SPECIFIC PHYSICAL HEALTH PROVIDER REQUIREMENTS

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

12.1   Primary Care Physician (PCP) Assignments

12.1.1   Member Capacity

PCPs must follow the below guidelines regarding member capacity:

• The PCP must contact their Health Plan Provider Engagement Specialist 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 to members. PCPs are required to meet various requirements, which are described below.

12.2.1   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 assistants.

12.2.2   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 2000 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 monitors 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.

PCP assignment may be influenced by providers who demonstrate quality, cost-effective care; and may include providers participating in value-based purchasing initiatives.

Members may also request to be assigned to a homeless clinic as their primary PCP provider.  Members assigned to a homeless clinic may be referred out-of-network for needed specialty services if an in-network provider is not available.  The Health Plan will assist homeless clinics with issues such as obtaining prior authorizations and resolving claims issues.

PCP assignment rosters are available to providers on our secure provider portal and/or via request. The Provider Engagement team will educate providers on how to view and download their PCP assignment roster directly from the secure provider portal and/or provide the roster within ten business days of receipt of the request. The PCP assignment report will include the following:

1. Assigned members’ name,
2. Assigned members’ date of birth,
3.  Assigned members’ AHCCCS ID,
4.  AHCCCS ID of the assigned PCP, and
5. The effective date of members' assignment to the PCP.

12.2.3   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 twelve 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.

12.2.4   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 with 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 Policy 430,  AHCCCS EPSDT Clinical Sample Templates 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 11.2 Medical Record Standards);
• Enrolling as a Vaccines for Children (VFC) provider for members under age twenty one;
• Providing health care services to the Health Plan members within the scope of the provider’s practice and qualifications to include the ability of a member’s PCP to treat behavioral health conditions within the scope of their practice;
• Providing medically necessary, cost-effective, and federally and state reimbursable behavioral health services within their scope of practice. For the antipsychotic class of medications, prior authorization may be required. This includes the monitoring and adjustments of behavioral health medications.
• 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 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 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 contracted 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 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:

• 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) AHCCCS Clinical Visit Sample Template;
  • 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.

12.2.5   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.

12.3.1   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 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.

AHCCCS and the Health Plan collect, and track member outcomes related to Social Determinants of Health. The use of specific International Classification of Diseases, 10^th 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, for health inequities. They include factors like:

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

As appropriate and within the scope of practice, providers are required to routinely screen for, and document, the presence of social determinants using the ICD-10-CM (z-codes). Regardless of the screening tool selected, the provider are required to screen for the following social risk factors of health at a minimum:

• Homeless/Housing Instability (housing insecurities)
• Transportation Assistance
• Employment Instability
• Utility assistance
• Interpersonal safety
• Justice/Legal Involvement
• Social Isolation/Social Support (nutrition-food security)

Any identified social determinant diagnosis codes shall be documented and provided on all claims for AHCCCS members to comply with state and federal coding requirements.

While SDOH are the broader social conditions, HRSN are more immediate individual, and-or family needs impacted by those conditions. For example, housing insecurity, food insecurity, or lack of reliable transportation can lead to decreased health and a lower quality of life. While determinants (SDOH) may shape health for better or worse, risk factors (HRSN) have an inherently negative influence, and needs vary depending upon the person’s context and in-the-moment desires. To make an impact on improving health equity and providing more culturally health centered care, it is necessary to better understand and address the underlying causes of poor and good health.

The Health Plan encourages provider usage of the AHCCCS-Approved Closed-Loop Referral System (CLRS) to refer members properly and efficiently to Community Based Organizations (CBOs) providing services addressing SDOH-HRSN. To learn more visit https://www.azahcccs.gov/communitycares. Closing-the-loop for SDOH-HRSN referrals improves member safety and satisfaction, and care coordination. Providers can use the CLRS to streamline referrals and access to vital services that will help address member SDOH-HRSN through a closed-loop referral process that provides efficient screening of the members determinants of health and that provides confirmation when social care services have been delivered.  The CLRS is a part of the Whole Person Care Initiative (to learn more visit the AHCCCCS Website  ).

