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2023 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 08/2023

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 Manual
1.4 - Provider Responsibilities and Expectations
1.5 - Arizona System Values and Guiding Principles
1.6 - Provider Services Department Overview
1.7 - Joining the Arizona Complete Health-Complete Care Plan Provider Network
1.8 - Arizona Complete Health - Complete Care Plan Organizational Structure
1.9 - 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-Complete Care Plan 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

5.1 - Introduction and Processes
5.2 - Delegation of Credentialing
5.3 - Initial Credentialing Process and Requirements
5.4 - Additional Credentialing Requirements for Organizational Providers
5.5 - Hiring Non-Participating Providers
5.6 - Investigations
5.7 - Modifications
5.8 - Provisional Credentialing Process and Requirements
5.9 - Recredentialing Process and Requirements
5.10 - Credentialing Approval/Denial Process
5.11 - Fairness of Process
5.12 - Notification Requirement
5.13 - Additional Standards
5.14 - Provider’s Right for Reconsideration
5.15 - Ongoing Monitoring Process Between Re-Credentialing Cycles
5.16 - Notice of Requirements (Limited to Providers)
5.17 - Provider Locations that Accommodate Members with Accessibility Needs

6.1 - Enrollment, Disenrollment and Other Data Submission

7.1 - General Information
7.2 - Claims versus Encounters
7.3 - Claim or Encounter Submission Requirements
7.4 - Claim Submission Time Frames
7.5 - Claim Reimbursement
7.6 - Remittance Advice and Electronic Funds Transfer (EFT)
7.7 - Reports
7.8 - Filing a Claim
7.9 - Overpayment Recovery Procedures
7.10 - Prior Period Coverage
7.11 - Professional Claim Editing
7.12 - Remittance Advice
7.13 - Specific Billing Requirements
7.14 - Vaccines for Children Billing Procedures
7.15 - Claim Coding Policies
7.16 - Billing AHCCCS Recipients
7.17 - Resubmissions, Replacements and Voids
7.18 - Submissions for Non-Title XIX/XXI Enrolled Persons
7.19 - Provider Preventable Conditions and Fraud Waste and Abuse Edits
7.20 - Copayments
7.21 - Third Party Liability and Coordination of Benefits
7.22 - Transportation
7.23 - Refunds or Overpayments on Services Rendered
7.24 - Financial Sanctions and Notice to Cure

8.1 - Member Grievance and Provider Complaint Process
8.2 - The Health Plan Grievance Resolution Process
8.3 - Grievances and Investigations Concerning Persons with Serious Mental Illness (SMI)
8.4 - Notice Requirements and Appeal Process (Title XIX/XXI)
8.5 - Notice Requirements and Appeal Process (SMI and GMH/SA Non-Title XIX/XXI)
8.6 - Provider Claim Disputes

9.1 - Member Rights
9.2 - Cultural Competence System of Care Requirements
9.3 - Verification of U.S. Citizenship or Lawful Presence for Public Behavioral Health Benefits
9.4 - Reporting Discovered Violations of Immigration Status
9.5 - Duty to Report Abuse, Neglect or Exploitation
9.6 - Duty to Warn
9.7 - Confidentiality
9.8 - Fraud, Waste and Program Abuse Reporting
9.9 - Provider Corporate Compliance Program
9.10 - Encounter Validation Studies
9.11 - Provider Reporting of Moral Or Religious Objection

10.1 - Advance Directives
10.2 - Medical Record Standards
10.3 - Performance Measures
10.4 - Performance Improvement Projects
10.5 - Evidenced Based Practices and Practice Protocol
10.6 - Peer Review
10.7 - Quality of Care Concerns
10.8 - Medical Institution Reporting of Medicare Part D
10.9 - Seclusion and Restraint Reporting
10.10 - Reporting of Incidents, Accidents and Deaths

11.1 - Primary Care Physician (PCP) Assignment
11.2 - Primary Care Provider (PCP) Requirements
11.3 - PCP After-Hours Access Guidelines
11.4 - Conditions of PCP Practice Closure
11.5 - Covering and Collaborating Physicians
11.6 - Additional Referral Requirements for SMI Members
11.7 - Social Determinants of Health
11.8 - Referrals to Entities Where Providers Have a Financial Relationship
11.9 - Appointment Requirements Applicable to Physical Health Providers (Non- Hospitalized Persons)
11.10 - Audiology Coverage
11.11 - PCP Treatment and Referrals
11.12 - Breast Reconstructive Surgery after Mastectomy
11.13 - Conscious Sedation Coverage
11.14 - Hemodialysis and Peritoneal Dialysis Coverage
11.15 - Durable Medical Equipment Coverage
11.16 - Foot and Ankle Services
11.17 - Flu Shots/Immunizations
11.18 - Hospital Observation Services
11.19 - Skilled Nursing Facilities
11.20 - Polysomnography-Inpatient and Outpatient
11.21 - Telehealth Services
11.22 - Transplants
11.23 - Emergency Transportation Services
11.24 - Genetic Testing Provisions
11.25 - Radiology Services

