Children s Rehabilitative Services: Eligibility Verification Overview This document will provid assistance with how to identify a Children s Rehabilitative Services (CRS) member on Arizona Health Care Cost Containment System () Online. Member List - Sample Plan /Name First Name Last Name DOB Begin DOS DOS 010115 - CRS FULLY INTEGRATED A00010115 CRS FULLY INT 12/05/2000 010145 - CRS PARTIAL ACUTE A00010145 CRS PARTIAL ACUTE 06/13/1992 999125 - CRS PARTIAL BH A00999125 CRS PARTIAL BH 10/23/1949 999135 CRS ONLY PLAN A00999135 CRS ONLY 06/09/1981 Screen prints containing de-identified data are provided for the following areas for each sample member. Online Eligibility and Enrollment Status 5010 version replaces 4010 version Notes: For Only you will only be able to look up using the member s name and date of birth or the. The system is not yet able to search using the CRS number. The CRS Only Group on the 4010 version (10/1-10/10) is the most difficult to identify as there is no indicator.
Online - Eligibility and Enrollment Status 5010 CRS Fully Integrated Example Arizona Health Care Cost Containment System Requested Data: A00010115 Last Name First Name DOB 12/05/2000 Begin of Service of Service Returned Data: A00010115 Last Name FULLYINT First Name CRS DOB 12/05/2000 DOD Gender F Demographics Mailing Address 1 Mailing Address 2 City State Zip 701 E JEFFERSON PHOENIX AZ 85002 Eligibility Renewal : 05/31/2013 Eligibility Renewal Eligibility Eligibility Group Description Insurance Begin Added On ACUTE DISABLED MC MEDICA 04/01/2013 03/29/2013 Medical Enrollment Health Plan /Description Start Rate Code Contract Insurance 010115 CRS FULLY INTEGRAT ED 2200 - SSI DISABLED WITH MEDICARE A ACU/CAP HM HEALTH MAINTENANCE ORGANIZATION (HMO) Service Codes 2
30-HEALTH BENEFIT PLAN COVERAGE Third Party Liability NO TPL FOUND CoPayment CoPay Level Start 00 04/12/2013 HMO NO MEDICARE HMO Claim Number Indicator Start Insurance Service 010115123A A Y 01/01/2013 010115123A B Y 01/01/2013 MA MEDICARE PART A MB MEDICARE PART B 010115123A D Y 01/01/2013 OT OTHER 30 HEALTH BENEFIT PLAN COVERAGE Part D Enrollment Health Plan/Name Start Service S7694028 ENVISIONRXPLUS SILVER 05/01/2013 88 PHARMACY Category/Des cription Start C CHILDREN SERVICES 04/11/2013 Behavioral Health Services Site/Description 33 UHCP/CHILDRENS REHAB Service CH MENTAL HEALTH FACILITY - OUTPATIENT Indicator Y Share of Cost NO SOC FOUND Targeted Support Coordination/DDD NO TSC FOUND Children s Rehabilitative Services CRS Indicat or Be gin CRS Service Y 04/11/2013 A9 REHABILITATION 7
Arizona Early Intervention Program NO AzEIP FOUND *** This verification does not constitute a guarantee of payment *** 8
Online - Eligibility and Enrollment Status 5010 CRS Partially Integrated Acute Example Arizona Health Care Cost Containment System Requested Data: A00010145 Last Name First Name DOB 06/13/1992 Begin of Service of Service Returned Data: A00010145 Last Name PARTIALACUTE First Name CRS DOB 06/13/1992 DOD Gender F Demographics Mailing Address 1 Mailing Address 2 City State Zip 701 E JEFFERSON PHOENIX AZ 85002 Eligibility Renewal : 06/30/2013 Eligibility Renewal Eligibility Eligibility Group Description Insurance Begin Added On ACUTE MC MEDICA 07/01/2011 06/24/2011 Medical Enrollment Health Plan /Description Start Rate Code Contract Insurance 010145 CRS PARTIAL ACUTE 07/01/2013 3617 - AHC CARE/MI FEMALE 21-44 NO MDC A ACU/CAP HM HEALTH MAINTENANCE ORGANIZATION (HMO) 9
Service Codes 30-HEALTH BENEFIT PLAN COVERAGE Third Party Liability NO TPL FOUND CoPayment CoPay Level Start 00 07/01/2011 HMO NO MEDICARE HMO NO MEDICARE PART A NO MEDICARE PART B NO MEDICARE PART D Part D Enrollment NO DRUG PLAN Category/Descri ption Start G GENERAL MEN TAL HEALTH SERVICES 04/10/ 2012 Behavioral Health Services Site/Description 14 NAVAJO NATION Service CH MENTAL HEALTH FACILITY - OUTPATIENT Indicator Y Share of Cost NO SOC FOUND Targeted Support Coordination/DDD NO TSC FOUND Children s Rehabilitative Services CRS Indicator Be gin CRS Service Y 07/01/2013 A9 REHABILITATION Arizona Early Intervention Program NO AzEIP FOUND *** This verification does not constitute a guarantee of payment *** 10
