For Providers contracted with University Family Care, Maricopa Health Plan, University Care Advantage,

Transcription

1 Revised /201 For Providers contracted with University Family Care, Maricopa Health Plan, University Care Advantage, University Healthcare Marketplace, Maricopa Care Advantage

2 Revised 10/2014 Section Introduction to University of Arizona Health Plans Section Definitions Section Contact Lists Section Network Development Section Provider Standards & Responsibilities Section Claims Section Member Copayments Section Covered Services Section Referral & Prior Authorization Section Quality Management Section Behavioral Health Services Section Dental Care Services Section EPSDT Section AzEIP Section

3 Revised 10/2014 CRS Section Maternity & Family Planning Section Pharmaceutical Services Section Eligibility & Enrollment Section Model of Care Section KidsCare Section Business Continuity Plan Section Member ID

4 SECTION 1 INTRODUCTION 1.0

5 Introduction This manual has been organized to present the Health Plan s participating providers with specific and pertinent information to which all providers must adhere. This Provider Manual contains information for all product lines; University Family Care, Maricopa Health Plan, University Care Advantage and University Healthcare Marketplace. Each chapter contains information that is common to all product lines. In instances where information is specific to a particular product line, it will be noted within that specific chapter. INTRODUCTION 1.1

6 Welcome! The University of Arizona Health Plans (Health Plan) would like to thank you for providing quality medical care to our members. We remain committed to developing a positive working relationship with all of our providers and welcome any comments or suggestions on how we can improve our operations and interactions with you, our customer. The Health Plans are part of The University of Arizona Health Network (UAHN). Our integrated health care system includes The University of Arizona Medical Center University Campus and South Campus, as well as a comprehensive network of UAHN primary care and specialty care providers and services. We also have a robust and diversified community provider network across all counties of operation. Our goal is to ensure that our members have access to care nearby and that providers have a good selection of local providers to work with and refer to. The Health Plans consist of University Family Care, University Care Advantage and University Healthcare Marketplace. In addition, the Health Plan is the Plan Administrator for Maricopa Health Plan and Maricopa Care Advantage. University Family Care (UFC) and Maricopa Health Plan (MHP) UFC and MHP are two plans offered to Arizona Health Care Cost Containment System (AHCCCS) eligible members. Eligibility is determined by the Department of Economic Security, AHCCCS Administration. Maricopa Care Advantage (MCA) and University Care Advantage (UCA) MCA and UCA is a Special Needs Plans (SNP) for our dual eligible members (members with both Medicare and Medicaid). Members must be entitled to Medicare Part A, enrolled in Medicare B and AHCCCS and reside in a contracted service area to be eligible. The Health Plan has been an AHCCCS plan contractor since In 2005, the Health Plan began the management of Maricopa Health Plan and in January, 2008, the Health Plan started the Special Needs Plans. The Provider Manual is an extension of your Provider Agreement. The Health Plans have designed the manual to supply participating providers and their staff with policies and procedures the Health Plans use to administer health plan products. INTRODUCTION 1.2

7 Please feel free to contact your Provider Relations Representative with any questions you may have. James V. Stover Chief Executive Officer The University of Arizona Health Plans Important! Please note that our Provider Manual is also available online at: INTRODUCTION 1.3

8 SECTION 2

9 Definitions Eligible individuals and families under the 1931 provision of the Social Security Act, with household income levels at or below 100% of the Federal Poverty Level (FPL). ARIZONA ADMINISTRATION CODE (A.A.C.) -State regulations established pursuant to relevant statutes. Referred to in Contract as Rules. AHCCCS Rules are State regulations which have been promulgated by the AHCCCS Administration and published by the Arizona Secretary of State. ARIZONA REVISED STATUTES (A.R.S.) - Laws of the State of Arizona. ABUSE (BY PROVIDER) - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost. Abuse of a member means any intentional, knowing or reckless infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, emotional or sexual abuse, or sexual assault. AGENT - Any person who has been delegated the authority to obligate or act on behalf of a provider [42 CFR ]. AMBULATORY CARE - Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and other health care providers. ANNUAL ENROLLMENT CHOICE (AHCCCS ONLY) - The opportunity, given to each member every 12 months to change to another contractor in his or her Geographic Service Area (GSA) ; effective their anniversary date. ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS) BEHAVIORAL HEALTH RECIPIENT - A Title XIX or Title XXI acute care member who is eligible for, and is receiving, behavioral health services through Arizona Department of Health Services (ADHS) and its subcontractors. ARIZONA DEPARTMENT OF HEALTH SERVICES, DIVISION OF BEHAVIORAL HEALTH (ADHS/DBHS) - The state agency mandated to provide behavioral health services to DEFINITIONS 2.0

10 Title XIX and Title XXI Acute care members who are eligible for behavioral health services. Services are provided through the ADHS Division of Behavioral Health and its Contractors. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS) - The state agency mandated to provide behavioral health services to Title XIX and Title XXI Acute care members who are eligible for behavioral health services. Services are provided through the ADHS Division of Behavioral Health and its Contractors. ARIZONA LONG TERM CARE SYSTEM (ALTCS) - An AHCCCS program which delivers long-term, acute, behavioral health and case management services as authorized by A.R.S et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with developmental disabilities, through contractual agreements and other arrangements. ARIZONA STATE IMMUNIZATION INFORMATION SYSTEM (ASIIS) - Arizona State Immunization Information System (ASIIS) is the central database maintained by the Arizona Department of Health Services to record all immunizations administered to children younger than age 19. Arizona law requires physicians to report all immunizations given to children in this age group at least monthly. PC immunize is free software which assists physicians in capturing and collecting this data for reporting to the State central registry. AUDIT- A formal review of compliance with a particular set of standards (e.g., policies and procedures, laws and regulations) used as a base measure BOARD CERTIFIED - An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification. BREAST AND CERVICAL CENTER TREATMENT PROGRAM (BCCTP) - Eligible individuals under the Title XIX expansion program for women with income up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare. BUSINESS PARTNERS - The collective grouping of all UAHP first tier, downstream and related entities, subcontractors and agents. CAPITATION - Payment to a provider by UAHP of a fixed monthly payment per person in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S and DEFINITIONS 2.1

11 CATEGORICALLY LINKED TITLE XIX MEMBER - A member who is eligible for Medicaid under Title XIX of the Social Security Act including those eligible under 1931 provisions of the Social Security Act (previously AFDC), Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), SSI-related groups. To be categorically linked, the member must be aged 65 or over, blind, disabled, a child under age 19, parent of a dependent child, or pregnant. CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) - Federal Agency which administers Medicare and Medicaid programs. CLAIM FORMS UB-04 form is used to bill for: hospital inpatient, outpatient, emergency room, and hospital- based clinic charges, home health (dependent on the product line), and pharmacy charges for services provided as an integral part of a hospital service, dialysis clinic, nursing home, free standing birthing center, residential treatment center, and hospice services. CMS 1500 form is used to bill for: services other than those described above, including professional services, transportation, and durable medical equipment. Dental ADA form is used to bill for charges for dental services identified with D codes. CLEAN CLAIM - A claim that may be processed without obtaining additional information for the provider of service or from a third party; but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by A.R.S CONVICTED - A judgment of conviction has been entered by a Federal, State or local court, regardless of whether an appeal from that judgment is pending. COPAYMENT - A monetary amount that the member pays directly to a provider at the time covered services are rendered, as defined in 9 A.A.C. 22, Article 7. CO-INSURANCE - The portion of a covered service expense for which the member is responsible. CONCURRENT REVIEW - Concurrent review is a utilization management function performed by registered nurses for each inpatient admission to acute care hospitals or extended care facilities. The concurrent review process determines the appropriateness of the hospital stay and level of care, and is based on standardized review criteria (MCG and InterQual criteria are used for inpatient/hospital stays). Services that extend over a long period of time, such as home health services, may be subject to the concurrent review process. DEFINITIONS 2.2

12 CONTINUATION AREA - An area outside of the contracted service area within which the Health Plan arranges to furnish services to our continuation of enrollment members. Members must reside in a continuation area on a permanent basis. A continuation area does not expand the service area of the Health Plan. COVERED SERVICES - Covered services are medically necessary health services (which may vary by benefit package) that are delivered to the Health Plan members at the direction of the member s primary care provider (PCP). CHILDREN S REHABILITATIVE SERVICES (CRS) - is a State program administered by the Arizona Department of Health Services. Federal matching funds are available for the provision of services to Title XIX eligible children enrolled in an AHCCCS Health Plan. See the CRS Section in this manual for additional information. CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) - Children under age 19 who are: Blind/Disabled Children and Related Populations (eligible for SSI under Title XVI). Children eligible under section 1902 (e)(3) of the Social Security Act; in foster care or other outof-home placement; Receiving foster care or adoption assistance or receiving services through a family-centered community-based coordinated care system that receives grant funds of Title V (CRS). DEDUCTIBLE - The amount a member must pay each calendar year for certain benefits before University Marketplace will pay for covered services. DEEMED PROVIDER, SUPPLIER OR BUSINESS PARTNER- A provider or supplier that has been accredited by a national accreditation program (approved by CMS) as demonstrating compliance with certain conditions. DISENROLLMENT - The discontinuance of a member s ability to receive covered services through any Health Plan product line. DOWNSTREAM ENTITY- An organization or individual that enters into an acceptable written arrangement below the level of the arrangement between UAHN and a first tier entity. This continues down to the level of the ultimate provider of a service or product. Example: A health care services group. DUAL ELIGIBLE - Members who are dually eligible for Medicare and Medicaid or are living in institutions or have a severe, chronic or disabling condition. DURABLE MEDICAL EQUIPMENT (DME) - An item that can withstand repeated use and is designated to serve a medical purpose such as hospital beds, wheelchairs, and crutches and is generally not useful to a person in the absence of a medical condition, illness, or injury. DEFINITIONS 2.3

13 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) - A comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services. ELIGIBILITY DETERMINATION - A process of determining, through a written application, and including required documentation, whether an applicant meets the requirements for Title XIX or Title XXI. EMDEON (formerly MediFax) - A company that makes available electronic claims processing software and electronic eligibility verification information. Providers may contract directly with MediFax for these services. EMERGENCY MEDICAL CONDITION - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a) placing the patient s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b)serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part [42 CFR (a)]. EMERGENCY MEDICAL SERVICE - Covered inpatient and outpatient services provided after the sudden onset of an emergency medical condition. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize the emergency medical condition [42 CFR (a)]. ENCOUNTER - An encounter is a term often used interchangeably with claim. Generally, capitated claims are referred to as encounters. Encounters are a claims record of medically related services rendered by a provider or providers to a member who is enrolled with a contractor (health plan) on the date of service. Providers are required to report all services to the Health Plan, including services under capitated arrangements. The Health Plan, in turn, electronically reports these encounters. DEFINITIONS 2.4

14 ENROLLEE - A Medicaid recipient who is currently enrolled with a Contractor [42 CFR (a)]. ENROLLMENT (AHCCCS/SNP) - The process by which a person who has been determined eligible to receive AHCCCS and/or SNP benefits will become a member of a health plan. FAMILY PLANNING SERVICES (AHCCCS) - Family planning services are those services available to members, who are eligible to receive full health care coverage and are enrolled with an AHCCCS health plan and who voluntarily choose to delay or prevent pregnancy. FAMILY PLANNING SERVICES EXTENSION PROGRAM (AHCCCS) - A program that provides family planning services only for a maximum of 24 months to SOBRA women whose pregnancy has ended and the woman is not otherwise eligible for Title XIX. FEDERALLY QUALIFIED HEALTH CENTER (FQHC) - A public or private non-profit health care organization which meets the requirements and receives a grant and funding pursuant to Section 330 of the Public Health Service Act. An FQHC includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (PL93-638) or an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act. FEE-FOR-SERVICE (FFS) - A method of payment to registered providers on an amount-perservice basis, up to a maximum allowable fee. FEDERAL EMERGENCY SERVICES (FES) - Federal emergency services program covered under R to treat an emergency medical condition for an AHCCCS member who is determined eligible. FEDERAL FINANCIAL PARTICIPATION (FFP) - Federal financial participation (FFP) refers to the contribution that the Federal government makes to the Title XIX and Title XXI program portions of AHCCCS. FIRST TIER ENTITY - An organization or individual that enters into an acceptable written arrangement with UAHN to provide administrative or health care services. Example: A call center contracted directly with UAHN is a first tier entity. FISCAL AGENT- Any person (individual or corporation) serving as the Health Plan s financial agent (e.g., paying claims on behalf of the Health Plan). DEFINITIONS 2.5

15 FRAUD - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. FREEDOM OF CHOICE (FC) - The opportunity given to each member who does not specify a Contractor preference at the time of enrollment to choose between the Contractors available within the Geographic Service Area (GSA) in which the member is enrolled. GATEKEEPER - Primary care provider who is primarily responsible for all medical treatment rendered, who makes referrals as necessary, and who coordinates and monitors the member s treatment. Except for annual well woman exams, behavioral health and children's dental services and consistent with the terms of the demonstration, covered services must be provided by or coordinated with a primary care provider. GEOGRAPHIC SERVICE AREA (GSA) - The locations (counties, cities, etc.) covered by the Health Plans. HEALTH INSURANCE FLEXIBILITY AND ACCOUNTABILITY ACT (HIFA) - A demonstration initiative by Centers for Medicare and Medicaid Services (CMS), which targets State Children s Health Insurance Program (Title XXI) funding for populations with incomes below 200 percent of the Federal Poverty Level, seeking to maximize private health insurance coverage options. HIFA PARENTS - Parents of Medicaid and KidsCare eligible children who are eligible for AHCCCS benefits under the HIFA Waiver. All eligible parents must pay a monthly premium based on household income. HIGH RISK PREGNANCY - A pregnancy in which the mother, fetus, or newborn is, or will be, at increased risk for morbidity or mortality before or after delivery. High risk is determined through the use of standardized medical risk assessment tools such as the AMERICAN COLLEGE OF GYNECOLOGY tool, as well as a physical assessment. INTEGRATED REGIONAL BEHAVIORAL HEALTH AUTHORITY (INTEGRATED RBHA) - Organization or entity contracted with ADHS to provide, manage and coordinate all medically necessary behavioral healthcare services either directly or through subcontracts with providers for Title XIX eligible adults. In addition, the organization provides, manages and coordinates all medically necessary physical health services for individuals with Serious Mental Illness. INTERDISCIPLINARY CARE - A meeting of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the member based on the most current information available. DEFINITIONS 2.6

16 KIDSCARE - Federal and State Children s Health Insurance Program (Title XXI SCHIP) administered by AHCCCS. The KidsCare I program offers comprehensive medical, preventive and treatment services and a full array of behavioral health care services Statewide to eligible children under the age of 19, in households with income at or below 200% Federal Poverty Level (FPL). The KidsCare II program has the same benefits and premium requirements as KidsCare I, however household income limits cannot be greater than 175% FPL. The KidsCare II program is available May 1, 2012 through January 31, All members, except American Indian members, are required to pay a premium amount based on the number of children in the family and the gross family income. MEDICAL PRACTITIONER - A physician, physician assistant or registered nurse practitioner. MEDICARE ADVANTAGE (MA) - Statutes and regulations pertaining to benefits and beneficiary protections. MEDICARE ADVANTAGE ORGANIZATION (MAO) - A offering an MA plan to enrollees with both Part A and Part B services if entitled under both parts. MEDICAID - A Federal/State program authorized by Title XIX of the Social Security Act, as amended, which provides Federal matching funds for a medical assistance program for recipients of Federally aided public assistance, Supplemental Security Income (SSI) benefits and other specified groups. Certain minimal populations and services must be included to receive Federal financial participation (FFP); however, States may optionally include additional populations and services at State expense and also receive FFP. MEDICAL EMERGENCY - A medical emergency is a condition when your life, body parts or bodily functions are at risk of damage or loss unless immediate care is received. MEDICALLY NECESSARY - As defined in 9 A.A.C. 22 Article 1. Medically necessary refers to those covered services provided by a physician or other licensed practitioner within the scope of his/her practice under State law to a) prevent death, treat/ cure disease, and ameliorate disabilities or other adverse health conditions; and/or b) prolong life. Only medical services that are deemed to be medically necessary and covered will be authorized. MEDICARE - A Federal program authorized by Title XVIII of the Social Security Act, as amended that generally serves members 65 or older and selected others. MEDICARE HMO - A Health Maintenance Organization or Comprehensive Medical Plan, which provides Medicare services to Medicare beneficiaries pursuant to a Medicare risk contract with Centers for Medicare and Medicaid Services (CMS). DEFINITIONS 2.7

17 MEMBER - An eligible person who is enrolled in AHCCCS, as defined in A.R.S , , and A.R.S MISCONDUCT- Any action or behavior that does not conform to the organization s stated or intended standards, guidelines or procedures; or is a violation of any federal/ state law or regulation. MONITORING ACTIVITIES-- Regular reviews performed as part of UAHP s normal operations to confirm ongoing compliance and to ensure that corrective actions are undertaken and effective NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) - An independent, nonprofit organization that reviews and accredits managed care organizations. NON-COMPLIANCE - Failure or refusal to act in accordance with the organization s Compliance Program; or other standards or procedures; or with federal or state laws or regulations. NON-COMPLIANT - A non-compliant member is one whose behaviors conflict with a prescribed plan of care, or the service provider s recommendations or instructions. These behaviors put the member at a higher risk for an adverse outcome. NON-CONTRACTED PROVIDER - A person and/or facility that provides services and who does not have a contract with The University of Arizona Health Plans. OFFSHORE SUBCONTRACTING - Provide services that are performed by workers located in Offshore countries, regardless of whether the workers are employees of American or foreign companies. PERFORMANCE STANDARDS - A set of standardized indicators designed to assist AHCCCS in evaluation, comparing and improving the performance of its contractors. POST STABILIZATION SERVICES - Medically necessary services, related to an emergency medical condition, provided after the member s condition is sufficiently stabilized so that the member could alternatively be safely discharged or transferred to another location. The services must be provided at the site where the member was treated for the emergency condition. PRIMARY CARE PROVIDER (PCP) - This term is used interchangeably with primary care physician. The PCP is a provider who is responsible for the overall management of a member s health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic physician or a practitioner defined as a licensed physician assistant or a licensed nurse practitioner. DEFINITIONS 2.8

18 PRIOR AUTHORIZATION (PA) - A process whereby services are reviewed prospectively to determine if they are medically necessary and appropriate. This review also includes verification of member enrollment, verification that the request is a covered benefit, and determination of the provider s eligibility to perform the service. PRIOR PERIOD COVERAGE - The period of time, prior to the member s enrollment in an AHCCCS Plan, during which a member is eligible for covered services. The time frame is from the effective date of eligibility to the day a member is enrolled with UFC or MHP. PROSPECTIVE REVIEW - A utilization management process that requires review and approval of services in advance of service provision. PROTECTED HEALTH INFORMATION (PHI) - Any information about health status, provision of health care, or payment for health care that can be linked to a specific individual. PROVIDER - Any person or entity that contracts with AHCCCS or a Contractor for the provision of covered services to members according to the provisions A.R.S or any subcontractor of a provider delivering services pursuant to A.R.S QUALITY MANAGEMENT - Activities that focus on measuring, monitoring, and improving the quality of care outcomes for members and internal and external processes. QUALITY IMPROVEMENT SYSTEM FOR MANAGED CARE (QISMC) - Developed by the Centers for Medicare/ Medicaid (CMS), formerly (HCFA), for use in evaluation and management of the quality of care provided by Medicare and Medicaid managed care Contractors. QUALIFIED MEDICARE BENEFICIARY DUAL ELIGIBLE (QMB) - A person, eligible under A.R.S (4), who is entitled to Medicare Part A insurance, meets certain income, resource and residency requirements of the Qualified Medical Beneficiary program (QMB). A QMB who is also eligible for Medicaid is commonly referred to as a QMB dual eligible. RATE CODE - A rate code identifies the AHCCCS member s eligibility category status, age and sex. It is used to determine the capitation payment amount to health plans and to providers for prepaid services. REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA) - These entities are contracted by the Arizona Department of Health Services (ADHS) to cover behavioral health services for eligible AHCCCS members in a specific geographical area of the State. RISK GROUP - Grouping of rate codes that are paid at the same capitation rate. DEFINITIONS 2.9

19 SERIOUSLY MENTALLY ILL (SMI) - A person 18 years of age or older who is seriously mentally ill as defined in A.R.S SIXTH OMNIBUS BUDGET AND RECONCILATION ACT (SOBRA)- Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of 1988, 42 U.S.C. 1396(a)(10)(A)(ii)(IX), November 5, 1990, with individually budgeted incomes at or below 150% of the FPL, and children in families with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child SPECIFIED LOW INCOME MEDICARE BENEFICIARY (SLMB) - A State program similar to medical assistance for people who need help paying for Medicare services. Members must be eligible for Medicare Part A, have limited income but not be financially eligible for medical assistance. SPECIAL HEALTH CARE NEEDS - Members with special health care needs are those members who have serious and chronic physical, developmental or behavioral conditions, and who also require medically necessary health and related services of a type or amount beyond that required by members generally. SPECIAL NEEDS PLAN (SNP) - Special Needs Plans (SNP) is available to people with Medicare benefits that are also enrolled in Medicaid. Members enrolled in AHCCCS for their Medicaid benefits may choose to receive their Medicare benefits, as well as their prescription drug coverage, through a SNP like University Care Advantage and Maricopa Care Advantage. STATE CHILDREN S HEALTH INSURANCE PROGRAM (SCHIP) - State Children s Health Insurance Program under Title XXI of the Social Security Act. ). The Arizona version of CHIP is referred to as KidsCare. SUBCONTRACTOR - See first tier, downstream and related entities. SUPPLEMENTAL SECURITY INCOME (SSI) - Federal cash assistance program under Title XVI of the Social Security Act. SUBSTANCE ABUSE As specified in R , an individual s misuse of alcohol or other drug or chemical that: a) Alters the individual s behavior or mental functioning b) Has the potential to cause the individual to be psychologically or physiologically dependent on alcohol or the drug or chemical and c) Impairs, reduces or destroys the individual s social or economic functioning. DEFINITIONS 2.10

20 TEMPORARY ASSISTANCE TO NEEDY FAMILIES PROGRAM (TANF) - A Federal cash assistance program that replaced the Aid to Families with Dependent Children (AFDC) program. TICKET TO WORK (FREEDOM TO WORK) - Eligible individuals under the Title XIX expansion program that extends eligibility to individuals, 16 thought 64 years old who meet SSI disability criteria, whose earned income, after allowable deduction, is at or below 250% of the Federal Provider Level (FPL) and who are not eligible for any other Medicaid program. These members must pay a premium to AHCCCS ranging from $10 to $35, depending on income. TITLE XIX MEMBER - Member eligible for Federally funded Medicaid programs under Title XIX of the Social Security Act including those eligible under 1931 provisions of the Social Security Act (previously AFDC), Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), SSI-related groups, Title XIX Waiver Groups, Medicare Cost Sharing groups and Breast and Cervical Cancer Treatment Program, Title IV-E Foster Care and Adoption Subsidy, Young Adult Transitional Insurance, and Freedom to Work. TITLE XIX WAIVER GROUP MEMBER - Eligible individuals and couples whose income is at or below 100% of the Federal Poverty Level who are not categorically linked to another Title XIX program. Formerly known as Non-MED members. TITLE XXI MEMBER - Member eligible for acute care services under Title XXI of the Social Security Act, referred to in Federal legislation at the State Children s Health Insurance Program (SCHIP and HIFA). The Arizona version of SCHIP is referred to as KidsCare. Note: An enrollment cap is in place for the KidsCare Program due to a lack of funding. This means that we cannot approve applications for KidsCare. However, you can still apply and be placed on a waiting list, and we will contact you if funding becomes available. URGENT - An acute, but not necessarily life-threatening disorder, which, if not attended to, could endanger the member. VACCINES FOR CHILDREN (VFC) PROGRAM (AHCCCS) - The program is an entitlement program (a right granted by law) for eligible children, The Centers for Disease Control and Prevention (CDC) recommends immunizing children for 12 preventable diseases. VFC helps families of children who may not otherwise have access to vaccines by providing free vaccines to doctors that serve them. Providers serving children must be enrolled in the Vaccines for Children (VFC) program. WASTE - Over-utilization or inappropriate utilization of services, misuse of resources, or practices that result in unnecessary costs to the Medicaid Program. DEFINITIONS 2.11

21 WELL WOMAN HEALTHCHECK PROGRAM (WWHP) - Well Woman Health Check Program administered by the Arizona Department of Health Services and funded by the Centers for Disease Control and Prevention DEFINITIONS 2.12

22 SECTION 3

23 REVISED 10/2014 Department Contact Lists Network Development Management Staff Title/Department Telephone Alison Blackwell Erika Bowman Rosie Rascon Director of Network Development Manager of Network Development Network Development Assistant Phoenix-Based Provider Relations Staff Derrick Harris Connie Leonardo Gail Vanko Sr. Provider Relations Rep Provider Relations Rep Provider Relations Rep Tucson-Based Provider Relations Staff Diane Bradford Staci Garcia Barbara (Barb) Kindred Marta Rosengren Jamie Swanson Provider Relations Rep Provider Relations Rep Claims Educator II Sr. Provider Relations Rep Provider Relations Supervisor Contracting Staff Carl Barnes Patricia (Patti) Cooper Torie Middleton Alphonso Villela Sr. Contract Negotiator Assoc. Contracting Negotiator Assoc. Contracting Negotiator Sr. Contract Negotiator DEPARTMENT CONTACTS 3.0

24 REVISED 10/2014 Departmental Contact List Phoenix Office Department Telephone Fax Behavioral Health or Case Management or Claims Customer Care or Contracting or Compliance Confidential and Anonymous Hotline: Provider Relations Credentialing or Customer Care EPSDT Coordinator Grievance & Appeals Hospital Admission Notification or Maternal Child Health Maternity Maternal Child Health Pediatric Member Eligibility or Member Outreach Pharmacy or Prior Authorization (MHP) (UFC) DEPARTMENT CONTACTS 3.1

25 REVISED 10/2014 Quality Management Translation Services or Transportation Dialysis: All other transport: Utilization Management DEPARTMENT CONTACTS 3.2

26 REVISED 10/2014 Departmental Contact List Tucson Office Department Telephone Fax Behavioral Health or Case Management Claims Customer Care or or Contracting Compliance Confidential and Anonymous Hotline: Provider Relations Credentialing Customer Care or or ClaimsInquiry EPSDT Coordinator Grievance & Appeals or or Hospital Admission Notification Maternal Child Health Maternity Maternal Child Health Pediatric Member Eligibility or Outreach Pharmacy or DEPARTMENT CONTACTS 3.3

27 REVISED 10/2014 Prior Authorization or Quality Management Translation Services or Transportation Dialysis: All other transport: Utilization Management DEPARTMENT CONTACTS 3.4

28 SECTION 4 REVISED 10/2014

29 REVISED 10/2014 Network Development Overview The Network Development Department is responsible for helping to develop and maintain our network of PCPs, specialists, hospitals and ancillary providers. Each contracted provider is assigned a Provider Relations Representative. The Provider Relations Representatives serve as a provider s vital link to the Health Plans services. The Provider Relations staffing is maintained to enable providers to receive prompt resolution to problems or inquiries and appropriate education about participation in the AHCCCS program. The Network Development Department coordinates with other departments and agencies to provide valuable information on services and programs. Provider Relations Representatives also conduct provider training activities, and keep you informed of your responsibilities as a provider. They can help in resolving many administrative issues or concerns you may have. A list of ways Network Development assists provider offices: Acts as the primary liaison between internal departments and the provider network Provides in-services and Provider Manuals to all newly contracted providers. Sends time sensitive bulletins and communications regarding health plan changes and updates. Visits provider offices and provides ongoing communication and education. Helps resolve benefit, enrollment, contracting, claims and reimbursement issues. Publishes an online provider newsletter that provides education, news and updates. Conducts provider satisfaction surveys. Assists in negotiations of new or renewing contracts. Assists in monitoring activities regarding compliance and network accessibility. Assists with claims billing and education. NETWORK DEVELOPMENT 4.0

