Fillable Printable Bhs Policy 902

Bhs Policy 902

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 1 of 10

1. PURPOSE:

a. In Arizona, the acute care Medicaid program (Title XIX) and the State Children’s Health

Insurance Program (KidsCare/SCHIP/Title XXI) were developed as behavioral health

“carve-outs,” a model in which eligible persons receive general medical services through

health plans and covered behavioral health services through behavioral health managed

care organizations, also known as Tribal and Regional Behavioral Health Authorities

(T/RBHAs). Because of this separation in responsibilities, communication and

coordination between behavioral health providers, the Arizona Health Care Cost

Containment System (AHCCCS) Health Plan Primary Care Providers (PCPs) and

Behavioral Health Coordinators is essential to ensure the well-being of persons receiving

services from both systems.

b. Some behavioral health recipients are Medicaid (Title XIX/XXI) and Medicare (Title

XVIII) eligible and are referred to as “dual eligible” persons. Medicare covers limited

inpatient behavioral health services, outpatient behavioral health services and

prescription medication coverage. Medicare covered behavioral health services are

provided on either a fee-for-service basis or a managed care basis (through Medicare

Advantage Plans). The term Medicare Provider refer s to both the fee-for-service

Medicare providers and the Medicare Advantage Plans. Coordination of care must also

occur with Medicare providers to achieve positive health outcomes for Medicare eligible

behavioral health recipients.

c. Holistic treatment requires integration of physical health with behavioral health to

improve the overall health of an individual. Behavioral health recipients may be receiving

care from multiple health care entities. Duplicative medication prescribing,

contraindicated combinations of prescriptions and/or incompatible treatment approaches

could be detrimental to a person. For this reason, communication and coordination of

care between behavioral health providers, PCPs and Medicare providers must occur on

a regular basis to ensure safety and positive clinical outcomes for persons receiving

care. For T/RBHA enrolled persons not eligible for Title XIX or Title XXI coverage,

coordination and communication should occur with any known health care provider(s).

2. TERMS:

Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php

The following terms are referenced in this section:

Acute Health Plan and Provider Coordinator

Behavioral Health Medical Practitioner

Medicare Advantage Prescription Drug Plan (MA-PD)

Presc r ip tion Drug Plan (PDP)

Prior Period Coverage

3. PROCEDURES:

a. Coordinating care with AHCCCS Health Plans

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 2 of 10

i. The following procedures will assist behavioral health providers in coordinating care

with AHCCCS Health Plans:

(1) If the identity of the person’s primary care provider (PCP) is unknown, a

behavioral health provider must contact the Acute Health Plan and Provider

Coordinator(s) for the T/RBHA or the Behavioral Health Coordinator of the

person’s designated health plan to determine the name of the person’s assigned

PCP. See the AHCCCS Contracted Health Plans, Policy Attachment 902.1

for

contact information for the Behavioral Health Coordinators for each AHCCCS

Health Plan.

(2) T/RBHA enrolled persons who have never contacted their PCP prior to entry into

the behavioral health system should be encouraged to seek a baseline medical

evaluation. T/RBHA enrolled persons should also be prompted to visit their PCP

for routine medical examinations annually or more frequently if necessary.

(3) Behavioral health providers should request medical information fro m the person’s

assigned PCP. Examples include current diagnosis, medications, pertinent

laboratory results, last PCP visit, Early Periodic Screening, Diagnosis and

Treatment (EPSDT) screening results and last hospitalization . ADHS/DBHS has

developed a sample request form that may be utilized for this purpose (see

Policy

Form 902.2, Request for Information from PCP or Medicare Provider). T/RBHAs

must develop and make available to providers any additional standardized forms

that have been developed for requesting information from PCP. If the PCP does

not respond to the request, contact the health plan’s Behavioral Health

Coordinator for assis tance.

