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Specific Physical Health Provider Requirements

The Health Plan’s network includes various different behavioral and physical health care providers to meet the needs of the membership, including Primary Care Providers, Behavioral Health Homes and Specialty Providers.

11.1.1 Member Capacity

PCPs must follow the below guidelines regarding member capacity:

  • The PCP must contact their Health Plan Services representative if they declare a specific member capacity for their practice and want to make a change to that capacity.
  • The PCP must not refuse to treat members as long as the PCP has not reached requested member capacity.
  • Providers must notify the Health Plan at least 45 days in advance of their inability to accept additional Medicaid members.

The Health Plan prohibits all providers from intentionally segregating members from fair treatment and covered services provided to other non-Medicaid members.

The Health Plan’s contracted PCPs provide integrated delivery of behavioral and physical health care Members. PCPs are required to meet various requirements, which are described below.

11.2.1 Provider Type

PCPs are required to be: (a) Arizona licensed as allopathic or osteopathic physicians that generally specialize in family practice, internal medicine, obstetrics, gynecology, or pediatrics; (b) certified nurse practitioners or certified nurse midwives; or (c) physician‘s assistants.

11.2.2 PCP Assignments

Members are auto-assigned to PCPs based on PCP and member location.  Auto-assignment is also based on PCP Panel size.  Members are auto-assigned to PCPs that have panel sizes under 1000 members.  When determining assignments to a PCP, The Health Plan also considers the PCP‘s ability to meet AHCCCS appointment availability, wait times and Quality of Care (QOC) standards.  The Health Plan PCP Panel Size and will adjust the size of a PCP’s panel, as needed, for the PCP to meet AHCCCS appointment and clinical performance standards. The Health Plan will only assign Members diagnosed with AIDS or as HIV positive to PCPs that comply with criteria and standards set forth in the AHCCCS Medical Policy Manual.

11.2.3 Freedom of Choice Within Network

The Health Plan offers Members freedom of choice in selecting a PCP within the network and does not restrict PCP choice unless a Member has shown an inability to form a relationship with a Primary Care Provider (PCP), as evidenced by frequent changes, or when there is a medically necessary reason.

The Health Plan informs each Member in writing of their enrollment and PCP assignment within five days of The Health Plan’s receipt of notification of a new member assignment by AHCCCS. The Health Plan informs each Member in writing of any PCP change, and allows Members to make the initial PCP selection and any subsequent PCP changes verbally or in writing.

11.2.4 Primary Care Provider (PCP) Responsibilities

PCPs shall be responsible for:

  • Consent form requirements;
  • Supervising, coordinating and providing of care to each assigned Member (except for dental services provided to EPSDT Members without a PCP referral);
  • Initiating referrals for medically necessary specialty care in accordance to AHCCCS AMPM Policy 510 ;
  • Maintaining continuity of care for each assigned Member;
  • Maintaining each assigned Member‘s medical record, including documentation of all services provided to the Member by the PCP, as well as any specialty or referral services;
  • Utilizing the AHCCCS-approved AHCCCS AMPM, Appendix B, EPSDT Tracking Forms (PDF) to document services provided and compliance with AHCCCS standards when serving EPSDT Members (see Section 2.4 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT);
  • Providing clinical information regarding a Member’s health and medications to a treating provider, including behavioral health providers, within ten business days of a request from the provider;
  • In lieu of developing a medical record when a PCP receives behavioral health information on a Member before seeing the Member, a PCP may establish a separate file to hold behavioral health information. The behavioral health information must, however, be added to the Member’s medical record when the Member becomes an established patient (see Section 10.2 - Medical Record Standards); 
  • Enrolling as a Vaccines for Children (VFC) provider for Members, age eighteen only;
  • Providing health care services to the Health Plan members within the scope of the provider’s practice and qualifications;
  • Providing care that is consistent with generally accepted standards of practice prevailing in the provider’s community and the health care profession;
  • Accepting the Health Plan Members as patients on the same basis that the provider accepts other patients (non- discrimination);
  • When consistent with provision of appropriate quality of care, referring the Health Plan Members only to participating providers in compliance with the Health Plan w written policies and procedures;
  • Obtaining current insurance information from the Member;
  • Cooperating with the Health Plan in connection with plan performance of utilization management and quality improvement activities, including prior authorization of necessary service and referrals;
  • Informing the member that referral services may not be covered by the Health Plan when referring to non-participating providers;
  • Providing The Health Plan with medical record information if requested for a member for processing their application for coverage; prior authorizing services or processing claims for benefits; or for purposes of health care provider credentialing, quality assurance, utilization review, case management, peer review, and audit. The Health Plan has a valid signed authorization from our members authorizing any physician, health care provider, hospital, insurance or reinsurance company, the Medical Information Bureau, Inc. (MIB), or other insurance information exchange to release information to The Health Plan if requested. Participating providers may obtain a copy of this authorization by contacting The Health Plan. The Health Plan does not reimburse for the cost of retrieval, copying and furnishing of medical records.

Cooperating with any authorized The Health Plan employee who may need to access member records that may include payment or medical records to determine the proper application of benefits, as well as the propriety of payments (including any claims payment recovery actions performed on behalf of The Health Plan.

  • In the event of provider termination, cooperating with The Health Plan and other participating providers to provide or arrange for continuity of care to members undergoing an active course of treatment, subject to the requirements and limitations of Arizona statute.
  • Operating and providing contracting services in compliance with all applicable local, state and federal laws, rules, regulations, and institutional and professional standards of care, including federal laws and regulations designed to prevent or ameliorate fraud, waste and abuse, including, but not limited to, applicable provisions of federal criminal law, the False Claims Act (31 U.S.C. 3729 et. seq.), the anti-kickback statute (section 1128B(b)) of the Social Security Act), and Health Insurance Portability and Accountability Act (HIPAA) administrative simplification rules at 45 CFR parts 160, 162, and 164.

The following responsibilities are minimum requirements to comply with contract terms and all applicable laws. Providers are contractually obligated to adhere to and comply with all terms of The Health Plan, provider contract and requirements in this manual. The Health Plan s may or may not specifically communicate such terms in forms other than the contract and this manual. This section outlines general provider responsibilities; however, additional responsibilities are included throughout the manual.

Participating providers must ensure the following, described below in detail:

  • Adhere to the Arizona Health Care Cost Containment Systems (AHCCCS) appointment standards; refer to Appointment Standards section for more information;
  • Provide service coverage on a 24/7 basis (including on-call);
  • Respect AHCCCS member rights;
  • Provide services in a culturally sensitive manager;
  • Adhere to Americans with Disability Act (ADA) requirements;
  • Provide services in a non-discriminatory manner;
  • Report suspected fraud, waste and abuse;
  • PCPs must utilize the AHCCCS-approved and Periodic Screening, Diagnosis and Treatment (EPSDT) tracking form;
  • PCPs must provide clinical information regarding a member’s health and medication to a treating physician (including behavioral health) within 10 business days of the request;
  • If treating children, enroll as a Vaccines for Children (VFC) provider; and
  • Provider complaint and appeal procedures.

