The last progress note from the Behavioral Health Medical Provider proving the judicial review was discussed with member and reporting recommendations.

As a reminder, the Court could request additional documentation.

Cochise County: The form “The Psychiatric Reports RE: Request for Judicial Review” must be completed and filed with the clerk of court along with the following documents:

1. The Psychiatric Report RE: Request for Judicial Review (The medical director’s letter);
2. The Right to Notification and Legal Counsel of Judicial Review form;
3. The last psychiatric evaluation that was completed.

Maricopa County: Providers should follow the protocols already established by the Maricopa Court.

The Behavioral Health Medical Provider appointment should be scheduled no later than 48 hours from request, so the Judicial Review form is received by the County Attorney or law firm the next day, to meet the 72-hour timeframe.

If the individual declines a Judicial Review, the Health Care Coordinator completes the same form - Judicial Review - right to Speak to Legal Counsel, and the individual signs this form (or the Health Care Coordinator marks the form indicating the offer was given telephonically). The individual provides a current address and location. The Provider maintains this form in the clinical record. If the individual is unavailable at the time the Judicial Review is due, the Health Care Coordinator completes the same form - Judicial Review - right to speak to Legal Counsel. The Health Care Coordinator must provide reasons why the individual was not available for the Judicial Review and include outreach and re-engagement attempts made. The provider maintains this form in the clinical record. It should match the progress notes regarding outreach.

Court requires the psychiatric report to contain sufficient clinical information to render a decision regarding whether the individual needs continued court-ordered treatment or not. This psychiatric report can be in the form of a progress note. At a minimum the Judicial Review must include information regarding the individual’s insight regarding mental illness and information regarding adherence to court-ordered treatment plan. If the individual does not attend the Judicial Review appointment, all attempts should be made to reschedule the appointment. If the member does not attend, the health care coordinator should then confirm with the member that they have changed their mind and are no longer requesting a judicial review hearing. If an individual is hospitalized pursuant to an amended outpatient treatment plan and requests a Judicial Review, merely stating the individual is involuntarily hospitalized is not enough factual information for Court to render a decision. The BHMP should attempt to contact the inpatient Behavioral Health Medical Provider to gather information for the Judicial Review. Failure to provide sufficient evidence of need for continued treatment could result in Court requesting a hearing on the matter. A hearing can be set by the Judge/Commissioner or if requested by the defense attorney.

 

13.10.5.13                Status Reports

At the original hearing for court order, the Judge/Commissioner may direct the provider to submit status reports to Court. The Judge/Commissioner will set the dates when the reports are to be submitted.

 

13.10.5.14       Annual Review A.R.S. 36-543

A Chart review should be completed within 90 days of a member’s COT expiring.  The review is used to determine whether the member’s COT should continue or if it should expire. From this date, the Face-to-Face annual review should then be scheduled as soon as possible.  (Per A.R.S. Title 36, Chapter 5, Article 5, § 36-543-D.)

Within 60 to 90 days for Maricopa County and within 45 to 90 days for other counties of the expiration of the court order, the provider must conduct an annual review of an individual who was court-ordered to treatment as Gravely Disabled or Persistently or Acutely Disabled (GD & PAD) to determine if continuation of COT is appropriate and assess the needs of the individual for guardianship or conservatorship or both. The annual review includes a review of the mental health treatment and clinical records contained in the individual’s treatment file. In Maricopa County, this could be a Final Status Report if the member’s COT is not recommended to continue. The annual review may be completed via tele-med, if necessary.

If the Medical Director believes that continuation of the court-ordered treatment is appropriate, the Medical Director appoints one or more psychiatrists (depending on the County) to carry out a psychiatric examination of the individual. Each psychiatrist participating in the psychiatric examination must submit a report to the Medical Director that includes the following:

1. 1.    The psychiatrist’s opinions as to whether the individual continues to have a grave disability or persistent or acute disability as a result of a mental disorder and is in need of continued COT;
2. A statement as to whether suitable alternatives to COT are available;
3. A statement as to whether voluntary treatment would be appropriate;
4.  Review of the individual’s need for a guardian or conservator or both;
5. Whether the individual has a guardian with mental health powers that would not require continued COT;
6. The result of any physical examination that is relevant to the psychiatric condition of the individual.

Additionally, the individual’s clinical team shall hold a service planning meeting, not less than 45 days (60 days in Maricopa County) prior to the expiration of the court-ordered treatment to determine if the court order should continue. The following information must be indicated and written in the BHMP progress notes of the service planning meeting for the annual review that you submit:

• That this appointment is for the face to face annual review appointment;
• That the recommendation is either to roll/continue the members COT or to allow the COT to expire;
• That the recommendation was discussed with the member; and
• Note: In Maricopa County, if the Medical Director has determined that the member’s court order can expire, providers only submit a final status report to the Court. AzCH-Complete Care Plan will not require a face-to-face annual review appointment in Maricopa County for these members; but there should be progress notes to indicate that the member was informed the Court Order would be allowed to expire. Copies of those progress notes along with the Final Status Report should be submitted to AzCH-Complete Care Plan.

If the Medical Director believes after reviewing the annual review that continued COT is appropriate, the Medical Director files with Court, no later than forty-five days before the expiration of the court order for treatment, an application for continued court-ordered treatment and the psychiatric examination conducted as part of the annual review. If the individual is under guardianship, the Medical Director must mail a copy of the application to the individual’s guardian.

The annual exam must have current contact information for the individual. This includes full address, zip code, and telephone number. If the individual’s location and/or other contact information changes, provider staff must contact the individual’s attorney with this new information.

Should an annual review appointment not be scheduled and completed, a Quality of Care Concern may be submitted. Similarly, if the agency fails to submit a petition to continue court ordered treatment based on the agency’s psychiatrist’s recommendation, a Quality of Care Concern will be submitted.

 

13.10.5.15                Annual Review for Members Who Are Incarcerated or Missed Annual Review Appointments

For the Annual Review requirement, please ensure that the Psychiatrist/Behavioral Health Medical Provider does the following within the allotted time frame (45-90 days) of the Annual Review dates:

1. For Incarcerated members, all efforts should be attempted to complete a “doc to doc” appointment review; or the jail psychiatrist can be requested to complete an annual review and provide the written notes. 
   If neither option can be completed, a note is required in the chart that consists of the following information:
   • This is an annual review;
   •  Circumstances as to why the member was not present;
   • Indicate the date the member was booked to jail and that the member is still incarcerated;
   • If the medical director is willing, indicate whether their recommendation is to roll the order or to allow it to expire. If the recommendation is to roll based on the member’s clinical record and a Petition for Continued Treatment with the Court is unable to be filed, indicate that due to lack of coordination from the jail, this is not possible;
   • Indicate the date when you attempted to reach out to the jail psychiatrist to discuss member’s annual review;
   • File in the member’s medical record;

A copy of this note is required to be sent to the Title 36 Coordinator indicating this is an annual review for an incarcerated member.

1.   For members who have missed scheduled annual review appointments within the required time frame, prior to the 45^th day of the COT expiring, a chart review may be necessary. A note is required in the chart that consists of the following information:
   1. This is a chart review for the required annual review;
   • Dates of annual review appointments scheduled, missed, and re-scheduled;
   • Circumstances as to why the member was not present;
   • Date a revocation was filed with the Court, when appropriate;
   • Indicate whether their recommendation is to roll the order or to allow it to expire. If recommendation would be to roll, indicate that due to lack of contact with the member, this is not possible;
   • Indicate that re-engagement protocols have been attempted to locate the member (A request for progress notes to review re-engagement attempts may be asked for);
   • File in the member’s medical record;
   • Send a copy to the Title 36 Coordinator indicating this is an annual review for a missing member.

If your agency uses a psychiatric annual review examination form, please use that document and include the above information. (Please note that you should still enter these reviews as the annual review for the member.)

A hearing is conducted if requested by the individual’s attorney on behalf of the request of the individual or otherwise ordered by Court.

For individuals determined DTS and/or DTO the provider must initiate the pre-petition screening process pursuant to Arizona Administrative Code.

For individuals whose Court Order is currently being tolled, the annual review will not be required until the member is re-engaged into services.

Progress notes for the annual review can be emailed as soon as the annual review has been completed, but no later than the 2^nd business day of the following month the annual review must have been completed.

Pima County: For continued treatment examinations for individuals found to be GD, utilize PIMA County Psych Exam for Annual Review for GD Persons form. For continued treatment examinations for individuals found to be PAD, utilize the PIMA County Psych Exam for Annual Review for PAD Persons. The Health Plan law firm will forward to the provider the conformed copy of the petition and order. The provider is required to give the paperwork to the individual and obtain a signature using the Confirmation of Receipt form. This form provides evidence to Court and defense counsel the individual is aware of the petition and the right to speak to an attorney. This original signed form must submit the Health Plan law firm within five (5) business days of receipt. If set for hearing, the Provider’s Behavioral Health Medical Provider who completed the Annual Exam must testify at the hearing. The COT/COE Liaison is responsible for coordinating the hearing with the Health Plan law firm, provider staff and the Behavioral Health Medical Provider. The Health Care Coordinator must inform the individual of the hearing and arrange for transportation to the hearing. The Health Care Coordinator may be called as a witness.

 

13.10.5.16                Termination/Release from Court-Ordered Treatment A.R.S. 36-541.01

Upon written request of the individual’s Behavioral Health Medical Provider, a Court may order an individual to be released from court-ordered treatment prior to the expiration of the court-ordered period.

Specifically, the Title 36 Statute states “A patient who is ordered to undergo treatment pursuant to this article may be released from treatment before the expiration of the period ordered by the court if, in the opinion of the medical director of the mental health treatment agency, the patient no longer is, as a result of a mental disorder, a danger to others or a danger to self or no longer has a persistent or acute disability or a grave disability. A person who is ordered to undergo treatment as a danger to others may not be released or discharged from treatment before the expiration of the period for treatment ordered by the court unless the medical director first gives notice of intention to do so as provided by this section.”

 

13.10.5.17                Termination from Reporting a Member Who is on Court-Ordered Treatment

There are certain circumstances when an Integrated Health Home may no longer be required to report to the Health Plan a member who is on Court Ordered Treatment. These conditions would be as follows: 1) a member has been sentenced to the Department of Corrections, 2) a member has died, 3) the member has lost AHCCCS benefits and is NOT Severely Mentally Ill (SMI) and does not meet SMI criteria, 5) the member’s Court Order has been Tolled for 180 days and the Court approves the Integrated Health Home’s request to terminate the Court Order, 6) the Order is dismissed during a Judicial Review hearing, and 7) the member has agreed to become voluntary.

 

 

13.10.5.18                Suspension of Outpatient Treatment Plan

In some Counties, there are certain circumstances where a motion to request a suspension of the agency supervision of the outpatient treatment may be submitted to the Court. This is done on a case-by-case basis. This suspension relieves the Integrated Health Home of the responsibility of services specifically for the court ordered treatment. 

In Maricopa County, the suspension (or closure)  is used for members who have gone missing and are not complying with treatment. When an agency has discovered that a member is missing, the County Attorney requires the agency to perform 8 weeks of outreach attempts to locate the member and bring the member back to treatment. If after 8 weeks the member has not been found and re-engaged, the agency may file the request to suspend the outpatient treatment plan. Should the member be found and re-engaged prior to the COT expiring, the agency will submit a new treatment plan to the court.

 

13.10.5.19                Termination of a Court Order that has been Tolled

Per Revised ARS Title 36 Statute 36-544, if a member’s Court Order has been tolled for 180 days, the Integrated Health Home may petition the court to terminate the member’s Court Ordered Treatment. The Court may or may not approve of the request.

 

13.10.5.20                Transfers

 

13.10.5.20.1        Members Currently Being Served by an Integrated Health Home

A Provider serving as an Integrated Health Home is required to provide all services including outpatient treatment plan services for members on Court Ordered Treatment.

However, there are some Integrated Health Homes who cannot typically provide the services required by the Outpatient Treatment Plan for Court Ordered Treatment. If the member is currently receiving services from one of these providers, the member may need to be transferred/assigned to an Integrated Health Home who will assume responsibility for the members Court Ordered Outpatient Treatment Plan. Should this occur, please contact the Health Plan Title 36 Coordinator for additional Technical Assistance.

 

13.10.5.20.2        Agency Transfers for Members on Court-Ordered Treatment

This section pertains to court ordered treatment under A.R.S. § 36, Chapter 5 and the Arizona Administrative Code R9-21-507.

Note: the following are general guidelines-each County has the right to request additional or different documentation. When the specific County process is known, it shall be included in this guide.

A person ordered by the court to undergo treatment and who is without a guardian may be transferred from one provider to another provider, as long as the medical director of the provider initiating the transfer has established that:

• The member’s Court Ordered Treatment is not expiring within 90 days of the transfer;
• There is no reason to believe that the person will suffer more serious physical harm or serious illness as a result of the transfer;
• The person is being transitioned to a level and type of treatment that is more appropriate to the person’s treatment needs; and
• The medical director of the receiving provider has accepted the person for transition.

The medical director of the provider requesting the transition must have been the provider that the court committed the person to for treatment or have obtained the court’s consent to transition the person to another provider as necessary.

The medical director of the provider requesting the transition must provide notification to the receiving provider allowing sufficient time (but no less than 3 days) for the transition to be coordinated between the providers. Notification of the request to transition must include:

• A summary of the person’s needs;
• A statement that, in the medical director’s judgment, the receiving provider can adequately meet the person’s treatment needs;
• A modification to the individual service plan, if applicable;
• Documentation of the court’s consent, if applicable;
•  A written compilation of the person’s treatment needs and suggestions for future treatment by the medical director of the transitioning provider to the medical director of the receiving provider. The medical director of the receiving provider must accept this compilation before the transition can occur; and

This is best accomplished by sending an email to the provider the member has requested to be transferred to and requesting a “Letter of Intent to Treat”.

The receiving Provider’s Title 36 liaison should be cc’d on any emails when a member on court ordered treatment is going to be transferred.

The Letter of Intent can be a letter from the Medical Director of the receiving Behavioral Health Clinic that includes:

• Name and DOB of the individual on COT
• COT start and end date
• The standard under which the person is court ordered (DTO; /DTS; PAD; GD)
• Printed name and signature of the receiving Provider’s Medical Director
• Effective transfer date (date of intake)
• The letter can read simply: “This letter is to verify that Dr. X and Provider Y has agreed to provide court ordered treatment to member Z.”
• The Behavioral Health Clinic must keep a copy of the letter in the clinical record.

The Medical Director of the receiving Provider notifies Court in writing that there has been a change in oversight of the individuals COT. It is recommended that an official document from the court be requested that reflects the current treatment Provider/Medical Director as the responsible party overseeing the court ordered treatment.

Transportation from the sending provider to the receiving provider is the responsibility of the sending behavioral health provider.

If transferring to another Health plan, you must also follow guidelines in Section 14.2.4.2 Inter-T/RBHA Health Plan Transfer Process.

NOTE: Inter-T/RBHA transfers are not to be initiated when a person is under pre-petition screening or court ordered evaluation.

13.10.5.21                Arizona State Hospital (ASH) Conditional Release

If a person is being released from ASH after serving a sentence under the guilty except insane (GEI) standard, the release of this person is reviewed by the Superior Court.  If the court finds that the person still has a mental disease or defect or that the mental disease or defect is in stable remission but the person is no longer dangerous, the court shall order the person's conditional release. The person shall remain under the court's jurisdiction.  This will often include a referral to the Regional Behavioral Health Authority/Managed Care Organization /Health Plan where the individual plans to reside upon release and often consideration for court ordered treatment. In these situations, the local County Attorney’s office is notified by ASH to initiate the court ordered evaluation process.

Pima County: A transfer hearing must be set if a COT individual objects to the transfer to ASH.

 

13.10.5.22                Change of Venue

Change of Venue – Counties other than Pima

When a client transfers from one county to another, the receiving provider must agree to accept the individual on COT through an LOI and once transferred, must request the change of venue from the County in which the COT originated. Although, Change of Venue is a Court jurisdiction process, the receiving provider must follow-up with Court to ensure the change of venue is completed to ensure there is an accurate record of COT individuals by provider.

 

Change of venue from Pima County to another County

Change of venue should be requested by the outpatient provider at the time of the initial Court Ordered Treatment hearing. The provider should appear in court with an outpatient treatment plan and request the judge to change the venue to the receiving County. If a change of venue needs to occur after the initial Court Ordered Treatment hearing, the outpatient provider must submit: 1) Motion for approval of court-ordered outpatient treatment plan, accompanied by a Court Ordered Treatment Plan, 2) Motion to Change Venue, Order to Change Venue, accompanied by a Letter of Intent. The documents must be mailed to the Health Plan approved law firm to file with the Court.

 

13.10.5.23                Reporting

Per AHCCCS, monthly reporting is required for all persons on court ordered treatment. All providers must identify and track treatment engagement of Court Ordered Treatment (COT) individuals.

• The Provider Title 36 Liaison/Coordinator should be submitting documentation, at a minimum, on a weekly basis.  If the Provider has more than 100 members on COT, they should be submitting documentation daily.
• Providers must submit initial or continuing COTs as soon as they are received from Court.
•  It is highly recommended that each Provider designate a backup designee for the COT/COE Coordinator and Liaison to manage report submission and any questions from the Health Plan T-36 Coordinator if the Provider’s COT/COE Coordinator and Liaison is not available.
• There may be multiple events that need to be entered for a member during the current reporting month.
• The EC-302 COT Title 36 Reporting Monthly Deliverable is due on the 2^nd business day of the next month, as outlined in Section 17 – Deliverable Requirements.

 

 

13.10.6   Persons Who Are Title XIX/XXI Eligible or Non-Title XIX/XXI and/or Determined to Have a Serious Mental Illness (SMI)

When a person referred for court-ordered treatment is Title XIX/XXI or non-Title XIX/XXI eligible and/or determined or suspected to have SMI, the provider must:

• Conduct an evaluation to determine if the person has a Serious Mental Illness in accordance with Section 13.7 SMI and SED Eligibility Determination, and conduct a behavioral health assessment to identify the person’s service needs in conjunction with the person’s clinical team, as described in Section 13.6 Assessment and Service Planning;
• Provide necessary court-ordered treatment and other covered services in accordance with the person’s needs, as determined by the person’s clinical team, the member, family members, and other involved parties (see Section 13.6 Assessment and Service Planning); and
• Perform, either directly or by contract, all treatment required by ARS Title 36, Chapter 5, Article 5 and 9 AAC 21, Article 5.

 

13.10.7   Court-Ordered Treatment for Persons Charged with or Convicted of a Crime

The Health Plan or providers may be responsible for providing evaluation and/or treatment services when an individual has been ordered by a court due to conviction of a domestic violence offense; or upon being charged with a crime when it is determined that the individual is court ordered to treatment, or programs, as a result of being charged with a crime and appears to be an “alcoholic.”

 

13.10.8   Domestic Violence Offender Treatment

Domestic violence offender treatment may be ordered by a court when an individual is convicted of a misdemeanor domestic violence offense. Although the order may indicate that the domestic violence (DV) offender treatment is the financial responsibility of the offender under A.R.S. § 13-3601.01 the Health Plan will cover Domestic Violence services with Title XIX/XXI funds when the person is Title XIX/XXI eligible, the service is medically necessary, required prior authorization is obtained if necessary, and the service is provided by an in-network provider. For Non-TXIX/XXI eligible person’s court ordered for DV treatment, the individual can be billed for the DV services.

 

13.10.9   Court-Ordered DUI Services

Substance use disorder evaluation and/or treatment (i.e., DUI services) ordered by a court under A.R.S. § 36-2027 is the financial responsibility of the county, city, town, or charter city whose court issued the order for evaluation and/or treatment. Accordingly, if AHCCCS or the Health Plan receives a claim for such services, the claim will be denied with instructions to the provider to bill the responsible county, city, or town.

 

13.10.10        Court-Ordered Treatment for American Indian Tribal Members in Arizona

Arizona Tribes are sovereign nations, and tribal courts have jurisdiction over their members residing on reservation. Tribal court jurisdiction, however, does not extend to tribal members residing off the reservation or to State court-ordered evaluation or treatment ordered because of a behavioral health crisis occurring off reservation.

Although some Arizona Tribes have adopted procedures in their tribal codes that are similar to Arizona law for court-ordered evaluation and treatment, each Tribe has its own laws which must be followed for the tribal court process. Tribal court ordered treatment for American Indian tribal members in Arizona is initiated by tribal behavioral health staff, the tribal prosecutor, or other person authorized under tribal laws. In accordance with tribal codes, tribal members who may be a danger to themselves or others and in need of treatment due to a mental health disorder are evaluated and recommendations are provided to the tribal judge for a determination of whether court ordered treatment is necessary. Tribal court orders specify the type of treatment needed.

Additional information on the history of the tribal court process, legal documents, and forms as well as contact information for the tribes the Health Plan liaisons, and tribal court representatives can be found on the AHCCCS web page titled, Tribal Court Procedures for Involuntary Commitment - Information Center.

Since many Tribes do not have treatment facilities on reservation to provide the treatment ordered by the tribal court, tribes may need to secure treatment off reservation for tribal members. To secure court ordered treatment off reservation, the court order must be “recognized” or transferred to the jurisdiction of the State.

The process for establishing a tribal court order for treatment under the jurisdiction of the State is a process of recognition, or “domestication” of the tribal court order (see A.R.S. § 12-136). Once this process occurs, the State recognized tribal court order is enforceable off reservation. The State recognition process is not a rehearing of the facts or findings of the tribal court. Treatment facilities, including the Arizona State Hospital, must provide treatment, as identified by the tribe and recognized by the (A.R.S. § 12-136 Recognition and Enforcement of Tribal Court Involuntary Commitment Orders in the Arizona Superior Courts.

The Health Plan providers must comply with State recognized tribal court orders for Title XIX/XXI and Non-Title XIX/XXI SMI persons. When tribal providers are also involved in the care and treatment of court-ordered tribal members, the Health Plan and providers must involve tribal providers to verify the coordination and continuity of care of the Members for the duration of court ordered treatment and when members are transitioned to services on the reservation, as applicable.

This process must run concurrently with the tribal staff’s initiation of the tribal court ordered process in an effort to communicate and ensure clinical coordination with the appropriate RBHA/MCO/Health Plan. This clinical communication and coordination with the RBHA/MCO/Health Plan is necessary to assure continuity of care and to avoid delays in admission to an appropriate facility for treatment upon State/county court recognition of the tribal court order. The Arizona State Hospital should be the last placement alternative considered and used in this process.

A.R.S. § 36-540(B) states, “The Court shall consider all available and appropriate alternatives for the treatment and care of the patient. The Court shall order the least restrictive treatment alternative available.” RBHA/MCO/Health Plans are expected to partner with American Indian Tribes and tribal courts in their geographic service areas to collaborate in finding appropriate treatment settings for American Indians in need of services.

Due to the options American Indians have regarding their health care, including services, payment of services for AHCCCS eligible American Indians may be covered through a TRBHA, RBHA/MCO/Health Plan or Indian Health Services/638 provider (see Behavioral Health Services Payment Responsibilities on the AHCCCS Tribal Court Procedures for Involuntary Commitment web page.

AHCCCS receives Federal grants and State appropriations to provide services to Non-Title XIX/XXI eligible populations in addition to Federal Medicaid (Title XIX) and the State Children’s Health Insurance Program (Title XXI) funding. The federal grants are awarded by a Federal agency, typically by the Substance Abuse and Mental Health Services Administration (SAMHSA) and made available to the State. The Arizona State legislature annually issues appropriations targeting specific needs in the State. The grants and State appropriations may vary significantly from year to year. AHCCCS disburses the grant and State appropriations funding throughout Arizona for the delivery of covered services in accordance with the requirements of the fund source.

The Substance Use Prevention, Treatment and Recovery Block Grant (SUBG), the Mental Health Block Grant (MHBG) are annual formula grants authorized by the United States Congress. The Substance Abuse and Mental Health Services Administration (SAMHSA) facilitates these grant awards to states in support of a national system of mental health and substance use disorder prevention and treatment services.

