4.3 Coordination of Care with AHCCCS Health Plans, Primary
Care Providers and Medicare Providers
4.3.4 Did you know…?
4.3.7-A. Coordinating Care with AHCCCS Health Plans
4.3.7-B. The T/RBHA Acute Health Plan and
4.3.7-C. Sharing Information with the PCPs,
AHCCCS Acute Health Plans, other treating professionals and involved
4.3.7-D. Responsibility for fee for service
4.3.7-E. Responsibility for
persons enrolled in an AHCCCS Health Plan
4.3.7-F. PCPs prescribing psychotropic medications
4.3.7-G. Coordination of care with Medicare providers
In Arizona, the acute care Medicaid program (Title XIX) and the
State Children’s Health Insurance Program (KidsCare/SCHIP/Title XXI)
were developed as behavioral health “carve-outs,” a
model in which eligible persons receive general medical services
through health plans and covered behavioral health services through
behavioral health managed care organizations, also known as Tribal
Behavioral Health Authorities (T/RBHAs). Because of this separation in responsibilities,
communication and coordination between behavioral health providers,
the Arizona Health Care Cost Containment System (AHCCCS) Health Plan Primary Care Providers (PCPs)
and Behavioral Health Coordinators is essential
to ensure the well being of persons receiving services from both
Some behavioral health recipients are Medicaid (Title XIX/XXI) and Medicare
(Title XVIII) eligible and are referred to as “dual eligible” persons.
Medicare covers limited inpatient behavioral health services, outpatient behavioral
health services and prescription medication coverage. Medicare covered behavioral
health services are provided on either a fee-for-service basis or a managed care basis
(through Medicare Advantage Plans). The term Medicare Provider refers to both the
fee-for-service Medicare providers and the Medicare Advantage Plans. Coordination of care must also occur with Medicare providers to achieve positive health outcomes for Medicare eligible behavioral health recipients.
Holistic treatment requires integration of physical health with behavioral health to improve the overall health of an individual. Behavioral health recipients may be receiving care from multiple health care entities. Duplicative medication prescribing, contraindicated combinations
of prescriptions and/or incompatible treatment approaches could
be detrimental to a person. For this reason, communication and
coordination of care between behavioral health providers, PCPs
and Medicare providers must occur on a regular basis to ensure safety and positive clinical
outcomes for persons receiving care. For T/RBHA enrolled persons
not eligible for Title XIX or Title XXI coverage, coordination and
communication should occur with any known health care provider(s).
The following citations can serve as additional resources for this
42 CFR 400.202
42 CFR 409.62
42 CFR 422.2
42 CFR 422.4
42 CFR 422.106
42 CFR 422.114
42 CFR 423.4
42 CFR 423.34
42 CFR 423.100
42 CFR 423.104
42 CFR 423.272
42 CFR 423.505
A.R.S. § 36-545.04
CMS Medicare Benefit Policy Manual
AHCCCS Behavioral Health Services Guide
AHCCCS Medical Policy Manual
Section 3.2, Appointment
Standards and Timeliness of Service
Section 3.3, Referral
and Intake Process
- Section 3.5,
Third Party Liability and Coordination of Benefits
3.17, Transition of Process
3.21, Service Package for Non-title XIX/XXI Persons Determined
to Have a Serious Mental Illness (SMI)
Section 3.22, Out-of-State
Placements for Children and Young Adults
Section 4.1, Disclosure
of Behavioral Health Information
- Section 6.1,
Submitting Tribal Fee For Service Claims to AHCCCS
Section 6.2, Submitting Claims and Encounters to the RBHA
- Section 7.5,
Enrollment, Disenrollment and Other Data Submission
- Section 9.1,
ADHS/DBHS Covered Behavioral Health Services Guide
ADHS/DBHS Practice Improvement Protocol, Pervasive Developmental
Disorders and Developmental Disabilities
Policy Clarification Memorandum: Coordination of Care Between
AHCCCS Health Plan PCPs and Other PCPs in the Behavioral Health
ADHS/DBHS Policy Clarification Memorandum: Coordination of Care
with AHCCCS Health Plans and Primary Care Physicians
To whom does this apply?
XIX and Title XXI eligible persons; and all other
T/RBHA enrolled persons with other health care provider(s).
Did you know?
