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Division of Behavioral Health Services

ADHS/DBHS Provider Manual: Section 13.0 Forms and Attachments

Section Effective Date
Section 3.1 Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health Insurance
PM Attachment 3.1.1 Key Code Index 01/16/08
PM Form 3.1.1 Tracking of Medicare Part D Enrollment 03/15/06
PM Attachment 3.1.2 Rate Codes Descriptions 01/01/04
PM Form 3.1.2 Tracking of Limited Income Subsidy Status 03/15/06
PM Attachment 3.1.3 Rate Codes 01/01/04
AHCCCS Eligibility Screening 05/04/10
PM Form ADHS AE-08 Decline Screening and Referral 06/26/06
Forma PM ADHS AE-08 Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS 10/01/06
Section 3.3 Referral Process
PM Form 3.3.1 ADHS DBHS Referral to Behavioral Health Services 04/01/11
Section 3.5 Third Party Liability (TPL) and Coordination of Benefits
PM Attachment 3.5.1 Third Party Liability (TPL) and Coordination of Benefits Title XIX/XXI Eligible Persons 07/01/10
PM Attachment 3.5.2 Third Party Liability (TPL) and Coordination of Benefits Non-Title XIX/XXI Eligible Persons Determined to Have a Serious Mental Illness (SMI) 07/01/10
Section 3.6 Member Handbooks
PM Form 3.6.1 Member Handbook Receipt (English and Spanish) 09/01/11
Section 3.9 Assessment and Service Planning
PM Attachment 3.9.1, Service Plan Rights Acknowledgement Template 08/01/11
Section 3.10 SMI Eligibility Determination
PM Attachment 3.10.1 SMI Qualifying Diagnosis 10/15/13
PM Attachment 3.10.2 Subst Abuse Psych Symptom 10/15/13
PM Form 3.10.1 SMI Determination Form 10/15/13
Section 3.11 General and Informed Consent to Treatment
PM Form ADHS MH-103 Application for Voluntary Evaluation 07/15/05
Forma PM ADHS/DBHS MH-103 Solicitud de Una Evaluación Voluntaria 08/01/04
PM Form 3.11.1 Substance Abuse Prevention Program and Evaluation Consent 07/15/10
Forma PM 3.11.1 Permiso Para Participar en la Evaluación del Programa de Prevención para El Abuso de Drogas Y Alcohol 07/15/10
Section 3.13 Covered Behavioral Health Services
PM Attachment 3.13.1 Covered Services Matrix 07/01/12
Section 3.14 Securing Services and Prior Authorization
PM Attachment 3.14.1 Admission Psych Acute Hosp & Sub-Acute Auth Criteria 08/01/07
PM Attachment 3.14.2 Cont Stay Psych Acute Hosp & Sub-Acute Auth Criteria 08/01/07
PM Attachment 3.14.3 ADHS/DBHS Level One Psychiatric Residential Treatment Center Admission Authorization Criteria 08/01/07
PM Attachment 3.14.4 ADHS/DBHS Level One Psychiatric Residental Treatment Center Continued Stay Authorization Criteria 08/01/07
PM Form 3.14.1 Certification of Need (CON) 08/01/07
PM Form 3.14.2 Recertification of Need (RON) 08/01/07
PM Form 3.14.3 TRBHA Prior Authorization Request 08/01/07
Section 3.15 Psychotropic Medications: Prescribing and Monitoring
PM Form 3.15.1 Informed Consent for Psychotropic Medication Treatment 03/01/10
Forma PM 3.15.1 Consentimiento Informado para Tratamiento con Medicamentos  Psicotrópicos 03/01/10
Section 3.16 Medication List
PM Attachment 3.16.1 Prior Authorization Instructions for Medications 07/01/12
Section 3.18 Pre-Petition Screening, Court-Ordered Evaluation and Court-Ordered Treatment
ADHS/DBHS Form MH-100, Application for Involuntary Evaluation 09/01/93
ADHS/DBHS Form MH-103, Application for Voluntary Evaluation 07/15/05
ADHS/DBHS Forma MH-103, Solicitud de Una Evaluación Voluntaria 08/01/04
ADHS/DBHS Form MH-104, Application for Emergency Admission for Evaluation 09/01/93
ADHS/DBHS Form MH-105, Petition for Court-Ordered Evaluation 09/01/93
ADHS/DBHS Form MH-110, Petition for Court-Ordered Treatment 09/01/93
ADHS/DBHS Form MH-112, Affidavit, Addendum No. 1 and Addendum No. 2 09/01/93
PM Attachment 3.18.1, ARS 12-136 Flow Chart 04/01/11
Section 3.19 Special Populations  
PM Attachment 3.19.1 Notice to Individuals Receiving Substance Abuse Services 04/01/09
Documento Adjunto PM 3.19.1 Notificación a Individuos Quienes Reciben Servicios para el abuso de sustancias 04/01/09
PM Form 3.19.1 Quarterly PATH Report 10/15/04
PM Attachment 3.19.2 Arizona PATH Program-Administrators Contact List 04/01/11
Section 3.22 Out-of-State Placements for Children and Young Adults
PM Form 3.22.1 Out of State Placement Initial Notice 09/15/13
PM Form 3.22.2 Out of State Placement 90-Day Update 09/15/13
