Source: https://www.azcompletehealth.com/providers/resources/provider-manual/pm_section_10.html
Timestamp: 2019-04-25 08:02:54+00:00

Document:
An advance directive is a written set of instructions developed by an adult member in the event the member becomes incapable of making decisions regarding their health care. An advance directive instructs others regarding the member’s wishes, if they become incapacitated and can include the appointment of a friend or relative to make health care decisions for the member. An adult member prepares an advance directive when competent and capable of making decisions, and the directive is followed when the member is incapable of making treatment decisions. This section outlines the requirements of providers with regard to advance directives (see 42 CFR 489.102).
A health care power of attorney gives an adult member, not under legal guardianship, the right to designate another adult person to make health care treatment decisions on their behalf. The designee may make health care decisions on behalf of the adult member if/when they are found incapable of making these types of health care decisions. However, the designee must not be a provider directly involved with the health treatment of the adult member at the time the health care power of attorney is executed.
See A.R.S. § 36-3281 for additional information regarding a mental health power of attorney and a member who is “found incapable” of making their own health care decisions.
May consent to admitting the adult member to an Inpatient Facility licensed by the Arizona Department of Health Services if this authority is expressly stated in the mental health care power of attorney or health care power of attorney.
See A.R.S. § 36-3283 for a complete list of the powers and duties of an agent designated under a mental health care power of attorney.
Changes to State law as soon as possible, but no later than 90 days after the effective date ofhe change [42CFR 438.6(i) (4)].
Written information regarding advance directives shall be provided to members at the time of enrollment with the member handbook. Refer to The Health Plan Member Handbook and AHCCCS ACOM Policy 404 (Member Information) for member information and AHCCCS ACOM Policy 406 (Member Handbook and Provider Directory) for member handbook requirements.
If an adult member is incapacitated at the time of enrollment, providers may give advance directive information to the member’s family or surrogate in accordance with state law. Providers must also follow up when the member is no longer incapacitated and verify that the information is given to the member directly.
Providers must assist adult members or their legal guardians who are interested in developing and executing an advance directive. Providers must maintain written policies that address the rights of adult members to make decisions about medical care, including the right to accept or refuse medical care and the right to execute an advance directive. Members must be provided information about formulating advance directives (see AHCCCS AMPM, Policy 640 Advanced Directives).
For members in an Alternative Home and Community Based setting or a behavioral health residential setting that have completed an advance directive, the document must be kept confidential but be readily available. For example: in a sealed envelope attached to the refrigerator. Staff must have immediate access to executed Advance Directive documents to provide to first responder requests.
Providers shall reference the AHCCCS AMPM Policy 640 (Advance Directives for additional information related to the requirements for providers and what must be disseminated to members upon enrollment and/or as needed.
Additional information regarding advance directives can be obtained by calling The Health Plan Customer Service at 1-866-796-0542.
Provide education to staff on issues concerning advance directives including notification of direct care providers of services, such as home health care, hospice and personal care, of any advance directives executed by member’s to whom they are assigned to provide services.
The provider is not relieved of its obligation to provide the above information to the member once they are no longer incapacitated or unable to receive such information. Follow-up procedures shall be in place to provide the information to the member directly at the appropriate time.
End of Life (EOL) care is is member-centric care that includes Advance Care Planning, and the delivery of appropriate health care services and practical supports. The goals of EOL care focuses on providing treatment, comfort, and quality of life for the duration of the member’s life.
Share the member’s wishes with friends, family and providers.
Advance care planning often results in the development of an executed Advance Directive for the member (see AHCCCS AMPM Policy 640).
Assist the member, legal guardian or designated representative in identifying practical supports to meet the member’s needs.
Practical supports are non-billable services provided by a family member, friend or volunteer to assist or perform functions such as housekeeping, personal care, food preparation, shopping, pet care and non-medical comfort measures.
The Health Plan provides care/case management to qualifying members and coordinates with and supports the member’s provider in meeting the member’s needs. In addition, the care/case manager assists the member/guardian/designated representative in ensuring practical supports and community referrals are maintained or revised to meet the member’s current needs.
The purpose of this section is to ensure that providers maintain medical records that document medical needs, changes and the delivery of medically necessary services. Medical records must be complete accurate, accessible and permit systematic retrieval of information while maintaining confidentiality. Documentation in the medical record facilitates diagnosis and treatment, coordination of care, supports billing reimbursement information, provides evidence of compliance during periodic medical record reviews and can protect practitioners against potential litigation.
The medical record contains clinical information pertaining to a member’s physical and behavioral health. Maintaining current, accurate, well organized and comprehensive medical records assists providers in successfully treating and supporting member care. A member may have more than one medical record kept by various health care providers that have rendered services to the member.
Providers must maintain legible, signed and dated medical records in paper or electronic format that are written in a detailed and comprehensive manner; conform to good professional practices; permit effective professional review and audit processes; and facilitate an adequate system for follow up treatment. Medical records must contain documentation of referrals to other providers, coordination of care and transfer of care to other providers.
All providers must maintain and store records and data that document and support the services provided to members and the associated encounters/billing for those services. In addition to any records required to comply with providers’ contracts with The Health Plan, there must be adequate documentation to support that all billings or reimbursements are accurate, justified and appropriate.
