DELIVERABLE REQUIREMENTS
The following table is a summary of the periodic reporting requirements and is subject to change at any time during the term of the contract. The table is presented for convenience only and should not be construed to limit provider’s responsibilities in any manner. Content for all deliverables is subject to ongoing review. All contractual obligations apply. Reports are to be submitted to AzCHdeliverables@azcompletehealth.com, unless otherwise noted, in the following format: DELIVERABLE #, DUE DATE, PROVIDER NAME. An example is ND601_120115_ABCCOUNSELING.
“Days” means calendar days unless otherwise specified. If the due day is a weekend or a State of Arizona holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday.
Templates will be provided upon request.
Report # | Deliverable Name | Providers Required to Submit | Due Date |
AMPM-1020I –Attachment A | Psychiatric Security Review Board/GEI Conditional Release Monthly Report | Behavioral Providers with Psychiatric Security Review Board (PSRB) Members | 2nd day of the month for the previous months date |
CA-905 | RSS Inventory | Behavioral Health Providers employing Peer Supports | 5th calendar day after quarter end. Submit within the AHCCCS QM Portal https://qmportal.azahcccs.gov/ |
CA-906 | Credentialed P/FSS Inventory | Any BH Provider that employ Credentialed Parent/Family Support Specialists | 5th calendar day after quarter end. Submit within the AHCCCS QM Portal https://qmportal.azahcccs.gov/ |
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CA-909 | Member and Family Advocacy Council Deliverable | Integrated Health Homes | 15th day of each month |
CA-910 | Monthly Warm Line Report | HOPE, Inc. | 5th calendar day of each month |
CD-502 | Department of Economic Security - Professional Foster Care Home License | TFC & BH therapeutic Homes | Within 15 calendar days prior to expiration of each license |
CO-115 | Justice Services Report | Community Health Associates | 5th calendar day of the Month |
EC-301-1b | Daily Pending Inpatient Placement Report | CBI, CHA, Spectrum, Terros | Daily by 10am for previous day. Send to Email Distribution List as agreed upon by parties |
EC-301-6 | Acute Health Plan & Provider Inquiry Log and Detail | AzCH-Complete Care Plan Nurse Assist Line | 20th calendar day of month for previous month |
EC-301-17 | Secondary Responder Activation Report | Devereux, La Frontera-EMPACT, HOPE, Inc., Old Pueblo, TLCR, CFSS | 10th of month for previous month |
EC-301-19 | Report for Pima County-COE detail | CRC | 20th calendar day of month for previous month |
EC-301-22 | Crisis Notifications to Providers | AzCH–CCP Statewide Crisis Line | Daily by 10am to individual/applicable providers |
EC-301-26 | Tribal Crisis Call Template | AzCH-Complete Care Plan Statewide Crisis Line | Quarterly
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EC-301-99 | Crisis Line Dashboard | AzCH-Complete Care Plan Statewide Crisis Line | 10th of every month |
AZ400 | ACC Daily Crisis Notification | AzCH-Complete Care Plan Statewide Crisis Line | Daily |
EC-301-31 | Crisis Observation (COU) Notification of Admissions | CBI, CRC, Southwest, The Guidance Center, ChangePoint | 5th calendar day of the month for previous month |
EC-302 | COT Title 36 Reporting | Behavioral | 2nd business day of the month. All COT portal entries not yet entered for the current reporting month and all required documents that have not yet been submitted for the current reporting month. When sending report, CC the AZCHtitle36@azcompletehealth.com mailbox. |
EC-304 | Prevention Report | Prevention Providers (except COPE & SAAF) | 15th calendar day after month end |
EC-305 | Annual Prevention Report | Prevention Providers | Submission by September 15. |
EC-306 | Prevention Program Description/Logic Model | Prevention Providers | Submission by April 1st |
EC-310 | Annual Heat Plan Update | Integrated Health Home Providers | April 15th |
EC-312 | Crisis Mobile Team Readiness Review | Providers with Crisis Mobile Teams (CBI, CHA, Spectrum, Terros) | 5th of the month for the previous month |
EC-313 | Coalition Detailed Implementation Plan | Prevention Providers | September 15th or 30 days after approved program changes |
EC-314 | HIV Early Intervention Monthly Report | HIV Early Intervention Providers COPE SAAF | 5th calendar day after month end