30 REVISED 10/2014 Network Development contact information can be found in the Quick Reference Guide. Role of Provider Relations Representatives Provider Relations Representatives serve a variety of roles. They serve as both provider educator and advocate. They also participate in network development and monitoring activities. Provider Relations Representatives often serve as the intermediary between the provider and internal departments. Provider Relations Representatives are available to provide initial and follow-up training for office staff. They will visit your office to review changes and update the Health Plan policies and procedures, and review specific provider profile information. Visits include discussions about problems or issues that have occurred since the last visit, information about the Health Plan changes and offer an opportunity for the provider to express any concerns. Please consult with your Provider Relations Representative as questions arise. Provider Relations Representatives can answer many of your questions, research your problem or issue, or help direct you to the proper information resources. Network Management The Network Development Contractors routinely review information for each plan about the provider network. They work with many other health plan personnel to identify potential areas for network expansion or modification. The Contractors monitor the services that the network is providing for each plan and assists the Network Development Director and Network Development Managers in securing new contracts and services. New provider associates are considered to be joining a group if they are sharing the same tax identification number of the currently contracted provider(s). Associates will be added to the network after they have been credentialed. Providers who share office space will be considered for participation solely on the basis of network need under his/her own contract. Satellite offices of contracted groups are not automatically added to the network unless a network need exists. Your Provider Relations Representative can assist you with these issues. The Health Plans contract with providers on a geographic and plan-specific basis. Network need is determined by a variety of factors including the membership, utilization and existing coverage in an area. You must supply the Health Plan with prior notification of any changes to address, tax identification numbers, telephone numbers, or professional staffing in order to comply with contractual requirements and ensure correct payment and continuity of care. Lack of timely notification to the Health Plan may result in payment denials or delays in patient referrals. Changes in the location of your office may result in contract termination if the new location is not in an area where additional practitioners are needed. NETWORK DEVELOPMENT 4.1

31 REVISED 10/2014 Physicians, mid-level professionals and dentists are credentialed prior to participation. Practitioner performance is reviewed at least every three years. This process requires the practitioner to complete a reappointment application and provide proof of license renewal and current liability coverage. Failure to respond timely to these requests for information may be interpreted as voluntary withdrawal from the network. Facility licensure and accreditation are also regularly reviewed and must be updated to maintain contracted status with the plan. The DHHS OIG and Government Services Administration ( GSA ) exclusion lists are also checked with respect to all employees, governing body members, and FDRs monthly and coordinating any resulting personnel issues with the sponsor s Human Resources, Security, Legal or other departments, as appropriate. AHCCCS Minimum Subcontract Provisions All subcontracts must reference the provisions of Attachment A, Minimum Subcontract Provisions located on the AHCCCS website at subject to updates as received. Please remember as a part of your agreement with our organization you are required to adhere to the contractual obligations as outlined in the AHCCCS Subcontract Provisions. Changes in Professional and Administrative Staff Changes in the professional staff in your office, for example Physicians, Physicians Assistants, Nurse Practitioners, or Nurse Midwives, must be reported to your Provider Relations Representative. All professionals rendering care to the Health Plan AHCCCS (UFC, MHP) or Special Needs Plans (MCA or UCA) members must be registered by the AHCCCS Administration and Medicare and all office based providers must be credentialed by the Health Plan. Lack of timely notification to the Health Plan may result in payment denials or delays in patient referrals. When reporting services for claims or encounter purposes for any product line, his or her provider number (i.e. AHCCCS, Medicare, NPI), must identify the individual rendering the care. Failure to identify the individual rendering care when reporting claims is considered to be fraud under Federal reporting regulations. Administrative changes in your office staff may result in the need for additional training. Contact your Provider Relations Representative to schedule any needed staff training. Regular visits are intended to provide updates, education, review of compliance issues, and address concerns of the Plan and provider. The Provider Relations Representatives will meet with the office manager and/or providers, when available. Visits are usually completed in less than one hour. Provider Feedback and Communication The Health Plan is very interested in your opinions, both compliments and suggestions for improvement. Provider and member satisfaction surveys are conducted to help improve service to our providers and members. You will receive feedback from the member survey if the responding members make specific mention of you or your office. Your comments need not be reserved for these surveys. The Health Plan welcomes your opinions/feedback at any time. NETWORK DEVELOPMENT 4.2

32 SECTION 15

33 REVISED 10/2014 Children s Rehabilitative Services (CRS) Children s Rehabilitative Services (CRS) is a State program administered by the Arizona Health Care Cost Containment System (AHCCCS). Federal matching funds are available for the provision of services to Title XIX eligible children enrolled in an AHCCCS health plan. The purpose of CRS is to provide rehabilitative medical care to children with special health care needs, utilizing a multidisciplinary approach that provides medical treatment, rehabilitation, and related support services. Children must be AHCCCS enrolled, completed the CRS application and meet the medical eligibility criteria in order to receive CRS Services. CRS members receive the same AHCCCS covered services as non-crs AHCCCS members; however, services to treat CRS conditions for Acute Care members may only be provided to children enrolled with CRS. CRS members will be able to receive care in the community or in multispecialty interdisciplinary clinics that bring all specialties together in one location. Thus the child receives all treatment for their CRS condition and all medical/behavioral health services in a coordinated system. AHCCCS members are eligible for CRS services without additional fees. A. Eligibility Requirements: Arizona resident Under 21 years of age Have a physical, chronic illness or condition that is potentially disabling and the condition requires active treatment. (See attachment for Covered Conditions) Title XlX (Medicaid/AHCCCS) enrollment B. Referral Process: A PCP and/or a Specialist must perform the diagnostic work-up for the CRS eligible diagnosis A PCP and/or a Specialist as well as a family member can initiate the application form A member identified by nurse reviewer or case manager can be redirected to CRS when they have a CRS diagnosis and are not enrolled CRS 15.0

34 REVISED 10/2014 If a child with a CRS eligible diagnosis is identified while an inpatient, social services staff may initiate a referral to CRS. The Health Plan Utilization Management Nurse may also identify a CRS eligible child during an inpatient review and request an application be initiated. Medical records will be requested from the PCP and/or specialist provider to support the potential CRS diagnosis. Parents can choose to not enroll their child into CRS however they may be responsible for any costs associated for the treatment of the child s CRS condition. Parents can choose to not enroll their child into CRS however they may be responsible for any costs associated for the treatment of the child s CRS condition. The CRS application (see attachment for English or Spanish) must be printed, filled out, and mailed or faxed with medical documentation that supports the potential CRS condition to the CRS Enrollment Unit. AHCCCS/Children s Rehabilitative Services ATTENTION: CRS Enrollment Unit 801 East Jefferson MD 3500 Phoenix, Arizona Fax: Phone: or , Monday Friday 8:00 AM to 5:00 PM (excluding weekends and holidays). The Case Managers at UAHP are available to assist with the CRS application process. When the child becomes eligible for CRS United Healthcare Community Plan CRS becomes the AHCCCS health plan that manages the care for CRS conditions, acute health and behavioral health services. CRS 15.1

35 REVISED 10/2014 APPENDIX CRS 15.2

36 Effective 10/1/13 R Medical Eligibility The following lists identify those medical condition(s) that do qualify for the CRS program as well as those that do not qualify for the CRS program. The covered condition(s) list is all inclusive. The list of condition(s) not covered by CRS is not an all-inclusive list: 1. Cardiovascular System a. CRS condition(s): i. Congenital heart defect, ii. Cardiomyopathy, iii. Valvular disorder, iv. Arrhythmia, v. Conduction defect, vi. Rheumatic heart disease, vii. Renal vascular hypertension, viii. Arteriovenous fistula, and ix. Kawasaki disease with coronary artery aneurysm; b. Condition(s) not medically eligible for CRS: i. Essential hypertension; ii. Premature atrial, nodal or ventricular contractions that are of no hemodynamic significance; iii. Arteriovenous fistula that is not expected to cause cardiac failure or threaten loss of function; and iv. Benign heart murmur; 2. Endocrine system: a. CRS condition(s): i. Hypothyroidism, ii. Hyperthyroidism, iii. Adrenogenital syndrome,

37 iv. Addison's disease, v. Hypoparathyroidism, vi. Hyperparathyroidism, vii. Diabetes insipidus, viii. Cystic fibrosis, and ix. Panhypopituitarism; b. Condition(s) not medically eligible for CRS: i. Diabetes mellitus, ii. Isolated growth hormone deficiency, iii. Hypopituitarism encountered in the acute treatment of a malignancy, and iv. Precocious puberty; 3. Genitourinary system medical condition(s): a. CRS condition(s): i. Vesicoureteral reflux, with at least mild or moderate dilatation and tortuosity of the ureter and mild or moderate dilatation of renal pelvis; ii. Ectopic ureter; iii. Ambiguous genitalia; iv. Ureteral stricture; v. Complex hypospadias; vi. Hydronephrosis; vii. Deformity and dysfunction of the genitourinary system secondary to trauma after the acute phase of the trauma has passed; viii. Pyelonephritis when treatment with drugs or biologicals has failed to cure or ameliorate and surgical intervention is required; ix. Multicystic dysplastic kidneys; x. Nephritis associated with lupus erythematosis; and xi. Hydrocele associated with a ventriculo-peritoneal shunt; b. Condition(s) not medically eligible for CRS:

38 i. Nephritis, infectious or noninfectious; ii. Nephrosis; iii. Undescended testicle; iv. Phimosis; v. Hydrocele not associated with a ventriculo-peritoneal shunt; vi. Enuresis; vii. Meatal stenosis; and viii.hypospadias involving isolated glandular or coronal aberrant location of the urethralmeatus without curvature of the penis; 4. Ear, nose, or throat medical condition(s): a. CRS condition(s): i. Cholesteatoma; ii. Chronic mastoiditis; iii. Deformity and dysfunction of the ear, nose, or throat secondary to trauma, after the acute phase of the trauma has passed; iv. Neurosensory hearing loss; v. Congenital malformation; vi. Significant conductive hearing loss due to an anomaly in one ear or both ears equal to or greater than a pure tone average of 30 decibels, that despite medical treatment, requires a hearing aid; vii. Craniofacial anomaly that requires treatment by more than one CRS provider; and viii. Microtia that requires multiple surgical interventions; b. Condition(s) not medically eligible for CRS i. Tonsillitis, ii. Adenoiditis, iii. Hypertrophic lingual frenum, iv. Nasal polyp, v. Cranial or temporal mandibular joint syndrome, vi. Simple deviated nasal septum,

39 vii. Recurrent otitis media, viii. Obstructive apnea, ix. Acute perforation of the tympanic membrane, x. Sinusitis, xi. Isolated preauricular tag or pit, and xii. Uncontrolled salivation; 5. Musculoskeletal system medical condition(s): a. CRS condition(s): i. Achondroplasia; ii. Hypochondroplasia; iii. Diastrophic dysplasia; iv. Chondrodysplasia; v. Chondroectodermal dysplasia; vi. Spondyloepiphyseal dysplasia; vii. Metaphyseal and epiphyseal dysplasia; viii. Larsen syndrome; ix. Fibrous dysplasia; x. Osteogenesis imperfecta; xi. Rickets; xii. Enchondromatosis; xiii. Juvenile rheumatoid arthritis; xiv. Seronegative spondyloarthropathy; xv. Orthopedic complications of hemophilia; xvi. Myopathy; xvii. Muscular dystrophy; xviii. Myoneural disorder; xix. Arthrogryposis; xx. Spinal muscle atrophy; xxi. Polyneuropathy; xxii. Chronic stage bone infection;

40 xxiii. Chronic stage joint infection; xxiv. Upper limb amputation; xxv. Syndactyly; xxvi. Kyphosis; xxvii. Scoliosis; xxviii. Congenital spinal deformity; xxix. Congenital or developmental cervical spine abnormality; xxx. Hip dysplasia; xxxi. Slipped capital femoral epiphysis; xxxii. Femoral anteversion and tibial torsion: xxxiii. Legg-Calve-Perthes disease; xxxiv. Lower limb amputation, including prosthetic sequelae of cancer; xxxv. Metatarsus adductus; xxxvi. Leg length discrepancy of five centimeters or more; xxxvii. Metatarsus primus varus; xxxviii. Dorsal bunions; xxxix. Collagen vascular disease; xxxx. Benign bone tumor; xxxxi. Deformity and dysfunction secondary to musculoskeletal trauma; xxxxii. Osgood Schlatter's disease that requires surgical intervention; and xxxxiii. Complicated flat foot, such as rigid foot, unstable subtalar joint, or significant calcaneus deformity b. Condition(s) not medically eligible for CRS i. Ingrown toenail; ii. Back pain with no structural abnormality; iii. Ganglion cyst; iv. Flat foot other than complicated flat foot; v. Fracture; vi. Popliteal cyst; vii. Simple bunion; and

41 viii. Carpal tunnel syndrome; ix. Deformity and dysfunction secondary to trauma or injury if: 1. Three months have not passed since the trauma or injury; and 2. Leg length discrepancy of less than five centimeters at skeletal maturity. 6. Gastrointestinal system medical condition(s): a. CRS condition(s): i. Tracheoesophageal fistula; ii. Anorectal atresia; iii. Hirschsprung's disease; iv. Diaphragmatic hernia; v. Gastroesophageal reflux that has failed treatment with drugs or biologicals and requires surgery; vi. Deformity and dysfunction of the gastrointestinal system secondary to trauma, after the acute phase of the trauma has passed; vii. Biliary atresia; viii.congenital atresia, stenosis, fistula, or rotational abnormalities of the gastrointestinal tract; ix. Cleft lip; x. Cleft palate; xi. Omphalocele; and xii. Gastroschisis; b. Condition(s) not medically eligible for CRS i. Malabsorption syndrome, also known as short bowel syndrome, ii. Crohn's disease, iii. Hernia other than a diaphragmatic hernia, iv. Ulcer disease, v. Ulcerative colitis, vi. Intestinal polyp,

42 vii. Pyloric stenosis, and viii. Celiac disease; 7. Nervous system medical condition(s): a. CRS condition(s): i. Uncontrolled seizure disorder, in which there have been more than two seizures with documented adequate blood levels of one or more medications; ii. Cerebral palsy; iii. Muscular dystrophy or other myopathy; iv. Myoneural disorder; v. Neuropathy, hereditary or idiopathic; vi. Central nervous system degenerative disease; vii. Central nervous system malformation or structural abnormality; viii. Hydrocephalus; ix. Craniosynostosis of a sagittal suture, a unilateral coronal suture, or multiple sutures in a child less than 18 months of age; x. Myasthenia gravis, congenital or acquired; xi. Benign intracranial tumor; xii. Benign intraspinal tumor; xiii. Tourette's syndrome; xiv. Residual dysfunction after resolution of an acute phase of vascular accident, inflammatory condition, or infection of the central nervous system; xv. Myelomeningocele, also known as spina bifida; xvi. Neurofibromatosis; xvii. Deformity and dysfunction secondary to trauma in an individual; xviii. Residual dysfunction after acute phase of near drowning; and xix. Residual dysfunction after acute phase of spinal cord injury; b. Condition(s) not medically eligible for CRS i. Headaches; ii. Central apnea secondary to prematurity;

43 iii. Near sudden infant death syndrome; iv. Febrile seizures; v. Occipital plagiocephaly, either positional or secondary to lambdoidal synostosis; vi. Trigonocephaly secondary to isolated metopic synostosis; vii. Spina bifida occulta; viii. Near drowning in the acute phase; and ix. Spinal cord injury in the acute phase; x. Chronic vegetative state; 8. Ophthalmology: a. CRS condition(s): i. Cataracts; ii. Glaucoma; iii. Disorder of the optic nerve; iv. Non-malignant enucleation and post-enucleation reconstruction; v. Retinopathy of prematurity; and vi. Disorder of the iris, ciliary bodies, retina, lens, or cornea; b. Condition(s) not medically eligible for CRS i. Simple refraction error, ii. Astigmatism, iii. Strabismus, and iv. Ptosis; 9. Respiratory system medical condition(s): a. CRS condition(s): i. Anomaly of the larynx, trachea, or bronchi that requires surgery; and ii. Nonmalignant obstructive lesion of the larynx, trachea, or bronchi; b. Condition(s) not medically eligible for CRS:

44 i. Respiratory distress syndrome, ii. Asthma, iii. Allergies, iv. Bronchopulmonary dysplasia, v. Emphysema, vi. Chronic obstructive pulmonary disease, and vii. Acute or chronic respiratory condition requiring venting for the neuromuscularly impaired; 10. Integumentary system medical condition(s): a. CRS condition(s): i. A craniofacial anomaly that is functionally limiting, ii. A burn scar that is functionally limiting, iii. A hemangioma that is functionally limiting, iv. Cystic hygroma, and v. Complicated nevi requiring multiple procedures; b. Condition(s) not medically eligible for CRS: i. A deformity that is not functionally limiting, ii. A burn other than a burn scar that is functionally limiting; iii. Simple nevi, iv. Skin tag, v. Port wine stain, vi. Sebaceous cyst, vii. Isolated malocclusion that is not functionally limiting, viii. Pilonidal cyst, ix. Ectodermal dysplasia, and x. A craniofacial anomaly that is not functionally limiting; 11. Metabolic CRS condition(s) : i. Amino acid or organic acidopathy,

45 ii. Inborn error of metabolism, iii. Storage disease, iv. Phenylketonuria, v. Homocystinuria, vi. Maple syrup urine disease, vii. Biotinidase deficiency, 12. Hemoglobinopathies CRS condition(s): a. Sickle cell anemia, b. Thalassemia. 13. Medical/behavioral condition(s) which are not medically eligible for CRS: a. Allergies; b. Anorexia nervosa or obesity; c. Autism; d. Cancer; e. Depression or other mental illness; f. Developmental delay; g. Dyslexia or other learning disabilities; h. Failure to thrive; i. Hyperactivity; j. Attention deficit disorder; and k. Immunodeficiency, such as AIDS and HIV.

46 AHCCCS is Arizona s Medical Assistance Program (Medicaid) Application for Enrollment into AHCCCS Children s Rehabilitative Services Please return application and all required documentation to: Fax: Mail: AHCCCS-CRS Attn: CRS Enrollment 801 E. Jefferson St. MD 3500 Phoenix, AZ For questions contact the CRS Enrollment Unit at: or SECTION 1: APPLICANT INFORMATION Does the applicant have AHCCCS? YES NO If yes: AHCCCS ID Number: AHCCCS Health Plan: If no: has an application been submitted? YES NO Child s First Name M.I. Child s Last Name Date of Birth Parent/Representative s First Name Age Gender: Male Female Parent/Representative s Last Name Child s Social Security Number Relationship to Child: Parent Foster Parent Legal Guardian Representative Other: Parent/Representative s Mailing Address City State Zip Code Phone Number Alternate Phone Number Address Name of Child s Primary Care Provider Address, City, State, Zip Code Phone Number Address List Primary Diagnosis: Please send medical records with this form Planned Treatment: SECTION 2: REFERRAL INFORMATION The individual making the referral verifies that the child s parent/representative listed in Section 1 has been notified of this referral. If expedited request, please contact AHCCCS CRS Enrollment. Name of Person Making Referral (First, Last) Address, City, State, Zip Code Phone Number Relationship to Child: Parent Legal Guardian Provider Social Worker Self AHCCCS Contractor Other: SECTION 3: AUTHORIZATION TO RELEASE INFORMATION (TO BE COMPLETED BY PARENT/REPRESENTATIVE) AHCCCS cannot share information about a child s CRS enrollment without signed consent from the parent/representative listed in Section 1. Please provide the medical provider or referral source contact information and sign below to authorize AHCCCS to release information about the AHCCCS CRS decision. Medical Provider/Referral Source Name Phone Number Address Mailing Address City State Zip Code I (full name of parent/representative listed in Section 1) give my consent to the Arizona Health Care Cost Containment System s (AHCCCS) Children s Rehabilitative Services (CRS) to share any information with the above named provider relating to the receipt of (full name of child) CRS application, application processing time, and the final CRS decision. Signature of Parent/Representative Date <<Form Number>>

47 AHCCCS is Arizona s Medical Assistance Program (Medicaid) Solicitud de Inscripción en los Servicios de Rehabilitación de Menores de Envíe la solicitud y toda la documentación requerida a: Fax: Correo: AHCCCS-CRS Attn: CRS Enrollment 801 E. Jefferson St. MD 3500 Phoenix, AZ Para mayores informes llame a la CRS Enrollment Unit al: o SECCIÓN 1: DATOS DEL SOLICITANTE Tiene el solicitante AHCCCS? SÍ NO Si tiene, el número de ID de AHCCCS El Plan de Salud AHCCCS: Si no tiene, ha presentado solicitud? SÍ NO Nombre del menor Inicial Apellido del menor Fecha de nacimiento Edad Sexo: Hombre Mujer No. de Seguro Social del menor Nombre del Padre/Representante Apellido del Padre/Representante Relación con el menor: Padre Padre de acogida Tutor legítimo Representante Otro: Dirección del Padre/Representante Ciudad Estado Código Postal Número de teléfono Número de teléfono alterno Correo electrónico Nombre del doctor principal del menor Dirección, Ciudad, Estado, Código Postal Número de teléfono Correo electrónico Ponga la diagnosis primaria. Envíe los informes médicos con este cuestionario El tratamiento programado: SECCIÓN 2: DATOS DEL REFERIDO La persona que hace el referido verifica que se le ha notificado al padre/representante del menor incluido en la Sección 1 de este referido. Si la petición es acelerada, llame a Inscripciones de AHCCCS CRS. Nombre de la persona que manda el referido (nombre Dirección, Ciudad, Estado, Código Postal Número de teléfono de pila, apellido) Relación con el menor: Padre Tutor legítimo Doctor Trabajador Social Propio AHCCCS Contratista Otro: SECCIÓN 3: AUTORIZACIÓN DE PROPORCIONAR INFORMACIÓN(A LLENARSE POR EL PADRE/REPRESENTANTE) AHCCCS no podrá revelar información acerca de la inscripción del menor sin el consentimiento firmado del padre/representante incluido en la Sección 1. Ponga los datos del doctor o la fuente del referido y firme abajo para autorizar a AHCCCS a dar a conocer la información acerca de la decisión de AHCCCS CRS. Nombre del Doctor/Fuente del Referido Número de teléfono Correo electrónico Dirección Ciudad Estado Código Postal Yo (nombre completo del padre/representante incluido en la Sección 1) doy mi consentimiento al Arizona Health Care Cost Containment System s (AHCCCS) Children s Rehabilitative Services (CRS) para compartir cualquier información con el doctor mencionado arriba en relación al recibo de la solicitud, el tiempo para tramitar la solicitud, y la decisión final de CRS para (nombre completo del menor). Firma del Padre/Representante Fecha <<Form Number>>

48 SECTION 6

49 Rev 03/2015 Introduction to Claims The Claims Department adjudicates claims submitted to the Health Plan. The Health Plan claims, in addition to being used to pay the Provider, contain information the Health Plan must send (encounter) to AHCCCSA. All services, capitation or fee for service, must be submitted to the Claims Department. Accuracy is extremely important to ensure timely payment. Providers must meet standard reporting requirements. It is the Claims Department intent to make claims processing as simple and effortless as possible. To do this, it is important that procedures are followed and the necessary information is supplied with the initial claim submission. AHCCCS Provider Number Any provider who renders services to AHCCCS and SNP members must be registered with AHCCCS and have an active AHCCCS provider number. Provider registration packets are available on the AHCCCS Website; For additional information contact the AHCCCS Provider Registration Unit; In Maricopa County: and select option 5 Outside Maricopa County: Out of State: Claim Submission Guidelines The Claims Department will adjudicate all properly submitted, authorized claims that meet clean claims criteria within 45 days of receipt. A claim is considered a clean claim if it is submitted on the appropriate form, contains the correct billing information according to CMS 1500, ADA 2002 and UB 04 requirements and has all the supporting documentation necessary for medical and claims review. If any standard information is omitted on the claim, it may be denied or returned for correction. If the claim form is returned to the provider for correction without being adjudicated, the original filing limit still applies from the date of service, not the date of return. These claim forms should be resubmitted with a copy of the original return letter attached. Detailed requirements for CMS 1500, ADA 2002 and UB 04 forms are in this section. INTRODUCTION TO CLAIMS 6.0

50 Rev 03/2015 Providers must submit all claims for covered services provided to members within the timely filing guidelines identified in their contract, whether fee for service or capitation. Claims initially received outside of the filing deadlines will be denied as Past Filing Deadline (PFD). The deadline will be determined by the ending date of service for claims involving hospitalization. If any claim is accepted but denied for a reason, which can be corrected and resubmitted, the claim form should be resubmitted following the resubmission guidelines. A tracer claim form is a follow up submission or second submission when a claim has been determined to be not received or not in system by the Health Plan. Tracer claims must be received within 120 days from the date of service and be marked as a tracer or second submission. Please do not submit tracer claims less than 60 days from first submission. If the claim form is not marked as such, it may be denied for timely filing. ORIGINAL claim submissions, tracers and resubmissions (excluding dental) should be mailed to: MHP P.O.Box 37169, Phoenix, AZ UFC P.O.Box 35699, Phoenix, AZ MCA P.O. Box 38549, Phoenix, AZ UHM P.O. Box Phoenix, AZ ELECTRONIC claim submissions, tracers (excluding resubmissions and dental) should be sent through Emdeon or SSI Group to: MHP & MCA Payor ID#: Emdeon / 9999 Sub ID#0651 SSI UFC Payor ID#: Emdeon / 9999 Sub ID#0651 SSI UHM Payor ID#45437 Resubmissions A resubmission is a claim previously denied for an unclean claim status, billing corrections, supporting documentation and/or the need for reconsideration due to an error in payment. Resubmitted claims are not considered grievances and will not be treated as such. See the Standard Appeals and Request for a State Fair Hearing, Section 5, page 5.35, for your appeals rights. The following documentation is required when filing resubmissions to the Claims Department: Clean, corrected claim with resubmission clearly marked on the claim with the original claim number. Claims with writing, white out or marker will be returned. INTRODUCTION TO CLAIMS 6.1

51 Rev 03/2015 Copy of the remittance advice on which the claim was denied or incorrectly paid. Supporting documentation. Brief explanation of the correction needed The claim must be clearly marked as a resubmission. The word resubmission and the original claim number must be written on the front of the CMS 1500 (box 22), UB 04 (box 84) or ADA 2002 (box 35) claim form. When resubmitting a claim previously filed electronically, a paper claim can be resubmitted.. Electronic resubmissions must reference the original claim number in the Loop 2300 Element REF02. Resubmissions must be received within 120 days from the date on the Health Plan EOB. Claims not received within the timeline will be denied as PFD. All claims must be resubmitted through the resubmission process before any will be considered for the appeal process. Coordination of Benefits The AHCCCS plans have members enrolled who are eligible for both Medicaid and Medicare. These members are referred to as dual eligible. Please refer to Section 8, Covered Services for more information. The AHCCCS plan claims will be paid according to the AHCCCS Medicare Cost Sharing Policy. The Health Plan will have no cost sharing responsibility if the Medicare payment matches or exceeds what would have been paid per the provider s contract. This also applies to members enrolled in other commercial insurance plans. NOTE: The AHCCCS Plans are the payor of last resort. It is necessary that other insurance coverage is identified and billed as the primary carrier. The claim must be submitted to the Health Plan within 60 days from the date of the primary payer s Remittance Advice or Explanation of Benefits. Providers are required to notify the Health Plan if additional payors are known, per the provider s contract. Billing Members The AHCCCS plan members cannot be billed for covered services in accordance with A.A.C. (the Health Plan) R Eligible AHCCCS members cannot be denied covered services if they are unable to pay non mandatory applicable co payments. Providers cannot bill members for covered services regardless of whether the member has signed a release form for assumption of liability. INTRODUCTION TO CLAIMS 6.2

