Mercy Maricopa Integrated Care Provider Deliverables

Transcription

1 Scope Work (A-100) - General Requirements ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID Network Cultural Competency January 1st, July CC-01 Language Language CulturalC_CC-01_YYYYMMDD_AgencyID 1st Cultural Competence Cultural Competence Cultural Competency CC-02 Organizational Self- Survey Monkey Organizational Self-Assessment Assessment CC-03 Cultural Competency Plan Develop a written Cultural Competency Plan (CCP) in an outcome based format including expected results, measurable Cultural Competency outcomes and outputs with a CulturalC_CC-03_YYYYMMDD_AgencyID Annually focus on national level priorities and current initiatives in the field cultural competency. Deaf and Hard Hearing Deaf and Hard Hearing Services Cultural Competency CC-04 Survey Monkey Services Survey Survey CSOC -11 Access to Care 7 and 21 days Access to Care CSOC_AccesstoCare_YYYYMM_AgencyID Initial Individual Clinician Initial Individual Clinician Credentialing Application Director CRED-01 Credentialing Application and Provider Relations Fax to: (860) and Supporting Credentialing supporting documentation Documentation For providers receiving >$250,000 FIN-01 Unaudited Financial per year, Attachments A-G in the ing MMIC Financial ing Guide Finance_UnauditedFinancials_YYYYMMDD_AgencyID Finance Quarterly Attachments. For providers receiving >$500,00 FIN-02 Audited Financials per year, due 4 months after Finance Yearly Finance_AuditedFinancials_YYYYMMDD_AgencyID provider fiscal year end. Provider-Deliverables-(V4) xlsx /10/2016

2 GMHSA-06 NETWORK-01 Access to Care Provider Comprehensive Roster All Intake Providers. Focuses on the 7 day and 23 day access to care requirements Roster all BH Providers providing Direct Client Care (Includes Facilities, Staff Listing, & Key Contracts) Mercy Maricopa Integrated Care GMHSA_AccesstoCare_YYYYMM_AgencyID Network_CompProvRoster_YYYYMM_AgencyID GMH/SA Network NETWORK-02 Network Change Send a written letter notifying MMIC 90 days prior to the material change to get approval from MMIC before making any Contractor initiated change in the size, scope or configuration the provider network. Network_MaterialChange_YYYYMMDD_AgencyID or MaterialChanges@mercymaricopa.org Network AdHOC - 90 Days Prior to Change Provider-Deliverables-(V4) xlsx /10/2016

3 Scope Work (A-100) - General Requirements (Continued) NETWORK-06 NETWORK-07 Key Workforce Reduction Network Changes Notification Key Workforce Reduction, with a plan to not fill, or delay filling the staff vacancies (no plan to fill within 60 days) Request (i.e. clinical director, BHTs, BHPs, peer/family support staff, etc.) Notification Service Capacity Addition/Reduction Requests (i.e. loss a prescriber, specialty clinician or any staff or program that would cause disruption services or availability services, or would require a change to Scope Work. Anything Network_NETWORK-06_YYYYMMDD_AgencyID Network_NETWORK-07_YYYYMMDD_AgencyID Network Network Prior Approval Required Prior Approval Required (Notification to Mercy Maricopa 90 days prior to any cahnge to the network) NETWORK-08 Change in Provider Billing Type Requests (i.e. level care conversion, etc.) Change in Provider Billing Type Requests (i.e. level care conversion, etc.) Network_NETWORK-08_YYYYMMDD_AgencyID Network Prior Approval Required NETWORK-09 Provider Relocation/Move Request (Notification Changes To The Network Required Information) Provider Relocation/Move Request Network_NETWORK-09_YYYYMMDD_AgencyID Network Prior Approval Required for Moves Greater than 5 Miles, 90 Day Notification for All Moves NETWORK-11 Provider Requests to Stop Accepting Provider Requests to Stop Accepting Network_NETWORK-11_YYYYMMDD_AgencyID Network Immediate Notification Required Once NETWORK-13 Notification Changes To The Network Required Information Provider Termination, Suspension, Limitation or Material Change RBHA Contract Notification (i.e. site closure, facility fire, foreclosure, staff strike, etc.) Network_NETWORK-13_YYYYMMDD_AgencyID Network 90 Day Notification Prior to Any Change Provider-Deliverables-(V4) xlsx /10/2016

4 NETWORK-14 Provider Corrective Action Plans Provider Corrective Action Plans Network_ProvCAP_YYYYMMDD_AgencyID Network AdHOC Provider-Deliverables-(V4) xlsx /10/2016

5 Scope Work (A-100) - General Requirements (Continued) QM-02 QM-03 QM-04 QM-05 QM-08 QM-10 Seclusion/Restraint Summary High Prile Alerts Incidents, Accidents, and Deaths Incident, Accident, and Death Forms Incident, Accident, and Death s for Behavioral Health Members Individual Clinician Re- Credentialing Application & Supporting Documentation Organizational Credentialing Application each use Seclusion / Retraint concerning all enrolled personsseclusion / Restraint Summary Concerning Persons with SMI each use Seclusion / Restraint Concerning Persons with SMISeclusion / Restraint Summary Concerni Forms to: MMIC@aetna.com Fax Forms to: Incident Accident Death Form Fax Forms to: Allegations Attempted Suicide, Sexual Abuse and Death Incident s Incident Accident Death Form Individual Clinician recredentialing application & supporting documentation Organizational Credentialing Application and supporting documentation QM Portal QM Portal Provider Relations Fax to: (860) Provider Relations Fax to: (860) Quality Quality Quality Quality Quality Quality Within 24 Hours Awareness Within 48 Hours Awareness Within Five (5) Business Days Awareness 63 Days Prior to Expiration 15 Days After Approval Letter from Mercy Maricopa is Received QM-11 Organizational Re- Credentialing Application and Supporting Documentation Organizational re-credentialing application and supporting documentation Provider Relations Fax to: (860) Quality 63 Days Prior to Expiration ADHS Division Licensing QM-12 ADHS DLS License Services - Facility License Provider Relations Fax to: (860) Quality 30 Days Prior to Expiration Provider-Deliverables-(V4) xlsx /10/2016

