Regional Behavioral Health Authority

HEALTH

White Mountain Apache

ABHS

FORMS AND ATTACHMENTS

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ARIZONA DEPARTMENT OF HEALTH SERVICES


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AHCCCS INFORMATION




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Indian Health Service Behavioral Health



FORMS

FORM 3.1  Refuse to Screen

FORM 3.1.1  Tracking of Medicate Part D Enrollment

FORM 3.1.2   Tracking of Limited Income Subsidy Status

FORM 3.1.6  Eligibility Screening Report

FORM 3.2.1  ADBHS-DBHS Referral to Behavioral Health Services

FORM 3.4.1  Non-Title XIX and XXI Co-Pay Assess

FORM 3.6.1  Member Handbook Receipt

FORM 3.9.1  Behavioral Health Assessment and Services Plan

ATTACHMENTS

FORM 3.9.2  Behavioral Health Assessment Birth - 5 and Service

FORM 3.10.1  SMI Determination

FORM 3.11.1  Prev. Evaluation Permission

FORM 3.14.1  Certification of Need (CON) for Level 1 Facilities

FORM 3.14.2  Re-certification of Need (RON) for Level 1 Facilities

FORM 3.14.3  Prior Authorization Request

FORM 3.15.1  Inform Consent for Psychotropic Meds

FORM 3.18 MH-100  Application for Involuntary Evaluaation

FORM 3.18 MH-103  Application for voluntary Evaluation

FORM 3.18 MH-104  Appl. For emergency Adm. for Evaluation

FORM 3.18 MH-105  Petition for Court-Ordered Evaluation

FORM 3.18 MH-110  Petition for Court-Ordered Treatment

FORM 3.18 MH-112  Affidavit

FORM 3.20.1  Supervision of Clinical Liaisons

FORM 3.20.2  BHT Case Supervision

FORM 3.21.1  Notification to Waive Medicare Part D Co-Payment

FORM 3.22.1  Out of State Placement Initial Notice

FORM 3.22.2  Out of State Placement 90 Day Update

FORM 4.2.1   Clinical Documentation

FORM 4.3 1  Communication Document

FORM 4.3.2  Request for Info. From PCP or Medicare Plan/Provider

FORM 4.3.4  Recipient Transition Form RBHS to PCP Log

FORM 5.1  NOA Letter

FORM 5.1.1  Notice of Action

FORM 5.1.2  Notice of Extension of Timeframe for Service

FORM 5.3.1  ADHS-DBHS Appeal or SMI Grevance

FORM 5.4.1  Request for Special Assistance

FORM 5.5  MH-209 Notice of Discrimination Prohibited

FORM 5.5.1  MH-211 Notice of Legal Rights for Persons with SMI

FORM 7.1.1  Suspected Fraud and Abuse

FORM 7.2.1  Notice to Waive Medical Part D

FORM 7.3.1  Seclusion and Restraint Reporting Level 1 Facility

FORM 7.4.1  Incident Report

FORM 7.5.1  ADHS-DBHS Behaviroal Health Clinet Demographic

FORM 8.5.1  Request for Registration MCE

FORM 8.5.2  Summary of MCE Evaluation Methodology

FORM 9.1.1  CTF Tool

FORM 10.3  TRBHA Admission Contract From

FORM 10.14.1  Service Authorization

FORM 10.14.2  Single Case Agreement

FORM ADHS AE-01  AHCCCS Eligibility Screen

FORM ADHS AE-08  Decline to participate in the Screening

3.1.1 Key Codes 3-24-03

3.1.2 AHCCCS Rate Codes

3.1.3 AHCCCS Rage Codes

3.5.1 Third Party Liability (TPL) XIX/XXI Eligible Persons

3.5.2 Title XIX SMI Flow Chart

3.9 Instruction Guide

3.9.A Instruction Guide B-5

3.9.1 Service Plan Rights Acknowledgment Adults

3.10.1 SMI Qualifying Diagnosis

3.10.2 Subst Abuse Psysch Symptom

3.13.1 Covered Service Matrix

3.14.1 Authorization Criteria Level 1

3.14.2 RON

3.14.3 RTC Authorization Criteria

3.14.4 RTC Continued Stay Authorization Criteria

3.19.1 Notice to Individuals Receiving Substance

3.19.2 Arzona PATH Program - Administrator Contact List

3.20.1 Relevent College Classes

3.21.1 Health Plan and RBHS Medical Institution

3.21.2 Part D Voluntary Prescription Drug Benefits

4.3.1 AHCCCS Contracted Health Plans Contact Info.

4.4.1 ACYS Child Welfare Time Frames

4.4.2 Fmailies First Flow Chart

5.5.1 ADHS/DBHS Notice of SMI Grievance and Appeal

5.6.1 Provider Claim Disputes Contract List

5.6.2 Process for Provider Claim Disputes

6.0.1 Where Do I submit My Claim

6.0.2  Billing Instructions Crisis Services

6.1.1  Psuedo ID Numbers

7.5  Data Elements Required for Creating

7.5.1 Time frames for Data Submissions

7.5. 2 Required 834 Data Elements

7.5.3 SMI and SED Qualifying DX Table

7.5.4 Diagnostic Code Preamble

8.5  Instructions for Completion of Medical

 9.1.1  CFT Guide