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Definitions and Acronyms

The definitions specified in Part 1 below refer to terms found in all AHCCCS Contracts. The definitions specified in Part 2 below refer to terms that exist in one or more Contracts but do not appear in all Contracts

638 TRIBAL FACILITY
A facility that is owned and/or operated by a Federally recognized American Indian/Alaskan Native Tribe and that is authorized to provide services pursuant to Public Law 93-638, as amended. Also referred to as: tribally owned and/or operated 638 facilities, tribally owned and/or operated facility, 638 tribal facility, and tribally-operated 638 health program.

ABUSE OF THE AHCCCS PROGRAM
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care, noncompliance with licensure standards, misuse of billing numbers, or misuse or abuse of billing privileges. It also includes beneficiary practices that result in unnecessary cost to the AHCCCS Program [42 CFR 455.2].

ACTUARY
An individual who meets the qualification standards established by the American Academy of Actuaries for an actuary and follows the practice standards established by the Actuarial Standards Board. An actuary develops and certifies the capitation rates. [42 CFR 438.2]

ADJUDICATED CLAIM
A claim that has been received and processed by the Contractor which resulted in a payment or denial of payment.

ADMINISTRATIVE SERVICES SUBCONTRACT/SUBCONTRACTOR
An agreement that delegates any of the requirements of the Contract with AHCCCS, including, but not limited to the following:

1. Claims processing, including pharmacy claims,
2. Credentialing, including those for only primary source verification (i.e. Credential Verification Organization),
3. Management Service Agreements,
4. Service Level Agreements with any Division or Subsidiary of a corporate parent owner,
5. DDD Subcontracted Health Plan.

A person (individual or entity) who holds an Administrative Services Subcontract is an Administrative Services Subcontractor.

Providers are not Administrative Services Subcontractors.

ADULT
An individual 18 years of age or older, unless the term is given a different definition by statute, rule, or policies adopted by AHCCCS.

AGENT
Any individual who has been delegated the authority to obligate or act on behalf of a provider [42 CFR 455.101].

AHCCCS AMERICAN INDIAN HEALTH PROGRAM (AIHP)
A Fee-For-Service program administered by AHCCCS for Title XIX/XXI eligible American Indians which reimburses for physical and behavioral health services provided by and through the Indian Health Service (IHS), tribal health programs operated under 638 or any other AHCCCS registered provider.

AHCCCS COMPLETE CARE CONTRACTOR
A contracted Managed Care Organization (also known as a health plan) that, except in limited circumstances, is responsible for the provision of both physical and behavioral health services to eligible Title XIX/XXI persons enrolled by the administration.

AHCCCS CONTRACTOR OPERATIONS MANUAL (ACOM)
The ACOM provides information related to AHCCCS Contractor operations and is available on the AHCCCS website at www.azahcccs.gov.

AHCCCS ELIGIBILITY DETERMINATION
The process of determining, through an application and required verification, whether an applicant meets the criteria for Title XIX/XXI funded services.

AHCCCS MEDICAL POLICY MANUAL (AMPM)
The AMPM provides information regarding covered health care services and is available on the AHCCCS website at www.azahcccs.gov.

AHCCCS MEMBER
See “MEMBER”.

AHCCCS RULES
See “ARIZONA ADMINISTRATIVE CODE”.

AMBULATORY CARE
Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and/or other health care providers.

AMERICANS with DISABILITIES ACT (ADA)
The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for individuals with disabilities in employment, State and local government services, public accommodations, commercial facilities transportation, and telecommunications. Refer to the Americans with Disabilities Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C. 5.

APPEAL
The request for review of an adverse benefit determination.

APPEAL RESOLUTION The written determination by the Contractor concerning an appeal.

ARIZONA ADMINISTRATIVE CODE (A.A.C.)
State regulations established pursuant to relevant statutes. Referred to in Contract as “Rules.” AHCCCS Rules are State regulations which have been promulgated by the AHCCCS Administration and published by the Arizona Secretary of State.
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS)
The State agency that has the powers and duties set forth in A.R.S. §36-104 and A.R.S. Title 36, Chapters 5 and 34.

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)
Arizona’s Medicaid Program, approved by the Centers for Medicare and Medicaid Services as a Section 1115 Waiver Demonstration Program, and described in A.R.S. Title 36, Chapter 29.

ARIZONA LONG TERM CARE SYSTEM (ALTCS)
An AHCCCS program which delivers long-term, acute, behavioral health and case management services as authorized by A.R.S. §36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with developmental disabilities, through contractual agreements and other arrangements.

ARIZONA REVISED STATUTES (A.R.S.)
Laws of the State of Arizona.

ATTACHMENT
Any item labeled as an Attachment in the Contract or placed in the Attachments section of the Contract.

AUTHORIZED REPRESENTATIVE
An individual who is authorized to apply for medical assistance or act on behalf of another individual (A.A.C. R9-22-101).

BALANCED BUDGET ACT (BBA)
See “MEDICAID MANAGED CARE REGULATIONS.”

BEHAVIORAL HEALTH (BH)
Mental health and substance use collectively.

BEHAVIORAL HEALTH DISORDER
Any behavioral, mental health, and/or substance use diagnoses found in the most current version of the Diagnostic and Statistical Manual of International Classification of Disorders (DSM) excluding those diagnoses such as intellectual disability, learning disorders and dementia, which are not typically responsive to mental health or substance use treatment.

BEHAVIORAL HEALTH PROFESSIONAL

1. An individual licensed under A.R.S. Title 32, Chapter 33, whose scope of     practice allows the individual to:
    a. Independently engage in the practice of behavioral health as defined in         A.R.S. §32-3251, or
    b. Except for a licensed substance abuse technician, engage in the practice of         behavioral health as defined in A.R.S. §32-3251 under direct supervision as         defined in A.A.C. R4-6-101,
2. A psychiatrist as defined in A.R.S. §36-501,
3. A psychologist as defined in A.R.S. §32-2061,
4. A physician,
5. A behavior analyst as defined in A.R.S. §32-2091, or
6. A registered nurse practitioner licensed as an adult
    psychiatric and mental health nurse, or
7. A registered nurse with:
    a. A psychiatric-mental health nursing certification, or
    b. One year of experience providing behavioral health services.


BEHAVIORAL HEALTH SERVICES
Physician or practitioner services, nursing services, health-related services, or ancillary services provided to an individual to address the individual’s behavioral health issue. See also “COVERED SERVICES”.

BOARD CERTIFIED
An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification and when applicable, requirements for maintenance of certification.

BORDER COMMUNITIES
Cities, towns, or municipalities located in Arizona and within a designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding neighboring countries, due to service availability or distance.

CAPITATION
Payment to a Contractor by AHCCCS of a fixed monthly payment per person in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S. §36-2904 and A.R.S. §36-2907.

CENTERS OF EXCELLENCE
A facility and/or program that is recognized as providing the highest levels of leadership, quality, and service. Centers of Excellence align physicians and other providers to achieve higher value through greater focus on appropriateness of care, clinical excellence, and patient satisfaction.

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)
An organization within the United States Department of Health and Human Services, which administers the Medicare and Medicaid programs and the State Children’s Health Insurance Program.

CHILD
An individual under the age of 18, unless the term is given a different definition by statute, rule or policies adopted by AHCCCS.

CHILD AND FAMILY TEAM (CFT)
A defined group of individuals that includes, at a minimum, the child and their family, a behavioral health representative, and any individuals important in the child’s life that are identified and invited to participate by the child and family. This may include teachers, extended family members, friends, family support partners, healthcare providers, coaches, and community resource providers, representatives from churches, synagogues, or mosques, agents from other service systems like (DCS) Department of Child Safety or the Division of Developmental Disabilities (DDD). The size, scope, and intensity of involvement of the team members are determined by the objectives established for the child, the needs of the family in providing for the child, and by who is needed to develop an effective service plan, and can therefore expand and Contract as necessary to be successful on behalf of the child.

