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 with Special Circumstance

AMPM Chapter 300 Exhibit 300-2A, AHCCCS Covered Services Behavioral Health

AMPM Chapter 300 Exhibit 300-2B, AHCCCS Covered Non-Title XIX XXI Behavioral Health Services/

AMPM Chapter 300 310-B - Title XIX XXI Behavioral Health Service Benefit

AMPM Chapter 300, Exhibit 320-S, Observation Services

AMPM Chapter 300, Exhibit 320-T1 Block Grants and Discretionary Grants

AMPM Chapter 300, Exhibit 320-T2 Non-Title XIX XXI Services and Funding (Excluding Block Grants and Discretionary)

2.1.2     {Reserved}

2.1.3     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. See Section 13.1 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 9.5 Notice Requirements and Appeal Process (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

•   AMPM Chapter 300, Exhibit 320-T2 Non-Title XIX XXI Services and Funding (Excluding Block Grants and Discretionary)

 

 

2.1.4     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:

•  Medically necessary preconception counseling
• Pregnancy identification through the submission of Provider Manual Form 2.3.2 Notification of Pregnancy form (can be obtained by calling the Customer Service at 866-796-0542),
•  Medically necessary education and prenatal services for the care of pregnancy,
• Treatment of pregnancy related conditions,
•  Labor and delivery services,
•  Postpartum depression screening, and postpartum care.
• Doula services are covered, if provided by a certified doula acting within their scope of practice, as a complement to, but not replacement for, maternity care services.
• Maternity services may be provided in a group setting, more commonly known as group prenatal care, if requirements are met as outlined in AMPM Policy 410 - Maternity Care Services.

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 provide quality maternity care services with the goal of achieving optimal birth outcomes. 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 Customer Service at 866-796-0542). For members who are identified as being medically or socially at-risk/high-risk should be referred to the Health Plan to coordinate care with the member’s physical/behavioral health providers 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, and substance use disorders.

Members who transition to a new Health Plan 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.

The Health Plan confirms 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. https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/400/410.pdf

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 licensed midwives.

According to the American College of Obstetricians and Gynecologists (ACOG) guidelines, all cesarean section deliveries must be medically necessary and include medical documentation to attest to medical necessity. Inductions and cesarean section deliveries prior to 39 weeks must be medically necessary.  Any inductions performed prior to 39 weeks or cesarean sections performed at any time that are found to not be medically necessary based on nationally established criteria are not eligible for payment.

 

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, and 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 embers 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, interconception health and spacing, family planning options, including LARC/IPLARC options; importance of timely postpartum follow-up, breast feeding, dangers of lead exposure to parent and child, safe sleep and ways to reduce SIDS/SUID; support resources and programs including but not limited to WIC, home visiting programs, ADHS Breastfeeding Hotline, etc.; and other infant care information, as well as availability of assistance with medically necessary transportation. Providers are also required to educate members about the risks associated with 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 inform members of voluntary prenatal HIV/AIDS testing and the availability of medical counseling and treatment, as well as the benefits of treatment for birthing parent and baby, if the test is positive. In the event where a member loses eligibility, the member must be notified where they may obtain low-cost or no-cost maternity services. In preparation for delivery, it is important for providers to discuss pain management/pain treatment plan options with the member and offer Immediate Postpartum Long-Acting Reversible Contraception (IPLARC). For members with barriers to care, providers can contact the Health Plan Care Management Team to assist the member with 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.

Health Plan Care Management Staff are available to assist providers with managing pregnant members with substance use disorders. The AzCH-CCP Maternal Child Health Care Management Team can be reached by calling Customer Service at 1-866-796-0542 (TTY/TDD: 711); by faxing 1-844-816-6047; or by emailing AzCHChildClinicalServices@azcompletehealth.com. 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. All pregnant members must be screened for STI’s, including syphilis at the first prenatal visit, third trimester, and time of delivery.  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 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. Maternity care providers are encouraged to use the Arizona Perinatal Psychiatry Access Line (A-PAL) when questions surrounding mental health or substance use treatment, including medication management, arise.

 

2.2.3     Maternity Appointment Standards

Maternity care appointments for initial prenatal care for all pregnant 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.

Maternity care appointments are conducted within ACOG standards. Prenatal visits are to be completed as soon as possible, but no later than within the first trimester or 42 days after enrollment. Postpartum services can be provided for a full 12-month period that begins on the last day of pregnancy. This extends providers ability to address complications that contribute to postpartum morbidity and mortality and ensure ongoing mental health and management of infant care. Postpartum visit should occur on or between seven and 84 days after delivery. It is the provider's responsibility to monitor and evaluate maternal mortality and implementation of interventions to decrease pregnancy-related mortality and health disparities in the prenatal and postpartum periods. Providers shall submit to the Health Plan “zero dollar” claims for all prenatal and postpartum visits. For any questions, please reach out to your Provider Engagement Specialist or Customer Service.

 

 

 

2.2.4     Newborns

AHCCCS covers no less than 48 hours of inpatient hospital care after a routine vaginal delivery and no less than 96 hours of inpatient care after a cesarean delivery.

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:

• Circumcision (for males) is only covered when it is determined to be medically necessary. The procedure requires prior authorization by the Health Plan Medical Director or designee for enrolled members.
• Extended stays for newborns related to status of birthing parent’s stay:
  •  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 an agreement by the member, may discharge the member or newborn prior to the minimum length of stay. A newborn may be granted an extended stay in the hospital of birth when the member’s continued stay in the hospital is beyond the minimum 48- or 96-hour stay, whichever is applicable. In addition, if the member’s stay is to extend beyond 48/96 hours, an extended stay for the newborn shall be granted if the member’s condition allows for member-infant interaction and the child is not a ward of the State or is not to be adopted.
  • Home uterine monitoring technology:
  • AHCCCS covers medically necessary home uterine monitoring technology for members with premature labor contractions before 35 weeks gestation, as an alternative to hospitalization.
  •  If the member has one or more of the following conditions, home uterine monitoring may be considered:
    •  Multiple gestation, particularly triplets or quadruplets,
    • Previous obstetrical history of one or more births before 35 weeks gestation, or
    • Hospitalization for premature labor before 35 weeks gestation with a documented change in the cervix, controlled by Tocolysis and ready to be discharged for bed rest at home.
•   These guidelines refer to home uterine activity monitoring technology and do not refer to daily provider contact by telephone or home visit.
  •  Labor and delivery services provided in freestanding birthing centers.
  • Services rendered in a freestanding birthing center must be provided by a physician by a Certified Nurses midwife (CNM) who has hospital admitting privileges for labor and delivery services, or a Licensed Midwife (LM) who is following licensing and practice requirements as specified in A.A.C. R9-16-111-113.
  • 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. Risk status shall be determined by the attending physician or CNM using standardized assessment tools for high-risk pregnancies. The age of the member shall also be a consideration in the risk status evaluation, members younger than 18 years of age are generally considered high risk.
•  Labor and delivery services provided in a home setting:
  • For members who meet specified medical criteria, labor and delivery services provided in the home by the member’s maternity provider, physicians, CNMs, or LMs would be covered.
  • Only members with an anticipated uncomplicated prenatal course and a low-risk labor and delivery should deliver in member’s home.
  •  Risk status shall initially be determined at the time of the first visit, and each trimester thereafter, by the member’s maternity care provider, using current standardized assessments for high-risk pregnancies.
  •  A risk assessment shall be conducted when a new presenting complication or concern arises to ensure appropriate care and referral to a qualified provider, if necessary.
  • 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.
  • For anticipated home labor and delivery, LMs shall have a plan of action, including the name and address of an AHCCCS registered physician who can be contacted immediately and an acute care hospital in close proximity to the planned location of labor and delivery for referral in the event that complications should arise. This plan of action shall be submitted to the Health Plan Medical Director or designee for enrolled members.
  • Upon delivery of the newborn, the physician, CNM or LM is responsible for conducting newborn examination procedures, including a mandatory Bloodspot Newborn Screening Panel and referral of the infant to an appropriate health care provider for a mandatory hearing screening, as well as a second mandatory Bloodspot Newborn Screening Panel and a second newborn hearing screening (if infant’s first hearing screening indicates further assessment is needed). Refer the infant and/or member to an appropriate health care provider for follow-up care of any assessed problematic conditions.
  • In addition, the maternity care provider shall notify the birthing parent’s Health Plan, of the birth no later than one day from the date of birth, in order to enroll the newborn with AHCCCS.