CommunityCares (Unite Us) is the Arizona statewide CLRS. CommunityCares-CLRS is a free web-based tool available to provider network and community-based organizations to screen and refer members for social determinant of health-health related social needs. Health care providers and community-based organizations can use CommunityCares on the web for free or integrate it into their Electronic Health Record at an additional cost. To learn more visit the Community Care Website . Providers are also able to screen and refer members to organizations that do not use CommunityCares.

How Providers can use and how CommunityCares-CLRS works:

Providers can use the CLRS to streamline referrals and access to vital services that will help address member SDOH-HRSN through a closed-loop referral process that provides efficient screening of the members determinants of health and that provides confirmation when social care services have been delivered.

Why is utilizing CommunityCares-CLRS critical?

• Increases coordination and quality of care.
• Improving health with a whole-person care perspective.
• Lead with a data driven approach and tracks outcomes.
• Easily connects members to vital resources in one platform.
• Alerts and communicates about member referral and case progress.
• Help members address HRSN.
• Help members improve their overall health and wellbeing.
• Using z-codes (ICD-10 codes) and the CLRS are essential to mapping SDOH-HRSN and creates a tangible journey to better outcome for that person and-or family.
• Opportunity to improve member’s quality of life.
• Trust and credibility are gained when taking action to help address these conditions.
• Supports cultural responsiveness & cultural programming.
• Opportunity in every interaction with a member to acknowledge and celebrate their resiliency.

Targeted Investment and Closed Loop Referral System CLRS

The Arizona Health Care Cost Containment System (AHCCCS) Targeted Investments (TI) program and closed-loop referral requirements are both intended to improve health outcomes for AHCCCS members. The TI program incentivizes providers to develop closed-loop referral processes, while the closed-loop referral system allows providers to screen members for health-related social needs (HRSNs).

The Targeted Investments Program (TI 2.0) aligns with AHCCCS’ strategic plan and Arizona’s Section 1115 Waiver to support and incentivize providers to develop and enhance comprehensive whole person care systems that effectively address the social risk factors that adversely affect health. Eligible Medicaid provider organizations that meet certain benchmarks will receive financial incentives through managed care plans for developing infrastructure and protocols to optimize coordination of services designed to meet the member’s acute, behavioral, and health-related social needs (HRSN) and address identified health inequities among their member population.

Targeted Investments (TI) program

Goal: Improve health outcomes for targeted populations

Incentives: Providers are incentivized to develop closed-loop referral processes, provide culturally and linguistically appropriate services, and reduce healthcare disparities

Requirements: Providers must be in good standing with AHCCCS, including being registered and financially stable

Closed-loop referral requirements

Goal: Standardize referrals and coordination with community-based organizations

Process: Health care providers send referrals to community-based organizations through CommunityCares, a no cost closed-loop referral system

Benefits: Allows providers to screen members for HRSNs and refer them to local community organizations for assistance

Further information on TI 2.0 can be found at: The AHCCCSS website 

Differential Adjustment Payment  (DAP)

The AHCCCS Differential Adjusted Payment (DAP) is a short-term incentive payment for providers who improve member care, health, and reduce costs. The Targeted Investments (TI) program is a separate program that provides financial incentives to eligible provider organizations.

The Differential Adjusted Payment (DAP) is a positive adjustment to the AHCCCS Fee-for-Service (FFS) rates to distinguish providers who have committed to supporting designated actions that improve members’ care experience, improve members’ health, and reduce cost of care. AHCCCS health plans are required to pass through DAP increases to their contracted rates to match the corresponding AHCCCS Fee-For-Service rate increase percentages.

Differential Adjusted Payment (DAP)

• A positive adjustment to the AHCCCS Fee-for-Service (FFS) rates.
• Providers must meet certain criteria to qualify.
•  Providers must include the DAP increase when billing AHCCCS or an MCO.
• Health plans must pass through DAP increases to their contracted rates.

The Arizona Health Care Cost Containment System (AHCCCS) Targeted Investments Program (TI 2.0) provides incentive payments to eligible participants. The amount of the payment depends on the organization's size and performance.

Explanation

• The TI 2.0 program is a five-year initiative that began on October 1, 2022.
• The program is funded by the Centers for Medicare & Medicaid Services (CMS).
• The amount of the incentive payment varies by year and depends on the organization's performance.
• AHCCCS also offers Differential Adjusted Payments (DAP) to providers who improve member care, health, and reduce costs.

