Network Management Mailing Fall 2018

Transcription

1 Network Management Mailing Fall 2018 Reference Tools Radiology Grid {UPDATED} Quick Reference Guide {UPDATED} Care1st Website Guide EDI & EFT Important Details Prior Authorization Forms Medical Prior Authorization Form (Treatment Authorization Request) Pharmacy Prior Authorization Form Authorization/Pregnancy Risk Assessment Form Other Important Forms AzAHP Credentialing Alliance Practitioner Data Form (To obtain a Word template version, call Provider Network Operations at the phone numbers below for assistance) AzAHP Credentialing Alliance Organizational Data Form (To obtain a Word template version, call Provider Network Operations at the phone numbers below for assistance) Other Important Forms (continued) Behavioral Health Services Referral Form MMIC Behavioral Health Services Referral Form CIC Behavioral Health Services Referral Form - HCIC (NEW) EFT Authorization Form No Show Appointment Log Provider Directory Correction Form RSV Prophylaxis Eligibility Assessment Form {UPDATED} Prior Authorization Guidelines and Dental Clinical & Billing Guidelines Prior Authorization Guidelines are available on our website (Providers > Prior Authorization Guidelines & Criteria). Dental Clinical and Billing Guidelines are available on our website (Providers > Dental). Blast Fax Communications Recent communications are available on our website (Providers > Blast Faxes). Network Management PHONE or (OPTIONS IN ORDER: 5, 7) FAX sm_az_pno@care1staz.com Visit our website at

2 RADIOLOGY NETWORK (sorted by County/City/Zip) Revised D M X E C M M U P R X C T R A A R R E G E E C B N A FACILITY NAME ADDRESS CITY ZIP COUNTY PHONE FAX A T A O AL L L A I N A D T T X D Y SIMONMED IMAGING INC 3618 W Anthem Way D104 & D108 Anthem Maricopa X X X X X x AZ-TECH RADIOLOGY - APACHE JNCTN 1840 W Apache Trail Apache Junction Maricopa X X X X X X X X SMI LLC-APACHE JUNCTION 2080 W Southern Ave Bldg C Apache Junction Maricopa X X X X X X SMI IMAGING LLC - AVONDALE W McDowell Rd Ste 102 Avondale Maricopa X X X X X X X SIMONMED IMAGING - BUCKEYE 818 S Watson Rd #102 Buckeye Maricopa X X X X X X X AZ TECH RADIOLOGY-CHANDLER 600 S Dobson Rd Ste E42 Chandler Maricopa X X X X MODERN DIAGNOSTIC IMAGING PC 600 S Dobson Rd #B16 Chandler Maricopa X X X X X X X X X SIMONMED IMAGING - CHANDLER SOUTH CENTER 725 S Dobson Rd Ste B105 Chandler Maricopa X SMI IMAGING LLC - CHANDLER SOUTH CAMPUS 725 S Dobson Rd Ste A105 Chandler Maricopa X X X X SMIL IMAGING-CHANDLER 1076 W Chandler Blvd Ste 120 Chandler Maricopa X X X X X X X X SMI IMAGING LLC - DOBSON VILLAGE S Dobson Rd Bldg L, Unit 1 Chandler Maricopa X X X X X SMI IMAGING LLC - DOBSON VILLAGE II 1870 W Frye Rd Ste 3 Chandler Maricopa X X SOLIS BENORA MAMMOGRAPHY 2081 W Frye Rd Bldg 1, #110 Chandler Maricopa X TMC ADVANCED IMAGING - CHANDLER 1351 N Alma School Rd Ste 115 Chandler Maricopa X X X X X X SMIL - FOUNTAIN HILLS E Palisades Blvd Ste C151 Fountain Hills Maricopa X X X X X X X AZ-TECH RADIOLOGY - GILBERT 4915 E Baseline Rd Ste 116 Gilbert Maricopa X X X X X X X SMI IMAGING LLC - NORTH GILBERT SUPERSTITION 875 N Greenfield Rd Ste 107 Gilbert Maricopa X X X X SMIL IMAGING 665 N Gilbert Rd Ste 154 Gilbert Maricopa X X X X X X X MARQUIS DIAGNOSTIC IMAGING- GILBERT 1760 E Pecos Rd Gilbert Maricopa X X X X X X X X SMI IMAGING LLC - SPECTRUM 2680 S Val Vista Dr Bldg 7 Ste 135 Gilbert Maricopa X X X X X X SIMONMED IMAGING INC-COPPERPOINTE 3570 S Val Vista Dr 101 Gilbert Maricopa X X X X X SMIL - GILBERT 3645 S Rome St Ste 101 Gilbert Maricopa X X X X X X X X X X X X VALLEY RADIOLOGISTS - PASEO I 5601 W Eugie Ave Ste 102 Glendale Maricopa X X X X VALLEY RADIOLOGISTS - PASEO II 5605 W Eugie Ave Ste 110 Glendale Maricopa X X X X X X X X SIMONMED IMAGING INC-FOUNTAINS 5620 W Thunderbird Rd Ste A Glendale Maricopa X X X X X X SIMONMED IMAGING INC THUNDERBIRD BIOPSY CENTER 5410 W Thunderbird Rd. Ste 240 Glendale Maricopa X SMI IMAGING LLC-THUNDERBIRD I 5410 W Thunderbird Rd. Ste 100 Glendale Maricopa X X X X X X X SMI IMAGING LLC-THUNDERBIRD II 5410 W Thunderbird Rd. Ste 221 Glendale Maricopa X X X SMI IMAGING LLC-THUNDERBIRD III 5410 W Thunderbird Rd. Ste 210 Glendale Maricopa X X X SOLIS BENORA MAMMOGRAPHY 5310 W Thunderbird Rd Ste 213 Glendale Maricopa X SUN RADIOLOGY-GLENDALE N 59TH AVE C 150 Glendale Maricopa X X X X X X X X X VALLEY RADIOLOGISTS 5757 W Thunderbird Rd Ste W 100 Glendale Maricopa X X X VALLEY RADIOLOGISTS - SUNWEST WOMEN'S CENTER 5757 W Thunderbird Rd Ste W 101 Glendale Maricopa X X X VALLEY RADIOLOGISTS - THUNDERBIRD OFFICE 5310 W Thunderbird Rd Ste 100 Glendale Maricopa X SMI IMAGING LLC-ARROWHEAD 6320 W Union Hills Dr Bldg A #120 Glendale Maricopa X X X X X X X SUN RADIOLOGY 7200 W Bell Rd Bldg B Glendale Maricopa X X SIMONMED IMAGING INC-GOODYEAR West McDowell Ste 100 Goodyear Maricopa X X X X X X X SIMONMED IMAGING-PALM VALLEY W McDowell Rd Ste 207 Goodyear Maricopa X SMI-PALM VALLEY W McDowell Rd Ste 111 Goodyear Maricopa X X X X X VALLEY RADIOLOGISTS - PALM VALLEY W McDowell Rd Ste 106 Goodyear Maricopa X X X X X X SMI IMAGING - MESA DRIVE 456 N Mesa Dr Mesa Maricopa X X X SMIL IMAGING -WEST 1450 S Dobson Ste A100 Mesa Maricopa X X AZ-TECH RADIOLOGY-MESA (Women's Ctr) 2653 W Guadalupe Rd Ste 100 Mesa Maricopa X X X SMI IMAGING LLC- MESA DESERT CAMPUS 1111 S Dobson Rd Ste 105 Mesa Maricopa X X X X X X X X ARISTA MEDICAL IMAGING LLC DBA ARISTA IMAGING 1345 E McKellips #103 Mesa Maricopa X ARIZONA ADVANCED IMAGING CENTER LLC 4566 E Inverness Ave Ste 102 Mesa Maricopa X X X X SMIL-EAST MESA 6424 E Broadway Rd Ste 101 Mesa Maricopa X X X X X X X X DESERT VALLEY RADIOLOGY PLC 5424 E Southern Ave Ste 104 Mesa Maricopa X X X X X SIMONMED IMAGING - WOMEN'S AND BIOPSY CENTER 1425 S Greenfield Rd Bldg 2 Ste 112 Mesa Maricopa X SMI IMAGING LLC - GREENFIELD 1425 S Greenfield Rd Bldg 2 Ste 114 Mesa Maricopa X X X X X X X SMI IMAGINGL-EAST 6553 E Baywood Ave Mesa Maricopa X X SMI IMAGING LLC - BAYWOOD 130 S 63rd St Ste 123 Mesa Maricopa X X X X X X SMIL - TATUM & SHEA N Tatum Blvd Ste C128 Paradise Valley Maricopa X X X X X X X X SIMONMED IMAGING 9139 W Thunderbird Rd Ste 112 Peoria Maricopa X X X X X X SIMONMED IMAGING - PEORIA 9125 W Thunderbird Rd #105 Peoria Maricopa X SMI IMAGING LLC - SUN CITY PEORIA 9403 W Thunderbird Rd Peoria Maricopa X X X X SUN RADIOLOGY - PEORIA/SUN CITY N 94th Dr Ste 103 Peoria Maricopa X X X X X X X X X MARQUIS DIAGNOSTIC IMAGING- PHOENIX 2830 N 3rd St Phoenix Maricopa X X X X X X X SIMONMED IMAGING 2620 N 3rd St Ste 101 Phoenix Maricopa X X SIMONMED IMAGING INC-PHOENIX BIOPSY 2620 N 3rd St Ste 105 Phoenix Maricopa X SMI IMAGING- PHOENIX 2620 N 3rd St Ste 102 Phoenix Maricopa X X X X X X X SMI IMAGING LLC-PHOENIX HIGHFIELD OPEN MRI 1331 N 7th St #150 Phoenix Maricopa X X X 11 of of 3 F L U O I N T E R V E N T I O N M A M M O D I G I T M R I - O P N U C L E A R - M P E T - R A D - G U I D E - U L T R A S O U

3 RADIOLOGY NETWORK (sorted by County/City/Zip) Revised D M X E C M M U P R X C T R A A R R E G E E C B N A FACILITY NAME ADDRESS CITY ZIP COUNTY PHONE FAX A T A O AL L L A I N A D T T X D Y INSIGHT IMAGING-GATEWAY 690 N Cofco Center Ct #130 Phoenix Maricopa X X OPEN MRI SOLUTIONS LLC 4130 E Van Buren Phoenix Maricopa X AZ-TECH RADIOLOGY - OSBORN 444 W Osborn Rd Ste 105 Phoenix Maricopa X X X X X X X AMERICAN DYNAMIC IMAGING LTD 1110 E Missouri Ave Ste 410 Phoenix Maricopa X X ARIZONA ADVANCED IMAGING CENTER LLC 5501 N 19th Ave Ste 111 Phoenix Maricopa X X X X X SMI IMAGING LLC-19TH AVENUE 6707 N 19th Ave #108 Phoenix Maricopa X X X X SMI IMAGING LLC-19TH AVENUE WOMENS CTR 6707 N 19th Ave #101 Phoenix Maricopa X X X SIMONMED IMAGING INC-CAMELBACK 2141 E Camelback Rd 110 Phoenix Maricopa X X SMI IMAGING LLC - BILTMORE WOMEN'S CENTER 2502 E Camelback Rd #167 Phoenix Maricopa X X X X MRI OF ARIZONA INC 3139 E Lincoln Dr Phoenix Maricopa X X SMI IMAGING LLC - BILTMORE 2502 E Camelback Rd #160 Phoenix Maricopa X X X X X SMIL - HIGHLAND 2222 E Highland Ave Ste 120 Phoenix Maricopa X X X X X X X SOLIS BENORA MAMMOGRAPHY 1661 E Camelback Rd #140 Phoenix Maricopa X MRI OF ARIZONA INC 701 W Glendale Ave Phoenix Maricopa X X SIMONMED IMAGING INC-NOVACK N 19th Ave #230 Phoenix Maricopa X SMI IMAGING LLC - DEER VALLEY N 27th Ave Ste 150 Phoenix Maricopa X X X X X X SOLIS BENORA MAMMOGRAPHY N Tatum Blvd #105 Phoenix Maricopa X DESERT VALLEY RADIOLOGY PLC 2225 W Peoria Ave Ste 150 Phoenix Maricopa X X X X X SIMONMED IMAGING-METRO W Peoria Ave Ste B301 Phoenix Maricopa X SMI IMAGING LLC-METRO W Peoria Ave Ste B402 Phoenix Maricopa X X DESERT VALLEY RADIOLOGY PLC 4045 E Bell Rd Ste 143 Phoenix Maricopa X X X X X RAPIDRAY LLC 4646 E Greenway Blvd Phoenix Maricopa SMI-PARADISE VALLEY 4219 E Bell Rd Phoenix Maricopa X X X X X X X VALLEY RADIOLOGISTS - PARADISE VALLEY N 40th Street Ste 1 & 2 Phoenix Maricopa X X X X X X X X X DESERT VALLEY RADIOLOGY PLC 9150 W Indian School Rd Ste 136 Phoenix Maricopa X X X X X VALLEY RADIOLOGISTS 9305 W Thomas Road Ste 100 Phoenix Maricopa X X X X X X X X X X VALLEY RADIOLOGISTS - ESTRELLA WOMEN'S CENTER 9305 W Thomas Road Ste 200 Phoenix Maricopa X X X X X X X AZ-TECH RADIOLOGY- AHWATUKEE 4530 E Ray Rd Ste 160 Phoenix Maricopa X X X X X X SMI IMAGING LLC-AHWATUKEE S 46th Place #200 Phoenix Maricopa X X SMI IMAGING LLC - AHWATUKEE S 45th St Ste 110 Phoenix Maricopa X X X X X X X SMI IMAGING LLC - DESERT RIDGE N Tatum Blvd Ste 190 Phoenix Maricopa X X X X X X X SMI IMAGING LLC - FASHION SQUARE 6740 E Camelback Rd Ste 100 Scottsdale Maricopa X X X X X X X X SMIL-SPINE CENTER 3621 N Wells Fargo Ave Scottsdale Maricopa X SMI IMAGING LLC-THOMPSON PEAK 7304 Deer Valley Rd Ste 105 Scottsdale Maricopa X X SIMONMED IMAGING INC. MT VIEW WOMENS CENTER 9201 E Mountain View Rd Ste 112 Scottsdale Maricopa X SMI IMAGING LLC - MOUNTAIN VIEW 9201 E Mountain View Rd Ste 137 Scottsdale Maricopa X X X X X X X ASSURED IMAGING WOMENS WELLNESS 9180 E Desert Cove Ste 105 Scottsdale Maricopa X X X X SMIL - SOUTH IMAGING 3501 N Scottsdale Rd Ste 130 Scottsdale Maricopa X X X X X X X X SMIL - TOWN CTR MED PLAZA - WOMEN'S CTR 7301 E 2nd Street Ste 112 & 114 Scottsdale Maricopa X X X X X SMIL - NORTH FAMILY OFFICE 6501 E Greenway Parkway Ste 160 Scottsdale Maricopa X SMIL - THOMPSON PEAK N Scottsdale Healthcare Dr Ste 190 Scottsdale Maricopa X X X X X X X X SMIL - INTERVENTIONAL RADIOLOGY CLINIC 9220 E Mountain View Rd Ste 201 Scottsdale Maricopa X X SMIL - MOUNTAIN VIEW 9220 E Mountain View Rd Ste 100 Scottsdale Maricopa X X X X X X X X X X SMIL - NORTH IMAGING CENTER N 92nd St Ste 100 Scottsdale Maricopa X SMIL - PET CENTER 9003 E Shea Blvd PET/MRI Suite Scottsdale Maricopa X X SMIL - CAREFREE N Scottsdale Rd Ste 120 Scottsdale Maricopa X SMI IMAGING LLC W Camino Del Sol Ste 300 Sun City West Maricopa X X X X X X X VALLEY RADIOLOGISTS - SUN CITY WEST W Camino Del Sol Ste 101 Sun City West Maricopa X X X X X X X SMI IMAGING LLC-SUN LAKES E Riggs Rd #120, 110 Sun Lakes Maricopa X X X X X X SMI IMAGING LLC- STADIUM VILLAGE W Bell Rd Ste 110 Surprise Maricopa X X X X X X AZ-TECH RADIOLOGY & OPEN MRI 2501 E Southern Ave Ste 8 & 11 Tempe Maricopa X X X X X X X X SMIL IMAGING-TEMPE 1840 W Warner Rd Ste114 Tempe Maricopa X X X X X X X X DESERT VALLEY RADIOLOGY PLC 8380 S Kyrene Rd Ste 105 Tempe Maricopa X X X X X CARONDELET MEDICAL MALL - GREEN VALLEY 400 W Camino Verde Ste 200 Green Valley Pima X X X X X X RAPID SOUND 450 W Continental Rd Green Valley Pima X X X X X X X X RADIOLOGY LTD - RANCHO VISTOSO DIAGNOSTIC IMAGING 2551 E Vistoso Commerce Loop Oro Valley Pima X X X X X X CARONDELET RIVERSTON IMAGING CENTER 4892 N Stone Ave Ste 180 Tucson Pima X X X X X SMI IMAGING LLC - ORANGE GROVE 1845 W Orange Grove Rd Bldg 5 Ste 103 Tucson Pima X X RAPIDRAY LLC 7220 E Rosewood St Tucson Pima X X RLC LLC 6567 E Carondelet Dr Ste 105 Tucson Pima X X X X RADIOLOGY LTD 6567 E Carondelet Dr Ste 145 Tucson Pima X X X X X CARONDELET IMAGING CENTER 630 N Alvernon Way Ste 150 Tucson Pima X X X X X X X 2 of 3 F L U O I N T E R V E N T I O N M A M M O D I G I T M R I - O P N U C L E A R - M P E T - R A D - G U I D E - U L T R A S O U