 

2.2.6     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.

• Risk status shall initially be determined at the time of the first visit, and each trimester, thereafter, using the current standardized assessment criteria and protocols for high-risk pregnancies from the American College of Obstetricians and Gynecologists (ACOG) or Mutual Insurance Company of Arizona (MICA).
• A risk assessment from the ACOG or MICA shall be conducted when a new presenting complication or concern arises to ensure proper care and referral to a qualified physician or CNM, if necessary.
• Before providing midwife services, documentation certifying the risk status of the member’s pregnancy shall be submitted to the Health Plan. In addition, a consent form signed and dated by the member shall be submitted, indicating that the member has been informed and understands the scope of services that shall be provided by the  LM, including the risks to a home delivery. Members initially determined to have a high-risk pregnancy, or members whose physical condition changes to high-risk during the course of pregnancy, shall immediately be referred to an AHCCCS registered physician within the provider network of the member’s Health Plan for Maternity Care Services.
• Labor and delivery services provided by a LM cannot be provided in a hospital. LMs shall have a plan of action, including the name and address of an AHCCCS registered physician and an acute care hospital in close proximity to the planned location of labor and delivery for referral in the event that complications should arise. This plan of action shall be submitted to the Health Plan Medical Director or designee for enrolled members,
• Upon delivery of the newborn, the LM is responsible for conducting newborn examination procedures, including a mandatory Bloodspot Newborn Screening Panel and referral of the infant to an appropriate health care provider for a mandatory hearing screening, as well as a second mandatory Bloodspot Newborn Screening Panel and a second newborn hearing screening (if infant’s first hearing screening indicates further assessment is needed). Refer the infant and/or member to an appropriate health care provider for follow-up care of any assessed problematic conditions.
• In addition, the LM shall notify the birthing parent’s Health Plan, of the birth no later than one day from the date of birth, to enroll the newborn in AHCCCS.

 

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:

1. phenylketonuria
2. homocystinuria
3. maple syrup urine disease
4. galactosemia (requires soy formula)
5. beta keto-thiolase deficiency
6. citrullinemia
7. glutaric acidemia type I
8. 3 methylcrotonyl CoA carboxylase deficiency
9.  isovaleric acidemia
10. methylmalonic acidemia
11. propionic acidemia
12. arginosuccinic acidemia
13.  tyrosinemia type I
14. HMG CoA lyase deficiency
15. Very long chain acyl-CoA Dehydrogenase deficiency (VLCAD)
16.  Long Chain acyl-CoA Dehydrogenase deficiency (LCHAD)
17.  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.

 

Level of Care		Transfer Criteria
From	To
Primary	Secondary	1.        The nursing and medical staff of the sending hospital cannot provide: •    The level of care needed to manage the infant beyond stabilization to transport. •    The required diagnostic evaluation and consultation services needed. 2.        Transportation orders specify the type of transport, the training level of the transport crew and the level of life support
	Tertiary	Same as above
Secondary	Tertiary	Same as above
	Primary	Same as above
Tertiary	Tertiary (rare)	1.        The sending and receiving neonatologists (and surgeons, if involved) have spoken and agreed that the transfer is safe. 2.        The infant is expected to remain stable, considering the period of time required for the distance to be traveled. 3.        Transport orders specify the type of transport and training level of the transport crew.
	Secondary	Same as above
	Primary	Same as above

 

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 based upon the NOP form submitted by provider or member. The Health Plan Maternal Child Health Care Management Team can be reached by calling Customer Service at 1-866-796-0542 (TTY/TDD: 711); by faxing 1-844-816-6047; or by emailing AzCHChildClinicalServices@azcompletehealth.com.

 

The Health Plan’s Maternal Child Health Team 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. The Maternal Child Health Team take a collaborative approach in working with outpatient behavioral health providers, PCPs and OB/GYNs to engage high risk pregnant members throughout their pregnancy and postpartum period. Members who present with high-risk perinatal conditions should be referred to the Health Plan care management team. 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.
• Hyperemesis.
• Poor weight gain.
• Advanced maternal age.
•  Member populations identified as having high mortality rates
• 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 providers, 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 use 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 providers, PCPs, OB/GYNs and other treating providers are expected to ask about pregnancy status when members call for appointments, and 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 Customer Service at 1-866-796-0542) 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 and OBGYNs 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 Department of Health Services (ADHS) 24 hour Breastfeeding Hot Line at 800-833-4642.

2.1.12   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 (TTY/TDD: 711) 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, regardless of gender, who choose to delay or prevent pregnancy.

Covered family planning services and supplies for members include the following medical, surgical, pharmacological, and laboratory services as well as contraceptive devices (including Intrauterine Devices (IUDs) and subdermal implantable contraceptives):

1. Contraceptive counseling, and/or medication and supplies, including, but not limited to oral and injectable contraceptives, LARC (Long-Acting Reversible Contraceptive) (including placement of Immediate Postpartum Long-Acting Reversible Contraceptives [IPLARC]), diaphragms, condoms, foams and suppositories.
2. Associated medical and laboratory examinations and radiological procedures, including ultrasound studies related to family planning.
3. Treatment of complications resulting from contraceptive use, including emergency treatment.
4. Natural family planning education or referral to qualified health professionals.
5. Post-coital emergency oral contraception within 72 hours after unprotected sexual intercourse (mifepristone, also known as Mifeprex or RU-486, is not a post-coital emergency oral contraception).
6. Sterilization:
   1.  Clarification related to hysteroscopic tubal sterilization:
      • 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. Therefore, during the first three months the member must continue using another form of birth control to prevent pregnancy, and
      • At the end of the three months, it is expected that a hysterosalpingogram will be performed confirming that the member is sterile. After the confirmatory test, the member is considered sterile.