6 Provider-Deliverables-(V4) xlsx /10/2016

7 Scope Work (A-100) - General Requirements (Continued) QM-13 Pro Insurance/Facility Pro Insurance/Facility Provider Relations Fax to: (860) QM-14 Individual Clinician license Individual Clinician license Provider Relations Fax to: (860) QM-15 DEA (if applicable) DEA (if applicable) Provider Relations Fax to: (860) QM-16 QM-18 Accreditation Certificate and Survey QM Practice Improvement Plans (PIPs) and QM CAPs UM-04 Form UM-07 Form Accreditation certificate and survey report Provide QM Department with corrective actions/pips as requested Request for Psychological Testing Preauthorization ECT Prior Authorization Request Form Provider Relations Fax to: (860) QMPM_QM-18_YYYYMMDD_AgencyID Fax to: (844) Fax to: (844) Quality Quality Quality Quality Quality 30 Days Prior to Expiration 30 Days Prior to Expiration 30 Days Prior to Expiration 30 Days Prior to Expiration Scope Work (ACCP-100) - Access Point CRISIS-04 Crisis Access Point Weekly Crisis Access Point Weekly Crisis_CRISIS-04_YYYYMMDD_AgencyID Crisis Fridays 9:00 AM Scope Work (ACT-100) - ACT Team SMI-04 ACT Census ACT Census SMI-05 ACT Outcomes ACT Outcomes ASOC_ACTCensus_YYYYMM_AgencyID-AHCCCSID ASOC_ACTOutcomes_YYYYMM_AgencyID-AHCCCSID SMI Services SMI Services Due every Friday Due 5th every month Provider-Deliverables-(V4) xlsx /10/2016

8 SMI-06 ACT Attestation ACT Outcomes Attestation Mercy Maricopa Integrated Care ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID SMI Services Due 5th every month Provider-Deliverables-(V4) xlsx /10/2016

9 Scope Work (ADIOP-100) - Alcohol and / or Drug Services - IOP NETWORK-05 Prescriber Availability Prescriber availability and access for Members Network_PrescriberAvail_YYYYMMDD_AgencyID Network month Scope Work (AFSP-100) - Adult Family Support Partner There are no additional for AFSP-100 ASOC-02 COURTS-01 Comprehensive Persons Identified as in Need Special Assistance COT Summary s Comprehensive Persons Identified as in Need Special Assistance Outpatient Commitment COT Monitoring Data ASOC_ASOC-02_YYYYMM_AgencyID ASOC_OCM_YYYYMM_AgencyID ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID GA-02 GA-03 GMHSA-04 Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance HIV ly Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance HIV ly Terros only. Populations served with HIV services and locations where these members were served Scope Work (AOP-100) - Adult OP Services G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com GMHSA_HIV_YYYYMM_TERROS PNO Liaison Court Liaison Network Grievance System Grievance System GMH/SA Provider-Deliverables-(V4) xlsx /10/2016 Within Five (5) Business Days Within 24 Hours

10 GMHSA-05 GMHSA-06 SAPT LEVEL II Providers ONLY Wait List Access to Care SAPT LEVEL II Providers only. Services that were delivered to SAPT recipients in this level care broken out by SAPT priority population. All Intake Providers. Focuses on the 7 day and 23 day access to care requirements Mercy Maricopa Integrated Care GMHSA_SAPTLEVEL11_YYYYMM_AgencyID GMHSA_AccesstoCare_YYYYMM_AgencyID GMH/SA GMH/SA NETWORK-05 Prescriber Availability Prescriber availability and access for Members Network_PrescriberAvail_YYYYMMDD_AgencyID Network month NETWORK-12 New TXIX or Priority Recipients New TXIX or Priority Recipients Network_NETWORK-12_YYYYMMDD_AgencyID Network When Decision has been Made OIFA-02 PR-02 Tribal-03 Peer Support Specialist/Recovery Support Specialist Assignment Roster Outpatient Appointment Availability San Lucy Outpatient Roster Peer Support Specialist/Recovery Support Specialist Assignment Rooster Outpatient Appointment Availability Database - (For Intake providers only) Number persons/families receiving outpatient services within the San Lucy District per month OIFA_OIFA-02_YYYYMM_AgencyID Survey Monkey TribalLiaison_Tribal-03_YYYYMM_AgencyID Individual and Family Affairs Provider Relations Manager Tribal Liaison 10 Days after Quarter End 1 Scope Work (ASMI-100) - Adult SMI Clinic ASOC-01 HEA Screenings and Attestation Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with ADHS/DBHS Policy on Eligibility Screening for AHCCCS Health Insurance, including Title XIX services. (A.R.S ) ASOC_HEA_YYYYMM_AgencyID Adult SOC Provider-Deliverables-(V4) xlsx /10/2016