Targeted Investments (TI)

• A program that provides financial incentives to eligible provider organizations.
• Providers must complete milestone requirements to earn incentive payments.
• Participants can earn a percentage of the incentive based on the milestones they meet.
• Participants are not required to meet all milestones each year.
• Participants are notified of their incentive amount once it's calculated.

Additional information on TI 2.0 can be found at: The AHCCCS Website 

How CLRS can be utilized in grants-applications

• Leverage data to demonstrate the clear need for the proposed program by highlighting the volume and source of referrals.
• Showcases the significant population that requires the services aim to provide.
• Emphasizes the credibility of project by citing reputable referral sources.
• Contextualize the data.
• Explain what the referral data signifies in terms of the problem being addressed.
• For example, "organization received 200 referrals last year from local healthcare providers, indicating and closing the gap to significant barriers in access to _______ health services in the community”, resulting in…
• For example, "organization sent 200 referrals last year to local healthcare providers, indicating and closing the gap to significant barriers in access to ______ health services in the community “, resulting in…
•  Source credibility: Clearly identifies the source of looped-referral data, ensuring it's a recognized and reliable entity. This could be local hospitals, community centers, social service agencies, etc.
• Data analysis: Analyze trends, demographics, and patterns within the referral data to support program focus, gap closures, and design.
• Use detailed examples of referral cases to illustrate the types of individuals who benefited from the program and the specific health gaps closed.
• Use referral data to substantiate the problem or gap the program aims to address, demonstrating the scale of the issue.
• Explain how the program will be tailored to meet the needs identified through closed-referral data, such as specific services or outreach strategies.
• Describe how the organization will track the impact of the program using closed-referral data as a baseline measure, showing how the organization plans to monitor and evaluate the effectiveness of CLRS interventions.

Unite Us Dashboard: What data is pulled

A closed-loop referral system typically pulls data including member demographics, referral reason, referring provider details, date of referral, appointment details with the receiving provider, status updates on the referral (scheduled, completed, cancelled), outcome of the appointment, and any relevant clinical information to ensure complete communication between providers and track the full referral process from initiation to completion. 

Member information: Name, date of birth, contact details, insurance information

Referring provider details: Name, practice, contact information

Referral reason: Diagnosis, presenting symptoms, specific concerns

Referral date: Date the referral was initiated

Appointment details: Date, time, location, receiving provider

Referral status updates: Pending, scheduled, completed, cancelled, no-show

Outcome information: Treatment plan, diagnosis, relevant clinical findings from the receiving provider

Important aspects of a closed-loop referral system:

Bi-directional communication: Both referring and receiving providers need to be able to update the system with relevant information

Real-time updates: The system should provide timely updates on the referral status to all involved parties

Integration with EMRs: Data should be able to flow seamlessly between the referral system and electronic medical records

The ICD-10-CM diagnosis codes are defined as Social Determinants of Health codes under ICD-10-CM. The ICD-10 can be found at the following location: https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/Exhibit_4-1SocialDeterminantsHealthICD-10List.pdf and https://www.cms.gov/files/document/cms-2023-omh-z-code-resource.pdf. These codes are not to be used as primary ICD-10 diagnosis codes. Social Determinant of Health codes should instead be listed as secondary, tertiary, etc

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 Provider Appointments:

• Urgent care appointments as expeditiously as the member’s health condition requires but no later than two (2) business days of the request; and
• Routine care appointments within twenty-one (21) calendar days of request.
• For Specialty Provider Appointments, including Dental Specialty:
• Urgent care appointments as expeditiously as the member’s health condition requires but no later than two (2) business days from the request; and
• Routine care appointments within forty-five (45) calendar days of referral.

For Dental Provider Appointments to SMI Members

• Urgent appointments as expeditiously as the member’s health condition requires but no later than three (3) business days of request;
• ·Routine care appointments within forty-five (45) calendar days of request; and
• For Comprehensive Health Plan (CHP) only, routine care appointments within 30 calendar days of request.

