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
- 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