11 ASOC-02 Comprehensive Persons Identified as in Need Special Assistance Comprehensive Persons Identified as in Need Special Assistance ASOC_ASOC-02_YYYYMM_AgencyID PNO Liaison ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID COURTS-01 FIN-03 FIN-04 COT Summary s MHBG ing A-133 Audit Outpatient Commitment COT Monitoring Data For providers receiving any MHBG funds, Attachment J in the MMIC Financial ing Guide Attachments. For providers receiving >$750,00 per year in either MHBG or SABG combined funds, due 4 months after provider fiscal year end. ASOC_OCM_YYYYMM_AgencyID Finance_MHBG_YYYYMMDD_AgencyID Finance_A133Audit_YYYYMMDD_AgencyID Network Court Liaison Finance Finance Quarterly Yearly EMPLOY-05 Psychiatric Rehabilitation APNO Rehabilitiaon Specialist to complete Psychiatric Rehabilitition ly report Rehabilitaion & Employent related training, referrals for services and coordination with RSA/VR ASOC_PsychRehab_YYYYMM_AgencyID Employment GA-02 GA-03 HOUSING-04 Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Supervisory Care Home Admission and Status Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Supervisory Care Home Admission and Status G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Housing_HOUSING-04_YYYYMM_AgencyID Grievance System Grievance System Housing Within Five (5) Business Days Within 24 Hours NETWORK-05 Prescriber Availability Prescriber availability and access for Members Network_PrescriberAvail_YYYYMMDD_AgencyID Network month NETWORK-12 New TXIX or Priority Recipients New TXIX or Priority Recipients Network_NETWORK-12_YYYYMMDD_AgencyID Network When Decision has been Made Provider-Deliverables-(V4) xlsx /10/2016

12 OIFA-02 Peer Support Specialist/Recovery Support Specialist Assignment Roster Peer Support Specialist/Recovery Support Specialist Assignment Rooster OIFA-04 Arnold Expansion Arnold Expansion OIFA-05 OIFA-06 OIFA-07 OIFA-08 SMI-01 SMI-02 SMI-03 Committee Contract Technical Assistance Contract Family and Youth Roles Inventory Fidelity s Consumer Operated Programs Adult PNO ly and Attestation Flex Fund Usage MHBG Provider Policies and Procedures Committee Contract Technical Assistance Contract Method for tracking agency s hiring system involved adults, and young adults. Fidelity s Consumer Operated Programs Adult PNO ly and Attestation Tracks the use flex funds by individuals in the system. MHBG providers must submit all their MHBG related policies and procedures on an annual basis on or before September 30 th. Mercy Maricopa Integrated Care OIFA_OIFA-02_YYYYMM_AgencyID OIFA_OIFA-04_YYYYMM_AgencyID OIFA_OIFA-05_YYYYMM_AgencyID OIFA_OIFA-06_YYYYMM_AgencyID CSOC_YFRoleInventory_YYYYMMDD_AgencyID OIFA_FidConOpPrg_YYYYMMDD_AgencyID ASOC_AdultPNO_YYYYMM_AgencyID CSOC_FlexFund_YYYYMM_AgencyID ASOC_MHBGPP_YYYYMMDD_AgencyID Individual and Family Affairs Individual and Family Affairs Individual and Family Affairs Individual and Family Affairs Individual and Family Affairs SMI Services SMI Systems 30 Days after Quarter End 30 Days after the Ends On or before September 30 th every year QMPI-01 SMI Clinic Gaps in Care List SMI Integrated members with gaps in HEDIS & HEDIS-like performance measures; report actions taken on at least 30% members on the list (appointments made or screenings completed) QMPI_GapsInCare_yyyymmdd_AgencyID Performance Improvement Project Manager Last business day October, January, April and July Scope Work (ATCSA-100) - Adult Transition Team CSA Provider-Deliverables-(V4) xlsx /10/2016

13 There are no additional Provider Deliverables for ATCSA-100 Mercy Maricopa Integrated Care Scope Work (BHRA-100) - BH Residential Facility - Adult GA-02 GA-03 NETWORK-05 Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber Availability UM-01 Form Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber availability and access for Members Certification Need for Level I Facilities (CON) UM-02 Form Re-Certification Need (RON) UM-03 Form UM-05 Form UM-06 Form UM-08 Level I RTC Form Prior Authorization Request: Level I RTC, BH Residential Facility, or HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization HCTC Bed Hold or Therapeutic Leave Request or Level I RTC Form G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Network_PrescriberAvail_YYYYMMDD_AgencyID RTC CON and RON Fax: (844) , Subacute Fax: (844) RTC CON and RON Fax: (844) , Subacute Fax: (844) Fax: (855) Fax Child: (844) Fax Child: (844) Fax Child: (844) Grievance System Grievance System Network Within Five (5) Business Days Within 24 Hours month Scope Work (BHRC-100) - BH Residential Facility - Children's Provider-Deliverables-(V4) xlsx /10/2016

14 There are no additional Provider Deliverables for BHRC-100 Scope Work (BHRTP-100) - BH Residential Facility - Transition Point There are no additional for BHRTP-100 Scope Work (CAIP-100) - Child / Adolescent Independent Practitioner There are no additional for CAIP-100 Scope Work (CASA-100) - Child / Adolescent Substance Abuse There are no additional for CASA-100 Scope Work (CASP-100) - Child / Adolescent Specialty Provider There are no additional for CASP-100 Scope Work (CASS-100) - Central Arizona Shelter Services There are no additional for CASS-100 Provider-Deliverables-(V4) xlsx /10/2016