CLAIM DISPUTE
A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance.

CLEAN CLAIM
A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by A.R.S. §36-2904.

CLIENT INFORMATION SYSTEM (CIS)
The centralized processing system for files from each TRBHA/RBHA to AHCCCS as well as an informational repository for a variety of BH related reporting. The CIS system includes Member Enrollment and Eligibility, Encounter processing data, Demographics, and SMI determination processes.

CODE OF FEDERAL REGULATIONS (CFR)
The general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government.

COMPREHENSIVE RISK CONTRACT
A risk contract between the State and an MCO that covers comprehensive services, that is, inpatient hospital services and any of the following services, or any three or more of the following services [42 CFR 438.2]:

1. Outpatient hospital services,
2. Rural health clinic services,
3. Federally Qualified Health Center (FQHC) services,
4. Other laboratory and X-ray services,
5. Nursing facility (NF) services,
6. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services,
7. Family planning services,
8. Physician services, and
9. Home health services


CONTRACT SERVICES
See “COVERED SERVICES”.

CONTRACTOR
An organization or entity that has a prepaid capitated Contract with AHCCCS pursuant to A.R.S. §36-2904, A.R.S. §36-2940, A.R.S. §36-2944, or Chapter 34 of A.R.S. Title 36, to provide goods and services to members either directly or through subcontracts with providers, in conformance with contractual requirements and State and Federal law, rule, regulations, and policies.

CONVICTED
A judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending.

COPAYMENT
A monetary amount that a member pays directly to a provider at the time a covered service is rendered (A.A.C. R9-22-711).

CORRECTIVE ACTION PLAN (CAP)
A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/ tasks to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish CAP goals and objectives, and staff responsible to carry out the CAP within established timelines. CAPs are generally used to improve performance of the Contractor and/or its providers, to enhance Quality Management/Process Improvement activities and the outcomes of the activities, or to resolve a deficiency.

COST AVOIDANCE
The process of identifying and utilizing all confirmed sources of first or third-party benefits before payment is made by the Contractor.

COVERED SERVICES
The health and medical services to be delivered by the Contractor as described in Section D, Program Requirements, or the Scope of Work Section.

CREDENTIALING
The process of obtaining, verifying and evaluating information regarding applicable licensure, accreditation, certification, educational and practice requirements to determine whether a provider has the required credentials to deliver specific covered services to members.

DAY
A calendar day unless otherwise specified.

DAY – BUSINESS/WORKING
Monday, Tuesday, Wednesday, Thursday, or Friday unless a legal holiday falls on Monday, Tuesday, Wednesday, Thursday, or Friday.

DELEGATED AGREEMENT
A type of subcontract agreement with a qualified organization or individual to perform one or more functions required to be performed by the Contractor pursuant to this Contract.

DEPARTMENT OF ECONOMIC SECURITY/DIVISION OF DEVELOPMENTAL DISABILITIES (DES/DDD)
The Division of a State agency, as defined in A.R.S. Title 36, Chapter 5.1, which is responsible for serving eligible Arizona residents with a developmental/intellectual disability. AHCCCS contracts with DES/DDD to serve Medicaid eligible individuals with a developmental/intellectual disability.

DISENROLLMENT
The discontinuance of a member’s eligibility to receive covered services through a Contractor.

DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)
The State agency that formerly had the duties set forth by the legislature to provide BH services within Arizona.

DIVISION OF HEALTH CARE MANAGEMENT (DHCM)
The division responsible for Contractor oversight regarding AHCCCS Contractor operations, quality, maternal and child health, behavioral health, medical management, case management, rate setting, encounters, and financial/operational oversight.

DUAL ELIGIBLE MEMBER
A member who is eligible for both Medicare and Medicaid. There are two types of Dual Eligible Members: a Qualified Medicare Beneficiary (QMB) Dual Eligible Member (a QMB Plus or a QMB Only), and a Non-QMB Dual Eligible Member (a Special Low-Income Beneficiary [SLMB] Plus or an Other Full Benefit Dual Eligible).

DURABLE MEDICAL EQUIPMENT (DME)
Equipment that provides therapeutic benefits; is designed primarily for a medical purpose; is ordered by a physician/provider; is able to withstand repeated use; and is appropriate for use in the home. See also Medical Equipment and Appliances.

EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT)
A comprehensive child health program of prevention, treatment, correction, and improvement of physical and behavioral health conditions for AHCCCS members under the age of 21. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 U.S.C. 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

EMERGENCY MEDICAL CONDITION
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health (or, with respect to a pregnant individual, the health of the individual or their unborn child) in serious jeopardy, b)serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part [42 CFR 438.114(a)].

EMERGENCY MEDICAL SERVICE
Covered inpatient and outpatient services provided after the sudden onset of an emergency medical condition as defined above. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize the emergency medical condition [42 CFR 438.114(a)].

EMERGENCY SERVICES
Medical or behavioral health services provided for the treatment of an emergency medical condition.

ENCOUNTER
A record of a health care-related service rendered by a provider or providers registered with AHCCCS to a member who is enrolled with a Contractor on the date of service.

ENROLLEE
A Medicaid recipient who is currently enrolled with a Contractor [42 CFR 438.2].

ENROLLMENT
The process by which an eligible individual becomes a member of a Contractor’s plan.

EVIDENCE-BASED PRACTICE
An intervention that is recognized as effective in treating a specific health-related condition based on scientific research; the skill and judgment of health care professionals; and the unique needs, concerns and preferences of the individual receiving services.

EXCLUDED
Services not covered under the State Plan or the 1115 Waiver, including but not limited to, services that are above a prescribed limit, experimental services, or services that are not medically necessary.

EXHIBITS
All items attached as part of the original Solicitation.

FEDERAL FINANCIAL PARTICIPATION (FFP)
FFP refers to the contribution that the Federal government makes to the Title XIX and Title XXI program portions of AHCCCS, as defined in 42 CFR 400.203.

FEE-FOR-SERVICE (FFS)
A method of payment to an AHCCCS registered provider on an amount-per-service basis for services reimbursed directly by AHCCCS for members not enrolled with a managed care Contractor.

FEE-FOR-SERVICE MEMBER
A Title XIX or Title XXI eligible individual who is not enrolled with an AHCCCS Contractor.

1. FISCAL AGENT
2. A Contractor that processes or pays vendor claims on behalf of the Medicaid     agency [42 CFR 455.101].

FRAUD
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themself or some other person. It includes any act that constitutes fraud under applicable State or Federal law, as defined in 42 CFR 455.2.

GEOGRAPHIC SERVICE AREA (GSA)
An area designated by AHCCCS within which a Contractor of record provides, directly or through subcontract, covered health care service to a member enrolled with that Contractor of record, as defined in 9 A.A.C. 22, Article 1.

GRIEVANCE
A member’s expression of dissatisfaction with any matter, other than an adverse benefit determination.

GRIEVANCE AND APPEAL SYSTEM
A system that includes a process for member grievances and appeals including, SMI grievances and appeals, provider claim disputes. The Grievance and Appeal system provides access to the State fair hearing process.

HEALTH CARE DECISION MAKER
An individual who is authorized to make health care treatment decisions for the patient. As applicable to the particular situation, this may include a parent of an unemancipated minor or a person lawfully authorized to make health care treatment decisions pursuant to A.R.S. title 14, chapter 5, article 2 or 3; or A.R.S. §§ 8-514.05, 36-3221, 36-3231 or 36-3281.

HEALTH CARE PROFESSIONAL
A physician, podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), licensed social worker, registered respiratory therapist, licensed marriage and family therapist and licensed professional counselor.

