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Patagonia-Sonoita Creek, Santa Cruz County
  
  Provider Manual Forms                                                            Large Print Forms    

Revised September 1, 2010
      Revision Notices

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3.1 Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance
   Attachment 3.1.1 Key Code Index
   Attachment 3.1.2 AHCCCS Rate Codes Descriptions
   Attachment 3.1.3 AHCCCS Rate Codes
   Form ADHS AE-08 Decline to Participate in the Screening (Available in Large Print)
   Forma ADHS AE-08 Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS (Español) (Letra de imprenta disponible)
   Form 3.1.1 Tracking of Medicare Part D Enrollment
   Form 3.1.2 Tracking of Limited Income Subsidy Status
3.3 Referral Process
   Form 3.3.1 ADHS/DBHS Referral to Behavioral Health Services
3.5

TPL and Coordination of Benefits
   Attachment 3.5.1 TPL and Coordination of Benefits for TXIX Persons
   Attachment 3.5.2 TPL and Coordination of Benefits for Non-TXIX Persons
3.8 Outreach, Engagement, Re-Engagement and Closure
   Form 3.8.1 Member Closure Form
3.9 Intake, Assessment and Service Planning
   Form 3.9.1 ADHS/DBHS Behavioral Health Assessment and Service Plan Checklist
   Forma 3.9.1 Evaluación de Salud Mental y Plan de Servicios (Español)
   Instruction Guide 3.9.1 Instruction Guide for Behavioral Health Assessment and Service Plan (pdf)
   Form 3.9.2 ADHS/DBHS Behavioral Health Assessment & Service Plan Checklist, Birth through 5
   Forma 3.9.2 Hoja de Cobertura del Cliente de Salud de Comportamiento ADHS-DBHS
   Instruction Guide 3.9.2 Instruction Guide for Birth to 5 Behavioral Health Assessment & Service Plan
3.10 SMI Eligibility Determination
   Attachment 3.10.1 SMI Qualifying Diagnosis
   Attachment 3.10.2 Substance Abuse Psychiatric Symptomatology
   Form 3.10.1 SMI Determination Module
3.11 General and Informed Consent to Treatment
   Form ADHS MH-103 Application for Voluntary Evaluation
   Forma ADHS MH-103 Solicitud de Una Evaluación Voluntaria (Español)
   Form 3.11.1 Substance Abuse Prevention Program and Evaluation Consent (Available in Large Print)
   Forma 3.11.1 Permiso de Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol (Español) (Letra de imprenta disponible)
3.13 Covered Behavioral Health Services
   Attachment 3.13.1 Covered Service Matrix
   Form 3.13.1 Request for Flex Funds
3.14 Securing Services and Prior Authorization
   Attachment 3.14.1 Admission Psych Acute Hospital and Sub Acute
   Attachment 3.14.2 Continued Stay Psych Acute Hospital and Sub-Acute Authorization Criteria
   Attachment 3.14.3 Admission Residential Treatment Center Authorization Criteria
   Attachment 3.14.4 Continued Stay Residential Treatment Center Authorization Criteria
   CPSA Attachment 3.14.5 Prior Authorization Criteria Level II (Child)
   CPSA Attachment 3.14.6 Prior Authorization Criteria Level III (Child)
   CPSA Attachment 3.14.7 Prior Authorization Criteria HCTC (Child)
   CPSA Attachment 3.14.8 Prior Authorization Criteria Level II (Adult)
   CPSA Attachment 3.14.9 Prior Authorization Criteria Level III (Adult)
   CPSA Attachment 3.14.10 Prior Authorization Criteria HCTC (Adult)
