Mercy Care RBHA Visit: www.MercyCareAZ.org MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS Mercy Care Provider Manual Chapter 400 – Mercy Care RBHA – Plan Specific Terms Content highlighted in yellow represents changes since the last Provider Manual iteration. RBHA Chapter 1 – Mercy Care RBHA Overview 1.00 – About Mercy Care RBHA 1.01 – Overview of the Arizona Public Behavioral Health System 1.02 – Overview of Mercy RBHA RBHA Chapter 2 – Network Provider Service Delivery Requirements 2.00 Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage and Low Subsidy Program 2.01 – Additional Behavioral Health Appointment Availability Information 2.02 – Referral and Intake Process 2.03 – Outreach, Engagement, Reengagement and Closure 2.04 – Emergency Services 2.05 – Crisis Intervention Services 2.06 – Assessment and Service Planning 2.07 – Clinical Guidelines 2.08 – Serious Mental Illness Decertification 2.09 – General and Informed Consent 2.10 – SMI Patient Navigator 2.11 – Pre-Petition Screening, Court Ordered Evaluation, and Court Ordered Treatment 2.12 – Housing for Individuals Determined to have Serious Mental Illness (SMI) 2.13 Services with Special Circumstances - Non-Title XIX/XXI Behavioral Health Services Benefit 2.14 – Special Assistance for Members Determined to have a Serious Mental Illness (SMI) 2.15 – Arizona State Hospital (AzSH) Page 1 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 3 – Additional Mercy Care RBHA Provider Responsibilities 3.00 – Provider Selection 3.01 – Health Information Exchange 3.02 – Psychiatric Visit Information 3.03 – Case Management Contact Guidelines 3.04 – Care Management Caseload Ratio Guidelines 3.05 – Intra-RBHA Clinic Transfers 3.06 – Provider Financial Reporting 3.07 – Provider Deliverables 3.08 – Business Continuity and Disaster Preparedness 3.09 – Behavioral Health Satisfaction Survey RBHA Chapter 4 – Covered and Non-Covered Services 4.00 – Covered and Non-Covered Services RBHA Chapter 5 – Network Requirements 5.00 – Provider Network Development and Management 5.01 – Material Changes 5.02 – Peer/Recovery Support Training, Certification and Supervision Requirements 5.03 – Parent/Family Support Provider Training, Credentialing and Supervision Requirements 5.04 – Out of State Treatment for Behavioral Health 5.05 – Family and Youth Involvement in the Children’s Behavioral Health System 5.06 – Use of Telemedicine Page 2 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 6 – Pharmacy Management 6.00 – Pharmacy Management Overview 6.01 – Updating the Preferred Drug Lists (PDLs) 6.02 – Notification of PDL Updates 6.03 – Prior Authorization Required 6.04 – Over the Counter (OTC) Medications 6.05 – Generic vs. Brand 6.06 – Diabetic Supplies 6.07 – Injectable Drugs 6.08 – Exclusions 6.09 – Family Planning Medications and Supplies 6.10 – Behavioral Health Medications 6.11 – Request for Non-PDL Drugs 6.12 – Discarded Physician-Administered Medications 6.13 – Other Pharmacy Management RBHA Chapter 7 – Partnership Requirements with Families and Family Run Organizations 7.00 – Peer and Family Support Services 7.01 – Incorporating Peer and Family Voice and Choice in Integrated Care RBHA Chapter 8 – Dental and Vision Services 8.00 – Dental Services 8.01 – Vision Services 8.02 – Dental and Vision Community Resources for Adults RBHA Chapter 9 – Care Coordination 9.00 – Integrated Care Management 9.01 – Chronic Condition Management Page 3 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 10 – Coordination of Care 10.00 – Inter-T/RBHA Coordination of Care 10.01 – Coordination of Care with AHCCCS Health Plans, PCPs and Medicare Providers 10.02 – Coordination of Behavioral Health Care with Other Governmental Entities 10.03 – Care Coordination for Management of Hospitalized Members Related to Integrated Health Program Service Requirements 10.04 – Transition from Child to Adult Services RBHA Chapter 11 – Concurrent Review 11.00 – Concurrent Review RBHA Chapter 12 – Quality Management 12.00 Quality Management 12.01 – Performance Improvement Projects 12.02 – Peer Review 12.03 – Behavioral Health Satisfaction Survey Page 4 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 13 – Service Authorizations 13.00 – Securing Services and Prior Authorization 13.01 – Securing