(4) Behavioral health providers must address and attempt to resolve coordination of

care issues with AHCCCS Health Plans and PCPs at the lowest possible level. If

problems persist, contact . T/RBHAs must develop and make available to

providers, policies and procedures that indicated specific information regarding

responsible person, i.e. Health Plan Liaison, or other at the T/RBHA.

b. The T/RBHA Acute Health Plan and Provider Coordinator

i. T/RBHAs are required to designate an Acute Health Plan and Provider Coordinator

who must gather, review and communicate clinical information requested by PCPs,

Acute Care Plan Behavioral Health Coordinators and other treating professionals or

involved stakeholders (see

Policy Attachment 902.2, T/RBHA Acute Health Plan and

Provider Coordinator Contact Information).

ii. The T/RBHA must have a designated and published phone number for the Acute

Health Plan and Provider Coordinator or a clearly recognized prompt on an existing

phone number that facilitates prompt access to the Acute Health Plan and Provider

Coordinator and that must be staffed during business hours.

iii. T/RBHAs must ensure that T/RBHA Acute Health Plan and Provider Coordinator s

receive training which includes, at a minimum, the following elements:

(1) Provider inquiry processing and tracking (including resolution timeframes);

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 3 of 10

(2) T/RBHA procedures for initiating provider contracts or AHCCCS provider

registration;

(3) Claim submission methods and resources (see

Policy 501, Submitting Claims and

Encounters);

(4) Claim dispute and appeal procedures (Policy 1805, Provider Claims Disputes);

and

(5) Identifying and referring quality of care issues.

c. Sharing information with PCPs, AHCCCS Acute Health Plans, other treating

professionals, and involved stakeholders

i. To support quality medical management and prevent duplication of services,

behavioral health providers are required to disclose relevant behavioral health

information pertaining to Title XIX and Title XXI eligibl e persons to the assigned

PCP, AHCCCS Acute Health Plans, other treating professionals and other involved

stakeholders within the followi ng required timeframes:

(1) “Urgent” – requests for intervention, information, or response within 24 hours.

(2) “Routine – Requests for intervention, information, or response within 10 days.

ii. For all behavioral health recipients referred by the PCP and have been det ermined to

have a Serious Mental Illness and/or a diagnosis of a chronic medical condition on

Axis III, the following information must be provided to the person’s assigned PCP:

(1) The person’s diagnosis; and

(2) The person’s current prescribed medications (including strength and dosage).

iii. T/RBHAs and/or subcontracted providers must provide the required information

annually, and/or when there is a significant change in the person’s diagnosis and/or

prescribed medications.

iv. For all Title XIX/XXI enrolled persons, behavioral health providers are required to:

(1) Notify the assigned PCP of the results of PCP initiated behavioral health referrals;

(2) Pr ovide a final disposition to the health plan Behavioral Health Coordinator in

response to PCP initiated behavioral health referrals, (for more information on the

referral proce ss, s ee Policy 103, Intake and Referral Process

);

(3) Coor dinat e the placement of persons in out-of-state treatment settings as

described in Policy 408, Out -of State Placement for Children and Young Adults

;

(4) Not if y, consult with or disclose information to the assigned PCP regarding persons

with Pervasive Developm ent al Disorders and Developmental Disabilities, such as

the initial assessment and treatment plan and care and consultation between

specialists;

(5) Pr ovide a copy to the PCP of any executed advance directive, or documentation

of refusal to sign an advance directive, for inclusion in the behavioral health

recipient’s medical record; and

(6) Not if y, consult with or disclose other events requiring medical consultation with

the person’s PCP.

v. Upon request by the PCP or member, information for any enrolled member must be

provided to the PCP consistent with requirements outlined in

Policy 1401,

Confidentiality.

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 4 of 10

vi. When contacting or sending any of the above referenced information to the person’s

PCP, behavioral health providers must provide the PCP with an agency contact

name and telephone number in the event the PCP needs further information.

vii. ADHS/DBHS has developed a communications form (Policy Form 902.1

) for

coordinating care with the AHCCCS Health Plan PCP or Behavioral Health

Coordinator. The form includes the required elements for coordination purposes and

must be completed in full for coordination of care to be considered to occur. For

complex problems, direct provider-to-provider contact is recommended to support

written communications.

viii. Policy Form 902.1 will not have to be used if there is a properly documented

progress note. To be considered properly documented the progress note must:

(1) Include a header that states “Coordination of Care”;

(2) Be leg ible; and

(3) Include all of the required elements contained in Policy Form 902.1

(4) The T/RBHA must track/log all the requests received from PCPs, AHCCCS Acute

Health Plans, other treating professionals and other involved stakeholders, (see

Policy Form 902.3, T/RBHA Acute Health Plan and Provider Inquiry Monthly Log).

