Provider Manual : Forms and Attachments
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| 3.1 | Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance |
|---|---|
| Attachment 3.1.1 | Key Code Index |
| Attachment 3.1.2 | AHCCCS Rate Codes Descriptions |
| Attachment 3.1.3 | AHCCCS Rate Codes |
| Form ADHS AE-01 | AHCCCS Title XIX-XXI Eligibility Screening |
| Form ADHS AE-08 | Decline to Participate in the Screening |
| Forma ADHS AE-08 | Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS (Español) |
| Form 3.1.1 | Tracking of Medicare Part D Enrollment |
| Form 3.1.2 | Tracking of Limited Income Subsidy Status |
| 3.3 | Referral Process |
|---|---|
| Form 3.3.1 | ADHS/DBHS Referral to Behavioral Health Services |
| 3.4 | Co-payments |
|---|---|
| Form 3.4.1 | Non-XIX or XXI Co-Payment Assessment |
| Forma 3.4.1 | Evaluación de Pago Colateral Sin Título XIX/XXI (Español) |
| 3.8 | Outreach, Engagement, Re-Engagement and Closure |
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| 3.9 | Intake, Assessment and Service Planning |
|---|---|
| Form 3.9.1 | Behavioral Health Assessment and Service Plan |
| Forma 3.9.1 | Evaluación de Salud Mental y Plan de Servicios (Español) |
| Instruction Guide 3.9.1 | Instruction Guide for Behavioral Health Assessment and Service Plan |
| Form 3.9.2 | Birth to 5 Behavioral Health Assessment & Service Plan |
| Instruction Guide 3.9.2 | Instruction Guide for Birth to 5 Behavioral Health Assessment & Service Plan |
| Forma PM 3.9.2 | Hoja de Cobertura del Cliente de Salud de Comportamiento ADHS-DBHS (Español) |
| 3.10 | SMI Eligibility Determination |
|---|---|
| Attachment 3.10.1 | SMI Qualifying Diagnosis |
| Attachment 3.10.2 | Substance Abuse Psychiatric Symptomatology |
| Form 3.10.1 | SMI Determination Module |
| 3.11 | General and Informed Consent to Treatment |
|---|---|
| Form ADHS MH-103 | Application for Voluntary Evaluation |
| Forma ADHS MH-103 | Solicitud de Una Evaluación Voluntaria (Español) |
| Form 3.11.1 | Substance Abuse Prevention Program and Evaluation Consent |
| Forma 3.11.1 | Permiso de Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol (Español) |
| Form 3.11.2 | Consent for Electroconvulsive Therapy (ECT) |
| Form 3.11.3 | Consent for Treatment - Sample |
| Form 3.11.4 | Consent for ALOC |
| Forma 3.11.4 | Consentimiento para la Evaluatión del Nivel de Cuidado |
| 3.12 | Advance Directives |
|---|---|
| Advance Directives Resources | |
| Form 3.12.1 | Advance Directives Form |
| 3.13 | Covered Behavioral Health Services |
|---|---|
| Attachment 3.13.1 | Covered Service Matrix |
| 3.14 | Securing Services and Prior Authorization |
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| Attachment 3.14.1 | Admission Psych Acute Hospital and Sub-Acute Authorization Criteria |
| Attachment 3.14.2 | Continued Stay Psych Acute Hospital and Sub-Acute Authorization Criteria |
| Attachment 3.14.3 | Admission Residential Treatment Center Authorization Criteria |
| Attachment 3.14.4 | Continued Stay Residential Treatment Center Authorization Criteria |
| Form 3.14.1 | Certification of Need for Level I Facilities (CON) |
| Form 3.14.2 | Re-Certification of Need (RON) |
| Form 3.14.3 | T/RBHA Prior Authorization Request |
| Outpatient Electroconvulsive Therapy Criteria for Authorization | |
| Request For Electroconvulsive Therapy (ECT) | |
