This section applies to notice and appeal requirements for:
- Persons who
have been determined to have a Serious Mental Illness (SMI);
who are applying for an SMI eligibility determination; and
health recipients who do not have a SMI and
who are not Title XIX or Title XXI eligible.
The notice requirements
and the appeal process for persons who are Title XIX/XXI eligible
are described in Section 5.1, Notice Requirements and Appeal Process
for Title XIX and Title XXI Eligible Persons.
have been determined to have a SMI and who are receiving non-Title XIX/XXI (state funded) services must only receive notice of, and may only appeal, pursuant to this section, decisions regarding those services that are covered benefits
or services established by the State. The notice and appeal requirements described within this section do not apply to actions or decisions that deny, suspend, reduce, or terminate a person’s or persons’ services as a result of change in state or federal law which require an automatic change, or in order to avoid exceeding the state funding legislatively appropriated for those services or benefits.
are evaluated for an eligibility determination or who have been determined to have a SMI must be provided notice under certain circumstances. Notice
facilitates a behavioral health recipient to exercise his/her right to appeal a decision. This section describes those circumstances when notice must be provided.
Persons who are evaluated for an eligibility determination or who have been determined to have a SMI can appeal certain decisions. These include, but are not limited to:
regarding an SMI eligibility determination;
regarding the need for, the timely provision of, or the continuation
of behavioral health services; and
regarding charges or co-payments for behavioral health services.
Definitions for terms are located online at
http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:
General requirements for notice and appeals
Behavioral health providers must be aware of general requirements
guiding notice and appeal rights for the populations covered in
this section. Behavioral health providers may have direct responsibility
for designated functions (i.e., sending notice) as determined by
the RBHA and/or may be asked to provide assistance to persons who
are exercising their rights to appeal.
How is time
In computing any time prescribed or allowed in this section, the
period begins the day after the act, event or decision occurs. If the period is 11 days or more, the time period must be calculated using calendar days, which means that weekends and legal holidays are counted. If however, the period of time is less than 11 days, the time period is calculated using working days, in which case, weekends and legal holidays must not be included in the computation. In either case, if the final day of the period is a weekend or legal holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday.
format and comprehensive clinical record requirements
Notice and related forms must be available in each prevalent, non-English
language spoken in the RBHA’s geographic service area (GSA). As
designated by the RBHA, behavioral health providers must provide
free oral interpretation services to all persons who speak non-English
languages for purposes of explaining the appeal process and/or information
contained in the notice.
Notice and other
written documents pertaining to the appeal process must be available
in alternative formats, such as Braille, large font or enhanced
audio and must take into consideration any special communication
needs of the person applying for or receiving behavioral health
of notice must be documented by placing a copy of the notice in
the person’s comprehensive clinical record.
of notices and appeal decisions
All notices and appeal decisions must be personally delivered or
mailed by certified mail to the required party, at
their last known residence or place of business. In the event that it may be unsafe to
contact the person at his or her home, or the
person has indicated that he or she does not want to receive mail
at home, the alternate
methods identified by the person for communicating notices must
Notice requirements for persons applying for or who have been determined
to have a serious mental illness
Under what circumstances does a notice have to be provided?
For actions (see definition) related to Title XIX/XXI covered services,
see Section 5.1, Notice Requirements and Appeal Process for Title
XIX and Title XXI Eligible Persons.
provisions apply to notice requirements for persons determined to
have a SMI and for persons for which an SMI eligibility
determination is being considered:
are evaluated for an SMI eligibility determination must receive
Attachment 5.5.1, Notice of SMI Grievance and Appeal
Procedure, at the time of application.
Form 5.5.1, Notice of Decision and Right to Appeal
must be provided to persons determined to have a serious mental
illness or to persons applying for SMI services when:
- Initial eligibility
for SMI services is determined. The notice must be sent within
3 days of the eligibility determination;
- A decision
is made regarding fees or waivers;
- The assessment
report, service plan or individual treatment and discharge
plan is developed, provided or reviewed;
- A decision
is made to modify the individual service plan, reduce, suspend or
terminate any service that is a covered service funded through Non-Title XIX funds. In this case,
notice must be provided at least 30 days prior to the effective
date unless the person consents to the change in writing or a qualified
clinician determines that the action is necessary to avoid a
serious or immediate threat to the health or safety of the person
receiving services or others;
- A decision
is made that the person is no longer eligible for SMI services;
Pre-Admission Screening and Resident Review (PASRR)
determination in the context of either a preadmission screening or
an annual resident review, which adversely affects the person.
that must be provided to persons determined to have a SMI
The following additional notices must be provided to persons determined
to have a serious mental illness or persons applying for SMI services:
- Notice of
legal rights for persons determined to have SMI (see
Form MH-211) at the time of admission to a behavioral health provider
agency for evaluation or treatment. The person receiving this
notice must acknowledge in writing the receipt of the notice and
the behavioral health provider must retain the acknowledgement
in the person’s comprehensive clinical record. All behavioral
health providers must post
ADHS Form MH-211, “Notice of
Legal Rights for Persons with Serious Mental Illness”, in
both English and Spanish, so that it is readily visible to behavioral
health recipients and visitors;
- Notice of
discrimination prohibited (ADHS Form MH-209),
posted in English
or Spanish, so that it is visible to persons visiting the
agency, and a copy provided at the time of discharge from the behavioral health
Who is responsible for providing the notice?
