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 CC-01 Language Language CC-02 CC-03 CC-04 Cultural Competence Organizational Self- Assessment Cultural Competency Plan Deaf and Hard Hearing Services Survey Cultural Competence Organizational Self-Assessment Develop a written Cultural Competency Plan (CCP) in an outcome based format including expected results, measurable outcomes and outputs with a focus on national level priorities and current initiatives in the field cultural competency. Deaf and Hard Hearing Services Survey CulturalC_CC-01_YYYYMMDD_AgencyID Survey Monkey CulturalC_CC-03_YYYYMMDD_AgencyID Survey Monkey Network Cultural Competency Cultural Competency Cultural Competency Cultural Competency January 1st, July 1st Annually CSOC -11 Access to Care 7 and 23 days Access to Care CSOC_AccesstoCare_YYYYMM_AgencyID CRED-01 Initial Individual Clinician Credentialing Application and Supporting Documentation Initial Individual Clinician Credentialing Application and supporting documentation Provider Relations Fax to: (860) Director Credentialing FIN-01 Unaudited Financial ing For providers receiving >$250,000 per year, Attachments A-G in the MMIC Financial ing Guide Attachments. Finance_UnauditedFinancials_YYYYMMDD_AgencyID Finance Quarterly FIN-02 Audited Financials For providers receiving >$500,00 per year, due 4 months after provider fiscal year end. Finance_AuditedFinancials_YYYYMMDD_AgencyID Finance Yearly Provider_Deliverables_(v3.2).xlsx /16/2015

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_(v3.2).xlsx /16/2015

3 Scope Work (A-100) - General Requirements (Continued) NETWORK-06 Key Workforce Reduction 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.) Network_NETWORK-06_YYYYMMDD_AgencyID Network Prior Approval Required NETWORK-07 Network Changes 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. Any changes. Network_NETWORK-07_YYYYMMDD_AgencyID Network 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 Referrals Provider Requests to Stop Accepting Referrals 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_(v3.2).xlsx /16/2015

4 NETWORK-14 Provider Corrective Action Plans Provider Corrective Action Plans Network_ProvCAP_YYYYMMDD_AgencyID Network AdHOC Provider_Deliverables_(v3.2).xlsx /16/2015

5 Scope Work (A-100) - General Requirements (Continued) each use Seclusion / Retraint concerning all enrolled personsseclusion / Restraint Forms to: Summary Concerning MMIC@aetna.com Seclusion/Restraint Quality QM-02 Persons with SMI each Summary use Seclusion / Restraint Fax Forms to: Concerning Persons with SMISeclusion / Restraint Summary Concerni High Prile Alerts Quality Within 24 Hours QM-03 Incidents, Accidents, and Incident Accident Death Form Fax Forms to: Awareness Deaths Allegations Attempted Suicide, Incident, Accident, and QM Portal Quality Within 48 Hours QM-04 Sexual Abuse and Death Death Forms Awareness Incident s Incident, Accident, and Within Five (5) Death s for QM Portal Quality QM-05 Incident Accident Death Form Business Days Behavioral Health Awareness Members Individual Clinician Re- Individual Clinician re-credentialing Credentialing Application Quality 63 Days Prior to QM-08 application & supporting Provider Relations Fax to: (860) & Supporting Expiration documentation Documentation 15 Days After Organizational Credentialing Approval Letter Organizational Quality QM-10 Application and supporting Provider Relations Fax to: (860) from Mercy Credentialing Application documentation Maricopa is Received Organizational Re- Organizational re-credentialing Credentialing Application Quality 63 Days Prior to QM-11 application and supporting Provider Relations Fax to: (860) and Supporting Expiration documentation Documentation ADHS Division Licensing Services - Quality 30 Days Prior to QM-12 ADHS DLS License Provider Relations Fax to: (860) Facility License Expiration Provider_Deliverables_(v3.2).xlsx /16/2015

6 Provider_Deliverables_(v3.2).xlsx /16/2015

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) Quality Quality Quality 30 Days Prior to Expiration 30 Days Prior to Expiration 30 Days Prior to Expiration Accreditation Certificate Accreditation certificate and survey Quality 30 Days Prior to QM-16 Provider Relations Fax to: (860) and Survey report Expiration Provide QM Department with QM Practice Improvement Quality QM-18 corrective actions/pips as Plans (PIPs) and QM CAPs QMPM_QM-18_YYYYMMDD_AgencyID requested Request for Psychological Testing UM-04 Form Fax to: (844) Preauthorization ECT Prior Authorization Request UM-07 Form Fax to: (844) Form Scope Work (ACCP-100) - Access Point Crisis Access Point Weekly CRISIS-04 Crisis Access Point Weekly Crisis Fridays 9:00 AM Crisis_CRISIS-04_YYYYMMDD_AgencyID Scope Work (ACT-100) - ACT Team SMI Services Due every SMI-04 ACT Census ACT Census ASOC_ACTCensus_YYYYMM_AgencyID-AHCCCSID Friday SMI Services Due 5th SMI-05 ACT Outcomes ACT Outcomes ASOC_ACTOutcomes_YYYYMM_AgencyID-AHCCCSID every month Provider_Deliverables_(v3.2).xlsx /16/2015

