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

8.2.1 Introduction
ADHS/DBHS is required to oversee the performance of an Independent Case Review (ICR) to ascertain the extent to which established guidelines regarding access to services, timeliness of services and quality outcomes are being adhered to in the public behavioral health delivery system. The Independent Case Review is an annual evaluation of the statewide behavioral health system, conducted by a Professional Review Organization, to assess contractor performance and to identify areas of needed improvement in the provision of behavioral health services. Currently, the evaluation process is primarily conducted through case reviews but may also involve interviews of behavioral health recipients and others involved (e.g., service providers) when deemed necessary. Independent case review findings are utilized to improve care for persons receiving behavioral health services. This section provides an overview of the Independent Case Review and describes expectations for behavioral health providers to assist with:

  • Implementation of the Independent Case Review Tool; and
  • Implementation of any recommended actions to improve performance.

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

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8.2.3 Scope
To whom does this apply?

All behavioral health recipients and their behavioral health records and service providers may be part of the Independent Case Review.

8.2.4 Did you know…?

  • An independent entity, also known as a professional review organization (PRO) or an EQRO, conducts the Independent Case Review.
  • Independent Case Review results are used to assess the quality of behavioral health services.
  • Each standard in the Independent Case Review Tool has pre-determined level of performance established by ADHS/DBHS.

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8.2.5 Objectives
To describe behavioral health provider’s obligations regarding the Independent Case Review.

8.2.6 Procedures

8.2.6-A. Independent Case Review
Behavioral health providers must cooperate with ADHS, the independent Professional Review Organization and the T/RBHA by allowing access to provider staff, behavioral health recipients and their behavioral health records.

The Gila River RBHA coordinates with ADHS to ensure that the independent entity conducting the review has easy access to clinical records included in the Independent Case Review (ICR) sample. Behavioral health providers must make clinical records available to the Gila River RBHA upon request and implement any recommended actions to improve performance.

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8.2.6-B. Additional RBHA medical record review activities
In addition to the ICR, the Gila River RBHA conducts periodic case file reviews by a master’s level clinician to assess the overall quality of care provided to Gila River RBHA behavioral health recipients. The scope of the review includes an assessment of the quality of covered behavioral health services provided directly by the RBHA as well as care and treatment provided by behavioral health providers within the network. Findings from case file reviews are analyzed and trended and are reported to the Gila River RBHA’s Quality Management Committee. Corrective action may be required of behavioral health providers based on case file review findings.

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8.2 Independent Case Review
Last Revised: 12/08/2005
Effective Date: 06/01/2006

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