Federal grant funds can be used to provide behavioral health and substance use services to the Non-Title XIX/XXI parent/guardian/custodian of a Title XIX/XXI, Non-Title XIX/XXI, or Title XIX/XXI child/children who is/are at risk of being removed from their home by the Department of Child Safety (DCS) and is/are eligible under the Block Grant SED or SUD eligibility criteria. The grant-funded provider is required to ensure the Non-Title XIX/XXI parents, guardians, or custodians of a child who is at risk of being removed from the family receive the services and supports needed to preserve the family unit and enable the child with SED or SUD to remain in the home. These services should include, but are not limited to, life skills training such as parenting classes, skill building, and anger management. The provider shall adhere to eligibility requirements as specified in Section 13.11 of this Provider Manual for eligibility criteria for the MHBG/SUBG Grants.

Federal Grant and State Appropriation funding shall not be used to supplant other funding sources; if funds from the Indian Health Services and/or Tribal owned/or operated facilities are available, the IHS/638 funds shall be treated as the payor of last resort. Reference AMPM 320-T1 and AMPM 320-T2.

All the requirements of the SUBG and MHBG provisions outlined in The Health Plan Provider Manual apply to SUBG and MHBG funded providers. Many of the service provisions in this section are Best Practices for the delivery of SUD and MHD services and apply to all providers delivering SUD and MHD services to Title XIX/XXI and Non-Title XIX/XXI members, including those providers who do not receive Block Grant or State Appropriation funds.

13.11.1   Non-Title XIX/XXI Contracted Provider Requirements (Federal Block Grant and State Appropriation Funds)

Providers receiving Federal Block Grant funds and/or State Appropriation funds are required to use funds for authorized purposes as directed by The Health Plan, account for funds in a manner that permits separate reporting by fund source and track and report expenditures, including unexpended funds. Unexpended or inappropriately used funds are subject to recoupment.

Providers receiving grant and/or State Appropriation funding are required to ensure all members receiving Federal Grant and/or State Appropriation funded services are screened for Title XIX/XXI eligibility at intake and annually, documenting the eligibility screening in the medical record. Providers shall enroll the individual in Non-Title XIX/XXI funded services immediately, while continuing to assist the individual with the processes to determine Title XIX/XXI eligibility. If the individual is deemed eligible for Title XIX/XXI funding, the member can choose a Contractor and American Indian members may choose either a Contractor, or AIHP, or a TRBHA if one is available in their area and receive covered services through that Contractor or AIHP or a TRBHA.

The provider shall work with the Care Coordination teams of all involved Contractors or payers to ensure each member’s continuity of care. Members designated as SMI are enrolled with a RBHA. American Indian members designated as SMI have the choice to enroll with a TRBHA for their behavioral health assignment if one is available in their area. If a Title XIX/XXI member loses Title XIX/XXI eligibility while receiving behavioral health services, the provider shall attempt to prevent an interruption in services. The provider shall work with the care coordinators of the Contractor or RBHA in the GSA where the member is receiving services, or Contractor enrolled or AIHP enrolled members, or the assigned TRBHA, to determine whether the member is eligible to continue services through available Non-Title XIX/XXI funding. If the provider does not receive Non-Title XIX/XXI funding, the provider and member shall work, together to determine where the member can receive services from a provider that does receive Non-Title XIX/XXI funding. The provider shall then facilitate a transfer of the member to the identified provider and work with the Care Coordination teams of all involved Contractors or payors.

Providers will be paid for treating members while payment details between entities are determined. If a Title XIX/XXI member, whether Contractor or AIHP enrolled, requires Non-Title XIX/XXI services, the provider shall work with the RBHA in the GSA where the member is receiving services, or the assigned TRBHA, to coordinate the Non-Title XIX/XXI services. Behavioral health providers are required to assist individuals with applying for Arizona Public Programs (Title XIX/XXI, Medicare Savings Programs, Nutrition Assistance, and Cash Assistance), and Medicare Prescription Drug Program (Medicare Part D), including the Medicare Part D “Extra Help with Medicare Prescription Drug Plan Costs” low-income subsidy program prior to receiving Non-Title XIX/XXI covered behavioral health services, at the time of intake for behavioral health services.

An individual who is found not eligible for Title XIX/XXI covered services may still be eligible for Non-Title XIX/XXI services. An individual may also be covered under another health insurance plan, including Medicare. Individuals who refuse to participate in the AHCCCS screening/application process are ineligible for state funded behavioral health services. Refer to A.R.S. §36-3408 and AMPM Policy 650. The following conditions do not constitute an individual’s refusal to participate:

• An individual’s inability to obtain documentation required for the eligibility determination, and/or;
• An individual is incapable of participating as a result of their mental illness and does not have a legal guardian. Pursuant to the U.S. Attorney General’s Order No. 2049–96 (61 Federal Register 45985, August 30, 1996), individuals presenting for and receiving crisis, mental health or SUD treatment services are not required to verify U.S. citizenship/ lawful presence prior to or in order to receive crisis services.

Members can be served through Non-Title XIX funding while awaiting a determination of Title XIX/XXI eligibility. However, upon Title XIX eligibility determination the covered services billed to Non-Title XIX, that are Title XIX covered, will be reversed by the Contractor and charged to Title XIX funding for the retro covered dates of Title XIX eligibility. This does not apply to Title XXI members, as there is no Prior Period Coverage for these members.

If there are any barriers to care, the provider shall work with the Care Coordination teams of all involved health plans or payers. If the provider is unable to resolve the issues in a timely manner to ensure the health and safety of the member, the provider shall contact AHCCCS/DHCM, Clinical Resolutions Unit (CRU). If the provider believes that there are systemic problems, rather than an isolated concern, the provider shall notify AHCCCS/DHCM, CRU of the potential barrier v. AHCCCS will conduct research and work with the Contractors and responsible entities to address or remove the potential barriers.

Providers receiving Non-Title XIX/XXI funds (Federal Block Grant and/or State Appropriation Funds) are required to meet the following additional service delivery and reporting requirements:

• Develop and maintain internal policies and procedures related to the type of funds received. The policies and procedures must meet grant and funding guidelines and be approved by The Health Plan.  The policies and procedures are subject to audits by the Health Plan at least annually;
• Ensure grant and state appropriation funds are expended in conformance with grant and/or state appropriation rules;
• Employ and document strategies and monitoring of targeted interventions to improve health outcomes including, but not limited to Social Determinants of Health (SDOH) and National Outcome Measures (NOMS);
• Employ and document the use of and expansion of Evidence Based Practices and Programs (EBPPs) and demonstrate ongoing fidelity;
• Deliver evidence-based services to special populations requiring substance use interventions and supports; including, homeless individuals, individuals with sight limitations, who are deaf or hard of hearing, persons with criminal justice involvement and persons with co-occurring mental health disorders;
• Provide specialized, evidence-based treatment and recovery support services for all populations as contracted;
• Providers of treatment services that include clinical care to those with a SUD shall also be designed to have the capacity and staff expertise to utilize FDA approved medications for the treatment of SUD/OUD and/or have collaborative relationships with other providers for service provision;
• Specific requirements regarding preferential access to services and the timeliness of responding to a member’s identified needs;
• Report program descriptions, service utilization, outreach activities, total enrolled members and similar data upon request to AzCH to effectively identify programs available in the community, measure capacity, unmet needs and respond to requests from AHCCCS;
• Treat the family as a unit, admitting women and their children into treatment as appropriate;
• Arrange and coordinate primary medical care for women who are receiving SUD services, including prenatal care;
•  Arrange for gender-specific SUD treatment and other therapeutic interventions for women that address issues of relationships, sexual abuse, physical abuse, parenting and childcare while women are receiving services;
• Arrange for childcare while women receive SUD services to facilitate access to care;
• Make available and document continuing education in the delivery of grant or State appropriation funded services or activities (or both, as the case may be) to employees of the facility who provide the services or activities;
• Submit specific data elements and record limited information in the AHCCCS DUGless Portal Guide (Reference: AHCCCS DUGless Portal Gide for requirements).
• Providers are required to comply with AHCCCS demographic requirements, submitting demographic data to AHCCCS through the AHCCCS DUGLess portal. The AHCCCS Demographic & Outcomes Data Set User Guide c and describes the minimum required data elements that comprise the demographic data set, in part.

 

13.11.2   Mental Health Room and Board Funded Through Grants and State Appropriation Funds

Mental Health Room and Board is not a Medicaid reimbursable service. Specialized populations may be eligible to receive Federal grant or State appropriation funding to cover the cost of Mental Health Room and Board. Room and Board includes the provision of lodging and meals to an individual residing in a residential facility or supported independent living setting which may include but is not limited to:

• Housing costs;
• Services such as food and food preparation;
• Personal laundry; and
• Housekeeping.

For providers who own the properties, room and board comprises real estate costs (debt service, maintenance, utilities, and taxes) and food and food preparation, personal laundry, and housekeeping. Room and Board may also be used to report bed hold/home pass days in Behavioral Health Residential facilities.

Room and Board services do not require prior authorization for payment. Contracted providers are required to verify member eligibility and maintain accurate accounting of expenses and utilization. For room and board services (H0046 SE), the following billing limitations apply:

• All other fund sources (e.g., Arizona Department of Child Safety (DCS) funds for foster care children, SSI) shall be exhausted prior to billing this service; and
• Room and Board services funded by the SUBG are limited to children/adolescents with a Substance Use Disorder (SUD), and adult priority population members (pregnant females, females with dependent child(ren), and people who use drugs by injection with a Substance Use Disorder) to the extent in which funding is available. Room and Board services may be available for a member’s dependent child(ren) as a support service for the member when they are receiving medically necessary residential treatment services for a SUD. The Room and Board would apply to a member with dependent children when the child(ren) reside with the member at the Behavioral Health Residential Facility. The use of this service is limited to:  members receiving residential services for SUD treatment where the family is being treated as a whole, but the child is not an enrolled member receiving billable services from the provider.
• Room and Board Services funded by the MHBG are limited to youth with SED qualifying diagnoses.
• Room and Board Services funded through State Appropriation Funds are limited to members meeting eligibility requirements for State Appropriation Funds and requires prior approval by The Health Plan.

 

13.11.3   Federal Block Grant Specific Requirements

Providers receiving MHBG and/or SUBG funds are required to obtain and maintain an  Inventory of Substance Use and Mental Health Treatment Facilities (I-TF) number through SAMHSA. Grant funded providers may not discriminate against members receiving services on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. If a member objects to the religious nature or religious practice of a provider organization, the provider must give the member the right to a referral to another provider of substance use disorder treatment that provides a service of at least equal value and facilitate the receipt of services from the other provider within seven (7) days of the request or earlier based on the member’s condition (see AMPM Policy 320-T1, Attachment A).

Providers receiving Federal Block Grant funds are required to meet all the applicable requirements outlined in the AHCCCS Policy Manual, AMPM 320 T1-Block Grants and Discretionary Grants and 2 CFR Part 200; including demonstrating full knowledge and adherence to the following:

• Member eligibility criteria to receive services through these funding sources;
• Prioritization of funding;
• Federal grant requirements and notifications;
• Prohibited use of the funds;
• Separate reporting, single audit requirements, subaward information; and
• ·vailable services through each funding source.

Providers may not use grant funds, directly or indirectly, to purchase, prescribe, or provide marijuana or treatment using marijuana. Treatment in this context includes the treatment of opioid use disorder. Grant funds also cannot be provided to any individual or organization that provides or permits marijuana use for the purpose of treating substance use or mental disorders. For example, refer to 45 CFR 75.300(a) which requires Health and Human Services HHS to ensure that federal funding is expended in full accordance with U.S. statutory requirements; and 21 U.S.C. 812(c) (10) and 841 which prohibits the possession, manufacture, sale, purchase, or distribution of marijuana. This prohibition does not apply to those providing such treatment in the context of clinical research permitted by the Drug Enforcement Administration (DEA) and under the Food and Drug Administration (FDA) approved investigational new drug application where the article being evaluated is marijuana or a constituent thereof that is otherwise a banned controlled substance under federal law.

Grant funded providers are required to ensure expenditures are in accordance with 2 CFR Part 200, Grants and Agreements, and ensure compliance with approved indirect cost agreements and/or use of a de minimis rate (Reference: 2 CFR 200.414). The policies and procedures must be comprehensive regarding SUBG, MHBG, and other federal grants that include, but are not limited to, a listing of prohibited expenditures, references to the SUBG and MHBG FAQs, AMPM 320-T1, Exhibit 300-2b, monitoring and separately reporting of funds by SUBG, MHBG and other federal grant funding categories. Provider grant recipients are required to utilize the AHCCCS Federal Grant FAQs document to educate staff about the grants (Reference document: AHCCCS FAQs- Substance Use Prevention, Treatment and Recovery Block Grant (SUBG) and Mental Health Block Grant (MHBG).

 

13.11.4   Substance Use Prevention, Treatment and Recovery Block Grant (SUBG) Specific Requirements

 

13.11.4.1   Services and Prioritization

The SUBG  funds support primary prevention services, early intervention services, and treatment services for persons with substance use disorders. SUBG treatment services shall be designed to support the long-term treatment and substance-free recovery needs of eligible members. The funds are used to plan, implement, and evaluate activities to prevent and treat substance use disorders. Grant funds are also used to provide referral and early intervention services for HIV, tuberculosis disease, hepatitis C and other communicable diseases in high-risk substance users.

The Goals of the SUBG include, but are not limited to the following:

• To ensure access to a comprehensive system of care, including employment, housing services, case management, rehabilitation, dental services, and health services, as well as SUD services and supports;
• To promote and increase access to evidence-based practices for treatment to effectively provide information and alternatives to youth and other at-risk populations to prevent the onset of substance use or misuse;
• To ensure specialized, gender-specific, treatment as specified by AHCCCS and recovery support services for females who are pregnant or have dependent children and their families in outpatient/residential treatment settings;
• To ensure access for underserved populations, including youth, residents of rural areas, veterans, Pregnant Women, Women with Dependent Children, People Who Inject Drugs (PWID) and older adults, e. to promote recovery and reduce risks of communicable diseases; and
• To increase accountability through uniform reporting on access, quality, and outcomes of services.

Substance use treatment services shall be available to all eligible Mmmbers with a SUD based upon medical necessity and the availability of funds, including youth and adults with Opioid Use Disorders. SUBG funds are used to ensure access to treatment and long-term supportive services for the following populations (in order of priority):

• Pregnant individuals/teenagers who use drugs by injection,
• Pregnant individuals/teenagers who use substances;
• Other persons who use drugs by injection;
• Substance Using women and teenagers with dependent children and their families, including females who are attempting to regain custody of their children; and
• All other individuals with a SUD, regardless of gender or route of use, (as funding is available).

Families involved with DCS who are in need of substance use disorder treatment and are not Title XXI/XXI eligible, can receive services paid for with SUBG funds as long as funds are available.

All members receiving SUBG-funded services are required to have a Title XIX/XXI eligibility screening and application completed and documented in the medical record at the time of intake and annually thereafter. Members shall be required to indicate active substance use within the previous 12-months to be eligible for SUBG treatment services. This includes individuals who were incarcerated and reported using while incarcerated. The 12-month standard may be waived for individuals on medically necessary methadone maintenance upon assessment for continued necessity, and/or incarcerated for longer than 12 months that indicate opioid use in the 12 months prior to incarceration.

 

13.11.4.2   Choice of SUBG Substance Use Disorder Providers (Charitable Choice)

Members receiving SUD treatment services under the SUBG have the right to receive services from a provider to whose religious character they do not object. Behavioral health providers providing SUD treatment services under the SUBG shall notify members at the time of intake of this right as required in AHCCCS AMPM Policy 320-T1 Attachment A. Providers shall document that the member has received notice in the member’s medical record. If a member objects to the religious character of a behavioral health provider, the provider shall refer the member to an alternate provider within seven days, or earlier when clinically indicated, after the date of the objection. Upon making such a referral, providers shall notify the RBHAs, of the referral and ensure that the member makes contact with the alternative provider.

Intake Providers must utilize the Health Plan web-based member transfer system to facilitate all transfers between provider agencies, including transfers associated with religious considerations (see Section 14.1 Transition of Persons).

 

13.11.4.3   Substance Use Disorder Services and Program Requirements

Substance Use Disorder treatment services must be designed to support the long-term recovery needs of eligible persons and meet the applicable requirements set forth in the Health Plan Provider Manual. Specific requirements apply regarding preferential access to services and the timeliness of responding to a person’s identified needs (see Section 13.2 Appointment Standards and Timeliness of Service).

Substance Use Disorder treatment programs must include the following minimum core components: outreach, screening, referral, early intervention, case management, relapse prevention, childcare services and continuity of addiction treatment. These are critical components for treatment programs targeting individuals who use substances. . In addition, medical providers must be included in the treatment planning process from the initial contact for services to verify continuity and coordination of care. The overall goal in a continuum of comprehensive addiction treatment is improved life functioning and wellbeing, as measured by an increase in medical wellness and improved psychosocial, spiritual, social, and family relationships.

Additional non-Medicaid reimbursable services available to Title XIX/XXI and Non-Title XIX/XXI members through SUBG funding include:

• Auricular acupuncture to the pinna, lobe, or auditory meatus to treat alcoholism, substance use disorders or chemical dependency by a certified acupuncturist practitioner pursuant to A.R.S. 32-3922.
• Mental Health Services (Traditional Healing Services) for mental health or substance use provided by qualified traditional healers. These services include the use of routine or advanced techniques aimed to relieve the emotional distress evident by disruption to the person’s functional ability.
  • Childcare Services (also referred to as child sitting services): Childcare supportive services are covered when providing medically necessary Medicated Assisted Treatment or outpatient (non-residential) SUD treatment or other supportive services for SUD to members with dependent children, when the family is being treated as a whole. The following limitations apply:
  • The amount of childcare services and duration shall not exceed the duration of MOUD or Outpatient (non-residential) treatment or support services for SUD being provided to the member whose child(ren) is present with the member at the time of receiving services;
  • Childcare services shall ensure the safety and well-being of the child while the member is receiving services that prevent the child(ren) from being under the direct care or supervision of member;
  • The child is not an enrolled member receiving billable services from the provider; and
  •  Other means of support for childcare for the children are not readily available or appropriate.
• Supported housing services provided by behavioral health professionals, behavioral health technicians, or behavioral health paraprofessionals, to assist individuals or families to obtain and maintain housing in an independent community setting including the individual’s own home or apartments and homes owned or leased by a provider;
• Mental Health Services, Room and Board;
• Other Non-Title XIX/XXI Behavioral Health Services: For Non-Title XIX/XXI eligible populations, most behavioral health services that are covered through Title XIX/XXI funding are also covered through Non-Title XIX/XXI funding including but not limited to: services provided in a residential setting, counseling, case management, and supportive services, but Non-Title XIX/XXI funded services may be restricted to certain members as described in The Health Plan Provider Manual and as specified in AMPM Exhibit 300-2B, and are not an entitlement.

Services provided through Non-Title XIX/XXI funding are limited by the availability of funds.

 

13.11.4.4   Additional SUBG Contracted Provider Requirement

The following SUBG contracted provider requirements are applicable to all SUBG contracted SUD treatment providers:

• Ensure preference is given to pregnant women who are seeking SUD treatment;
• Notify the AzCH Behavioral Health and Grants Administration department immediately when the provider has reached capacity and can no longer accept more pregnant women into the program;
• Arrange interim services within 48 hours of a pregnant member not being able to be accepted into the program;
• Clearly indicate on program materials that pregnant women are the first priority for referral into the program;
• SUBG funded providers are required to maintain service utilization, attendance and capacity records and report the information utilizing the AHCCCS SUBG Capacity Management Report template (AMPM 320-T1, Attachment J) as required by AHCCCS;
• Provide HIV Activity Reports, training materials and Ad hoc reports as requested;
  • Participate in the annual AHCCCS Independent Case Review process, providing treatment and documentation in compliance with the AHCCCS Substance Use Prevention, Treatment and Recovery Block Grant (SUBG) Case File Review Tool;
  • SUBG treatment providers are required to train and educate provider staff and audit staff performance related to the most recent Case File Review Tool standards; correcting deficiencies to promote ongoing performance improvement. (Reference: AHCCCS Substance Abuse Prevention Case File Review Findings).
  • SUBG treatment providers are required to respond timely to record requests to facilitate the annual audit.
  • SUBG funded providers shall develop, monitor, and continually evaluate its processes for timely referral, assessment, service, and treatment planning for behavioral health services.
  • The SUBG funded provider shall have identified staff members to ensure that requests for behavioral health services made by the member, family, guardian, or any health care professional are referred within one business day to ensure that the request for services results in the member receiving a referral to a behavioral health provider.
  • A direct referral for a behavioral health assessment may be made by the member. A direct referral for a behavioral health assessment may be made by any health care professional.
  • For referrals received from a PCP requesting a member receive a psychiatric evaluation or medication management, the appointments with a behavioral health medical professional shall be provided according to the needs of the member and within AHCCCS appointment standards with appropriate interventions to prevent a member from experiencing a lapse in medically necessary psychotropic medications.

 

13.11.4.5   Waitlist and Interim Services for Pregnant and Parenting Individuals/Teenagers and People Who Use Drugs by Injection (Non-Title XIX/XXI Only)

BHRF providers serving members with substance use disorders and receiving SUBG funding are required to promptly submit information for Priority Population members (i.e., Pregnant Women/Teenagers, Women/Teenagers with Dependent Children, and People Who Use Drugs by Injection who are waiting for placement in a Behavioral Health Residential Facility (BHRF), to the AHCCCS online Residential Waitlist System. Title XIX/XXI members may not be added to the Residential Waitlist. Priority Population members who are not pregnant, parenting women/teenagers, or People Who Use Drugs by Injection shall be added to the Residential Waitlist if the provider is not able to place the member in a BHRF within the Response Timeframes for Designated Behavioral Health Services as outlined herein. For women/teenagers who are pregnant, the requirement is within 48 hours, for women with dependent children the requirement is within 5 calendar days and for individuals who use drugs by injection the requirement is within 14 calendar days.

The purpose of interim services is to reduce the adverse health effects of substance use disorders, promote the health of the individual, and reduce the risk of transmission of disease. Interim services must be made available for Non-Title XIX/XXI priority populations who are maintained on an actively managed wait list. Provision of interim services must be documented in the member’s chart as well as reported to the State through the State SUBG Waitlist System. The minimum required interim services include education that covers the following:

• Prevention of and types of behaviors which increase the risk of contracting HIV, Hepatitis C, and other sexually transmitted diseases;
• Effects of substance use on fetal development;
•  Risk assessment/screening;
• Referrals for HIV, Hepatitis C, and tuberculosis screening and services; and
• Referrals for primary and prenatal medical care.

 

13.11.4.6   Provider Program Requirements Related to Gender-Specific Services and SUBG Priority Populations and Parents with Children

SUBG funded providers are required to disseminate information about Priority Population eligibility by posting and advertising at community provider locations and through strategic methods; including, but not limited to street outreach programs, posters placed in targeted community areas and other locations where pregnant women, women with dependent children, persons who inject drugs, and uninsured or underinsured people with SUD who do not meet eligibility for Title XIX/XXI are likely to attend, in accordance with the specifications in 45 CFR 96.131(a)(1-4). SUBG providers shall publicize admission preferences by frequently disseminating information about treatment availability to community-based organizations, healthcare providers, and social services agencies.

Providers shall publicize the availability of gender-based substance use disorder treatment services for pregnant women or women who have dependent children. Publication must include, at minimum, the posting of fliers at each SUBG service delivery site notifying pregnant women or women with dependent children of the availability and right to receive substance use disorder treatment services at no cost.

SUD treatment providers serving parents with dependent children shall:

• Deliver the following services as needed: referral for primary medical care for women and primary pediatric care for children; gender-specific substance use treatment; therapeutic interventions for children; and case management and medically necessary transportation to access medical and pediatric care.
• Eliminate barriers to access treatment through incorporation of childcare, case management and medically necessary transportation to medical and pediatric care and treatment services.
• Prioritize services available for substance use disorder treatment services for pregnant women pursuant to A.R.S. § 36-141.

Specific goals of women-focused treatment include reducing fetal exposure to alcohol/drugs, verifying a healthy birth outcome as an immediate priority, and addressing issues relevant to women, such as, domestic abuse and violence, demands of child-rearing, vocational and employment skills.

SUD treatment providers are required to ensure that Case Management, Child Care and Transportation do not pose barriers to access to obtaining substance use disorder treatment. Contracted providers with approved funding may bill “Childcare T1009 - for Dependent Children” to provide childcare support services for a member who meets the criteria for SUBG funding as defined in the Health Plan Provider Manual and the AMPM 320-T1.