Coverage for the following family planning services are as follows:

1. Pregnancy screening is a covered service.
2. Pharmaceuticals are covered when associated with medical conditions related to family planning or other medical conditions.
3. Screening and treatment for Sexually Transmitted Infections (STI) are covered services for members, regardless of gender. This includes testing members, beginning at age 15 years, for syphilis at least annually.
4. Sterilization services are covered regardless of member’s gender when the requirements specified in AHCCCS Policy for sterilization services are met (including hysteroscopic tubal sterilizations, if available), and Sterilization services are covered regardless of member’s gender when the requirements specified in AHCCCS Policy for sterilization services are met (including hysteroscopic tubal sterilizations, if available).
5. Pregnancy termination is covered only as specified in AMPM Policy 410.

Limitations - The following are not covered for the purpose of family planning services and supplies:

1. Infertility services including diagnostic testing, treatment services and reversal of surgically induced infertility,
2. Pregnancy termination counseling,
3.  Pregnancy terminations except as specified in AMPM Policy 410, and
4. Hysterectomies for the purpose of sterilization. Refer to AMPM Policy 310-L for hysterectomy coverage requirements.

 

2.1.1     Requirements for Providing Family Planning Services and Supplies

Providers are required to collaborate with the Health Plan to implement effective family planning services which includes:

1. Notifying members of reproductive age of the specific covered family planning services and supplies 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 and supplies available, including counseling regarding availability and benefits of LARC and IPLARC;
   • Information advising how to request/obtain these services.
   •  Information that assistance with scheduling is available; and
   • A statement that there is no copayment or other charge for family planning services and supplies.
   •  A statement that medically necessary transportation services are available.
2. 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 services and supplies.
3. Provide translation/interpretation of information related to family planning in accordance with the requirements of the cultural competency policy. (See Section 10.2 Cultural Competence System of Care Requirements).
4. 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.
5. 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:

• Informing pregnant members by the end of the second trimester of family planning services and supplies and how to request them, including information on LARC/IPLARC.
• 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.
• Notify members of reproductive age either directly or to the appropriate Health Care Decision Maker (HCDM), whichever is most appropriate, of the specific covered family planning services and supplies available to them, and a plan to deliver those services to members who request them.
  • Members of any age whose sexual behavior exposes them to possible conception or Sexually Transmitted Infections (STIs) 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 infections, 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. Information should include all of the family planning services and supplies covered through AHCCCS as well as instructions to members regarding how to access these services and supplies. 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 infections (including HIV/AIDS). Such discussions must be documented in the member’s medical record.

 

2.3.2     Sterilization

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 the sterilization of a member to occur:

•  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 The Health Plan.
• Mental competency is determined; member has not been declared mentally incompetent.
• 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 shall have been given a copy of the consent form and offered factual information that includes all of the following:

1. Consent form requirements (specified in 42 CFR 441.250 et seq.),
2.  Answers to questions asked regarding the specific procedure to be performed.
3.  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.
4. A description of available alternative methods.
5. Advice that the sterilization procedure is considered to be irreversible,
6.  A thorough explanation of the specific sterilization procedure to be performed,
7. A description of available alternative methods
8.  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.
9. A full description of the advantages or disadvantages that may be expected as a result of the sterilization; and
10. Notification that sterilization cannot be performed for at least 30 days post consent.
11. 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. Therefore, during the first three months the member must continue using another form of birth control to prevent pregnancy. At the end of the three months, it is expected that a hysterosalpingogram will be performed confirming that the member is sterile. After the confirmatory test, the member is considered sterile.  

 

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/Health care Decision Maker (HCDM) indicating approval of the pregnancy termination procedure is required.

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 to which it was reported, the report number (if available), and the date that the report was filed. This documentation requirement shall be waived if the treating provider certifies that, in his/her/their professional opinion, the member was unable, for physical or psychological reasons, to comply with the requirement.

Follow Food and Drug Administration (FDA) medication guidance for the use of medications to end a pregnancy. Current standards of care per ACOG shall be utilized when the duration of pregnancy is unknown or if ectopic pregnancy is suspected.

Pregnancy termination by surgery is recommended in cases when medications are used and fail to induce termination of the pregnancy. When medications are administered, the following documentation is also required:

•  Name of medication(s) used,
• Duration of pregnancy in days,
•  The date medication was given,
• The date any additional medications were given (unless a complete abortion was already confirmed), 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. The Health Plan monitors all claims and encounters with a primary diagnosis of pregnancy termination.

To obtain authorization for sterilization, complete the applicable forms:

• ·AHCCCS AMPM, Chapter 400, Exhibit 420

 (Consent for Sterilization Form) and

• AHCCCS AMPM, Chapter 800, Exhibit 820-1

 (Hysterectomy Consent and Acknowledgement Form)

• Forms can be located on the AHCCCS Website 

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) https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/400/410C.docx 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 include:

•  The benefits of preventive care,
•  A complete description of services available,
• Assistance in obtaining information on how to obtain medically necessary transportation,
•  A statement that there is no copayment or other charges for the preventive care.

The information must also 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 

As such, the annual preventative care visit is inclusive of a minimum of the following:

1. A physical exam (well exam) that assesses overall health.
2. Clinical breast exam (if/as necessary).
3. Pelvic exam (if/as necessary, according to current recommendations and best standards of practice).
4. Review and administration of immunizations, screenings and testing as appropriate for age and risk factors. NOTE: Genetic screening and testing is not covered.
5. Screening and counseling are 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:
   1. Proper nutrition.
   2. Physical activity.
   3.  Elevated BMI indicative of obesity.
   4. Tobacco/substance use, abuse, and/or dependency.
   5. Depression screening.
   6. 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.
   7.  Sexually transmitted infections.
   8.  Human Immunodeficiency Virus (HIV); and
   9.  Family planning counseling and supplies.
   10. Preconception counseling that includes discussion regarding a healthy lifestyle before and between pregnancies that includes: (NOTE: Preconception counseling does not include genetic testing.)
       •  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 use; and
       •  Recommended intervals between pregnancies.

• 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 45 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 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 up to 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/Health Care Decision Makers (HCDMs)/Designated
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 up to 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.Representatives (DRsHealth Care Decision Makers (HCDMs)/Designated
Representatives (DRs

EPSDT services include all screenings and services described below, as well as the referenced AHCCCS EPSDT Periodicity Schedule (AHCCCS Medical Policy Manual [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:

1. Immunizations.
2.  Blood Led Screening;
3. Covered Transplantation Services (refer to AHCCCS AMPM, Chapter 310 / for detailed coverage).
4. Metabolic Medical Foods.
5. Nutritional Therapy.
6. Oral Health Services.
7. Cochlear and Osseointegrated Implantation;
8. Conscious Sedation;
9. Behavioral Health Services;
10.  Religious Non-Medical Health Care Institution Services;
11.  Care Management Services;
12. Chiropractic Services;
13.  Personal Care Services;
14. Incontinence Briefs;
15. Medically Necessary Therapies;
16. Breastfeeding Support.
17. Pasteurized Human Donor Milk.

