Medical Management/Utilization Management Requirements
The Health Plan Utilization Management (UM) program is designed to ensure members receive access to the right care at the right place and right time. Our program is comprehensive and applies to all eligible members across all product types, age categories, and range of diagnoses. The UM program incorporates all care settings including preventive care, emergency care, primary care, specialty care, acute care, short-term care, and ancillary care services.
Our UM initiatives are focused on optimizing each member’s health status, sense of well-being, encouraging self-management skills, productivity, and access to quality health care, while at the same time actively managing cost trends. The UM program aims to provide Covered Services that are medically necessary, appropriate to the patient's condition, rendered in the appropriate setting and meet professionally recognized standards of care.
Utilization Management program goals include:
- Monitoring utilization patterns to guard against over-or under-utilization;
- Development and distribution of clinical practice guidelines to providers to promote improved clinical outcomes and satisfaction;
- Identification and provision of Care and/or disease management for members at risk for significant health expenses or ongoing care;
- Development of an infrastructure to ensure that all Health Plan members establish a relationship with their Primary Care Provider (PCP) to obtain preventive care;
- Implementation of programs that encourage preventive services and chronic condition self-management;
- Creation of partnerships with members/providers to enhance cooperation and support for UM goals.
It is important that persons receiving services have timely access to the most appropriate services. It is also important that limited resources are allocated in the most efficient and effective ways possible.
The clinical team (Behavioral Health Home), or Primary Care Provider (PCP) in coordination with the clinical team, is responsible for identifying and securing the service needs of each behavioral health or integrated member through the assessment and service planning processes. During the treatment planning process, the clinical team may use established tools and nationally recognized standardized criteria to guide clinical practice and to help determine the types of services and supports that will result in positive outcomes for the member. Clinical teams should make decisions based on a member’s unique and individual identified needs and should not use these tools as criteria to deny or limit services. Rather than identifying pre-determined services, the clinical team should focus on identifying the underlying needs of the behavioral health or integrated member, including the type, intensity, and frequency of support and treatment needed.
As part of the service planning process, it is the clinical team’s responsibility to identify available resources and the most appropriate provider(s) for services using The Health Plan’s network of participating healthcare providers. This is done in conjunction with the clinical team, the PCP (as needed), the behavioral health member, family, and/or natural supports. If the service is available through a contracted provider the member can access the services directly. If the requested service is only available through a non-contracted provider, the clinical team is responsible for coordinating with The Health Plan to obtain the requested services as outlined below.
Prior authorization is not required for the following physical health services:
- Emergency Services;
- Medical Observation stays.
4.2.1 Securing Services with a Non-Contracted Outpatient Provider
In cases where The Health Plan does not have a contracted participating healthcare provider and it is necessary to secure services through a non-contracted provider in order to provide the needed, covered, medically necessary physical or behavioral health service or to fulfill a clinical team’s request. Non-contracted service requests are prior authorized and a member may be referred if:
- The services required are not available within The Health Plan network.
- The Health Plan prior authorized the services.
In order to prior authorize the service, a provider must be AHCCCS registered in order to receive reimbursement for service delivery. The Health Plan is not required to offer services outside the contracted provider network if the service is available within the contracted network.
If non-contracted services are not prior authorized, the referring and servicing providers may be responsible for the cost of the service. The member may not be billed if the provider fails to follow The Health Plan policies. Both referring and receiving providers must comply with The Health Plan’s policies, documents, and requirements that govern referrals (paper or electronic), including prior authorization. If the clinical team has made all attempts to find a contracted provider for a medically necessary service and is unable to secure the service within the required timeframes, the clinical team may submit a Single Case Agreement to The Health Plan for the service.
The Health Plan requires the following information in order to process the prior authorization request:
- Requested services, including covered service codes and units;
- Provider information, including name, license, address, phone number, and AHCCCS ID. If the provider does not have an AHCCCS ID, they can be directed to the AHCCCS Provider Registration website for instructions on how to apply;
- Copy of the service plan indicating needed services have been documented;
- Reason for going to a non-contracted provider (i.e., specialty no available in network);
- Timeframes for processing the request:
- Expedited Prior Authorization request – A decision is made within 72 hours after receipt of the request. Extension of 14 calendar days may be granted if it is in the best interests of the member;
- Standard Prior Authorization request – A decision is made within 14 calendar days after receipt of the request. Extension of 14 calendar days may be granted if it is in the best interests of the member.
The process for securing behavioral health and physical health services through a non-contracted provider is as follows:
- Authorization requests have to be made no more than 60 days before the intended service date;
- If a needed covered outpatient service is unavailable within The Health Plan’s contracted provider network, the provider submits a completed Provider Manual Form 10.1.15 Out Of Network Request Attachment (can be obtained by calling the Provider Services Call Center at 866-796-0542) to The Health Plan’s Medical Management Department. This form is submitted as an attachment to the completed prior authorization forms;
- A completed Request contains pertinent clinical information on the Member, the requested out-of-network service(s) and the requested out-of-network provider. The request must be accompanied by the current service plan and/or any relevant clinical records, including reasons why a contracted provider cannot provide the requested services;
- All requested providers must be licensed by the applicable Arizona licensing board. All providers must have an AHCCCS Provider ID Number and a National Provider ID (NPI) Number, failure to have an AHCCCS provider ID will result in denial of the request. All non-contracted providers must agree to provide the requested services, possess appropriate insurance, and agree to The Health Plan-approved reimbursement rates. If for any reason The Health Plan’s Contracts Department is unable to establish a single case agreement with an authorized but non-contracted provider. The Health Plan’s Contracts Department will notify Medical Management of an approved single case agreement or unapproved. The Medical Management Department will notify the requesting Provider and/or clinical team;
- The clinical team will then meet to consider alternative services. The clinical team is responsible for ensuring that a similar level of equivalent services is in place for the Member;
- The Health Plan secures services through and provides payment to non-contracted providers through single case agreements. If a provider applies for an AHCCCS provider ID, the request for provided services will be reviewed retrospectively; and
- The Health Plan notifies the requesting provider and the servicing provider of prior authorization approvals. The requesting provider is expected to notify the member of the approval of the service(s).
In the event that a request to secure covered services through a non-contracted provider is denied, The Health Plan will provide notice of the decision in accordance with Section 8.4 - Notice Requirements and Appeal Process for Title XIX/XXI Eligible Persons, and Section 8.5 - Notice and Appeal Requirements (SMI and GMH/SA Non-Title XIX).
Claims are not eligible for payment (does not apply to emergency services) unless the single case agreement is in place and the authorization has been obtained.
The purpose of the prior authorization function is to monitor the use of designated services before services are delivered in order to confirm they are:
- Provided in an appropriate level of care and place of service;
- Included in the defined benefits,
- Appropriate, timely and cost effective;
- Coordinated as necessary with additional departments such as Quality Management;
- Accurately documented in order to facilitate accurate and timely reimbursement
Prior authorization processes are used to promote appropriate utilization of physical and behavioral health services while effectively managing associated costs. Except during an emergency situation, The Health Plan requires prior authorization before accessing inpatient services in a licensed inpatient facility and for accessing medications reflected as requiring prior authorization on The Health Plan’s Behavioral Health Drug List (for non-integrated members) or The Health Plan’s Comprehensive Drug List (for integrated members). In addition, The Health Plan also requires prior authorization of covered physical and behavioral health services other than inpatient services.
- Prior authorization (PA) is a request to The Health Plan Utilization Management (must be obtained prior to the delivery of certain elective and scheduled services. Authorizations can be submitted through the secure web portal or by use of a fax form available on our website under Provider Resources. Prior authorization should be requested at least five (5) business days before the scheduled service delivery date or as soon as need for service is identified. Most services that require The Health Plan’s authorization are listed in the following table. The Health Plan website offers a pre-screen tool that provides authorization requirements at the billing code level. (Please seek further information in this Manual for authorization requirements for home health, physical, occupational and speech therapy prior authorization information.
When it is determined that a person is in need of a physical and/or behavioral health service requiring prior authorization, a utilization management professional applies the designated medical necessity criteria to approve the provision of the covered service. When appropriate, The Health Plan will provide a consultation with the requesting provider to gather additional information to make a determination. A decision to deny a prior authorization request must be made by The Health Plan’s Chief Medical Officer, physician or Dental Medical Director designee. In addition, when system partners, including guardians, disagree with a treatment decision, resulting in the denial of a prior authorized level of care, the provider is obligated to send the request to The Health Plan Medical Management department. The request must include the provider’s recommendation and supporting evidence.
4.3.1 Emergency Situations
Definition of Emergency Medical Condition
The Health Plan defines emergency medical condition as follows: Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
- Placing the health of the individual (or, with respect to a pregnant individual, the health of the individual or their unborn child) in serious jeopardy;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part. (42 CFR. 1396-u2(b)(2)(C), as amended).
Members may access emergency services at any time without prior authorization or prior contact with The Health Plan. If members are unsure as to the urgency or emergency of the situation, they are encouraged to contact their Primary Care Provider (PCP) and/or The Health Plan’s 24 hour Nurse Line, AzCH Nurse Assist Line at 1-866-534-5963 for assistance. However, this is not a requirement to access emergency services.
Emergency services are covered by The Health Plan when furnished by a qualified provider, including non-network providers, and will be covered until the member is stabilized. Any screening examination services conducted to determine whether an emergency medical condition exists will also be covered by The Health Plan. Emergency services will be covered and will be reimbursed regardless of whether the provider is in The Health Plans provider network.
The Health Plan will not deny payment for treatment obtained under either of the following circumstances:
- A member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition; or
- A representative from the Plan or AzCH Nurse Assist Line instructs the member to seek emergency services.