(5) Completed Policy Form 902.3, T/RBHA Acute Health Plan and Provider Inquiry

Monthly Log, must be submitted to ADHS/ DBHS by the 30

day after the end of

the month.

ix. Submission of the Acute Health Plan and Provider Inquiry Logs must be timely. The

T/RBHA may be subject to corrective action if not compliant with this requirement.

x. ADHS/DBHS will communicate items of concern with T/RBHAs, if there are systemic

issues evident in the information submitted on the T/RBHA Acute Health Plan and

Provider Inquiry Monthly Log. T/RBHAs must resolve any such noted systemic

issues.

d. Responsibility fo r fee-for-service persons

i. It is t he r espon s ibility of the T/RBHA to provide fee-for-service behavioral health

services to Title XIX/XXI eligible persons not enrolled with an AHCCCS Health Plan.

ii. The T/RBHA is responsible for providing all inpatient emergency behavioral health

services for fee-for-service persons with psychiatric or substance abuse diagnoses.

iii. T he T/RBHA is responsible for behavioral health services to Native American Title

XIX and Title XXI eligible persons referred by an Indian Health Services (IHS) or

triba l facility for emerg e ncy ser vic es rendered at non-IHS facilities.

e. Responsibility for persons enrolled in an AHCCCS Health Plan

i. Services which may have been covered by the AHCCCS Health Plan Contractor for

Prior Period Coverage will now be the responsibility of the T/RBHA. This is limited to

the behavioral health services only and after the individual has been medically

cleared. The Health Plan Contractor is still obligated to provide all necessary

medical services.

ii. The following rules apply for other areas of coverage:

(1) Pre-petition Screenings and Court Ordered Evaluations

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 5 of 10

(a) Payment for p re-petition screenings and court ordered evaluations is the

responsibility of the county. RBHAs must develop and make available to

providers any additional informat ion as part of their policies and procedures.

(2) Em erg enc y Behavioral Health Services

(a) W hen a Title XIX or Title XXI eligible person presents in an emergency room

setting, the person’s AHCCCS Health Plan is responsible for all emergency

medical services including triage, physician assessment, and diagnostic

tests.

(b) The T/RBHA, or when applicable, its designated behavioral health provider,

is responsible for psychiatric and/or psychological evaluations in emergency

room settings provided to all Title XIX and Title XXI persons enrolled with a

T/RBHA.

behavioral health services to Title XIX and Title XXI eligible persons.

Examples of non-inpatient emergency services include assessment,

psychiatric evaluation, mobile crisis, peer support and counseling. 1

(d) The T/RBHA is responsible for providing all inpatient emergency behavioral

health services to persons with psychiatric or substance abuse diagnoses

for all Title XIX and Title XXI eligible persons.

(e) Emergency transportation of a Title XIX or Title XXI eligible person to the

emergency room (ER) when the person has been directed by the T/RBHA or

T/RBHA provider to present to this setting in order to resolve a behavioral

health crisis is the responsibility of the T/RBHA. The T/RBHA or

subcontracted provider directing the person to present to the ER must notify

the emergency transpo rtation provider of the T/RBHAs fiscal responsibi li ty

for the service.

(f) Emergency transportation of a Title XIX or Title XXI eligible person required

to manage an acute medical condition, which includes transportation to the

same or higher level of care for immediate medically necessary treatment, is

the responsibility of the person’s AHCCCS Health Plan.

(g) For information on emergency services for Non-Title XIX/XXI persons see

Policy 111, Crisis Intervention Services

(3) Non-emergency Behavioral Health Services

(a) For Title XIX and Title XXI eligible persons, the T/RB HA is responsible for

the provision of all non-emergency behavioral health services.

(b) If a Title XIX or Title XXI eligible person is assessed as needing inpatient

psychiatric services by the T/RBHA or subcontracted provider prior to

admission to an inpatient psychiatric setting, the T/RBHA is responsible for

authorization and payment for the full inpatient stay, as per

Policy 1101,

Securing Services and Prior Authorization.