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/HCDM/DR  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, vision services, hearing services, eyeglasses, transportation, and family planning services and supplies, women’s preventive care services and
maternity care services when applicable. Long Term Services and Supports (LTSS)
must also be considered when needs are identified. 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:

1.  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;
2. Complete a developmental screening 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;
3.  Complete the Autism Spectrum Disorder (ASD) Specific Developmental Screening at the 18 month and 24 month visits;
4.  Per AAP recommendation,  ensure that families receive evidence-based breastfeeding information and support;
5.  Document immunizations within 30 days of administration of an immunization into the Arizona State Immunization Information System (ASIIS);
6.  Enroll every year in the Vaccines for Children (VFC) program;
7. Use and complete all applicable elements of the AHCCCS EPSDT Clinical Sample Templates as required by the AHCCCS AMPM, Chapter 430, Attachment E ,  (or an electronic equivalent that includes all components from the hard-copy form);
8.  Provide and document EPSDT screening services in accordance with the AHCCCS EPSDT Periodicity Schedule (AHCCCS AMPM, Chapter 430, Attachment A) and the Dental Periodicity Schedule (AHCCCS AMPM Chapter 431, Attachment A);
9.  Refer members for follow up, diagnosis and treatment, ensuring that treatment is initiated within 60 days of screening services;
10. If appropriate, document in the medical record the member’s/HCDM’s/DR’s decision not to utilize EPSDT services or receive immunizations;
11.  Document a health assessment on each EPSDT participant. The assesssment 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;
12. Ensure all infants receive both the first and second newborn screening tests;
13.  Ensure all infants with confirmed hearing loss receive services prior to turning six months of age;
14. Implement protocols for care and coordination of members who received Tuberculosis (TB) testing to ensure timely reading of the TB skin test and treatment, if medically necessary;
15.  Send copies of the completed AHCCCS EPSDT Clinical Sample Templates to the Health Plan’s Quality Management Department by secure fax at (844) 266-5339;
16. 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), ;
17. Schedule the next appointment at the time of the current office visit for children ages 24 months and younger;
18. Submit claims for EPSDT services  on a CMS 1500 form (formerly HCFA). Providers must bill for preventative EPSDT services using the preventive service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier;
19. Refer members to Children’s Rehabilitative Services (CRS) when they have conditions covered by the CRS program;
20. Initiate and coordinate referrals to ALTCS, Audiology, 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.

Each Hospital or birthing center shall screen all newborns using a physiological hearing screening method prior to initial hospital discharge, including outpatient re-screening for babies who were missed or are referred from the initial screening. Outpatient re-screening shall be scheduled at the time of the initial discharge and completed between two and six weeks of age. Additionally, when there is an indication that a newborn or infant may have a hearing loss or congenital disorder, the family shall be referred to the PCP for appropriate assessment, care coordination and referral(s).

 

2.4.3     A Well-Child Exam Basic Elements

A Well-Child exam includes the following elements:

1.  Comprehensive health and developmental history, including growth and development screening PER 42 CFR 441.56(b)(1) which includes physical, nutritional, and behavioral health assessments;
2. Developmental screening.  Providers are required to complete a developmental screening 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 surveilance with anticipatory guidance is part of each EPSDT visit so that if concerns are noted, a screening can be done.
3.  Autism Spectrum Disorder (ASD) Specific Developmental Screening at the 18 month and 24 month visits;
4. A comprehensive unclothed physical examination;
5. Appropriate immunizations according to age and health history;
6.  Laboratory tests appropriate to age and risk for blood lead, tuberculosis, anemia and sickle cell trait;
7.  Yearly syphilis testing for EPSDT-eligible members who are 15 years of age and older. Testing may be performed for members under the age of 15 at the discretion of the provider, based on risk.
8. Health education, counseling, chronic disease self-management, counseling about child development, healthy lifestyles and accident and disease prevention;
9. 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;
10. Fluoride varnish application as often as every three months between the ages of 6 months and 5 years of age, after the eruption of the first tooth (by providers who have completed training);
11. Provide appropriate vision and hearing/speech testing;
12. Nutritional Screening by a PCP;
13. Nutritional Assessment by a PCP;
14. Obesity screening using the body mass index (BMI) percentile for children (or weight-for-length percentile for members less than two years of age). Refer to the Centers for Disease Control and Prevention (CDC) for Body Mass Index (BMI) and growth chart resources;
15.  Behavioral health screening, referrals, and services, including adolescent suicide and depression screening annually beginning t 10 years of age,  postpartum depression screening of mother/parent during the one, two, four and six-month Well-Child visits, and adolescent substance use disorder screening (SUD) annually beginning at 12 years of age;
16. 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 a Human Immunodeficiency Virus (HIV) infected person or the child is infected with HIV, and/or
    • Traveling/emigrating from, or having significant contact with persons indigenous to, endemic countries;
17. Provision of anticipatory guidance;
18. Vision exam appropriate to age, according to the AHCCCS EPSDT Periodicity Schedule; and
19. 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 a Well-Child Visit

A “sick visit” can be performed at the same time as a Well-Child if a separately billable service if:

1. 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.
2. The “sick visit” is documented on a separate note in the medical record.
3. The history, exam, and medical decision-making components of the separate “sick visit” already performed during the course of an Well-Child visit are not to be considered when determining the level of the additional service (CPT Code 99202-99215). 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 Well-Child visit and should not be billed separately.
4. The current status (not history) of the abnormality or preexisting condition is the basis of determining medical necessity. Resource Coding Related Exhibits and Policy Reference, EPSDT Service Code
5.  

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 the most up to date  developmental screening tools. Training resources may be found at the Arizona Department of Health Services.

The following developmental screening tools are available for members at their 9-, 18- and 30-month Well-Child visit:

• Accepted tools are described in the CMS Core Measure Developmental Screening in the First Three Years of Life and shall be used for screening purposes. Technical specifications for the measure can be accessed here
• Autism Spectrum Disorder (ASD) Specific Developmental Screening should occur at the 18 months and 24 month Well-Child visits;
• ASD specific developmental screening should occur at the 18 months and 24 months Well-Child visits. Accepted tools are described in the CMS Core Measure, Developmental Screening in the First Three Years of Life (DEV) Measure Specifications, and shall be used for screening purposes.

An additional payment for use of screening tools is covered when the following criteria are met:

• The member’s Well-Child 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 with Z13.42 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 Well-Child visit. Training resources may be found at the Arizona Department of Health Services website 

Application of fluoride varnish may be billed separately from the Well-Child visit using CPT Code 99188. Fluoride varnish can be applied as often as every three months between the ages of 6 months and 5 years of age, after the eruption of the first tooth. Application of fluoride varnish by the PCP does not take the place of a visit at the dental provider.

 

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  months through six years who have not been previously tested or who missed either the 12- 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 HCDM/DR concerns.
• Additional screening for children through six years of age must be provided utilizing the Arizona Department of Health Services (ADHS) Parent Questionnaire based on the child’s risk, as determined by either the member’s residential zip code or presence of other known risk factors.
• All blood lead levels 10-45 µg/dL must be reported to ADHS by providers within five working days. For blood lead levels ≥ 45 µg/dL, providers must report within one working day or as determined by CDC recommendations to ADHS (A.A.C. R9-4-302).
•  In-office capillary blood draws utilizing validated CLIA waived testing equipment will be covered for in-network point of care Well-Child visits.