8 SMI-06 ACT Attestation ACT Outcomes Attestation ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID SMI Services Due 5th every month Provider_Deliverables_(v3.2).xlsx /16/2015

9 Scope Work (ADIOP-100) - Alcohol and / or Drug Services - IOP Prescriber Availability Prescriber availability and access Network NETWORK-05 Network_PrescriberAvail_YYYYMMDD_AgencyID for Members month Scope Work (AFSP-100) - Adult Family Support Partner There are no additional for AFSP-100 Scope Work (AOP-100) - Adult OP Services Comprehensive Comprehensive Persons ASOC-02 Persons Identified as in Identified as in Need Special PNO Liaison ASOC_ASOC-02_YYYYMM_AgencyID Need Special Assistance Assistance Outpatient Commitment COT Court Liaison COURTS-01 COT Summary s Monitoring Data ASOC_OCM_YYYYMM_AgencyID ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID Network Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance HIV ly Terros only. Populations served with HIV GMH/SA GMHSA-04 HIV ly services and locations where these GMHSA_HIV_YYYYMM_TERROS members were served Provider_Deliverables_(v3.2).xlsx /16/2015

10 SAPT LEVEL II Providers only. Mercy Maricopa Integrated Care Services that were delivered to SAPT LEVEL II Providers GMH/SA GMHSA-05 SAPT recipients in this level care ONLY Wait List GMHSA_SAPTLEVEL11_YYYYMM_AgencyID broken out by SAPT priority population. All Intake Providers. Focuses on the GMH/SA GMHSA-06 Access to Care 7 day and 23 day access to care GMHSA_AccesstoCare_YYYYMM_AgencyID requirements Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month New TXIX or Priority Network When Decision NETWORK-12 New TXIX or Priority Recipients Recipients Network_NETWORK-12_YYYYMMDD_AgencyID has been Made Peer Support Peer Support Specialist/Recovery Specialist/Recovery Individual and Family OIFA-02 Support Specialist Assignment Support Specialist OIFA_OIFA-02_YYYYMM_AgencyID Affairs Rooster Assignment Roster Outpatient Appointment Outpatient Appointment Provider Relations 10 Days after PR-02 Availability Database - (For Intake Survey Monkey Availability Manager Quarter End providers only) Number persons/families 1 Tribal-03 San Lucy Outpatient Roster receiving outpatient services within Tribal Liaison TribalLiaison_Tribal-03_YYYYMM_AgencyID the San Lucy District per month Scope Work (ASMI-100) - Adult SMI Clinic Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with HEA Screenings and Adult SOC ASOC-01 ADHS/DBHS Policy on Eligibility Attestation ASOC_HEA_YYYYMM_AgencyID Screening for AHCCCS Health Insurance, including Title XIX services. (A.R.S ) Comprehensive Comprehensive Persons ASOC-02 Persons Identified as in Identified as in Need Special PNO Liaison ASOC_ASOC-02_YYYYMM_AgencyID Need Special Assistance Assistance Provider_Deliverables_(v3.2).xlsx /16/2015

11 ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID Network Outpatient Commitment COT Court Liaison COURTS-01 COT Summary s Monitoring Data ASOC_OCM_YYYYMM_AgencyID For providers receiving any MHBG funds, Attachment J in the MMIC FIN-03 MHBG ing Finance Quarterly Financial ing Guide Finance_MHBG_YYYYMMDD_AgencyID Attachments. For providers receiving >$750,00 per year in either MHBG or SABG FIN-04 A-133 Audit Finance Yearly combined funds, due 4 months Finance_A133Audit_YYYYMMDD_AgencyID after provider fiscal year end. APNO Rehabilitiaon Specialist to complete Psychiatric Rehabilitition ly report Employment EMPLOY-05 Psychiatric Rehabilitation ASOC_PsychRehab_YYYYMM_AgencyID Rehabilitaion & Employent related training, referrals for services and coordination with RSA/VR Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance Supervisory Care Home Supervisory Care Home Admission HOUSING-04 Admission and Status Housing and Status Housing_HOUSING-04_YYYYMM_AgencyID Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month New TXIX or Priority Network When Decision NETWORK-12 New TXIX or Priority Recipients Recipients Network_NETWORK-12_YYYYMMDD_AgencyID has been Made Peer Support Peer Support Specialist/Recovery Specialist/Recovery Individual and Family OIFA-02 Support Specialist Assignment Support Specialist OIFA_OIFA-02_YYYYMM_AgencyID Affairs Rooster Assignment Roster Individual and Family OIFA-04 Arnold Expansion Arnold Expansion OIFA_OIFA-04_YYYYMM_AgencyID Affairs Provider_Deliverables_(v3.2).xlsx /16/2015