Services Does No Require Authorization 13.02 – Accessing Services with Non-Contracted Providers 13.03 – Accessing Services that Require Prior Authorization 13.04 – How to Request a Prior Authorization 13.05 – Third Party Liability (TPL) 13.06 – Requirements for Certification of Need (CON) and Recertification of Need (RON) 13.07 – Discharge Planning 13.08 – Medical Necessity Criteria 13.09 – Coverage and Payment of Emergency Services 13.10 – Newborn Notification Process 13.11 – Technology 13.12 – Pre-Admission Screening and Resident Review (PASRR) 13.13 – Retrospective Review 13.14 – Provider-Preventable Conditions 13.15 – Inter-Rater Reliability RBHA Chapter 14 – Contract Compliance 14.00 – Confidentiality 14.01 – Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits 14.02 – Reporting Discovered Violations of Immigration Status RBHA Chapter 15 – Demographic and Other Member Data 15.00 – Enrollment, Disenrollment and Other Data Submission RBHA Chapter 16 – Reporting Requirements 16.00 – Medical Institution Reporting of Medicare Part D 16.01 – Reporting of Seclusion and Restraint Page 5 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 17 – Grievance System and Member Rights 17.00 – Title XIX/XXI Notice and Appeal Requirements 17.01 – Complaint Resolution 17.02 – Conduct of Investigations Concerning Members with Serious Mental Illness 17.03 – Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI) 17.04 – Provider Claim Disputes Page 6 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS RBHA Chapter 1 – Mercy Care RBHA Overview 1.00 – About Mercy Care RBHA Mercy Care RBHA (herein Mercy RBHA), as part of MC, is a not-for-profit partnership sponsored by Dignity Health and Ascension Care Management. Mercy RBHA is committed to promoting and facilitating quality health care services with special concern for the values upheld in Catholic social teaching, and preference for the poor and persons with special needs. Aetna Medicaid Administrators, LLC administers Mercy RBHA for Dignity Health and Ascension Care Management. Mercy RBHA is a managed care organization that provides health care services to people in Arizona's Medicaid program that integrates member’s behavioral health and physical health needs. Mercy RBHA provides services to the Arizona Medicaid populations that include: . Serious Mental Illness: Persons who, as a result of a “mental disorder” (as defined in A.R.S. §36-501), exhibit emotional or behavioral functioning that is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long-term or indefinite duration. In these persons, mental disability is severe and persistent, resulting in a long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, self-care, employment and recreation, as defined in A.R.S. §36-550 diagnosed in persons 18 years and older. Comprehensive Medical and Dental Program (CMDP): CMDP is a health plan established to provide medical and dental care, inpatient, outpatient, and other services for individuals in foster care through agreements between the Arizona Department of Economic Security (ADES), the Arizona Health Care Cost Containment System (AHCCCS - the State’s Medicaid Authority) and ADHS. Crisis: Behavioral health members receiving emergency/crisis services through our Crisis Response Network. Grants: Behavioral health members may be covered under grants such as: o Substance Abuse Block Grant (SABG) is a Formula Grant, which supports treatment services for Title XIX/XXI and Non-Title XIX/XXI members with substance use disorders (SUD) and primary substance use and misuse prevention efforts. The SABG is used to plan, implement, and evaluate activities to prevent and treat substance abuse disorders. Grant funds are also used to provide Early Intervention Services for HIV and tuberculosis disease in high-risk individuals who use substances. SABG funds are only to be used for allowable services identified in AMPM Exhibit 300-2B for priority populations within AMPM 320-T. Page 7 of 309 Mercy Care Provider Manual – Chapter 400 – Mercy RBHA – Plan Specific Terms Last Update: February 2020 Proprietary MERCY CARE RBHA PROVIDER MANUAL PLAN SPECIFIC TERMS o Governor's Office - Substance Use Disorder Services (GO-SUDS) are dollars allocated to Mercy Care by the state of Arizona. These funds