15 Scope Work (CAT-100) - Child to Adulthood Transition There are no additional for CAT-100 Scope Work (CATSA-100) - Child / Adolescent Treatment Substance Abuse There are no additional for CATSA Scope Work (CATSD-100) - Child / Adolescent Treatment Substance Use Disorders There are no additional for CATSD Scope Work (CAYAT-100) - Child/Adolescent Youth to Adulthood Transition Team CSOC-02 CSOC-04 CSOC-10 Young Adult Transition Roster TAPIS Outcomes (TIP Programs) Transition-age Youth Staff Inventory Information on youth enrolled in TIP programs TAPIS Outcomes (TIP Programs) Information on staff working with transition-age youth CSOC_YAT_YYYYMM_AgencyID CSOC_TAPIS_YYYYMM_AgencyID CSOC_TAY_YYYYMM_AgencyID Transition Youth Coordinator Transition Youth Coordinator Transition Youth Coordinator Quarterly on the after the Quarter End Scope Work (CCC-100) - Crisis Call Center Provider-Deliverables-(V4) xlsx /10/2016

16 CRISIS-05 CRISIS-06 DCS Rapid Response ly Ambulance Dispatches Summary DCS Rapid Response ly Ambulance Dispatches Summary CRISIS-07 Crisis PAD Crisis PAD CRISIS-08 CRISIS-09 Crisis Services DCS Stabilization > 90 Days Roster Formerly Crisis Call Center Quality Formerly, CRN kids in the program >90 days. CRISIS-10 Children's Crisis Formerly CRN 148 CRISIS-11 CRISIS-12 CRISIS-14 NETWORK-05 DCS Rapid Response Structural Hospital Rapid Response ly DBHS Crisis Call Center Monitoring Tool Prescriber Availability Formerly CRN 156 Formerly CRN 161 DBHS Crisis Call Center Monitoring Tool Prescriber availability and access for Members Mercy Maricopa Integrated Care Crisis_CRISIS-05_YYYYMM_AgencyID Crisis_CRISIS-06_YYYYMM_AgencyID Crisis_CRISIS-07_YYYYMM_AgencyID Crisis_CRISIS-08_YYYYMM_AgencyID Crisis_CRISIS-09_YYYYMM_AgencyID Crisis_CRISIS-10_YYYYMM_AgencyID Crisis_CRISIS-11_YYYYMM_AgencyID Crisis_CRISIS-12_YYYYMM_AgencyID Crisis_CRISIS-14_YYYYMM_AgencyID Network_PrescriberAvail_YYYYMMDD_AgencyID Crisis Crisis Crisis Crisis Crisis Crisis Crisis Crisis Crisis Network th the 1 13th the month Scope Work (CDSP-100) - Children's Direct Support Provider CSOC-01 CSOC-07 CSOC-14 Direct Support Provider Birth to 5 Level Competency Matrix Referral Capacity Direct Support Provider ly Roster Birth to 5 Level Competency Matrix/ITMHCA Endorsement Criteria Number available referrals accepted for the current week, this should also include Spanish speaking capacity CSOC_DSPRoster_YYYYMM_AgencyID CSOC_Birthtivematrix_YYYYMMDD_AgencyID DSP_SpecialtyProviders@mercymaricopa.org 30 Days after Quarter End Every Monday Scope Work (CHT-100) - Child Hospital Team Provider-Deliverables-(V4) xlsx /10/2016

17 There are no additional for CHT-100 Scope Work (CHTE-100) - Child Hospital Team plus Emergent There are no additional for CHTE-100 Scope Work (CQSP-100) - Qualified Service Provider CSOC -11 Access to Care 7 and 21 days Access to Care CSOC_AccesstoCare_YYYYMM_AgencyID CSOC-07 Birth to 5 Level Competency Matrix Birth to 5 Level Competency Matrix/ITMHCA Endorsement Criteria CSOC-12 ly Flex Fund ly Flex Fund CSOC_Birthtivematrix_YYYYMMDD_AgencyID CSOC_FlexFund_YYYYMM_AgencyID 30 Days after Quarter End CSOC-08 Children's Provider NOA Log Children's Provider NOA Log CSOC_NOALog_YYYYMMDD_AgencyID 30 Days after Quarter End CSOC-13 FIN-03 ly Flex Fund Supporting Documents MHBG ing Client specific details and documentation required to support the ly Flex Fund For providers receiving any MHBG funds, Attachment J in the MMIC Financial ing Guide Attachments. CSOC_FlexFundDOCS_YYYYMMDD_AgencyID Finance_MHBG_YYYYMMDD_AgencyID Finance Quarterly FIN-04 A-133 Audit For providers receiving >$750,00 per year in either MHBG or SABG combined funds, due 4 months after provider fiscal year end. Finance_A133Audit_YYYYMMDD_AgencyID Finance Yearly Provider-Deliverables-(V4) xlsx /10/2016

18 GA-02 GA-03 NETWORK-05 CSOC-17 Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber Availability MHBG Provider Policies and Procedures Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber availability and access for Members MHBG providers must submit all their MHBG related policies and procedures on an annual basis on or before September 30 th. CSOC-09 Unmet Needs Roster Unmet Needs Roster Mercy Maricopa Integrated Care G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Network_PrescriberAvail_YYYYMMDD_AgencyID CSOC_MHBGPP_YYYYMMDD_AgencyID CSOC_Unmet_YYYYMM_AgencyID SMI Services SMI Services Network Within Five (5) Business Days Within 24 Hours month On or before September 30 th every year Scope Work (CSA-100) - Community Service Agency OIFA-01 Peer and Family Run Organizations / Referral and Recovery Tracking Roster Peer and Family Committee Members OIFA_OIFA-01_YYYYMM_AgencyID Individual and Family Affairs after Quarter end (Jan, April, June, Oct) Scope Work (CSS-100) - CPS - Crisis Stabilization Services There are no additional for CSS-100 Scope Work (CTN-100) - Crisis Transition Navigator Provider-Deliverables-(V4) xlsx /10/2016

