COVERED SERVICES AND RELATED PROGRAM REQUIREMENTS
Arizona Health Care Cost Containment System (AHCCCS) has developed a comprehensive array of covered health services to meet the individual needs of eligible persons. Covered services assist and encourage each person to achieve and maintain the highest possible level of health and self-sufficiency. The type of service covered is contingent on each person’s current eligibility status and, for some persons, is based on available funding. All health services are required to be medically necessary, based upon the needs of the person. Providers are required to operate within their scope of practice.
The AHCCCS Medical Policy Manual and the AHCCCS Covered Behavioral Health Services Guide contain information regarding each of the covered services that are available through the publicly funded health care system including: a definition of each service; the requirements of individuals or agencies providing the service; and any limitations to using or billing for the service. Providers must deliver covered services in accordance with the AHCCCS Medical Policy Manual, the AHCCCS Covered Behavioral Health Services Guide, the AHCCCS Policy and Procedures Manual, The Health Plan Policies and Procedures, the AHCCCS Contractor Operations Manual, and the requirements of any other funding source (i.e., Medicare Advantage requirements for dual eligible Members).
2.1.1 Covered and Non-Covered Services
For covered medical benefits, details service descriptions, exclusions, limitations for physical and behavioral health services, refer to the AHCCCS Medical Policy Manual (AMPM):
AMPM Chapter 300 Medical Policies for Covered Services
AMPM Chapter 300, Exhibit 300-1, AHCCCS Covered Services Acute Care
AMPM Chapter 300, Exhibit 300-2A, AHCCCS Covered Services Behavioral Health
AMPM Chapter 300, Exhibit 300-2B, AHCCCS Covered Services Behavioral Health Non-Title XIX-XXI Persons
AMPM Chapter 300, 310-B - TITLE XIX/XXI Behavioral Health Service Benefit
AMPM Chapter 300, Exhibit 320-S, Behavioral Analysis Services
2.1.2 Eligibility Requirements
Providers must screen individuals for AHCCCS eligibility and, as applicable, assist individuals with applying for AHCCCS and/or enrolling in Medicare Part D Section 12.1 — Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage and the Limited Income Subsidy Program).
Services for Non-Title XIX/XXI persons determined to have a Serious Mental Illness (SMI) are subject to available funding, as appropriated by the Arizona Legislature. Tribal and Health Plans are required to verify that Non-Title XIX/XXI funding allocated by the State for each geographic service area is available for services throughout the fiscal year.
Decisions made with respect to the coverage and provision of services are subject to Section 8.5 — Notice and Appeal Requirements (SMI and GMH/SA Non-Title XIX/XXI).
Services must be provided in collaboration with other agencies to coordinate the culturally appropriate delivery of covered behavioral health services with other services provided to the person and the person’s family.
Covered behavioral health services may be available to family members of Title XIX/XXI eligible persons enrolled within a Tribal and/or Health Plan to the extent that services are provided in support of the treatment goals of the identified eligible or enrolled person.
Members and families are also eligible to receive services as described in
- AMPM Chapter 300, Exhibit 320-T1 Block Grants and Discretionary Grants (PDF)
AMPM Chapter 300, Exhibit 320-T2 Non-Title XIX XXI Services and Funding (Excluding Block Grants and Discretionary) (PDF)
2.1.3 Medicare Part D Prescription Drug Coverage
Persons eligible for Medicare Part D must access the Medicare Part D prescription drug coverage by enrolling with a Medicare Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug Plan (MA-PD).Persons eligible for both Medicare Part D and Title XIX/XXI (AHCCCS) will continue to have coverage of excluded Part D drugs such as prescription vitamin and minerals or certain over the counter drugs through Title XIX/XXI, if not included in the PDP or MA plans’ formulary.
Maternity care services include, but are not limited to, pregnancy identification through the submission of Provider Manual Form 2.3.2 Notification of Pregnancy form (can be obtained by calling the Provider Services Call Center at 866-796-0572), prenatal services, treatment of pregnancy related conditions, labor and delivery services, postpartum depression screening, and postpartum care. In addition, related services such as outreach and family planning services are provided (AHCCCS AMPM Policy 420 – Maternity Care Services), whenever appropriate, based on the member’s current eligibility and enrollment.
2.2.1 Maternity Care Provider Standards
Providers must confirm that members who are receiving physical health care services and who are pregnant have a designated maternity care provider for the duration of the Member’s pregnancy and postpartum care. AHCCCS AMPM Policy 410 (Maternity Care Services) provides detailed descriptions of maternity care requirements and expectations. Members have a choice to be assigned a Primary Care Provider that provides obstetrical care consistent with the freedom of choice requirements for selecting health care professionals so as not to compromise the Member's continuity of care. For anticipated low-risk deliveries, Members may elect to receive labor and delivery services in their home from their maternity provider and may also elect to receive prenatal care, labor and delivery, and postpartum care by certified nurse midwives or licensed midwives.
Members will receive up to 48 hours of inpatient hospital care after a routine vaginal delivery and up to 96 hours of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the member, may discharge the member prior to the minimum length of stay. According to American College of Obstetricians and Gynecologists guidelines, cesarean section deliveries must be medically necessary. Inductions and cesarean section deliveries prior to 39 weeks must be medically necessary. Cesarean sections and inductions performed prior to 39 weeks that are not found to be medically necessary based on nationally established criteria are not eligible for payment.
For Members receiving maternity services from a certified nurse midwife or a licensed midwife, The Health Plan will assign a Primary Care Provider (PCP) to provide other health care and medical services. A certified nurse midwife may provide those primary care services that they are willing to provide and that the Member elects to receive from the certified nurse midwife. Members receiving care from a certified nurse midwife may also elect to receive some or all of their primary care from the assigned PCP. Licensed midwives may not provide any additional medical services as primary care that are not within their scope of practice.
All physicians and certified nurse midwives who perform deliveries are required to have OB hospital privileges or a documented hospital coverage agreement for those practitioners performing deliveries in alternate settings. Licensed midwives perform deliveries only in the Member's home. Physicians, certified nurse practitioners, and certified nurse midwives within the scope of their practice may provide labor and delivery services in the Member's home.
Upon identification of Member pregnancy, all Maternity Care Providers are required to submit the Provider Manual Form 2.3.2 Notification of Pregnancy Form (NOP) (can be obtained by calling the Provider Services Call Center at 866-796-0542) and coordinate care with the member’s Health Care Coordinator and behavioral health treatment team throughout the pregnancy, delivery and postpartum treatment. This includes identified difficulties with navigating the health care system, evidenced by missed visits, transportation difficulties, or other perceived barriers. Particular attention should be given to the screening, assessment and treatment of perinatal mood disorders, to include post-partum depression.
Members who transition to a new Contractor or become enrolled during their third trimester must be allowed to complete maternity care with their current AHCCCS-registered provider, regardless of contractual status, to ensure continuity of care. Inform newly-assigned Members and those currently under the care of a non-network provider, that they have the opportunity to change Contractors to ensure continuity of prenatal care.
2.2.2 General Obstetrical Standards of Care
All providers must follow the American College of Obstetrics and Gynecology (ACOG) standards of care, which include, but are not limited to the following:
- Use of a standardized prenatal medical record and risk assessment tool, such as the ACOG Form, documenting all aspects of maternity care.
- Completion of history including medical and personal health (including infections and exposures), menstrual cycles, past pregnancies and outcomes, family and genetic history.
- Clinical expected date of confinement.
- Performance of physical exam (including determination and documentation of pelvic adequacy).
- Performance of laboratory tests at recommended time intervals.
- Comprehensive risk assessment incorporating psychosocial, nutritional, medical, and educational factors.
Routine prenatal visits with blood pressure, weight, fundal height (tape measurement), fetal heart tones, urine dipstick for protein and glucose, ongoing risk assessment with any change in pregnancy risk recorded and an appropriate management plan. Providers are required to screen all pregnant members through the Controlled Substances Prescription Monitoring Program (CSPMP) once a trimester, and for those members receiving opioids, appropriate intervention and counseling must be provided, including referral of members for behavioral health services as indicated for Substance Use Disorder (SUD) assessment and treatment.
In addition, providers must educate Members about healthy behaviors during pregnancy, including proper nutrition, effects of alcohol, drugs, prescription opioid use, tobacco cessation, the physiology of pregnancy, screening for sexually transmitted infections, the process of labor and delivery, breast feeding, dangers of lead exposure to mother and child, and other infant care information. Providers are also required to educate Members about elective deliveries prior to 39 weeks and/or Cesarean-sections (C-Sections) unless medically necessary; signs and symptoms of preterm labor; effects of smoking, diabetes, hypertension on pregnancy and/or fetus/infant; prenatal and postpartum visits. Providers are required to offer Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) testing and confidential post testing counseling to all Members. In the event where a member loses eligibility, the member must be notified where they may obtain low-cost or no-cost maternity services.
Health Plan Care Management Staff are available to assist providers with managing pregnant members with substance use disorders. The staff includes nurses with OB clinical expertise and social workers. They are available to assist providers with coordination of care and collaboration between the OBGYN and other providers. This can be done through the provision of education, providing support and resources to the member including behavioral health services, and alternative nutritional supplementation plans if the member is breastfeeding. Because many do not view prescription medications as a “substance,” it is important to engage in a face-to-face discussion about all types of substance use with a pregnant member and with all members of reproductive age even when the member does not report or denies use. An individualized plan of care should be developed using American College of Obstetrics and Gynecologists (ACOG) guidelines for each member identified with a history of Substance Use Disorder (SUD), including medication adjustment needs, evidenced-based breastfeeding recommendation and precautions, and Narcan prescription. It is also important that screening be done for additional health issued related to SUD, including Hepatitis C, as well as inquiring about any barriers to care. In preparation for delivery, it is important for providers to discuss pain management/pain treatment plan options with the member and offering Immediate Postpartum Long-Acting Reversible Contraception (IPLARC). For members with barriers to care, providers can contact the Health Plan Care Management staff to assist the member with a a plan of safe care prior to discharge including behavioral health services, alternative infant care, and alternative nutritional supplementation plans if the member is breastfeeding.
Perinatal and Postpartum depression screenings are conducted at least once during the pregnancy and then repeated at the postpartum visit with appropriate counseling and referral made if a positive screening is obtained.
2.2.3 Maternity Appointment Standards
Maternity care appointments for initial prenatal care for pregnant SMI Members:
- First trimester: within fourteen (14) calendar days of request;
- Second trimester: within seven (7) calendar days of request;
- Third trimester: within three (3) business days of request; and
- High risk pregnancies as expeditiously as the member’s health condition requires and no later than three (3) business days of identification of high risk by the contractor or maternity care provider, or immediately if an emergency exists.
A normal newborn may be granted an extended stay in the hospital of birth when the mother’s continued stay in the hospital is beyond the 48 or 96 hour stay. However, for payment purposes, inpatient limits will apply to the extent consistent with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).
The newborn may be covered under The Health Plan. Prior to the birth of the baby, the mother will be asked to select a PCP for the newborn. The newborn is assigned to the pre-selected PCP after delivery. The mother may elect to change the assigned PCP at any time.
2.2.5 Special Policies
Covered related services with special policy and procedural guidelines include, but are not limited to:
- Routine circumcision of newborn male infants, which is not a covered service unless it is determined to be medically necessary (ARS 36-2907(b));
- Inpatient hospital stays;
- Home uterine monitoring - Medically necessary home uterine monitoring technology for members with premature labor contractions before 35 weeks gestation, as an alternative to hospitalization, is a covered benefit;
- Labor and delivery services provided in freestanding birthing centers;
- Services rendered in a freestanding birthing center must be provided by a physician (the member’s primary care physician (PCP) or obstetrician with hospital admitting privileges) or by a registered nurse midwife who is accredited/certified by the American College of Nurse Midwives and has hospital admitting privileges for labor and delivery services;
- Only members for whom an uncomplicated prenatal course and a low-risk labor and delivery can be anticipated may be scheduled to deliver at a freestanding birthing center
- Labor and delivery services provided in a home setting:
- Only members with an anticipated uncomplicated prenatal course and a low-risk labor and delivery should deliver in the member’s home, and
- Physicians and practitioners who render home labor and delivery services must have admitting privileges at an acute care hospital in close proximity to the site where the services are provided in the event of complications during labor and/or delivery.