All providers must prepare, maintain and make available to The Health Plan or AHCCCS, adequate documentation related to services provided and the associated encounters/billings.
Adequate documentation is electronic records and “hard-copy” documentation that can be readily discerned and verified with reasonable certainty. Adequate documentation must establish medical necessity and support all medically necessary services rendered and the amount of reimbursement received (encounter value/billed amount) by a provider; this includes all related clinical, financial, operational and business supporting documentation and electronic records. It also includes clinical records that support and verify that the member’s assessment, diagnosis and Individual Service Plan (ISP) are accurate and appropriate and that all services (including those not directly related to clinical care) are supported by the assessment, diagnosis and ISP.
For monitoring, reviewing and auditing purposes, all documentation and electronic records must be made available at the same site at which the service is rendered. If requested documents and electronic records are not available for review at the time requested, they are considered missing. All missing records are considered inadequate. If documentation is not available due to off-site storage, the provider must submit their applicable policy for off-site storage, demonstrate where the requested documentation is stored and arrange to supply the documentation at the site within twenty-four (24) hours of the original request.
A provider’s failure to prepare, retain and provide to The Health Plan or AHCCCS adequate documentation and electronic records for services encountered or billed, may result in the recovery and/or voiding (not to be resubmitted) of the associated encounter values or payments for those services not adequately documented and/or result in financial sanctions to the provider and The Health Plan.
Inadequate documentation may be determined to be evidence of suspected fraud or program abuse that may result in notification or reporting to the appropriate law enforcement or oversight agency. These requirements continue to be applicable in the event the provider discontinues as an active participating and/or provider as the result of a change of ownership or any other circumstance.
If a rubber-stamp signature is used to authenticate the document or entry, the individual whose signature the stamp represents is accountable for the use of the stamp.
A progress note is documented on the date that an event occurs. Any additional information added to the progress note is identified as a late entry and dated appropriately.
Electronic signatures used to authenticate a document are properly safeguarded and the individual whose signature is represented is accountable for the use of the electronic signature.
Maintain a backup system including initial and revised information.
Providers must meet all federal electronic health record requirements. The federal government may impose penalties on the provider of service in the form of rate reductions for non-compliance.
The provider of care must verify the development and maintenance of a comprehensive clinical record for each member. The comprehensive clinical record, whether electronic or hard copy, may contain information contributed by several service providers involved with the care and treatment of a member. This section describes categories of information to be included in a member’s comprehensive clinical record: (a) the minimum information; (b) physical health record; (c) the behavioral health record; and (d) information from Community Service Agencies, Home Care Training for the Home Care Client (HCTC) providers and Habilitation providers.
Identification of other Stakeholder involvement (DES/DDD, Juvenile Probation Officer/ Department of Corrections(DOC), Department of Child Safety(DCS), DES Adult Protective Services (APS), etc.).
Behavioral health history and behavioral health information received from a Regional Behavioral Health Authority/Managed Care Organization or a Health Plan behavioral health provider who is also treating the member.
Signature/initials of the provider for each service.
Require documentation in the member’s medical record showing supervision by a licensed professional, who is authorized by the licensing authority to provide supervision, whenever health care assistants or para professionals provide services.
Contact information for the member’s primary care provider (PCP), if applicable.
For members receiving services via telemedicine, copies of electronically recorded information of direct, consultative or collateral clinical interviews.
For members receiving services via telemedicine, electronically recorded information of direct, consultative or collateral clinical interviews.
Documentation of any requests for and forwarding of behavioral health record information.
Information regarding establishment of any copayments assessed, if applicable (see Section 7.22- Copayments).
Documentation of authorization of any mental health care power of attorney that appoints a designated person to make behavioral health care decisions on behalf of the member if they are found to be incapable of making these decisions.
Any extension granted for the processing of an appeal must be documented in the case file, including the Notice regarding the extension sent to the member and their legal guardian or authorized representative if applicable (see Section 8.4 - Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons).
If required records are kept in more than one location, the agency/provider shall maintain a list indicating the location of the records.
Daily documentation of the service(s) provided and monthly summary of progress toward treatment goals.
Every thirty (30) days, a summary of the information required in this section must be transmitted from the CSA, HCTC Provider or Habilitation Provider to the member’s clinical team for inclusion in the comprehensive clinical record.
Signature of the member, parent and/or guardian/caregiver, verifying services were rendered. If the member refuses to sign the trip validation form, then the driver should document their refusal to sign and this documentation must be placed into the comprehensive medical record.
It is the provider's responsibility to maintain documentation that supports each transport provided. Transportation providers put themselves at risk of recoupment of payment if the required documentation is not maintained or covered services cannot be verified.
The Health Plan Primary Care Providers must maintain a medical record that incorporates behavioral health information when received from a behavioral health provider about an assigned member even if the provider has not yet seen the assigned member. In lieu of actually establishing a medical record, such information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established.
In addition to treating physical health conditions, PCPs may treat behavioral health conditions within their scope of practice. Such treatment shall include but not be limited to substance use disorders, anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD). For purposes of medication management, it is not required that the PCP be the member’s assigned PCP. PCPs who treat members with these behavioral health conditions may provide medication management services including prescriptions, laboratory and other diagnostic tests necessary for diagnosis, and treatment. For antipsychotic class of medications, prior authorization may be required. PCPS prescribing medications to treat Opioid Use Disorder (OUD) must refer the member to a behavioral health provider for the psychological and/or behavioral therapy component of the Medication Assisted Treatment (MAT) model and coordinate care with the behavioral health provider.