2.4.8     Missed/No-Show EPSDT Appointments

Providers are expected to follow up with member's HCDM/DR 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 (AzCH EPSDT Provider Quick Reference Guide). 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 Program (AzEIP)

AHCCCS and AzEIP jointly developed procedures for the coordination of services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and AzEIP to ensure the coordination and provision of EPSDT and AzEIP services to children birth up to three years of age who are identified with developmental disabilities.

PCP-Initiated 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.
• AzEIP providers may only be reimbursed:
  • If they are AHCCCS registered and
  • for the categories of services for which they are registered and that were provided.  Billing must be completed in accordance with AHCCCS guidelines.
• The AHCCCS AzEIP Speech Therapy Fee Schedule shall be utilized for payment of speech services when provided to an AHCCCS member who is receiving AzEIP services unless the Contractor intends to contract for AzEIP services and has notified AHCCCS of the proposed rates in advance.

The Health Plan provides a decision as expeditiously as the member’s health condition requires, but not later than 48 hours following the receipt of a standard authorization request, with a possible extension of up to 48 hours 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:

1.  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;
2. The Health Plan authorizes services with a participating provider whenever possible;
3. 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;
4. 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.;
5. 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.

If the requested services do not show a 50% developmental delay:

• If the evaluation report received by a PCP, licensed provider, or AzEIP indicated that the child does not have a 50% developmental delay, medically needed services and therapies will be provided as needed.
• The Health Plan EPSDT Coordinator will continue to coordinate medically necessary care and services for the child, including anticipatory guidance for the member’s HCDM/DR or physician.
• The EPSDT services are provided by the Health Plan until the services are determined to no longer be medically necessary.

 

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 Health Care Decision Maker/Designated 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:

1.   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;
2.  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
3. 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 staffing 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.

Copayments

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 two 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	Obese
85th to < 95th percentile	Overweight
5th to < 85th percentile	Healthy Weight
< 5th percentile	Underweight

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, Diagnostic 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, Total Parenteral Nutrition (TPN ) therapy, 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.     

• Pasteurized Human Donor Milk
  • Medically necessary pasteurized human donor milk is a covered service for EPSDT-eligible infants who cannot tolerate or have a medical contraindication to formula use, under conditions specified in AMPM 430.

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 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.

Providers are required to provide education, support and training, if the member, parent or guardian elects to prepare the member's food, regarding proper sanitation and temperatures to avoid contamination of foods that are blended or specially prepared for the member, and provide encouragement and assistance to the HCDM/DR in weaning the member from the necessity for supplemental nutritional feedings.

 

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 Certificate of Medical Necessity for Commercial Oral Nutritional Supplements for and indicate on the form which criteria were met when assessing medical necessity of providing commercial oral nutritional supplements.

2.4.15   Behavioral Health Screening and Services Provided by a PCP

Behavioral health services are covered for members eligible for EPSDT. PCP’s may provide behavioral health services within their scope of practice. Refer to (AHCCCS AMPM, Chapter 510), 

American Indian/Alaska Native members may receive behavioral health services through an Indian Health Service or tribally operated 638 facility, regardless of Health Plan enrollment or behavioral health assignment.

Screenings including:

1. Postpartum consisting of a standard criterion-referenced screening tool to be performed for screening the birthing parent for signs and symptoms of postpartum depression during the one-, two-, four- and six-month Well-Child visits. Positive screening results require referral to appropriate case managers and services at the respective maternal Health Plan, and
2. Adolescent Suicide consisting of a standardized, criterion-referenced screening tool specific for suicide and depression shall be performed at annual Well-Child visits beginning at age 10 years of age. Positive screening results require appropriate and timely referral for further evaluation and service provision.
3. Adolescent Substance Use Disorder (SUD) screening consisting of a standard criterion-referenced screening tool specific for substance use shall be performed at annual Well-Child visits beginning at 12 years of age. Positive screening results require appropriate and timely referral for further evaluation and service provision.

A developmental surveillance with anticipatory guidance must be performed by the PCP at each Well-Child visit.

The Health Plan has a comprehensive dental network for members. To serve the needs of its members, the Health Plan partners with Centene Dental who administers the Health Plan’s dental benefits. Dental Providers must submit claims and prior authorizations to Centene Dental, or by phone at 844-876-2028. For dental related issues, providers should contact the Health Plan at AZCHQualityManagement@azcompletehealth.com.

The Health Plan offers dental services for:

•  Oral Health Care for Early and Periodic Screening, Diagnostic 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 5 years of age
•  Emergency dental services coverage up to $1000 for members age 21 years and older

Eligible EPSDT members up to 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 the Health Care Decision Maker(HCDM)/Designated Representative (DR) 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 the AHCCCS AMPM, Chapter 431, 

 

2.51.1     Oral Health Care For EPSDT-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 business days from the request.
•  ROUTINE- Within 45 calendar days of request.

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 (AHCCCS AMPM Chapter 430). Evidence of this referral must be documented on the AHCCCS Clinical Sample Template 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 Well-Child Visit as often as every three months between the ages of 6 months and 5 years of age, after the eruption of the first tooth.

AHCCCS recommended training for fluoride varnish application . 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 Plan via 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 (AHCCCS AMPM Chapter 431, Attachment A).  Evidence of this referral must be documented on the AHCCCS Clinical Visit Sample Template 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, , including but not limited to:

• Diagnostic services include comprehensive and periodic examinations. The Health Plan allows two oral examinations and two oral prophylaxes per member per year for all members up to 21 years of age. For members up to five (5) years of age,  fluoride varnish may be applied four times a year (i.e., one every three months). 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:

• Oral prophylaxis performed by a dentist or dental hygienist which includes self-care oral hygiene instructions to member, if able, or to the HCDM/DR;
• 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 twice per first or second molar, per provider/location, allowing for three years intervention between application up to 15 years of age. This includes the ADHS school-based dental sealant program (Cavity Free AZ) and the participating providers. Additional applications must be deemed medically necessary; and
• Space maintainers when posterior primary teeth are lost and when deemed medically necessary.

 

 

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.

These services include, but are not limited to:

1.  Periodontal procedures, scaling/root planing, curettage, gingivectomy, and osseous surgery;
2.  Crowns:
   1.  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
   2. 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.
3. 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);
4. 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;
5.  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;
6.  Removable dental prosthetics, including complete dentures and removable partial dentures; and
7.  Orthodontic services and orthognathic surgery are covered only when these services are 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 dental provider 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:

1.  Congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services;
2. Trauma requiring surgical treatment in addition to orthodontic services; or
3. Skeletal discrepancy involving maxillary and/or mandibular structures.

 

2.1.5     Emergency Dental Coverage for Members Under 21 Years of Age

EPSDT covers the following emergency dental services:

1. Treatment for pain, infection, swelling and/or injury;
2. 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
3. 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 (AHCCCS AMPM, Chapter 430, Section E, Item No. 8) regarding conscious sedation, https://www.azahcccs.gov/shared/MedicalPolicyManual/.

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:

1. Emergency dental services up to $1,000 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 (AHCCCS AMPM, Chapter 310-D1, Section B), ;
2.  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 and A.A.C. R9-28-202(A));
3. 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 $1,000 adult emergency dental limit.