Note: in inpatient settings, these services would be included in the per diem rate.

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 6 of 10

psychiatric evaluation prior to the implementation of a surgery, medical

procedure or medical therapy to determine if there are any behavioral health

contraindications, the T/RBHA is responsible for the provision of this service.

Surgeries, procedures or therapies can include gastric bypass, interferon

therapy or other procedures for which behavioral health support for a patient

is indicated.

(4) Non-emergency Transportation

(a) Transportation o f a Title XIX or Title XXI eligible person to an initial

behavioral health intake appointment is the responsibility of the T/RBHA.

(5) Medical T r eatment for Persons in Behavioral Health Treatment Facilities

(a) When a Title XIX or Title XXI eligible person is in a Level II or Level III

residential treatment center and requires medical treatment, the AHCCCS

Health Plan is responsible for the provision of covered medical services.

(b) If a Title XIX or Title XXI eligible person is in a Level I psychiatric facility and

requires medical treatment, those services are included in the per diem rate

for the treatment facility. If the person requires inpatient medical services

that are not available at the Level I psychiatric facility, the pers on must be

discharged from the psychiatric facility and admitted to a medical facility.

The AHCCCS Health Plan is responsible for medically necessary services

received at the medical facility, even if the person is enrolled with a T/RBHA.

f. PCPs prescribing psychotropic medications

i. W ithin their scope of practice and comfort level, an AHCCCS Health Plan PCP may

elect to treat select behavioral health disorders. The select behavioral health

disorders that AHCCCS Health Plan PCPs can treat are:

(1) Attention-Deficit/Hyperact ivit y Disorder;

(2) Uncom plicat ed depressive disorders; and

(3) Anxiet y disorders .

ii. The “Agreed Conditions”

(1) Certain requirements and guiding principles regarding medications for psychiatric

disorders have been established for persons under the care of both a health plan

PCP and behavioral health provider simultaneously. The following conditions

apply:

(a) Title XIX and Title XXI eligible persons must no t receiv e medications for

psychiatric disorders from the health plan PCP and behavioral health

provider simultaneously. If a person is identified to be simultaneously

receiving medications from the health plan PCP and behavioral health

provider, the behavioral health provider must immediately contact the PCP

to coordinate care and agree on who will continue to medically manage the

person’s behavioral health condition.

(b) Medications prescribed by providers within the T/RBHA behavioral health

system must be filled by T/RBHA contracted pharmacies under the T/RBHA

pharmacy benefit (see exceptions to this requirement for dual eligible

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 7 of 10

persons in subsection 4.3.7-F, Coordination of care with Medicare

providers). This is particularly important when the pharmacy filling the

prescription is part of the contracted pharmacy network for both the

prescribing T/RBHA and the person’s AHCCCS Health Plan. The T/RBH A

and contracted providers must take active steps to ensure that prescriptions

written by providers within the T/RBHA system are not charged to the

person’s AHCCCS Health Plan.

iii. Transitions of persons with ADHD, depression, and/or anxiety to the care of their

Primary Care Physician

(1) Members who have a diagnosis of Attention Deficit Hyperactivity Disorder

(ADHD), depression, and/or anxiety and who are stable on their medications may

transition back to the care of their PCP for the management of these diagnoses,

as long as the member, their guardian or parent and the PCP agree to this

treatment transition. The T/RBHA is re quired to facilitate this process and to

ensure that the followi ng steps are taken:

(a) The T/RBHA must con ta ct the member’s PCP to discuss the member’s

current medication regime and to confirm that the PCP is willing and able to

provide treatment for the member’s ADHD, depression, and/or anxiety.

(b) If the PCP agrees to transition treatment for the member’s diagnosis of

ADHD, depression and/or anxiety, the T/RBHA must provide the PCP with a

transition packet that includes (at a minimum):

(i) A written statement indicating that the member is stable on a medication

regime;

(ii) A medication sheet or list of medications currently prescribed by the

T/RBHA Behavioral Health Medical Practitioner (BHMP);

(iii) A psychiatric evaluation;

(iv) Any relevant psychiatric progress notes that may assist in the ongoing

trea tme nt o f th e member; and

(v) A discharge summary outlining the member’s care and any adverse

responses the member has had to treatment or medication.

