For Providers

Provider Manual : Forms & Attachments

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3.1	Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance	Effective Date
Attachment 3.1.1	Key Code Index	01/16/2008
Attachment 3.1.2	AHCCCS Rate Codes Descriptions	09/21/2006
Attachment 3.1.3	AHCCCS Rate Codes	09/21/2006
Form ADHS AE-08	Decline to Participate in the Screening	09/21/2006
Forma ADHS AE-08	Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS (Español)	10/01/2006
Form 3.1.1	Tracking of Medicare Part D Enrollment	03/15/2006
Form 3.1.2	Tracking of Limited Income Subsidy Status	10/15/2008

3.3	Referral Process	Effective Date
Form 3.3.1	ADHS/DBHS Referral to Behavioral Health Services	04/01/2011

3.4	Co-payments	Effective Date
Form 3.4.1	Non-XIX or XXI Co-Payment Assessment	04/01/2008
Forma 3.4.1	Evaluación de Pago Colateral Sin Título XIX/XXI (Español)	04/01/2008

3.5	Third Party Liability & Coordination of Benefits	Effective Date
Attachment 3.5.1	TPL and Coordination of Benefits - Title XIX/XXI Eligible Persons	07/01/2010
Attachment 3.5.2	TPL and Coordination of Benefits - Non-Title XIX/XXI Eligible Persons Determined to Have a Serious Mental Illness (SMI)	07/01/2010

3.6	Member Handbooks	Effective Date
Form 3.6.1	Member Handbook Receipt	09/01/2011

3.9	Assessment and Service Planning	Effective Date
Attachment 3.9.1	Service Plan Rights Acknowledgment Template	07/29/2011

3.10	SMI Eligibility Determination	Effective Date
Attachment 3.10.1	SMI Qualifying Diagnosis	09/09/2004
Attachment 3.10.2	Substance Abuse Psychiatric Symptomatology	09/09/2004
Form 3.10.1	SMI Determination Module	09/09/2004
Form 3.10.2	Disposition Data Sheet - SMI Eligibility Department	12/12/2011
Form 3.10.3	Waiver of 3-Day SMI Eligibility Determination	04/04/2011
Form 3.10.4	SMI Assessment Packet Checklist - SMI Eligibility Department	07/01/2011

3.11	General and Informed Consent to Treatment	Effective Date
Form ADHS MH-103	Application for Voluntary Evaluation	04/12/2005
Forma ADHS MH-103	Solicitud de Una Evaluación Voluntaria (Español)	04/12/2005
Form 3.11.1	Substance Abuse Prevention Program and Evaluation Consent	07/15/2010
Forma 3.11.1	Permiso de Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol (Español)	07/15/2010
Form 3.11.2	Consent for Electroconvulsive Therapy (ECT)	10/15/2009
Form 3.11.3	Consent for Treatment - Sample	09/21/2007
Form 3.11.4	Consent for ALOC	07/08
Forma 3.11.4	Consentimiento para la Evaluatión del Nivel de Cuidado	07/08

3.12	Advance Directives	Effective Date
Form 3.12.1	Advance Directives Form	09/01/2007
	Advance Directives Resources	09/01/2007
Form 3.12.1 (Spanish)	Forma de Directivas por Adelantado
	Recursos para Directivas por Adelantado

