Click Here For Emergency
PM Section 13.0 FORMS AND ATTACHMENTS
Arizona Department of Health Services
Division of Behavioral Health Services
PROVIDER MANUAL
NARBHA Edition
Section 13.0 FORMS AND ATTACHMENTS
Section 3.1 Eligibility Screening for AHCCCS Health Insurance Medicare Part D Prescription Drug Coverage
PM Attachment 3.1.1 Key Code Index
PM Attachment 3.1.2 Rate Codes Descriptions
PM Attachment 3.1.3 Rate Codes
PM Form 3.1.1 Tracking of Medicare Part D Enrollment
PM Form 3.1.2 Tracking of Limited Income Subsidy Status
PM Form ADHS AE-01 AHCCCS Elig Screen
PM Form ADHS AE-08 Decline Screening and Referral
Section 3.3 Referral Process
PM Attachment 3.3.1 Urgent Behavioral Health Response for CPS Removal Process
PM Form 3.3.1 ADHS DBHS Referral to Behavioral Health Services
Section 3.4 Co-Payments
PM Form 3.4.1 Non Title XIX and XXI Co Pay Assess
Forma PM 3.4.1 Evaluación de Pago Colateral sin Titulo XIX/XXI
Section 3.5 Third Party Liability and Coordination of Benefits
PM Form 3.5.1 AHCCCS Third Party Change Form
Section 3.9 Intake, Assessment and Service Planning
PM Form 3.9.1 Behavioral Health Assessment and Service Plan
PM Form 3.9.2 ADHS/DBHS Behavioral Health Assessment: Birth-5 and Service Plan
Forma PM 3.9.1 Evaluación de Salud Mental y Plan de Servicios
Assessment Instruction Guide: Birth-5
Section 3.10 SMI Eligibility Determination
PM Attachment 3.10.1 SMI Qualifying Diagnosis
PM Attachment 3.10.2 Substance Use/Psychiatric Symptomatology Table
PM Form 3.10.1 SMI Determination Form
Section 3.11 General and Informed Consent to Treatment
PM Form 3.11.1 Substance Abuse Prevention Program and Evaluation Consent
PM Form 3.11.2 Informed Consent to Participate in Telemedicine Services
PM Form 3.11.3 Informed Consent to Record Participation in Telemedicine Services
PM Form ADHS MH-103 Application for Voluntary Evaluation
Forma PM ADHS/DBHS MH-103 Solicitud de Una Evaluación Voluntaria
Section 3.13 Covered Behavioral Health Services
PM Attachment 3.13.1 Covered Services Matrix
Section 3.14 Securing Services and Prior Authorization
PM Attachment 3.14.1 Admission to Psychiatric Acute Hospital and Sub-Acute Facilities
PM Attachment 3.14.4 ADHS/DBHS Continued Residential Treatment Center Stay Authorization Criteria
PM Form 3.14.1 Certification of Need/Recertification of need
PM Form 3.14.2 (No Form, combined with 3.14.1)
PM Form 3.14.3 TRBHA Prior Authorization Request Form
PM Form 3.14.5 Level 1 Hospital Admission criteria
PM Form 3.14.6 NARBHA Continued Stay Level I Inpatient Hospitalization/Subacute
PM Form 3.14.7 NARBHA Level 1 Residential Treatment Center Admission
PM Form 3.14.8 NARBHA Level 1 Residential Treatment Center Continued Stay
Section 3.15 Psychotropic Medications: Prescribing and Monitoring
PM Form 3.15.1 Informed Consent for Psychotropic Medication Treatment
Forma PM 3.15.1 Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos
PM Form 3.15.2 TMED Informed Consent for Medications (Telemedicine)
PM Form 3.15.3 Informed Consent for Children under 5 Psychotropic Medication Treatment
3.16 Medication Formulary
PM Form 3.16.1 NARBHA Medication Formulary
PM Form 3.16.2 INTENTIONALLY LEFT BLANK
PM Form 3.16.3 Laboratory Formulary Summary
PM Form 3.16.4 NARBHA Medication/Lab Pharmacy Edit Notification Form
PM Form 3.16.5 Ineligible Person Pharmacy Enrollment Form
PM Form 3.16.6 NARBHA Pharmacy/Medication Pre-Enrollment Request
PM Form 3.16.7 NARBHA Temporary Prescriber Override Form
PM Form 3.16.8 Prescriber Registration Form
PM Form 3.16.9 Medicare Part D Coverage Determination Request Form