- As of October 1, 2010, AHCCCS began automatically enrolling
all Acute Care eligible members with a behavioral health benefit
into a T/RBHA. Members are assigned based on the zip code in
which they reside.
- Each quarter, ADHS/DBHS is partnering with the T/RBHAs to
introduce particular medical topics which impact individuals
receiving behavioral health services.
AHCCCS Health Plan has a “Behavioral Health Coordinator.”
The Behavioral Health Coordinator can serve as a contact person
and resource for behavioral health providers when problems arise
concerning a person’s medical care or any other health plan
related issue. A Behavioral Health Coordinator may act on behalf of the PCP. See
Attachment 4.3.1 for contact information for each
AHCCCS Health Plan and Behavioral Health Coordinator.
- T/RBHAs are required to identify at least one single point of contact within the T/RBHA to be named the Acute Health Plan and Provider Coordinator. This contact person(‘s) main role is to respond to coordination of care inquiries from AHCCCS Health Plans, primary care providers (PCP’s) and other involved clinicians to facilitate clinical coordination of care. When coordinating
care with the person’s PCP, Medicare provider or other
health care provider, information must be disclosed
in accordance with Section
4.1, Disclosure of Behavioral Health Information.
- In accordance with
R9-22-210.01; hospitals, emergency room providers, or fiscal agents are required to notify T/RBHAs
or their subcontracted providers no later than the 11th day from
presentation of Title XIX/XXI eligible members for emergency
inpatient behavioral health services.
- AHCCCS eligible individuals who are automatically assigned to a T/RBHA may or may not access behavioral health services. When an AHCCCS eligible individual does receive behavioral health services through a T/RBHA, the T/RBHA must track an individual’s “episode of care” in accordance with
Section 7.5, Enrollment, Disenrollment and Other Data Submission.
- As of January 1, 2006, AHCCCS no longer provides prescription drug coverage for dual eligible persons, except for certain excluded Medicare Part D drugs, in accordance with the Medicare Prescription Drug Modernization and Improvement Act of 2003. Medicare eligible persons must enroll in a Medicare Part D plan to receive prescription drug coverage through Medicare. Some Medicare Advantage plans contract with the T/RBHAs to provide the Part A, Part B and/or Part D benefit.
Acute Health Plan and Provider Coordinator
Behavioral Health Medical Practitioner
Medicare Advantage Prescription Drug Plan (MA-PD)
Prescription Drug Plan (PDP)
Prior Period Coverage
To ensure that timely communication and coordination of
care occurs between the T/RBHAs, subcontracted behavioral health
providers, AHCCCS Health Plan PCPs, Medicare Providers, or other
health care provider(s), regarding a T/RBHA enrolled person’s
behavioral health and general medical care and treatment.
Coordinating Care with AHCCCS Health
following procedures will assist behavioral health providers in
coordinating care with AHCCCS Health Plans:
- If the identity
of the person’s primary care provider (PCP) is unknown,
a behavioral health provider must contact the Acute Health Plan
and Provider Coordinator(s) for the T/RBHA or the Behavioral
of the person’s designated health plan to determine the
name of the person’s assigned PCP. See the
Health Plans, PM
Attachment 4.3.1 for contact information for the
Behavioral Health Coordinators for each
AHCCCS Health Plan.
- T/RBHA enrolled
persons who have never contacted their PCP prior to entry into
the behavioral health system should be encouraged to seek a baseline
medical evaluation. T/RBHA enrolled persons should also be prompted
to visit their PCP for routine medical examinations annually or
more frequently if necessary.
health providers should request medical information from the
person’s assigned PCP. Examples
include current diagnosis, medications, pertinent laboratory results,
last PCP visit, Early Periodic Screening, Diagnosis and Treatment
(EPSDT) screening results and last hospitalization. ADHS/DBHS has developed
a sample request form that may be utilized for this purpose (see
PM Form 4.3.2,
Request for Information from PCP or Medicare Provider). If the PCP does not respond to the request, contact the health plan’s Behavioral Health Coordinator for assistance.
health providers must address and attempt to resolve
coordination of care issues with AHCCCS Health Plans and PCPs at the lowest possible level.