52 Rev 03/2015 The Health Plan members may receive services from providers that are not covered by AHCCCS or Medicare. Providers must have the member sign a release form stating that he/she understands the service is not a covered benefit and he/she is responsible for payment of the charges. Claims Customer Care Representatives The Claims Customer Care Representatives are available to providers to answer questions regarding claims submissions and to assist in resolving problems and issues regarding the status of a claim. The representatives will explain claim adjudication and assist in tracking the disposition of specific claims. The Claims Customer Care Representative will also assist in identifying and correcting claim processing errors. The Claims Customer Care Representatives are not able to correct a provider error in claims preparation and submission. The Provider must resubmit claims requiring corrected information. Corrected claims must be submitted per the resubmission guidelines. The Claims Customer Care Representatives may be contacted Monday through Friday (see Quick Reference Guide). Your call may be answered by our automated service. Please leave a message and your call will be returned within 48 hours. Any claims received through the Claims Customer Care Representatives, are considered a resubmitted claim and will not be considered for the appeal processes until it has completed the resubmission process. Guidelines for Submitting Documentation Listed below are general guidelines for submitting documentation with claims. While it is impossible to offer specific guidelines for each situation, the tables below are designed to give providers general guidance regarding submission of documentation. CMS 1500 Claims Billing For Documents Required Comments Level 5 Professional Fees for Emergency Room Visits Emergency room record Billing physician s signature must be on ER Record UB 04 Claims Billing For Documents Required Comments Critical Care All statutory required documents Physician orders and progress notes to substantiate level of care billed INTRODUCTION TO CLAIMS 6.3

53 Rev 03/2015 Providers should NOT submit the following unless specifically requested to do so: Emergency Admission authorization forms Patient follow up care instructions Nurses notes Blank medical documentation forms Consents for treatment forms Operative consent forms (exception: BTL & hysterectomy) Ultrasound/X ray films Medifax information Nursing care plans Medication administration records (MAR) DRG/Coding forms Medical documentation on prior authorized procedures/inpatient hospital stays Entire medical records If submitting a claim electronically, the claim will be reviewed. If documentation is required, the claim will be denied, requesting the necessary information and a paper claim should be submitted following the resubmission guidelines. Anesthesia Services AHCCCS uses the limits and guidelines as established by ASA for base and time units for most anesthesia procedures. Every 15 minutes or any portion thereof is equal to one unit of time. Therefore, a total time of 34 minutes is equivalent to 3 units ( ). In this example the third unit is payable, even though it is less than 15 minutes. OB Billing Requirements In order to ensure members receive necessary prenatal and OB care and to properly document the provision of that care, The University of Arizona Health Plan s (UAHP s) billing requirements are as follows: INTRODUCTION TO CLAIMS 6.4

54 Rev 03/2015 Global Billing Codes When appropriate, obstetrical service should be billed under a global services code. The Global Package consists of: Five (5) or more prenatal visits, delivery, and postpartum care: Routine obstetric care including ante partum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. With this CPT the standard diagnosis code would be: 650 indicating a normal delivery Routine obstetric care including ante partum care, cesarean delivery, and postpartum care Routine obstetric care including ante partum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care after previous cesarean delivery Routine obstetric care including ante partum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Prenatal and Post Partum Visits in Global Billing Additional billing lines should include visit information (HEDIS line). This information can be provided in two ways: (The following includes suggested guidelines for diagnosis codes to be reported when billing for OB services) For the additional billing line (HEDIS line), provide the date range of service for each visit followed by the appropriate place of service, CPT evaluation & management (E&M) code and the number of visits (units). Please note that the visit line should contain diagnoses that are consistent with the office visit, not the delivery (e.g., prenatal care relates to a diagnosis of pregnancy not a delivery). When billing with CPT , the standard diagnoses codes would be: V22.0 V23.9. Provide each date of service along with the appropriate CPT E&M code and ICD 9 code. Again, note that the visit line should contain diagnoses that are consistent with the office visit not the delivery. For UAHP members who receive their first prenatal visit with an OB provider prior to enrolling with the health plan, the additional billing line (HEDIS line) should contain the dates of service for the member after enrollment with UAHP as well as the appropriate ICD 9 code. If providers are in a group/multi specialty practice, one package must be billed for all services whether more than one provider in the group rendered services. The billing provider is the delivering provider for the package. INTRODUCTION TO CLAIMS 6.5

55 Rev 03/2015 Non Global Billing If less than 5 prenatal visits are provided, the OB package is not billed. The components provided are broken down into their individual billable services. The individual applicable ranges of services are: Ante partum Care Only: 1 3 visits Evaluation and Management Codes ( ). Bill each visit individually with individual dates of service. 4 6 visits Use Ante partum care only. Bill this as a single line item, indicate one visit in unit field, and include from/to dates. The total flat rate allowed for this code includes all visits. 7 or more visits Use Ante partum care only. Bill this as a single line item, indicate one visit in unit field and include date of service span (from/to dates). The total flat rate allowed for this code includes all visits. Delivery Only: Vaginal delivery only (with or without episiotomy and/or forceps) Cesarean delivery only Vaginal delivery only, after previous cesarean delivery (with episiotomy and/or forceps) Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery Postpartum Care Only: Postpartum care only (separate procedure) Delivery and Postpartum Care: Vaginal delivery (with or without episiotomy and/or forceps), including postpartum care Cesarean delivery only, including postpartum care Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, including postpartum care. INTRODUCTION TO CLAIMS 6.6

56 Rev 03/2015 DO NOT BILL ANY ADDITIONAL hospital admission or discharge services outside of these codes. No additional hospital E&M codes will be paid. Other suggested diagnosis codes that can be used as appropriate are: 640.x1 640.x3 641.x1 641.x3 642.x3 643.x1 643.x x3 645.x1 645.x3 646.x1 646.x2 646.x3 647.x2 647.x3 648.x1 648.x2 648.x3 649.x1 649.x2 651.x1 651.x3 652.x1 652.x3 653.x1 653.x3 654.x x2 654.x3 655.x1 655.x x x3 658.x1 658.x3 659.x1 659.x3 660.x1 661.x1 662.x1 663.x1 664.x1, x1 665.x2 666.x2 667.x2 668.x1 668.x2 669.x1 669.x x1 671.x x1 673.x2 671.x1 674.x2 675.x1 675.x2 676.x1 676.x2 678.x1 679.x1 679.x2 V22 V23 V28. If in doubt, call a UAHP Claims Educator for more information (See Quick Reference Network Development Contact List for contact information) Overview of Claims Editing System The Claims Department uses the Interactive Claims Editing System (ICES) to support the AHCCCS and Medicare regulatory guidelines, Correct Coding Initiative (CCI) and provider contract conditions. Here are some billing tips: Unbundling is the billing of multiple procedure codes for a group of services that are covered by a single comprehensive code. Some examples of incorrect coding include: Fragmenting one service into components and coding each as if it were a separate service. Billing separate codes for related services when one code includes all related services. Breaking out bilateral procedures when one code is appropriate. Down coding a service in order to use an additional code when one higher level, more comprehensive code is appropriate. Mutually exclusive. All services that are integral to a procedure are considered bundled into that procedure as components of the comprehensive code when: INTRODUCTION TO CLAIMS 6.7

57 Rev 03/2015 The services represent the standard of care for the overall procedure, or The services are necessary to accomplish the comprehensive procedure, or The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure. Determine if the code to be billed is a comprehensive code or a component of a Modifiers comprehensive code. Component codes cannot be billed if the comprehensive code is the most appropriate code. If it is a comprehensive code and one of its components has been billed and paid, the claim for the component code must be refunded before the comprehensive code can be paid. If the component code is being billed, be sure to include a modifier, if appropriate (24, 25, 50, 57, 58, 59, 78, E1 E4, F1 F9, 1T 9T, RT or LT). For example, a radiologist may bill a comprehensive code identifying he/she performed the technical and the professional components of the service. It would be incorrect coding to bill separately for each piece. However, if the radiologist only took the x rays and someone else read the x rays, they would each bill their piece, with the modifiers 26 (professional component) and TC (technical component), representing which service they performed. Determine if the code to be billed is a mutually exclusive code. Mutually exclusive procedures are those that cannot reasonably be performed in the same session (e.g. codes for initial and subsequent services). If a mutually exclusive code and a subsequent code are billed on the same claim, the system will allow the code with the highest capped fee. The other code will then be denied. Modifier 25 (significant, separately identifiable E&M service by the same provider for the same day as a procedure) modifier identified service that is unrelated to the original procedure. This modifier is used for those services rendered on the same day as a procedure that is above or beyond the other service provided or beyond the usual pre op and postoperative (i.e. after the date of service in question). This modifier is not used to report an E/M service that resulted in a decision to perform surgery. (See modifier 57). Modifier 57 (Decision for surgery) An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier 57 to the appropriate level of E/M service. Modifier 59 (Distinct procedural service) must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. INTRODUCTION TO CLAIMS 6.8

58 Rev 03/2015 Modifier 59 cannot be billed with evaluation and management codes ( ) or radiation therapy codes ( ). (See Modifier 57). Modifier 50 (Bilateral procedure) may be billed with the component code if no code exists that identifies a bilateral service as bilateral. Modifier 51 (Multiple procedures) AHCCCS established the Outpatient Prospective Fee System (OPFS) as the methodology for reimbursement of outpatient facility claims. Included in this methodology is a fee schedule which allows payment based on procedures billing the UB 04 Form. Use the modifier 51 if more than one procedure is rendered on any secondary procedures when billing for outpatient surgery on a CMS 1500 or UB 04 form. Modifier 58 (Staged or related procedures, same physician) or Modifier 78 (Return to operating room for related procedure) may be used to bill separate services during the postoperative period. Modifier 26 (Professional component), Modifier TC (Technical Component). Modifier 80 (Assistant surgeon) and similar modifiers may be appropriately attached to comprehensive codes. INTRODUCTION TO CLAIMS 6.9

59 Rev 03/2015 Claims Instructions for CMS 1500s A CMS 1500 claim form should be used to bill for non facility services, including professional services, transportation and durable medical equipment. The numbered instructions correspond to the box numbers on a CMS 1500 form. 1. Program Block Check the appropriate box Medicare, Medicaid or Marketplace 1a. Insured s ID Number Enter the recipient s AHCCCS/Medicare or Plan ID number 2. Patient s Name Enter the recipient s last name, first name, and middle initial as shown on the AHCCCS ID, Healthcare Group and SNP Plan card 3. Patient s Date of Birth and Sex Enter the recipient s date of birth. Check the appropriate box to indicate the patient s gender. 4. Insured s Name Required for Healthcare Group 5. Patient Address 6. Patient Relationship to Insured Required for Healthcare Group 7. Insured s Address Required for Healthcare Group 8. Patient Status Required for Healthcare Group 9. Other Insured s Name If the recipient has no coverage other than AHCCCS, leave this section blank. If other coverage exists, enter the name of the insured. If the other insured is the recipient, enter Same. 9a. Other Insured s Policy or Group Number Enter the policy or group number of the other insurance. 9b. Other Insured s Date of Birth and Sex 9c. Employer s Name or School Name 9d. Insurance Plan Name or Program Enter name of insurance company or Program Name that provides the insurance coverage. 10. Is Patient s Condition Related to: Not required 11. Insured s Group Policy or FECA Not required Number 11a. Insured s Date of Birth and Sex Not required 11b. Employer s Name or School Name Not required 11c. Insurance Plan Name or Program Not required Name 11d. Is there Another Health Benefit Plan? Check the appropriate box to indicate other coverage. If Yes, you must complete Fields 9a d 12. Patient or Authorized Person s Not required Signature 13. Insured s or Authorized Person s Not required Signature 14. Date of Illness or Injury Enter the date of the onset of symptoms or date of INTRODUCTION TO CLAIMS 6.10

60 Rev 03/2015 injury, if available. 15. Date of Same or Similar Illness Not required 16. Dates Patient Unable to Work in Current Not required Occupation 17. Name of Referring Physician Required if applicable 17a ID Number of Referring Physician Required only for podiatry services. 17 b NPI of Referring Provider Required if applicable 18. Hospitalization Dates Related to Current Not required Services 19. Additional Claim Information As required 20. Outside Lab Not required 21. Diagnosis Codes At least one ICD 9 diagnosis code is required. Behavioral health providers should not use DSM 4 diagnosis codes 22. Medicaid Resubmission Code Enter the appropriate code (A or V) to indicate whether this claim is a resubmission of a denied claim, an adjustment of a paid claim, or a void of a paid claim. Enter the Claim Reference Number (CRN) of the claim being resubmitted. 23. Prior Authorization Number Indicate if appropriate 24a. Date of Service Enter the beginning and ending service dates in MM/DD/YY or MM/DD/YYYY format. If the service was completed in one day, the dates will be the same. The From date must be equal to or prior to the To date. The To date must be equal to or prior to the billing date (Field 31). 24b. Place of Service Enter the two digit code that describes the place of service (POS listing is included in this section of the manual). 24c. EMG Emergency Indicator Mark this box if the service was an emergency service. 24D. Procedure and Procedure Modifier Enter the CPT or HCPCS procedure code that identifies the service provided. If the same procedure is provided multiple times on the same date of service, enter the procedure only once. Use the Units field (Field 24G) to indicate the number of times the service was provided on that date. Unit definitions must be consistent with the HCPCS and CPT standards at the time of service. For some claims billed with CPT/HCPCS codes, procedure modifiers must be used to accurately identify the service provider and avoid delay or denial of payment. 24E. Diagnosis Relate the service provided to the diagnosis code(s) listed in Field 21 by entering the number of the appropriate diagnosis. Enter only the reference INTRODUCTION TO CLAIMS 6.11

61 Rev 03/2015 numbers from Field 21 A through L), not the diagnosis code itself. If more than one number is entered, they should be in descending order of importance. 24F. Charges Enter the total charges of each procedure. If more than one unit of service was provided, enter the total charges for all units. For example, if each unit is billed at $50.00 and three units were provided, enter $ here and three units in Field 24G. 24G. Units Enter the units of service provided on the date(s) in Field 24A. Bill all units of service provided on a given date on one line. 24H. EPSDT/Family Planning Not required 24I. ID Qualifier Required if applicable 24J. (Shaded Area) COB Information Use this shaded field to report Medicare and/or other insurance information. Always attach a copy of the other insurer s EOB to the claim. 24J. (Non Shaded Area) Rendering Provider ID# Enter the Provider s NPI#. Leaving the field blank will cause the claim to be denied. 25. Federal Tax ID Enter the tax ID number and check the box labeled EIN. Use this field to report Medicare and/or other insurance deductible/coinsurance data. For Medicare, report coinsurance to the left and deductible to the right of the vertical line. If a recipient s deductible has been met, enter zero (0) for the deductible amount. If the service is not covered by Medicare or the provider has received no reimbursement from Medicare, the provider should zero fill Field 26. Patient Account Number Enter your account number for posting remittance. Enter the tax ID number and check the box labeled EIN. 27. Accept Assignment Check yes or no. Enter your account number for posting remittance. 28. Total Charge Enter the total for all charges for all lines on claim. Check yes or no. 29. Amount Paid Enter the total amount that you have been paid for this claim by all sources other than the Health Plan. Do not enter any amounts expected to be paid by the Health Plan. Enter the total for all charges for all lines on claim. 30. Balance Due Enter the total amount that you have been paid for this claim by all sources other than the Health Plan. Do not enter any amounts expected to be paid by the Health Plan. 31. Signature and Date The rendering providers name should be indicated within this field. Provider or authorized representative INTRODUCTION TO CLAIMS 6.12

62 Rev 03/2015 must sign claims or indicate Signature on File. Enter the date on which the claim was signed. 32. Name and Address of Facility If other than home or office, indicate where services were rendered Must be street address, not a P.O. Box. The provider or his/her authorized representative must sign the claim. Rubber stamp signatures are acceptable if initialed by the provider representative. Enter the date on which the claim was signed a Billing Provider Name, Address and Phone # Billing Provider NPI# Enter the provider name, address, and phone number. If a group is billing, enter the group biller s name, address, and phone number. Enter the service 33B: Other D number (AHCCCS/Medicare) provider s six digit AHCCCS provider ID number and two digit locator code next to PIN #. Do not enter more than two digits for locator code. Behavioral health providers must not enter their BHS provider ID number. If a group is billing, enter the service provider s six digit AHCCCS provider ID and twodigit locator code next to PIN #. Enter the group biller ID in the GRP # field. Place of Service List 11 Office 42 Ambulance Air or Water 12 Patient s Residence 51 Inpatient Psychiatric Facility 20 Urgent Care 52 Community Mental Health Center 21 Inpatient Hospital 53 ICF/Mentally Retarded Residential Substance Abuse Treatment Outpatient Hospital Facility 23 ER Hospital 55 Psychiatric Residential Treatment Center 24 SC Ambulatory Surgery Center 56 Psychiatric Residential Treatment Center Comprehensive Inpatient Rehabilitation Birthing Center Facility Comprehensive Outpatient Military Treatment Facility Rehabilitation Facility 31 Skilled Nursing Facility 65 ESRD Treatment Facility 32 Nursing Facility 71 State or Local Public Health Clinic 33 Custodial Care Facility 72 Rural Health Clinic 34 Hospice 81 Independent Laboratory 41 Ambulance Land 99 Other Unlisted Facility INTRODUCTION TO CLAIMS 6.13

63 Rev 03/2015 INTRODUCTION TO CLAIMS 6.14

64 Rev 03/2015 Claims Instructions for UB 04 The UB 04 claim form is used to bill for all hospital inpatient, outpatient, emergency room, hospitalbased clinic charges, pharmacy charges for services provided as part of a hospital service. Dialysis clinic, nursing home, home health (dependent on the product line), freestanding birthing center, ambulatory surgery center, residential treatment center, and hospice services also are billed on the UB 04. The following instructions correspond to the box number on the UB 04 form. 1. Provider Data Enter the name, address, and phone number of the provider rendering service. 2. Pay To Name and Address Enter the address that the provider submitting the bill intends payment to be sent IF different than that of the Billing provider information (see #1). 3. Patient Control Number This unique patient number is assigned by the provider. The Health Plan will report this number in Remittance Advices to provide cross reference between the Health Plan Claim Number and the Provider Member Number. 3a. Medical/Health Record Number Required, if applicable 4. Bill Type Facility type (1st digit), bill classification (2nd digit) and frequency (3rd digit) 5. Fed Tax No. Facility s Federal tax identification number. 6. Statement Covers Period Beginning and ending dates for the billing period in a MM/DD/YY or MM/DD/YYYY format. (#12) 7. Reserved Not Required 8a e. Patient Name/Identifier Required 9. Patient Address Mailing address of the patient 10. Patient Birth Date Required 11. Patient Sex Required 12. Admission/Start of Care Date The start date for this episode of care for outpatient. For inpatient services, this is the date of admission. 13. Admission Hour Enter the hour during which the patient was admitted for inpatient or outpatient care. 14. Priority (Type) of Visit Enter the code that best indicates the priority of this admission/visit. Required only for inpatient services. 15. Source of Referral for Admission or Visit Required. Code of the referral for this admission or visit. Inpatient only. 16. Discharge Hour Hour that the patient was discharged. Inpatient or observation. 17. Patient Discharge Status Required. Code indicating the disposition or discharge status of the patient at the time of discharge. Inpatient only Condition Codes Required, if applicable 29. Accident State Required, if applicable 30. Reserved Not required Occurrence Codes and Dates Required, if applicable 35 Occurrence Span Codes and Required, if applicable INTRODUCTION TO CLAIMS 6.15

65 Rev 03/ Dates 37. Reserved Not required 38. Responsible Party Name and Required, if applicable Address Value Codes and Amounts Required for all claims with coordination of benefits. Enter the appropriate code(s) and amount(s). The following codes are required on Medicare/TPL claims: A1 Medicare Part A Deductible A2 Medicare Part A Coinsurance B1 Medicare Part B Deductible B2 Medicare Part B Coinsurance C1 Third Party Payer Deductible C2 Third Party Payer Coinsurance The following codes are required on dialysis claims billing for administration of Erythropoietin (EPO). 49 Hematocrit test results 50 EPO units administered SNP Claims A8 Height A9 Weight 42. Revenue Code Enter the appropriate revenue code(s) that describe the service(s) provided. Accommodation days should not be billed on outpatient bills. Revenue codes should be billed chronologically for accommodation days and in ascending order for non accommodation revenue codes. 43. Revenue Code Description Enter the description of the revenue code billed in Field HCPCS/Rates Enter the inpatient (hospital or nursing facility) accommodation rate. Dialysis facilities and hospitals billing for outpatient services should enter the appropriate CPT/HCPCS code for certain lab, radiology, therapy and pharmacy revenue codes. 45. Service Date Required 46. Service Units Enter the service units provided in this field. If accommodation days are billed, the number of units billed must be consistent with the patient status field (Field 22) and Statement covers period (Field 6). If the recipient has been discharged, the Health Plan covers the admission date to, but not including, the discharge date. Accommodation days reported must reflect this. If the recipient expired or has not been discharged, the Health Plan covers the admission date through the last date billed. 47. Total Charges by Revenue Code Total charges are obtained by multiplying the units of service by the unit charge for each revenue code. Each line other than the sum of all charges may include charges up to $999, Total charges are represented by revenue code 001 and must be the last entry in Field 47. Charges on one claim cannot exceed $999,999, INTRODUCTION TO CLAIMS 6.16

66 Rev 03/ Non covered Charges Enter any charges that are not payable by the Health Plan. The last entry is total non covered charges, represented by revenue code 001. Do not subtract this amount from total charges. 49. Reserved Not required 50. Payer Enter the name and identification number, if available, of each payer who may have full or partial responsibility for the charges incurred by the recipient and from which the provider might expect some reimbursement. If there are no other payers, the Health Plan should be the only entry. 51. Provider No. Enter the number assigned to the Indicator provider by the payer indicated in locator 50 A, B, C. 52. Release of Information Not Required 53. Assignment of Benefits Certification Enter the code indication the provider has signed a form authorizing the third party to remit payment directly to the provider. 54. Prior Payments For Coordination of Benefits 55. Estimated Amount Due Not required 56. National Provider Identifier (NPI) Billing Provider Enter the identification number assigned to the provider submitting the bill. 57. Other (Billing) Provider Identifier Required if applicable. Enter AHCCCS # for atypical providers. 58. Insured s Name Not required 59. Patient s Relationship to Insured Not required 60. Insured s Unique Identifier AHCCCS, Medicare, ID Enter the patient ID# related to the payer(s) in Field 50. AHCCCS ID must be listed last. If you have questions about eligibility or the ID#, contact the Health Plan Customer Care Center Department. 61. Insured s Group Name Enter insured s group name 62. Insurance Group Number Enter the group number of the insured 63. Treatment Authorization Code Enter the prior authorization number if required 64. Document Control Number Not required (DCN) 65. Employer Name (of the Insured) Not required 66. Diagnosis & Procedure Code Enter the applicable ICD 9 codes Qualifier (ICD) 67aq. Principal and other Diagnosis Required Codes and POA Indicator 68. Reserved Not required 69. Admitting Diagnosis Enter the ICD 9 diagnosis code that represents the significant reason for admission. INPATIENT ONLY. 70a c. Patient s Reason for Visit Outpatient only Not required 71. Prospective Payment System Not required Code (PPS) 72a c. External Cause of Injury Code Required if applicable INTRODUCTION TO CLAIMS 6.17

67 Rev 03/2015 (ECI) 73. Reserved Not required 74a e. Principal and other Procedure Codes and Dates Enter the ICD 9 principal procedure code that identifies the procedure performed during the Statement from and to dates. INPATIENT ONLY. 75. Reserved Not required 76. Attending Provider Name and INPATIENT SERVICES ONLY NPI 77. Operating Physician Name and Required if a surgical procedure code is listed on claim. NPI Other Provider (Individual Not required Names and NPI) 80. Remarks Field Required when a claim is a replacement or void to a previously adjudicated claim and a void or replacement. 81. Code Code Field Required if applicable INTRODUCTION TO CLAIMS 6.18

68 Rev 03/2015 INTRODUCTION TO CLAIMS 6.19

69 Rev 03/2015 Claims Instructions for Dental Forms The Dental claim form is used to bill for dental treatment and used for pre treatment prior authorizations. The bolded fields are required when billing for dental services. The numbered instructions correspond to the box numbers on a dental claim form. 1. Type of Transaction X indicate intention of claim 2. Authorization # X Type of claim 3. Carrier Enter the Health Plan information Other Carrier Required if applicable Policy Holder Information Complete all fields Patient information Complete all fields Record of services provided Complete all fields 34. Missing teeth information X indicating missing teeth 35. Remarks If applicable 36. Authorizations Parent/Guardian signature 37. Authorization Patient signature Ancillary claim/treatment information Complete all applicable 48 52A. Billing Dentist or Dental Entity Complete all applicable fields Treating Dentist and Treatment Location information Complete all fields (Treating Dentist signature required) INTRODUCTION TO CLAIMS 6.20

70 Rev 03/2015 INTRODUCTION TO CLAIMS 6.21

71 Rev 03/2015 Remittance Notices (Explanation of Benefits EOB) Checks and electronic funds transfers (EFT) are processed on a weekly basis. Written and electronic notice of claims payment or denial will be reported on your remittance advice or 835 file based on your contract with the Health Plan. HOW TO SET UP FOR ELECTRONIC FUNDS TRANSFERS (see Section 22, Forms) HOW TO SET UP FOR ELECTRONIC REMITS 835 (see Section 22, Forms for Emdeon Application. For SSI users please call (800) ) How To Read Your Remittance Advice (see example) Section 1 1. Date of remittance advice 2. Name of plan/program member is enrolled with 3. Internal number assigned to provider 4. Name/address of service provider Section 2 1. Member name 2. Member identification number 3. Referral/authorization number 4. Referral/authorization type 5. From to service dates 6. Claim number 7. Date payment posted to the Health Plan accounts payable 8. Service provider account number 9. Identified statistical (capitation) claim from non statistical (Fee for Service) claim Section 3 Line item detail 1. Procedure code 2. Disposition reason (denial, contract adjustment, prompt pay discounts, etc. 3. Description of procedure code 4. From To service dates 5. Total billed amount per service line 6. Amount rejected per service line INTRODUCTION TO CLAIMS 6.22

72 Rev 03/ Member deductible amount per service line 8. Member copay amount per service line 9. Amount approved for payment per service line 10. Amount withheld (for contracts with a withhold provision) 11. Net amount of payment per service line 12. Breakdown of adjudication (total lines for entire claim appear **claims totals**) 13. Total claim for member 14. Total amount billed for all service lines 15. Total amount rejected for all service lines 16. Total amount applied to member deductibles for all service lines 17. Total amount applied to member copays for all service lines 18. Total amount approved for payment to all service lines 19. Total amount withheld for all service lines 20. Net amount for claims for all service lines Remit also includes appeal rights, instructions and address for submission. **For questions, see page 6.2 in this section, Claims Resubmissions. INTRODUCTION TO CLAIMS 6.23