Participating providers must complete initial, annual and ongoing Health Plan trainings that include, but are not limited to, the following topics:

  • Member appeals and grievances;
  • Appointment standards and wait times;
  • Language line services;
  • Proper emergency department usage;
  • Fraud, waste and abuse/ false claims act training;
  • Contacting the health plan; and
  • How to file claims and claim disputes.

11.2.5 Second Opinion

Health Plan members have the right to seek a second opinion for diagnosis and treatment at no cost from a qualified health care provider in or out of The Health Plan’s participating provider network. Prior authorization is required to access a non-participating provider.

As required by applicable statutes, under Code of Federal Regulations (CFR) 42 Section 422.112(a)(7) and 42 Section 438.206(c)(1)(iii)) and according to the signed Health Plan Contract, The Health Plan participating providers must ensure that, when medically necessary, services are available 24 hours a day, seven days a week; and primary care providers are required to have appropriate back-up for absences. Medical groups and PCPs who do not have services available 24 hours a day may use an answering service or answering machine to provide members with clear and simple instruction on after-hours access to medical care.

After office hours (outside of normal business hours or when the offices are closed), PCPs or on-call physicians are required to return calls and pages within four hours. If an on-call physician cannot be reached, the after- hours answering service or machine must direct the member to a medical facility where emergency or urgent care treatment can be provided. According to Arizona Administrative Code (AAC) Section R-20-6-1914(4), in- area urgent care services from a participating provider must be available seven days per week.

The PCP or the on-call physician designee must provide urgent and emergency care. The member must be transferred to an urgent care center or hospital emergency room as medically necessary.

11.3.1 Answering Services

The provider is responsible for the answering service they use. There must be a message immediately stating, “If this is an emergency, hang up and call 911 or go to the nearest emergency room.” If a member calls after hours or on a weekend for a possible medical emergency, the practitioner is liable for authorization of, or referral to, emergency care given by the answering service. After office hours (outside of normal business hours or when the offices are closed) physicians are required to return calls and pages within four hours. If the member indicates a need to speak with the physician or calls for an urgent matter, PCPs or on-call physicians should return telephone calls and pages within four hours and be available 24 hours a day, seven days a week.

Answering service staff handling member calls cannot provide telephone medical advice if they are not a licensed, certified or registered health care professional. Staff members may ask questions on behalf of a licensed professional in order to help ascertain the condition of the member so that the member can be referred to licensed staff; however, they are not permitted, under any circumstance, to use the answers to questions in an attempt to assess, evaluate, advise, or make any decision regarding the condition of the member, or to determine when a member needs to be seen by a licensed medical professional. Unlicensed staff should have clear instructions on the parameters relating to the use of answers in assisting a licensed provider.

Additionally, non-licensed, non-certified or non-registered health care staff cannot use a title or designation when speaking to a member that may cause a reasonable person to believe that the staff member is a licensed, certified or registered health care professional. Answering services frequently have high staff turnover, so providers should monitor the answering service to be sure that it follows emergency procedures.

The Health Plan encourages answering services to follow these steps when receiving a call:

  • Inform the member that if they are experiencing a medical emergency, they should hang up and call 911 or proceed to the nearest emergency medical facility.
  • Question the member according to the PCP’s or medical group’s established instructions (who, what, when, and where) to assess the nature and extent of the problem and offer interpreter services assistance as needed.
  • Contact the on-call physician with the facts as stated by the member.
  • After office hours, the on-call physician must return telephone calls and pages within four hours. If an on-call physician cannot be reached, direct the member to a medical facility where they can receive emergency or urgent care treatment. This is considered authorization, which is binding and cannot be retracted.
  • In the event of a hospitalization, the medical group/ independent practice association (IPA) or hospital must contact The Health Plan Hospital Notification Unit within 24 hours or the next business day of the admission
  • Document all calls.

Participating primary care physicians (PCPs) may close their practices to new Health Plan members while remaining open to members of other insured or managed health care plans, provided that the PCP meets The Health Plan threshold of 300 Health Plan members before closing the panel.

If a patient of the PCP, while a member of another health care plan, joins The Health Plan, the PCP must continue to accept the member as a patient even if their practice is closed to new The Health Plan members.

A PCP may close their practice to all new patients from all insurance or health plans at any time.

Health Plan providers who use other physicians to cover their practice while on vacation or leave must use their best efforts to find a The Health Plan participating physician within the same specialty. If a Health Plan participating physician is unable to cover the practice, the following must occur:

  • The non-participating physician must agree in writing to abide by the terms of the Health Plan contract and all Health Plan policies and procedures.
  • The Health Plan must give prior approval for the use of a non-participating physician.

Providers may request approval to use a non-participating, covering physician by contacting The Health Plan’s Provider Network Management Department.

When choosing a provider to collaborate on a case, providers must use participating providers. Payment for surgical assistants as well as second opinions may be the responsibility of the requesting provider if the provider utilized is not participating with The Health Plan. Payment by The Health Plan for these services is dependent on medical appropriateness, contract status, member eligibility, and the member’s benefit plan.  Non-participating providers must have an AHCCCS ID number.

For SMI Members receiving physical health care services, Providers must follow the following procedures for referrals to specialists or other services. Providers shall use the Specialist Referral Form and refer the Member to the appropriate provider (a provider directory is available on The Health Plan’s website).

  • Referrals to specialty physician services must be from a PCP, except as follows: Members will have direct access to in-network OB/GYN providers, including physicians, physician assistants and nurse practitioners within the scope of their practice, without a referral for preventive and routine services
  • SMI Members that need a specialized course of treatment or regular care monitoring may directly access a specialist (i.e. through a standing referral or an approved number of visits) as appropriate for the Member‘s condition and identified needs. Specialty physicians cannot begin a course of treatment for a medical condition other than that for which the Member was referred, unless approved by the Member’s PCP.

AHCCCS and the Health Plan collect and track member outcomes related to Social Determinants of Health. The use of specific International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) diagnostic codes representing Social Determinants of Health are a valuable source of information that relates to member health.

The Social Determinants of Health codes identify the conditions in which people are born, grow, live, work, and age. They are often responsible, in part, to health inequities. They include factors like:

  • Education
  • Employment
  • Physical environment
  • Socioeconomic status
  • Social support networks

As appropriate and within a scope of practice, providers should be routinely screening for, and documenting, the presence of social determinants.  Any identified social determinant diagnosis codes should be provided on all claims for AHCCCS members in order to comply with state and federal coding requirements.

The following ICD-10-CM diagnosis codes are defined as Social Determinants of Health codes under ICD-10-CM.  Please note that Social Determinants of Health codes may be added or updated on a quarter.

