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

7.5.1 Introduction
The collection and reporting of accurate complete, and timely enrollment, demographic, clinical and disenrollment data is of vital importance to the successful operation of the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) behavioral health service delivery system. It is necessary for behavioral health providers to submit specific data on each person who is actively receiving services from the behavioral health system. As such, it is important for behavioral health provider staff (e.g., intake workers, clinicians, data entry staff) to have a thorough understanding of why it is necessary to collect the data, how it can be used and how to accurately label the data. This policy has particular relevance for those providers that conduct assessments, ongoing service planning, and annual updates.

Note: This provider manual section describes the overall process, however, it should be noted that Gila River Behavioral Health Services conducts centralized intakes for all Gila River clients. Individuals seeking services from providers should be referred to Gila River Behavioral Health Services for an intake assessment and for an episode of care to be initiated.

This data in turn is used by ADHS/DBHS to:

  • Monitor and report on outcomes of individuals in active care (e.g., changes in diagnosis or Global Assessment of Functioning (GAF), employment/educational status, place of residence, substance use, number of arrests);
  • Comply with federal and state funding and/or grant requirements;
  • Assist with financial-related activities such as budget development, and rate setting;
  • Support quality management and utilization management activities; and
  • Respond to requests for information.

The intent of this section is to describe requirements for behavioral health providers to submit the following data in a timely, complete and accurate manner:

  • Non-Title XIX enrollment and disenrollments; and
  • Demographic and clinical data, including changes in a person’s behavioral health status.

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7.5.5 Terms
The following terms are referenced in this section:

Annual Update

Assessment

Behavioral Health Category Assignment

Change

Client Information System (CIS)

Closure

Crisis Episode

Day

Demographics

Edit

Episode of Care

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Intake/Enrollment

Outcome Measures

7.5.3 Procedures

7.5.3-A. Enrollment and disenrollment transactions
General requirements

  • Arizona Health Care Cost Containment System (AHCCCS) enrolled individuals are considered enrolled with the Tribal/Regional Behavioral Health Authority (T/RBHA) at the onset of their eligibility. They are provided an AHCCCS identification card listing their assigned T/RBHA. This assignment is sent daily from ADHS/DBHS to the T/RBHA.
  • For a Non-Title XIX/XXI eligible person to be enrolled, providers must submit an 834 enrollment transaction to the T/RBHA. All AHCCCS enrolled individuals with a mental health benefit are considered enrolled with the T/RBHA at the time of their AHCCCS eligibility.
  • For a Non-Title XIX/XXI eligible person who receives a covered behavioral health service, he/she must be enrolled effective the date of first contact by a behavioral health provider.
  • All persons who are served through the ADHS/DBHS behavioral health system must have an active episode of care, even if the person only receives a single service (e.g., crisis intervention, one time face-to-face consultation).
  • An episode of care is the start and end of services for a behavioral health need as documented by transmission of a demographic record. For both AHCCCS enrolled and Non-Title XIX/XXI eligible individuals, the individuals must have an open episode of care starting at the first date of service and ending with the last service.

When is enrollment information collected?
For Non-Title XIX/XXI-eligible individuals, information necessary to complete an 834 transaction is usually collected during the intake and assessment process (see Section 3.9, Intake, Assessment and Service Planning). PM Attachment 7.5.2, 834 Transaction Data Requirements, contains a list of the data elements necessary to create an 834 enrollment transaction.

For AHCCCS enrolled individuals, the 834 information will be provided to the T/RBHA by ADHS/DBHS daily for the providers to access.

ADHS/DBHS has developed a flow chart that includes the timeframes for all data submissions. See PM Attachment 7.5.1.

What kind of data is included in an 834?
The data fields that are included in the 834 transmittals are dictated by HIPAA and consist of:

  • Key client identifiers used for file matching (e.g., person’s name, address, date of birth);
  • Basic demographic information (e.g., gender, marital status); and
  • Information on third party insurance coverage.

For a specific list of data elements necessary to create an 834 enrollment and disenrollment for Non-Title XIX/XXI eligible individuals, see PM Attachment 7.5.2.

What happens if there is not enough information to complete an enrollment?
Providers must actively secure any needed information to complete the enrollment (834 transaction) for a Non-Title XIX/XXI eligible individual. An 834 transaction will not be accepted by the T/RBHA if required data elements are missing. For Title XIX/XXI eligible individuals, the 834 information will be provided to the T/RBHA by ADHS/DBHS.

What are the timeframes for submitting enrollment and disenrollment data for a Non-Title XIX/XXI eligible individual?
The following data submittal timeframes apply to the enrollment/disenrollment transactions:
The 834-enrollment transaction must be submitted by Gila River Behavioral Health Services within 14 days of the first contact with a behavioral health recipient;
The 834 disenrollment transaction must be submitted by Gila River Behavioral Health Services within 14 days of the person being disenrolled from the system; and any changes to the enrollment/disenrollment transaction data fields (e.g., change in address, insurance coverage) must be submitted 55 days from the date of identifying the need for the change.