Section 3.17 Transition of Persons
PM Form 3.17.1 Inter-RBHA Transfer Request Form
PM Form 3.17.2 NARBHA Intra-RBHA Transfer Checklist
PM Form 3.17.3 Universal Consent to Treat Form
PM Attachment 3.17.1 Hometown Assigned to Each SAA/TAA
Section 3.18 Pre-Petition Screening, Court-Ordered Evaluation and Court-Ordered Treatment
ADHS/DBHS Form MH-100 Application for Involuntary Evaluation
ADHS/DBHS Form MH-103 Application for Voluntary Evaluation
Forma ADHS/DBHS MH-103 Solicitud de Una Evaluación Voluntaria
ADHS/DBHS Form MH-104 Application for Emergency Admission for Evaluation
ADHS/DBHS Form MH-105 Petition for Court-Ordered Evaluation
ADHS/DBHS Form MH-110 Petition for Court-Ordered Treatment
ADHS/DBHS Form MH-112 Affidavit
Section 3.19 Special Populations
PM Attachment 3.19.1 Notice to Individuals Receiving Substance Abuse Services
PM Attachment 3.19.2 Charitable Choice Procedure Requirements
PM Attachment 3.19.3 SAPT Program Flow Chart
PM Form 3.19.1 Quarterly PATH Report
PM Form 3.19.2 Monthly Non-T19 SAPT Data Report
Section 3.20 Credentialing and Privileging
PM Attachment 3.20.1 Examples of College Classes Relevant to Behavioral Health
PM Attachment 3.20.2 Core Criteria
PM Attachment 3.20.3 Staff Credentialing/Primary Source Verification Criteria
PM Attachment 3.20.4 Clinical Staff Qualifications Matrix
PM Form 3.20.2 BHT Case Supervision
PM Form 3.20.3 RA Monthly Privileging Report
PM Form 3.20.4 Specialty Practice Attestation
PM Form 3.20.5 Specialty Provider Reference Addendum
PM Form 3.20.6 Certification/Degree/Licensure Status Form
Section 3.21 Service Prioritization for Non-Title XIX/XXI Funding
PM Attachment 3.21.1 Health Plan and RBHA Medical Institution Notification for Dual Eligible Members
Section 3.22 Out-of-Sate Placements for Children and Young Adults
PM Form 3.22.1 Out of State Placement Reporting
PM Form 3.22.2 Out of State Placement 90-Day Update
PM Form 3.22.3 Out of State Placement Coordination of Care with AHCCCS Health Plans
Section 3.23 Cultural Competence
PM Attachment 3.23.1 Interpreter Etiquette
Section 4.2 Behavioral Health Medical Record Standards
PM Form 4.2.1 Clinical Record Documentation Form
Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs
PM Attachment 4.3.1 AHCCCS Contracted Health Plans
PM Form 4.3.1 Communication Document
PM Form 4.3.2 Request for Information from PCP
Section 4.4 Coordination of Care with Other Government Entities
PM Attachment 4.4.1 ACYF Child Welfare Time Frames
PM Form 4.4.1 Consent to Consult with ADJC on Pre-Release Referrals Form
PM Attachment 4.4.2 Overview of the AZ Families F.I.R.S.T. Program Model & Referral Process
Section 5.1 Member Notice Requirements
PM Form 5.1.1 Notice of Action
Forma PM 5.1.1 Aviso De Acción
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
Forma PM 5.3.1 Forma De Apelación ADHS/DBHS o Queja SMI
Section 5.4 Special Assistance for SMI Members
PM Form 5.4.1 Request for Special Assistance
Forma PM 5.4.1 Solicitud De Asistencia Especial
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
Documento Adjunto PM 5.5.1 Aviso De Queja y Apelación Formal De SMI De ADHS/DBHS
PM Form 5.5.1 Notice of DSN and Right to Appeal
Forma PM 5.5.1 Aviso De Decisión y Derecho De Apelación
PM Form 5.5.2 Process for Provider Appeals
PM Form ADHS MH-209 Notice of Discrimination Prohibited
PM Form ADHS MH-211 Notice of Legal Rights for SMI
Forma PM MH De ADHS-211 Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave
Section 5.6 Provider Claims Disputes
PM Attachment 5.6.1 Provider Claims Disputes Contact List