For Maternity Care Provider Appointments

• First trimester – within fourteen (14) calendar days of request
• Second trimester within seven (7) calendar days of request
• Third trimester within three (3) business days of request
• High risk pregnancies as expeditiously as the member’s health condition requires and no later than three (3) business days of identification of high risk by the Contractor or maternity care provider or immediately if an emergency exists.

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
• 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.
• For coverage details on Augmentative and Alternative Communication (AAC) Devices, see Durable Medical Equipment

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.

12.10.1   Treatment of Behavioral Health Disorders

In addition to treating physical health conditions, PCPs can treat behavioral health conditions within their scope of practice. For purposes of medication management, it is not required that the PCP be the member’s assigned PCP. PCPs who treat members with behavioral health conditions may provide medication management services including prescriptions, laboratory and other diagnostic tests necessary for diagnosis and treatment.

12.10.2   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 use disorder 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 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, postpartum depression, and opioid use disorder (OUD). Step therapy is required for medication not on the Arizona Health Care Cost Containment System (AHCCCS) preferred drug list or behavioral health 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 Preferred Drug List, available on the provider website. For additional information regarding pharmacy benefits, contact the Health Plan Pharmacy Department.

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  Health Plan DME provider. Prosthetic and orthotic services are not available through the Health Plans’ preferred DME provider, but they may be obtained through prosthetic and orthotic providers.

Augmentative and Alternative Communication (AAC) Devices

Medically necessary Augmentative and Alternative Communication (AAC) devices are a covered benefit including:

• Evaluations for speech-generating and non-speech-generating AAC 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.

Members and providers can contact the health plan for assistance in locating a qualified specialist for AAC evaluations and devices.

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.

12.14.1   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.

12.14.2   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.

12.14.2.1   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.

12.14.2.2   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 another physician orders the orthotic.

12.14.2.3   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.

12.15.1   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 non-ambulatory member, has a condition that is likely to result in significant medical complications in the absence of such treatment.

12.15.2   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 45 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.

12.18.1   Care Coordination

Participating providers should identify and refer potentially eligible the Health Plan members to ALTCS. If 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.

12.18.2   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.

12.19.1   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.

12.19.2   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, non-experimental, and cost-effective telehealth services provided by AHCCCS registered providers. There are no geographic restrictions for Telehealth; services delivered via Telehealth are covered by the Health Plan in rural and urban regions. The Health Plan promotes the use of Telehealth to support an adequate provider network.

12.20.1   Definitions

12.20.2   Use of Telemedicine

AHCCCS covers medically necessary, non-experimental, and cost-effective Telehealth services provided by AHCCCS registered providers. There are no geographic restrictions for Telehealth; services delivered via Telehealth are covered by the health plan in rural and urban regions. The Health Plan promotes the use of Telehealth to support an adequate provider network.

Asynchronous (store and forward) does not require real-time interaction with the member. Reimbursement for this type of consultation is limited to:

• Allergy/Immunology
• Cardiology
• Dermatology
• Infectious diseases
• Neurology
• Ophthalmology
• Pathology
• Radiology
• Behavioral Health

12.20.3   Use of Telemedicine and Remote Patient Monitoring

Synchronous (real-time) Telemedicine and Remote Patient Monitoring:

• Shall not replace provider choice for healthcare delivery modality.
• Shall not replace member choice for healthcare delivery modality.
• Shall be AHCCCS-covered services that are medically necessary and cost effective.

Audio-Only Services

The Health Plan shall cover audio-only services if a telemedicine encounter is not reasonably available due to the member’s functional status, the member’s lack of technology or telecommunications infrastructure limits, as determined by the provider. To submit a claim for an audio-only service, the provider shall make the telehealth services generally available to members through telemedicine. The Health Plan Programs shall reimburse providers at the same level of payment for equivalent in-person office/facility setting for mental health and substance use disorder services, as identified by HCPCS, if provided through telehealth using an audio-only format. The AHCCCS Telehealth code set defines which codes are billable as an audio-only service and the applicable modifier(s) and place of service providers shall use when billing for an audio-only service.

12.20.4   Use of Teledentistry

The Health Plan covers Teledentistry for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) aged members when provided by an AHCCCS registered dental provider. Refer to AMPM Policy 431 for more information on Oral Health Care for EPSDT aged members including covered dental services.

