| Section |
Effective Date |
| Section 3.1 Accessing and Interpreting Eligibility and Enrollment
Information and Screening and Applying for AHCCCS Health Insurance |
| PM Attachment 3.1.1 Key Code Index |
1/16/08 |
| PM Form 3.1.1 Tracking of Medicare Part D Enrollment |
3/15/06 |
| PM Attachment 3.1.2 Rate Codes Descriptions |
1/1/04 |
| PM Form 3.1.2 Tracking of Limited Income Subsidy Status |
3/15/06 |
| PM Attachment 3.1.3 Rate Codes |
1/1/04 |
| AHCCCS Eligibility Screening |
5/4/10 |
| PM Form ADHS AE-08 Decline Screening and Referral |
6/26/06 |
| Forma PM ADHS AE-08 Negación a Participar en la Evaluación y/o en el
Proceso de
Remisión al Seguro de Salud de AHCCCS |
10/1/06 |
| Section 3.3 Referral Process |
| PM Form 3.3.1 ADHS DBHS
Referral to Behavioral Health Services |
04/01/11 |
| Section 3.4 Co-payments |
| Section 3.5 Third Party Liability (TPL) and Coordination of Benefits |
| PM Attachment 3.5.1 Third Party Liability (TPL) and Coordination of Benefits
Title XIX/XXI Eligible Persons |
7/1/10 |
| PM Attachment 3.5.2 Third Party Liability (TPL) and Coordination of Benefits
Non-Title XIX/XXI Eligible Persons Determined to Have a Serious Mental Illness (SMI) |
7/1/10 |
| Section 3.6 Member Handbooks |
| PM Form 3.6.1 Member Handbook Receipt (English and Spanish) |
09/01/11 |
| Section 3.9 Assessment and Service Planning |
| PM Attachment 3.9.1, Service Plan Rights Acknowledgement Template |
08/01/11 |
| Section 3.10 SMI Eligibility Determination |
| PM Attachment 3.10.1 SMI
Qualifying Diagnosis |
9/9/04 |
| PM Attachment 3.10.2 Subst
Abuse Psych Symptom |
9/9/04 |
| PM Form 3.10.1 SMI
Determination Form |
9/9/04 |
| Section 3.11 General and Informed Consent to Treatment |
| PM Form ADHS MH-103 Application
for Voluntary Evaluation |
7/15/05 |
| Forma PM ADHS/DBHS MH-103
Solicitud de Una Evaluación Voluntaria |
8/1/04 |
| PM Form 3.11.1 Substance Abuse
Prevention Program and Evaluation Consent |
7/15/10 |
| Forma PM 3.11.1 Permiso Para Participar en la Evaluación del Programa de Prevención para El Abuso de Drogas Y Alcohol |
7/15/10 |
| Section 3.13 Covered Behavioral Health Services |
| PM Attachment 3.13.1 Covered
Services Matrix |
07/01/12 |
| Section 3.14 Securing Services and Prior Authorization |
| PM Attachment 3.14.1 Admission
Psych Acute Hosp & Sub-Acute Auth Criteria |
8/1/07 |
| PM Attachment 3.14.2 Cont Stay
Psych Acute Hosp & Sub-Acute Auth Criteria |
8/1/07 |
| PM Attachment 3.14.3 ADHS/DBHS Level One Psychiatric Residential Treatment Center Admission Authorization Criteria |
8/1/07 |
| PM Attachment 3.14.4 ADHS/DBHS Level One Psychiatric Residental Treatment Center Continued Stay Authorization Criteria |
8/1/07 |
| PM Form 3.14.1 Certification of
Need (CON) |
8/1/07 |
| PM Form 3.14.2 Recertification
of Need (RON) |
8/1/07 |
| PM Form 3.14.3 TRBHA Prior
Authorization Request |
8/1/07 |
| Section 3.15 Psychotropic Medications: Prescribing and Monitoring |
| PM Form 3.15.1 Informed Consent
for Psychotropic Medication Treatment |
3/01/10 |
| Forma PM 3.15.1
Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos |
