| 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
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PM Form 3.1.1 Tracking of Medicare Part D Enrollment |
3/15/06 |
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PM Attachment 3.1.2 Rate Codes Descriptions |
1/1/04 |
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PM Form 3.1.2 Tracking of Limited Income Subsidy Status |
3/15/06 |
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PM Attachment 3.1.3 Rate Codes |
1/1/04 |
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PM Form ADHS AE-01 AHCCCS Elig Screen |
4/1/08 |
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PM Form ADHS AE-08 Decline Screening and Referral |
6/26/06 |
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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 |
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Section 3.3 Referral Process |
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PM Form 3.3.1 ADHS DBHS
Referral to Behavioral Health Services |
7/01/09 |
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Section 3.4 Co-payments |
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PM Form 3.4.1 Non Title XIX
& XXI Co Pay Assess |
4/1/08 |
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Forma PM 3.4.1 Evaluación
de Pago Colateral sin Titulo XIX/XXI |
4/1/08 |
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|
Section 3.9 Intake, Assessment and Service Planning |
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PM Form 3.9.1 Behavioral Health
Assessment and Service Plan |
1/1/06 |
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Forma PM 3.9.1 Evaluación
de Salud Mental y Plan de Servicios |
7/28/09
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PM Form 3.9.2 Behavioral Health
Assessment: Birth-5 and Service Plan |
1/1/06 |
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Forma PM 3.9.2 Evaluación de
Salud de Comportamiento ADHS/DBHS: Nacimiento-5 y Lista de
Verificación del Plan de Servicio |
1/1/06 |
|
ADHS/DBHS Instruction Guide for
the Assessment, Service Plan and Annual Update |
1/1/06 |
|
ADHS/DBHS Instruction Guide for
the Assessment: Birth-5, Service Plan and Annual Update |
1/1/06 |
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Section 3.10 SMI Eligibility Determination |
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PM Attachment 3.10.1 SMI
Qualifying Diagnosis |
9/9/04 |
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PM Attachment 3.10.2 Subst
Abuse Psych Symptom |
9/9/04 |
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PM Form 3.10.1 SMI
Determination Form |
9/9/04 |
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|
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Section 3.11 General and Informed Consent to Treatment |
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PM Form ADHS MH-103 Application
for Voluntary Evaluation |
7/15/05 |
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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 |
2/1/09 |
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Forma PM 3.11.1 Permiso de
Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol |
2/1/09 |
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Section 3.13 Covered Behavioral Health Services |
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PM Attachment 3.13.1 Covered
Services Matrix |
09/15/09 |
| |
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Section 3.14 Securing Services and Prior Authorization |
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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 |
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PM Form 3.14.2 Recertification
of Need (RON) |
8/1/07 |
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PM Form 3.14.3 TRBHA Prior
Authorization Request |
8/1/07 |
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Section 3.15 Psychotropic Medications: Prescribing and Monitoring |
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PM Form 3.15.1 Informed Consent
for Psychotropic Medication Treatment |
8/15/07 |
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Forma PM 3.15.1
Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos |
8/15/07 |
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Section 3.18 Pre-Petition Screening, Court-Ordered Evaluation and
Court-Ordered Treatment |
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ADHS/DBHS Form MH-100, Application
for Involuntary Evaluation |
9/93 |
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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 |
| |
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Section 3.19 Special Populations |
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PM Attachment 3.19.1 Notice to
Individuals Receiving Substance Abuse Services |
04/01/09 |
|
Documento Adjunto PM 3.19.1 Notificación a Individuos Quienes Reciben Servicios para el abuso de sustancias |
04/01/09 |
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PM Form 3.19.1 Quarterly PATH
Report |
10/15/04 |
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Section 3.20 Credentialing and Privileging |
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PM Attachment 3.20.1 Examples
of College Classes Relevant to Behavioral Health |
4/15/05 |
|
PM Form 3.20.1 Supervision of
Clinical Liaisons |
4/15/05 |
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PM Form 3.20.2 BHT Case
Supervision |
4/15/05 |
| |
|
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Section 3.22 Out-of-State Placements for Children and Young Adults
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PM Form 3.22.1 Out of State
Placement Initial Notice |
6/1/08 |
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PM Form 3.22.2 Out of State
Placement 90-Day Update |
6/1/08 |
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Section 4.2 Behavioral Health Medical Record Standards |
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PM Form 4.2.1 Clinical Record
Documentation Form |
9/1/06 |
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Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs |
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PM Attachment 4.3.1 AHCCCS
Contracted Health Plans |
11/10/09 |
|
PM Form 4.3.1 Communication
Document |
12/1/07 |
|
PM Form 4.3.2 Request for
Information from PCP or Medicare Plan/Provider |
12/1/07 |
| |
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Section 4.4 Coordination of Care with Other Government Entities |
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PM Attachment 4.4.1 ACYF Child
Welfare Time Frames |
3/15/05 |
| PM Attachment 4.4.2 Overview of the Arizona Families F.I.R.S.T (AFF) Program Model & Referral Process |
7/01/09 |
| |
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Section 5.1 Member Notice Requirements |
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PM Form 5.1.1 Notice of Action |
9/1/08 |
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Forma PM 5.1.1 Aviso De
Acción |
9/1/08 |
|
PM Form 5.1.2 Notice of
Extension of Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health
Services |
9/15/08 |
|
Forma PM 5.1.2 Aviso de
Extension de Plazo para Autorizacion de Decision para Servicios de Salud Mental Titulo XIX/XXI |
9/15/08 |
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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 |
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