Following a decision requiring notice to a behavioral health recipient, the assigned Gila River Behavioral Health Clinician must ensure the communication of a notice to the person.
ADHS/DBHS sends notices to persons determined to have a SMI who are enrolled with a Tribal RBHA when making a decision on behalf of the Tribal RBHA, and persons adversely affected by a PASRR determination.
Notice requirements for Non-Title XIX/XXI/ Non-SMI populations
Behavioral health recipients who do not have a determination of
and who are not Title XIX or Title XXI eligible are not required
to receive notice under any circumstances.
Filing an appeal
Appeals that are related to a RBHA or one of their contracted behavioral
health providers’ decisions must be filed with the RBHA. Appeals
that are related to a Tribal RBHA or one of their contracted behavioral
health providers’ decisions and appeals that relate to PASRR
determinations must be filed with and processed by
the ADHS/DBHS Office of Grievance and Appeals.
eligible persons applying for or who have been determined to have
a SMI and who are appealing an action (see definition)
affecting Title XIX/XXI covered services may elect to use either
the Title XIX/XXI appeal process (see
Section 5.1, Notice Requirements
and Appeal Process for Title XIX and Title XXI Eligible Persons)
or the appeal process for persons determined to have a SMI described within subsection 5.5.7-E.
of appeals exist?
There are two appeal processes applicable to this section:
- Appeals of
persons applying for an eligibility determination or who have
been determined to have a SMI;
for other covered service related issues.
file an appeal?
The following persons and entities may file an appeal:
- An adult
applying for or receiving behavioral health services, their legal
guardian, guardian ad litem, designated representative or attorney if Special Assistance, the person meeting Special Assistance needs;
- A legal
guardian or parent who is the legal custodian of a person under
the age of 18 years;
- A court
appointed guardian ad litem or an attorney of a person under the
age of 18 years;
- A state or
governmental agency that provides behavioral health services
through an Interagency Service Agreement/Intergovernmental
Agreement (ISA/IGA) with ADHS, but which does not have legal custody
or control of the person to the extent
specified in the ISA/IGA between the agency and the ADHS; and
- A provider,
acting on the behavioral health recipient’s behalf and with
the written authorization of the person.
the timeframes for filing an appeal?
Appeals must be filed orally or in writing with the responsible
RBHA, or ADHS/DBHS when required, within 60 days from the date of
the decision being appealed. Late appeals must be accepted upon
showing good cause.
appeals be directed?
- For oral
appeals to ADHS/DBHS: Call ADHS/DBHS at this toll free number-1-800-867-5808
or (602) 364-4575 within Maricopa County.
- To submit
a written appeal to ADHS/DBHS: Mail the appeal to 150 North 18th
Avenue, Suite 230, Phoenix, Arizona 85007.
Appeal process for persons applying for or who have been determined
to have a serious mental illness
An appeal may be filed concerning one or more of the following:
eligibility for SMI services;
- A decision
regarding fees or waivers;
assessment report, and recommended services in the service plan
or individual treatment and discharge plan;
denial, reduction, suspension or termination of any service that
is covered service funded through Non-Title XIX funds2;
of the clinical team with regard to the person’s competency,
capacity to make decisions, need for guardianship or other protective
services or need for Special Assistance;
- A decision
is made that the person is no longer eligible for SMI services; and
- A PASRR
determination, in the context of either a preadmission screening
or an annual resident review, which adversely affects the person.
A person, or a provider on the person’s behalf, may request
an expedited appeal for the denial or termination of crisis or emergency services,
the denial of admission to or the termination of a continuation
of inpatient services or for good cause.
Continuation of services for appeals involving persons determined to
have a SMI
For persons determined to have a SMI, the person’s
behavioral health services will continue while an appeal of a modification
to or termination of a covered behavioral health service is pending
- A qualified
clinician determines the modification or termination is necessary
to avoid a serious or immediate threat to the health or safety
of the person or another individual; or
- The person
or, if applicable, the person’s guardian, agrees in writing
to the modification or termination.
General Appeals for Non-Title XIX/XXI/ Non-SMI populations
Based on available funding, a person who is Non-Title XIX/XXI and
Non-SMI may file an appeal of a decision that is related to a determination
of need for covered service (e.g. modification to previously authorized
services for a non-Title XIX/XXI eligible person).
In these circumstances,
there is no continuation of services available during the appeal
Behavioral health provider responsibilities
While providers are not directly responsible for the resolution
of appeals, they are required to actively participate in the process
information deemed to be necessary by the RBHA, ADHS/DBHS or the
Office of Administrative Hearings (e.g., documents and other evidence);
and participate as necessary throughout the appeal process.
providers must be available to assist a person in the filing of
an appeal. For persons determined to have a SMI,
the Office of Human Rights may be available to assist the person
in filing as well as resolving the appeal.
providers must not retaliate against any persons who file appeals
or interfere with a person’s right to file an appeal. Additionally,
no punitive action may be taken against a behavioral health provider
who supports a person’s appeal.
The following citations can serve as additional resources for this
Notice and Appeal
Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
Last Revised: 8/8/2013
Effective Date: 8/15/2013