What is an Eligibility Determination?

A person can request to be evaluated/ considered for SED or SMI Services. The person must request through their healthcare provider or their AHCCCS provider.

The provider must complete an assessment packet with the member within seven (7) days after the request is made.

The Provider will then send the completed Assessment Packet to Solari. Solari will then review the packet and determine whether the individual is eligible for SED/SMI services by following the state’s guidelines/criteria.

The provider sends the completed packet to Solari within one (1) business day.

Solari follows the State’s guidelines/criteria to determine SMI and SED eligibility:

• The person has a qualifying diagnosis (mental illness) as described in the AMPM 320-P SMI Qualifying Diagnosis section; and
• The person experiences serious functional dysfunction as a result of that diagnosis (the person has trouble with day-to-day activities or interactions). This includes social, occupational and psychological functioning of adults, e.g., how well or how flexible a person is when meeting different day-to-day problems.
• The person does not currently experience serious functional dysfunction but may be expected to deteriorate to such a level without treatment.

Solari has three (3) days after receiving the packet and all the information they need to review and make a decision (determination) about whether the person is eligible for SED/SMI services. Solari must make a decision based on the information we get from the provider. This means that if information is missing or a packet is not complete Solari may determine that you are not eligible for SED/SMI services (this mostly happens when Solari does not receive records from past providers).

In order to properly assess your eligibility for services, additional time may be necessary to obtain sufficient information to make an informed decision. You have two choices:

• Pending (or extending) the eligibility determination for 20 days. Solari can still make the decision before the 20 days once we receive all the necessary information.
• If you agree to it, the eligibility determination process can be extended up to to 30 or 60 (calendar) days for an Extended Evaluation Period (EEP): This is a 30 or 60 day period of abstinence or reduced use of drugs and alcohol in order to help the reviewing psychologist make an informed decision regarding eligibility.

Solari will send you a letter by mail to let you know what the final decision on your determination is. This letter is called a Notice of Decision. 

If Solari finds that you are not eligible for services, the letter will tell you why. If you do not get the letter/notice by the end of the time you agreed to (three (3), 20 or 30/60 days), please call Solari at 855-832-2866.

If your letter says that you DO qualify for services, Solari will notify Arizona Health Care Cost Containment System (AHCCCS), the T/RBHA and your provider.