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2025 Medicaid Provider Operations Manual

AZCompleteHealth.com 2018-2019 Provider Operations Manual Arizona Complete Health-Complete Care Plan

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Provider Manual Last Updated 5/1/2025

Table of Contents

1.1 - Overview of the Arizona Public Health System
1.2 - Overview of Arizona Complete Health and Populations Served
1.3 - Provider Responsibilities and Expectations
1.4 - Arizona System Values and Guiding Principles
1.5 - Provider Realations (Provider Engagement) Department Overview
1.6 - Joining the Arizona Complete Health Provider Network
1.7 - Arizona Complete Health Organizational Structure
1.8 - Advertising

2.1 - Covered Health Services Based on Eligibility
2.2 - Maternity Services
2.3 - Family Planning for Title XIX/XXI Adults with SMI
2.4 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
2.5 - Dental Services
2.6 - Optical Services
2.7 - Immunization Information
2.8 - Crisis Intervention Services
2.9 - Second Responder Crisis Services
2.10 - Statewide Housing Requirements

3.1 - General
3.2 - Distribution
3.3 - Arizona Complete Health Member Handbook Review

4.1 - Securing Services and Prior Authorization/Retrospective Authorization
4.2 - Securing Services that Do Not Require Prior Authorization
4.3 - Purpose of Utilization Review Process
4.4 - Technology
4.5 - Retrospective Review
4.6 - Pre-Admission Screening and Resident Review (PASRR)
4.7 - Inter-Rater Reliability Testing
4.8 - Integrated Care Management and Care Coordination Services
4.9 - Integrated Care Management Team
4.10 - Disease Management
4.11 - Out-of-Home Services Requirements
4.12 - Discharge Planning
4.13 - Pharmaceutical Requirements
4.14 - Medicaid School Based Claiming
4.15 - Electronic Visit Verification

Reserved

6.1- Introduction and Processes
6.2 - Delegation of Credentialing
6.3 - Initial Credentialing Process and Requirements
6.4 - Additional Credentialing Requirements for Organizational Providers
6.5 - Hiring Non-Participating Providers
6.6 - Investigations
6.7 - Modifications
6.8 - Provisional Credentialing Process and Requirements
6.9 - Recredentialing Process and Requirements
6.10 - Credentialing Approval/Denial Process
6.11 - Fairness of Process
6.12 - Notification Requirement
6.13 - Additional Standards
6.14 - Provider’s Right for Reconsideration
6.15 - Ongoing Monitoring Process Between Re-Credentialing Cycles
6.16 - Notice of Requirements (Limited to Providers)
6.17 - Provider Locations that Accommodate Members with Accessibility Needs

7.1 - Enrollment, Disenrollment and Other Data Submission

8.1 - General Information
8.2 - Claims versus Encounters
8.3 - Claim or Encounter Submission Requirements
8.4 - Claim Submission Time Frames
8.5 - Claim Reimbursement
8.6 - Remittance Advice and Electronic Funds Transfer (EFT)
8.7 - Reports
8.8 - Filing a Claim
8.9 - Overpayment Recovery Procedures
8.10 - Prior Period Coverage
8.11 - Professional Claim Editing
8.12 - Remittance Advice
8.13 - Specific Billing Requirements
8.14 - Vaccines for Children Billing Procedures
8.15 - Claim Coding Policies
8.16 - Billing AHCCCS Recipients
8.17 - Resubmissions, Replacements and Voids
8.18 - Submissions for Non-Title XIX/XXI Enrolled Persons
8.19 - Provider Preventable Conditions and Fraud Waste and Abuse
8.20 - Copayments
8.21 - Reserved
8.22 - Third Party Liability and Coordination of Benefits
8.23 - Transportation
8.24 - Financial Sanctions and Notice to Cure

9.1 - Member Grievance and Provider Complaint Process
9.2 - The Health Plan Grievance Resolution Process
9.3 - Grievances and Investigations Concerning Persons with Serious Mental Illness (SMI)
9.4 - Notice Requirements and Appeal Process (Title XIX/XXI)
9.5 - Notice Requirements and Appeal Process (SMI and GMH/SA Non-Title XIX/XXI)
9.6 - Provider Claim Disputes

10.1 - Member Rights
.10.2 - Cultural Competence System of Care Requirements
10.3 - Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits
10.4 - Reporting Discovered Violations of Immigration Status
10.5 - Duty to Report Abuse, Neglect or Exploitation
10.6 - Duty to Warn
10.7 - Confidentiality
10.8 - Fraud, Waste and Program Abuse Reporting
10.9 - Provider Corporate Compliance Program
10.10 - Encounter Validation Studies
10.11 - Provider Reporting of Moral Or Religious Objection

11.1 - Advance Directives
11.2 - Medical Record Standards
11.3 - Performance Measures
11.4 - Performance Improvement Projects
11.5 - Evidenced Based Practices and Practice Protocol
11.6 - Peer Review
11.7 - Quality of Care Concerns
11.8 - Medical Institution Reporting of Medicare Part D
11.9 - Seclusion and Restraint Reporting
11.10 - Reporting of Incidents, Accidents and Deaths