12 Committee Contract Individual and Family OIFA-05 Committee Contract OIFA_OIFA-05_YYYYMM_AgencyID Affairs Technical Assistance Technical Assistance Contract Individual and Family OIFA-06 Contract OIFA_OIFA-06_YYYYMM_AgencyID Affairs Method for tracking agency s hiring Family and Youth Roles 30 Days after OIFA-07 system involved adults, and Inventory CSOC_YFRoleInventory_YYYYMMDD_AgencyID Quarter End young adults. Fidelity s Individual and Family Fidelity s Consumer OIFA-08 Consumer Operated Affairs Operated Programs OIFA_FidConOpPrg_YYYYMMDD_AgencyID Programs Adult PNO ly Adult PNO ly and SMI Services SMI-01 and Attestation Attestation ASOC_AdultPNO_YYYYMM_AgencyID Tracks the use flex funds by 30 Days after SMI-02 Flex Fund Usage individuals in the system. CSOC_FlexFund_YYYYMM_AgencyID the Ends MHBG providers must submit all On or before MHBG Provider Policies and their MHBG related policies and SMI Systems SMI-03 Procedures procedures on an annual basis on or ASOC_MHBGPP_YYYYMMDD_AgencyID September 30 th every year before September 30 th. Scope Work (ATCSA-100) - Adult Transition Team CSA There are no additional Provider Deliverables for ATCSA-100 Scope Work (BHRA-100) - BH Residential Facility - Adult Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance Provider_Deliverables_(v3.2).xlsx /16/2015

13 Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Certification Need for Level I RTC CON and RON Fax: (844) , UM-01 Form Facilities (CON) Subacute Fax: (844) RTC CON and RON Fax: (844) , UM-02 Form Re-Certification Need (RON) Subacute Fax: (844) Prior Authorization Request: Level I UM-03 Form RTC, BH Residential Facility, or Fax: (855) HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior UM-05 Form Fax Child: (844) Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical UM-06 Form Review for Continued Prior Fax Child: (844) Authorization HCTC Bed Hold or Therapeutic Leave UM-08 Level I RTC Form Fax Child: (844) Request or Level I RTC Form Scope Work (BHRC-100) - BH Residential Facility - Children's 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 Provider_Deliverables_(v3.2).xlsx /16/2015

14 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 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 Provider_Deliverables_(v3.2).xlsx /16/2015

15 There are no additional for CATSD Scope Work (CAYAT-100) - Child/Adolescent Youth to Adulthood Transition Team Young Adult Transition Information on youth enrolled in Transition Youth CSOC-02 Roster TIP programs CSOC_YAT_YYYYMM_AgencyID Coordinator Quarterly on TAPIS Outcomes TAPIS Outcomes (TIP Transition Youth the CSOC-04 (TIP Programs) Programs) CSOC_TAPIS_YYYYMM_AgencyID Coordinator after the Quarter End Transition-age Youth Staff Information on staff working with Transition Youth CSOC-10 Inventory transition-age youth CSOC_TAY_YYYYMM_AgencyID Coordinator Scope Work (CCC-100) - Crisis Call Center DCS Rapid Response DCS Rapid Response ly 1 CRISIS-05 Crisis ly Crisis_CRISIS-05_YYYYMM_AgencyID Ambulance Dispatches Ambulance Dispatches Summary 1 CRISIS-06 Crisis Summary Crisis_CRISIS-06_YYYYMM_AgencyID 1 CRISIS-07 Crisis PAD Crisis PAD Crisis Crisis_CRISIS-07_YYYYMM_AgencyID Formerly Crisis Call Center Quality 1 CRISIS-08 Crisis Services Crisis Crisis_CRISIS-08_YYYYMM_AgencyID DCS Stabilization > 90 Days Formerly, CRN kids in the 1 CRISIS-09 Crisis Roster program >90 days. Crisis_CRISIS-09_YYYYMM_AgencyID 1 CRISIS-10 Children's Crisis Formerly CRN 148 Crisis Crisis_CRISIS-10_YYYYMM_AgencyID DCS Rapid Response 12th the CRISIS-11 Formerly CRN 156 Crisis Structural Crisis_CRISIS-11_YYYYMM_AgencyID Hospital Rapid Response 1 CRISIS-12 Formerly CRN 161 Crisis ly Crisis_CRISIS-12_YYYYMM_AgencyID Provider_Deliverables_(v3.2).xlsx /16/2015

