Provider Forms & Checklist

Please submit court documents for cases when applicants are COT and do not consent, if there is a legal guardian of an adult, if the Health Care Decision Maker (HCDM) for a child is someone other than their parent.

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Part C Additional Addenda (this form must be signed by a licensed clinician), the assessment cannot be processed without this form signed and dated appropriately.

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This form must be signed by a licensed clinician; the assessment cannot be processed without this form signed and dated appropriately.

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This must be dated within six months of the submission and cannot be a “part E”. Please include the CALOCUS report with SED assessments.

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Please note that applicants are encouraged to waive their right to a three-day determination. Generally speaking, evidence suggests that additional time to review and pursue historical treatment records result in a positive outcome.

If this form is not submitted, the determination will be made in three days.

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It is helpful to have the most current address, phone number and other pertinent demographic information in order to most effectively communicate with the client and other involved parties through the determination process.

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It is helpful to have an ROI for the emergency contact or family members that the client would like us to be able to communicate with regarding their care/determination as well as any prior outpatient and inpatient providers if the client would like these records considered as part of the determination.

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Evaluators should make applicants aware that asking for additional time may improve the likelihood of being determined eligible for SMI/SED services.

The points below are designed to assist you in making appropriate referrals for an SED evaluation and to provide guidance on what information is especially relevant when an evaluation is being reviewed for determination.

Please consider the information below when deciding whether to refer someone for a SED evaluation:

• Does the child/adolescent have a current SED qualifying diagnosis on record AND does the record support the diagnosis by clear description of corresponding symptoms (symptom type, onset, duration, and frequency), behaviors consistent with the diagnosis, and clinical observations consistent with the diagnosis?
• Does the child/adolescent have, documented in the hospital record, severe functional impairment that is directly linked to the SED qualifying diagnosis, AND has that functional impairment been occurring for at least the past 6 months or 3 months with an expected continued duration of another 3 months?
• In addition to the above, is it clear that the symptoms and functional impairment are not primarily due to substance use/dependence, medical conditions (i.e., chronic pain, brain injury, seizure disorder, diabetes, etc.), intellectual developmental disability, situational stressors, or other diagnoses or factors? If any of those factors are present, is there documentation to show that they have been ruled out as the primary reason for their impairment?
• For those children/adolescents admitted with recent or current substance use:
  • Is there evidence of periods of sustained sobriety with persistence of symptoms and functional impairment during those periods?
  • Is there evidence that symptom onset was prior to the onset of substance use?
• Is there a history of mental illness in the family; have family members been treated for mental illness and/or attempted/died by suicide?

For inpatient children:

• Does the child/adolescent have a history of outpatient mental health treatment that has been unsuccessful in managing the symptoms of a qualifying diagnosis?
• Does the child/adolescent have a history of chronic SI, suicide attempts, and/or psychiatric hospitalizations (not all while using substances)?
• Has the psychiatric provider seen the child/adolescent, and do they agree that a SED evaluation referral is warranted?

For incarcerated individuals:

• Does the child/adolescent have a history of outpatient mental health treatment while not incarcerated? History of suicide attempts and psychiatric hospitalizations? What has been effective in managing their symptoms?

Once you have determined that a referral is appropriate, we highly encourage you to provide the evaluator with all behavioral health records that you can obtain (from current or previous providers), including psychiatric assessments and progress notes, other clinical or counseling notes, psychological/psychometric testing, medication list, educational records, and other documents that would support the above points.

The points below are designed to assist providers in submitting a thorough evaluation so that this commitment can be met.

• Double-check to ensure that ALL required forms are completed, signed, and dated prior to submission. Failure to do so may delay the determination. *For SED evaluations be sure you have appropriate parent/guardian signatures and include any custody/guardianship documentation.
• If a behavioral health technician (BHT) or other unlicensed assessor completes the evaluation, ensure that the appropriate supervisor or behavioral health professional (BHP) reviews the evaluation and signs off before submitting
• While an assessment can be up to 6 months old, it may not reflect current symptoms and functioning, please also include a more recent assessment
  • We strongly advise you to use the Core Assessment found above, as it was created to capture relevant information needed to make a determination.
• Submit treatment records if you have them, including the most recent psychiatric evaluation.
• It may be beneficial to extend (“pend”) the decision/determination for up to 20 business days to obtain additional records or to an informal conference or for an extended evaluation program (EEP) of up to 60 days to clarify recent substance use issues.
  • Please attempt to provide the above options on the 3-Day Waiver form.
• To be determined eligible for SED/SMI benefits, the criteria, as defined by AHCCCS, must be well-documented.
  • There must be at least one SED/SMI-qualifying diagnosis in which the symptoms documented are consistent with the diagnostic criteria and information in the assessment and records.
    • While you may list the actual DSM-5-TR/ICD-10 diagnostic criteria that the individual meets, be sure to also include specific examples of symptoms, behaviors, quotes, and provider/assessor observations.
      • Include type, onset, frequency, duration, and severity. In other words, explain how the symptoms are manifested in this individual.
      • Be as detailed as possible and avoid vague terms (i.e., “mood swings”).
    • If a person has an SED/SMI-qualifying diagnosis with either “other specified disorder” or “unspecified disorder,” please explain why a more specific diagnosis has not been given and what other diagnoses the provider may need to rule out or consider.
  • There must be at least one area of Functional Impairment that is due to the Qualifying Diagnosis (SED: for at least 6 months or 3 months with an expected continued duration of another 3 months; SMI: for at least 12 months or 6 months with an expected continued duration of another 6 months).
    • Explain how the diagnosis is directly linked to the impairment and how the duration criterion is met.
    • If the person has additional conditions that are not SED/SMI-Qualifying Diagnoses (including but not limited to Substance Use/Dependence, a head injury or TBI, Chronic Pain, Intellectual Developmental Disorder, Mood Disorder due to General Medical Condition, incarceration/legal issues, other stressors), then please explain how their functional impairment is primarily caused by the qualifying SED/SMI diagnosis and not those other conditions or stressors. *For a comprehensive list of SED/SMI qualifying diagnoses, please refer to the respective SED/SMI Determination Form.
• If there is a history of (or current) substance use, explain whether there is evidence of periods of sustained sobriety and persistence of symptoms and functional impairment during those periods.
  • Submit UDS results if available.
• Explain the individual’s treatment history.
  • What has been successful?
  • Can the individual obtain services through a GMH/SA or other provider?
    • If so, what services does the treating provider believe the person requires that the GMH/SA provider cannot offer?
• Clearly explain the history of DTS/DTO behaviors, hospitalizations/COE/COT, and family history of mental illness.
• Occasionally, providers may be asked to submit a SED/SMI Evaluation for an individual even when the provider does not believe that SED/SMI criteria are fully supported at that time.

Please ensure that you document this accurately and explain the reason for the referral.