The following services and procedures are covered as emergency dental services:

1.  Emergency oral diagnostic examination (limited oral examination – problem focused);
2. Radiographs and laboratory services, limited to the symptomatic teeth;
3. Composite resin due to recent tooth fracture for anterior teeth;
4.  Prefabricated crowns, to eliminate pain due to recent tooth fracture only;
5. Recementation of clinically sound inlays, onlays, crowns, and fixed bridges;
6. Pulp cap, direct or indirect plus filling;
7. Root canals and vital pulpotomies when indicated for the treatment of acute infection or to eliminate pain;
8. Apicoectomy performed as a separate procedure, for treatment of acute infection or to eliminate pain, with favorable prognosis;
9.  Immediate and palliative procedures, including extractions if medically necessary, for relief of pain associated with an oral or maxillofacial condition,
10. Tooth reimplantation of accidentally avulsed or displaced anterior tooth, with favorable prognosis;
11. Temporary restoration which provides palliative/sedative care (limited to the tooth receiving emergency treatment);
12. Initial treatment for acute infection, including, but not limited to, periapical and periodontal infections and abscesses by appropriate methods;
13. Preoperative procedures and anesthesia appropriate for optimal patient management; and
14.  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.

 

2.5.8     Limitations

Adult Emergency Dental Services Limitations for Persons age 21 Years and Older.

1.  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.
2. Diagnosis and treatment of temporomandibular joint dysfunction (TMD or TMJ) is not covered except for the reduction of trauma.
3. Routine restorative procedures and routine root canal therapy are not emergency dental services and are not covered.
4. 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.
5. Fixed bridgework to replace missing teeth is not covered.
6. Dentures are not covered.

Exceptions for Transplants, Members with Cancer and Ventilator Cases

• Transplant Cases: For members who require medically necessary dental services as a pre-requisite to AHCCCS-covered organ or tissue transplantation, covered dental services include the elimination of oral infections and the treatment of oral disease, which include dental cleanings, treatment of periodontal disease, medically necessary extractions, and the provision of simple restorations. For purposes of this Policy, a simple restoration means silver amalgam and/or composite resin fillings, stainless steel crowns or preformed crowns. AHCCCS 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 $1,000 adult emergency dental limit.
• Members with Cancer: Covered dental services are limited to prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head is covered. These services are not subject to the $1000 adult emergency dental limit.
• 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 $1,000 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 $1,000 annual limit is permitted only when the provider meets the requirements of A.A.C R9-22-702 and/or A.A.C. R9-28-701.10.

In order to bill the member for emergency dental services exceeding the $1,000 limit, the provider must first inform the member in a way s/he understands, that the requested dental service exceeds the $1,000 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 $1,000 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, the member’s HCDM/DR 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.

1. Informed consent for oral health treatment:
   1.  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
   2. A separate written consent for any irreversible, invasive procedure, including but not limited to dental fillings, pulpotomies. In addition, a written treatment plan shall be reviewed and signed by both parties, as described below, with the member’s HCDM/DR receiving a copy of the complete treatment plan.
2. 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 member, member’s HCDM/DR. 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 member or members HCDM/DR. 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 $1,000 emergency dental limit.

Dentist performing general anesthesia on adult emergency members must bill dental codes that count towards the $1,000 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 $1,000 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 HCDM/DR. 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 (AHCCCS AMPM Chapter 430, Attachment A) 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 identified through an oral screening;
• Document evidence of referrals on the AHCCCS Clinical Visit Sample Template 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 Dental Periodicity Schedule (AHCCCS AMPM Chapter 431, Attachment A).
• Encourage eligible members to see a dentist regularly.

Although the AHCCCS Dental Periodicity Schedule (AHCCCS 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:

1. Comprehensive oral health care, including acute care and preventive services in accordance with the AHCCCS Dental Periodicity Schedule, (AHCCCS AMPM 431, Attachment A), 
2. Comprehensive assessment for oral diseases and conditions;
3. Individualized preventive dental health program based upon a caries-risk assessment and a periodontal disease risk assessment;
4.  Anticipatory guidance about growth and development issues (such as teething, digit or pacifier habits);
5. Plan for acute dental trauma;
6. 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;
7. Dietary counseling; and
8. Referrals to dental specialists when care cannot directly be provided within the Dental Home.

Members must be assigned to a dental home by six months of age or upon assignment to a contractor and seen by a dentist for routine preventive care according to the AHCCCS Dental Periodicity Schedule (AHCCCS AMPM, Chapter 431, Attachment A),https://www.azahcccs.gov/shared/MedicalPolicyManual/. 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 Centene Vision Services.

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 Age 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 photo screening with interpretation and report, bilateral (CPT code 99177) is covered for children aged three (3) to six (6) as part of the EPSDT visit due to challenges with a child’s ability to cooperate with traditional vision screening techniques. Ocular photo screening 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 Centene Vision Services at https://visionbenefits.envolvehealth.com/.

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 Centene Vision Services. 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 Older

All medical vision services should be verified with the Health Plan. Centene Vision Services 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 Well-Child 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 9 and 10 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 at  for current immunization schedules.

For adult immunization coverage, refer to AHCCCS AMPM, Chapter 310-M, for AHCCCS Covered Services, or to the CDC website at  for adult immunization recommendations.

2.7.1     Vaccines 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.

1. Providers must coordinate with the Arizona Department of Health Services Vaccines for Children (VFC) program in the delivery of immunization services.
2. Providers must enroll and re-enroll annually with the VFC program in accordance with AHCCCS Contract requirements.
3. Providers will not utilize AHCCCS funding to purchase VFC vaccines for members over 19 years of age.
4. Providers shall maintain a sufficient supply of vaccines for EPSDT aged members.
5. Immunizations must be provided according to the Advisory Committee on Immunization Practices (ACIP) Recommended Schedule or when medically necessary for the member’s health.
6. 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.
7. 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.
8. 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 2020..

 

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:

1. Telephone crisis intervention services provided by the Health Plan contracted Crisis Call Center available 24 hours per day, seven days a week:
2.  All Arizona Residents: can access  crisis services by calling 844-534-4673, via text 4HOPE (44673), or via chat crisis.solari-inc.org/start-a-chat.
3. Mobile crisis intervention services, available 24 hours per day, seven days a week and can be activated/contacted via the crisis line.
   •  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.
4.  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.
   • All Arizona residents can access crisis services by calling 844-534-4673, via text 4HOPE (44673), or via chat.
5.  Up to 24 hours of additional crisis stabilization as funding is available for mental health and substance use disorder related services.

For assistance in finding services near you:

• Call 844-534-4673.
• Text 4HOPE (44673), or
• Chat .

 

For program requirements related to the Health Plan Crisis Intervention Services, see Section 15 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 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 SMI 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, or through the Statewide Crisis Line). It is not a second responder crisis service if it is preventative care. 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.