16 DBHS Crisis Call Center DBHS Crisis Call Center Monitoring 13th the CRISIS-14 Crisis Monitoring Tool Tool Crisis_CRISIS-14_YYYYMM_AgencyID Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Scope Work (CDSP-100) - Children's Direct Support Provider Direct Support Provider Direct Support Provider ly CSOC-01 Roster CSOC_DSPRoster_YYYYMM_AgencyID Birth to 5 Level Competency Birth to 5 Level 30 Days after CSOC-07 Matrix/ITMHCA Endorsement Competency Matrix CSOC_Birthtivematrix_YYYYMMDD_AgencyID Quarter End Criteria Number available referrals accepted for the current week, this CSOC-14 Referral Capacity should also include Spanish Every Monday DSP_SpecialtyProviders@mercymaricopa.org speaking capacity Scope Work (CHT-100) - Child Hospital Team 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 Provider_Deliverables_(v3.2).xlsx /16/2015

17 CSOC -11 Access to Care 7 and 23 days Access to Care CSOC_AccesstoCare_YYYYMM_AgencyID Birth to 5 Level Competency Birth to 5 Level 30 Days after CSOC-07 Matrix/ITMHCA Endorsement Competency Matrix CSOC_Birthtivematrix_YYYYMMDD_AgencyID Quarter End Criteria CSOC-12 ly Flex Fund ly Flex Fund CSOC_FlexFund_YYYYMM_AgencyID Children's Provider NOA 30 Days after CSOC-08 Children's Provider NOA Log Log CSOC_NOALog_YYYYMMDD_AgencyID Quarter End Client specific details and ly Flex Fund CSOC-13 documentation required to support Supporting Documents CSOC_FlexFundDOCS_YYYYMMDD_AgencyID the ly Flex Fund For providers receiving any MHBG funds, Attachment J in the MMIC FIN-03 MHBG ing Finance Quarterly Financial ing Guide Finance_MHBG_YYYYMMDD_AgencyID Attachments. For providers receiving >$750,00 per year in either MHBG or SABG FIN-04 A-133 Audit Finance Yearly combined funds, due 4 months Finance_A133Audit_YYYYMMDD_AgencyID after provider fiscal year end. Within Five (5) Notification a Person No G&A Intake Line (602) Notification a Person No Longer SMI Services Business Days GA-02 Longer In Need Special or In Need Special Assistance Assistance us at MMICGANDA@aetna.com G&A Intake Line (602) Within 24 Hours Notification a Person In Notification a Person In Need SMI Services GA-03 or Need Special Assistance Special Assistance us at MMICGANDA@aetna.com Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month MHBG providers must submit all On or before MHBG Provider Policies and their MHBG related policies and CSOC-17 Procedures procedures on an annual basis on or CSOC_MHBGPP_YYYYMMDD_AgencyID September 30 th every year before September 30 th. CSOC-09 Unmet Needs Roster Unmet Needs Roster CSOC_Unmet_YYYYMM_AgencyID Provider_Deliverables_(v3.2).xlsx /16/2015

18 Scope Work (CSA-100) - Community Service Agency Peer and Family Run after Roster Peer and Family Individual and Family OIFA-01 Organizations / Referral Quarter end Committee Members OIFA_OIFA-01_YYYYMM_AgencyID Affairs and Recovery Tracking (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 Crisis Transitional Crisis Transitional Navigator 14th the CRISIS-17 Crisis Navigator ly ly Crisis_CRISIS-17_YYYYMM_AgencyID Transitional Point ly 1 CRISIS-21 Transitional Point ly Crisis Crisis_CRISIS-21_YYYYMM_AgencyID 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 Provider_Deliverables_(v3.2).xlsx /16/2015

19 Scope Work (ES-100) - Employment Services Network Employment Providers to complete Outcomes Employment Provider Employment 10th the EMPLOY-04 Template provided. List members Outcome ASOC_EmpPro_YYYYMM_AgencyID engaged in employment related servcies and data fields associated. Scope Work (FACT-100) - Forensic ACT Team ASOC_ACTCensus_YYYYMM_AgencyID- SMI Services Due every SMI-04 ACT Census ACT Census AHCCCSID Friday ASOC_ACTOutcomes_YYYYMM_AgencyID- SMI Services Due 5th SMI-05 ACT Outcomes ACT Outcomes AHCCCSID every month SMI Services Due 5th SMI-06 ACT Attestation ACT Outcomes Attestation ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID every month Scope Work (GDSP-100) - Generalist Direct Support Provider CSOC-05 MMWIA ly Roster MMWIA ly Roster CSOC_MMWIARoster_YYYYMM_AgencyID Number available referrals accepted for the current week, this CSOC-14 Referral Capacity Every Monday should also include Spanish DSP_SpecialtyProviders@mercymaricopa.org speaking capacity Scope Work (HCTCA-100) - HCTC - Adult Provider_Deliverables_(v3.2).xlsx /16/2015

