Definitions and Acronyms
AHCCCS Definitions as set forth in the current AHCCCS ACC, RBHA, and NTXIX contracts and amendments, ACOM and AMPM policies, AHCCCS Contract and Policy Dictionary, and relevant AHCCCS manuals as periodically amended and published by AHCCCS at the links below.
24 HOUR URGENT REFERRAL.
A referral that results in an intake that must be completed in a community setting within 24 hours of the request. It includes care coordination, discharge planning services and an SMI screening when appropriate. The 24 Hour Mobile Team Urgent Referral services are provided in hospitals, nursing homes, foster homes, detention facilities and other community settings.
72 HOUR DCS RAPID RESPONSE
A mobile response that includes an intake in a community setting within 72 hours of the request. It includes an assessment, care coordination services and coordination with DCS and the courts. 72 Hour Rapid Response services are provided in hospitals, homes, shelters and other community settings.
834 TRANSACTION ENROLLMENT/DISENROLLMENT
AHIPAA compliant transmission, by a health care provider to a T/RBHA and by a T/RBHA to AHCCCS that contains information to establish or terminate a person’s enrollment in the AHCCCS service delivery system.
AHCCCS – AzCH-CCP - Arizona Complete Health-Complete Care Contract
Contract entered into between AHCCCS and AzCH-CCP - Arizona Complete Care, including all attachments and exhibits thereto, as such contract may be amended or supplemented from time to time.
Administrative expenses incurred to manage the health system, including, but not limited to provider relations and contracting; provider billing; provider sub-capitation administration provision; non-encounterable PBM fees (e.g., pharmacy network management, pharmacy discount negotiating, drug utilization review, coordination of specialty drugs, pharmacy claims processing, pharmacy call center operations, etc.); quality improvement activities; accounting; information technology services; processing and investigating grievances and appeals; legal services, which includes legal representation of the Contractor at administrative hearings; planning; program development; program evaluation; personnel management; staff development and training; provider auditing and monitoring; utilization review and quality assurance. Administrative costs do not include expenses incurred for the direct provision of health care services, including case management, or integrated health care services.
ADULT RECOVERY TEAM ("ART")
A defined group of individuals that includes, at a minimum, the member, their family, a behavioral health representative, and any individuals important in the member’s life that are identified and invited to participate by the member. This may include system partners such as extended family members, friends, family support partners, healthcare providers, community resource providers, representatives from churches, synagogues or mosques, agents from other service systems like the Department of Developmental Disabilities (DDD), Probation, or the Administrative Office of the Courts (AOC). The size, scope and intensity of involvement of the team members are determined by the objectives established for the adult, the needs of the family in providing for the adult, and by which individuals are needed to develop an effective service plan, and can therefore expand and contract as necessary to be successful on behalf of the adult should this be needed or required.
ADVERSE BENEFIT DETERMINATION
- The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
- The reduction, suspension, or termination of a previously authorized service;
- The denial, in whole or in part, of payment for a service;
- The failure to provide services in a timely manner;
- The failure of the Health Plan to act within the established timeframes regarding the standard resolution of grievances and appeals;
- The denial of a member's request to obtain services outside the network; and/or
- The denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.
A person or entity controlling, controlled by, or under common control with AzCH-CCP.
AHCCCS REGISTERED PROVIDER
A provider that enters into an agreement with AHCCCS under A.A.C. R9-22-703(A), and meets licensing or certification requirements to provide covered services.
A written document that is issued for the purpose of making changes to a document.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY ("ADES")
The State agency that has the powers and duties set forth in A.R.S. § 41-1951, et seq.
ASSESSMENT INTERVENTION CENTER (“AIC”)
A time limited, intensive program serving children and families that delivers services in an ADHS-licensed BHRF (Provider Type B8). The program’s focus is on thorough psychiatric, psychological, and family systems evaluations, a comprehensive behavioral analysis; and development of targeted interventions individualized for each member and family. The program is designed for up to a thirty (30) day treatment period. The initial fourteen (14) days of service do not require prior authorization. Additional services require a concurrent authorization on or before the fourteenth (14th) day of service. The maximum length of stay is thirty (30) days. The goal of the program is to answer the question “What supports and interventions are needed for this member to live successfully in the community?”
Any attachment, amendment, exhibit and/or schedule to a document.