Online - Eligibility and Enrollment Status 5010 CRS Partially Integrated Behavioral Health Example Arizona Health Care Cost Containment System Requested Data: A00999125 Last Name First Name DOB 10/23/1949 Begin of Service of Service Returned Data: A00999125 Last Name PARTIALBH First Name CRS DOB 10/23/1949 DOD Gender F Demographics Mailing Address 1 Mailing Address 2 City State Zip 701 E JEFFERSON PHOENIX AZ 85002 Eligibility Renewal : 01/31/2014 Eligibility Renewal Eligibility Eligibility Group Description Insurance Begin Added On LTC LC LONG TERM CARE 11/01/1993 10/26/1993 Medical Enrollment Health Plan /Description Start Rate Code Contract Insurance 110007 LTC DD DES 10/01/2003 2220 - SSI DISABLED WITH QMB J LTC/CAP HM HEALTH MAINTENANCE ORGANIZATION (HMO) 11
Service Codes 30-HEALTH BENEFIT PLAN COVERAGE Third Party Liability NO TPL FOUND CoPayment CoPay Level Start 00 10/01/2003 HMO NO MEDICARE HMO Claim Number Indicator Start Insurance Service 999125123A A Y 04/01/1990 999125123A B Y 04/01/1990 MA MEDICARE PART A MB MEDICARE PART B 999125123A D Y 01/01/2006 OT OTHER 30 HEALTH BENEFIT Part D Enrollment Health Plan/Name Start Service S5601056 SILVERSCRIPT BASIC 01/01/2013 88 PHARMACY Category/Des cription Start Behavioral Health Services Site/Description Service Indicator G GENERAL MEN TAL HEALTH SERVICES 06/19/2013 33 UHCP/CHILDRENS REHAB CH MENTAL HEALTH FACILITY - OUTPATIENT Y Share of Cost Please direct any questions regarding share of cost data to the member's program contractor Share of Cost Share of Cost Month.00 09/2013 Targeted Support Coordination/DDD NO TSC FOUND 12
Children s Rehabilitative Services CRS Indicat or Be gin CRS Service Y 06/19/2013 A9 REHABILITATION Arizona Early Intervention Program NO AzEIP FOUND *** This verification does not constitute a guarantee of payment *** 13
Online - Eligibility and Enrollment Status 5010 CRS Only Example Arizona Health Care Cost Containment System Requested Data: A00999135 Last Name First Name DOB 06/09/1981 Begin of Service of Service Returned Data: A00999135 Last Name ONLY First Name CRS DOB 06/09/1981 DOD Gender M Demographics Mailing Address 1 Mailing Address 2 City State Zip 701 E JEFFERSON PHOENIX AZ 85002 Eligibility Renewal Eligibility Renewal : Eligibility Eligibility Group Description Insurance Begin Added On ACUTE MC MEDICA 04/01/2013 04/19/2013 Medical Enrollment Health Plan /Description Start Rate Code Contract Insurance 999998 AMERICAN INDIAN HP 04/19/2013 1016 - TANF 21-44 MALE NON- MEDICARE E ACU/FFS MC MEDICA 14
Service Codes AL-VISION (OPTOMETRY) BY-PHYSICIAN VISIT - OFFICE: SICK BZ-PHYSICIAN VISIT - OFFICE: WELL MH-MENTAL HEALTH PT-PHYSICAL THERAPY UC-URGENT CARE 1-MEDICAL CARE 2-SURGICAL 33-CHIROPRACTIC 35-DENTAL CARE 47-HOSPITAL 82-FAMILY PLANNING 86-EMERGENCY SERVICES 88-PHARMACY 93-PODIATRY 98-PROFESSIONAL (PHYSICIAN) VISIT - OFFICE Third Party Liability NO TPL FOUND CoPayment CoPay Level Start 00 04/20/2013 HMO NO MEDICARE HMO NO MEDICARE PART A NO MEDICARE PART B NO MEDICARE PART D Part D Enrollment NO DRUG PLAN Category/Descri ption Start G GENERAL MENTAL HEALTH SERVICES Behavioral Health Services Site/Description 04/19/2013 22 CENPATICO 4 Service CH MENTAL HEALTH FACILITY OUTPATIENT Indicator Y Share of Cost NO SOC FOUND 15
Targeted Support Coordination/DDD NO TSC FOUND Children s Rehabilitative Services CRS Indicat or Begi n CRS Service Y 04/19/2013 09/10/2013 A9 REHABILITATION Arizona Early Intervention Program NO AzEIP FOUND *** This verification does not constitute a guarantee of payment *** 16