   Form 3.14.1 Certification of Need for Level I Facilities (CON)
   Form 3.14.2 Re-Certification of Need
   Form 3.14.3 Prior Authorization Request – Level I
   Form 3.14.4 Prior Authorization Request For Medication
   Form 3.14.5 CPSA Prior Authorization Request Level II, III and HCTC
   Form 3.14.6 Medical Management/Utilization Management Prior Authorization Referral Fax Cover Sheet
   Form 3.14.7 Comprehensive Service Provider Admission Request Level II
   Form 3.14.8 Comprehensive Service Provider Admission Request Level III
   Form 3.14.9 Comprehensive Service Provider Admission Request HCTC
   Form 3.14.10 Continued Stay Request Level II, III HCTC Fax Cover Sheet
   Form 3.14.11 Comprehensive Service Provider Continued Stay Request Level II
   Form 3.14.12 Comprehensive Service Provider Continued Stay Request Level III
   Form 3.14.13 Comprehensive Service Provider Continued Stay Request HCTC
   Form 3.13.14 CPSA Notification of Authorization Level II, III and HCTC
   Form 3.14.15 Notification of Level II, II, HCTC Admission, Discharge and Gap Days
   Form 3.14.16 Facility Monthly Review of Member's Progress
   Form 3.14.17 Comprehensive Service Provider Discharge Plan
   Form 3.14.18 Bed Hold Request
   Form 3.14.19 CPSA Notification of Authorization - Level I
   Form 3.14.20 Comprehensive Service Provider Justification of ECU Placement
   Form 3.14.21 Previous Out-of-Home Placement Information
   Form 3.14.22 Comprehensive Service Provider Justification for RTC Placement
3.15 Psychotropic Medications: Prescribing and Monitoring
   Form 3.15.1 Informed Consent for Psychotropic Medication (Available in Large Print)
   Forma 3.15.1 Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos (Español) (Letra de imprenta disponible)
3.17 Transition of Persons
   CPSA Form 3.17.1 Member Transfer Cover Sheet
   CPSA Form 3.17.2 Member Transfer Tracking Log
   CPSA Form 3.17.3 Member Application for Provider Transfer (Available in Large Print)
   Forma CPSA 3.17.3 Solicitud del Afiliado Para Transferencia de Proveedor (Español) (Letra de imprenta disponible)
3.18 Pre--Petition Screening, Court Ordered Evaluations and Treatment
   Form ADHS MH-100 Application for Involuntary Evaluation
   Form ADHS MH-103 Application for Voluntary Evaluation (Available in Large Print)
   Forma ADHS MH-103 Solicitud de Una Evalución Voluntaria (Letra de imprenta disponible)
   Form ADHS MH-104 Application For Emergency Admission For Evaluation
   Form ADHS MH-105 Petition For Court-Ordered Evaluation
   Form ADHS MH-110 Petition For Court-Ordered Treatment – Gravely Disabled Person
   Form ADHS MH-112 Affidavit
   CPSA Form 3.18.1 Court Ordered Treatment Plan
   CPSA Form 3.18.2 Law Enforcement Committal Information
   CPSA Form 3.18.3 Request for Revocation of Outpatient Treatment Plan
   CPSA Form 3.18.4 Notification of Member's Right to Judicial Review and to Speak to Legal Counsel
   CPSA Form 3.18.5 Release from Court Ordered Treatment Worksheet
   CPSA Form 3.18.6 Court Ordered Treatment Status Report
   CPSA Form 3.18.7 Psychiatric Examination for Annual Review of Gravely Disabled Person
   CPSA Form 3.18.8 Psychiatric Examination for Annual Review of Persistently or Acutely Disabled Person