4 RADIOLOGY NETWORK (sorted by County/City/Zip) D M X E C M M U P R X C T R A A R R E G E E C B N A FACILITY NAME ADDRESS CITY ZIP COUNTY PHONE FAX A T A O AL L L A I N A D T T X D Y RADIOLOGY LTD - St. JOSEPH'S IMAGING CENTER 330 N Wilmot Rd Tucson Pima X X RADIOLOGY LTD - WILMOT CENTER FOR DIAGNOSTIC IMAGING & TREATMENT 677 N Wilmot Rd Tucson Pima X X X X X X X RADIOLOGY LTD - WILMOT CENTER FOR WOMEN'S IMAGING 677 N Wilmot Rd Tucson Pima X X X SMI IMAGING LLC-WILMOT 310 N Wilmot Rd Ste 302 Tucson Pima X X X X X RADIOLOGY LTD - CAMP LOWELL IMAGING CENTER 4640 E Camp Lowell Tucson Pima X X X X X X OPEN MRI SOLUTIONS LLC 1020 E Palmdale St Ste 150 Tucson Pima X ARIZONA WOMENS IMAGING 4566 N 1st Ave Ste 100 Tucson Pima X X X RADIOLOGY LTD - LA CHOLLA CENTER FOR DIAGNOSTIC IMAGING & TREATMENT 5960 N La Cholla Tucson Pima X X X X X X X ASSURED IMAGING WOMENS WELLNESS 7717 N Hartman Ln Tucson Pima X X X X SMI IMAGINGLLC-ST MARYS 1313 W St Mary's Rd Tucson Pima X X X X RADIOLOGY LTD - MIDVALE IMAGING CENTER 1598A W Commerce Court Tucson Pima X X X X X CARONDELET MEDICAL MALL - RITA RANCH 8290 S Houghton Way Ste 100 Tucson Pima X RADIOLOGY LTD - RINCON IMAGING CENTER E Drexel Rd Tucson Pima X X X X X SIMONMED IMAGING INC-CATALINA 4566 North 1st Ave # 8 & 9 Tucson Pima X X X AZ-TECH RADIOLOGY & OPEN MRI - CASA GRANDE 1669 E McMurray Blvd. Casa Grande Pinal X X X X X X X X X X X SIMONMED IMAGING INC-CASA GRANDE 1664 E Florence Blvd #18 Casa Grande Pinal X X X X X X AZ-TECH RADIOLOGY & OPEN MRI - JOHN WAYNE PKWY N John Wayne Pkwy Ste 113 Maricopa Pinal X X X X X X SMI IMAGING LLC - QUEEN CREEK N Gantzel Rd Ste 101 Queen Creek Pinal X X X X X X RAPIDRAY LLC 1701 Emerald Dr Unit B Prescott Yavapai SIMONMED IMAGING - PRESCOTT 790 Gail Gardner Way Prescott Yavapai X X X X X X X SMI IMAGING LLC - PRESCOTT VALLEY 3033 N Windsong Dr Ste 102 Prescott Valley Yavapai X X X X X X X X F L U O I N T E R V E N T I O N M A M M O D I G I T M R I - O P N U C L E A R - M P E T - R A D - G U I D E - U L T R A S O U Revised of 3

5 INDEX Quick Reference Guide Index Advance Directives Ambulance Services... 7 American Sign Language Interpretation Anesthesia Services... 7 AHCCCS Mandatory Copays... 6 Appointment Availability & Wait Time Standards ASIIS AzEIP Behavioral Health (including Crisis Referral) Care Management Children s Rehabilitative Services (CRS) Chiropractic Services Claims Address... 3 Claims Customer Service... 3 Claim Dispute & Appeal Process Claim Forms... 3 Claims Liaison... 3 Contact Us... 2 Coordination of Benefits... 7 CPT Codes & Age Ranges... 8 Cultural Competency Data Validation Dental Services Developmental Screening Tools Diagnosis Codes... 5 Disease Management DME and Medical Supplies Drug Billing... 8 Duplicate Claims... 5 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)... 8 Electronic Data Interchange (EDI)... 4 Electronic Funds Transfer (EFT)... 5 Enterals Family Planning Formulary FQHC PPS Rate... 9 Fraud, Waste & Abuse Glucose Monitors GMH/SU and Children s BH Billing Guidelines...11 Hearing Services HIPAA 5010 Transactions... 5 Home Health Home Infusion Immunizations... 8 Insurance Requirements Laboratory Services Member Billing... 6 Member Eligibility Modifiers... 9 Multiple Page Claims... 5 Multiple Services... 5 National Provider Identification (NPI) Number... 4 No Show Appointment Log Non-Formulary & Five Day Overrides OB/GYN Services Operative Report...11 Orthotics Outpatient Rehab Services Paper Claims... 5 Peak Flow Meters Prior Authorization Provider Directories & Website Search Function Provider Forums Provider Manuals Psychotropic Prescribing Refunds...11 Remittance Advices Available on Website... 6 Resubmissions/Corrected Claims...11 Scanning Tips... 5 Specialty Medications Purchasing Program Timely Filing Guidelines... 3 Translation Services Transportation Services Vaccines for Children (VFC) Program... 8 Vision Services Website Wound Vac /2018 Topics are applicable to all lines of business unless otherwise designated in the topic header. page 1 of 38

6 CONTACT US CARE1ST or ONECARE or DEPARTMENT PHONE FAX DEPARTMENT PHONE FAX Care Management Options 4, Extension 8301 Claims Customer Options 5, Service - Medical Claims Customer Service - Dental Claim Disputes and Options 5, Appeals Claim Liaison Extension Disease Management Extension Hospital/SNF See Prior Admission Notification Authorization Medical Customer Service Options 5, Prior Authorization Dental Prior Authorization Status Inquiry Care Management Options 4, Extension 8301 Claims Customer Options 5, Service - Medical Claims Customer Service - Dental Claim Disputes and Options 5, Appeals Claim Liaison Extension Disease Management Extension Hospital/SNF See Prior Admission Notification Authorization Medical Customer Service Options 5, Prior Authorization Dental Prior Authorization Status Inquiry Contact Us Urgent Telephonic Requests, Options 5, 6, 2 Revisions to Existing Prior Options 5, 6, 3 Auths or Questions on Denied Auths Prior Authorization- Options 5, Pharmacy Network Management Options 5, Urgent Telephonic Requests, Options 5, 6, 2 Revisions to Existing Prior Options 5, 6, 3 Auths or Questions on Denied Auths Prior Authorization- Options 5, Pharmacy Network Management Options 5, /2018 page 2 of 38

7 CLAIMS & REIMBURSEMENT CLAIMS CUSTOMER SERVICE Medical/Behavioral Health Claims (CMS 1500 and UB-04 Claim Types): Claim status can be checked 24 hours a day, seven days a week online at Our Claims Customer Service Team is also available to assist you during the business hours listed below: Monday Friday 8:00 a.m. - 12:00 p.m. & 1:00 p.m. - 4:30 p.m. Care1st Ph / (options in order 5, 4). ONECare Ph / (options in order 5, 4). Dental Claims: Advantica manages the dental benefits provided to Care1st & ONECare members on behalf of Care1st. Claim status can be checked 24 hours a day, seven days a week online at Advantica s website, For questions on dental claim submissions, contact Advantica directly Monday Friday 8:30 AM 4:30 PM at CLAIMS LIAISON Our Claims Liaison is an excellent resource and is available to assist your office via phone or in person with questions regarding claim submission and processing. TIMELY FILING GUIDELINES When Care1st & ONECare are primary, the initial claim submission must be received within six months from the date of service. Secondary claim submissions must include a copy of the primary payer s remittance advice and be received within 60 days of the date of the primary payer s remittance advice or six months from the date of service, whichever is greater. Resubmissions/reconsiderations must be received within the following time frames: 12 months from date of service 60 days of the date of recoupment or within 90 days from the date of a reversed claims dispute decision, if greater than 12 months from the date of service 60 days from the date on the primary payer s remittance advice, if greater that 12 months from the date of service CLAIMS ADDRESS Medical/Behavioral Health Claims: Direct CMS 1500 and UB-04 claim forms (initial and resubmissions) and medical records to: Care1st or ONECare Attention Claims Department 2355 East Camelback Rd #300 Phoenix, AZ Dental Claims: Direct dental claim forms (initial and resubmissions) and medical records to: Advantica PO Box 8510 St. Louis, MO CLAIM FORMS The Centers for Medicare and Medicaid Services (CMS) now requires providers to submit all claims on the newest version of each claim form. The current claim versions are: Practitioners CMS-1500 (02/12) Facilities UB-04 Dental J430D All paper claims must be submitted on the current CMS1500 form (version 02/12). Claims received on the old CMS form (version 8/5) will be denied. Faxed claims are not accepted. As a reminder, the rendering provider name, Box 31 on the CMS1500 form, is required when it does not match Box 33, Billing Provider. Claims & Reimbursement 9/2018 page 3 of 38

8 NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER Care1st & ONECare require all providers to submit the rendering/ servicing provider s NPI on every claim. Care1st & ONECare require that when applicable, the prescribing, referring, attending and operating provider NPI(s) also be present on claim submissions. Claims without the required NPI(s) will be denied. Please work with your billing team to ensure that NPI(s) are submitted appropriately with each claim submission and call us if you have any questions or need assistance. To apply for an Individual NPI and/or Organizational NPI online, go to or contact the National Provider Identifier Enumerator Call Center to request a paper application. If you have not yet notified Care1st & ONECare of your NPI(s), please fax a copy of your NPI(s) confirmation to Network Management at Providers must also communicate their NPI(s) to AHCCCS Provider Registration. A copy of the NPI Number Notification, along with the provider s name, AHCCCS ID Number and signature of the provider or authorized signor may be mailed or fax to the following: AHCCCS Provider Registration PO Box Mail Drop 8100 Phoenix, AZ Fax Number: ELECTRONIC DATA INTERCHANGE (EDI) We encourage you to submit claims electronically! Advantages include: decreased submission costs faster processing and reimbursement allows for documentation of timely filing EDI is for primary claims only with the exception of claims when a member s primary insurance is ONECare and their secondary insurance is Care1st as our system automatically coordinates processing for these services submitted. Any other claims that require secondary payments must be submitted on paper with a copy of the primary remittance advice attached. Medical/Behavioral Health (CMS 1500 & UB 04) Claims We work with CHANGE Healthcare (fka Emdeon) for acceptance of EDI CMS 1500 & UB 04 claims. Our CHANGE Healthcare Payer I.D. is Questions may be directed to CHANGE Healthcare at Claims may be submitted electronically directly to CHANGE Healthcare or from your clearinghouse to CHANGE Healthcare. If you experience problems with your EDI submission, first contact your software vendor to validate the claim submissions and upon verification of successful submission, contact CHANGE Healthcare directly at Dental (J430D) Claims Dental claims may be submitted electronically using one of the methods below: 1. CHANGE Healthcare (fka Emdeon). CHANGE Healthcare partners with most dental software vendors. To begin submitting claims electronically to Advantica contact your software vendor and discuss set up for submission of electronic claims to CHANGE Healthcare. Make sure you provide the Advantica Payer ID EHG EDI Health Group, Inc. DentalXChange. To enroll go to: and click on Services > Provider Services > Claims Connect > Get Started or call ext Advantica Payer ID Tesia. To enroll call Advantica Payer ID Advantica Web Portal. Providers can also submit claims, check eligibility and confirm benefits through Advantica s online provider portal. To register, go to and click on Dental Provider Registration. Submit attachments such as x-rays (submitted as a TIF or JPG document) using NEA-Fast. To register online, go to and click on REGISTER NOW. Select the appropriate option and click Next. You can also register via phone by calling (Select Option 2). You will receive an assigned NEA number to reference on the electronic claim submission. Claims & Reimbursement 9/2018 page 4 of 38

9 ELECTRONIC FUNDS TRANSFER (EFT) EFT allows payments to be electronically deposited directly into a designated bank account without the need to wait for the mail and then make a trip to the bank to deposit your check! Medical/Behavioral Health Claims The EFT form is available on our website under the Forms section of the Provider menu. If you do not have internet access, contact Network Management and we will provide you with the form. Dental Claims Advantica works with RedCard: To enroll for EFT online, register by visiting: and create your account by filling out all the fields and click submit. You will receive a Welcome . Using the URL in the , log in using the temporary password and select Continue Enrollment. When prompted, enter Advantica Payer ID PAPER CLAIMS Scanning Paper claims are scanned into our system using a process called data lifting. To assist with clean scanning, below are several reminder tips: Use black ink for all claims submissions and if a stamp is required, refrain from red ink as this may be removed during the scanning process Always attempt to ensure that clean character formation occurs when printing paper claims (i.e. one side of the letter/number is not lighter/darker than the other side of the letter/number) Avoid placing additional stamps on the claim such as received dates, sent dates, medical records attached, resubmission, etc. (characters on the claim from outside of the lined boxes have a tendency to throw off the registration of the characters within a box) Multiple Page Claims When a claim is greater than one page, place the grand total dollar amount for the claim on the bottom of the last page; do not enter sub-totals on each individual page. Multiple Services All services for the same date of service (less than 6 lines on a CMS 1500) are submitted on a single claim form. When multiple units are performed for the same service and date of service, the service is submitted on one line with the appropriate number of units. For additional guidelines on bilateral procedures, refer to page 10 for Modifier 50 information. DIAGNOSIS CODES Paper and electronic CMS 1500 claims can contain a maximum of 12 diagnosis codes per claim. All diagnosis codes submitted must be effective for the date(s) of service on the claim. DUPLICATE CLAIMS To avoid duplicate claims, we recommend checking claims status via the Care1st website after 14 days following submission and allowing 60 days prior to resubmission of a claim. The 60 days allows us to meet our goal of paying claims within 30 days from the date of receipt and also allows enough time for billing staff to post payments. Resubmission of claims prior to 60 days causes slower payment turnaround times and increases your administrative costs. Your claim status can be verified 24 hours a day, seven days a week on our website. Contact Network Management to obtain a login or confirm your login status. HIPAA 5010 TRANSACTIONS Care1st is compliant with the AHCCCS implementation of all 5010 transactions. Trading partners are required to begin sending electronic transactions in the 5010 format. We encourage you to reach out to your respective clearinghouse to obtain specific instructions to Claims & Reimbursement 9/2018 page 5 of 38

