Fillable Printable Form 580
Fillable Printable Form 580
Form 580
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-1
AHCCCS MEDICAL POLICY MANUAL
580 BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
INITIAL
EFFECTIVE DATE: 07/01/2016
I. PURPOSE
This Policy applies to AHCCCS Contractors responsible for the provision of
behavioral health services and Tribal Regional Behavioral Health Authorities
(TRBHAs) for Title XIX/XXI and Non-Title XIX/XXI members. This Policy
outlines requirements for referral and intake in order to ensure individuals are ab le t o
gain prompt access to behavioral health services.
II. DEFINITIONS
A
SSESSMENT
The ongoing collection and analysis of a person’s medical,
psychological, psychiatric and social conditions in order to
initially determine if a health disorder exist s, if there is a need
for behavioral health services, and on an ongoing basis ensure
that the person’s service plan is desi gned to meet the person’s
(and family’s) current needs and long term goals.
I
NITIAL
E
VALUATION
(INTAKE)
The collection by appropriately trained staff of basic
demographic information and preliminary determination of
the member’s needs.
R
EFERRAL
Any oral, written, faxed, or electronic request for behavioral
health services made by a member, or member’s legal
guardian, a fami ly mem ber, an AH CCC S healt h p lan, p rimar y
care provider, hospital, jail, court, probation and parole
officer, tribal government, Indian Health Services, school, or
other governmental or community agency; and for members
in the legal custody of the Department o f Chi ld S afet y (DCS),
the out-of-home placement, in accordance with A.R.S. §8-
512.01 in accordance with ACOM 449.
SMI
D
ETERMINATION
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.
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-2
AHCCCS MEDICAL POLICY MANUAL
III. POLICY
A. GENERAL REQUIREMENTS FOR BEHAVIORAL HEALTH SERVICES REFERRAL
AND
INTAKE
To facili tate a memb er’s acc ess to behav ioral heal th servi ces in a ti mely manner ,
Contractors and TRBHAs are t o ensure an eff ecti ve refe rral and i ntake process is
in place for behavioral health services. This process shall include:
1. Engaging with the member and/or member’s legal guardian/family member,
2. Communicating to potential referral sources the process for making referrals,
3. Keeping information or documents collected in the referral process
confidential and protected in accordance with applicable federal and state
statutes, regulations and policies,
4. After obtaining appropriate consents, informing the referral source as
appropriate about the final disposition of the referral,
5. Conducting intakes that ensure the accurate collection of all the required
information and ensure that members who have difficulty communicating
because of a disability or who require language services are afforded
appropriate accommodations to assist them in fully expressing their needs.
6. Collecting sufficient information about the member to determine the urgency
of the situation and subsequently scheduling an assessment within the
required timeframes and with an appropriate provider. (For Contractor
appointment standards, see ACOM Policy 417.)
B. REFERRALS FOR INDIVIDUALS ADMITTED TO A HOSPITAL
Contractors and TRBHAs must respond to referrals regarding individuals
admitted to a hospital for psychiatric reasons. Contractors and TRBHAs shall
attempt to conduct a face-to-face intake evaluation with the individual prior to
discharge from the hospital.
C. REFERRALS INIT I ATED BY DEPARTMENT OF CHILD SAFETY (DCS) PENDING
THE
REMOVAL OF A CHILD
1. Upon notification from DCS that a child has been placed in DCS custody, or
is at risk of disruption of placement, Contractors shall ensure that the
behavioral health providers respond according to A.R.S. §8-512.01 and
ACOM Policy 449. Foster caregivers and adoptive parents may call for and
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-3
AHCCCS MEDICAL POLICY MANUAL
consent to an urgent crisis response and/or 72 hour rapid response in
accordance with ACOM Policy 449.
2. TRBHAs are responsible for coordinating care with DCS to ensure continuity
of care.
D. SENDING REFERRALS
Contractors’ provider directories shall be maintained in accordance with ACOM
Policy 404 and ACOM Policy 416 and must indicate which providers are
accepting referrals and conducting initial intake evaluations. Providers shall
promptly notify the Contractor of an y chan ges tha t wo uld i mpact t he accu rac y of
the provider directory (e.g. change in telephone or fax number, no longer
accepting referrals).
Referrals may be submitted in written format or provided orally. Oral referrals
shall be documented in writing.
E. ACCEPTING REFERRALS
1. Contractors and TRBHAs shall ensure referrals are accepted for behavioral
health services 24 hours a day, seven days a week.
2. Timely triage and processing of referrals must not be delayed due to missing
or incomplete information.
3. When psychotropic medications are a part of a member’s treatment or have
been identified as a need by the referral source, Contractors must ensure
referrals meet the time requirements as outlined in ACOM Policy 417.