12.1 - Eligibility Screening For AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program
12.2 - Appointment Standards and Timeliness of Service
12.3 - Non-Title XIX/XXI Individuals with SUDs
12.4 - Referral and Intake Process
12.5 - Outreach, Engagement, Re-Engagement, and Closure
12.6 - Assessment and Service Planning
12.7 - SMI Eligibility Determination
12.8 - General and Informed Consent to Treatment
12.9 - Psychotropic Medication: Prescribing and Monitoring
12.10 - Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment
12.11 - Special Assistance for Members Determined to Have a Serious Mental Illness
12.12 - Arizona State Hospital
12.13 - Out-of-State Placements for Children and Young Adults
12.14 - Cultural Competence for the Behavioral Health System Requirements
12.15 - Business Continuity/ Recovery Plan and Emergency Response/ Pandemic Plan / Heat Plan Requirements
12.16 - Program Changes
12.17 - Additional Behavioral Health Home Requirements
12.18 - Laboratory Provider Requirements
12.19 - Specialty Behavioral Health Provider Requirements
12.20 - Requirements for Service Delivery on the Tohono O’odham Nation
12.21 - Requirements of Organizations Providing Employment Services

13.1 - Transition of Persons
13.2 - Inter-RBHA/MCO Coordination of Care
13.3 - Coordination of Care with AHCCCS Health Plans, Primary Care Providers and Medicare Providers
13.4 - Coordination of Care with Other Governmental Entities
13.5 - Partnerships with Families and Family-Run Organizations in the Children’s Behavioral Health System
13.6 - Warm Line Provider Program

14.1 - Urgent Engagement (UE) Program Requirements
14.2 - Behavioral Health Respite Home Requirements
14.3 - Birth To Five Provider Program Requirements
14.4 - Brief Intervention Provider Program Requirements
14.5 - Consumer Operated Provider Program Requirements
14.6 - Crisis Line Provider Program Requirements
14.7 - Crisis Mobile Team Provider Program Requirements
14.8 - Crisis Stabilization/Crisis Living Room Provider Program Requirements
14.9 - Crisis Transportation Provider Program Requirements
14.10 - Health Education, Health Promotion And Counseling Program Requirements Related To Human Immunodeficiency Virus (HIV)
14.11 - Therapeutic Foster Care (TFC) Services to Children – Program Requirements
14.12 - Substance Use Disorder Treatment Requirements
14.13 - Program Requirements for Providers of Services to Adolescents Who Act Out Sexually
14.14 - Program Requirements for Providers of Services to Adults Who Act Out Sexually
14.15 - Community Observation Centers
14.16 - ACT (Assertive Community Treatment)
14.17 - Adult Behavioral Health Therapeutic Homes
14.18 - Behavioral Health Residential Facilities
14.19 - Personal Care Services (Outpatient)
14.20- Transition Age Youth

15.1 - Purpose
15.2 - Workforce Development (WFD) All Lines of Business
15.3 - Training/Compliance Requirements
15.4 - Relias Learning Management System (LMS)
15.5 - Network Workforce Data Collection
15.6 - Required Training Specific to Child and Family Team (CFT) Initiatives
15.7 - Required Training Specific to General Mental Health (GMH)/Substance Use (SU)
15.8 - Required Training Specific to Professional Foster TFC Services
15.9 - Training Contact Person
15.10 - Monitor Provider Workforce Development Activities
15.11 - Peer Support/Recovery Support Training, Certification and Supervision Requirements
15.12 - Parent/Family Support Training, Certification and Supervision Requirements

16 - Deliverable Requirements

17.1 - Statutory And Regulatory References
17.2 - Reference Documents
17.3 - Clinical Guidance Documents

18.1 - FORMS
18.2 - ATTACHMENTS

19.1 - PART I: Definitions Pertaining to All AHCCCS Contracts
19.2 - Part 2: Definitions Pertaining to One or More AHCCCS Contracts
19.3 - The Health Plan Definitions
19.4 - Acronyms