10 HIPAA 5010 TRANSACTIONS (continued) ensure you understand how the changes with 5010 may impact your submissions and receipt of data. Some of the major changes with the 5010 claims submission process are listed below: Service and billing address: The service and billing address must be the physical address associated with the NPI and can no longer be a post office box or lock box. The pay to address may still contain a post office box or lock box. State and Postal Codes: State and zip codes are required when the address is in the US or Canada only. Postal codes must be a 9-digit code for billing and service location addresses. Rendering tax identification number: The rendering provider tax identification number requirement has been removed. The only primary identification number allowed is the NPI. Secondary identification numbers are only for atypical providers (such as non-emergent transportation) and we recommend you use the G2 qualifier. The billing tax ID is still required. Number of diagnosis codes on a claim: For electronic submissions, it is a requirement that diagnoses are reported with a maximum of 12 diagnosis codes per claim under the 5010 format and paper CMS 1500 submissions contain a maximum of 12 diagnosis codes per claim. REMITTANCE ADVICES AVAILABLE ON WEBSITE Medical/Behavioral Health For your convenience, remittance advices are available for reviewing and printing on our website for up to 6 months from the date of payment, minimizing delay between receipt of dollars and the ability to post payment. Contact Network Management to obtain a login or confirm your login status. Dental Dental remittance advices are available for reviewing and printing on Advantica s website. For instructions on how to obtain a login refer to Dental Services on page 29. If you have any questions regarding the registration process, please contact Advantica at AHCCCS COPAYS (CARE1ST) Mandatory Copays: AHCCCS members who have mandatory copays for certain services are: Transitional Medical Assistance (TMA) members (Copay Level 50) Pharmacy $2.30 Office Visits $4.00 Outpatient Professional Therapies $3.00 Surgeries (In Office; Outpatient non-emergent; ASCs) $3.00 AHCCCS Online, aspx, has the most current eligibility and copay information for all AHCCCS members. If you are not registered to use this system, register by choosing the Register under New Account. The Co- Payment tab at the top of the member s eligibility verification screen indicates the member copay level and provides a link to the AHCCCS Copay Grid, which provides you the detail on the mandatory copay levels and applicable services. Ongoing updates from AHCCCS regarding copayment requirements can be found at: html. MEMBER BILLING A member may request a copy of their medical record free of charge. A provider may bill a member only if: 1) the member claiming to be AHCCCS eligible was not eligible on the date of service or 2) the member has a mandatory co-payment for the service in question or 3) the services were not AHCCCS Covered Services and the provider has provided the member with a document listing the requested non-covered services and the estimated cost of each service; the member signs the document prior to the provision of these services indicating the member understood and accepted responsibility for payment. Care1st members may not be billed, or reported to a collection agency for any AHCCCS covered service. Providers cannot collect copayments, coinsurance or deductibles from members with other insurance regardless of the type of carrier. Providers must bill Care1st as the secondary plan and Care1st will coordinate benefits. Claims & Reimbursement 9/2018 page 6 of 38

11 AMBULANCE SERVICES Claims for emergent transportation, including transport transfer services to a higher level of care (such as member transfer from Skilled Nursing Facility to Hospital), must indicate Emergency in Box 24C. Emergent services do not require prior authorization; however non-emergent services must be authorized accordingly. The appropriate modifier for ambulance services must also be billed. Fractional mileage is now accepted by AHCCCS and should be billed on transport claims when applicable. The pickup address (or location if an address is not available) and drop off address are required in box 32 for ambulance services. For electronic claims, the pickup location must be billed in loop 2310E and the drop off location must be billed in loop 2310F. No trip ticket is required if these are populated correctly. For paper claims, a trip ticket is required on each claim. Pick-up and drop-off requirements are as follows: 1. Pickup and/or drop off location = facility, i.e. hospital, SNF Facility name, city, state, zip OR street address, city, state, zip required in box Pick up and/or drop off location facility Street address, city, state, zip required in box Pick up location = area where there is NO street address Description of where service was rendered (e.g. crossroad of State Road 34 and 45 or exit near mile marker 265 on Interstate 80 ) required in box 32 Claims that do not contain the minimum requirements are denied. Do you know who your Provider Rep is? If you aren t sure, visit our website to find out! Click on Care1st > Providers > Provider Rep Contact Info ANESTHESIA SERVICES Anesthesia time is required for all anesthesia services and the total number of minutes is required in the unit field (25G). The start and end time must also be indicated on the claim form. The QX modifier is billed with the CRNA service when medical direction is provided by a physician. The QY modifier is billed by the supervising physician to indicate medical direction was provided to the CRNA. The QK modifier is billed by the supervising physician to indicate that medical direction was provided to multiple concurrent anesthesia procedures. As a reminder, the anesthesia record is required anytime the anesthesia starts and stops during a procedure. BEHAVIORAL HEALTH SERVICES Effective 10/1/18, ACOM Policy 432 was revised to reflect the ACC model. COORDINATION OF BENEFITS Please verify if other coverage exists at the time of member s appointment. When Care1st or ONECare is the secondary insurance, all pages of the primary payer s remittance advice are submitted with the claim, including the remark code/remittance comments section of the remittance advice. A legible copy of the remittance advice is needed with claim submission. Whenever possible, when a member is ONECare primary and Care1st secondary we coordinate processing for these services and submission of the primary remittance advice along with another claim will not be necessary. This is only when the member is both Care1st and ONECare. Please contact our Claims Customer Service Team if you have not received a remittance advice for both lines of business within 90 days. There are certain circumstances when crossover is not possible, i.e. DME, if you have questions on these exceptions please call Claim Customer Service or Network Management to discuss. Claims & Reimbursement 9/2018 page 7 of 38

12 CPT CODES & AGE RANGES Below are several CPT Codes and associated age ranges that are often billed incorrectly therefore resulting in claim denials. Please double-check the member s age prior to billing these specifics codes: CPT Code CPT Description Age Range 90633** Hepatitis A Vaccine 1 21 years 90649** HPV Vaccine Gardisil 90650** HPV Vaccine Cervarix Males and Females 9 26 years; Coverage for 9 10 years is limited to high risk only Females only Ages 9 26 years; Coverage for 9 10 years is limited to high risk only Influenza Virus Vaccine 6 months 35 months 90658** Influenza Virus Vaccine 3-18 years 90680** Rotavirus Vaccine 1 month 8 months 90698** DTaP Hib IPV 6 weeks 260 weeks Subsequent inpatient pediatric critical care 29 days 744 days **90633, 90649, 90650, 90658, and are not covered by ONECare VACCINES FOR CHILDREN (VFC) PROGRAM (CARE1ST) PCPs rendering services to children under the age of 19 and covered by AHCCCS must participate in the VFC program and coordinate with the Arizona Department of Health Service Vaccines for Children (VFC) program in the delivery of immunization services. Through the VFC program, the federal government purchases and makes available to the states, free of charge, vaccines for children under the age of 19 who are Title XIX eligible, Native American, or Alaskan Native, not insured, or whose insurance does not cover immunizations. Immunizations must be provided according to the Advisory Committee on Immunization Practices Recommended Schedule which is found at or on our website (See Practice & Preventive Health Guidelines under the Provider menu). For more information regarding the VFC program or to enroll as a VFC provider please call the Vaccine Center at When E&M services and VFC services are performed on the same day, billing for these services are submitted on the same claim. One administration fee is reimbursed for each immunization, including combination vaccines. To receive reimbursement for the administration of a VFC vaccine, bill the vaccine CPT code (including the NDC) with an SL modifier and the applicable vaccine administration code with an SL modifier (refer to the SL modifier information on page 10). Administration fees should be billed on a single line, with the appropriate number of units. DRUG BILLING AHCCCS requires drugs administered in outpatient clinical settings be billed in accordance with Federal Deficit Reduction Act of In order to receive reimbursement, all paper and electronic UB-04 and CMS 1500 claims must include the appropriate National Drug Code (NDC) number for drugs administered in an outpatient setting. Claim lines billed without the NDC code are denied. J3490 is used for unclassified drugs the unit of measure and dosage quantity should be billed following the NDC billing guidelines. The line level quantity billed should always reflect 1 (one). EPSDT CPT CODES AND ASSOCIATED AGE RANGES Below are CPT codes and associated age ranges that are frequently billed incorrectly, resulting in a denial. Please double check the member s age prior to billing for these procedures. EPSDT Visit Billing: New Patient CPT Code Established Patient CPT Code Ages 0 12 months Ages 0 12 months Ages 1 4 years Ages 1 4 years Ages 5 11 years Ages 5 11 years Ages years Ages years Ages years Ages years E&M codes for sick visits billed in conjunction with an EPSDT visits are reimbursed at 50% of the rendering providers fee schedule Claims & Reimbursement 9/2018 page 8 of 38

13 FQHC/RHC PPS RATE AHCCCS health plans reimburse FQHC/RHC claims at the PPS rate in accordance with AHCCCS billing requirements. There are specific requirements for reimbursement, which are posted to the AHCCCS website in Chapter 10 FQHC/RHC Addendum of the AHCCCS Fee-for-Service Provider Manual. Please reference this Chapter for important claim submission details. Reminders: 1. The billed amount for the T1015 must be greater than or equal to the PPS rate or lesser of is applied 2. The rendering provider on the claim is the FQHC facility not the practitioner. The site specific NPI and/or the FQHC entity name is placed in the following fields of the claim: Medical Paper Claims Dental Paper Claims Medical & Dental EDI Claims Box 24J Box 54 and 56 Loop 2310B and 2310C 3. The participating/performing practitioner information is listed the following fields of the claim: Medical Paper Claims Dental Paper Claims Medical & Dental EDI Claims Box 19 Box 35 Loop 2310 NTE segment 4. Services provided in some places of service outside the FQHC/ RHC, i.e. services rendered in an inpatient hospital setting, should be billed under the servicing practitioner vs. the FQHC/ RHC 5. When submitting a paper claim, populate box 31 on medical and box 53 on dental claims with Signature on file. (For 837 submissions this field, loop 2300, clm, 06 should be left blank) 6. At a minimum, there should at least be 2 codes billed. The T1015 and the actual service(s) rendered. All services performed at the visit should be billed on the same claim. 7. For maternity claims: All prenatal and post-partum visits should be billed by the FQHC/RHC site and are paid the PPS rate The delivery is billed under the practitioner that performed the delivery 8. Coordination with other primary insurance is applied to the whole claim to determine secondary payment 9. For members that have ONECare (Medicare) and Care1st coverage, the secondary claim must be submitted to Care1st on paper with a copy of the ONECare remittance advice. MODIFIERS Below are a few commonly used modifiers and tips on appropriate usage: EP Modifier (Care1st) Modifier EP is billed in conjunction with for reimbursement of developmental testing utilizing any of the three AHCCCS approved Developmental Tools: PEDS Tool, MCHAT or ASQ. Providers must first complete the training for the tool that is utilized to be eligible for reimbursement of this service. Refer to the Developmental Screening Information on page 23. The EP modifier is also required on preventative EPSDT services (CPT codes , ) and to designate all services related to the EPSDT well child visit, including routine vision and hearing screenings. For more information, see our blast fax communication from August 28, 2014 on our website and the AHCCCS Medical Policy Manual (AMPM) Chapter 400 Policy Section H. See the SL modifier section below for an example of how to bill a sick visit, EPSDT visit and VFC vaccine administration. Modifier 25 (Separate identifiable E&M service) When an EPSDT visit ( or ) is performed in conjunction with a sick visit ( ) for members less than 21 years of age, modifier 25 is required on the sick visit CPT code in order to be reimbursed for both the EPSDT visit and the sick visit. If both visits are performed in conjunction with VFC immunizations, the modifier 25 is required on both the E&M and EPSDT codes. Modifier EP is required on the EPSDT visit code. The sick visit is reimbursed at 50% of the applicable fee schedule. Please remember that both visits must be billed on the same claim form. See the SL modifier section below for an example of how to bill a sick visit, EPSDT visit and VFC vaccine administration. Claims & Reimbursement 9/2018 page 9 of 38

14 MODIFIERS (continued) SL Modifier (State supplied vaccine) (Care1st) Vaccines administered to members under the age of 19 are supplied through the Vaccines for Children (VFC) program. For a complete listing of eligible VFC codes, refer to To be eligible for reimbursement, bill vaccines supplied through the VFC program as outlined in the claim example below. CLAIM EXAMPLE: Billing sick visit, EPSDT visit and vaccine code(s) for single date of service: Patient (under the age of 19) makes appointment because of an earache. Office determines it is time for EPSDT evaluation and vaccine. Office bills: Both the sick and well diagnosis codes Sick visit with appropriate E&M ( ) with modifier 25 EPSDT visit with appropriate E&M ( or ) with modifier 25 and modifier EP Vision screening is performed as part of the EPSDT visit with modifier EP VFC vaccine code with the applicable NDC and the SL modifier Vaccine administration code with the SL modifier Modifier 50 (bilateral procedure) Modifier 50 is required for all bilateral procedures. Please refer to the current coding guidelines for a listing of appropriate bilateral procedures. Bilateral procedures are billed on one line with the 50 modifier: EXAMPLE: Line 1: 69436, with 50 modifier, full dollar amount, 1 unit Total payment: 150% of fee schedule Modifier 59 (distinct procedural service) Modifier 59 is required to identify a truly distinct and separate service and should not be used if the procedure is performed on the same site. When an already established modifier is appropriate, it should be used instead of modifier 59 (example modifier 91 for repeat clinical procedures). Care1st & ONECare apply NCCI (National Correct Coding Initiative) bundling edits to claims. Claims submitted with modifier 59 are subject to medical review and office notes/operative reports are required with the claim submission for consideration. Additional HCPCS modifiers that define subsets of the modifier 59, are defined below: XE: Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter XS: Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP: Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner XU: Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service Records are required for modifier 59, XE, XS, XP & XU when billed with the following codes: 36600, , , , , , , , , , or Records are also required for these modifiers for billed with pain management procedures or billed with Modifier 76 (repeat procedure by same physician) Modifier 76 is required to identify repeat procedures performed by the same physician. When multiple procedures are performed by the same provider, both services are submitted on the same claim. Claims submitted with modifier 76 are subject to the medical review and records are required with the claim submission in order to be considered. Modifier 77 (repeat procedure by a different physician) Modifier 77 is required to identify repeat procedures performed by different physicians. Claims submitted with modifier 77 are subject to medical review and records are required with the claim submission in order to be considered. Modifier 91 (repeat clinical diagnostic laboratory test) Modifier 91 is required to identify repeat procedures performed by the same physician. When multiple procedures are performed by the same provider, both services are submitted on the same claim. Claims submitted with modifier 91 are subject to medical review and records are required with the claim submission in order to be considered. Claims & Reimbursement 9/2018 page 10 of 38