When a PCP has initiated medical management services for a member to treat a behavioral health disorder, and it is subsequently determined by the PCP and The Health Plan that the member should receive care through the behavioral health system for evaluation and/or continued medication management services, providers will assist the PCP with the coordination of the referral and transfer of care. The PCP will document in the medical record the coordination of care activities and transition of care. The PCP must document the continuity of care (See Section 11.11 – PCP Treatment and Referrals and Section 13.3 - Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers).
Transfer of a member’s medical records due to transitioning of the member to a new T/RBHA/Health Plan and/or provider (see Section 13.1 - Transition of Persons for additional information on Inter-RBHA/MCO transfers) or due to The Health Plan terminating the provider contract, is important to ensure that there is minimal disruption to the member’s care and provision of services. The medical record must be transferred in a timely manner that ensures continuity of care.
When a member changes their provider, the member’s medical record or copies of it must be forwarded to the new provider within ten (10) business days from receipt of the request for transfer of the medical record.
Federal and State law allow the transfer of medical records from one provider to another, without obtaining the member’s written authorization if it is for treatment purposes (45 C.F.R. § 164.502(b), 45 C.F.R. § 164.514(d) and A.R.S. 12-2294(C)). Generally, the only instance in which a provider must obtain written authorization is for the transfer of alcohol/drug and/or communicable disease treatment information (see Section 9.6. – Confidentiality for other situations that may require written authorization).
The original provider must send that portion of the medical record that is necessary to the continuing treatment of the member. In most cases, this includes all communication that is recorded in any form or medium and that relates to patient examination, evaluation or behavioral or physical health treatment. Records include medical records that are prepared by a health care provider or other providers. Records do not include materials that are prepared in connection with utilization review, peer review or quality assurance activities, including records that a health care provider prepares pursuant to section A.R.S. § 36-441, A.R.S. § 36-445, A.R.S. § 36-2402 or A.R.S. § 36-2917.
Federal privacy law indicates that the Designated Record Set (DRS) is the property of the provider who generates the DRS. Therefore originals of the medical record are retained by the terminating or transitioning provider. The cost of copying and transmitting the medical record to the new provider shall be the responsibility of the transitioning provider (see AHCCCS ACOM, Policy 402).
The Health Plan will conduct routine medical record audits to assess compliance with established standards and audit tools in accordance with The Health Plan Provider Manual, AMPM, ACOM, Arizona Administrative Code and AHCCCS contract requirements. Medical records may be requested when The Health Plan, AzAHIP or AHCCCS are conducting audits or investigating quality of care issues. Providers must respond to these requests within seven (7) days. Medical records must be made available to AHCCCS for quality review upon request.
The Health Plan utilizes a collaborative and transparent audit approach with providers. For behavioral health providers, medical record reviews are conducted by The Health Plan on at least an annual basis per AHCCCS AMPM Policy 920 Attachment A. For PCPs, Pediatricians and OB/GYNs medical records are conducted under the Arizona Association of Health Plans (AzAHP). AzAHP serves as an association of contracted AHCCCS health plans.
Behavioral health providers must send copies of any information maintained in their own behavioral health record that must also be maintained in the comprehensive clinical record.
All medical records, data and information obtained, created or collected by the provider related to the member, including confidential information must be made available electronically to The Health Plan, AHCCCS or any government agency upon request.
A provider shall furnish records requested by AHCCCS, AzAHIP or The Health Plan at no charge. Also if the provider utilizes a copy service, no charge will occur.
When requested by a member’s behavioral health provider, primary care provider or the member’s DES/DDD/ALTCS support coordinator, the member’s health record or copies of health record information must be forwarded within ten (10) business days of the request. The response should include all pertinent information, including, but not limited to, current diagnoses, medications, laboratory results, last provider visit and recent hospitalizations (see Section 13.3 – Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers and AHCCCS AMPM, Policy 940 for more information).
Providers must obtain consent and authorization to disclose protected health information in accordance with 42 CFR 431, 42 CFR part 2, 45 CFR parts 160 and 164 and A.R.S. § 36-509. Unless otherwise prescribed in federal regulations or statute, it is not necessary to obtain a signed release in order to share health related information with the member‘s parent/legal guardian, behavioral health provider, primary care provider (PCP), The Health Plan Health Coordinator acting on behalf of the PCP or authorized state social service agency.
AHCCCS or its designee may inspect Title XIX/XXI medical records at any time during regular business hours at the offices of AHCCCS, The Health Plan or its providers. The Department of Economic Security, Division of Developmental Disabilities (DES/DDD) or its designee may inspect the medical records of their enrolled Title XIX, Title XXI, and DES/DDD Arizona Long Term Care Services (ALTCS) members at any time during regular business hours at the offices of AHCCCS, The Health Plan or its providers.
The Health Plan has the discretion to obtain a copy of a member’s medical records without written approval by the member if the reason for such request is directly related to the administration of service delivery. Furthermore, The Health Plan has the discretion to release information related to fraud and abuse so long as protected HIV-related information is not disclosed (see A.R.S. § 36-664) and substance abuse information is only disclosed consistent with federal and state law, including but not limited to 42 CFR 2.1, et seq.
