CARE1ST HEALTH PLAN ARIZONA

PROVIDER MANUAL
TABLE OF CONTENTS

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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
• 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
• Provision of Covered Services
• ASIIS
• Referrals and Prior Authorization
• Submitting Claims and Encounters
• Inappropriate Use of the Emergency Room
• Documentation
• Data Validation
• Advance Directives
• Non-Discrimination Policy
• Culturally Competent Care

SECTION IV - MEMBER RIGHTS & RESPONSIBILITIES
• Member Rights
• Member Responsibilities
• Grievances
• Advance Directives

SECTION V - ELIGIBILITY AND ENROLLMENT
• Eligibility Determination and Enrollment
• KidsCare
• DES/DDD
• 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
• Family Planning Extension Services
• Family Planning Services
• Home Health
• Hearing
• Laboratory
• Maternity Care
• Optometry/Vision
• Orthotics and Prosthetics
• Pharmacy
• Podiatry
• Radiology
• Rehabilitation
• Transportation

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 - CLAIM DISPUTES AND APPEALS
• Claim Disputes & Appeals Process
• Member Appeals

SECTION IX - MEDICAL OPERATIONS
•Overview
• Prior Authorization and Referral Process
• Case Management
• Disease Management
• Pharmacy Management
• Concurrent Review
• Retrospective Review

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

SECTION XI - BILLING, CLAIMS AND ENCOUNTERS
• Claim Submissions
• Required ID Numbers
• Billing for Services Rendered
• Medical Claims Review

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

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

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