Provider Manual

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TABLE OF CONTENTS:

SECTION I - INTRODUCTION

• Welcome
• Mission Statement
• Introduction to Care1st
• Department Organization

SECTION II - QUICK REFERENCE CONTACT LIST

• Department Contacts
• Website
• Contracted Vendors
• Arizona Health Care Cost Containment System (AHCCCS)
• Hearing Impaired
• Translation Services

SECTION III - PROVIDER ROLES AND RESPONSIBILITIES

• General and Informed Consent to Treatment
• PCP Gatekeeper Role
• Specialist Responsibility
• Service Delivery Responsibilities
• Care Coordination
• Appointment and Wait Time Standards
• Provider Network Changes
• Removal of Member from Panel
• Provider Inquiries, Complaints, Requests for Information & General Grievances/Disputes
• Provider Directory
• Eligibility Verification
• Cancelled and Missed Appointments
• AHCCCS Cost Sharing & Co-payments
• ASIIS
• Referrals and Prior Authorization
• Submitting Claims and Encounters
• Inappropriate Use of the Emergency Room
• Medical Records
• Record Retention
• End of Life Care/Advance Care Planning
• Non-Discrimination Policy
• Culturally Competent Care
CLAS Standards

SECTION IV - MEMBER RIGHTS & RESPONSIBILITIES

• Member Rights
• Member Responsibilities
• Grievances
• Advance Directives

SECTION V - ELIGIBILITY AND ENROLLMENT

• Eligibility Determination and Enrollment
• Change of Contractor
• Transition of Members
• KidsCare
• Rate Codes
• Member Identification Cards
• PCP Assignment
• Eligibility Verification
• Newborn Coverage
• AHCCCS Cost Sharing & Co-Payments

SECTION VI - COVERED SERVICES

• Covered Services
• Chiropractic Services
• Children’s Rehabilitative Services (CRS)
• Dental
• Emergency Services
• EPSDT Services
• Developmental Screening Tools
• Family Planning Services
• Home Health
• Hearing
• Laboratory
• Maternity Care
• Optometry/Vision
• Orthotics and Prosthetics
• Pharmacy
• Podiatry
• Radiology
• Rehabilitation
• Transportation
• Non-covered Services

SECTION VII - BEHAVIORAL HEALTH SERVICES

• Overview
• System Values and Guiding Principles
• Pharmacy Management
• Crisis Intervention Services
• Referral & Intake Process
• Outreach, Engagement, Reengagement and Closure
• Assessment and Service Planning
• Coordination of Care with Other Governmental Agencies
• SMI Eligibility Determination
• Partnerships with Families and Family-run Organizations in the Children’s Behavioral Health System
• Workforce Development and Training Requirements
• Peer/Recovery Support Specialist Training, Credentialing, and Supervision Requirements
• Parent/Family Support Provider Training, Credentialing, and Supervision Requirements
• Telephonic Consultation Services
• Face-to-Face Consultation Services
• Coordination of Care
• Transfer of Care
• Out of State Placement
• Pre-Petition Screening, Court-Ordered Evaluation, and Court-Ordered Treatment
• Fiscal Responsibility

SECTION VIII - CLAIM DISPUTES AND APPEALS

• Claim Disputes & Appeals Process
• Member Appeals

SECTION IX - MEDICAL OPERATIONS

• Overview
• Prior Authorization and Referral Process
• Care Coordination
• Case Management
• Disease Management
• Pharmacy Management
• Concurrent Review
• Retrospective Review
• Practice Guidelines

SECTION X - QUALITY IMPROVEMENT

• Overview
• Confidentiality and Conflict of Interest
• Credentialing and Recredentialing
• Peer Review
• Fair Hearing
• Duty to Warn
• Incidents, Accidents, and Death Reporting
• Medical Record Guidelines
• Medical Record Retention

SECTION XI - BILLING, CLAIMS AND ENCOUNTERS

• Claim Submissions
• Required ID Numbers
• Billing for Services Rendered
• Medical Claims Review
• Encounter Data
• Encounter Data Validation

SECTION XII - FRAUD, WASTE AND/OR ABUSE

• Fraud and Abuse
• Anti-Fraud Plan
• Deficit Reduction Act

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