   CPSA Form 3.18.9 Notification to CPSA of Release from Title 36 Court Ordered Treatment
3.19 Special Populations
   Attachment 3.19.1 Notice to Individuals Receiving Substance Abuse (Available in Large Print)
   Documento Adjunto 3.19.1 Notificacion a Individuos Quienes Reciben Servicios para el Abuso de Estupefacients (Español) (Letra de imprenta disponible)
   Form 3.19.1 Quarterly PATH Report
   Form 3.19.2 Monthly Admissions and Capacity Information Report
3.20 Credentialing and Privileging
   Attachment 3.20.1 Examples of College Classes Relevant to Behavioral Health (pdf)
   Attachment 3.20.2 Credentialing/Re-credentialing Appeals Policy
   Form 3.20.1 Supervisor of Clinical Liaisons Attestation of Competencies
   Form 3.20.2 BHT Case Supervision Report
   Form 3.20.3 ADHS/DBHS Attestation Specialty Clinicians and Providers
   CPSA Form 3.20.4 Status of Privileges and/or Professional License
3.21 Service Prioritization for Non-Title XIX/XXI Funding
   Attachment 3.21.1 Health Plan & RBHA Medical Institution Notification for Dual Eligible Members
   Attachment 3.21.2 Benefits and Cost For People With Medicare (Part D)
   Form 3.21.1 AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medical Institution Funded by Medicaid
3.22 Out-of-State Placements for Children and Young Adults
   Form 3.22.1 Out-of-State Placement Initial Notice
   Form 3.22.2 Out-of-State Placement, 90-Day Update
4.2 Behavioral Health Medical Record Standards
   Form 4.2.1 Community Service Agency/HCTC Provider/Habilitation Provider Daily Clinical Record Documentation
4.3 Coordination of Care with AHCCCS Health Plans and PCPs
   Attachment 4.3.1 AHCCCS Contracted Health Plans Contact Information (pdf)
   Form 4.3.1 Communication Document
   Form 4.3.2 Request for Information from PCP
   Form 4.3.3 T/RBHA Acute Health Plan and Provider Coordinator Inquiry Log
4.4 Coordination of Care with Other Government Entities
   Attachment 4.4.2 Overview of Arizona Families First (AFF)
   Attachment 4.4.3 Guide to Completing PM Form 4.4.6, Monthly Service Report for Children and Parents Involved with Child Protective Services
   Form 4.4.2 COOL Attendance Verification
   Form 4.4.3 Notification of Incarcerated Member
   Form 4.4.4 Coordination of Extended Supported Employment
   Form 4.4.5 Authorization for Disclosure of Confidential Information
   Form 4.4.6 Monthly Service Report for Children and Parents Involved with Child Protective Services
5.1 Member Notice Requirements
   Attachment 5.1.1 Notice of Action & Notice of Decision Timeframe Guide (for use with PM Forms 5.1.1 & 5.5.1)
   Form 5.1.1 Notice of Action
   Form 5.1.2 Notice of Extension of Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health Services (Available in Large Print)
   Forma 5.1.2 Aviso de Extensión de Plazo Para Autorizacion de Decisión Para Servicios de Salud Mental Titulo XIX/XXI (Letra de imprenta disponible)
5.3 Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)
   Form 5.3.1 ADHS/DBHS Appeal or SMI Grievance (Available in Large Print)
   Forma 5.3.1 Forma De Apelación ADHS/DBHS o Queja SMI (Letra de imprenta disponible)
5.4 Special Assistance for SMI Members