4. When a Serious Mental Illness (SMI) eligibility determination is being
requested as part of the referral or by the member directly, Contractors
TRBHAs, Indian Health Service facilities, or Tribally owned or operated 638
facilities shall ensure an eligibility assessment is conducted in accordance
with AMPM Policy 320-P. The SMI eligibility assessment, and pending
determination, shall not delay behavioral health service delivery to the
member, regardless of Title XIX or Title XXI eligibility as funding allows.
F. FINAL DISPOSITIONS
1. Within 30 days of receiving the intake evaluation, or if the member declines
behavioral health services, Contractors and TRBHAs shall ensure
notification regarding the final disposition shall be provided to the referring
individual or entity, with appropriate release of information signed by the
member, as applicable including but not limited to:
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-4
AHCCCS MEDICAL POLICY MANUAL
a. Contractor,
b. Behavioral Health Coordinator,
c. PCP,
d. Arizona Department of Child Safety and adoption subsidy,
e. Arizona Department of Economic Security/Division of Developmental
Disabilities,
f. Arizona Department of Corrections,
g. Arizona Department of Juvenile Corrections,
h. Administrative Offices of the Court,
i. Arizona Department of Economic Security/Rehabilitation Services
Administration, and
j. Arizona Department of Education and affiliated school districts.
2. The final disposition must include:
a. The date the member was seen for the intake evaluation, and the name
and contact information of the provider who will assume primary
responsibility for the member’s behavioral health care, or
b. If no services will be provided, the reason why. Authorization to release
information will be obtained prior to communicating the final disposition
to the referral sources referenced above. See AMPM Policy 550.
G. DOCUME NTING AND TRACKING REFERRALS
Contractors and TRBHAs shal l en su r e r efe rral s for behavi o r al h e alt h s ervices are
tracked and include at a minimum, the following information:
1. Member name and, if available, AHCCCS identification number;
2. Date of birth,
3. Name and affiliation of referral source,
4. Type of referral per ACOM Policy 417,
5. Date and time the referral was received,
6. If applicable, date and location of first available appointment and, if
different, date and location of actual scheduled appointment, and
7. Final disposition of the referral.
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-5
AHCCCS MEDICAL POLICY MANUAL
H. INTAKE
1. The intake process by the provider shall include:
a. The collection of member contact and insurance information,
b. The reason why the member is seeking services and information on any
accommodations the member may require to effectively participate in
treatment services (e.g. need for oral interpretation or sign language
services, consent forms in large font).
c. The collection of required demographic information and completion of
member demographic information sheet, including the member’s
primary/preferred language in accordance with AHCCCS Technical
Interface Guidelines,
d. The completion of any applicable authorizations for the release of
information to other parties,
e. The dissemination of a Member Handbook to the member,
f. The review and completion of a general consent to treatment,
g. The collection of financial information, including the identification of
third party payers and information necessary to sc reen and apply for Title
XIX/XXI eligibility,
h. Advising members with an SMI designation if they are found to be Non-
Title XIX/XXI they may be assessed a copayment,
i. The review and dissemination of Contractors and TRBHA’s Notice of
Privacy Practices (NPP) and the AHCCCS Notice of Privacy Practices
(NPP) in compliance with 45 CFR 164.520 (c)(1)(B), and
j. The review of the member’s rights and responsibilities, including an
explanation of the Title XIX/XX I member grievance and appeal process,
if applicable. The member and/or the member’s legal guardian/family
member, advocate, and/or person providing special assistance, may
complete some of the paperwork associated with the intake evaluation, if
acceptable to the member and/or the member’s legal guardian/family
members, advocate, and/or person providing special assistance as
referenced in AMPM 320-R.
2. Behavioral health providers conducting intake interviews must be
appropriately trained in accordance with AMPM Policy 1060, and must
approach the member and family in an strength-based manner and possess a
clear understanding of the information that needs to be collected.
I. ELIGIBILITY SCREENING
1. Persons who are not already determined eligible for Title XIX/XXI must be
screened at the time of the intake interview for Title XIX/XXI eligibility.
2. The individual conducting the intake interview must request the supporting
documentation listed below and explain to the applicant supporting
CHAPTER 500
CARE COORDINATION REQUIREMENTS
POLICY 580
BEHAVIORAL HEALTH REFERRAL AND INTAKE PROCESS
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM 580-6
AHCCCS MEDICAL POLICY MANUAL
documentation will only be used for the purpose of assisting in applying for
Title XIX/XXI benefits through AHCCCS.
a. Verification of gross famil y income for the last m onth and current month
(e.g., pay check stubs, social security award letter, retirement pension
letter),
b. For those who have other health insurance, bring the corresponding
health insurance card (e.g., Medicare card),
c. For all applicants, documentation to prove United States citizenship or
immigration status and identity in accordance with AHCCCS Eligibility
Policy and Procedure Manual,
d. For those who pay for dependent care (e.g., adult or child daycare), proof
of the amount paid for the dependent care, and
e. Verification of out-of-pocket medical expenses.