What other events require a submittal of an 834 transaction for a Non-Title XIX/XXI eligible individual?
In addition to submitting an 834 transaction at enrollment and disenrollment, an 834 transaction must also be submitted when any of the following elements of the 834 transaction have changed:

  • Name,
  • Address,
  • Date of birth,
  • Gender,
  • Marital status, or
  • Third party insurance information.

Other considerations for both Non-Title XIX/XXI eligible and AHCCCS enrolled individuals

  • For an AHCCCS enrolled individual, AHCCCS will notify ADHS/DBHS of changes to the above information. That information will be provided from ADHS/DBHS to the T/RBHA on a daily file.
  • When a person in an episode of care permanently re-locates from one T/RBHA’s geographic area to another T/RBHA’s geographic area, an inter-T/RBHA transfer must occur (see Section 3.17, Transition of Persons). The steps that are necessary to facilitate an inter-T/RBHA transfer include the following data submission requirements:
    • The home T/RBHA must submit an 834 disenrollment transaction effective on the date of transfer and end the episode of care; and
    • The receiving T/RBHA must submit an 834 disenrollment transaction on the date of accepting the person for services and start an episode of care.
  • AHCCCS will notify ADHS/DBHS when a T/RBHA enrolled person is determined eligible for the Arizona Long Term Care System (ALTCS) Elderly and Physically Disabled (EPD) Program. This information will be passed to the T/RBHA on a daily file.

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7.5.3-B. Demographic and clinical data
When is demographic and clinical data collected?
Demographic and clinical data will be collected starting at the first date of service. For Non-Title XIX/XXI eligible individuals, an 834 must be completed. For both AHCCCS enrolled and Non-Title XIX/XXI eligible individuals, a demographic record must be collected within 45 days of the first service and submitted to ADHS/DBHS within 55 days . Additional clinical data may be collected at subsequent assessment and service planning meetings with the person (e.g., education, vocation) as well as during periodic and annual updates. Demographic and clinical data recorded in the person's behavioral health medical record must match the demographic file on record with ADHS/DBHS.

What are the specific data elements?
The ADHS/DBHS Demographic Data Set User Guide describes the data elements that comprise the demographic data set and timeframe requirements for submitting the demographic data set. T/RBHAs must ensure that providers collect required demographic data set elements in accordance with the ADHS/DBHS Demographic Data Set User Guide. When ADHS/DBHS issues updates to the demographic data set, T/RBHAs are responsible for communicating changes to their providers.

What are the timeframes for submitting demographic and clinical data?
The following timeframes apply to demographic and clinical data submissions (see the ADHS/DBHS Demographic Data Set User Guide):

  • All required demographic data submitted by Gila River Behavioral Health Services within 55 days of the initial intake for all enrolled persons.
  • Outcome measures, for children birth through age 17, submitted by Gila River Behavioral Health Services within the 6 month anniversary date of the last demographic submission (See Section 3.9, Intake, Assessment and Service Planning). For outcome measures submission dates that do not coincide with the annual update, the reason for submission will be indicated as a “change” (see specific instructions in the ADHS/DBHS Demographic Data Set User Guide).
  • All required demographic data submitted by Gila River Behavioral Health Services on the annual update (see Section 3.9, Intake, Assessment and Service Planning).
  • All required demographic data submitted by Gila River Behavioral Health Services within 55 days of a recorded change in the person’s demographic data record. Providers must ensure that the person’s medical record matches the demographic data set on file with ADHS/DBHS.
  • All required data elements submitted by Gila River Behavioral Health services within 14 days of the end of the episode of care. The required data elements include the reason for the person’s disenrollment. See the ADHS/DBHS Demographic Data Set User Guide to determine the specific data elements that must accompany a demographic disenrollment transaction.

Determining a recipient’s category assignment
Behavioral health providers must designate a person’s behavioral health category assignment during the assessment process as well as at any other times that necessitate changes to the person’s assignment (e.g., transition to adulthood). Behavioral health categories include:

Behavioral health providers must initially assign and update, as necessary, behavioral health category assignments as follows (see the ADHS/DBHS Demographic Data Set User Guide for more detailed instructions on assignment of behavioral health categories):

  • For a child who is non-SED, enter “C”;
  • For a child who is SED, enter "Z";
  • For a person determined to have a Serious Mental Illness in accordance with Section 3.10, SMI Eligibility Determination, enter “S”, then enter "a" or "b";
  • For an adult non-SMI person with a general mental health need (who does not have a substance abuse problem) enter “M”; and
  • For an adult non-SMI person with a reported substance abuse problem enter “G”.

How can demographic and clinical data be used?
Providers are encouraged to utilize demographic and clinical data to improve operational efficiency and gain information about the persons who receive behavioral health services. Providers may consider:

  • Utilizing and integrating collected demographic data into the person’s assessments;
  • Monitoring the nature of the provider’s behavioral health recipient population; and
  • Evaluating the effectiveness of the provider’s services towards improving the clinical outcomes of persons enrolled in the ADHS/DBHS system.

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

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7.5 Enrollment, Disenrollment and Other Data Submission
Last Revised: 2/25/2014
Effective Date: 2/25/2014

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