Teledentistry includes the provision of preventative and other approved therapeutic services by the AHCCCS registered Affiliated Practice Dental Hygienist, who provides dental hygiene services under an affiliated practice relationship with a dentist. Refer to AMPM Policy 431 for information on Affiliated Practice Dental Hygienist.

Teledentistry does not replace the dental examination by the dentist, limited periodic and comprehensive examinations cannot be billed through the use of Teledentistry alone.

12.20.5   Conditions, Limitations, and Exclusions

1. All Telehealth reimbursable services shall be provided by an AHCCCS registered provider.
2. Non-emergency transportation (NEMT) is a covered benefit for member transport to and from the Originating Site where applicable and billed through the Plan’s contracted broker/vendor.
3. Informed consent standards for Telehealth services should adhere to all applicable statutes and policies governing Telehealth, including A.R.S. §36-3602.
4. Confidentiality standards for Telehealth services should adhere to all applicable statutes and policies governing Telehealth.
5. There are no Place of Service (POS) restrictions for Distant Site.
6. The POS on the service claim is the Originating Site.

12.20.6   Other General Information

Refer to the AHCCCS coding webpage for coding requirements for Telehealth services, including applicable modifiers and place of service (POS).

12.21.1   Covered Transplants

Federal law 42 U.S.C. §1396b(i) and 42 CFR 441.35 describe general requirements for Title XIX coverage of transplants. For individuals age 21 and older, organ transplant services are not mandatory covered services under Title XIX and States have discretion to choose whether or not transplants will be covered for members age 21 years and older.

For members ages 21 years and older, AHCCCS limits transplantation coverage to the specific transplant types set forth in this Policy. All other transplant types for members 21 years and older are excluded from AHCCCS reimbursement.

Under the Early and Periodic Screening Diagnostic and Treatment (EPSDT) Program for persons under age 21, AHCCCS covers all non-experimental transplants medically necessary to correct or ameliorate defects, illnesses and physical conditions. Transplants for EPSDT members are covered when medically necessary irrespective of whether or not the particular non-experimental transplant is specified as covered in the AHCCCS State Plan.

Table one summarizes coverage for EPSDT-age members and adult members age 21 years and older by transplant type. Transplants shall be medically necessary, non-experimental, and federally reimbursable, State reimbursable, and fall within the medical standard of care for coverage. 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” (A.A.C. R9-22-101, R9-28-101). AHCCCS utilizes national standards for transplantation which include policy from Organ Procurement Transplant Network (OPTN), Centers for Medicare and Medicaid Services (CMS), United Network for Organ Sharing (UNOS), and the Foundation for the Accreditation of Cellular Therapy (FACT).

Additional Arizona State laws and regulations specifically address transplant services and related topics are as follows:

1. Specific non-experimental transplants which are approved for Title XIX reimbursement are covered services (A.R.S. §§36-2907 and 2939).
2. Services which are experimental, or which are provided primarily for the purpose of research are excluded from coverage (A.A.C. R9-22-202, R9-22-203, R9-28-201, R9­28-202).
3. 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 health conditions, or their progression, or prolong life” (A.A.C. R9-22-101, R9-28-101).

AHCCCS COVERED TRANSPLANTS TABLE 1:

*All other medically necessary, non-experimental transplants for members under the age of 21 are covered.

Circulatory Assist Devices (CADs) including Left Ventricular Assist Devices (LVADs) are AHCCCS covered services for destination therapy and as bridge to transplant when medically necessary and non-experimental.

Corneal transplants and bone grafts are covered when medically necessary cost effective, and non-experimental as specified in AMPM Exhibit 300-1 and AMPM Policy 820.

Refer to the AHCCCS Specialty Contract For Transplantation Services on the AHCCCS website for detailed information regarding coverage and payment for transplants and transplant-related services.

For questions regarding transplant authorizations coverage and general inquires contact AHCCCS/DHCM, Medical Management at medicalmanagement@azahcccs.gov.

12.21.2   Transplant Services and Settings

Transplant services, including evaluation, are covered only when performed in specific settings:

• Solid organ transplant services shall be provided in a Centers for Medicare & Medicaid Services (CMS) certified and United Network for Organ Sharing (UNOS) approved transplant center which meets the Medicare conditions for participation and special requirements for transplant centers delineated in 42 CFR Part 482.
• Hematopoietic stem cell transplant services shall be provided in a facility that has achieved Foundation for the Accreditation of Cellular Therapy (FACT) accreditation. The facility shall also satisfy the Medicare conditions of participation and any additional federal requirements for transplant facilities.