   Form 5.4.1 Request for Special Assistance
5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
   GUIDE Notice of Action & Notice of Decision Timeframe Guide (for use with PM Forms 5.1.1 & 5.5.1) (.pdf)
   Attachment 5.5.1 Notice of SMI Grievance and Appeal Procedure (Available in Large Print)
   Documento Adjunto 5.5.1 Aviso de Queja y Apelación Formal de SMI de ADHS/DBHS (Español) (Letra de imprenta disponible)
   Form 5.5.1 Notice of Decision and Right to Appeal (SMI) (Available in Large Print)
   Forma 5.5.1 Aviso de Decisión y Derecho de Apelación (Español) (Letra de imprenta disponible)
   Form ADHS MH-209 Notice of Discrimination Prohibited (English and Español) (Available in Large Print)
   Form ADHS MH-211 Notice of Legal Rights for SMI (Available in Large Print)
   Forma ADHS MH-211 Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave (Español) (Letra de imprenta disponible)
5.6 Provider Claims Disputes
   Attachment 5.6.1 Provider Claims Disputes Contact List (pdf)
   Attachment 5.6.2 Process for Provider Claims Disputes
6.0 Data and Billing Requirements
   Attachment 6.0.1 Where Do I Submit My Claim?
   Attachment 6.0.2 Billing Instructions Used to Identify Crisis Services
6.1 Submitting Tribal Fee-for-Service Claims to AHCCCS
   Form 6.1.1 CMS 1500 (pdf)
   Form 6.1.2 UB-92 Claim Form (pdf)
6.2 Submitting Claims and Encounters to the RBHA
   Attachment 6.2.1 Pseudo Identification Numbers
7.1 Fraud and Abuse Reporting
   Form 7.1.1 Suspected Fraud or Abuse Report
   Form 7.1.2 Certification Regarding Debarment, Suspension and Other Responsibility Matters
7.2 Medical Institution Reporting for Medicare Part D
   Form 7.2.1 AHCCCS Notification to Waive Medicare Part D Co-payments for Members in a Medical Institution Funded by Medicaid
7.3 Seclusion and Restraint Reporting for Level I Facilities
   Attachment 7.3.1 Seclusion and Restraint Monitoring Requirements (pdf)
   Form 7.3.1 Seclusion and Restraint Reporting for Level I Facilities
7.4 Reporting of Incidents, Accidents and Deaths
   Form 7.4.1 Reporting Incident-Accident-Deaths
7.5 Enrollment, Disenrollment and other Data Submission
   Attachment 7.5.1 Timeframes for Data Submission
   Attachment 7.5.2 834 Transaction Data Requirements
   Attachment 7.5.3 SMI and SED Qualifying Diagnoses Table
   Attachment 7.5.4 Substance Abuse Disorders Qualifying Diagnoses Table
   Form 7.5.1 Change of Enrollment Status Fax Form
   Form 7.5.2 Behavioral Health Member Demographic Information
   CPSA Form 7.5.3 Member Enrollment Form and Instructions (pdf)
   CPSA Form 7.5.4 Notification of Determination of SMI (Large Print Available)
   Forma CPSA 7.5.4 Notificación de Determinación de SMI (Letra de imprenta disponible)
8.5 Medical Care Evaluation (MCE) Studies
   Attachment 8.5.1 Instructions for Completion of Medical Care Evaluation
   Form 8.5.1 Medical Care Evaluation (MCE) Study Request for Registration
   Form 8.5.2 Summary of Medical Care Evaluation (MCE) Study Methodology
   Form 8.5.3 FY 2004 Medical Care Evaluation (MCE) Annual Study Final Results
   Form 8.5.4 FY 2004 Medical Care Evaluation (MCE) Study Quarterly Program Report
   Form 8.5.5 FY 2004 Medical Care Evaluation (MCE) Study Review of Final Results
9.1