HEALTH INSURANCE
Coverage against expenses incurred through illness or injury of the individual whose life or physical well-being is the subject of coverage.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
The Health Insurance Portability and Accountability Act; also known as the Kennedy-Kassebaum Act, signed August 21, 1996 as amended and as reflected in the implementing regulations at 45 CFR Parts 160, 162, and 164.

HEALTH PLAN
See “CONTRACTOR.”

HOME HEALTH CARE
See “HOME HEALTH SERVICES”.

HOME HEALTH SERVICES
Nursing services, home health aide services, therapy services, and medical supplies, equipment, and appliances as described in 42 CFR 440.70 when provided to a member at their place of residence and on their physician's orders as part of a written plan of care [42 CFR 440.70].

HOSPICE SERVICES
Palliative and support care for members who are certified by a physician as being terminally ill and having six months or less to live.

HOSPITALIZATION
Admission to, or period of stay in, a health care institution that is licensed as a hospital as defined in R9-22-101.

INCURRED BUT NOT REPORTED (IBNR)
Liability for services rendered for which claims have not been received.

INDIVIDUAL RECOVERY PLAN (FORMERLY KNOWN AS THE INDIVIDUAL SERVICE PLAN)
See “SERVICE PLAN”

INDIAN HEALTH SERVICES (IHS)
The operating division within the U.S. Department of Health and Human Services, responsible for providing medical and public health services to members of federally recognized Tribes and Alaska Natives as outlined in 25 U.S.C. 1661.

INFORMATION SYSTEMS
The component of the Contractor’s organization which supports the Information Systems, whether the systems themselves are internal to the organization (full spectrum of systems staffing), or externally contracted (internal oversight and support).

IN-NETWORK PROVIDER
An individual or entity which has signed a provider agreement as specified in A.R.S. §36-2904 and is authorized through a subcontract with an AHCCCS Contractor to provide services prescribed in A.R.S. §36-2901 et seq. for members enrolled with the Contractor.

INSTITUTION FOR MENTAL DISEASE (IMD)
A hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of individuals with mental diseases (including substance use disorders), including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual Disabilities is not an institution for mental diseases [42 CFR 435.1010].

INTERGOVERNMENTAL AGREEMENT (IGA)
When authorized by legislative or other governing bodies, two or more public agencies or public procurement units by direct Contract or agreement may contract for services or jointly exercise any powers common to the contracting parties and may enter into agreements with one another for joint or cooperative action or may form a separate legal entity, including a nonprofit corporation to Contract for or perform some or all of the services specified in the Contract or agreement or exercise those powers jointly held by the contracting parties. A.R.S. Title 11, Chapter 7, Article 3 (A.R.S. §11-952.A).

LIABLE PARTY
An individual, entity, or program that is or may be liable to pay all or part of the medical cost of injury, disease or disability of an AHCCCS applicant or member as defined in A.A.C. R9-22-1001.

LIEN
A legal claim, filed with the County Recorder’s office in which a member resides and in the county an injury was sustained for the purpose of ensuring that AHCCCS receives reimbursement for medical services paid. The lien is attached to any settlement the member may receive as a result of an injury.

LIMITED ENGLISH PROFICIENCY (LEP)
Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English may have LEP and may be eligible to receive language assistance for a particular type of service, benefit, or encounter.

LONG -TERM SERVICES AND SUPPORTS (LTSS)
Services and supports provided to members of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability of the member to live or work in the setting of their choice, which may include the individual’s home, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting [42 CFR 438.2].

MAJOR UPGRADE
Any systems upgrade or change to a major business component that may result in a disruption to the following: loading of contracts, providers, or members, issuing prior authorizations or the adjudication of claims.

MANAGED CARE
Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality, medical management and the coordination of care.

MANAGED CARE ORGANIZATION
An entity that has, or is seeking to qualify for, a comprehensive risk Contract under 42 CFR Part 438 and that is [42 CFR 438.2]:

1. A Federally qualified HMO that meets the advance directives requirements of     subpart I of 42 CFR Part 489, or
2. Any public or private entity that meets the advance directives requirements     and is determined by the Secretary to also meet the following conditions:
a. Makes the services it provides to its Medicaid enrollees as accessible (in terms     of timeliness, amount, duration, and scope) as those services are to other     Medicaid beneficiaries within the area served by the entity.
b. Meets the solvency standards of 42 CFR 438.116.

MANAGED CARE PROGRAM
A managed care delivery system operated by a State as authorized under section 1915(a), 1915(b), 1932(a), or 1115(a) of the Social Security Act [42 CFR 438.2].

MANAGEMENT SERVICES AGREEMENT
A type of subcontract with an entity in which the owner of the Contractor delegates all or substantially all management and administrative services necessary for the operation of the Contractor.

MANAGING EMPLOYEE
A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency [42 CFR 455.101].

MATERIAL CHANGE TO BUSINESS OPERATIONS
Any change in overall operations that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as required in Contract including, but not limited to, any change that would impact or is likely to impact more than 5% of total membership and/or provider network in a specific GSA. Changes to business operations may include, but are not limited to, policy, process, and protocol, such as prior authorization or retrospective review. Additional changes may also include the addition or change in:

1. PBM,
2. Dental Benefit Manager,
3. Transportation vendor,
4. Claims Processing system,
5. System changes and upgrades,
6. Member ID Card vendor,
7. Call center system,
8. Covered benefits delivered exclusively through the mail, such as mail order     pharmaceuticals or delivery of medical equipment,
9. MSA, and
10. Any other Administrative Services Subcontract.

MATERIAL CHANGE TO PROVIDER NETWORK
Any change in composition of or payments to a Contractor’s provider network that affects, or can reasonably be foreseen to affect, the Contractor's adequacy of capacity and services necessary to meet the performance and/or provider network standards as described in Contract. Changes to provider network may include but are not limited to:

1. A change that would cause or is likely to cause more than 5% of the members     in a GSA to change the location where services are received or rendered.
2. Any change impacting 5% or less of the membership but involving a provider     or provider group who is the sole provider of a service in a service area, or     operates in an area with limited alternate sources of the service.

MATERIAL OMISSION
A fact, data or other information excluded from a report, Contract, etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, Contract, etc.

MEDICAID
A Federal/State program authorized by Title XIX of the Social Security Act, as amended.

MEDICAID MANAGED CARE REGULATIONS
The Federal law mandating, in part, that States ensure the accessibility and delivery of quality health care by their managed care Contractors. These regulations were promulgated pursuant to the Balanced Budget Act (BBA) of 1997.

MEDICAL EQUIPMENT AND APPLIANCES
Any item, appliance, or piece of equipment (pursuant to 42 CFR 440.70) that is not a prosthetic or orthotic: and

1. Is customarily used to serve a medical purpose, and is generally not useful to     an individual in the absence of an illness, disability, or injury,
2. Can withstand repeated use, and
3. Can be reusable by others or removable.

Medical equipment and appliances may also be referred to as Durable Medical Equipment (DME).

MEDICAL MANAGEMENT (MM)
An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the continuum of care (from prevention to hospice).

MEDICAL RECORDS
A chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the provider's physical findings, behavioral health findings, the results of diagnostic tests and procedures, medications and therapeutic procedures, referrals and treatment plans.

MEDICAL SERVICES
Medical care and treatment provided by a Primary Care Provider (PCP), attending physician, or dentist or by a nurse or other health related professional and technical personnel at the direction/order of a licensed physician or dentist.

MEDICAL SUPPLIES
Health care related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness or injury [42 CFR 440.70].

MEDICALLY NECESSARY
A covered service provided by a physician or other licensed practitioner of the health arts within the scope of practice under State law to prevent disease, disability or other adverse conditions or their progression, or to prolong life (A.A.C. R9-22-101).

MEDICALLY NECESSARY SERVICES
Those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life.