73 Rev 03/2015 INTRODUCTION TO CLAIMS 6.24

74 Rev 03/2015 Electronic Funds Transfer (EFT) Banking Information Instructions: Please answer the questions below and attach a copy of a voided check and an up to date W-9 to ensure accuracy of information. Please fax it to: The EFT set-up can take up to 30 days before it becomes effective. Your Provider Relations Representative will contact you and let you know when the set-up is complete. Vendor Name: Vendor Tax ID: Vendor Contact Name: Vendor Contact Phone: Vendor Address: (Please note address listed should denote where EOB is sent) Is this a new address? Yes No ACH Bank Routing Number: Bank Account Number: Do you submit claims via Emdeon (Medifax, Envoy/NEIC, WebMD) or the SSI Group? Yes No Can you accept an Electronic Remittance Advice (ERA) EDI 835 through Emdeon (Medifax, Envoy/NEIC, WebMD) or the SSI Group? Yes No (If Yes, check if you would like an application for ERA?) If not, please list what software vendor or clearinghouse you use: Who is your Provider Relations Representative? NOTE: University Physicians Health Plans (including University Family Care, Maricopa Health Plan, Maricopa Care Advantage and University Healthcare Marketplace) are not responsible for monies deposited to an incorrect account due to non notification of a change in bank or account number. For Internal Use Only: Date Received Scan Date List All Master Vendor #s Provider Relations internal phone and INTRODUCTION TO CLAIMS 6.25

75 Rev 03/2015 INTRODUCTION TO CLAIMS 6.26

76 SECTION 7 RESIVED 10/2014

77 RESIVED 10/2014 Member Copayments The Health Plan AHCCCS members (except for TMA members discussed below) cannot be denied services because of their inability to pay their nominal copayment. Nominal copayments are nonmandatory copayments. A member may be billed for the copayment, but not sent to collections. Nominal Copays Prescriptions $2.30 per prescription drug Outpatient services for physical occupation and speech therapy $2.30 Doctor or other provider outpatient office visits for evaluation and management of care $3.40 Copayments are collected by the facility providing services. Only one copay per provider/facility site per day may be collected. The following are exempt from AHCCCS copayments: Any member under age 19, including KidsCare members All persons determined to be Seriously Mentally Ill (SMI) receiving RBHA services All members who are receiving Children s Rehabilitative Services Members on SOBRA Family Planning Services Only Program Admission in the hospital, nursing home, hospice or long term care facility Prenatal Care including OB doctor visits and tests Well Baby and Well Child Program for children Services related to a pregnancy or any other medical condition that may complicate the pregnancy, including tobacco cessation treatment for a pregnant woman Native American Health Plan enrolled parents Family planning services and supplies Please call the Customer Care Center or review member eligibility status on the Health Plan web sites or AHCCCS web site to determine if the AHCCCS member has a required copayment. MEMBER COPYAMENTS 7.0

78 RESIVED 10/2014 TMA Copayments Transitional Medical Assistance (TMA) members are required to pay copayments. Providers may deny services if the member fails to make the required copayment. Providers may elect to reduce or waive copayments; however it is not a requirement and is on a case-by-case basis. Prescriptions Doctor or other provider outpatient office visits for evaluation and management of care $2.30 per prescription drug $4.00 Outpatient physical, occupational and speech therapies $3.00 Outpatient non-emergency or voluntary surgical procedures $3.00 For current co-pay information, please contact the Customer Care Center at or check eservices. SPECIAL NEEDS PLAN (SNP) MEMBERS Special Needs Plan (SNP) members do not have copays. Services not paid by Medicare will be covered by their AHCCCS plan if correct referral and/or Prior Authorization are in place and the service is a covered benefit. The Health Plan SNP member s office and facility copays are determined by their AHCCCS Rate Code. Member s Prescription Drug Copay Levels are calculated by their Low Income Subsidy levels as determined by the Social Security Administration: Level Deductible Generic Copay Brand Copay 1 $0 $2.55 $ $0 $1.20 $ $0 $0 $0 4 $63 maximum 15% $2.55 generic $6.35 brand name Each of the five product lines has specific covered and non-covered services. MEMBER COPYAMENTS 7.1

79 RESIVED 10/2014 UHM (Marketplace) information required The Special Needs Plans (SNP), Maricopa Care Advantage and University Care Advantage, includes Value Added services: Dental Vision Hearing Aids Hearing Tests Podiatrist OTC Card Transportation Providers must receive an authorization for services requiring prior authorization (PA) before rendering those services to an eligible member. Please see Section 9 for detailed information on the referral and Prior Authorization processes. All non-emergent services to a non-contracted facility or provider due to lack of participating specialty providers in the member area must be prior authorized. Referrals to non-contracted providers and facilities for non-emergent services in areas where contracted providers exist are discouraged and subject to medical review and prior authorization. The Health Plan may offer additional benefits to our Medicare Advantage Beneficiaries. We shall reimburse these added benefits at the lesser of billed charges or at one hundred percent (100%) of the Health Plan s current Summary of Benefits. We reserve the right to change, alter, or modify these benefits or the percentage indicated at its discretion. The Health Plan shall notify the Provider of any changes to the Health Plan s Benefit Summary via the Health Plan s Provider Resource Guide. The Prior Authorization Grid lists services and procedures and identifies the referral and authorization process for each plan. Please note that covered benefits vary between product line (AHCCCS, SNP and Marketplace). This grid is intended to serve as a guideline only. If you have any questions concerning services that require Prior Authorization, please contact the Prior Authorization department. EMERGENCY SERVICES DO NOT REQUIRE PRIOR AUTHORIZATION MEMBER COPYAMENTS 7.2

80 SECTION 8 COVERED SERVICES 8.1

81 Covered Services UFC and MHP UAHP AHCCCS Plans cover medically necessary services with limitations as outlined in the AHCCCS Medical Policy Manual, Chapters 300 and 400: ( ) ( All services must be provided in-network, except in Emergent situations or when Prior Authorization has been obtained. Some services, even when provided in-network, require Prior Authorization. Please refer to the PA grid for a list of services that require Prior Authorization. Services that are not covered by AHCCCS may not be on the PA grid. Please refer to the AHCCCS Medical Policy Manual for a full listing of covered services, or contact the Plan for further information. Behavioral Health Most Behavioral Health services are the responsibility of the Regional Behavioral Health Authority. Primary care physicians, within the scope of their practice, who wish to provide psychotropic medications and medication adjustment and monitoring services may do so for members diagnosed with ADD/ADHD, depressive and/or anxiety disorders. Please see the AHCCCCS Medical Policy Manual, section 310-B, for additional information and clinical guidelines to aid in treatment decisions. Vision Services The AHCCCS Plans Vision Coverage For Children (Under Age 21) Covered services include eye examinations and provision of glasses for members under the age of 21. Notification or Prior Authorization is not required if done in-network. Primary Care Providers are required to furnish initial vision screening in his/her office as part of the EPSDT program. Members under 21 with vision of 20/60 or greater should be referred to the Health Plan specific contracted provider for further examination and possible provision of glasses COVERED SERVICES 8.0

82 ADULTS Adults are not covered for routine eye exams and glasses Adults 21 years of age and older should be directed to a contracted ophthalmologist for the diagnosis and treatment of eye disease. Prior authorization or notification is not required for the office visit if done in-network. Diabetic eye screenings can be provided by qualified eye/optometry professionals for Adults 21 years of age and older, however, the member must be directed to a contracted ophthalmologist if it is determined that the member has eye disease. Prescriptive lenses are not covered unless they are the sole visual prosthetic device used by the member after a cataract extraction. Note: Eye care for adults and children is covered for emergency medical conditions. Prior Authorization is not required in emergencies. Special Needs Plans (MCA and UCA) University Care Advantage and Maricopa Care Advantage Medicare Special Needs Plans are available to individuals who are entitled to Medicare Part A, enrolled in Medicare Part B and AHCCCS. SNP members enjoy the advantage of having care and services coordinated for both their Medicare and AHCCCS benefits. SNP members have the same benefits as other Medicare and AHCCCS members. Prior Authorization is required for certain services. Please the Prior Authorization section of the Manual or contact the Plan for additional information. Additional benefits are based on specific Plan type and if the member is a QMB recipient. Please refer to the Plan s website ( for up-to-date information, includes Part D/Pharmacy information. Qualified Medicare Beneficiaries (QMB) Services Qualified Medical Beneficiaries (QMB) recipients are Medicare eligible persons qualified under the Medicare Catastrophic Coverage Act of For these members Medicare coverage is primary. QMB members are eligible for the following services under Medicare that the AHCCCS Health Plan usually does not cover: Chiropractic services Outpatient occupational therapy coverage Inpatient psychiatric services Psychological services Respite services COVERED SERVICES 8.1

83 Any services covered by or added to the Medicare program, which are not covered by the AHCCCS Health Plan The Health Plan will pay claims for QMB members according to the AHCCCS Medicare Cost Sharing Policy. The Health Plan will have no cost sharing responsibility if the Medicare payment matches or exceeds what would have been paid per the provider s contract. University Healthcare Marketplace The University of Arizona Health Plans-University Healthcare Marketplace offers a wide range of health benefits, including doctor s visits, preventive care, hospitalization coverage and prescriptions. Benefits, co-pays and deductibles vary based on the plan chosen. Non-emergent service may require a referral or prior authorization. For the most current information, contact University Healthcare Marketplace at or visit the Marketplace web site: COVERED SERVICES 8.2

84 SECTION 9

85 REVISED 10/2014 Referral/Prior Authorization The following section contains detailed information for the referral and Prior Authorization process. Topics addressed in this section are: What is the Primary Care Provider s role regarding referrals? What is the specialty care providers role regarding referrals? Can specialty care providers and ancillary vendors write referrals or request Prior Authorization? A list of services that require Prior Authorization or notification How to handle expedited referrals How to complete a referral form Definitions Prior Auth. Form: Referral: No Notification: The form used to request Prior Authorizations, notify specialty care providers or the Health Plan of referrals. Services that are outside the scope of the Primary Care Provider may be referred to a contracted specialty care provider. The Primary Care Provider will complete the Referral Form or acceptable substitute and fax it to the specialty care provider s office along with applicable test results and other pertinent documents. If no notification to the Health Plan is required the Primary Care Provider will provide written instructions (i.e. note on prescription pad or Referral Form) and applicable test results and other applicable documents to the specialty care provider. Notification to Plan: If notification to the Plan is required, the Primary Care Provider will complete the Prior Authorization Form, send/fax it to the specialty care provider s office and to the Prior Authorization Department (see Quick Reference Guide for fax information). Prior Authorization: If Prior Authorization is required the Primary Care Provider or specialty care provider will complete the Prior Authorization Form, attach supporting documentation and fax to the Prior Authorization Department. Some medications (including non-generic medications) require Prior Authorization. For Prior Authorization please complete a REFERRAL AND PRIOR AUTHORIZATION 9.0

86 REVISED 10/2014 non-formulary drug form located in Section 22 Forms of this manual, and fax to the Hospital and Pharmacy Coordinator (see Quick Reference Guide). Although administration of chemotherapy does not require Prior Authorization, in some cases the chemotherapy drugs may. Please contact Pharmacy Prior Authorization to assist in that determination. (See Quick Reference Guide). General Guidelines 1. The Primary Care Provider is the coordinator for medical services. For services requiring authorization, all providers must receive Prior Authorization BEFORE rendering services to member. The Prior Authorization Guidelines follow in this section. Please call your Provider Relations Representative if you would like a copy of any guideline. Primary care physicians, specialists, hospitals and vendors should fax Prior Authorization requests to the Prior Authorization Department (see Quick Reference Guide). If PA is not required, per the Prior Authorization Grid, the primary care physician must refer the patient with a form of written instruction (i.e. note on prescription pad or Referral Form) with reason for visit (consult only consult & treat, diagnosis, findings, etc.) to present to the specialty care provider. Only consults with pain management and podiatry providers require Prior Authorization. Specialty care providers must obtain Prior Authorization from the Prior Authorization Department for all services as listed on the Prior Authorization Grid. 2. Referrals and Prior Authorizations are typically valid for at least 90 days from the date of the request. Length of approval is dependent upon the medical condition being treated. 3. All providers should verify a member s eligibility on the day services are rendered. Contact the Customer Care Center to verify a member s eligibility. A Prior Authorization is not a guarantee of payment. 4. All inpatient admissions must be called or faxed to the Utilization Management department. 5. All referral requests must be to contracted providers. Contact the Network Development Department to verify that a provider is contracted. ALL REFERRALS TO NON- CONTRACTED PROVIDERS MUST HAVE PRIOR AUTHORIZATION THROUGH THE PRIOR AUTHORIZATION DEPARTMENT. 6. Members inquiring about the status of a referral should contact the requesting provider s office. The provider should call the Prior Authorization line for information. 7. Requests for planned admissions, elective surgery/procedures, and specialist appointments that require authorization should be sent at least two weeks in advance whenever possible. REFERRAL AND PRIOR AUTHORIZATION 9.1

87 REVISED 10/ Determinations for requested services will be made within the following timeframes: For AHCCCS and Medicare members, standard requests will be completed within 14 calendar days unless an extension is requested by the Health Plan. For AHCCCS members, expedited requests will be completed within three (3) business days unless an extension is requested by the Health Plan. For Medicare members, expedited requests will be completed within 72 hours from the time of receipt of the request. To ensure timelines of determinations for your request, please submit clinical notes to support the services you are requesting. All Prior Authorization referrals must be submitted with supporting documentation and completed Prior Authorization form. 1. Members may have a second opinion from a qualified health care professional within the network, or out of network if there is not one available in network. Prior Authorization is required for out of network referrals. Outpatient Services, Planned, Hospital Admissions Prior Authorization is required for many outpatient services, (refer to Prior Authorization Grid). All planned and unplanned hospital admissions require Prior Authorization. The notification requirements may vary depending upon the members plan. Please check with your assigned Provider Relations Representative for notification requirements. The covered services are outlined and summarized in Section 8, Covered Services. Notification to the Prior Authorization Department must be provided within 72 hours of inpatient admission status. If the required notification day falls on a weekend or State holiday, notification must be provided no later than the next business day. Medical Records Upon the request for medical records from the concurrent review nurse, medical records must be received within 72 hours of request or may be subject to denial of day, until records are received. If the required notification day falls on a weekend or State holiday, notification must be provided no later than the next business day. To Request an Authorization Fax to: (This is a RightFax Computer System, which reproduces the referral electronically). This is the preferred method for obtaining authorization: Submit your request on a completed Prior Authorization Form. Please ensure that the provider s name and fax number are clearly noted on the form. Please note whether the request is Standard or Expedited. REFERRAL AND PRIOR AUTHORIZATION 9.2

88 REVISED 10/2014 Standard AHCCCS Requests: under 42 CFR , means a request for which a Contractor must provide a decision as expeditiously as the member s health condition requires, but not later than 14 calendar days if the member or provider requests an extension or if the Contractor justifies a need for additional information and the delay is in the member s best interest. Expedited AHCCCS Requests (up to 72 hours for app roval): under 42 CFR , means a request for which a provider indicates or a Contractor determines that using the standard timeframe could seriously jeopardize the member s life or health or ability to attain, maintain or regain maximum function. The Contractor must make an expedited authorization decision and provide notice as expeditiously as the member s health condition requires no later than three working days following the receipt of the authorization request, with a possible extension of up to 14 days if the member or provider requests an extension or if the Contractor justifies a need for additional information and the delay is in the member s best interest. Other member plans may have different criteria and timelines associated with prior authorization requests. Please contact your Provider Relations Representative for plan specifics. NOTE: If calling the Prior Authorization Department because faxing is not an option, please have the following information available for the intake staff: Member identification number Member name and date of birth Reason for referral (including CPT codes if possible) Diagnosis (including ICD-9 code) Specialty care providers full name (phone and fax if available) Supporting documentation Making Referrals to Specialists Primary care physicians are responsible for making appropriate referrals to specialty care providers when members have medical needs the PCP cannot reasonably be expected to treat. Primary care physicians should refer members to specialty care providers who are part of the provider network and are registered with AHCCCS if the member has an AHCCCS plan. Please call your Provider Relations Representative if you need additional information about our contracted provider network or you may access an updated Provider Directory on the plan specific web sites. REFERRAL AND PRIOR AUTHORIZATION 9.3

89 REVISED 10/2014 Services Requiring Prior Authorization The Prior Authorization Grid is your source for determining what services require Prior Authorization. Be sure to reference the date of the grid on the web page since revisions to the grid may occur Prior Authorization Guidelines Sterilization Services Any woman over the age of 21 years and determined to be mentally competent can consent to sterilization. Voluntary consent must be obtained without coercion. AHCCCS requires that a Form Consent Form be filled out when a woman requests sterilization (sample found in forms section). Thirty days, but not more than 180 days must have passed between the date of informed consent and the date of sterilization. In the case of premature delivery or emergency abdominal surgery if at least 72 hours have passed since the informed consent was given, the procedure may be performed. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected delivery date. Transplantation Referrals Transplant requests should be submitted in writing along with the corresponding specialist s recommendation and supporting documentation of medical necessity. Members requiring a transplant are case managed by the Case Manager/Transplant Coordinator. Prior Authorization Form Completion The referring provider, during business hours, may obtain Prior Authorization by faxing the preprinted referral form or calling the Prior Authorization Department. Administrator-on-call will respond after-hours and on weekends. Prior Authorization is staffed 24 hours per day, 7 days per week with both professionals and para-professionals. Referring providers must use the pre-printed referral forms. Prior Authorization can only be given for services that will be provided to eligible and enrolled members. The following information is required on the referral form. A. DATE: The date the Prior Authorization form is initiated. B. REQUESTING PROVIDER: Name of the provider requesting the Prior Authorization. C. PCP: Name of Primary Care Provider if different from requesting provider. D. OFFICE CONTACT: Name of office staff personnel completing Prior Authorization Form. This should be a staff member that can be contacted by the Prior Authorization Nurses for further information. Staff member s direct phone, fax and office address are required. E. PRIORITY: Check either Standard or Expedited. Please note: Providers should use Expedited ONLY when medically necessary. Inappropriate use of the Expedited request may cause PA to be down-graded to Standard if appropriate. F. MEMBER NAME: Name of patient G. DATE OF BIRTH: Birth date of member H. MEMBER ID#: The identification number of the member found on member s ID card. I. SPECIALIST CONSULT TO: Name of specialist being referred to (if applicable) REFERRAL AND PRIOR AUTHORIZATION 9.4

90 REVISED 10/2014 J. SPECIALIST LOCATION: Address of specialist (if applicable) K. NAME OF PROCEDURE: Be specific and include all CPT codes and descriptions applying to the requested services. Indicate estimated length of stay for inpatient procedures. L. CONTRACTED FACILITY TO BE USED: Place where procedure will take place M. DATE SCHEDULED (IF KNOWN): Date procedure is scheduled for. Note: It is not recommended that procedures be scheduled prior to receipt of Prior Authorization. N. ANCILLARY SERVICE REQUEST: If requesting an ancillary service, please check the appropriate box. O. DIAGNOSIS/ICD-9 CODE: Include both the description and the code numbers P. PROCEDURE/CPT CODE: Include all CPT codes that apply to the procedure listed above Q. COMMENTS: Please include any comments pertinent to this request R. RESPONSE: This section is for the Health Plan use only. Please do not mark in this section. All parties have the right to submit a grievance or an appeal. To initiate a grievance or appeal contact the Health Plan by calling customer service to get the specific timeframes and processes. REFERRAL AND PRIOR AUTHORIZATION 9.5

91 REVISED 10/2014 Prior Authorization Form Fax form to or Date: Requesting provider: Address: Phone: NPI or TAX ID: Office contact name: Phone: ( ) Fax: ( ) Standard (up to 14 days for approval) Expedited (up to 72 hours for approval) *Providers must use the Expedited only when medically necessary! Please Note: Inappropriate Expedited request may be downgraded to Standard by UAHP. Inpatient Outpatient In-Office Member name: Date of birth: Member ID#: First and last name of the specialist consult to: Address: NPI or TAX ID: OON Provider? YES NO Date scheduled (if known) Procedure requesting: CPT CODES: CPT CODES: CPT CODES: CPT CODES: Number of visits: Date of procedure: Facility to be used: Address: Phone: Diagnosis ICD-9 Codes: Diagnosis ICD-9 Codes: Diagnosis ICD-9 Codes: Diagnosis ICD-9 Codes: Comments: REFERRAL AND PRIOR AUTHORIZATION 9.6 (04/12)

92 REVISED 10/2014 Pharmacy Prior Authorization and Non-Formulary Request Date Provider Name Provider Phone # Member Name Insurance ID # Date of Birth Phone # Provider Fax # Type of Request Standard Expedited Insurance Plan University Family Care Maricopa Health Plan University Care Advantage University Healthcare Group Medical Information Requested Medication: Dosing Regimen: Quantity: Duration of Therapy: Diagnosis Pertaining to Requested Medication: Reason for Exception: Alternative Medication(s) Tried and Reason(s) for Failure: The University of Arizona Health Plans Office Use Only Please fax this completed form to UAHP 4/12 REFERRAL AND PRIOR AUTHORIZATION 9.7

93 SECTION 10

94 REVISED 10/2014 Quality Management Goals 1. To provide accurate, understandable data to help facilitate the maintenance and enhancement of high-quality member care and services. 2. To assure compliance with AHCCCS and Medicare quality-related standards. 3. To assess the quality and appropriateness of services to members through the conduction of Performance Improvement Projects. 4. To identify opportunities for improvement through the tracking and trending of member and provider staff issues. Quality Management Performance Improvement Committee (QM/PI) The Quality Management Performance Improvement (QM/PI) Committee headed by the Chief Medical Officer and overseen by the Board of Directors directs the Quality Management process. The QM/PI Committee is comprised of contracted providers, the Health Plan Director of Clinical Operations, Director of Clinical Programs and Systems, Director of Quality Management, Utilization Manager and Clinical Pharmacist. If you would like to participate in this committee, please contact the Chief Medical Officer, the Manager of Quality Management or your Provider Relations Representative. Performance Standards Contracted providers are required to meet the Minimum Performance Standards as defined below. The Minimum Performance Standard is the minimally expected level of performance. The Goal is a reachable standard. The benchmark is the ultimate standard to be achieved. It is based on Healthy People 2010 goals for health promotion and disease prevention as determined by the US Department of Health and Human Services. QUALITY MANAGEMENT 10.0

95 REVISED 10/2014 The following table identifies the Minimum Performance Standards, Goals and Benchmarks for each performance measure. ADULT MEASURES Acute Care Contractor Performance Standards Contract Year Ending (CYE) 2015 Performance Measure Minimum Performance Standard (MPS) Goal Inpatient Utilization* TBD TBD ED Utilization* TBD TBD Readmissions within 30 days of discharge* TBD TBD Adult asthma Admission Rate* TBD TBD Use of Appropriate Medications for People with Asthma 86% 93% Follow-up After Hospitalization (all cause) within 7 Days 50% 80% Follow-up After Hospitalization (all cause) within 30 Days 70% 90% Adults Access to Preventive/Ambulatory Health Services 75% 90% Breast Cancer Screening 50% 60% Cervical Cancer Screening: Women Aged with a Cervical Cytology Performed Every Three (3) Years 64% 70% Cervical Cancer Screening: Women Aged with a Cervical Cytology/Human Papillomavirus (HPV) Co-Testing Performed 64% 70% Every Five (5) Years Chlamydia Screening in Women Aged 16 to 24 63% 70% Comprehensive Diabetes Management HbA1c Testing 77% 89% LDL-C Screening 70% 91% Eye Exam 49% 68% Flu Shots for Adults Ages % 90% Ages % 90% Diabetes Admissions, short-term complications* TBD TBD Chronic obstructive pulmonary disease admissions* TBD TBD Congestive heart failure admissions* TBD TBD Annual monitoring for patients on persistent medications: Combo Rate Timeliness of Prenatal Care: prenatal care visit in the first trimester or within 42 days of enrollment Prenatal and Postpartum Care: Postpartum Care Rate (second component to CHIPRA core measure Timeliness of Prenatal Care)* 75% 80% 80% 90% 64% 90% QUALITY MANAGEMENT 10.1

96 REVISED 10/2014 CHILDRENS MEASURES Children's Access to PCPs, by age: mo. 93% 97% Children's Access to PCPs, by age: 25 mo.- 6 yrs. 84% 90% Children's Access to PCPs, by age: 7-11 yrs. 83% 90% Children's Access to PCPs, by age: yrs. 82% 90% Well-Child Visits: 15 mo. 65% 90% Well-Child Visits: 3-6 yrs. 66% 80% Adolescent Well-Child Visits: yrs. 41% 50% Children's Dental Visits (ages 2-21) 60% 75% EPSDT Participation (2) 68% 80% EPSDT Dental Participation (3) 46% 54% Emergency Department (ED) Utilization* TBD TBD Inpatient Utilization* TBD TBD Hospital Readmission Rate* TBD TBD Childhood Immunization Status DTaP 85% 90% IPV (1) 91% 95% MMR (1) 91% 95% Hib (1) 90% 95% HBV (1) 90% 95% VZV (1) 88% 95% PCV (1) 82% 95% 4:3:1:3:3:1 Series 74% 80% 4:3:1:3:3:1:4 Series 68% 80% Hepatitis A (HAV) 40% 60% Rotovirus 60% 80% Influenza 45% 80% Immunizations for Adolescents Adolescent Meningococcal 75% 90% Adolescent Tdap 75% 90% Adolescent Combo 75% 90% Notes: Contractor Performance is evaluated annually on the AHCCCS-reported rate for each measure. Rates for measures that include only members less than 21 years of age are reported and evaluated separately for Title XIX and Title XXI eligibility groups. Goals are currently based on Healthy People 2010 Objectives; if there was no comparable objective set for a particular measure, the most recent HEDIS 90th percentile rate for Medicaid plans nationally was used as the benchmark. Performance Measures Performance measures analyze the success of the Health Plan and its providers in providing basic health screening exams (such as mammography rates) as well as service indicators (such as appointment availability standards). Member and provider satisfaction are also monitored. QUALITY MANAGEMENT 10.2

97 REVISED 10/2014 The Quality Management and Network Development Departments actively disseminate information from these performance measure studies to clinics and providers in the form of biannual dashboards as well as through outreach activities. If there is any particular performance measure you are interested in, please let us know and we will be happy to furnish you with additional information. Quality Management activities are called for in accordance with AHCCCS policies and requirements, and minimum standards must be achieved. Corrective action plans and interventions must be developed to achieve these standards. We will actively seek collaboration with the providers concerned in formulating such plans. All performance measurements are reviewed by a specific work group. The work group makes recommendations to the QM/PI Committee for action based on the data. We are eager to have provider input and participation on these work groups. If you would like to participate, please contact the Chief Medical Officer, the Manager of Quality Management, or your Provider Relations Representative. Performance Improvement Projects The Health Plan identifies an area each year for intensive quality improvement monitoring. These projects may be undertaken with other AHCCCS plans in order to provide a broad population base, minimize the paperwork for providers and in order to disseminate standardized, consistent information (issued by NIH or other academic agencies) regarding the treatment and monitoring of certain disease processes. The results of these Performance Improvement Projects (PIP) are reported to AHCCCS and, in turn, are reported to CMS. Each PIP runs over a four-year period, with the following annual sequence: Year 1 Year 2 Year 3 Year 4 Baseline measurement, planning for possible quality interventions Intervention that is expected to result in improvements over the baseline values Re-measurement to quantify the result of the intervention Second re-measurement to confirm the stability of the outcomes from the intervention The success of quality improvement projects depend greatly on the extent to which providers participate in and get involved in the design, measurement, intervention and leadership of implementation. If you would be interested in participating in such activities, please contact the QUALITY MANAGEMENT 10.3

98 REVISED 10/2014 Chief Medical Officer, Quality Management Manager or your Provider Relations Representative. Quality Management Data Processes Most data used in generating performance standard reports are obtained from administrative databases maintained by the Health Plan; however, these reports may require validation through medical record audit. We will periodically request access to members medical records for this purpose. Audit findings are shared with providers without violating either patient or clinic confidentiality. Individual Quality of Care Issues The Quality Management department also responds to quality of care concerns received from members and providers or issues identified during routine clinical review of members care. If substantiated as a true quality of care issue, the concern may be tracked and trended or may be forwarded to the Peer Review Committee. (Policy # QM 122 and QM 123) Summary information on quality of care reviews is furnished to the credentialing committee at the time of the providers re-credentialing. All of these activities concerning provider information may be used for future Performance Improvement Projects. Peer Review Process The Health Plans conducts regular and ongoing peer review of clinical practice. The Quality Management department identifies issues that may ultimately be referred for peer review. These issues may come from members, providers or clinical review activities of member care. A copy of the Evaluating Quality of Care and the Peer Review Policy are available to you by contacting the Quality Management department or your Provider Relations Representative. Medical Record Documentation In accordance with AHCCCS, Medicare and other quality standards, the Health Plan ensures effective and continuous patient care through accurate medical record documentation of each member s health status, changes in health status, health care needs and health care services provided. The Health Plan has an on-going program to monitor compliance with the established Medical Record Documentation requirements. The Health Plan will monitor the medical record documentation for any provider that sees more than 50 members per contract year. This QUALITY MANAGEMENT 10.4