2.3.6 Licensed Midwife Services
Licensed midwife services may only be provided to members for whom an uncomplicated prenatal course and a low-risk labor and delivery is anticipated. The age of the member must be included as a consideration in the risk status evaluation;
Labor and delivery services provided by a licensed midwife cannot be provided in a hospital or other licensed health care institution
2.2.7 Medical Food
The Health Plan covers medical foods when medically necessary for members diagnosed with one of the following inherited metabolic conditions:
- maple syrup urine disease
- galactosemia (requires soy formula)
- beta keto-thiolase deficiency
- glutaric acidemia type I
- 3 methylcrotonyl CoA carboxylase deficiency
- isovaleric acidemia
- methylmalonic acidemia
- propionic acidemia
- arginosuccinic acidemia
- tyrosinemia type I
- HMG CoA lyase deficiency
- cobalamin A, B, C deficiencies
Medical foods are metabolic formula or modified low- protein foods produced or manufactured specifically for persons with a qualifying metabolic disorder and are not generally used by persons in the absence of a qualifying metabolic disorder. Soy formula is covered for members receiving Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and KidsCare members diagnosed with galactosemia and only until they are able to eat solid lactose-free foods.
Upon completion of the member’s initial consultation with a genetics physician and metabolic nutritionist, and the determination that metabolic formula and/or low-protein foods are necessary to meet the member’s nutritional needs, providers forward the request for metabolic nutrition to the Health Plan’s Prior Authorization unit for review and processing. All approvals and payments for medical foods are the responsibility of The Health Plan.
2.2.8 Neonate Transfers Between Acute Care Facilities
Acutely ill neonates may be transferred from one acute care center to another, given certain conditions. The chart that follows provides the levels of care, conditions appropriate for transfer, and criteria for transfer.
Refer to the below table for neonatal care:
Neonatel care table (image)
2.2.9 High Risk Maternity and Perinatal Care Management
The Health Plan Integrated Care Managers, together with providers, identify pregnant members who are at risk for adverse pregnancy outcomes. The Health Plan assists providers in managing the care of at risk pregnant Members due to medical conditions, social determinants, severe mental illness or non-compliant behaviors. The Health Plan evaluates At Risk Members for ongoing follow up during their pregnancy.
The Health Plan’s perinatal care management provides comprehensive care management services to high risk pregnant Members, for the purpose of improving maternal and fetal birth outcomes. The perinatal care management team consists of a social worker, care management associates, and professional registered nurses skilled in working with the unique needs of high risk pregnant members. Perinatal Integrated Care Managers take a collaborative approach in working with Behavioral Health Home Health Care Coordinators and PCPs and OB/GYNs to engage high risk pregnant Members throughout their pregnancy and post-partum period. Members who present with high risk perinatal conditions should be referred to perinatal care management. These conditions include:
- A history of preterm labor before 37 weeks of gestation;
- Bleeding and blood clotting disorders;
- Chronic medical conditions;
- Polyhydramnios or oligohydramnios;
- Placenta previa, abruption or accreta;
- Cervical changes;
- Multiple gestation;
- Teenage mothers;
- Poor weight gain;
- Advanced maternal age;
- Substance abuse;
- Prescribed psychotropic drugs;
- Domestic violence; and
- Non-adherence with Obstetrics appointments.
2.2.10 Reporting High Risk and Non-Adherent Behaviors in Pregnant Members
Behavioral Health Home Health Care Coordinators, obstetrical physicians and practitioners must refer all “at risk” pregnant Members to The Health Plan. The following types of situations must be reported to The Health Plan for Members that:
- Are diabetic and display consistent complacency regarding dietary control and/or use of insulin.
- Fail to follow prescribed bed rest.
- Fail to take tocolytics as prescribed or do not follow home uterine monitoring schedules.
- Admit to or demonstrate continued alcohol and/or other substance abuse disorder.
- Show a lack of resources that could influence well-being (e.g. food, shelter, and clothing).
- Frequently visit the emergency department/urgent care setting with complaints of acute pain and request prescriptions for controlled analgesics and/or mood altering drugs.
- Fail to appear for two or more prenatal visits without rescheduling and fail to keep rescheduled appointment. Providers are expected to make two attempts to bring the member in for care prior to contacting The Health Plan.
2.2.11 Outreach, Education and Community Resources for Pregnant Members
The Health Plan is committed to maternity care outreach. Maternity care outreach is an effort to identify currently enrolled pregnant individuals and to enter them into prenatal care as soon as possible, but no later than within the first trimester or 42 days after enrollment. Behavioral Health Home Health Care Coordinators, PCPs, OB/GYNs and other treating providers are expected to ask about pregnancy status when Members call for appointments, to report positive pregnancy tests to The Health Plan through submission of Provider Manual Form 2.3.2 Notification of Pregnancy form (NOP), (can be obtained by calling the Provider Services Call Center at 866-796-0542) and to provide general education and information about prenatal care, when appropriate, during Member office visits.
The Health Plan is involved in many community efforts to increase the awareness of the need for prenatal care. PCPs are strongly encouraged to actively participate in these outreach and education activities, including the Women, Infants and Children (WIC) Nutritional Program. Please encourage Members to enroll in this program in order to support healthy pregnancy outcomes. Various other services are available in the community to help pregnant individuals and their families. Please call The Health Plan for information about how to help your patients use these services.
Questions regarding the availability of community resources may also be directed to the Arizona Health Care Cost Containment System (AHCCCS) Hot Line at 800-833-4642.
2.2.12 Loss of AHCCCS Coverage During Pregnancy
Members may lose AHCCCS eligibility during pregnancy. Although Members are responsible for maintaining their own eligibility, providers are encouraged to notify The Health Plan if they are aware that a pregnant Member is about to lose or has lost eligibility. The Health Plan Member Services can assist in coordinating or resolving eligibility and enrollment issues so that pregnancy care may continue without a lapse in coverage. Please call Member Services at 888-788-4408 to report eligibility changes for pregnant Members.
The Health Plan covers family planning services in accordance with the AHCCCS AMPM Policy 420 (Family Planning) for all Members who choose to delay or prevent pregnancy. Services include, but are not limited to, contraceptive counseling, medication and supplies (such as oral and injectable contraceptives, Long-Acting Reversible Contraceptives, subdermal implantable contraceptives, intrauterine devices, diaphragms, condoms, foams and suppositories), medical and laboratory examinations, treatment of complications resulting from contraceptive use (including emergency treatment), natural family planning education and referrals to health professionals, and post-coital emergency oral contraception within 72 hours after unprotected sexual intercourse (RU 486 is not a post-coital emergency oral contraception). Screening and treatment for Sexually Transmitted Infections are covered services for all Members.
Family planning services do not include infertility services, pregnancy termination counseling, pregnancy terminations, or hysterectomies.
2.3.1 Requirements for Providing Family Planning Services
Providers are required to collaborate with The Health Plan to implement effective family planning services which includes:
- Notifying Members of reproductive age of the specific covered family planning services available and how to request them. Notification must be in accordance with ARS § 36.2904(L). The information provided to Members should include, but is not limited to:
- A complete description of covered family planning services available;
- Information advising how to request/obtain these services;
- Information that assistance with scheduling is available; and
- A statement that there is no charge for these services.
- Provide family planning services that are:
- Provided in a manner free from coercion or behavioral/mental pressure;
- Available and easily accessible to Members;
- Provided in a manner which assures continuity and confidentiality;
- Provided by, or under the direction of, a qualified physician or practitioner; and
- Documented in the medical record. In addition, documentation must be recorded that each Member of reproductive age was notified verbally or in writing of the availability of family planning.
- Provide translation/interpretation of information related to family planning in accordance with the requirements of the cultural competency policy. (See Section 9.2— Cultural Competence).
- Have a process for ensuring prior to insertion of intrauterine and subdermal implantable contraceptives, the family planning provider has provided proper counseling to the eligible Member to minimize the likelihood of a request for early removal. Counseling information is to include a statement to the Member indicating if the implant is removed within two years of insertion, the Member may not be an appropriate candidate for reinsertion for at least one year after removal.
- Establish procedures for referral of those Members who may lose AHCCCS eligibility to low-cost/no-cost agencies for family planning services.
In addition, providers are responsible for the following:
- Making appropriate referrals to health professionals who provide family planning services.
- Keeping complete medical records regarding referrals.
- Verifying and documenting a Member’s willingness to receive family planning services.
- Providing medically necessary management of Members with family planning complications.
- Notifying Members of available contraceptive services and making these services available to all Members of reproductive age using the following guidelines:
- Information for Members between 12 and 55 years of age must be provided directly to the Member or legal guardian. Whenever possible, contraceptive services should be offered in a broad-spectrum counseling context, which includes discussion of mental health and sexually transmitted diseases, including HIV/AIDS.
- Members of any age whose sexual behavior exposes them to possible conception or Sexually Transmitted Diseases (STDs) should have access to the most effective methods of contraception.
- Every effort should be made to include partners in such services.
- Providing counseling and education to Members of all genders that is age appropriate and includes information on prevention of unplanned pregnancies.
- Counseling should include the following:
- The Member’s short- and long- term goals;
- Spacing of births to promote better outcomes for future pregnancies; and
- Preconception counseling to assist Members in deciding on the advisability and timing of pregnancy, to assess risks and to reinforce habits that promote a healthy pregnancy.
- Sexually transmitted diseases, to include methods of prevention, abstinence, and changes in sexual behavior and lifestyle that promote the development of good health habits.
Contraceptives should be recommended and prescribed for sexually active Members. Providers are required to discuss the availability of family planning services annually. If a Member’s sexual activity presents a risk or potential risk, the provider should initiate an in-depth discussion on the variety of contraceptives available and their use and effectiveness in preventing sexually transmitted diseases (including AIDS). Such discussions must be documented in the Member’s medical record.
The Health Plan requires all participating providers to comply with the informed consent forms and procedures for sterilization as specified in the AHCCCS Specifications Manual (42 CFR Part 441, Sub-part B). The following criteria must be met for consent:
- The Member is at least 21 years of age at the time the consent is signed.
- For Members under the age of 21, the provider must be able to demonstrate medical necessity for the procedure with supporting documentation including Prior Authorization. The medical necessity prior authorization and supporting documentation must be submitted to AHCCCS with the Monthly Sterilization Report;
- Mental competency is determined;
- Voluntary consent was obtained without coercion; and
- Thirty (30) days, but not more than 180 days, have passed between the date of informed consent and the date of sterilization, except in the case of a premature delivery or emergency abdominal surgery. Members may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since they gave informed consent for the sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.
Any Member requesting sterilization must sign an AHCCCS AMPM, Chapter 400, Exhibit 420 Attachment A, (AHCCCS Consent to Sterilization Form Attachment A), with a witness present when the consent is obtained. Suitable arrangements must be made to ensure that the information in the consent form is effectively communicated to Members with limited English proficiency or reading skills and those with diverse cultural and ethnic backgrounds, as well as Members with visual and/or auditory limitations. Prior to signing the consent form, a Member must first have been offered factual information that includes all of the following:
- Consent form requirements;
- Answers to questions asked regarding the specific procedure to be performed;
- Notification that withdrawal of consent can occur at any time prior to surgery without affecting future care and/or loss of federally funded program benefits; A description of available alternative methods;
- Advice that the sterilization procedure is considered to be irreversible,
- A thorough explanation of the specific sterilization procedure to be performed,
- A description of available alternative methods
- A full description of the discomforts and risks that may accompany or follow the performing of the procedure, including an explanation of the type and possible effects of any anesthetic to be used;
- A full description of the advantages or disadvantages that may be expected as a result of the sterilization; and
- Notification that sterilization cannot be performed for at least 30 days post consent.