15 MODIFIERS (continued) Modifier SG (Ambulatory Surgical Center facility service) Modifier SG is required on surgical procedures to identify the facility billing and is not used for professional services. Additional Modifier Requirements Don t Forget! Modifiers are required for all DME, Prosthetics and Orthotics and Ambulance services. When both the technical and professional component are performed by the same provider of service, the service code(s) should be billed on a single service line without a modifier, and not billed on two separate lines with the TC and 26 modifiers. OPERATIVE REPORT An operative report is required for the following surgical procedures: Multiple procedures with a total allowed amount greater than $ Any surgical procedure billed with the following modifier(s): 59, 62, 66, 76, 77, 78, XE or XP Claims 59, XS, XU Claims with codes billed in the ranges under modifier 59 section Any unlisted procedures Any surgical procedure billed for a higher level of care than originally prior authorized REFUNDS When submitting a refund, please include a copy of the remittance advice, a letter or memo explaining why you believe there is an overpayment, a check in the amount of the refund, a copy of the primary payer s remittance advice (if applicable), and a corrected claim (if applicable). If multiple claims are impacted, submit a copy of the applicable portion of the remittance advice for each claim and note the claim in question on the copy. When a refund is the result of a corrected claim, please submit the corrected claim with the refund check. Refunds are mailed to Care1st/ONECare, Attention: Finance, 2355 E Camelback Road, Suite 300, Phoenix, Arizona RESUBMISSIONS/CORRECTED CLAIMS When submitting a corrected claim, please include an attachment indicating the reason for resubmission along with the corrected claim/ resubmission and the original claim number to expedite handling. If you feel that you have identified a billing issue that may result in a larger volume of resubmissions, please work directly with your Network Management Representative or our Claims Liaison. GENERAL MENTAL HEALTH/SUBSTANCE USE AND CHILDREN S BEHAVIORAL HEALTH BILLING GUIDELINES Integrated Clinics and Behavioral Health Outpatient Clinics Services received at an Integrated Clinic or Behavioral Health Outpatient Clinic are billed under the clinic location as indicated below. Rendering Provider = service location, not a practitioner. The site specific NPI is used and is placed in the following location: Paper claim-box 24J EDI claim-loop 2310B bill (Note: If Loop 2010AA: NM109 also contains the site location NPI, Loop 2310B can be left blank) Signature field is left blank for clinic facility billing. The signature field is located as follows: Paper claim-box 31 EDI claim-loop 2300: CLM06 AHCCCS Registered Practitioner Services rendered by an AHCCCS registered practitioner, i.e. Licensed Marriage/Family Therapist (LMFT), Licensed Professional Counselor (LPC), Licensed Independent Substance Abuse Counselor(LISAC), Physician (MD), Physician Assistant (PA), Nurse Practitioner (NP), Licensed Clinical Social Worker (LCSW) or a Psychologist, are billed under the rendering practitioner. Rendering provider = the practitioner. The practitioner s NPI is placed in the following location: Paper claim-box 24J EDI claim-loop 2310B Claims & Reimbursement 9/2018 page 11 of 38

16 GENERAL MENTAL HEALTH/SUBSTANCE USE AND CHILDREN S BEHAVIORAL HEALTH BILLING GUIDELINES (continued) Signature field is populated with the rendering practitioner s name. The signature field is located as follows: Paper claim-box 31 EDI claim-loop 2300: CLM06 Please refer to the Behavioral Health section on page 17 for additional information PRIOR AUTHORIZATION TIPS AUTHORIZATION FORMS The Treatment Authorization Request Form (TAR) is used to request prior authorizations for medical services (including inoffice injectables). The Pharmacy Prior Authorization Form is used to request prior authorization for nonformulary drugs. The TAR and the Pharmacy Prior Authorization Forms are available on our website under the Forms section of the Provider menu. For Dental prior authorization information refer to the Dental Services section on page 29. For Total OB prior authorization information refer to the OB/ GYN Services section on page 27. For the most up to date information, visit our website: PRIOR AUTHORIZATION NUMBER SUBMISSION ON CLAIM A prior authorization number is issued by the Prior Authorization Department when a treatment authorization is approved. The prior authorization number must be included on the claim in order for claim adjudication and payment to occur. UB-04 place authorization number in field 63 CMS 1500 place authorization number in field 23 Procedures for obtaining prior authorization are described in detail in the Provider Manual: Care1st Manual Section IX ONECare Manual Section X Claims & Reimbursement Prior Authorization Tips 9/2018 page 12 of 38

17 GENERAL PRIOR AUTHORIZATION REMINDERS 1. Prior Authorization Guidelines and Formularies are available on our website under the Provider menu. You may also contact Network Management for copies to be mailed to your office. 2. Please refer to our Prior Authorization Guidelines for prior authorization requirements. Prior authorization is required for some services when Care1st is the secondary payer. 3. Direct members to contracted providers including when Care1st is the secondary payer. 4. All services requested for a non-contracted provider require prior authorization. 5. For specialties that require prior authorization for the initial consult (AHCCCS covered only), follow-up visits, procedures and medical/behavioral services, all authorized services performed must fall within the authorization date range approved. 6. For timely processing of services requiring prior authorizations, fax completed requests with all applicable notes and records to Urgent Our goal is to process and return within one working day from the date received by the Prior Authorization Team as long as all necessary medical documentation is included for review. Requests may also be obtained over the telephone by calling (Options 5, 6, 3) 7. Please make certain your treatment authorization requests are checked Routine or Urgent as medically appropriate. This reduces additional outreach to you, resulting in faster turnaround for all authorization requests! Care1st reserves the right to review and downgrade urgent requests to routine status if determined not to be urgent. AHCCCS define an Urgent request as: A request for services in which either the requesting provider indicates or the Contractor determines that following the standard timeframes for issuing an authorization decision could seriously jeopardize the member s life or health or ability to attain, maintain, or regain maximum function. 8. To check the status of a prior authorization request contact (Options 5, 6, 2). 9. Revisions to existing prior authorizations previously submitted may be updated if no claims have been adjudicated and it is within 30 days from receipt of original authorization approval. Contact (Options 5, 6, 3) to request changes. DOCUMENTATION Provide the past year s medical records and/or any supporting documentation to justify your request. Failure to submit support documents may delay processing Provide laboratory results and diagnostic tests, office notes, x-ray reports and specialist consult notes to expedite the medical necessity reviews for both medical and pharmacy requests. Network Management Phone: or (Options in order: 5, 7) sm_az_pno@care1staz.com Fax: Visit our website at Prior Authorization Tips 9/2018 page 13 of 38

18 FRAUD, WASTE & ABUSE Care1st & ONECare prohibit fraud, waste, or abuse and are committed to responding appropriately in the event potential or suspected fraud, waste, or abuse is committed by employees, vendors, subcontractors, contracted providers, or business associates. Our Fraud, Waste & Abuse Compliance Program is organized to follow, in sequence, the core elements of a compliance plan built in accordance with the Centers for Medicare and Medicaid (CMS) Guidelines. CMS requires Medicare plans to provide compliance related training materials to contracted providers, i.e. First tier, downstream and related entities (FDRs), and their employees who are involved in the administration or delivery of Medicare benefits. Your attestation is required as proof you received the training materials and rolled them out to staff. AHCCCS and CMS also require that we provide you our fraud, waste and abuse policies and procedures, our standards of conduct, our Anti-Fraud Plan and HIPAA Training. In order to prove you received them your attestation is required. As a result of this requirement, two attestations are needed by September 30, 2017 and annually thereafter: Fraud, Waste, & Abuse Training Attestation Policies & Procedures, Anti-Fraud Plan, Standards of Conduct for Providers, and HIPAA Training Attestation Training materials and the attestations are located at: Click on Care1st > Providers > Compliance Resources > FDR/General Compliance Information If you do not have internet access or have questions, please contact the Compliance Department at x8343 or us at ComplianceDepartmentAZ@care1staz.com. Health care fraud is a serious and costly reality. It places members at risk and increases the cost of health care for all of us. The following are highlights of our Fraud, Waste & Abuse Program: 1. The purpose of the Fraud, Waste & Abuse policy is to articulate our commitment to doing the right thing when it comes to fraud, waste and abuse. 2. We are committed to being compliant with all government requirements associated with fraud, waste and abuse. 3. We work to prevent fraud, waste and abuse through awareness training and communication. 4. We develop our Fraud, Waste & Abuse infrastructure to assess risk, monitor and audit our systems to detect signs of fraud, waste or abuse. 5. Allegations of fraud, waste, or abuse are investigated and where appropriate, corrective action is taken. Corrective action may include operational or policy changes, disciplinary action up to and including termination, and legal action. Health care fraud is a problem that concerns everyone in our health care system and a reality that we cannot afford to ignore. REPORTING POTENTIAL FRAUD, WASTE AND ABUSE Medicare Fraud Hotline of the HHS office Inspector General You may report direct to AHCCCS by completing the fraud and abuse referral available at Arizona Health Care Cost Containment System (AHCCCS) Office of Inspector General or Care1st/ONECare Anonymous Compliance Hotline Care1st/ONECare Compliance (if sending PHI, ensure it is sent securely) ComplianceDepartmentAZ@care1staz.com Fraud, Waste & Abuse 9/2018 page 14 of 34

19 REPORTING POTENTIAL FRAUD, WASTE AND ABUSE (continued) Care1st/ONECare Compliance Officer Compliance Officer Care1st ONECare 2355 E. Camelback Road Suite 300 Phoenix, AZ x8302 There is no tolerance for retaliation against any employee, physician, vendor, or contractor for making a good faith report of possible wrongdoing. Retaliation is against the law, and it is a violation of our policy. If you wish, you may also call our Hotline anonymously. Additional educational materials are available on our website under the Fraud, Waste & Abuse/Compliance Resources section of the Provider menu. EXCLUDED PARTICIPATION IN FEDERAL HEALTH CARE PROGRAMS Important reminder, as a registered provider with the AHCCCS Administration and/or Medicare, you are obligated under 42 C.F.R (b), to screen all employees, contractors, and/or subcontractors to determine whether any of them have been excluded from participation in Federal health care programs. You can search the HHS-OIG website, at no cost, by the names of any individuals or entities. The database is called LEIE, and can be accessed at Do you know who your Provider Rep is? If you aren t sure, visit our website to find out! Click on Care1st > Providers > Provider Rep Contact Info CLAIMS DISPUTE & APPEAL PROCESS CARE1ST Care1st encourages providers to check claim status on our website or contact Claims Customer Service for assistance with questions or issues regarding claim payment, partial payment, or non-payment. As a reminder, claims must be received within six months from the date of service. A claim payment, payment reduction or claim denial may be disputed by filing a claim dispute. AHCCCS guidelines require that all claim disputes (i.e. complete or partial denial of a claim) must be submitted in writing within 12 months from the date of service; within 12 months after the date of eligibility posting; the date of discharge (for an inpatient claim); or within 60 days of the last adverse action, whichever is greater. All requests for dispute should include: A completed Claim Dispute Form OR a letter detailing the factual and legal basis for the dispute. (Please submit one Claim Dispute Form or a letter for each disputed claim. You may download the Claim Dispute Form from our website (under the Forms section of the Provider menu) or contact Network Management for a copy. A copy of the original claim and remittance advice. Supporting documentation for reconsideration. For provider disputes with a clinical component such as denied inpatient days, or services denied for no prior authorization, additional documentation should include a narrative describing the situation, an operative report and medical records as applicable. Mail the completed form(s) and documentation to: Care1st Provider Claim Disputes 2355 E Camelback Road, Ste 300 Phoenix, AZ Disputes that fail to detail the facts of the case, the legal argument or are submitted with incomplete information will be denied without medical review. Care1st will not solicit supporting documentation. Corrected claims (adding or subtracting a modifier, changing units or CPT codes, etc.) are not considered claim disputes and may be addressed directly to our Claims Department for review and adjudication. Fraud, Waste & Abuse Claims Dispute & Appeal Process 9/2018 page 15 of 38

20 CLAIMS DISPUTE & APPEAL PROCESS - CARE1ST (continued) Care1st acknowledges claim dispute requests within five business days of receipt. The dispute is reviewed and a decision issued within 30 calendar days of receipt. An extension of up to 14 calendar days may be requested if a need for additional information is established. Care1st issues ALL decisions, whether approved or denied, in writing. ONECARE Providers should check claims status on our website and contact Claims Customer Service for assistance with questions or issues regarding claim payment, partial payment, or non-payment. As a reminder, claims must be received within six months from the date of service. Provider Appealing on Behalf of a ONECare Member If ONECare denies your pre-service or authorization request for a member, in whole or part, you may file an appeal on behalf of the member within 60 calendar days of the original denial notice. You have all rights and responsibilities of a member in obtaining an organization determination or managing the levels of the appeal process. Have any of the following changes occurred in your practice? New practitioners? Practitioner departures? Address additions or closures? Phone or fax change? Tax ID or pay to address change? REMEMBER Please Notify Network Management!! MEDICAL SERVICES ASIIS (CARE1ST) The State of Arizona (ARS and AAC R and R ) requires that all immunizations administered to children under the age of 19 be reported to the Arizona Department of Health Services ASIIS system. ASIIS, which stands for the Arizona State Immunization Information System, requires all immunizations to be reported at least monthly, and it is recommended that high volume immunization providers report more frequently. Your office can report to ASIIS electronically via the ASIIS website or through data exports directly from patient management/billing systems. Training by Arizona Department of Health Services is provided free of charge. While the law does not require reporting adult immunizations, ASIIS recommends doing so. Contact Information: ASIIS website epidemiology-disease-control/immunization/asiis/index.php. Training - contact ASIIS Hotline at For Technical Support call or For free ASIIS web-based application call or For assistance with other methods of electronic data transfer call AZEIP (CARE1ST) The Arizona Early Intervention Program, also known as AzEIP offers support and services to families of children birth to three years old with disabilities or developmental delays. During an EPSDT visit, if concerns about a child s development are identified, a referral for evaluation for possible AzEIP services should be made. Care1st is responsible for covering all medically necessary services such as diagnostic testing and speech or physical therapies under the EPSDT program and coordinating services with AzEIP. If the PCP identifies developmental delays, please submit a Treatment Authorization Request Form, including clinical information to support the request, to the Prior Authorization Department. A determination on the request will be made based on medical necessity. Claims Dispute & Appeal Process Medical Services 9/2018 page 16 of 38