Once the member’s emergency medical condition is stabilized, The Health Plan requires notification for hospital admission or Prior Authorization for follow-up care as noted elsewhere in this handbook.
4.3.2 Prior Authorization Process
Authorizations are not a guarantee of payment, the member must be eligible on the date the service is provided and the services provided must be aligned with the prior authorized service request. Prior authorization seeks to ensure that persons are treated in the most appropriate, least restrictive and most cost effective setting, with sufficient intensity of service and supervision to safely and adequately treat the person’s physical and/or behavioral health condition. Failure to obtain authorization may result in administrative claim denials. The Health Plan providers are contractually prohibited from holding any The Health Plan member financially liable for any service administratively denied by The Health Plan for the failure of the provider to obtain timely authorization.
4.3.3 Accessing services that require prior authorization
Prior authorization seeks to ensure that persons are treated in the most appropriate, least restrictive and most cost effective setting, with sufficient intensity of service and supervision to safely and adequately treat the person’s physical and/or behavioral health condition. When a clinical team initiates a request for a service requiring prior authorization, the request must immediately be forwarded to the personnel responsible for making prior authorization decisions. Authorizations are not a guarantee of payment.
4.3.4 Availability of Prior Authorization
The Health Plan has appropriate utilization management professionals, including licensed nurses and physicians available 24 hours a day, seven days a week to receive requests for any service that requires prior authorization.
4.3.5 Prior Authorization Decisions Making
The Health Plan utilization management professional is required to prior authorize services unless it issues a decision to deny. A decision to deny a service is required to be made by a The Health Plan physician or physician designee.
The Health Plan has Arizona licensed prior authorization staff that includes a nurse or nurse practitioner, physician or physician assistant, pharmacist or pharmacy technician, or licensed behavioral health professional with appropriate training to apply The Health Plan’s medical criteria or make medical decisions.
4.3.6 Criteria Used in Prior Authorization Decisions
The Health Plan uses nationally recognized standardized criteria through McKesson’s InterQual, the American Society of Addiction Medicine (ASAM), adopted practice guidelines and/or other AHCCCS approved criteria to make determinations for prior authorizations of services. The Health Plan’s Medical Management Committee reviews medical necessity criteria at least annually.
4.3.7 Prior Authorization When The Health Plan is not the Primary Payer
The Health Plan does not require prior authorization when The Health Plan is not the primary payer. Providers are required to pursue payment and submit the EOB (explanation of benefits) from all primary payers prior to billing The Health Plan any co-pays and deductibles. In instances when the member has exhausted the primary payer’s benefit, a provider may submit prior authorization to The Health Plan for primary coverage. All Health Plan prior authorization requirements are required. The provider MUST submit evidence of the member’s primary benefits being exhausted.
4.3.8 Timeframes for Decisions
Decisions to prior authorize services must be made according to these guidelines:
- Standard Requests: A decision must be made as expeditiously as the member’s health condition requires, but not later than fourteen (14) calendar days after the receipt of the authorization request. A possible extension of up to fourteen (14) calendar days can be requested by the member or provider, or if The Health Plan justifies a need for additional information and the delay is in the member’s best interest. The Health Plan or the provider may determine that using the standard timeframe could seriously jeopardize the member’s life and/or health or ability to attain, maintain or regain maximum function, in this case the authorization can be changed to an expedited request.
- Expedited Requests: A decision must be made as expeditiously as the member’s health condition requires, but not late that three (3) business days after the receipt of the authorization request. A possible extension of up to fourteen (14) calendar days can be requested by the member or provider, or if The Health Plan justifies a need for additional information and the delay is in the member’s best interest. If The Health Plan receives an expedited request for authorization and the requested service is not of an urgent medical nature, The Health Plan may downgrade the expedited request to a standard request. Prior to the request being downgraded, The Health Plan will contact the provider immediately to discuss the authorization being downgraded to a standard request. If the provider agrees with the downgrade it is documented in the authorization request and changed to a standard request. If the provider disagrees with the downgrade and supplies additional information regarding the urgent nature of the request it is documented in the authorization request and processed as an expedited request.
4.3.9 Authorization procedures for providers contracted by The Health Plan
184.108.40.206 Services that must be authorized
Providers are encouraged to access the Pre-Authorization Check Tool online for the most current services, procedures and equipment requiring prior authorization for The Health Plan. The Pre-Authorization Check Tool can be found on the Provider Section of the website at www.azcompletehealth.com.
Reimbursement is based on the accuracy of the information received with the prior authorization request, on whether the service is substantiated through concurrent and medical review, and/or on whether the claim meets claim submission requirements. All other coverage requirements must also be met in order for a claim to be eligible for payment.
- Acute Inpatient Hospital Services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- Sub-acute services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- Behavioral Health Inpatient Facility (BHIF) residential treatment services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- Behavioral Health Residential Facility (BHRF) (excluding BHRFs for Substance Use Disorder (SUD) treatment) services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- BHRF for SUD treatment services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- BHRF and HCTC services: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- Initiation and continuation of Out of Network inpatient, observation and outpatient services;
- Skilled Nursing Facilities, Long Term Acute Care Facilities and Rehabilitation Facilities: Notification of Admission and continued stay, pre-scheduled admissions must be approved by Prior Authorization at least 5 days prior to the admission;
- Physical Health Service authorizations may be required for a number of ancillary services, facility services, pharmaceuticals, physician services, radiology and laboratory services, surgeries and other procedures and Out of Network (OON) services. To identify services requiring prior authorizations please go to www.azcompletehealth.com.
4.3.10 Notice of Admission
All facilities are required to send a notification of admission to The Health Plan within 1 business day of the admission. The notice of admission must include the member’s name, date of birth, AHCCCS ID#, facility name, NPI of facility, date of admission, admitting diagnosis and level of care admitted to. The notice of admission can be completed by any of the following means:
- Enter the admission via The Health Plan Web Portal;
- Fax a facesheet to 1-866-796-0542;
- Fax a Notice of Admission form, Provider Manual Form 10.1.3 Notice of Admission to the above fax numbers. Providers are directed to call the Provider Service Center to obtain a copy of this form, if needed, at 1-866-796-0542.
- A CON (Certificate of Need) can be submitted as notice of admission but it MUST be received within 1 business day of the admission. The form must be signed by a treating provider and have appropriate clinical documentation regarding the need for admission.
A Certificate of Need (CON) must be completed within 72 hours of an admission for members age 21 and older and within 14 days of admission for members under the age of 21 years. A notice of admission MUST be received within 1 business day of the admission to the facility.
A CON must be completed if a member applies for Medicaid Assistance (AHCCCS) while in the hospital, before Medicaid (AHCCCS) funding is authorized. The facility MUST notify The Health Plan of the admission as soon as the member receives AHCCCS eligibility. If the member is still hospitalized when eligibility starts, notification of admission to The Health Plan must occur immediately so medical review and discharge planning can be initiated. In cases where eligibility confirmation occurs after discharge, the facility may submit for retrospective review, these requests must be received within 30 days of the eligibility determination.
Prior authorization will never be applied in an emergency situation. A retrospective review may be conducted after the person’s immediate health needs have been met. If upon review of the circumstances, the physical and/or behavioral health service did not meet admission authorization criteria, payment for the service may be denied. The provider must notify The Health Plan within 1 business day of an inpatient admission or demonstrate why timely notification was not possible. If the provider fails to timely notify The Health Plan of admission or demonstrate why it was not possible, a request for retrospective review may be denied. The test for appropriateness of the request for emergency services must be whether a prudent layperson, similarly situated, would have requested such services.
220.127.116.11 Certification of Need (CON) for Services
- A CON is a certification made by a physician that inpatient services are or were needed at the time of the person’s admission. Although a CON must be submitted prior to a person’s admission (except in an emergency), a CON is not an authorization tool designed to approve or deny an inpatient service, rather it is a federally required attestation by a physician that inpatient services are or were needed at the time of the person’s admission. The decision to authorize a service is dependent on the individualized clinical documentation meeting the medical necessity criteria for admission. Providers must use Provider Manual Form 10.1.1, Certification of Need (CON) for Level I Facilities. Providers are directed to call the Provider Service Center to obtain a copy of this form, if needed, at 1-866-796-0542.
In the event of an emergency, the CON must be submitted:
- For persons age 21 or older, within 72 hours of admission; and
- For persons under the age of 21, within 14 calendar days of admission.
18.104.22.168 Re-certification of Need (RON) for Services
- A RON is a re-certification made by the treating physician, nurse practitioner or physician assistant. The RON must recertify for each applicant or beneficiary that inpatient services are needed. A RON must be completed at least every 60 days for a person who is receiving services in an inpatient facility. An exception to the 60-day timeframe exists for inpatient services provided to persons under the age of 21. The treatment plan (individual plan of care) for persons under the age of 21 in an inpatient facility must be completed and reviewed every 30 days. The completion and review of the treatment plan in this circumstance meets the requirement for the re-certification of need. Providers must use Provider Manual Form 10.1.2, Re-Certification of Need (RON). Providers are directed to call the Provider Service Center to obtain a copy of this form, if needed, at 1-866-796-0542.
22.214.171.124 Documentation on a CON or RON for Behavioral Health Services
Providers must utilize The Health Plan CON and RON forms for Behavioral Health Inpatient Facility and Licensed Hospital Services requests. The following documentation is needed on a CON and RON:
- Proper treatment of the person’s health condition requires services on an inpatient basis under the direction of a physician;
- The service can reasonably be expected to improve the person’s condition or prevent further regression so that the service will no longer be needed;
- Outpatient resources available in the community do not meet the treatment needs of the person;
- CONs must have a dated physician’s signature; and
- RONs must have a dated signature by a physician, nurse practitioner or physician assistant.