3.13	Covered Behavioral Health Services	Effective Date
Attachment 3.13.1	Covered Service Matrix	04/01/2011

3.14	Securing Services and Prior Authorization	Effective Date
Attachment 3.14.1	Admission Psych Acute Hospital and Sub-Acute Authorization Criteria	08/01/2007
Attachment 3.14.2	Continued Stay Psych Acute Hospital and Sub-Acute Authorization Criteria	08/01/2007
Attachment 3.14.3	Admission Residential Treatment Center Authorization Criteria	08/01/2007
Attachment 3.14.4	Continued Stay Residential Treatment Center Authorization Criteria	08/01/2007
Attachment 3.14.5	Child/Adolescent Therapeutic Group Home (OBHL Level II) Admission & Continued Stay Authorization Criteria	07/01/2010
Attachment 3.14.6	Child/Adolescent Therapeutic Group Home (OBHL Level III) Admission & Continued Stay Authorization Criteria	07/01/2010
Attachment 3.14.7	Child/Adolescent HCTC Admission & Continued Stay Authorization Criteria	07/01/2010
Attachment 3.14.8	Adult Residential Treatment Criteria Level II Admission & continued Stay Authorization Criteria	08/01/2010
Attachment 3.14.9	Adult Residential Treatment Criteria Level III Admission & Continued Stay Authorization Criteria	08/01/2010
Attachment 3.14.10	HCTC Admission & Continued Stay Authorization Criteria	08/01/2010
Form 3.14.1	Certification of Need for Level I Facilities (CON)	08/01/2007
Form 3.14.2	Re-Certification of Need (RON)	08/01/2007
Form 3.14.3	T/RBHA Prior Authorization Request	08/01/2007
Form 3.14.4	Adult Level II, III and HCTC Continued Stay Review	08/01/2010
Form 3.14.5	Adult Level II, III and HCTC Preadmission Review	08/01/2010
Form 3.14.6	Request for Child/Adolescent HCTC Intervention	07/01/2010
Forma 3.14.6	Solicitud de Intervencion de HCTC Para Ninos/Adolescentes	07/01/2010
Form 3.14.7	Request for Child/Adolescent Level II or III Intervention	07/01/2010
Forma 3.14.7	Solicitud de Intervencion de Nivel II or III Para Ninos/Adolescentes	07/01/2010
Form 3.14.8	Guardian Request for Level I Residential Treatment Child/Adolescent Only	07/01/2010
Form 3.14.9	Level I Residential Additional Request Information Child/Adolescent Only	07/01/2010
Form 3.14.10	Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization of Residential Levels I, II and III	07/01/2010
Form 3.14.11	Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization of HCTC	07/01/2010
Form 3.14.12	30 Day Prior Authorization Request for NT XIX/XXI SMI Brand Atypical Antipsychotic for Bridging	05/06/2011
Form 3.14.13	Prior Authorization Request for Risperdal Consta	05/06/2011
	Prior Authorization Request for Medication
	Outpatient Electroconvulsive Therapy Criteria for Authorization	09/01/2007
	Psychological Testing Criteria for Authorization	09/01/2007
	Request for Psychological Testing Preauthorization	03/04/2010
	Request for Electroconvulsive Therapy (ECT)	10/15/2009
	CON - Medically Monitored Inpatient Detoxification (ASAM Level III.7D) RON - Medically Monitored Inpatient Detoxification (ASAM Level III.7D)	05/01/2010
	CON - Adult Psychiatric Acute Hospital RON - Adult Psychiatric Acute Hospital	05/01/2010
	CON - Adult Sub-Acute Facility RON - Adult Sub-Acute Facility	05/01/2010
	CON - Child and Adolescent Residential Treatment Center - Chemical Dependency RON - Child and Adolescent Residential Treatment Center - Chemical Dependency	05/01/2010
	CON - Child and Adolescent SECURE Residential Treatment Center - Chemical Dependency RON - Child and Adolescent SECURE Residential Treatment Center - Chemical Dependency	05/01/2010
	CON - Child and Adolescent Inpatient Psychiatric Admission RON - Continued Child/Adolescent Inpatient Stay	05/01/2010
	CON - Child and Adolescent Residential Treatment Center RON - Child and Adolescent Residential Treatment Center	05/01/2010
	CON - Child and Adolescent SECURE Residential Treatment Center RON - Child and Adolescent SECURE Residential Treatment Center	05/01/2010

3.15	Psychotropic Medications: Prescribing and Monitoring	Effective Date
Form 3.15.1	Informed Consent for Psychotropic Medication	03/01/2010
Forma 3.15.1	Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos (Español)	03/01/2010

3.16	Medication Formularies	Effective Date

3.17	Transition of Persons	Effective Date
Form 3.17.1	Interagency PNO Client Transfer Form (For Title 19/Title 21 and HB Children Only)	04/29/2010
Attachment 3.17.1	Magellan Youth Transition to Adulthood Planning Checklist Reference Guide
Attachment 3.17.2	Transfer Protocol Between Provider Network Organizations (PNOs)	04/29/2010
Form 3.17.3	Single Point of Contact Update Form	04/29/2010

