INTRODUCTION TO ARIZONA COMPLETE HEALTH-COMPLETE CARE PLAN
Health Net Access Inc. dba Arizona Complete Health-Complete Care Plan (The Health Plan) is an Arizona-based, locally operated Managed Health Services company dedicated to our mission: “Transforming the health of our community, one person at a time”. We seek to ensure that Members receive ready access to high quality, effective and culturally responsive care. The Health Plan recognizes that the needs of each community and county are uniquely based on each community’s and county’s challenges and resources. The Health Plan tailors services to meet the needs of each community and supports local community-based efforts to effectively coordinate care and promote health and wellness.
The Arizona Health Care Cost Containment System (AHCCCS) is the single state Medicaid Agency that provides funding to administer health care benefits for persons who are Title XIX/XXI eligible and manages grants to serve Substance Use Disorder Services, Federal Grants and State Appropriations Fund Requirements. AHCCCS contracts with Managed Care Organizations (MCOs) to secure a network of providers, clinics, and other appropriate facilities and services to deliver behavioral health and physical health services to eligible Members within contracted geographic service areas. In addition, Arizona state law requires AHCCCS to administer community-based treatment services for adults who have been determined to have a Serious Mental Illness (see AAC R9-21 (PDF)).
AHCCCS is responsible for the oversight of the administration of behavioral health services for several populations funded through various state and federal sources. These programs include Arizona state funded crisis services and services to Non-Title XIX adults with a SMI designation, Governor’s office grants serving residents with Opioid Use Disorders, state and federal housing grants and the Substance Abuse and Mental Health Services Administration (SAMHSA) funded grants. SAMHSA provides funding to the State through specialty grants, including the State Opioid Response (SOR) grant, and two block grants:
- The Substance Abuse Block Grant (SABG) supports a variety of substance abuse disorder services in both specialized addiction treatment and more generalized behavioral health settings, as well as primary prevention and Early Intervention Screening and Testing.
- The Mental Health Block Grant (MHBG) supports Non-Title XIX/XXI services to children determined to have Serious Emotional Disturbance (SED), youth and adults experiencing First Episode Psychosis and adults determined to have a Serious Mental Illness (SMI).
More information about AHCCCS programs is available online on our website.
The Health Plan in collaboration with its parent company, Centene Corporation, is committed to bringing the best care possible to vulnerable populations through a focus on innovative programs and services delivered through Medicaid (Title XIX), Medicare, CHIP (Title XXI), and other programs for uninsured and under-insured adults and families.
The Health Plan monitors provider performance to verify Members are receiving timely access to quality services that support recovery, resiliency, and wellness. For more information about the Health Plan and its services, please visit the Arizona Complete website.
The Health Plan’s network structure is designed to promote recovery, resiliency, and wellness through maximizing Member “voice and choice.” The Health Plan wants Members to have a choice of providers and services and be in charge of their individual service plans. The Health Plan’s network is designed to remove barriers that prevent people from reaching their wellness and recovery goals and help Members lead productive lives in their communities.
The Health Plan Members can elect to receive services from any Primary Care Provider, Behavioral Health Home and/or Specialty Provider in The Health Plan network based on their benefit plan. The Health Plan serves the following populations and manages the associated benefit plans assigned to The Health Plan for each population.
1.2.1 AHCCCS Enrolled Title XIX/XXI Adults with SMI (Integrated Physical Health and Behavioral Health Services)
The Health Plan serves AHCCCS enrolled Title XIX Adults with SMI in seven Arizona counties— Pima, La Paz, Yuma, Santa Cruz, Cochise, Greenlee, and Graham Counties. The Health Plan manages a full array of AHCCCS approved behavioral health and physical health services to meet the whole person health care needs of the Members. The AHCCCS Title XIX benefit plan coverage for these members is outlined in Section 12 of this Provider Manual.
