Magellan Health

For Providers

Provider Forms

 

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3.1Accessing and Interpreting Eligibility and Enrollment Information and Screening and Applying for AHCCCS Health InsuranceEffective Date
Attachment 3.1.1 Key Code Index 01/16/2008
Attachment 3.1.2 AHCCCS Rate Codes Descriptions 09/21/2006
Attachment 3.1.3 AHCCCS Rate Codes 09/21/2006
Form ADHS AE-08 Decline to Participate in the Screening 09/21/2006
Forma ADHS AE-08 Negación a Participar en la Evaluación y/o en el Proceso de Remisión al Seguro de Salud de AHCCCS (Español) 10/01/2006
Form 3.1.1 Tracking of Medicare Part D Enrollment

03/15/2006

Form 3.1.2 Tracking of Limited Income Subsidy Status 10/15/2008

 

3.3Referral Process

Effective Date

Form 3.3.1

ADHS/DBHS Referral to Behavioral Health Services

04/01/2011

 

3.4Co-paymentsEffective Date
Form 3.4.1 Non-XIX or XXI Co-Payment Assessment 04/01/2008
Forma 3.4.1 Evaluación de Pago Colateral Sin Título XIX/XXI (Español) 04/01/2008

 

3.5Third Party Liability & Coordination of BenefitsEffective Date
Attachment 3.5.1 TPL and Coordination of Benefits - Title XIX/XXI Eligible Persons 07/01/2010
Attachment 3.5.2 TPL and Coordination of Benefits - Non-Title XIX/XXI Eligible Persons Determined to Have a Serious Mental Illness (SMI) 07/01/2010

 

3.6Member HandbooksEffective Date
Form 3.6.1 Member Handbook Receipt 09/01/2011

 

3.9Assessment and Service PlanningEffective Date
Attachment 3.9.1 Service Plan Rights Acknowledgment Template 12/20/2013

 

3.10SMI Eligibility DeterminationEffective Date
Attachment 3.10.1 SMI Qualifying Diagnosis 10/15/2013
Attachment 3.10.2 Substance Abuse Psychiatric Symptomatology 10/15/2013
Form 3.10.1 SMI Determination Module 10/15/2013
Form 3.10.2 Disposition Data Sheet - SMI Eligibility Department 12/12/2011
Form 3.10.3 Waiver of 3-Day SMI Eligibility Determination 04/04/2011
Form 3.10.4 SMI Assessment Packet Checklist - SMI Eligibility Department 07/01/2011

 

3.11General and Informed Consent to TreatmentEffective Date
Form ADHS MH-103 Application for Voluntary Evaluation 07/15/2005
Forma ADHS MH-103 Solicitud de Una Evaluación Voluntaria (Español) 08/1/2004
Form 3.11.1 Substance Abuse Prevention Program and Evaluation Consent 07/15/2010
Forma 3.11.1 Permiso de Participación en la Evaluación del Programa de Prevención del uso de Drogas y Alcohol (Español) 07/15/2010
Form 3.11.2 Consent for Electroconvulsive Therapy (ECT) 10/15/2009
Form 3.11.3 Consent for Treatment - Sample 09/21/2007
Form 3.11.4 Consent for ALOC 07/08
Forma 3.11.4 Consentimiento para la Evaluatión del Nivel de Cuidado 07/08

 

3.12Advance DirectivesEffective Date
Form 3.12.1 Advance Directives Form 06/15/2013
  Advance Directives Resources 06/15/2013
Form 3.12.1 (Spanish) Forma de Directivas por Adelantado 06/15/2013
  Recursos para Directivas por Adelantado 06/15/2013
                                                                                                            
3.13Covered Behavioral Health ServicesEffective Date

Attachment 3.13.1

PM Form 3.13.1

Covered Service Matrix

SAPT/CMHS Flex Fund Request

12/20/2013

12/20/2013

 