| Psychological Testing Criteria for Authorization | |
| Request for Psychological Testing Preauthorization | |
| Pharmacy Prior Authorization Request Form |
| 3.15 | Psychotropic Medications: Prescribing and Monitoring |
|---|---|
| Form 3.15.1 | Informed Consent for Psychotropic Medication |
| Forma 3.15.1 | Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos (Español) |
| 3.17 | Transition of Persons |
|---|---|
| Form 3.17.1 | Interagency PNO Client Transfer Form (For Title 19/Title 21 and HB Children Only) |
| Form 3.17.2 | Transfer Protocol Between Provider Network Organizations (PNOs) |
| Form 3.17.3 | Clinical Liaison Update Form |
| 3.18 | Pre-Petition Screening, Court Ordered Evaluation and Treatment |
|---|---|
| Form 3.18.1 | Police Mental Health Detention Information Sheet for Court-Ordered Detention |
| Form 3.18.2 | Pre-petition Screening Report |
| Form ADHS MH-100 | Application for Involuntary Evaluation |
| Form ADHS MH-103 | Application for Voluntary Evaluation |
| Forma ADHS MH-103 | Solicitud de Una Evalución Voluntaria (Español) |
| Form ADHS MH-104 | Application For Emergency Admission For Evaluation |
| Form ADHS MH-105 | Petition For Court-Ordered Evaluation |
| Form ADHS MH-110 | Petition For Court-Ordered Treatment - Gravely Disabled Person |
| Form ADHS MH-112 | Affidavit |
| 3.19 | Special Populations |
|---|---|
| Attachment 3.19.1 | Notice to Individuals Receiving Substance Abuse Services |
| Documento Adjunto 3.19.1 | Notificacion a Individuos Quienes Reciben Servicios para el Abuso de Estupefacients (Español) |
| Form 3.19.1 | Quarterly PATH Report |
| 3.20 | Credentialing and Privileging |
|---|---|
| Attachment 3.20.1 | Examples of College Classes Relevant to Behavioral Health |
| Form 3.20.1 | Supervisor of Clinical Liaisons Attestation of Competencies |
| Form 3.20.2 | BHT Case Supervision Report |
| Form 3.20.3 | Staff Add/Change/Delete |
| 3.21 | Service Prioritization for Non-Title XIX/XXI Funding |
|---|---|
| Attachment 3.21.1 | Health Plan & RBHA Medical Institution Notification for Dual Eligible Members |
| Attachment 3.21.2 | Benefits and Cost For People With Medicare (Part D) |
| Form 3.21.1 | AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medical Institution Funded by Medicaid |
| 3.22 | Out-of-State Placements for Children and Young Adults |
|---|---|
| Form 3.22.1 | Out-of-State Placement Initial Notice |
| Form 3.22.2 | Out-of-State Placement, 90-Day Update |
| 4.2 | Behavioral Health Medical Record Standards |
|---|---|
| Form 4.2.1 | Clinical Record Documentation Form |
| 4.3 | Coordination of Care with AHCCCS Health Plans and PCPs |
|---|---|
| Attachment 4.3.1 | AHCCCS Contracted Health Plans Contact Information |
| Form 4.3.1 | Communication Document |
| Form 4.3.2 | Request for Information from PCP |
| 4.4 | Coordination of Care with Other Government Entities |
|---|---|
| Attachment 4.4.1 | ACYF Child Welfare Timeframes |
| 5.1 | Member Notice Requirements |
|---|---|
| Form 5.1.1 | Notice of Action |
| Forma 5.1.1 | Aviso De Acción (Español) |
| Form 5.1.2 | Notice of Extension of Timeframe for SErvice Authorization Decision Regarding Title XIX/XXI Behavioral Health Services |
| Forma 5.1.2 | Aviso de Extensión de Plazo Para Autorizacion de Decisión Para Servicios de Salud Mental Titulo XIX/XXI(Español) |