1.2.2 AHCCCS Enrolled Non-Title XIX Adults with SMI (Behavioral Health Services Only)
The Health Plan serves AHCCCS enrolled Non-Title XIX Adults with SMI in seven Arizona counties— Pima, La Paz, Yuma, Santa Cruz, Cochise, Greenlee, and Graham Counties. The Health Plan manages a limited array of AHCCCS approved behavioral health services to meet the behavioral health care needs of these members. The AHCCCS Non-Title XIX behavioral health benefit plan coverage for these members is outlined in Section 12 of this Provider Manual.
1.2.3 AHCCCS Enrolled Title XIX/XXI Adults and Children, excluding Adults with SMI (Integrated Physical Health and Behavioral Health Services)
The Health Plan serves AHCCCS enrolled Title XIX/XXI Children and Adults (excluding adults with SMI in ten Arizona counties— Maricopa, Gila, Pima, La Paz, Yuma, Santa Cruz, Cochise, Greenlee, Graham, and Pinal Counties). The AHCCCS Title XIX/XXI benefit plan coverage for these members is outlined in Section 12 of this Provider Manual.
1.2.4 Health Care Services to American Indians
American Indians have a choice about what Plan manages their services. American Indians can elect to enroll with the AHCCCS American Indian Health Program, an AHCCCS Arizona Complete Care Plan in their Geographic Service Area or a Tribal Regional Behavioral Health Authority in their Geographic Service Area, if available. The Health Plan works with Tribal Communities to educate tribal members about their options. American Indians can access Indian Health Services providers, Tribal 834 providers, and Urban Indian Health providers for services as well. The Health Plan will provide services to American Indians based on member benefit plans for members in our assigned Geographical Service Area with a Serious Mental Illnesses and Members served by the Department of Economic Security/Division of Developmental Disabilities.
1.2.5 Grant Funded Mental Health, Opioid Use Disorder and Substance Use Disorder Services
The Health Plan offers Mental Health, Opioid Use Disorder and Substance Use Disorder treatment services to uninsured and underinsured residents living in Graham, Greenlee, Cochise, Santa Cruz, Pima, Yuma, or LaPaz Counties funded through state and federal grant funds. For questions about how members can access these services, please call Customer Service at 866-796-0542.
1.2.6 Crisis Services to Arizona Residents
All residents of Arizona have access to crisis services 24 hour a day, 7 days a week. Crisis intervention services are funded through state and federal funds and include crisis telephone services, 23-hour facility-based crisis stabilization services, community based crisis mobile team services and similar stabilization and support services.
Southern Region Residents (Cochise, Graham, Greenlee, La Paz, Pima, Santa Cruz, Yuma County or on the San Carlos Apache Reservation): can access The Health Plan crisis services by calling 866-495-6735.
Maricopa County Residents: can access The Health Plan crisis services by calling 800-327-9254.
Pinal County Residents: can access The Health Plan crisis services by calling 866-495-6735.
Gila County Residents: can access The Health Plan crisis services by calling 877-756-4090.
1.2.7 Documents Incorporated by Reference
The Health Plan developed this Provider Manual in support of our AHCCCS Complete Care contract, provider contractual agreements and in conformance with Arizona Health Care Cost Containment System (AHCCCS) policies. View the AHCCCS Contractor Operation Manual (ACOM) and the AHCCCS Medical Policy Manual (AMPM) for additional information. All these documents and provisions are incorporated by reference and the associated obligations and requirements are considered part of these Provider Manual requirements as applicable.
Consistent terminology throughout The Health Plan’s Provider Manual is used to the extent possible. Persons receiving services are generally referred to as “Members”; however, Members are sometimes referenced as “participants,” “individuals,” or simply as “persons.”
The Health Plan’s Provider Manual is applicable to all defined populations that may access services through The Health Plan as defined in this Provider Manual and documents incorporated by reference.