SUBG contracted treatment providers must comply with Program Requirements for Pregnant Women and Women with Dependent Children in accordance with this Provider Manual as follows:

• Engage, retain, and treat pregnant women and women with dependent children who request and are in need of substance use disorder treatment.
• Deliver outreach, specialized evidence-based treatment, and recovery support services for pregnant women, women with dependent children or women attempting to regain custody of children.
• Deliver services to the family as a unit and for residential treatment programs, admit both women and their children into treatment.
• Deliver medically necessary covered services to each pregnant individual who requests and is in need of substance use disorder treatment within forty-eight (48) hours of the request.
• Deliver medically necessary covered services for women with dependent children within five (5) days.

 

13.11.4.7   SUBG Funded Child Care Support Services (Amount, Duration, and Scope of SUBG Funded Child Care Support Service)

The amount of services and duration is dependent upon the BHRF or Outpatient (non-residential) treatment or recovery support services for SUD being provided to the member and whose child is present with the member at the time of the treatment. Childcare supportive services are covered when providing medical necessary BHRF or outpatient (non-residential) treatment or other supportive services for SUD to members with dependent children, when the family is being treated as a whole, the following limitations apply:

• The amount of Childcare services and duration shall not exceed the duration of BHRF or Outpatient (non-residential) treatment or support services for SUD being provided to the member whose child(ren) is present with the member at the time of receiving services;
• Childcare services shall ensure the safety and well-being of the child while the member is receiving services, which prevent the child(ren) from being under the direct care or supervision of member;
• The child is not an enrolled member receiving billable services from the provider, and;
• Other means of support for childcare for the children are not readily available or appropriate.

The scope of the Child Care Recovery Support Services should be what is necessary to ensure the safety and well-being of the child while the member is in treatment services, which prevent the child(ren) from being under the direct care or supervision of the member.

The service is to be billed in 15-minute increments not to exceed the amount of time the enrolled member received services.

The use of SUBG Funded Child Care Support Services is limited to:

• Enrolled members receiving BHRF or Outpatient (non-residential) treatment or recovery support services for SUD treatment where the family is being treated as a whole, but the child is not an enrolled member receiving billable services from the provider.
• Where other means of supports for childcare for the child are not readily available or appropriate.
• Only Provider Types that provide BHRF or Outpatient (non-residential) SUD treatment or recovery support services are eligible for this service.

Each Provider providing SUD treatment services to parents with Dependent Children shall have policies and procedures that address informed consent, case management, transportation, facilities, staffing, supervision, monitoring, documentation, service description, safety measures, ages accepted, and schooling/service accessibility to the children. The content of the policies and procedures must be included in the informed consent documentation that must be reviewed and signed by the member acknowledging the potential benefits and risks associated with receiving the Child Care Recovery Support Service as a part of the member’s treatment.

 

13.11.4.8   Program Requirements for Persons Involved with Injection Drug Use

Providers must engage in evidence-based best practice outreach activities to encourage individuals in need of services to undergo treatment and deliver medically necessary covered services to persons involved with injection drug use who request and are in need of substance use disorder treatment.  SUBG contracted providers must ensure that each individual who requests, and is in need of treatment for intravenous drug abuse is admitted to a program of such treatment not later than 14 days after making the request for admission to such a program; or 120 days after the date of such request, if no such program has the capacity to admit the individual on the date of such request and if interim services, including referral for prenatal care, are made available to the individual not later than 48 hours after such request. MOUD providers must notify the Health Plan when an intravenous drug use program has reached ninety percent (90%) of its capacity. Providers are prohibited from using SUBG funds to supply individuals with hypodermic needles or syringes to use illegal drugs.

 

13.11.4.9   Human Immunodeficiency Virus (HIV), Tuberculosis (TB), Hepatitis C, and Other Communicable Diseases (Referrals, Screening, and Early Intervention Services)

SUD treatment providers must refer persons with substance use disorders for HIV, tuberculosis, hepatitis C and other communicable disease screening. In addition, providers must deliver services to persons with HIV in accordance with requirements in this Provider Manual.

Because individuals with substance use disorders are considered at high risk for contracting HIV-related illness, the SUBG requires the use of HIV intervention services to reduce the risk of transmission of this disease. SUBG funded HIV Early Intervention services are available exclusively to members receiving substance use disorder treatment. SUBG funded HIV services may not be provided to incarcerated populations per 45 CFR 96.135.2.

SUD treatment providers are required to establish linkages with a comprehensive community resource network of related health and social services organizations to ensure a wide-based knowledge of the availability of these services and must provide locations and specified times for members to access HIV Early Intervention services. Providers shall inform members of the opportunity to receive HIV education, screenings and early intervention services and facilitate members’ access to the services. Substance use treatment providers must make their facilities available for HIV Early Intervention providers contracted with the Health Plan and verify members have access to HIV Early intervention services. Providers may contact AzCH customer service for assistance in locating and obtaining access to HIV Early Intervention Services.

 

13.11.4.10                Requirements for Providers Offering HIV Early Intervention Services

HIV early intervention service providers who accept funding under the SUBG must provide HIV testing services. Providers must administer HIV testing services in accordance with the Clinical Laboratory Improvement Amendments (CLIA) requirements, which requires that any agency that performs HIV testing must register with Centers for Medicare and Medicaid (CMS) to obtain CLIA certification. However, agencies may apply for a CLIA Certificate of Waiver, which exempts them from regulatory oversight if they meet certain federal statutory requirements.

Many of the Rapid HIV tests are waived. For a complete list of waived Rapid HIV tests. Waived rapid HIV tests can be used at many clinical and non-clinical testing sites, including community and outreach settings. Any agency that is performing waived rapid HIV tests is considered a clinical laboratory. Any provider planning to perform waived rapid HIV tests must develop a quality assurance plan, designed to verify any HIV testing will be performed accurately. (See Centers for Disease Control Quality Assurance Guidelines).

HIV early intervention service providers cannot provide HIV testing until they receive a written HIV test order from a licensed medical doctor, in accordance with A.R.S. § 36-470. HIV rapid testing kits must be obtained from the ADHS Office of HIV Prevention.

HIV early intervention providers are required to collect and report early intervention activities to the Health Plan utilizing the AHCCCS SUBG HIV Activity Report (AMPM Policy 320-T, Attachment E). In addition, HIV early intervention providers are required to regularly provide education and training to members and staff at SUD treatment facilities, collecting and reporting education and training site visits utilizing the AHCCCS SUBG HIV site visit Report (AMPM Policy 320-T, Attachment F).

Contracted HIV early intervention providers are required to administer a minimum of one test per $600 in HIV funding.

 

13.11.4.11                HIV Education and Pre-/Post-Test Counseling

The HIV Prevention Counseling training provided through Arizona Department of Health Services (ADHS) must be completed by all the Health Plan HIV Coordinators, provider staff and provider supervisors whose duties are relevant to HIV services. Staff must successfully complete the training with a passing grade prior to performing HIV testing. HIV education and pre/post-test counseling. The Health Plan HIV Coordinators and provider staff delivering HIV Early Intervention Services for the SUBG also must attend an HIV Early Intervention Services Webinar issued by the State on an annual basis, or as indicated by the State. The Webinar will be recorded and made available by the State. New staff assigned to duties pertaining to HIV services must view the Webinar as part of their required training prior to delivering any HIV Early Intervention Services reimbursed by the SUBG. HIV early intervention service providers are required to actively participate in regional community planning groups to verify coordination of HIV services.

 

13.11.4.12                Reporting Requirements for HIV Early Intervention Services

For every occurrence in which an allere antigen/antibody rapid fingerstick test  provides a reactive result, a confirmatory blood test must be conducted and the blood sample sent to the Arizona State Lab for confirmatory testing. Therefore, each provider who conducts rapid testing must have capacity to collect blood for confirmatory testing whenever rapid testing is conducted.

The number of the confirmatory lab slip shall be retained and recorded by the provider. This same number will be used for reporting in the Affirm statewide data base as required by ADHS. The HIV Early Intervention service provider must establish a Memorandum of Understanding (MOU) with their local County Health Department to define how data and information will be shared. Providers must use the database to submit HIV testing data after each test administered.

 

13.11.4.13                Monitoring Requirements for HIV Early Intervention Services

HIV early intervention services providers are required to submit monthly progress reports to the Health Plan. The Health Plan will conduct annual site visits to providers offering HIV Early Intervention Services. The  Health Plan HIV Coordinator, provider staff, and supervisors relevant to HIV services must be in attendance during site visits. As part of the site visit, provider must make available materials used at outreach events, a budget review and a description/justification for use of the SUBG funding.

13.11.4.14                Oxford House Program Requirements

Providers contracted to provide Oxford House services are required to employ evidence-based practices and abide by all approved program description requirements and applicable grant requirements as outlined in The Health Plan Provide Manual and by AHCCCS.  Providers are required to maintain processes to demonstrate continuing fidelity to the model. Oxford House providers are required to collect, analyze, and report service utilization, outcomes, financial and program data as requested by The Health Plan and AHCCCS, including completing the Oxford House Model Report (AMPM 320-T1, Attachment H) and the Oxford House Financial Report (AMPM 320-T1, Attachment F-1).

 

13.11.4.15                SUBG Program and Financial Management Policies

SUBG contracted providers must establish program and financial management policies and procedures for services funded by the SUBG to meet all requirements in the provider agreement, the Provider Manual and the requirements of the Children's Health Act of 2000, P.L. 106-310 Part B of Title XIX of the Public Health Service Act (42 USC 300 et seq.) and 45 CFR Part 96 as amended. The policies and procedures should include, but are not limited to, a listing of prohibited expenditures, references to the SUBG FAQs, monitoring and reporting of funds by priority populations and funding category.

All providers who receive SUBG funding are required to submit their SUBG Policy and Procedure to AzCH-Complete Care Plan annually, each November. As applicable, Procedures should include reporting and monitoring requirements to track encountering of SUBG funds and to verify that treatment services are delivered at a level commensurate with funding under the SUBG. Providers must submit SUBG related program reports. These reports must be submitted in a format prescribed by the Health Plan.

The Health Plan must submit an annual plan regarding outreach activities and coordination efforts with local substance use disorder coalitions. Providers receiving SUBG funds are required to provide the Health Plan with requested information to complete the report.

Grant funding is the payor of last resort for Title XIX/XXI behavioral health covered services which have been exhausted (e.g., respite), Non-Title XIX/XXI covered services, and for Non-Title XIX/XXI eligible members for any services. Grant funding shall not be used to supplant other funding sources, if funds from the Indian Health Services and/or Tribal owned/or operated facilities are available, the IHS/638 funds shall be treated as the payor of last resort. Copayments, or any other fee, are prohibited for the provision of services funded by SUBG Block Grants.  Reference AMPM 320-T1 and AMPM 320-T2.

 

13.11.4.16                Restrictions of the Use of SUBG Grant Funds

Providers may not expend SUBG funds on the following activities:

• Inpatient hospital services,
• Acute Care or physical health care services including payment of copays, unless otherwise specified for Priority Populations,
• Make cash payments to intended recipients of health services,
• Purchase or improvement of land, purchase, construct, or permanently improve any building or facility except for minor remodeling with written approval from AHCCCS,
• Purchase of major medical equipment,
• To satisfy any requirement for the expenditure of non-federal funds as a condition for the receipt of federal funds,
• Provide financial assistance (grants) to any entity other than a public or nonprofit private entity,
• Provide individuals with hypodermic needles or syringes for illegal drug use, unless the Surgeon General of the Public Health Service determines that a demonstration needle exchange program would be effective in reducing drug use and the risk that the public will become infected with the etiologic agent for Acquired Immune Deficiency Syndrome (AIDS),
•  Pay the salary of an individual through a grant or other extramural mechanism at a rate in excess of Level I of the Executive Salary Schedule for the award year, see,
• Purchase of treatment services in penal or correctional institutions in the State of Arizona,
• Flex funds purchases, or
• Sponsorship for events and conferences.

 

13.11.5   Mental Health Block Grant (MHBG) Contracted Provider Requirements

The MHBG  provides funds to establish or expand an organized community-based system of care for providing Non-Title XIX/XXI mental health services to children with serious emotional disturbances (SED), youth and young adults experiencing Early Serious Mental Illness/First Episode Psychosis (ESMI/FEP) and adults with a Serious Mental Illness (SMI). MHBG funding may be used to provide Non-Title XIX/XXI services for Title XIX/XXI members meeting the above criteria. The MHBG Block Grant funds are used to: (1) carry out the State plan contained in the federal grant application; (2) evaluate programs and services; and (3) conduct planning, administration, and educational activities related to the provision of services.  The goals of the MHBG include, but are not limited to the following:

• Ensuring access to a comprehensive system of care, including employment, housing services, case management, rehabilitation, dental services, and health services, as well as mental health services and supports;
• Promoting participation by consumer/survivors and their families in planning and implementing services and programs, as well as in evaluating State mental health systems;
• Ensuring access for underserved populations, including people who are homeless, residents of rural areas, and older adults;
• Promoting recovery and community integration for adults with SMI and children with SED; and
• Increasing accountability through uniform reporting on access, quality, and outcomes of services.

The MHBG Block Grant requires AHCCCS to maintain a statewide planning council with representation by members, family members, State employees and providers.

 

13.11.5.1   Populations Covered and Prioritization

To be eligible for services under MHBG, members shall be determined to have an SMI, an SED, or ESMI/FEP. Screenings/assessments may be covered for Non-Title XIX/XXI eligible members when they are conducted to determine SMI or SED eligibility, for block grant funding regardless of the assessment’s determination. Providers are required to verify and document that members indicate active mental health symptoms in the previous 12-months to be eligible for MHBG federal block services.

Other funding sources, such as the State General Fund appropriations for SMI shall be utilized before block grant funding to ensure block grants are the payor of last resort. Refer to AMPM 320-O for additional information on behavioral health assessments and treatment/service planning.

In serving children with SED, youth and young adults experiencing ESMI/FEP, and adults with SMI, MHBG funds may be used for the following:

• To ensure access to a comprehensive system of care, including employment, housing, case management, rehabilitation, dental, and health services, as well as mental health services and supports;
• To promote participation by member/survivors and their families in planning and implementing services and programs, as well as in evaluating State mental health systems;
• To verify access for underserved populations, including people who are homeless, residents of rural areas, and older adults;
• To promote recovery and community integration for adults with a SMI youth and young adults experiencing ESMI/FEP, and children with SED;
  • To provide for a system of integrated services to include:
  • Social services;
  • Educational services;
  • Juvenile justice services;
  • Substance use disorder services; and
  • Health and services.
• To provide for training of providers of emergency health services regarding behavioral health.

 

13.11.5.2   MHBG Specific Provider Requirements

• MHBG funded providers are required to ensure members receiving services under the MHBG are given access to comprehensive system of care services offered through the AzCH provider network or community; including, employment, housing services, case management, rehabilitation, dental, health services as well as mental health services;
• MHBG funded providers must account for funds separately; and ensure staff resources are appropriately allocated and employed according to grant requirements; including:
  • Ensuring MHBG funded positions or interventions are not used to fulfill the requirement of other contracts; including Title XIX/XXI contract requirements;
  • Ensuring MHBG funded positions do not simultaneously bill for services, unless specified in AzCH award letter.
• MHBG funded providers shall develop, monitor, and continually evaluate its processes for timely referral, assessment, service, and treatment planning for behavioral health services.
• The MHBG funded provider shall have identified staff members to ensure that requests for behavioral health services made by the member, family, guardian, or any health care professional are referred within one business day to ensure that the request for services results in the member receiving a referral to a behavioral health provider.
• A direct referral for a behavioral health assessment may be made by the member. A direct referral for a behavioral health assessment may be made by any health care professional.
• For referrals received from a PCP requesting a member receive a psychiatric evaluation or medication management, the appointments with a behavioral health medical professional shall be provided according to the needs of the member and within AHCCCS appointment standards with appropriate interventions to prevent a member from experiencing a lapse in medically necessary psychotropic medications.

 

13.11.5.3   Early Serious Mental Illness (ESMI)/First Episode Psychosis (FEP) Programs

Providers delivering ESMI/FEP programs funded through MHBG and Title XIX/XXI funding are required to develop an annual Program Description and Operating Plan and obtain approval of the Plan from the Health Plan and AHCCCS. Once approved the provider must implement the Plan as written and document adherence and performance of the Plan; including, conducting outreach as outlined in the Plan and serving the required number of members outlined in the Plan.  The provider must collect, analyze and timely report all data required in the Plan.  All ESMI/FEP programs must be based on Evidence Based Practices approved by AHCCCS. FEP providers must develop, implement, and demonstrate a process to verify ongoing fidelity to the model.  ESMI/FEP providers are required to develop and execute an Annual Community Education and Marketing Plan to educate families, high schools, and institutions of higher learning, first responders and communities about the early signs and symptoms of FEP. The provider is required to document and report educational and marketing efforts, including dates, venues, attendees, or recipients training and education. In addition, the ESMI/FEP provider is required to collect, analyze, and report data required in the First Episode Psychosis Program Status Report (See AMPM 320-T1, Attachments C and C-1).

The following are diagnoses that qualify under ESMI/FEP. These are not intended to include conditions that are attributable to the physiologic effects of an SUD, are attributable to an intellectual/developmental disorder, or are attributable to another medical condition:

• Delusional Disorder;
• Brief Psychotic Disorder;
• Schizophreniform Disorder;
• Schizophrenia;
•  Schizoaffective Disorder;
• Other specified Schizophrenia Spectrum and Other Psychotic Disorder;
• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder;
• Bipolar and Related Disorders, with psychotic features; and
• Depressive Disorders, with psychotic features.

Members do not have to be or designated as SMI or SED to be eligible for ESMI/FEP services. Individuals who are accessing FEP MHBG services can be GMH at the beginning, or throughout their ESMI/FEP episode of care.

 

13.11.5.4   Adolescents in Detention

Most adjudicated youth from secure detention do not have community follow-up or supervision, therefore, risk factors remain unaddressed. Youth in juvenile justice systems often display a variety of high-risk characteristics that include inadequate family support, school failure, negative peer associations, and insufficient use of community-based services. MHBG services to adolescents in detention is contingent upon funding availability, and Health Plan and AHCCCS approval.

MHBG funded providers may deliver services to Adolescents with SED in detention in accordance to the following requirements:

• Services may only be provided in juvenile detention facilities meeting the description provided by the OJJDP;
•  Juvenile detention facilities are used only for temporary and safe custody, are not punitive, and are not correctional or penal institutions.

Services shall be provided:

• Only to voluntary members with SED;
• By qualified BHPs/BHTs/BHPPs;
• Based upon assessed need for SED services;
• Utilizing EBPPs;
• Following an individualized service plan;
• For a therapeutically indicated amount of duration and frequency; and
• With a transition plan completed prior to transfer to a community-based provider.

 

13.11.5.5   Non-Encounterable MHBG Activities or Positions

Contracted MHBG SED services for outreach activities or positions that are non-encounterable can be an allowable expense, but they shall be tracked, activities monitored, and outcomes collected on how the outreach is getting access to care for those members with SED.

The use of MHBG SED funds in schools is allowable as long as the following requirements are met:

• Funded positions or interventions cannot be used to fulfill the requirement for the same populations as the funds for Behavioral Health Services for School-Aged Children listed in the Title XIX/XXI Contract;
• Funded positions cannot bill for services provided;
• Funded positions or interventions need to focus on identifying those with SED and getting those who do not qualify for Title XIX/XXI engaged in services through the MHBG; and
• This funding shall be utilized for intervention, not Prevention, meaning that members who are displaying behaviors that could be signs of SED can be assisted, but MHBG funding shall not be used for general Prevention efforts to children who are not showing any risks of having SED.

 

13.11.5.6   Provider Management of MHBG Funds

Providers must comply with all terms, conditions, and requirements of the MHBG including the Children's Health Act of 2000, P.L. 106-310 Part B of Title XIX of the Public Health Service Act (42 U.S.C. 300 et seq.) and 45 CFR Part 96 as amended. Providers must retain documentation of compliance with Federal requirements, and produce upon the Health Plan request, financial, performance, and program data that is subject to audit. These services will be available based upon medical necessity and the availability of funds.

Providers must report MHBG and SUBG funds and services separately and report or produce information related to block grant expenditures to the Health Plan upon request. Providers must manage the MHBG funds during each fiscal year to make funds available for obligation and expenditure until the end of the fiscal year for which the funds were paid.

Providers must have internal MHBG policies and procedures that should include, but are not limited to, a listing of prohibited expenditures, references to the MHBG FAQs, monitoring and reporting of funds by priority populations and funding category. All providers who receive MHBG funding are required to submit their MHBG Policy and Procedure to AzCH-Complete Care Plan annually, each November. Copayments, or any other fee, are prohibited for the provision of services funded by MHBG Block Grants.

 

13.11.5.7   Restrictions on the Use of MHBG Block Grant Funds

Providers must ensure that MHBG Block Grant funds are not expended on the following activities:

• Inpatient hospital services,
• Acute Care or physical health care services including payment of copays, unless otherwise specified for priority populations,
• Cash payments to intended recipients of health services,
• Purchase or improvement of land, purchase, construct, or permanently improve any building or other facility, except for minor remodeling with written approval from AHCCCS,
• Purchase major medical equipment,
• To satisfy any requirement for the expenditure of non-Federal funds as a condition for the receipt of Federal funds,
• Provide financial assistance (grants) to any entity other than a public or nonprofit private entity,
• Provide individuals with hypodermic needles or syringes so for illegal drug use, unless the Surgeon General of the Public Health Service determines that a demonstration needle exchange program would be effective in reducing drug use and the risk that the public will become infected with the etiologic agent for Acquired Immune Deficiency Syndrome (AIDS),
• Pay the salary of an individual through a grant or other extramural mechanism at a rate in excess of Level I of the Executive Salary Schedule for the award year (see National Institutes of Health (NIH) Grants & Funding Salary Cap Summary),
• Purchase treatment services in penal or correctional institutions of the State of Arizona,
• Flex fund purchases,
•  Sponsorship for events and conferences,
• Childcare Services.

For Non-TXIX/XXI eligible persons court ordered for DV treatment, the individual can be billed for the DV services (ACOM Policy 423).

 

13.11.6   State Opioid Response Grant (SOR) – CFDA #93.788

The SOR program aims to address the opioid crisis by increasing access to medication assisted treatment using the three FDA-approved medications including: methadone, buprenorphine products, including single-entity buprenorphine products, buprenorphine/naloxone tablets, films, buccal preparations, long-acting injectable buprenorphine products, buprenorphine implants, and injectable extended-release naltrexone for the treatment of Opioid Use Disorder (OUD). The overarching goal of the SOR project is to increase access to Medication for Opioid Use Disorder (MOUD) treatment, coordinated and integrated care, opioid use disorder (OUD)/stimulant use disorder recovery support services and prevention activities to reduce the prevalence of OUDs, stimulant use disorder and opioid-related overdose deaths.  The grant provides for the provision of prevention, treatment, and recovery activities for OUD (including illicit use of prescription opioids, heroin, and fentanyl and fentanyl analogs). This program also supports evidence-based prevention, treatment, and recovery support services to address stimulant misuse and use disorders, including for cocaine and methamphetamine.

Eligible populations are individuals with OUD, stimulant use disorder, and populations at risk for developing either and related behavioral health consequences.

SOR Grant funded providers are required to:

• Implement evidence-based treatments, practices, and interventions for OUD and make available FDA-approved Medications for Opioid Use Disorder (MOUD) to those diagnosed with OUD.
• Implement and maintain a robust peer support program and support sustained recovery.
• Coordinate with AzCH and correctional facilities to sustain and identify early MOUD eligible individuals re-entering the community.
• Coordinate care with hospitals and emergency departments to facilitate warm handoffs and entry into treatment.
• Provide street-based outreach.
•  Provide or coordinate access to supportive housing services.
• Implement FDA-approved MOUD. Medical withdrawal (detoxification) is not the standard of care for OUD, is associated with a very high relapse rate, and significantly increases an individual’s risk for opioid overdose and death if opioid use is resumed. Therefore, medical withdrawal (detoxification) when done in isolation is not an evidence-based practice for OUD. If medical withdrawal (detoxification) is performed, it shall be accompanied by injectable extended-release naltrexone to protect such individuals from opioid overdose in relapse and improve treatment outcomes.
• Employ effective prevention and recovery support services to ensure that individuals are receiving a comprehensive array of services across the spectrum of prevention, treatment, and recovery.
• Implement evidence-based prevention, treatment, and recovery support services to address stimulant misuse and use disorders.
• Collect and report outreach activities and treatment data as requested by AzCH and/or AHCCCS.
• Develop and maintain internal policies and procedures for federal grant tracking, including the SOR grant, which should include, but are not limited to, a listing of prohibited expenditures, monitoring and reporting of funds. All providers who receive SOR funding are required to submit their SOR Policy and Procedure to AzCH-Complete Care Plan annually, each November.