AzCH – ARIZONA COMPLETE CARE PROVIDER MANUAL
Provider Manual including any amendments, appendices, modifications, supplements, bulletins, or notices related to the AzCH-CCP Provider Manual that may be made from time to time and available on AzCH-CCP’s website. AzCH-CCP shall use its reasonable efforts to give Subcontractor advance notice of any amendment or modification of the AzCH-CCP Provider Manual that materially affects Subcontractor's
Evidence-based practices, promising practices, or emerging practices.
BOARD ELIGIBLE PSYCHIATRY
A physician with documentation of completion of an accredited psychiatry residency program approved by the American College of Graduate Medical Education, or the American Osteopathic Association. Documentation would include either a certificate of residency training including exact dates, or a letter of verification of residency training from the training director including the exact dates of training.
BRIEF INTERVENTION PROGRAM (BIP)
Is a time-limited, intensive crisis intervention program, currently for AzCH-CCP members, that delivers services in an ADHS licensed BHRF (Provider Type B8) to help persons live successfully in the community. The program includes crisis, supportive and treatment services. No prior authorization is needed for the first 5 days.
A CFT or ART meeting must be conducted within three (3) business days of a member’s admission to the program.
If an extension in the stay is needed to further stabilize after the initial 5 days, an authorization is required for an extension of 5 additional days. The clinical documentation must be submitted to support medical necessity. The maximum length of stay is ten (10) days.
There are limited beds in the community designed as discharge BIP beds for members who do not qualify for medical necessity in a behavioral health level 1 facility but the member needs stabilization prior to returning to their previous living arrangements.
A service billed under a fee-for-service arrangement.
COMMUNITY SERVICE AGENCY ("CSA")
An agency that is contracted directly by the Health Plan and registered with AHCCCS to provide rehabilitation and support services consistent with the staff qualifications and training. Refer to the AHCCCS Covered Behavioral Health Services Guide for details, AHCCCS AMPM 965 - COMMUNITY SERVICE AGENCIES.
The presence of significant behavioral challenges that impact the safety of a member, facility personnel, and/or other members for which additional staff support is needed to address and successfully treat the member’s behavioral challenges in the facility.
CONFLICT OF INTEREST ("COI")
Any situation in which the Subcontractor or an individual employed or retained by the Subcontractor is in a position to exploit a contractual, professional, or official capacity in some way for personal or organizational benefit that otherwise would not exist.
CONTRACT YEAR ("CY")
The time period that corresponds to the federal fiscal year, October 1 through September 30 used for financial reporting purposes.
A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals which enables that system, agency, or those professionals to work effectively in cross-cultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities.
DEDICATED HEALTH CARE COORDINATOR
The job title used by AzCH-CCP to describe the role Subcontractor employees perform related to assisting a High Needs Member and family in achieving recovery. These duties include all duties formerly assigned to the role of the Case Manager and include intensive case management services, management of care, coordination of services, employment support, health promotion, motivational interviewing, assisting with service planning and other similar services to support recovery.
The reports and other deliverables the Subcontractor is required to provide to AzCH-CCP pursuant to the AzCH-CCP Provider Manual.
DIRECT CARE STAFF
In the case where a Subcontractor is a health care entity, a person or entity who is employed by or otherwise engaged by Subcontractor to provide Covered Services to Members.
NATIONAL CLAS STANDARDS
The U.S. Department of Health and Human Services Office of Minority Health standards for Culturally and Linguistically Appropriate Services ("CLAS"), which may be amended or supplemented from time to time and is are included as Exhibit F. The National CLAS Standards aim to improve health care quality and advance health equity by establishing a framework for organizations to serve the nation's increasingly diverse communities.
FISCAL YEAR ("FY")
The State budget year: July 1 through June 30. This is to be distinguished from the Contract Year, as defined above.
A list of covered medications available for treatment of Members.
FREEDOM TO WORK (also referred to as TICKET TO WORK)
Eligible individuals under the Title XIX program that extends eligibility to individuals 16 through 64 years old who meet SSI disability criteria, and whose earned income after allowable deductions is at or below 250% of the FPL, and who are not eligible for any other Medicaid program. These members must pay a premium to AHCCCS, depending on income.
GENERAL MENTAL HEALTH/SUBSTANCE ABUSE (GMH/SA)
Behavioral health services provided to adult members age 18 and older who have not been determined to have a serious mental illness.
