ValueOptions - Arizona Service Center

Arizona Department of Health Services
Division of Behavioral Health Services
PROVIDER MANUAL
ValueOptions Edition

	Forms and Attachments

SECTION 3	CLINICAL OPERATIONS SECTION

Section 3.1	Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug coverage and the Limited Income Subsidy Program
3.1.1	Tracking of Medicare Part D Enrollment
3.1.1 (Attachment)	AHCCCS Title XIX/XXI Behavioral Health Eligibility Key Code Index
3.1.2	AHCCCS Tracking of Limited Income Subsidy Status
3.1.2 (Attachment)	AHCCCS Rate Codes and Descriptions
3.1.3 (Attachment)	AHCCCS Rate Codes
ADHS AE-01	AHCCCS Eligibility Screening
ADHS AE-08	PM Form ADHS AE-08
ADHS AE-08	FORMA PM ADHS AE-08

Section 3.3	Referral Process
3.3.1	ADHS/DBHS Referral For Behavioral Health Services
3.3.1 (Attachment)	Script for Prompting Invitation of Family

Section 3.4	Co-Payments
3.4.1	Non Title XIX and XXI Co-payment Assessment
3.4.1	Evaluación de Pago Colateral Sin Título XIX/XXI

Section 3.5	Third Party Liability and Coordination of Benefits
3.5.1	AHCCCS Third Party Change Form

Section 3.7	Clinical Liaison
	Clinical Liaison Update Form
	EAD ValueOptions CHILD CSP/Agency/Clinical Liaison Update Form

Section 3.9	Intake, Assessment and Service Planning
3.9.1	ADHS/DBHS Behavioral Health Assessment and Service Plan
3.9.1	ADHS/DBHS Evaluacion de Salud Mental y Plan de Servicios
	Instruction Guide for the Assessment, Service Plan and Annual Update
3.9.1 E	ADHS/DBHS Behavioral Health Assessment and Service Plan - Part E
3.9.1 E	ADHS/DBHS Evaluacion de Salud Mental y Plan de Servicios - Parte E
3.9.2	ADHS/DBHS Birth-5 Assessment
3.9.2	Evaluacion de Salud de Comportamiento ADHS/DBHS: Nacimiento- 5
	Instruction Guide for the Assessment: Birth-5 Service Plan and Annual Update
	EAD ValueOptions 834 EA1011 and Supplemental Demographic Form
	EAD ValueOptions 834 EA1011 and Supplemental Form Instructions
	EAD ValueOptions ADULT CSP/Agency/Clinical Liaison Update Form
	EAD ValueOptions ADULT Quick Reference Guide: Managing CSP, Agency and Clinical Liaison
	EAD ValueOptions CHILD CSP/Agency/Clinical Liaison Update Form
	EAD ValueOptions CHILD Quick Reference Guide: Managing CSP, Agency and Clinical Liaison
	EAD ValueOptions Client Demographic EA1013 Assessment
	EAD ValueOptions Form FAX Submission Sheet

Section 3.10	SMI Eligibility Determination
3.10.1	SMI Determination
3.10.1 (Attachment)	SMI Qualifying Diagnosis
3.10.2 (Attachment)	Substance Use/Psychiatric Symptomatology Table
	Disposition Data Sheet
	Waiver of 3-Day Eligibility Determination
	Renuncia de la Determinación de Elegibilidad de 3 Días
	Provider Checklist

Section 3.11	General and Informed Consent to Treatment
	ADHS/DBHS Form MH-103 Application for Voluntary Evaluation
	ADHS/DBHS Forma MH-103 Solicitud de Una Evaluacion Voluntaria
	Consent for Treatment
	Consentimiento para el Tratamiento
3.11.1	Substance Abuse Prevention Program and Evaluation Consent
	Permiso de Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol

Section 3.12	Advance Directives
3.12.1	Advance Directives Form
3.12.1	Forma de Directivas Avanzadas
3.12.1 (Attachment)	Sample Verbal Explanation About Advance Directives
3.12.1 (Attachment)	MUESTRA DE UNA EXPLICACIÓN VERBAL SOBRE LAS DIRECTIVAS AVANZADAS
	Advance Directives Resource Sheet
	Hoja de Recursos para Directivas Avanzadas
	Advance Directives - Poster
	Directivas de Salud - Poster

Section 3.13	Covered Behavioral Health Services
3.13.1 (Attachment)	Covered Services Matrix

