Provider Forms, Attachments & Deliverables

Provider Manual Attachments

3.2 – Appointment Standards and Timeliness of Service

3.3 - Referral and Intake Process  

3.5 – Assessment and Service Planning

3.6 – SMI Eligibility Determination

3.8 – Psychotropic Medication: Prescribing and Monitoring

3.9 – Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment

3.10 – Special Populations

3.11 – Special Assistance for Persons Determined to Have a Serious Mental Illness

3.17 – Intake and Coordination of Care Agency (ICC Agency) Requirements

4.3 – Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers

4.4 – Coordination of Care with Other Governmental Entities

7.1 – Credentialing and Recredentialing

8.1 – Submitting Claims

8.3 – Third Party Liability and Coordination of Benefits

9.1 – Advance Directives

9.9 – Seclusion and Restraint Reporting

10.1 – Securing Services and Prior Authorization/Retrospective Authorization

10.11 – Securing Services and Prior Authorization/Retrospective Authorization

11.1 – Training Requirements

11.2 – Peer Support / Recovery Support Training, Centeification and Supervision Requirements

12.2 – Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits

13.1 – Enrollment, Disenrollment and Other Data Submission

15.1 – Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons

15.2 – Complaint Resolution

15.3 – Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX)

Provider Manual Forms

2.3 - Maternity Services for Title XIX/XXI Adults with SMI

2.10 - Housing for Adults with a Serious Mental Illness

3.1 - Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Low Income Subsidy Program

3.3 – Referral and Intake Process

3.4 – Outreach, Engagement, Re-Engagement, and Ending an Episode of Care and Disenrollment

3.5 – Assessment and Service Planning

3.6 – SMI Eligibility Determination

3.7 – General and Informed Consent to Treatment

3.8 – Psychotropic Medication: Prescribing and Monitoring

3.9 – Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment

3.10 – Special Populations

3.11 – Special Assistance for Persons Determined to have a Serious Mental Illness

3.12 – Arizona State Hospital

3.13 – Out-of-State Placements for children and Young Adults

3.17 – Intake and Coordination of Care Agency (ICC Agency) Requirements

4.1 – Transition of Persons

4.2 – Inter-RBHA Coordination of Care

4.3 – Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers

4.4 – Coordination of Care with Other Governmental Entities

7.1 – Credentialing and Recredentialing

8.1 – Submitting Claims

9.1 – Advance Directives

9.2 – Medical Record Standards

9.8 – Medical Institution Reporting of Medicare Part D

9.9 – Seclusion and Restraint Reporting

9.11 – ICC Agency Quality Management Plan Requirements

10.1 – Securing Services and Prior Authorization/Retrospective Authorization

10.5 – Pre-Admission Screening and Resident Review

10.11 – Securing Services and Prior Authorization/Retrospective Authorization

11.1 – Training Requirements

14.2 – Distribution

15.1 – Notice Requirements and Appeals Process for TitleXIX/XXI Eligible Persons

15.3 – Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX)

15.4 – Conduct of Investigations Concerning Persons with Serious Mental Illness

Provider Deliverable Templates

For additional information in regards to provider responsibilities in relation to these delverables please refer to the Provider Manual Section 16