Additionally, providers must provide each member who makes a request one copy of their medical record free of charge annually.
Upon request, providers must allow members to view and amend their medical record as specified in 45 C.F.R. § 164.524, 45 C.F.R. § 164.526 and A.R.S. § 12-2293 and must have policies in place indicative of such.
For a child, either for at least three (3) years after the child’s eighteenth (18th) birthday or for at least six (6) years after the last date the child received medical or health care services from The Health Plan or a provider, whichever occurs later.
The maintenance and access to the member’s medical record shall survive the termination of a provider’s contract with The Health Plan, regardless of the cause of the termination.
In addition, the provider shall comply with the record retention periods specified in HIPAA laws and regulations, including, but not limited to, 45 CFR 164.530(j) (2).
The Health Plan may conduct surveys or authorize a third party to conduct surveys of a representative sample of the membership and providers.
The Health Plan may provide the survey tool or require the providers to develop the survey tool, which shall be approved in advance.
The results of the surveys will become public information and available to all interested parties on the Health Plan website. Providers may be required to participate in workgroups and efforts that are initiated as a result of the survey results.
The Health Plan may conduct surveys of a representative sample of the membership and providers.
A scope of work and a timeline for the survey project is submitted if the survey is not initiated by The Health Plan. The Health may require inclusion of certain questions.
Data, results and the analysis of the results is submitted to The Health Plan within 45 days of the completion of the project.
Providers shall bear all costs associated with the survey.
Note that surveys may include Home and Community Based Services Member experience surveys, Health Effectiveness Data and Information Set (HEDIS) Experience of Care Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.
Survey findings may result in the provider being required to develop a corrective action plan (CAP) to improve any areas noted by the survey or a requirement to participate in workgroups and efforts as a result of the survey results. Failure of the provider to develop a Corrective Action Plan (CAP) and improve the area may result in regulatory action.
The Health Plan is committed to establishing high quality services. One method for achieving this is through adherence to the standards and guidelines set by the Centers for Medicare and Medicaid Services (CMS) and AHCCCS, which includes implementation of performance improvement projects (PIP) specific to member needs and data identified through internal/external surveillance of trends (42 CFR 438.240; AM/PM Section 980). PIP methodologies are developed according to CMS and AHCCCS requirements. This policy provides information regarding the responsibilities of The Health Plan and providers in implementing and reporting PIPs as required by CMS or AHCCCS, or The Health Plan topics approved by AHCCCS.
Result in significant performance improvement sustained over time.
PIPs are designed to achieve two primary goals. The first goal is to demonstrate achievement and sustainment of improvement for significant aspects of clinical care and non-clinical services, with the expectation of improved health outcomes and member satisfaction. A second goal is to correct significant systemic issues.
A clinical study topic would be one for which outcome indicators measure a change in behavioral or physical health acute or chronic conditions, health status or functional status; high risk services; or continuity and coordination of care. A non-clinical or administrative study topic would be one for which indicators measure changes in availability, accessibility and adequacy of the service delivery system, cultural competency of service, inter-personal aspects of care, and appeals, grievances or complaints.
PIP topics may come to the attention of AHCCCS in part through data from the AHCCCS functional areas (e.g.: network, medical director’s office); statewide contractor performance data and contract monitoring activities; tracking and trending of grievance and appeal data and quality of care concerns; provider credentialing and profiling as well as other oversight activities, such as chart reviews; Quality Management/Medical Management data analysis and reporting; and member and/or provider satisfaction surveys and feedback.
The Health Plan providers play an integral role in the implementation of AHCCCS PIPs. When applicable, contracted providers are expected to collaborate with The Health Plan, other providers, stakeholders, and community members to identify, plan and implement recommended improvement strategies that are developed as a result of an identified performance improvement project.
Plan: Plan the change(s) or intervention(s), including a plan for collecting data. State the objective(s) of the intervention(s).
Do: Try out the intervention(s) and document any problems or unexpected results.
Study: Analyze the data and study the results. Compare the data to predictions and summarize what was learned.
Act: Refine the change(s)/intervention(s), based on what was learned, and prepare a plan for retesting the intervention(s).
Repeat: Continue the cycle as new data becomes available until improvement is achieved.
All Performance Improvement Projects conducted by The Health Plan and its providers must use the Performance Improvement Project reporting templates included in the AHCCCS AMPM, Section 980-2.
Evidenced Based Practices are interventions recognized as effective in treating a specific health-related condition based on scientific research; the skill and judgment of care health professionals; and the unique needs, concerns and preferences of the person receiving services (AHCCCS Contract General Requirements Exhibit 1-Definitions). Clinical practice guidelines are systematically developed statements to assist practitioners and member decisions about appropriate health care for specific circumstances.
Providers must ensure they coordinate and provide member access to quality health care services, regardless of type, amount, duration, scope, service delivery method and population served, that are informed and supported by evidence-based practice guidelines; will reasonably prevent injury and result in improved health outcomes; and are cost effective (AHCCCS Contract General Requirements 4.2.1 & 10.1.2.2). The delivery of services should be consistent with values, principles and goals of effective, innovation promoting, evidence-based practices. (AHCCCS Contract System Values and Guiding Principles 1.2). Providers should complete member service plans with written descriptions of all covered health services and other informal supports which reflect applicable evidence-based practice guidelines (AHCCCS Contract System Values and Guiding Principles 1.2).