20 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 CSOC-12 ly Flex Fund ly Flex Fund CSOC_FlexFund_YYYYMM_AgencyID High Needs Case CSOC-15 HNCM Inventory CSOC_HNCMInventory_YYYYMMDD_AgencyID Inventory High Needs Case CSOC-16 HNCM Roster CSOC_HNCMRoster_YYYYMMDD_AgencyID Roster HNCM Roster/HNCM CSOC- 06 HNCM Roster/HNCM Inventory CSOC_HNCMRoster_YYYYMMDD_AgencyID: Bi-weekly Inventory CSOC_HNCMInventory_YYYYMMDD_ProvideName Scope Work (HOS-100) - Housing On-Site Services/Community Living Flex Care Plus, Community Monday 10:00 HOUSING-03 Housing Census Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Placement AM Scope Work (HTLP-100) - Housing Transitional Living Program Provider_Deliverables_(v3.2).xlsx /16/2015

21 HOUSING-07 Transitional Living Program Transitional Living Program Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Daily Scope Work (HRR-100) - Hospital Rapid Response Hospital Rapid Response 1 CRISIS-12 Formerly CRN 161 Crisis ly Crisis_CRISIS-12_YYYYMM_AgencyID Hospital Rapid Response Hospital Rapid Response Daily CRISIS-13 Crisis Daily 9:00 AM Daily Discharge Ready Discharge Ready Crisis_CRISIS-13_YYYYMMDD_AgencyID Scope Work (HSGP-100) - Housing Provider HOUSING-03 Housing Census Community Placement Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Monday 10:00 AM Permanent Supportive Housing 10th the HOUSING-06 Supportive Housing Housing_HousingOutcomes_YYYYMMDD_AgencyID Housing Scope Work (HUD-100) - Housing - HUD There are no additional for HUD-100 Scope Work (IC-100) - Integrated Health Clinic Provider_Deliverables_(v3.2).xlsx /16/2015

22 Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with HEA Screenings and Adult SOC ASOC-01 ADHS/DBHS Policy on Eligibility Attestation ASOC_HEA_YYYYMM_AgencyID Screening for AHCCCS Health Insurance, including Title XIX services. (A.R.S ) Comprehensive Comprehensive Persons ASOC-02 Persons Identified as in Identified as in Need Special PNO Liaison ASOC_ASOC-02_YYYYMM_AgencyID Need Special Assistance Assistance ASOC-03 Access to Care 7 and 23 days Access to Care ASOC_AccesstoCare_YYYYMM_AgencyID Network Outpatient Commitment COT Court Liaison COURTS-01 COT Summary s Monitoring Data ASOC_OCM_YYYYMM_AgencyID APNO Rehabilitiaon Specialist to complete Psychiatric Rehabilitition ly report Employment EMPLOY-05 Psychiatric Rehabilitation ASOC_PsychRehab_YYYYMM_AgencyID Rehabilitaion & Employent related training, referrals for services and coordination with RSA/VR Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance For providers receiving any MHBG funds, Attachment J in the MMIC FIN-03 MHBG ing Finance Quarterly Financial ing Guide Finance_MHBG_YYYYMMDD_AgencyID Attachments. For providers receiving >$750,00 per year in either MHBG or SABG FIN-04 A-133 Audit Finance Yearly combined funds, due 4 months Finance_A133Audit_YYYYMMDD_AgencyID after provider fiscal year end. Supervisory Care Home Supervisory Care Home Admission HOUSING-04 Admission and Status Housing and Status Housing_HOUSING-04_YYYYMM_AgencyID Provider_Deliverables_(v3.2).xlsx /16/2015