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EC-319 | Evidence Based Prevention Assessment | Prevention Providers | 15th of July |
EC-321 | T36 Pre-Petition Data | CBI | Last day of the month for previous month’s data |
EC-322 | Scorecard | CRC, HHW, CBI | 29th calendar day after month end |
EC-325 | Living Room Center Admission Report | CHA | 10th day of the month for previous month |
EC-326 | Quarterly SUBG Prevention Activity Report | Prevention Providers (except COPE & SAAF) | 45-days after quarter end |
EC-327 | Prevention Performance Measure Tables 31 & 32 | Prevention Providers (except COPE & SAAF) | 45-days after quarter end |
FN-101 (Formerly FN-501 for the North GSA) | Quarter End YTD Financial Statements (including Year to Date Income Statement, Balance Sheet, Statement of Cash Flow, and financial ratios) | Integrated Health Home Includes RBHA Integrated Health Homes on Case Rate payment method, Fee for Service Payment, Block Payment, or receiving RBHA Integrated Health Home assignments. | 30th calendar day after quarter end. Quarter ending: 3/31/20XX 6/30/20XX 9/30/20XX 12/31/20XX
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FN-401 (Formerly FN-501 for the North GSA) | Quarterly Financial Statements (including Year to Date income statement, Balance Sheet, Statement of Cash Flow, and financial ratios) | -All RBHA behavioral health providers paid via Block Payment. -All Crisis Providers paid via Block Purchase -Excludes specialty, non-crisis providers that are ONLY paid Block Purchase | 30th calendar day after quarter end Quarter ending: 3/31/20XX 6/30/20XX 9/30/20XX 12/31/20XX |
FN-402 (Formerly FN-502 for the North GSA) | *Final Audited Financial Statements *Final Audited Financial Statements for All Related Parties Earning Revenue under this Contract *Final Audited Financial Statements including Income Statement, Balance Sheet, Statement of Cash Flow *Liquidity Ratios and Profit Percentage calculations per terms of the contract | All RHBA providers submitting the FN-101 and FN-401 and all RBHA FFS or as requested by the Health Plan. All providers considered Sub-Recipients of Federal grant funds that are required to complete a Uniform Guidance Audit (see FN-405). | Includes - Integrated Health Home -Crisis Providers -RBHA behavioral health Block Payment -RBHA behavioral health FFS providers receiving Non-Title XIX/XXI funds Due 120 days after provider’s fiscal year end |
FN-403 (Formerly FN-503 for the North GSA) | Non-Title Funding Expenditure Report | Providers that receive funding (Fee for Service or Block) in the following categories: SUBG, MHBG, NTXIX SMI (excluding supported housing), NTXIX Crisis, NTXIX Substance Use Disorder Services (SUD), NTXIX Children’s Behavioral Health Services Funds (CBHSF), Pima County IGA | 30th calendar day after quarter end Quarter ending: 3/31/20XX 6/30/20XX 9/30/20XX 12/31/20XX |
FN-405 (Formerly FN-505 for the North GSA) | Uniform Guidance Audit/ Single Audit | Providers that expend $750,000 or more in federal funds (provider fiscal year), or as threshold is updated in 2 C.F.R. Part 200 from time to time. (Including, but not limited to SUBG (CFDA# 93.959), MHBG (CFDA# 93.958), SOR (CFDA# 93.788), COVID19 Emergency (CFDA# 93.665), MAT-PDOA or PPW-PLT (CFDA# 93.243), and other federal grants as applicable for subawards | 150 days after provider’s fiscal year end
Banner Healthcare Only - 210 days after provider’s fiscal year end |
FN-408 (Formerly FN-508 for the North GSA) | Federal Grant Policies | Providers receiving federal grants including SUBG and MHBG Block Grant Funds, MAT-PDOA, SOR, COVID-19 Emergency, PPW-PLT, and any other future grant subawards. Includes Fee for Service or Block Payment or Block Purchase or Contractor Expenditure Report | By November 1 of each contract year and within 30-days of a new subaward. |
OI-201 | Child Dedicated Health Care Coordinator Inventory | All Integrated Health Home Providers and Specialty providers who have HNCM | 5th calendar day after quarter end. |
OI-202 | Adult Dedicated Health Care Coordinator Inventory | All Integrated Health Home Providers | 5th calendar day after quarter end. |
OI-206 | Housing Roster Report | Achieve, Horizon Health and Wellness, SEABHS, Marana Health, CODAC, COPE, Community Partners Integrated Healthcare, Old Pueblo Community Services, CBI, Pinal Hispanic Council | 2nd calendar day of the Month |