MEDICARE
A Federal program authorized by Title XVIII of the Social Security Act, as amended.

MEDICATION ASSISTED TREATMENT (MAT)
The use of medications in combination with counseling and behavioral therapies for the treatment of substance use disorders.

MEMBER
An eligible individual who is enrolled in AHCCCS, as defined in A.R.S. §36-2931, §36-2901, §36-2901.01 and A.R.S. §36-2981. Also referred to as Title XIX/XXI Member or Medicaid Member.

MEMBER INFORMATION MATERIALS
Any materials given to the Contractor’s membership. This includes, but is not limited to: member handbooks, member newsletters, provider directories, surveys, on hold messages and health related brochures/reminders and videos, form letter templates, and website content. It also includes the use of other mass communication technology such as e-mail and voice recorded information messages delivered to a member’s phone.

MINIMUM PERFORMANCE STANDARD (MPS)
The minimal expected level of performance by the Contractor.

NATIONAL PROVIDER IDENTIFIER (NPI)
A unique identification number for covered health care providers, assigned by the CMS contracted national enumerator.

NETWORK
A list of doctors, or other health care providers, and hospitals that a Contractor contracts with directly, or employs through a subcontractor, to provide medical care to its members.

NON-CONTRACTING PROVIDER
An individual or entity that provides services as prescribed in A.R.S. §36-2901 who does not have a subcontract with an AHCCCS Contractor.

OUT OF NETWORK PROVIDER
An individual or entity that has a provider agreement with the AHCCCS Administration pursuant to A.R.S. §36-2904 but is not authorized through a subcontract with an AHCCCS Contractor to provide services specified in A.R.S. §36-2901 et seq. for members enrolled with the Contractor.

PARENT
A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction.

PERFORMANCE IMPROVEMENT PROJECT (PIP)
A planned process of data gathering, evaluation, and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery. Formerly referred to as Quality Improvement Projects (QIP).

PERFORMANCE STANDARDS
A set of standardized measures designed to assist AHCCCS in evaluating, comparing, and improving the performance of its Contractors.

PHYSICIAN SERVICES
Medical assessment, treatments, and surgical services provided by licensed allopathic or osteopathic physicians within the scope of practice.

PLAN
See “SERVICE PLAN”.

POSTSTABILIZATION CARE SERVICES
Medically necessary services, related to an emergency medical condition provided after the member’s condition is sufficiently stabilized in order to maintain, improve or resolve the member’s condition so that the member could alternatively be safely discharged or transferred to another location [42 CFR 438.114(a)].

POTENTIAL ENROLLEE
A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR 438.10(a)].

PREMIUM
The amount an individual pays for health insurance every month. In addition to the premium, an individual usually has to pay other costs for their health care, including a deductible, copayments, and coinsurance.

PREMIUM TAX
The premium tax is equal to the tax imposed pursuant to A.R.S. §36-2905 and A.R.S. §36-2944.01 for all payments made to Contractors for the Contract Year.

PREPAID MEDICAL MANAGEMENT INFORMATION SYSTEM (PMMIS)
An integrated information infrastructure that supports AHCCCS operations, administrative activities, and reporting requirements.

PRESCRIPTION DRUGS
Any prescription medication as defined in A.R.S §32-1901 is prescribed by a health care professional to a subscriber to treat the subscriber's condition.

PRIMARY CARE
All health care services and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by the State Medicaid program, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them [42 CFR 438.2].

PRIMARY CARE PHYSICIAN
A physician defined as an individual licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17 and who otherwise meets the definition of Primary Care Provider (PCP).

PRIMARY CARE PROVIDER (PCP)
An individual who meets the requirements of A.R.S. §36-2901, and who is responsible for the management of the member’s health care. A PCP may be a physician defined as an individual licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15. The PCP must be an individual, not a group or association of individuals, such as a clinic.

PRIMARY PREVENTION
The focus on methods to reduce, control, eliminate, and prevent the incidence or onset of physical or mental health disease through the application of interventions before there is any evidence of disease or injury.

PRIOR AUTHORIZATION
Process by which the Administration or contractor, whichever is applicable, authorizes, in advance, the delivery of covered services based on factors including but not limited to medical necessity, cost effectiveness, compliance with this Article and any applicable contract provisions. Prior authorization is not a guarantee of payment (A.A.C. R9-22-101).

PRIOR PERIOD
See “PRIOR PERIOD COVERAGE”.

PRIOR PERIOD COVERAGE (PPC)
For Title XIX members, the period of time prior to the member’s enrollment, during which a member is eligible for covered services. The timeframe is from the effective date of eligibility to the day a member is enrolled with a Contractor. Refer to 9 A.A.C. 22 Article 1. If a member made eligible via the Hospital Presumptive Eligibility (HPE) program is subsequently determined eligible for AHCCCS via the full application process, prior period coverage for the member will be covered by AHCCCS Fee For Service and the member will be enrolled with the Contractor only on a prospective basis.


PRIOR QUARTER COVERAGE
The period of time prior to an individual’s month of application for AHCCCS coverage, during which a member (limited to children under 19, individuals who are pregnant, and individuals who are in the 60-day postpartum period beginning the last day of pregnancy) may be eligible for covered services. Prior Quarter Coverage is limited to the three month time period prior to the month of application. An applicant may be eligible during any of the three months prior to application if the applicant:

1. Received one or more covered services described in 9 A.A.C. 22, Article 2 and     Article 12, and 9 A.A.C. 28, Article 2 during the month, and
2. Would have qualified for Medicaid at the time services were received if the     individual had applied regardless of whether the individual is alive when the     application is made. Refer to A.A.C. R9-22-303.

AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter.

PROGRAM CONTRACTOR
See “CONTRACTOR”

PROVIDER
Any individual or entity that is engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the State in which it delivers the services, pursuant to 42 CFR 438.2.

PROVIDER GROUP
Two or more health care professionals who practice their profession at a common location (whether or not they share facilities, supporting staff, or equipment).

PRUDENT LAYPERSON
(for purposes of determining whether an emergency medical condition exists) An individual without medical training who relies on the experience, knowledge and judgment of a reasonable individual to make a decision regarding whether or not the absence of immediate medical attention will result in: 1) placing the health of the individual in serious jeopardy, 2) serious impairment to bodily functions, or 3) serious dysfunction of a bodily part or organ.

QUALIFIED MEDICARE BENEFICIARY DUAL ELIGIBLE MEMBER (QMB DUAL)
An individual determined eligible under A.A.C. R9-29 Article 2 for Qualified Medicare Beneficiary (QMB) and eligible for acute care services provided for in 9 A.A.C. Chapter 22 or ALTCS services provided for in 9 A.A.C. Chapter 28. A QMB Dual receives both Medicare and Medicaid services and cost sharing assistance.

QUALITY MANAGEMENT
The evaluation and assessment of member care and services to ensure adherence to standards of care and appropriateness of services; can be assessed at a member, provider, or population level.

REFERRAL
A verbal, written, telephonic, electronic, or in-person request for health services.

REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA)
A contracted Managed Care Organization (also known as a health plan) responsible for the provision of comprehensive behavioral health services to all eligible individuals assigned by the administration and provision of comprehensive physical health services to eligible individuals with a Serious Mental Illness enrolled by the Administration.

REHABILITATION
Physical, occupational, and speech therapies, and items to assist in improving or restoring an individual’s functional level (A.A.C. R9-22-101).

REINSURANCE
A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of certain Contract service costs incurred for a member beyond a predetermined monetary threshold.

RELATED PARTY
A party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by a Contractor. "Related parties" include, but are not limited to, agents, managing employees, individuals with an ownership or controlling interest in the Contractor and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and other entities controlled or managed by any such entities or individuals.