If problems persist, contact the assigned Gila River BHS clinician
4.3.7-B. The T/RBHA Acute Health Plan and Provider Coordinator
T/RBHAs are required to designate an Acute Health Plan and Provider Coordinator who must gather, review and communicate clinical information requested by PCPs, Acute Care Plan Behavioral Health Coordinators and other treating professionals or involved stakeholders
(see PM Attachment 4.3.2, T/RBHA Acute Health Plan and Provider Coordinator Contact Information).
The T/RBHA must have a designated and published phone number for
the Acute Health Plan and Provider Coordinator or a clearly
recognized prompt on an existing phone number that facilitates
prompt access to the Acute Health Plan and Provider Coordinator and
that must be staffed during business hours.
T/RBHAs must ensure that T/RBHA Acute Health Plan and Provider Coordinators receive training which includes, at a minimum, the following elements:
- Provider inquiry processing and tracking (including resolution timeframes)
- T/RBHA procedures for initiating provider contracts or AHCCCS provider registration;
- Claim submission methods and resources (see PM 6.2, Submitting Claims and Encounters to the RHBA);
- Claim dispute and appeal procedures (PM 5.6, Provider Claims Disputes); and
- Identifying and referring quality of care issues.
4.3.7-C. Sharing information with the PCPs, AHCCCS Acute
Health Plans, other treating professionals and involved stakeholders
To support quality medical management and prevent duplication of services, behavioral health providers are required to disclose relevant
behavioral health information pertaining to Title XIX and Title
XXI eligible persons to the assigned PCP, AHCCCS Acute Health Plans, other treating professionals and other involved stakeholders within the following required timeframes:
- “Urgent” – requests for intervention, information or response within 24 hours.
- “Routine” – Requests for intervention, information or response within 10 days.
For all behavioral health recipients referred by the PCP and have been determined to have a Serious Mental Illness and/or a diagnosis of a chronic medical condition on Axis III, the following information must be provided to the person’s assigned PCP:
- The person’s
- The person’s
current prescribed medications (including strength and dosage).
subcontracted providers must provide the required information annually,
and/or when there is significant change in the person’s diagnosis
and/or prescribed medications.
For all Title
XIX/XXI enrolled persons, behavioral health providers are required
- Notify the assigned PCP of the results of PCP initiated
behavioral health referrals;
- Provide a
final disposition to the health plan Behavioral Health
Coordinator in response to PCP initiated behavioral health referrals.
(For more information on the referral process, see Section 3.3,
Intake and Referral
the placement of persons in out-of-state treatment settings as
described in Section 3.22, Out-of
State Placement for Children and Young Adults;
- Notify, consult with or disclose information to the assigned PCP regarding persons with Pervasive Developmental Disorders and Developmental Disabilities, such as the initial assessment and treatment plan and care and consultation between specialists;
- Provide a copy to the PCP of any executed advance directive, or documentation of refusal to sign an advance directive, for inclusion in the behavioral health recipient’s medical record; and
- Notify, consult with or disclose other events requiring medical consultation with the person’s PCP.
by the PCP or member, information for any enrolled member must be provided
to the PCP consistent with requirements outlined in Section
4.1, Disclosure of Behavioral Health Information.
or sending any of the above referenced information to the person’s
PCP, behavioral health providers must provide the PCP with an
agency contact name and telephone number in the event the PCP needs
developed a communications form (DBHS Policy Form 902.1, Communication Document) for coordinating care with the AHCCCS Health
Plan PCP or Behavioral Health Coordinator. The form includes the required elements for coordination
purposes and must be completed in full for coordination of care to
be considered to occur. For
complex problems, direct provider-to-provider contact is recommended
to support written communications.
DBHS Policy Form 902.1 will not have to be used if there is a properly documented progress note. To be considered properly documented the progress note must:
Submission of the Acute Health Plan and Provider Inquiry Logs must be timely. The T/RBHA may be subject to corrective action if not compliant with this requirement.
ADHS/DBHS will communicate items of concern with T/RBHAs, if there are systemic issues evident in the information submitted on the T/RBHA Acute Health Plan and Provider Inquiry Monthly Log. T/RBHAs must resolve any such noted systemic issues in a timely manner
4.3.7-D. Responsibility for fee-for-service persons
It is the responsibility of the T/RBHA to provide fee-for-service behavioral health services to Title XIX/XXI eligible persons not enrolled with an AHCCCS Health Plan.