3.14Securing Services and Prior AuthorizationEffective Date
Attachment 3.14.1 Admission Psych Acute Hospital and Sub-Acute Authorization Criteria 08/01/2007
Attachment 3.14.2 Continued Stay Psych Acute Hospital and Sub-Acute Authorization Criteria 08/01/2007
Attachment 3.14.3 Behavioral Health Inpatient Facility Admission - Auth Criteria 02/05/2014
Attachment 3.14.4 Behavioral Health Inpatient Facility Continued Stay - Auth Criteria 02/05/2014
Attachment 3.14.5 Child/Adolescent Behavioral Health Residential Facility Admission & Continued Stay Authorization Criteria (formerly Level II) 02/05/2014
Attachment 3.14.6 Child/Adolescent Behavioral Health Residential Facility Admission & Continued Stay Authorization Criteria (formerly Level III) 02/05/2014
Attachment 3.14.7 Child/Adolescent HCTC Admission & Continued Stay Authorization Criteria 02/05/2014
Attachment 3.14.8 Adult Behavioral Health Residential Facility Admission & Continued Stay Authorization Criteria (formerly Level II) 02/05/2014
Attachment 3.14.9 Adult Behavioral Health Residential Facility Admission & Continued Stay Authorization Criteria (formerly Level III) 02/05/2014
Attachment 3.14.10 Adult HCTC Admission & Continued Stay Authorization Criteria 02/05/2014
Form 3.14.1 Certification of Need (CON) for Inpatient Facilities for T/RBHAs and their Contracted Providers 02/05/2014
Form 3.14.2 Re-Certification of Need (RON) for Inpatient Facilities for T/RBHAs and their Contracted Providers 02/05/2014
Form 3.14.3 T/RBHA Prior Authorization Request 02/05/2014
Form 3.14.4 Adult Behavioral Health Residential Facility or HCTC Continued Stay Review 02/05/2014
Form 3.14.5 Adult Behavioral Health Residential Facility or HCTC Preadmission Review 02/05/2014

Form 3.14.6

Forma 3.14.6

Request for Child/Adolescent HCTC Intervention

Solicitud de Intervencion de HCTC Para Ninos/Adolescentes

02/05/2014

07/01/2010

Form 3.14.7 Request for Child/Adolescent Behavioral Health Inpatient Facility or Behavioral Health Residential Facility Intervention 02/05/2014
Forma 3.14.7 Solicitud de Intervencion de Para Ninos/Adolescentes en una Institucion de Salud Mental o en una Institucion Residencial de Salud Mental 02/05/2014
Form 3.14.8 Guardian Request for Behavioral Health Inpatient Facility Child/Adolescent Only 02/05/2014
Form 3.14.9 Behavioral Health Inpatient Facility or Behavioral Health Residential Facility Additional Request for Information Child/Adolescent Only 02/05/2014
Form 3.14.10 Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization of Behavioral Health Inpatient Facility or Behavioral Health Residential Facility 02/05/2014
Form 3.14.11 Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization of HCTC 02.05/2014
Form 3.14.12 30 Day Prior Authorization Request for NT XIX/XXI SMI Brand Atypical Antipsychotic for Bridging 05/06/2011
Form 3.14.13 Prior Authorization Request for Risperdal Consta 05/06/2011
Prior Authorization Request for Medication
  Outpatient Electroconvulsive Therapy Criteria for Authorization 09/01/2007
  Psychological Testing Criteria for Authorization 09/01/2007
  Request for Psychological Testing Preauthorization 03/04/2010
  Request for Electroconvulsive Therapy (ECT) 07/11/2013
 

CON - Adult Psychiatric Acute Hospital Detoxification

RON - Adult Psychiatric Acute Hospital Detoxification

02/05/2014
 

CON - Adult Psychiatric Acute Hospital

RON - Adult Psychiatric Acute Hospital

02/05/2014

 

CON - Adult Sub-Acute Facility

RON - Adult Sub-Acute Facility

02/-5/2014

 

CON - Child and Adolescent Behavioral Health Inpatient Facility - Chemical Dependency

RON - Child and Adolescent Behavioral Health Inpatient Facility - Chemical Dependency

02/05/2014

 

 

CON - Child and Adolescent Psychiatric Acute Hospital - Admission

RON - Child and Adolescent Psychiatric Acute Hospital - Continued Stay

02/05/2014
 

CON - Child and Adolescent Behavioral Health Inpatient Facility

RON - Child and Adolescent Behavioral Health Inpatient Facility

02/05/2014
 
 

 

3.15Psychotropic Medications: Prescribing and MonitoringEffective Date
Form 3.15.1 Informed Consent for Psychotropic Medication 03/01/2010
Forma 3.15.1 Consentimiento Informado para Tratamiento con Medicamentos Psicotrópicos (Español) 03/01/2010

 

3.16Medication ListEffective Date
Attachment 3.16.1 Prior Authorization Instructions for Medications 10/01/2013

 

3.17Transition of PersonsEffective Date
Form 3.17.1 Interagency PNO Client Transfer Form (For Title 19/Title 21 and HB Children Only) 04/29/2010
Attachment 3.17.1 Magellan Youth Transition to Adulthood Planning Checklist Reference Guide
Attachment 3.17.2 Transfer Protocol Between Provider Network Organizations (PNOs) 02/13/2014
Form 3.17.3 Single Point of Contact Update Form 04/29/2010