Sterilization consents may NOT be obtained when a Member:
- Is in labor or childbirth;
- Is seeking to obtain, or is obtaining, a pregnancy termination; or
- Is under the influence of alcohol or other substances that affect the Member’s state of awareness.
The Health Plan submits a Monthly Sterilization Report to AHCCCS which documents the number of sterilizations performed for all Members under the age of 21 years of age during the month. If no sterilizations were performed for Members under the age of 21 years of age during the month, the monthly report must still be submitted to attest to that information.
Hysteroscopic tubal sterilization is not immediately effective upon insertion of the sterilization device. It is expected that the procedure will be an effective sterilization procedure three months following insertion. At the end of the three months, confirmatory testing, a hysterosalpingogram, will be performed confirming that the Member is sterile and reported on the monthly sterilization report.
2.3.3 Medically Necessary Pregnancy Termination for Title XIX/XXI Adults With SMI
Prior authorization is required for pregnancy termination except in emergency situations where the life of the mother is threatened. In these situations, authorization may be sought post procedure. Prior authorization must be obtained before the services are rendered or the services will not be eligible for reimbursement. Pregnancy termination services are covered when one of the following occurs:
- The pregnant member suffers from a physical disorder, physical injury, or physical illness including a life-endangering physical condition caused by, or arising from, the pregnancy itself that would, as certified by a physician, place the member in danger of death unless the pregnancy is terminated.
- The pregnancy is a result of incest;
- The pregnancy is a result of rape; or
- The pregnancy termination is medically necessary according to the medical judgment of a licensed physician, who attests that continuation of the pregnancy could reasonably be expected to pose a serious physical or mental health problem for the pregnant Member by:
- Creating a serious physical or mental health problem for the pregnant Member;
- Seriously impairing a bodily function of the pregnant Member;
- Causing dysfunction of a bodily organ or part of the pregnant Member;
- Exacerbating a health problem of the pregnant Member; or
- Preventing the pregnant Member from obtaining treatment for a health problem.
For medical necessary pregnancy terminations, providers must submit AHCCCS AMPM Chapter 410 Attachment D – (AHCCCS Verification of Diagnosis by Contractor for a Pregnancy Termination Request) to The Health Plan Medical Director including a written explanation describing why the procedure is medically necessary, a copy of the Member’s medical record and written informed consent from the Member. The provider is required to obtain the written informed consent and retain it in the Member’s medical record for all pregnancy terminations. For pregnant Members younger than 18 years of age, or those 18 or older and considered incapacitated, providers must secure a dated signature of the pregnant Member's parent or legal guardian or a certified copy of a court order indicating approval of the pregnancy termination procedure.
In addition, if the pregnancy termination is requested as a result of incest or rape, providers must include identification of the proper authority to which the incident was reported. This must include the name of the agency, the report number, and the date that the report was filed.
Additional Considerations Related to the Use of Mifepristone
Mifepristone (also known as Mifeprex or RU-486) is not a post-coital emergency oral contraceptive. The administration of Mifepristone, for the purposes of inducing intrauterine pregnancy termination, is covered by AHCCCS when a minimum of one AHCCCS required criterion is met for pregnancy termination, as well as conditions specific to Mifepristone, see AHCCCS AMPM Chapter 400 (Medical Policy for Maternal and Child Health) for additional criteria. When it is administered, the following documentation is also required: duration of pregnancy in days, the date Intrauterine Device (IUD) was removed if the Member had one, the date Mifepristone was give, , and documentation that pregnancy termination occurred.
2.3.4 Prior Authorization Requirements for Sterilization and Pregnancy Termination.
Prior authorization is required for sterilization of Members under the age of 21 or pregnancy termination. Prior authorization must be obtained before the services are rendered or the services will not be eligible for reimbursement.
To obtain authorization for sterilization, complete the applicable forms:
- For sterilization: AHCCCS AMPM, Chapter 400, Exhibit 420-A (Consent for Sterilization Form) and AHCCCS AMPM, Chapter 800, Exhibit 820-1 (Hysterectomy Consent and Acknowledgement Form)
To obtain authorization for pregnancy termination, except in cases of medical emergencies, the provider shall obtain a Prior Authorization from The Health Plan Medical Director. A completed AHCCCS AMPM Section 410 Attachment C (Certificate of Necessity for Pregnancy Termination) and the AHCCCS AMPM Section 410 Attachment D (Verification of Diagnosis by Contractor for Pregnancy Termination Request) forms shall be submitted with the request for Prior Authorization, along with the lab, radiology, consultation or other testing results that support the justification/necessity for pregnancy termination. The Health Plan Medical Director or designee will review the Prior Authorization request and supporting documentation and expeditiously authorize the procedure, if the documentation meets the criteria for justification of pregnancy termination.
In cases of medical emergency, the provider must submit all documentation of medical necessity to The Health Plan within two working days of the date on which the pregnancy termination procedure was performed.
For pregnancy termination: A completed AHCCCS AMPM Section 410 Attachment C (Certificate of Necessity for Pregnancy Termination) is required.
2.3.5 Annual Preventative Care
An annual preventive care visit is intended for the identification of risk factors for disease, identification of existing medical/mental health problems, and promotion of healthy lifestyle habits essential to reducing or preventing risk factors for various disease processes. An annual well-person preventative care visit is a covered benefit for members to obtain the recommended preventive services, including preconception counseling. Providers are responsible for having a process to inform members about preventative health services annually and within 30 days of enrollment for newly enrolled members. The information must be provided in a second language, in addition to English, in accordance with the requirements of the AHCCCS Division of Health Care Management (DHCM) “Cultural Competency” policy available in the AHCCCS ACOM Section 405.
As such, the annual preventative care visit is inclusive of a minimum of the following:
- A physical exam (well exam) that assesses overall health;
- Clinical breast exam (if/as necessary);
- Pelvic exam (if/as necessary, according to current recommendations and best standards of practice);
- Review and administration of immunizations, screenings and testing as appropriate for age and risk factors. NOTE: Genetic screening and testing is not covered;
- Screening and counseling is included as part of the well-person preventive visit and is focused on maintaining a healthy lifestyle and minimizing health risks. Screening and counseling addresses at a minimum the following:
- Proper nutrition;
- Physical activity;
- Elevated BMI indicative of obesity;
- Tobacco/substance use, abuse, and/or dependency;
- Depression screening;
- Interpersonal and domestic violence screening that includes counseling involving elicitation of information from members of all ages about current/past violence and abuse, in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems;
- Sexually transmitted infections;
- Human Immunodeficiency Virus (HIV); and
- Family planning counseling.
- Preconception counseling that includes discussion regarding a healthy lifestyle before and between pregnancies that includes:
- Reproductive history and sexual practices;
- Healthy weight, including diet and nutrition, as well as the use of nutritional supplements and folic acid intake;
- Physical activity or exercise;
- Oral health care;
- Chronic disease management;
- Emotional wellness;
- Tobacco and substance use (caffeine, alcohol, marijuana and Other drugs), including prescription drug us; and
- Recommended intervals between pregnancies;
NOTE: Preconception counseling does not include genetic testing.
- Initiation of necessary referrals when the need for further evaluation, diagnosis, and/or treatment is identified;
- Immunizations – The Health Plan will cover the Human Papilloma Virus (HPV) vaccine for members 11 to 26 years of age. Providers must coordinate with The Arizona Department of Health Services (ADHS) Vaccines for Children (VFC) Program in the delivery of immunization services if providing vaccinations to Early and Periodic Screening, Diagnostic and Treatment (EPSDT) aged members less than 19 years of age. Immunizations must be provided according to the Advisory Committee on Immunization Practices Recommended Schedule.
Refer to the CDC website at www.cdc.gov/vaccines/schedules/index.html where this information is included.
Providers must enroll and re-enroll annually with the VFC program, in accordance with AHCCCS contract requirements in providing immunizations for EPSDT aged members less than 19 years of age, and must document each EPSDT age member’s immunizations in the Arizona State Immunization Information System (ASIIS) registry. The VFC program must be used for members under 19 years of age.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and behavioral/mental health conditions for AHCCCS members under 21 years of age. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid members in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health conditions for AHCCCS members under 21 years of age. 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 USC 1396d (a) to correct or ameliorate defects and physical and behavioral/mental illnesses and conditions identified in an EPSDT screening, whether or not the services are covered under the AHCCCS State Plan. Members receiving EPSDT and Oral Health services through the RBHA are only covered for members 18 up to 21 years of age. All members age out of Oral Health & EPSDT services at age 21. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.
A well child visit is synonymous with an EPSDT visit. EPSDT services include all screenings and services described below, as well as the referenced AHCCCS EPSDT Periodicity Schedule (AMPM Chapter 430, Attachment A) and the AHCCCS Dental Periodicity Schedule, (AHCCCS AMPM, Chapter 431, Attachment A).
2.4.1 EPSDT Coverage
EPSDT coverage includes the following:
- Blood Lead Screening;
- Covered Services (refer to AHCCCS AMPM, Chapter 310 for detailed coverage);
- Metabolic Medical Foods;
- Nutritional Therapy;
- Oral Health Services;
- Cochlear and Osseointegarted Implantation;
- Conscious Sedation;
- Behavioral Health Services;
- Religious Non-Medical health care Institution Services;
- Care Management Services;
- Chiropractic Services;
- Personal care;
- Incontinence Briefs;
- Medically Necessary therapies.
In addition, federal and State law govern the provision of EPSDT services for Members under the age of 21 years. The provider is responsible for providing these services to pregnant Members under the age of 21, unless the Member has selected an Obstetrics (OB) provider to serve as both the OB and Primary Care Provider. In that instance, the OB provider must provide EPSDT services to the pregnant Member.
EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, naturopathic services; nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical equipment; medical appliances; and medical supplies, orthotics, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also including a comprehensive history, developmental and behavioral health screenings, comprehensive unclothed physical examination, appropriate vision testing, hearing testing, laboratory tests, dental screenings and immunizations. However, EPSDT services do not include services that are experimental, that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions or treatments.
2.4.2 PCP EPSDT Regulatory Requirements
PCPs are required to comply with EPSDT regulatory requirements, including the following:
- Provide EPSDT services in accordance with Section 42 USC 1396d (a) and (r), 1396a (a) (43), 42 C.F.R. 441.50 et seq. and AHCCCS rules and policies;
- Providers must complete a Developmental screening (using an AHCCCS-approved developmental screening tool) for members ages 9, 18 and 30 months;
- Providers must complete the Autism Spectrum Disorder (ASD) Specific Developmental Screening at the 18 month and 24 month visits;
- Document immunizations within 30 days of administration of an immunization into the Arizona State Immunization Information System (ASIIS);
- Enroll every year in the Vaccines for Children (VFC) program;
- Providers must use and complete all applicable elements of the AHCCCS EPSDT Clinical Sample Templates as required by the AHCCCS AMPM, Chapter 430, Section A, (or an electronic equivalent that includes all components from the hard-copy form);
- AHCCCS EPSDT Clinical Sample Template located within the AHCCCS AMPM Chapter 430, Attachment E.
- Provide and document EPSDT screening services in accordance with the AHCCCS EPSDT and Dental Periodicity Schedules AHCCCS EPSDT Periodicity Schedule (AHCCCS AMPM, Chapter 430, Attachment A) and the Dental Periodicity Schedule (AHCCCS AMPM Chapter 431, Attachment A),
- Refer members for follow up, diagnosis and treatment, ensuring that treatment is initiated within 60 days of screening services;
- If appropriate, document in the medical record the member’s or legal guardian’s decision not to utilize EPSDT services or receive immunizations;
- Document a health database assessment on each EPSDT participant. The database must be interpreted by a physician or licensed health professional who is under the supervision of a physician, and provide health counseling/education at initial and follow up visits;
- Ensure all infants receive both the first and second newborn screening tests;
- Send copies of the completed EPSDT Clinical Sample Templates to the health plan’s Quality Management Department by secure fax at (844)266-5339;
- Providers must verify that Members receive EPSDT services in compliance with the AHCCCS EPSDT Periodicity Schedule (AHCCCS AMPM, Chapter 430, Attachment A) and the Dental Periodicity Schedule (AHCCCS AMPM Chapter 431, Attachment A), https://www.azahcccs.gov/shared/MedicalPolicyManual/;
- Schedule the next appointment at the time of the current office visit for children ages 24 months and younger;
- Claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier;
- Refer members to Children’s Rehabilitative Services (CRS) when they have conditions covered by the CRS program;
- Initiate and coordinate referrals to ALTCS, Audiology, DDD, Dental, Occupational Therapy, Physical Therapy, Speech, Developmental, behavioral health, Women, Infants and Children (WIC), the Arizona Early Intervention Program (AzEIP) and Head Start as necessary.