21 AZEIP (CARE1ST) (continued) Your office or a family member may make a direct referral to AzEIP for services. AzEIP will perform an evaluation; develop an Individualized Family Service Plan (IFSP); and send an EPSDT Form and copies of the evaluation/developmental summaries to Care1st. Care1st will work with the PCP in determining if the services requested by AzEIP and documented on the IFSP are medically necessary. If the PCP determines the services requested are not medically necessary, the Care1st AzEIP Coordinator notifies the AzEIP Service Coordinator and parents of the determination. AzEIP may provide services that are determined NOT to be medically necessary. EPSDT early intervention services are provided by the Care1st provider (or AzEIP service provider) until services are no longer medically necessary or the child turns three years old. Open communication between the PCP, Care1st and AzEIP continues as long as coordination of care is required. Contact Information: Care1st Care Coordination Ext Arizona Early Intervention Program Website Phone Fax allazeip2@azdes.gov BEHAVIORAL HEALTH Effective October 1, 2018, AHCCCS Complete Care begins. This new integrated system will join physical and behavioral health services together to treat all aspects of the members health. This section will provide a brief overview of the behavioral health services and guidelines. For more detailed information, please see Section VII of the Provider Services Manual. General and Informed Consent to Treatment General Requirements As per AHCCCS AMPM 320-Q General and Informed Consent, each member has the right to participate in decisions regarding their behavioral health care, including the right to refuse treatment. It is important for members seeking behavioral health services to agree to those services and be made aware of the service options and alternatives available to them as well as specific risks and benefits associated with these services. Documentation All evidence of informed consent and general consent to treatment must be documented in the comprehensive clinical record as per AMPM Policy 940 Medical Records and Communication of Clinical Information for: General Consent to Treatment Psychotropic Medications Electroconvulsive Therapy Consent for Complementary and Alternative Treatment (CAM) Use of Telemedicine Application for A Voluntary Evaluation Research Admission for medical detoxification, an inpatient facility or a residential program (for members determined to have a Serious Mental Illness); and Procedures or services with known substantial risks or side effects Psychotropic Medication: Prescribing And Monitoring Psychotropic medication will be prescribed by a licensed psychiatrist psychiatric nurse practitioner, licensed physician assistant, or other physician trained or experienced in the use of psychotropic medication. The prescribing clinician must have seen the member and is familiar with the member s medical history or, in an emergency, is at least familiar with the member s medical history. When a member on psychotropic medication receives a yearly physical examination, the results of the examination will be reviewed by the physician prescribing the medication. The physician will note any adverse effects of the continued use of the prescribed psychotropic medication in the member s record. Whenever a prescription for medication is written or changed, a notation of the medication, dosage, frequency or administration, and the reason why the medication was ordered or changed will be entered in the member s record. Medical Services 9/2018 page 17 of 38

22 CRISIS INTERVENTION SERVICES Crisis intervention services are provided to a member for the purpose of stabilizing or preventing sudden, unanticipated, or potentially dangerous behavioral health condition, episode or behavior. Crisis intervention services are delivered in a variety of settings, such as hospital emergency departments, face-to-face at a member s home, over the telephone or in the community. These intensive and time limited services may include screening (i.e. triage and arranging for the provision of additional crisis services) assessing, evaluating or counseling to stabilize the situation, medication stabilization and monitoring, observation, and/or follow-up to ensure stabilizations, and/or therapeutic and supportive services to prevent, reduce, or eliminate a crisis situation. In the event crisis intervention services are needed, the following toll free numbers are available 24 hours per day, seven days a week: Central GSA (Maricopa) Crisis Response Network (CRN) Northern GSA (Apache, Coconino, Gila, Mohave, Navajo and Yavapai) Health Choice Crisis Line Southern GSA (Cochise, Graham, Greenlee, La Paz, Pima, Pinal, Santa Cruz and Yuma) Nursewise REFERRAL & INTAKE PROCESS To facilitate a member s access to behavioral health services in a timely manner, Care1st maintains an effective process for the referral for behavioral health services that includes: Members may self-refer for behavioral health services Communicating to potential referral sources the process for making referrals Collecting basic information about the member to determine the urgency of the situation and subsequently scheduling the initial assessment within the required timeframes and with an appropriate provider; Adopting a welcoming and engaging manner with the member and/or a member s legal guardian/family member; Informing, as appropriate, the referral source about the final disposition of the referral; and Ensuring members, who have difficulty communicating, because of a disability or who require language services are afforded the appropriate accommodations to assist them in fully expressing their needs. Accepting Referrals Primary Care Providers may use the Behavioral Health Services Referral Form to refer for behavioral health services (although not required). The following information will be collected from referral sources: Date and time of referral Information about the referral source including name, telephone number, fax number, affiliated agency and relationship to the member being referred Name of the member being referred, address, telephone number, gender, age, date of birth and, when applicable, name and telephone number of parent or legal guardian Whether or not the member, parent or legal guardian is aware of the referral Include a summary of any identified special needs for assistance due to impaired mobility, visual/hearing impairments or development or cognitive impairment Accommodations due to cultural uniqueness and/or the need for interpreter services Information regarding payment source (i.e. AHCCCS, private insurance, Medicare or self-pay) including the name of the AHCCCS health plan or insurance company Name, telephone number and fax number of AHCCCS primary care provider (PCP) or other PCPC as applicable Reason for referral including identification of any potential risk factors such as recent hospitalization, evidence of suicidal or homicidal thoughts, pregnancy, and current supply of prescribed psychotropic medications; and The names and telephone numbers of individuals the member, parent or guardian may wish to invite to the initial appointment with the referred member. Medical Services 9/2018 page 18 of 38

23 REFERRAL & INTAKE PROCESS (continued) While the information listed above will facilitate evaluating the urgency and type of practitioner the person may need to see, timely triage and processing of referrals should not be delayed because of missing or incomplete information. When psychotropic medications are a part of an enrolled member s treatment or has been identified as a need by the referral source, the behavioral health providers must respond as outlined in AHCCCS ACOM Policy 417 Appointment Availability, Monitoring and Reporting. Member s and referrals sources may contact Care1st Customer Service line at or for additional assistance. SMI Eligibility Determinations When an SMI eligibility determination is requested as part of the referral or by the member directly, the behavioral health provider must conduct an eligibility determination for SMI. Intake-Behavioral Health Behavioral health providers must conduct intake interviews in an efficient and effective manner that is both member friendly and ensures the accurate collection of all the required information necessary for enrollment into the system or for collection of information for AHCCCS eligible individuals who are already enrolled. The intake process must: Be flexible in terms of when and how the intake occurs. For example, in order to best meet the needs of the member seeking services, the intake might be conducted over the telephone prior to the visit, at the initial appointment prior to the assessment and/or as part of the assessment; and Make use of readily available information (e.g., referral form, AHCCCS eligibility screens, Department of Child Safety related documentation) in order to minimize any duplication in the information solicited from the member and his/her family. During the intake, the behavioral health provider will collect, review and disseminate certain information to members seeking behavioral health services. Examples can include: The collection of contact information, insurance information, the reason why the member is seeking services and information on any accommodations the member may require to effectively participate in treatment services (i.e., need for oral interpretation or sign language services, consent forms in large font, etc.). The collection of required demographic information and completion of client demographic information sheet, including the behavioral health member s primary/preferred language; The completion of any applicable authorizations for the release of information to other parties; The dissemination of a Member Handbook to the member; The review and completion of a general consent to treatment; The collection of financial information, including the identification of third party payors and information necessary to screen and apply for AHCCCS health insurance, when necessary; The review and dissemination of Care1st s Notice of Privacy Practices (NPP) and the AHCCCS HIPAA Notice of Privacy Practices (NPP) in compliance with 45 CFR (c)(1)(b); and The review of the rights and responsibilities as a member of behavioral health services, including an explanation of the grievance and appeal process. The member and/or the member s legal guardian/family member, advocate, and/or person providing special assistance, may complete some of the paperwork associated with the intake evaluation, if acceptable to the member and/or the member s legal guardian/family members, advocate, and/or person providing special assistance as referenced in AMPM 320-R. Behavioral health providers conducting intakes must be appropriately trained to approach the member and family in an engaging and strength-based manner and possess a clear understanding of the information that needs to be collected. Referring Provider s Responsibilities Confirm that the required service is covered under the member s benefit plan prior to referring the member. Confirm that the receiving provider is contracted with Care1st Obtain prior authorization for services that require prior authorization or are performed by a non-participating provider. The services need to be documented on the member s individual service plan. Medical Services 9/2018 page 19 of 38

24 REFERRAL & INTAKE PROCESS (continued) Receiving Provider s Responsibilities Providers may render services to members for services that do not require prior authorization or single case agreements when the provider has received a completed referral (or has documented the referral in the member s medical record). The provider rendering services based on the referral is responsible to: Schedule and deliver the medically necessary services in compliance with Care1st s requirements and standards related to appointment availability Verify the member s enrollment and eligibility for the date of service. If the member is not enrolled with Care1st on the date of service, Care1st will not render payment regardless of referral or prior authorization status. Verify that the service is covered under the member s benefit plan. Verify that the prior authorization has been obtained, if applicable, and includes the prior authorization number on the claim when submitted for payment. Inform the referring provider of the consultation or service by sending a report and applicable medical records to allow the referring provider to continue the member s care. Period of Referral Unless otherwise stated in a provider s contract or Care1st documents, a referral is valid for the full extent of the member s care starting from the date it is signed and dated by the referring provider, as long as the member is enrolled and eligible with Care1st on the date of service. Network Management Phone: or (Options in order: 5,7) sm_az_pno@care1staz.com Fax: Visit our website at OUTREACH, ENGAGEMENT, REENGAGEMENT AND CLOSURE The behavioral health system must provide outreach activities to inform the public of the benefits and availability of behavioral health services and how to access them. Care1st will disseminate information to the general public, other human service providers, school administrators and teachers and other interested parties regarding the behavioral health services that are available to eligible members. Out-of-State Relocations: A member s episode of care must be ended for a person who relocates out-of-state after appropriate transition of care. A Non-Title XIX individual would also be disenrolled. This does not apply to member s placed out-of-state for purposes of providing behavioral health treatment. Transfers: A member who changes to another ACC or T/RBHA and requires ongoing behavioral health services must be closed from one ACC or T/RBHA or transferred to the new ACC or T/RBHA. Services must be transitioned. Arizona Department of Corrections Confinements: A member age 18 or older must be disenrolled upon acknowledgement that the member has been placed in the longterm control and custody of a correctional facility. Children Held At County Detention Facilities Children who become incarcerated should not automatically have their Episode of Care closed. Inmates of public institutions: Members who become incarcerated should not automatically have their Episode of Care closed. Deceased Persons: A member s episode of care must be ended following acknowledgement that the person is deceased, effective on the date of the death. The Non-Title XIX member would be disenrolled from the system. Medical Services 9/2018 page 20 of 38

25 OUTREACH, ENGAGEMENT, REENGAGEMENT AND CLOSURE (continued) Crisis Episodes: The behavioral health provider conducts all applicable and required re-engagement activities and such attempts are unsuccessful; or the behavioral health provider and the member or the member s legal guardian mutually agrees that ongoing behavioral health services are not needed; a Non-Title XIX member would be dis-enrolled from the system. For members who are enrolled as a result of a crisis episode, the member s episode of care would end if the following conditions have been met: The behavioral health provider conducts all applicable and required re-engagement activities and such attempts are unsuccessful; or The behavioral health provider and the member or the member s legal guardian mutually agrees that ongoing behavioral health services are not needed; a Non-Title XIX member would be disenrolled from the system. One-Time Consultations: For members who are in the system for the purpose of a one-time consultation, the member s episode of care may be ended if the behavioral health provider and the member or the member s legal guardian mutually agrees that ongoing behavioral health services are not needed. The Non-Title XIX individual would also be dis-enrolled. Data Submission Behavioral health providers must follow all applicable data submission procedures following a decision to end an episode of care or disenrollment. SMI ELIGIBILITY DETERMINATION General Requirements As per AMPM 320-P Serious Mental Illness Eligibility Determination, this section applies to: Members who are referred for, request or have been determined to need an eligibility determination for SMI; Members determined to be SMI for whom a review of the determination is indicated; and Care1st, subcontracted providers and the AHCCCS Determining Entity (Crisis Response Network). All members must be evaluated for SMI eligibility by a qualified assessor (as defined in A.A.C. R (B)), and have an SMI determination made by the Crisis Response Network, if: The member requests an SMI determination; or A guardian/legal representative who is authorized to consent to inpatient treatment pursuant to A.R.S for the member makes a request on their behalf; or An Arizona Superior Court issues an order instructing the person to undergo an SMI evaluation. Additional details can be found in Section VII of the provider manual. Network Management Phone: or (Options in order: 5, 7) sm_az_pno@care1staz.com Fax: Visit our website at Medical Services 9/2018 page 21 of 38

26 CARE MANAGEMENT & DISEASE MANAGEMENT Care Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the member s health needs. Care Management is used to facilitate care of individual members in order to achieve optimal outcomes and quality of care. Care Managers are Registered Nurses and licensed Social Workers that assist member with multiple complex health problems. By providing care management services, Care1st Care Managers will work with the PCP/Specialist to facilitate timely access to and utilization of appropriate services thus reducing unnecessary services such as emergency room usage and hospital admissions. The care manager serves as an important link between the member, the healthcare team, the payer, and the community. Care management occurs across a continuum of care, is individually focused, and member centric. Care Managers manages the following members: High-Cost or Complex Medical/Behavioral Health Needs Solid Organ and Tissue Transplants Chronic Illness Catastrophic Illness or Injuries High Risk Pregnancy Children with Special Health Care Needs Disease Management services are available to members with certain targeted chronic conditions that frequently result in exacerbations and hospitalizations, that require high usage of resources and that have been shown to respond to coordinated management strategies. We partner with providers, community programs, and families to help members achieve optimal health outcomes. Our objectives include: Increased member engagement with PCP and PCP-referred specialists Increased member understanding and use of plan benefits Increased member awareness of community resources available to help improve their quality of life Decreased unnecessary Emergency Department utilization Decreased unnecessary inpatient admissions Optimizing member health outcomes Contact our Team at Ext for more information and assistance. Guidelines are also available on our website under the Disease Management section of the Provider menu. CHILDREN S REHABILITATIVE SERVICE (CRS) (CARE1ST) The Children s Rehabilitative Services (CRS) Program is a unique program that services children below 21 years old with specified chronic and/or disabling or potentially disabling health conditions as defined in A.A.C. R Enrollment in CRS is based upon a member s qualifying condition and the need for active treatment of the CRS conditions in A.A.C. R through medical, surgical, or therapy modalities. Children with a CRS qualifying condition typically require multiple clinician/specialties to manage their care. In additional to the Primary Care Provider, children may receive services from subspecialist who manage care related to the CRS condition(s) and coordinate with other specialty services such as pharmacy, therapy, and durable medical equipment providers. Anyone can fill out a CRS application form, including, a family member, provider, or health plan representative. To apply for the CRS program, a CRS application needs to be completed and mailed or faxed to the AHCCCS CRS Enrollment Unit, with medical documentation that supports that the applicant has a CRS qualifying condition. Please submit the application with supporting documentation applicable to the diagnosis to: AHCCCS/Children s Rehabilitative Services Attn: CRS Enrollment Unit 801 East Jefferson MD3500 Phoenix, AZ Or Fax to The AHCCCS CRS Enrollment Unit may also assist an applicant with completing the form. You can contact them at: or Medical Services 9/2018 page 22 of 38