OI-214 | Quarterly Rehab Progress Report | All Integrated Health Homes and Employment Specialty Providers | 2nd calendar day after quarter end |
OI-217 | Tohono O’odham Nation Quarterly Report | Intermountain Centers for Human Development. Community Bridges, Community Health Associates, Spectrum Healthcare | 5th calendar day after quarter end |
OI-235 | Employment Services Monthly Report | All Integrated Health Homes and Employment Specialty Providers | 5th calendar day of the month following |
OI–236 | MAT Census Report | CBI, La Frontera, COPE, CODAC, CMS, HHW, New Hope BH, Wellbeing | 5th calendar day after month end |
RF-101 | Weekly BIP Report | CBI, Cope, CODAC, CPI-H, Devereux, ICHD | Every Friday |
RF-1005 | Incidents, Accidents, and Death Report | All Providers | Within (2) two business days of the incident and the IAD must be entered into the AHCCCS QMS Portal https://qmportal.azahcccs.gov/WF_Public_Default.aspx |
RF-1008 | Notification of Persons in Need of Special Assistance | Integrated Health Home Providers | Due to OHR within (5) five business days of identifying need for special assistance, copy to the Health Plan |
RF-1009 | Notification of Persons No Longer in Need of Special Assistance | Integrated Health Home Providers | Due to OHR within (10) days of identifying individual is no longer in need of special assistance, copy to the Health Plan via secure email |
RF-1010 | Complaint Resolution Confirmation Response | All Providers | Within two (2) business days of the request |
RF-1013 | PASRR Level II Evaluations completed by a Psychiatrist | Contracted/ Approved PASRR Providers | When requested by AHCCCS or the Health Plan, complete evaluation within (3) three business days for hospitalized individuals and within 5 business days for all others. |
RF-1015 | Notification of Change by email or letter of an unexpected material facility change that could impact the Provider Network | All Providers | Within one (1) business day of becoming aware of the unexpected change. |
RF-1016 | Notification of Change Form – for expected material facility changes that could impact the Provider Network | All Providers | At least (90) ninety calendar days prior to the anticipated change that could impact the Provider Network. |
RF-1018 | Ad Hoc Reports not listed | All Providers | As requested |
RF-1022 | Medicare Advantage D-SNP Member Pre-Service Appeals Report | Banner | 10th calendar day of the month |
RF-1023 | Total number of incidents of the use of S&R involving AHCCCS members in the prior month | All Level 1 facilities | 5th of the month for previous month |
RF-1024 | DME Service Delivery Reporting | DME providers (Provider Type 30) | 5th calendar day after quarter end |
RF-1025 | BH Referral to Intake | Integrated Health Homes | 25th calendar day after quarter end |
RF-1026 | Annual Behavioral Health Trauma Informed Care Services Deliverable | Integrated Health Homes | Annually on March 10th |
RF-1028 | TFC 320W Deliverable | All Child Therapeutic Foster Care agencies | Due Semi Annual on June 5th and December 5th and within 30 days of a significant staffing change |
RF-1029 | Therapist Grid | Integrated Health Homes and any Behavioral Health Specialty Provider Agency | June 1st and December 1st |
RF-1031 | Key Provider Contacts Project | Behavioral Health Providers | Due February 1st and August 1st |
RF-1032 | BHRF Smartsheet | Behavioral Health Residential Facilities | Due July 15th and January 15th |
RF-1033 | IOP Smartsheet | Intensive Outpatient Providers | Due August 1st and February 1st |
TR-001 | Call Stats - Service Level | Transportation Broker/Provider | 15th of the month for previous month |
TR-002 | Complaints & Grievances | Transportation Broker/Provider | 15th of the month for previous month |
TR-003 | Executive Summary | Transportation Broker/Provider | 15th of the month for previous month |
TR-004 | Detail and Summary Trip Report | Transportation Broker/Provider | 15th of the month for previous month |
TR-005 | Quarterly Executive Summary | Transportation Broker/Provider | 15th of the month following quarter end for previous quarter |
TR-006 | Blank Grievance Report by LOB | Transportation Broker/Provider | 15th of the month for previous month |
TR-007 | On Time Performance (ACOM 417) | Transportation Broker/Provider | 5th of the month following quarter end for previous quarter |