Section 3.27 Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits
PM Attachment 3.27.1 Documents Accepted by AHCCCS to Verify Citizenship and Identity 06/15/11
PM Attachment 3.27.2 Non-Citizen/Lawful Presence Verification Documents 06/15/11
PM Attachment 3.27.3 Persons Who Are Exempt from Verification of Citizenship During the Prescreening and Application Process 06/15/11
PM Attachment 3.27.4 Citizenship/Lawful Presence Verification Process Through Health-e-Arizona 06/15/11
Section 4.2 Behavioral Health Medical Record Standards  
PM Form 4.2.1 Clinical Record Documentation Form 04/01/08
Section 4.3 Coordination of Care with AHCCCS Health Plans and PCPs
PM Attachment 4.3.1 AHCCCS Contracted Health Plans 07/15/10
PM Form 4.3.1 Communication Document 12/01/07
PM Attachment 4.3.2 T/RBHA Acute Health Plan and Provider Coordinator Contact Information 01/30/12
PM Form 4.3.2 Request for Information from PCP or Medicare Plan/Provider 12/01/07
PM Form 4.3.3 T/RBHA Acute Health Plan and Provider Inquiry Monthly Log 06/15/11
PM Form 4.3.4 Recipient Transition from RBHA to PCP Log 06/15/11
Section 4.4 Coordination of Care with Other Government Entities  
PM Attachment 4.4.1 ACYF Child Welfare Time Frames 09/01/11
PM Attachment 4.4.2 Overview of the Arizona Families F.I.R.S.T (AFF) Program Model & Referral Process 09/01/11
Section 5.1 Member Notice Requirements  
PM Form 5.1.1 Notice of Action 07/01/12
Forma PM 5.1.1 Aviso De Acción 07/01/12
PM Form 5.1.2 Notice of Extension of Timeframe for Service Authorization Decision Regarding Title XIX/XXI Behavioral Health Services 07/01/12
Forma PM 5.1.2 Aviso de Extension de Plazo para Autorizacion de Decision para Servicios de Salud Mental Titulo XIX/XXI 07/01/12
Section 5.3 Grievance and Request for Investigation for Persons Determined to have a Serious Mental Illness (SMI)
PM Form 5.3.1 ADHS/DBHS Appeal or SMI Grievance 07/01/09
Forma PM 5.3.1 Forma De Apelación ADHS/DBHS o Queja SMI 01/01/04
Section 5.4 Special Assistance for SMI Members  
PM Form 5.4.1 Notification of Person in Need of Special Assistance 01/23/14
Section 5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non Title XIX/XXI)  
PM Attachment 5.5.1 Notice of SMI Grievance and Appeal Procedure 09/15/08
Documento Adjunto PM 5.5.1 Aviso De Queja y Apelación Formal De SMI De ADHS/DBHS 08/01/04
PM Form 5.5.1 Notice of DSN & Right to Appeal 09/15/08
Forma PM 5.5.1 Aviso De Decisión y Derecho De Apelación 09/15/08
PM Form ADHS MH-209 Notice of Discrimination Prohibited 09/15/08
PM Form ADHS MH-211 Notice of Legal Rights for SMI 09/15/08
Forma PM MH De ADHS-211 Aviso de los Derechos Legales para Personas con una Enfermedad Mental Grave 09/15/08
Section 5.6 Provider Claims Disputes  
PM Attachment 5.6.1 Provider Claims Disputes Contact List 07/01/12
PM Attachment 5.6.2 Process for Provider Claims Disputes 04/27/06
Section 6.0 Data and Billing Requirements  
PM Attachment 6.0.1- Behavioral Health Services - Where Do I Submit My Claim? (TXIX/TXXI Only) 09/01/10
PM Attachment 6.0.2 - Billing Instructions Used to Identify Crisis Services 09/01/10
Section 6.2 Submitting Claims and Encounters to the RBHA  
PM Attachment 6.2.1 Pseudo Identification Numbers 09/01/10
Section 7.2 Medical Institution Reporting for Medicare Part D  
PM Form 7.2.1, AHCCCS Notification to Waive Medicare Part D Co-Payments for Members in a Medicaid Funded Medical Institution 12/01/10
Section 7.3 Seclusion and Restraint Reporting for Level I Facilities  
PM Form 7.3.1 Seclusion & Restraint Reporting Level 1 Facility Reporting 08/01/04
Section 7.4 Reporting of Incidents, Accidents and Deaths  
PM Form 7.4.1 Reporting Incident Accident Deaths 07/01/07
Section 7.5 Enrollment, Disenrollment and other Data Submission  
PM Attachment 7.5.1 Timeframes for Data Submission 12/22/10
PM Attachment 7.5.2  834 Transaction Data Requirements 12/22/10
PM Attachment 7.5.3 SMI and SED Qualifying Diagnoses Table 04/01/08
PM Attachment 7.5.4 Substance Abuse Disorders Qualifying Diagnoses Table 04/01/08
Section 9.1 Training Requirements
PM Attachment 9.1.1 Arizona Child and Family Teams Proficiency Measurement Tool for   Facilitation – User's Guide 07/15/07
PM Form 9.1.1 Arizona Child and Family Teams Proficiency Measurement Tool for Facilitation 07/15/07

Note: Information provided in PDF files, unless otherwise indicated.