23 Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Peer Support Peer Support Specialist/Recovery Specialist/Recovery Individual and Family OIFA-02 Support Specialist Assignment Support Specialist OIFA_OIFA-02_YYYYMM_AgencyID Affairs Rooster Assignment Roster Individual and Family OIFA-04 Arnold Expansion Arnold Expansion OIFA_OIFA-04_YYYYMM_AgencyID Affairs Committee Contract Individual and Family OIFA-05 Committee Contract OIFA_OIFA-05_YYYYMM_AgencyID Affairs Technical Assistance Technical Assistance Contract Individual and Family OIFA-06 Contract OIFA_OIFA-06_YYYYMM_AgencyID Affairs Method for tracking agency s hiring Family and Youth Roles 30 Days after OIFA-07 system involved adults, and Inventory CSOC_YFRoleInventory_YYYYMMDD_AgencyID Quarter End young adults. Fidelity s Individual and Family Fidelity s Consumer OIFA-08 Consumer Operated OIFA_FidConOpPrg_YYYYMMDD_AgencyID Affairs Operated Programs Programs Outpatient Appointment Outpatient Appointment Provider Relations 10 Days after PR-02 Availability Database - (For Intake Survey Monkey Availability Manager Quarter End providers only) Adult PNO ly SMI Services SMI-01 Adult PNO ly and Attestation ASOC_AdultPNO_YYYYMM_AgencyID Tracks the use flex funds by 30 Days after SMI-02 Flex Fund Usage individuals in the system. CSOC_FlexFund_YYYYMM_AgencyID the Ends MHBG providers must submit all On or before MHBG Provider Policies and their MHBG related policies and SMI Systems SMI-03 Procedures procedures on an annual basis on or ASOC_MHBGPP_YYYYMMDD_AgencyID September 30 th every year before September 30 th. Number persons/families 1 Tribal-03 San Lucy Outpatient Roster receiving outpatient services within Tribal Liaison TribalLiaison_Tribal-03_YYYYMM_AgencyID the San Lucy District per month Scope Work (IP-100) - Independent Practitioner There are no additional for IP-100 Provider_Deliverables_(v3.2).xlsx /16/2015

24 Scope Work (IRMP-100) - Information and Referral Program There are no additional for IRMP-100 Scope Work (L1PH-100) - Level I Hospital with Psych Unit Hospital Rapid Response Hospital Rapid Response Daily CRISIS-13 Crisis Daily 9:00 AM Daily Discharge Ready Discharge Ready Crisis_CRISIS-13_YYYYMMDD_AgencyID Weekly Hospital Hold Weekly hospital hold Summary CRISIS-19 Crisis Fridays 9:00 AM Summary s reports Crisis_CRISIS-19_YYYYMMDD_AgencyID Notification Hospital Immediately as CRISIS-20 Notification Hospital Hold Appropriate MMIC Staff Crisis Hold It Occurs Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Certification Need for Level I RTC CON and RON Fax: (844) , UM-01 Form Facilities (CON) Subacute Fax: (844) RTC CON and RON Fax: (844) , UM-02 Form Re-Certification Need (RON) Subacute Fax: (844) Prior Authorization Request: Level I UM-03 Form RTC, BH Residential Facility, or Fax: (855) HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior UM-05 Form Fax Child: (844) Authorization Residential Levels I, II and III Provider_Deliverables_(v3.2).xlsx /16/2015

25 Child/Adolescent 60 Day Clinical UM-06 Form Review for Continued Prior Fax Child: (844) Authorization HCTC Bed Hold or Therapeutic Leave UM-08 Level I RTC Form Fax Child: (844) Request or Level I RTC Form COE Converted to GMHSA-08 COE Converted to Voluntary Status crisis@mercymaricopa.org Crisis Voluntary Status month Scope Work (L1SAF-100) - Sub-Acute Facility - Level I - without 24 Hour Hospital Rapid Response Hospital Rapid Response Daily CRISIS-13 Crisis Daily 9:00 AM Daily Discharge Ready Discharge Ready Crisis_CRISIS-13_YYYYMMDD_AgencyID CRISIS-15 Subacute Census Subacute Census Crisis Daily 9:00 AM Crisis_CRISIS-15_YYYYMMDD_AgencyID Weekly Hospital Hold Weekly hospital hold Summary CRISIS-19 Crisis Fridays 9:00 AM Summary s reports Crisis_CRISIS-19_YYYYMMDD_AgencyID Notification Hospital Immediately as CRISIS-20 Notification Hospital Hold Appropriate MMIC Staff Crisis Hold It Occurs Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Certification Need for Level I RTC CON and RON Fax: (844) , UM-01 Form Facilities (CON) Subacute Fax: (844) RTC CON and RON Fax: (844) , UM-02 Form Re-Certification Need (RON) Subacute Fax: (844) Prior Authorization Request: Level I UM-03 Form RTC, BH Residential Facility, or Fax: (855) HCTC Services Provider_Deliverables_(v3.2).xlsx /16/2015