ICD-Code

Description

Z55.0

Illiteracy and low-level literacy

Z55.1

Schooling unavailable and unattainable

Z55.2

Failed school examinations

Z55.3

Underachievement in school

Z55.4

Educational maladjustment and discord with teachers and classmates

Z55.8

Other problems related to education and literacy

Z55.9

Problems related to education and literacy, unspecified

Z56.0

Unemployment, unspecified

Z56.1

Change of job

Z56.2

Threat of job loss

Z56.3

Stressful work schedule

Z56.4

Discord with boss and workmates

Z56.5

Uncongenial work environment

Z56.6

Other physical and mental strain related to work

Z56.81

Sexual harassment on the job

Z56.82

Military deployment status

Z56.89

Other problems related to employment

Z56.9

Unspecified problems related to employment

Z57.0

Occupational exposure to noise

Z57.1

Occupational exposure to radiation

Z57.2

Occupational exposure to dust

Z57.31

Occupational exposure to environmental tobacco smoke

Z57.39

Occupational exposure to other air contaminants

Z57.4

Occupational exposure to toxic agents in agriculture

Z57.5

Occupational exposure to toxic agents in other industries

Z57.6

Occupational exposure to extreme temperature

Z57.7

Occupational exposure to vibration

Z57.8

Occupational exposure to other risk factors

Z57.9

Occupational exposure to unspecified risk factor

Z59.0

Homelessness

Z59.1

Inadequate housing

Z59.2

Discord with neighbors, lodgers and landlord

Z59.3

Problems related to living in residential institution

Z59.4

Lack of adequate food and safe drinking water

Z59.5

Extreme poverty

Z59.6

Low income

Z59.7

Insufficient social insurance and welfare support

Z59.8

Other problems related to housing and economic circumstances

Z59.9

Problem related to housing and economic circumstances, unspecified

Z60.0

Problems of adjustment to life-cycle transitions

Z60.2

Problems related to living alone

Z60.3

Acculturation difficulty

Z60.4

Social exclusion and rejection

Z60.5

Target of (perceived) adverse discrimination and persecution

Z60.8

Other problems related to social environment

Z60.9

Problem related to social environment, unspecified

Z62.0

Inadequate parental supervision and control

Z62.1

Parental overprotection

Z62.21

Child in welfare custody

Z62.22

Institutional upbringing

Z62.29

Other upbringing away from parents

Z62.3

Hostility towards and scapegoating of child

Z62.6

Inappropriate (excessive) parental pressure

Z62.810

Personal history of physical and sexual abuse in childhood

Z62.811

Personal history of psychological abuse in childhood

Z62.812

Personal history of neglect in childhood

Z62.819

Personal history of unspecified abuse in childhood

Z6.2820

Parent-biological child conflict

Z62.821

Parent-adopted child conflict

Z62822

Parent-foster child conflict

Z62.890

Parent-child estrangement NEC

Z62.891

Sibling rivalry

Z62.898

Other specified problems related to upbringing

Z62.9

Problem related to upbringing, unspecified

Z63.0

Problems in relationship with spouse or partner

Z63.1

Problems in relationship with in-laws

Z63.31

Absence of family member due to military deployment

Z63.32

Other absence of family member

Z63.4

Disappearance and death of family member

Z63.5

Disruption of family by separation and divorce

Z63.6

Dependent relative needing care at home

Z63.71

Stress on family due to return of family member from military deployment

Z63.72

Alcoholism and drug addiction in family

Z63.79

Other stressful life events affecting family and household

Z63.8

Other specified problems related to primary support group

Z63.9

Problem related to primary support group, unspecified

Z64.0

Problems related to unwanted pregnancy

Z64.1

Problems related to multiparity

Z64.4

Discord with counselors

Z65.0

Conviction in civil and criminal proceedings without imprisonment

Z65.1

Imprisonment and other incarceration

Z65.2

Problems related to release from prison

Z65.3

Problems related to other legal circumstances

Z65.4

Victim of crime and terrorism

Z65.5

Exposure to disaster, war and other hostilities

Z65.8

Other specified problems related to psychosocial circumstances

Z65.9

Problem related to unspecified psychosocial circumstances

Z71.41

Alcohol abuse counseling and surveillance of alcoholic

Z71.42

Counseling for family member of alcoholic

Z71.51

Drug abuse counseling and surveillance of drug abuser

Z71.52

Counseling for family member of drug abuser

Z72.810

Child and adolescent antisocial behavior

Z72.811

Adult antisocial behavior

Z72.89

Other problems related to lifestyle

Z72.9

Problem related to lifestyle, unspecified

Z73.0

Burn-out

Z73.1

Type A behavior pattern

Z73.2

Lack of relaxation and leisure

Z73.3

Stress, not elsewhere classified

Z73.4

Inadequate social skills, not elsewhere classified

Z73.89

Other problems related to life management difficulty

Z73.9

Problem related to life management difficulty, unspecified

Providers shall comply with all applicable physician referral requirements and conditions defined in §§ 1903(s) and 1877 of the Social Security Act and corresponding regulations which include, but are not limited to, 42 CFR Part 411, Part 424, Part 435 and Part 455. §§ 1903(s) and 1877 of the Act prohibits physicians from making referrals for designated health services to health care entities with which the physician or a member of the physician‘s family has a financial relationship. Designated health services include, at a minimum, clinical laboratory services physical therapy services; occupational therapy services; radiology services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; prosthetics, orthotics and prosthetic devices and supplies; home health services; outpatient prescription drugs, and inpatient and outpatient hospital services.

For SMI Members eligible to receive physical health care services, the following appointment requirements apply:

For Primary Care Appointments:

  • Urgent care appointments as expeditiously as the member’s health condition requires but no later than two (2) business days of the request
  • Routine care appointments within twenty-one (21) calendar days of request.

For Specialty Care Appointments:

  • Urgent care appointments as expeditiously as the member’s health condition requires but no later than three (3) business days from the request or referral; and
  • Routine care appointments within forty-five (45) calendar days of referral.

For Dental Provider Appointments to SMI Members under age twenty-one (21).

  • Urgent appointments as expeditiously as the member’s health condition requires but no later than three (3) days of request; and
  • Routine care appointments within forty-five (45) calendar days of request.

For Maternity Care Provider Appointments, see Section 2.3 - Maternity Services for Title XIX/XXI Adults with SMI.

The Health Plan covers medically necessary audiology services, within certain limitations, to evaluate hearing loss and rehabilitate persons with hearing loss through means other than medical/surgical procedures.

Covered services include:

  • Exams or evaluations for hearing aids
  • Exams or evaluations for cochlear implants
  • Evaluations for prescription of speech-generating and non-speech-generating augmentative and alternative communicating devices
  • Therapeutic service(s) for the use of speech-generating and non-speech-generating devices, including programming and modification, and devices such as hearing aids, cochlear implants, speech-generating and non- speech-generating
  • Audiology services must be provided by an audiologist who is licensed by the Arizona Department of Health Services (ADHS) and who meets federal requirements specified under 42 CFR 440.110.

Hearing aids can be dispensed only by a dispensing audiologist or an individual with a valid hearing aid dispensing license. Hearing aids, provided as a part of audiology services, are covered only for members under age 21 receiving Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services or those enrolled in KidsCare. The Health Plan does not cover hearing aids for members ages 21 and older.