REQUEST FOR PROPOSAL (RFP)
A RFP includes all documents, whether attached or incorporated by references that are used by the Administration for soliciting a Proposal under 9 A.A.C. 22 Article 6 and 9 A.A.C. 28 Article 6.

RISK CONTRACT
A Contract between the State and MCO, under which the Contractor:

1. Assumes risk for the cost of the services covered under the Contract, and
2. Incurs loss if the cost of furnishing the services exceeds the payments under     the Contract. [42 CFR 438.2]

ROOM AND BOARD (or ROOM)
The amount paid for food and/or shelter. Medicaid funds can be expended for room and board when an individual lives in an institutional setting (e.g. NF, ICF). Medicaid funds cannot be expended for room and board when a member resides in an Alternative HCBS Setting (e.g. Assisted Living Home, Behavioral Health Residential Facilities) or an apartment like setting that may provide meals.

SCOPE OF SERVICES
See “COVERED SERVICES”.

SERVICE LEVEL AGREEMENT
A type of subcontract with a corporate owner or any of its Divisions or Subsidiaries that requires specific levels of service for administrative functions or services for the Contractor specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this Contract.

SERVICE PLAN
A complete written description of all covered health services and other informal supports which includes individualized goals, peer-and-recovery support and family support services, care coordination activities and strategies to assist the member in achieving an improved quality of life.

SPECIAL HEALTH CARE NEEDS (SHCN)
Serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that required by members generally; that lasts or is expected to last one year or longer and may require ongoing care not generally provided by a primary care provider.

SPECIALIST
A Board-eligible or certified physician who declares themself as a specialist and practices a specific medical specialty. For the purposes of this definition, Board-eligible means a physician who meets all the requirements for certification but has not tested for or has not been issued certification.

SPECIALTY PHYSICIAN
A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.

STATE
The State of Arizona and Department or Agency of the State that executes the Contract.

STATEWIDE
Of sufficient scope and breadth to address the health care service needs of members throughout the State of Arizona.

STATE FISCAL YEAR
The budget year-State fiscal year: July 1 through June 30.

STATE PLAN
The written agreements between the State and CMS, which describes how the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children’s Health Insurance Program.

SUBCONTRACT
An agreement entered into by the Contractor with any of the following: a provider of health care services who agrees to furnish covered services to member; or with any other organization or individual who agrees to perform any administrative function or service for the Contractor specifically related to fulfilling the Contractor's obligations to AHCCCS under the terms of this Contract, as defined in 9 A.A.C. 22 Article 1.

SUBCONTRACTOR

1. A provider of health care who agrees to furnish covered services to members.
2. An individual, agency, or organization with which the Contractor has contracted     or delegated some of its management/administrative functions or     responsibilities.
3. An individual, agency or organization with which a fiscal agent has entered into     a Contract, agreement, purchase order or lease (or leases of real property) to     obtain space, supplies equipment or services provided under the AHCCCS     agreement.

SUBSIDIARY
An entity owned or controlled by the Contractor.

SUBSTANCE USE DISORDER (SUD)
A range of conditions that vary in severity over time, from problematic, short-term use/abuse of substances to severe and chronic disorders requiring long-term and sustained treatment and recovery management.

SUPPLEMENTAL SECURITY INCOME (SSI) AND SSI RELATED GROUPS
Eligible individuals receiving income through Federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or have a disability and have household income levels at or below 100% of the FPL.

THIRD PARTY LIABILITY (TPL)
See “LIABLE PARTY.”

TITLE XIX
Known as Medicaid, Title XIX of the Social Security Act provides for Federal grants to the states for medical assistance programs. Title XIX enables states to furnish medical assistance to those who have insufficient income and resources to meet the costs of necessary medical services, rehabilitation, and other services, to help those families and individuals become or remain independent and able to care for themselves. Title XIX members include but are not limited to those eligible under Section 1931 of the Social Security Act, Supplemental Security Income (SSI), SSI-related groups, Medicare cost sharing groups, Breast and Cervical Cancer Treatment Program and Freedom to Work Program. Which includes those populations described in 42 U.S.C. 1396 a (a)(10)(A).

TITLE XIX MEMBER
Title XIX members include those eligible under Section 1931 provisions of the Social Security Act (previously AFDC), Supplemental Security Income (SSI) or SSI-related groups, Medicare Cost Sharing groups, Adult Group at or below 106% Federal Poverty Level (Adults </= 106%), Adult Group above 106% Federal Poverty Level (Adults > 106%), Breast and Cervical Cancer Treatment program, Title IV-E Foster Care and Adoption Subsidy, Young Adult Transitional Insurance, and Freedom to Work.

TREATMENT
A procedure or method to cure, improve, or palliate an individual’s medical condition or behavioral health issue. Refer to A.A.C. R9-10-101.

TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHA)
A tribal entity that has an intergovernmental agreement with the administration, the primary purpose of which is to coordinate the delivery of comprehensive behavioral health services to all eligible individuals assigned by the administration to the tribal entity. Tribal governments, through an agreement with the State, may operate a Tribal Regional Behavioral Health Authority for the provision of behavioral health services to American Indian members. Refer to A.R.S. §36-3401 and A.R.S. §36-3407.

ABUSE (OF A CHILD)
The infliction or allowing of physical injury, impairment of bodily function or disfigurement or the infliction of or allowing another person to cause serious emotional damage as evidenced by severe anxiety, depression, withdrawal or untoward aggressive behavior and which emotional damage is diagnosed by a medical doctor or psychologist and is caused by the acts or omissions of an individual who has the care, custody and control of a child. As specified in A.R.S. §8-201(2), abuse includes:

1. Inflicting or allowing sexual abuse, sexual conduct with a minor, sexual assault,     molestation of a child, commercial sexual exploitation of a minor, sexual     exploitation of a minor, incest, or child sex trafficking as those acts are     described in the Arizona Revised Statutes, Title 13, Chapter 14.
2. Physical injury that results from permitting a child to enter or remain in any     structure or vehicle in which volatile, toxic or flammable chemicals are found or     equipment is possessed by any person for the purpose of manufacturing a     dangerous drug as defined in section 13-3401.
3. Unreasonable confinement of a child.

ABUSE (OF A MEMBER)
Abuse of a Vulnerable Adult or the Abuse of a Child who is a member as specified in A.R.S. §46-451(A)(1), A.R.S. §8-201(2), A.R.S. §46-451(A)(9).

ABUSE (OF A VULNERABLE ADULT)
An intentional infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, and sexual abuse or sexual assault as specified in A.R.S. §46-451(A)(1).

ACTIVE TREATMENT
A current need for treatment. The treatment is identified on the member’s service plan to treat a serious and chronic physical, developmental or behavioral condition requiring medically necessary services of a type or amount beyond that generally required by members that lasts, or is expected to last one year or longer, and requires ongoing care not generally provided by a primary care provider.

ACUTE CARE ONLY (ACO)
The enrollment status of a member who is otherwise financially and medically eligible for ALTCS but who 1) refuses HCBS offered by the case manager; 2) has made an uncompensated transfer that makes them ineligible; 3) resides in a setting in which Long Term Services and Supports (LTSS) cannot be provided; or 4) has equity value in a home that exceeds $552,000. These ALTCS enrolled members are eligible to receive acute medical services but not eligible to receive LTC institutional, alternative residential or HCBS.

ADMINISTRATIVE OFFICE OF THE COURTS (AOC)
The Arizona Constitution authorizes an administrative director and staff to assist the Chief Justice with administrative duties. Under the direction of the Chief Justice, the administrative director and the staff of the Administrative Office of the Courts (AOC) provide the necessary support for the supervision and administration of all State courts.

ADULT GROUP ABOVE 106% FEDERAL POVERTY LEVEL (ADULTS > 106%)
Adults aged 19-64, without Medicare, with income above 106% through 133% of the Federal Poverty Level (FPL).

