Fillable Printable Bhs Policy 902
Fillable Printable Bhs Policy 902
![Bhs Policy 902](/resources/formfile/images/gov1218/bhs-policy-902-page1.png)
Bhs Policy 902
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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
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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);
![](/resources/formfile/htmls/gov1218/bhs-policy-902/bg3.png)
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.
![](/resources/formfile/htmls/gov1218/bhs-policy-902/bg4.png)
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
th
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
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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.
(c) The T/RBHA is responsible for providing all non-inpatient emergency
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.
1
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
(c) W hen a medical team or health plan requests a behavioral health or
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
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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.
(c) The T/RBHA will ensure that the member’s transition to the PCP is
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
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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
![](/resources/formfile/htmls/gov1218/bhs-policy-902/bg9.png)
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
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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