Additional CON requirements:
- If a person becomes eligible for Title XIX/XXI (AHCCCS) services while receiving inpatient services, the CON must be completed and submitted to The Health Plan’s Medical Management Department prior to the authorization of payment; and
- Federal rules set forth additional requirements for completing CONs when persons under the age of 21 are admitted to, or are receiving inpatient psychiatric services in a Behavioral Health Inpatient Facility. These requirements include the following:
- For an individual who is Title XIX/XXI eligible when admitted, the CON must be completed by the clinical team that is independent of the facility and must include a physician who has knowledge of the person’s situation and who is competent in the diagnosis and treatment of mental illness, preferably child psychiatry;
- For emergency admissions, the CON must be completed by the team responsible for the treatment plan within 14 days of admission. This team is defined in 42 CFR §441.156 as “an interdisciplinary team of physicians and other personnel who are employed by, or provide services to patients in the facility”; and
- For persons who are admitted and then become Title XIX/XXI eligible while at the facility, the team responsible for the treatment plan must complete the CON. The CON must cover any period of time for which claims for payment are made.
4.3.11 Continued Stay When Medically Necessary Services are not available at Discharge
If a person receiving hospital or sub-acute services no longer requires such services under the direction of a physician, but services suitable to meet the person’s physical and/or behavioral health needs are not available or the person cannot return to the person’s residence because of a risk of harm to self or others, services may continue to be authorized as long as there is an ongoing, active attempt to secure a suitable discharge placement or residence in collaboration with the community or other state agencies as applicable and is documented daily. In these instances, the facilities may request “Administrative Days”. The request must be made while the member is still hospitalized, all requests MUST be made to The Health Plan UM reviewer who will review for approval with The Health Plan Medical Director. The Health Plan contracts team will negotiate a payment rate comparable to the level of care the member’s condition requires. Upon approval of the “Administrative Days” the initial authorization will be terminated and a new authorization will be issued for “Administrative Days”, Providers must bill separately for these services.
4.3.12 Issuance of a Notice of Action
For Title XIX/XXI covered services requested by persons who are Title XIX/XXI eligible or persons with SMI, The Health Plan provides the person(s) requesting services with a Notice of Action as described in Provider Manual Section 8.
4.3.13 Further Considerations for Denials of Requested Services
Inpatient Facilities Denials for Unplanned Admission or Continued Stay - After The Health Plan notifies a facility of a denial for an unplanned admission or a continued stay, the requesting clinician has the opportunity to contact The Health Plan physician to discuss the decision. This request should occur within 24 hours of the issuance of the denial but providers are encouraged to contact The Health Plan as soon as possible. The Health Plan will ensure 24 hour access to a delegated physician for any denials of hospital admission.
Providers may obtain the criteria used to make a specific adverse determination by contacting the Medical Management department at 866-796-0542. Practitioners also have the opportunity to discuss any adverse decisions with a physician or other appropriate reviewer at the time of notification to the requesting practitioner/facility of an adverse determination. Please call the number on the denial notice to set up a ‘peer to peer’ discussion.
After this collaboration, The Health Plan physician may rescind the denial or let the denial stand. If the denial is not rescinded, the requesting provider may appeal the decision as outlined in Section 8 of the Provider Manual.
Outpatient Authorizations and Planned Admissions - After The Health Plan notifies a provider of the decision to deny a requested authorization the requesting provider has several options.
- The provider can resubmit another authorization request with additional clinical documentation to substantiate the request;
- The provider can request reconsideration either in writing or via a peer to peer with The Health Plan physician who issued the denial; and/or
- The provider can appeal the denial as outlined in Section 8.4.
Special Instructions for submitting documentation to support medical necessity.
The Health Plan must receive individualized clinical documentation of the member’s status in order to conduct clinical review for medical necessity.
Supporting documentation includes:
Behavioral Health and Physical Health Inpatient/Sub-Acute Admissions
- Notice of Admission – facesheet, Notification of Admission form Provider Manual or CON;
- Admission notes that support the current level of care;
- Progress notes, including supporting labs, radiology reports, etc.;
- Case management activities, including discharge planning, CFT/ART notes;
- Any other supporting relevant clinical information.
Initial inpatient stays are based on the adopted criteria, the member’s specific conditions, and the projected discharge date. Reviews will occur on a schedule dictated by the member’s diagnosis and condition. Emergency initial concurrent reviews are completed within one (1) business day of The Health Plan receipt of notification of admission. Subsequent reviews will be determined based on the member’s specific condition. Providers are notified of the next review date and are responsible for providing updated clinical information on the scheduled review date (last covered day).
Behavioral Health Residential Facilities
- Notice of Admission – facesheet, Notification of Admission form Provider Manual or CON;
- Admission notes that support the current level of care;
- The most current behavioral health individual service plan;
- Documentation showing member’s most recent intense outpatient treatments (90 days) and the results of the services rendered;
- Most recent psychiatric evaluation and progress notes;
- Case management and CFT progress notes;
- Psychological or psycho-educational evaluations;
- Hospital or residential discharge summaries;
- Any other relevant clinical information.
Initial behavioral health stays are based on the adopted criteria, the member’s specific conditions, and the projected discharge date. Reviews will occur on a schedule dictated by the member’s diagnosis and condition. Initial concurrent reviews are completed within one (1) business day of The Health Plan receipt of notification of admission. Subsequent reviews will be determined based on the member’s specific condition. Providers are notified of the next review date and are responsible for providing updated clinical information on the scheduled review date (last covered day).
For requests for continued stay, RONs are submitted as outlined above:
- Hospital, sub-acute service and residential BHIF providers submit additional clinical information to The Health Plan’s Medical Management Department verbally at 888-788-4408 or by secure fax.
Skilled Nursing Facility (SNF)
The Health Plan provides medically necessary skilled nursing facility services for integrated members receiving physical healthcare services, including when the member has ALTCS pending. On-going reviews of members in skilled nursing facilities are conducted on a schedule dictated by the members’ diagnosis and condition, not to exceed 7 days. Providers are notified of the next review date and are responsible for providing updated clinical information on the scheduled review date.
The Health Plan tracks the number of SNF days utilized by a member in a contract year and will only be responsible for reimbursement during the time the member is enrolled with The Health Plan and if the member becomes ALTCS eligible and is enrolled with an ALTCS contractor before the end of the maximum ninety (90) days per contract year. The ninety (90) days per AHCCCS contract year limitation is monitored and will be applied for nursing facility services. AHCCCS is notified electronically when a member has been residing in a nursing facility for forty-five (45) days and ninety (90) days.
Only the information necessary to certify the length of stay, frequency or duration of services, or continued stay in authorized services will be collected and will be accepted from any reasonably reliable source that can assist in the authorization process.
The Health Plan makes a decision to authorize or deny coverage of these services based on available clinical information utilizing the policies and procedures developed for determining medical necessity for ongoing institutional care.
The Medical Management team will ensure a process to share all clinical information on individuals in hospital, BHIF, BHRF, Skilled Nursing Facility (SNF) and HCTC services among its various clinical and administrative departments that have a need to know, to avoid duplicate requests for information from consumers and providers, exceptions include substance use and HIV information. The Health Plan bases concurrent review determinations solely on the medical information obtained by the reviewer at the time of the review determination. The Health Plan verifies that the frequency of reviews for the extension of the initial determinations is based on the severity or complexity of the member’s condition or on necessary treatment and discharge planning activity but will also meet the prescribed review timelines according to InterQual® criteria. Authorization for hospital and institutional stays will have a specified date by which the need for continued stay will be reviewed and this will be documented in and relayed to the requesting provider to ensure coordination and understanding of when additional member condition updates are required. Admission reviews must be conducted within one business day after notification is provided to the Contractor by the hospital or institution (this does not apply to pre-certifications) (42 C.F.R. 456.125).
For members being transferred for respite or other reasons, a notice of transfer must be submitted within three (3) business days of the admission.
Providers are directed to call the Provider Service Call Center to obtain a copy of these forms, if needed, at 1-866-796-0542.
Provider Manual Attachment 10.1.1 Admission Psychiatric Acute Hospital & Sub-Acute Criteria,
Provider Manual Attachment 10.1.2 Continued Psychiatric Acute or Sub-Acute Facilities Authorization Criteria,
Provider Manual Attachment 10.1.3 Prior Authorization Criteria for Admission and Continued Stay for Behavioral Health Residential Facilities,
Provider Manual Attachment 10.1.3a BHRF Substance Abuse Treatment Placement FAQs,
Provider Manual Attachment 10.1.4 Prior Authorization Criteria for Admission and Continued Stay for Behavioral Health Supportive Homes,
Provider Manual Attachment 10.1.5 Prior Authorization Criteria for Continued Stay for HCTC
Provider Manual Attachment 10.1.6 Authorization Criteria for Behavioral Health Inpatient Facilities
Provider Manual Attachment 10.1.15 Prior Authorization Criteria for HCTC
Provider Manual Form 10.1.1 Certificate of Need (CON)
Provider Manual Form 10.1.2 Recertification of Need (RON)
Provider Manual Form 10.1.3 Notice of Admission to ALL LEVELS OF CARE
Provider Manual Form 10.1.6 Concurrent Review
Provider Manual Form 10.1.8 Pre-Authoirization Out-of-Home
Provider Manual Form 10.1.12 Outpatient Medicaid Prior Authorization Fax Form
Provider Manual Form 10.1.13 Inpatient Medicaid Prior Authorization Fax Form
Provider Manual Form 10.1.14 Intensive Staffing
Provider Manual Form 10.1.15 Out-of-Network Request
Provider Manual Form 10.1.16 Notice of Temporary Placement MASTER
Provider Manual Form 10.1.17 Notice of Transfer Out-of-Home Facilities MASTER
4.3.14 Prior Authorizing Medications
The Health Plan has developed drug lists for use by all providers. These lists denote all drugs which require prior authorization. These prior authorization criteria have been developed and approved by the AHCCCS pharmacy and therapeutics committee and/or the Arizona Complete Health pharmacy and therapeutics committee and must be used by The Health Plan’s providers. For specific information on medications requiring prior authorization, see Section 4.13.4 – The Health Plan’s Drug Lists. The approved prior authorization criteria are posted on The Health Plan Provider Portal. The prior authorization requirements for provision of Notice are the same as those outlined for prior authorized services. For pharmacy prior authorization requests, a decision or request for more information will be provided within 24 hours. If additional information is requested, a decision will be rendered within 7 business days of the request. The Health Plan and providers must assure that a person will not experience a gap in access to prescribed medications due to a change in prior authorization requirements. The Health Plan and providers are required to ensure continuity of care in cases in which a medication that previously did not require prior authorization is now required to be prior authorized.
