Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.2 Appointment Standards and Timeliness of Service

3.2.1 Introduction
3.2.2 Terms
3.2.3 Procedures
3.2.3-A. Type of response by a Tribal/Regional Behavioral Health Authority (T/RBHA) or a behavioral health provider (non-hospitalized persons)
3.2.3-B. 72-hour urgent behavioral health response for children taken into DES/CPS custody
3.2.3-C. Appointments for psychotropic medications
3.2.3-D. Referrals for hospitalized persons not currently T/RBHA enrolled
3.2.3-E. Waiting times
3.2.3-F. Other requirements
3.2.3-G. Special populations
3.2.4 References


3.2.1 Introduction
It is vital that the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) system be responsive and accessible to all the persons it serves. It is the expectation of ADHS/DBHS that provider response to a person’s identified behavioral health service need is timely and based on clinical need, resulting in the best possible behavioral health outcome for that person.

Response time is always determined by the acuity of a person’s assessed behavioral health condition at the moment he/she is in contact with the provider. ADHS/DBHS has organized responses into three categories: immediate responses, urgent responses, and routine responses.

Please note that at the time it is determined that an immediate response is needed, a person’s eligibility and enrollment status may not be known. Behavioral health providers must respond to all persons in immediate need until the situation is clarified that the behavioral health provider is not financially responsible. Persons who are determined ineligible for covered services may be referred to applicable community resources.

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3.2.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:

Behavioral Health Medical Practitioner (BHMP)

Immediate Response

Routine Response

Urgent Response

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3.2.3 Procedures

3.2.3-A. Type of response by a T/RBHA or a behavioral health provider (non-hospitalized persons)

  WHEN WHAT WHO
IMMEDIATE Behavioral health services provided within a timeframe indicated by behavioral health condition, but no later than 2 hours from identification of need or as quickly as possible when a response within 2 hours is geographically impractical

Services can be telephonic or face-to-face; the response may include any medically necessary, covered behavioral health service

  • All persons requesting assistance unless determined not to be eligible. At the time of determination that an immediate response is needed, a person’s eligibility and enrollment status may not be known. Behavioral health providers must respond to all persons in immediate need of behavioral health services until the situation is clarified that the behavioral health provider is not financially responsible.
URGENT DES/CPS child referral Behavioral health services must be provided within a timeframe indicated by behavioral health condition but no later than 72 hours after notification by DES/CPS that a child has been or will be removed from their home. Includes medically necessary covered behavioral health services. (See section 3.2.7-B for detailed information)
  • Upon notification from ADES/DCYF/CPS that a child has been, or will imminently be, taken into the custody of ADES/DCYF/CPS, regardless of the child’s Title XIX or Title XXI eligibility status
URGENT  All other urgent responses Behavioral health services provided within a timeframe indicated by behavioral health condition but no later than 24 hours from identification of need. Includes any medically necessary covered behavioral health service.
  • Referrals for hospitalized persons not currently T/RBHA enrolled;
  • All Title XIX/XXI eligible persons;
  • All non-Title XIX persons determined to have a Serious Mental Illness; and
  • All other non-Title XIX/XXI persons in need of crisis or emergency services.
  WHEN WHAT WHO
ROUTINE Appointment for initial assessment within 7 days of referral or request for behavioral health services Includes any allowable assessment service as identified in the ADHS/DBHS Covered Behavioral Health  Services Guide
  • All Title XIX/XXI eligible persons;
  • All Non-Title XIX/XXI persons determined to have a Serious Mental Illness; and
  • All persons referred for determination as a person with a Serious Mental Illness.
The first behavioral health service following the initial assessment appointment within timeframes indicated by clinical need, but no later than 23 days of the initial assessment Includes any medically necessary covered behavioral health service including additional assessment services
  • All Title XIX/XXI persons; and
  • All Non-Title XIX/XXI persons determined to have a Serious Mental Illness.
All subsequent behavioral health services within time frames according to the needs of the person Includes any medically necessary covered behavioral health service
  • All Title XIX/XXI persons; and
  • All Non-Title XIX/XXI persons determined to have a Serious Mental Illness.