Ensure PCP providers treating members with anxiety, depression and Attention Deficit Hyperactivity Disorder (ADHD) are aware of clinical tool kits available in the AHCCCS AMPM and/or are utilizing other recognized, clinical tools/ evidenced-based guidelines. Also have a monitoring process in place to ensure that evidence-based guidelines/recognized clinical tools are used when prescribing medications to treat depression, anxiety, and ADHD (AHCCCS Contract 4.13.2).
Behavioral health providers should receive training on the AHCCCS National Practice Guidelines and Clinical Guidance Documents with required elements before providing services, but must receive training within six months of the staff person's hire date (protocol training is only required if pertinent to populations served) (https://www.azahcccs.gov/; AHCCCS AMPM Policy 1060).
Providers are required to also verify all services are performed in accordance and in compliance with State Clinical and Recovery Practice Protocols and any revisions or additions to the State Clinical and Recovery Practice Protocols.
The Health Plan and providers shall disseminate to members and potential members upon request, Clinical Practice Guidelines based on valid and reliable clinical evidence or a consensus of health care professionals in the field that considers member needs, 42 CFR 438.236 (c) (AHCCCS Contract Practice Guidelines 8.9). Providers must be able to provide a basis for consistent decisions for utilization management, member education, coverage of services and other areas to which the guidelines apply, 42 CFR 438.236 (d) (AHCCCS Contract Practice Guidelines 8.9; AHCCCS Contract Drug Utilization Review 8.15).
Implement interventions to improve performance, based on an evaluation of barriers to care/use of services and evidence-based approaches to improving performance (AHCCCS AMPM Policy 980).
Peer Review Committee (PRC) scope includes member treatment concerns where there is evidence that a provider has not met standard of care, or there was omission of care or services by a participating or non-participating health care professional or provider whether delivered in or out of state. The Chief Medical Officer may, at their discretion, refer other cases and/or practitioner reviews to the PRC for evaluation and corrective action recommendation. All Peer Review proceedings are protected by statute from discovery in any legal proceeding. Any correspondence pertaining to a peer review is labeled “Privileged and Confidential, Peer Review” thus maintaining the protection under applicable State and Federal laws. Adverse actions taken as a result of the Peer Review Committee must be reported to AHCCCS within 24 hours of an adverse decision being made. The Health Plan also must implement recommendations made by the AHCCCS Peer Review Committee. Some AHCCCS Peer Review recommendations may be appealable agency actions under State law. A The Health Plan provider may appeal such a decision through the administrative process described in A.R.S. § 41-1092, et seq.
Allegations from any source that bring into question the standard of practice.
The Peer Review Committee, using their clinical judgment, is responsible for making recommendations to the Chief Medical Officer. The assigned lead reviewer for each case gives a clinical summation of the case and highlights any points of concern or discussion to the committee. The peer review process ensures that providers of the same or similar specialty participate in the review. If the PRC requires additional information prior to making a determination, the case is pended and information is obtained for review at a future PRC. The Peer Review Committee must determine appropriate action and next steps. The Chief Medical Officer is responsible for implementing all peer review actions.
Within 15 calendar days of the PRC meeting, the reviewed provider will receive a written notification informing them of the outcome of the review including corrective action and timeframes for completion if applicable. This letter will also notify provider of the procedure for provider appeals and hearings related to peer review committee. Providers are informed in the written notification that any appeal must be received within 30 days of receipt of the notification. The provider is entitled to an opportunity for a hearing in the event the PRC recommends corrective action(s) for reasons relating to the competence or professional conduct of the provider, or in the event the provider is entitled by law to an opportunity for a hearing. The Procedure for Provider appeals and hearings related to Peer Review corrective actions is the same as that outlined in the Credentialing Practitioner Appeal Hearing Process. Upon completion of the corrective actions and satisfactory behavioral changes by the provider, the provider is notified of completion in writing. If the Peer Review Committee review results in a recommendation for termination of a provider, the recommendation is presented to the Credentialing Committee for final determination. Reviews resulting in the reduction, suspension, or termination of a provider’s participation are reported to appropriate boards, regulatory agencies and the National Practitioner’s Data Back.
The Quality Management department responds to quality of care concerns received from Members and providers or issues identified during routine clinical review of Members’ care, or received from anywhere within The Health Plan or from anywhere in the community. If substantiated as a true quality of care issue, the concern will be tracked and trended or may be forwarded to the Peer Review Committee. Summary information on quality of care reviews is furnished to the Credentialing Committee at the time of the providers’ re-credentialing. All of these activities concerning provider information may be used for future Performance Improvement Projects.
Quality of Care (QOC) concerns may be referred by State agencies, internal AHCCCS sources (e.g., Customer Service, the Office of the Deputy Director), and external sources (e.g., Members; providers; other stakeholders; Incident, Accident, and Death reports).
Upon receipt of a QOC concern, The Health Plan follows the procedures below.
First, The Health Plan documents each issue raised, when and from whom it was received, and the projected time frame for resolution. The Health Plan then promptly determines whether the issue is to be resolved through one or more of the following operational areas: Quality of Care; Customer Service; Grievance and Appeal process; and/or Fraud, waste, and program abuse.