4.3.15 Notification of Prior Authorization Changes
The Health Plan makes every effort to give providers at least thirty days’ notice, when possible, of changes in authorization processes or criteria through monthly Essential Provider Communication Meetings. Updated materials are posted to The Health Plan website for provider and Member access.
The Health Plan reviews and considers adoption of new technologies and/or adoption of new uses to existing technologies utilizing evidence-based research and guidelines. The process includes evaluation of the Food and Drug Administration (FDA) approved use, evidence based research, guidelines and analyses of related peer reviewed literature published in the United States. Peer-reviewed medical literature must include well-designed investigations that have been reproduced by nonaffiliated authoritative sources. The literature must also include positive endorsements by national medical bodies or panels regarding scientific efficacy and rationale.
New technologies include new delivery systems of medications if that delivery system is a device. Newly developed non-delivery systems (such as microspheres, oral dissolving systems) are not considered new technologies and aren’t subject to these requirements.
Providers may initiate a request for The Health Plan coverage of new approved technologies including the usage of new applications for established technologies by submitting the proposal in writing to The Health Plan’s Medical Director for review. The proposals shall include:
- FDA approval of the new technology and the approved indication;
- Medical necessity criteria and supporting documentation;
- A cost analysis including the financial impact to the provider for the new technology;
- Peer reviewed literature indicating the efficacy of the new technology or the modification in usage of the existing technology, if available; and
- Relevant coverage decisions made by Medicare intermediaries and carriers, national Medicare coverage decisions, and Federal and State Medicaid coverage decisions.
The Health Plan will participate in the review of newly requested technologies, including the usage of new applications for established technologies through The Health Plan Pharmacy and Therapeutics (P&T) Committee and the Medical Management Committee. The Health Plan will consider coverage rules, practice guidelines, payment policies and procedures, utilization management, and oversight that allows for the individual member's medical needs to be met during this review.
The Health Plan will review requests for the use of a new technology at the quarterly Pharmacy and Therapeutics Committee meeting following the request. The Health Plan Providers are informed of AHCCCS approval of new technology and any applicable prior authorization criteria through the AzCH website, the monthly Essential Provider Communication Call, and pharmacy webinar. Discussion reflecting consideration of a new FDA approved technology, including the usage of a new application for established technology and The Health Plan’s determination of coverage will be documented in the P&T Committee meeting minutes and the Medical Management Committee meeting minutes.
Consideration for systemic implementation of the coverage of the technology will be prioritized for consideration by AHCCCS based on member needs, utilization trends, financial considerations, and the meta-analysis of peer reviewed literature.
The Health Plan completes retrospective reviews (review after services have initiated or been provided) in response to a provider request for authorization of services after the initiation of services or after services have been rendered or to investigate quality of care concerns. Services eligible for retrospective review are outlined below:
- All services rendered during a member’s Prior Period Coverage when the request is received within 30 days of the Add-on Date;
- Post-discharge physical health or behavioral health hospital services (“hospital services”) and behavioral health inpatient facility sub-acute facility services (“BHIF-SAF services”) when The Health Plan received timely notification of admission (within 72 hours) and when the request is received no later than 30 days after the date of discharge;
- Continuation of hospital services or BHIF-SAF services (pre-discharge) when The Health Plan did not receive timely notification of admission;
- Outpatient services requiring prior authorization when an authorization is requested after initiation of, but prior to completion of, a course of a treatment when the provider asserts completion of the course of treatment is necessary to ensure continuity of care (“course of treatment outpatient services”);
- Post-discharge out-of-home treatment that does not require prior authorization but does require notification of admission when The Health Plan received timely notification of admission and when the request is received no later than 30 days after the date of discharge; and
- Continuation (pre-discharge) of out-of-home treatment that does not require prior authorization but does require notification of admission when The Health Plan did not receive timely notification of admission.
Upon receipt of a written request for retrospective review, The Health Plan will screen the request to determine if it is eligible for retrospective review. If it is not eligible for retrospective review based on the above criteria, a denial letter will be sent to the provider. The denial letter will explain the appeal process.
Upon receipt of a verbal request for retrospective review, The Health Plan will ask the provider to explain the reason for the request and will describe to the provider the circumstances under which The Health Plan will conduct a retrospective review. If The Health Plan believes the request is eligible for retrospective review, the provider will be given instructions about how to submit the written request. If The Health Plan does not believe the request is eligible for retrospective review, but the provider nevertheless would like to submit a written request, The Health Plan will provide information to the provider about how to submit the request.
Upon determining a request is eligible for retrospective review, The Health Plan will review the submitted records within seven (7) calendar days of receipt to ascertain if The Health Plan has received all clinical information necessary to conduct an adequate review. If the provider fails to submit sufficient information to render an authorization determination, The Health Plan will notify the provider and specifically describe the information needed. The facility will be given up to fourteen (14) calendar days to submit the additional information or to inform The Health Plan why the information cannot be submitted for review. The Health Plan will make a one-time request if clinical information is not sufficient to make a decision.
Review decisions are rendered within 30 days of the initial receipt of request for retrospective review. The Health Plans UM Reviewers can be reached Monday – Friday, 8am to 5pm, for prior authorization, continued stay authorization, and technical assistance at 888-788-4408. After hours, providers may contact The Health Plan at 888-788-4408, 24 hours per day, 365 days per year to request assistance. After hours calls are handled by The Health Plan’s crisis line contractor, AzCH Nurse Assist Line.
The PASRR screening consists of a two-stage identification and evaluation process and is conducted to assure appropriate placement and treatment for those identified with Serious Mental Illness (SMI) and/or Intellectual disability.
- PASRR Level I screenings are used to determine whether the person has any diagnosis or other presenting evidence that suggests the potential presence of SMI and/or intellectual disability.
- PASRR Level II evaluations are used to confirm whether the person indeed has SMI and/or intellectual disability. If the person is determined to have SMI and/or intellectual disability, this stage of the evaluation process determines whether the person requires the level of services in a Nursing Facility (NF) and/or specialized services (inpatient/hospital psychiatric treatment).
Medicaid certified NFs must provide PASRR Level I screening, or verify that screening has been conducted, in order to identify SMI and/or intellectual disability prior to initial admission of persons to a nursing facility bed that is Medicaid certified or dually certified for Medicaid/Medicare.
4.6.1 PASRR Level I Screenings
See AHCCCS AMPM Exhibit 1220-1, PASRR Level I Screening Document and instructions.
PASRR Level I screenings can be performed by the following professionals:
- Arizona Long Term Care System (ALTCS) Pre-Admission Screening assessors, or case managers;
- Hospital discharge planners;
- Social workers; or
- Other nursing facility staff that have been trained to conduct the Level I PASRR screening and make Level II PASRR referrals.
ALTCS Pre-Admission Screening assessors or case managers may conduct Level I PASRR screenings, but it is the ultimate responsibility of the facility where the Member is located to ensure that the Level I and Level II PASRR is completed prior to the Member being admitted into the receiving nursing facility.
A PASRR Level I screening is not required for readmission of persons who were hospitalized and are returning to the nursing facility, or for inter-facility transfers from another nursing facility, if there has not been a significant change in their mental condition. The PASRR Level I screening form and PASRR Level II evaluation must accompany the readmitted or transferred person.
A PASRR Level I screening is required if a person is being admitted to a nursing facility for a convalescent period, or respite care, not to exceed 30 days. If later it is determined that the admission will last longer than 30 days, a new PASRR Level I screening is required. The PASRR Level II evaluation must be done within 40 calendar days of the admission date.
Upon completion of a PASRR Level I screening, documents are forwarded to the PASRR Coordinator within the AHCCCS Bureau of Quality Management Operations. If necessary, referrals for a PASRR Level II evaluation to determine if a person has a SMI diagnosis are forwarded to the AHCCCS Office of the Medical Director. Alternatively, referrals for a PASRR Level II evaluation are forwarded to the Arizona Department of Economic Security/Division of Developmental Disabilities (ADES/DDD) PASRR Coordinator to determine if a person has Intellectual Disability. For dually diagnosed persons (both SMI and intellectual disability), referrals for a PASRR Level II evaluation are forwarded to both ADES/DDD and AHCCCS.
When a PASRR Level I screening is received by AHCCCS, the PASRR Coordinator reviews it and, if needed, consults with the AHCCCS Medical Director or designee (must be a Board-eligible or Board-certified psychiatrist and have an unrestricted, active license to practice medicine in Arizona) to determine if a PASRR Level II evaluation is necessary. If it is determined that a PASRR Level II evaluation should be conducted, the PASRR coordinator must:
- Forward copies of the PASRR Level I screening and any other documentation to The Health Plan; and
- Send a letter to the person/legal representative that contains notification of the requirement to undergo a Level II PASRR evaluation.