PM Attachment 5.6.2 Process for Provider Claims Disputes
Section 6.1 Submitting Claims and Encounters
PM Attachment 6.1.1 Pseudo ID Numbers
PM Form 6.1.1 Health Insurance Claim Form
Section 7.1 Fraud and Abuse Reporting
PM Form 7.1.1 Suspected Fraud and Abuse Report
Section 7.2 Medical Institution Reporting for Medicare Part D
PM Form 7.2.1 Medical Institution Reporting for Medicare Part D
Section 7.3 Seclusion and Restraint Reporting for Level I Facilities
PM Form 7.3.1 Seclusion and Restraint Reporting Level I Programs
PM Attachment 7.3.1 Seclusion and Restraint Monitroing Requirements
PM Form 7.3.2 Seclusion and Restraint Level I Facility Monthly Occurrence Summary Report
PM Form 7.3.3 Medical Director/Clinical Director Seclusion and Restraint Monthly Review Report
Section 7.4 Reporting of Incidents, Accidents and Deaths
PM Form 7.4.1 Reporting Incident Accident Deaths
Section 7.5 Enrollment, Disenrollment and other Data Submission
PM Attachment 7.5.1 Timeframes for Data Submission
PM Attachment 7.5.2 Data Elements Required for Creating an 834 Enrollment/Disenrollment
PM Attachment 7.5.3 Submittal Requirements for Demographic Data Set
PM Attachment 7.5.4 Behavioral Health Services Diagnostic Code Table
PM Form 7.5.1 ADHS/DBHS Behavioral Health Client Demographic Information Sheet
PM Form 7.5.2 Admit/Discharge Data Collection V6.00.00
PM Form 7.5.3 Disenrollment Data Collection V6.00.00
PM Form 7.5.4 NARBHA Enrollment Final Companion Requirements V6.00.00
PM Form 7.5.5 NARBHA Enrollment Initial Companion Data Requirements V6.00.00
Section 8.5 MCE Studies
PM Attachment 8.5.1 Instructions for the Completion of Medical Care Evaluation Study Forms
PM Form 8.5.1 Medical Care Evaluation (MCE) Study Request for Registration
PM Form 8.5.2 Summary of Medical Care Evaluation Methodology
Section 9.1 Training and Development
PM Form 9.1.1 AZ CFT Proficiency Measurement Tool for facilitation
PM Attachment 9.1.1 AZ CFT Proficiency Measurement Tool for facilitation User's Guide
Section 10.1 Financial Management
PM Attachment 10.1.1 NARBHA Sanctions Schedule - Possible Sanctions
PM Attachment 10.1.2 Provider Income Statement
PM Form 10.1.1 HB 2003 Children's Services Progress Report
Section 10.2 Environment of Care and Infection Control
PM Form 10.2.1 Environment of Care Annual On-Site Review Tool
Section 10.3 Care Delivery
PM Form 10.3.1 Universal Policy of Inpatient Units of all NARBHA Service Area Agencies
PM Form 10.3.2 Jail Transportation Information
Section 10.7 Sentinel Events
PM Attachment 10.7.1 Sentinel Event System
PM Attachment 10.7.2 Sentinel Events System Sample Worksheet
Section 10.9 HIPAA Joing NARBHA/SAA/TAA Privacy Notice
PM Form 10.9.1 Disclosure of Medical Information
Section 10.14 Requesting Financial Authorization for Initial and Continued Fee for Service Provider Services
PM Form 10.14.1 Responsible Agency (RA) Covered Services Notice of Intent to Pay
PM Form 10.14.2 Covered Services Notice of Intent to Pay
PM Form 10.14.3 Notice of Intent to Pay Error Notice
Section 10.15 Crisis Triage, Walk-Ins and Mobile Crisis Services
PM Form 10.15.1 Crisis Triage Form
PM Attachment 10.15.1 Crisis Logs - Instructions for Data Completion and Submission to NARBHA
Section 10.16 Move-In Assistance and Community Tenure Support Program
PM Attachment 10.16.1 Move-In Assistance Application
PM Attachment 10.16.2 Community Tenure Support Application
Section 10.17 Member Choice and Transfers between Providers
PM Form 10.17.1 NARBHA Responsible Agency Transfer Checklist
PM Form 10.17.2 Universal Consent to Treatment