The Health Plan then acknowledges receipt of the issue and explains to the Member or provider the process that will be followed to resolve the issue through written correspondence. If the issue is being addressed as other than a QOC investigation, The Health Plan explains to the Member or provider the process that will be followed to resolve their issue using written correspondence. QOC related concerns remain with the Quality Management department due to state and federal regulations: 42 U.S.C. 1320c-9, 42 U.S.C. 11101 et seq., A.R.S. §36-2401, A.R.S. §36-2402, A.R.S. §36-2403, A.R.S. §36-2404, A.R.S. §36-2917.
The Health Plan assist the Member or provider as needed to complete forms or take other necessary actions to obtain resolution of the issue. The Health Plan ensures the confidentiality of all Member information and informs the Member or provider of all applicable mechanisms for resolving the issue.
Finally The Health Plan documents all follow-up with the Member that includes, but is not limited to: assistance as needed to verify that the immediate health care needs are met, and a closure/resolution letter that provides sufficient detail to verify all covered, medically necessary care needs are met and a contact name/telephone number to call for assistance or to express any unresolved concerns.
The quality of care concern process at The Health Plan includes documentation of identification, research, evaluation, intervention, resolution, and trending of Member and provider issues. Resolution must include both Member and system interventions when appropriate. The quality of care process must be a standalone process and shall not be combined with other agency meetings or processes.
Quantitative and qualitative analysis of the research, which may include root cause analysis.
Implementing new interventions/approaches, when necessary.
Substantiated – The alleged complaint (allegation) or reported incident was verified or proven to have happened based on evidence and had a direct effect on the quality of the Members health care. Substantiated allegations require a level of intervention such as a corrective action plan of steps to be taken to improve the quality of care or service delivery and/or to verify the situation will not likely happen again.
Unable to Substantiate – There was not enough evidence at the time of the investigation to show whether a QOC allegation did occur or did not occur. The evidence was not sufficient to prove or disprove the allegation. No intervention or corrective action is needed or implemented.
Unsubstantiated – There was enough credible evidence (preponderance of evidence) at the time of the investigation to show that a QOC allegation did not occur. The allegation is based on evidence, verified or proven, to have not occurred. No intervention or corrective action is needed or implemented.
Level 0 (Track and Trend Only) – An issue no longer has an immediate impact and has little possibility of causing, and did not cause, harm to the recipient and/or other recipients, an allegation that is unsubstantiated or unable to be substantiated when the QOC is closed.
Level 1 – Concern that MAY potentially impact the Member and/or other Members if not resolved.
Level 2 – Concern that WILL LIKELY impact the Member and/or other Members if not resolved promptly.
Level 3 – Concern that IMMEDIATELY impacts the Member and/or other Members and is considered potentially life threatening or dangerous.
Level 4 – Concern that NO LONGER impacts the Member. Death or an issue no longer has an immediate impact on the Member, an allegation that is substantiated when the QOC is closed.
The Health Plan, as an active participant in the process, will report issues to the appropriate regulatory agency including Adult Protective Services, AHCCCS, Department of Child Safety, the Attorney General’s Office, or law enforcement for further research/review or action. Initial reporting may be made verbally, but must be followed by a written report within one business day.
The Health Plan, as an active participant in the process, must notify AHCCCS of any adverse action taken against a provider.
Upon receiving notification that a health care professional’s organizational provider or other provider’s affiliation with their network is suspended or terminated as a result of a quality of care The Health Plan, as an active participant in the process, is required to notify AHCCCS of the same.
An overall substantiation determination and level of severity for the case.
Written response from or summary of the documents received from referrals made to outside agencies such as accrediting bodies, or medical examiner.
The Health Plan uses data pulled from the QOC database to monitor the effectiveness of QOC-related activities to include grievances and allegations received from Members and providers, as well as from outside referral sources. The Health Plan, as an active participant in the QOC process, also tracks and trends QOC data and reports trends and potential systemic problems to AHCCCS.
The data from the QOC database will be analyzed and evaluated to determine any trends related to the quality of care or service in The Health Plan’s service delivery system or provider network, and aggregated for AHCCCS. When problematic trends are identified through this process, The Health Plan will incorporate the findings in determining systemic interventions for quality improvement. The Health Plan, as an active participant in the QOC process, also incorporates trended data into systemic interventions.
As evaluated trended data is available, The Health Plan will prepare and present analysis of the QOC tracking and trending information for review and consideration of action by the Quality Management Committee and Chief Medical Officer, as Chairperson of the Quality Management Committee.
Resolution status of “substantiated”, “unsubstantiated” and “unable to substantiate” QOC issues.
If a significant negative trend is found, The Health Plan may choose to consider it for a performance improvement activity to improve the issue resolution process itself, and/or to make improvements that address other system issues raised during the resolution process.