99 REVISED 10/2014 includes primary care, OB/GYN, specialty providers who have had >50 referrals in the prior calendar year. Complete details of Medical Record Documentation requirements are available upon request from Quality Management or your Provider Relations Representative. (Policy # QM SNP 6 102) A copy of the Medical Records Audit tool is included. A copy of the results of the Medical Record is provided to each office manager and/or provider who has been reviewed. The Health Plan conducts a medical record audit at least every three years in accordance with the credentialing cycle. Credentialing and Recredentialing The qualifications of contracted providers are obtained and reviewed through the credentialing and re-credentialing process. An initial site survey is conducted prior to the completion of the providers initial credentialing. The Quality Management and Network Development departments provide the following information at the time that the provider is scheduled for recredentialing: Complaints and Quality of Care Concerns Information Member Grievance Information Performance Measure rates on selected Performance Measures Results of provider Medical Record Audit Results of providers most recent Appointment Availability Survey The Credentialing Committee will review the information during the re-credentialing process. A copy of the site review tool is included. QUALITY MANAGEMENT 10.5

100 REVISED 10/2014 QUALITY MANAGEMENT 10.6

101 REVISED 10/2014 QUALITY MANAGEMENT 10.7

102 REVISED 10/2014 Policy Number: QM102 Medical Record Documentation Indicator Guidelines 2011 Indicator 1. The medical records reflect all aspects of patient care including the following: A. Member identification B. Identifying demographics C. Current medications noted D. Current problem list 2. The medical record reflects the following for the last visit in the study period: A.1. Provider, signature identifiable A.2. Four digit ID number present A.3. Entries legible A.4. Entries dated Guidelines The member's name, date of birth, medical record number or AHCCCS identification number is on all pages with entries. The member's name, address, telephone number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin, and if applicable, guardian or authorized representative, should be documented in a consistent location. A completed medication list with dates of entry should be found which summarizes all current, chronically prescribed medications. This information will be found in a consistent location in the medical record. A completed problem list with dates of entry should be found which summarizes all significant illnesses, medical conditions, past surgical procedures, or chronic health problems and is updated as new problems are encountered, as documented in the progress notes. This information will be found in a consistent location in the medical record. The provider identifiably signs all entries of service provided to a member. If a typed or stamped signature is used, it must be accompanied by the provider's initials/signature. If recorded electronically, the author must be identified. For UPI providers only, a four digit ID number accompanies all signatures for entries of service provided to a member. The record is legible to someone other than the author. The reviewer must be able to ascertain the essential data on an entry and the resulting plan of care. All provider entries of service provided to a member are dated. A.5. Co-signature, as appropriate B.1. PCT, signature identifiable B.2. Title present B.3. Entries legible B.4. Entries dated C.1. Allergies/adverse events When a health care assistant (e.g. students and unlicensed assistive personnel) provides services to a member, their entries are co-signed by a licensed professional who is authorized by the licensing authority to provide supervision. Residents must have a co-signature by an attending provider. The patient care team member must identifiably sign their first initial and last name on all entries of service provided to a member. If recorded electronically, the author must be identified. A title accompanies all signatures for patient care team member entries of service provided to a member (e.g. MA, LPN, RN). Patient care team member entries are legible to someone other than the author. The reviewer must be able to ascertain the essential data on an entry. All patient care team member entries of service provided to a member are dated. Medication allergies and adverse drug reactions must be noted on the progress note for each visit. Absence of allergies should also be documented (e.g. NKDA). QUALITY MANAGEMENT 10.8

103 REVISED 10/2014 Indicator C.2. Positive symptoms documented D. Current problem and exam E. Plan of treatment F. Follow up visit need documented 3. The following should be documented for members who have had at least three visits: A. Initial hx is noted B. Past medical hx is noted C. Grava/para > 14 yrs. D. Family planning services (15-55 yrs.) E. Immun. rcds. (pediatric) < 21 yrs. F. Immun. Rcds. (adult) > 20 yrs. G. Substance use/abuse hx > 15 yrs. H. Dental history < 21 yrs. I. Advance directives documented > 20 yrs. J. EPSDT Tracking Forms < 21 yrs. Guidelines Positive symptoms for each medication allergy or adverse drug reaction are documented (e.g. PCN - hives). Each progress note should contain the chief complaint or purpose for the visit, and the physical exam findings. The progress note should include a plan of care which addresses all treatments, and instructions to the patient, as applicable. A scheduled return visit (in days, weeks, months or PRN) is documented for each encounter. An initial history for all members should include family medical history (a record of the State of health and medical history of members in the immediate family), social history (family situation), and preventative lab screenings. The initial history for members under age 21 should also include prenatal care (documentation of mother receiving prenatal care and/or complications of pregnancy) and birth history. This can be in the form of a progress note or a history form completed by the patient. If there is a past history in the chart that was completed while the patient had another form of insurance, the indicator will be met. A past medical history should be found for all members (for the previous 5 years if available). It should include disabilities, previous illnesses or injuries, hospitalizations, surgeries and emergencies. This can be in the form of a history form completed by the patient, a progress note or a detailed problem list. The number of pregnancies and live births are documented for females 15 years of age and older. Annual notice verbally or in writing of the availability of family planning services for men and women age (inclusive) is documented. Any notation regarding any form of birth control is acceptable. Mark N/A if a women has had a hysterectomy or a tubal ligation or if a man has had a vasectomy An immunization record is present for children under 21 years, and vaccine name, dose and route is documented. Documentation of "up to date" (UTD) does not meet this indicator. An appropriate immunization history has been made in the medical record for adults 21 years of age and older (Td, influenza, pneumococcal 65 years of age and older). For members 16 years or age and older, there is documentation addressing the use of alcohol, tobacco and substances. A dental history, if available, is present for all members under 21 years of age. Evidence of dental discussion (e.g. gums checked, dental caries noted, referral given to dentist, etc.) is documented. There should be documentation as to whether or not an adult member 21 years of age and older has completed advance directives. EPSDT Tracking Forms are to be used by providers to document all age specific, required information related to EPSDT screenings according to the following minimum service intervals: 2-4 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 3 years, 4 years, 5 years, 6 years, 8 years, years, years, and years. QUALITY MANAGEMENT 10.9

104 REVISED 10/2014 Indicator K. PEDS Tool - NICU grads 4. Responses for the following should be based on materials received since the last recredentialing cycle/medical record documentation audit: A. Diagnostic information noted B. Consult/referral info noted C. Emergency/UC reports noted D. Hospital discharge noted E. Behavioral health services noted F. Release of information documented G. Communication between providers H. Notification to BH provider if change in health status or new Rx prescribed. J. Referrals to low/no cost primary care services as appropriate Guidelines PEDS Tools are to be used by trained providers to evaluate all NICU graduates born after 1/1/06. All laboratory tests and screenings, radiology reports, physical exam notes should show PCP's initial or indication that the physician has reviewed the results. All reports from referrals, consultations and specialists should show PCP's initial or indication that the physician has reviewed the results. All emergency/urgent care reports should show PCP's initial or indication that the physician has reviewed the results. All hospital discharge summaries should show PCP's initial or indication that the physician has reviewed the results. All behavioral health services provided, if applicable, should show PCP's initial or indication that the physician has reviewed the results. Signed release of information should be documented. This can be in the form of present facility requests to send or receive materials as well as past facility requests. HIPAA consent forms that specifically address release of information can be used in conjunction with materials sent or received for adequate documentation. Notation of follow through should be documented (e.g. date information released and signature of staff member showing completion). Documentation that reflects diagnostic, treatment and disposition information (including records received from previous health care providers) related to a specific member was transmitted to the PCP and other providers as appropriate to promote continuity of care and quality management of the member's health care. Documentation that reflects communication between the PCP and BH provider related to a change in the member's health status or a new medication There is evidence in the medical record that the provider has referred the member to low/no cost primary care services as appropriate. (Members who are losing AHCCCS/SOBRA eligibility) Revised 9/08 QUALITY MANAGEMENT 10.10

105 REVISED 10/2014 QUALITY MANAGEMENT 10.11

106 REVISED 10/2014 OB AUDIT INDICATOR GUIDELINES 2007 Indicator Guidelines Policy Number: QM Gravida/para The number of pregnancies and live births are documented. 2. Risk assessment tool for OB A risk assessment tool is completed for obstetric patients in the form of a MICA or ACOG form. 3. WIC referral A WIC referral is required for all the Health Plan members. 4. EPSDT form < 21 yrs. An EPSDT form must be completed for all members under 21 years of age. 5. Dental referral < 21 yrs. A dental referral is required for all members under 21 years of age. 6. ACOG labs - total OB panel 7. HIV screening offered 7.a. HIV screening accepted or declined Lab screenings for members requiring obstetric care must conform to ACOG guidelines upon initiation of prenatal care and at other appropriate times during the pregnancy. ACOG guidelines include the following: HGB/HCT, UA, RH type, RH antibody screen, Rubella, Hepatitis B surface antigen, VDRL, Pap smear (as needed), MSFP (offered at 18 weeks), diabetes screen at weeks, antibody screen for RH negative mothers before RhoGam, and periodic testing when indicated/elected. All pregnant women are offered HIV testing as a routine component of prenatal care. This is an ACOG requirement. The member's acceptance or declination of the HIV screening offer should be documented in the chart on the ACOG or MICA form or on a separate consent form. HIV lab results can also be counted as the member's acceptance for HIV screening. This data will be gathered for departmental information and will not be included in the scoring. 8. Member education 8.a. Member education 8.b. Childbirth classes 8.c. Labor warnings 9. Postpartum - notation about contraception 10.a. OB appointments per ACOG 10.b. Missed appointments 11. Low/no cost referrals to primary care services as appropriate Members receive basic prenatal care materials at the onset of prenatal care. Members who initiate prenatal care at least six weeks prior to delivery are referred for childbirth classes. Members receive information regarding fetal movement warnings, preterm labor warnings, and labor warnings. A notation about contraception is included on the progress notes for the postpartum visit. There is evidence in the medical record that OB patients are seen according to ACOG standards The provider has a process in place to call and reschedule patients who miss appointments. There is evidence in the medical record that the provider has referred the member to low/no cost primary care services as appropriate. (Members who are losing AHCCCS/SOBRA eligibility). Revised 9/08 QUALITY MANAGEMENT 10.12

107 REVISED 10/2014 Audit Date: Reviewer Initials: Clinic Name: OB Audit Score Sheet 1 = Information present and complete 0 = Information absent or incomplete X = Not Applicable Medical Record Number Patient Initials DOB Maternal Care Provider 1. Gravida/para 2. Risk assessment tool for OB 3. WIC referral 4. EPSDT form < 21 yrs. 5. Dental referral < 21 yrs. 6. ACOG labs - total OB panel 7. HIV screening offered 7.a. HIV screening accepted [A] or declined [D] (not included in scoring) 8.a. Member education at the onset of prenatal care 8.b. Childbirth classes if enrolled at least six weeks prior to delivery 8.c. Labor warnings 9. Postpartum - notation about contraception 10.a. OB appointments are scheduled according to ACOG standards 10.b. Provider has a process to contact OB patients who fail to keep appointments Low/no cost referrals to primary care services as appropriate Please refer to OB Audit Guidelines for detailed description. Comments: 10/07 QUALITY MANAGEMENT 10.13

108 REVISED 10/2014 QUALITY MANAGEMENT 10.14

109 REVISED 10/2014 Guidelines For Medical Office Site Audit 1. There should be a system for 24-hour provider on-call coverage. 2. Medical records must be located in a private area non-accessible to non-staff. 3. A current CLIA certificate should be present, if any lab functions are performed, even those deemed as waived status i.e.: urine dips, urine pregnancy tests, etc. Additional info is also available at 4. A current State radiology license should be present, if any radiology services are performed. Most sites do not have on site radiology services. 5. Staff must be able to recite process for medical and site emergencies i.e.: fire. The presence of a written policy is optimal. Inquire about presence of on-site emergency equipment, which are listed individually later. 6. A dedicated refrigerator should be in place to store medications. Refrigerator temperatures must be monitored and recorded daily and a process must be in place to handle out of range values. Appropriate refrigerator temperatures = 2-8 C (35-46 F). Appropriate freezer temperatures = below freezing (32 F) and -15 C (+5 F), if Varicella vaccine is stored. Optimally a frost-free refrigerator should not be used for Varicella vaccine storage. Vaccine should never be placed in the door of a refrigerator, due to unstable temperatures. A good test for freezer temperature stability is to place a coin on top of a cup of frozen water and place in the mid freezer area. If the coin is ever found to be below the surface, the freezer temperature has been compromised. 7. Medications, including samples, must be stored in a secure location non-accessible to non-staff. A system must be in place to monitor that all are current. Multi-dose vials should be labeled when open with the new expiration date, if different from that on the container. Follow the manufacturer s guidelines. 8. There must be a process in place regarding the handling and disinfection of contaminated instruments. Cold sterilants must have a complete chemical label. Usage of disposable instruments or autoclave sterilization is strongly recommended for instruments used for invasive procedures. If an autoclave is used, a spore test such as ATTEST, should be used to validate the efficiency weekly. A log should be maintained for tracking of instruments sterilized in each autoclave run. Sterile equipment is considered sterile until the package integrity is broken. The autoclave manufacturer s guidelines should be followed. 9. Outdoor signage should be adequate to identify the office and have good visibility. 10. Parking availability must be adequate for patient volume and should include dedicated handicapped spaces. 11. The site should appear clean and well maintained. 12. Hallways should be a minimum of 3 feet, to allow wheelchair access, and should be free of obstacles. 13. All exits should be clearly marked. Lighted exit signs are optimal. 14. All areas of member access, including the lobby, hallways, exam rooms, and restrooms, should be wheelchair accessible. QUALITY MANAGEMENT 10.15

110 REVISED 10/ There should be at least one exam room per provider, with optimally more. 16. A process should be in place to assess and provide professional interpretation for members as needed. Ensure provider/staff knowledge and accessibility of the Health Plan interpretation service. 17. A process should be in place for routine maintenance of medical equipment. 18. Fire extinguishers should be present in sufficient number for the size of the site and in locations of highest risk. They should show evidence of current maintenance. 19. A process should be in place to identify and isolate contagious or immune compromised patients. 20. A process should be in place to triage routine/urgent/emergent patients. 21. If an emergency cart is present, there should be a process for routine upkeep of equipment and for ensuring that all medications are current. 22. If oxygen tanks are present, they should be secured to a wall or to a wheeled stand. 23. At least 2 staff should be trained in CPR. 24. There should be a needle disposal system in all areas in which injections are prepared or administered i.e.: nurses station, exam rooms, treatment rooms, etc. These should be disposed of when 2/3 full, to avoid injury. 25. There should be a system to dispose of medical hazardous waste, optimally through contract with a disposal service. Biohazard supplies i.e.: clearly marked waste bags and a clearly marked waste container should be in evidence. 26. Clean and dirty work areas should be separated and clearly designated. 27. MSDS (Material Safety Data Sheets) information should be available for all chemicals on site and all staff should be trained in their purpose. Optimally these should be placed in a red binder and be located in the area of highest chemical usage. They will most easily be accessed during an emergency by placing them in alphabetical order and by including an index in the front of the binder. MSDS sheets are available through the site s medical products supplier or at Vision and hearing monitoring equipment should be present and there should be a system in place for routine maintenance. 29. Prescription pads should be stored in areas non-accessible to non-staff. 30. If controlled substances are present they should be stored in a locked area. QUALITY MANAGEMENT 10.16

111 REVISED 10/2014 QUALITY MANAGEMENT 10.17

112 REVISED 10/2014 PROVIDER PROFILE CONFIDENTIAL (ARS ET SEQ.) PERFORMANCE MEASURE CYE 2006 GOAL CURRENT PLAN AVERAGE THIS PROVIDER S AVERAGE* REFERENCE DATE PATIENT COMPLAINTS AND GRIEVANCES Total number of patients with complaints or grievances Number of complaints per 1000 encounters <5 patients with complaints per year To be determined Number: QUALITY MANAGEMENT DATA Actual results*: Denom - Seen - Percent Well child visits, 3 6 years Adolescent well care visits 67% 34% % % % % Annual mammography utilization rate of women 52 to 64 years old 61% % % Annual rate of adult diabetic retinal eye exam rate 75% % % UTILIZATION MANAGEMENT DATA EPSDT visits, 0-21 yrs % compliance EPSDT dental utilization, 3-20 yrs, % compliance 80% 56% % % % % PROVIDER SERVICE Compliance with service standards: Routine appointment availability standards Urgent appointment availability standards Emergent appointment availability standards Waiting time 21 days 1 day 8 hours 45 minutes days day hrs min Actual results*: *Performance measure results may represent a small population at the individual provider level. QUALITY MANAGEMENT 10.18

113 SECTION 11 REVISED 10/2014

114 REVISED 10/2014 Behavioral Health Services Behavioral health benefits vary depending on the member plan. The behavioral health benefit for AHCCCS members is provided through the Arizona Department of Health Services, Regional Behavior Health Authority (RBHA) system. University Healthcare and Maricopa Health Plan member may access a full continuum of care (based on medical necessity through the RBHA for the geographic area in which they live. UFC and MHP members may obtain medication from a primary care provider for limited behavioral health disorders (uncomplicated anxiety, depression & ADHD). The UFC / MHP formulary makes available psychotropic agents for the treatment of these disorders All other psychiatric diagnoses must be referred to the RBHA for specialty care through a behavioral health practitioner. Members with serious mental illness must be referred to the RBHA for specialty care, as well. Maricopa Care Advantage and University Care Advantage (Special Needs Plans or SNP plans) administer Medicare-covered behavioral health benefits and contract with local RBHA providers for the Medicaid portion of the benefit for continuity of care (Most SNP members obtain behavioral health benefits through RBHA contracted providers). University Healthcare Marketplace (UHM) members have a full continuum of mental health, autism spectrum disorder and substance abuse treatment benefits covered by the health plan. University Healthcare Marketplace has a network of contracted specialty providers to provide these services. The Health Plan s Behavioral Health Case Managers are available to assist with referrals to community agencies, coordination of referrals to the RBHA and other specialty providers for all lines of business. Behavioral Health Case Manager scan be reached Monday through Friday during normal business hours Eligibility AHCCCS, SNP and University Healthcare members, except for SOBRA Family Planning members, are eligible for behavioral health services with limitations and depending upon medical necessity. BEHAVIOR HEALTH SERVICES 11.0

115 REVISED 10/2014 Referrals Members can access behavioral health services through the following: Referral by a Primary Care Provider (PCP) or the Health Plan Referral by a state agency, other community agency or entity Referral through crisis services Self-referral by calling a contracted provider agency in the community. The attached Behavioral Health Services Referral forms (see page ) are used to initiate an episode of care care for AHCCCS and SNP members with the RBHA and can be completed by any staff member at the clinic. Members do not need a referral from their PCP or Health Plan approval to contact the RHBA or other contracted behavioral health provider for services. Developmental and behavioral health screenings for AHCCCS members up to 21 years of age are a required part of the EPSDT. AHCCCS Plans offer the Pediatric Screening Checklist as a tool for this purpose. If a referral is needed for behavioral health services as determined through the EPSDT screening process, discuss with the members parent or guardian (they must give permission and agree with the referral) and then the Behavioral Health box at the bottom of the EPSDT form in the referral section should be checked. Providers should then follow their usual process for making the RBHA referral. Behavioral Health and Maternal Child Health staff review EPSDT forms to identify and follow up on behavioral health referrals that were made to ensure the member received identified services. The provider may contact a Behavioral Health Case Manager directly to discuss referrals or instruct the member to call, if preferred. The Health Plan provides transportation for AHCCCS members to initial behavioral health intake appointments. Please call the Customer Care Center for more information (see Quick Reference Guide). BEHAVIOR HEALTH SERVICES 11.1

116 REVISED 10/2014 Referral Follow Up Please forward a copy of Behavioral Health Referral Forms to: Behavioral Project Coordinator The University of Arizona Health Plans 2701 E. Elvira Road Tucson, AZ (see Quick Reference Guide for current fax number) The Behavioral Health Project Coordinator will follow up on member intake and enrollment with the RBHA to ensure members have the opportunity to obtain services. When an AHCCCS has an intake at a RBHA provider site, the PCP s office should receive a Notification of Intake form indicating pertinent information, regardless of the referral source. This form must be kept even if the PCP has not seen the patient yet. When the patient establishes care, the form can then be integrated into the chart. If the PCP makes a referral and receives no RBHA feedback, the medical record should reflect what follow-up was initiated by the PCP s office to determine the outcome of the referral. The PCP or designated staff may contact a Behavioral Health Case Manager to request information on referral as needed. Health plan behavioral health staff can directly assist members or providers with obtaining needed referrals for all lines of business, and can provide follow-up case management services as needed. Simply call our Customer Care Center and request assistance from a Behavioral Health Case Manager. Behavioral Health Benefits and Services The Health Plan educates eligible members in the member handbook and other printed documents about covered behavioral health services and where and how to access them. During routine office visits, EPSDT screenings or other appropriate visits, we ask that the PCP reminds their patients that they are eligible for behavioral health services, andof how to access services. BEHAVIOR HEALTH SERVICES 11.2

117 REVISED 10/2014 The following covered services are available through RBHA Networks for AHCCCS members, based on member eligibility and subject to benefit limitations. To verify member benefits or for questions about enrollment, call the respective RBHA Member Services department. Behavioral Management (behavioral health personal assistance, family support, peer support) Behavioral Health Case Management Services (limited) Behavioral Health Nursing Services Emergency Behavioral Health Care Emergency and Non-Emergency Transportation Evaluation and Assessment Individual, Group and Family Therapy and Counseling Inpatient Hospital Services (the contractor may provide services in alternative inpatient settings that are licensed by the Arizona Department of Health Services, Division of Assurance and Licensure, the Office of Behavioral Health Licensure, in lieu of services in an inpatient hospital. These alternative settings must be lower cost than traditional inpatient settings. The cost of the alternative settings will be considered in capitation rate development). Non-Hospital Inpatient Psychiatric Facilities Services (Level I residential treatment centers and sub-acute facilities) Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosis Opioid Agonist Treatment Partial Care (supervised day program, therapeutic day program, and medical day program) Psychosocial Rehabilitation (living skills training; health promotion; supportive employment services) Psychotropic Medication Psychotropic Medication Adjustment and Monitoring Respite Care (with limitations) Rural Substance Abuse Home Transitional Services Screening BEHAVIOR HEALTH SERVICES 11.3

118 REVISED 10/2014 Behavioral Health Therapeutic Home Care Services SNP members are eligible for all Medicare covered behavioral health benefits with limitations. Those enrolled with and receiving services from the RBHA may have co-insurance for services rendered covered through the AHCCCS portion of the benefit. University Healthcare Marketplace members are eligible for mental health, autism spectrum disorder and substance abuse treatment services as designated in their benefit packages and member handbooks. Please check member eligibility and benefits prior to rendering services. Psychotropic Medication Management PCP s who wish to provide psychotropic medication and monitoring services are encouraged to do so for members diagnosed with uncomplicated Attention Deficit disorder, depression, and anxiety disorders. At any time, the PCP may choose to transfer members to RBHA if the illness becomes complicated or has not responded to PCP s attempts to treat. Prior Authorization is required for some psychotropic medications. Please see Section 17, Pharmacy. The first authorization will generally be in effect for one year; once the member has stabilized on the medication, and if there have been no sentinel event during the year, the second authorization will be open-ended with no further authorization required as long as the patient remains stable. PCP s are expected to refer to the plan specific formulary for covered medications and use them prior to requesting a non-formulary medication. The Health Plan formularies offer various psychotropic medications for behavioral health disorders depending on member plan. For AHCCCS members, PCP s may choose to treat Attention Deficit Disorder, depression, and anxiety disorders; co-morbid behavioral health, complicated behavioral health, and all other behavioral health diagnoses require referral to the RBHA. For SNP members the PCP may choose to treat a broader range of behavioral health diagnoses and this is reflected in the formularies. PCP s treating behavioral health disorders are expected to choose and adhere to a nationally recognized evidence-based guidance. Health Plan websites contain links to evidence-based guidelines for provider convenience. Additional guidelines may be easily accessed at the National Guideline Clearinghouse ( Additionally, AHCCCS-endorsed behavioral health tool kits are posted on AHCCCS Health Plan websites under the provider tab; these resources include treatment algorithms and screening tools for depression, anxiety, and ADHD for both adults and children. BEHAVIOR HEALTH SERVICES 11.4

119 REVISED 10/2014 Members who are receiving counseling at the RBHA can receive prescription medication through their PCP if they are and not seeing a prescriber at the RBHA. Members cannot receive medication from a RBHA prescriber and the PCP simultaneously. Members who present with complicated psychiatric problems must be referred to the RBHA for specialty care. See Pharmacy Section 17 for prescribing guidelines. If at any time the Health Plan becomes aware of information about the members behavioral health condition that would indicate co-morbidity or complex behavioral health needs, we may require the member be referred to the RBHA and discontinue coverage of psychotropic medication prescribed by the PCP. If this occurs, a Behavioral Health Case Manager will facilitate the RBHA referral and transfer of medical records to ensure continuity of care. Members being transitioned from the RBHA are exempt from Step-Therapy programs. The Health Plan s AHCCCS members must receive treatment via a RBHA Psychiatrist following these sentinel events: Medication overdose Suicide attempt/homicide Attempt Psychiatric hospitalization In order to achieve optimal member benefit from health care services rendered by Health Plan providers and RBHA providers, coordination of care between the PCP s office and the RBHA provider is required for those members who are receiving behavioral health services from the RBHA. Coordination of care is facilitated by an active ongoing dialogue between the primary care and behavioral health systems. The AHCCCS contract and the Arizona Administrative Code require the exchange of information between the RBHA and AHCCCS Health Plan providers (Final Acute Care RFP p.31; R ). PCPs are required to respond to RBHA provider information requests pertaining to RBHA behavioral health recipients within 10 (ten) business days of receipt of request. The response should include (but is not limited to) current diagnosis, medication, pertinent lab results, last PCP visit and last hospitalization. BEHAVIOR HEALTH SERVICES 11.5

120 REVISED 10/2014 Medical Record Documentation PCPs are required to maintain the following documentation: 1. Notification of Assessment forms sent from the RBHA when a member has an intake. If the PCP has not yet seen the member, such information may be kept temporarily in an appropriately labeled file but must be integrated into the member s medical record as soon as one is established. 2. The Behavioral Health Referral Confirmation Form faxed from RBHA upon receipt of the referral from the PCP and assignment to a behavioral health provider. 3. Notes regarding follow-up pertaining to the behavioral health referral, status of the referral, or contact with the psychiatrist, case manager or other mental health professionals reflecting close coordination of care and communication between systems. If a PCP is treating a member for a behavioral health diagnosis, a complete behavioral health medical record must be kept including: 1. Current status of RBHA enrollment prior to the PCP beginning treatment for a behavioral health disorder. 2. Documentation reflecting consideration of potential medical etiology for the condition, and how it was ruled out. 3. Documentation of the symptomology supporting the diagnosis and target symptoms to be addressed with treatment. 4. An identifiable plan of treatment for the behavioral health diagnosis. 5. Documentation of follow-up visits to assess the efficacy of the prescribed medication within 30 days of prescription, and at regular intervals thereafter. 6. Member education pertaining to the diagnosis, medication prescribed and what to do if symptoms worsen. 7. Documentation of coordination of care with the RBHA psychiatrist, case manager or other behavioral health professional. BEHAVIOR HEALTH SERVICES 11.6