HEALTH CARE COORDINATOR
Health Care Coordinator is the job title used by AzCH-CCP to describe the required duties performed by Subcontractor (Provider) employees related to coordinating physical health, behavioral health and social services in a member-focused manner with the goals of improving whole person health outcomes, and more effective and efficient use of resources. Health Care Coordinators, often referred to as Health Care Coordinators, Case Managers, Integrated Care Managers, or Care Coordinators; provide accessible, comprehensive, and continuous coordination of care based on effective working relationships with members and accumulated knowledge over time of members’ health care challenges and strengths. Health Care Coordinators build on members’ strengths to promote wellness, recovery, and resiliency.
HIGH NEED CASE MANAGEMENT
An intensive level of case management services provided to high need Members.
HIGH NEED RECOVERY MANAGEMENT ("HNRM")
Specially designed programs, care management services, treatment services and dedicated staff responsible to meet the care management and treatment needs of High Need Members. HNRM is required to be available 24/7/365 to monitor and facilitate the safety of High Need Members, the safety of communities, and assist High Need Members to live successfully in the community.
INTERAGENCY SERVICE AGREEMENT ("ISA")
An agreement between two or more agencies of the State wherein an agency is reimbursed for services provided to another agency or is advanced funds for services provided to another agency. (A.R.S. § 35-148(A))
LEVEL I BEHAVIORAL HEALTH FACILITY
An inpatient treatment program or behavioral health treatment facility that is licensed under A.A.C. Title 9, Chapter 10 and includes a psychiatric acute hospital, a residential treatment center for individuals under the age of twenty-one (21), or a sub-acute facility.
LEVEL IV BEHAVIORAL HEALTH FACILITY
A behavioral health agency as defined in A.A.C. Title 9, Chapter 10.
LOW AND MODERATE NEED RECOVERY CENTER
A set of specially designed programs and services and designated staff responsible to meet the needs of Members with low to moderate needs. LMNR Centers are required to screen Members for "High Needs" and refer High Need Members to High Need Recovery Centers.
A temporary change in a provider network that may reasonably be foreseen to jeopardize the delivery of covered health services to an identifiable segment of the Member population.
Facts, data or other information excluded from a report, contract, the absence of which could lead to erroneous conclusions following reasonable review of such report or contract.
Something is permissive.
MEDICAL EXPENSE DEDUCTION
Title XIX waiver Member whose family income exceeds the limits of all other Title XIX categories (except ALTCS) and has family medical expenses that reduce income to or below 40% of the Federal Poverty Level. Medical Expense Deduction members may or may not have a categorical link to Title XIX.
An acute care hospital, psychiatric hospital—Non IMD, psychiatric hospital – IMD—, Residential Treatment Center—Non IMD, psychiatric hospital – IMD—, Skilled Nursing Facility, or Intermediate Care Facility for persons with intellectual disabilities.
MEDICARE MODERNIZATION IMPROVEMENT ACT OF 2003 ("MMA")
The federal law that created a prescription drug benefit called Medicare Part D for individuals who are eligible for Medicare Part A and/or enrolled in Medicare Part B.
MEDICARE PART D EXCLUDED DRUGS
Medicaid does not pay for Medicare Part D covered drugs for members eligible for Medicare Part D including Dual Eligible Members. Exceptions include behavioral health medications on the behavioral health drug list for members with a serious mental illness. Certain drugs that are excluded from coverage by Medicare continue to be covered by AHCCCS. Those medications include over-the-counter medications as defined in the AMPM. Prescription medications that are covered under Medicare, but are not on a Part D health plan’s formulary are not considered excluded drugs and are not covered by AHCCCS.
The same meaning as "Formulary” or “Preferred Drug List” (PDL).
MENTAL HEALTH BLOCK GRANT ("MHBG")
An annual formula grant from The Substance Abuse and Mental Health Services Administration (SAMHSA) that provides funds to establish or expand an organized community-based system of care for providing non-Title XIX mental health services to children with serious emotional disturbances (SED) and adults with serious mental illness (SMI). These funds are used to: (1) carry out the State plan contained in the application; (2) evaluate programs and services, and; (3) conduct planning, administration, and educational activities related to the provision of services.
Denotes the imperative.
NON-TITLE XIX/XXI FUNDING
Fixed, non-capitated funds, including funds from MHBG and SABG, County, and other funds, and State appropriations (excluding State appropriations for state match to support the Title XIX and Title XXI program), which are used for services to Non-Title XIX/XXI eligible persons and for medically necessary services not covered by Title XIX or Title XXI programs.