Note:  Standards for persons receiving services as part of SAPT Grant funding are in section 3.2.7-G, Special Populations

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3.2.3-B. 72-hour urgent behavioral health response for children taken into DES/CPS custody

An urgent response (within 72 hours) is required for all children who are taken into the custody of ADES/DCYF/CPS regardless of Title XIX or Title XXI eligibility status. The purpose for this urgent response is to:

  • Identify immediate safety needs and presenting problems of the child, to stabilize behavioral health crises and to be able to offer immediate services the child may need;
  • Provide behavioral health services to each child with the intention of reducing the stress and anxiety that the child may be experiencing, and offering a coherent explanation to the child about what is happening and what can be expected to happen in the near-term;
  • Provide needed behavioral health services to each child’s new caregiver, including guidance about how to respond to the child’s immediate needs in adjusting to foster care, behavioral health symptoms to watch for and report, assistance in responding to any behavioral health symptoms the child may exhibit, and identification of a contact within the behavioral health system;
  • Initiate the development of the CFT process for each child (see Child and Family Team Practice Protocol); and
  • Provide the ADES/DCYF/CPS Case Manager with findings and recommendations for medically necessary covered behavioral health services for the initial Preliminary Protective Hearing, which occurs within 5 to 7 days of the child’s removal. (See PM Attachment 4.4.1, ACYF Child Welfare Timelines, for more information.)

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3.2.3-C. Appointments for psychotropic medications
For persons who may need to be seen by a Behavioral Health Medical Practitioner (BHMP), it is required that the person’s need for medication be assessed immediately and, if clinically indicated, that the person be scheduled for an appointment within a timeframe that ensures:

  • The person does not run out of any needed psychotropic medications; or
  • The person is evaluated for the need to start medications to ensure that the person does not experience a decline in his/her behavioral health condition.

Response for referrals or requests for psychotropic medications:

  WHEN WHAT WHO
Referral for psychotropic medications Assess the urgency of the need immediately; If clinically indicated, provide an appointment with a BHMP within a timeframe indicated by clinical need, but no later than 30 days from the referral/initial request for services Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate
  • All Title XIX/XXI eligible persons;
  • All Non-Title XIX/XXI persons enrolled with a T/RBHA;
  • All persons determined to have a Serious Mental Illness; and
  • Any person in an emergency or crisis
All initial assessments and treatment recommendations that indicate a need for psychotropic medications The initial assessment and treatment recommendations must be reviewed by a BHMP within a timeframe based on clinical need. Screening, consultation, assessment, medication management, medications, and/or lab testing services as appropriate
  • All Title XIX/XXI eligible persons;
  • All persons determined to have a Serious Mental Illness; and
  • Any person in an emergency or crisis

 

3.2.3-D. Referrals for hospitalized persons
Behavioral health providers must quickly respond to referrals pertaining to eligible persons not yet enrolled in the T/RBHA or Title XIX/XXI eligible persons who have not been receiving behavioral health services prior to being hospitalized for psychiatric reasons and persons previously determined to have a SMI. Upon receipt of such a referral, the following steps must be taken:

  • For referrals of Title XIX/XXI eligible persons and persons previously determined to have a SMI:
    • Initial face-to-face contact, an assessment and disposition must occur within 24 hours of the referral/request for services.
  • For referrals of non-Title XIX/XXI eligible persons:
    Persons referred for eligibility determination of Serious Mental Illness:
    • Initial face-to-face contact and an assessment must occur within 24 hours of the referral/request for services. Determination of SMI eligibility must be made within timeframes consistent with and in accordance to Section 3.10, SMI Eligibility Determination; and
    • Upon the determination that the person is eligible for services and the person is in need of continued behavioral health services, the person must be enrolled and the effective date of enrollment must be no later than the date of first contact.

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3.2.3-E. Waiting times
ADHS/DBHS has established standards so that persons presenting for scheduled appointments do not have to wait unreasonable amounts of time. Unless a behavioral health provider is unavailable due to an emergency, a person appearing for an established appointment must not wait for more than 45 minutes.

Behavioral health providers arranging for, or providing, non-emergency transportation services for members must adhere to the following standards:

  • A person must not arrive sooner than one hour before his/her scheduled appointment; and
  • A person must not have to wait for more than one hour after the conclusion of his/her appointment for transportation home or to another pre-arranged destination.