ADULT GROUP AT OR BELOW 106% FEDERAL POVERTY LEVEL (ADULTS </= 106%)
Adults aged 19-64, without Medicare, with income at or below 106% of the Federal Poverty Level (FPL).

AFFILIATED ORGANIZATION
A party that, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with an entity.

ANNIVERSARY DATE
The anniversary date is 12 months from the date the member is enrolled with the Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date the member was given an opportunity to change.

ANNUAL ENROLLMENT CHOICE (AEC)
The opportunity for an individual to change Contractors every 12 months.

ARIZONA DEPARTMENT OF CHILD SAFETY (DCS)
The department established pursuant to A.R.S. §8-451 to protect children and to perform the following:

1. Investigate reports of abuse and neglect.
2. Assess, promote, and support the safety of a child in a safe and stable family     or other appropriate placement in response to allegations of abuse or neglect.
3. Work cooperatively with law enforcement regarding reports that include     criminal conduct allegations.
4. Without compromising child safety, coordinate services to achieve and     maintain permanency on behalf of the child, strengthen the family, and     provide prevention, intervention and treatment services pursuant to this     chapter.

ARIZONA DEPARTMENT OF JUVENILE CORRECTION (ADJC)
The State agency responsible for all juveniles adjudicated as delinquent and committed to its jurisdiction by the county juvenile courts.

BED HOLD
A 24 hour per day unit of service that is authorized by an ALTCS member’s case manager or the behavioral health case manager or a subcontractor for an acute care member, which may be billed despite the member’s absence from the facility for the purposes of short term hospitalization leave and therapeutic leave. Refer to the Arizona Medicaid State Plan, 42 CFR 447.40 and 42 CFR 483.12, 9 A.A.C. 28 and AMPM Chapter 100.

BEHAVIORAL HEALTH PARAPROFESSIONAL
As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for a health care institution according to the health care institution’s policies and procedures that:

1. If the behavioral health services were provided in a setting other than a     licensed health care institution, the individual would be required to be licensed     as a behavioral professional under A.R.S. Title 32, Chapter 33; and
2. Are provided under supervision by a behavioral health professional.

BEHAVIORAL HEALTH RESIDENTIAL FACILITY
As specified in A.A.C. R9-10-101, health care institution that provides treatment to an individual experiencing a behavioral health issue that:

1. Limits the individual’s ability to be independent, or
2. Causes the individual to require treatment to maintain or enhance     independence.

BEHAVIORAL HEALTH TECHNICIAN
As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for a health care institution according to the health care institution’s policies and procedures that:

1. If the behavioral health services were provided in a setting other than a     licensed health care institution, the individual would be required to be licensed     as a behavioral professional under A.R.S. Title 32, Chapter 33; and
2. Are provided with clinical oversight by a behavioral health professional.

BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)
Eligible individuals under the Title XIX expansion program for women with income up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.

CARE MANAGEMENT PROGRAM (CMP)
Activities to identify the top tier of high need/high cost Title XIX members receiving services within an AHCCCS contracted health plan; including the design of clinical interventions or alternative treatments to reduce risk, cost, and help members achieve better health care outcomes. Care management is an administrative function performed by the health plan. Distinct from case management, Care Managers should not perform the day-to-day duties of service delivery.

CARE MANAGEMENT
A group of activities performed by the Contractor to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost, and help achieve better health care outcomes. Distinct from case management, care management does not include the day-to-day duties of service delivery.

CASE MANAGEMENT
A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes. Contractor Case management for DES/DDD is referred to as Support Coordination.

CASH MANAGEMENT IMPROVEMENT ACT (CMIA)
Cash Management Improvement Act of 1990 [31 CFR Part 205]. Provides guidelines for the drawdown and transfer of Federal funds.

CHILDREN
Eligible children with incomes ranging from below 133% to 147% of the FPL, depending on the age of the child.

CLIENT ASSESSMENT AND TRACKING SYSTEM (CATS)
A component of AHCCCS’ data management information system that supports ALTCS and that is designed to provide key information to, and receive key information from ALTCS Contractors.

COMPREHENSIVE MEDICAL AND DENTAL PROGRAM (CMDP)
A Contractor that is responsible for the provision of covered, medically necessary AHCCCS services for foster children in Arizona. Refer to A.R.S. §8-512.

COMPETITIVE BID PROCESS
A State procurement system used to select Contractors to provide covered services on a geographic basis.

COUNTY OF FISCAL RESPONSIBILITY
The county of fiscal responsibility is the Arizona county that is responsible for paying the State's funding match for the member’s ALTCS Service Package. The county of physical presence (the county in which the member physically resides) and the county of fiscal responsibility may be the same county or different counties.

DES/DDD AMERICAN INDIAN HEALTH PLAN (DDD-AIHP)
A Fee for Service (FFS) program administered by DES/DDD for Title XIX/XXI eligible American Indians which reimburses for physical and behavioral health services provided by any AHCCCS registered provider, and for TXIX members, that are not provided by or through the Indian Health Services tribal health programs operated under 638. In this Contract DDD's Program is referred to as DDD-AIHP.

DEVELOPMENTAL DISABILITY (DD)
As defined in A.R.S. §36-551, a strongly demonstrated potential that a child under six years of age has a developmental disability or will become a child with a developmental disability, as determined by a test performed pursuant to A.R.S. §36-694 or by other appropriate tests, or a severe, chronic disability that:

1. Is attributable to cognitive disability, cerebral palsy, epilepsy, or autism.
2. Is manifested before age eighteen.
3. Is likely to continue indefinitely.
4. Results in substantial functional limitations in three or more of the following     areas of major life activity:
        a. Self-care,
        b. Receptive and expressive language,
        c. Learning,
        d. Mobility,
        e. Self-direction,
        f. Capacity for independent living, and
        g. Economic self-sufficiency.
5. Reflects the need for a combination and sequence of individually planned or     coordinated special, interdisciplinary, or generic care, treatment or other     services that are of lifelong or extended duration.

EQUITY PARTNERS
The sponsoring organizations or parent companies of the managed care organization that share in the returns generated by the organization, both profits and liabilities.
FAMILY-CENTERED Care that recognizes and respects the pivotal role of the family in the lives of members. It supports families in their natural care-giving roles, promotes normal patterns of living, and ensures family collaboration and choice in the provision of services to the member. When appropriate, the member directs the involvement of the family to ensure person centered care.

FAMILY OR FAMILY MEMBER
A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction, or other member representative responsible for making health care decisions on behalf of the member. Family members may encompass family of choice for adult members, which includes informal supports.

FAMILY-RUN ORGANIZATION
An entity that has a board of directors made up of more than 50% family members who have primary responsibility for the raising of a child, youth, adolescent or young adult with a serious emotional disturbance (SED), or have the lived experience as a primary informal support for an adult with emotional, behavioral, mental health or substance use needs.

FEDERAL EMERGENCY SERVICES (FES)
A program delineated in A.A.C. R9-22-217, to treat an emergency condition for a member who is determined eligible under A.R.S. §36-2903.03(D).

FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting criteria under Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act.

FEDERALLY QUALIFIED HEALTH CENTER LOOK-ALIKE
A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting the definition of “health center” under Section 330 of the Public Health Service Act, but does not receive grant funding under Section 330.

FIELD CLINIC
A “clinic” consisting of single specialty health care providers who travel to health care delivery settings closer to members and their families than the Multi-Specialty Interdisciplinary Clinics (MSICs) to provide a specific set of services including evaluation, monitoring, and treatment for CRS-related conditions on a periodic basis.

FREEDOM OF CHOICE (FC)
The opportunity given to each member who does not specify a Contractor preference at the time of enrollment to choose between the Contractors available within the Geographic Service Area (GSA) in which the member is enrolled.

