MEMBER ENROLLMENT FAX FORM INSTRUCTIONS Page 4 of 4

THE CPSA MEMBER ENROLLMENT FAX FORM IS COMPLETED BY A CPSA INTAKE PROVIDER AND FAXED TO CPSA MEMBER SERVICES NO LATER THAN THE REQUESTED DATE OF ENROLLMENT.

  1. DATE FORM SUBMITTED

Enter the date the CPSA intake provider is completing the form.

  1. CURRENT HOSPITAL LOCATION

If the member is hospitalized at the time of enrollment, identify the name of the facility where the member is located. CPSA Member Services will notify the hospital upon enrollment of the member.

  1. MEMBER’S CHOICE OF PROVIDER (GSA 5 Only)

If the member has selected an At-Risk Provider, enter the name of the provider.

  1. GRID ASSIGNMENT (GSA 5 Only)

If the member is to be enrolled as SMI, child or TXIX/TXXI has not selected an At-Risk Provider, call CPSA Member Services to obtain an At-Risk Provider assignment from the assignment grid. Enter the name of the At-Risk Provider.

PROVIDER INFORMATION

  1. INTAKE PROVIDER

Enter the name of the provider who completed the intake.

  1. ENROLLMENT EFFECTIVE DATE

Enter the date of enrollment. The Enrollment Effective Date may NOT be earlier than the fax date.

  1. ENROLLMENT CONTACT PERSON/PHONE/FAX

Enter the name, phone number and fax number of the person completing the Member Enrollment Fax Form. If there is a question about the form, CPSA Member Services will contact this person to clarify the information on the form.

NEW MEMBER INFORMATION

  1. LEGAL NAME

Enter the member’s legal name

  1. ALSO KNOWN AS

Enter any known alias the member may be using or may have used in the past.

  1. SOCIAL SECURITY NUMBER

This is a ten-character field but only the first nine are used for the Social Security Number. The tenth character should be left blank and only be provided if the member has a Social Security Number with a tenth digit other than zero. A social security number is not required for enrollment.

  1. MEMBER HOME ADDRESS

Enter the member’s home address including city and state.

·  If the member receives mail at an address other than the home, enter the mailing address.

·  If the member is in residential treatment, enter the member’s home address not the residential treatment address.

·  If the member is homeless, enter “HOMELESS” .

  1. MEMBER PHONE

Enter the phone number where the member can be reached.

  1. COUNTY OF RESIDENCE

Check the box that indicates the county in which the member resides or the guardian resides (if the member is a child)

14.  OTHER AGENCIES INVOLVED

Check the appropriate box when another Agency case worker, social worker, parole offices, or other designated agency staff is assigned to the member or if the member is in custody of the agency. Other agency involvement does not necessarily mean fiscal responsibility for services.

·  CPS (Dept of Economic Security/Child Protective Services) - Child Protective Services (CPS) is part of the division of Children, Youth, and Families (ACYF) within the Arizona State Department of Economic Security (DES). The role of CPS is to ensure the safety of children while maintaining the integrity of the family. Arizona law requires CPS to conduct an investigation when allegations of child abuse, neglect, exploitation, or abandonment indicate the need. Children referred to CPS are assigned an investigative or ongoing CPS Specialist (Caseworker). Children in the custody of CPS are Title XIX eligible.

·  DDD/ALTCS (Developmental Disabilities Division/Arizona Long Term Care System) - The Division of Developmental Disabilities (DDD), within the Arizona Department of Economic Security (DES), provides services and programs to eligible individuals with developmental disabilities. Any Arizona resident who has a chronic disability that is attributed to mental retardation, cerebral palsy, epilepsy, or autism that was manifested before the age of 18 may be eligible for services. The disability must also result in substantial limitations in 3 or more areas. Persons eligible for DDD services are assigned a DDD Support Coordinator. AHCCCS Title XIX medical services are provided by Arizona Long Term Care System (ALTCS) for DDD individuals who meet the financial criteria for enrollment and qualifies the individual for CPSA behavioral health services.