4.6.2 PASRR Level II Screenings
The Health Plan must develop an administrative process for conducting PASRR Level II evaluations and must ensure that:
- They are completed within 5 working days of receipt of the PASRR Level I screening;
- If the person is awaiting discharge from a hospital, the evaluation should be completed within 3 working days; and
- The criteria used to make the decision about appropriate placement are not affected by the availability of placement alternatives.
The PASRR Level II evaluation includes the following criteria:
- The evaluation report must include the components of the Level II PASRR Psychiatric Evaluation found at
- The evaluation must be performed by a physician who is a Board-eligible or Board-certified psychiatrist and has an unrestricted, active license to practice medicine in Arizona;
- The evaluation can only be performed by a psychiatrist who is independent of and not directly responsible for any aspect of the care or treatment of the person being evaluated;
- The evaluation and notices must be adapted to the cultural background, language, ethnic origin, and means of communication used by the individual being evaluated;
- The evaluation must involve the individual being evaluated, the individual’s legal representative, if one has been designated under state law, and the individual’s family, if available and if the individual or the legal representative agrees to family participation;
- Evaluators may use relevant evaluative data, obtained prior to initiation of preadmission screening or resident reviews, if the data are considered valid and accurate and reflect the current functional status of the individual. However, in the case of individualized evaluations, to supplement and verify the currency and accuracy of existing data, the State's PASRR program may need to gather additional information necessary to assess proper placement and treatment.
- Evaluators are to follow AHCCCS Policy 1009:
- Pre-Admission Screening and Residential Review LEVEL 1 (Exhibit 1220-1) PASRR found at https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/1200/1220-CExhibit1220-1 (PDF)
- Pre-Admission Screening and Psychiatric Review LEVEL II (Exhibit 1220-2) PASRR found at https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/1200/1220-CExhibit1220-2 (PDF)
The AHCCCS Medical Director or designee reviews all evaluations and makes final Level II placement determinations prior to the proposed/current placement.
AHCCCS must provide copies of the completed PASRR Level II evaluation to the referring agency, Arizona Health Care Cost Containment System, Division of Health Care Management (AHCCCS/DHCM) PASRR Coordinator, facility, primary care provider, and person/legal representative.
4.6.3 Cease Process And Documentation
If at any time in the PASRR process it is determined that the person does not have a SMI, or has a principal/primary diagnosis identified as an exemption in the Level I screening, the evaluator must cease the PASRR process of screening and evaluation and document such activity.
4.6.4 SMI Determination
AHCCCS reviews each person determined to have a SMI on an annual basis, or when a significant change in the resident’s physical or mental condition has been noted in order to ensure the continued appropriateness of nursing home level of care and the provision of appropriate behavioral health services.
The Health Plan shall report monthly to AHCCCS concerning the number and disposition of residents (1) not requiring nursing facility services, but requiring specialized services for SMI, (2) residents not requiring nursing facility services or specialized services for SMI, and (3) any appeals activities and dispositions of appeal cases.
Per 42 C.F.R. 483.118 (1 and 2), AHCCCS will work with the facility to arrange for the safe and orderly discharge of the resident. The facility in accordance with 42 C.F.R. 483.12(a) will prepare and orient the resident for discharge.
Per 42 C.F.R. 483.118 (c) (i-iv), AHCCCS will work with the facility to provide an alternative disposition plan for any residents who require specialized services and who have continuously resided in a NF for at least 30 months prior to the determination as defined in 42 C.F.R. 483.120. AHCCCS, in consultation with the resident’s family or legal representative and caregivers, offer the resident the choice of remaining in the facility or of receiving services in an alternative appropriate setting.
The AHCCCS Level II PASRR Psychiatric Evaluation includes the recommendations of services for lesser intensity by the evaluating Psychiatrist as per 42 C.F.R.483.120, 128(h)(i) (4 and 5).
The AHCCCS Medical Director or designee (must be a Board-eligible or Board-certified psychiatrist and have an unrestricted, active license to practice medicine in Arizona) will determine if the person requires nursing facility level of care and if specialized services are needed based on individualized evaluations or advance group determinations in accordance with 42 C.F.R. § 483.130-134. Individual evaluations or advance group determinations may be made for the following circumstances:
- The person has been diagnosed with a terminal illness; or
- Severe physical illness results in a level of impairment so severe that the person could not benefit from specialized services. The person will be reassessed when notified by the nursing facility of an improvement in their condition; and
- Other conditions as listed in 42 C.F.R. § 483.130-134.
4.6.8 Appeal and Notice Process Specific To PASRR Evaluations
AHCCCS shall send a written notice no later than three (3) working days following a PASRR determination in the context of either a preadmission screening or resident review that adversely affects a Title XIX/XXI eligible person.
Appeals shall be processed, consistent with the requirements in Section 8.4 – Notice Requirements and Appeal Processes for Title XIX/XXI Eligible Persons and Section 8.5 - Notice and Appeal Requirements (SMI and GMH/SA Non-Title XIX/XXI).
The Health Plan will provide AHCCCS with any requested information, and will make available witnesses necessary to assist with the defense of the decision on appeal, in the event that a person appeals the determination of the PASRR evaluation.
The Health Plan will retain case records for all Level II evaluations for a period of 6 years in accordance with A.R.S. § 12-2297.
The Health Plan will permit authorized AHCCCS personnel reasonable access to files containing the reports received and developed.
Training will be provided to psychiatrists and any other medical professionals that conduct Level II evaluations as needed.
4.6.11 Provider Requirements
Providers are required to follow PASRR requirements for Members who require services in a skilled nursing facility. Those requirements are:
- The provider is required to administer the PASRR Residential evaluations as requested and meet required time frames for assessment and submission to The Health Plan.
- The provider is required to determine the appropriateness of admitting persons with mental impairments to Medicaid-certified nursing facilities, to determine if the level of care provided by the nursing facility is needed and whether specialized services for persons with mental impairments are required.
- The provider is required to demonstrate that a licensed physician who is Board-Certified or Board-eligible in Psychiatry conducts PASRR Residential evaluations in accordance with 42 CFR Part 483, Subpart C and the AHCCCS Policy and Procedures Manual section on Pre-Admission Screening and Resident Review (PASRR).
- The provider is required to conduct PASRR Residential evaluations in person where the referred person is located.
To make utilization decisions, The Health Plan uses written criteria as required by contract with AHCCCS. The Health Plan evaluates the application of Medical Necessity Criteria annually, and maintains and uses a standardized instrument for measuring Medical Management staff’s application of the current Medical Necessity Criteria. A different measurement tool will be utilized during each measurement of Inter-Rater Reliability to maintain continuous objectivity in the evaluation. A plan of action is developed and implemented for staff who fail to meet the inter-rater reliability standards of 90%.
Care Management and Care Coordination services are available for all Title XIX/XXI Members. Care Management and Care Coordination services are provided by The Health Plan Care Managers and Care Coordinators. These services encompass a variety of coordination of care activities to assist a member in achieving individualized wellness and recovery goals.
Title XIX/XXI members identified as having less acute and less complex physical or behavioral health care needs, receive Care Coordination Services. Care Coordinators are assigned to serve this population. Members in this group typically have been more successful at managing their health care, may require varying needs for support with their psychosocial needs, but may be at risk of developing chronic conditions.
The Health Plan ensures the provision of care management to assist members who may or may not have a chronic disease but have physical or behavioral health needs or risks that need immediate attention. This care coordination assures members get the services they need to prevent or reduce an adverse health outcome. Care management is short term and time limited in nature and may include assistance in making and keeping needed medical and or behavioral health appointments, hospital discharge instructions, health coaching and referrals related to the members’ immediate needs, PCP reconnection and offering other resources or materials related to wellness, lifestyle, and prevention.
Care Managers and Care Coordinators seek to align services with the goals identified by members, goals associated with physical health care ordered by physical health providers and services described in the member’s Individual Service Plan in collaboration with the member’s Behavioral Health Home (when applicable). These activities, which can occur both at a clinical and system level, are performed by the member’s Care Manager or Care Coordinator in collaboration with the member’s treatment team or treating provider, depending on a member’s needs, goals, and functional status. This coordination ensures the provision of appropriate services in acute, home, chronic and alternative care settings that meet the member’s needs in the most cost-effective manner available.
Health Plan Care Management/Care Coordination staff consists of Arizona Licensed nurses and Behavioral Health clinicians; others are unlicensed with behavioral health backgrounds or/and expertise in community case management, but all are cross-trained in behavioral health, physical health and social determinants of health. Additionally, Care Management teams are comprised of staff that are trained in, and/or have expertise in person-centered care, the provision of self-management-skills coaching, motivational interviewing, implementing Evidence Based Practice modalities such as, Trauma Informed Care, health promotion and literacy, and member advocacy, while navigating complex systems and communicating across disciplines.
4.9.1 Role and Function of Care Management and Care Coordination
The Health Plan Care Management program is designed to help Title XIX/XXI Members achieve their wellness and recovery goals and assist eligible members in receiving appropriate treatment for chronic/non-chronic conditions (both primary and secondary chronic/non-chronic conditions) by providing proactive support to the member, and to the member’s treating providers. Care Management involves identifying the health care needs of members, providing clinical support and recommendations to provider agency treatment teams, verifying necessary referrals are made, and appropriate services are provided, maintaining health history, and facilitating access to additional evaluation/diagnosis and treatment when necessary. Care Managers have expertise in member self-management approaches, member advocacy, and are capable of navigating complex systems and communicating with a wide spectrum of professional and lay persons, including family members, physicians, specialists and other health care professionals.