 

13.11.6.1   Restrictions on the Use of SOR Grant Funds

Providers must ensure that SOR Grant funds are not expended on the following activities:

•  Pay the salary of an individual at a rate in excess of Executive Level II. The Executive Level II salary can be found in SAMHSA’s standard terms and conditions for all awards . This amount reflects an individual’s base salary exclusive of fringe and any income that an individual may be permitted to earn outside of the duties to the applicant organization.
• Pay for any lease beyond the project period.
• Pay for the purchase or construction of any building or structure to house any part of the program.
• Provide residential or outpatient treatment services when the facility has not yet been acquired, sited, approved, and met all requirements for human habitation and service provision. (Expansion or enhancement of existing residential services is permissible.)
• Provide detoxification services unless it is part of the transition to MOUD with extended-release naltrexone.
• Make direct payments to individuals to enter treatment or continue to participate in prevention or treatment services. Note: A recipient or treatment or prevention provider may provide up to $20 non-cash incentive to individuals to participate in required data collection follow-up. This amount may be paid for participation in each required follow-up interview.
• Meals are generally unallowable unless they are an integral part of a conference grant or specifically stated as an allowable expense in the FOA. Grant funds may be used for light snacks, not to exceed $3.00 per person.
• Support non-evidence-based treatment.

 

13.11.7   Non-Title XIX/XXI Services and Funding (Excluding Block Grant and Discretionary Grants)

AHCCCS receives specific appropriations of the general fund for Non-Title XIX/XXI behavioral health services from the Arizona State Legislature. The goals of the funding are:

To ensure access to a comprehensive system of care for children and adults, including

• Employment;
• Housing services;
• Case management;
• Rehabilitation;
• Mental health and substance abuse services and support.

Non-Title XIX/XXI eligible populations include:

• ·Non-Title XIX/XXI Persons with SMI;
• Non-Title XIX/XXI individuals in the GMH behavioral health category;
• Non-Title XIX/XXI individuals in the SUD behavioral health category.

AHCCCS covers Non-Title XIX/XXI behavioral health services (mental health and/or substance use) within certain limits for Title XIX/XXI and Non-Title XIX/XXI members when medically necessary. Payment for behavioral health services covered under Non-Title XIX/XXI Funds (excluding federal grants) are limited to providers contracted to deliver the services and subject to availability of funds and the approval of The Health Plan.

• Auricular Acupuncture Services is the application b of auricular acupuncture needles to the pinna, lobe, or auditory meatus to treat mental health, alcoholism, substance use or chemical dependency by a certified acupuncturist practitioner as specified in A.R.S. §32-3922. 2;
• Mental Health Services (Traditional Healing Services) Treatment services for mental health or substance use problems provided by traditional healers;
• Supported Housing services provided by behavioral health professionals, behavioral health technicians, or behavioral health paraprofessionals, to assist individuals or families to obtain and maintain housing in an independent community setting including the individual’s own home or apartments and homes owned or leased by a subcontracted provider;
• Mental Health Services, Room and Board;
• Other Non-Title XIX/XXI Behavioral Health Services For Title XIX/XXI Eligible Populations;
• Crisis Services; and
•  Assessments for Non-Title XIX/XXI members when they are conducted to determine SMI eligibility. Non-Title XIX/XXI SMI General Funds may be used for the assessment, regardless of whether the individual is found to have a SMI and includes individuals who are assessed at 17.5 years old and older.

 

13.11.7.1   Restrictions on the Use of Non-Title XIX/XXI State Appropriation Funds

Non-Title XIX/XXI Funding may not be utilized for the following:

• Cash payments to members receiving or intending to receive health services;
• Purchase or improvement of land, purchase, construct, or permanently improve any building or facility except for minor remodeling with written approval from AHCCCS;
• Purchase of major medical equipment;
• Flex funds purchases of non-medically necessary services and supports that are not reimbursable or covered under Title XIX/XXI or Non-Title XIX/XXI;
• Sponsorship for events and conferences; or
• Childcare Services.

 

13.11.8   American Rescue Plan Act (ARPA) Supplemental Block Grant

The American Rescue Plan Act of 2021 (ARPA) provides additional funds to support states through Block Grants to address the effects of the COVID-19 pandemic for Americans with substance use disorders. The COVID-19 pandemic has created health and social inequities in America, including the critical importance of supporting people with substance use disorders. Additionally, societal stress and distress over this newly emerging disaster created the need for nimble and evolving policy and planning in addressing mental and substance use disorder services.

ARPA Substance Use Prevention, Treatment and Recovery Block Grant (SUBG)

The substance use disorder (SUD) prevention, intervention, treatment, and recovery support services continuum includes various evidence-based services and supports for individuals, families, and communities. Integral to the SUBG are its efforts to support health equity through its priority focus on the provision of SUD prevention, treatment, and recovery support services to identified underserved populations.

These populations include, but are not limited to:

• Pregnant women and women with dependent children,
• Persons who inject drugs,
• Persons using opioids and/or stimulant drugs associated with drug overdoses,
• Persons at risk for HIV, TB, and Hepatitis,
• Persons experiencing homelessness,
• Persons involved in the justice system,
• Persons involved in the child welfare system,
• Black, Indigenous, and People of Color (BIPOC),
• LGBTQ individuals,
• Rural populations,
• Other underserved groups.

ARPA Mental Health Block Grant (MHBG)

Funds must be used for:

• Adults designated to have a serious mental illness (SMI),
• Children determined to have a serious emotional disturbance (SED), and first-episode psychosis (FEP) or early SMI programs.

Funding is focused on supporting behavioral health crisis continuum. An effective statewide crisis system which affords equal access to crisis support that meets needs anytime, anyplace, and for anyone. This includes those living in remote areas and underserved communities as well as youth, older adults, persons of diverse backgrounds, and other marginalized populations; the crisis service continuum will need to be able to equally and adeptly serve everyone.

Refer to Section 13.11 for SUBG and MHBG block grant requirements.

Integrated Health Homes and BH Inpatient Facilities must identify and report to the AHCCCS Office of Human Rights (OHR) on members determined to have a Serious Mental Illness (SMI) who meet the criteria for Special Assistance. If the person’s Special Assistance needs appear to be met by an involved family member, friend, designated representative, or guardian providers must still submit a notification to the OHR. Integrated Health Homes and the Behavioral Health Inspatient Facilities must ensure that the person designated to provide Special Assistance is involved at key stages.

Integrated Health Homes and contracted BH Inpatient Facilities are expected to follow the policies and procedures outlined in AMPM Policy 320-R,  all other applicable AHCCCS policies and state policies outlined in Arizona Revised Statutes and Arizona Administrative Code.

13.12.1   General Requirements

A member determined to have a Serious Mental Illness (SMI) is in need of Special Assistance if the member is unable to do any of the following:

• Communicate preferences for services;
• Participate effectively in Individual Service Planning (ISP) or Inpatient Treatment Discharge Planning (ITDP);
• Participate effectively in the appeal, grievance or investigation processes.

The member’s limitations described above must also be due to any of the following:

• Cognitive ability/intellectual capacity (i.e., cognitive impairment, borderline intellectual functioning, or diminished intellectual capacity);
• Language barrier (an inability to communicate, other than a need for an interpreter/translator); and/or
• Medical condition (including, but not limited to traumatic brain injury, dementia, or severe psychiatric symptoms).

A member who is subject to general guardianship has been found to be incapacitated under A.R.S. § 14-5304, and therefore automatically satisfies the criteria for Special Assistance. Integrated Health Homes must identify and notify, via the AHCCCS QM Portal, all enrolled members under general guardianship that have an SMI Determination.

For a member determined to have a SMI, the existence of any of the following circumstances may warrant the Integrated Health Home to more closely review whether the member is in need of Special Assistance:

• Developmental disability involving cognitive ability;
• Residence in a 24-hour setting;
• Limited guardianship, or The Health Plan or the Integrated Health Home is recommending the establishment of a limited guardianship; or
• Existence of a serious medical condition that affects intellectual and/or cognitive functioning (such as, dementia or traumatic brain injury).

 

13.12.2   Persons Qualified to Make a Special Assistance Determination

Specific staff and agencies are qualified to screen for Special Assistance and determine whether a member qualifies for Special Assistance (See AMPM Policy 320-R for specific requirements).

• A qualified clinician providing treatment for the member, 
• A case manager as specified in A.A.C. R9-21-101,
• A member of the clinical team as specified in A.A.C. R9-21-101,
• The Contractor, Tribal ALTCS, or TRBHA• A program director of a subcontracted provider
• The Deputy Director of AHCCCS or designee, or 
• A hearing officer assigned to an SMI appeal or grievance. 

13.12.3   Screening for Special Assistance

Integrated Health Homes and Behavioral Health Inpatient Facilities perform screenings to assess whether members determined to have a SMI are in need of Special Assistance, in accordance with the criteria set out in AHCCCS AMPM Policy 320-R. The Health Plan Provider Manual Attachment 3.11.2 Special Assistance Screening Tool is available to assist Integrated Health Homes and  Behavioral Health Inpatient Facilities screen for Special Assistance by calling Customer Service at 1-866-796-0542 to obtain a copy of this attachment.at 1-866-796-0542 to obtain a copy of this attachment, if needed.

 

13.12.4   Documentation

If a member is currently identified as a
member in need of Special Assistance, a notation of “Special Assistance” and a copy
of the Part A Notification of Member in Need of Special Assistance should exist
in the clinical record. Integrated Health Homes can utilize the AHCCCS QM
Portal to check a member’s Special Assistance status. Behavioral Health
Inpatient Facilities shall review the AHCCCS QM Portal upon a member's
admission to verify their Special Assistance status. The Behavioral Health
Inpatient Facility must coordinate with the person meeting Special Assistance
needs and involve them in all discharge planning. Integrated Health Homes and Behavioral
Health Inpatient Facilities can contact The Health Plan at
specialassistance@azcompletehealth.com to inquire about current status. The Health
Plan maintains a database on members in need of Special Assistance and shares
data with Health Homes and Behavioral Health Inpatient Facilities on a regular
basis. 

 

13.12.5   Notification Requirements to the Office of Human Rights

When a member
meets Special Assistance criteria Integrated Health Homes and Behavioral Health
Inpatient Facilities notify the Office of Human Rights by completing a Part A
notification in the AHCCCS QM Portal. Part A must be submitted within 5 business
days of determining a member meets criteria. Integrated Health Homes and  Behavioral Health inpatient Facilities must
use the current electronic Special Assistance Notification Form found on the
AHCCCS QM Portal.

All Notices of Adverse Benefit Determination (NOA) or Notices of
Decision (NOD) issued to the member/guardian/designated representative shall
also be copied to the individual designated to meet the Special Assistance
needs, and shall also be submitted to AHCCCS OHR at OHRts@azahcccs.gov, and all
investigation or grievance, including when an investigation/grievance is filed,
and circumstances when initiating a request for an investigation/grievance may
be warranted.

 

13.12.6   Members No Longer in Need of Special Assistance

When a member no longer meets Special Assistance criteria, Integrated Health Homes complete a Part C Notification within the AHCCCS QM Portal. Part C must be submitted with 10 business days of an event or determination that a member no longer meets criteria.  A member no longer meets criteria when any of the following apply:

• The original basis for the member meeting Special Assistance criteria is no longer applicable and the member does not otherwise meet criteria. This includes when it is determined that the SMI designation is no longer appropriate, and the designation has been removed. A Part C due to a change in SMI designation shall not be completed until after the period to appeal has expired,
• The member passes away• The member enters a Department of Corrections (DOC) facility,
• The member moves out of state and no longer receives behavioral health services in Arizona, or 
• The member elects not to receive services from the Contractor, Tribal ALTCS, or TRBHA and the member is not transferred to another Contractor, Tribal ALTCS, or TRBHA

13.12.7   Requirements to Help Ensure the Provision of Special Assistance

Integrated Health Homes and Behavioral Health Inpatient Facilities collaborate with and involve the person  (guardian, family member, friend, Office of Human Rights advocate, etc.) meeting Special Assistance needs in all  Behavioral Health treatment planning. Timely notification to the person meeting needs is required to ensure their participation. 

13.12.8   Integrated Health Home Reporting Requirements

Integrated Health Homes are required to update the AHCCCS QM portal (QMportal.azahcccs.gov), with any changes to a member’s demographics within 5 business days of the change taking place as outlined in AHCCCS AMPM 320-R. Demographic updates include:

1. Member residence information, residence type, address, city, state, zip, and phone number,
2. Provider information; Assigned Provider Agency, Treatment team names, phone numbers and email addresses, or
3. Clinical Information: Diagnosis and Clinical Basis for Special Assistance (e.g., Guardianship is assigned to a member who previously met criteria due to a Cognitive Barrier), or
4. Guardian/Advocate Information; relationship to member, name, address, and phone number, and email address. 

13.12.9   Confidentiality Requirements

Integrated Health Homes shall grant access to clinical records of members in need of Special Assistance to the Office of Human Rights in accordance with federal and state confidentiality laws (AHCCCS AMPM Policy 550).

Independent Oversight Committees receive confidential information related to Special Assistance members and are expected to safeguard the information in accordance with the requirements set out in AHCCCS ACOM, Policy 447

 

13.12.10        Other Procedures

Integrated Health Homes and Behavioral Health Inpatient Facility staff that serve the SMI population must take the Special Assistance training located in the Relias Learning System annually. The Health Plan provides live training to Integrated Health Homes and Behavioral Health Facilities upon recognized need or request. 

Integrated Health Homes and Behavioral Health Inpatient Facilities must assign one staff member to act as the Special Assistance Single Point of Contact. The Single Point of Contact must be proficient in all Special Assistance policies and procedures as outlined in AHCCCS AMPM, Policy 320-R and all other applicable Special Assistance policies. 

The Single Point of Contact responds to all communications from the Health Plan. The Single Point of Contact coordinates with internal staff to respond to requests for further information and required updates to the AHCCCS QM Portal. The Single Point of Contact is responsible for reviewing all information on the Part A Notification in the AHCCCS QM Portal, prior to submission to ensure member meets criteria. 

Integrated Health Home Single Point of Contact staff are required to attend the Special Assistance Single Point of Contact Monthly Conference Call. Integrated Health Homes should notify The Health Plan Special Assistance Department at specialassistance

 

13.12.11        Transfer of a Special Assistance Member

Transfer of a member to another Integrated Health Home or Health Plan must be entered into the AHCCCS QM Portal prior to completing the transfer. All changes and updates to a Special Assistance member’s services, including transfers, requires collaboration with the person assigned to meet Special Assistance needs.

Arizona State Hospital (ASH) is a Level I facility currently licensed under applicable State and local law, is accredited by the Joint Commission and certified by the Centers for Medicare and Medicaid Services (CMS). ASH is a long-term inpatient psychiatric hospital that provides the most restrictive setting for care in the state. Coordination between ASH and the Health Plan must occur in a manner that ensures persons being admitted meet medical necessity criteria. Pursuant to A.R.S. § 36-201 through 36-217, ASH provides inpatient care and treatment to patients with mental disorders, personality disorders or emotional conditions. The level of care provided at ASH must be the most appropriate and least restrictive treatment option for the person (A.R.S. § 36-‑501(21)). The provision of appropriate, medically necessary covered behavioral health services must be consistent with treatment goals outlined on the admission application and individual needs identified in the course of treatment of individuals admitted to ASH.

The goal of all hospitalizations of persons at ASH is to provide comprehensive evaluation, treatment, and rehabilitation services to assist each behavioral health recipient in their own recovery, and to achieve successful placement into a less restrictive community-based treatment option.

13.13.1   Admissions

To ensure that individuals are treated in the least restrictive and most appropriate environment that can address their individual treatment and support their needs, the criteria for clinically appropriate admissions to ASH are as follows:

• The member must not require acute medical care beyond the scope of medical care available at ASH.
• The referral source must make reasonably good-faith efforts to address the individual’s target symptoms and behaviors in an inpatient setting(s).
• The referral source must complete Utilization Review of the potential admission referral and it recommend admission to the ASH as necessary and appropriate, and as the least restrictive option available for the person based on clinical status.
• When a community provider agency or other referral source believes that a civilly committed or voluntarily admitted adult is a candidate to be transferred from another inpatient facility for treatment at ASH, the agency will contact the Health Plan ASH Liaison to discuss the recommendation for admission to ASH. The Health Plan must be in agreement with the referral source that a referral for admission to ASH is necessary and appropriate. If the candidate is not Health Plan enrolled, the member will be referred for SMI determination and the enrollment process prior to application or at the latest within twenty-four (24) hours of admission pursuant to Section 13.2 Appointment Standards and Timeliness of Service to ASH. The enrollment date is effective the first date of contact by the Health Plan contracted Integrated Health Home. The Health Plan Integrated Health Home is required to also complete a Title XIX/XXI application once enrollment is completed. For all non- T/RBHA enrolled Tribal behavioral health recipients, upon admission to ASH, the hospital will enroll the person, if eligible in the AHCCCS Indian Health Program.
• For T/RBHA (Tribal RBHA only) enrolled members, AHCCCS must also be in agreement with the referring agency that admission to ASH is necessary and appropriate, and AHCCCS must prior authorize the person’s admission (see Section 4.1 Securing Services and Prior Authorization/Retrospective Authorization).
• The Health Plan ASH Liaison will provide the referring agency with the ASH Application packet and list of requested documents. Upon completion of the ASH application packet, the Health Plan ASH Liaison will forward the completed packet to the Health Plan Medical Director for review. Upon approval from the Health Plan Medical Director, the completed application is submitted to ASH Admissions Office, and if determined to be SMI and previously assessed as requiring Special Assistance, then the existing Special Assistance form should be included in the package. If the form has not been completed, please refer to Section 13.12 Special Assistance for Persons Determined to have a Serious Mental Illness for further instructions.
• The ASH Admissions Office confirms receipt of the complete packet and notifies the Health Plan ASH Liaison of missing or inadequate documentation. ASH cannot accept any person for admission without copies of the necessary legal documents.
• For TXIX enrolled persons, the Health Plan needs to generate a Letter of Authorization (LOA) or issue a denial. Once the member is accepted, the Certification of Need (CON) and Letter of Authorization (LOA) are provided to ASH just prior to admit with other documents as outlined in the ASH Admission Workflow; an ASH document. See AHCCCS Prior Authorization Forms: Certification of Need.
• The Health Plan is responsible for notifying ASH’s Admissions Office of any previous court ordered treatment days utilized by the member. Members referred for admission must have a minimum of forty-five (45) inpatient court-ordered treatment days remaining to qualify for admission. The member’s AHCCCS eligibility will be submitted by the Health Plan to the ASH Admissions Office with the admission application and verified during the admission review by the ASH Admissions Office. The ASH Admissions Office will notify (AHCCCS) member Services of the behavioral health recipient’s admission to ASH and any change in health plan selection, or if any other information is needed.
• The ASH Chief Medical Officer or Acting Designee will review and determine whether the information supports admission and whether ASH can meet the member’s treatment and care needs.
• If the ASH Chief Medical Officer or Acting Designee determines that the member does not meet criteria for admission, the Chief Medical Officer or Acting Designee will provide a denial letter.
• If the admission is approved, the Admissions Office will send the acceptance statement from the Chief Medical Officer or Acting Designee to the referral source.
• A Court Order for transfer is not required by ASH when the proposed member is already under a Court Order for treatment with forty-five (45) remaining inpatient days. However, in those jurisdictions in which the court requires a court order for transfer be issued, the referring agency will obtain a court order for transfer to ASH.
• If a Court Order for transfer is not required, the ASH Admissions Office will set a date and time for admission. It is the responsibility of the referring agency to make the appropriate arrangements for transportation to ASH.
• When ASH is unable to admit the accepted behavioral health recipient immediately, ASH shall establish a pending list for admission. If the behavioral health recipient’s admission is pending for more than 15 days, the referral agency must provide ASH a clinical update in writing, including if any alternative placements have been explored while pending, and if the need for placement at ASH is still necessary.

 

13.13.2   Adult Members Under Civil Commitment

The member must have a primary diagnosis of Mental Disorder (other than Cognitive Disability, Substance use disorder, Paraphilia-Related Disorder, or Antisocial Personality Disorder) as defined in A.R.S. § 36-501, which correlates with the symptoms and behaviors precipitating the request for admission, and be determined to meet DTO, DTS, GD, or PAD criteria as the result of the mental disorder.

The member is expected to benefit from proposed treatment at ASH (A.R.S. § 36-202). The member must have completed 25 days of mandatory treatment in a local mental health treatment agency under T-36 COT, unless waived by the court as per A.R.S. § 36-541 or, if PAD, waived by the Chief Medical Officer of ASH.

ASH must be the least restrictive alternative available for treatment of the person (A.R.S. § 36-501) and the least restrictive long-term level of care available elsewhere in the State of Arizona to meet the identified behavioral health needs of the member.

The member must not suffer more serious harm from proposed care and treatment at ASH. (ACC R9-21-507(B)(1)) 

Hospitalization at ASH must be the most appropriate level of care to meet the person’s treatment needs, and the person must be accepted by the Chief Medical Officer for transfer and admission (AAC R9-21-507(B)(2)) 

13.13.3   Treatment and Community Placement Planning

ASH will begin treatment and community placement planning immediately upon admission. All treatment is patient-centered and is provided in accordance with AHCCCS-established five principles of person-centered treatment for adult members determined to have SMI.

Members shall remain assigned to their original clinic/outpatient treatment team throughout their admission unless the member initiates a request to transfer to a new clinic site or treatment team.

• Consideration of comprehensive information regarding previous treatment approaches, outcomes and recommendations/input from the Health Plan and other outpatient community treatment providers is vital.
• Representative(s) from the outpatient treatment team are expected to participate in treatment planning throughout the admission in order to facilitate enhanced coordination of care and successful discharge planning.
• Treatment goals and recommended assessment/treatment interventions must be carefully developed and coordinated with the outpatient providers (including the Health Plan, ALTCS Health Plan, other providers/other state agencies as appropriate), the member’s legal guardian, family members, significant others as authorized by the member and advocate/designated representative whenever possible.
• The first Inpatient Treatment and Discharge Plan (ITDP) meeting, which is held within 10 days of the member´s admission, should address specifically what symptoms or skill deficits are preventing the member from participating in treatment in the community and the specific goals/objectives of treatment at ASH. This information should be used to establish the treatment plan.
• The first ITDP meeting should also address the discharge plan for reintegration into the community. The member’s specific needs for treatment and placement in the community, including potential barriers to community placement and successful return to the community, should be identified and discussed.
• All required medical services for enrolled members residing at ASH that are not provided by ASH will be provided by Valleywise Health Medical Center. The Health Plan will provide payment to Valleywise Health Medical Center for all medically necessary services provided to enrolled T19/21 persons with a Serious Mental Illness (SMI) as described in contract.

ASH will provide all treatment plans to the responsible agency. The responsible agency should indicate review of an agreement/disagreement with the treatment plan on the document. Any disagreements should be discussed as soon as possible and resolved as outlined in AAC 9R-21 . Treatment plans are reviewed and revised collaboratively with the Adult Clinical Team at least monthly.

Any noted difficulties in collaboration with the outpatient provider treatment teams will be brought to the attention of the Health Plan to be addressed. The Health Plan Hospital Liaison will monitor the participation of the outpatient team and assist when necessary.

Through the Adult Clinical Team, ASH will actively address the identified symptoms and behaviors which led to the admission and link them to the community rehabilitation and recovery goals whenever possible. ASH will actively seek to engage the member and all involved parties to establish understandable, realistic, achievable, and practical treatment, discharge goals and interventions.