 

3.18Pre-Petition Screening, Court Ordered Evaluation and TreatmentEffective Date
Attachment 3.18.1 Domestication or Recognition of Tribal Court Order Process Flow Chart 08/31/2010
Form 3.18.1 Police Mental Health Detention Information Sheet for Court-Ordered Detention

03/25/2010

Form 3.18.2 Pre-petition Screening Report 09/01/2007
Form ADHS MH-100 Application for Involuntary Evaluation 09/93
Form ADHS MH-103 Application for Voluntary Evaluation 07/15/2005
Forma ADHS MH-103 Solicitud de Una Evalución Voluntaria (Español) 08/1/2004
Form ADHS MH-104 Application For Emergency Admission For Evaluation 09/93
Form ADHS MH-105 Petition For Court-Ordered Evaluation 09/93
Form ADHS MH-110 Petition For Court-Ordered Treatment - Gravely Disabled Person 09/93
Form ADHS MH-112 Affidavit 09/93

 

3.19Special PopulationsEffective Date
Attachment 3.19.1 Notice to Individuals Receiving Substance Abuse Services 04/01/2009
Documento Adjunto 3.19.1 Notificacion a Individuos Quienes Reciben Servicios para el Abuso de Estupefacients (Español) 04/01/2009
Attachment 3.19.2 Arizona PATH Program - Administrators Contact List 04/01/2011

 

3.20Credentialing and PrivilegingEffective Date
Attachment 3.20.1 Examples of College Classes Relevant to Behavioral Health 04/15/2005
Form 3.20.1 Supervisor of Clinical Liaisons Attestation of Competencies 04/15/2005
Form 3.20.2 BHT Case Supervision Report 04/15/2005
Form 3.20.3 Staff Add/Change/Delete 05/10/2010

 

3.21Service Prioritization for Non-Title XIX/XXI FundingEffective Date
Attachment 3.21.1 Health Plan & RBHA Medical Institution Notification for Dual Eligible Members 03/15/2006
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

03/15/2006

 

3.22Out-of-State Placements for Children and Young AdultsEffective Date
Form 3.22.1 Out-of-State Placement Initial Notice 9/15/2013
Form 3.22.2 Out-of-State Placement, 90-Day Update 9/15/2013

 

3.25Crisis Intervention ServicesEffective Date
Attachment 3.25.1 Crisis Intervention Services Delivered in Emergency Departments              02/14/2012

 

3.27Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health BenefitsEffective Date
Attachment 3.27.1 Documents Accepted by AHCCCS to Verify Citizenship and Identity 11/13/2013
Attachment 3.27.2 Non-Citizen/Lawful Presence Verification Documents 11/13/2013
Attachment 3.27.3 Persons who are Exempt for Verifcation of Citizenship during the Prescreening and Application Process 06/15/2011
Attachment 3.27.4 Citizenship/Lawful Presence Verification Process Through Health-e-Arizona 11/13/2013
Attachment 3.27.5 Requirement to Verify Citizenship for Non-AHCCCS Eligible Individual 11/13/2013

 

4.2Behavioral Health Medical Record StandardsEffective Date
Form 4.2.1 Community Service Agency/HCTC Provider/Habilitation Provider Daily Clinical Record Documentation Form 07/21/2008

 

4.3Coordination of Care with AHCCCS Health Plans and PCPsEffective Date
Attachment 4.3.1 AHCCCS Contracted Health Plans Contact Information 07/15/2010
Attachment 4.3.2 T/RBHA Acute Health Plan and Provider Coordinator Contact Information 01/30/2012
Form 4.3.1 Communication Document 12/15/2008
Form 4.3.2 Request for Information from PCP 12/01/2007
Form 4.3.3 T/RBHA Acute Health Plan & Provider Inquiry Monthly Log 06/15/2011
Form 4.3.4 Recipient Transition from RBHA to PCP Log 06/15/2011

 

4.4Coordination of Care with Other Government EntitiesEffective Date
Attachment 4.4.1 DCYF Child Welfare Timeframes 09/01/2011
Attachment 4.4.2 Overview of Arizona Families First 09/01/2011

 

5.1Member Notice RequirementsEffective Date
Form 5.1.1 Notice of Action 08/07/2013
Forma 5.1.1 Aviso De Acción (Español) 08/07/2013
Form 5.1.2 Notice of Extension of Timeframe for SErvice Authorization Decision Regarding Title XIX/XXI Behavioral Health Services 08/29/2013
Forma 5.1.2 Aviso de Extensión de Plazo Para Autorizacion de Decisión Para Servicios de Salud Mental Titulo XIX/XXI(Español) 08/29/2013