12.21.3   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:

• OPTN policies set the criteria for wait listing for organ transplantation. Transplant candidates shall meet the criteria to be wait listed based on OPTN policy.
• Medical comorbidities shall be assessed through history and physical with plans developed for appropriate care. Changes in medical conditions (cardiovascular, development of new malignancy, etc.) shall be assessed for impact upon transplant candidacy. All candidates shall undergo routine age-condition appropriate screening for disease.
• Identified indolent or chronic infections shall have a plan of containment in accord with an infectious disease specialist.
• Members with identified neoplasms shall be assessed in accord with an oncologist.
• The psychosocial environment shall be assessed, and appropriate plans generated to mitigate issues of adherence. For members with prior adherence issues, plans with a Behavioral Health Professional shall be developed.
• For members with substance use disorder(s), plans for treatment before and after the organ replacement shall be demonstrated in agreement with a Behavioral Health Professional.

12.21.4   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.

12.21.5   Additional Information and Requirements

1. AHCCCS provides out-of-network coverage for solid organ or hematopoietic stem cell transplants for those members who have current medical requirements that cannot be met by an AHCCCS contracted transplant center. These medical requirements must be manifested as requiring either a specific level of technical expertise or program coverage that is not currently provided by AHCCCS contracted facilities. The selection of an out-of-network transplant center is determined through the review of quality and outcome data published.
2. Reimbursement will only be available for transplant centers who meet requirements in Section D of AHCCCS AMPM 310DD. Please refer to “Transplant Services and Settings.”
3. The financial responsibility of AHCCCS and its Contractors for solid organ living donor-related costs is limited to pediatric kidney and liver transplants and adult kidney transplants. Living donor transplants may be considered on a case-by-case basis for solid organs other than kidney (pediatrics and adults) and liver (pediatric only) when medically necessary and cost effective. Payment by AHCCCS and its Contractors for the solid organ donor other than kidney (pediatrics and adults) and liver (pediatric only) is limited to surgical and follow up care provided to the donor through and including day 3 post surgery. For any additional charges, the living donor must accept the terms of financial responsibility for the charges associated with the transplant in excess of any payments under the AHCCCS Specialty Contract For Transplantation Services.
4. If a member receives a transplant that is not covered by AHCCCS, coverage for medically necessary and non-experimental services commence following discharge from the acute care hospitalization for the non-covered transplant.
   • Covered services include, but are not limited to:
     •  Transitional living arrangements appropriately ordered for post-transplant members when the member does not live in close proximity to the center
     •  Essential laboratory and radiology procedures
     •    Medically necessary post-transplant therapies
     •  Immunosuppressant medications (Refer to AMPM Policy 310-V, Prescription Medication/Pharmacy Services for more information related to AHCCCS medication coverage.)
     •   Medically necessary transportation
   •  Covered services do not include:
     •   Evaluations and treatments to prepare for transplant candidacy
     •  The actual transplant procedure and accompanying hospitalization, or
     •  Organ or tissue procurement
5. Refer to AHCCCS Specialty Contract for Transplantation Services on the AHCCCS website for information regarding a second covered organ transplant performed during the follow up care periods of the first transplant.
6. Refer to the AHCCCS Reinsurance Processing Manual for information regarding Contractor applications for transplantation reinsurance.

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

• Emergency ground and air ambulance services are 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.

12.22.1   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 needed 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 because 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 on emergency transportation services are available in the AHCCCS AMPM Chapter 300

12.22.2   Non-Emergency Medical Transportation Services

The Health Plan covers medically necessary non-emergency ground and air transportation to and from a required medical service. All non-emergency medical transportation should be billed through the Health Plan’s contracted broker/vendor.

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 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 non-emergency transportation to and from participating Health Plan providers is brokered through the Health Plan’s contracted broker/vendor and is considered 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 Health Plan provider capable of meeting the member’s medical needs. Transportation is only provided to transport the member to and from the required AHCCCS-covered medical service.

Details about 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.