19 CRISIS-17 Crisis Transitional Navigator ly Crisis Transitional Navigator ly Crisis_CRISIS-17_YYYYMM_AgencyID Crisis 14th the CRISIS-21 Transitional Point ly Transitional Point ly Crisis_CRISIS-21_YYYYMM_AgencyID Crisis 1 Scope Work (CYAT-100) - Child / Adolescent Youth to Adult Treatment There are no additional for CYAT-100 Scope Work (EFDP-100) - Emergency Food Distribution Program There are no additional for EFDP-100 Scope Work (ES-100) - Employment Services EMPLOY-04 Employment Provider Outcome Network Employment Providers to complete Outcomes Template provided. List members engaged in employment related servcies and data fields associated. ASOC_EmpPro_YYYYMM_AgencyID Employment Scope Work (FACT-100) - Forensic ACT Team SMI-04 ACT Census ACT Census SMI-05 ACT Outcomes ACT Outcomes ASOC_ACTCensus_YYYYMM_AgencyID- AHCCCSID ASOC_ACTOutcomes_YYYYMM_AgencyID- AHCCCSID SMI Services SMI Services Due every Friday Due 5th every month Provider-Deliverables-(V4) xlsx /10/2016

20 SMI-06 ACT Attestation ACT Outcomes Attestation Mercy Maricopa Integrated Care ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID SMI Services Due 5th every month Scope Work (GDSP-100) - Generalist Direct Support Provider CSOC-05 MMWIA ly Roster MMWIA ly Roster CSOC-14 Referral Capacity Number available referrals accepted for the current week, this should also include Spanish speaking capacity CSOC_MMWIARoster_YYYYMM_AgencyID DSP_SpecialtyProviders@mercymaricopa.org Every Monday Scope Work (HCTCA-100) - HCTC - Adult There are no additional for HCTCA-100 Scope Work (HCTCC-100) - HCTC - Child There are no additional for HCTCC-100 Scope Work (HEPN-100) - Health Exchange Peer Navigation There are no additional for HEPN-100 Scope Work (HNCM-100) - High Needs Case Provider-Deliverables-(V4) xlsx /10/2016

21 CSOC-12 ly Flex Fund ly Flex Fund CSOC-15 CSOC-16 CSOC- 06 HNCM Inventory HNCM Roster HNCM Roster/HNCM Inventory High Needs Case Inventory High Needs Case Roster HNCM Roster/HNCM Inventory Mercy Maricopa Integrated Care CSOC_FlexFund_YYYYMM_AgencyID CSOC_HNCMInventory_YYYYMMDD_AgencyID CSOC_HNCMRoster_YYYYMMDD_AgencyID CSOC_HNCMRoster_YYYYMMDD_AgencyID: CSOC_HNCMInventory_YYYYMMDD_ProvideName Bi-weekly Scope Work (HOS-100) - Housing On-Site Services/Community Living HOUSING-03 Housing Census Flex Care Plus, Community Placement Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Monday 10:00 AM HOUSING-07 Transitional Living Program Scope Work (HTLP-100) - Housing Transitional Living Program Transitional Living Program Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Daily Scope Work (HRR-100) - Hospital Rapid Response CRISIS-12 Hospital Rapid Response ly Formerly CRN 161 Crisis_CRISIS-12_YYYYMM_AgencyID Crisis 1 CRISIS-13 Hospital Rapid Response Daily Discharge Ready Hospital Rapid Response Daily Discharge Ready Crisis_CRISIS-13_YYYYMMDD_AgencyID Crisis Daily 9:00 AM Scope Work (HSGP-100) - Housing Provider Provider-Deliverables-(V4) xlsx /10/2016

22 HOUSING-03 Housing Census Community Placement Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing HOUSING-06 Supportive Housing Permanent Supportive Housing Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Monday 10:00 AM 10th the Scope Work (HUD-100) - Housing - HUD There are no additional for HUD-100 Scope Work (IC-100) - Integrated Health Clinic ASOC-01 ASOC-02 HEA Screenings and Attestation Comprehensive Persons Identified as in Need Special Assistance Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with ADHS/DBHS Policy on Eligibility Screening for AHCCCS Health Insurance, including Title XIX services. (A.R.S ) Comprehensive Persons Identified as in Need Special Assistance ASOC_HEA_YYYYMM_AgencyID ASOC_ASOC-02_YYYYMM_AgencyID Adult SOC PNO Liaison ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID COURTS-01 COT Summary s Outpatient Commitment COT Monitoring Data ASOC_OCM_YYYYMM_AgencyID Network Court Liaison Provider-Deliverables-(V4) xlsx /10/2016