2.4.3 An EPSDT Well-Child Basic Elements
A Well-Child exam includes the following elements:
- Comprehensive health and developmental history, including growth and development screening 42 CFR 441.56(b)(1) which includes physical, nutritional, and behavioral health assessments;
- Developmental screening. Providers are required to complete a developmental screening (using an AHCCCS-approved developmental screening tool) for members during visits at ages 9, 18 and 30 months. However, any time there is a potential developmental concern, it is appropriate for providers to screen the member. Developmental survey items are part of each EPSDT visit so that if concerns are noted, a screening can be done;
- Autism Spectrum Disorder (ASD) Specific Develpmental Screening at the 18 month and 24 month visits;
- A comprehensive unclothed physical examination;
- Provide appropriate immunizations according to age and health history;
- Laboratory tests appropriate to age and risk for blood lead, tuberculosis skin testing, anemia testing and sickle cell trait;
- Health education, counseling, chronic disease self-management, counseling about child development, healthy lifestyles and accident and disease prevention;
- An oral health screening must be part of an EPSDT screening conducted by a Primary Care Provider; however, it does not replace the need for examination through direct referral to a Dentist;
- Fluoride varnish application as often as every three months between the ages of 6 months and 2 years of age, after the eruption of the first tooth (by providers who have completed training);
- Provide appropriate vision and hearing/speech testing;
- Nutritional Screening by a PCP;
- Nutritional Assessment by a PCP;
- Obesity screening using the body mass index (BMI) percentile for children (or weight-for-length percentile for members less than two years of age);Behavioral health screening, referrals and services;
- Tuberculin skin testing as appropriate to age and risk. Children at increased risk of Tuberculosis (TB) include those who have contact with persons;
- Confirmed or suspected as having TB,
- In jail or prison during the last five years,
- Living in a household with an HIV-infected person or the child is infected with HIV, and
- Traveling/emigrating from, or having significant contact with persons indigenous to, endemic countries.
- Provide Anticipatory Guidance;
- Vision exam appropriate to age, according to the AHCCCS EPSDT Periodicity Schedule; and
- Documentation of the member’s AHCCCS Identification number on the AHCCCS EPSDT Clinical Sample Templates or electronic medical record.
2.4.4 Sick Visit Performed in Addition to an EPSDT Visit
Billing of a “sick visit” (CPT Codes 99201-99215) at the same time as an EPSDT if a separately billable service if:
- An abnormality is encountered, or a preexisting problem is addressed in the process of performing an EPSDT service and the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service.
- The “sick visit” is documented on a separate note.
- History, Exam, and Medical Decision-Making components of the separate “sick visit” already performed during the course of an EPSDT visit are not to be considered when determining the level of the additional service (CPT Code 99201-99215). An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service, and which does not require additional work and the performance of the key components of a problem-oriented E/M service is included in the EPSDT visit and should not be reported.
- The current status (not history) of the abnormality or preexisting condition is the basis of determining medical necessity.
Modifier 25 must be added to the Office/Outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service.
2.4.5 Developmental Screening Tools
Primary care providers (PCPs) must be trained in the use and scoring of developmental screening tools. Training resources may be found at Arizona Department of Health Services website at www.azdhs.gov/
The following developmental screening tools are available for members at their 9, 18 and 30 month EPSDT visit:
- Ages and Stages Questionnaires™ Third Edition (ASQ) is a tool used to identify developmental delays in the first five years of a child’s life. The sooner a delay or disability is identified, the sooner a child can be connected with services and support that make a real difference. The tool is available online at www.agesandstages.com.
- The Modified Checklist for Autism in Toddlers Revised (M-CHAT-R) used only as a screening tool by a PCP, for members ages 18 and 24 months, to screen for autism when medically indicated. The tool is available online at www.m-chat.org.
- The Parents’ Evaluation of Developmental Status (PEDS) used for developmental screening of EPSDT members from birth to 8 years of age. The tool is available online at www.pedstest.com or www.forepath.org
An additional payment for use of screening tools is covered when the following criteria are met:
- The member’s EPSDT visit is at 9, 18, or 30 months;
- Prior to providing the service, the provider must complete the required training for the developmental screening tool being utilized and submit a copy of the training certificate to the Council for Affordable Quality Healthcare (CAQH). Providers must also submit to the Health Plan via fax to (855) 872-1858 or email to HEDIS_Operations@azcompletehealth.com.
- The code is appropriately billed using CPT-4 code 96110 and the “EP” modifier. Providers must retain copies of the completed tools in the member’s medical record and submit it to the health plan with the completed AHCCCS EPSDT Clinical Sample Templates.
- Only for the 9, 18, or 30 month screening may the “EP” modifier be added to the CPT-4 code 96110.
2.4.6 PCP Application of Fluoride Varnish
Physicians who have completed the AHCCCS required training may be reimbursed for fluoride varnish applications completed at the EPSDT visit.
Application of fluoride varnish may be billed separately from the EPSDT visit using CPT Code 99188. Fluoride varnish can be applied as often as every three months between the ages of 6 months and 2 years of age, after the eruption of the first tooth.
2.4.7 Blood Lead Screening
- EPSDT requires blood lead screening for all members at 12 months and 24 months of age and for those members between the ages of 24 and 72 months who have not been previously tested or who missed either the 12-month or 24-month test.
- Lead levels may be measured at times other than those specified if thought to be medically indicated by the provider, by responses to a lead poisoning verbal risk assessment, or in response to parental concerns.
- Additional Screening for children under six year of age is based on the child’s risk as determined by either the member’s residential zip code or presence of other known risk-factors.
- Providers must report blood lead levels equal to or greater than ten micrograms of lead per deciliter of whole blood to ADHS (A.A.C. R9-4-302).
2.4.8 Missed/No-Show EPSDT Appointments
Providers are expected to follow up with members who miss or no-show their EPSDT appointments and notify the health plan when a member has missed or cancelled three or more visits. Providers may utilize the health plan’s Missed/No-Show Log. Providers are encouraged to use the recall system in order to reduce the number of missed or cancelled appointments.
2.4.9 Arizona Early Intervention
AHCCCS and AzEIP jointly developed procedures for the coordination of services under Early Periodic Screening, Diagnostic and Treatment (EPSDT) and AzEIP to ensure the coordination and provision of EPSDT and AzEIP services.
When concerns about a child’s development are initially identified by the child’s primary care physician (PCP), the PCP requests an evaluation and, if medically necessary, approval of services from the health plan.
Evaluation/Services: The Health Plan may pend approval for services until the evaluation has been completed by the provider and may deny services if the PCP determines there is no medical need for services based on the results of the evaluation.
- Requests for services from PCPs, licensed providers or the AzEIP service coordinator based on the Individual Family Service Plan (IFSP) must be reviewed for medical necessity prior to authorization and reimbursement.
- If services are approved, The Health Plan authorizes the services with The Health Plan
- participating provider, whenever possible, and notifies the PCP (requesting provider if other than the PCP) that (a) the services are approved, and (b) identifies the provider that has been authorized, the frequency, duration, and the service begin and end dates.
- The Health Plan follows the Code of Federal Regulation 42 438.210 for completion of prior authorization requests.
The Health Plan provides a decision as expeditiously as the member’s health condition requires, but not later than 14 calendar days following the receipt of a standard authorization request, with a possible extension of up to 14 calendar days if the member or provider requests an extension or if The Health Plan justifies a need for additional information and the delay is in the member’s best interest.
In the event that a provider indicates or The Health Plan determines that using the standard time frame could seriously jeopardize the member’s life or health or ability to attain, maintain or regain maximum function, the health plan makes an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires no later than three business days following the receipt of the authorization request (date of receipt of request), with a possible extension of up to 14 calendar days if the member or provider requests an extension or if the health plan justifies a need for additional information and the delay is in the member’s best interest.
Referral to AzEIP: After completing the evaluation, the provider who conducted the evaluation submits an evaluation report to the PCP (requesting provider if other than the PCP) and the Health Plan’s Prior Authorization Department for authorization of medically necessary services.
If the evaluation indicates that the child scored two standard deviations below the mean, which generally translates to AzEIP’s eligibility criteria of 50 percent developmental delay, the child continues to receive all medically necessary EPSDT covered services through the health plan. The health plan’s EPSDT Coordinator refers the child to AzEIP for non-medically necessary services that are not covered by Medicaid, but are covered under IDEA Part C. If the evaluation report indicates that the child does not have a 50 percent developmental delay, the EPSDT Specialist continues to coordinate medically necessary care and services for the child.
The Health Plan and AzEIP continue to coordinate services for Medicaid children who are eligible for and enrolled in both AzEIP and Medicaid. The EPSDT Coordinator assists the parent or caregiver in scheduling the EPSDT covered services, as necessary or as requested. The EPSDT services are provided by the health plan’s participating provider (or AzEIP service provider reimbursed by the health plan) until the services are determined by the PCP and provider to no longer be medically necessary.
AzEIP-Initiated Service Requests
When concerns about a Medicaid enrolled child’s development are initially identified by AzEIP:
- If an EPSDT-eligible child is referred to AzEIP, AzEIP screens and, if needed, conducts an evaluation to determine the child’s eligibility for AzEIP. AzEIP obtains parental consent to request and release records to and from the health plan and the child’s PCP;
- The PCP reviews all AzEIP documentation and determines which services are medically necessary based on review of the documentation;
- The PCP takes no longer than 10 business days from the date the EPSDT Specialist faxes the documentation to the PCP to determine which services are medically necessary and returns the signed AzEIP AHCCCS Member Service Request form (AHCCCS AMPM Chapter 430, Attachment D) to the EPSDT Coordinator.
The PCP will determine the requested services are medically necessary:
- Within two business days, the EPSDT Coordinator sends the completed AzEIP AHCCCS Member Service Request form located at (AHCCCS AMPM, Chapter 430, Attachment D) to the AzEIP service coordinator and PCP advising them that: (a) the services are approved, and (b) identifying the provider that has been authorized, the frequency, duration, and the service begin and end dates;
- The Health Plan authorizes services with a participating provider whenever possible;
- AzEIP providers may only be reimbursed (a) if they are AHCCCS registered and (b) for the categories of services for which they are registered and that were provided. Billing must be completed in accordance with AHCCCS guidelines;
- When services are determined by the PCP and service provider to be no longer medically necessary, the AzEIP service coordinator implements the process for amending the IFSP, which may include (a) non medically necessary services covered by AzEIP, and (b) changes made to IFSP outcomes and IFSP services, including payer, setting, etc;
- The AzEIP service coordinator, family and other IFSP team members review the IFSP at least every six months or sooner if requested by any team member. If services are changed (deleted or added) during an annual IFSP or IFSP review, the AzEIP service coordinator notifies the EPSDT Coordinator and PCP within two business days of the IFSP review. If a service is added, the AzEIP service coordinator’s notification to the EPSDT coordinator initiates the process for determining medical necessity and authorizing the service as outlined above.
2.4.10 Children’s Rehabilitative Services (CRS) Program
The Provider shall notify the Health Plan when a child is potentially in need of services related to CRS qualifying conditions, as specified in A.A.C. R9-22 Article 1303, and A.R.S. 36-2912. See AHCCCS ACOM, Chapter 426, for the referral process to obtain a CRS designation. In addition, the Provider shall notify the member, or their parent/guardian/authorized representative, and the Health Plan when a referral to a specialist for an evaluation of a CRS condition is being made.
