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 3.16.1 NARBHA TXIX/TXXI Medication Formulary
- PM Form 3.16.10 Medication Pre-Enrollment/SAPT Ineligible Child Request/Pharmacy Edit Notification
- PM Form 3.16.11 NARBHA Prescriber and Temporary Prescriber Registration Form
- PM Form ADHS AE-01 AHCCCS Elig Screen
- PM Form ADHS AE-08 Decline Screening and Referral
- Forma PM ADHS AE-08 Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS
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
Section 3.5 Third Party Liability and Coordination of Benefits
- PM Attachment 3.5.1 Third Party Liability and Coordination of Benefits, Title XIX/XXI Eligible Persons
- PM Attachment 3.5.2 Third Party Liability and Coordination of Benefits, Non-Title XIX/XXI Eligible Persons Determined to have Serious Mental Illness
- PM Form 3.5.1 AHCCCS Third Party Change Form
Section 3.6 Member Handbooks
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
- Forma PM 3.9.2 Evaluación de Salud de Comportamiento ADHS/DBHS: Nacimiento-5 y Lista de Verificación del Plan de Servicio
- Assessment Instruction Guide
- 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
- Forma PM 3.11.1 Permiso para Participar en la Evaluación del Programa de Prevención para el Abuso de Sustancias
- 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
Section 3.14 Securing Services and Prior Authorization
- PM Attachment 3.14.1 Admission to Psychiatric Acute Hospital and Sub-Acute Facilities Clinical Criteria
- PM Attachment 3.14.2 Continued Psychiatric Acute Hospital or Sub-Acute Facility Authorization Clinical Criteria
- PM Attachment 3.14.3 ADHS/DBHS Level One Psychiatric Residential Treatment Center Admission Authorization Clinical Criteria
- PM Attachment 3.14.4 ADHS/DBHS Continued Residential Treatment Center Stay Authorization Clinical Criteria
- PM Attachment 3.14.5 NARBHA Authorization Clinical Criteria for Level II Residential Treatment - Child/Adolescent
- PM Attachment 3.14.6 NARBHA Authorization Clinical Criteria for Level III Residential Treatment - Child/Adolescent (excluding Substance Abuse Residential)
- PM Attachment 3.14.7 NARBHA Authorization Clinical Criteria for Home Care Training for the Home Care Client (HCTC) (excluding Substance Abuse Residential)
- PM Attachment 3.14.8 NARBHA Authorization Criteria for Level II Residential Treatment - Adult (excluding Substance Abuse Residential)
- PM Attachment 3.14.9 NARBHA Authorization Criteria for Level III Residential Treatment - Adult (excluding Substance Abuse Residential)
- PM Attachment 3.14.10 NARBHA Authorization Criteria for Home Care Training for the Home Care Client (HCTC) (excluding Substance Abuse Residential)
- PM Form 3.14.1 Certification of Need/Recertification of need
- PM Form 3.14.5 NARBHA Continued Stay Level I Inpateint Hospitalization/Subacute Request Form
- PM Form 3.14.6 NARBHA Level 1 Residential Treatment Center Admission Request Form
- PM Form 3.14.8 NARBHA Adult/Child Level II, Level III, and HCTC Admission and Continued Stay Request Form
- PM Form 3.14.9 NARBHA Request for Electroconvulsive Therapy
- Click here to access Prior Authorization Request Forms
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)
- Forma 3.15.2 TMED Consentimiento Informado Para Medicamentos (Telemedicina)
- PM Form 3.15.3 Informed Consent for Children under 5 Psychotropic Medication Treatment
3.16 Medication Formulary
- PM Form 3.16.1 NARBHA XIX/XXI Medication Formulary
- PM Form 3.16.2 NARBHA Non-Title XIX SMI Medication Formulary
- 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
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
- PM Attachment 3.18.1 ARS 12-136 Flow Chart
Section 3.19 Special Populations
- PM Attachment 3.19.1 Notice to Individuals Receiving Substance Abuse Services
- PM Attachment 3.19.1 Notificación a Individuos Quienes Reciben Servicios para el Abuso de Estupefacientes
- PM Attachment 3.19.2 Arizona PATH Program Administrators Contact List
- 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
- PM Form 3.19.3 Notice to Individuals Receiving Substance Abuse Services under SAPT Federal Block Grant
Section 3.20 Credentialing and Privileging
- PM Form 3.20.1 Credentialing Application for Practitioners
- PM Form 3.20.2 Credentialing Application for Temporary Provisional
- PM Form 3.20.3 Credentialing Application for Initial/Re-credential Agencies
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
- PM Attachment 3.21.2 Part D Voluntary Prescription Drug Benefit Program Benefits and Cost for People with Medicare
- PM Form 3.21.1 AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medical institution that is funded by Medicaid
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
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
- PM Attachment 3.27.2 Non-Citizen/Lawful Presence Verification Documents
- PM Attachment 3.27.3 Persons Who Are Exempt From Verification of Citizenship During the Prescreening and Application Process
- PM Attachment 3.27.4 Citizenship/Lawful Presence Verification Process Through Health-e-Arizona
Section 3-9 Intake, Assessment and Service Planning
- PM Attachment 3.9.1 Service Plan Rights Acknowledgment Template
Section 4.2 Behavioral Health Medical Record Standards
Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs
- PM Attachment 4.3.1 AHCCCS Contracted Health Plans
- PM Attachment 4.3.2 T/RBHA Acute Health Plan and Provider Coordinator Contact Information
- PM Form 4.3.1 Communication Document
- PM Form 4.3.2 Request for Information from PCP
- PM Form 4.3.3 Acute Health Plan and Provider Inquiry Log
- PM Form 4.3.4 Recipient Transition From RBHA to PCP Log
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
- PM Form 5.1.2 Notice of Extension to Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health Services
- AHCCCS Attachment D - Notice of Extension
- Forma PM 5.1.2 Aviso de Extension de Plazo para Autorizacion de Decision para Servicios de Salud Mental Titulo XIX/XXI
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
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 6.0.1 Where Do I Submit My Claim
- PM Attachment 6.0.2 Billing Instructions Used to Identify Crisis Services
- PM Attachment 6.2.1 Pseudo ID Numbers
Section 7.1 Fraud and Abuse Reporting
Section 7.2 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
Section 7.5 Enrollment, Disenrollment and other Data Submission
- PM Attachment 7.5.1 Timeframes for Data Collection and Submission
- PM Attachment 7.5.2 834 Transaction Data Requirements
- PM Attachment 7.5.3 SMI and SED Qualifying Diagnoses Table
- PM Attachment 7.5.4 Substance Abuse Disorders Qualifying Diagnoses Table
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
- PM Attachment 9.1.2 ADHS/DBHS Attestion Speciality Clinicals and Providers
- Click here to access Training Information Forms
Section 10.1 Financial Management
- PM Attachment 10.1.1 NARBHA Sanctions Schedule - Possible Sanctions
- PM Attachment 10.1.2 Provider Income Statement
- PM Attachment 10.1.3 SAPT Federal Block Grant Revenue and Expense Report
- PM Form 10.1.1 HB 2003 Children's Services Progress Report
Section 10.2 Environment of Care and Infection Control
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
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