Fillable Printable 320P
Fillable Printable 320P
320P
AHCCCS MEDICAL POLICY MANUAL
SECTION 320 – SERVICES WITH SPECIAL CIRCUMSTANCES
320-P - Page 1 of 9
320-P - SERIOUS MENTAL ILLNESS ELIGIBILITY DETERMINATION
EFFECTIVE DATES: 07/01/16, 10/01/17
REVISION DATES: 01/04/17
I. PURPOSE
This Policy applies to Acute Care, ALTCS/EPD, CRS, and RBHA Contractors, Fee-For-
Services (FFS) Programs as delineated within this policy including: Tribal ALTCS,
TRBHAs, and all FFS populations, excluding Federal Emergency Services (FES). (For FES,
see AMPM Chapter 1100), and the AHCCCS designee which conducts Serious Mental
Illness (SMI) determinations.
This Policy also applies to subcontracted providers, including Indian Health Services (IHS)
and providers that are owned or managed by Tribal governments (including 638 facilities),
that choose to send assessments to the AHCCCS designee which conducts SMI
determinations.
This Policy establishes requirements regarding SMI Eligibility Determinations.
A critical component of the AHCCCS delivery system is the effective and efficient
identification of persons who have behavioral health needs due to the severity of their
behavioral health disorder. One such group is persons determined to have a SMI.
Without
receipt of the appropriate care, these persons are at high risk for further deterioration of their
physical and mental condition, increased hospitalizations and potential homelessness and
incarceration. In order to ensure that persons who may have a SMI are promptly identified
and enrolled for services, AHCCCS has developed a standardized process for the referral,
evaluation, and determination of SMI eligibility. The requirements associated with the
referral for a SMI evaluation and SMI eligibility determination are set forth in this Policy.
II. DEFINITIONS
ASSESSMENT
The ongoing collection and analysis of a person’s
medical, psychological, psychiatric and social
conditions in order to initially determine if a health
disorder exists, if there is a need for behavioral health
services, and on an ongoing basis ensure that the
person’s service plan is designed to meet the person’s
(and family’s) current needs and long term goals.
EVALUATION
The process of analyzing current and past treatment
information including assessment, treatment other
medical records and documentation for purposes of
making a decision as to a person’s eligibility for SMI
services.
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DETERMINING ENTITY
Either the AHCCCS designee authorized to make SMI
determinations or a TRBHA (for each TRBHA, tribal
members only) authorized to make the final
determination of SMI eligibility.
Seriously Mentally Ill (SMI) - A person 18 years of age
or older as defined in A.R.S. §36-550.
SMI DETERMINATION
A determination as to whether or not an individual
meets the diagnostic and functional criteria established
for the purpose of determining a person’s eligibility for
SMI services.
SMI DECERTIFICATION
The process that results in the removal of the SMI
behavioral health category designation from the
member’s record.
III. POLICY
A. GENERAL REQUIREMENTS
1. All persons must be evaluated for SMI eligibility by a qualified clinician, as defined
in A.A.C. R9-21-101(B), and have a SMI determination made by the determining
entity if:
a. The person makes such a request, or
b. A guardian/legal representative who is authorized to consent to inpatient
treatment pursuant to A.R.S. §14-5312
makes a request on behalf of the person,
c. An Arizona Superior Court issues an order instructing that a person is to undergo
a SMI evaluation/determination:
i. The SMI eligibility evaluation record must contain all of the documentation
that was considered during the review including, but not limited to current
and/or historical treatment records. The record may be maintained in either
hardcopy or electronic format. Contractor and TRBHAs must develop and
make available to providers any requirements or guidance on SMI eligibility
evaluation record location and/or maintenance,
ii. Computation of time is as follows:
1) Day Zero: The day the initial assessment is completed by a qualified
clinician, regardless of time of the assessment,
2) Day One: The next business day after the initial assessment is completed.
The individual or organization completing the initial assessment must
provide it to the determining entity as soon as practicable, but no later than
11:59 pm on Day One,
3) Day Three: The third business day after the initial assessment is
completed. The determining entity shall have at least two business days to
complete the final SMI determination but the final SMI determination
shall be completed no later than Day Three,
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4) Determination Due Date: Day Three - Three business days after Day Zero,
excluding weekends and holidays, and is the date that the determination
decision shall be rendered. This date may be amended if an extension is
approved in accordance with this policy.
iii. A TRBHA may delegate to the AHCCCS designee which conducts SMI
determinations some or part of the responsibilities established under this
Policy.
d. A member is at least the age of 17.5. Refer also to AHCCCS Transition to
Adulthood Practice Tool 8.0.