Reference AHCCCS ACOM, Chapter 426, for the processes used to process referrals for a CRS designation. The Provider is responsible for notifying the Health Plan of the date when a member with a CRS designation is no longer in need of treatment for the CRS qualifying condition(s) as specified in Section F, Monitoring of the CRS Designation. The notification requirements described above are applicable only to members under 21 years of age. The Provider shall consider members with a CRS qualifying condition as members with special health care needs.
Many children with Special Health Care Needs, including children with CRS-qualifying medical conditions typically require complex care and are medically fragile as specified in (AHCCCS AMPM, Chapter 560). For these children, CRS Providers must provide health care service delivery that involves multiple clinicians, covering the entire continuum of care. In addition to a primary care provider, these children may receive services from subspecialists who manage care related to their condition(s) and coordinate with other specialty services including but not limited to behavioral health, pharmacy, medical equipment and appliances, therapies, diagnostic services, and telemedicine visits.
Comprehensive care includes a multi-disciplinary team made up of subspecialists and caregivers such as pulmonologists, cardiologists, nutritionists, psychologists, and therapists. Because of the complexity of the needs of these children requiring multiple surgeries, hospitalization, and clinical care it is imperative that there be integrated health information and care coordination for the member. Services shall be provided using an integrated family-centered, culturally competent, multi-specialty, interdisciplinary approach that includes the following elements:
- A process for using a centralized, integrated medical record that is accessible to The Health Plan and service providers consistent with Federal and State privacy laws to facilitate well-coordinated, interdisciplinary care;
- A process for developing and implementing a Service Plan accessible to The Health Plan and service providers that is consistent with Federal and State privacy laws that contains the clinical, medical, and administrative information necessary to monitor coordinated treatment plan implementation; and
- Collaboration with individuals, groups, providers, organizations, and agencies charged with the administration, support, or delivery of services for persons with special health care needs.
Providers shall ensure that members with special health care needs that are determined through assessment to need a course of treatment or regular care monitoring have an individualized physical and behavioral treatment or service plan. In addition, the Provider shall conduct multi-disciplinary staffings for members with challenging behaviors or health care needs [42 CFR 438.208(c)(3)].
For members with special health care needs determined to need a specialized course of treatment or regular care monitoring, The Health Plan will allow members to directly access a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified needs [42 CFR 438.208(c)(4)]. The minimum performance standard established by AHCCCS for the initial visit for CRS-Identified Members is to occur within 30 days.
Multi-Specialty Interdisciplinary Clinics (MSICs): For members with special health care needs, including members with CRS conditions who could benefit from a multi-disciplinary approach, covered services shall be delivered through a combination of established Multi-Specialty Interdisciplinary Clinics (MSICs), Field Clinics, Virtual Clinics, and in community settings.
The Provider shall coordinate care for members that includes allowing members with a CRS designation turning 21 the choice to continue being served by an MSIC that is able to provide services and coordinate care for adults with special healthcare needs.
Members with a CRS qualifying condition are currently exempt from mandatory and optional copayments.
2.4.11 Body Mass Index or Weight-for-Length
Primary care providers (PCPs) should calculate each child’s body mass index (BMI) starting at age 2 until the member is age 21 (or weight-for-length percentile for members less than two years of age). BMI is used to assess underweight, overweight and those at risk for overweight. BMI for children is sex and age specific. PCPs are required to calculate the child’s BMI percentile utilizing the Centers for Disease Control and Prevention website for Body Mass Index (BMI) and growth chart resources or for children under age two, refer to the Centers of Disease Control and Prevention website for weight-for-length chart.
The following established percentile cutoff points are used to identify underweight and overweight in children:
≥ 95th percentile
85th to < 95th percentile
5th to < 85th percentile
< 5th percentile
Primary care providers (PCPs) should calculate the growth of children under 2 years of age by using the World Health Organization (WHO) growth standards to monitor growth for infants and children ages 0 to 2 years of age in the U.S., as the Centers for Disease Control and Prevention recommends the use of the WHO standards for children under age 2 to avoid incorrectly labeling a child as failure to thrive despite following the optimal growth pattern for children in this age group. Refer to the Centers for Disease Control and Prevention website for WHO growth chart resources.
Nutritional Assessment and Nutritional Therapy
Nutritional assessments are part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for the health plan’s members under age 21, whose health status may improve with nutrition intervention. Nutritional therapy is covered for EPSDT-eligible health plan members for the below enteral, parenteral, or oral basis when determined medically necessary to provide either complete daily dietary requirements, or to supplement a member’s daily nutritional and caloric intake.
- Enteral nutritional therapy –
Provides liquid nourishment directly to the digestive tract of a member who cannot ingest an appropriate amount of calories to maintain an acceptable nutritional status. Enteral nutrition is commonly provided by jejunostomy tube (J-tube), gastrostomy tube (G-tube) or nasogastric (N/G) tube Parenteral nutritional therapy - Provides nourishment through the venous system to members with severe pathology of the alimentary tract, which does not allow absorption of sufficient nutrients to maintain weight and strength.
- Commercial oral supplemental nutritional feedings
Provides nourishment and increases caloric intake as a supplement to the member’s intake of other age- appropriate foods, or as the sole source of nutrition for the member. Nourishment is taken orally and is generally provided through commercial nutritional supplements available without prescription
The Health Plan covers the following for members with a medical condition described in the section above:
- Special Supplemental Program for Women, Infants and Children (WIC)-eligible infant formulas, including specialty infant formulas;
- Medical foods;
- Parenteral feedings; and
- Enteral feedings.
Refer to the Medical Foods section for the health plan’s members with a congenital metabolic disorder, such as phenylketonuria, homocystinuria, maple syrup urine disease, or galasctosemia.
2.4.12 Nutritional Assessment and Nutritional Therapy – Members Ages 21 and Older
Nutritional assessments and nutritional therapy are provided for members whose health status may improve with nutrition intervention. Arizona Health Care Cost Containment System (AHCCCS) covers nutritional therapy on an enteral, parenteral, and oral basis when determined medically necessary to provide either complete daily dietary requirements, or to supplement a member’s daily nutritional and caloric intake.
Nutritional assessments and nutritional therapy are covered benefits for members ages 21 and older when all of the following apply:
- The member is currently underweight with a BMI of less than 18.5 presenting serious health consequences for the member, or the member has demonstrated a medically significant decline in weight within the past three months (prior to the assessment).
- The member is able to consume no more than 25 percent of their nutritional requirements from typical food sources.
- The member has been evaluated and treated for medical conditions that may cause problems with weight gain (such as feeding problems, behavioral conditions, or psychosocial problems, or endocrine or gastrointestinal problems).
- The member has had a trial of higher caloric foods, blenderized foods or commonly available products that may be used as dietary supplements for a period no less than 30 days in duration. After this trial, there is clinical documentation and other supporting evidence indicating that higher caloric foods would be detrimental to the member’s overall health.
2.4.13 Referrals for Nutritional Assessment
Nutritional assessments are conducted to assist members whose health status may improve with nutritional intervention. The health plan covers the assessment of nutritional status, as determined necessary and as a part of health risk assessment and screening services provided by the member’s primary care provider (PCP).
Nutritional assessment services provided by a registered dietitian are covered when ordered by the member’s PCP.
To initiate a referral for a nutritional assessment, complete the health plan’s referral form and fax it to the health plan’s Prior Authorization Department.
The assessment of a member’s nutritional status is covered as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program specified in the Arizona Health Care Cost Containment System (AHCCCS) EPSDT Periodicity Schedule (AMPM Chapter 430, Attachment A), and on an inter-periodic basis as determined necessary by the member’s primary care physician (PCP). This includes members who are under or overweight. A PCP may perform the nutritional assessment or may refer the member to a registered dietician.
2.4.14 Prior Authorization for Nutritional Therapy
Prior authorization is always required for nutritional therapy. Providers must submit all clinically relevant information for medical necessity review and prior authorization requests. To obtain prior authorization for enteral or parenteral nutritional therapy, providers must complete and submit a Request for Prior Authorization form to the health plan‘s Prior Authorization Department.
Prior authorization is required for commercial oral supplemental nutritional feedings, including specialty infant formulas, unless the member is also currently receiving nutrition through enteral or parenteral feedings. Prior authorization is not required for the first 30 days if the member requires commercial oral nutritional supplements on a temporary basis due to an emergent condition. An example of a nutritional supplement is an amino acid-based formula used by a member for eosinophilic gastrointestinal disorder.
The primary care physician (PCP) or attending physician must determine medical necessity on an individual basis for commercial oral nutritional supplements.
For prior authorization on commercial oral supplemental nutritional feedings, the member’s PCP or attending physician must complete and submit the Arizona Health Care Cost Containment System (AHCCCS)-approved Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form to the health plan’s Prior Authorization Department.
The PCP or attending physician must have documentation that nutritional counseling was provided as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and specify alternatives that were tried in an effort to boost caloric intake and change food consistencies before considering commercially available nutritional supplements for oral feedings, or to supplement feedings.
The PCP or attending physician must complete the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form and indicate on the form which criteria were met when assessing medical necessity of providing commercial oral nutritional supplements.
The Health Plan has a comprehensive dental network for members. To serve the needs of its members, the health plan partners with Envolve Dental who administers the health plan’s dental benefits. Dental Providers must submit claims and prior authorizations to Envolve Dental, or by phone at 844-876-2028.
The Health Plan offers dental services for:
- Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) aged members
- EPSDT and Oral Health services through the RBHA are covered only for members 18 to 21 years of age. All other members receive Oral Health and EPSDT services up to 21 years of age.
- Preventive dental services for EPSDT Members under the age of 21 years
- Therapeutic Dental Services for members under 21
- Emergency Dental Coverage for members under 21
- PCP Fluoride Varnish Application for children less than 2 years of age
Eligible EPSDT Members under the age of 21 years old have comprehensive dental service benefits which include preventive, therapeutic and emergency dental services. All members age out of the Oral Health & EPSDT program and services at age 21.
If a member does not qualify under their dental eligibility and a medical condition is present, medical necessity is determined by the health plan. Medical documentation is required and must be submitted directly to the health plan for review and prior authorization determination.
Dental Providers should include parent/guardian or caregivers in all consultations and counseling of members regarding preventive oral health care and the clinical findings.
The Health Plan adheres to the Dental Uniform Prior Authorization List and the Uniforms Warranty List as outlined in AHCCCS AMPM Policy 431.
2.5.1 Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment aged members
As part of the physical examination, the physician, physician’s assistant, or nurse practitioner must perform an oral health screening. A screening is intended to identify gross dental or oral lesions but is not a thorough clinical examination and does not involve making a clinical diagnosis resulting in a treatment plan. Depending on the results of the oral health screening, referral to a dentist must be made as outlined in the Contract:
- URGENT - As expeditiously as the member’s health condition requires but no later than three days from the request
- ROUTINE - Within 45 days of request·
- For CMDP only, routine care appointments within 30 calendar days of referral.
PCPs must refer EPSDT members for appropriate services based on needs identified through the screening process and for routine dental care based on the AHCCCS EPSDT Periodicity Schedule (AMPM Chapter 430). Evidence of this referral must be documented on the EPSDT Tracking Form and in the member’s medical record.
EPSDT Members may select a dentist within the health plans contracted network and receive preventive dental services without a referral.
2.5.2 PCP Application of Fluoride Varnish
Physicians who have completed the AHCCCS required training may be reimbursed for fluoride varnish applications completed at the EPSDT Well Child Visit as often as every three months between the ages of 6 months and 2 years of age, after the eruption of the first tooth.
AHCCCS recommended training for fluoride varnish application is located at http://www.smilesforlifeoralhealth.org. Refer to Training Module 6 that covers caries risk assessment, fluoride varnish and counseling. Upon completion of the required training, providers should upload a copy of their certificate to the Council for Affordable Quality Healthcare (CAQH) site. Providers should also submit a copy of their certification to the Health Planvia fax at (855) 872-1858 or email to HEDIS_Operations@azcompletehealth.com. This certificate is used in the credentialing process to verify completion of training necessary for reimbursement. An oral health screening must be part of an EPSDT screening conducted by a PCP; however, it does not substitute for examination through direct referral to a dentist. PCPs must refer EPSDT members for appropriate services based on needs identified through the screening process and for routine dental care based on the AHCCCS Dental Periodicity Schedule (AMPM Chapter 431, Attachment A). Evidence of this referral must be documented on the EPSDT Tracking Form and in the member’s medical record.