·  ADJC (Arizona Department of Juvenile Corrections) - Arizona Department of Juvenile Corrections is the state agency mandated to be responsible for delinquent youth committed to its care and custody by the Arizona Juvenile Courts. Children are in the custody of ADJC if placed in one of its Correctional Facilities and cannot be enrolled, as they are inmates of a public institution. Upon release, children are eligible for enrollment and will be assigned a Parole Officer by ADJC.

·  AOC/JPO (Administrative Office of the Court - Juvenile Probation Office) - The Juvenile Justice Service Division of the Arizona Supreme Court (Juvenile Court) has jurisdiction over delinquent and incorrigible youth as well as dependent children, who are abused, neglected, or abandoned, and involved in dependencies, severance, or adoptions. Delinquent and incorrigible children may be placed in the Pima County Juvenile Detention Center (PCJC) and/or be assigned a Probation Officer. Dependent children may be assigned a CPS Caseworker by DES/CPS. As of 7/28/99, adjudicated (decided by

·  DES/RSA (Dept of Economic Security/Rehabilitation Services Administration) – Vocational Rehabilitation services provided to persons with physical and/or mental disabilities enrolled in RSA. A person enrolled in RSA is assigned a Vocational Rehabilitation Counselor who assists in vocational rehabilitation efforts.

·  ADOPTION SUBSIDY - Adoption Subsidy is a division of Children, Youth, and Families (ACYF) under the Department of Economic Security (DES). Adoption Subsidy serves children who have been adopted through the State of Arizona from Child Protective Services (CPS). These children are categorically Title XIX regardless of their parent’s financial situation and may have private insurance as well. They can be served by Adoption Subsidy until their 22nd birthday and are TXIX until their 21st birthday as long as they remain in the home and are attending High School or obtaining their GED.

·  SCHOOLBASED SERVICES - CPSA School - Based Treatment Services are a collaborative effort between schools, providers and families, based upon a written agreement of mutual understanding and commitment, to provide behavioral health services. These services are supplied by CPSA subcontracted providers whose services are funded through CPSA. Children are identified and referred by specific school personnel. The CPSA subcontracted providers screen for financial eligibility and clinical need and enroll the children. Services may include, but are not limited to, individual, group, and family therapy in the school, home, or office. Funding sources include SEH dollars, Subvention funds, Title-XIX, Title-XXI, and non-Title XIX monies.

·  SCHOOLBASED- LIMITED - CPSA School - Based Treatment Services are a collaborative effort between schools, providers and families, based upon a written agreement of mutual understanding and commitment, to provide behavioral health services. These services are supplied by CPSA subcontracted providers whose services are funded through CPSA. Children are identified and referred by specific school personnel. The CPSA subcontracted providers conduct a brief financial and clinical screen and enroll the children. Children are eligible for limited School-Based services if they have no other State Agency involvement and need only limited services (Brief Individual and/or Group Therapy) for a school semester or less.

·  CO-OCCURRING DISORDERS PROGRAM (CDP)-Compass Only-Adults who are non-Title XIX General Mental Health or Substance Abuse and have a co-occurring disorder may receive residential or outpatient services from Compass.

·  ADULT PROBATION COURT – Adult Probation Court of the Superior Court in Pima, Santa Cruz, Cochise, Graham and Greenlee counties, has jurisdiction over probation eligible adults through the assignment of a probation officer or designee.

  1. DATE OP BIRTH

Enter the member’s date of birth; this date may not be later than the current date or the Date of Enrollment. It is formatted as Year____Month__Day__ (19981002)

  1. MARITAL STATUS

Check the box indicating member marital status.

  1. GENDER

Check the box that indicates the member’s gender

  1. PROGRAM INDICATOR

Check the box indicating the appropriate service program under which the member should be enrolled.

  1. AHCCCS ID

The AHCCCS ID is required for Title XIX, Title XXI, or AHCCCS eligible members.

  1. RATE CODE

Enter the four-digit number reported through Medifax or AHCCCS as the qualifying code for AHCCCS Eligibility.

  1. HEALTH PLAN ID#

The Health Plan ID number is a six (6) character AHCCCS number.