B. PROCESS FOR COMPLETION OF THE INITIAL SMI EVALUATION
Upon receipt of a referral, a request, or identification of the need for an SMI 1.
determination, The Contractor, TRBHA, Tribal ALTCS case manager, or designated
Arizona Department of Corrections (ADC) or Arizona Department of Juvenile
Corrections (ADJC) staff person will schedule an appointment for an initial meeting
with the person and a qualified clinician (see AMPM Policy 950). This shall occur no
later than seven business
days after receiving the request or referral.
For referrals seeking an SMI eligibility determination for individuals admitted to a
hospital for psychiatric reasons the entity scheduling the evaluation shall ensure that
documented efforts are made to schedule a face-to-face SMI assessment with the
member while hospitalized.
During the initial SMI evaluation meeting with the person and a qualified clinician,
2.
the clinician must:
a. Make a clinical judgement as to whether the person is competent enough to
participate in an evaluation,
b. Obtain written consent to conduct the assessment from the person or, if
applicable, the person’s guardian, unless the person has been ordered to undergo
evaluation as part of Court Ordered Treatment proceedings,
c. Provide to the person and, if applicable, the person’s guardian, the information
required in A.A.C. R9-21-301(D)(2), a client rights brochure, and the appeal
notice required by A.A.C. R9-21-401(B),
d. Obtain authorization for the release of information, if applicable, (see AMPM
Policy 550) for any documentation that would assist in the determination of the
person’s eligibility for SMI services,
e. Conduct an assessment if one has not been completed within the last six months,
f. Complete the SMI Determination Form (see AMPM Exhibit 320-P-1), and
g. Upon completion of the initial evaluation, submit all information to the
Determining Entity within one business day.
C. CRITERIA FOR SMI ELIGIBILITY
1. The final determination of SMI requires both a qualifying SMI diagnosis and
functional impairment because of the qualifying diagnosis (see AMPM Exhibit 320-
P-2 for a list of qualifying diagnoses).
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2. Functional Criteria for SMI eligibility: To meet the functional criteria for SMI status,
a person must have, as a result of a qualifying SMI diagnosis, dysfunction in at least
one of the following four domains, as described below, for most of the past twelve
months or for most of the past six months with an expected continued duration of at
least six months.
a. Inability to live in an independent or family setting without supervision – Neglect
or disruption of ability to attend to basic needs. Needs assistance in caring for self.
Unable to care for self in safe or sanitary manner. Housing, food and clothing
must be provided or arranged for by others. Unable to attend to the majority of
basic needs of hygiene, grooming, nutrition, medical and dental care. Unwilling
to seek prenatal care or necessary medical/dental care for serious medical or
dental conditions. Refuses treatment for life threatening illnesses because of
behavioral health disorder,
b. A risk of serious harm to self or others – Seriously disruptive to family and/or
community. Pervasively or imminently dangerous to self or others’ bodily safety.
Regularly engages in assaultive behavior. Has been arrested, incarcerated,
hospitalized or at risk of confinement because of dangerous behavior. Persistently
neglectful or abusive towards others in the person’s care. Severe disruption of
daily life due to frequent thoughts of death, suicide, or self-harm, often with
behavioral intent and/or plan. Affective disruption causes significant damage to
the person’s education, livelihood, career, or personal relationships,
c. Dysfunction in role performance – Frequently disruptive or in trouble at work or
at school. Frequently terminated from work or suspended/expelled from school.
Major disruption of role functioning. Requires structured or supervised work or
school setting. Performance significantly below expectation for
cognitive/developmental level. Unable to work, attend school, or meet other
developmentally appropriate responsibilities.
3. Risk of Deterioration:
a. A qualifying diagnosis with probable chronic, relapsing, and remitting course,
b. Co-morbidities (e.g. developmental/intellectual disability, substance
dependence, personality disorders),
c. Persistent or chronic factors such as social isolation, poverty, extreme chronic
stressors (e.g. life-threatening or debilitating medical illnesses, victimization),
or
d. Other (e.g. past psychiatric history, gains in functioning have not solidified or
are a result of current compliance only, court-committed, care is complicated
and requires multiple providers).
4. The following reasons shall not be sufficient in and of themselves for denial of SMI
eligibility:
a. An inability to obtain existing records or information, or
b. Lack of a face-to-face psychiatric or psychological evaluation.