121 REVISED 10/ PCP screening for suicidal/homicidal ideation initially and at follow up visits as needed. 9. A brief treatment history pertaining to the behavioral health diagnosis, previous treatment, complications or other relevant information. 10. Name, dosage, and start date for medications. 11. Documentation of the Nationally Recognized Guideline Psychiatric Consultation and Evaluation Services PCPs may obtain a one-time psychiatric consultation for AHCCCS members they may want to continue to manage or have questions about managing. The PCP may request a telephone consultation to ask questions of a general nature, or the PCP can request the psychiatrist provide a face to face consultation with the patient for diagnostic purposes and medication recommendations. Contact the Behavioral Health Coordinator for assistance with obtaining a consultation. Case Management The Health Plan offers case management services for those members with Special Health Care Needs (SHCN), including those with serious and chronic behavioral health conditions. We appreciate your assistance in the identification of members in need of behavioral health case management services. Our Behavioral Health Case Managers can partner with the primary care office and others involved in assisting members with accessing behavioral health services, coordination of care between primary care and the behavioral health or mental health provider, facilitation of special needs referrals, and member education and advocacy. We establish agreed upon goals with the member aimed at optimizing health and wellness, and provide professional assistance and support for obtaining those goals. Behavioral health Case Management services through the Health Plan are mainly telephonic or by mail; we sometimes attend case conferences or visit members at facilities or in their homes within the community. If a provider identifies a member who could benefit from behavioral health Case Management assistance, please call our Customer Care Center and ask to make a Health Plan behavioral health case management referral. A Behavioral Health Case Manager will be assigned and contact your office with an update or any questions. BEHAVIOR HEALTH SERVICES 11.7

122 REVISED 10/2014 Copies of the Health Plan policies and procedures concerning behavioral health are available upon request from the Behavioral Health Manager, including examples of members who are good candidates for referral (Policy# BH113). Emergency Services For AHCCCS members, the RBHA is responsible for all emergency behavioral health services, including emergency room psychiatric consultation and prior period coverage of behavioral health services. The Health Plan is responsible for medical services rendered in the emergency room for members with behavioral health disorders For UCA/MCA and UHM members the Health Plan is responsible for both medical and psychiatric service provision in an emergency. Crisis Services for MCA,UCA (SNP) University Healthcare Marketplace (UHM)Members SNP and UHM members have an inpatient behavioral health benefit; including substance abuse detoxification and treatment with certain limitations. If a SNP member exhausts inpatient psychiatric benefits then inpatient benefit would be covered under the RBHA provider for eligible members. Crisis Management 1. If a member is an immediate threat to themselves or others, call 911 and have the member transported via ambulance to the nearest emergency room. 2. Behavioral Health Case Managers are available to assist with crisis management during office hours. After-hours assistance can be obtained by calling the Health Plan 3. If the member can be stabilized and assessed as safely able to leave the premises, the member may be referred to crisis services through the following resources: BEHAVIOR HEALTH SERVICES 11.8

123 REVISED 10/2014 CRISIS SERVICES Pima County Crisis Response Network (520) hour crisis line (800) Cochise, Graham, Greenly, Santa Cruz, Pinal & Gila Counties Cenpatico Crisis Line (NurseWise) (866) Maricopa County Mercy Maricopa Integrated Care Crisis Line (602) or (800) National National Suicide Prevention Lifeline Hotline: 24/7, free & confidential, available to anyone in emotional distress TALK (8255) The above crisis lines can be utilized by AHCCCS, MCA or UCA members. Spanish Language Hotline: Hearing & Speech Impaired with TTY Equipment: TTY (4889) BEHAVIOR HEALTH SERVICES 11.9

124 REVISED 10/2014 RBHA GSA County Norther Arizona Behavioral Health (NARBHA) 1 Yavapai Counties Cenpatico Behavioral Health (CBHS) 2,3,4 La Paz, Yuma, Cochise, Santa Cruz, Gila, and Pinal Counties Community Partnership of Southern Arizona (CPSA) Mercy Maricopa Integrated Care (MMIC) 5 Pima County 6 Maricopa County BEHAVIOR HEALTH SERVICES 11.10

125 REVISED 10/2014 ADHS/DBHS REFERRAL FOR BEHAVIORAL HEALTH SERVICES BEHAVIOR HEALTH SERVICES 11.11

126 REVISED 10/2014 BEHAVIOR HEALTH SERVICES 11.12

127 REVISED 10/2014 BEHAVIOR HEALTH SERVICES 11.13

128 REVISED 10/2014 BEHAVIOR HEALTH SERVICES 11.14

129 REVISED 10/2014 BEHAVIOR HEALTH SERVICES 11.15

130 SECTION 12

131 REVISED 10/2014 Dental Care Services Introduction Denta Quest is delegated for the benefit administration of dental services for The Health Plan AHCCCS Plans (UFC and MHP), Maricopa Care Advantage (MCA) and University Care Advantage (UCA). The Health Plan Special Needs Plans (MCA or UCA) will cover oral exams, cleanings, fluoride treatment, and dental x-rays; benefit limitations.* Denta Quest is responsible for contracting with all dental providers, including clinics, and providing necessary authorizations and utilization management. Additionally, Denta Quest will process all dental claims, conduct some oversight of quality of care and provide all dental network communications and provider education. Denta Quest Claims Address: Denta Quest of AZ-Claims North Corporate Pkwy Mequon, WI To submit claims electronically via eclaims the Payor ID: CX014 Dedicated telephone line: Denta Quest Contact: or Please note: Outpatient and Anesthetic medical prior-authorizations related to dental care will continue to be managed by the Health Plans. Appointment Availability Standards Dental appointments must be available within the standards mandated by AHCCCS, Medicare and community standard. The dental provider is responsible for making office appointments available based on the dental needs of the member. Appointment standards also include inoffice waiting time parameters (45 minutes). The Health Plan monitors compliance with these standards as follows: DENTAL CARE SERVICES 12.0

132 REVISED 10/2014 Adult and Children Emergency dental appointments within 24 hours of referral Adult and Children Urgent dental appointments within three (3) days of referral Children under 21 Years of Age Routine dental appointments within forty-five (45) days of referral Members who request routine dental services are to be scheduled within 45 days of the request. *Benefit amounts are subject to change. Please contact the plan for current benefit coverage. Children s Dental Services AHCCCS members through the age of 20 years receive comprehensive health care including medical, dental and vision services through a Federally mandated program called EPSDT (Early Periodic Screening Diagnosis and Treatment). The goal of the EPSDT program is to encourage primary prevention, early intervention, diagnosis and medically necessary treatment of physical or intellectual disability. EPSDT dictates the frequency, or periodicity, of the required screening. Dental screening is to be scheduled at least once in a 12-month period (see Periodicity Schedule at end of chapter). All AHCCCS members through the age of 20 tears will be assigned to a Primary Dental Provider for their dental care. A Primary Dental Provider is also known as a Dental Home. Coordination with Children s Rehabilitative Services The Children s Rehabilitative Services (CRS) Program is administered by the Arizona Department of Health Services. CRS provides rehabilitative medical care to enrolled individuals with handicapping or potentially handicapping conditions that have the potential for functional improvement. All AHCCCS Plans are required by State statute to refer members who meet CRS eligibility criteria to CRS for care. Dental Services at CRS are limited to individuals enrolled in CRS for the following conditions: Cleft lip/cleft palate Significant functional malocclusion VP shunt Cardiac conditions, which place the individual at risk for septic bacterial endocarditis. Treatment related problems for seizure disorders such as dilantin hyperplasia DENTAL CARE SERVICES 12.1

133 REVISED 10/2014 Orthodontic services at CRS are limited to individuals enrolled in CRS for the following conditions: Significant Functional Malocclusion If a Health Plan AHCCCS member presents in a dental office with the above conditions, they may be CRS eligible. To verify CRS eligibility, dental providers should contact the Customer Care Center at (800) If a member is CRS enrolled or CRS eligible, the Health Plan will refer the member to a CRS dental provider. Summary of Covered and Excluded Dental Services As an AHCCCS contracted health plan, covered services are mandated by Federal and State law for AHCCCS members. Depending upon the member s plan, all therapeutic dental services will be covered when they are considered medically necessary and cost effective but may be subject to prior authorization by UFC or MHP, or AHCCCS Division of Fee-for-Service Management for FFS members. Covered Services for Children Although the AHCCCS Dental Periodicity Schedule identifies when routine referrals begin, the PCP may refer EPSDT members for a dental assessment at an earlier age if oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment by a dental professional. In addition to PCP referrals, EPSDT members are allowed self-referral to a dentist who is included in the Health Plan provider network. AHCCCS members 0 through 20 years of age (UFC or MHP) Non-Covered Services for Children 1. Services determined to be experimental or provided for the purpose of research 2. Services or items furnished solely for cosmetic purposes 3. Any new service or procedure started before the member ceased to be enrolled with a AHCCCS plan (MHP or UFC). Adult Dental Services for AHCCCS Members Dental coverage for AHCCCS members 21 years and older is limited to the following: Emergency dental services DENTAL CARE SERVICES 12.2

134 REVISED 10/2014 Pre-transplant dental services Emergency Dental Services AHCCCS will cover emergency dental services for infection in mouth, or pain in tooth, or jaw for members 21 years and older. The service must be related to a treatment of a medical condition. Pre-Transplant Dental Services Dental diagnosis and elimination of oral infection prior to transplantation of organs or tissue is a covered service only after the member has been established as an appropriate candidate for transplantation. Non-Covered Services for Adults 1. All services not directly related to acute emergency or pre-transplant 2. Medically necessary dentures are no longer a covered benefit for adults 3. Any new service or procedure started before the member became ineligible with an AHCCCS plan. (Procedures involving those teeth upon which treatment has been started but not yet completed at the time eligibility is lost, must be completed by the Subcontractor). DENTAL CARE SERVICES 12.3

135 SECTION 13

136 REVISED 10/2014 EPSDT Services University Family Care, (UFC) and Maricopa Health Plan, (MHP) providers are required to provide comprehensive health care and preventive services to eligible members. Those members are AHCCCS and children under the age of 21. These services are offered under the Early Periodic Screening Diagnosis and Treatment (EPSDT) program, which is governed by Federal and State regulations and community standards of practice. EPSDT-aged members are assigned to providers who are trained on and who use AHCCCS approved developmental screening tools. Requirements MHP and UFC providers are required to comply with the following: Provide early and periodic screening, diagnosis, and treatment services for all assigned members from birth through twenty years of age. All services must be provided according to the AHCCCS Periodicity Schedule and community standards of practice. The service intervals represent minimum requirements, and any services determined by the primary care provider, to be medically necessary, must be provided regardless of the interval. Document services provided and compliance with AHCCCS standards on the AHCCCS standardized EPSDT Tracking Forms. MHP AND UFC providers should send a copy to the Health Plan EPSDT Department at 2701 E. Elvira Road, Tucson AZ If the member chooses not to participate in the EPSDT program, document the decision in the medical record. Coordinate care and refer eligible members to Children s Rehabilitative Services (CRS).. The Health Plan can assist in the referral process if the need is identified on the EPSDT tracking form. Schedule the next EPSDT appointment at the time of the current visit for children 24 months of age and younger.fax No Show Logs to the Health Plan Outreach Department at (520) or Outreach@uahealth.com on a weekly basis to enable the Outreach Department will contact members with a pattern of missed appointments. Comply with the State requirements to report all childhood immunizations to Arizona Department of Health Services (ADHS)/Arizona State Immunization Information System (ASIIS). EPSDT SERVICES 13.0

137 REVISED 10/2014 Agree to participate in an annual review, which may include on-site visits and medical record audits. Report all EPSDT encounters on CMS 1500 claim forms, using Preventive Medicine Codes with the appropriate modifier. Screening and Physical Exam Requirements A comprehensive health and developmental history (including growth, developmental screening, physical, nutritional, and behavioral health assessments). Nutritional Assessment provided by a PCP: Nutritional assessments are conducted to assist EPSDT members whose health status may improve with nutritional intervention. Payment for the assessment of nutritional status provided by the member s PCP is part of the EPSDT screening. Payment for nutritional assessments is included in the EPSDT visit and is not a separately billable service. Behavioral Health Screening and Services provided by a PCP: Behavioral health services are covered for members eligible for EPSDT. PCPs may treat Attention Deficit Hyperactivity Disorder, depression and anxiety. All other behavioral health conditions must be referred to the Regional Behavioral Health Authority. PCPs that elect to prescribe medications to treat ADHD depression, or anxiety disorders must complete an annual assessment of the member s behavioral health condition and treatment plan. Payment for behavioral health screenings and assessments are included as part of an EPSDT visit and are not separately billable services. A comprehensive unclothed physical examination: Appropriate immunizations according to age and health history: Administration of immunizations may be billed in addition to the EPSDT visit using the CPT-4 code appropriate for the immunization with an SL modifier. Providers must be registered as Vaccines for Children providers and VFC vaccines must be used. Immunizations must be reported at least monthly to the Arizona Department of Health Services. Immunizations must be provided according to the Recommended Childhood Immunization Schedule. Reported immunizations are held in a central database known as the Arizona State Immunization Information System (ASIIS).Providers can access this database to obtain complete and accurate immunization records at Laboratory tests (including blood lead screening and assessment appropriate to age and risk, anemia testing and diagnostic testing for, sickle cell trait if a child has been previously tested with sickle cell, preparation or hemoglobin solubility test). EPSDT SERVICES 13.1

138 REVISED 10/2014 EPSDT covers blood lead screening. All children are considered at risk and must be screened for lead poisoning. All children must receive a screening blood lead test at 12 and 24 months of age. Children between 36 and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. A blood lead test result, equal to or greater than 10 micrograms of lead per deciliter of whole blood obtained by capillary specimen or finger stick, must be confirmed using a venous blood sample. A verbal blood lead screening risk assessment must be completed at each EPSDT visit for children six through 72 months of age to assist in determining risk. Providers must report blood lead levels equal to or greater than ten micrograms of lead per deciliter of whole blood to ADHS. Hemaglobin/Hematocrit Must be performed according to periodicity schedule. Sickle cell trait Screening should be done when indicated. Tuberculosis Screening Must be performed on children who are at risk at intervals indicated in the attached EPSDT Periodicity Schedule. Health Education, counseling and chronic disease self-management. These are not considered separately billable services and are considered part of the EPSDT visit payment. Oral health screening intended to identify oral pathology, including tooth decay and/ or oral lesions, and the application of fluoride varnish conducted by a physician, physician s assistant or nurse practitioner.. Application of fluoride varnish may be billed separately from EPSDT using the HCPCS code D1206. Fluoride varnish is limited in a primary care provider s office to once every six months, during an EPSDT visit for children who have reached six months of age with at least one tooth erupted, with recurrent applications up to two years of age. Referrals to a dentist should be encouraged by one (1) year of age. AHCCCS members are assigned to a dental home within the MHP or UFC provider network. Covered dental services include emergency, preventive and therapeutic treatment. The dentist will perform an evaluation on members and report findings and treatment to the PCP. The PCP will include documented dental findings and treatment in the member s medical record. Vision, hearing and speech screenings are covered during an EPSDT visit. EPSDT covers eye examinations as appropriate to age according to the AHCCCS Periodicity Schedule and as medically necessary using standardized visual tools. Payment for vision and hearing exams, or any other procedure that may be interpreted as fulfilling the vision and hearing requirements provided in a PCP s office during an EPSDT visit are considered part of the EPSDT visit and are not separately billable services. EPSDT SERVICES 13.2

139 REVISED 10/2014 Developmental Screening Tools: AHCCCS approved developmental screening tools should be utilized for developmental screening by all contracted PCPs who care for EPSDT-age members. PCPs must be trained in the use and scoring of the developmental screening tools, as indicated by the American Academy of Pediatrics. 1. The developmental screening should be completed for all EPSDT members from birth through age three years of age during the 9, 18, and 24 month EPSDT visits. 2. A copy of the developmental screening tool must be kept in the medical record 3. Use of AHCCCS approved developmental screening tools may be billed separately using CPT-4 code for a 9 month, 18 month and 24 month visit when the developmental screening tool is used. 4. A developmental screening CPT code with EP modifier must be listed in addition to the preventative medicine CPT code. 5. To receive the developmental screening tool payment, the modifier EP must be added to the For claims to be eligible for payment, the provider must have satisfied the training requirements, the claim must be a 9, 18 or 24 month EPSDT visit, and an AHCCCS approved developmental screening tool must have been completed. 7. Providers should send verification of training completion directly to the Council for Affordable Quality Healthcare (CAQH) 8. AHCCCS approved developmental screening tools include: The Parent s Evaluation of Developmental Status (PEDS) tool which may be obtained from or Ages and Stages Questionnaire (ASQ) tool which may be obtained from The Modified Checklist for Autism in Toddlers (MCHAT) may be used only as a screening tool by a primary care provider, for members month of age, to screen for autism when medically indicated. EPSDT SERVICES 13.3

140 REVISED 10/2014 EPSDT SERVICES 13.4

141 REVISED 10/2014 = EPSDT SERVICES 13.5

142 REVISED 10/2014 EPSDT SERVICES 13.6

143 REVISED 10/2014 EPSDT SERVICES 13.7

144 SECTION 14

145 REVISED 10/2014 Arizona Early Intervention Program (AzEIP) Arizona Early Intervention Program (AzEIP) is the collective effort of private and public programs and community members. AzEIP provides services such as Speech, Occupational and Physical Therapy and other supports to families and children, ages 0-3, at risk of or who have a developmental delay. The Health Plan strives to remove barriers to the implementation of EPSDT services for our youngest AHCCCS members who are 0-3 years of age in order to ensure that early developmental opportunities are maximized. Call your Provider Representative or Maternal Child Health for more information AzEIP Service Coordination Requirements: When the primary care physician (PCP) identifies a member under the age of 21 as having a potential developmental delay, he/she may arrange an evaluation with an innetwork provider and prior authorization is not required. Should the PCP arrange an evaluation with an out of network provider, prior authorization is required and medical documentation and continuity of care need, if applicable, is required. Based on the evaluation, medically necessary services can be arranged by the PCP with an in-network provider and prior authorization may not be required. Prior authorization is required for out-of-network providers. Regardless of member s AzEIP status, the Health Plan will pay for medically necessary services for EPSDT members. According to the AHCCCS/AzEIP agreement, when services are identified for an AzEIP eligible child s Individual Family Service Plan (IFSP), the Health Plan will fax the PCP the AzEIP EPSDT Service Request Form for approval or denial of the services within two (2) days of receiving it from AzEIP. THE PCP MUST RETURN THE AzEIP EPSDT SERVICE REQUEST FORM WITHIN FIVE (5) DAYS OF RECEIPT. According to Federal law, AzEIP service implementation is required within 45 days of the IFSP origination date. The AzEIP provider and coordinator, parent or guardian and PCP are provided the completed AzEIP Request Form for EPSDT services by the Health Plan. The denied or the approved type(s) of therapy, duration and frequency is included on the form. AZEIP 14.0

146 REVISED 10/2014 FAX AzEIP Service Request Upon notification of an AzEIP eligible member, the Maternal Child Health Department will fax the following to the member s PCP AZEIP 14.1

147 SECTION 15

148 REVISED 10/2014 Children s Rehabilitative Services (CRS) Children s Rehabilitative Services (CRS) is a State program administered by the Arizona Health Care Cost Containment System (AHCCCS). Federal matching funds are available for the provision of services to Title XIX eligible children enrolled in an AHCCCS health plan. The purpose of CRS is to provide rehabilitative medical care to children with special health care needs, utilizing a multidisciplinary approach that provides medical treatment, rehabilitation, and related support services. Children must be AHCCCS enrolled, completed the CRS application and meet the medical eligibility criteria in order to receive CRS Services. CRS members receive the same AHCCCS covered services as non-crs AHCCCS members; however, services to treat CRS conditions for Acute Care members may only be provided to children enrolled with CRS. CRS members will be able to receive care in the community or in multispecialty interdisciplinary clinics that bring all specialties together in one location. Thus the child receives all treatment for their CRS condition and all medical/behavioral health services in a coordinated system. AHCCCS members are eligible for CRS services without additional fees. A. Eligibility Requirements: Arizona resident Under 21 years of age Have a physical, chronic illness or condition that is potentially disabling and the condition requires active treatment. (See attachment for Covered Conditions) Title XlX (Medicaid/AHCCCS) enrollment B. Referral Process: A PCP and/or a Specialist must perform the diagnostic work-up for the CRS eligible diagnosis A PCP and/or a Specialist as well as a family member can initiate the application form A member identified by nurse reviewer or case manager can be redirected to CRS when they have a CRS diagnosis and are not enrolled CRS 15.0

149 REVISED 10/2014 If a child with a CRS eligible diagnosis is identified while an inpatient, social services staff may initiate a referral to CRS. The Health Plan Utilization Management Nurse may also identify a CRS eligible child during an inpatient review and request an application be initiated. Medical records will be requested from the PCP and/or specialist provider to support the potential CRS diagnosis. Parents can choose to not enroll their child into CRS however they may be responsible for any costs associated for the treatment of the child s CRS condition. Parents can choose to not enroll their child into CRS however they may be responsible for any costs associated for the treatment of the child s CRS condition. The CRS application (see attachment for English or Spanish) must be printed, filled out, and mailed or faxed with medical documentation that supports the potential CRS condition to the CRS Enrollment Unit. AHCCCS/Children s Rehabilitative Services ATTENTION: CRS Enrollment Unit 801 East Jefferson MD 3500 Phoenix, Arizona Fax: Phone: or , Monday Friday 8:00 AM to 5:00 PM (excluding weekends and holidays). The Case Managers at UAHP are available to assist with the CRS application process. When the child becomes eligible for CRS United Healthcare Community Plan CRS becomes the AHCCCS health plan that manages the care for CRS conditions, acute health and behavioral health services. CRS 15.1

150 REVISED 10/2014 APPENDIX CRS 15.2

151 Effective 10/1/13 R Medical Eligibility The following lists identify those medical condition(s) that do qualify for the CRS program as well as those that do not qualify for the CRS program. The covered condition(s) list is all inclusive. The list of condition(s) not covered by CRS is not an all-inclusive list: 1. Cardiovascular System a. CRS condition(s): i. Congenital heart defect, ii. Cardiomyopathy, iii. Valvular disorder, iv. Arrhythmia, v. Conduction defect, vi. Rheumatic heart disease, vii. Renal vascular hypertension, viii. Arteriovenous fistula, and ix. Kawasaki disease with coronary artery aneurysm; b. Condition(s) not medically eligible for CRS: i. Essential hypertension; ii. Premature atrial, nodal or ventricular contractions that are of no hemodynamic significance; iii. Arteriovenous fistula that is not expected to cause cardiac failure or threaten loss of function; and iv. Benign heart murmur; 2. Endocrine system: a. CRS condition(s): i. Hypothyroidism, ii. Hyperthyroidism, iii. Adrenogenital syndrome,

152 iv. Addison's disease, v. Hypoparathyroidism, vi. Hyperparathyroidism, vii. Diabetes insipidus, viii. Cystic fibrosis, and ix. Panhypopituitarism; b. Condition(s) not medically eligible for CRS: i. Diabetes mellitus, ii. Isolated growth hormone deficiency, iii. Hypopituitarism encountered in the acute treatment of a malignancy, and iv. Precocious puberty; 3. Genitourinary system medical condition(s): a. CRS condition(s): i. Vesicoureteral reflux, with at least mild or moderate dilatation and tortuosity of the ureter and mild or moderate dilatation of renal pelvis; ii. Ectopic ureter; iii. Ambiguous genitalia; iv. Ureteral stricture; v. Complex hypospadias; vi. Hydronephrosis; vii. Deformity and dysfunction of the genitourinary system secondary to trauma after the acute phase of the trauma has passed; viii. Pyelonephritis when treatment with drugs or biologicals has failed to cure or ameliorate and surgical intervention is required; ix. Multicystic dysplastic kidneys; x. Nephritis associated with lupus erythematosis; and xi. Hydrocele associated with a ventriculo-peritoneal shunt; b. Condition(s) not medically eligible for CRS:

153 i. Nephritis, infectious or noninfectious; ii. Nephrosis; iii. Undescended testicle; iv. Phimosis; v. Hydrocele not associated with a ventriculo-peritoneal shunt; vi. Enuresis; vii. Meatal stenosis; and viii.hypospadias involving isolated glandular or coronal aberrant location of the urethralmeatus without curvature of the penis; 4. Ear, nose, or throat medical condition(s): a. CRS condition(s): i. Cholesteatoma; ii. Chronic mastoiditis; iii. Deformity and dysfunction of the ear, nose, or throat secondary to trauma, after the acute phase of the trauma has passed; iv. Neurosensory hearing loss; v. Congenital malformation; vi. Significant conductive hearing loss due to an anomaly in one ear or both ears equal to or greater than a pure tone average of 30 decibels, that despite medical treatment, requires a hearing aid; vii. Craniofacial anomaly that requires treatment by more than one CRS provider; and viii. Microtia that requires multiple surgical interventions; b. Condition(s) not medically eligible for CRS i. Tonsillitis, ii. Adenoiditis, iii. Hypertrophic lingual frenum, iv. Nasal polyp, v. Cranial or temporal mandibular joint syndrome, vi. Simple deviated nasal septum,

154 vii. Recurrent otitis media, viii. Obstructive apnea, ix. Acute perforation of the tympanic membrane, x. Sinusitis, xi. Isolated preauricular tag or pit, and xii. Uncontrolled salivation; 5. Musculoskeletal system medical condition(s): a. CRS condition(s): i. Achondroplasia; ii. Hypochondroplasia; iii. Diastrophic dysplasia; iv. Chondrodysplasia; v. Chondroectodermal dysplasia; vi. Spondyloepiphyseal dysplasia; vii. Metaphyseal and epiphyseal dysplasia; viii. Larsen syndrome; ix. Fibrous dysplasia; x. Osteogenesis imperfecta; xi. Rickets; xii. Enchondromatosis; xiii. Juvenile rheumatoid arthritis; xiv. Seronegative spondyloarthropathy; xv. Orthopedic complications of hemophilia; xvi. Myopathy; xvii. Muscular dystrophy; xviii. Myoneural disorder; xix. Arthrogryposis; xx. Spinal muscle atrophy; xxi. Polyneuropathy; xxii. Chronic stage bone infection;

155 xxiii. Chronic stage joint infection; xxiv. Upper limb amputation; xxv. Syndactyly; xxvi. Kyphosis; xxvii. Scoliosis; xxviii. Congenital spinal deformity; xxix. Congenital or developmental cervical spine abnormality; xxx. Hip dysplasia; xxxi. Slipped capital femoral epiphysis; xxxii. Femoral anteversion and tibial torsion: xxxiii. Legg-Calve-Perthes disease; xxxiv. Lower limb amputation, including prosthetic sequelae of cancer; xxxv. Metatarsus adductus; xxxvi. Leg length discrepancy of five centimeters or more; xxxvii. Metatarsus primus varus; xxxviii. Dorsal bunions; xxxix. Collagen vascular disease; xxxx. Benign bone tumor; xxxxi. Deformity and dysfunction secondary to musculoskeletal trauma; xxxxii. Osgood Schlatter's disease that requires surgical intervention; and xxxxiii. Complicated flat foot, such as rigid foot, unstable subtalar joint, or significant calcaneus deformity b. Condition(s) not medically eligible for CRS i. Ingrown toenail; ii. Back pain with no structural abnormality; iii. Ganglion cyst; iv. Flat foot other than complicated flat foot; v. Fracture; vi. Popliteal cyst; vii. Simple bunion; and