27 CHILDREN S REHABILITATIVE SERVICE (CRS) (CARE1ST) (continued) As a provider if you submit an application on the member s behalf you need to contact the Health Plan through our Care Coordination team by calling or TTY 711 (select option 4 then option 9). Care1st is responsible to notify the member or his/her parent/guardian that an application for CRS designation has been submitted on the member s behalf. Website for the CRS application: GetCovered/Categories/CRS.htmlQRG REDLINE FALL v3.rtf List of qualifying medical conditions is on the AHCCCS website at: QualifyingMedicalConditions.pdf The services provided are family-centered, coordinated and culturally competent, in a manner that considers the unique medical and behavioral holistic needs of the member. Members with a CRS designation members may receive care and specialty services from an Multispecialty Interdisciplinary Clinics (MSIC) or community based providers in independent offices that are qualified to treat the member s condition. The Care1st will collaborate with the MSIC s and community based providers regarding availability and access to alternative methods for providing services such as field clinics and telemedicine in rural areas. AHCCCS Division of Developmental Disabilities (DDD) members, who meet the enrollment criteria for CRS, will be seen for the CRS condition services through United Healthcare Community Plan/CRS. Acute medical services and long term care services will continue to be provided through the Department of Economic Security (DES)/ Division of Developmental Disabilities (DDD) and Care1st. For more information, DDD members can contact their DDD support coordinator or the Care1st DDD Liaison at x1835. If unsure what documentation is required for submission with the CRS application, need assistance with completing the application or have other questions, please contact our CRS Coordinators at Ext DEVELOPMENTAL SCREENING TOOLS (CARE1ST) AHCCCS approved developmental screening tools should be utilized for developmental screenings by all participating PCPs who care for EPSDT age members. PCPs must be trained in the use and scoring of the developmental screening tools, as indicated by the American Academy of Pediatrics. The developmental screening should be completed for EPSDT members during the 9 month, 18 month and 24 month EPSDT visits. A copy of the screening tool must be kept in the medical record. Additional reimbursement may be received when: 1. One of the AHCCCS approved screening tools (listed below) is completed during a 9, 18 or 24 month EPSDT visit: a. Parents Evaluation of Developmental Status (PEDS) b. Modified Checklist for Autism in Toddlers (M-CHAT-R/F) c. Ages & Stages Questionnaire (ASQ) 2. PCP is trained in the use and scoring of the developmental screening tools, as indicated by the American Academy of Pediatrics (see Training section below for details on how to become certified); 3. The screening is billed separately from the EPSDT visit using CPT code with an EP modifier. Training To meet AHCCCS requirements for the enhanced reimbursement of services outlined above, a qualified medical professional must: 1. Complete training/certification for these services, and 2. Submit the proof of training/certification to CAQH. By submitting the proof of training/certification to CAQH, this information is accessible to all AHCCCS health plans with whom you contract. You can learn how to become certified by going to the clinician s page on the Arizona Department of Health Services website at Click on the Training Opportunities button and then on Developmental Screenings Training. Medical Services 9/2018 page 23 of 38

28 EPSDT (CARE1ST) EPSDT (Early and Periodic Screening, Diagnostic and Treatment synonymous with well-child visit) services cover comprehensive healthcare for members less than 21 years of age through primary prevention, early intervention, diagnosis and medically necessary treatment of physical and behavioral health problems. PCPs provide the health screening/preventative care in compliance with the AHCCCS EPSDT Periodicity Schedule. If a member shows for a sick visit and is due for an EPSDT visit, please take the opportunity to perform both the well visit and sick visit at the same time to ensure the EPSDT visit is received during the appropriate time frame. You will be reimbursed at the full fee schedule for the well visit and 50% of the fee schedule for the sick visit. Use the appropriate medicine CPT code when billing for EPSDT services (Refer to the Modifier 25 and EP sections on page 9). As part of the EPSDT physical exam, PCPs perform an oral health screening. PCPs must refer EPSDT members starting at 1 year old to a dentist for routine dental care. Application of fluoride varnish by a PCP during an EPSDT visit is reimbursed separately when: 1. The child is six months of age with at least one tooth erupted 2. Application of the varnish is performed by a physician, physician s assistant or nurse practitioner who has completed the appropriate Network Management Phone: or (Options in order: 5, 7) sm_az_pno@care1st.com Fax: Visit out website at training (see Training section below for details on how to become certified); 3. The varnish is billed separately from the EPSDT visit using CPT code 99188; 4. Recurrent applications may occur and be billed every six months up to two years of age. Training To meet AHCCCS requirements for the enhanced reimbursement of services outlined above, a qualified medical professional must: 1. Complete training/certification for these services, and 2. Submit the proof of training/certification to CAQH. By submitting the proof of training/certification to CAQH, this information is accessible to all AHCCCS health plans with whom you contract. You can learn how to become certified by going to the clinician s page on the Arizona Department of Health Services website at Click on the Training Opportunities button and then on Developmental Screenings & Flouride Varnish Training. The periodicity schedules are found on our website (See Practice & Preventive Health Guidelines under the Provider menu). Care1st provides a monthly list to PCPs of all children assigned who are due for EPSDT visits. EPSDT forms may be obtained/ordered by: Printing the forms from the AHCCCS website: gov/shared/downloads/medicalpolicymanual/appendixb.pdf Downloading the EPSDT Order Form from our website (See Forms section under the Provider menu). Complete and fax per the instructions on the form. EPSDT forms will be mailed to your office. REMINDERS: EPSDT forms were last revised April 1, Return the yellow copy of each completed EPSDT form or a copy of your Electronic Medical Record (EMR), with the required elements on the EPSDT form, to our EPSDT Team. Forms can be faxed to or mailed to Care1st Attn: EPSDT. Medical Services 9/2018 page 24 of 38

29 FAMILY PLANNING (CARE1ST) Family planning services for male and female members are covered when provided by physicians or practitioners to members who voluntarily choose to delay or prevent pregnancy. Members may self refer for family planning services. Each year, physicians and other practitioners should discuss and document in the medical record that each member of reproductive age has been notified verbally or in writing of the availability of family planning services. Family planning and family planning extension services include covered medical, surgical, pharmacological and laboratory benefits specified below. Covered services also include the provision of accurate information and counseling to allow members to make informed decisions about the specific family planning methods available. Family planning services include the following medical, surgical, pharmacological, and laboratory services: Contraceptive counseling, medications, supplies and associated medical and laboratory examinations, including, but not limited to, oral and injectable contraceptives, intrauterine devices, diaphragms, condoms, foams, and suppositories. Voluntary sterilization (male and female over the age of 21) Natural family planning education or referral to qualified health professional. Postcoital emergency oral contraception within 72 hours after unprotected sexual intercourse. Note: Mifepristone also known as Mifeprex or RU 486 is not postcoital emergency oral contraception. The following are not covered for the purpose of family planning services: Infertility services Pregnancy termination counseling Pregnancy terminations including the use of Mifepristone (Mifeprex or RU 486) and hysterectomies PHARMACY SERVICES FORMULARY SERVICES FORMULARY The Care1st & ONECare formularies are, along with quarterly updates and a link to the AHCCCS Drug List are available on our website Updated Drug Lists can be viewed on our website on the first day of the month following the previous quarter (ie. Quarter 2 updates are available on July1st. Please ensure your office is prescribing medications listed on the current formularies. Before submitting the Pharmacy Prior Authorization Request Form for a non-formulary medication, consider all formulary alternatives. Prior authorization requests and supporting documentation should be faxed to NON-FORMULARY & FIVE DAY OVERRIDES (CARE1ST) Prior authorization is required for all non-formulary drugs. A five day supply of medication following a hospital or ER discharge may be obtained by calling the Care1st Pharmacy Department at (Option 5, 5) SPECIALTY MEDICATIONS PURCHASING PROGRAM Specialty oral and injectable drugs may be obtained through our contracted vendor, Specialty Pharmacy formerly known as Apothecary Shop. Please use the following procedure to obtain specialty drugs: Prior Authorization Process: Complete the Pharmacy Authorization Form and fax to Once approved, the Pharmacy Department faxes back the approval to the practice and the specialty pharmacy. The specialty pharmacy will process the order, reaching out to the provider if necessary, and ship the medication. Pharmacy Prior Authorization turnaround times: URGENT REQUESTS Within 24 hours of receipt of the request for life and/or limb threatening circumstances Providers will be notified if STAT request is downgraded to Routine Medical Services Formulary Services 9/2018 page 25 of 38

30 FORMULARY SERVICES (continued) After 2 attempts to obtain additional information, the request will be pended up to 72 hours. If the information is not received, a decision will be made using the information provided. Provider will be notified of the decision. ROUTINE REQUESTS Within 24 hours of receipt of the request After 2 attempts to obtain additional information, the request will be pended up to 7 days. If the information is not received, a decision will be made using the information provided. Provider will be notified of the decision. Prior authorization requests first come to the health plan before an order is placed. If prior authorization is not obtained before the order is placed, the health plan decision and patient care may be delayed. * This program does not include vaccines. Please review the Prior Authorization Guidelines for J and Q codes that require prior authorization. In addition, all unclassified drugs (i.e. J3490, J9999) are evaluated on a case by case basis for approval and reimbursement. DME & HOME CARE DME & MEDICAL SUPPLIES (i.e., colostomy/ostomy, wound care, catheters, etc.) Covered durable medical equipment and medical supplies must be medically necessary and prescribed by a contracted provider and may require prior authorization. Preferred Homecare Phone: Fax: ENTERALS Requires prior authorization Option 1 Nutrition Solutions Phone: Fax: HOME HEALTH Home Health for ONECare members requires prior authorization. Professional Cares Phone: (Skilled Nursing and Phone: Home Therapy HOME INFUSION May require prior authorization Coram Phone: Fax: GLUCOSE MONITORS Care1st members use monitors by OneTouch like OneTouch Verio meter or OneTouch Ultra. A meter can be obtained by contacting OneTouch at or and input order code 738WEL001. Once a physician script is written, members obtain the test strips and lancets at a contracted pharmacy. PEAK FLOW METERS In order to ensure that asthma is managed as effectively as possible, it is vital that a PCP driven asthma action plan be developed for each member as they use the peak flow meter. When a peak flow meter is indicated, the physician/practice contacts the contracted DME provider who sends the peak flow meter to the member. WOUND VAC Requires prior authorization MedOne Phone: Fax: For the most up to date information, visit our website: DME & Home Care Formulary Services 9/2018 page 26 of 38

31 OB/GYN SERVICES All OB care requires authorization within 30 days of pregnancy confirmation. To request a total OB authorization, fax a copy of the completed ACOG Form to Care1st reimburses obstetrical care as a total OB (TOB) package. To qualify for a TOB package, a minimum of 5 antepartum visits must be rendered in addition to the delivery. To confirm this requirement was satisfied, the appropriate delivery CPT procedure code is billed in addition to the ante-partum visits. Antepartum and post partum visits are billed with the appropriate E&M CPT code ( ) on individual service lines with 1 in the units field for each date of service. AHCCCS requires health plans to collect all dates of service for obstetrical care. This change does not impact policies related to global billing, however it requires that all dates of service must be reported on the claim [AMPM Policy 410 Section D(3)(f)]. Consequently, each antepartum date of service must be billed individually. Claims received that are not billed in this format are denied. Total OB Example: OB physician performs 6 antepartum visits between January 1 and April 30 and delivery occurs May 5. *Line 5: 4th Antepartum visit billed with the date of service and E&M CPT code *Line 6: 5th Antepartum visit billed with the date of service and E&M CPT code *Line 7: 6th Antepartum visit billed with the date of service and E&M CPT code *Line 8: Post partum visit billed with the date of service and E&M CPT code. Claims for the total OB package can be billed prior to the post partum visit being rendered. Please be sure to submit the post partum visit once it is completed. Each visit must be billed on a separate line with the specific date of service and a unit of 1. All services included in the TOB package are billed with the delivery. Reimbursement is made on the total OB care delivery CPT code. If a patient transfers care following the receipt of a TOB authorization or if the minimum number of visits are not performed, contact Care1st to revise the authorization. OB/GYN Services Line 1: Appropriate total OB care delivery CPT code *Line 2: 1st Antepartum visit billed with the date of service and E&M CPT code *Line 3: 2nd Antepartum visit billed with the date of service and E&M CPT code *Line 4: 3rd Antepartum visit billed with the date of service and E&M CPT code Do you know who your Provider Rep Is? If you aren t sure, visit our website to find out! Click on Care1st > Providers > Provider Rep Contact Info 9/2018 page 27 of 38

32 OB/GYN SERVICES (continued) SERVICES INCLUDED IN THE TOTAL OB PACKAGE: *Physical Exams (Including sick exams) Initial and subsequent history Weight and blood pressure Breast stimulation studies Genetic counseling (excludes genetic testing) Artificial rupture of membrane Follow up visits Fetal scalp monitoring Induction of labor Delivery (includes multiple births) 5+ prenatal visits & 1 post partum (pap smear included) Laboratory services and handling fees by TOB provider Family planning Maternity counseling Nutritional Evaluation Inpatient & Observation services Wet preps and wet mounts External cephalic versions Risk Screening per ACOG Standards *All Prenatal Visits, including EPSDT and Sick visits WIC Referrals for Medically Eligible Members Prostaglandin Gel Insertion SERVICES EXCLUDED FROM THE TOTAL OB PACKAGE & REIMBURSED SEPARATELY Prior authorization may be required Amniocentesis Amnioinfusion OB Ultrasound (3 or more 2D ultrasounds require prior authorization) Post-partum Tubal Ligation RhoGAM Injection Surgical Assist Non-stress test Post Delivery D&C (59160) Lab Services not billed by TOB provider Colposcopy (CPT codes , , 57452, and ) *Effective for dates of service 10/1/18 and after: Evaluation and Management codes billed in an office or inpatient setting, in which the primary focus of the visit is a non-maternity illness/injury will be reimbursed outside of the total OB package if billed with an appropriate primary diagnosis code. Physical visits in which the primary focus is the members pregnancy, as well as all sick visits prior to date of service 10/01/18 will continue to be included in the reimbursement of the total OB package. Other services will be subject to the existing guidelines contained in the Care1st Provider Manual section VI. High risk OB care (including consults, follow up visits, procedures and medical services) provided by a Perinatologist requires prior authorization. Have any of the following changes occurred in your practice? New Practitioners? Practitioner departures? Address additions or closures? Phone or fax change? Tax ID or pay to address change? REMEMBER...Please send the Provider Directory Correction Request Form by faxing us at or by sm_az_pno@care1staz.com You can also contact your provider rep directly! This will help members find your practice and assist with claim payment accuracy. OB/GYN Services 9/2018 page 28 of 38

33 OB/GYN SERVICES (continued) DENTAL SERVICES HIGH RISK PRENATAL HOME CARE INFUSION SERVICES Our Care Management programs manage members experience a high-risk pregnancy. The goal of this specialty program is to improve pregnancy outcomes, reduce neonatal hospitalizations and rehospitalizations, and reduce medical costs associated with high-risk pregnancies. This clinical program will support contracted clinicians in providing prenatal education, promote safe health behaviors and lifestyle and coordinate healthcare services and resources. The physician plays a key role in the delivery of the program and this program is intended only to compliment the medical care received by the physician. For more information or to refer the member to the Care Management program, please call extension APPOINTMENT SCHEDULING Maternity Care appointment scheduling should occur as follows: First trimester Within 14 calendar days of request Second trimester Within 7 calendar days of request Third trimester Within 3 business days of request High risk pregnancies Within 3 business days of identification of high risk by the health plan or maternity care provider, or immediately if an emergency exists Return appointments are scheduled per the ACOG standards indicated below: Monthly through 28 weeks Bi-weekly between 29 and 36 weeks Weekly after the 36th week Advantica Dental Services, Inc. (Advantica) manages the dental benefits provided to Care1st and ONECare members on behalf of Care1st. Prior authorizations, claim submissions and claim inquiries are submitted to Advantica. The Advantica/Care1st Dental Clinical and Billing Guidelines for AHCCCS & DDD Members under 21 and DDD Members Over 21 $1000 Dental Benefit and for AHCCCS & DDD Members 21 and Over identify prior authorization requirements and claim submission requirements for Care1st members. These guidelines are found on our website > Care1st > Providers > Dental. You may also access the Advantica/Care1st Dental Clinical and Billing Guidelines on Advantica s website > Providers > Provider Login > Reference Manuals (review of the criteria online requires provider registration). Advantica s website secured features include: 1. Verifying member eligibility 2. Viewing claims history and claims status 3. Submitting claims 4. Reviewing and printing remittance advices 5. Submitting prior authorizations requests 6. Reviewing and downloading clinical guidelines and administrative policies and procedures. For provider registration follow these instructions: 1. Visit the Advantica website at 2. From the main page, select and click on the Providers Tab. 3. This will take you to the provider registration section. 4. Select and Click the Provider Registration option. 5. Complete the Provider Registration Form following the instructions and click on the Submit button. 6. You will receive an confirmation of your successful registration with the user name and the password you selected. OB/GYN Services Dental Services 9/2018 page 29 of 38