4.9.2 Provider Responsibilities Related to Care Management
Treating providers are required to collaborate effectively with The Health Plan Care Managers and Care Coordinators. This collaboration includes collaborating on the following duties:
- Assisting members in the completion of Health Risk Assessments;
- Identifying members who may qualify for Care Management services;
- Aligning The Health Plan Care Plans with Member Individualized Treatment Plans;
- Assisting members in obtaining necessary physical health and behavioral health services, including specialty care, preventive care, and well person visits;
- Assisting members in achieving medication adherence;
- Verifying members complete lab tests as appropriate;
- Providing or arranging transportation for members to receive medically necessary services;
- Facilitating effective transitions among providers and levels of care;
- Participating in Care Plan Rounds as requested;
- Coordinating and implementing disease management and wellness programs to meet the needs of members in the provider’s care;
- Coordinating with 24/7 community based programs to reduce justice system involvement, and unnecessary emergency department utilization and hospitalizations;
- Engaging the member to participate in service planning;
- Monitoring and facilitating adherence to treatment goals including medication adherence;
- Establishing a process to verify coordination of member care needs across the continuum based on early identification of health risk factors or special care needs;
- Monitoring individual health status and service utilization to determine use of evidence- based care and adherence to or variance from the members Treatment Plan;
- Monitoring member services and placements to assess the continued appropriateness, medical necessity and cost effectiveness of the services;
- Communicating among behavioral and physical health service providers regarding member progress and health status, test results, lab reports, medications and other health care information when necessary to promote optimal outcomes and reduce risks, and duplication of services or errors;
- Monitoring the member’s eligibility status for covered benefits and assisting with eligibility applications or renewals;
- Communicating with the member’s assigned Care Manager, treatment team members or other service providers to ensure management of care and services including addressing and resolving complex, difficult care situations;
- Participating in discharge planning from hospitals, jail or other institutions and follow up with members after discharge as appropriate;
- Verifying that periodic re-assessment occurs at least annually or more frequently when the member’s psychiatric and/or medical status changes.
4.9.3 Care Management
Care Management is essential to successfully improving healthcare outcomes for XIX/XXI members. Care Management is designed to cover a wide spectrum of episodic and chronic, complex health care conditions for members with an emphasis on proactive health promotion, health education, disease management, and self-management resulting in improved physical and behavioral health outcomes. Care Management is an administrative function and not a billable service.
The Health Plan assigns and monitors Care Management to member ratios based upon national standards, consistent with a member’s acuity and complexity of need for Care Management and evidence-based outcome expectations.
Members in this group typically include:
- Members at high risk of poor health outcomes and high utilization;
- Members with an acute or chronic diagnosis or condition;
- Members who have struggled unsuccessfully to manage their health care, and require more complex or frequent healthcare and services.
The Health Plan utilizes data from multiple sources to identity members who may benefit from Care Management to meet their individualized needs. These tools allow for members to be stratified into a case registry and their specific risks identified, including chronic co-morbid conditions (both primary and secondary chronic conditions), over utilization of behavioral health and physical health services, adverse events, high costs and specific gaps in care. Members may be identified through population-based tools (i.e., predictive modeling) and individual-based tools (i.e., Health Risk Assessment). These reports also assist in identifying the appropriate level of Care Management, particularly for those members with the greatest potential for improved health outcomes and an increased utilization of cost-effective treatment.
In addition, members are identified for Care Management through various referral sources from within The Health Plan and through external sources. These referral sources include, but are not limited to, the following:
- Member self-referral;
- Family and/or caregiver;
- Treatment Teams;
- Utilization Management (UM) referral;
- Quality Management (QM) referral;
- Various other The Health Plan departments;
- Discharge planner referral;
- Provider submissions of the American College of Obstetricians and Gynecologists [ACOG] comprehensive assessment tool ;
- Provider submission of an Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Tracking Form;
- Arizona Health Care Cost Containment System (AHCCCS);
- American Indian Health Program;
- Inpatient facilities, emergency departments, crisis providers; and
- Department of Economic Security (DES)/Division of Developmental Disabilities.
Referrals for Care Management (Title XIX/XXI members with the highest needs) can be made by calling the Care Management Referral Line at (888)788-4408 or through the Provider Portal. Upon receipt of a referral for Care Management, The Health Plan assesses the member’s eligibility and provides notification of the decision within 30 days of referral.
4.9.4 Disenrollment From Care Management
Members are dis-enrolled from the Care Management Program when they show successful completion of Care Management goals and a reduction of risk and utilization; when they cease to be willing to actively participate, and at loss of eligibility. Upon dis-enrollment from the Care Management Program, the member’s ongoing care is monitored through analysis of claims data. Members are also dis-enrolled from the Care Management when they expire, move out of state, or transfer to another health plan or service area.
4.9.5 Care Management/Care Coordination Team Responsibilities
The Health Plan Care Management Teams, under the direction of the health plan Chief Medical Officer and the Adult Administration and Child Administrator, perform the following functions:
- Researching claims data and clinical information to identify care gaps and opportunities for better coordination of care, better access to services and better treatment alternatives;
- Communicating findings to treating providers and collaborating with treatment teams to identify opportunities to enhance care and engage members into disease management and other treatment programs;
- Identifying opportunities with the treating providers to assist members in making lifestyle changes that enhance recovery and support wellness;
- Assisting treatment teams in identifying opportunities to improve medication adherence, reduce unnecessary emergency department and inpatient utilization;
- Assisting treating providers in identifying opportunities to decrease and eliminate justice system involvement and arrests, and use of crisis services;
- Facilitating and tracking completion of Health Risk Assessments;
- Reporting program needs to the Integrated Care/Program Development department to facilitate the development of new programs and services;
- Collaborating effectively with all The Health Plan departments, including Quality Management and Network Development;
- Monitoring member transitions from one level of care to another;
- Providing members with the tools to self-manage care in order to safely live, work, and integrate into the community;
- Completing a comprehensive Care Plan review for each member enrolled in the Care Management Program minimally on a quarterly basis. The Care Plan review includes, at a minimum:
- A medical record chart review;
- Consultation with the member’s treatment team;
- Review of administrative data such as claims/encounters; and
- Customer service data.
4.9.6 Care Planning
Care Managers collaborate with the member, the member’s physical health and/or behavioral health inpatient and/or outpatient treatment team to develop the care plan, which is designed to prioritize goals that consider the member’s and/or caregiver’s strengths, treatment needs, recovery and wellness goals, and preferences. All providers participating in the member’s care will be given access to the member’s Care Plan. The Care Plan is expected to align with the member’s Individual Treatment Plan, but will be neither a part of, nor a substitute for the Treatment Plan. The Care Plan describes the clinical interventions recommended and agreed to, by the clinical team and member; identifies the coordination gaps, strategies to improve coordination of care among service providers; and strategies required to monitor referrals and follow-up for specialty care and routine health care services, including medication monitoring.
As part of the care planning process, the Care Manager documents a schedule for follow up with the treatment team and member and convenes Care Plan reviews at intervals consistent with the identified member care needs, and to ensure progress and safety. Care Plan reviews are pre-scheduled and designed to evaluate progress toward Care Plan goals and meeting member needs. The Care Plan is additionally updated at any point apart from the schedule, based on member progress and outcomes. The Care Plan identifies the next point of review and is saved in the member’s electronic record in The Health Plan Care Management business application system.
4.9.7 Interdisciplinary Care Plan Rounds
A member’s unique care needs can also be addressed through formal interdisciplinary Care Plan Rounds. In Care Plan Rounds, both treatment and non-treatment staff may present member treatment concerns to their treatment peers and treatment leaders to seek guidance and recommendations on how to best address the member’s physical, behavioral and social care needs. Care Plan Rounds typically focus on members who are at high risk, have complex co-morbid conditions and/or have difficulty sustaining an effective working relationship with treatment and/or non-treatment staff. Interdisciplinary Care Plan Rounds are scheduled weekly.
The Health Plan disease management program is available to Members with high risk and/or chronic conditions. The program includes intervention plans that target chronic behavioral and physical health conditions such as, anxiety, chronic obstructive pulmonary disease, heart failure, chronic pain, and diabetes mellitus.
The goal of the program is to employ strategies such as health coaching and wellness to facilitate behavioral change to address underlying health risks and to increase Member self-management as well as improve practice patterns of providers, thereby improving healthcare outcomes for Members. The Health Plan evaluates the effectiveness of these programs including education specifically related to the identified Member‘s ability to self-manage disease and measurable outcomes.
Out of Home Services for review should include but not limited to: Necessity of admission and appropriateness of service setting, quality of care, length of stay, how the services meet the member’s needs, and discharge needs. Providers providing out-of-home services are required to provide the following additional documentation as identified below to The Health Plan:
- The Admission Face Sheet or Notice of Admission within one business day following admission.
- The Out-of-Home Program Intake Summary within one business day following admission.
- The most recent Psychiatric Evaluation within one business day following the admission.
- Concurrent reviews are completed by paper submission and /or telephonic review depending on your organizational needs. Please submit concurrent review by Fax to 1-855-764-8513 within 7 days prior to the last covered day.
- Discharge Planning begins 24 hours after admission to a residential or inpatient facility. Please follow the AHCCCS AMPM, Chapter 1000, Section 1020 (Discharge Planning). This includes post follow up appointment with PCP or specialist within 7 days, safe placement with community supports, prescription medicines, and medical equipment if needed.
4.12.1 General Overview
Discharge planning refers to the clinically appropriate process of assessment and preparation for member needs upon discharge from the emergency department, inpatient or out-of-home placements. Discharge planning is a collaborative process involving timely communication between the member/caregiver, inpatient/residential provider, plan care manager, and outpatient providers to ensure a smooth transition of care to the community or another level of care.