NON-TITLE XIX/XXI MEMBER OR NON-TITLE XIX/XXI PERSON
An individual who needs or may be at risk of needing covered health-related services, but does not meet federal and state requirements for Title XIX or Title XXI eligibility.
NON-TITLE XIX/XXI SMI MEMBER
A Non-Title XIX/XXI Member who has met the criteria to be designated as Seriously Mentally Ill.
OFFICE OF INDIVIDUAL AND FAMILY AFFAIRS (OIFA)
An AHCCCS bureau that builds partnerships with individuals, families of choice, youth, communities, organizations to promote recovery, resiliency and wellness. OIFA collaborates with key leadership and community members in the decision making process at all levels of the behavioral health system. In partnership with the community, OIFA advocates for the development of culturally inclusive environments that are welcoming to individuals and families. establishes structures to promote diverse youth, family and individual voices in leadership positions throughout Arizona, delivers training, technical assistance and instructional materials for individuals and their families, ensure peers support and family support are available to all persons receiving services and their families, and monitors contractor performance and measure outcomes.
Activities to identify and encourage Members or potential Members, who may be in need of, but not yet receiving physical or behavioral health services.
AzCH-CCP or another entity that is responsible for funding Covered Services to Members.
AzCH-CCP’s contract with any Payor that governs provision of Covered Services to Members. When AzCH-CCP is the Payor, "PAYOR CONTRACT" AzCH-CCP's contract with the State or federal agency or other entity that has contracted with AzCH-CCP to arrange for the provision of Covered Services to eligible individuals of such agency or other entity.
The process used to determine if credentialed clinicians are competent to perform certain treatment interventions, based on training, supervised practice, and/or competency testing.
The excess of revenues over expenditures, in accordance with Generally Accepted Accounting Principles, regardless of whether Subcontractor is a for-profit or a not-for-profit entity.
The agencies, facilities, professional groups, and professionals or other persons under subcontract to AzCH-CCP to provide Covered Services to Members, including the Subcontractor to the extent the Subcontractor directly provides Covered Services to Members.
A person who is a licensed physician as defined in A.R.S. Title 32, Chapter 13 or Chapter 17 and who holds psychiatric board certification from the American Board of Psychiatry and Neurology, the American College of Osteopathic Neurologists and Psychiatrists, or the American Osteopathic Board of Neurology and Psychiatry; or is board eligible.
REHABILITATION SERVICES ADMINISTRATION ("RSA")
The Division within Arizona Department of Economic Security.
The Substance Abuse and Mental Health Services Administration, which is a part of the U.S. Public Health Service leads public health efforts to advance the behavioral health of the nation.
Something is mandatory.
Denotes a preference.
SMI GRIEVANCE INVESTIGATION
A grievance or request for investigation that is filed by or on behalf of a person with Serious Mental Illness alleging a violation of the member’s rights or asserting that a condition requiring investigation exists.
A member who meets the criteria and has been enrolled with a Serious Mental Illness as defined in A.R.S. 36-550.
SMI MEMBER RECEIVING PHYSICAL HEALTH CARE SERVICES
A Title XIX eligible adult who is eligible to receive both behavioral and physical health care services through AzCH-CCP's provider network.
A specialized assessment written by a Specialty Provider to determine an eligible individual’s level of functioning and medical necessity for the specialty services provided by the Specialty Provider. All persons being served in the public health system must have an assessment upon an initial request for services with updates occurring at least annually. The Specialty Assessment must be utilized to collect necessary information that will inform providers of how to plan for effective care and treatment of the individual for the medical condition being treated. AzCH - Arizona Complete Care does not have a mandated Specialty Assessment template but all Behavioral Health Assessments must include all elements outlined in Policy 105, Assessment and Service Planning and be in accordance to all state and federal regulations.
A contracted provider type requiring full execution of specialty/sub-specialty services. Specialty/Sub-specialty Providers are required to deliver specialized programs and treatment services in treatment facilities, the community, Member homes, or specified offices to meet the unique needs of special populations. Specialty Providers include ADHS Division of Licensing Services licensed facilities, CSAs, MDs, DOs, Licensed Psychologists, NPs, LPCs, LISACs, and LCSWs.
SPECIALTY SERVICE PLAN
A written plan for services written by the Specialty Provider upon an eligible individual’s request for services. Specialty Service Plans require periodic updates to the plan to meet the changing health needs for persons who continue to meet medical necessity for requested services. AzCH - Arizona Complete Care does not mandate a specific service plan template. All Specialty Service Plans must be written in accordance to all state and federal regulations.