The T/RBHA is responsible for providing all inpatient emergency behavioral health services for fee-for-service persons with psychiatric or substance abuse diagnoses.
The T/RBHA is responsible for behavioral health services to Native American Title XIX and Title XXI eligible persons referred by an Indian Health Services (IHS) or tribal facility for emergency services rendered at non-IHS facilities.
Responsibility for persons enrolled in an AHCCCS Health Plan
Services which may have been covered by the AHCCCS Health Plan Contractor for Prior Period Coverage will now be the responsibility of the T/RBHA. This is limited to the behavioral health services only and after the individual has been medically cleared. The Health Plan Contractor is still obligated to provide all necessary medical services. The following
rules applyfor other areas of coverage:
Pre-petition Screenings and Court Ordered Evaluations
Payment for pre-petition screenings and court ordered evaluations is the responsibility of the county.
Behavioral Health Services
When a Title
XIX or Title XXI eligible person presents in an emergency room
setting, the person’s AHCCCS Health Plan is responsible
for all emergency medical services including triage, physician
assessment and diagnostic tests.
or when applicable, its designated behavioral health provider,
is responsible for psychiatric and/or psychological evaluations
in emergency room settings provided to all Title XIX and Title XXI
persons enrolled with a T/RBHA.
The T/RBHA is responsible for providing all non-inpatient emergency behavioral health services to Title XIX and Title XXI eligible persons. Examples of
non-inpatient emergency services include assessment, psychiatric
evaluation, mobile crisis, peer support and counseling.1
The T/RBHA is responsible for providing all inpatient emergency behavioral health services to persons with psychiatric or substance abuse diagnoses
for all Title XIX and Title XXI eligible persons.
Emergency transportation of a Title XIX or Title XXI eligible person to the emergency room
(ER) when the person has been directed by the T/RBHA or T/RBHA provider to present to this setting in order to resolve a behavioral health crisis is the responsibility of the T/RBHA. The T/RBHA or subcontracted provider directing the person to present to the ER must notify the emergency transportation provider of
the T/RBHAs fiscal responsibility for the service.
Emergency transportation of a Title XIX or Title XXI eligible person required to manage an acute medical condition which includes transportation to the same or higher level of care for immediate medically necessary treatment is the responsibility of the person’s AHCCCS Health Plan.
For information on emergency services for Non-title XIX/XXI persons see
Section 3.25, Crisis Intervention Services.
Non-emergency Behavioral Health Services
For Title XIX and Title XXI eligible persons, the T/RBHA
is responsible for the provision of all non-emergency behavioral
If a Title XIX or Title XXI eligible person is assessed as needing inpatient psychiatric services by the T/RBHA or subcontracted provider prior to admission to an inpatient psychiatric setting, the T/RBHA is responsible for authorization and payment for the full inpatient stay, as per
PM Section 3.14, Securing Services and Prior Authorization.
When a medical team or health plan requests a behavioral health or psychiatric evaluation prior to the implementation of a surgery, medical procedure or medical therapy to determine if there are any behavioral health contraindications, the
T/RBHA is responsible for the provision of this service. Surgeries, procedures or therapies can include gastric bypass, interferon therapy or other procedures for which behavioral health support for a patient is indicated.
Transportation of a Title XIX or Title XXI eligible person to an initial behavioral health intake appointment is the responsibility of the
Treatment for Persons in Behavioral Health Treatment Facilities
- When a Title
XIX or Title XXI eligible person is in a Level II or Level III
residential treatment center and requires medical treatment, the
AHCCCS Health Plan is responsible for the provision of covered
- If a Title
XIX or Title XXI eligible person is in a Level I psychiatric facility
and requires medical treatment, those services are included in
the per diem rate for the treatment facility. If the person requires
inpatient medical services that are not available at the Level
I psychiatric facility, the person must be discharged from the
psychiatric facility and admitted to a medical facility. The AHCCCS
Health Plan is responsible for medically necessary services received
at the medical facility, even if the person is enrolled with a
PCPs prescribing psychotropic medications
Within their scope of practice and comfort level, an AHCCCS
Health Plan PCP may elect to treat select behavioral health disorders.