3/01/10 |
| Section 3.16 Medication List |
| PM Attachment 3.16.1 Prior Authorization Instructions for Medications |
07/01/12 |
| Section 3.18 Pre-Petition Screening, Court-Ordered Evaluation and
Court-Ordered Treatment |
| ADHS/DBHS Form MH-100, Application
for Involuntary Evaluation |
9/93 |
| ADHS/DBHS Form MH-103, Application
for Voluntary Evaluation |
7/15/05 |
| ADHS/DBHS Forma MH-103,
Solicitud de Una Evaluación Voluntaria |
8/1/04 |
| ADHS/DBHS Form MH-104, Application
for Emergency Admission for Evaluation |
9/93 |
| ADHS/DBHS Form MH-105, Petition
for Court-Ordered Evaluation |
9/93 |
| ADHS/DBHS Form MH-110, Petition
for Court-Ordered Treatment |
9/93 |
| ADHS/DBHS Form MH-112, Affidavit,
Addendum No. 1 and Addendum No. 2 |
9/93 |
| PM Attachment 3.18.1, ARS 12-136 Flow Chart |
04/01/11 |
| Section 3.19 Special Populations |
|
| PM Attachment 3.19.1 Notice to
Individuals Receiving Substance Abuse Services |
4/01/09 |
| Documento Adjunto PM 3.19.1 Notificación a Individuos Quienes Reciben Servicios para el abuso de sustancias |
4/01/09 |
| PM Form 3.19.1 Quarterly PATH
Report |
10/15/04 |
| PM Attachment 3.19.2 Arizona PATH Program-Administrators Contact List |
04/01/11 |
| Section 3.22 Out-of-State Placements for Children and Young Adults |
| PM Form 3.22.1 Out of State
Placement Initial Notice |
12/01/11 |
| PM Form 3.22.2 Out of State
Placement 90-Day Update |
12/01/11 |
| Section 3.27 Verification of U.S. Citizenship or Lawful Presence for Public
Behavioral Health Benefits |
| PM Attachment 3.27.1 Documents Accepted by AHCCCS to Verify Citizenship and Identity |
06/15/11 |
| PM Attachment 3.27.2 Non-Citizen/Lawful Presence Verification Documents |
06/15/11 |
| PM Attachment 3.27.3 Persons Who Are Exempt from Verification of Citizenship During the Prescreening and Application Process |
06/15/11 |
| PM Attachment 3.27.4 Citizenship/Lawful Presence Verification Process Through Health-e-Arizona |
06/15/11 |
| Section 4.2 Behavioral Health Medical Record Standards |
|
| PM Form 4.2.1 Clinical Record
Documentation Form |
4/1/08 |
| Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs |
| PM Attachment 4.3.1 AHCCCS
Contracted Health Plans |
7/15/10 |
| PM Form 4.3.1 Communication
Document |
12/1/07 |
| PM Attachment 4.3.2 T/RBHA Acute Health Plan and Provider Coordinator Contact Information |
01/30/12 |
| PM Form 4.3.2 Request for
Information from PCP or Medicare Plan/Provider |
12/1/07 |
| PM Form 4.3.3 T/RBHA Acute Health Plan and Provider Inquiry Monthly Log |
06/15/11 |
| PM Form 4.3.4 Recipient Transition from RBHA to PCP Log |
06/15/11 |
| Section 4.4 Coordination of Care with Other Government Entities |
|
| PM Attachment 4.4.1 ACYF Child
Welfare Time Frames |
09/01/11 |
| PM Attachment 4.4.2 Overview of the Arizona Families F.I.R.S.T (AFF) Program Model & Referral Process |
09/01/11 |
| Section 5.1 Member Notice Requirements |
|
| PM Form 5.1.1 Notice of Action |
07/01/12 |
| Forma PM 5.1.1 Aviso De
Acción |
07/01/12 |
| PM Form 5.1.2 Notice of
Extension of Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health
Services |