1.2.9 Revisions to Arizona Complete Health - Complete Care Plan Provider Manual
The Arizona Complete Health Complete Care Plan Provider Manual is an extension of the provider Contract and contains contractually required provider obligations. The Provider Manual is updated once a month if changes are necessary. All sections of The Health Plan Provider Manual are reviewed annually. The Health Plan issues Provider Manual Clarification Memoranda to contracted providers and posts them to The Health Plan’s website. In addition, AHCCCS issues Policy Clarification Memoranda and posts them on the AHCCCS website. The Health Plan incorporates these changes upon receipt and as appropriate into The Health Plan Provider Manual.
Providers, stakeholders, and others may provide comments and request for revisions to The Health Plan Provider Manual by contacting Customer Service at 866-796-0542. The most current revision to the Provider Manual can be obtained on our website.
The Health Plan has no policies that prevent providers from advocating on behalf of Members as specified in 42 CFR 438.102 and 42 CFR 457.1222.
Documents Incorporated by Reference
The Health Plan developed this Provider Manual in support of our AHCCCS Complete Care contract, provider contractual agreements and in conformance with Arizona Health Care Cost Containment System (AHCCCS) policies. Please refer to AHCCCS Contractor Operation Manual (ACOM) and the AHCCCS Medical Policy Manual (AMPM) for additional information. All these documents and provisions are incorporated by reference and the associated obligations and requirements are considered part of these Provider Manual requirements as applicable.
AHCCCS has contracted with The Health Plan to provide integrated behavioral health and physical health care to Medicaid eligible adults and children, including adults with a Serious Mental Illness (SMI). This includes coordinating Medicare and Medicaid benefits for dual-eligible Members. Integrating the delivery of behavioral and physical health care is essential to improving the overall health and wellness of adults and children. From a member perspective, this integrated care approach will improve individual health outcomes, enhance Coordination of Care, and increase Member satisfaction. From a system perspective, it will increase efficiency, reduce administrative burden, and foster transparency and accountability.
Providers are responsible to facilitate whole person integrated care for our members, coordinating care effectively between and among disciplines.
Providers are obligated to adhere to and comply with all terms and conditions of The Health Plan Provider Manual, the provider’s contractual agreement with The Health Plan, and all applicable federal and State laws and regulations. In addition, providers are obligated to understand and comply with all Arizona Health Care Cost Containment System requirements. Please refer to: AHCCCS ACOM and AHCCCS AMPM for additional information regarding State requirements.
Primary Care Providers and Behavioral Health Homes are responsible for providing clinical intakes, assessments, service planning, and coordination of care; verifying Members are receiving the services they need to live safely and successfully in their communities; and verifying Members reach their recovery, resiliency, and wellness goals.
Specialty Providers are responsible for delivering specialty services and programs as authorized and identified on individualized service plans, regularly reporting progress to Primary Care Providers and/or Behavioral Health Homes and coordinating services with Primary Care Providers and/or Behavioral Health Homes. Many specialty provider services require prior authorization. Reference Provider Manual Section 12.19 Specialty Provider Requirements for additional information.
AHCCCS Provider Enrollment Portal (APEP): All new providers, as well as existing providers, who need to update their accounts with AHCCCS must use the APEP. This online system, available 24/7, streamlines the provider enrollment process and eliminates the need for paper-based applications. Providers must register for a Single-Sign-On (SSO) to access APEP by visiting this website. Use the AHCCCS PEP website and portal for the most current information about how to apply for or renew your registration. Certain provider types may require additional documentation. Review the “Special Instruction” section at the above website for details on requirements.
The following values, guiding system principles, and goals are the foundation of the public health system. Providers are required to follow the Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems and The Arizona Vision-Twelve Principles for Children Service Delivery.