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D. PERSON WITH CO-OCCURRING SUBSTANCE USE
1. For persons who have a qualifying SMI diagnosis and co-occurring substance use, for
purposes of SMI determination, presumption of functional impairment is as follows:
a. For psychotic diagnoses (bipolar I disorder with psychotic features, delusional
disorder, major depression, recurrent, severe, with psychotic features,
schizophrenia, schizoaffective disorder and psychotic disorder not due to a
substance or know psychological condition) functional impairment is presumed to
be due to the qualifying psychiatric diagnosis,
b. For other major mental disorders (bipolar disorders, major depression, and
obsessive-compulsive disorder), functional impairment is presumed to be due to
the psychiatric diagnosis, unless:
i. The severity, frequency, duration or characteristics of symptoms contributing
to the functional impairment cannot be attributed to the qualifying mental
health diagnosis, or
ii. The assessor can demonstrate, based on a historical or prospective period of
treatment, that the functional impairment is present only when the person is
abusing substances or experiencing symptoms of withdrawal from substances.
c. For all other mental disorders not covered above, functional impairment is
presumed to be due to the co-occurring substance use unless:
i. The symptoms contributing to the functional impairment cannot be attributed
to the substance use disorder, or
ii. The functional impairment is present during a period of cessation of the co-
occurring substance use of at least 30 days, or
iii. The functional impairment is present during a period of at least 90 days of
reduced use and is unlikely to cause the symptoms or level of dysfunction.
E. PROCESS FOR COMPLETION OF FINAL SMI DETERMINATION
1. The Contractor, TRBHA, and Tribal ALTCS shall develop and make available to
providers its policies and procedures that describe the providers’ requirements for
submitting the evaluation packet in order for the Determining Entity to make the final
SMI eligibility determination.
2. The licensed psychiatrist, psychologist, or nurse practitioner designated by the
Determining Entity must make a final determination as to whether the person meets
the eligibility requirements for SMI status based on:
a. A face-to-face assessment or reviewing a face-to-face assessment by a qualified
clinician (see AMPM Policy 950 ), and
b. A review of current and historical information, if any, obtained orally or in
writing by the assessor from collateral sources, and/or present or previous treating
clinicians.
3. The following shall occur if the designated reviewing psychiatrist, psychologist, or
nurse practitioner has not conducted a face-to-face assessment and has a disagreement
with the current evaluating or treating qualified behavioral health professional or
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behavioral health technician that cannot be resolved by oral or written
communication:
a. Disagreement regarding diagnosis: Determination that the person does not meet
eligibility requirements for SMI status must be based on a face-to-face diagnostic
evaluation conducted by a designated psychiatrist, psychologist, or nurse
practitioner. The resolution of (specific reasons for) the disagreement shall be
documented in the person’s comprehensive clinical record,
b. Disagreement regarding functional impairment: Determination that the person
does not meet eligibility requirements must be documented by the psychiatrist,
psychologist, or nurse practitioner in the person’s comprehensive clinical record
to include the specific reasons for the disagreement and will include a clinical
review with the qualified clinician.
4. If there is sufficient information to determine SMI eligibility, the person shall be
provided written notice of the SMI eligibility determination within three business
days of the initial meeting with the qualified clinician in accordance with this Policy.
F. ISSUES PREVENTING TIMELY COMPLETION OF SMI ELIGIBILITY DETERMINATION –
EXTENDING COMPLETION OF SMI ELIGIBILITY DETERMINATION TIME PERIOD
1. The time to initiate or complete the SMI eligibility determination may be extended no
more than 20 days if the person agrees to the extension and:
a. There is substantial difficulty in scheduling a meeting at which all necessary
participants can attend,
b. The person fails to keep an appointment for assessment, evaluation or any other
necessary meeting,
c. The person is capable of, but temporarily refuses to cooperate in the preparation
of the completion of an assessment or evaluation,
d. The person or the person’s guardian and/or designated representative requests an
extension of time,
e. Additional documentation has been requested, but has not yet been received, or
f. There is insufficient functional or diagnostic information to determine SMI
eligibility within the required time periods.
Insufficient diagnostic information shall be understood to mean that the information
available to the reviewer is suggestive of two or more equally likely working
diagnoses, only one of which qualifies as SMI, and an additional piece of existing
historical information or a face-to-face psychiatric evaluation is likely to support one
diagnosis more than the other(s).
2. The Determining Entity must:
a. Document the reasons for the delay in the person’s eligibility determination
record when there is an administrative or other emergency that will delay the
determination of a SMI status, and
b. Not use the delay as a waiting period before determining a SMI status or as a
reason for determining that the person does not meet the criteria for SMI
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eligibility (because the determination was not made within the time
standards).
3. In situations in which the extension is due to insufficient information:
a. The Determining Entity shall request and obtain the additional documentation
needed (e.g., current and/or past medical records) and/or perform or obtain
any necessary psychiatric or psychological evaluations,
b. The designated reviewing psychiatrist, psychologist, or nurse practitioner
must communicate with the person’s current treating clinician, if any, prior to
the determination of a SMI, if there is insufficient information to determine
the person’s level of functioning, and
c. SMI eligibility must be determined within three days of obtaining sufficient
information, but no later than the end date of the extension.