(vi) A copy of the packet must be sent to the member’s AHCCCS Health Plan

Behavioral Health Coordinator as well as to the member’s PCP.

seamless, and that the member doe s not go without medications during this

transition period.

(d) Each month, the T/RBHA will complete

Policy Form 902.4 Member

Transition from T/RB HA to PCP Tracking Log and submit it to ADHS/DBHS

in order to monitor the transition process.

(e) T/RBHAs m ust develop and make available to providers policies and

procedures which describe the process for handling referrals to the P CP

from the T/RBHA fo r these members and the coordination/communication

process for ongoing care/treatment.

iv. Gener al Psychiatric Consultations

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 8 of 10

(1) Behavioral health medical practitioners must be available to AHCCCS Health Plan

PCPs to answer diagnostic and treatment questions of a general nature.

(2) General psychiatric consultations are not person specific and are usually

conducted over the telephone between the PCP and the behavioral health

medical practitioner.

v. One-Time Face-to-Face Psychiatric Evaluations

(1) Behavioral health providers must be available to conduct a face-to-face evaluation

with a Title XIX/XXI eligible person upon his/her PCPs request in accordance with

Policy 102, Appointment Standards and Timeliness of Service

(2) A one-ti me face-to-face evaluation is used to answer PCPs specific questions and

provide clarification and evaluation regarding a person’s diagnosis,

recommendations for tre atment, need for behavioral health care, and/or ongoing

behavioral health care or medication management provided by the PCP.

(3) The PCP must have seen the person prior to requesting a one-time face-to-face

psychiatric evaluation with the behavioral health provider.

(4) AHCCCS Hea lth Plan PCPs must be provided current information about how to

access T/RBHA psychiatric c onsult ation services; T/RBHAs must provi de contact

information and/or additional information to providers. The T/RBHA is oblig a ted to

offer general consultations and one-time face-to-face psychiatric evaluations and

must provide direct and timely access to behavioral health medical practitioners

(physicians, nurse practitioners and physician assistants) or other behavioral

health practitioners if requested by the PCP.

g. Coordination of care with Medicare providers

i. Medicare Advantage plans

(1) Medicare health plans, also known as Medicare Advantage (MA) plans, are

managed care entities that have a Medicare contract with the Centers for

Medicare and Medicaid Services (CMS) to provide services to Medicare

beneficiaries. MA plans provide the full array of Medicare benefits, including

Medicare Part A, hospital insurance, and Medicare Part B, medical insurance. As

of January 1, 2006, MA plans also included Medicare Part D, prescription drug

coverage.

(2) Many of the AHCCCS Contracted Health Plans are MA plans (see

Policy

Attachment 902.1). These plans provide Medicare Part A, Part B and Part D

benefits in addition to Medicaid services for dual eligible persons and are referred

to as MA-PD SNPs (Medicare Advantage-Prescription Drug/Special Needs

Plans).

(3) Som e MA plans contract with the T/RBHA to provide some or all of the Medicare

covered behavioral health services. In such cases, coordination of care should be

simplified as the T/RBHA is providing Title XIX and state funded behavioral health

services, as well as Medicare behavioral health services. Coordination with MA

plans must be attempted by the T/RBHA and/or behavioral health provider when

the Medicare behavioral health services are provided by the MA plan.

ADHS/DBHS has developed sample forms for use when requesting or sharing

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 9 of 10

information for purposes of coordinating care with Medicare providers (see

Policy

Form 902.1, Communication Document, and Policy Form 902.2, Request for

Information from PCP or Medicare Plan/Provider).

(4) T/RBHAs must provide informat ion to providers indicating which MA plans, if any,

the T/RBHA contracts with to provide Medicare services.

ii. Medicare Fee-for-Service Program

(1) Instead of enrolling in a Medicare Advantage plan, Medicare eligible behavioral

health recipients may elect to receive all Medicare services (Parts A, B and/or D)

through any provider authorized to deliver Medicare services. Therefore,

behavioral health recipients in the Medicare Fee-for-Service program may receive

services from Medicare reg ist ered providers in the T/RBHA provider network.

iii. Inpat ient Psychiatric Services

(1) Medicare has a lifet ime benefit maximum for inpatient psychiatric services.