121.1 - Primary Care Physician (PCP) Assignment
121.2 - Primary Care Provider (PCP) Requirements
121.3 - PCP After-Hours Access Guidelines
121.4 - Conditions of PCP Practice Closure
121.5 - Covering and Collaborating Physicians
121.6 - Social Determinants of Health
121.7 - Referrals to Entities Where Providers Have a Financial Relationship
121.8 - Appointment Requirements Applicable to Physical Health Providers (Non- Hospitalized Persons)
121.9 - Audiology Coverage
121.10 - PCP Treatment and Referrals
121.11 - Breast Reconstructive Surgery after Mastectomy
12.12 - Conscious Sedation Coverage
12.13 - Durable Medical Equipment Coverage
12.14 - Hemodialysis and Peritoneal Dialysis Coverage
12.15 - Foot and Ankle Services
12.16 - Flu Shots/Immunizations
12.17 - Hospital Observation Services
12.18 - Skilled Nursing Facilities
12.19 - Polysomnography-Inpatient and Outpatient
12.20 - Telehealth Services
12.21 - Transplants
12.22 - Emergency Transportation Services
12.23 - Genetic Testing Provisions
12.24 - Radiology Services

13.1 - Eligibility Screening For AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program
13.2 - Appointment Standards and Timeliness of Service
13.3 - Non-Title XIX/XXI Individuals with SUDs
13.4 - Referral and Intake Process
13.5 - Outreach, Engagement, Re-Engagement, and Closure
13.6 - Assessment and Service Planning
13.7 - SMI Eligibility Determination
13.8 - General and Informed Consent to Treatment
13.9 - Psychotropic Medication: Prescribing and Monitoring
13.10 - Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment
13.11 - Mental Health and Substance Use Disorder Services, Including Federal Grant and State Appropriation Requirements
13.12 - Special Assistance for Members Determined to Have a Serious Mental Illness
13.13 - Arizona State Hospital
13.14 - Out-of-State Placements for Children and Young Adults
13.15 - Cultural Competence for the Behavioral Health System Requirements
13.16 - Requirements for Business Continuity/ Recovery Plan and Emergency Response Plan/ Pandemic Plan / Heat Plan Requirements
13.17 - Program Changes
13.18 - Additional Integrated Health Home Requirements
13.19 - Laboratory Provider Requirements
13.20 - Specialty Behavioral Health Provider Requirements
13.21 - Requirements for Service Delivery on the Tohono O’odham Nation
13.22 - Requirements of Organizations Providing Employment Services

14.1 - Transition of Persons
14.2 - Inter-RBHA/MCO Coordination of Care
14.3 - Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
14.4 - Coordination of Care with Other Governmental Entities
14.5 - Partnerships with Families and Family-Run Organizations in the Children’s Behavioral Health System
14.6 - Warm Line Provider Program

15.1 - Urgent Engagement (UE) Program Requirements
15.2 - Behavioral Health Respite Home Requirements
15.3 - Birth To Five Provider Program Requirements
15.4 - Brief Intervention Provider Program Requirements
15.5 - Consumer Operated Provider Program Requirements
15.6 - Crisis Line Provider Program Requirements
15.7 - Crisis Mobile Team Provider Program Requirements
15.8 - Crisis Stabilization/Crisis Living Room Provider Program Requirements
15.9 - Crisis Transportation Provider Program Requirements
15.10 - Health Education, Health Promotion And Counseling Program Requirements Related To Human Immunodeficiency Virus (HIV)
15.11 - Therapeutic Foster Care (TFC) Services to Children – Program Requirements
15.12 - Substance Use Disorder Treatment Requirements
15.13 - Program Requirements for Providers of Services to Adolescents Who Act Out Sexually
15.14 - Program Requirements for Providers of Services to Adults Who Act Out Sexually
15.15 - Community Observation Centers
15.16 - ACT (Assertive Community Treatment)
15.17 - Adult Behavioral Health Therapeutic Homes
15.18 - Behavioral Health Residential Facilities
15.19 - Personal Care Services
15.20- Transition Age Youth
15.21 - Behavioral Health Services for Children in DCS Care, Kinship Placement, or Adopted

16.1 - Purpose
16.2 - Workforce Development (WFD)
16.3 - Training/Compliance Requirements
16.4 - Child and Family Team (CFT)
Relias Learning Management System (LMS)
16.5 - Child and Adolescent Level of Care Utilization System
16.6 - Network Workforce Data Collection
16.7 - Training and Workforce Development Technical Assistance
16.8 - Relias Learning Management System (LMS)
16.9 - Workforce Development Planning (PWFDP)
16.10 - Training/WFD Key Contact
16.11 - WFD Provider Forum
16.12 - Required Training Specific to Professional Foster
16.13 - Peer Support/Recovery Support Training, Certification,
16.14 - Parent/Family Support Training, Certification, and Suprvision Requirements

17 - Deliverable Requirements

18 - References, Definitions, and Acronyms

19 - Provider Manual forms and Attahments