26 Child/Adolescent 45 Day Clinical Review for Continued Prior UM-05 Form Fax Child: (844) Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical UM-06 Form Review for Continued Prior Fax Child: (844) Authorization HCTC Bed Hold or Therapeutic Leave UM-08 Level I RTC Form Fax Child: (844) Request or Level I RTC Form Scope Work (L1SAFW-100) - Sub-Acute Facility - Level I - with 24 Hour Crisis Inpatient Summary 1 CRISIS-02 Crisis Inpatient Summary Crisis Crisis_CRISIS-02_YYYYMM_AgencyID 23 Hour Observation CRISIS Hour Observation Census Crisis Daily 9:00 AM Census Crisis_CRISIS-03_YYYYMMDD_AgencyID Hospital Rapid Response Hospital Rapid Response Daily CRISIS-13 Crisis Daily 9:00 AM Daily Discharge Ready Discharge Ready Crisis_CRISIS-13_YYYYMMDD_AgencyID CRISIS-15 Subacute Census Subacute Census Crisis Daily 9:00 AM Crisis_CRISIS-15_YYYYMMDD_AgencyID Weekly Hospital Hold Weekly hospital hold Summary CRISIS-19 Crisis Fridays 9:00 AM Summary s reports Crisis_CRISIS-19_YYYYMMDD_AgencyID Notification Hospital Immediately as CRISIS-20 Notification Hospital Hold Appropriate MMIC Staff Crisis Hold It Occurs Within Five (5) Notification a Person No Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special G&A Intake Line (602) or us at MMICGANDA@aetna.com In Need Special Assistance Assistance Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 G&A Intake Line (602) or us at MMICGANDA@aetna.com Need Special Assistance Special Assistance Prescriber Availability Prescriber availability and access Network NETWORK-05 for Members Network_PrescriberAvail_YYYYMMDD_AgencyID month Certification Need for Level I RTC CON and RON Fax: (844) , UM-01 Form Facilities (CON) Subacute Fax: (844) Provider_Deliverables_(v3.2).xlsx /16/2015

27 RTC CON and RON Fax: (844) , UM-02 Form Re-Certification Need (RON) Subacute Fax: (844) Prior Authorization Request: Level I UM-03 Form RTC, BH Residential Facility, or Fax: (855) HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior UM-05 Form Fax Child: (844) Authorization Residential Levels I, II and III Bed Hold or Therapeutic Leave UM-08 Level I RTC Form Fax Child: (844) Request or Level I RTC Form Scope Work (MACT-100) - Medical ACT Team ASOC_ACTCensus_YYYYMM_AgencyID- SMI Services Due every SMI-04 ACT Census ACT Census AHCCCSID Friday ASOC_ACTOutcomes_YYYYMM_AgencyID- SMI Services Due 5th SMI-05 ACT Outcomes ACT Outcomes AHCCCSID every month SMI Services Due 5th SMI-06 ACT Attestation ACT Outcomes Attestation ASOC_ACTOutcomesAttestation_YYYYMM_AgencyID-AHCCCSID every month Scope Work (MCS-100) - Mobile Crisis Services There are no additional for MCS-100 Scope Work (METH-100) - Methadone Clinic Prescriber Availability Prescriber availability and access Network NETWORK-05 Network_PrescriberAvail_YYYYMMDD_AgencyID for Members month Provider_Deliverables_(v3.2).xlsx /16/2015

28 Scope Work (MST-100) - Multi-Systemic Therapy 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 Provider_Deliverables_(v3.2).xlsx /16/2015

29 Number mental health 1 Tribal-02 PIMC Assessments Tribal Liaison assessments completed at PIMC TribalLiaison_Tribal-02_YYYYMM_AgencyID Scope Work (PSHS-100) - Permanent Supportive Housing Services Supportive Housing SFPT File Name Format: 10th the HOUSING-05 Housing Supportive Services Housing Services Housing_HousingOutcomes_YYYYMMDD_AgencyID Scope Work (PVT-100) - Prevention Provider 30 days after Includes: end Quarter 1. Prevention Quarterly/Annual (on next (Word) Prevention_PREVENT-01_YYYYMMDD_AgencyID business day) 2. EIRF tracking log (EXCEL) (For Attachments) QTR 1 (July-Sep) Prevention Quarterly / Prevention PREVENT Shoulder Tapping tracking log (if Prevention_PREVENT-01-A1_YYYYMMDD_AgencyID QTR 2 (Oct- Annual applicable) (EXCEL) Prevention_PREVENT-01-A2_YYYYMMDD_AgencyID Dec) 4. Party Patrol tracking log (if Prevention_PREVENT-01-A3_YYYYMMDD_AgencyID QTR 3 (Jan- applicable) (EXCEL) (Where A1, A2, and A3 are Attachements, and so on etc.) Mar) QTR 4 (Apr- Jun) Prevention_PREVENT-03_YYYYMMDD_AgencyID annually, every Includes: (For Attachments) April 15th or as Annual Prevention 1. Logic Model (Word) Prevention PREVENT-03 Prevention_PREVENT-03-A1_YYYYMMDD_AgencyID requested Ad- Program Descriptions 2. Strategic Plan (Word) Prevention_PREVENT-03-A2_YYYYMMDD_AgencyID hoc for new 3. Budget (Word) Prevention_PREVENT-03-A3_YYYYMMDD_AgencyID subcontractors (Where A1, A2, and A3 are Attachements, and so on etc.) Scope Work (RASA-100) - BH Residenital Facility - Adult SA Treatment Provider_Deliverables_(v3.2).xlsx /16/2015