T/RBHA cost sharing responsibilities and billing for inpatient psychiatric services

must be in accordance with

Policy 701, Third Party Liability and Coordination of

Benefits, and Policy 501, Submitting Claims and Encounters.

(2) T/RBHAs must develop and make available to providers inform ation specifying

coordination of care of inpatient psychiatric services with Medicare providers.

iv. Out patient Behavioral Health Services

(1) Medicare provides some outpatient behavioral health services that are also

ADHS/DBHS covered behavioral health services. T/RBHA cost sharing

responsibilities and billing for outpatient behavioral health services must be in

accordance with Policy 701, Thir d Party Liability and Coordination of Benefits

and

Policy 501, Submitt ing Claims and Encounters.

v. Prescript ion Medication Services

(1) Medicare eligible behavioral health recipients must enroll in a Medicare Part D

Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug Plan

(MA-PD) to receive the Part D benefit. PDPs only provide the Part D benefit and

any Medicare registered provider may prescribe medications to behavioral health

recipients enrolled in PDPs. Some MA-PDs may contract with the T/RBHA or

T/RBHA providers to provide the Part D benefit to Medicare eligible behavioral

health recipi ents.

(2) T/RBHAs must develop and make available to providers inf orm ation specifying

coordination of care of prescription medication services with MA plans.

(3) While PDPs and MA-PDs are responsible for ensuring prescription drug coverage

to behavioral health recipients enrolled in their plans, there are some prescription

medications that are not included on plan formularies (non-covered) or are

excluded Part D drugs. The T/RBHA is responsible for covering non-covered or

excluded Part D behavioral health prescription medications listed on the T/RBHA

formulary, in addition to Part D cost sharing, in accordance with

Policy 701 , Third

Party Liability and Coordination of Benefits.

4. REFERENCES:

42 CFR 400.202

Arizona Departm ent of Health Services Current Effective Date: 6/15/2011

Division of Behavioral Health Services Last Review Date: 5/13/2011

Policy and Procedures Manual

SECTION: 3 CH AP TER: 900

POLICY: 902, Coordination of Care with AHCCCS Health Plans, PCP and Medicare

Providers

____________________________________________________________________________

902, Coordination of Care with AHCCCS Health Pla ns ,

PCP and Medicare Providers

Page 10 of 10

42 CFR 409.62

42 CFR 422.2

42 CFR 422.4

42 CFR 422.106

42 CFR 422.114

42 CFR 423.4

42 CFR 423.34

42 CFR 423.100

42 CFR 423.104

42 CFR 423.272

42 CFR 423.505

42 CFR 438.208

A.R.S. § 32-1901

A.R.S. § 36-545.04

9 A.A.C.20

9 A.A.C.21

A.A.C. R9 -22-210.01

AHCCCS/ADHS Contract

ADHS/RBHA Contracts

ADHS/Tribal IGAs

CMS Medicare Benefit Policy Manual

AHCCCS Behavioral Health Services Guide

AHCCCS Medical Policy Manual

Policy 102, Appointment Standards and Timeliness of Service

Policy 103, Referral and Intake Process

Policy 403, Training Requirements

Policy 501, Submitting Claims and Encounters to the RBHA

Policy 701, Third Party Liability and Coordination of Benefits

Policy 801, Out-of-State Placements for Chil dren and Young Adults

Policy 901, Transition of Persons

Policy 1401, Confidentiality

Policy 1601, Enr ollment, Disenrollment and Other Data Submission

ADHS/DBHS Covered Behavioral Health Services Guide

ADHS/DBHS Practice Improvement Protocol, Pervasive Developmental Disorders and

Developmental Disabilities

ADHS/DBHS Policy Clarification Memorandum: Coordination of Care Between AHCCCS

Health Plan PCPs and Other PCPs in the Behavioral Health System

ADHS/DBHS Policy Clarification Memorandum: Co ordination of Car e with AHCCCS Hea lth

Plans and Primary Care Physicians