The Health Plan will submit to AHCCCS Clinical Quality Management all pertinent information regarding an incident of abuse, neglect, exploitation, serious incident (including suicide attempts) and unexpected death (including all unexpected transplant deaths) as soon as The Health Plan becomes aware of the incident, and no later than 24 hours. Pertinent information must not be limited to autopsy results only, but must include a broad review of all issues and possible areas of concern. Delays in the receipt of autopsy results shall not result in a delay in the investigation of a quality of care concern by The Health Plan. As The Health Plan receives delayed autopsy results, it will use them to confirm the resolution of the QOC concern. If the cause and manner of death gives reason to change the findings of the QOC concern, The Health Plan will notify AHCCCS and resubmit a revised resolution report. The Health Plan will also revise closing letters to AHCCCS if the cause and manner of death changes the findings of a QOC investigation.
The Health Plan, as an active participant in the QOC process, must verify that Member health records are available and accessible to authorized staff of their organization and to appropriate State and federal authorities, or their delegates, involved in assessing quality of care or investigating Member or provider quality of care concerns, grievance and appeals, allegations of abuse, neglect, exploitation grievances and Healthcare Acquired Conditions (HCAC). Member record availability and accessibility must be in compliance with federal and State confidentiality laws, including, but not limited to, Health Insurance Portability and Accountability Act (HIPAA) and 42 C.F.R. 431.300 et seq.
If a Health Care Acquired Condition (HCAC) or Other Provider-Preventable Condition (OPPC) is identified, The Health Plan will conduct a quality of care investigation and report the occurrence and results of the investigation to the AHCCCS Clinical Quality Management Unit.
All Health Care Acquired Conditions and Other Provider-Preventable Conditions are reported to the AHCCCS Quality Management Team on a quarterly basis.
Medicare eligible Members, including persons who are dually eligible for Medicare (Title XVIII) and Medicaid (Title XIX) receive Medicare Part D prescription drug benefits through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA- PDs). Medicare Part D coverage includes copayment and coinsurance requirements. However, Medicare Part D copayments are waived when a dual eligible person enters a Medicaid funded medical institution for at least a full calendar month. The facility must notify the Arizona Health Care Cost Containment System (AHCCCS) when a dual eligible person is expected to be in the medical institution for at least a full calendar month to verify copayments for Part D are waived. See AHCCCS ACOM Policy 201, Attachment A Notification to Waive Medicare Part D Co-Payments for Members in a Medicaid Funded Medical Institution. The waiver of copayments applies for the remainder of the calendar year, regardless of whether the person continues to reside in a medical institution. Given the limited resources of many dual eligible persons and to prevent the unnecessary burden of additional copay costs, it is imperative that these individuals are identified as soon as possible.
The objective of this policy is to inform providers designated as medical institutions of reporting and tracking requirements for dual eligible persons to verify Medicare Part D copays are waived.
To verify that dual eligible persons’ Medicare Part D copayments are waived when it is expected that dual eligible persons will be in a medical institution, funded by Medicaid, for at least a full calendar month, the facility must notify AHCCCS immediately upon admittance.
Persons who are in continuous placement in a single medical institution or any combination of continuous placements that are identified below.
Additional information regarding Medicare cost sharing for members covered by Medicare and Medicaid can be found in AHCCCS ACOM, Policy 201.
Seclusion and restraint are high-risk interventions that must be used to address emergency safety situations only when less restrictive interventions have been determined to be ineffective, in order to protect Members, staff members or others from harm. All persons have the right to be free from seclusion and restraint, in any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. Seclusion or restraint may only be imposed to ensure the immediate physical safety of the person, a staff member or others and must involve the least restrictive intervention, and be discontinued at the earliest possible time (42 CFR §482.13).
This section includes seclusion and restraint reporting requirements for contracted behavioral health inpatient facilities (42 CFR §482.13) (A.A.C. R9-21) and behavioral health inpatient facilities serving persons under the age of 21 (42 CFR §483 Subpart E).
The Health Plan is also required to collect certain aggregate data that compiles total seclusion and restraints for the reporting period, and forward that data to the State.
Contracted behavioral health inpatient facilities shall follow local, state and federal regulations and requirements related to seclusion and restraint.
Each occurrence of seclusion and restraint to The Health Plan within five (5) calendar days of the occurrence, via email AzCHQualityManagement@azcompletehealth.com, attention Quality Management. Failure to submit seclusion and restraint reports timely may result in a financial sanction for late submission of a contract deliverable.
Reports of seclusion and restraint are to be submitted using Provider Manual Form 9.9.1 Seclusion and Restraint Reporting Form which can be obtained from the Provider Services Call Center at 866-796-0542.
The Provider Manual Form 9.9.1, Seclusion and Restraint Reporting Form must be completed in its entirety and include the required information detailed on AHCCCS Policy Attachment 1702A.
In the event that a use of seclusion or restraint requires face-to-face monitoring, a report detailing face-to-face monitoring must be completed using the Provider Manual Form 9.9.1, Seclusion and Restraint Reporting Form or attached to the reporting form. The face-to-face monitoring form must include the requirements as per 42 CFR 482.13, 42 CFR § 483 Subpart 12, and R9-21-204.
The Health Plan may also request copies of provider agency Policies and Procedures pertaining to the use of seclusion and restraint, evidence of staff trainings, and any corrective actions taken to reduce the frequency of usage.
Each behavioral health inpatient facility or Mental Health Agency shall report the total number of incidents of the use of S&R involving AHCCCS members in the prior month to the Health Plan by the fifth calendar day of the month. If there were no incidents of Seclusion or restraint during the reporting period, the report should so indicate.