4. If the evaluation or information cannot be obtained within the required time period
because of the need for a period of observation or abstinence from substance use in
order to establish a qualifying mental health diagnosis, the person shall be notified by
the determining entity that the determination may, with the agreement of the person,
be extended for up to 90 (calendar) days for an Extended Evaluation Period (EEP).
This is a 90 day period of abstinence from drug and/or alcohol abuse in order to help
the reviewing psychologist make an informed decision regarding SMI eligibility.
This extension may be considered a technical re-application to ensure compliance
with the intent of A.A.C. R9-21-303. However, the person does not need to actually
reapply. Alternatively, the determination process may be suspended and a new
application initiated upon receipt of necessary information.
5. If the person refuses to grant an extension, SMI eligibility must be determined based
on the available information. If SMI eligibility is denied, the person will be notified
of his/her appeal rights and the option to reapply in accordance with this Policy.
G. NOTIFICATION OF SMI ELIGIBILITY DETERMINATION
1. If the person is determined a SMI, the SMI status must be reported to the person or
their legal guardian by the Determining Entity in writing, including notice of the
person’s right to appeal the decision (see ACOM Policy 444).
2. If the eligibility determination results in a denial of a SMI status, the Determining
Entity must provide written notice of the decision and include:
a. The reason for denial of SMI eligibility (see AMPM Exhibit 320-P-1),
b. The right to appeal (see ACOM Policy 414 and ACOM Policy 444), and
c. The statement that Title XIX/XXI eligible persons will continue to receive needed
Title XIX/XXI covered services. In such cases, the person’s behavioral health
category assignment must be assigned based on criteria in the AHCCCS
Technical Interface Guidelines.
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H. RE-ENROLLMENT OR TRANSFER
If the person’s status is SMI at disenrollment or transition to another Contractor, TRBHA
or Tribal ALTCS,
the person’s status shall continue as SMI.
A person shall retain their SMI status unless a determination is made by a Determining
Entity that the person no longer meets criteria.
I. REVIEW OF SMI ELIGIBILITY
1. The Contractor, TRBHA and Tribal ALTCS
must indicate in policies and procedures
made available to their providers the process for reviewing an SMI eligibility
determination.
2. The Contractor, TRBHA, Tribal ALTCS case manager, or contracted behavioral
health providers may seek a review of a person’s SMI eligibility from the
Determining Entity:
a. As part of an instituted, periodic review of all persons determined to have a SMI,
b. When there has been a clinical assessment that supports that the person no longer
meets the functional and/or diagnostic criteria, or
c. As requested by a member who has been determined to meet SMI eligibility
criteria, or their legally authorized representative.
3. A review of the determination may not be requested by the TRBHA, Contractor or
their contracted behavioral health providers within six months from the date an
individual has been determined SMI eligible.
J. SMI DECERTIFICATION
There are two established methods for removing a SMI designation, one clinical and the
other an administrative option, as follows:
1. A member who has a SMI designation or an individual from the member’s clinical
team may request a SMI Clinical Decertification from the AHCCCS designee which
conducts SMI determinations. A SMI Clinical Decertification is a determination that
a member who has a SMI designation no longer meets SMI criteria. If, as a result of
a review, the person is determined to no longer meet the diagnostic and/or functional
requirements for SMI status:
a. The Determining Entity shall ensure that written notice of the determination and
the right to appeal is provided to the affected person with an effective date of 30
days after the date the written notice is issued,
b. The Contractor, TRBHA or Tribal ALTCS shall ensure that services are
continued in the event an appeal is timely filed, and that services are appropriately
transitioned as part of the discharge planning process.
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2. SMI Administrative Decertification
A member who has a SMI designation may request a SMI Administrative
Decertification from AHCCCS, DHCM, and Clinical Resolution Unit
if the member
has not received behavioral health services for a period of two or more years.
a. Upon receipt of a request for Administrative Decertification, the Contractor shall
direct the member to contact AHCCCS DHCM Customer Service,
b. AHCCCS will evaluate the member’s request and review data sources to
determine the last date the member received a behavioral health service.
AHCCCS will inform the member of changes that may result with the removal of
the member’s SMI designation. Based upon review, the following will occur:
i. In the event the member has not received a behavioral health service within
the previous two years, the member will be provided with AMPM Exhibit
320-P-3. This form must be completed by the member and returned to
AHCCCS,
ii. In the event the review finds that the member has received behavioral health
services within the prior two year period, the member will be notified that
they may seek decertification of their SMI status through the Clinical
Decertification process.