Improvements in discharge planning can dramatically improve the outcome for members as they move to the next level of care. Research shows that good discharge planning is instrumental in improving health, and reducing avoidable readmissions when medications are prescribed and given correctly, and the member, their family or caregivers are adequately prepared to take over their care. Members, family, caregivers and providers are all involved in maintaining the health and stability of a member after discharge.
Recommended discharge planning activities:
- Assessment of the member by qualified personnel, including:
- Member’s social determinants of health (SDOH) which will affect their ability to successfully discharge to the community.
- Barriers/gaps in care that may lead to readmission
- Member needs upon discharge for services such as physical/behavioral therapy, home health, etc.
- Needs for DME
- Member’s understanding of medications, or need for education in this area.
- Past utilization patterns.
- To the member’s Health Plan/outpatient providers about the admission, to request records/treatment history, and to discuss needs for discharge.
- Discussion with the member about their needs; the type of care that will be required after discharge; what activities they might need assistance with when they go home; information about medications and diet; who will handle meal preparation, transportation and chores.
- Outreach to member’s family/caregivers/natural supports to engage them in member’s support and treatment according to member’s needs and desires.
- Include outpatient treatment team in treatment planning with the member where possible.
- Planning for discharge or transfer to another facility:
- Work with outpatient providers to develop continuing treatment plans if necessary.
- Arrange follow-up appointments with outpatient providers, including medication reconciliation if necessary.
- Arrange appointments for follow up testing if required.
- Ensure access to medications before discharge and member understanding of how to take medications and why.
- Make referrals to specialists, home care agencies and/or appropriate support organizations in the community.
- Arrange for DME, oxygen, etc. according to the member’s needs.
- Arrange for caregiver training or other support if it will be needed.
For licensure requirements with regards to discharge planning please check:
126.96.36.199 Best Practice References and Recommendations
- Care Transitions Model (Coleman Model)
- Transitional Care Model designed to prevent health complications and re-hospitalizations of chronically ill, elderly hospital patients
- Project Re-engineered Discharge (Project Red)
- Project Better Outcomes for Older Adults Through Safe Transitions (Project Boost)
- HSAG Top 10 Intervention Series to Reduce Inpatient Psychiatric Readmissions
- AHRQ Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions/Toolkit https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html
188.8.131.52 Administrative Days (formerly known as Avoidable Bed Days)
The Health Plan will consider administrative days for an acute hospitalized member who no longer meets medical necessity criteria and is ready for the next level of care; and the stay is being denied by the Health Plan Medical Director. In addition, it must be clearly documented in the member’s medical record that the inpatient facility has attempted to secure the next level of care but has been repeatedly refused by all network available facilities. Providers must submit daily documentation, including weekends, of reaching out to providers for an available placement for the member. The documentation must be submitted to reviewer every 3 days throughout duration of administrative stay.
- Discuss with the provider’s UM reviewer about the member’s lack of disposition per the finding of a facility available at time of discharge and request administrative days.
- The provider will be notified upon approval.
- It is the provider’s obligation to submit continued information on who is being contacted for bed placement daily, with the name of the facility, phone number, who was spoken with, and reason for not accepting member.
- Documentation of reaching out to providers for placement, including the information specified above, must be submitted daily, including weekends, and must also be submitted to the reviewer every 3 days throughout duration of administrative stay.
4.12.2 Discharge Planning for American Indian Members In an Out of Home Placement
- If an American Indian member is currently receiving services from an Outpatient Provider and a Tribal Provider (Tribal and/or IHS), providers are required to work in collaboration with the Tribal Provider.
- When American Indian members are placed out of home, the provider is expected to include the Tribal provider in ongoing discharge planning and ongoing service planning.
- If assistance is needed with Tribal providers, contact a member of the Health Plan Tribal Programs Team at AzCHTribalCOC@azcompletehealth.com
4.12.3 Discharge Planning for Behavioral Health Admissions
184.108.40.206 Behavioral Health Hospital Discharge Plan
- Member assessment needs:
- Use a screening tool to assess Social Determinants of Health (SDOH)
- Patient Centered Assessment Method (PCAM) (PDF)
- Health Leads Screening Toolkit (which includes a screening tool)
- Hennepin County Medical Center Life Style Overview (PDF)
- Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE)
- Accountable Health Communities Screening Tool (PDF)
- Use a screening tool to assess Social Determinants of Health (SDOH)
- Inform the Health Plan and Outpatient Providers of member’s admission
- Request treatment records including: most recent History & Physical, psychiatric evaluation, medication lists from both BHMP and PCP, current service plan and Crisis Plan, anticipated target level of functioning upon discharge from inpatient services.
- Invite member and outpatient provider participation in discharge planning meetings.
- Provide discharge summaries to the member’s Health Plan and outpatient treatment providers that includes a description of the patient’s condition and the services provided to the member.
- Provide the member with documented discharge instructions, and provide a copy to the member’s representative/caregiver.
- Treatment Planning:
- For members with an SMI determination develop an ITDP (Inpatient Treatment Discharge Plan) in collaboration with the outpatient clinical team.
- Identify the specific needs of the member after discharge.
- If member is going to need DME, treatment in Behavioral Health Residential Facility (BHRF) or other ongoing treatment, ensure that the appropriate requests for authorization have been submitted to the Health Plan.
- Provide sufficient medications to cover the member until they are able to meet with their outpatient provider/prescriber.
- For members with substance dependence issues ensure that services are offered such as: detoxification, opioid treatment, MAT, and referrals to treatment if necessary. If needed also ensure that these members are provided with naloxone.
- Ensure that post discharge appointments have been scheduled for medication reconciliation or other treatment needs.
For more information see: *ARTICLE 2. HOSPITALS (PDF). R9-10-209. Discharge Planning. ARTICLE 3. BEHAVIORAL HEALTH INPATIENT FACILITIES (PDF). R9-10-309. Discharge
220.127.116.11 Discharge Planning Activities for Behavioral Health Outpatient Providers:
- Provide a packet of clinical information about the member to the Inpatient facility, including: most recent History & Physical, psychiatric evaluation, Medications lists from both BHMP and PCP, current service plan and Crisis Plan, anticipated level of functioning upon discharge.
- Notify the outpatient clinical team staff of member’s current status/discharge plan.
- Coordinate/facilitate a treatment planning meeting (ART/CFT) with the member while inpatient and invite the Hospital Social Worker/discharge planner, member’s guardian, POA, Public Fiduciary, therapist, peer support, member’s natural supports, and unit charge nurse.
- Meet with the member within 48 hours of admission, and prior to discharge.
- Obtain a copy of the ITDP (developed in collaboration between the Inpatient and Outpatient treatment teams) and distribute to the treatment team.
- If necessary to develop a safe disposition plan, facilitate a conversation between the BHMP/PCP and the attending psychiatrist.
- If the member has any barriers to a safe discharge inform the inpatient social worker and the Health Plan UM reviewer/transitions of care CM.
- Treatment Planning:
- Review the recommendations on the ITDP and plan to implement them.
- Submit any required authorization requests for Behavioral Health placement, and other behavioral health needs on the ISP, including medication prior authorization to the Health Plan for approval.
- Provide the dates for follow-up appointments to the inpatient discharge planner and to the member. The scheduling is:
- BHMP: Within 7 calendar days of member’s discharge from facility for BH condition
- Primary Care Provider: Within 7 calendar days of member’s discharge unless medically indicated to see provider sooner.
- Plan to meet with the member after discharge to ensure member’s needs have been met.
- Update the annual assessment, ISP and Crisis plan in the member’s EHR, to ensure that all gaps in care have been identified and provided for to reduce the chance that the member will readmit.
Providers are required to comply with various pharmaceutical requirements within the AzCH-Complete Care Plan’s Provider Manual, AHCCCS AMPM Policy 310-V, and the Arizona Opioid Epidemic Act SB1001/HB2001.
4.13.1 E-Prescribing Software
Utilize e-prescribing software systems to submit prescriptions to pharmacies.
4.13.2 Tamper-Resistant Prescription Pads
Providers are required to ensure that processes are in place for the use of Tamper Resistant Prescription Pads (TRPP) for any non-electronic prescriptions. Written and non-electronic prescriptions are required to contain all three of the following characteristics:
- One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form.
- One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber, and
- One or more industry-recognized features designed to prevent the use of counterfeit prescription forms.
The tamper resistant requirement does not apply when a prescription is communicated by the prescriber to the pharmacy electronically, verbally, by fax, or in most situations when drugs are provided in designated institutional and clinical settings and paid for as part of a bundled or per diem payment methodology. The guidance also allows emergency fills with non-compliant written prescriptions as long as the prescriber provides a verbal, faxed, electronic, or compliant written prescription to the pharmacy within 72 hours.
4.13.3 Free Samples
Providers must ensure that no "free samples" of brand name medications will be provided to Health Plan Members and that Pharmaceutical Company Representatives are not allowed to provide, or make available, marketing materials of brand name medications to Health Plan Members. The Provider must also ensure that Health Plan Members do not participate in Pharmaceutical Company sponsored activities, such as free lunches or giveaways. In order to prevent drug representatives from having undue influence on prescribing practices, provider staff serving Health Plan Members also are discouraged from participating in Pharmaceutical Company sponsored activities, such as free lunches or giveaways.
4.13.4 The Health Plan Drug Lists (Formulary)
Providers are required to abide by The Health Plan's drug lists (formularies) as applicable, when prescribing medications for Members in accordance with this Provider Manual. Providers are also required to adhere to the requirements of the AHCCCS Psychotropic Medication informed consent requirements in accordance with this Provider Manual.
4.13.5 Prescriber Appointments
Providers must ensure that Members are scheduled for Prescriber appointments in a time frame that ensures that (1) the Member is evaluated for the need for medications so that the Member does not experience a decline in behavioral health status, and (2) the Member does not run out of medication.