Arizona Health Care Cost Containment Services (AHCCCS) eliminated coverage of bone- anchored hearing aid (BAHA), also known as osseointegrated implants, and cochlear implants for members ages 21 and older. Supplies, equipment maintenance and repair of component parts remain a covered benefit. Documentation that establishes the need to replace a component not operating effectively must be provided when requesting prior authorization

11.11.1 Treatment of Behavioral Health Disorders

PCPs may provide medication management services for select behavioral health disorders, such as anxiety, mild depression, postpartum depression, and attention deficit hyperactivity disorder (ADHD). Medication management services may include medication monitoring, prescriptions, laboratory services, and other diagnostic tests necessary to diagnose and treat behavioral disorders PCPs may use the Arizona Health Care Cost Containment System (AHCCCS) approved toolkits or other clinically approved tools or evidence-based guidelines for best practices addressing the treatment of these disorders. The AHCCCS toolkits include assessment tools, scoring instructions and recommended medication lists, and are available on the provider website at www.AzCompleteHealth.com or by contacting The Health Plan behavioral health coordinator.

11.11.2 Referrals

PCPs are required to comply with The Health Plan, AHCCCS and RBHA or T/RBHA guidelines for referring their assigned members for behavioral health services. Referrals are based on, but not limited to:

  • member request (members may also self-refer to a behavioral health provider);
  • sentinel event, such as a member-defined crisis episode;
  • psychiatric hospitalization;
  • identification of behavioral health diagnosis outside the scope of the PCP or substance abuse issues.

PCPs may refer members for the following services by contacting The Health Plan Behavioral Health Unit (for dual-eligible members) or T/ RBHA (for Medicaid-only members):

  • Behavioral health services;
  • Consultation with a The Health Plan or T/RBHA behavioral health provider;
  • One-time, face-to-face psychiatric evaluation with The Health Plan or RBHA or T/RBHA
  • Behavioral health provider for treatment, ongoing behavioral health care or medication management. To request this service, PCPs must complete and submit the behavioral health referral form and check one-time, face-to-face request.

PCPs must transfer the member to a behavioral health provider contracting with The Health Plan (for dual- eligible members) or the Regional Behavioral Health Authority (RBHA) or Tribal/Regional Behavioral Health Authority (T/RBHA) if symptoms become severe or if the member needs additional behavioral health services. PCPs must ensure members are not simultaneously receiving behavioral health medication from both the behavioral health provider and PCP. When the member is identified to be simultaneously receiving medications from the PCP and behavioral health provider, the PCP must immediately contact the behavioral health provider to coordinate care and agree on who will continue to medically manage the person’s behavioral health condition.

PCPs must use step therapy as needed for ADHD, anxiety disorder, mild depression, and postpartum depression. Step therapy is required for medication not on the Arizona Health Care Cost Containment System (AHCCCS) or Division of Behavioral Health Services (DBHS) preferred drug list. This includes the requirement that if the PCP receives documentation from The Health Plan, or T/RBHA behavioral health providers regarding completion of step therapy, the PCP continues prescribing the same brand and dosage of current medication unless a change in medical condition is clearly evident.

Psychotropic medications are listed in The Health Plan Drug List, available on the provider website at www.azcompletehealth.com. For additional information regarding pharmacy benefits, contact Envolve Pharmacy Solutions.

The Health Plan covers breast reconstruction surgery for eligible health plan members following a medically necessary mastectomy regardless of the member’s eligibility status at time of the mastectomy. The Health Plan does not cover services provided solely for cosmetic purposes.

A member may elect to have breast reconstruction surgery immediately following a mastectomy or may choose to delay breast reconstruction, but the member must be enrolled in The Health Plan at the time of breast reconstruction surgery. The type of breast reconstruction performed is determined by the physician in consultation with the member.

Breast reconstructive surgery coverage includes:

  • Reconstruction of the affected and the unaffected contralateral breast. Reconstructive breast surgery of the unaffected contralateral breast following mastectomy is considered medically necessary only when required to achieve relative symmetry with the reconstructed affected breast. The surgeon must determine medical necessity and request prior authorization for reconstructive breast surgery of the unaffected contralateral breast prior to the time of reconstruction or during the immediate post- operative period
  • Medically necessary implant removal and implant replacement when the original implant was the result of a medically necessary mastectomy. Implant replacements are not covered when the purpose of the original implant was cosmetic, such as augmentation
  • External prostheses, including a surgical brassiere, for members who choose not to have breast reconstruction, or who choose to delay breast reconstruction until a later time

Prior authorization is required for breast reconstruction surgery. Coverage for prosthetic devices and reconstructive surgery is subject to copayment that is applicable to the mastectomy and all other terms and conditions applicable to other benefits.

The Health Plan covers conscious sedation for members receiving Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. Conscious sedation provides a state of consciousness that allows the member to tolerate an unpleasant procedure while continuously maintaining adequate cardiovascular and respiratory function, as well as the ability to respond purposely to verbal command and/or tactile stimulation.

Additional applications of conscious sedation for members receiving EPSDT services are considered on a case-by-case basis and require medical review and prior authorization by The Health Plan for enrolled members.

Durable medical equipment (DME) is paid for in accordance with the Provider Participation Agreement (PPA). Fee-for- service (FFS) providers may be directed to any participating The Health Plan DME provider, including Preferred Homecare.

Prosthetic and orthotic services are not available through The Health Plans’ preferred DME provider (Preferred Homecare). They may be obtained through prosthetic and orthotic providers, such as Hanger Prosthetics and Orthotics.

The Health Plan covers hemodialysis and peritoneal dialysis services provided by participating Medicare-certified hospitals or Medicare-certified end-stage renal disease (ESRD) providers. Hemoperfusion is covered when medically necessary. Services may be provided on an outpatient basis or on an inpatient basis if the hospital admission is not solely to provide chronic dialysis services. Hospital admissions solely to provide chronic dialysis are not covered.

Medically necessary outpatient dialysis treatments are covered, including:

  • Supplies
  • Diagnostic testing (including routine medically necessary laboratory tests)
  • Medications

Inpatient dialysis treatments are covered when the hospitalization is for:

  • Acute medical condition requiring dialysis treatments (hospitalization related to dialysis)
  • Medical condition requiring inpatient hospitalization experienced by a member routinely maintained on an outpatient chronic dialysis program
  • Placement, replacement or repair of the chronic dialysis route

11.15.1 Exclusions and Limitations

The Health Plan does not cover the following items:

  • Personal care items, unless needed to treat a medical condition (except incontinence briefs and pads for members over age 3 and under age 21).
  • First aid supplies (except under a prescription).
  • Hearing aids for members ages 21 and older.
  • Prescriptive lenses for members ages 21 and older (except if medically necessary following cataract removal).
  • Penile implants or vacuum devices for members who are ages 21 and older.

11.15.2 Orthotics

Orthotics are rigid or semi-rigid devices affixed to the body externally and required to support or correct a defect of form or function of a permanently inoperative or malfunctioning body part, or to restrict motion in a diseased or injured part of the body.

11.15.2.1 Custom Orthotics

A prior authorization is required for custom orthotics. Coverage for Members Under Age 21

Orthotic devices are a covered benefit for The Health Plan members under age 21 when they are medically necessary and the orthotics cost less than other treatments that are as helpful for the condition.

11.15.2.2 Coverage for Members Ages 21 and Older

Orthotic devices are a covered benefit for The Health Plan members ages 21 and older when all of the following apply:

  • The use of the orthotic is medically necessary as the preferred treatment option consistent with Medicare guidelines.
  • The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition.
  • The member’s primary care physician (PCP) or other physician orders the orthotic.