34 DENTAL SERVICES (continued) If you cannot submit prior authorization requests through the website, you may submit them via mail by submitting the ADA form (check the Prior Determination Box) along with any x-rays and additional documentation, or by mailing Advantica s Prior Auth Form to: Advantica PO Box 8510 St. Louis, MO If you do not have internet access, you may contact Advantica directly at and request hard copies of the Clinical and Billing Guidelines. EDI Claim Submissions Dental claims may be submitted electronically using one of the methods below: 1. CHANGE Healthcare (fka Emdeon). CHANGE Healthcare partners with most dental software vendors. To begin submitting claims electronically to Advantica contact your software vendor and discuss set up for submission of electronic claims to CHANGE Healthcare. Make sure you provide the Advantica Payer ID EHG EDI Health Group, Inc. DentalXChange. To enroll go to: and click on Services > Provider Services > Claims Connect > Get Started or call ext Advantica Payer ID Tesia. To enroll contact call Advantica Payer ID Advantica Web Portal. Providers can also submit claims, check eligibility and confirm benefits through Advantica s online provider portal. To register, go to and click on Provider Registration. Submit attachments such as x-rays (submitted as a TIF or JPG document) using NEA-Fast. To register online, go to and click on REGISTER NOW. Select the appropriate options and click Next. You can also register via phone by calling (Select Option 2). You will receive an assigned NEA number to reference on the electronic claim submission. Electronic Fund Transfer (EFT) Payment Information EFT allows payments to be electronically deposited directly into a designated bank account without the need to wait for the mail and then make a trip to the bank to deposit your check! Advantica works with RedCard: To enroll for EFT online, register by visiting: and create your account by filling out all the fields and click submit. You will receive a Welcome . Using the URL in the , log in using the temporary password and select Continue Enrollment. Complete the process and begin receiving. When prompted, enter Advantica Payer ID COVERED DENTAL SERVICES (CARE1ST) Dental services are covered for all EPSDT members from ages 1 thru 20 years of age. This includes medically necessary emergent dental services such as dental screenings, preventive services, therapeutic dental services, medically necessary dentures, and pretransplantation dental services. All EPSDT age members, ages 20 years and younger are assigned to a Dental Home. What is a Dental Home? A Dental Home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and familycentered way, as defined by the American Academy of Pediatric Dentistry. Dental Services 9/2018 page 30 of 38

35 COVERED DENTAL SERVICES (continued) Member Assignment Members are assigned to a general or pediatric dentist based on their age and their residence. If you have more than one location, the member may see you at any location as long as the location is registered with Care1st. A member may change their assigned dentist by calling Care1st Customer Service at or (options 5,3) (TTY 711) from 8am 5pm Monday through Friday. Periodicity Schedule Requirements regarding the routine preventative care of AHCCCS members may be found via the AHCCCS Dental Periodicity Schedule (Exhibit 431-1). The schedule is available on our website Click on Care1st > Providers > Practice and Preventive Health Guidelines and scroll down to the Dental Periodicity Link. Dental care is critical to an individual s overall health! We are strongly encouraging our EPSDT aged members to schedule checkups with their dentist every 6 months. Beginning October 1, 2017 AHCCCS covers the following dental services for member 21 years and older: Emergency dental services up to $1000 per member per contract year (October 1 September 30). A dental emergency is defined as an acute disorder of oral health resulting in severe pain and/ or infection as a result of pathology or trauma. Medical and surgical services related to dental (oral). Covered dental services must be related to the treatment of medical conditions such as acute pain (excluding TMJ), infection, or fracture of the jaw. Covered dental services include a limited problem focused examination of the mouth, required x-rays, care of fractures of the jaw or mouth, giving anesthesia and pain medications and/or antibiotics. Certain pre-transplant services and prophylactic extraction of teeth in preparation for radiation treatment of cancer of the jaw, neck or head are also covered only after a transplant evaluation determines that the member is an appropriate candidate for organ or tissue transplantation. In addition to the above services for members over 21, AHCCCS has expanded dental benefits for DDD members who are 21 years and older. Beginning October 1, 2016, dental services, including dentures, are covered for AHCCCS DDD members 21 years of age and older. 1. Dental services are limited to a total benefit amount of $1,000 per member for each 12 month period beginning October 1, 2016 through September 30, Coverage is member specific and remains with the member if he or she transfers plans. 3. Any unused benefit with not roll over to the next year. 4. Frequency limitations and services that require prior authorization still apply. 5. General Anesthesia (GA) will be covered and will count towards the $1000 limit i. Physicians performing GA for a dental procedure will count towards the $1000 limit and be billed through medical COVERED DENTAL SERVICES (ONECARE) Contact ONECare Customer Service for benefit information or view the current Summary of Benefits available on our website at or view the Advantica/ Care1st ONECare Benefit Information document on our website Click on ONECare > Providers > Dental ADDITIONAL SERVICES Dental Services 9/2018 page 31 of 38

36 ADDITIONAL SERVICES CHIROPRACTIC SERVICES Prior authorization is required. Care1st Covered services are available for members under age 21 and QMB (Qualified Medicare Beneficiaries). Members are limited to manual manipulation of the spine to correct subluxation. ONECare Medicare covered chiropractic services are limited to manual manipulation of the spine to correct subluxation. Members may contact ONECare Customer Service for additional information. CULTURAL COMPETENCY Care1st & ONECare are aware of the diverse backgrounds of our members. We offer services that are sensitive to differences in race, ethnic background, language, age, religion, and that respect the traditions of our members. We offer a choice of qualified doctors and hospitals to meet member needs in a culturally appropriate manner. We provide interpretation services upon request or when a language need is identified. Listed below are two of the services available to our providers and members: American Sign Language Interpretation Valley Center of the Deaf (Maricopa County) and Community Outreach Program for the Deaf (Pima County) are contracted to provide American Sign Language Interpreters at no cost to members or providers. Services are available and arranged through Customer Service. Valley Center of the Deaf recommends setting up services five business days in advance of the appointment and Community Outreach Program for the Deaf recommends setting up services 10 business days in advance of appointment. Translation Services Care1st & ONECare have an agreement with CyraCom International to provide quality translation services. These services are provided at no cost to members and providers. Please contact Network Management at (options in order 5, 7) if you have not received your CyraCom Card. HEARING SERVICES Care1st Hearing evaluations and treatment (hearing aids) are covered for members under age 21. Prior authorization is required for hearing aids. Hearing evaluations are covered for members age 21 and older. ONECare One Medicare approved diagnostic hearing exam per year is covered as well as some additional benefits. Contact ONECare Customer Service for benefit information or view Section III of the current Summary of Benefits available on our website at LABORATORY SERVICES Sonora Quest is our exclusive laboratory vendor. All outpatient laboratory services are sent to Sonora Quest for processing. Sonora Quest patient service locations are available at by clicking on the patient service center locator tab. Web-based patient service center appointment scheduling is also available and offers members the ability to schedule an appointment for a convenient day and time, resulting in reduced wait time upon arrival at a patient service center. The web based scheduling system is available 24-hr a day. Walk-in appointments are still available during scheduled hours of operation as well, although appointments are encouraged. NO SHOW APPOINTMENT LOG When a Care1st/ONECare member no shows to a scheduled visit, please use our No Show Appointment Log to notify us. Member outreach and education will occur immediately. The No Show Appointment Log is available on our website under the Forms section of the Providers menu. You may also contact Network Management and a copy will be faxed/mailed to your office. If you have any questions about the Log or the outreach process, please contact our EPSDT Team at x1365. Additional Services 9/2018 page 32 of 38

37 ADDITIONAL SERVICES (continued) ORTHOTICS Care1st Prior Authorization is required. For members under the age of 21, AHCCCS covers orthotics when medically necessary and ordered by a Physician or Primary Care Practitioner. For members over the age of 21, orthotics are covered when all of the following apply: The use of the orthotic is medically necessary as the preferred treatment option consistent with Medicare Guidelines. The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition. The orthotic is ordered by a Physician or Primary Care Practitioner. ONECare Prior Authorization is required. OUTPATIENT REHAB SERVICES Care1st Prior Authorization is required for all DDD (Division of Developmental Disabilities) members and AHCCCS members under the age of 21. Physical Therapy for AHCCCS adults 21 and older does NOT require prior authorization; limited to 15 rehabilitation and 15 habilitation visits for a total of 30 PT visits per contract year (October 1 September 30). Append modifier GP to the billing code for physical therapy services. Occupational Therapy (effective 10/1/2017) for AHCCCS adults 21 years and older does not require authorization and are limited to 15 visits rehabilitation and 15 habilitation for a total of 30 OT visits per contract year (October 1 September 30). Append modifier GO to the billing code for OT services. Speech Therapy is not covered benefit for AHCCCS and DDD members 21 and older. ONECare Prior Authorization is required. TRANSPORTATION SERVICES Care1st Members are responsible for arranging transportation three business days prior to a routine appointment. However, under appropriate circumstances urgent and same day transportation is available. Members call (Option 4, 3) to arrange. ONECare Contact ONECare Customer Services for benefit information by calling (Option 5, 3) or view Section III of the current Summary of Benefits available on our website at VISION SERVICES Care1st & ONECare are contracted with Nationwide Vision Medical Centers to provide the following services: Diabetic eye exams Dry eye treatment Evaluation and treatment of diseases and problems of the cornea, conjunctiva Evaluation of ocular discomfort or pain Evaluation of transient loss of vision Evaluation of flashes and floaters Evaluation of hypertension in the fundus Evaluation of cataracts Evaluation of macular degeneration Evaluation of choroidal nevus Evaluation of collagen vascular effects on the eye Eyelid disease and treatment Foreign body removal from the cornea or the conjunctiva Inflammation of the anterior segment of the eye and it s treatment Red eye work ups and treatment Treatment of disease of the anterior segment of the eye Care1st Covered services are available for members under age 21. Members may self refer to Nationwide Vision. Covered services per contract year (i.e. October 1st through September 30th) include: 1 exam 1 pair of prescription lenses and glasses if medically necessary 1 repair or replacement of prescription lenses Additional Services 9/2018 page 33 of 38

38 ADDITIONAL SERVICES (continued) ONECare Glasses are covered for members under age 21 and/or following post operative cataract surgery. Additional benefits may vary, please contact ONECare Customer Services for information or view Section III of the current Summary of Benefits available on our website at Modifier Billing Requirement Below is a common modifier billing reminder for ophthalmology services: 92225, 92226, and are considered bilateral in nature. The services must be billed with modifier 50 and a unit of 1 when services are performed on a single date of service for both eyes. Please reference the guidelines on page 9 for additional questions on modifier requirements. OTHER REMINDERS ADVANCE DIRECTIVES The Patient Self-Determination Act, passed by Congress in 1991, requires that health care providers educate patients on issues related to Advance Directives. The Act requires all Medicare and Medicaid providers to furnish timely information so patients have the opportunity to express their wishes regarding the refusal of medical care. Care1st & ONECare as well as AHCCCS and CMS must comply with this Act, and request your cooperation. Documentation is required in the medical record as to whether or not an adult member (18 years and older) has completed an Advanced Directive. Below are suggestions to assist in bringing your medical records into compliance with this standard: 1. Add a line to your initial patient assessment record stating a. Advance Directive discussed Yes or No b. Do you have a Living Will or Power of Attorney Yes or No 2, For paper charts, stamp the front of the member s chart or place a sticker on the chart with the above statements(s). Please be sure to address the above questions with the member. For more information on health care directives, the following organizations offer assistance and resources: Arizona Hospital & Healthcare Association Arizona Aging and Adult Administration American Academy of Family Physicians American Association of Retired Persons American Hospital Association MEDICAL RECORDS Record Retention Providers must retain medical records in accordance with all federal and state regulations. This includes, but not is limited to compliance with A.R.S which provides, in part, that a health care provider shall retain patient medical records according to the following: 1. If the patient is an adult, the provider shall retain the patient medical records for at least six years after the last date the adult patient received medical or health care services from that provider. 2. If the patient is under 18 years of age, the provider shall retain the patient medical records either for at least three years after the child s eighteenth birthday or for at least six years after the last date the child received medical or health care services from that provider, whichever date occurs later. In addition, the provider shall comply with the record retention periods specified in HIPAA laws and regulations, including, but not limited to, 45 CFR (j)(2). In accordance with Arizona Administrative Code R (E) all providers shall furnish records requested by the Administration or a contractor to the Administration or the contractor at no charge. If the provider uses a vendor to store medical records, it is the provider s responsibility to work with the vendor and facilitate receipt of the requested records at no charge to Care1st. PCP Changes When a member changes PCPs, his or her medical records or copies of medical records must be forwarded to the new PCP within 10 business days from receipt of the request for transfer of the medical records. Other Reminders Additional Services 9/2018 page 34 of 38

39 APPOINTMENT AVAILABILITY & WAIT TIME STANDARDS PCP SPECIALTY/ DENTAL SPECIALTY DENTAL MATERNITY BEHAVIORAL HEALTH PROVIDER APPOINTMENTS BEHAVIORAL HEALTH PSYCHOTROPIC MED REFERRALS *Urgent As expeditiously as the member s health condition requires but no later than 2 business days of request. Routine Within 21 calendar days of request *Urgent As expeditiously as the member s health condition requires but no later than 2 business days of referral Routine Within 45 calendar days of referral *Urgent As expeditiously as the member s health condition requires but no later than 3 business days of referral Routine Within 45 calendar days of referral First Trimester Within 14 calendar days of request Second Trimester Within 7 calendar days of request Third Trimester Within 3 business days of request High Risk Pregnancies As expeditiously as the member s health condition requires and no later than 3 business days of identification of high risk by the contractor or immediately Referrals for if an Psychotropic emergency Medications exists. *Urgent As expeditiously as the member s health condition requires but no later than 24 hours from identification of need Routine Care Initial assessment within 7 calendar days of referral The first behavioral health service following the initial assessment Within the timeframe indicated by the behavioral health condition, but no later than 23 calendar days after the initial assessment All subsequent services As expeditiously as the member s health condition requires, but no later than 45 calendar days from the identification of need Assess the urgency of the need immediately If clinically indicated, provide an appointment with a Behavioral Health Medical Professional (BHMP) within the timeframe that ensures the member a) does not run out of needed medications; or b) does not decline in his/her behavioral health condition prior to starting medication, but no later than 30 calendar days from the identification of need. Appointment wait time standards: no more than 45 minutes (unless unforeseen circumstances/emergency). * Urgent appointment is defined as an appointment for medically necessary services to prevent deterioration of health following the acute onset of an illness, injury, condition or exacerbation of symptoms.. Appointment availability standards are measured for both Established and New patients for Primary Care, Specialist and Dental providers. An Established Patient is defined as a member that has received professional services from the physician or any other physician with that specific subspecialty that belongs to the same group or practice, within the past three years from the date of appointment. A New Patient is defined as a member that has not received any professional services from the physician or another physician with that specific specialty and subspecialty that belongs to the same group or practice, within the past three years from the date of appointment. DATA VALIDATION (CARE1ST) As part of an annual federal requirement, AHCCCS may request medical records from practitioners and hospitals or claim copies for services provided to AHCCCS members during a previous AHCCCS contract year (October 1st through September 30th). This process is referred to as Data Validation. The study audits the integrity of claims submitted to AHCCCS health plans and ultimately to AHCCCS Administration. Quality indicators are affected by the accuracy of the claims submitted and reimbursement to your practice can be negatively impacted by inaccurate claims submission. Omission and correctness errors are two examples of common data validation errors. An omission error is defined as an encounter for a medical record entry of a service that a plan paid a provider for but did not submit claim data to AHCCCS (or provider did not bill the service to the plan). Also, if a claim is inappropriately deleted from AHCCCS historical files, or voided and not resubmitted it is an omission. A correctness error is defined as an inconsistency between the medical record documentation and the claim submitted in respect to procedure, diagnosis, and/or date of service. Other Reminders 9/2018 page 35 of 38