While in ASH and depending upon the member’s individualized treatment needs, a comprehensive array of evaluation and treatment services are available and will be utilized as appropriate and as directed by the member’s treatment plan and as ordered by the member’s treating psychiatrist.

13.13.4   Recertification of Need (RON)

The ASH Utilization Manager is responsible for the recertification process, when recertification is required, for all Title XIX/XXI eligible persons and is the contact for ASH for all the Health Plan continued stay reviews.

The ASH Utilization Manager will work directly with the member’s attending physician to complete the Provider Manual Form 10.1.2, Recertification of Need (RON) which can be obtained by calling Customer Service at 1-866-796-0542 For members 65 and over, the RONs cover up to a 60-day span, for members under 21 the RONs cover a 30-day span and are submitted accordingly. The RON will be sent to the Health Plan within five (5) days of expiration of the current CON/ RON. If required by the Health Plan, the ASH Utilization Manager will send to the Health Plan Utilization Review staff additional information/documentation needed for review to determine continued stay. The Health Plan pays the first 30 days following admission to the ASH for T19 members; following this period, a 1-day authorization is created for all members regardless of age, and then denies.

All Health Plan decisions regarding to the approval or denial for continued stay will be rendered prior to the expiration date of the previous authorization and upon receipt of the RON for those members. The Health Plan authorization decisions are based on review of chart documentation supporting the stay and application of the AHCCCS Level Continued Stay criteria. If continued stay is approved, the Health Plan sends a Letter of Approval (LOA) to the ASH Utilization Management Department with the completed RON and updated standard nomenclature diagnosis codes (if applicable). Denials will be issued upon completion of the denial process described in Section 4.1 Securing Services and Prior Authorization/Retrospective Authorization.

13.13.5   Transition to Community Placement Setting

The member is considered to be ready for community placement and is placed on the Discharge Pending List when the following criteria are met:

• The agreed upon discharge goals set at the time of admission with the Health Plan have been met by the member.
• The member presents no imminent danger to self or others due to psychiatric disorder. Some members, however, may continue to exhibit occasional problematic behaviors. These behaviors must be considered on a case-by-case basis and do not necessarily prohibit the person from being placed on the Discharge Pending List. If the member is psychiatrically stable and has met all treatment goals but continues to have medical needs, the member remains eligible for discharge/community placement.
• All legal requirements have been met.

Once a member is placed on the Discharge Pending List, the Health Plan must immediately take steps necessary to transition the member into community-based treatment as soon as possible. The Health Plan has up to thirty (30) days to transition the member out of ASH. The Health Plan outpatient treatment team should identify and plan for community services and supports with the member’s inpatient clinical team 60 – 90 days out from the member’s discharge date. This will allow sufficient time to identify appropriate community covered behavioral health services.

When the member has not been placed in a community placement setting within 30 days, a quality of care concern will be initiated by the Health Plan or AHCCCS, if an agreement has not been made between ASH and the outpatient treatment team that the discharge will take place after 30 days.

For Title XIX/XXI persons with a Serious Mental Illness and insulin-dependent diabetes, the Health Plan will provide at discharge the same brand and model glucose monitoring device as used competently at ASH. Care must be coordinated with the ASH prior to discharge to ensure that all supplies are authorized and available to the member upon discharge.

13.13.6   ASH Conditional Release Requirements

The Health Plan has processes in place to provide high touch care management and/or other behavioral health and related services to members on Conditional Release from the Arizona State Hospital (ASH) that are consistent with the Conditional Release Plan (CRP) per AHCCCS AMPM Policy 320Z : Members on Conditional Release. This includes but is not limited to assignment to a contractor care manager, which may be the assigned Health Plan ASH liaison or another team care manager working in conjunction with the Health Plan ASH liaison. Care management functions may not delegate these functions to a subcontracted provider.

 The Health Plan Care Manager or ASH Liaison acts as the single point of contact and is responsible to provide, at a minimum, the following:

• Collaboration with the outpatient treatment team, ASH, and the Superior Court;
• Discharge planning coordination with ASH;
• Participation in developing and implementing Conditional Release Plans;
• Participation in the modification of an existing Individual Service Plan (ISP) or the modification of an existing ISP that complies with the Conditional Release Plan (CRP);
• Member outreach and engagement to help evaluate compliance with CRP;
• Attendance in outpatient staffing at least once per month;
• Coordination of care with member’s treatment team, TRBHA, and physical and behavioral health providers to implement the ISP and CRP;
• Routine delivery of comprehensive status reporting to AHCCCS, ASH and Superior Court as specified in A.R.S. § 133991 and A.R.S. §13-3994 – 4000;
• In the event that a member violates any term of their CRP, psychiatric decompensation, or use of alcohol, illegal substances or prescription medications not prescribed to the member, the Health Plan will confirm immediate notification to the Superior Court and ASH was completed by the outpatient provider and provide a copy to AHCCCS;
• The Health Plan agrees and understands that is will follow all obligations, including those stated above, applicable to it as set forth in A.R.S. § 133991 and A.R.S. §13-3994 - 4000.

The Health Plan provides training and technical assistance to outpatient providers serving members on Conditional Release and assures providers demonstrate understanding of A.R.S. § 133991 and A.R.S. §13-3994 – 4000 duties of outpatient providers. The Health plan ensures the monthly Conditional Release Deliverable is received from the outpatient provider team monthly by the 2^nd day of the month for the previous months’ date and submitted to AHCCCS as required by AMPM 320Z. The Conditional Release Report can be found at https://www.azahcccs.gov/Resources/Downloads/ConditionalReleaseMonthlyMonitoringReport.pdf. The Health Plan will coordinate with the outpatient provider for additional documentation at the request of AHCCCS Medical Management.

In the event that a member’s mental status renders them incapable or unwilling to manage their medical condition and the member has a skilled medical need, the Health Plan must arrange ongoing medically necessary nursing services in a timely manner.

At times, it may be necessary to consider an out-of-state placement for a child or young adult to meet the person’s unique circumstances or clinical needs, as outlined in the AHCCCS AMPM Policy 450, Out of State Placements for Children or Young Adults for Behavioral Health Treatment.

 

13.14.1   Initial Notification to AHCCCS

All Provider Manual Forms and Attachments can be obtained by calling Customer Service at 1-866-796-0542, if needed.

Providers are required to assist the Health Plan in gathering the required information to notify the AHCCCS prior to a referral for out-of-state placement using Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30 Day Update. Prior authorization must be obtained prior to making a referral for out-of-state placement, in accordance with the Health Plan criteria (See Section 4.1 Securing Services and Prior Authorization/Retrospective Authorization).

 

13.14.2   Process for Providing Initial Notification to the State

For providers subcontracted with the Health Plan, the provider notifies the Health Plan of the intent to make a referral for out-of-state placement on Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update.

Prior to placing the child or young adult the Integrated Health Home provider must complete Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update and submit it to the Health Plan. The Health Plan will review the documentation and submit the information to  AHCCCS for approval of the out-of-state placement request. The Health Plan will notify the Division of Healthcare Management through the AHCCCS QM portal prior to or upon notification of a member being placed in an Out-of-Home placement.

 

13.14.3   Periodic Updates to AHCCCS

In addition to providing initial notification, the provider is required to submit updates to the Health Plan for review. The updates will be sent to AHCCCS regarding the person’s progress in meeting the identified criteria for discharge from the out-of-state placement every 30 days. To adhere to this requirement, providers must use Provider Manual Form 3.13.1, Out-of-State Placement, Initial Notice and 30-Day Update.

Once completed, the Integrated Health Home must submit the form to the Health Plan Medical Management department every 30 days the person continues to remain in out-of-state placement. The 30 day update timelines will be based upon the date of approval by AHCCCS of the out-of-state placement. The Health Plan will review the form and forward the information to AHCCCS through the QM Portal.  Notification of members discharge from the out of state placement shall be sent to AHCCCS within five business days of notification.

 

13.14.4   Required Reporting of an Out-of-State Provider

All out-of-state providers are required to meet the reporting requirements of all incidences of injury/accidents, abuse, neglect, exploitation, healthcare acquired conditions, and/or injuries from seclusion/restraint implementations as specified under Quality Management Requirements.

See Section 10.2 Cultural Competence System of Care Requirements

In addition, behavioral health providers report appropriately for Language Assistance - T1013, Interpretation.

• T1013 must be reported when providing language assistance delivered by certified bilingual staff, licensed ASL or provided by a language vendor or any qualified interpreter. This code is used to track language assistance that is being provided at any time (languages other than English, including ASL). T1013 does not require a modifier.
• Interpretation must be reported with another service that cannot be delivered effectively without sign language or interpreter assistance, never a standalone code.

13.16.1   Business Continuity/Recovery Plan

In order to effectively manage unexpected events that may negatively and significantly impact the ability to deliver services to members, all Administrative Service Subcontractors, and all of the following provider types must develop, maintain, and annually test a Business Continuity/Disaster Recovery and Emergency Response Plan.

Provider Type (provider type licensing code number)

• Level 1 Hospitals (02)
• Level 1 Psych Hospitals (71)
• Behavioral Health Outpatient Clinics (77)
• Integrated Clinics (77)
• Level 1 Residential Treatment Center Secure (non-IMD) (78)
• Community Service Agency (A3)
• Rural Substance Abuse Transitional Agency (A6)
• Level 1 Residential Treatment Center Secure (IMD) (B1)
• Level 1 Residential Treatment Center Non-Secure (non-IMD) (B2)
• Level 1 Residential Treatment Center Non-Secure (IMD) (B3)
• Level 1 Subacute Facility (IMD) (B6)
• Crisis Service Provider (B7)
• Federally Qualified Health Center (FQHC) (C2)
• Community/Rural Health Center (RHC) (29)

13.16.2   Business Continuity and Emergency Response Plan Provisions

The above provider types must develop, maintain, and annually test a Business Continuity/Recovery and Emergency Response Plan to manage unexpected events that may negatively and significantly impact its ability to deliver services to members. Providers must develop a process to train key personnel and organizational staff to be familiar with and implement the Business Continuity/Recovery Plan and Emergency Response when necessary.

The Business Continuity and Emergency Response Plan must specify, at a minimum, strategies to address the following:

1. Indicate that the Plan is reviewed annually and updated.
2.  The Plan contains staff training requirements including how often training is conducted.
3. The Plan is specific to the Contractor’s operations in Arizona and references local resources.
4. The Plan contains planning and training for:
   • Electronic/telephonic failure at the Contractor’s main place of business and any satellite offices in or out of State;
   • Complete loss of use of the main site and any satellite offices out of State’
   • Loss of primary computer system/records;
   • Extreme weather conditions;
   • How the Contractor will communicate with the Health Plan during a business disruption;
   • Directing the Contractor staff to contact AHCCCS Security at 602-417-4888 in the event of a disruption outside of normal business hours;
   • Provisions for periodic testing, at least annually. Results of the tests are documented.
5. The Plan must address key customer priorities and key factors that could cause disruption, including access to the following key customer priorities:
   • Customer Services
   • Scheduling
   • Clinic and/or Physician Visits
   • Transportation Services
   • Prior Authorization
   • Outpatient or Inpatient Procedures
   • Utilization Review/ Concurrent Review
   • Provider Services
   • Claims/ Provider Payments
   • Grievance/Appeals and Quality of Care Concerns
   • Any other critical services identified by the Contractor.
6. The Plan addresses emergency plan provisions for facilities and hospitals in the event members are displaced in an emergency;
7. The Plan includes timelines for resumption of services including percentages of recovery; and
8.  The Contractor has designated a Business Continuity Planning Coordinator and includes contact information in the Plan.
9. (See the adjacent link for details; refer to AHCCCS ACOM Policy 104, Attachment A  for additional template.

 

13.16.3   Pandemic Plan

In the event of a pandemic, as declared the Governor of Arizona, U.S. Government, or the World Health Organization, which makes performance of any term outlined in the AHCCCS Contract with the Health Plan impossible or impracticable, the State shall have the following rights:

• After the official declaration of a pandemic, the State or the Health Plan may temporarily void the provider agreement in whole or specific sections, if the provider cannot perform to the standards agreed upon in the initial terms.
• The State and the Health Plan shall not incur any liability if a pandemic is declared, and emergency procurements are authorized by the Director as per A.R.S. 41-2537 of the Arizona Procurement Code.
• Once the pandemic is officially declared over and/or the provider can demonstrate the ability to perform, the State or the Health Plan, at their sole discretion, may reinstate the temporarily voided provider agreement.
• The State or the Health Plan, at any time, may request to see a copy of the written plan from the provider. The provider shall produce the written plan within seventy-two (72) hours of the request.

13.16.4   Emergency Preparedness

Upon the Health Plan’s request, the provider shall participate in health emergency response planning, preparation, and deployment in the event of a Presidential, State, or locally-declared disaster and be prepared for the following actions to participate in the development of a comprehensive disaster response plan, including, at a minimum, specific measures and plans for assessing the needs of individuals, first responders and their families, victims, survivors, family members, and other community caregivers following an emergency or disaster considering short and long term stress management techniques.

Upon the Health Plan’s request, the provider shall collaborate with local hospitals, emergency rooms, fire, and police to provide emergency health supports for first responders and coordinate with other RBHAs and health care organizations to assist in the event of a disaster.

13.16.5   Heat Plan Requirements

Integrated Health Home Provider must have a Heat Plan in place to mitigate the effects of extreme heat on members. This plan must be reviewed and updated on an annual basis. The Heat Plan must include, at a minimum:

1. Address the Integrated Health Home process to ensure that medically necessary routine transportation is available for individuals who are at increased risk, and unable to access public transportation.
2. Address a process to ensure that heat advisory messages and public health information on extreme heat protection are communicated to members.

Address a process of identifying and outreaching members who are at risk to extreme heat complications due to their living conditions. 

The Health Plan is responsible to ensure members have adequate access to a broad array of behavioral health services and programs. As such, the Health Plan requires that Behavioral Health providers give the Health Plan written notice via completion of the Notification of Change Form RF-1016 deliverable or by certified mail of intent to eliminate a behavioral health program, add a behavioral health program or discontinue being designated as an Integrated Health Home, no less than ninety (90) days prior to the change. Contracted Integrated Health Home providers are required to meet all the Health Plan Provider Manual requirements and cannot elect to discontinue specific programs or services that are required in the Health Plan Provider Manual and remain a designated Integrated Health Home.

 

Providers shall notify the Health Plan before making any material change in the size, scope, or configuration of Provider’s services. The Provider is required to notify the Health Plan via the Notification of Change deliverable (RF-1015) in writing within one (1) day of knowledge of or anticipation of the following: (i) any unexpected material change or deficiency; (ii) any material change to Provider’s license, certification or registration; (iii) any condition which terminates, suspends or limits Provider from effectively participating in the network, including the necessity for transition of members to a different provider; (iv) any situation which develops involving Provider when notice of that situation must be given to any regulatory body with authority over Provider; or (v) when a change in Provider’s license to operate is affected, or may reasonably be affected, as a result of any investigation conducted by, or complaint filed with, the official body with regulatory authority over Provider.

Providers of behavioral health services shall submit notification to the Health Plan 90 days prior to the effective date of change via the Notification of Change deliverable (RF-1016) for any expected material change to (i) the Provider’s license, certification, or registration; (ii) a change in programming or population served; (iii) a site move, closure, or opening of a new site; or (iv) the addition or closure of a program. See Section 17 Deliverable Requirements.

All providers must update credentialing or other personnel information filed with the Health Plan within 15 days of new hires or terminations by the provider agency. Providers are responsible for the maintaining the accuracy of their staff and facility information, so that the provider listings made available to members by the Health Plan is current and relevant.

The Health Plan requires contracted Integrated Health Home providers to meet additional service delivery requirements as outlined below, in addition to all behavioral health requirements outlined in the Health Plan Provider Manual. These include recovery support, access to care, outreach and engagement, enrollment, staffing, and system partner coordination of care. Members can select an Integrated Health Home to receive their services. Members with chronic behavioral health care conditions are encouraged to receive their coordination of care services through a contracted Integrated Health Home. The following contracted Integrated Health Homes are required to meet the requirements identified in this section in addition to all behavioral health requirements identified in the Health Plan Provider Manual.

The Integrated Health Homes serving children required to meet these requirements include: Casa de los Ninos, ChangePoint Integrated Health, Child and Family Support Services, Clarvida (formerly known as Pathways of Arizona), Community Health Associates, Community Partners Integrated Health, COPA Health (Partners in Recovery), COPE Community Services, Easterseals Blake Foundation, El Rio Health Center, Encompass Health Services, Horizon Health and Wellness, Intermountain Health Care, Jewish Family & Children’s Service, La Frontera Center, La Frontera-EMPACT Suicide Prevention Center, Little Colorado Behavioral Health, Marana Health Care, Mohave Mental Health Clinic, Pinal Hispanic Council, Polara Health, La Frontera-SEABHS-Southeastern Arizona Behavioral Health Services, Southwest Behavioral & Health Services, Spectrum Healthcare Group, The Guidance Center Touchstone Behavioral Health, and Valle Del Sol Inc.

The Integrated Health Homes serving adults required to meet these requirements include: Banner U of A Healthcare, ChangePoint Integrated Health, Clarvida (formerly known as Pathways of Arizona), CODAC Health Recovery and Wellness, Community Bridges, Inc., Community Health Associates, Community Partners Integrated Health, Compass Recovery Center, COPA Health (Partners in Recovery), COPE Community Services, El Rio Health Center, Encompass Health Services, Horizon Health and Wellness, Intermountain Health Care, Jewish Family and Children’s Services, La Frontera Center, La Frontera-EMPACT Suicide Prevention Center, Little Colorado Behavioral Health, Marana Health Care, Mohave Mental Health Clinic, Pinal Hispanic Council, Polara Health, Pronghorn Psychiatry, SEABHS-Southeastern Arizona Behavioral Health Services, Southwest Behavioral & Health Services, Spectrum Healthcare Group, Summit Behavioral Health of Arizona, The Guidance Center, Westcare AZ, Steps to Recovery, and Valle Del Sol Inc.

 

13.18.1   Screening and Serving Members with Complex Needs

Members with complex needs will be identified by the Health Plan utilizing the Integrated and Non-Integrated Risk Rosters. The risk rosters will be uploaded to the provider FTP sites monthly. Providers must review the uploaded documents to determine if any members have been added or removed to the rosters.

All children, including birth to five, must be screened and assessed for High Needs at the time of the initial comprehensive assessment and annually thereafter, per AHCCCS AMPM 320-O ,  the  Child and Adolescent Level of Care Utilization System (CALOCUS) is a standardized assessment tool used for children ages 6-17.  In addition, PCPs shall use validated screening tools for all adults related to behavioral health needs, SDOH, and trauma.

Providers must place a copy of screening tools utilized in the member’s Electronic Health Record. A progress note is required following each screening, describing the actions taken as a result of the screening.

Providers must develop and implement service plans for members with High/Complex Needs that include strategies to address a crisis and that deliver all appropriate services to help the member remain at home, minimize placement disruptions, and avoid the inappropriate use of the police and the criminal justice system.

 

13.18.1.1   Declination of Intensive Services

Providers are required to follow evidenced based practices and must ensure members with High Needs receive appropriate services and take action to address risk management concerns when members decline against medical advice to receive services. Permitted actions include: 1) notifying members, guardians, and families in writing of the risks associated with declining to accept more intensive treatment, 2) seek a court order for treatment when the adult member/guardian declines more intensive treatment and the member is a risk to themselves or others, or 3) with sufficient notice to the member, decline to continue to provide treatment services which are ineffective in meeting the member's needs.

 

13.18.1.2   Dedicated Health Care Coordinators

Integrated Health Homes providing services to enrolled members are expected to employ an adequate number of Dedicated Health Care Coordinators (Case Managers) to maintain low member to staff ratios and meet the needs of  High Needs members.

Case Managers, regardless of their job/position title at the provider agency, who are carrying a caseload and providing services as specified in AMPM 570 Attachment A are responsible for monitoring the member’s current needs, services required to address those needs, and progress in achieving goals or desired outcomes through regular and ongoing contact with the member/HCDM. The frequency and type of contact between the provider case manager and the member/HCDM is determined during the treatment planning process and is adjusted as needed by routine discussion that evaluates and considers clinical need and member preference.

Integrated Health Homes shall ensure that children who require high needs case management and all members with a Serious Mental Illness (SMI) designation are assigned to a case manager in accordance with A.A.C. R9-21-101 et. seq and that all other members are assigned a provider case manager as needed, based upon a determination of the member’s service acuity needs.

Appropriate case management intensity is paramount in assisting members in meeting their recovery goals and is based on member need and acuity of symptoms.  AMPM Policy 570, Attachment A   has identified four levels of case management intensity with different levels of required case manager to member contact:

• Assertive Community Treatment (ACT) Case Management with a ratio of 12:1
  • o   Individuals with Serious Mental Illness (SMI) designation. One component of a comprehensive model of treatment based upon fidelity criteria developed by the Substance Abuse and Mental Health Services Administration. ACT case management focuses upon individuals with severe and persistent mental illness that seriously impairs their functioning in community living, in conjunction with a multidisciplinary team approach to coordinating care across multiple systems (e.g., social services, housing services, health care).
• High Needs Case Management for Children with a ratio of 25:1.
  • Focuses upon providing case management and other support and rehabilitation services to children with complex needs and multiple systems involvements for whom less intensive case management would likely impair their functioning. Children with high service intensity needs who require to be offered the assignment of a high needs case manager are identified as:
    • Children 0 through five years of age with two or more of the following:
• Other agency involvement; specifically: AzEIP, DCS, and/or DDD, and/or
• Out of home placement for behavioral health treatment (within past six months), and/or
• Psychotropic medication utilization (two or more medications), and/or
• Evidence of severe psycho-social stressors (e.g., family member serious illness, disability, death, job loss, eviction), and
  • Children six through 17 years of age: CALOCUS level of 4, 5 or 6.
• Supportive Case Management for Children and Adults with a ratio of 30:1
  • Individuals with an SMI designation, General Mental Health/ Substance Use (GMH/SU), or children. Supportive Case Management: Focuses upon individuals for whom less intensive case management would likely impair their functioning. Supportive case management provides assistance, support, guidance and monitoring in order to achieve maximum benefit from services. Caseloads may include individuals with an SMI designation as well as individuals with a general mental health condition or substance use disorder as clinically indicated.
• Connective Case Management for Children and Adults with a ratio of 70:1
  • Individuals with an SMI designation, GMH/SU, or children. Focuses on individuals who have largely achieved recovery and who are maintaining their level of functioning. Connective case management involves careful monitoring of the individual’s care and linkage to service. Caseloads may include individuals with an SMI designation and individuals with a general mental health condition or substance use disorder as clinically indicated.

Providers are responsible for ensuring the integrity of the role of the Dedicated Health Care Coordinator, as outlined in AMPM 570, by empowering the DHCC to facilitate the delivery of behavioral health services; enhance treatment goals and treatment effectiveness; and coordinate services for members with High Needs.

Integrated Health Homes should not blend or otherwise combine caseload ratios, as specified in Attachment A, without express written approval from AHCCCS.

 

13.1.8.3   Requirements for Integrated Health Homes in Meeting the Needs of Members with High/Complex Needs

Support and rehabilitation services are an essential part of home and community-based practice and culturally competent care. These services help children live successfully with their families and in the community. These services, in combination with all covered behavioral health services, are included in a service plan that is individualized to the strengths, needs, and culture of the family. Services are continually monitored by the Child and Family Team (CFT) for effectiveness per AMPM 580, Child and Family Team. Refer to AMPM Policy 310-B and AMPM 582 for further information on support and rehabilitation services.

Integrated Health Homes are expected to:

•  Provide 24/7/365 wraparound services as clinically appropriate when planned in advance.
•  Maintain low Dedicated Health Care Coordinator to member ratios. Requires Integrated Health Homes that serve children with High Needs to ensure that the ratio of DHCC’s to Children with High Needs does not exceed 1:25. A ratio of 1:15 is preferred.
• Provide Intensive Community Based Support that improves member outcomes and reduces the number of members in Out of Home placements, reduces Emergency Department visits, and reduces Inpatient stays by providing appropriate support in the member’s community and home.
• Maintain an adequate number of Direct Support Staff to meet the needs of High Needs members.

 

13.18.2   Integrated Health Home Access to Care Requirements

Providers must adhere to the following access to care requirements.