11.15.2.3 Prosthetics NOT Covered for Members Ages 21 and Older

  • bone-anchored hearing aids (BAHA), also known as osseointegrated implants
  • cochlear implants
  • insulin pumps
  • percussive vests

Orthotic services are not available through The Health Plans’ preferred DME provider (Preferred Homecare). They may be obtained through prosthetic and orthotic providers, such as Hanger Prosthetics and Orthotics.

The Health Plan covers medically necessary foot and ankle care services, including the following, when ordered by a member’s primary care physician (PCP), attending physician or practitioner within certain limits for eligible The Health Plan.

Under age 21 - Bunionectomies, casting for the purpose of constructing or accommodating orthotics, medically necessary orthopedic shoes that are an integral part of a brace, and medically necessary routine foot care for patients with a severe systemic disease that prohibits care by a non-professional person Age 21 or older - Wound care, treatment of pressure ulcers, fracture care, reconstructive surgeries, and limited bunionectomy services. Medically necessary routine foot care services are only available for members with a severe systemic disease that prohibits care by a nonprofessional. Services are not covered when provided by a podiatrist or podiatric surgeon. Members can be referred to other contracting providers who can perform medically necessary foot and ankle procedures, including reconstructive surgeries. A prescription written by a podiatrist would not automatically disqualify the prescribed medication (device or service) from payment.

However, the prescribed medication, device or service may be subject to prior authorization to determine whether it is covered. Bunionectomies are covered only when the bunion is present with:

  • Overlying skin ulceration;
  • Neuroma secondary to bunion (neuroma to be removed at same surgery and documented by pathology report).

Bunionectomies are not covered if the sole indications are pain and difficulty finding appropriate shoes.

11.16.1 Routine Foot Care

Routine foot care is defined as services performed in the absence of localized illness, injury or symptoms involving the foot. Routine foot care is considered medically necessary in very limited circumstances. These services include:

  • Cutting or removal of corns or calluses
  • Nail trimming (including mycotic nails)
  • Other hygienic and preventive maintenance care in the realm of self-care (such as cleaning and soaking the feet, and the use of skin creams to maintain skin tone of both ambulatory and bedfast patients)

Routine foot care is considered medically necessary when the member has a systemic disease of sufficient severity that performance of foot care procedures by a nonprofessional would be hazardous. Conditions that might necessitate medically necessary foot care include metabolic, neurological and peripheral vascular systemic diseases. Examples include, but are not limited to:

  • Anticoagulation therapy in progress;
  • Arteriosclerosis obliterans (arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis);
  • Buerger’s disease (thromboangiitis obliterans);
  • Chronic thrombophlebitis;
  • Diabetes mellitus;
  • Peripheral neuropathies involving the feet;
  • Chemotherapy in progress;
  • Pernicious anemia;
  • Hereditary disorder, such as hereditary sensory radicular neuropathy or Fabry’s disease;
  • Hansen’s disease or neurosyphilis;
  • Malabsorption syndrome;
  • Multiple sclerosis;
  • Traumatic injury;
  • Uremia (chronic renal disease).

Treatment of a fungal (mycotic) infection is considered medically necessary foot care and is covered when the member has all of the following:

  • A systemic condition
  • Clinical evidence of mycosis of the toenail
  • Compelling medical evidence documenting the member either:
    • Has a marked limitation of ambulation due to the mycosis, which requires active treatment of the foot
    • In the case of a nonambulatory member, has a condition that is likely to result in significant medical complications in the absence of such treatment.

11.16.2 Limitations

Coverage is limited as follows:

  • Coverage for medically necessary routine foot care must not exceed two visits per quarter or eight visits per contract year (this does not apply to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) members)
  • Coverage of mycotic nail treatments does not exceed one bilateral mycotic nail treatment (up to 10 nails) per 60 days (this does not apply to EPSDT members)
  • Neither general diagnoses, such as arteriosclerotic heart disease, circulatory problems, vascular disease, venous insufficiency, or incapacitating injuries or illnesses, such as rheumatoid arthritis, CVA (stroke) or fractured hip, are diagnoses under which routine foot care is covered.

Flu shots are available to all members. Copayments may only be collected for flu shots when given in conjunction with an office visit.

Primary care providers (PCPs) are responsible for immunizing members and maintaining all immunization information in the member’s medical record. Local health departments (LHDs) may also immunize The Health Plan members.

PCPs must be available to administer immunizations during routine office hours. It is the PCP’s responsibility to update the immunization record card or other form of immunization record, and enter all immunizations into the Arizona State Immunization Information System (ASIIS) registry.

At each visit, the PCP should inquire whether the patient has received immunizations from another provider. The PCP should also educate members regarding their responsibility to inform the PCP if they receive immunizations elsewhere (such as from an LHD or nonparticipating provider). This information is necessary for documentation and for the member’s safety.

Observation services are reasonable and necessary services provided on a hospital’s premises, on an outpatient basis, for evaluation to determine whether the member should be admitted for inpatient care, discharged or transferred to another facility. Observation services include use of a bed, periodic monitoring by a hospital’s nursing staff or, if appropriate, other staff necessary to evaluate, stabilize or treat medical conditions of significant instability or disability on an outpatient basis.

Observation services do not apply when a member with a known diagnosis enters a hospital for a scheduled procedure or treatment that is expected to keep the member in the hospital for less than 24 hours. This is considered an outpatient procedure, regardless of the hour in which the member presented to the hospital, whether a bed was utilized or whether services were rendered after midnight. Extended stays after outpatient surgery must be billed as recovery room extensions.

Observation services must be ordered in writing by a physician or other individual authorized to admit patients to the hospital or to order outpatient diagnostic tests or treatments. There is no maximum time limit for observation services as long as medical necessity exists. Factors taken into consideration when ordering observation services include:

  • Severity of the patient’s signs and symptoms;
  • Degree of medical uncertainty where the patient may experience an adverse occurrence;
  • Need for diagnostic studies that appropriately are outpatient services (their performance does not ordinarily require the member to remain in the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted;
  • The availability of diagnostic procedures at the time and location where the patient presents;
  • It is reasonable, cost-effective and medically necessary to evaluate a medical condition or to determine the need for inpatient admission length of stay observation services are medically necessary for the patient’s condition.

The medical record must document the basis for the observation services and at a minimum must include:

  • Physician notes;
    • Condition necessitating observation
    • Justification of need to continue observation
    • Discharge plan
  • Medical records documentation;
    • Written orders for observation services
    • Written follow-up orders at least every 24 hours
    • Changes from observation to inpatient or inpatient to observation
    • Changes from inpatient to observation must occur within 12 hours after admission as an inpatient and have supporting medical documentation
    • Physician’s daily written progress note.

The Health Plan covers medically necessary services provided in contracting skilled nursing facilities (SNFs) for members who need defined nursing care 24 hours a day, but who do not require acute hospital care under the daily direction of a physician.

Prior authorization is required for SNF services prior to admission, except in those cases for which retro-eligibility precludes the ability to obtain prior authorization. In these cases, the case is subject to medical review.