1.5.1 Adult Service Delivery Nine Guiding Principles
AHCCCS requires that providers implement adult services consistent with the Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems. Those nine guiding principles are outlined in AHCCCS Medical Policy Manual Chapter 100 – Manual Overview and are listed below:
- Persons in recovery choose services and are included in program decisions and program development efforts;
- Focus on individual as a whole person, while including and/or developing natural supports;
- Empower individuals taking steps towards independence and allowing risk taking without fear of failure;
- Integration, collaboration, and participation with the community of one's choice;
- Partnership between individuals, staff, and family members/natural supports for shared decision making with a foundation of trust;
- Persons in recovery define their own success;
- Strengths-based, flexible, responsive services reflective of an individual's cultural preferences; and
- Hope is the foundation for the journey towards recovery.
1.5.2 The Arizona Vision-Twelve Principles for the Children’s Service Delivery
AHCCCS requires that services be delivered to all children consistent with the “Arizona Vision" and according to the twelve Arizona Children’s Principles. Those twelve guiding principles are outlined in AHCCCS Medical Policy Manual Chapter 100 – Manual Overview and are listed below:
The Twelve Principles for Children Service Delivery are:
- Collaboration with the child and family;
- Functional outcomes;
- Collaboration with others;
- Accessible services;
- Evidenced-Based Best Practices;
- Most appropriate setting;
- Services tailored to the child and family;
- Respect for the child and family's unique cultural heritage;
- Independence; and
- Connection to natural supports.
The Health Plan Provider Engagement Specialists are responsible to receive and track provider inquiries and verify timely responses. Provider Engagement Specialists are available 8:00 AM to 5:00 PM Monday through Friday to provide immediate responses to provider inquiries via phone, email, and letters. The Health Plan seeks to resolve each request for information and assistance during the initial call, email, or letter. If additional information is needed to respond to the provider’s inquiry (call, email, or letter), it will be logged and routed to the subject matter expert best able to answer the provider’s question. The Health Plan Provider Engagement Team tracks all inquiries referred to subject matter experts to verify timely responses and satisfaction with the responses. The Health Plan will acknowledge all provider calls within three (3) business days of receipt and will communicate the final resolution to the provider within thirty (30) business days of receipt (including provider referrals from AHCCCS). If you ever feel like you are not receiving the assistance you need, please escalate your request by calling Customer Service at 866-796-0542 for assistance with any questions and/or to identify the assigned Provider Engagement Specialist and the supervisor contact information.
The process to join the Health Plan Provider Network begins with the submission of an application through our Provider Network Development and Contracting Department. Applications to join the Health Plan Network are available on our website. All applications are filed and archived for one year. Only applicable applications that fit within a network adequacy and/or member need will be reviewed at the Provider Network Development and Contracting Potential Provider Committee. The Committee reviews the application and the needs of the Network and issues a determination, which may include approval to move forward, denial, or pend for more information. If approved, the application is assigned to a Contractor to work with the applicant to begin the the preparation and negotiation of a contract. If the application is denied, a denial letter will be sent to the provider.
The Health Plan’s organizational structure has been established to facilitate consistent communication with providers for all product lines, effective integration of behavioral, physical, and social determinants of health, promote wellness and recovery, maximize member and family voice, and promote continuous quality improvement. The leadership team, led by the Medicaid President, is responsible for care management and medical management, integrated services including social determinants of health, quality management, network management, operations, compliance, and finance. The Chief Medical Officer is accountable for clinical oversight and decisions. Providers are encouraged to contact their Provider Engagement Specialist for immediate assistant and problem resolution. The Medicaid President and other key members of the leadership team serve as points of contact for critical Health Plan communication and decision making.
All advertising bearing any Arizona Complete Health-Complete Care Plan name, mark or logo must be approved by the Arizona Department of Insurance (ADOI) or Arizona Health Care Cost Containment System (AHCCCS) before use. The Centers for Medicaid and Medicare Services (CMS) and accreditation entities have additional restrictions and requirements. Providers must submit any advertising bearing an Arizona Complete Care-Completed Care Plan name, mark, or logo to Arizona Complete Health-Complete Care Plan prior to use in order to secure regulatory approval.