156 viii. Carpal tunnel syndrome; ix. Deformity and dysfunction secondary to trauma or injury if: 1. Three months have not passed since the trauma or injury; and 2. Leg length discrepancy of less than five centimeters at skeletal maturity. 6. Gastrointestinal system medical condition(s): a. CRS condition(s): i. Tracheoesophageal fistula; ii. Anorectal atresia; iii. Hirschsprung's disease; iv. Diaphragmatic hernia; v. Gastroesophageal reflux that has failed treatment with drugs or biologicals and requires surgery; vi. Deformity and dysfunction of the gastrointestinal system secondary to trauma, after the acute phase of the trauma has passed; vii. Biliary atresia; viii.congenital atresia, stenosis, fistula, or rotational abnormalities of the gastrointestinal tract; ix. Cleft lip; x. Cleft palate; xi. Omphalocele; and xii. Gastroschisis; b. Condition(s) not medically eligible for CRS i. Malabsorption syndrome, also known as short bowel syndrome, ii. Crohn's disease, iii. Hernia other than a diaphragmatic hernia, iv. Ulcer disease, v. Ulcerative colitis, vi. Intestinal polyp,

157 vii. Pyloric stenosis, and viii. Celiac disease; 7. Nervous system medical condition(s): a. CRS condition(s): i. Uncontrolled seizure disorder, in which there have been more than two seizures with documented adequate blood levels of one or more medications; ii. Cerebral palsy; iii. Muscular dystrophy or other myopathy; iv. Myoneural disorder; v. Neuropathy, hereditary or idiopathic; vi. Central nervous system degenerative disease; vii. Central nervous system malformation or structural abnormality; viii. Hydrocephalus; ix. Craniosynostosis of a sagittal suture, a unilateral coronal suture, or multiple sutures in a child less than 18 months of age; x. Myasthenia gravis, congenital or acquired; xi. Benign intracranial tumor; xii. Benign intraspinal tumor; xiii. Tourette's syndrome; xiv. Residual dysfunction after resolution of an acute phase of vascular accident, inflammatory condition, or infection of the central nervous system; xv. Myelomeningocele, also known as spina bifida; xvi. Neurofibromatosis; xvii. Deformity and dysfunction secondary to trauma in an individual; xviii. Residual dysfunction after acute phase of near drowning; and xix. Residual dysfunction after acute phase of spinal cord injury; b. Condition(s) not medically eligible for CRS i. Headaches; ii. Central apnea secondary to prematurity;

158 iii. Near sudden infant death syndrome; iv. Febrile seizures; v. Occipital plagiocephaly, either positional or secondary to lambdoidal synostosis; vi. Trigonocephaly secondary to isolated metopic synostosis; vii. Spina bifida occulta; viii. Near drowning in the acute phase; and ix. Spinal cord injury in the acute phase; x. Chronic vegetative state; 8. Ophthalmology: a. CRS condition(s): i. Cataracts; ii. Glaucoma; iii. Disorder of the optic nerve; iv. Non-malignant enucleation and post-enucleation reconstruction; v. Retinopathy of prematurity; and vi. Disorder of the iris, ciliary bodies, retina, lens, or cornea; b. Condition(s) not medically eligible for CRS i. Simple refraction error, ii. Astigmatism, iii. Strabismus, and iv. Ptosis; 9. Respiratory system medical condition(s): a. CRS condition(s): i. Anomaly of the larynx, trachea, or bronchi that requires surgery; and ii. Nonmalignant obstructive lesion of the larynx, trachea, or bronchi; b. Condition(s) not medically eligible for CRS:

159 i. Respiratory distress syndrome, ii. Asthma, iii. Allergies, iv. Bronchopulmonary dysplasia, v. Emphysema, vi. Chronic obstructive pulmonary disease, and vii. Acute or chronic respiratory condition requiring venting for the neuromuscularly impaired; 10. Integumentary system medical condition(s): a. CRS condition(s): i. A craniofacial anomaly that is functionally limiting, ii. A burn scar that is functionally limiting, iii. A hemangioma that is functionally limiting, iv. Cystic hygroma, and v. Complicated nevi requiring multiple procedures; b. Condition(s) not medically eligible for CRS: i. A deformity that is not functionally limiting, ii. A burn other than a burn scar that is functionally limiting; iii. Simple nevi, iv. Skin tag, v. Port wine stain, vi. Sebaceous cyst, vii. Isolated malocclusion that is not functionally limiting, viii. Pilonidal cyst, ix. Ectodermal dysplasia, and x. A craniofacial anomaly that is not functionally limiting; 11. Metabolic CRS condition(s) : i. Amino acid or organic acidopathy,

160 ii. Inborn error of metabolism, iii. Storage disease, iv. Phenylketonuria, v. Homocystinuria, vi. Maple syrup urine disease, vii. Biotinidase deficiency, 12. Hemoglobinopathies CRS condition(s): a. Sickle cell anemia, b. Thalassemia. 13. Medical/behavioral condition(s) which are not medically eligible for CRS: a. Allergies; b. Anorexia nervosa or obesity; c. Autism; d. Cancer; e. Depression or other mental illness; f. Developmental delay; g. Dyslexia or other learning disabilities; h. Failure to thrive; i. Hyperactivity; j. Attention deficit disorder; and k. Immunodeficiency, such as AIDS and HIV.

161 AHCCCS is Arizona s Medical Assistance Program (Medicaid) Application for Enrollment into AHCCCS Children s Rehabilitative Services Please return application and all required documentation to: Fax: Mail: AHCCCS-CRS Attn: CRS Enrollment 801 E. Jefferson St. MD 3500 Phoenix, AZ For questions contact the CRS Enrollment Unit at: or SECTION 1: APPLICANT INFORMATION Does the applicant have AHCCCS? YES NO If yes: AHCCCS ID Number: AHCCCS Health Plan: If no: has an application been submitted? YES NO Child s First Name M.I. Child s Last Name Date of Birth Parent/Representative s First Name Age Gender: Male Female Parent/Representative s Last Name Child s Social Security Number Relationship to Child: Parent Foster Parent Legal Guardian Representative Other: Parent/Representative s Mailing Address City State Zip Code Phone Number Alternate Phone Number Address Name of Child s Primary Care Provider Address, City, State, Zip Code Phone Number Address List Primary Diagnosis: Please send medical records with this form Planned Treatment: SECTION 2: REFERRAL INFORMATION The individual making the referral verifies that the child s parent/representative listed in Section 1 has been notified of this referral. If expedited request, please contact AHCCCS CRS Enrollment. Name of Person Making Referral (First, Last) Address, City, State, Zip Code Phone Number Relationship to Child: Parent Legal Guardian Provider Social Worker Self AHCCCS Contractor Other: SECTION 3: AUTHORIZATION TO RELEASE INFORMATION (TO BE COMPLETED BY PARENT/REPRESENTATIVE) AHCCCS cannot share information about a child s CRS enrollment without signed consent from the parent/representative listed in Section 1. Please provide the medical provider or referral source contact information and sign below to authorize AHCCCS to release information about the AHCCCS CRS decision. Medical Provider/Referral Source Name Phone Number Address Mailing Address City State Zip Code I (full name of parent/representative listed in Section 1) give my consent to the Arizona Health Care Cost Containment System s (AHCCCS) Children s Rehabilitative Services (CRS) to share any information with the above named provider relating to the receipt of (full name of child) CRS application, application processing time, and the final CRS decision. Signature of Parent/Representative Date <<Form Number>>

162 AHCCCS is Arizona s Medical Assistance Program (Medicaid) Solicitud de Inscripción en los Servicios de Rehabilitación de Menores de Envíe la solicitud y toda la documentación requerida a: Fax: Correo: AHCCCS-CRS Attn: CRS Enrollment 801 E. Jefferson St. MD 3500 Phoenix, AZ Para mayores informes llame a la CRS Enrollment Unit al: o SECCIÓN 1: DATOS DEL SOLICITANTE Tiene el solicitante AHCCCS? SÍ NO Si tiene, el número de ID de AHCCCS El Plan de Salud AHCCCS: Si no tiene, ha presentado solicitud? SÍ NO Nombre del menor Inicial Apellido del menor Fecha de nacimiento Edad Sexo: Hombre Mujer No. de Seguro Social del menor Nombre del Padre/Representante Apellido del Padre/Representante Relación con el menor: Padre Padre de acogida Tutor legítimo Representante Otro: Dirección del Padre/Representante Ciudad Estado Código Postal Número de teléfono Número de teléfono alterno Correo electrónico Nombre del doctor principal del menor Dirección, Ciudad, Estado, Código Postal Número de teléfono Correo electrónico Ponga la diagnosis primaria. Envíe los informes médicos con este cuestionario El tratamiento programado: SECCIÓN 2: DATOS DEL REFERIDO La persona que hace el referido verifica que se le ha notificado al padre/representante del menor incluido en la Sección 1 de este referido. Si la petición es acelerada, llame a Inscripciones de AHCCCS CRS. Nombre de la persona que manda el referido (nombre Dirección, Ciudad, Estado, Código Postal Número de teléfono de pila, apellido) Relación con el menor: Padre Tutor legítimo Doctor Trabajador Social Propio AHCCCS Contratista Otro: SECCIÓN 3: AUTORIZACIÓN DE PROPORCIONAR INFORMACIÓN(A LLENARSE POR EL PADRE/REPRESENTANTE) AHCCCS no podrá revelar información acerca de la inscripción del menor sin el consentimiento firmado del padre/representante incluido en la Sección 1. Ponga los datos del doctor o la fuente del referido y firme abajo para autorizar a AHCCCS a dar a conocer la información acerca de la decisión de AHCCCS CRS. Nombre del Doctor/Fuente del Referido Número de teléfono Correo electrónico Dirección Ciudad Estado Código Postal Yo (nombre completo del padre/representante incluido en la Sección 1) doy mi consentimiento al Arizona Health Care Cost Containment System s (AHCCCS) Children s Rehabilitative Services (CRS) para compartir cualquier información con el doctor mencionado arriba en relación al recibo de la solicitud, el tiempo para tramitar la solicitud, y la decisión final de CRS para (nombre completo del menor). Firma del Padre/Representante Fecha <<Form Number>>

163 SECTION 16

164 REVISED 10/2014 Maternity and Family Planning Services University of Arizona Health Plans requires that quality family planning, pre-pregnancy and postpartum services are available to every member. The continuum of care is a critical component in the good health of the mother and child. Primary Care Obstetricians are responsible for the provision of comprehensive care to meet primary and obstetrical needs. Members may select or be assigned to a PCP specializing in obstetrics while they are pregnant. University Family Care, Maricopa Health Plan, University Care Advantage and Maricopa Care Advantage cover a full continuum of family planning and maternity care services for all eligible, enrolled members of childbearing age. University Marketplace Health Plan benefits are plan specific and cover medically necessary services please verify benefits with eligibility through our Customer Care Center. Maternity care services include, but are not limited to, identification of pregnancy, medically necessary prenatal services, the treatment of pregnancy related conditions, labor and delivery services and postpartum care. UAHP benefits provide a hospital stay of up to 48 hours after vaginal delivery, and up to 96 hours after Cesarean section, unless, due to medical necessity, an extended stay is needed. However, for payment purposes, inpatient limits will apply. In addition, related services such as outreach, education and family planning services are provided when appropriate. Care Coordination The Health Plan offers a multi-disciplinary program to assist providers in managing the care of pregnant members who are at risk because of medical conditions, social circumstances, or noncompliant behaviors. Obstetrical care coordination links expectant mothers with appropriate community resources such as WIC, parenting classes, shelters, and substance abuse counseling. Care Managers provide support and promote compliance with prenatal appointments and prescribed medical regimens (see Quick Reference Guide). The Health Plan places critical importance on good prenatal health. The Maternal Child Health Department at the Health Plan is available to assist you in coordinating obstetrical care services: High Risk OB care authorization Referrals to perinatology and special services MATERNITY AND FAMILY PLANNING SERVICES 16.0

165 REVISED 10/2014 Developing effective outreach Case Management for identified high-risk members MATERNITY CARE PROGRAM MINIMUM REQUIREMENTS Covered Services Covered services for UAHP maternity members: Preconception counseling Routine and medically necessary prenatal care Treatment of pregnancy related conditions Intrapartum and postpartum care Transportation when needed to assist members in accessing maternity care. Education UAHP provides pregnant members and their partners with childbirth classes. Members should register before the sixth month of pregnancy. Individuals may call the Maternal and Child Health department (see Quick Reference Guide). Provider Standards The Health Plan providers are required to comply with the following standards in the provision of maternity care services to pregnant members: Adhere to the most current standards of care of the American College of Obstetrics and Gynecology, including the use of a standardized risk assessment tool and ongoing risk assessment. Submit notification with Prior Authorization TOB form (see Section 22, Forms), to initiate maternity care services at the first and no later than the second prenatal visit. A complete Prior Authorization TOB form notification will include estimated date of conception (EDC), gravida /para (GP), risk status information and place of delivery. Educate members about health behaviors during pregnancy including: proper nutrition, adverse effects of smoking and smoking cessation, alcohol and illicit drugs on the fetus, and the physiology of pregnancy. MATERNITY AND FAMILY PLANNING SERVICES 16.1

166 REVISED 10/2014 Provide information regarding the process of labor and delivery, breast-feeding, family planning and preconception counseling, and infant care. Inform all pregnant women of voluntary prenatal HIV testing and the availability of counseling and treatment if the test is positive. Refer and facilitate registration of members to childbirth education classes. Educate members about Family Planning Extension services. Refer members under the age of 21 years for yearly diagnostic, preventive and treatment dental services (EPSDT) Mainstream AHCCCS members into his/her practice. Notify women that in the event they lose eligibility, they may contact the Arizona Department of Health Services toll free Hot Line at (800) for referrals to low or no cost services, such as family planning and other community resources. Provide patient data as requested/required by the Health Plan. Comply with all the Health Plan reporting requirements and participate in required audits. Refer members who lose AHCCCS eligibility to low/no cost agencies for family planning services. Refer members to other agencies offering support services such as Women, Infants and Children (WIC). Perform EPSDT screening and referral to dentists on members through the age of 20 years. MATERNITY APPOINTMENT STANDARDS Prenatal Appointments Provide initial and routine prenatal care appointments in compliance with AHCCCS standards: Initial prenatal appointments for enrolled pregnant members must be provided as follows: First trimester - within 14 days of request Second trimester - within 7 days of request Third trimester - within 3 days of request MATERNITY AND FAMILY PLANNING SERVICES 16.2

167 REVISED 10/2014 High risk pregnancy within 3 days of identification of high risk by PCP or maternity care provider or immediately if an emergency exists Follow-up prenatal care appointments for pregnant members must be provided as follows: First 28 weeks - every 4 weeks weeks - every 2 to 3 weeks After the 36th week - weekly until delivery High Risk maternity care members return visits intervals must be scheduled appropriately to their individual needs. Home Uterine Monitoring (HUM) UFC and MHP cover home uterine monitoring technology for members with premature labor contractions before 35 weeks as an alternative to hospitalization. At least one of the following conditions must be present to receive authorization for HUM: Multiple gestations, particularly triplets or quadruplets One or more births before 35 weeks Hospitalization for premature labor before 35 weeks with a documented change in the cervix, controlled by tocolysis and ready to be discharged for bed rest at home Loss of Coverage During Pregnancy Sometimes members lose AHCCCS eligibility during pregnancy. Although members are responsible for their own eligibility, providers are encouraged to notify the Health Plan. We will assist in coordinating or resolving eligibility and enrollment issues so pregnancy care may continue without lapse in coverage. To report concerns about eligibility contact the Maternal Child Health department (see Quick Reference Guide). Perinatology Care The Health Plan may approve assignment or transfer of a pregnant woman to a perinatologist for Total OB Care for the following conditions: MATERNITY AND FAMILY PLANNING SERVICES 16.3

168 REVISED 10/2014 Insulin dependent diabetes in non-pregnant State Chronic renal disease or insufficiency Epilepsy requiring medications Chronic hypertension requiring medications A history of two or more preterm deliveries at 32 weeks or less Malignancy Current diagnosis of highly probable IUGR Rupture of Membranes (ROM) before 32 weeks Triplets or more Potential need for cerclage Diagnosis of Lupus Erthematous Twin pregnancy with discordant growth Positive HIV mother Polyhydramnios Oligohydramnios Pregnancy Termination University of Arizona Health Plan covers pregnancy termination when it is the result of rape, incest, or in circumstances as determined by the attending provider, in collaboration with the Health Plan Medical Director or the AHCCCS Chief Medical Officer or designee, when one of the following conditions is present: 1. The member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would, as certified by a provider, place the member in danger of death unless the pregnancy is terminated. 2. The pregnancy is a result of rape or incest. (This standard applies only to categorically eligible female members). 3. The pregnancy termination is medically necessary to prevent death, treat/cure disease, and ameliorate disabilities or other adverse health conditions; and/or prolong life. Conditions, Limitations and Exclusions The attending provider must acknowledge that a pregnancy termination has been determined medically necessary by submitting the Certificate of Medical Necessity for Pregnancy Termination in this section. The form must be submitted with the Prior Authorization request form to obtain the Health Plan Medical Director s signature. The certificate must certify that in the provider s professional judgment, one or more of the above criteria have been met. MATERNITY AND FAMILY PLANNING SERVICES 16.4

169 REVISED 10/2014 The attending provider must also provide documentation that demonstrates the member has: 1. Been informed about alternatives to the pregnancy termination; and 2. Not responded to the appropriate treatment for the medical problem contributing to the need for the pregnancy termination; or the pregnancy may exacerbate the medical problem; or documentation to support why treatment is not indicated. If the member is pregnant beyond an estimated gestational age of 24 weeks, a second opinion from an independent provider with the appropriate specialty must be submitted with the Certificate of Medical Necessity for Pregnancy Termination. The independent provider must specify the medical need for a termination of pregnancy. These members must be individually case managed throughout this process of obtaining a second opinion and until considered to be in stable condition. If the pregnancy is the result of rape or incest, and the member is less than eighteen years of age, or is older than 18 years of age and considered an incapacitated adult, additional documentation must be included by the provider when submitting the Certificate of Medical Necessity for Pregnancy Termination. Pursuant to Federal and State law, the following information is required: 1. Documentation that the incident was reported to the proper authorities, including the name of the agency to which it was reported, the report number if available, and the date the report was filed. 2. The dated signature of the member s parent or legal guardian indicating approval of the pregnancy termination procedure. 3. Informed consent from an adult or a minor in the manner prescribed by law. To the extent written consent is required by law, a copy of the consent shall be provided with the Certificate of Medical Necessity for Pregnancy Termination. Prior Authorization Except in cases of medical emergencies, the provider must obtain prior authorization for all medically necessary pregnancy terminations from the Health Plan Medical Director or his/her designee. Prior authorization for fee-for-service members must be obtained from the AHCCCS Chief Medical Officer, or designee. A completed Certificate of Medical Necessity for Pregnancy Termination must be submitted with the request for prior authorization. The Health Plan Medical Director or AHCCCS Chief Medical Officer or designee will review the request and the Certificate, and expeditiously authorize the procedure if the documentation establishes the termination to be medically necessary. MATERNITY AND FAMILY PLANNING SERVICES 16.5

170 REVISED 10/2014 In cases of medical emergencies, the provider must submit all documentation of medical necessity to the Health Plan Medical Director and/or the AHCCCS Chief Medical Officer within two (2) working days of the date on which the termination procedure was performed. EXHIBIT ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM CERTIFICATE OF NECESSITY FOR PREGNANCY TERMINATION MATERNITY AND FAMILY PLANNING SERVICES 16.6

171 REVISED 10/2014 MATERNITY AND FAMILY PLANNING SERVICES 16.7

172 REVISED 10/2014 Family Planning Services Family Planning (FP) Services are available to UFC and MHP members who are eligible to receive health care coverage and are enrolled with a health plan and who voluntarily choose to delay or prevent pregnancy. Family Planning Services include covered medical, surgical, pharmacological and laboratory benefits specified in the matrix on page Covered services also include the provision of accurate information and counseling to allow members to make informed decisions about contraceptive method of their choice. The FP covered services for AHCCCS members includes: Contraceptive counseling, medication and supplies, including but not limited to, oral and injectable contraceptives, intrauterine devices, diaphragms, condoms, foams and suppositories. Associated medical and laboratory examinations including ultrasound studies related to family planning. Treatment of complications resulting from contraceptive use, including emergency treatment. Natural family planning education and referrals for same qualified health professionals. Post-coital emergency oral contraception within 72 hours after unprotected sexual intercourse. MATERNITY AND FAMILY PLANNING SERVICES 16.8

173 REVISED 10/2014 Services FP Covered Benefit Pregnancy screening Pharmaceuticals Screening and Treatment for Sexually Transmitted Disease Yes Yes Yes Sterilization Yes, including hysteroscopic tubal sterilizations for female and male members when AHCCCS eligibility requirements are met Note: member must be 21 years of age and consent must be signed at least 30 days prior to the procedure but less than 180 days. Pregnancy Termination and Hysterectomy Yes, per AHCCCS stipulations including Mifepristone or RU 486 See Section 9, Referral/Prior Authorization for detailed information. Benefit Matrix Members OC Depo IUD Dia Con Foam Supp EC Nat. Ster AB Infer WWE Pap STD STD tx Rubella Rubella Imm UFC/MH Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y MATERNITY AND FAMILY PLANNING SERVICES 16.9

174 REVISED 10/2014 MATERNITY AND FAMILY PLANNING SERVICES 16.10

175 REVISED 10/2014 Covered Services/Claims Requirements AHCCCS has defined the procedure codes that require an FP modifier and those services that may be billed without an FP modifier. Claims that do not follow these guidelines will be denied. Family Planning ACCEPTED diagnoses: CPT CODE PROCEDURE V25.01 Prescription of oral contraceptives V25.02 Initiation of other contraceptive measures V25.03 Encounter for emergency contraceptive counseling and prescription V25.09 Other general counseling and advise V25.1 Insertion of intrauterine contraceptive device V25.2 Sterilization V25.40 Contraceptive surveillance, unspecified V25.41 (Surveillance) Contraceptive pill V25.42 (Surveillance) Intrauterine Contraceptive device V25.43 (Surveillance) Implantable subdermal contraceptive V25.49 (Surveillance) Other contraceptive method V25.8 Other specified contraceptive management V25.9 Unspecified contraceptive management V45.51 (Presence of) Intrauterine contraceptive device V45.52 (Presence of) Subdermal contraceptive implant V45.59 (Presence of) Other contraceptive device MATERNITY AND FAMILY PLANNING SERVICES 16.11

176 REVISED 10/2014 Family Planning ACCEPTED ICD-9 Codes CPT CODE PROCEDURE Bilateral endoscopic ligation and crushing of fallopian tubes Bilateral endoscopic ligation and division of fallopian tubes Other bilateral ligation and crushing of fallopian tubes Other bilateral ligation and division of fallopian tubes Other bilateral destruction or occlusion of fallopian tubes 66.4 Total unilateral salpingectomy Removal of both fallopian tubes at the same operative session Removal of remaining fallopian tube Bilateral partial salpingectomy, not otherwise specified Other partial salpingectomy Insertion destruction or occlusion of fallopian tube 66.7 Insertion of intrauterine contraceptive device Insertion of vaginal diaphragm Removal of intrauterine contraceptive device Removal of vaginal diaphragm 63.7 Vasectomy and ligation of vas deferens Male sterilization procedure, not otherwise specified Ligation of vas deferens Ligation of spermatic cord Vasectomy The FP Modifier IS NOT REQUIRED for the following services CPT CODE PROCEDURE Norplant Removal Diaphragm or Cervical Cap Fitting with Instructions Insertion of Intrauterine Device Removal of Intrauterine Device 58600, 58605, Ligation of Tubes, Abdominal or Vaginal Occlusion of Fallopian Tubes by Device Laparoscopy, Surgical with Oviducts MATERNITY AND FAMILY PLANNING SERVICES 16.12

177 REVISED 10/ A4261 Anesthesia for intra-peritoneal procedures in lower abdomen, including laparoscopy; ligation of tubes Cervical Cap A4266 J1055 J1056 J7300 J7302 J7303 S4989 CPT CODE The FP Modifier IS NOT REQUIRED for the following services Diaphragm Injection 150mg Depo-Provera Injection 5mg/25mg Lunelle Intrauterine copper contraceptive PROCEDURE Levonorgestrel-releasing intrauterine contraceptive system, 52mg Contraceptive supply, hormone releasing vaginal ring, each Contraceptive intrauterine device (e.g., Progestacert IUD) including implants and supplies Vasectomy, unilateral or bilateral Ligation, (percutaneous) of vas deferens, unilateral or bilateral The FP Modifier IS REQUIRED for the following services CPT CODE PROCEDURE Office or other outpatient visit Office consultation Handling and/or conveyance of specimen Venipuncture Urinalysis by Dipstick Automated with microscopy Non-automated, without microscopy Urine Pregnancy Test Glucose; Blood, Reagent Strip Glucose; Tolerance Test (GTT) Gonadotropin, Chronic (hcg) 85014, Blood Count Syphilis Test Antibody; HTLV or HIV Antibody, Confirmatory Test Antibody; HIV MATERNITY AND FAMILY PLANNING SERVICES 16.13

178 REVISED 10/ Hepatitis B surface antibody (HbsAb) Antibody; Treponema Pallidum Hepatitis C Antibody Culture, Bacterial, Any Source Culture, Fungi, Definitive Identification of Each Fungus CPT CODE The FP Modifier IS REQUIRED for the following services Culture, Chlamydia PROCEDURE Smear; Primary Source; Special Stain for Inclusion Bodies Smear; Primary Source Virus Identification Infectious agent antigen detection by enzyme immunoassay, multiple step method, Hepatitis B antigen (HbsAg) Hepatitis B antigen (HbeAg) HIV 1 & HIV Cytopathology slides/smears, cervical or vaginal Cytopathology slides, cervical or vaginal Cytopathology Level II Surgical Pathology, Gross & Microscopic Examination MATERNITY AND FAMILY PLANNING SERVICES 16.14

179 SECTION 17

180 REVISED 10/2014 Pharmaceutical Services Listed below are general guidelines for pharmaceutical services: 1. Pharmaceutical services may be provided by a contracted inpatient or outpatient provider. 2. Pharmaceutical services shall be available during customary business hours and within reasonable travel distance of a member s residence. 3. Pharmaceutical services shall be covered if prescribed by the PCP, dentist, or specialty care provider (upon referral from the PCP). 4. The following limitations shall apply to pharmaceutical services: a. A medication dispensed by a Provider or Dentist is not covered, except in geographically remote areas where there is no participating pharmacy or when pharmacies are closed. b. A prescription in excess of a 30-day supply or a 100 unit dose is not covered unless: The medication is for chronic illness and is limited to no more than 100- day supply or 100-unit dose, whichever is greater The member will be out of the provider s service area for an extended period of time, not to exceed 100 days or 100-unit dose, whichever is greater The medication is prescribed for birth control and the prescription is limited to no more than a 100-day supply Prescriptions for narcotic medications are limited to a 30-day supply c. An over-the-counter medication may be covered for the Health Plan AHCCCS or SNP members only as an alternative to a prescription medication only if it is available and less costly than a prescribed medication. (OTC Meds are not a covered benefit under Medicare - they would only be covered under the AHCCCS plan) d. A prescription is not covered if filled or refilled in excess of the number specified, or if the initial prescription or refill is dispensed more than 1 year from the original prescribed order. PHARMACEUTICAL SERVICES 17.0