Medically necessary SNF services are covered for a period not to exceed 90 days per contract year (October 1 to September 30). The following criteria apply:

  • A participating physician has ordered SNF services.
  • The medical condition of the member is such that if SNF services are not provided, it would result in hospitalization, or the treatment is such that it cannot be rendered safely in a less restrictive setting, such as at home by a home health services provider;
  • The 90 days of coverage is per member, per contract year and does not restart if the member transfers to a different nursing facility. The Health Plan members residing in a SNF at the beginning of a new contract year begin a new 90-day coverage period.  Unused days do not carry over.
  • The 90 days of coverage begins on the day of admission regardless of whether the member is covered by a third- party insurance carrier, including Medicare.
  • If the member has applied for Arizona Long Term Care System (ALTCS) and a decision is pending, the Health Plan must notify the ALTCS eligibility administrator when the member has been residing in the nursing facility for 60 days. This allows time to follow-up on the status of the ALTCS application.

If the member becomes ALTCS-eligible and is enrolled with the ALTCS program before the end of the maximum 90 days of coverage, the Health Plan is only responsible for the SNF coverage during the time the member is enrolled with The Health Plan. The SNF must coordinate with the member or their representative on alternate methods of payment for continuation of services beyond the 90-day coverage with the Health Plan until the member is enrolled in the ALTCS program or until the beginning of the new contract year.

11.19.1 Care Coordination

Participating providers should identify and refer potentially eligible The Health Plan members to ALTCS. If a The Health Plan member is referred to and approved for ALTCS enrollment, the Health Plan coordinates the transition with the assigned ALTCS contractor to assure continuity and quality of care is maintained during and after the transition.

11.19.2 Limitations

Services that are not covered separately when provided in a Skilled Nursing Facility include:

  • Nursing services, including:
    • medication administration
    • tube feedings
    • personal care services
    • routing testing of vital signs and blood glucose monitoring
    • assistance with eating
    • catheter maintenance
  • Basic patient care equipment and sickroom supplies, such as bedpans, urinals, diapers, bathing and grooming supplies, walkers, and wound dressings or bandages;
  • Dietary services, including, but not limited to, preparation and administration of special diets and adaptive tools for eating;
  • Administrative physician visits made solely for the purpose of meeting state certification requirements;
  • Non-customized durable medical equipment (DME) and supplies, such as manual wheelchairs, geriatric chairs and bedside commodes;
  • Rehabilitation therapies ordered as a maintenance regimen;
  • Administration, medical director services, plant operations, and capital;
  • Over-the-counter medications and laxatives;
  • Social activity, recreational and spiritual services.
  • Any other services, supplies or equipment that are state or county regulatory requirements or are included in the SNF’s room and board charge.

The Health Plan provides benefits for standard polysomnography inpatient and outpatient sleep studies in the following settings:

  • A licensed and certified hospital facility;
  • A nonhospital facility that meets one of the following sets of criteria:
    • Is licensed by the Arizona Department of Health Services (ADHS) and the facility is accredited by the American Academy of Sleep Medicine
    • Has a medical director who is certified by the American Board of Sleep Medicine and has a managing sleep technician who is registered by the Board of Registered Polysomnographic Technologists;
    • For sleep electroencephalogram (EEG) only, the facility must have a physician who is a board- certified neurologist. No ADHS license is required.

11.20.1 Criteria for Coverage

Standard polysomnography is covered in the following indications.

Suspected sleep-related breathing disorders, such as obstructive sleep apnea (OSA), when one of the following two criteria are met:

  • Witnessed apnea during sleep greater than 10 seconds in duration
  • Suspected sleep-related breathing disorders, such as obstructive sleep apnea (OSA) when one of  the following two criteria are met:
    • Excessive daytime sleepiness - Must rule out as a cause for these symptoms: poor sleep hygiene, medication, drugs, alcohol, hypothyroidism, other medical diagnoses, psychiatric or psychological disorders, social or work schedule changes;
    • Persistent or frequent snoring;
    • Obesity (body mass index (BMI) greater than 30 kg/M2 or hypertension);
    • Choking or gasping episodes associated with awakenings.
  • Suspected narcolepsy, demonstrated by symptoms, such as sleep paralysis, hypnagogic hallucinations and cataplexy;
  • Suspected period movement disorder, including excessive daytime sleepiness together with witnessed periodic limb movements of sleep;
  • Suspected parasomnias that are unusual or atypical based on patient’s age, frequency or duration of behavior;
  • Suspected restless leg syndrome, when uncertainty exists in the diagnosis;
  • To assist with the diagnosis of paroxysmal arousals or other sleep disruptions that are thought to be seizure-related when the initial clinical evaluation and results of a standard EEG are inclusive;
  • Under limited circumstances, titration of positive airway pressure in adults with a documented diagnosis of OSA for whom positive airway pressure has been approved;
  • Other health conditions in which sleep studies have been shown to be medically necessary for their proper diagnosis or treatment.

The preferred method is a split night study in which the sleep study is performed during the first half of the night and positive air pressure system, such as continuous positive airway pressure (CPAP) or biphasic intermittent positive airway pressure (BiPAP), titration is performed during the second half of the night. In cases where testing and titration cannot be completed in one session, the Health Plan may authorize a second night subject to medical necessity criteria.

11.20.2 Limitations

Polysomnography is not covered for the following symptoms or conditions existing alone in the absence of other features suggestive of OSA:

  • Snoring;
  • Obesity;
  • Hypertension;
  • Morning headaches;
  • Decrease in intellectual functions;
  • Memory loss;
  • Frequent nighttime awakenings;
  • Other sleep disturbances, such as insomnia (acute or chronic), night terrors, sleep walking, epilepsy where nocturnal seizures are not suspected;
  • Common uncomplicated non-injurious parasomnias;
  • Follow-up sleep studies are not covered unless the member’s condition has changed significantly and those changes are likely to modify the need for CPAP or other treatments;
  • Sleep studies performed in the home or in a mobile unit are not covered;
  • Pulse oximetry alone as a sleep study is not covered;
  • Repeat polysomnography in follow-up patients with OSA treated with CPAP when symptoms attributable to sleep study have resolved is not covered.

The Health Plan covers medically necessary consultative and/or treatment telemedicine services for all eligible members within the limitations described in this policy when provided by an appropriate Arizona Health Care Cost Containment System (AHCCCS) registered provider.

11.21.1 Definitions

Term

Definition

Consulting provider

Any AHCCCS provider who is not located at the originating site who provides an expert opinion to assist in the diagnosis or treatment of a member

Store and forward

The transmission of a patient’s medical information from the originating site to the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present

Telehealth

The use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance
  • Telemedicine - The practice of health care delivery, diagnosis, consultation and treatment, and the transfer of medical data between the originating and distant sites through real- time interactive audio, video or data communications that occur in the physical presence of the member
  • Telecommunications technology (which includes store and forward) - Transfer of medical data from one site to another through the use of a camera, electronic data collection system, such as an electrocardiogram (ECG) or other similar device, that records (stores) an image which is then sent (forwarded) via telecommunication to another site for consultation. Services delivered using telecommunications technology, but not requiring the member to be present during their implementation, are not considered telemedicine

Distant site

The location of the telemedicine consulting provider, which is considered the place of service

Originating site

The location where the member is receiving the telemedicine service

Telepresenter

A designated individual who is familiar with the member’s case and has been asked to present the member’s case at the time of telehealth service delivery if the member’s originating site provider is not present. The telepresenter must be familiar, but not necessarily medically expert, with the member’s medical condition in order to present the case accurately

11.21.2 Use of Telemedicine

For the services listed below, The Health Plan provides benefits for medically necessary services provided via telemedicine. Services must be real-time visits otherwise reimbursed by The Health Plan. Both the member and the originating provider or knowledgeable telepresenter must be present. Prior authorization is not required when covered services are provided as described in this section.