07/01/12 |
| Forma PM 5.1.2 Aviso de
Extension de Plazo para Autorizacion de Decision para Servicios de Salud Mental Titulo XIX/XXI |
07/01/12 |
| Section 5.3 Grievance and Request for Investigation for Persons
Determined to have a Serious Mental Illness (SMI) |
| PM Form 5.3.1 ADHS/DBHS Appeal
or SMI Grievance |
7/01/09 |
| Forma PM 5.3.1 Forma De
Apelación ADHS/DBHS o Queja SMI |
1/1/04 |
| Section 5.4 Special Assistance for SMI Members |
|
| PM Form 5.4.1 Notification of Person in Need of Special Assistance |
12/01/10 |
| Section 5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non
Title XIX/XXI) |
|
| PM Attachment 5.5.1 Notice of
SMI Grievance and Appeal Procedure |
9/15/08 |
| Documento Adjunto PM 5.5.1
Aviso De Queja y Apelación Formal De SMI De ADHS/DBHS |
8/1/04 |
| PM Form 5.5.1 Notice of DSN
& Right to Appeal |
9/15/08 |
| Forma PM 5.5.1 Aviso De
Decisión y Derecho De Apelación |
9/15/08 |
| PM Form ADHS MH-209 Notice of
Discrimination Prohibited |
9/15/08 |
| PM Form ADHS MH-211 Notice of
Legal Rights for SMI |
9/15/08 |
| Forma PM MH De ADHS-211
Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave |
9/15/08 |
| Section 5.6 Provider Claims Disputes |
|
| PM Attachment 5.6.1 Provider
Claims Disputes Contact List |
07/01/12 |
| PM Attachment 5.6.2 Process for
Provider Claims Disputes |
4/27/06 |
| Section 6.0 Data and Billing Requirements |
|
| PM Attachment 6.0.1- Behavioral Health Services - Where Do I Submit My Claim? (TXIX/TXXI Only) |
9/01/10 |
| PM Attachment 6.0.2 - Billing Instructions Used to Identify Crisis Services |
9/01/10 |
| Section 6.2 Submitting Claims and Encounters to the RBHA |
|
| PM Attachment 6.2.1 Pseudo Identification Numbers |
9/01/10 |
| Section 7.2 Medical Institution Reporting for Medicare Part D |
|
| PM Form 7.2.1, AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medicaid Funded Medical Institution |
12/01/10 |
| Section 7.3 Seclusion and Restraint Reporting for Level I
Facilities |
|
| PM Form 7.3.1 Seclusion &
Restraint Reporting Level 1 Facility Reporting |
8/1/04 |
| Section 7.4 Reporting of Incidents, Accidents and Deaths |
|
| PM Form 7.4.1 Reporting Incident
Accident Deaths |
7/1/07 |
| Section 7.5 Enrollment, Disenrollment and other Data Submission |
|
| PM Attachment 7.5.1
Timeframes for Data Submission |
12/22/10 |
| PM Attachment 7.5.2
834 Transaction Data
Requirements |
12/22/10 |
| PM Attachment 7.5.3 SMI and SED Qualifying Diagnoses Table |
04/01/08 |
| PM Attachment 7.5.4
Substance Abuse Disorders Qualifying Diagnoses Table |
04/01/08 |
| Section 8.5 Medical Care Evaluation Studies |
| PM Form 8.5.1 Medical Care
Evaluation (MCE) Study Request for Registration and Evaluation Methodology |
10/15/12 |
| PM Form 8.5.2 Medical Care Evaluation (MCE) Provider and T/RBHA Review of Final Results |
10/15/12 |
| Section 9.1 Training
Requirements |
| PM Attachment 9.1.1 Arizona
Child and Family Teams Proficiency Measurement Tool for Facilitation – User's Guide |
7/15/07 |
| PM Form 9.1.1 Arizona Child and
Family Teams Proficiency Measurement Tool for Facilitation |
7/15/07 |