2.5.3 Preventive Dental Services
Preventive dental services provided as specified in the AHCCCS Dental Periodicity Schedule AHCCCS AMPM 431, Attachment A, https://www.azahcccs.gov/shared/MedicalPolicyManual/, including but not limited to:
- Diagnostic services include comprehensive and periodic examinations. The Health Plan allows two oral examinations and two oral prophylaxes in one year and up to four fluoride treatments per member in one year for member’s ages 12 months until members 21 years of age. Additional examinations or treatments shall be deemed medically necessary;
- Radiology services screening for diagnosis of dental abnormalities and/or pathology, including panoramic or full-mouth x-rays, supplemental bitewing x-rays, and occlusal or periapical films, as medically necessary and following the recommendations by the American Academy of Pediatric Dentistry (AAPD); and
- Panorex films are covered as recommended by AAPD, up to three times maximum per provider for members between ages three (3) to twenty (20). Additional panorex films needed above this limit must be deemed medically necessary through the health plan prior authorization process.Preventive services, including:
Preventive services, including:
- Oral prophylaxis performed by a dentist or dental hygienist which includes self-care oral hygiene instructions to member, if able, or to the parent/ legal guardian;
- Application of topical fluoride varnish. The use of a prophylaxis paste containing fluoride or fluoride mouth rinses do not meet the AHCCCS standard for fluoride treatment;
- Dental sealants for first and second molars are covered every three years up to age 15, with a two- time maximum benefit. Additional applications must be deemed medically necessary and require prior authorization through The Health Plan;
- Space maintainers when posterior primary teeth are lost and when deemed medically necessary through The Health Plan prior authorization process.
2.5.4 Therapeutic Dental Services
All therapeutic dental services will be covered when they are considered medically necessary and cost effective but may be subject to PA by the health plan or AHCCCS Division of Fee-For-Service Management for FFS members.
These services include, but are not limited to:
- Periodontal procedures, scaling/root planing, curettage, gingivectomy, and osseous surgery;
- When appropriate, stainless-steel crowns may be used for both primary and permanent posterior teeth; composite, prefabricated stainless steel crowns with a resin window or crowns with esthetic coatings should be used for anterior primary teeth; or
- Precious or cast semi-precious crowns may be used on functional permanent endodontically treated teeth, except third molars, for members who are 18 to 21 years of age.
- Endodontic services including pulp therapy for permanent and primary teeth, except third molars (unless a third molar is functioning in place of a missing molar);
- Restoration of carious permanent and primary teeth with accepted dental materials other than cast or porcelain restorations unless the member is 18 to 21 years of age and has had endodontic treatment;
- Restorations of anterior teeth for children under the age of five, when medically necessary. Children, five years and over with primary anterior tooth decay should be considered for extraction, if presenting with pain or severely broken-down tooth structure, or be considered for observation until the point of exfoliation as determined by the dental provider;
- Removable dental prosthetics, including complete dentures and removable partial dentures; and
- Orthodontic services and orthognathic surgery are covered only when these services are necessary to treat a handicapping malocclusion. Services must be medically necessary and determined to be the primary treatment of choice or an essential part of an overall treatment plan developed by both the PCP and the dentist in consultation with each other. Orthodontic services are not covered when the primary purpose is cosmetic.
Examples of conditions that may require orthodontic treatment include the following:
- Congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services;
- Trauma requiring surgical treatment in addition to orthodontic services; or
- Skeletal discrepancy involving maxillary and/or mandibular structures.
2.5.5 Emergency Dental Coverage for Members under 21 Years of Age
EPSDT covers the following dental services:
Emergency dental services including:
- Treatment for pain, infection, swelling and/or injury;
- Extraction of symptomatic (including pain), infected and non-restorable primary and permanent teeth, as well as retained primary teeth (extractions are limited to teeth which are symptomatic); and
- General anesthesia, conscious sedation or anxiolysis (minimal sedation, members respond normally to verbal commands) when local anesthesia is contraindicated or when management of the member requires it. (See AHCCCS AMPM Policy 430, Section E, Item No. 8 regarding conscious sedation.)
2.5.6 Dental Services Not Covered For EPSDT Age Members
Orthodontic services are not covered when the primary purpose is cosmetic. Extraction of asymptomatic teeth are generally not covered services; this includes third molars. Services or items furnished solely for cosmetic purposes are not covered.
2.5.7 Emergency Dental Coverage For Members 21 Years of Age and Older
Medically necessary emergency dental care and extractions are covered for persons age 21 years and older who meet the criteria for a dental emergency. A dental emergency is an acute disorder of oral health resulting in severe pain and/or infection as a result of pathology or trauma.
AHCCCS covers the following dental services provided by a licensed dentist for members who are 21 years of age or older:
- Emergency dental services up to $1000 per member per contract year (October 1st to September 30th) as a result of A.R.S. §36-2907. The emergency dental services are described in subsection A;
- Medical and surgical services furnished by a dentist only to the extent such services may be performed under state law either by a physician or by a dentist when such services would be considered a physician service if furnished by a physician (A.A.C. R9-22-207);
- These services must be related to the treatment of a medical condition such as acute pain (excluding Temporomandibular Joint Dysfunction [TMJ] pain), infection, or fracture of the jaw. Covered services include a limited problem focused examination of the oral cavity, required radiographs, complex oral surgical procedures such as treatment of maxillofacial fractures, administration of an appropriate anesthesia and the prescription of pain medication and antibiotics. Diagnosis and treatment of TMJ is not covered except for reduction of trauma. Services described in this paragraph are not subject to the $1000 adult emergency dental limit.
The following services and procedures are covered as emergency dental services:
- Emergency oral diagnostic examination (limited oral examination – problem focused);
- Radiographs and laboratory services, limited to the symptomatic teeth;
- Composite resin due to recent tooth fracture for anterior teeth;
- Prefabricated crowns, to eliminate pain due to recent tooth fracture only;
- Recementation of clinically sound inlays, onlays, crowns, and fixed bridges;
- Pulp cap, direct or indirect plus filling;
- Root canals and vital pulpotomies when indicated for the treatment of acute infection or to eliminate pain;
- Apicoectomy performed as a separate procedure, for treatment of acute infection or to eliminate pain, with favorable prognosis;
- Immediate and palliative procedures, including extractions if medically necessary, for relief of pain associated with an oral or maxillofacial condition,
- Tooth reimplantation of accidentally avulsed or displaced anterior tooth, with favorable prognosis;
- Temporary restoration which provides palliative/sedative care (limited to the tooth receiving emergency treatment);
- Initial treatment for acute infection, including, but not limited to, periapical and periodontal infections and abscesses by appropriate methods;
- Preoperative procedures and anesthesia appropriate for optimal patient management; and
- Cast crowns limited to the restoration of root canal treated teeth only.
Follow up procedures necessary to stabilize teeth as a result of the emergency service are covered and subject to the $1000 limit.
Adult Emergency Dental Services Limitations for Persons age 21 Years and Older.
Maxillofacial dental services provided by a dentist are not covered except to the extent prescribed for the reduction of trauma, including reconstruction of regions of the maxilla and mandible.
Diagnosis and treatment of temporomandibular joint dysfunction (TMD or TMJ) is not covered except for the reduction of trauma.
Routine restorative procedures and routine root canal therapy are not emergency dental services and are not covered.
Treatment for the prevention of pulpal death and imminent tooth loss is limited to non-cast fillings, crowns constructed from pre-formed stainless steel, pulp caps, and pulpotomies only for the tooth causing pain or in the presences of active infection.
Fixed bridgework to replace missing teeth is not covered.
Dentures are not covered.
Exceptions for Transplants and Members with Cancer
I. Transplant Cases
- For members who require medically necessary dental services as a pre-requisite to AHCCCS covered organ or tissue transplantation, covered dental services are limited to the elimination of oral infections and the treatment of oral disease. Covered dental services are limited to the following:
- Dental cleaning (Prophylaxis);
- Treatment of periodontal disease;
- Medically necessary extractions;
- Simple restorations. A simple restoration means silver amalgam and/or composite resin fillings, stainless steel crowns or preformed crowns.
The health plan covers these services only after a transplant evaluation determines that the member is an appropriate candidate for organ or tissue transplantation. These services are not subject to the $1000 adult emergency dental limit.
II. Members with Cancer
Covered dental services are limited to the following:
- Prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head is also covered. These services are not subject to the $1000 adult emergency dental limit.
III. Members on Ventilators
- Cleanings for members who are in an inpatient hospital setting and are placed on a ventilator or are physically unable to perform oral hygiene are covered for dental cleanings performed by a hygienist working under the supervision of a physician. These services are not subject to the $1,000 adult emergency dental limit. If services are billed under the physician, then medical codes will be submitted and are not subject to the $1000 adult emergency dental limit.
2.5.9 Charging of Members
Emergency dental services of $1000 per contract year are covered for AHCCCS member’s age 21 years and older. Billing of AHCCCS members for emergency dental services in excess of the $1000 annual limit is permitted only when the provider meets the requirements of A.A.C R9-22-702 and A.A.C. R9-28-701.10.
In order to bill the member for emergency dental services exceeding the $1000 limit, the provider must first inform the member in a way s/he understands, that the requested dental service exceeds the $1000 limit and is not covered by AHCCCS. Before providing the dental services that will be billed to the member, the provider must furnish the member with a document to be signed in advance of the service, stating that the member understands that the dental service will not be fully paid by AHCCCS and that the member agrees to pay for the amount exceeding the $1000 emergency dental services limit, as well as services not covered by AHCCCS.
The member must sign the document before receiving the service in order for the provider to bill the member. It is expected that the document contains information describing the type of service to be provided and the charge for the service
2.5.10 Informed Consent
Informed consent is a process by which the provider advises the member, member’s guardian, and/or designated representative of the diagnosis, proposed treatment and alternate treatment methods with associated risks and benefits of each, as well as the associated risks and benefits of not receiving treatment.
- Informed consent for oral health treatment:
- A written consent for examination and/or any treatment measure, which does not include an irreversible procedure, as mentioned below. This consent is completed at the time of initial examination and is updated at each subsequent six-month follow-up appointment, and
- A separate written consent for any irreversible, invasive procedure, including but not limited to dental fillings, pulpotomies, etc. In addition, a written treatment plan shall be reviewed and signed by both parties, as described below, with the member/ guardian/designated representative receiving a copy of the complete treatment plan.
- All providers shall complete the appropriate informed consents and treatment plans for AHCCCS members as listed above, in order to provide quality and consistent care, in a manner that protects and is easily understood by the the member, member’s guardian, and/or designated representative. This requirement extends to all Contractor mobile unit providers. Consents and treatment plans shall be in writing, signed and dated by both the provider and the patient or patient’s representative, if the patient is a) under 18 years of age or b) is 18 years of age or older and considered an incapacitated adult (as specified in A.R.S. §14-5101). Completed consents and treatment plans shall be maintained in the members’ chart and are subject to audit.
2.5.11 Facility and Anesthesia Charges
Adult members requiring general anesthesia in an ambulatory service center or outpatient hospital the general anesthesia are subject to the $1000 emergency dental limit.
Dentist performing general anesthesia on adult emergency members must bill dental codes that count towards the $1000 adult emergency benefit.
Physicians performing general anesthesia on adult emergency members for a dental procedure must bill medical codes and it will count towards the $1000 emergency dental limit.
2.5.12 Dental Referrals
Dental services may be initiated by a Primary Care Provider (PCP) through referral to a participating dental provider, the member or member’s legal guardian. No referral is required for an eligible member to make a dental appointment or receive dental care from one of the contracted health plan dental providers. Prior authorizations may be required for therapeutic services.