3.2.3-F. Other requirements
All referrals from a person’s primary care provider (PCP) requesting a psychiatric evaluation and/or psychotropic medications must be accepted and acted upon in a timely manner according to the needs of the person, and the response time must help ensure that the person does not experience a lapse in necessary psychotropic medications, as described in subsection 3.2.7-C, Appointments for psychotropic medications.

Title XIX and Title XXI persons must never be placed on a “wait list” for any Title XIX/XXI covered behavioral health service. If the T/RBHA network is unable to provide medically necessary covered behavioral health services for Title XIX or Title XXI persons, it must ensure timely and adequate coverage of needed services through an alternative provider until a network provider is contracted. In this circumstance, the T/RBHA must ensure coordination with respect to authorization and payment issues. In the event that a covered behavioral health service is temporarily unavailable to a Title XIX/XXI eligible person, the behavioral health provider must adhere to the following procedure. The behavioral health provider notifies a Gila River RBHA Clinical Manager within 1 working day of identifying that a medically necessary covered service is temporarily unavailable to a Title XIX/XXI eligible person. The Gila River RBHA Clinical Manager can be reached by telephone at (602) 528-7100. The Gila River Clinical Manager coordinates with the Gila River Network Manager as needed to address the service gap. In the event that the Title XIX/XXI person is in an inpatient or residential facility, the Gila River may recommend to ADHS that the person remain in the facility until clinically appropriate outpatient services can be made available.

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3.2.3-G. Special populations

ADHS/DBHS receives some funding for behavioral health services through the Federal Substance Abuse Prevention and Treatment Block Grant (SAPT). SAPT funds are used to provide substance abuse services for Non-Title XIX/XXI eligible persons. As a condition of receiving this funding, certain populations are identified as priorities for the timely receipt of designated behavioral health services. Currently, not all T/RBHAs receive SAPT Block Grant funding through ADHS/DBHS; any providers contracted with a T/RBHA or for SAPT funds must follow the requirements found in this section. For all other contracted behavioral health providers that do not currently receive these funds, the following expectations do not apply.

SAPT Block Grant Populations
The following populations are prioritized and covered under the SAPT Block Grant:

First: Pregnant females who use drugs by injection;
Then: Pregnant females who use substances;
Then: Other injection drug users;
Then: Substance-using females with dependent children, including those attempting to regain custody of their child(ren); and
Finally: All other persons in need of substance abuse treatment

Response Times for Designated Behavioral Health Services Under the SAPT Block Grant (Based on available funding):

WHEN WHAT WHO
Behavioral health services provided within a timeframe indicated by clinical need, but no later than 48 hours from the referral/initial request for services Any needed covered behavioral health service, including admission to a residential program if clinically indicated;

If a residential program is temporarily unavailable, an attempt shall be made to place the person within another provider agency facility, including those in other geographic service areas. If capacity still does not exist, the person shall be placed on an actively managed wait list and interim services must be provided until the individual is admitted. Interim services include: counseling/education about HIV and Tuberculosis (include the risks of transmission), the risks of needle sharing and referral for HIV and TB treatment services if necessary, counseling on the effects of alcohol/drug use on the fetus and referral for prenatal care

Pregnant women/teenagers referred for substance abuse treatment (includes pregnant injection drug users and pregnant substance abusers) and substance-using females with dependent children, including those attempting to regain custody of their child(ren)
Behavioral health services provided within a timeframe indicated by clinical need but no later than 14 days following the initial request for services/referral.

All subsequent behavioral health services must be provided within timeframes according to the needs of the person.

Includes any needed covered behavioral health services;

Admit to a clinically appropriate substance abuse treatment program (can be residential or outpatient based on the person’s clinical needs); if unavailable, interim services must be offered to the person. Interim services shall minimally include education/interventions with regard to HIV and tuberculosis and the risks of needle sharing and must be offered within 48 hours of the request for treatment.

All other injection drug users
Behavioral health services provided within a timeframe indicated by clinical need but no later than 23 days following the initial assessment

All subsequent behavioral health services must be provided within timeframes according to the needs of the person.

Includes any needed covered behavioral health services All other persons in need of substance abuse treatment

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3.2.4 References
The following citations can serve as additional resources for this content area:

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3.2 Appointment Standards and Timeliness of Service
Last Revision: 07/17/2013
Effective Date: 09/15/2013

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