Section 3.14	Securing Services and Prior Authorization
3.14.1	Certificate of Need (CON)
3.14.1 (Attachment)	Admission to Psychiatric Acute Hospital and Sub-Acute Facilities Authorization Criteria
3.14.2	Re-Certification of Need (RON)
3.14.2 (Attachment)	Continued Psychiatric Acute Hospital and Sub-Acute Facility Authorization Criteria
3.14.3	TRBHA Prior Authorization Request Form
3.14.3 (Attachment)	Admission to Residential Treatment Center Authorization Criteria
3.14.4 (Attachment)	ADHS/DBHS Continued Residential Treatment Center Stay Authorization Criteria
	Adult Transitional Treatment Program Application: v.10
	Proposal for Child/Adolescent Residential Treatment Program
	REQUEST for ECT CONSULTATION
	ECT Referral Process
	ValueOptions Authorization Criteria
	THERAPEUTIC FOSTER CARE Family Finding Information and Treatment Goal Summary

Section 3.15	Psychotropic Medications: Prescribing and Monitoring
3.15.1	Informed Consent for Psychotropic Medication Treatment
3.15.1	Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos
	Informed Consent for Electroconvulsive Therapy (ECT)
	Consentimiento e Información para Terapia Electroconvulsiva (ECT)
	MedWatch 3500
	Medication Monitoring Minimum Requirements

Section 3.16	Medication Formulary
	ADHS/DBHS Medication List - Psychotropic Medications
	Prior Authorization Form
	ValueOptions Medication Formulary

Section 3.17	Transition of Persons
3.17.1 (Attachment)	Transfer Protocols Between Comprehensive Service Providers (CSPs)
3.17.1	Interagency CSP Client Transfer Form

Section 3.18	Pre-Petition Screening, Court Ordered Evaluation and Treatment
3.18.1	Police Mental Health Detention Information Sheet
3.18.2	Pre-Petition Screening Report
	ADHS MH-100, Application For Involuntary Evaluation
	ADHS MH-103 Application for Voluntary Evaluation
	ADHS MH-103 Solicitud de Una Evaluacion Voluntaria
	ADHS MH-104, Application for Emergency Admission for Evaluation
	ADHS MH-105, Petition for COE
	ADHS MH-110, Petition for COT
	ADHS MH-112, Affidavit

Section 3.19	Special Populations
3.19.1	Quarterly PATH Report
	SAPT Block Grant Monthly Wait List
3.19.1 (Attachment)	Notice to Individuals Receiving Substance Abuse Services
3.19.1 (Adjunto)	Notificación a Individuos Quienes Reciben Servicios para el Abuso de Estupefacientes

Section 3.20	Credentialing and Privileging
3.20.1	Supervisors of Clinical Liaisons Attestation Form
3.20.1 (Attachment)	Examples of College Classes Relevant to Behavioral Health
3.20.2	Behavioral Health Technician Case Supervision Report
3.20.3	Attestation of Competencies for Clinical Liaisons Performing Assessments (Re-credentialing)

	ValueOptions Credentialing, Re-Credentialing and Privileging Forms
	ValueOptions Forms

Section 3.21	Service Prioritization for Non-Title XIX/XXI Funding
3.21.1	AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medical Institution that is funded by Medicaid
3.21.1 (Attachment)	Health Plan and RBHA Medical Institution Notification for Dual Eligible Members
3.21.2	Benefits and Costs for People With Medicare

Section 3.22	Out-of-State Placements for Children and Adults
3.22.1	Out of State Placement Initial Notice
3.22.2	Out of State Placement 90 Day Update

SECTION 4	COMMUNICATION AND CARE COORDINATION

Section 4.1	Disclosure of Behavioral Health Record Information
4.1.1	Authorization for Release of Information
4.1.1	Autorización para Liberar Información
4.1.2	Family Member request for Release of Information
4.1.3	Notification to Family Member of Clinical Decision to Deny Request for Release of Information
4.1.4	Request for Administrative Review (Family Member)
4.1.5	Notification to Consumer of Clinical Decision to Release Information to a Family Member
4.1.6	Request for Administrative Review (Consumer)
4.1.7	Notice of Confidentiality of Alcohol and Drug Abuse Information

Section 4.2	Behavioral Health Medical Record Standards
4.2.1	Clinical Record Documentation

Section 4.3	Coordination of Care with AHCCCS Health Plans and PCPs
4.3.1 (Attachment)	AHCCCS Contracted Health Plans Contact Information
4.3.1	PCP Communication Document
4.3.2	Request for Information from PCP