  1. TITLE XIX OR TXXI

Check the box indicating if the AHCCCS rate code qualifies the person for Title XIX or Title XXI coverage.

  1. COOL PROGRAM

Check the box that indicates a member’s enrollment in the Correctional Officer/Offender Liaison Aftercare or General Parole Program (COOL). A person is referred for COOL Aftercare/General Parole drug and alcohol services by the Department of Corrections Parole Officer, upon release from a correctional facility. The CPSA COOL Liaison tracks this referral and can verify the referral. The member may have insurance coverage and still be eligible for COOL services.

  1. NON-AHCCCS GMH/A/D COT – COPE ONLY

Check this box when a person with no AHCCCS coverage has been court ordered under Title 36 and will be enrolled with COPE as the supervising agency. For individuals with Title XIX or Title XXI coverage do not check this box; the assigned At-Risk Provider is the supervising agency for court ordered treatment.

  1. FUNDING SOURCE

Check the box that describes the fund source for the member.

·  SEH = SEH (SPECIAL EDUCATION WITH AN INDIVIDUAL EDUCATIONAL PLAN (IEP) - Children who have an IEP (Individualized Education Program) which qualifies them for Special Education under the Department of Education. CPSA receives monies to provide treatment to these children via school-based services and for residential placement if needing placement in order to benefit from special education. An ADE (Arizona Department of Education) Letter of Agreement needs to be signed by the school signifying that the child is a special education student. The signed form is kept in the child’s Behavioral Health clinical file to validate the child is a special education student and eligible to receive SEH monies for Behavioral Health Treatment Services.

·  PROJECT MATCH – GSA 5 ONLY = Project Match is a grant-funded project for selected Seriously Emotionally Disturbed (SED) children, adolescents (birth to 18 years old) and their families which starts in July 2000. The goal of the project is to implement family-centered, community-based, culturally relevant and integrated service delivery system. Children in the project must have two or more state agencies involved in their care and meet diagnostic and service intensity criteria for SED services.

·  Empower Plus (GSA 5 only) = An adult, who is a parent, guardian or custodian of a child named in a report by CPS as a victim of abuse or neglect, and whose substance abuse is a significant barrier to maintaining, preserving or reunifying the family; or an adult whose substance abuse is a significant barrier to maintaining or obtaining employment if the person is receiving DES cash assistance; or an adult who is referred to CPSA Member Services for the provision of covered services by a CPSA or Jobs Case Manager.

·  Sells/Child Welfare – GSA 5 ONLY = Tohono O’odham children residing on the reservation in the village of Sells and outlying areas who are placed under the guardianship of Tohono O’odham Tribal Child Welfare services. Children may or may not have AHCCCS coverage. CPSA provides behavioral health services.

·  Sells/Child Other – GSA 5 ONLY = Tohono O’odham children residing on the reservation in the village of Sells and outlying areas whose guardianship remains with the family and who have selected CPSA to provide behavioral health services.

·  HB 2003 = ADULT- HB 2003 participants are Non-Title XIX adults with major mental illnesses (DSM diagnoses 295, 296, 297 or 298) with or without co-occurring substance use, abuse or dependence who are homeless, living with families of origin, in substandard or unsafe housing, in ASH, inpatient, in a residential program or in transition from other non-permanent subsidized housing.

HB 2003 CHILD – Non-Title XIX children, ages birth to eighteen years, who are involved with ADES, AOC, or ADJC and who have a DSM IV diagnosis. Parents who are non-Title XIX and their Title XIX ADES children. Parents of AOC and ADJC children as part of the child’s treatment program.

HB 2003 ENROLLED CHILD NAME /ENROLLED PARENT NAME AND ID#

If the adult or child being enrolled through the HB2003 program has a family member already receiving services through CPSA, enter the name of the existing family member and the CPSA ID#. Enter the enrolled parent’s name and ID#, if the new enrollee is a child. If the new enrollee is an adult whose child is already enrolled with CPSA, enter the name of the child on this line with the child’s CPSA Member ID#.

CPSA revised date: April 16, 2001 C:\DATA.BLB\form instructions\Member Enrollment Fax Form Instructions.doc 04.16.2001