Program**	Location	Population	Funds	Referral process	2nd responder paperwork required
The Hope, Inc. Peer After Crisis Team (PACT)	Pima	All adult members: T19 and NT19	NT19 & T19	Referred 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	Yuma	All adult members: T19 and NT19	NT19 & T19	Referred by a crisis provider	Short assessment & crisis treatment plan.  DX on claim must match DX in the second responder chart.
Devereux - BOOST Placement Preservation	Pima	All T19 CMDP enrolled children in DCS custody	T19	Referred by a crisis provider	Short assessment & crisis treatment plan.  DX on claim must match DX in the second responder chart.
Old Pueblo Housing	Pima	All SMI designated members; Both T19 and NT19	NT19 & T19 SMI	Referred by a crisis provider	Short assessment & crisis treatment plan.  DX on claim must match DX in the second responder chart.
Southwest Behavioral Health	Mohave Coconino	All youth members:  T19 and NT19	NT19 & T19	Referred by a crisis provider	Short assessment & crisis treatment plan.  DX on claim must match DX in the second responder chart.
Spectrum	Coconino Yavapai	All youth members:  T19 and NT19	NT19 & T19	Referred by a crisis provider	Short assessment & crisis treatment plan.  DX on claim must match DX in the second responder chart.

 

2.10.1     AHCCCS Housing Program Overview

AHCCCS provides housing programs throughout Arizona, through the AHCCCS Housing Program (AHP). AHP comprises permanent supportive housing and supportive services. AHCCCS recognizes that supportive services are critical to housing stability. AHP promotes a Housing First model in accordance with best practices as defined by the Substance Abuse and Mental Health Service Administration (SAMHSA), called Permanent Supportive Housing (PSH). PSH includes subsidies (help with the finances of housing) and services.  AHCCCS, PSH, and AzCH-CCP hold to the belief that people with mental illness have the right to choose their home, and live by themselves, without any special rules or service requirements.

AzCH-CCP partners with AHCCCS to provide members with options for housing and support services. Arizona Behavioral Health Corporation (ABC) is the Statewide Housing Administrator for AHP. AHP manages subsidies (administered through ABC Housing and HOM Inc.) and most of the AHCCCS-funded housing subsidies support members with a Serious Mental Illness (SMI) designation but limited funding may be available for General Mental Health and/or substance use disorder (GMHSU) needs. Refer to ABC’S website (https://azabc.org/) for more details about AHP, member eligibility, and how to refer members to AHP. The ABC site for referring to AHP is here: https://azabc.org/ahp-housing-application/. ABC’s role includes coordinating referrals, managing the Statewide Housing Waitlists in accordance with AHCCCS identified waitlist priorities, and training on the AHP application process for referring providers and members.

PSH supportive services for members in AHCCCS subsidized housing are funded by Medicaid and managed by AzCH-CCP as part of the AzCH-CCP PSH network. AzCH-CCP oversees the service aspect of PHC, with help from our robust statewide network of EBP PSH providers. Providers ensure that caseloads for their dedicated EBP PSH staff are aligned with SAMHSA EBP PSH fidelity ratios. PSH services help members in need of support to attain and retain stable housing. Evidence Based Permanent (EBP) PSH programs are provided to members with a designation of Serious Mental Illness (SMI).

PSH services include but are not limited to finding and selecting safe housing, help learning about and developing daily living skills, help with daily functions of life, case management (including SOAR assistance for SSDI applications), conflict resolution, communication with landlords, and more.

To locate a EBP PSH provider in your county, or for a member, please see the PSH Network list on the AzCH-CCP Find a Provider website (https://www.azcompletehealth.com/find-a-doctor.html ) or contact the AzCH-CCP Housing Team: AzCHHousing@azcompletehealth.com.

 

2.10.2 Accessing Statewide Housing Resources and PSH Services

AzCH-CCP ensures there are enough EBP PSH services offered continuously, in the member’s choice of location. EBP PSH services are available to all eligible members, regardless of their housing location. PSH services aim to help people maintain permanent housing in the community of their choice.   

 

AzCH-CCP helps connect members with local community and housing resources and assists with care coordination.  The AzCH-CCP housing team can be reached by email at AzCHHousing@azcompletehealth.com or by calling Provider Customer Services (1-866-796-0542) and asking to speak with a Housing Management Specialist or Housing Liaison. 

Applying for AHP:

The member must meet the following eligibility criteria:

• Be a member with an SMI (T19 and Nt19) or GMHSU (T19/Medicaid eligible) designation AND be determined High Need/High Cost by AzCH-CCP (or another health plan when relevant).
• Be a United States citizen or have eligible immigrant status.
• Be at least 18 years old.
• Have an identified homeless or housing need documented by the member’s clinical provider or treatment team.

 

The referring agency must be approved by AHCCCS.  AHCCCS Managed Care Organizations (MCOs) and their contracted providers, including but not limited to health homes, behavioral health providers, SMI clinics/BH health homes, and integrated clinics, and residential facilities are qualified representatives.  (American Indian Health Program providers for applicable Fee-for-Service members, Tribal Regional Behavioral Health Authorities (TRBHAs), Tribal ALTCS, Indian Health Service facilities, tribally owned or operated 638 facilities, and Project for Assistance to Transition from Homelessness (PATH) Team are other qualifying representatives.)

 

For additional details please see the AHCCCS Housing Program Guidebook, at their website: https://www.azahcccs.gov/AHCCCS/Initiatives/AHP/

 

Arizona Balance of State Continuum of Care

AzCH-CCP provides a sufficient network of AHCCCS Housing Providers (AHP) and partners with AHCCCS, ABC Housing, and HOM Inc. to ensure health plan Permanent Supportive Housing (PSH) policy and procedures are consistent with AHCCCS policies and guidelines.  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.

When a member identifies a need for housing services and/or for housing supports, Providers are required to add the identified need to the member’s Individual Service Plan (ISP). The provider must then complete the AHP housing application forms (AzCH-LTC Case Managers complete these updates and forms for ALTCS members). Once the application is submitted and complete, the member will be added to the ABC statewide housing list. When the Statewide Housing Administrator has available housing, the member, their treatment team, and their health plan will be notified. This communication supports full coordination of care between Providers and the Statewide Housing Administrator.

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’s application process can be found at the ABC Housing web site https://azabc.org/ahp/. Phone: 602-712-9200. Only Provider Agencies and Clinics shall contact ABC Housing.

Contact for members/clients and Health Home or Housing Staff about a housing concern for people already housed or approved for a housing voucher are made to HOM Inc. 602 265-4640 Phoenix 520 534-2941 Pima & BOS Visit https://www.hominc.com/ or https://www.hominc.com/ahp-faqs/.  

2.10.3 Provider Responsibilities  

All PSH providers, including in network Integrated Health Homes (as designated in PM 13.18) must, at a minimum, follow, in their entirety with the Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services. Provider agencies are responsible for assisting and supporting members to secure and maintain housing as part of overall health service provision. This includes coordination with the Statewide Housing Administrator, 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 member housing needs, providers 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. Assessment might AHCCCS approved standardized assessment tools that include housing evaluation, coordinate with the Statewide Housing Administrator and contracted providers to identify and refer members identified with a high need for housing services.

All Health Homes and PSH Provider Agencies shall designate a primary clinical or housing point of contact for the Statewide Housing Administrator to reach when applications for housing have been approved and a member receives a unit/voucher. Providers are required to submit the point of contact via email to CAZHousing@azcompletehealth.com.