 

13.18.2.1   Screening

Providers must perform various screening and assessment services:

• Providers must apply for AHCCCS coverage on behalf of members through Health-e Arizona Plus and assist members in renewing their AHCCCS enrollment by completing applications on their behalf through Health-e Arizona Plus and not refer persons to DES offices.
• Offer in-person screenings and assessments for Medicaid, SMI, SED, SUBG and MHBG eligibility at no cost to members or persons requesting the screening/assessment.
• Provide intake, assessment and coordination services in the community, hospitals, nursing homes, state agency offices, detention, jail and prison facilities, specialty provider offices and member's homes.
  • Providers must screen youth and adults for substance use disorders utilizing a standardized screening tool, at minimum:
  • At intake;
  • Bi-annually for children and annually for adults; and
  • Within 7 days of reported or suspected problematic use.
• If a screening yields positive results, members must receive a more comprehensive assessment to include substance use history, current use, and trauma.
• Ensure that all Comprehensive Assessments, Individualized Service Plans, and Assessment Updates are signed by a Health Plan-Credentialed, Licensed Behavioral Health Professional or Behavioral Health Medical Professional within 72 hours after the member received the assessment.

 

13.18.2.2   Referrals

Providers must perform various activities related to referrals:

• Establish written criteria and procedures for accepting and acting upon referrals, including emergency referrals. The written criteria must include the definition of a referral for health services as described by the State.
• When a member requests to access Covered Services, there shall be no wrong door. The Health Plan and Provider are required to respond when a member requests Covered Services and follow through to ensure the member receives appropriate services. Provider is required to assist any member with obtaining Covered Services for which the member is eligible, from the Participating Health Care Providers best suited to deliver effective services to member.
• Integrated Health Home providers must accept all referrals for intakes and services for populations identified provider’s contract with the Health Plan unless the Health Plan grants a written waiver or suspension of this requirement.
• Accept all referrals regardless of diagnosis, level of functioning, age, member's status in family or level of service needs.
• Make appropriate referrals to and schedule appointments with In-Network Specialty Providers to meet members' treatment needs and effectively coordinate care.
• Have a process to verify all Network options have been explored and exhausted before completing a request for out-of-network services. Providers must notify the Health Plan of all Out-of-Network requests.
• Providers understands that all community residents, including visitors, are eligible to receive crisis services and providers must assist anyone experiencing a crisis in obtaining crisis services through the Health Plan contracted crisis provider by calling the statewide crisis line.

 

13.18.2.3   Outpatient Services

Providers must offer outpatient services identified in the provider’s agreement with the Health Plan, including intakes, comprehensive assessments, service planning, coordination of care and outpatient services to all populations specified in the provider’s agreement with the Health Plan.

Case management services shall be provided by individuals who are qualified BHPs or BHTs/BHPPs supervised by BHPs. Case Management is a provider level supportive service provided to improve treatment outcomes (reference AHCCCS AMPM 310-B and AMPM 570). Examples of case management activities to meet member’s Service Plan goals include: 

•  Assistance in maintaining, monitoring, and modifying behavioral health services
• Assistance in finding necessary resources other than behavioral health services
• Coordination of care with the member’s healthcare providers, Family, community resources, and other involved supports including educational, social, judicial, community and other state agencies
  • Coordination of care activities related to continuity of care between levels of care (e.g., inpatient to outpatient care) and across multiple services (e.g., personal assistance, nursing services, and family counseling)
  • Assisting members in applying for Social Security benefits when using the SSI/SSDI Outreach, Access, and Recovery (SOAR) approach; including:
  • Face-to-face meetings with member
  • Phone contact with member, and 
  • Face-to-face and phone contact with records and data sources (e.g., jail staff, hospitals, treatment providers, schools, Disability Determination Services, Social Security Administration, physicians).
    • SOAR services shall only be provided by staff certified in SOAR through SAMHSA SOAR Technical Assistance Center.
    • When using the SOAR approach, billable activities do not include:
    • Completion of SOAR paperwork without member present
    • Copying or faxing paperwork
    • Aiding members with applying for benefits without using the SOAR approach, and
    • Email.
  • For provider case management used when assisting members in applying for Social Security benefits (using the SOAR approach) the modifier HK is required.
  • Billing T1016 with an HK modifier indicates the specific usage of the SOAR approach and it cannot be used for any other service.
• Outreach and follow-up of crisis contacts and missed appointments, and
• Participation in staffing, case conferences, or other meetings with or without the member or their Family participating.
• For provider case management used to facilitate a Child and Family Team (CFT), the modifier U1 is required.

Case Management limitations include:

• Billing for case management is limited to providers who are directly involved with providing services to the member;
• Provider Case Management is not a reimbursable service for ALTCS E/PD, including Tribal ALTCS. Case Management is provided through the ALTCS E/PD Contractors or Tribal ALTCS Program;
• Provider Case management services provided by licensed inpatient, residential (BHRF) or day program providers are included in the rate for these settings and cannot be billed separately. However, providers other than the inpatient, residential (BHRF) facility, or day program can bill case management services provided to the member;
• A single practitioner may not bill case management simultaneously with any other service;
• For assessments, the provider may bill all time spent in direct or indirect contact (e.g., indirect contact may include email or phone communication specific to a member’s services) with the member and other involved parties involved in implementing the member’s Treatment/Service Plan;
• More than one provider agency may bill for case management at the same time if it is clinically necessary and documented within the member’s Treatment/Service Plan;
• More than one individual within the same agency may bill for case management at the same time, if it is clinically necessary and documented within the member’s Treatment/Service Plan; and
•  When a provider is picking up and dropping off medications for more than one member, the provider shall divide the time spent and bill the proper case management code for each involved member. 

 

13.18.2.4   Transportation

Effective October 1, 2021, all transportation claims for non-emergency medical transportation must be routed through the Health Plan’s contracted broker/vendor. Integrated Health Homes are required to ensure members have transportation to medically necessary services including pharmacy. Integrated Health Homes and eligible providers may contract with the Health Plan’s transportation broker/vendor to provide transportation through their own fleet of vehicles.

Any subcontracted transportation provider is required to be credentialed with the Health Plan and broker.

Providers shall maintain all records in compliance with the noted specifications for record keeping related to transportation services. It is the responsibility of the provider to maintain documentation that supports each transport provided and as outlined in AHCCCS AMPM Policy 310-BB https://www.azahcccs.gov/shared/MedicalPolicyManual/. Transportation and non-emergency transportation services are covered to transport a member to AHCCCS registered facilities for medically necessary, covered services, as identified in the treatment plan. Services may also include any of the following local community-based support programs as identified in the member’s service plan:

• Alcoholics Anonymous (AA)
• Narcotics Anonymous (NA) Cocaine Anonymous
• Crystal Meth Anonymous
• Dual Recovery Anonymous
• Heroin Anonymous
• Marijuana Anonymous
• Self-Management and Recovery Training (SMART Recovery)
• National Alliance on Mental Illness (NAMI) Family Support
• Living Well with a Disability and Working Well with a Disability Program

 

13.18.2.5   Answering Service

After-Hour Requirements	PCPs and specialist providers are required to maintain sufficient access to needed health care services on an ongoing basis and must ensure that such services are accessible to members as needed 24 hours a day, seven days a week.
Answering Machine and or Answering Service	·  Must meet language requirements ·  Should be able to reach the PCP or other designated medical provider ·  All calls need to be returned within 30 minutes ·  Should be on after business hours ·  Should direct members to call another number to reach the PCP or other designated medical provider ·  A live person should be available to answer the designated phone number; another recording is not acceptable ·  Provide members with clear and simple instruction on after-hours access to medical care
Transferred Phone Call	·  Calls can be transferred to another location where a live person will be able to assist and can contact the PCP or another designated medical provider ·  All calls need to be returned within 30 minutes
Examples of unacceptable after-hours coverage include, but are not limited to	·  Calls received after-hours are answered by a recording telling callers to leave a message; ·  Not returning calls or responding to messages left by patients’ after-hours within 30 minutes

 

13.18.3   Integrated Health Home Outreach, Engagement, Re-Engagement, and Closure Requirements

In addition to the requirements of Section 13.5 Outreach, Engagement, Re-Engagement, and Closure, Providers must cooperate with the State and the Health Plan outreach and marketing initiatives, and conduct outreach, engagement, re-engagement and closure as described in this Provider Manual. Providers funded to employ dedicated outreach staff must work closely with all community system partners and residents, including incarcerated community members to educate them about services and help them get enrolled in Medicaid and/or the Health Exchange. Providers must offer outreach and engagement services to persons who are homeless, involved in the criminal justice system, experiencing co-occurring mental health disorders and at-risk populations. Providers must offer regular contact with members residing in detention centers a minimum of once every (30) days up to the time the member is released from detention. Upon request, providers must provide outreach and dissemination of information to the general public, other human service providers, county and state governments, school administrators and teachers and other interested parties regarding available services.

Providers may be notified when a member has been booked into a detention center. For those members who are active, the provider must hold an emergency Integrated Team Meeting within one (1) business day of notification of release. For those members who are inactive, the provider must outreach the individual upon notification of booking and schedule an intake to be held within seven (7) days of release.

Providers must facilitate and document in the member's clinical record effective engagement, including obtaining and maintaining accurate support system names and contact information, up-to-date member information with contact information, following up after missed appointments, and engaging peers and support systems to facilitate effective engagement.

 

13.18.3.1   Marketing Limitations

Providers must comply with various outreach and marketing limitations.  All marketing materials shall identify the provider as the Health Plan, AHCCCS and the State provider.

In addition, all marketing materials produced by the provider that refer to the services defined in the agreement must specify that the services are funded through the provider agreement with the Health Plan. The provider is also required to list the Health Plan and the State as the funding source on all brochures, flyers, and other promotional materials that involve services funded by the Health Plan and the State. Providers must include the Health Plan logo on these marketing materials and confirm approval from the health plan prior to dissemination.

 

13.18.4   Integrated Health Home Enrollment, Demographic, Connectivity, Software, Web and Electronic Health Record Requirements

13.18.4.1   Electronic Health Record (EHR) and Health Information Exchange (HIE) Requirements

Providers must meet various requirements regarding paper and electronic records. Providers must:

• Have a fully operational EHR, including, electronic signature, and remote access. In addition, allow the State and the Health Plan staff remote read-only access to the EHR for the purpose of conducting audits.
• Ensure all paper files are fully archived and the provider is no longer dependent on paper files to conduct or document treatment services.
• Ensure provider is EHR is certified to fully meet the Federal "Meaningful Use Requirements".
• Establish and maintain membership with, and bi-directional data connectivity to, the state Health Information Exchange, “The Network/AZHeC.”

 

13.18.4.2   Software

Providers must meet various requirements regarding equipment and licenses. Providers must:

• Ensure each outpatient clinic location licensed by the ADHS Division of Licensing has access to video equipment to facilitate treatment and treatment team meetings for persons with health, or disability limitations and special circumstances that prevent them from traveling to an office. Provider must maintain availability of telemedicine and video equipment to meet this requirement.
• Ensure members have access to specialty services and consultation services through telemedicine, portable telemedicine, or video equipment and not be required to travel more than thirty miles to receive specialty services (except when required by state or federal law). In addition, utilize clinical expertise through consultants when appropriate to provide treatment services in the community, prevent out-of-home placements and allow members to remain in their communities.
• Ensure that each outpatient clinic location licensed by the ADHS Division of Licensing is equipped with at least one (1) fully functional Polycom Speaker Phone system with (2) two microphones to facilitate effective communication during treatment team meetings to allow access to system partners and family members who desire to attend treatment team meetings telephonically.

 

13.18.4.3   Access to Web and Website

Providers must make available to the Benefits Coordinator and members at least one computer with internet access at each outpatient facility licensed by the ADHS Division of Licensing. The computers must be available during hours of operation to conduct eligibility screening activities through Health-e Arizona. Providers must make available easy access of information by members, family members, providers, system partners, and the general public in compliance with the American with Disabilities Act (ADA).

In addition, providers must develop and maintain a website and include the following information on its website that is easy to find, understand and navigate:

• Identify the Health Plan as an MCO/Health Plan for your service area and provide a link to the Health Plan website.
• Toll-free customer service telephone number and a Telecommunications Device for the Deaf telephone number.
• General customer service information, including information on community resources, how to file a grievance or grievance, and interpreter services.
• Crisis phone numbers and how to access the crisis services.
• Identify site locations and services provided to members.

 

13.18.4.4   Management Information System (MIS) and Performance Criteria

Providers must meet the following MIS and performance criteria:

• Use the Health Plan approved MIS to collect, analyze, integrate, and report data.
• Utilize electronic transactions in conformance with requirements.
• Prior to implementation, notify the Health Plan of planned MIS changes, the estimated impact upon the interface process, and test with the Health Plan, if the provider plans to make any modifications that may affect any of the data interfaces. Provider shall not implement the proposed change until the Health Plan evaluates and approves such.
• Verify that changing or making upgrades to or implementing new systems that are or are related to the core MIS, claims processing, or any other business component, will be accompanied by a plan which includes a timeline, milestones, and adequate testing before implementation date, the Provider must provide the system change plan to the Health Plan for review and comment.
• Notify the Health Plan in advance of the exact implementation date of all changes and cooperate with the Health Plan if the Health Plan elects to monitor MIS changes for operability and sustainability.

 

13.18.4.5   Compliance with Health Information Portability and Accountability Act (HIPAA)

Compliance with Health Information Portability and Accountability Act (HIPAA); including 42 CFR Part 2 regulations.

Providers must comply with all federal HIPAA requirements, verifying the safety of all member information. In addition, providers are required to document ongoing employee education on the confidentiality requirements and the facts that disciplinary action may occur upon inappropriate disclosures.

 

13.18.4.6   Notice of Changes

The Health Plan shall provide provider with at least ninety (90) day notice before implementing a change to its MIS system unless the Health Plan determines that the system change must be implemented sooner, and in that instance, provide provider with as much notice as possible under the circumstances.

 

13.18.5   Integrated Health Home Staffing Requirements

Integrated Health Homes are required to have organizational, management, and administrative systems capable of meeting all contract requirements with clearly defined lines of responsibility, authority, communication, and coordination within and between departments, units, or functional areas of operation. Integrated Health Home’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with contract requirements, including the requirement to provide culturally competent services. Providers are required to have sufficient staff and utilize appropriate resources to comply with contract requirements. Providers must require all staff, whether employed or under contract, to have the training, education, experience, orientation, and credentialing, as applicable, to perform assigned job duties.

 

13.18.5.1   Certified Health Care Coordinators and Dedicated Health Care Coordinators

Providers must maintain a sufficient number of Certified Health Care Coordinators and Dedicated Health Care Coordinators who are able to coordinate services for members. Providers must verify the Professional job responsibilities associated with the role of Certified Health Care Coordinator are clearly defined and include:

• A clear understanding of how to help facilitate an effective treatment team meeting.
• The empowerment of members to direct their own care.
• Monitoring treatment to verify services are identified and performed in accordance to the wishes of members and Evidenced Based Practices.
• Verify the availability of direct support including support and rehabilitation services to optimize opportunities for recovery and increased resiliency.
• Verify appropriate coordination among providers of care and Stakeholders.
• Verify children have the resources and services to progress to be successful adults.

 

13.18.5.2   Behavioral Health Professionals

Providers must assign credentialed Behavioral Health Professionals to provide clinical oversight in the member's care and monitor progress towards meeting goals in the Service Plan, coordinate and communicate with other systems where clinical knowledge of the member's care is important (42 CFR 438 208(b) (1)); and verify that all services provided to the member, including Transportation meet medical necessity. Additionally, providers will meet requirements regarding sufficient BHPs for oversight and supervision of BHTs and BHPSS as outlined in AMPM 310-B 

Providers must verify Behavioral Health Medical Professionals, Behavioral Health Professionals, Behavioral Health Technicians and Behavioral Health paraprofessionals meet all of the requirements as identified by the ADHS Division of Licensing. Providers must verify all persons hired into these roles meet the requirements as defined by any additional state regulation.

The Health Plan promotes a network of Trauma Informed Care (TIC)-certified therapists. The Health Plan will analyze the network sufficiency of TIC-certified, and/or trauma-competent therapists. Integrated Health Homes must provide trauma screenings for youth, adults, and families. Behavioral Health Providers must ensure the provision of Trauma Informed Care Services, including routine trauma screenings and ensuring sufficient capacity of therapists trained to work with members with trauma, preferably, TIC Certified and/or certified in trauma-focused Evidence.

Clinical Oversight and Supervision by BHPs

In addition to possessing the requisite licenses and other qualifications, BHPs providing clinical oversight and/or supervision of BHTs and/or BHPPs shall have demonstrated competence in delivering the same or similar services to members of comparable acuity and intensity of service needs as the BHTs they supervise. BHPs providing clinical oversight of BHTs shall also demonstrate the following key competencies:

1. Demonstrated knowledge of the relevant best clinical practices and policies that guide the services being provided,
2. Demonstrated knowledge of the policies and principles governing ethical practice,
3. Demonstrated ability to develop individualized BHT competency development goals and action steps to accomplish these goals, and
4. Demonstrated ability to advise, coach, and directly model behavior to improve interpersonal and service delivery skills.

 

13.18.5.3   Child and Family Team and Adult Recovery Team Facilitators

Providers must verify an adequate number of staff are trained and certified as Child and Family Team (CFT) Facilitators, and/or Adult Recovery Team (ART) Facilitators.

 

13.18.5.4   Administrator On Call

Providers must maintain an administrator–on-call to address any after-hours, weekend or holiday concerns or issues related to coordination of care or the health and/or safety of members. The Administrator-on-call must respond to all requests, including requests from the Health Plan contracted Crisis Line Provider, within one (1) hour of being called.

 

13.18.5.5   Independently Licensed Staff

Provider must verify the availability of the Health credentialed independently licensed staff to determine medical necessity, provide adequate oversight and supervision of service delivery.

 

13.18.5.6   Clinical Supervisors

Providers must verify all Clinical Supervisors meet the requirements of the appropriate Arizona Licensing Board to conduct Clinical Supervision.

 

13.18.5.7   Medical Director

Providers must employ a Medical Director to oversee prescribing practices at the provider’s facilities, process Court Ordered Treatment (COT) documents, provide clinical consultation and serve as the collaborating physician for Nurse Practitioners in the agency. Medical Directors, or their designee, need to be available after hours for revocations of outpatient court ordered treatment under Title 36. A.R.S. § 36-540. Providers must verify the Medical Director Attends the regular Medical Director Meetings with the Health Plan.

 

13.18.5.8   COT/COE Coordinator

Providers must designate a staff person to serve as COT/COE Coordinator and Liaison for Title 36 and Court Ordered services.

 

13.18.5.9   Information Liaison of the Day/Point of Contact

Providers must designate one person to serve as the Information Liaison of the Day (point-of-contact) for system partners, foster families seeking services, and specialty providers to call to obtain information about services, referrals, updated Comprehensive Assessments, Individualized Service Plans, and monthly reports. They must provide the name and contact number for the Information Liaison of the Day monthly to the Health Plan as part of the key contact list. The phone number for the Information Liaison of the Day must be live answered. All calls to the Information Liaison of the Day must be addressed and resolved within one (1) business hour of the call. Callers must be warm line transferred to the Information Liaison of the Day and callers are not to be told to call another number.

Providers must also orient members and their Healthcare Decision Maker (HCDM) or Designated Representative (DR) to the Information Liaison of the Day protocol. Ensuring members and their HCDM/DRs are aware of this process will ensure that their needs are addressed even if an assigned case manager is not available.

 

13.18.5.10                Peer Support

Integrated Health Homes are required to educate members about the role of Peer Support / Recovery Support Specialists and are required to make Peer Support / Recovery Support Specialists available to all members receiving services and to ensure members are introduced to Peer and Family Run Organizations.

In addition, providers must demonstrate that Peer Support Specialists and Family Support Specialists meet minimum training requirements. Providers must empower members and family members to take "personal ownership" of their Individualized Service Plans, Crisis and WRAP Plans, treatment services, recovery strategies, and to advocate for themselves.

 

13.18.5.11                Parent/Family Support Partners

Integrated Health Homes are required to educate members about the role of Parent/Family Support Partners and are required to make Parent/Family Support Partners available to all families of members receiving services. Adult members’ families are defined as “families of choice,” determined by the adult member.

 

13.18.5.12                Substance Use Treatment Staff

Providers serving adults and youth with substance use disorders must train 100% of all Assessors, and Behavioral Health Professionals in the Best Practice of ASAM through a training program approved by the Health Plan. In addition, providers providing substance use treatment services must verify that services are delivered by staff competent to assess and treat substance use disorders in individuals and families. Providers serving adults must employ or make available an adequate number of registered/wavered Buprenorphine Prescribers to meet the needs of members with substance use disorders under the Provider’s care.

 

13.18.5.13                Nursing Staff

Providers must employ or make available adequate nursing staff to administer injectable psychotropic medications at all Outpatient Treatment Centers.

 

13.18.5.14                Psychiatrists

Providers must employ a sufficient number of BHMPs to meet member access to care standards.

 

13.18.5.15                Telemedicine

Providers delivering telemedicine services must ensure adequately and appropriately trained staff are available prior to the provision of the telemedicine service to conduct any required vitals.

Providers delivering telemedicine services must adhere to confidentiality expectations of the telehealth session by ensuring no other person, other than those agreed to by the member receiving services, will observe or monitor the service either electronically or from “off camera. For more information regarding confidentiality during a telemedicine session. Please see AHCCCS AMPM Policy 320-I and AHCCCS AMPM Policy 940 for more information regarding confidentiality safeguards.

The provider must, however, offer the member the option of having a telepresenter present during the telehealth session. A telepresenter is defined as a designated individual who is familiar with the member‘s case and has been asked to present the member‘s case at the time of telehealth service delivery if the member‘s originating site provider is not present. The telepresenter must be familiar, but not necessarily a medical expert with the member‘s medical condition, in order to present the case accurately. The telepresenter also is required to assist the member after the telehealth session in scheduling any required follow-up appointments and/or getting prescriptions filled.

In addition, for providers that have BHMPs and BHPs providing eighteen or more hours a week of telemedicine services on behalf of the provider, it is recommended to host semi-annual one-day “meet and greet” events “in person” in the communities where the telemedicine services are provided to give members and system partners the opportunity to meet telemedicine BHMPs and BHPs in person.