GENERAL MENTAL HEATH/SUBSTANCE USE (GMH/SU)
Behavioral health services provided to adult members age 18 and older who have not been determined to have a Serious Mental Illness.

GENERALIST SUPPORT AND REHABILITATION SERVICES PROVIDERS
Configure their program operations to the needs of the Child and Family Team without arbitrary limits on frequency, duration, type of service, age, gender, population, or other factors associated with the delivery of Support and Rehabilitation Services.

GUEST DOSING
A mechanism for patients who are not eligible for take-home medication to travel from their home clinic for business, pleasure, or family emergencies and which also provides an option for patients who need to travel for a period of time that exceeds the amount of eligible take-home doses.

HABILITATION
The process by which an individual is assisted to acquire and maintain those life skills that enable the individual to cope more effectively with personal and environmental demands and to raise the level of the individual’s physical, mental and social efficiency (A.R.S. §36-551 (18)).

HOME
A residential dwelling that is owned, rented, leased, or occupied at no cost to the member, including a house, a mobile home, an apartment, or other similar shelter. A home is not a facility, a setting or an institution, or a portion of any of these, licensed or certified by a regulatory agency of the State as a defined in A.A.C. R9-28-101.

HOME AND COMMUNITY BASED SERVICES (HCBS)
Home and community-based services, as defined in A.R.S. §36-2931 and A.R.S. §36 2939.

INTEGRATED MEDICAL RECORD
A single document in which all of the medical information listed in Chapter 900 of the AMPM is recorded to facilitate the coordination and quality of care delivered by multiple providers serving a single patient in multiple locations and at varying times.

INTERDISCIPLINARY CARE
A meeting of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the member based on the most current information available.

INTERMEDIATE CARE FACILITY FOR PERSONS WITH INTELLECTUAL DISABILITIES (ICF/IID)
A facility that primarily provides health and rehabilitative services to persons with developmental disabilities that are above the service level of room and board or supervisory care services or personal care services as defined in section 36-401 but that are less intensive than skilled nursing services (A.R.S. §36-551 (28)).

JUVENILE PROBATION OFFICE (JPO)
An officer within the Arizona Department of Juvenile Corrections assigned to a juvenile upon release from a secure facility. Having close supervision and observation over juvenile’s who are ordered to participate in the intensive probation program including visual contact at least four times per week and weekly contact with the school, employer, community restitution agency or treatment program (A.R.S. §8-353).

KIDSCARE (TITLE XXI)
Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare program offers comprehensive medical, preventive, treatment services, and behavioral health care services statewide to eligible children under the age of 19, in households with income between 133% and 200% of the Federal Poverty Level (FPL).

MEDICAL PRACTITIONER
A physician, physician assistant or registered nurse practitioner.

MEDICARE MANAGED CARE PLAN
A managed care entity that has a Medicare Contract with CMS to provide services to Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or Medicare Prescription Drug Plan.

MULTI-SPECIALTY INTERDISCIPLINARY CLINIC (MSIC)
An established facility where specialists from multiple specialties meet with members and their families for the purpose of providing interdisciplinary services to treat members.

PARENTS/CARETAKER RELATIVES
Eligible individuals and families under Section 1931 of the Social Security Act, with household income levels at or below 100% of the Federal Poverty Level (FPL).

PEER-RUN ORGANIZATION
Peer-Operated Services that are:

1. Independent - Owned, administratively controlled, and managed by peers,
2. Autonomous - All decisions are made by the program,
3. Accountable - Responsibility for decisions rests with the program, and
4. Peer – controlled - Governance board is at least 51% peers.

PERFORMANCE BOND
A written promise by a Surety to pay AHCCCS (as the obligee) an amount specified in Contract and ACOM Policy 305, if the Contractor (as the principal), fails to meet the Contractor’s obligation under the Contract. A Performance Bond is also called a Surety Bond.

PERSON-CENTERED
An approach to planning designed to assist the member to plan their life and supports. This model enables individuals to increase their personal self-determination and improve their own independence.

PERSON WITH A DEVELOPMENTAL/ INTELLECTUAL DISABILITY
An individual who meets the Arizona definition as outlined in A.R.S. §36-551 and is determined eligible for services through the DES Division of Developmental Disabilities (DDD). Services for AHCCCS-enrolled acute and long term care members with developmental/intellectual disabilities are managed through the DES Division of Developmental Disabilities.

PRE-ADMISSION SCREENING (PAS)
A process of determining an individual’s risk of institutionalization at a NF or ICF level of care as specified in 9 A.A.C. 28 Article 1.

PREGNANT WOMEN
Eligible pregnant women, with income at or below 156% of the FPL.

PRESCRIPTION DRUG COVERAGE
Prescription medications prescribed by an AHCCCS registered qualified practitioner as a pharmacy benefit, based on medical necessity, and in compliance with Federal and state law including 42 U.S.C 1396r-8 and A.A.C. R9-22-209.

RAPID RESPONSE
A process in which, a behavioral health service provider is dispatched within 72 hours, to assess a child’s immediate behavioral health needs, and refer for further assessments through the behavioral health system when a child first enters into DCS custody.

RATE CODE
Eligibility classification for capitation payment purposes.

RISK GROUP
Grouping of rate codes that are paid at the same capitation rate.

ROSTER BILLING
Any claim that does not meet the standardized claim requirements of 9 A.A.C. 22, Article 7 is considered roster billing.

RURAL HEALTH CLINIC (RHC)
A clinic located in an area designated by the Bureau of Census as rural, and by the Secretary of the DHHS as medically underserved or having an insufficient number of physicians, which meets the requirements under 42 CFR 491.

SERIOUS MENTAL ILLNESS (SMI)
A designation as defined in A.R.S. §36-550 and determined in an individual 18 years of age or older.

SMI ELIGIBILITY DETERMINATION
A determination as to whether or not an individual meets the diagnostic and functional criteria established for the purpose of determining an individual’s eligibility for SMI services.

SPECIALIST SUPPORT AND REHABILITATION SERVICES PROVIDERS
Provide either a limited scope of Support and Rehabilitation Services (such as primarily specializing in respite services or skills training services) and/or services that may be designed for a specific population, age, gender, frequency, duration or some other factor (such as a service specializing in working with teenagers or those with a history of displaying harmful sexual behaviors).

STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP)
State Children’s Health Insurance Program under Title XXI of the Social Security Act (Also known as CHIP). The Arizona version of CHIP is referred to as “KidsCare.” See also “KIDSCARE.”

STATE ONLY TRANSPLANT MEMBERS
Individuals who are eligible under one of the Title XIX eligibility categories and found eligible for a transplant, but subsequently lose Title XIX eligibility under a category other than Adult Group due to excess income become eligible for one of two extended eligibility options as specified in A.R.S. §36-2907.10 and A.R.S. §36-2907.11.

SUBSTANCE ABUSE
As specified in A.A.C. R9-10-101, an individual’s misuse of alcohol or other drug or chemical that:

1. Alters the individual’s behavior or mental functioning;
2. Has the potential to cause the individual to be psychologically or physiologically     dependent on alcohol or other drug or chemical; and
3. Impairs, reduces, or destroys the individual’s social or economic functioning.

TITLE XXI
Title XXI of the Social Security Act provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low income children in an effective and efficient manner that is coordinated with other sources of child health benefits coverage.

TITLE XXI MEMBER
Member eligible for acute care services under Title XXI of the Social Security Act, referred to in Federal legislation as the “Children’s Health Insurance Program” (CHIP). The Arizona version of CHIP is referred to as “KidsCare.”

TREATMENT PLAN
A written plan of services and therapeutic interventions based on a complete assessment of a member's developmental and health status, strengths and needs that are designed and periodically updated by the multi-specialty, interdisciplinary team.

