CARE1ST HEALTH PLAN ARIZONA

PROVIDER MANUAL
TABLE OF CONTENTS

The Care1st Provider Manual is available in PDF format.
Click on the appropriate section title to view the contents.

SECTION I - INTRODUCTION
• Welcome
• Mission Statement
• Introduction to Care1st
• Organization of Care1st

SECTION II - QUICK REFERENCE CONTACT LIST
• Key Departmental Contacts
• Care1st Contracted Vendors
• Arizona Health Care Cost Containment System (AHCCCS)
• Hearing Impaired
• Translation Services

SECTION III - PROVIDER ROLES AND RESPONSIBILITIES
• PCP Gatekeeper Role
• Specialist Responsibility
• PCP Assignment/Provider Enrollment Limit
• Service Delivery Responsibilities
• Appointment and Wait Time Standards
• Provider Network Changes
• Removal of Member from Panel
• Provider Grievances
• Provider Directory
• Member Eligibility Verification
• Follow Up of Cancelled and Missed Appointments
• AHCCCS Cost Sharing Copayments
• Provision of Covered Services
• Receiving Prior Authorization
• Submitting Claims and Encounters
• Use of the Emergency Room
• Documentation
• Data Validation
• Advance Directives
• Non-Discrimination Policy
• Culturally Competent Care
• ASIIS

SECTION IV - MEMBER RIGHTS & RESPONSIBILITIES
• Member Rights
• Member Responsibilities

SECTION V - ELIGIBILITY AND ENROLLMENT
• Eligibility Determination and Enrollment
• KidsCare
• DES/DDD
• Rate Codes
• Member Rosters and Eligibility Verification
• Member Identification Cards
• Newborn Coverage
• Change of Primary Care Physician- Member Initiated

SECTION VI - COVERED SERVICES
• Covered Services
• Chiropractic Services
• Childrens Rehabilitative Services
• Dental Services
• Emergency Services
• EPSDT Services
• Family Planning Extension Services
• Family Planning Services
• Hearing Services
• Laboratory Services
• Maternity Care Services
• Optometry/Vision Services
• Pharmacy Services
• Rehabilitation Services
• Transportation Services

SECTION VII - BEHAVIORAL HEALTH SERVICES
• Overview
• Psychotropic Medication Prescribing/Adjustment/Monitoring
• Behavioral Health Crisis Services
• Behavioral Health Referrals
• Telephonic Consultation Services Through Magellan
• Face-to-Face Consultation Services through Magellan
• Coordination of Care
• Transfer of Care
• Provider Information

SECTION VIII - PROVIDER CLAIM DISPUTES AND APPEALS
• Claim Disputes/Appeals Process

SECTION IX - MEDICAL MANAGEMENT
• Overview of Medical Management
• Prior Authorization and Referral Process
• Case Management
• Concurrent Review
• Retroactive Review
• Pharmacy Management
• Disease Management

SECTION X - QUALITY MANAGEMENT
• Overview
• Confidentiality and Conflict of Interest
• Credentialing
• Peer Review
• Medical Record Guidelines
• Advance Directives

SECTION XI - BILLING, CLAIMS AND ENCOUNTERS
• Required ID Numbers
• Medical Claims Review
• Billing for Services
• Electronic Data Interchange (EDI)
• Electronic Funds Transfer (EFT)

SECTION XII - FRAUD, WASTE AND/OR ABUSE
• Fraud and Abuse
• Deficit Reduction Act

SECTION XIII - HEALTHCARE GROUP
• Healthcare Group Overview
• Member Eligibility
• Other Information

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