The select behavioral health disorders that AHCCCS Health Plan PCPs
can treat are:
depressive disorders; and
Certain requirements and guiding principles regarding
medications for psychiatric disorders have been established for
under the care of both a health plan PCP and behavioral health
provider simultaneously. The following conditions
- Title XIX
and Title XXI eligible persons must not receive medications for
psychiatric disorders from the health plan PCP and behavioral
health provider simultaneously. If a person is identified to be
simultaneously receiving medications from the health plan PCP
and behavioral health provider, the behavioral health provider
must immediately contact the PCP to coordinate care and agree
on who will continue to medically manage the person’s behavioral
- Medications prescribed by providers within the
T/RBHA behavioral health system must be filled by T/RBHA contracted
pharmacies under the T/RBHA pharmacy benefit (see exceptions to
this requirement for dual eligible persons in subsection
4.3.7-F, Coordination of care with Medicare providers). This is particularly
important when the pharmacy filling the prescription is part of
the contracted pharmacy network for both the prescribing T/RBHA
and the person’s AHCCCS Health Plan. The T/RBHA and contracted
providers must take active steps to ensure that prescriptions
written by providers within the T/RBHA system are not charged
to the person’s AHCCCS Health Plan.
Transitions of persons with ADHD, depression, and/or anxiety
to the care of their Primary Care Physician
Members who have a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), depression, and/or anxiety and who are stable on their medications may transition back to the care of their PCP for the management of these diagnoses, as long as the member, their guardian or parent and the PCP agree to this treatment transition. The T/RBHA is required to facilitate this process and to ensure that the following steps are taken:
- The T/RBHA must contact the member’s PCP to discuss the member’s current medication regime and to confirm that the PCP is willing and able to provide treatment for the member’s ADHD, depression, and/or anxiety.
- If the PCP agrees to transition treatment for the member’s diagnosis of ADHS, depression and/or anxiety, the T/RBHA must provide the PCP with a transition packet that includes (at a minimum):
- A written statement indicating that the member is stable on a medication regime;
- A medication sheet or list of medications currently prescribed by the T/RBHA Behavioral Health Medical Practitioner (BHMP);
- A psychiatric evaluation;
- Any relevant psychiatric progress notes that may assist in the ongoing treatment of the member; and
- A discharge summary outlining the member’s care and any adverse responses the member has had to treatment or medication.
- A copy of the packet must be sent to the member’s AHCCCS Health Plan Behavioral Health Coordinator as well as to the member’s PCP.
- The T/RBHA will ensure that the member’s transition to the PCP is seamless, and that the member does not go without medications during this transition period.
- Each month, the T/RBHA will complete
PM Form 4.3.4 Member Transition from T/RBHA to PCP Tracking Log and submit it to ADHS/DBHS to monitor the transition process
health medical practitioners must be available to AHCCCS Health
Plan PCPs to answer diagnostic and treatment questions of a general
- General psychiatric consultations are not person specific and
are usually conducted over the telephone between the PCP and the
behavioral health medical practitioner.
Behavioral health providers must be available to conduct a face-to-face evaluation with a Title XIX/XXI eligible person upon his/her PCPs request in accordance with
Section 3.2, Appointment Standards and Timeliness of Service;
A one-time face-to-face evaluation is used to answer PCPs specific questions and provide clarification and evaluation regarding a person’s diagnosis, recommendations for treatment, need for behavioral health care, and/or ongoing behavioral health care or medication management provided by the PCP.
The PCP must have seen the person prior to requesting a one-time face-to-face psychiatric evaluation with the behavioral health provider.
AHCCCS Health Plan PCPs must be provided current information about how to access T/RBHA psychiatric consultation services. AHCCCS health plans may contact Gila River BHS at 602-528-7100. The T/RBHA is obligated to offer general consultations and one-time face-to-face psychiatric evaluations and must provide direct and timely access to behavioral health medical practitioners (physicians, nurse practitioners and physician assistants) or other behavioral health practitioners if requested by the PCP.
4.3.7-G. Coordination of care with Medicare providers
Medicare Advantage plans
Medicare health plans, also known as Medicare Advantage (MA) plans, are managed care entities that have a Medicare contract with the Centers for Medicare and Medicaid Services (CMS) to provide services to Medicare beneficiaries. MA plans provide the full array of Medicare benefits, including Medicare Part A, hospital insurance, and Medicare Part B, medical insurance. As of January 1, 2006, MA plans also included Medicare Part D, prescription drug coverage.