 

13.18.5.16                Discharge Planners/Hospital Liaison Role Definition and Responsibilities

In addition to the requirements of Section 4.12 Discharge Planning, the Integrated Health Home or FFS provider discharge planner/hospital liaison is also responsible for the following:

• Integrated Health Home Discharge Planner/hospital liaison serves as the lead for coordination of care for members for the duration of hospitalization upon notification of admission.
• Integrated Health Home discharge planner/hospital liaison is responsible to notify the Health Care Coordinator of member’s inpatient status.
  • Integrated Health Home discharge planner/hospital liaison is responsible to send the clinical packet of information to inpatient facility. Documents include:
  • Most recent psychiatric evaluation,
  • History & Physical from Primary Care Provider, if available,
  •  Medications list from Behavioral Health Medical Provider & PCP,
  • Most recent BHMP note,
  • List of current diagnoses,
  • Current Individualized Service Plan & Crisis Plan,
  • Allergies or past poor reactions to medications,
  • Anticipated target level of functioning upon discharge from hospital services,
  •  Tentative Discharge Plan
• Behavioral discharge planner/hospital liaison is required to make contact with members within 48 hours of admission date/time. This can be via phone if admission occurs out of county or state, preferred method is a face-to-face visit.
• Health Home discharge planner/hospital liaison is required to document discharge planning efforts in the member’s medical record.
• Integrated Health Home discharge planner/hospital liaison is required to connect with the Health Plan Discharge Integrated Care Managers to provide an update on the initial discharge plan at 72 hours from date and time of admission, and to communicate updated discharge plans prior to discharge. The Integrated Health Home Discharge Planner/hospital liaison is required to communicate any barriers to discharge to the Health Plan Discharge Integrated Care Managers. If the Health Home discharge planner/hospital liaison encounters barriers related to the discharge plan and resources, the Health Plan Discharge Integrated Care Managers will outreach the Utilization Management Reviewer and/or the Integrated Care Managers/Care Coordinator for assistance.
  • Integrated Health Home discharge planner/hospital liaison schedules an Adult Recovery Team Meeting (ART) /Child & Family Team (CFT) meeting to take place at the inpatient facility, for every behavioral health admission and as clinically needed for physical health admissions. Attendees required to attend for both behavioral and physical health and behavioral health ART/CFT Meetings, should include the following at a minimum:
  • Representation from inpatient facility such as hospital social worker/discharge planner/Health Care Coordinator (with updates on member status, medication changes, doctor recommendations, estimated discharge date),
  • Integrated Health Home Discharge Planner/Hospital Liaison, Integrated Health Home Health Care Coordinator, & member, (Guardian if under 18, POA, Public Fiduciary or Title 14.)
  • The Integrated Health Home Discharge Planner/hospital liaison facilitates ART/CFT. Other attendees may include, therapist, peer support, member’s natural support, and inpatient facility unit charge nurse.
• Integrated Health Home discharge planner/hospital liaison is required to facilitate scheduling a conversation between the Integrated Health Home BHMP and Attending Psychiatrist, PCP and attending physician, as requested or if the team is unable to agree on a safe disposition plan. Integrated Health Home medical director and the Health Plan medical director may take part in these discussions, as appropriate.
• Integrated Health Home discharge planner/hospital liaison is required to create a new Individualized Service Plan and Crisis Plan that provides additional resources and supports to decrease chance of member readmission in addition to updating the annual assessment.
  • Integrated Health Home discharge planner/hospital liaison is required to work closely with Integrated Health Home Utilization Management Point of Contact and the Health Plan Utilization Management Reviewer regarding authorizations related to step down from the hospital to another level of care. Requests, which may come from the Integrated Health Home or the inpatient or out-of-home facility, are required to be submitted via Provider Portal or via fax according to instruction. Any questions related to receipt of authorization requests, status updates, or general questions related to authorization procedure or required documents should go to the Health Utilization Management PA #: 866-796-0542.
  • Modification for type of authorization: It is the responsibility of the Integrated Health Home discharge planner/hospital liaison to submit the request for authorization for Behavioral Health placement, and other behavioral health needs on the ISP;
  • It is the responsibility of the Hospital Social Worker/Discharge planner/Health Care Coordinator to submit authorization request for physical health placement, Durable Medical Equipment, Home Health-IC Inpatient Utilization Management reviewer to follow up with the Health Plan outpatient reviewer on status of authorizations related to discharge plan, such as placement, medical equipment, etc.
• Integrated Health Home discharge planner/hospital liaison must provide the member with the following appointments:
  • For Behavioral Health Admission: behavioral health medical Provider within 7 calendar days of member’s discharge from facility.
  • For Physical Health Admission: primary care provider within 7 calendar days of member’s discharge unless medically indicated to see provider sooner.
• Integrated Health Home discharge planner/hospital liaison is required to complete a verbal and written handoff to the ongoing RC upon member discharge, including review of the discharge summary from the hospital.
• Ongoing, the Health Care Coordinator is required to outreach the member to ensure follow through with aftercare plan including but not limited to placement, behavioral health services, pharmacy issues, outpatient appointments, and medical equipment.
• Ongoing, the Health Care Coordinator is required to outreach the Health Plan Integrated Care Managers/Care Coordinators with a status update on the member’s discharge and aftercare within 14 business days from date of discharge.

 

13.18.5.17                Integrated Health Home Requirements Related to the Discharge Planner/Hospital Liaison Role

• Discharge planning begins at the time of notification of admission to any inpatient facility for Physical and Behavioral Health needs.
• All Integrated Health Home discharge planners/hospital liaisons are required to have a dedicated phone number with voicemail and email address to communicate with the inpatient facility and the Health Plan Utilization Management Reviewer and the Health Plan Integrated Health Care Coordinator.
• The Integrated Health Home discharge planner/hospital liaison must be a Behavioral Health Technician or Behavioral Health Professional; complete the Discharge Planning Curriculum in Relias Learning Management System and pass post‐test with at least 80% accuracy. If the position is filled by a Behavioral Health Technician, all clinical forms related to the discharge planning process must be reviewed and signed by a Behavioral Health Professional at the Integrated Health Home. This includes but is not limited to: Individualized Service Plan, Crisis Plan and Updated Annual Assessment.
•  

13.18.6   Integrated Health Home Requirements Related to Member and Family Involvement

Providers must verify that members, their family members, caregivers, and peers provide input and assist with decision making.

 

13.18.6.1   Member and Family Involvement

Providers must develop a process for members to have regular and ongoing input to assist in decision making, program development, and enhancement of customer service at each provider site where Case Management services are delivered.

Providers must also collaborate with families, children and members as partners, including Family-Run Organizations to facilitate child and family involvement in all aspects of the assessment process, service planning, service delivery, and the evaluation of services and the system.

Providers must verify that the following member-involvement activities are performed as part of the service delivery process:

• Ongoing engagement of the ember, family and others who are significant in meeting the needs of the member, including active participation in decision-making process.
•  Develop and implement service plans that address likely events in a member’s life including transitions to different stages of life, new relationships, new schools, new placements, and transitions to other service delivery systems.
• For members referred for or identified as needing ongoing psychotropic medications for a health condition, verify the review of the initial assessment and treatment recommendations by a licensed medical practitioner with prescribing privileges.
• Members on psychotropic medications receive an updated annual psychiatric evaluation before the twelve (12) month anniversary of the date of last evaluation;
• Continuous evaluation of the effectiveness of treatment through the ongoing assessment of the member and input from the member and other relevant persons resulting in modification to the Treatment Plan, if necessary.
• Child and Family Team/Adult Recovery Team Meetings are scheduled within three (3) business days for all members placed in Brief Intervention Programs or the Assessment Intervention Center.
• Transfers out-of-area, or to an ALTCS Contractor, as applicable.
• Development and implementation of transition discharge, and aftercare plans prior to discontinuation of services.
• Documentation of the above is maintained in the member's health record by the point of contact.
• Assist members locate and obtain permanent housing.
• Providers must accept all transfer following a 24-hour mobile crisis intervention and engage member into services within seven (7) days.
• Additional provider requirements include:
•  Demonstrate documentary evidence to show participation of at least one peer or family member in the interview process when hiring all direct service staff positions. Maintain interview sign-in sheets and produce the sign-in sheets to document compliance with this expectation.
• Verify that every TXIS (T19) adult has a Peer Support Specialist available to be involved with the member’s Adult Recovery Team.
• Verify that members, families, and youth have a voice in their individual treatment decisions and a voice in the operations of the delivery system.
• Obtain and document in the member's record, member and family input in treatment decisions.
• Providers providing substance use treatment must involve peer support staff in all aspects of the treatment process, including outreach, engagement, assessing readiness for treatment, maintaining sobriety and re-engagement.
• Assess the member's perspective on treatment progress, in order to verify that the member and family's perspectives are honored, and they are effectively engaged in treatment planning and in the process of care.

Additional provider requirements specific to Family Involvement include:

• Providers must train their staff on individual implicit bias against families to gain tools to adjust automatic patterns of thinking and reduce discriminatory behaviors towards families engaged in the system.
• Providers must train their staff on best practices of meaningful family involvement for all employees as part of orientation, during the performance review process, and on an ongoing basis. Training shall include frequent review of Arizona Vision and 12 Principles and review of their utilization by individual providers.
• Providers must develop a qualitative and quantitative annual plan to include strategies to incorporate and sustain family involvement.
• Providers must utilize billing modifier, CG, for credentialed parent peer support and track outcomes related to services provided by credentialed parent peer supports.

 

13.1.6.2   Integration of Family into Prevention and Treatment Programs

Parents/caregivers are the first line of “treatment” for their children. Their ability to fully engage and collaborate with providers is critical to positive outcomes. Parent/Caregivers need opportunities for cultivation of skills, development and training, empowerment in practice through mentoring.  Providers must:

• Give to all parents/caregivers information and education on the availability of Parent Peer Partners/Youth Partners, and support groups at Family-Run Organizations (FROs) or in the community to all parents at first contact and at every CFT thereafter.
• Ensure that FRO referral and family inclusion are built into service plan objectives.
• Be sensitive to recognize each family’s  unique background  and relationships and shall draft a treatment plan within consideration of such.
• Give parents/caregivers the opportunity to understand the difference between family support provided by a professional who does not have lived experience and parent peer support provided by a parent peer with lived experience raising a child with behavioral health challenges and other complex needs.
• Ensure that the holistic (physical and behavioral) well-being of the child and family is addressed.
• Include parent, caregiver and youth input when developing training materials at all system levels related to family support, family involvement, and Child and Family Team (CFT) practice.

 

13.18.6.3   Family Run Organization (FRO) Partnership

Description of Family Run Organizations:  AzCH and AHCCCCS recognize FROs as the premier consultants on how meaningful family involvement can be implemented. Integrating Family-Run tools of parent peer support, advocacy, and modeling strategies within all levels of treatment, practice, and policy is critical. Inherent in the identity of FROs is the natural ability and necessary environment to link families with individuals in their communities who share similar experiences in their life’s journey. Without these parent peer connections to other families, stigma may create isolation, self–blame, and other unnecessary barriers that prevent families from reaching out and connecting with available supports and services. To achieve these goals, BH Health Home providers must:

• Create strict capacity limits for parent peer support providers at health homes.
• Ensure consistent, ongoing connection to and collaboration with FROs to strengthen and enhance family voice and choice.
• Ensure connection of any family beginning services with parent peer support partner and/or other forms of FRO support. Parent peer support is not a clinical intervention and therefore not subject to approval by the clinical team. Families shall be allowed to self-refer.
• Recognize FRO’s as the premier source for what family involvement is and how it can be meaningfully implemented.
• Ensure provider staff are educated on the benefits and role  of FROs and  connect members, families, and caregivers to their services upon request.

 

13.18.6.4   Integration of Family into Professional Roles in the Organizational System

AHCCCS System of Care requires that opportunities exist for family members to participate at all levels of the system. This includes the incorporation  of Credentialed Family Support Partners as staff at Health Home locations.  Family voice enriches and strengthens system and treatment outcomes as family members bring an array of experience with raising a child with complex needs. Integration of family members inspires a paradigm shift that focuses on removing barriers and discrimination created by stigma and implicit bias.  Health Home providers must:

• Create substantive positions for family members that include appropriate professional development, training, and mentoring opportunities.
• Create a pathway for professional growth, including a parent/caregiver workforce development plan.
• Understand and create family work roles. Examples of family work roles include Outreach Specialist, Navigator, Community and Family Integration Coordinator/Consultant, Parent/Peer Support Partner, etc.

 

13.18.6.5   Councils and Meetings

Integrated Health Home sites serving multiple members must have regular and ongoing means for members to participate in administrative decision making, quality improvement, and enhancement of customer service at the provider site. Changes made resulting from member or family member participation/feedback shall be reported back to the members and family members served at the site. Child and Family Teams and Adult Recovery Teams do not fulfill this requirement.

The purpose of the Member and Family Advocacy Council is to gather, implement, and report on member and family member feedback. Council members discuss provider-level issues, concerns, and barriers. Council members work together to problem solve identified challenges and strategize on methods to strengthen the service delivery system. Member and Family Advocacy Council requirements include:

• Monthly Member and Family Advocacy Councils
• Provider Executive Leadership Attendance
• Member Inclusion
•  Member and Family Advocacy Champion
• Member and Family Advocacy Council Deliverable

 

1. Council Levels/Structure (3 Levels):
   •  Level I: Provider Level Member and Family Advocacy Council (facilitated by provider)
   • Level II: Health Plan Level Member and Family Advocacy Council (facilitated by Arizona Complete Health-Complete Care Plan)
   • Level III: Health Plan Level Governance Council (facilitated by Arizona Complete Health-Complete Care Plan)
2. Integrated Health Homes shall facilitate, at least monthly, a Member and Family Advocacy Council. This council shall consist of members enrolled with the Health Plan and their family members.
   • The Provider may have their own level or tiered council system in place.
3. Providers shall ensure that all members, family members and required attendees are informed and invited to attend councils.
   • Member and Family Advocacy Council schedule shall be posted in all common areas that are accessible to members/family members, with care and attention to language, and formatting to meet member’s needs.
   • Health Plan Office of Individual and Family Affairs Department shall be provided with a schedule of each council and may attend council meetings periodically.
   • Providers must recruit/recommend members/family members to participate in the Level II: Arizona Complete Health Member and Family Advocacy Council.
   • A staff from the provider’s Executive Leadership Team shall be in attendance to at least 2 meetings per year, and the staff’s full name/title is recorded on the agenda, minutes, sign-in sheet, and deliverable.
4. Member and Family Advocacy Council agendas, meeting minutes, and sign-in sheets shall be made available to Health Plan upon request.
   •  Agendas, sign-in sheets, and meeting minutes shall be maintained and document:
     •  Members and family members had the opportunity to provide feedback and suggest improvements.
     • Changes were made resulting from the feedback.
   • All interventions or activities assigned by the Provider Executive Leadership Staff.   
   •  Unresolved concerns and/or ideas shall be brought to the Level II: Arizona Complete Health Member and Family Advocacy Council.
5. The Provider shall ensure that the composition of their Council is inclusive and diverse enough to be representative of the Providers membership throughout the regions in which they serve (Please see Section 10.2 for full cultural competence requirements).
6. Providers must appoint a Member and Family Advocacy Champion who will be the single point of contact regarding all council matters. The Member and Family Advocacy Champion:
   • Has extensive knowledge/experience pertaining to advocacy and member and family voice inclusion.
   • Holds Peer Support Specialist and/or Family Support Partner credential. Providers who do not currently employ a credentialed Peer Support Specialist or Family Support Partner must contact the Health Plan Office of Individual and Family Affairs at Advocates@azcompletehealth.com for verification and establishment of an appropriate staff to fulfill the Champion role.
   • Identifies as Member and Family Advocacy Council Subject Matter Expert - Responsible for council technical assistance and education for their respective organization.
   • Assumes responsibility for council coordination and ensures all council requirements are met.
   • Ensures all required documentation is maintained and available upon Health Plan request.
   • Attends all required Health Plan technical assistance meetings and/or any other required meetings relevant to the councils.
   • Understands Member and Family Advocacy Council Deliverable requirements and ad hoc requests.

All Integrated Health Homes are required to submit the Member and Family Advocacy Council Monthly Deliverable. This deliverable is due on the 15^th day of each month (for previous month’s data).

A Guidance document and online training is available to assist providers in creating and maintaining Member and Family Advocacy Councils. The Health Plan Office of Individual and Family Affairs is also available for technical assistance and questions. Providers must collaborate with Peer-Run and Family-Run Organizations, involving them in program development activities, peer and family support training, staff trainings, committee meetings, and strategic planning.

 

Youth Advisory Councils

• Integrated Health Homes that serve youth are required to have a Youth Advisory Council (YAC). Members no younger than 14 and no older than 17 are eligible to participate in the Integrated Health Home’s Youth Advisory Council. All youth that meet this criteria at the Integrated Health Home are encouraged to participate.
• Integrated Health Home Youth Advisory Council must meet at a minimum of one time per month but may meet as often as determined by the Youth Advisory Council.
• Each Integrated Health Home must have a sufficient number of facilitators to assure the safety and growth of the Youth Advisory Council.

Providers are expected to assist members to attend Health Plan committee meetings, provider Member and Family Advisory Councils, and the Health Plan Member and Family Councils and Boards.

 

 

 

13.18.7   Integrated Health Home Requirements Related to System Partner Coordination of Care

 

13.18.7.1   Co-Location

Providers are encouraged to seek out and facilitate opportunities to co-locate with state agencies (The Department of Child Safety, Juvenile Probation, and Adult Probation), first responder settings (police, fire, emergency service) or other community settings that facilitate coordination of care between and among systems of care for members receiving services through multiple systems.

 

13.18.7.2   Collaboration with System Partners

Integrated Health Homes must have systems in place to ensure effective collaboration with system partners in accordance with Provider Manual Section 14.4 Coordination of Care with Other Governmental Agencies, by communicating appropriate clinical information, to individuals or entities that are involved in the member's care including primary care providers, schools, child welfare, juvenile or adult probations, ADES, Arizona Department of Corrections (ADOC), Arizona Department of Juvenile Corrections (ADJC), ADES/RSA, ADES/Department of Child Safety (DCS) and other service providers.

 

13.18.8   Integrated Health Home Requirements Related to Delivery of Care

 

13.18.8.1   Medically Necessary Covered Services

Providers must provide all members with medically necessary covered services that are:

• In accordance with the State System Principles in this Provider Manual;
• Identified in collaboration with the member and other persons identified by the member that (a) determine strengths, needs and goals of the member and (b) identify the need for further evaluations necessary for Service Plan development;
• Identified with clinical involvement by a credentialed and trained clinician who is either a Behavioral Health Professional or a Behavioral Health Technician under the supervision of a BHP (42 CFR 438 208 (2) and (3)); and
• Strengths-based and include an emphasis on goals to increase member’s quality of life and involvement in meaningful community activities, including goals related to living, learning, working, and social connectedness. Goals must reflect the member's hopes, dreams, and recovery vision.

 

13.18.8.2   Service Plans

Providers must verify Service Plans meet State, AHCCCS and the Health Plan requirements as outlined in Provider Manual Section 13.6 Assessment and Service Planning.

 

13.18.8.3   Transportation

Providers must provide medically necessary transportation services through the Plan’s broker/vendor or directly to members receiving services as appropriate to facilitate access to care, including evenings and weekends as necessary. Direct provision of transportation services is paid through the Plan’s contracted broker/vendor and requires the provider to contract with the broker directly.

 

13.18.8.4   Assessment

Providers must assess all members for the need for specialty services and ensure the provision and monitoring of the quality and reliability of specialty services. Providers must also ensure that members are assessed for co-occurring mental health conditions and physical disability/disease and these co-occurring issues are addressed, including referral to SOAR if member has no income or seems likely to be eligible.

 

13.18.8.5   Psychiatric Care for Persons with Developmental Disabilities

Providers must verify that all children and adults with Developmental Disabilities who are on psychotropic medications or need to be screened for the need for psychotropic medications receive treatment services from a psychiatrist trained specifically to work with children or adults (appropriate to the member’s age) and with persons with Developmental Disabilities.

 

13.18.8.6   Alternatives to Out-of-Home Care

Providers must promote community-based alternatives to out-of-home care. In situations where a more restrictive level of care is temporarily necessary, providers must work with the member to transition back into community-based care settings as rapidly as is clinically feasible and partner with community provider agencies to develop and offer services that are alternatives to more restrictive institutionally based care.

Providers must deliver services to the extent possible, in the member's home and community in order to minimize out-of-home placements and facilitate a rapid return to the home and community when a member is in an out-of-home placement. Providers must notify the Health Plan Utilization Management (UM) department within 1 business days of placing the Health Plan member into an out-of-home placement.

 

13.18.9   Integrated Health Home Requirements Related to Medical Integration

Providers must provide the following services related to medical integration:

• Encourage all adult members to receive a full physical examination with labs at least once per year, facilitate, and coordinate access to PCPs to reach this goal and monitor member compliance with this expectation.
• Develop and maintain a list of members with chronic conditions including obesity, cardiac conditions, pulmonary conditions, and diabetes.
• Identify reasonable target dates for achieving medical integration goals and maintain acceptable progress toward reaching those goals.
• Collect and maintain vital signs for all adults including blood pressure, pulse, and BMI.
• Collect and monitor lab results specific to any chronic condition including HbA1c (Hemoglobin A1c), Cholesterol, Low-Density Lipoprotein (LDL), High-Density Lipoprotein (HDL), and Triglyceride.
• Incorporate the eight dimensions of wellness into each Title XIX/XXI adult member's Comprehensive Assessment and Individualized Service Plan.
• Collaborate with the Health Plan to reduce the use of emergency rooms for non-life threatening behavioral or medical reasons.
• Collect and submit outcome data as outlined by the Health Plan.
• Become a primary care provider or work with community health clinics to coordinate behavioral health and physical health services and provide integrated behavioral health and physical health care to members.
• Maintain wellness programs and wellness equipment to serve members in each community in which the Provider has an outpatient clinic licensed by the ADHS Division of Licensing.
• Ensure Health Care Coordinators are skilled in promoting wellness and coordinating health and wellness Treatment Plans, and are able to accompany members to PCP appointments, arrange for other health care as needed and monitor health outcomes.

 

13.18.10        Integrated Health Home Requirements Related to ASAM

Providers must maintain at least one current American Society of Addiction Medicine (ASAM) manual at each clinic location.

13.18.11        Integrated Health Home Requirements Related to Hospital Admissions

Providers must comply with all UM and Out-of-Home Provider requirements, per this Provider Manual.

 

13.18.11.1                Information Upon Admission

Providers must provide the following clinical information to the Licensed Hospital, or BH Inpatient Facility and unit staff for all members admitted into the facility on the day of notification of the admission:

• Most recent psychiatric evaluation;
• History and Physical from the Primary Care Provider (PCP), if available;
• Current psychotropic medications to include dosages and frequencies from the Behavioral Health Medical Provider and current physical health medications from the PCP;
• Most recent BHMP note;
• List of current diagnoses;
• Current Individualized Service Plan (ISP) and Crisis Plan;
• Allergies or past poor reactions to medications;
• Anticipated target level of functioning upon discharge from Hospital services; and
• Initial, tentative Discharge Plan.

 

13.18.11.2                Performance Requirements

Providers must meet the following performance requirements:

• Demonstrate that 50% of members that discharge from a hospital facility keep a follow-up appointment within seven (7) days of that discharge;
• Provide a member a minimum of two (2) appointments within eight (8) to thirty (30) days of discharge from a Hospital Facility;
• Demonstrate that 70% of members that discharge from a Hospital Facility keep follow-up appointments within eight (8) to thirty (30) days of that discharge; and
• Demonstrate that readmissions within thirty (30) days do not exceed 12.5% of all Hospital admissions for provider members.

 

13.18.12        Integrated Health Home Requirements Related to Facilities (Licensed Hospital Facilities, Behavioral Health Inpatient Facilities, Behavioral Health Residential Facilities, Behavioral Health Supportive Homes, and Therapeutic Foster Admissions)

Providers must submit the Out Of Home (OOH) request packet to the Health Plan within two work days following a treatment team request for out-of-home placements, and receive prior authorization for Behavioral Health Inpatient Facilities (formerly RTC), Licensed Hospital Facilities (formerly Level I Inpatient), Behavioral Health Inpatient Facility (formerly Level I Sub-Acute Facilities), Behavioral Health Residential, Behavioral Health Supportive Home and Therapeutic Foster Care (TFC) services before admitting a member, unless exemption in writing to this requirement is provided by the Health Plan. See Provider Manual Form 10.1.6, Concurrent Review which can be obtained by calling Customer Service at 1-866-796-0542.

Providers must verify all Child and Family Team (CFT) meetings and Adult Recovery Team (ART) meetings are coordinating regularly with the facility. In addition, providers must verify that all CFT/ART meetings involving persons admitted into out-of-home care include, at a minimum: member and legal guardian, collateral parties, such as Juvenile Probation Officer (JPO) or out-of-home facility staff, and provider agency staff who have clinical knowledge and a relationship with the member. The member's family/natural supports must be included in out-of-home treatment services once the member is admitted.

In addition, providers must verify that an agency representative with clinical knowledge and a relationship with the member attend all scheduled juvenile/adult court hearings in which participation of provider staff would be beneficial to the Courts.

 

13.18.12.1                Discharge Plans/Outpatient Follow Up

Providers must identify and develop discharge aftercare plans prior to admission to an out-of-home placement and must provide outpatient clinical services within seven (7) days of a member’s discharge from a facility.

 

13.18.12.2                Performance Requirements

Providers must meet the following performance requirements:

• Demonstrate that at least 50% of members that discharge from a facility keep a follow-up appointment within seven (7) days of that discharge;
• Provide a member a minimum of two (2) appointments within eight (8) to thirty (30) days of discharge from a facility;
• Demonstrate that at least 70% of members that discharge from a facility keep follow-up appointments within thirty (30) days of that discharge.