The AHCCCS EPSDT Periodicity Schedule gives providers necessary information regarding timeframes in which age-related required screenings and services must be provided. Depending on the results of the oral health screening, a referral to a dentist must be made.
PCP Providers must:
- Encourage Members who call for a dental referral to obtain any routine or follow up care and document all referrals in the Member’s medical record.
- Identify appropriate dental services based on needs
- Document evidence of referrals on the EPSDT tracking form or in the member’s electronic medical records;
- Refer members for a dental assessment if their oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment by a dental professional according to the AHCCCS EPSDT Dental Periodicity Schedule (AMPM Chapter 431, Attachment A)..
- Encourage eligible Members to see a dentist regularly;
- Obtain appropriate prior authorization before rendering non-emergency dental services.
Although the AHCCCS Dental Periodicity Schedule (AMPM Chapter 431, Attachment A) identifies when routine referrals begin, PCP’s may refer EPSDT members for a dental assessment at an earlier age if their oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment by a dental professional. In addition to PCP referrals, EPSDT members are allowed self-referral to dentists who are in the health plan provider network.
2.5.13 Dental Home Assignment for EPSDT age Members under the age of 21
The American Academy of Pediatric Dentistry (AAPD) defines the dental home as the ongoing relationship between dentist and the member, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. The dental home must include:
- Comprehensive oral health care, including acute care and preventive services in accordance with the Arizona Health Care Cost Containment System (AHCCCS) Dental Periodicity Schedule;
- Comprehensive assessment for oral diseases and conditions;
- Individualized preventive dental health program based upon a caries-risk assessment and a periodontal disease risk assessment;
- Anticipatory guidance about growth and development issues (such as teething, digit or pacifier habits);
- Plan for acute dental trauma;
- Information about proper care of the child’s teeth and gingivae. This would include the prevention, diagnosis, and treatment of disease of the supporting and surrounding tissues and the maintenance of health, function and esthetics of those structures and tissues;
- Dietary counseling; and
- Referrals to dental specialists when care cannot directly be provided within the dental home.
Members must be assigned to a dental home by age one and seen by a dentist for routine preventive care according to the AHCCCS Dental Periodicity Schedule (AHCCCS AMPM Chapter 400, Exhibit 431- Members must also be referred for additional oral health care concerns requiring additional evaluation and/or treatment.
2.5.14 Provider Request for Dental Home Re-assignment of an EPSDT Age Member
Dental home providers can request that a covered member be removed from their panel by issuing the person a written notice and allowing up to 60 days for assignment to a new dental home provider.
The Health Plan covers eye and optometric services provided by qualified eye/optometry professionals within certain limits based on Member age and eligibility. All vision services related to medical issues should be verified with the Health Plan. All preventative vision services should be verified with Envolve Vision.
Emergency eye care, which meets the definition of an emergency medical condition, is covered for all Members. For Members who are 21 years of age or older, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses, are covered through the Health Plan. Vision examinations and the provision of prescriptive lenses are covered for Members under the EPSDT program and for adults when medically necessary following cataract removal. Cataract removal is a covered medical service for all eligible Members with certain conditions. For more information, visit the AHCCCS website under Medical Policy for AHCCCS Covered Services.
2.6.1 Coverage for EPSDT aged members
Appropriate vision screenings are covered during an EPSDT visit. EPSDT benefits cover eye examinations as appropriate to age according to the AHCCCS EPSDT Periodicity Schedule (AHCCCS AMPM, Chapter 430, Attachment A) and as medically necessary using standardized visual tools. Payment for vision and hearing exams, (including, but not limited to CPT codes 92015, 92081, 92285, 92551, 92552, 92553, 92567, 92568, 92285, 92286, 92587, 92588, 95930, and 99173) or any other procedure that may be interpreted as fulfilling the vision requirements provided in a PCP’s office during an EPSDT visit, are considered part of the EPSDT visit and are not a separately billable service.
Ocular photoscreening with interpretation and report, bilateral (CPT code 99177) is covered for children aged three to five as part of the EPSDT visit due to challenges with a child’s ability to cooperate with traditional vision screening techniques. Ocular photoscreening is limited to a lifetime coverage limit of one. This procedure, although completed during the EPSDT visit, is a separately billable service through the Health Plan. Automated visual screening, described by CPT code 99177, is for vision screening only, and not recommended for or covered by AHCCCS when used to determine visual acuity for purposes of prescribing glasses or other corrective devices. All vision services related to medical issues should be verified with the Health Plan. All Preventative vision services should be verified with Envolve Vision.
Coverage for EPSDT members includes:
- Medically necessary emergency eye care, vision examinations, prescriptive lenses, frames for eyeglasses and treatments for conditions of the eye;
- PCPs are required to provide initial vision screening in their office as part of the EPSDT program. Vision exams provided in a PCP’s office during an EPSDT visit are not a separately billable service;
- Replacement of lost or broken glasses, or due to a change in prescription is a covered benefit.
Vision CPT codes with the EP modifier must be listed on the claim form in addition to the preventive medicine CPT codes for visit screening assessment. With the exception of CPT code 99177, no additional reimbursement is allowed for these codes.
Medical condition-related vision services should be billed through the Health Plan. Preventative vision services and hardware should be billed through Envolve Vision. Providers can verify all non-emergency services with the appropriate entity in advance of care, as needed.
2.6.2 Emergency Eye coverage for members 21 Years and Over
All medical vision services should be verified with the Health Plan. Envolve Vision does not cover vision services to adults 21 years and over.
- Emergency care for eye conditions when the eye condition meets the definition of an emergency medical condition; for cataract removal and/or medically necessary vision examinations; and for prescriptive lenses if required following cataract removal.
- Routine eye exams and glasses are not a covered service for adults.
- Adults 21 years of age and older should work with the Health Plan to be referred for the diagnosis and treatment of eye diseases.
Primary care providers (PCPs) are responsible for immunizing members and maintaining all immunization information in the member’s medical record. Local health departments (LHDs) may also immunize the health plan’s members. PCPs must be available to administer immunizations during routine office hours. It is the PCP’s responsibility to update the immunization record card or other form of immunization record and enter all immunizations into the Arizona State Immunization Information System (ASIIS) registry. At each visit, the PCP should inquire whether the patient has received immunizations from another provider. The PCP should also educate members regarding their responsibility to inform the PCP if they receive immunizations elsewhere (such as from an LHD or nonparticipating provider). This information is necessary for documentation and for the member’s safety.
The EPSDT Program covers all child and adolescent immunizations, as specified in the Centers for Disease Control and Prevention (CDC) recommended childhood immunization schedules. Appropriate immunizations according to age and health history (administration of the immunizations may be billed in addition to the EPSDT visit using the CPT-4 code appropriate for the immunization with an SL modifier). Combination vaccines are paid as one vaccine.
The health plan will cover the human papilloma virus (HPV) vaccine for EPSDT members aged 11 to 21 years of age. The health plan will cover members nine and ten years of age if the member is deemed to be in a high-risk situation. All appropriate immunizations must be provided to establish and maintain up-to-date immunization status for each member based on their age. Refer to the CDC website for current immunization schedules.
2.7.1 Vaccine for Children (VFC)
Through the Vaccines for Children (VFC) Program, the federal and State governments purchase, and make available to providers at no cost, vaccines for Medicaid eligible members under age nineteen (19). Members, 18 years of age, are eligible to receive VFC vaccines.
- Providers must coordinate with the Arizona Department of Health Services Vaccines for Children (VFC) program in the delivery of immunization services.
- Providers must enroll and re-enroll annually with the VFC program in accordance with AHCCCS Contract requirements.
- Providers will not utilize AHCCCS funding to purchase VFC vaccines for members over 19 years of age.
- Providers shall maintain a sufficient supply of vaccines for EPSDT aged members.
- Immunizations must be provided according to the Advisory Committee on Immunization Practices (ACIP) Recommended Schedule or when medically necessary for the member’s health.
- Providers are encouraged to offer simultaneous administration of all vaccines for which a member 18 years of age is eligible at the time of EPSDT visit.
- Providers must enroll with and document EPSDT member’s immunizations in the Arizona State Immunization Information System (ASIIS) and maintain the ASIIS immunization records of each EPSDT member in ASIIS in accordance with A.R.S. Title 36, Section 135.
- The ADHS ASIIS immunization registry can be accessed by the providers to obtain accurate immunization records for EPSDT members.
More information is available in the Vaccines for Children (VFC) Program Operations Guide (PDF).
2.7.2 Arizona State Immunization Information System (ASIIS)
Providers must document each EPSDT age member’s immunizations in the Arizona State Immunization Information System (ASIIS) registry within 30 days of administering an immunization. In addition, providers must maintain the ASIIS immunization records of each EPSDT member in ASIIS, in accordance with A.R.S. Title 36, Section 135.
Crisis intervention services are provided to a person for the purpose of stabilizing or preventing a sudden, unanticipated, or potentially dangerous behavioral health condition, episode, or behavior. Crisis intervention services are provided in a variety of settings, such as hospital emergency departments, face-to-face at a person’s home, over the telephone, or in the community. These intensive and time limited services may include screening, (e.g., triage and arranging for the provision of additional crisis services) assessing, evaluating, or counseling to stabilize the situation, medication stabilization and monitoring, observation and/or follow-up to verify stabilization, and/or other therapeutic and supportive services to prevent, reduce or eliminate a crisis situation.
At the time behavioral health crisis intervention services are provided, a person’s enrollment or eligibility status may not be known. However, crisis intervention services must be provided, regardless of enrollment or eligibility status.
Any person presenting with a behavioral health crisis in the community, regardless of Medicaid eligibility or enrollment status. Collaboration agreements between Health Plans and local law enforcement/first responders address continuity of services during a crisis, jail diversion and safety, and strengthening relationships between first responders and providers.
2.8.1 Overview of Crisis Intervention Services
To meet the needs of individuals in communities throughout Arizona, The Health Plan provides the following crisis services:
- Telephone crisis intervention services provided by The Health Plan contracted Crisis Call Center available 24 hours per day, seven days a week:
Southern Region Residents (Cochise, Graham, Greenlee, La Paz, Pima, Santa Cruz, Yuma, County or on the San Carlos Apache Reservation): can access The Health Plan crisis services by calling 866-495-6735.
Maricopa County Residents: can access The Health Plan crisis services by calling 800-327-9254.
Pinal County Residents: can access The Health Plan crisis services by calling 866-495-6735.
Gila County Residents: can access The Health Plan crisis services by calling 877-756-4090.
- Mobile crisis intervention services, available 24 hours per day, seven days a week.
- If one person responds, this person shall be a Behavioral Health Professional or a Behavioral Health Technician; and
- If a two-person team responds, one person may be a Behavioral Health Paraprofessional, including a peer or family member, provided they have supervision and training as currently required for all mobile team members.
- Crisis stabilization/observation services, including detoxification services;
- The Health Plan provides crisis stabilization and detoxification services through Behavioral Health Inpatient Facilities, Behavioral Health Hospital Facilities, and Substance Abuse Transitional Facilities.
- If you live in Cochise, Graham, Greenlee, La Paz, Pima, Santa Cruz, Yuma County or on the San Carlos Apache Reservation, you can access crisis services by calling 866-495-6735.
- If you live in Pinal County, you can access crisis services by calling 866-495-6735
- If you live in Maricopa County, you can access crisis services by calling the Maricopa County Crisis Line 1-602-222-9444 or 800-327-9254.
- If you live in Gila County, you can access crisis services by calling 877-756-4090
- Up to 24 hours of additional crisis stabilization as funding is available for mental health and substance abuse disorder related services.
For program requirements related to The Health Plan Crisis Intervention Services, see Section 14 — Specific Behavioral Health Program Requirements.