3.18	Pre-Petition Screening, Court Ordered Evaluation and Treatment	Effective Date
Attachment 3.18.1	Domestication or Recognition of Tribal Court Order Process Flow Chart	08/31/2010
Form 3.18.1	Police Mental Health Detention Information Sheet for Court-Ordered Detention	03/25/2010
Form 3.18.2	Pre-petition Screening Report	09/01/2007
Form ADHS MH-100	Application for Involuntary Evaluation	09/93
Form ADHS MH-103	Application for Voluntary Evaluation	04/12/2005
Forma ADHS MH-103	Solicitud de Una Evalución Voluntaria (Español)	04/12/2005
Form ADHS MH-104	Application For Emergency Admission For Evaluation	09/93
Form ADHS MH-105	Petition For Court-Ordered Evaluation	09/93
Form ADHS MH-110	Petition For Court-Ordered Treatment - Gravely Disabled Person	09/93
Form ADHS MH-112	Affidavit	09/93

3.19	Special Populations	Effective Date
Attachment 3.19.1	Notice to Individuals Receiving Substance Abuse Services	04/01/2009
Documento Adjunto 3.19.1	Notificacion a Individuos Quienes Reciben Servicios para el Abuso de Estupefacients (Español)	04/01/2009
Attachment 3.19.2	Arizona PATH Program - Administrators Contact List	04/01/2011

3.20	Credentialing and Privileging	Effective Date
Attachment 3.20.1	Examples of College Classes Relevant to Behavioral Health	04/15/2005
Form 3.20.1	Supervisor of Clinical Liaisons Attestation of Competencies	04/15/2005
Form 3.20.2	BHT Case Supervision Report	04/15/2005
Form 3.20.3	Staff Add/Change/Delete	09/25/2007

3.21	Service Prioritization for Non-Title XIX/XXI Funding	Effective Date
Attachment 3.21.1	Health Plan & RBHA Medical Institution Notification for Dual Eligible Members	03/15/2006
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	03/15/2006

3.22	Out-of-State Placements for Children and Young Adults	Effective Date
Form 3.22.1	Out-of-State Placement Initial Notice	12/01/2011
Form 3.22.2	Out-of-State Placement, 90-Day Update	12/01/2011

3.25	Crisis Intervention Services	Effective Date
Attachment 3.25.1	Crisis Intervention Services Delivered in Emergency Departments	04/26/2011

3.27	Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits	Effective Date
Attachment 3.27.1	Documents Accepted by AHCCCS to Verify Citizenship and Identity	06/15/2011
Attachment 3.27.2	Non-Citizen/Lawful Presence Verification Documents	06/15/2011
Attachment 3.27.3	Persons who are Exempt for Verifcation of Citizenship during the Prescreening and Application Process	06/15/2011
Attachment 3.27.4	Citizenship/Lawful Presence Verification Process Through Health-e-Arizona	06/15/2011

4.2	Behavioral Health Medical Record Standards	Effective Date
Form 4.2.1	Community Service Agency/HCTC Provider/Habilitation Provider Daily Clinical Record Documentation Form	07/21/2008

4.3	Coordination of Care with AHCCCS Health Plans and PCPs	Effective Date
Attachment 4.3.1	AHCCCS Contracted Health Plans Contact Information	07/15/2010
Attachment 4.3.2	T/RBHA Acute Health Plan and Provider Coordinator Contact Information	06/15/2011
Form 4.3.1	Communication Document	12/15/2008
Form 4.3.2	Request for Information from PCP	12/01/2007
Form 4.3.3	T/RBHA Acute Health Plan & Provider Inquiry Monthly Log	06/15/2011
Form 4.3.4	Recipient Transition from RBHA to PCP Log	06/15/2011

4.4	Coordination of Care with Other Government Entities	Effective Date
Attachment 4.4.1	DCYF Child Welfare Timeframes	09/01/2011
Attachment 4.4.2	Overview of Arizona Families First	09/01/2011

5.1	Member Notice Requirements	Effective Date
Form 5.1.1	Notice of Action	04/15/2011
Forma 5.1.1	Aviso De Acción (Español)	04/15/2011
Form 5.1.2	Notice of Extension of Timeframe for SErvice Authorization Decision Regarding Title XIX/XXI Behavioral Health Services	10/22/2009
Forma 5.1.2	Aviso de Extensión de Plazo Para Autorizacion de Decisión Para Servicios de Salud Mental Titulo XIX/XXI(Español)	10/22/2009

