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Data Systems/Reporting Requirements

With respect to decisions on enrollment providers shall defer to AHCCCS, which has exclusive authority to enroll and dis-enroll Medicaid eligible members in accordance with the rules set forth in A.A.C., R9-22, Article 17 and R9-31, Articles 3 and 17. Providers shall also defer to AHCCCS, which has exclusive authority to designate who will be enrolled and dis-enrolled as Non-Medicaid eligible members.

The collection and reporting of accurate, complete and timely enrollment, and disenrollment data is of vital importance to the successful operation of the AHCCCS health service delivery system. It is necessary for providers to submit specific data on each person who is actively receiving services from the health system. As such, it is important for provider staff (e.g., intake workers, clinicians, data entry staff) to have a thorough understanding of why it is necessary to collect the data, how it can be used and how to accurately label the data. This policy has particular relevance for those providers that conduct assessments, ongoing service planning, and annual updates. This data in turn is used by the AHCCCS to:

  • Monitor and report on outcomes of individuals in active care (e.g., changes in diagnosis, employment/educational status, behavioral health category, substance use,);
  • Comply with federal and state funding and/or grant requirements;
  • Assist with financial-related activities such as budget development and rate setting;
  • Support quality management and utilization management activities; and
  • Inform stakeholders and community members.

The intent of this section is to describe requirements for providers to submit the following data in a timely, complete, and accurate manner:

  • Non-Title XIX/XXI 834 batch enrollment and dis-enrollments.

The Health Plan’s Management Information System has the capability to automatically receive and load data from a provider‘s EHR to collect enrollment data for submission to AHCCCS. The Health Plan providers required to transmit 834 records to The Health Plan, must have a certified EHR and use their system to electronically send data in the required format.

Additionally, The Health Plan and AHCCCS shall have access privileges and user-rights to any and all Member information within Contractor‘s MIS system, and that of any Management Information System (MIS)/Electronic Health Record (EHR) system operated by a subcontracted provider. At a minimum, The Health Plan and AHCCCS shall be permitted real-time access to client level data, claims and billing, service planning, assessment, and grievance and appeal data.

6.1.1 Enrollment And Disenrollment Transactions

6.1.1.2 General Requirements:

  • Arizona Health Care Cost Containment System (AHCCCS) enrolled individuals are considered enrolled with The Health Plan at the onset of their eligibility. They are provided an AHCCCS identification card listing their assigned Health Plan. This assignment is sent daily from AHCCCS to The Health Plan.
  • For a Non-Title XIX/XXI eligible person to be enrolled, providers must submit an 834 enrollment transaction to The Health Plan. All AHCCCS enrolled individuals with a mental health benefit are considered enrolled with The Health Plan at the time of their AHCCCS eligibility.
  • For a Non-Title XIX/XXI eligible person who receives a covered service, they must be enrolled effective the date of first contact by a provider.

6.1.1.2 When to Collect Enrollment Information

For Non-Title XIX/XXI eligible individuals, information necessary to complete an 834 transaction is usually collected during the intake and assessment process (see Section 12.5 - Assessment and Service Planning). Provider Manual Attachment 13.1.1, 834 Transaction Data Requirements that can be obtained by calling the Provider Services Call Center at 866-796-0542 which contains a list of the data elements necessary to create an 834 enrollment transaction.

For AHCCCS enrolled individuals, the 834 information will be provided to The Health Plan by AHCCCS.

6.1.1.3 Data Included in an 834

The data fields that are included in the 834 transmittals are dictated by HIPAA and consist, in part, of:

  • Key client identifiers used for file matching (e.g., person’s name, address, date of birth);
  • Basic member information (e.g., gender, marital status); and
  • Information on third party insurance coverage.

Reference The Health Plan 834 file specification document for full details on what to collection and how to submit Non-Title 834 files. You can obtain a current version of the 834 file specifications by contacting EDI Help Desk at 1-888-460-4310.

6.1.1.4 Lack of Information to Complete an Enrollment

Providers must actively secure any needed information to complete the enrollment (834 transaction) for a Non-Title XIX/XXI eligible individual. An 834 transaction will not be accepted by the Health Plan if required data elements are missing. For Title XIX/XXI eligible individuals, the 834 information will be provided to The Health Plan by AHCCCS.

6.1.1.5 Timeframes for Submitting Enrollment and Disenrollment Data for A Non-Title XIX/XXI Eligible Individual

  • The following data submittal timeframes apply to the enrollment/disenrollment transactions: The 834-enrollment transaction must be submitted to Health Plan within 7 calendar days of the first contact with a member.
  • The 834 disenrollment transaction must be submitted to The Health Plan within 7 calendar days of the person being dis-enrolled from the system; and any changes to the enrollment/disenrollment transaction data fields (e.g., change in address, insurance coverage) must be submitted 7 calendar days from the date of identifying the need for the change.

6.1.1.6 Other Events Requiring a Submittal of an 834 Transaction For A Non-Title XIX/XXI Eligible Individual

In addition to submitting an 834 transaction at enrollment and disenrollment, an 834 transaction must also be submitted when any of the following elements of the 834 transaction have changed:

  • Name;
  • Address;
  • Date of birth;
  • Gender;
  • Marital status; or
  • Third party insurance information.

6.1.1.7 Other Considerations for Both Non-Title XIX/XXI Eligible and AHCCCS Enrolled Individuals

For an AHCCCS enrolled individual, AHCCCS will notify The Health Plan of changes to the above information.

When a person in an active care permanently relocates from one RBHA/MCO/Health Plan’s geographic area to another RBHA/MCO/Health Plan’s geographic area, an Inter-RBHA/MCO transfer must occur (see Section 13.2 – Inter-RBHA/MCO Coordination of Care). The steps that are necessary to facilitate an Inter-RBHA/MCO transfer include the following data submission requirements:

  • The home T/RBHA/Health Plan must submit an 834 disenrollment transaction effective on the date of transfer;
  • The receiving T/RBHA/Health Plan must submit an 834 enrollment transaction on the date of accepting the person for services and start of treatment; and
  • AHCCCS will notify The Health Plan when The Health Plan enrolled person is determined eligible for the Arizona Long Term Care System (ALTCS) Elderly and Physically Disabled (EPD) Program. This information will be passed to The Health Plan in a daily file.

6.1.1.8 Technical Assistance Available to Help with Problems Associated with Electronic Data Submission

At times, technical problems or other issues may occur in the electronic transmission of the data from the provider to The Health Plan. If a provider requires assistance for technical related problems or issues, please email The Health Plan EDI Help Desk at 1-888-460-4310.

6.1.2 Member and Clinical Data

6.1.2.1 When Member and Clinical Data Is Collected

Member and clinical data shall be collected starting at the first date of service. For Non-Title XIX/XXI eligible individuals, an 834 must be completed. The AHCCCS Demographic & Outcomes Data Set User Guide describes minimum required data elements that comprise the demographic data set, in part.  Providers are required to comply with AHCCCS demographic requirements, submitting demographic data to AHCCCS through the AHCCCS DUGLess portal.