PSH Referral Process

PSH is a service model which supports member’s individual housing needs, regardless of housing status. EBP PSH services are provided to individuals designated SMI and are based on the member’s service plan created by the member and the member’s clinical team and meeting the SAMHSA Permanent Supportive Housing Fidelity Model criteria. All Integrated Health Homes (please refer to AzCH-CCP Provider Manual Section 13.18 for a complete list) and PSH providers are responsible for proactively identifying and referring members to PSH services. The following steps must be completed for all members:

1.    Referrals to PSH: Integrated Health Homes (IHH), BHRFs, and PCPs are required to use standard screening tools to assess Social Determinants of Health (SDOH) and Health Related Social Needs (HRSN), to include housing stability support service needs. For more information about SDOH, please refer to PM Section 12.6 Social Determinants of Health.

2.    When a member reports housing instability, homelessness, or a need for housing support services, the provider staff (usually case manager) adds the appropriate Z-code to the member’s clinical chart and adds the housing need to the member’s individual service plan.

3.    The referring clinical team helps the member select a dedicated PSH Provider, if appropriate, for support and services.

a.    To locate a EBP PSH provider in your county, or for a member, please see the PSH Network list on the AzCH-CCP Find a Provider website (https://www.azcompletehealth.com/find-a-doctor.html) or contact the AzCH-CCP Housing Team: AzCHHousing@azcompletehealth.com

4.    When referring to an external housing-specific agency, the clinical team/case manager reaches out to the dedicated housing team and sets up an ART and/or intake for care coordination.

5.    Additionally, housing-specific assistance from AzCH-CCP’s Housing Department, can be requested by reaching out directly to AzCHHousing@azcompletehealth.com.

In addition to the above referral process, Integrated Health Homes and PSH Provider Agencies shall follow the policies and procedures set forth by AHCCCS, ABC Housing (https://azabc.org/ahp ), and Hom Inc (http://www.hominc.com/) including but not limited to AMPM 930, AMPM 1710, AzCH-CCP Provider Manual, and the AHCCCS Housing Program Guidebook (https://www.azahcccs.gov/AHCCCS/Downloads/HousingPrograms/AHCCCSHousingProgramGuidebook.pdf).

PSH Providers 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.

PSH Providers are required to coordinate with an individual’s treatment team or care coordinator, to participate and support Statewide Housing 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).

PSH services focus on helping members learn to live independently, and may include any combination and intensity of the following, as identified and articulated through individual service planning with the Adult Recovery Team (ART):

• ·         Supportive and Rehab Services, Independent Living Skills/Skills Building and Communication skills, Crisis intervention, Peer and Family Support Services, Case management/service coordination, (refer to AMPM 310-B) for more information.
• New tenant orientation & tenant’s rights education (in partnership with a Housing Provider).
• Supportive counseling targeted toward housing permanency, including Personal hygiene/self-care and housekeeping skills.
• Financial management & budgeting and assistance in securing benefits Meal preparation skills (with an emphasis on nutrition).
• Landlord/Tenant education.
• Education and support for gaining transportation skills/using public transportation.
• Accessing community resources.
• Learning how to identify and address safety and/or hazard concerns.

2.10.4     Agency Staffing and Training

AzCH-CCP maintains (and ensures contracted providers maintain) a sufficient number of dedicated staff of housing professionals with knowledge, expertise, experience, and skills, to coordinate with the ABC/Home Inc. and Providers to expedite housing processes. AzCH-CCP ensures that AzCH-CCP 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.

Providers shall have a sufficient number of qualified staff to deliver, manage and coordinate PSH service delivery. All staff must demonstrate the expertise and capacity to serve all members in their programs. AzCH-CCP requires all contracted providers to ensure that their staff who work in EBP PSH programs complete the AZCH-CCP PSH Training Plans listed below. This includes, but is not limited to, full time/part time/on-call, direct care, clinical, medical, administrative, leadership, executive and support dedicated PSH staff. The confirmation of training must be supplied to the health plan within 10 working days of request.

AzCH-CCP will work with providers to determine how many housing providers they need and which staff are required to be trained as a housing specialist. Within 90 days for new hires, housing specialists need to complete the Core Training Plan requirements, and these trainings must be repeated annually. Training curriculum includes:

• SAMHSA PSH EBP (available at - https://store.samhsa.gov/product/permanent-supportive-housing-evidence-based-practices-ebp-kit/sma10-4509)
• Harm Reduction (offered on AzCH-CCP Housing Service Provider meeting monthly)
• Motivational Interviewing (offered on AzCH-CCP Housing Service Provider meeting monthly)
• Trauma Informed Care (offered on Relias)
• Landlord Tenant ACT (offered by Southwest Fair Housing)Fair Housing ACT (offered by Southwest Fair Housing)
• Co-Occurring disorders (offered on Relias)
• Case Management Best Practices (offered on Relias)
• Time Management (offered on Relias)
• Self-Care/Burnout (offered on Relias)

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 Agency 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.

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. The Provider Agency 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.

Starting October 1, 2024, eligible AHCCCS members with an SMI designation  can get help with housing services through the AHCCCS Housing and Health Opportunities (H2O) Demonstration.

AzCH-CCP collaborates with Solari, the H2O administrator, to support members eligible for H2O, including coordination of care with our providers. For more information regarding eligibility and referrals on the Solari website, visit https://community.solari-inc.org/h2o/.

 

2.10.5     Z-Codes

Housing instability is established and documented by 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).

2.10.6     Provider Agency Audits and Reports

AzCH-CCP monitors housing providers for compliance with the SAMHSA EBP PSH Fidelity Monitoring tool. Health Homes and PSH Provider Agencies are required to respond and report to communications, including requests, from AzCH-Complete Care Plan and/or AHCCCS, Statewide Housing Administrator, and respond within 2 business days . 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 in danger of having jeopardized 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.

AzCH-CCP develops and makes available to the providers, policies and procedures regarding specific housing coordination and related requirements and ensures all services, including housing supports, are provided in a culturally competent manner and are non-discriminatory. The health plan educates providers regarding the availability of Housing Trust Funds (HTF). For more information about HTF and how to apply, please refer to https://www.azahcccs.gov/AHCCCS/Initiatives/AHP/ . The AzCH-CCP Housing Team can provide support with navigating the application tool for providers and communities as requested, as well as advising on possible SMI HTF projects and applications to expand housing capacity for individuals determined SMI. AzCH-CCP is committed to recognizing and connecting the opportunity for HTF projects and funding through collaboration with community stakeholders, including but not limited to CoCs, Community Consensus Collaborative, Community Affairs outreach, Grant funded programs and relationships, and other partnerships with an SDOH focus.

PSH (including IHHs) Providers will follow reporting requirements as noted in the AzCH-CCP Provider Manual. All reports must be timely and accurate. AzCH-CCP expects Providers to submit regular and/or ad hoc request related to deliverables. PSH providers must develop and maintain a tracking system for members in need of, referred to, and/or receiving EBP PSH services, including the Monthly Outcomes Report, and other reports required by AHCCCS and AzCH-CCP.