The practice of initiating drug therapy for a medical condition with the most cost-effective and safest drug, and stepping up through a sequence of alternative drug therapies as a preceding treatment option fails.
SUBSTANCE ABUSE BLOCK GRANT (“SABG”)
An annual formula grant from The Substance Abuse and Mental Health Services Administration (SAMHSA) that supports primary prevention services and treatment services for persons with substance use disorders. It is used to plan, implement and evaluate activities to prevent and treat substance abuse. Grant funds are also used to provide early intervention services for HIV and tuberculosis disease in high-risk substance abusers.
Covered Services as defined in the AHCCCS Covered Behavioral Health Services Guide.
TICKET TO WORK
Has the same meaning as "Freedom to Work."
TITLE XIX COVERED SERVICES
The covered services identified in the AHCCCS Covered Behavioral Health Services Guide and the physical health care covered services described in Solicitation No. ADHS 15-00004276, Scope of Work Section 4.7, Physical Health Care Covered Services.
TITLE XIX WAIVER GROUP – AHCCCS CARE (NON-MED)
Eligible individuals and couples whose income is at or below one hundred percent (100%) of the FPL and who are not categorically linked to another Title XIX program.
TRAUMA-INFORMED CARE ("TIC")
An approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in the lives of people who receive services and people who provide services (SAMHSA Center for Trauma Informed Care).
Written materials that are critical to obtaining services which include, at a minimum, the following:
- Member Handbooks
- Provider Directories
- Consent Forms
- Appeal and Grievance Notices,
- Denial and Termination Notices
YOUNG ADULT TRANSITION INSURANCE (“YATI”)
Transitional medical care for individuals age 18 through age 25 who were enrolled in the foster care program under jurisdiction of the Department of Child Safety in Arizona on their 18th birthday.
Competency is defined as worker’s demonstrated ability to perform the basic requirements of a job intentionally, successfully, and efficiently, multiple times, at or near the required standard of performance.
Competency Development is a systematic approach for ensuring that workers are adequately prepared to perform the basic requirements of their jobs. Competency based WFD.
Workforce Capability is the interpersonal, cultural, clinical/medical, and technical competence of the collective workforce or individual worker.
Workforce Capacity is the number of qualified, capable, and culturally representative personnel required to sufficiently deliver services to members.
Workforce Connectivity is the workplace’s linkage to sources of potential workers, information required by workers to perform their jobs, and technologies for connecting to workers and/or connecting workers to information.
Workforce Development is an approach to improve outcomes by enhancing the knowledge, skills, and competencies of the workforce in order to create, sustain, and retain a viable workforce. It aids in changes to culture, changes to attitudes, and changes to people’s potential to influence outcomes.
Network Workforce Data Collection
It is the responsibility of the Contractor to produce a Network Workforce Development Plan. A portion of this data will be supported by the AzAHP Workforce Development Plan, the ACOM 407 Attachment A Survey, and any additional means that are identified.
ACOM 407, Attachment A Survey
The Health Plan requires that all contracted provider types listed below complete the ACOM 407 Attachment A Survey annually to fulfill the requirements from ACOM 407. To meet this requirement, all Health Plans and lines of business have collaborated extensively to create a single provider survey that will be disseminated from one source (AZAHP vs. seven separate surveys being disseminated and duplicated). The survey will remain open for one month for providers to complete.
Provider types include: Nursing Homes, Home Health Agencies, Personal Care Attendant, Group Homes (DD), Adult Day Health, Assisted Living Homes, Homemaker, Attendant Care, Assisted Living Center, Supervisory Care Homes, Respite, Day Programs, Developmental Homes, Employment Programs, Habilitation Provider, In-home Nursing Services, Occupational Therapist, Physical Therapist, Speech/Hearing Therapist, ACC Core Codes, Integrated Clinics, Community Service Agency, Rural Substance Abuse Transitional Agency, Crisis Services Provider, Behavioral Health Residential Facility, Level I Residential Treatment Center – Secure (IMD), Level I Residential Treatment Center – Secure, Level I Residential Treatment Center – Nonsecure (non-IMD), Level I Residential Treatment Center – Nonsecure (IMD), Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Behavioral Health Outpatient Clinic, and additional BH providers to be considered.