 

5.3Grievance and Request for Investigation for Persons Determined to Have a Serious Mental Illness (SMI)Effective Date
Form 5.3.1 ADHS/DBHS Appeal or SMI Grievance 07/01/2009
Forma 5.3.1 Forma De Apelación ADHS/DBHS o Queja SMI (Español) 01/01/2004

 

5.4Special Assistance for SMI MembersEffective Date
Form 5.4.1 Notification of Person in Need of Special Assistance 01/23/2014

 

5.5Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)Effective Date
Attachment 5.5.1 Notice of SMI Grievance and Appeal Procedure 05/15/2013
Documento Adjunto 5.5.1 Aviso de Queja y Apelación Formal de SMI de ADHS/DBHS(Español) 05/15/2013
Form 5.5.1 Notice of Decision and Right to Appeal (SMI) 02/29/2008
Forma 5.5.1 Aviso de Decisión y Derecho de Apelación (Español) 02/29/2008
Form ADHS MH-209 Notice of Discrimination Prohibited (English and Español) 05/2013
Form ADHS MH-211 Notice of Legal Rights for SMI 02/2008
Forma ADHS MH-211 Notice of Legal Rights for SMI (Español) 05/2013

 

5.6Provider Claims DisputesEffective Date
Attachment 5.6.1 Provider Claims Disputes Contact List 07/01/2012
Attachment 5.6.2 Process for Provider Claims Disputes 04/27/2006

 

6.0Submitting Claims and EncountersEffective Date
Attachment 6.0.1 BHS Where Do I Submit My Claims (Title XIX/XXI Only) 09/01/2010
Attachment 6.0.2 Billing Instructions Used to Identify Crisis Services 09/01/2010
Attachment 6.2.1 Pseudo ID Numbers 09/01/2010

 

7.1Fraud and Program Abuse ReportingEffective Date
Form 7.1.1 Suspected Fraud or Abuse Report 01/02/2008
Forma 7.1.1 Sospecha de Fraude o Reporte de Abuso de Programas 01/02/2008

 

7.2Medical Institution Reporting for Medicare Part DEffective Date
Form 7.2.1 AHCCCS Notification to Waive Medicare Part D Co-payments for Members in a Medical Institution that is Funded by Medicaid 12/1/2010

 

7.3Seclusion and Restraint Reporting for Level I FacilitiesEffective Date
Form 7.3.1 Seclusion and Restraint Reporting for Level I Facilities 07/15/2009
Attachment 7.3.1 Seclusion and Restraint Monitoring Requirements 09/15/2009

 

7.4Reporting of Incidents, Accidents and DeathsEffective Date
Form 7.4.1 Reporting Incident-Accident-Deaths 06/21/2010

 

7.5Enrollment, Disenrollment and other Data SubmissionEffective Date
Attachment 7.5.1 Timeframes for Data Submission 12/22/2010
Form 7.5.1 Demographic Form 02/04/2013
Attachment 7.5.2 834 Transaction Data Requirements 12/22/2010
Form 7.5.2 Initial Intake Form 03/23/2011
Attachment 7.5.3 SMI and SED Qualifying Diagnoses Table 04/01/2008
Attachment 7.5.4 (Preamble) Behavioral Health Services Diagnosis Code Table 09/01/2005
Attachment 7.5.4 (Table) Substance Abuse Disorders Qualifying Diagnoses Table 04/01/2008

 

8.5Medical Care Evaluation (MCE) StudiesEffective Date
Attachment 8.5.1 Instructions for Completion of Medical Care Evaluation 05/31/2011
Form 8.5.1 Medical Care Evaluation (MCE) Study - Request for Registration and Evaluation Methodology  10/15/2012
Form 8.5.2 Medical Care Evaluation (MCE) - Provider and T/RBHA Review of Final Results 10/15/2012
Form 8.5.3 Medical Care Evaluation (MCE) Quarterly Progress Report 09/01/2007

 

9.1Training and DevelopmentEffective Date
Attachment 9.1.1 Supervision Process User Guide 07/15/2007
Form 9.1.1

CFT Supervision Tool

07/15/2007
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Are You in Crisis?

If you are in crisis, call the Crisis Line at (800) 631-1314, TTY (800) 327-9254. For emergencies, always call 9-1-1

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Contact Information

Mercy Maricopa Integrated Care (Mercy Maricopa) is now the Regional Behavioral Health Authority (RBHA) serving members in the Maricopa County Region. For questions regarding your services, please call 1-800-564-5465 or TDD/TTY 711.

** To file a grievance or appeal for services provided on or before March 31, 2014 please call Magellan Health Services 602-652-5907, x8590