| 5.3 | Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI) |
|---|---|
| Form 5.3.1 | ADHS/DBHS Appeal or SMI Grievance |
| Forma 5.3.1 | Forma De Apelación ADHS/DBHS o Queja SMI (Español) |
| 5.4 | Special Assistance for SMI Members |
|---|---|
| Form 5.4.1 | Notification of Person in Need of Special Assistance |
| Forma 5.4.1 | Notificación de persona con necesidad de atención especial (Español) |
| 5.5 | Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI) |
|---|---|
| Attachment 5.5.1 | Notice of SMI Grievance and Appeal Procedure |
| Documento Adjunto 5.5.1 | Aviso de Queja y Apelación Formal de SMI de ADHS/DBHS(Español) |
| Form 5.5.1 | Notice of Decision and Right to Appeal (SMI) |
| Forma 5.5.1 | Aviso de Decisión y Derecho de Apelación (Español) |
| Form ADHS MH-209 | Notice of Discrimination Prohibited (English and Español) |
| Form ADHS MH-211 | Notice of Legal Rights for SMI |
| Forma ADHS MH-211 | Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave (Español) |
| 5.6 | Provider Claims Disputes |
|---|---|
| Attachment 5.6.1 | Provider Claims Disputes Contact List |
| Attachment 5.6.2 | Process for Provider Claims Disputes |
| 6.1 | Submitting Claims and Encounters |
|---|---|
| Attachment 6.1.1 | Pseudo ID Numbers |
| 7.1 | Fraud and Program Abuse Reporting |
|---|---|
| Form 7.1.1 | Suspected Fraud or Abuse Report |
| Forma 7.1.1 | Sospecha de Fraude o Reporte de Abuso de Programas |
| 7.2 | Medical Institution Reporting for Medicare Part D |
|---|---|
| Form 7.2.1 | AHCCCS Notification to Waive Medicare Part D Co-payments for Members in a Medical Institution that is Funded by Medicaid |
| 7.3 | Seclusion and Restraint Reporting for Level I Facilities |
|---|---|
| Form 7.3.1 | Seclusion and Restraint Reporting for Level I Facilities |
| 7.4 | Reporting of Incidents, Accidents and Deaths |
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| Form 7.4.1 | Reporting Incident-Accident-Deaths |
| 7.5 | Enrollment, Disenrollment and other Data Submission |
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| Attachment 7.5.1 | Timeframes for Data Submission |
| Form 7.5.1 | Demographic Form |
| Attachment 7.5.2 | Timeframes for Data Submission |
| Attachment 7.5.2 | 834 Transaction Data Requirements |
| Form 7.5.2 | Initial Intake Form |
| Attachment 7.5.3 | SMI and SED Qualifying Diagnoses Table |
| Attachment 7.5.4 (Preamble) | Behavioral Health Services Diagnosis Code Table |
| Attachment 7.5.4 (Table) | Substance Abuse Disorders Qualifying Diagnoses Table |
| 8.5 | Medical Care Evaluation (MCE) Studies |
|---|---|
| Attachment 8.5.1 | Instructions for Completion of Medical Care Evaluation |
| Form 8.5.1 | Medical Care Evaluation (MCE) Study Request for Registration |
| Form 8.5.2 | Summary of Medical Care Evaluation (MCE) Study Methodology |
| Form 8.5.3 | Medical Care Evaluation (MCE) Quarterly Progress Report |
| Form 8.5.4 | Annual Medical Care Evaluation (MCE) Study Report for Level I Providers |
| 9.1 | Training and Development |
|---|---|
| Attachment 9.1.1 | Supervision Process User Guide |
| Form 9.1.1 | CFT Supervision Tool |
If you have any questions about your services, please call Magellan at 800-564-5465 (TTY: 800-424-9831). For emergencies, call the Crisis Line at 800-631-1314 (TTY: 800-327-9254).
This page last updated: Dec 17, 2008
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