4.13.6 Physician Oversight
Providers are required to provide physician oversight when providing medical treatments, including methadone, medications, and detoxification to ensure services are rehabilitative in focus and directed to long-term recovery management, when applicable.
4.13.7 Medication Assisted Treatment
Providers are required to ensure Behavioral Health Medical Professionals assist Members with Substance Use Disorders receive Medication Assisted Treatment when appropriate to support Members' recovery.
4.13.8 Registration with Controlled Substance Prescription Monitoring Program
All medical practitioners are required to register and utilize the Arizona Controlled Substance Prescription Monitoring Program (CSPMP, PMP). Practitioners must obtain a patient utilization report for the preceding 12 months from the controlled substances PMP central database tracking system before prescribing opioid analgesics or benzodiazepines in schedules II-IV. Practitioners are not required to obtain a report if the patient is:
- receiving hospice care or being treated for cancer or cancer-related illness;
- if the practitioner will administer the controlled substance;
- if the patient is receiving the controlled substance during the course of inpatient or residential treatment in a hospital, nursing care facility or mental health facility;
- if the medical practitioner, under specific legislation, prescribed controlled substances for no more than five day after oral surgery, and
- as outlined in AHCCCS AMPM Chapter 300, Policy 310-FF.
Medical practitioners may be subject to liability or disciplinary action for failing to request or receive prescription monitoring data from the PMP, or for acting or failing to act on the basis of the PMP monitoring data provided. Evidence of registration is required to be maintained in personnel records.
4.13.9 The Health Plan Drug Lists
The Health Plan’s Drug Lists ensure the availability of safe, cost-effective and efficacious medications for eligible Members. Medications may be added or deleted from the list based on factors such as obsolescence, toxicity, and substitution of superior products or newer treatment options.
Medicare eligible Members, including persons who are dually eligible for Medicare (Title XVIII) and Medicaid (Title XIX), receive Medicare Part D prescription drug benefits through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs). Prescription drug coverage for Medicare eligible Members enrolled in Part D is based on the Part D plans’ drug lists (formularies). There may be an occasion when a Member’s prescribed drug is not available through their Part D plan’s formulary. This is considered a non-covered Part D drug. The Health Plan and/or providers must make attempts to obtain a drug not on a Part D plan’s formulary by requesting an exception from the Part D plan.
To ensure coverage of medications through The Health Plan, providers are required to utilize The Health Plan drug lists. These drug lists can be found on The Health Plan’s website at www.azcompletehealth.com or can be requested in hard copy by calling the Pharmacy Service Center at 888-788-4408.
To use the drug list, providers are encouraged to look in the index which lists all of the drugs on the drug list and includes both the brand name and generic name. Abbreviations that may appear in the Drug Tier column on the drug list include: “F” for Formulary which means the drugs are covered by Arizona Complete Health-Complete Care Plan and “NF” or Non-Formulary for drugs that require authorization to be covered.
Title XIX/XXI eligible persons receiving medication(s) have the right to notice and appeal when a decision affects coverage for medication(s), in accordance with Section 8.4 - Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons. Non-Title XXI/XXI persons determined to have a SMI have the right to notice and appeal when a decision affects medication coverage, in accordance with Section 8.5 - Notice and Appeal Requirements (SMI and GMH/SA Non-Title XIX).
Members with third party coverage, such as Medicare and private insurance, will have access to medications on their health plan’s formulary through their third party insurer. If the desired/recommended prescription drug is not included on the health plan’s formulary but may be covered by requesting an exception or submitting an appeal, the provider is required to attempt to obtain an exception for the medication or assist the Member in submitting an appeal with the health plan, The Health Plan will cover medications for persons determined to have a SMI, regardless of Title XIX/XXI eligibility, when their third party insurer will not grant an exception for a medication that is a medication on the Behavioral Health Drug List or The Health Plan Drug List.
Applicable copayments must only be collected in accordance with Section 7.22 - Copayments. For Persons with Coverage from Third Party Payers, copayments are collected in accordance with Section 7.24 - Third Party Liability and Coordination of Benefits.
4.13.10 Prior Authorization
AHCCCS requires The Health Plan to prior authorize coverage of those medications indicated in the AHCCCS Health Plan Drug Lists as requiring prior authorization and those that have age limits. Please see the preferred drug lists (PDLs) for additional information on which medications require prior authorization or have coverage limitations. You may also refer to the health plan web-site for pharmacy forms and criteria: https://www.azcompletehealth.com/providers/pharmacy.html or by request by calling provider services.
When these prior authorization criteria are utilized, the requirements outlined in Section 4.1 - Securing Services and Prior Authorization, Section 8.4 - Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons, and Section 8.5 - Notice and Appeal Requirements (SMI and GMH/SA Non-TXIX/TXXI), must be met.
4.13.11 Input from The Health Plan Pre Contracted Providers
The Health Plan contracted providers can offer suggestions for adding or deleting medications to/from the AHCCCS Health Plan Drug Lists directly with AHCCCS.
To propose additions or deletions to The Health Plan Drug Lists, providers may submit a written request to The Health Plan’s Pharmacy Administrator:
Arizona Complete Health- Complete Care Plan
333 E. Wetmore Road
Tucson, AZ 85705
Requests for additions must include the following information:
- Medication requested (trade name and generic name, if applicable);
- Dosage forms, strengths and corresponding costs of the medication requested;
- Average daily dosage;
- Indications for use (including pharmacological effects, therapeutic uses of the medication and target symptoms);
- Advantages of the medication (including any relevant research findings if available);
- Adverse effects reported with the medication;
- Specific monitoring required; and
- The drugs on the current formulary that this medication could replace.
Requests for deletions must include a detailed summary of the reason for requesting the deletion.
The Health Plan Pharmacy Administrator or designee will present requests, as determined appropriate, to the AHCCCS Pharmacy and Therapeutics Committee.
The Health Plan will provide specific information for their providers regarding requests and changes to the Preferred Drug Lists on our web-site https://www.azcompletehealth.com/providers/pharmacy.html or through fax/e-mail communications or pharmacy webinars.
4.14.1 Compliance with The Health Plan, Agency Requirements and Laws
Providers must comply with various utilization management requirements, including Chapter 1000 of the AMPM, the QM/MM/UM Performance Improvement Specifications Manual, this Provider Manual, The Health Plan’s Utilization Management Plan, and Federal utilization control requirements limiting respite services to six hundred (600) hours per Member per year.
4.14.2 Communication of Guidelines
The Health Plan will communicate guidelines, including any admission, continued stay and discharge criteria to all affected providers and to Members when appropriate and to individual Members upon their request. Decisions regarding utilization management, Member and provider education, coverage of services, provision of services, and other areas to which guidelines are applicable must be consistent with 42 CFR 438.230(c) and (d). Providers must also communicate notice of decision requirements as described in this Provider Manual, and federal and State laws and regulations, including federal requirements regarding Utilization Review Plans, Utilization Review Committees, Plan of Care and Medical Care Evaluation studies as prescribed in 42 CFR, Parts 441 and 456.
4.14.3 Emergency Room Utilization
The Health Plan tracks emergency room utilization, including waiting times members are in an emergency room awaiting a behavioral health inpatient placement. The Health Plan tracks emergency department utilization by members and Behavioral Health Home, providing reports to Behavioral Health Homes on a monthly basis. Behavioral Health Homes are required to proactively work with members to minimize unnecessary utilization of emergency rooms by providing members 24/7 access to physicians and developing and utilizing alternative 24/7 community based services to help members manage crises and receive appropriate medical care. The Health Plan reports appropriate and non-appropriate use of emergency departments to Behavioral Health Homes regarding individual members. Non-appropriate and repeat appropriate use of emergency departments by individual members is reported to providers through the provider portal. Behavioral Health Homes are required to review the data and help members receive the most appropriate care in the most appropriate settings and facilitate access to preventive care services to reduce the need for emergency department utilization.
4.14.4 Responsibilities of The Health Plan Medical Management/ Utilization Management Committees
The Health Plan convenes Medical Management/Utilization Management (MM/UM) Committee meetings on a regularly scheduled and ongoing basis. The Health Plan discusses data submitted to AHCCCS as part of the MM/UM Committee. The Health Plan’s MM/UM Committee is expected to conduct the following Utilization Data Management Activities specific to data that is reported to AHCCCS:
- Review and analyze data to identify trends;
- Interpret variances;
- Review Outcomes;
- Determine, based on the review of data, if action (new or changes to current intervention) is required to improve the efficient utilization of services;
- Develop and/or approve corrective action and interventions based on findings; and
- Review and evaluate the effectiveness/outcomes of the intervention.
Both AHCCCS and The Health Plan’s evaluation of findings and interventions must include a review of the impact to service utilization, quality, and outcome.
Both AHCCCS and The Health Plan’s intervention strategies are to address both over and under- utilization of services and must be integrated throughout the organization. All strategies must have measurable outcomes and must be reported in MM/UM minutes. The Health Plan must also incorporate its evaluation of over and under-utilization into its annual Medical Management Plan and summarize action taken to correct areas of concern.
Minimum Required Utilization Data Elements include, but are not limited to:
- Over- and Under-utilization of services and costs;
- Avoidable hospital admissions and readmissions, and average length of stay for all psychiatric inpatient stays;
- Follow-up after discharge;
- Court-ordered treatment;
- Emergency Department utilization and crisis services;
- Prior Authorization, denials and notices of action;
- Pharmacy Utilization;
- Lab and diagnostic utilization;
- Medicare Utilization;
- Serious Mental Illness Eligibility Determination; and
- Bed days per 1000 admissions.