 

13.18.13        Integrated Health Care Service Delivery for Integrated Health Homes

Providers must incorporate several elements into its Integrated Health Care service delivery system approach. This includes effective use of a comprehensive Care Management Program. There must be a Treatment Team with an identified single point of contact. The team must include a Psychiatrist or equivalent Behavioral Health Medical Professional and an assigned Primary Care Provider. Care must be whole person oriented and encompass member and family voice and choice, plus use of peer and family delivered support services. There must be an emphasis on quality and safety, accessible care, coordination of care, health education and health promotion services, referrals to appropriate community and social support services, including referral to SOAR if member has no income and/or seems likely to be eligible, use of health information technology to link services, and improved whole health outcomes of members.

 

13.18.13.1                Health Education and Health Promotion

Providers must provide assistance and education for appropriate use of health care services; health risk-reduction and health lifestyle choices including tobacco cessation and screening for tobacco use with the Ask, Advise, and Refer model and refer to the Arizona Smokers Helpline utilizing the proactive referral process; to Adults with SMI to access the Health Plan Crisis Line Provider; for self-care and management of health conditions including wellness coaching; EPSDT services for members including identifying providers that are trained and use AHCCCS approved developmental screening tools; about maternity care programs and services for pregnant members; and self-help programs or other community resources that are designed to improve health and wellness.

• Driving under the influence (DUI) health promotion education and training shall be approved by ADHS, Division of Licensing Services (DLS),
• Health promotion shall be provided by qualified BHPs or BHTS supervised by BHPS, and
• More than one provider agency may bill for health promotion provided to a member at the same time if indicated by the member’s clinical needs as identified in their Service Plan.

 

13.18.14        Additional Integrated Health Home Referral Requirements

 

13.18.14.1                Written Procedures for Referrals to Physical Health Specialists

Providers must establish and implement written procedures for referrals to specialists or other services, to include, at a minimum, the following:

• Referrals to Specialty Physician Services must be from a PCP, except that members have direct access to in-network OB/GYN providers, including Physicians, Physician Assistants and Nurse Practitioners within the scope of their practice, without a referral for preventive and routine services (42 CFR 438.206(b)(2)).
• Adults with SMI that need a specialized course of treatment or regular care monitoring have a mechanism for direct access to a Specialist (for example through a standing referral or an approved number of visits) as appropriate for the member's condition and identified needs. Any waiver of this requirement by the Health Plan is required be approved in advance by the Health Plan.
• A process for the member's PCP to receive all Specialist and Consulting reports and a process for the PCP to follow-up on all referrals. A process to refer any member who requests information or is about to lose AHCCCS eligibility or other benefits to options for low-cost or no-cost health care services.

Laboratory services must be provided by a Participating laboratory provider. Services provided by a non-participating provider or facility must be authorized by the Health Plan prior to the services being provided or the member is responsible for payment. Medically necessary diagnostic testing and screening are covered services.

Participating providers may offer laboratory work in their offices; however, some services are considered bundled charges and are not paid in addition to an office visit fee.

 

13.19.1   Clinical Laboratory Improvement Amendments (CLIA) Certification

Providers must have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver or a certificate of registration along with a CLIA Identification number. In addition, providers must meet all the requirements of 42 CFR § 493, Subpart A. Providers must provide verification of CLIA Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in termination of the Agreement and denial of laboratory claims.

13.19.2   Rules

Pass-through billing or other similar activities with the intent to avoid the requirements listed above is prohibited. Laboratories with certificates of waiver are limited to providing only the types of tests permitted under the terms of their waiver. Laboratories with certificates of registration are allowed to perform a full range of laboratory tests. Providers must manage and oversee the administration of all laboratory services in accordance with all state and federal laws.

Medical tests ordered for diagnosis, screening or monitoring of a condition will be paid by the Health Plan as defined and limited in the AHCCCS Covered Behavioral Health Services Guide and in accordance with the fee schedule in provider’s agreement with the Health Plan.

 

13.19.3   Service Standards/Provider Qualifications

Laboratory and medical imaging services may be prescribed by a licensed physician, nurse practitioner, or physician assistant within the scope of their practice. With the exception of specimen collections in a medical practitioner's office, laboratory services must be provided in CLIA approved hospitals, medical laboratories and other health care facilities that meet state licensure requirements as specified in A.R.S. Title 36, Chapter 4, Federal Clinical Laboratory Improvement Amendments in AAC R9-14-101 and the Federal Code of Regulations 42 CFR 493, Subpart A.

 

13.19.4   Billing/Coding Specific Information

Current Procedural Terminology (CPT) codes are restricted to independent practitioners with specialized training and licenses as outlined in the AHCCCS B-2 Allowable Procedure Code Matrix.

13.20.1   Specialty Providers

13.20.1.1   Staffing Requirements

Specialty Agencies are required to have organizational, management, and administrative systems capable of meeting all contract requirements with clearly defined lines of responsibility, authority, communication, and coordination within and between departments, units, or functional areas of operation. Specialty Agency’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with the requirements of this section, including the requirement to provide culturally competent services. The provider is required to have sufficient staff and utilize appropriate resources to comply with this Provider Manual. Providers must require all staff, whether employed or under contract, to have the training, education, experience, orientation, and credentialing, as applicable, to perform assigned job duties.

 

13.20.1.2   Referrals

Providers must accept all referrals for specialty services that are consistent with its program admission criteria, licensure status, and level of care.

Specialty Providers are responsible for ensuring their agency’s compliance with medical records standards mandated by licensure and/or certification authorities at all times. Crisis providers must obtain appropriate documentation to effectively provide and bill for Crisis Services.

 

13.20.1.3   Refusal/Termination of Services

Specialty providers are not allowed to refuse to serve a referred person except for good cause related to inability of the provider to meet the person's needs safely and professionally, or due to inability to serve the member due to capacity restrictions. Providers may not refuse or terminate services to the Health Plan enrolled member or discharge the Health Plan enrolled member without first coordinating and arranging interim, follow-up or alternative services.

 

 

 

 

13.20.1.4   After-Hours Services

Specialty providers must provide after-hours clinical on-call services to address member concerns and facilitate treatment services as needed. Providers must maintain an administrator–on-call to address any after-hours, weekend or holiday concerns or issues related to coordination of care or the health and/or safety of members.

 

13.20.1.5   Individualized Service Plan

Specialty providers must ensure services identified on the Individualized Service Plan are provided in the timeframe, frequency, and duration as identified on the Service Plan.

 

13.20.1.6   Child and Family Team and Integrated Treatment Team Participation

Specialty providers must participate in person or telephonically in Child and Family Team or Integrated Treatment Team meetings pertaining to members receiving services from the provider as clinically appropriate.

 

13.20.1.7   Treatment Updates

Specialty providers must provide the PCP and Integrated Health Home (if the member has an Integrated Health Home) with regular treatment updates related to services rendered to members as clinically appropriate.

 

13.20.1.8   Diagnosis on Claims

Specialty providers must ensure claims submitted for services contain a diagnosis identified on either the Integrated Health Homes Comprehensive Assessment or the Specialty Agency Assessment at the time of the date of service. Failure to meet this requirement can result in recoupment of payment. Crisis providers must maintain appropriate documentation to effectively bill for Crisis Services.

13.20.1.9   Community-Based Alternatives

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

 

13.20.1.10                Continuity of Care

Specialty providers must ensure coordination and continuity within and between service providers and natural supports to reduce premature discharge/disenrollment and support continuity of care over time.

 

13.20.1.11                Individualized Services and Member Involvement

Specialty providers must ensure services are individualized to meet the needs of members and families. In addition, 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. Providers must obtain and document ongoing engagement of the member, family and others who are significant in meeting the needs of the member, including active participation in treatment decisions which may result in modifications to the member’s service plan.

 

 

 

 

13.20.1.12                HIV Education and Screening

Specialty providers must provide or make available HIV education and screening services to all persons receiving Substance Use Disorder (SUD) treatment services. Providers must work with the Health Plan’s contracted providers of HIV education and screening services to verify all persons have access to the services.

 

13.20.1.13                SUD Treatment Services

Specialty Providers offering SUD treatment services must ensure adherence to the Health Plan’s Provider Manual Section 15.12 Substance Use Disorder Treatment Requirements.

 

13.20.1.14                Quality Improvement Activities

Providers must participate in clinical quality improvement activities that are designed to improve outcomes for Arizona members.

 

13.20.1.15                Electronic Health Record/Electronic Medical Records

Providers are encouraged to have in place a fully operational Electronic Health Record (EHR); including, electronic signature, and remote access, as required to meet Federal Medicaid and Medicare requirements. In addition, providers must allow AHCCCS and the Health Plan staff access to the EHR for the purpose of conducting audits. Providers are required to establish and maintain membership with, and bi-directional data connectivity to, the state Health Information Exchange, “The Network/a”.

 

13.20.1.16                Peer and Family Support Training

Providers must verify that all staff who provide Peer Support or Family Support have the required certification training, ongoing education, and required supervision to support them in fulfilling their position's role.

13.20.2   Behavioral Health Inpatient Facilities and Licensed Hospitals

Providers must comply with the Health Plan’s quality improvement programs and the utilization control and review procedures specified in 42 CFR, Parts 441 and 456, as implemented by AHCCCS and the State. Providers must participate in periodic Quality Management audits and respond to Corrective Action Letters (CALs) related to trends in average length of stay and member satisfaction, polypharmacy, timeliness of staffing, discharge planning and quality care. Providers must not arbitrarily or prematurely reject or eject a member from services without prior authorization from the Health Plan.

Providers must comply with all Utilization Management and facility requirements as outlined in this Provider Manual. This includes the following:

• Timeliness for submission of the Certification of Need (CON) and Re-Certification of Need (RON).
• Required contact with the Health Plan UM Department to discuss clinical rationale for emergent admissions.
• Appropriate documentation of the need for emergent services, including admitting psychiatric evaluation and other clinical data.
• Documentation required within seventy-two (72) hours of the admission date.

 

13.20.2.1   Inpatient Care Assessments

Providers delivering inpatient care (AHCCCS provider types 2, 71, B1, B2, B3, B5 and B6) must provide a comprehensive assessment and treatment plan involving close daily (including holidays and weekends) psychiatric and/or medical supervision based upon provider type and reason for admission. Failure to provide a daily psychiatric and/or medical claim or encounter verifying daily contact with the physician or nurse practitioner will result in a denial of payment.

 

13.20.2.2   Lab Work

All lab work for members must be conducted within industry standards for completeness and timeliness. For example, therapeutic blood levels must be reported within thirty-six to forty-eight (36-48) hours.

 

13.20.2.3   Discharge Planning

In addition to the requirements of Section 4.12 Discharge Planning, providers must demonstrate that discharge planning is started at the time of admission for emergent admissions. Providers must submit the discharge plan to the Health Plan within twenty-four (24) hours of discharge from the facility.

 

13.20.2.4   Medical Care Evaluation Study Methodology and Study Results

Providers must submit the Medical Care Evaluation Study Methodology and Study Results in accordance with this Provider Manual, State Policy and Procedures, AHCCCS Quality Management/Utilization management Plan as requested by the Health Plan.

 

13.20.3  Licensed Hospitals – Specific Requirements

13.20.3.1   Licensing

Providers must meet the requirements of 42 CFR 440.10 and Part 482 and be licensed pursuant to A.R.S. 36, Chapter 4, Articles 1 and 2; or,

• For adults age twenty-one (21) or over, certified as a provider under Title XVIII of the Social Security Act; or,
• For adults age twenty-one (21) or over, currently determined by ADHS Assurance and Licensure to meet such requirements.

Providers must be licensed as a Hospital by the ADHS Division of Licensing if providing emergency inpatient services beyond seventy-two (72) hours. If providers maintain a freestanding psychiatric facility, providers must meet the specific requirements of the ADHS Division of Licensing (i.e., provision of psychiatric acute care). If seclusion and restraint is provided, the facility must meet the requirements set forth by the ADHS Division of Licensing.

 

13.20.3.2   Billing

Providers must abide by the billing limitations as outlined in the AHCCCS Covered Behavioral Health Services Guide; including the following limitations:

• Medical supplies provided to a person while in a hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
• Laboratory, Radiology and Medical Imaging provided by the hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
• Medication provided/dispensed by the hospital/psychiatric hospital are included in the per diem rate and cannot be billed separately.
• The hospital/psychiatric hospital cannot bill for therapeutic leave/bed hold.
• No more than 30% of an individual’ gross monthly household income be sued for the purposes of room and board. This limitation applies only to beneficiaries enrolled with the RBHA, determined to have a serious Mental Illness and residing in a Behavioral Health Residential Facility.
• Outside of Room and Board covered by N19 funding (please refer to section 13.11.2), Room and Board is covered only for Inpatient Hospitals, Intermediate Care Facilities, for individuals with Intellectual Disability (ICF/ID), and Nursing Facilities.

Case management, medical services, family support and peer support services may be billed on the same day as H0018 as long as they are billed through an Outpatient Clinic (77) and not excluded on the AHCCCS B-5 matrix (billing limitations). Providers must accept the Medicaid payment as “payment in full” for all Medicaid enrolled members receiving residential services and cannot bill the member for any ancillary costs.

 

13.20.3.3   Medical Clearance

Providers must maintain capacity to provide basic medical clearance, including vitals, medical history, and review of symptoms. Providers must not require members to obtain a medical clearance prior to accepting the member unless there is an obvious identifiable present or past medical concerns warranting formal medical evaluation or medical tests.

13.20.4   Behavioral Health Hospital Facilities – Specific Requirements

Providers must provide continuous treatment to a person who is experiencing acute and severe behavioral health and/or substance use symptoms. Crisis services may include emergency reception and assessment; crisis intervention and stabilization; individual, group and family counseling; detoxification and referral.

 

13.20.4.1  Accreditation and Licensing

Providers must ensure all Behavioral Health inpatient facilities are accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO"), Commission on Accreditation of Rehabilitation (CARF), or a similar agency and licensed by the ADHS Division of Licensing as a Behavioral Health Inpatient Facility. Providers must meet the requirements set forth by the ADHS Division of Licensing in accordance with 42 CFR 441 and 483 for seclusion and restraint if the facility has been authorized by ADHS Division of Licensing to provide seclusion and restraint. Crisis intervention services may be provided in a setting licensed as a Behavioral Health Inpatient Facility, but which does not require the member to be admitted to the facility.

 

13.20.4.2   Laboratory Services

Providers must complete routine lab services and not refer to emergency rooms to complete routine labs. Laboratory and medical imaging services may be prescribed by a licensed physician, nurse practitioner, or physician assistant within the scope of their practice. With the exception of specimen collections in a medical practitioner's office, provider must verify laboratory services are provided in CLIA approved hospitals, medical laboratories and other health care facilities that meet state licensure requirements as specified in A.R.S. Title 36, Chapter 4, Clinical Laboratory Improvement Amendments in AAC R9-14-101 and the federal code of regulations 42 CFR 493, Subpart A.

 

13.20.4.3   Medical Clearance Exams

Providers must maintain capacity to provide basic medical clearance, including vitals, medical history, and review of symptoms. Providers must not require members to obtain a medical clearance prior to accepting the member unless there are obvious identifiable present or past medical concerns warranting formal medical evaluation or medical tests. Providers must conduct uncomplicated medical clearance examinations and refer to emergency rooms for medical clearance only when medical complications warrant such a referral.

 

13.20.4.4  Weekend and Holiday Discharges

Providers must facilitate weekend and holiday discharges from Behavioral Health Inpatient Facilities and coordinating discharges through the Health Plan Crisis Line provider and the member's affiliated Integrated Health Home.

 

13.20.5   Behavioral Health Inpatient Facilities – Specific Requirements

Providers must provide an integrated residential inpatient program of therapies, activities, and experiences provided to members who are under twenty-one (21) years of age and have severe or acute behavioral health symptoms.

 

13.20.5.1   Notification of Placement

Providers must notify the Health Plan UM department within 2 business days of accepting placement of the Health Plan member into provider’s facility.

 

13.20.5.2   Accreditation and Licensing

Provider Behavioral Health inpatient facilities must be accredited by the Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") or by the Commission on Accreditation of Rehabilitation (CARF) and licensed by the ADHS Division of Licensing as a Behavioral Health Inpatient Facility meeting the specific requirements of the ADHS Division of Licensing. Behavioral Health Inpatient Facilities must meet the requirements set forth by the ADHS Division of Licensing, and in accordance with 42 CFR 441 and 483 for seclusion and restraint if the facility has been authorized by the ADHS Division of Licensing to provide seclusion and restraint.

 

13.20.5.3  Bed Holds

Providers must reserve a member’s bed (bed hold) in the Behavioral Health Inpatient Facility while the member is on an authorized/planned overnight leave. Payment for bed holds is limited to:

• Therapeutic leave to enhance psychosocial interaction or as a trial basis for discharge planning, or
• Admittance to a hospital for a short stay.

 

Payment for bed hold leave days is limited to up to twenty-one (21) days per year (July 1st through June 30th) per member. In addition, Providers must manage bed hold days so as to verify billed bed hold days do not exceed twenty-one (21) days per year.

 

13.20.5.4   Coordination with Health Care Coordinators

Providers must create opportunities for Integrated Health Home Health Care Coordinators to provide face-to-face contact at least once a month with all members placed in out-of-home care.

 

13.20.5.5   Involvement of Family and Other Parties

Providers must make reasonable efforts to verify that all Child and Family Team meetings involving children placed in Behavioral Health Licensed Facilities include, at a minimum: member and legal guardian, collateral parties, such as Juvenile Probation Officer, Division of Developmental Disabilities, or out-of-home facility staff, and provider agency staff who has clinical knowledge and a relationship with the child. Providers must make reasonable efforts to verify that at least one facility staff member who has clinical knowledge and a relationship with the member attends all scheduled court hearings. Providers must make reasonable efforts to verify that the child's family/natural supports are included in out-of-home treatment services while the child is in placement.

 

13.20.5.6   Discharge Plans

Providers must assist in the development of discharge aftercare plans prior to accepting a referral. Providers must make reasonable efforts to provide continuity of care services for children who are placed in detention and assist with discharge and transitional planning to an alternative setting if they are not able to treat the member upon discharge from the detention facility.

 

13.20.6   Residential Facilities – Specific Requirements

Behavioral Health Residential Facility (BHRF) providers must provide an integrated residential program of therapies, activities, and experiences to members in compliance with all relevant provisions in A.R.S § 36-1201.

Providers must collaborate with community system partners, State agency partners, federal agencies, and other entities to identify, educate, and inform on Brief Intervention Programs, Behavioral Health Residential Facility, and Assessment Intervention Center programs, in accordance with the frequency and deadlines as established by the contractor.

 

13.20.6.1   Behavioral Health Residential Facility Services

Behavioral Health Residential Facilities are contracted as an all-inclusive daily rate that includes all program and treatment services (including standard assessments, counseling, peer support and transportation) provided by the BHRF provider. Specialty assessments, counseling, peer and family support, non-program transportation may be provided and billed by third party providers as clinically appropriate but not billed by the BHRF provider. Providers must assist members in maintaining and/or preparing for employment as appropriate and in accordance with AHCCCS protocols. In addition, providers must verify educational resources are available and accessible based upon the individual needs of the member. In addition, AMPM 320-V, providers must provide ongoing psychoeducation services and vocational skills, educational needs assessment, and skill building. Providers must verify that treatment is provided to all members while in the facility including daily life skills training, behavioral management training, emotional regulation training, vocational/academic preparation and support, and social skills training. All members must receive regular medical (PCP) examinations and treatment, as appropriate.

 

13.20.6.2   Mental Health Room and Board and Child Care Services

Reference Provider Manual Section 13.11 Mental Health and Substance Use Disorder Services; Including, Federal Grant and State Appropriations Requirements for eligibility information and requirements related to Mental Health and Child Care Services for members in BHRF facilities accessing these services.

 

13.20.6.3  Referrals

Providers may not arbitrarily or prematurely reject or eject a member from services without prior approval  from the Health Plan. Providers must notify the Health Plan’s UM department within 1 business days of accepting placement of the Health Plan member into a facility. Providers must immediately notify the Health Plan Crisis Line provider whenever a member leaves a facility against medical advice (or AMA), is hospitalized or arrested.

 

 

13.20.6.4   Prior Authorization and Continued Stay Requirements

Providers must meet all prior authorization and continued stay requirements for residential services as spelled out in this Provider Manual, unless granted an exception to this requirement in writing from the Health Plan. Only prior authorized services are eligible for payment by the Health Plan. Respite services provided in a Residential facility do not require prior authorization.

 

13.20.6.5   Treatment Setting and Supervision

Providers must provide residential services that provide a structured treatment setting with twenty-four (24) hour supervision and counseling or other therapeutic activities for persons who do not require on-site medical services, under the supervision of an on-site or on-call Behavioral Health Professional.

 

13.20.6.6   Licensing and Staffing

Residential facilities must be licensed by the ADHS Division of Licensing as a BH Residential Facility. Providers must provide appropriate staffing (including one-on-one staff as needed) to accommodate all referrals who do not require a higher level of care.

 

13.20.6.7  Program Outcomes

Providers must promote and demonstrate the following program outcomes:

• Improved self-regulation;
• Development of appropriate social skills;
• Expeditious return to less restrictive environment;
• Minimal readmission rate;
• Increase in member self-sufficiency;
•  Development of health leisure activities;
• Engagement in ongoing services;
• Decreased risk factors (less runaway behavior, self-harm, aggressive behavior);
• Increased community connections and readiness for employment.

Per the Memorandum of Agreement between the Tohono O’odham Nation and the Health Plan, any provider wishing to deliver services within the exterior boundaries of the Tohono O’odham Nation will need prior approval from the Health Plan and the Tohono O’odham Nation.

 

13.21.1   Approved Providers

A listing of providers approved by the Health Plan and the Tohono O’odham Nation to provide services within the boundaries of the Nation can be located on the Health Plan’s website at https://www.azcompletehealth.com.

 

13.21.2   Quarterly Reporting

All approved providers located and/or delivering services within the exterior boundaries of the Nation, must submit a quarterly service report OI-217 Tohono O’odham Nation Quarterly Report using the designated template outlined in Provider Manual Section 17 Deliverable Requirements.

 

132.1.3   Requesting Approval

Any provider that would like to request approval to deliver services on the Nation should contact the Health Plan’s Tribal Program Development team to initiate the process.

All contracted behavioral health providers and integrated health care providers are required to deliver or assist members in obtaining employment and rehabilitation services. Provider Organizations delivering and billing employment and rehabilitation related activities shall employ at least one fully dedicated Employment Specialist. Provider Organizations delivering and billing for employment and rehabilitation services are required to employ an adequate number of fully dedicated Employment Specialists to meet the needs of the members served in each clinic. It may be permissible with prior approval from the Health Plan Employment Administrator and AHCCCS for the employment/rehabilitation staff to cover more than one clinical team or split time with other duties, based on staffing, availability, regional locations, and enrollment numbers.

Provider Organizations delivering employment and rehabilitation services are required to:

• Monitor employment service utilization including job placement data and ensure accurate and reliable employment status within the Supplemental Member Data Provider Portal.
• Implement Supported Employment and meet SAMHSA Supported Employment fidelity.
• Fulfill the requirements listed in all employment Technical Assistance Documents and provide annual training to all clinical staff on the Technical Assistance Documents.
• Provide benefits planning utilizing Disability Benefits 101 (DB101).
• Adhere to the guidelines within the Interagency Service Agreement (ISA) between AHCCCS and ADES/RSA.
• Provider Organizations serving adults determined Seriously Mentally Ill (SMI) are responsible for ensuring at least a 7% of members with SMI determinations are engaged with RSA/VR services versus the providers’ overall enrollment of members with SMI determinations.
• Make all reasonable efforts to become mutually contracted with ADES/RSA.
• Adhere to AHCCCS ACOM 447 – Employment:

Employment Specialists must:

• Connect members to sustainable employment resources in the community including RSA/VR, AZ@Work, Linkages of Arizona, etc.
• Provide individualized supports to assist members in obtaining and maintaining competitive employment.
• Fulfill responsibilities listed in the ISA/Statewide Collaborative Protocol with ADES/RSA and refer all adults interested in employment services to the RSA VR Program.
• Participate in Health Plan sponsored meetings/events and ad hoc coordination meetings with AHCCCS and ADES/RSA.

 

13.22.1   Referrals for Employment Services

ACC-RBHA members can be referred by their Health Home case manager and/or Health Home employment specialist to employment specialty providers and/or Vocational Rehabilitation (VR) services. Members may also access these employment services directly at an employment specialty provider or VR office.