Training and Development
   Attachment 9.1.1 Supervision Process User Guide
   Form 9.1.1 CFT Supervision Tool
10.1 Members Residing in Boarding Homes
   CPSA Form 10.1.1 Boarding Home Resident Assessment
   CPSA Form 10.1.2 Quarterly Summary of Resident Assessments
10.3

Supported Housing Services
   CPSA PM Attachment 10.3.1 HUD FY 2010 Income Limits
   CPSA PM Form 10.3.1 Project Opportunity Enrollment
   CPSA PM Form 10.3.2 Income Certification
   Forma CPSA PM 10.3.2 Certificación de Ingresos
   CPSA PM Form 10.3.3 Certification of No Income
   Forma CPSA PM 10.3.3 Proyecto Oportunidad Certificación de No Ingresos
   CPSA PM Form 10.3.4 Certification of Other Income
   Forma CPSA PM 10.3.4 Proyecto Oportunidad Certificación de Otros Ingresos
   CPSA PM Form 10.3.5 Project Opportunity Approval
   CPSA PM Form 10.3.6 Request for Payment Billing (Excel)
   CPSA PM Form 10.3.7 Project Opportunity Participant Exit
   CPSA PM Form 10.3.8 Additional Adult Exiting Household
   CPSA PM Form 10.3.9 Child Exiting Household
10.4 Document Translation Services
   CPSA Form 10.4.1 Document Translation Request
10.6 Youth Transitioning to Adulthood
   CPSA Attachment 10.6.1 16-16.5 Year Old Checklist Instructions (pdf)
   CPSA PM Attachment 10.6.2 17-17.5 Year Old Checklist Instructions (pdf)
   CPSA Attachment 10.6.3 18-18.5 Year Old Checklist Instructions (pdf)
   CPSA PM Attachment 10.6.4 Transition to Adulthood Monitoring Plan for Adult Networks (pdf)
   CPSA PM Attachment 10.6.5 Transition to Adulthood Monitoring Plan for Childrens Networks (pdf)
   CPSA Form 10.6.1 Child and Family Team/Young Adult Team (Age 16-16½) Transition Checklist
   CPSA Forma 10.6.1 Lista De Verificación del Equipo del Niño y de la Famlia/Equipo Para Jóvenes Adultos Para la Transición (de 16-16½ Años)
   CPSA Form 10.6.2 Child and Family Team/Young Adult Team (Age 17-17½) Transition Checklist
   CPSA Forma 10.6.2 Lista De Verificación del Equipo del Niño y de la Famlia/Equipo Para Jóvenes Adultos Para la Transición (de 17-17½ Años)
   CPSA Form 10.6.3 Adult Recovery Team/Young Adult Team (Age 18-18½) Transition Checklist
10.8 Inquiry from Potential Provider
   CPSA Form 10.8.1 Potential Service Provider Referral
   CPSA Form 10.8.2 Potential Service Provider Referral Outcome
10.11 Network Provider ASAM Protocol for Detoxification Services
   CPSA Form 10.11.1 ASAM PPC-2R Assessment
   CPSA Attachment 10.11.2 Risk Assessment Grid (pdf)
   CPSA Attachment 10.11.3 Placement Grid (pdf)
   CPSA Attachment 10.11.4 ASAM and AZ Levels of Care (pdf)
   CPSA Attachment 10.11.5 Continued Service & Discharge Criteria (pdf)
   CPSA Attachment 10.11.6 Continued Psychiatric Acute Hospital
10.14 Crisis Planning and Risk Assessment
   CPSA Form 10.14.1 Functional Assessment Worksheet
   CPSA Attachment 10.14.2 Recommended Crisis Plan
   CPSA Attachment 10.14.3 Assessing Suicidal Risk (pdf)
   CPSA Form 10.14.4 Special Suicide Risk Assessment Addendum
   CPSA Form 10.14.5 DD-BH Emergency Information
10.23 Mother Child Addictions Services / Mothers Caring About Self GSA5
   CPSA Attachment 10.23.1 Partnering Agencies Responsibilities (pdf)
   CPSA Attachment 10.23.2 Process for Referrals Originating from CPSA Member Services (pdf)
   CPSA Attachment 10.23.3 Process for Walk-In and Other Referrals (pdf)
10.26 Telemedicine Services
   CPSA Form 10.26.1 Telemedicine Services Consent to Participate
10.30

Network/Community Service Agency Coordination of Care
   CPSA Attachment 10.30.1 Referral Contact Grid (pdf)
   CPSA Attachment 10.30.2 Coordination of Care AXIX I and AXIS II Diagnosis Code Flow (pdf)
   CPSA Form 10.30.1 CSA Referral Packet Checklist
   CPSA form 10.30.2 Member Referral Packet Request
   CPSA PM Form 10.30.3 Referral Packet Deficiency Notice and List
Reference Documents

 
   Birth to 5 User Guide Birth to 5 User Guide (January 2006) (pdf)
   Covered Services Matrix Covered Services Matrix (June 2004) (pdf)
   CPSA Demographic User Guide CPSA Demographic User Guide-Version 4.0 (1/08/2010) (pdf)

 
CPSA receives funding from the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS), Arizona Health Care Cost Containment System (AHCCCS), and Substance Abuse and Mental Health Services Administration (SAMHSA).
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