30 There are no additional Provider Deliverables for RASA-100 Mercy Maricopa Integrated Care 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 Certification Need for Level I RTC CON and RON Fax: (844) , UM-01 Form Facilities (CON) Subacute Fax: (844) RTC CON and RON Fax: (844) , UM-02 Form Re-Certification Need (RON) Subacute Fax: (844) Prior Authorization Request: Level I UM-03 Form RTC, BH Residential Facility, or Fax: (855) HCTC Services Child/Adolescent 45 Day Clinical Review for Continued Prior UM-05 Form Fax Child: (844) Authorization Residential Levels I, II and III Child/Adolescent 60 Day Clinical UM-06 Form Review for Continued Prior Fax Child: (844) Authorization HCTC Bed Hold or Therapeutic Leave UM-08 Level I RTC Form Fax Child: (844) Request or Level I RTC Form Provider_Deliverables_(v3.2).xlsx /16/2015

31 Scope Work (SABGOP-100) - SABG - GMH/SA Outpatient Services For providers receiving >$750,00 per year in either MHBG or SABG FIN-04 A-133 Audit Finance Yearly combined funds, due 4 months after Finance_A133Audit_YYYYMMDD_AgencyID provider fiscal year end. For providers receiving any SABG funds, Attachment J in the MMIC FIN-05 SABG ing Finance Quarterly Financial ing Guide Finance_SABG_YYYYMMDD_AgencyID Attachments. SABG providers must submit all their On or before SABG Provider Policies and SABG related policies and procedures GMHSA System GMHSA-07 Procedures on an annual basis on or before GMHSA_SABGPP_YYYYMMDD_AgencyID September 30 th every year September 30 th. Scope Work (SABGRS-100) - SABG - GMH/SA Residential Services For providers receiving >$750,00 per year in either MHBG or SABG FIN-04 A-133 Audit Finance Yearly combined funds, due 4 months after Finance_A133Audit_YYYYMMDD_AgencyID provider fiscal year end. For providers receiving any SABG funds, Attachment J in the MMIC FIN-05 SABG ing Finance Quarterly Financial ing Guide Finance_SABG_YYYYMMDD_AgencyID Attachments. SABG providers must submit all their On or before SABG Provider Policies and SABG related policies and procedures GMHSA System GMHSA-07 Procedures on an annual basis on or before GMHSA_SABGPP_YYYYMMDD_AgencyID September 30 th every year September 30 th. Provider_Deliverables_(v3.2).xlsx /16/2015

32 The data collected in this deliverable will asisst Systems Care to monitor provider length GMHSA Residential Length stay averages and outliers. ASAM GMHSA System 5th each GMHSA-09 Stay scores are also being collected to GMHSA_ResLOS_YYYYMMDD_AgencyID month ensure that providers are suing ASAM correctly when deciding on appropriate tratments and levels care fo rmembers. Scope Work (SEE-100) - Supported Employment Expansion Network Supported Employment Expansion Providers to complete Supported Employment Outcomes Supported Employment SFPT File Name Format: Employment 10th the EMPLOY-06 Template provided. List Outcome ASOC_EmpProSupEmp_YYYYMM_AgencyID members engaged in supported employment servcies and data fields associated. Scope Work (SMIE-100) - SMI Evaluations There are no additional Provider Deliverables for SMIE-100 Scope Work (SSG-100) - Survivor Support Group Provider_Deliverables_(v3.2).xlsx /16/2015

33 Peer Attempt Survivor Peer Attempt Survivor Support CRISIS-18 Support Group Satisfaction Crisis Quarterly Group Satisfaction Surveys Crisis_CRISIS-18_YYYYMM_AgencyID Surveys Scope Work (SUPH-100) - Supportive Housing There are no additional for SUPH-100 Scope Work (TCMC-100) - Tribal Community Mobile Crisis Disposition report regarding Tohono O'odham 1 Tribal-01 Tohono O'odham and Ft. McDowell Tribal Liaison Disposition TribalLiaison_Tribal-01_YYYYMM_AgencyID crisis responses Scope Work (WHC-100) - Whole Health Clinic Within Five (5) Notification a Person No G&A Intake Line: (602) Notification a Person No Longer Grievance System Business Days GA-02 Longer In Need Special or In Need Special Assistance Assistance us at: MMICGANDA@aetna.com G&A Intake Line: (602) Within 24 Hours Notification a Person In Notification a Person In Need Grievance System GA-03 or Need Special Assistance Special Assistance us at: MMICGANDA@aetna.com Provider_Deliverables_(v3.2).xlsx /16/2015