Providers are directed to call the Provider Service Center to obtain a copy of these forms, if needed, at 1-866-796-0542.
Because of the high-risk nature of seclusion and restraint interventions, it is possible that a person may be injured or that a serious occurrence may occur during a seclusion and restraint event.
Contracted behavioral health inpatient facilities authorized to use seclusion and restraint shall report any occurrence of injury or serious occurrence during a seclusion and restraint following the guidelines in Section 10.10 - Reporting of Incidents, Accidents and Deaths.
Behavioral health inpatient facilities must report any incident, accident or death that pertain to the following, of an enrolled Member to The Health Plan within 2 business days, following the guidelines in Section 10.10 – Reporting Of Incidents, Accidents and Deaths.
AHCCCS: fax number 602-417-4162 Attention DHCM Senior Clinical and Quality Consultant.
Licensed behavioral health inpatient facilities must notify the ADHS Division of Licensing within one working day of discovering a serious occurrence that requires medical services, or death that occurs as a result of a seclusion and/or restraint. This notification must be followed up by a written ADHS Division of Licensing report within five days of initial notification. Reporting to ADHS Licensing would not utilize the QMS Portal or the AHCCCS Incident, Accident, Death report form.
Each death known to the facility that occurs within one week after the restraint or seclusion where it is reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to a resident’s death. “Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or deaths related to chest compression, restriction of breathing or asphyxiation.
Each death must be reported to CMS by telephone within one working day following knowledge of the resident’s death. All staff must document the death in the program’s incident/accident log. Staff must document in the member’s medical record the date and time the death was reported to CMS, and the names of the individuals who received the report.
CMS Regional Office (to report a death only): Division of Survey & Certification phone: 415-744-3501.
Licensed behavioral health inpatient facilities must know what information is to be reported, including any applicable forms and/or reports; where the requisite information must be sent within the agencies identified above and the reporting timeframes.
The trending and analysis of significant events can identify opportunities for behavioral health system improvements.
The intent of this section is to identify reporting requirements for providers following an incident, accident, or death involving a Member. In addition, The Health Plan may require providers to submit a written summary of their review of deaths of adult Non-Seriously Mentally Ill Members.
Providers must know what information is to be reported, including any applicable forms and/or reports; and where the requisite information must be sent within the agencies identified above.
Each state has a designated protection and advocacy system. In Arizona, the Arizona Center for Disability Law serves as the designated protection and advocacy agency.
Health Care-Acquired and Provider Preventable Conditions as described in the AHCCCS AMPM Chapter 900.
Death while a Member is a resident of a Behavioral Health Inpatient Facility or other psychiatric hospital or other inpatient institution.
The QMS Portal has links for: Registration Guide, Quick Start-Creating an IAD (Incident, Accident, Death Reports), Current Build Release Notes and Technical Assistance.
Providers are required to report to The Health Plan any incident, accident or death of a Member participating in the health plan provider sponsored prevention activity, as defined in this section, regardless of their enrollment status with The Health Plan, within 48 hours.
The Health Plan submits all behavioral health incident reports involving enrolled children and adults to the Office of Human Rights upon review of the incident report. The Health Plan removes all information that personally identifies the members, in accordance with federal and state confidentiality laws.
This subsection is applicable to Title XIX/XXI certified ADHS Division of Licensing Behavioral Health Inpatient Facilities that provide inpatient psychiatric services to persons under the age of 21.
CMS Regional Office (for deaths only).
Any serious occurrence involving a Member in a Behavioral Health Inpatient Facility must be reported to AHCCCS, the Arizona Center for Disability Law, and the CMS Regional Office (for deaths only) no later than close of business of the next business day following the serious occurrence.
CMS Regional Office (to report a death only): fax number 415-744-2692 Attention Survey & Certification Coordinator.
Specific documentation requirements apply to ADHS Division of Licensing licensed provider records. Please see Section 10.2 - Medical Record Standards.
In the case of a minor (person under the age of 18), the behavioral health inpatient facility must also notify the person’s parent(s) or legal guardian(s) as soon as possible, but no later than 24 hours from the serious occurrence.
Note that these reporting requirements pertain only to serious occurrences (see definition). Reports of non-serious occurrences and other events are not made to AHCCCS, the Arizona Center for Disability Law, or CMS.
Behavioral Health Home providers must meet each Minimum Performance Standard (MPS) for both the Integrated and Non-Integrated Plans as identified below.
Behavioral Health Home providers must participate in The Health Plan or State process improvement projects as requested and engage in Practice Improvement Processes to generate positive improvement in provider practices. Providers must participate in clinical quality improvement activities that are designed to improve outcomes for Arizona Members. Providers are also required to participate in the Children's System of Care Practice Reviews; including, at a minimum, participation in family interviews, chart reviews, team observation, providing accurate contact information, and participating in Feedback Meetings, as requested.
Behavioral Health Home providers must respond to all Corrective Action Letters as requested and develop effective Corrective Action Plans, utilizing PM Form 9.11.4 Corrective Action Plan Template, to overcome the identified problems. Providers must cover the cost of a second The Health Plan audit resulting from provider’s failure to pass the minimum performance standards associated with a The Health Plan audit, and must cover the travel costs associated with the repeat/second audit which may include hotel, meals, car rental and gasoline.

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