VIRTUAL CLINICS
Integrated services provided in community settings through the use of innovative strategies for care coordination such as Telemedicine, integrated medical records and virtual interdisciplinary treatment team meetings.

VULNERABLE ADULT
As defined in A.R.S. §46-451, an individual who is eighteen years of age or older and who is unable to protect themself from abuse, neglect, or exploitation by others because of a physical or mental impairment. Vulnerable adult includes an incapacitated person as defined in A.R.S. §14-5101.

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 COSTS

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

  1. 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;
  2. The reduction, suspension, or termination of a previously authorized service;
  3. The denial, in whole or in part, of payment for a service;
  4. The failure to provide services in a timely manner;
  5. The failure of the Health Plan to act within the established timeframes regarding the standard resolution of grievances and appeals;
  6. The denial of a member's request to obtain services outside the network; and/or
  7. The denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.

AFFILIATE

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.

AMENDMENT 

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?”

ATTACHMENT

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

BEST PRACTICES

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. 

CLAIM

A service billed under a fee-for-service arrangement.

COMMUNITY SERVICE AGENCY ("CSA")

An agency that is contracted directly by AzCH-CCP 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.

COMPLEX NEEDS

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.

CULTURAL COMPETENCY

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.

DELIVERABLES

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.

FORMULARY

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.

MATERIAL GAP

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.

MATERIAL OMISSION

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.

MAY

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.

MEDICAL INSTITUTION

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.

MEDICATIONS LIST

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.

MUST

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.

OUTREACH

Activities to identify and encourage Members or potential Members, who may be in need of, but not yet receiving physical or behavioral health services.

PAYOR

AzCH-CCP or another entity that is responsible for funding Covered Services to Members.

PAYOR CONTRACT

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.

PRIVILEGING

The process used to determine if credentialed clinicians are competent to perform certain treatment interventions, based on training, supervised practice, and/or competency testing.

PROFIT

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.

PROVIDER NETWORK

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.

PSYCHIATRIST

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.

SAMHSA

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.

SHALL

Something is mandatory.

SHOULD

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.

SMI MEMBER

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.

SPECIALTY ASSESSMENT

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.

SPECIALTY/SUB-SPECIALITY PROVIDER

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.

STEP THERAPY

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.

SUPPORT SERVICES

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).

VITAL MATERIALS

Written materials that are critical to obtaining services which include, at a minimum, the following:

  1. Member Handbooks
  2. Provider Directories
  3. Consent Forms
  4. Appeal and Grievance Notices,
  5. 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.

Acronym Definition
A.A.C.  Arizona Administrative Code
AAR  Arizona Administrative Register
ACOM  Arizona Healthcare Cost Containment System Contractor Operational Manual
ACT  Assertive Community Treatment
ADA  Americans with Disabilities Act
ADOE  Arizona Department of Education
ADES or DES  Arizona Department of Economic Security
ADES/DDD or DDD  Arizona Department of Economic Security, Division of Developmental Disabilities
ADES/RSA or RSA  Arizona Department of Economic Security, Rehabilitation Services Administration
ADHS  Arizona Department of Health Services 
ADJC  Arizona Department of Juvenile Correction
ADOC  Arizona Department of Corrections
ADOH  Arizona Department of Housing
AHCCCS  Arizona Healthcare Cost Containment System
AIHP  American Indian Health Program
ALTCS  Arizona Long Term Care System
AMPM  Arizona Healthcare Cost Containment System Medical Policy Manual
AOC  Administrative Office of the Courts of the Supreme Court
A.R.S.  Arizona Revised Statutes
ASAM  American Society of Addiction Medicine
ASAM PPC  American Society of Addiction Medicine Patient Placement Criteria
ASDB  Arizona State Schools for the Deaf and Blind
AzSH  Arizona State Hospital
ASIIS  Arizona State Immunization Information System
AzEIP  Arizona Early Intervention Program
BHP  Behavioral Health Professional
CAP  Corrective Action Plan
CFR  Code of Federal Regulations
CFT  Child and Family Team
CLAS  National Culturally Linguistically and Appropriate Service Standards
CLIA  Clinical Laboratory Improvement Amendments
CMDP  Comprehensive Medical and Dental Plan
CMS  Centers for Medicare and Medicaid Services
CPHQ  Certified Professional in Healthcare Quality
CRS  Children’s Rehabilitative Services
DASIS  Drug and Alcohol Services Information System
DBHS  Division of Behavioral Health Services
DCS  Department of Child Safety
DHHS or HHS  U.S. Department of Health and Human Services
DME  Durable Medical Equipment
DSM  Diagnostic and Statistical Manual of International Classification of Disorders
EHR  Electronic Health Records
EPLS  Excluded Provider List System
EPSDT  Early Periodic Screening Diagnostic and Treatment Service
F.I.R.S.T.  Families in Recovery Succeeding Together
FQHC  Federally Qualified Health Centers
FTP  File Transfer Protocol
GME  Graduate Medical Education
GMH  General Mental Health Adults
GSA  Geographical Service Area
HCAC  Heath Care Acquired Condition
HCTC  Home Care Training to Home Care Client
HIE  Health Information Exchange
HIPAA  Health Insurance Portability and Accountability Act
HITECH  Health Information Technology for Economic and Clinical Health Act
HMIS  Homeless Management Information System
HRC  Human Rights Committee
HUD  Housing and Urban Development
IAD  Incident, Accident and Death
ICT  Integrated Care Team
IDEA  Individuals with Disabilities Education Act
IEP  Individual Education Plan
IGA  Intergovernmental Agreement
IHS  Indian Health Services
IMD  Institution for Mental Disease
ISA  Interagency Service Agreement
ISP  Individual Service Plan
IVR  Interactive Voice Response
LEIE  List of Excluded Individuals/Entities
LEP  Limited English Proficiency
MAP  Medicare Advantage Plan
MAPDP  Medicare Advantage Prescription Drug Plan
MCO  Managed Care Organization
MHBG  Mental Health Block Grant
MIS  Management Information System
MM/UM  Medical Management/Utilization Management
MPS  Minimum Performance Standard
MRPDL  AHCCCS Minimum Required Prescription Drug List
NOMS  National Outcome Measures
NPI  National Provider Identifier
OHR  Office of Human Rights
OIG  Office of Inspector General
OMB  Office of Management and Budget
OPI  Office Program Integrity
OPPC  Other Provider-Provider Condition
NON-MED  Non-Medical Expense Deduction Member
PASRR   Pre-Admission Screening and Resident Review
PATH  Project for Assistance in Transition from Homelessness
PCP  Primary Care Provider
PDSA  Plan Do Study Act
PHA  Public Housing Authorities
PIP   Performance Improvement Plan,  Process or Projects
PMMIS  AHCCCS Prepaid Medical Management Information System
PPS  Prospective Payment System
QIO  Quality Improvement Organizations
QM  Quality Management
QOC  Quality of Care Concern
RBHA/MCO/Health Plan  Regional Behavioral Health Authority/Managed Care Organization/Health Plan
RFP  Request for Proposal
SAMHSA  Substance Abuse and Mental Health Services Administration
SABG  Substance Abuse Block Grant
SCHIP  State Children's Health Insurance Program
SED  Serious Emotional Disturbance
SMI  Serious Mental Illness
SNF  Skilled Nursing Facility
SOBRA  Sixth Omnibus Budget and Reconciliation Act of 1986,  amended by the Medicare Catastrophic Coverage Act of 1988
SSI  Supplemental Security Income
SSI-MAO  Social Security Income Management Administration Office
TANF  Temporary Assistance to Needy Families
TDD  Telecommunications Device for the Deaf
TRBHA  Tribal Regional Behavioral Health Authority
VFC  Vaccine for Children
ZIP  Zone Improvement Plan