Section 4.4	Coordination of Care with Other Government Entities
4.4.1 (Attachment)	ACYF Child Welfare Timeframes
	COOL Contact Log
	COOL Information Form
	COOL Provider Parole Officer Report Form

SECTION 5	MEMBER RIGHTS AND PROVIDER APPEALS

Section 5.1	Member Notice Requirements
5.1.1	Notice of Action
5.1.1	Aviso de Accion
5.1.2	Notice of Extension of Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health Services
5.1.2	Aviso de Extension de Plazo Para Autorizacion de Decisión de Para Servicios de Salud Mental Titulo XIX/XXI
5.1.4	Notice of Discrimination Prohibited

Section 5.3	Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)
5.3.1	ADHS/DBHS Appeal or SMI Grievance Form
5.3.1	Forma de Apelacion ADHS/DBHS O Queja SMI
MH-211	Notice of Legal Rights for Persons with SMI
MH-211	Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave

Section 5.4	Special Assistance for SMI Members
5.4.1	Request for Special Assistance
5.4.1	Solicitud de Asistencia Especial

Section 5.5	Provider Appeals
5.5.1	Notice of Decision and Right to Appeal
5.5.1	Aviso De Decision Y Derecho de Apelacion
5.5.1 (Attachment)	ADHS/DBHS Notice of SMI Grievance and Appeal Procedure
5.5.1 (Adjunto)	Aviso De Queja y Apelacion Formal De SMI De ADHS/DBHS
5.5.2	Process for Provider Appeals

Section 5.6	Provider Claims Disputes
5.6.1 (Attachment)	Provider Claims Disputes Contact List
5.6.2 (Attachment)	Process for Provider Claims Disputes

SECTION 6	DATA AND BILLING REQUIREMENTS

Section 6.1	Submitting Claims and Encounters
6.1.1	Health Insurance Claim Form - HFCA 1500
6.1.1 (Attachment)	Pseudo Identification Numbers
6.1.2	UB-92 Form

SECTION 7	REPORTING REQUIRMENTS

Section 7.1	Fraud and Abuse Reporting
7.1.1	Suspected Fraud Or Abuse Report

Section 7.3	Seclusion and Restraint Reporting for Level I Facilities
7.3.1	Seclusion and Restraint Reporting
	Monthly Provider Seclusion and Restraint Report

Section 7.4	Reporting of Incidents, Accidents and Deaths
7.4.1	Incident/Accident/Death Report Form
7.4.2	Medication Incident Reporting Form
7.4.3	Adverse Drug Event Form

Section 7.5	Enrollment, Disenrollment and Other Data Submission
7.5.1	ADHS/DBHS Behavioral Health Client Demographic Information Sheet
7.5.1 (Attachment)	Timeframes for Data Submission
7.5.2	Submittal Requirements for Demographic Data
7.5.2 (Attachment)	834 Transaction Data Requirements
7.5.4 (Attachment)	BHS Diagnosis Code Table Preamble
7.5.4 (Attachment)	BHS Diagnosis Code Table

SECTION 8	PERIODIC AUDITS AND SURVEYS

Section 8.5	Medical Care Evaluation Studies
8.5.1 (Attachment)	Instructions for the Completion of Medical Care Evaluation Study Forms
8.5.1	Medical Care Evaluation Study Request for Registration
8.5.2	Summary of Medical Care Evaluation Methodology
8.5.3	Medical Care Evaluation Study Quarterly Update
8.5.4	Medical Care Evaluation Review of Final Results

SECTION 9	TRAINING REQUIREMENTS
9.1.1	RBHA System Overview Attendance Report Child/Adolescent
9.1.1 (ADHS)	Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation (CFT Supervision Tool)
9.1.1 (Attachment)	Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation User's Guide
9.1.2	RBHA System Overview Attendance Report General Mental Health
9.1.3	RBHA System Overview Attendance Report Substance Abuse Providers
9.1.4	RBHA System Overview Attendance Report SMI Providers

SECTION 10	T/RBHA SPECIFIC REQUIREMENTS

Section 10.1	Network Management
	Program Development and Design Financial Deliverables
	Budget Template for PDD
	Program Description Template

Section 10.2	ValueOptions Human Subject Review Committee
10.2.1	Application for Review of Research Involving Human Subjects
10.2.2	Quarterly Research Progress Report

Section 10.3	ValueOptions Duty to Report Abuse, Neglect or Exploitation; duty to Warn Potential Victims of Serious Danger or Harm
10.3.1	Protective Services Report

Section 10.9	Role and Appointment of a Designated Representative
10.9.1	Appointment of Designated Representative