The following medical services are covered:

  • Cardiology;
  • Dermatology;
  • Endocrinology;
  • Hematology/oncology;
  • Infectious diseases;
  • Neurology;
  • Obstetrics/gynecology;
  • Oncology/radiation;
  • Ophthalmology;
  • Orthopedics;
  • Pain clinic;
  • Pathology;
  • Pediatrics and pediatric subspecialties;
  • Radiology;
  • Behavioral Health (per the Covered Behavioral Health Services Guide found at http://www.azahcccs.gov/);
  • Rheumatology.

11.21.3 Use of Telecommunications

Services delivered using telecommunications are generally not covered by The Health Plan as telemedicine services. The exceptions to this are described below:

  • A provider in the role of telepresenter may be providing a separately billable service under the scope of practice, such as performing an ECG or an X-ray. In this case, the separately billable service is covered, but the specific act of telepresenting is not covered;
  • A consulting provider at the distant site may offer a service that does not require real-time interaction with the member. Reimbursement for this type of service is limited to dermatology, radiology, ophthalmology, and pathology, and is subject to review by The Health Plan medical management. The consulting physician should bill covered services using modifier GQ;
  • In the special circumstance of the onset of acute stroke symptoms within three hours of presentation, The Health Plan recognizes the critical need for a neurology consultation in rural areas to aid in the determination of suitability for thrombolytic administration. Therefore, when the member presents within three hours of onset of stroke symptoms, The Health Plan reimburses the consulting neurologist if the consult is placed for assistance in determining appropriateness of thrombolytic therapy even when the patient’s condition is such that real-time video interaction cannot be achieved due to an effort to expedite care.

11.21.4 Conditions, Limitations and Exclusions

Both the referring and consulting providers must be registered with AHCCCS.

A consulting service delivered via telemedicine by other than an Arizona registered provider licensed to practice in the state or jurisdiction from which the consultation is provided or, if employed by an Indian Health Services (IHS), tribal or urban Indian health program, be appropriately licensed based on IHS and 638 tribal facility requirements.

At the time of service delivery via real-time telemedicine, the member’s health care provider may designate a trained telepresenter to present the case to the consulting provider if the member’s primary care physician (PCP) or attending physician, or other medical professional who is familiar with the member’s medical condition, is not present. The telepresenter must be familiar with the member’s medical condition in order to present the case accurately. Medical questions may be submitted to the referring provider when necessary, but no payment is made for such questions.

The Health Plan provides benefits for nonemergency transportation to and from the telemedicine originating site to receive a medically necessary covered consultation or treatment service

The following describes covered services for transplants under The Health Plan product:

  • The Health Plan covers medically necessary transplants based on Arizona Health Care Cost Containment System (AHCCCS) direction. In order to be covered, a transplant must be medically necessary, cost effective, and federally and state reimbursable. Arizona state laws and regulations specifically address transplant services and related topics as follows: Specific non-experimental transplants which are approved for reimbursement are covered services (Arizona Revised Statute (ARS) §36-2907);
  • Services which are experimental, or which are provided primarily for the purpose of research are excluded from coverage (Arizona Administrative Code (AAC) R9-22- 202);
  • Medically necessary is defined as those covered services “provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability or other adverse conditions, or their progression, or prolong life” (AAC R9-22-101);
  • Experimental services as defined in AAC R9-22-203;
  • Standard of care is defined as “a medical procedure or process that is accepted as treatment for a specific illness, injury or medical condition through custom, peer review or consensus by the professional medical community” (AAC R9-22-101)
  • Transplant coverage is limited for members ages 21 and older; however, the Health Plan covers all medically necessary, non-experimental transplants for members under age 21 under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Transplants are excluded for members who are eligible for only emergency services under the Federal Emergency Services Program;
  • Covered transplants must meet nationally recognized criteria for nonexperimental, non-investigational and not primarily for purposes of research. Details of transplant coverage and criteria are available in the AHCCCS Medical Policy Manual Chapter 300, Policy 310-DD.

11.22.1 Covered Transplants for Members Ages 21 and Older

The following organ and tissue transplant services are covered for members ages 21 and older if prior authorized and coordinated with The Health Plan:

  • Heart, including transplants for the treatment of non-ischemic cardiomyopathy;
  • Lung;
  • Liver, including transplants for patients with Hepatitis C;
  • Kidney (cadaveric and liver donor);
  • Simultaneous pancreas/kidney (SPK);
  • Pancreas after a kidney transplant (PAK);
  • Autologous and allogeneic related and unrelated hematopoietic cell transplants;
  • Cornea;
  • Bone.

The Health Plan may consult with the AHCCCS consultant for guidance in those cases requiring medical determinations. If The Health Plan does not use the AHCCCS consultant, the Health Plan obtains its own expert opinion.

11.22.2 Non-Covered Transplants for Members Ages 21 and Older

  • Pancreas only, if not performed simultaneously with or following a kidney transplant
  • Partial pancreas (including autologous and allogeneic islet cell transplants)
  • Visceral transplantation of:
    • Intestine alone;
    • Intestine with pancreas;
    • Intestine with liver;
    • Intestine, liver, pancreas en bloc.

Any other transplants not specifically listed under Covered Transplants for Members Ages 21 and Older

Where there is a transplant of multiple organs, only the covered transplants are reimbursed.

The following transplant and transplant-related services are not covered when the transplant procedure itself is not covered:

  • Artificial or mechanical hearts or xenografts
  • Workups to evaluate the patient as a possible transplant candidate
  • Hospitalization for the above procedures
  • Organ procurement

11.22.3 Transplant Services and Settings

Transplant services are covered only when performed in specific settings, as follows:

  • Solid organ transplantation services must be provided in a Centers for Medicare and Medicaid Services (CMS) certified transplant center that is contracted with AHCCCS and that is also a United Network for Organ Sharing (UNOS) approved transplant center, unless otherwise approved by the Health Plan, and/or the AHCCCS chief medical officer (AHCCCS medical director or designee
  • Hematopoietic stem cell transplant services must be provided in a facility that has achieved Foundation for the Accreditation of Cellular Therapy (FACT) accreditation and is contracted with AHCCCS, unless otherwise approved by The Health Plan and/or the AHCCCS chief medical officer), AHCCCS medical director or designee