Many of the AHCCCS Contracted Health Plans are MA plans (see
PM Attachment 4.3.1). These plans provide Medicare Part A, Part B and Part D benefits in addition to Medicaid services for dual eligible persons and are referred to as MA-PD SNPs (Medicare Advantage-Prescription Drug/Special Needs Plans).
Some MA plans contract with the T/RBHA to provide some or all of the Medicare covered behavioral health services. In such cases, coordination of care should be simplified as the T/RBHA is providing Title XIX and state funded behavioral health services, as well as Medicare behavioral health services. Coordination with MA plans must be attempted by the T/RBHA and/or behavioral health provider when the Medicare behavioral health services are provided by the MA plan. ADHS/DBHS has developed sample forms for use when requesting or sharing information for purposes of coordinating care with Medicare providers (see
DBHS Policy Form 902.1, Communication Document, and
PM Form 4.3.2, Request for Information from PCP or Medicare Plan/Provider). Gila River BHS is a department of an IHS health care facility which manages multiple health plan contracts along with IHS funding. Please contact Gila River BHS at 602-528-7100 for further assistance with the coordination of services with Medicare providers.
Medicare Fee-for-Service Program
Instead of enrolling in a Medicare Advantage plan, Medicare eligible behavioral health recipients may elect to receive all Medicare services (Parts A, B and/or D) through any provider authorized to deliver Medicare services. Therefore, behavioral health recipients in the Medicare Fee-for-Service program may receive services from Medicare registered providers in the T/RBHA provider network.
Inpatient Psychiatric Services
Medicare has a lifetime benefit maximum for inpatient psychiatric services. T/RBHA cost sharing responsibilities and billing for inpatient psychiatric services must be in accordance with
Section 3.5, Third Party Liability and Coordination of Benefits, and
Section 6.1, Submitting Tribal Fee for Service Claims to AHCCCS and
Section 6.2, Submitting Claims and Encounters to the RBHA. Gila River BHS is a department of an IHS health care facility which manages multiple health plan contracts along with IHS funding. Please contact Gila River BHS at 602-528-7100 for further assistance with the coordination of services with Medicare providers.
Outpatient Behavioral Health Services
Medicare provides some outpatient behavioral health services that are also ADHS/DBHS covered behavioral health services. T/RBHA cost sharing responsibilities and billing for outpatient behavioral health services must be in accordance with
Section 3.5, Third Party Liability and Coordination of Benefits,
Section 6.1, Submitting Tribal Fee For Service Claims to AHCCCS and
Section 6.2, Submitting Claims and Encounters to the RBHAs. Gila River BHS is a department of an IHS health care facility which manages multiple health plan contracts along with IHS funding. Please contact Gila River BHS at 602-528-7100 for further assistance with the coordination of services with Medicare providers.
Prescription Medication Services
Medicare eligible behavioral health recipients must enroll in a Medicare Part D Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD) to receive the Part D benefit. PDPs only provide the Part D benefit and any Medicare registered provider may prescribe medications to behavioral health recipients enrolled in PDPs. Some MA-PDs may contract with the T/RBHA or T/RBHA providers to provide the Part D benefit to Medicare eligible behavioral health recipients. Gila River BHS is a department of an IHS health care facility which manages multiple health plan contracts along with IHS funding. Please contact Gila River BHS at 602-528-7100 for further assistance with the coordination of services with Medicare providers.
While PDPs and MA-PDs are responsible for ensuring prescription drug coverage to behavioral health recipients enrolled in their plans, there are some prescription medications that are not included on plan formularies (non-covered) or are excluded Part D drugs. The T/RBHA is responsible for covering non-covered or excluded Part D behavioral health prescription medications listed on the T/RBHA formulary, in addition to Part D cost sharing, in accordance with
Section 3.5, Third Party Liability and Coordination of Benefits, and
Section 3.21, Service Package for Non-Title XIX/XXI
Persons Determined to Have a Serious Mental Illness (SMI).
1 Note: in inpatient settings, these services would be included in the per diem rate.
Care with AHCCCS Health Plans and Primary Care Providers and
Last Revised: 05/10/2011
Effective Date: 06/15/2011