23 EMPLOY-05 GA-02 GA-03 FIN-03 FIN-04 HOUSING-04 NETWORK-05 OIFA-02 Psychiatric Rehabilitation Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance MHBG ing A-133 Audit Supervisory Care Home Admission and Status Prescriber Availability Peer Support Specialist/Recovery Support Specialist Assignment Roster APNO Rehabilitiaon Specialist to complete Psychiatric Rehabilitition ly report Rehabilitaion & Employent related training, referrals for services and coordination with RSA/VR Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance For providers receiving any MHBG funds, Attachment J in the MMIC Financial ing Guide Attachments. For providers receiving >$750,00 per year in either MHBG or SABG combined funds, due 4 months after provider fiscal year end. Supervisory Care Home Admission and Status Prescriber availability and access for Members Peer Support Specialist/Recovery Support Specialist Assignment Rooster OIFA-04 Arnold Expansion Arnold Expansion OIFA-05 OIFA-06 OIFA-07 Committee Contract Technical Assistance Contract Family and Youth Roles Inventory Committee Contract Technical Assistance Contract Method for tracking agency s hiring system involved adults, and young adults. Mercy Maricopa Integrated Care ASOC_PsychRehab_YYYYMM_AgencyID G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Finance_MHBG_YYYYMMDD_AgencyID Finance_A133Audit_YYYYMMDD_AgencyID Housing_HOUSING-04_YYYYMM_AgencyID Network_PrescriberAvail_YYYYMMDD_AgencyID OIFA_OIFA-02_YYYYMM_AgencyID OIFA_OIFA-04_YYYYMM_AgencyID OIFA_OIFA-05_YYYYMM_AgencyID OIFA_OIFA-06_YYYYMM_AgencyID CSOC_YFRoleInventory_YYYYMMDD_AgencyID Employment Grievance System Grievance System Finance Finance Housing Network Individual and Family Affairs Individual and Family Affairs Individual and Family Affairs Individual and Family Affairs Within Five (5) Business Days Within 24 Hours Quarterly Yearly month 30 Days after Quarter End Provider-Deliverables-(V4) xlsx /10/2016

24 OIFA-08 PR-02 SMI-01 Fidelity s Consumer Operated Programs Outpatient Appointment Availability Adult PNO ly and Attestation Fidelity s Consumer Operated Programs Outpatient Appointment Availability Database - (For Intake providers only) Adult PNO ly Mercy Maricopa Integrated Care OIFA_FidConOpPrg_YYYYMMDD_AgencyID Survey Monkey ASOC_AdultPNO_YYYYMM_AgencyID Individual and Family Affairs Provider Relations Manager SMI Services 10 Days after Quarter End SMI-02 Flex Fund Usage Tracks the use flex funds by individuals in the system. CSOC_FlexFund_YYYYMM_AgencyID 30 Days after the Ends SMI-03 Tribal-03 MHBG Provider Policies and Procedures San Lucy Outpatient Roster MHBG providers must submit all their MHBG related policies and procedures on an annual basis on or before September 30 th. Number persons/families receiving outpatient services within the San Lucy District per month ASOC_MHBGPP_YYYYMMDD_AgencyID TribalLiaison_Tribal-03_YYYYMM_AgencyID SMI Systems Tribal Liaison On or before September 30 th every year 1 QMPI-01 SMI Clinic Gaps in Care List SMI Integrated members with gaps in HEDIS & HEDIS-like performance measures; report actions taken on at least 30% members on the list (appointments made or screenings completed) QMPI_GapsInCare_yyyymmdd_AgencyID Performance Improvement Project Manager Last business day October, January, April and July Scope Work (IP-100) - Independent Practitioner There are no additional for IP-100 Scope Work (IRMP-100) - Information and Referral Program There are no additional for IRMP-100 Provider-Deliverables-(V4) xlsx /10/2016

25 Scope Work (L1PH-100) - Level I Hospital with Psych Unit CRISIS-13 CRISIS-19 CRISIS-20 GA-02 GA-03 NETWORK-05 Hospital Rapid Response Daily Discharge Ready Weekly Hospital Hold Summary s Notification Hospital Hold Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber Availability UM-01 Form Hospital Rapid Response Daily Discharge Ready Weekly hospital hold Summary reports Crisis_CRISIS-13_YYYYMMDD_AgencyID Crisis_CRISIS-19_YYYYMMDD_AgencyID Crisis Crisis Notification Hospital Hold Appropriate MMIC Staff Crisis Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber availability and access for Members Certification Need for Level I Facilities (CON) UM-02 Form Re-Certification Need (RON) UM-03 Form UM-05 Form UM-06 Form UM-08 Level I RTC Form Prior Authorization Request: Level I RTC, BH Residential Facility, or HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization HCTC Bed Hold or Therapeutic Leave Request or Level I RTC Form G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Network_PrescriberAvail_YYYYMMDD_AgencyID RTC CON and RON Fax: (844) , Subacute Fax: (844) RTC CON and RON Fax: (844) , Subacute Fax: (844) Fax: (855) Fax Child: (844) Fax Child: (844) Fax Child: (844) Grievance System Grievance System Network Daily 9:00 AM Fridays 9:00 AM Immediately as It Occurs Within Five (5) Business Days Within 24 Hours month Provider-Deliverables-(V4) xlsx /10/2016