11.22.4 Assessment for Transplant Considerations

The first step in the assessment for transplant consideration is the initial evaluation by the member’s primary care physician (PCP) and/or the specialist treating the condition necessitating the transplant. In determining whether the member is appropriate for referral for transplant consideration, the PCP and/or specialist must determine that all of the following conditions are satisfied:

  • The member will be able to attain an increased quality of life and chance for long-term survival as a result of the transplant
  • There are no significant impairments or conditions that would negatively impact the transplant surgery, supportive medical services, or inpatient and outpatient post-transplantation management of the member
  • There are strong clinical indications that the member can survive the transplantation procedure and related medical therapy (such as, chemotherapy and immunosuppressive therapy)
  • There is sufficient social support to ensure the member’s compliance with treatment recommendations, such as, but not limited to, immunosuppressive therapy, other medication regimens and pre- and post-transplantation physician visits. For a pediatric/adolescent member, there is adequate evidence that the member and parent or guardian will adhere to the rigorous therapy, daily monitoring and re-evaluation schedule after transplant
  • The member has been adequately screened for potential comorbid conditions that may impact the success of the transplant. When the member’s medical condition is such that the evaluation must proceed immediately, the screenings may be provided by the PCP concurrent with the transplant evaluation
  • The member’s condition has failed to improve with all other conventional medical and surgical therapies. The likelihood of survival with transplantation, considering the member’s diagnosis, age and comorbidities, is greater than the expected survival rate with conventional therapies. This information must be documented and submitted to the Health Plan at the time of request for evaluation

11.22.5 Exceptions for Transplant and Cancer

For members who require medically necessary dental services as a prerequisite to AHCCCS covered organ or tissue transplantation, covered dental services are limited to the elimination of oral infections and the treatment of oral disease, which include dental cleanings, treatment of periodontal disease, medically necessary extractions, and the provision of simple restorations. A simple restoration means silver amalgam and/or composite resin fillings, stainless steel crowns or preformed crowns. Benefits are provided for these services only after a transplant evaluation determines that the member is an appropriate candidate for organ or tissue transplantation.

11.22.6 AHCCCS Covered Solid Organ and Hematopoietic Stem Cell Transplants

Only solid organ and hematopoietic stem cell transplants that are AHCCCS covered services when medically necessary, cost effective, nonexperimental, and not primarily for purposes of research, are covered under The Health Plan product. Live donor kidney transplants are covered for pediatric and adult members. Live donor transplants may be considered on a case-by-case basis for solid organs, other than kidney, when medically appropriate and cost effective. Detailed criteria regarding specific transplants are found under the heading Solid Organ Transplants and Related Devices: Specific Indications and Contraindications/Limitations located in the AHCCCS AMPM Chapter 300, Policy 310-DD.

11.22.7 Other Transplants and Devices

Following is additional information on coverage for other transplants and devices under the Health Plan product:

  • Circulatory Assist Device (CAD) is an AHCCCS covered service when used as a bridge to transplantation and other specific criteria are met, when medically necessary and prior authorized by The Health Plan. Refer to Solid Organ Transplants and Related Devices: Specific Indications and Contraindications/Limitations located in the Medical Policy Manual Chapter 300, Policy 310-DD;
  • Bone grafts and corneal transplants are AHCCCS covered services, based on medical necessity and prior authorized by the Health Plan.

The Health Plan covers emergency ground and air ambulance transportation services within certain limitations. Covered transportation services include:

  • Emergency ground and air ambulance services required to manage an emergency medical condition at an emergency scene and in transport to the nearest appropriate facility

Maternal transport program (MTP), newborn intensive care program (NICP), basic life support (BLS), advanced life support (ALS), and air ambulance services depending upon the member’s medical needs.

11.23.1 Coverage Limitations and Exclusions

The following limitations and exclusions apply to emergency transportation services:

  • Coverage of ambulance transportation is limited to those emergencies in which specially equipped transportation is required to safely manage the member’s medical condition
  • Emergency transportation is covered only to the nearest appropriate facility medically equipped to provide definitive medical care
  • Emergency transportation to an out-of-state facility is covered only if it is to the nearest appropriate facility
  • Mileage reimbursement is limited to loaded mileage. Loaded mileage is the distance traveled, measured in miles while a member is on board the ambulance and being transported to receive emergency services

A provider who responds to an emergency call and provides medically necessary treatment at the scene, but does not transport the member is eligible for reimbursement limited to the approved base rate and medical supplies used

  • A provider who responds to an emergency call, but does not treat or transport a member as a result of the call is not eligible for reimbursement
  • When two or more members are transported in the same ambulance, each shall be charged an equal percentage of the base rate and mileage charges
  • Air ambulance services are covered under the following conditions:
    • The point of pick-up is inaccessible by ground ambulance
    • Great distances or other obstacles are involved in getting the member to the nearest hospital with appropriate facilities
    • The member’s medical condition requires air ambulance services and ground ambulance services will not suffice
  • Details regarding emergency transportation services are available in the AHCCCS AMPM Chapter 300

11.23.2 Non-Emergency Medical Transportation Services

The Health Plan covers medically necessary non- emergency ground and air transportation to and from a required medical service.

Round-trip air or ground ambulance transportation services may be covered when a hospitalized member is transported to another facility for necessary specialized diagnostic and/or therapeutic services, if all of the following requirements are met:

  • The member’s condition is such that the use of any other method of transportation is not appropriate
  • Services are not available in the hospital in which the member is an inpatient
  • The hospital furnishing the services is the nearest one with such facilities
  • The member returns to the point of origin

Medically necessary nonemergency transportation to and from participating The Health Plan providers is a covered service for members who are not able to arrange or pay for transportation. Transportation is limited to the cost of transporting the member to the nearest The Health Plan provider capable of meeting the member’s medical needs. Transportation is only provided to transport the member to and from the required Access-covered medical service.

Details regarding nonemergency medical transportation services are available in the AHCCCS Medical Policy Chapter 300, Policy 310-BB.

All genetic testing requires prior authorization. Prior authorization requests must include documentation regarding how the genetic testing is consistent with the genetic testing coverage limitations.

Genetic testing is only covered when the results of such testing are necessary to differentiate between treatment option specific diagnoses or syndromes

Genetic testing is not covered to determine the likelihood of associated medical conditions occurring in the future.

Routine, non-genetic testing for other medical conditions (such as renal disease and hepatic disease) that may be associated with an underlying genetic condition is covered when medically necessary.

Genetic testing is not covered as a substitute for ongoing monitoring or testing of potential complications or sequelae of a suspected genetic anomaly.

Genetic testing is not covered to determine whether a member carries a hereditary predisposition to cancer or other diseases.

Genetic testing is also not covered for members diagnosed with cancer to determine whether their particular cancer is due to a hereditary genetic mutation known to increase the risks of developing that cancer.

The Health Plan provides benefits for medically necessary radiology and medical imaging services for all eligible members when ordered by a primary care physician (PCP) or other practitioner for diagnosis, prevention, treatment, or assessment of medical conditions.

Radiology services must be provided by a participating radiology provider. Members may be responsible for copayments that correspond to the type of facility where services are rendered.

Complete the entire radiology order form when requesting radiology services, including all insurance information.

Participating providers with applicable radiology equipment can provide diagnostic radiology services in their office.