181 REVISED 10/2014 e. Approval by the authorized prescriber is required for all changes in, or additions to, an original prescription. The date of a prescription change shall be clearly indicated and initialed by the dispensing pharmacist. f. Prescribed medications must be on the drug formulary. g. If generic is available, generic must be dispensed. h. Prior authorization is required for medication not on the drug formulary, see the Pharmacy Prior Authorization Form. Note: To obtain a copy of Pharmacy Listings, please contact your Provider Relations Representative. Drug Formulary The Drug Formulary is developed by the Pharmacy and Therapeutics Committee, which is comprised of Providers, Pharmacy Specialists and the Health Plan Medical Director.. The AHCCCS Minimum Required Preferred Drug List will be included in the Health Plan Drug Formulary. Non- formulary drugs are not covered without prior authorization and documentation in the patient s medical record that a formulary drug is ineffective or cannot be taken due to an adverse reaction. The formulary contains guidelines for use of certain medications. The Health Plans Drug Formulary is located on the plan specific web sites. If a provider supplies sample medication to a member and the medication is not on the formulary, the provider must be willing to: convert the patient to a formulary medication, or continue providing samples for the patients use Note: Provider shall obtain approval before prescribing medications in accordance with prior authorization policy. The formulary process is ongoing with changes occurring at any time. For questions about formulary medications, please call the Pharmacy Help Desk (see Quick Reference Guide). Psychotropic Medications Primary Care Providers (PCP) are able to prescribe psychiatric medications to treat selected behavioral disorders including ADD/ADHD, mild depressive disorders and anxiety disorders. PHARMACEUTICAL SERVICES 17.1

182 REVISED 10/2014 Members should not receive medications for psychiatric disorders from their PCP and the Regional Behavioral Health Authority (RBHA) simultaneously. Please see guidelines below when prescribing a psychotropic medication to a member. Psychotropic Drug Formulary ANTIDEPRESSANTS GENERIC BRAND GENERIC BRAND Amitriptyline (Elavil) Citalopram (Celexa) Desipramine (Norpramin) *Escitalopram (Lexapro) Doxepin (Sinequan) Fluoxetine (Prozac) Imipramine (Tofranil) Paroxetine (Paxil) Nortriptyline (Pamelor) Sertraline (Zoloft) Bupropion (Wellbutrin (Wellbutrin SR) ANTIANXIETY *Venlafaxine (Effexor) (Effexor SR) GENERIC BRAND GENERIC BRAND *Buspirone (Buspar) Diazepam (Valium) Lorazepam (Ativan) Oxazepam (Serax) Alprazolam (Xanax) Flurazepam (Dalmane) Temazepam (Restoril) CNS STIMULANTS (ADD/ADHD) GENERIC BRAND GENERIC BRAND Methylphenidate (Ritalin) *Amphetamine (Adderall XR) Salts ER Dextroamphetamine (Dexadrine) *Methylphenidate (Concerta) Amphetamine Salts (Addreall) *Atomoxetine (Strattera) *Denotes Prior Authorization required. Please complete and fax the Pharmacy Prior Authorization Request to the Pharmacy Coordinator (see Quick Reference Guide). Any questions on Psychotropic Medications or Behavioral Health for UFC or MHP members should be directed to the Behavioral Health Coordinator (see Quick Reference Guide). PHARMACEUTICAL SERVICES 17.2

183 REVISED 10/2014 PCP Prescribing Psychotropic Medications 1. For medications that do require prior authorization the first prior authorization is valid for up to one (1) year; the second authorization can be open-ended as long as the patient remains stable and has no sentinel event warranting treatment by a psychiatrist 2. Check the member s RHBA enrollment status: Review the chart for a Notification of Assessment form from your local RHBA. To check enrollment status, the local RHBA will require the following patient information: name, social security number, your telephone and/or fax number. 3. Use formulary medications. 4. List the name of the attending physician if you are not the Health Plan credentialed provider. 5. List the behavioral health diagnosis for which you are prescribing the medication. Please see Behavioral Health, Section 11 of this manual for medical record requirements when treating a Behavioral Health diagnosis and for information on available benefits and services for our members. The comprehensive formulary for each plan can be found at the following web sites: University Care Advantage, University Family Care, Maricopa Health Plan, - Maricopa Care Advantage PHARMACEUTICAL SERVICES 17.3

184 REVISED 10/2014 Non-Formulary Prior Authorization Pharmacy Prior Authorization and Non-Formulary Request Date Provider Name Provider Phone # Member Name Insurance ID # Date of Birth Phone # Provider Fax # Type of Request Standard Expedited Insurance Plan University Family Care Maricopa Health Plan University Care Advantage University Healthcare Group Medical Information Requested Medication: Dosing Regimen: Quantity: Duration of Therapy: Diagnosis Pertaining to Requested Medication: Reason for Exception: Alternative Medication(s) Tried and Reason(s) for Failure: The University of Arizona Health Plans Office Use Only Please fax this completed form to UAHP 4/12 PHARMACEUTICAL SERVICES 17.4

185 SECTION 18 REVISED 10/2014

186 REVISED 10/2014 Eligibility and Enrollment The Customer Care Center provides assistance to all Health Plan members. AHCCCS and Medicare determine benefits. The Customer Care Center provides answers to member s questions, facilitates Primary Care Provider (PCP) changes and answers provider s eligibility inquiries. The main focus of the Customer Care Center is to assist and coordinate medical care for our members. All new members will receive a welcome packet which includes: Welcome letter identifying assigned (PCP) Including PCP address and telephone contact information Process to change PCP Process to obtain a Member handbook Process to obtain a Provider directory Family planning information Health history questionnaire Coordination of benefits (COB questionnaire) Health Information Portability and Accountability Act (HIPAA) Pre-addressed, postage paid return envelope for return of questionnaires Benefit Change Information University of Arizona Health Plans issues an identification card for MHP and UFC when a member becomes eligible for benefits. This card includes the member s name, identification number and the name of the AHCCCS plan they are assigned to. Providers can use the plastic identification card with the Medifax system, the Health Plan web site, the Customer Care Center at (800) , or AHCCCS at (800) , or the AHCCCS web site to verify a member s eligibility. The Health Plan will provide identification cards to our dual eligible SNP members that enroll in our Special Needs Plan. Please remember it is the provider s responsibility to verify eligibility and benefits prior to providing services. Providers should always verify a member s PCP assignment by calling the Customer Care Center or on the Health Plan web sites (see Quick Reference Guide). ELIGIBILITY AND ENROLLMENT 18.0

187 REVISED 10/2014 You may determine a member s eligibility in the following ways: 1. Providers who are electronically linked to the Health Plan computer system will have access to daily membership updates. 2. PCP s will receive a member roster on a regular basis. However, the Customer Care Center can provide the most current member eligibility information. 3. Call the Customer Care Center at (800) for updated eligibility information. 4. Providers can also call AHCCCS Administration at (800) to verify eligibility. AHCCCS Administration will inform the provider of a member s AHCCCS plan; however, they do not have PCP assignment information. 5. Providers who have access to the Internet can verify eligibility on the AHCCCS web site at Choose the Plan/Providers link and then Provider web site (AHCCCS online). AHCCCS obtains photos from the Arizona Department of Transportation Motor Vehicle Division (MVD) of all AHCCCS members who have an Arizona driver s license or a State issued Identification Card. When providers use the online member verification system and enter a member s social security n umber, the member s photo will be displayed on the screen along with coverage information. 6. Eligibility can also be verified at the Health Plan specific web sites. Choose the Providers Services and then check Enrollment Inquiry. Providers must register for this service. This service is provided at no charge. Children s Rehabilitative Services Members under 21 years of age with handicapping or potentially handicapping conditions that are likely to improve through medical, surgical or therapy modalities are eligible for care through Children s Rehabilitative Services (CRS). This is a Statewide, State and Federally funded program that services Arizona residents who qualify based on medical and financial criteria established by the Arizona Department of Health Services. For additional information, see CRS Section 15 in this manual. Member s Use of Emergency and Urgent Care Services The University of Arizona Health Plans expects the Primary Care Provider (PCP) to educate members of the differences between urgent and emergent conditions and instruct members to contact their PCP before visiting an emergency room or calling an ambulance unless they have a lifethreatening emergency. Information regarding appropriate use of the emergency room is below. This can be photocopied and distributed to members. ELIGIBILITY AND ENROLLMENT 18.1

188 REVISED 10/2014 The Emergency Room is for Emergencies!!! Call your doctor if you have a problem that is not a threat to your life. You can call your doctor at any time. Your doctor will tell you the kind of care you need. Your doctor or an urgent care is the place to take care of earaches, colds, or flu. Examples of Non-Emergencies are: Sprained ankle Minor burns A minor allergic reaction Rashes Flu Sore throat with a fever Earache What to Do if You Have an Emergency: Emergencies are a threat to your life. Emergencies can cause death if not taken care of quickly. Examples of Emergencies are: Extreme shortness of breath Poisoning Bleeding that will not stop Fainting Chest Pains Seizures If you are having any of these signs, go to the nearest Emergency Room or Call 911. ELIGIBILITY AND ENROLLMENT 18.2

189

190 SECTION 19

191 REVISED 10/2014 Model of Care Provider Overview Special Needs Plans Background Special Needs Plans (SNPs) were created by the Medicare Modernization Action (MMA) of The MMA authorized SNPs to limit enrollment to 3 specific vulnerable populations. Chronic Condition ( C-SNP) Dual Eligibles (D-SNP) Institutional (I-SNP) University of Arizona Health Plans (UAHP) manages the Maricopa Care Advantage (MCA) D- SNP plan. MCA has been operational since January 1, 2014, and serves dual eligible members (Medicaid and Medicare) residing in Maricopa County. Effective January 1, 2015 UAHP will be offering University Care Advantage (UCA) D-SNP. UAHP will serve dual eligible members (AHCCCS and Medicare) residing in the following counties: Cochise, Pima, Pinal, Gila, Graham, Greenlee, La Paz, Yavapai, Yuma and Santa Cruz counties. Model of Care SNP plans were mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) to have a Model of Care (MOC) to ensure that these vulnerable populations receive the care and services necessary to help them manage and improve their health status. The MOC is the framework for Case Management policy, procedures and operational systems. The MOC sets guidelines for: Assessing member needs Delivering Case Management Services Ensuring communication among member, caregiver, provider and plan The use of an Interdisciplinary Care Team (ICT) of health professionals to ensure care coordination and integration of primary care Measurement of individual and program outcomes Through the MOC every member is evaluated annually via a Health Risk Assessment. The ICT works with members, caregivers, and families as appropriate in order to develop an individualized Plan of Care that meets each member s needs. Through the assessment process members are also directed to the appropriate UAHP case management program. The case managers and PCPs work closely together to monitor the member s progress against the goals established in the Plan of Care. The case managers also work to help members identify MODEL OF CARE 19.2

192 REVISED 10/2014 problems and barriers to care, provide health education, coach members, and offer community resources when appropriate. The partnership with the providers is a critical component to the success of the MOC. The MOC offers the opportunity for UAHP and providers to work together to benefit our members, your patients. The Providers Role in the Model of Care As a UAHP contracted provider, you play an important role in the delivery of the MOC. As a key partner in the MOC your role is to: Know who your UAHP members are Communicate with the UAHP case managers regarding the care needs of your member Collaborate with the UAHP ICT as needed Contribute to the development of the Plan of Care Maintain the Plan of Care as part of the member s medical record Model of Care Division of Responsibility Function UAHP Provider Implement Health Risk Assessment X Develop Individualized Plan of Care X X Case Management X Coordination of Services X X Participate in the Interdisciplinary Care Team X X Integrate communication between members, X X providers and plan Use Evidence Based Guidelines to deliver care X Analysis and Reporting of Outcomes Measures X Implement Annual Provider Training X UAHP has developed a comprehensive MOC document which includes information on all the required elements. Below is a summary of the approach UAHP has taken in implementing the MOC for MCA and UCA plans. 1. Description of SNP-specific Target Population: MCA and UCA is a D-SNP plan, providing services for members who qualify for both Medicaid and Medicare. Approximately 50% of our SNP members qualify for Medicare through a mental health disability. The UAHP MOC has a strong focus on coordinating behavioral health services for our members in addition to needed medical care. MODEL OF CARE 19.3

193 REVISED 10/ MCA and UCA Model of Care Measurable Goals: Improve access to medical and mental health services Improve access to affordable care Improve coordination of care Improve transitions or care across health care settings and providers Improve access to preventive health services Assure appropriate utilization of services Assure cost-effective service delivery Improving member health outcomes 3. Staff Structure and Roles MCA and UCA are organizationally aligned with essential Case Management roles and has trained staff designated to provide administrative support, adequate care delivery and oversight of the MOC functions. 4. Health Risk Assessment MCA and UCA utilizes and comprehensive health assessment that evaluates medical, psychosocial, cognitive and functional needs with medical and mental health history. The results are used to develop the member s care plan and direct members to needed care and services. 5. Interdisciplinary Care Team UCA and MCA utilizes the Interdisciplinary Care Team to provide guidance and input into the development of the member s care plan. The team collaborates to ensure that the member s care plan is updated and members are receiving medical and mental health services as needed. They also help communicate the care plan to all caregivers and family members involved in the member s care. The ICT is comprised of physicians, mental or behavioral health experts, case managers, social worker, pharmacists and other health care professionals that may be germane to the development of the member s care plan. 6. Individualized Plan of Care (POC) Each member has a POC that includes measurable goals and objectives. The POC is communicated to the member, caregivers and providers and maintained by the plan and provider. All communications are conducted in compliance with HIPPA privacy standards. 7. Specialized Provider Network / Clinical Guidelines UAHP ensures that all contracted providers are vetted through a credentialing review process. UAHP has a broad network of specialists that include palliative care, pain management, chiropractors and psychiatrists. In addition the network includes specialty services such as dialysis, transportation, DME and home health. UCA continually reviews the network adequacy for specialty services needed by our MODEL OF CARE 19.4

194 REVISED 10/2014 vulnerable SNP population and ensures that providers are contracted for both our Medicaid and Medicare lines of business. UAHP supports physician management of chronic conditions my disseminating best practice, and evidence based guidelines to promote the delivery of quality care to our members. 8. Model of Care Training UAHP has developed and conducted training on the elements and delivery of the Model of Care to employees and contracted providers. The training for providers is conducted through the Provider Services Representatives. 9. Communication Network UAHP has an integrated system of communication with members and providers. Communication is both scheduled and ad hoc if needed. The table below outlines some of the modes of communication used through the Model of Care to promote care coordination and service delivery. UAHP MODEL OF CARE COMMUNICATION Mode of Communication Used For Exchange of Coordination Member/Provider Pertinent of Care Education Information Person to Person X X X Blast Fax X X ICT Meetings X X Telephonic X X X X X X Go-to-Meeting X X X Video Conferencing X X X Right Fax X X X UAHP Website X Provider Manual X Member Handbook X MODEL OF CARE 19.5

195 REVISED 10/ Case Management for the most vulnerable subpopulations Through various data sources UAHP has identified several subpopulations within our SNP plan. o Members with chronic medical conditions o Members with psychosocial needs o Frail and elderly members To serve these members, UAHP utilizes a process to risk stratify the member with highest needs and directs them to the appropriate specialty services, case management programs including complex case management. 11. Performance and Health Outcomes UAHP uses standardized quality improvement outcome and process measure to assess the performance of the Model of Care and measure member health improvements. Sources for this data include but is not limited to: o HEDIS o Chronic Condition Improvement Programs o Quality Improvement Projects o Health Outcome Survey (HOS) o Consumer Assessment of Health Plan and Provider Survey o Utilization metrics Summary UAHP s Model of Care for MCA and UCA provides a comprehensive process and infrastructure to meet the unique needs of our dual eligible population. Through the establishment of measurable goals, the delivery of care through a specialized network of provider, and services UAHP can ensure that members receive needed care. In addition, through the assessment, interdisciplinary care team and case management services, UAHP is able to provide individualized care that meets the unique medical, psychosocial and functional needs of our members. If you would like more information about the UAHP Model of Care for MCA and UCA, or request a copy of the Model of Care document, please contact your Provider Relations Representative. MODEL OF CARE 19.6

196 SECTION 20 KIDSCARE 20.0

197 KidsCare KidsCare is Arizona s health insurance for children under 19. Children age 18 and younger that qualify, can get medical, dental and visions services all three services combined in one simple plan. Eligibility Requirements A resident of Arizona Either a U.S. Citizen or a qualified eligible immigrant regardless of the status of the parents Not covered by any other health insurance A member of a family that meets the KidsCare income requirements Eligible Services: KidsCare members are eligible for the same services covered for members under the Title XIX Program. KidsCare covers the following medically necessary services: Doctor s office visits Specialist care, if necessary Hospital services Pregnancy care Laboratory and X-ray services 24-hour emergency medical care Family planning services, but not abortion or abortion counseling Complete physical exams Dental screening and treatment Eye exams and corrective glasses Hearing tests and hearing aids Emergency and non-emergency medical transportation KIDSCARE 20.1

198 Behavioral health services Immunizations Prescriptions For more information call KidsCare at (877) or Eligibility and Enrollment The Customer Care Center provides services and assistance to KidsCare members. The State AHCCCS Program determines benefits. The Customer Care Center provides answers to member s questions, facilitates PCP changes and answers provider s eligibility inquiries. The focus of the Customer Care Center is to assist and coordinate medical care for KidsCare members. All new members will receive a welcome packet which includes: 1) a letter identifying his/her assigned Primary Care Physician (PCP), 2) a member handbook, 3) a PCP directory, 4) a dental provider list and 5) educational materials. AHCCCS issues an identification card when a member becomes eligible for benefits. This card includes the member s name, identification number, and the name of the health plan they are assigned to. Providers can use the plastic identification card with the Medifax system, or on the AHCCCS web site, to verify a member s AHCCCS eligibility. Please remember it is the provider s responsibility to verify eligibility prior to providing services. Providers should always verify a member s PCP assignment by either calling the Customer Care Center or verifying the current eligibility roster. You may determine a member s eligibility in the following ways: 1. Providers who are electronically linked with the Health Plans computer system will have access to daily membership updates. 2. PCP s will receive a member roster on a regular basis. However, the Customer Care Center can provide the most current member eligibility information. 3. Call the Customer Care Center at (800) , for updated eligibility information. 4. Providers can also call AHCCCS Administration to verify eligibility. AHCCCS Administration will inform providers of member s AHCCCS plan; however, they do not have PCP assignment information. 5. Providers who have access to the Internet can verify eligibility on the AHCCCS web site at Go to Links and choose KidsCare. KIDSCARE 20.2

199 6. Eligibility can also be verified at or Choose the Provider link and then check Member Eligibility Payment is not guaranteed for services rendered to an ineligible member. Please verify eligibility each time a member presents for services. KIDSCARE 20.3

200 SECTION 21

201 REVISED 10/2014 Business Continuity Plan The Health Plan has created a Business Continuity Plan, policy number AD 216 (located in the back of this section) in order to maintain the viability and integrity of the Health Plan should there be a disaster. This policy will be followed to manage any situation that significantly disrupts critical, important, or marginal business functions that have been defined as a disaster. Critical: Health Plan functions are identified as communication with health plan staff, health plan members, contracted providers and. Ensuring members continue to receive immediate medically necessary services through contracted providers, Prior Authorizations, and concurrent review. Ensuring providers have minimal to no disruption of services. Important: Health Plan functions are identified as telephone systems, voice mail, computers and software, safety and security and finance operations. Marginal: Health Plan functions are identified as grievance/appeals, plan changes, network development and claims processing. Command Centers are established under the direction of the Health Plan CEO in response to any disruption in critical, important or marginal functions that have been defined as a disaster. Currently, the Health Plan servers are backed up daily. Each morning the previous nights back up tapes are taken to a secured off sight storage facility. In the event of disaster, the following alternatives will be initiated: Key personnel will perform functions at alternate locations In the event of systems failure, as soon as work can resume, each department will utilize the manual backup system to ensure workflow continues with minimal interruption If required, telephone calls will be re-routed to pre-designated areas If voice mail is not functional, messages will be taken and callers will be provided with alternate numbers (i.e.; cellular or pager numbers) to reach their parties Network Development staff will communicate information and any special arrangements necessary to conduct business with the Provider Network BUSINESS CONTINUITY PLAN 21.0

202 REVISED 10/2014 All medically necessary services will be covered without prior authorization until normal business operations are recovered Healthcare Facility Closure/Loss of Provider In the event of an unexpected change that will result in a healthcare facility closure or loss of a major network provider with less than 30 days of notification of the change to UFC, MHP, UCA, MCA, or KidsCare, the health plan will call an urgent meeting of the Contract Status Committee the same day as the notification. A major provider is defined as one of the following: PCP and OB Provider Specialist, Ancillary Provider or Vendor Inpatient Facility The Contract Status Committee will assess the situation, make recommendations and implement interventions to ensure members receive uninterrupted care. Loss of PCP or OB If through facility closure or any other circumstance a provider leaves the network with less than 30-day notice to the Health Plan, The Contract Strategy Committee will have an urgent meeting to assess the impact on member care and the network, communication within the Plan, and short and long term interventions for ensuring continuity of member care and the adequacy of the network. Network Development Department (ND) 1. The provider office will be contacted by the health plan to determine the extent of the loss, providers ability to render care and any plan the provider has for continuation of care with another provider. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 2. ND will assess the loss. If a provider is leaving a group but is going to remain in the community, we will attempt to obtain contract with him/her at his/her new location. Members would be given the option of retaining the PCP or OB at his/her new location, or choosing another PCP or OB. BUSINESS CONTINUITY PLAN 21.1

203 REVISED 10/ If the provider is not going to continue to see members in the network or it is a loss of an entire group, ND will assess the network in the given area of town. ND will present the Contract Status Committee short and long term recommendations for the network. Recommendations will include member reassignment, possible short-term solutions for member care and long-term solutions for member care and adequacy of the network. 4. If necessary, ND will contact other contracted and non-contracted providers in the service area to discuss reassignment of members to their practice. In the case of non- contracted providers, ND will negotiate either a Letter of Agreement or Contract with the provider. ND will also assist in temporary credentialing of the providers. 5. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits and phone calls. 6. With the assistance of Customer Care Center, ND will ensure that member records are transferred to the new provider. Customer Care Center (CC) 1. CC will be responsible for identification of members assigned to the PCP. 2. CC will notify members of the change. Members will be notified directly via personal letter. 3. CC will assist members in the selection of a new PCP or OB if necessary. 4. CC will assess any special cultural needs of the affected members and ensure the member continues to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management and Prior Authorization (PA) 1. MM will be responsible for identifying members with open referral to an OB provider. 2. MM will identify any members with special health care needs. MM will ensure that members with special health care needs receive uninterrupted care during the transition period. BUSINESS CONTINUITY PLAN 21.2

204 REVISED 10/ In the case of an OB provider termination, the Maternal Child Health department will ensure, with assistance from CC, that current OB patients are transitioned to another OB provider. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. Loss of Specialist, Ancillary Provider or Vendor If through facility closure or other means a specialist, ancillary provider or vendor leaves the network with less than 30-day notice to the Health Plan, The Contract Strategy Committee will have an urgent meeting to assess the impact on member care and the network, and short and long term interventions for ensuring continuity of member care and an adequate network. Network Development Department (ND) 1. The Health Plan will call an urgent meeting of the ND and Strategy Team upon notification of the loss. 2. The ND and Strategy Team will create the overall plan and strategy for the loss. 3. The office will be contacted by the Health Plan to determine the loss, the providers ability to render care and any plan the provider may have for continuation of care with another provider or vendor. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 4. ND will assess the loss. If a provider is leaving a group but is going to remain in practice in the community, we will attempt to obtain a contract with the provider. 5. At the new location. The new provider information would be in the provider listings for the member. 6. If the provider is not going to continue to see members in the network or it is a loss of an entire group, ND will assess the network in the given area of town. ND will present the ND and Strategy Team and identify short and long term recommendations for the network. Recommendations will include possible shortterm solutions for member care and long-term solutions for member care and adequacy of the network. BUSINESS CONTINUITY PLAN 21.3

205 REVISED 10/ If necessary, ND will contact other contracted and non-contracted providers in the service area to discuss possible rendering of care to members due to the loss. If it is a single source provider and there are no providers in the community who provide the service, ND will identify other means for member care, i.e. sending a patient to another city for care if the care does not exist in that city. In the case of noncontracted providers, ND will negotiate either a Letter of Agreement or Contract with the provider. ND will also assist in the temporary credentialing of the providers. 8. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits, phone calls, etc. Customer Care Center (CC) 1. CC will identify potential members affected by the change by running claims data for the provider indicating members who have seen the specialist in the past six (6) months. This will only occur if the contracted facility will not be able to continue to care for the members. 2. CC will notify members of the change. Notification will occur as either a general letter to the members or through the Member Newsletter depending on the situation and recommendation of the Network Development and Strategy Team. 3. CC will assist members in obtaining services with another provider if necessary. 4. CC will assess any special cultural needs and ensure members continue to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management and Prior Authorization (PA) 1. MM will be responsible for identifying members with open referrals to the specialist, ancillary provider or vendor, when a referral is required. 2. MM will also review the member list obtained through claims data to identify members with special health care needs. MM will ensure that known members with special health care needs receive uninterrupted care during the transition period. BUSINESS CONTINUITY PLAN 21.4

206 REVISED 10/ If a member is identified as being in case management, the case manager will ensure, with assistance from MS, that the member is transitioned to another Specialty Care Provider. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. Loss of an Inpatient Facility If through facility closure or other means an inpatient facility leaves the network with less than 30-day notice to the Plan, the Contract Strategy Committee will have an urgent meeting to assess the short and long term interventions for ensuring continuity of member care and an adequate network. Network Development Department (ND) 1. The Health Plan will contact the facility to determine the loss, the providers ability to render care and any plan the provider may have for continuation of care with another provider or vendor, i.e. patient care diversion plans for hospitals. We will continue to communicate with the office to inform them of the plan to transition members to another provider. Communication with the office will occur in whatever way the office is able to communicate, i.e. phone, fax, site visit, etc. 2. ND will assess the loss. ND will determine if it is a short term, long term or complete closure or loss of the facility. 3. If it is a short-term loss, ND, with the assistance of the facility will estimate the length of time the facility will be closed. Short-term interventions will be created to supplement the network until the facility can again render care. Short-term interventions may include diversion of members to another network facility, another facility out of the service area or contracting with other facilities in the services area. ND will consider using Letters of Agreement until a contract can be negotiated with another facility. 4. If it is a long-term loss, ND will first identify the short-term interventions listed above and implement these interventions. Once the short-term interventions are implemented, ND will identify long-term interventions. ND will assess the impact of the facility loss to the network. If the loss is determined to hinder the ability of the Plan to render services to the member, ND will identify facilities that can render the same or similar services. ND will contact these facilities and begin contract negotiations. BUSINESS CONTINUITY PLAN 21.5

207 REVISED 10/ A complete loss or closure will be handled in the same manner as a long-term loss. 6. ND will communicate the loss and interventions with other network providers as necessary. Communication may include but is not limited to bulletins, newsletters, site visits, phone calls, etc. Customer Care Center (CC) 1. CC will notify members of the change. Notification will occur as either a general letter to the members or through the Member Newsletter depending on the situation and recommendation of the Network Development and Strategy Team. 2. CC will assist members in obtaining services with another provider if necessary. 3. CC will assess any special cultural needs and ensure members continue to receive culturally appropriate services. Medical Management (MM), including Maternal Child Health, Behavioral Health, Case Management, Utilization Review (UR) and Prior Authorization (PA) 1. MM will be responsible for identifying inpatient members at the facility through utilization review records and inpatient notifications. 2. The UR nurse will work closely with The Contract Strategy Committee to ensure the members are transferred to another facility and they continue to receive appropriate care. UR nurses will report back to the Team on the status of members and transition of care. Quality Management (QM) QM will be responsible for ensuring that the interventions developed do not interfere with quality of member care or Performance Standards. BUSINESS CONTINUITY PLAN 21.6

208 SECTION 22 MEMBER ID CARDS 22.0

209 Member ID Cards Medicaid AHCCCS Health Plans Maricopa Health Plan (MHP) University Family Care (UFC) MEMBER ID CARDS 22.1