26 GMHSA-08 COE Converted to Voluntary Status COE Converted to Voluntary Status Mercy Maricopa Integrated Care Crisis month Scope Work (L1SAF-100) - Sub-Acute Facility - Level I - without 24 Hour CRISIS-13 Hospital Rapid Response Daily Discharge Ready Hospital Rapid Response Daily Discharge Ready CRISIS-15 Subacute Census Subacute Census CRISIS-19 CRISIS-20 GA-02 GA-03 NETWORK-05 Weekly Hospital Hold Summary s Notification Hospital Hold Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber Availability UM-01 Form Weekly hospital hold Summary reports Crisis_CRISIS-13_YYYYMMDD_AgencyID Crisis_CRISIS-15_YYYYMMDD_AgencyID Crisis_CRISIS-19_YYYYMMDD_AgencyID Crisis Crisis Crisis Notification Hospital Hold Appropriate MMIC Staff Crisis Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber availability and access for Members Certification Need for Level I Facilities (CON) UM-02 Form Re-Certification Need (RON) UM-03 Form UM-05 Form Prior Authorization Request: Level I RTC, BH Residential Facility, or HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization Residential Levels I, II and III G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Network_PrescriberAvail_YYYYMMDD_AgencyID RTC CON and RON Fax: (844) , Subacute Fax: (844) RTC CON and RON Fax: (844) , Subacute Fax: (844) Fax: (855) Fax Child: (844) Grievance System Grievance System Network Daily 9:00 AM Daily 9:00 AM Fridays 9:00 AM Immediately as It Occurs Within Five (5) Business Days Within 24 Hours month Provider-Deliverables-(V4) xlsx /10/2016

27 UM-06 Form UM-08 Level I RTC Form Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization HCTC Bed Hold or Therapeutic Leave Request or Level I RTC Form Mercy Maricopa Integrated Care Fax Child: (844) Fax Child: (844) Scope Work (L1SAFW-100) - Sub-Acute Facility - Level I - with 24 Hour CRISIS-02 CRISIS-03 CRISIS-13 Crisis Inpatient Summary 23 Hour Observation Census Hospital Rapid Response Daily Discharge Ready Crisis Inpatient Summary 23 Hour Observation Census Hospital Rapid Response Daily Discharge Ready CRISIS-15 Subacute Census Subacute Census CRISIS-19 CRISIS-20 GA-02 GA-03 NETWORK-05 Weekly Hospital Hold Summary s Notification Hospital Hold Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber Availability UM-01 Form Weekly hospital hold Summary reports Crisis_CRISIS-02_YYYYMM_AgencyID Crisis_CRISIS-03_YYYYMMDD_AgencyID Crisis_CRISIS-13_YYYYMMDD_AgencyID Crisis_CRISIS-15_YYYYMMDD_AgencyID Crisis_CRISIS-19_YYYYMMDD_AgencyID Crisis Crisis Crisis Crisis Crisis Notification Hospital Hold Appropriate MMIC Staff Crisis Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Prescriber availability and access for Members Certification Need for Level I Facilities (CON) UM-02 Form Re-Certification Need (RON) G&A Intake Line (602) or us at MMICGANDA@aetna.com G&A Intake Line (602) or us at MMICGANDA@aetna.com Network_PrescriberAvail_YYYYMMDD_AgencyID RTC CON and RON Fax: (844) , Subacute Fax: (844) RTC CON and RON Fax: (844) , Subacute Fax: (844) Grievance System Grievance System Network 1 Daily 9:00 AM Daily 9:00 AM Daily 9:00 AM Fridays 9:00 AM Immediately as It Occurs Within Five (5) Business Days Within 24 Hours month Provider-Deliverables-(V4) xlsx /10/2016

28 UM-03 Form UM-05 Form UM-08 Level I RTC Form Prior Authorization Request: Level I RTC, BH Residential Facility, or HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization Residential Levels I, II and III Bed Hold or Therapeutic Leave Request or Level I RTC Form Mercy Maricopa Integrated Care Fax: (855) Fax Child: (844) Fax Child: (844) Scope Work (MACT-100) - Medical ACT Team SMI-04 ACT Census ACT Census SMI-05 ACT Outcomes ACT Outcomes SMI-06 ACT Attestation ACT Outcomes Attestation ASOC_ACTCensus_YYYYMM_AgencyID- AHCCCSID ASOC_ACTOutcomes_YYYYMM_AgencyID- AHCCCSID ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID SMI Services SMI Services SMI Services Due every Friday Due 5th every month Due 5th every month Scope Work (MCS-100) - Mobile Crisis Services There are no additional for MCS-100 Scope Work (METH-100) - Methadone Clinic NETWORK-05 Prescriber Availability Prescriber availability and access for Members Network_PrescriberAvail_YYYYMMDD_AgencyID Network month Scope Work (MST-100) - Multi-Systemic Therapy Provider-Deliverables-(V4) xlsx /10/2016

29 There are no additional for MST-100 Scope Work (PASSG-100) - Peer Attempt Survivor Skills Group There are no additional for PASSG-100 Scope Work (PFOO-100) - Peer & Family Operated Organization There are no additional for PFOO-100 Scope Work (PFRO-100) - Peer & Family Run Organization There are no additional for PFRO-100 Scope Work (PREG-100) - Pregnanacy Program There are no additional for PREG-100 Scope Work (PIMC-100) - PIMC Assessments Tribal-02 PIMC Assessments Number mental health assessments completed at PIMC TribalLiaison_Tribal-02_YYYYMM_AgencyID Tribal Liaison 1 Provider-Deliverables-(V4) xlsx /10/2016