2.8.2 Management of Crisis Services
The Health Plan maintains availability of crisis services in each county served. The Health Plan utilizes the following in managing crisis services:
- The Health Plan allocates and manages funding to maintain the availability of required crisis services for the entire fiscal year;
- The Health Plan works collaboratively with local hospital-based emergency departments to determine whether a The Health Plan -funded crisis provider should be deployed to such locations for crisis intervention services;
- The Health Plan works collaboratively with local Behavioral Health Inpatient Facilities to determine whether and for how many hours such locations are used for crisis observation/stabilization services; and
- When Non-Title XIX/XXI eligible individuals are receiving crisis services and require medication, The Health Plan uses the generic medication formulary identified in the Non-Title XIX/XXI Crisis benefit (see Section 4.13 - Pharmaceutical Requirements).
The Health Plan seeks to ensure Members receive crisis services on a timely basis and, when appropriate, in their homes and communities. Crisis mobile teams are available to help Members obtain the appropriate crisis services. The Health Plan discourages providers from sending Members to emergency rooms for non-medical reasons.
Second Responder Services are provided following a crisis service (Crisis Mobile Team, Community Observation Unit [23 Hour Stabilization], Crisis Living Room Intervention). It is not a second responder crisis service if it is preventative care. Second Responder Services must be dispatched from the Southern Arizona Crisis Line following a crisis intervention.
When billing for Second Responder Services, the diagnosis on the claim must match the diagnosis in the Second Responder clinical chart. Program descriptions and coverage areas are listed in the below table.
2nd responder paperwork required
The Hope, Inc. Peer After Crisis Team
Adult members: T19
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
TLC-R Peer After Crisis Team
All adult members: T19 and NT19
NT19 & T19
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
BOOST Placement Preservation
All T19 CMDP enrolled children in DCS custody
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
CFSS Challenging Behavioral Support
All T19 Children
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
Old Pueblo Housing
All SMI designated members; Both T19 and NT19
T19 & NT19 SMI
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
EMPACT Placement Preservation
All T19 Medicaid Enrolled Children in Foster Care
Referred through AZ Crisis Line by a crisis provider
Short assessment & crisis treatment plan. DX on claim must match DX in the second responder chart.
** Per ARS 36-501 (24) Definitions - Medical Director of a mental health treatment Provider" means a psychiatrist, or other licensed physician experienced in psychiatric matters, who is designated in writing by the governing body of the Provider as the person in charge of the medical services of the Provider for the purposes of this chapter and includes the chief medical officer of the state hospital.”
2.10.1 Provider and Statewide Housing Administrator Responsibilities
Health Plan Provider Agencies shall designate a primary clinical or housing point of contact for the AHP Administrator to reach when applications for housing have been approved and a member receives an available unit/voucher. Please provide that POC via email to CAZHousing@azcompletehealth.com.
AHCCCS Housing Program (AHP) is administered by Arizona Behavioral Health Corporation (ABC) and HOM Inc. All applications and waitlist questions are to be directed to ABC. The Housing Application and ABC process can be found at the ABC Housing web site https://azabc.org/ahp/. 602-712-9200 Only Provider Agencies and Clinics shall contact ABC Housing.
HOM Inc. 602 265-4640 Phoenix 520 534-2941 Pima & BOS
Contact HOM Inc. for Members/Clients and Health Home or Housing Staff about a housing concern for people already housed or approved for a housing voucher.
When a member identifies a need for housing services and supports Provider Agencies are required to add to the Individual Service Plan (ISP) and fill out the AHP housing application forms. The AHP forms are fillable and will require signatures from all parties. These forms are emailed via secure email to the AHP Administrator for processing. The member will be added to the statewide housing list. When the AHP Administrator has a housing option available the member will be notified via email along with the Provider clinical teams, case managers and the health plan. This is in effort to coordinate care as much as possible with AHCCCS Providers and the AHP Administrator.
AHCCCS is responsible for the overall oversight, fund distribution, operation, and ensuring that AHP funds are utilized for their intended purposes and in compliance with all federal, state, and local laws and regulations. To achieve these goals, AHCCCS utilizes a statewide Housing Administrator to manage and operate the AHCCCS Housing Program.
The Provider Agency is responsible for assisting and supporting members to secure and maintain housing as part of overall physical and behavioral health service provision. This includes coordination with the AHP Administrator for AHP programs if eligible, as well as other community-based housing and programs (e.g., Housing Choice Vouchers, Department of Housing and Urban Development (HUD) COC programs). To adequately support members housing needs, the Provider Agencies shall: Ensure identification, assessment, screening, and documentation of individuals that have housing needs including homelessness, housing instability, or adequate and appropriate setting at discharge from residential, crisis or inpatient facility. It may also include administration of any AHCCCS approved standardized assessment tools that include housing evaluation, coordinate with the AHP Administrator and contracted providers to identify and refer members identified with a high need for housing services.
The Provider Agency shall assist members to identify, apply and qualify for housing options they may be eligible for including AHP subsidies and supports as well as other mainstream affordable and PSH programs (e.g., HUD Housing Choice Vouchers, HUD McKinney Vento COC grants), to ensure a range of housing settings and programs are available to individuals consistent with the individual’s recovery goals, individual’s service plan, choice and offer the least restrictive environment necessary to support the member. Shelters, hotels, and similar temporary living arrangements do not meet this expectation.
The Provider Agency is required to coordinate with an individual’s treatment team or care coordinator, to participate and support AHP Administrator and other mainstream housing processes including assistance in securing eligibility documentation, attending housing briefings to ensure tenant understand housing rights, duties and processes, assist in housing search and lease up process help with move in and ongoing requirements (e.g., lease renewal).
Whenever possible, not actively refer or place individuals in a homeless shelter, licensed Supervisory Care Homes, unlicensed board and care homes, or other similar facilities upon discharge from an institutional setting. For individuals enrolled in AHP housing, Provider Agencies shall provide coordination between the housing provider, AHP Administrator, and clinical teams to ensure members receive appropriate wraparound supportive services to ensure housing stability and progress towards case plan goals. This may include delivery of services within the individual’s housing placement as appropriate. Ensure coordination of services and housing for all eligible members including those from other systems of care (e.g., Fee for Services) as appropriate to ensure members have access to housing programs and services,
The Provider Agency shall demonstrate that the provider agency staff and provider housing program staff have received training, demonstrated competency, and utilized evidence-based practices to coordinate housing based supportive services to assist individuals in attaining and maintaining permanent housing placement and retention.
The Provider Agencies shall demonstrate they can capably conduct and utilize any AHCCCS-required current or emerging standardized assessment tool for assessing and documenting housing needs such as the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) or other AHCCCS approved acuity tool.
The Provider Agency shall participate in the local HUD COC Homeless Management Information System (HMIS), a software application designed to record and store client-level information on the characteristics and service needs of homeless persons. The HMIS is used to coordinate care, manage program operations, and better serve clients. Examples and suggested HMIS coordination requirements are included in the plan contracts, Collaborate with State, County and local government agencies to support homeless and housing initiatives to resolve issues, develop new housing capacity, and address barriers to housing that affect members.
RBHA will monitor housing providers for compliance with the SAMHSA Fidelity Monitoring tool as required. Provision of required housing specific data will require coordination with AHCCCS Housing Administrator.
Develop and make available to the Providers, policies, and procedures regarding specific housing coordination and related requirements and ensure all services including housing supports are provided in a culturally competent manner and do not intentionally or unintentionally discriminate, and work with providers and community to identify new projects for possible SMI HTF application to AHCCCS to expand housing capacity for individuals determined SMI.
It is the responsibility of the Provider Agency to be aware of AHP eligibility requirements and ensure that all members referred for AHP housing are eligible. Provider shall verify eligibility upon issuance of housing support or renewal of the housing support. Have an established and publish processes verifying eligibility upon issuance of housing support or renewal of the housing support.
2.10.2 Housing Eligibility Criteria:
- Must be at least 18 years old and legally able to enter into a binding lease or housing contract at the time of referral to AHP Administrator. A legally emancipated minor under the age of eighteen may qualify for AHP housing services or subsidy if they also met the other AHP criteria including mental health status,
- Have lawful presence in the United States pursuant to A.R.S. § 1-502,
- Be determined Seriously Mentally Ill (SMI), identify with a GMH/SUD and Title XIX eligible.
- Have an identified and documented housing need by a provider. A “housing need” may include the following:
- Actual Homelessness: An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
- Has a primary nighttime residence that is a public or private place not meant for human habitation and is living in a publicly or privately operated shelter designated to provide temporary living arrangements including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, and local government programs.
- Institutional or Hospital Discharge – an individual exiting an institution who is likely to be homeless (per Eligibility Criteria section), or who does not have a safe residence to go to upon discharge. An institution may include physical or behavioral health inpatient or residential facilities, emergency rooms or other short term crisis facilities, Arizona State Hospital (ASH), jails, prisons, or other criminal justice settings, or recently transition out of the Foster Care system. Institutional settings also include similar tribal settings or systems (e.g., tribal jails),
- Other Identified Housing Crisis or Instability – a “housing need” may also be established by the presence of the following indicators:
- Fleeing domestic violence or other living situation that may result in physical harm or violence,
- Living in a setting other living situation that may result in physical or behavioral health harm, illegality, violence or be otherwise inconsistent with member’s service or treatment plan (i.e., overcrowding, COVID exposure),
- Frequent physical or behavioral health inpatient hospitalization or treatment or Emergency Department or emergency department visits (three or more visits in past 12 months).
- Actual Homelessness: An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
Housing instability established and documented in at least two of the following indicators: Appropriate Z Code of “homelessness” or “housing instability” in medical record, Housing need assessed and identified an AHCCCS approved evidence-based assessment tool that incudes Housing assessment tool.
Housing is needed to “prevent disease, disability or other adverse conditions of progression, or to prolong life”, Permanent Housing and subsidy identified in an individual’s service plan, Member self-attestation of homelessness, or housing insecurity.
Prior or repeated past history of homelessness, evictions, or housing instability (three or more episodes in past 12 months or less) as documented to Contractor by individuals or entity with direct knowledge of housing condition or situation including peers, Community Based Organizations. (e.g., homeless providers, CoC, coordinated entry system, outreach teams)
AHP Administrator will not base housing eligibility criteria on the following: Prior evictions or rental history, Income or Poverty level Criminal Background, Substance Use Disorder including current substance abuse, use or prior history, Specific behavioral or physical health Diagnoses, and/or treatment Compliance or Program Participation.
2.10.4 Agency Staffing and Training
Maintain (and ensure its contracted providers maintain) a sufficient number of dedicated staff of housing professionals with knowledge, expertise, experience, and skills, to coordinate with the AHCCCS Housing Administrator and Providers to expedite housing processes, Demonstrate that the Contractor’s staff and provider housing program staff have received training, demonstrated competency and utilized evidence based practices to coordinate housing based supportive services to assist individuals in attaining and maintaining permanent housing placement and retention.
2.10.5 Provider Agency Audits
Provider Agencies are required to respond promptly to communications from AzCH-Complete Care Plan and/or AHCCCS, AHP Administrator and report Member information as requested. When member activity is affecting housing eligibility, tenancy status, or is indicative of a clinical problem, then the provider shall cooperate with and initiate, as necessary, an individualized service planning process or a staffing for any member who may be jeopardizing their housing eligibility. Providers must attend required meetings, including grievance, appeal and Service Plan hearings and Housing briefings.
Appropriate notice shall be given to provider agencies requested to attend these meetings. Providers must grant AzCH-Complete Care Plan and any other appropriate agent of the State or Federal government, or any of their duly authorized representatives, access to the provider’s facilities for the purpose of inspecting facilities and reviewing records. Providers must allow AzCH-Complete Care Plan to inspect, audit, monitor, and evaluate the Housing program Provider Organization Agreement during the term of the agreement, and within 365 days after the termination of the agreement.
Providers must make available to AzCH-Complete Care Plan, AHCCCS and a State and Federal government agency copies of all requested Housing Assistance Records within five (5) business days of any request at no charge. AzCH-Complete Care Plan, the AHCCCS, ADOH and HUD shall have full and complete rights to analyze, reproduce, duplicate, adapt, distribute, display, disclose and otherwise use all reports, information, data, and material prepared by the provider agency. RBHA to monitor housing providers for compliance with requirements of the SAMHSA Fidelity Monitoring as required. Provision of required housing specific data will require coordination with AHCCCS Housing Administrator.