5.3	Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)	Effective Date
Form 5.3.1	ADHS/DBHS Appeal or SMI Grievance	07/01/2009
Forma 5.3.1	Forma De Apelación ADHS/DBHS o Queja SMI (Español)	01/01/2004

5.4	Special Assistance for SMI Members	Effective Date
Form 5.4.1	Notification of Person in Need of Special Assistance	12/01/2010

5.5	Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)	Effective Date
Attachment 5.5.1	Notice of SMI Grievance and Appeal Procedure	02/29/2008
Documento Adjunto 5.5.1	Aviso de Queja y Apelación Formal de SMI de ADHS/DBHS(Español)	02/29/2008
Form 5.5.1	Notice of Decision and Right to Appeal (SMI)	02/29/2008
Forma 5.5.1	Aviso de Decisión y Derecho de Apelación (Español)	02/29/2008
Form ADHS MH-209	Notice of Discrimination Prohibited (English and Español)
Form ADHS MH-211	Notice of Legal Rights for SMI	02/08
Forma ADHS MH-211	Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave (Español)	02/08

5.6	Provider Claims Disputes	Effective Date
Attachment 5.6.1	Provider Claims Disputes Contact List	06/16/2010
Attachment 5.6.2	Process for Provider Claims Disputes	04/27/2006

6.0	Submitting Claims and Encounters	Effective Date
Attachment 6.0.1	BHS Where Do I Submit My Claims (Title XIX/XXI Only)	09/01/2010
Attachment 6.0.2	Billing Instructions Used to Identify Crisis Services	09/01/2010
Attachment 6.2.1	Pseudo ID Numbers	09/01/2010

7.1	Fraud and Program Abuse Reporting	Effective Date
Form 7.1.1	Suspected Fraud or Abuse Report	01/02/2008
Forma 7.1.1	Sospecha de Fraude o Reporte de Abuso de Programas	01/02/2008

7.2	Medical Institution Reporting for Medicare Part D	Effective Date
Form 7.2.1	AHCCCS Notification to Waive Medicare Part D Co-payments for Members in a Medical Institution that is Funded by Medicaid	12/1/2010

7.3	Seclusion and Restraint Reporting for Level I Facilities	Effective Date
Form 7.3.1	Seclusion and Restraint Reporting for Level I Facilities	07/15/2009
Attachment 7.3.1	Seclusion and Restraint Monitoring Requirements	09/15/2009

7.4	Reporting of Incidents, Accidents and Deaths	Effective Date
Form 7.4.1	Reporting Incident-Accident-Deaths	06/21/2010

7.5	Enrollment, Disenrollment and other Data Submission	Effective Date
Attachment 7.5.1	Timeframes for Data Submission	12/22/2010
Form 7.5.1	Demographic Form	01/01/2012
Attachment 7.5.2	834 Transaction Data Requirements	12/22/2010
Form 7.5.2	Initial Intake Form	03/23/2011
Attachment 7.5.3	SMI and SED Qualifying Diagnoses Table	04/01/2008
Attachment 7.5.4 (Preamble)	Behavioral Health Services Diagnosis Code Table	09/01/2005
Attachment 7.5.4 (Table)	Substance Abuse Disorders Qualifying Diagnoses Table	04/01/2008

8.5	Medical Care Evaluation (MCE) Studies	Effective Date
Attachment 8.5.1	Instructions for Completion of Medical Care Evaluation	05/31/2011
Form 8.5.1	Medical Care Evaluation (MCE) Study - Request for Registration and Evaluation Methodology	07/15/2010
Form 8.5.2	Medical Care Evaluation (MCE) - Provider and T/RBHA Review of Final Results	07/15/2010
Form 8.5.3	Medical Care Evaluation (MCE) Quarterly Progress Report	09/01/2007

9.1	Training and Development	Effective Date
Attachment 9.1.1	Supervision Process User Guide	07/15/2007
Form 9.1.1	CFT Supervision Tool	07/15/2007

If you have any questions about your services, please call Magellan at (800) 564-5465, TTY (800) 424-9831. If you are in crisis, call the Maricopa Crisis Line at (800) 631-1314, TTY (800) 327-9254. For emergencies, please always dial 911.

This page last updated: Tuesday, December 27, 2011.

For Providers

Provider Manual : Forms & Attachments

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