30 Scope Work (PSHS-100) - Permanent Supportive Housing Services HOUSING-05 Supportive Housing Services Housing Supportive Services SFPT File Name Format: Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing 10th the Scope Work (PVT-100) - Prevention Provider PREVENT-01 Prevention Quarterly / Annual Includes: 1. Prevention Quarterly/Annual (Word) 2. EIRF tracking log (EXCEL) 3. Shoulder Tapping tracking log (if applicable) (EXCEL) 4. Party Patrol tracking log (if applicable) (EXCEL) Prevention_PREVENT-01_YYYYMMDD_AgencyID (For Attachments) Prevention_PREVENT-01-A1_YYYYMMDD_AgencyID Prevention_PREVENT-01-A2_YYYYMMDD_AgencyID Prevention_PREVENT-01-A3_YYYYMMDD_AgencyID (Where A1, A2, and A3 are Attachements, and so on etc.) Prevention 30 days after end Quarter (on next business day) QTR 1 (July-Sep) QTR 2 (Oct- Dec) QTR 3 (Jan- Mar) QTR 4 (Apr- Jun) PREVENT-03 Annual Prevention Program Descriptions Includes: 1. Logic Model (Word) 2. Strategic Plan (Word) 3. Budget (Word) Prevention_PREVENT-03_YYYYMMDD_AgencyID (For Attachments) Prevention_PREVENT-03-A1_YYYYMMDD_AgencyID Prevention_PREVENT-03-A2_YYYYMMDD_AgencyID Prevention_PREVENT-03-A3_YYYYMMDD_AgencyID (Where A1, A2, and A3 are Attachements, and so on etc.) Prevention annually, every April 15th or as requested Adhoc for new subcontractors Scope Work (RASA-100) - BH Residenital Facility - Adult SA Treatment There are no additional Provider Deliverables for RASA-100 Provider-Deliverables-(V4) xlsx /10/2016

31 Scope Work (RMP-100) - Referral Program There are no additional for RMP-100 Scope Work (RRC-100) - CPS - Rapid Response - Children There are no additional for RRC-100 Scope Work (RTC-100) - Level I RTC - Secure and Non-Secure UM-01 Form Certification Need for Level I Facilities (CON) UM-02 Form Re-Certification Need (RON) UM-03 Form UM-05 Form UM-06 Form UM-08 Level I RTC Form Prior Authorization Request: Level I RTC, BH Residential Facility, or HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical Review for Continued Prior Authorization HCTC Bed Hold or Therapeutic Leave Request or Level I RTC Form RTC CON and RON Fax: (844) , Subacute Fax: (844) RTC CON and RON Fax: (844) , Subacute Fax: (844) Fax: (855) Fax Child: (844) Fax Child: (844) Fax Child: (844) Provider-Deliverables-(V4) xlsx /10/2016

32 Scope Work (SABGOP-100) - SABG - GMH/SA Outpatient Services FIN-04 FIN-05 GMHSA-07 A-133 Audit SABG ing SABG Provider Policies and Procedures For providers receiving >$750,00 per year in either MHBG or SABG combined funds, due 4 months after provider fiscal year end. For providers receiving any SABG funds, Attachment J in the MMIC Financial ing Guide Attachments. SABG providers must submit all their SABG related policies and procedures on an annual basis on or before September 30 th. Finance_A133Audit_YYYYMMDD_AgencyID Finance_SABG_YYYYMMDD_AgencyID GMHSA_SABGPP_YYYYMMDD_AgencyID Finance Finance GMHSA System Yearly Quarterly On or before September 30 th every year Scope Work (SABGRS-100) - SABG - GMH/SA Residential Services For providers receiving >$750,00 FIN-04 A-133 Audit per year in either MHBG or SABG combined funds, due 4 months Finance_A133Audit_YYYYMMDD_AgencyID Finance after provider fiscal year end. FIN-05 GMHSA-07 SABG ing SABG Provider Policies and Procedures For providers receiving any SABG funds, Attachment J in the MMIC Financial ing Guide Attachments. SABG providers must submit all their SABG related policies and procedures on an annual basis on or before September 30 th. Finance_SABG_YYYYMMDD_AgencyID GMHSA_SABGPP_YYYYMMDD_AgencyID Finance GMHSA System Yearly Quarterly On or before September 30 th every year Scope Work (SEE-100) - Supported Employment Expansion Provider-Deliverables-(V4) xlsx /10/2016

33 EMPLOY-06 Supported Employment Outcome Network Supported Employment Expansion Providers to complete Supported Employment Outcomes Template provided. List members engaged in supported employment servcies and data fields associated. SFPT File Name Format: ASOC_EmpProSupEmp_YYYYMM_AgencyID Employment Scope Work (SMIE-100) - SMI Evaluations There are no additional Provider Deliverables for SMIE-100 Scope Work (SSG-100) - Survivor Support Group CRISIS-18 Peer Attempt Survivor Support Group Satisfaction Surveys Peer Attempt Survivor Support Group Satisfaction Surveys Crisis_CRISIS-18_YYYYMM_AgencyID Crisis Quarterly Scope Work (SUPH-100) - Supportive Housing There are no additional for SUPH-100 Scope Work (TCMC-100) - Tribal Community Mobile Crisis Tribal-01 Tohono O'odham Disposition Disposition report regarding Tohono O'odham and Ft. McDowell crisis responses TribalLiaison_Tribal-01_YYYYMM_AgencyID Tribal Liaison 1 Provider-Deliverables-(V4) xlsx /10/2016

34 Scope Work (WHC-100) - Whole Health Clinic GA-02 GA-03 Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance Notification a Person No Longer In Need Special Assistance Notification a Person In Need Special Assistance G&A Intake Line: (602) or us at: MMICGANDA@aetna.com G&A Intake Line: (602) or us at: MMICGANDA@aetna.com Grievance System Grievance System Within Five (5) Business Days Within 24 Hours Provider-Deliverables-(V4) xlsx /10/2016