40 DATA VALIDATION (CARE1ST) (continued) Following the tips below will reduce the errors defined above and will help to ensure each Data Validation study is successful: 1. Medical record copies must be legible. Please check the ink in your printers or review the quality of the photocopies before records are packaged and mailed. 2. Physician signatures must be legible on all documentation per Medicare requirements. If the signature is not legible, the printed name should be included under the signature and must be legible. 3. All medical record documentation must have the date of services and the patient s name on every page. 4. Documentation for office visits/consults must support the level of service being billed. 5. Documentation must support the number of units billed. 6. Documentation for time based services (i.e. anesthesia) must include the time element. 7. Diagnoses must be reported to the highest level of specificity. 8. Ambulance mileage must be documented on the medical record. Care1st appreciates and values your assistance and partnership during the annual data validation study. INSURANCE REQUIREMENTS (CARE1ST) The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability and Worker s Compensation and Employers Liability. Each requirement is outlined below: Commercial General Liability (CGL) Occurrence Form Policy should include bodily injury, property damage, and broad form contractual liability coverage. The amounts below are the minimum requirements. General Aggregate $2,000,000 Products Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Damage to Rented Premises $50,000 Each Occurrence $1,000,000 Network Management Phone: or (Options in order: 5, 7) sm_az_pno@care1staz.com Fax: Visit out website at Have any of the following changes occurred in your practice? New Practitioners? Practitioner departures? Address additions or closures? Phone or fax change? Tax ID or pay to address change? REMEMBER...Please send the Provider Directory Correction Request Form by faxing us at or by sm_az_pno@care1staz.com You can also contact your provider rep directly! This will help members find your practice and assist with claim payment accuracy. Other Reminders 9/2018 page 36 of 38

41 INSURANCE REQUIREMENTS (CARE1ST) (continued) a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor. b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. c. For Subcontracts providing direct services to children and/ or vulnerable adults (as defined by A.R.S (a)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM coverage may be sub-limited to no less than $500,000. The limits may be included within the General Liability limit, provided by separate endorsement with its own limits. If you are unable to obtain SAM coverage under your General Liability because the insurance market will not support it, it should be included with the Professional Liability. d. The following statement must be included on the Certificate(s) of Insurance: Sexual Abuse and Molestation coverage is included or Sexual Abuse Molestation coverage is not excluded. Business Automobile Liability Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance of the services under contract. The amount below is the minimum required. Combined Single Limit (CSL) $1,000,000 a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor, involving automobiles owned, leased, hired and/or non-owned by the Subcontractor. b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. Worker s Compensation and Employers Liability Workers Compensation Statutory Employers Liability Each Accident $1,000,000 Disease Each Employee $1,000,000 Disease Policy Limit $1,000,000 Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. MEMBER ELIGIBILITY Providers are responsible for verifying member eligibility for all medical services provided. Verify member eligibility using the following methods: Website Our website offers member eligibility, claims status and remittance advice viewing and printing. A one-time registration process is required in order to obtain a log on and temporary password. To complete the registration process: Other Reminders 9/2018 page 37 of 38

42 MEMBER ELIGIBILITY (continued) 1. Choose Provider Login in the top right hand corner of the home page 2. Complete the Request Access On-Line Form 3. You will receive your login and temporary password via Customer Service Care1st or (options 5,3) ONECare or (options 5,3) PROVIDER DIRECTORIES & WEBSITE SEARCH FUNCTION Our provider, ancillary and retail pharmacy directories/listings are available online at under the Our Network section of the Provider menu. Also available on our website under Our Network of the Provider menu is a Provider Search function. This option allows you to search by provider name, specialty, language or zip code and provides real time information from our system. In accordance with the Centers for Medicare and Medicaid Services (CMS) regulations at 42 C.F.R , directories must provide patients with a list of providers from whom the patient may reasonably be expected to obtain services. The directory may not list providers that the patient cannot call the phone number listed and make an appointment with the provider or on-call and substitute providers who are not regularly available to provide covered services at the practice location. Only providers who regularly practice at the specified location may be listed. For group practices, the directory will only list individual providers at locations where they routinely see patients, as opposed to every location of the group practice. Care1st does not require the provider to be listed at all locations for claim payment and requests you help by providing accurate information to assist the patients in finding you. Please use the Provider Directory Correction Request Form available on our website in the Forms section of the Provider menu to notify us of inaccurate information displayed in the provider directories/listings. Fax completed forms to Network Management at If you have questions or do not have internet access and wish to request paper directories/listings, please contact Network Management. PROVIDER MANUALS Care1st & ONECare Provider Manuals are also available on our website at Click on Care1st or ONECare > Providers > Manual If you have any questions or do not have internet access and would like to request a copy be mailed to your office, please contact Network Management. PROVIDER FORUMS Provider forums are held semi-annually in Maricopa and Pima in the spring and fall each year. We encourage our providers and/or staff to attend. Presentations are focused on AHCCCS and Care1st updates. We strive for an informative and interactive experience. Agendas, presentations and survey results from past forums are available on our website at Click on Care1st > Providers > Forums. Other Reminders 9/2018 page 38 of 38

43 Page 1 of 1 Care1st Website Guide Welcome to the Care1st network. We are excited to work with you! The purpose of this document is to provide details to assist you with location of information on our website. Our website is located here: 1. Quick Reference Guide. This guide provides a great deal of information including key phone and fax numbers. It s found in the following spot on our website: Click on the Care1st or ONECare logo in middle of home page > Providers > Mailings & Newsletters > Quick Reference Guide. An updated version of this guide will be in your Welcome Packet. 2. Prior Authorization Guidelines. Located here: Click on the Care1st or ONECare logo in middle of home page > Providers > Prior Authorization Guidelines & Criteria 3. Forms. All forms are found here: Click on the Care1st or ONECare logo in middle of home page > Providers > Forms 4. Dental. Advantica manages the dental benefits provided to Care1st members. Advantica also pays Care1st dental claims. Details about Advantica including phone, claims address, etc. are available in our Quick Reference Guide listed above. 5. Dental Clinical and Billing Guidelines. Located here: Click on the Care1st or ONECare logo in middle of home page > Providers > Dental 6. Provider Manual. Our manual is available to be viewed and downloaded as entire document as well as by chapter: Click on the Care1st or ONECare logo in middle of home page > Providers > Manual 7. Provider Search, Ancillary Directory, Pharmacy Look up, and Provider Listing. These tools are located on our website here: Click on the Care1st or ONECare logo in middle of home page > Providers > Our Network 8. Formulary. The formulary is located here: Click on the Care1st logo or ONECare logo in middle of home page > Providers > Formulary 9. Secure Web Portal. The separate provider portal of our website will allow you to view eligibility, claims and remittance advices. The portal log on page is located here: Click on the Care1st or ONECare logo in middle of home page > Providers > Login. To become a registered user follow the instructions under the Registration heading. Dental providers register for the Advantica portal located on the Advantica website: Registration. Additional information including clinical guidelines, detailed information on fraud, waste and abuse and how to report it, quality results, community resources and information on disease management is also available on our website. Please call us with any questions. Thank you! Care1st Network Management 2355 E. Camelback Rd. #300 Phoenix, AZ Phone or (Options in order: 5, 7) Fax SM_AZ_PNO@Care1stAZ.com Visit our website at

44 Electronic Data Interchange (EDI) & Electronic Funds Transfer (EFT) Important Details Care1st understands that time-consuming administrative tasks can jeopardize time spent with patients and result in added costs for your practice. That is why we offer quality provider technology and services that improve operational efficiencies and minimize expenditures. Please review the EDI and EFT options below and take advantage of them today! Electronic Data Interchange (EDI) We strongly encourage you to submit your medical claims electronically! Advantages include: decreased submission costs faster processing and reimbursement allows for documentation of timely filing EDI is for primary claims only with the exception of claims when a member s primary insurance is ONECare and their secondary insurance is Care1st as our system automatically coordinates processing for these services submitted. Any other claims that require secondary payments submit on paper with a copy of the primary remittance advice attached. Claims may be electronically submitted from your clearinghouse or directly. Your practice management system may offer integration options with one or more of these solutions. If you experience problems with your EDI submission, first contact your software vendor to validate the claim submissions and upon verification of successful submission, contact your clearinghouse. Medical/Behavioral Health (CMS1500 & UB-04) Claims We work with CHANGE Healthcare (Emdeon) for acceptance of EDI CMS 1500 claims. Our CHANGE Healthcare Payer I.D. is Questions may be directed to CHANGE Healthcare at Dental (J430D) Claims Electronic claims can be submitted through CHANGE Healthcare (Emdeon), EHG, Tesia, or directly through Advantica s website. 1. CHANGE Healthcare (Emdeon). CHANGE Healthcare partners with most dental software vendors. To begin submitting claims electronically to Advantica contact your software vendor and discuss set up for submission of electronic claims to CHANGE Healthcare. Make sure you provide the Advantica Payer ID EHG EDI Health Group, Inc. DentalXChange. To enroll go to: and click on Services > Provider Services > Claims Connect > Get Started or call ext Advantica Payer ID Tesia. To enroll contact call Advantica Payer ID Advantica Web Portal. Providers can also submit claims, check eligibility and confirm benefits through Advantica s online provider portal. To register, go to and click on Dental Provider Registration. Page 1 of 2 Rev

45 Electronic Funds Transfer (EFT) EFT allows payments to be electronically deposited directly into a designated bank account without the need to wait for the mail and then make a trip to the bank to deposit your check! Medical/Behavioral Health Claims The EFT form is available on our website under the Forms section of the Provider menu. If you do not have internet access, contact Provider Network Operations and we will provide you with the form. Dental Claims Advantica works with RedCard: 1. To enroll visit: and create your account by filling out all the fields and click submit. 2. You will receive a Welcome . Using the URL in the , log in using the temporary password and select Continue Enrollment. 3. Fill out the required fields and click Submit a. You also will be prompted to enter an NPI. If you have multiple NPIs under one TIN and want payments for all NPIs going to the same financial institution account, just leave the NPI fields blank. 4. Complete the Test Deposit Verification Process 5. Within 48 hours of test deposit, RedCard completes verification phone call, i.e. they locate your practice phone number via independent online web search and call to confirm enrollment Page 2 of 2 Rev

46 Treatment Authorization Request Ph (Options 5, 6) Fax AHCCCS DDD ONECare Routine Urgent [May seriously jeopardize member s life, health or function level] Patient Information Member Name: Date of Birth: Member Address (Street): Retroactive Member Address (City, State, Zip): Male Female Member ID: Requesting Physician s Name: (PLEAST PRINT) Group/Practice Affiliation: Office Contact Name: Phone: Fax: Service Information Referred To: Group/Practice Affiliation: Date of Request: Anticipated Date of Service: Specialty: Provider Address: Phone: Fax: FQHC Location?: Yes No Comments: Hospital Name: Other: Service(s) Requested Hospital Admit Anticipated LOS: Hospital Outpatient ASC In-Office Proc/Testing Consult Only Follow-up Visits (Attach Relevant Data, Notes, Tests, Etc.) Requested Service/Procedure: CPT 4 Code(s): Unit(s): Health Education Diagnosis Description: Diagnosis Code(s) : Submission of appropriate documentation with your initial request will expedite processing of your request. Please include: Office Notes X-ray Reports Other Diagnostic Tests Lab Results Specialist Consult Notes Authorization for specialist office visits are valid 90 days for a consultation and 2 follow up visits unless otherwise noted. Comments: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. Authorization is subject to member eligibility and benefit coverage on date of service. If the member is determined to be ineligible on the date of service, does not have benefit coverage for the service or has exceeded benefit limits, the member may be responsible for the service. To ensure proper payment for services rendered, the provider/facility must verify eligibility or benefits on the date of service. Payment will not be made for unauthorized services. All services must be ordered/ performed by contracted providers unless an out of network authorization is obtained. Please send specialist findings to the PCP. This authorization is good for 90 days unless otherwise noted. 5/19/15

47 Care1st Health Plan of Arizona: Pharmacy Prior Authorization Request form Phone: (Options 5, 5) Fax: INSTRUCTIONS: Please fill out all *Required Information completely and legibly. Attach any additional documentation that is important for the review to support the prior authorization request. (Chart notes, Lab results, Diagnostic tests, etc.) LINE OF BUSINESS AND PRIORITY AHCCCS DDD Routine Retroactive Expedite/Urgent: By checking AND signing below, I certify that applying the standard of review time frame may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function. PATIENT INFORMATION Signature of Prescriber or Prescriber's Designee *Last Name: *First Name: *DOB: *SEX: M / F Phone: Address: City: State/ZIP Code: *Care1st Health Plan (AHCCCS) ID#: INSURANCE INFORMATION (Care1st ID is Required) Other Coverage (If applicable): ID: PHARMACY INFORMATION Name: Phone: Fax: PRESCRIBER INFORMATION *First Name: *Last Name: *Specialty: *Phone: *Fax: Address: City/State: ZIP Code: NPI#: DEA# *Office Contact: REQUESTED MEDICATION INFORMATION *Drug Requested: *Strength: *Quantity: *Directions (or provide copy of RX): *Formulation: (tablet, capsule, lotion, injection, etc) Refills: New Therapy: Y / N Duration of Therapy: *Diagnosis (ICD-10): Pharmacy Department Phone: or (Options in order: 5, 5) Fax: Visit our website at

48 Care1st Health Plan of Arizona: Pharmacy Prior Authorization Request form Phone: (Options 5, 5) Fax: *DRUGS PATIENT HAS TAKEN FOR THIS DIAGNOSIS:(Provide to the best of your knowledge) IMPORTANT NOTE: Samples provided by the provider are not accepted as continuation of therapy or as an adequate trial and failure. Drug Name, Strength, Frequency Dates started and stopped or Approximate Duration Describe Response, Reason for Failure, or Allergy *ATTACH OR LIST BELOW RELEVANT LABORATORY VALUES AND DATES: Date Test Value *MEDICAL JUSTIFICATION OR OTHER NOTES: SIGNATURE *Signature of Requestor: *Date: Pharmacy Department Phone: or (Options in order: 5, 5) Fax: Visit our website at

49 AUTHORIZATION/PREGNANCY RISK ASSESSMENT Phone (Options 5, 6) Fax Date: PROVIDER INFORMATION: Physician Name: Fax: Street Address: Phone #/Office Contact: Group Name/TIN #: FQHC? : Yes City, State, ZIP: Date of 1 st visit in your office (required for auth): MEMBER INFORMATION: Member Name: EDC (required for auth): Member ID: High Risk: Why: Street Address: LMP: Weeks: WIC: City, State, Zip: Weight Now: Pre Preg: Phone Number: Date of Birth: Age: Primary Language Spoken: Other Insurance: PREGNANCY HISTORY (circle or fill in the blank with number) How many pregnancies? Multiple Pregnancy: Twins Triplets Other Number of living children? Induced abortions: Premature Labor: Premature Deliveries: Miscarriages: Vaginal deliveries: C/Sections: Why? Smoke? Yes No How much? Drink Alcohol? Yes No How Much? Street Drugs: Yes No All Current Medications: Medication Allergies? Yes No Any problems with pregnancy? Any Problems with Previous Pregnancies? Significant social history? MEDICAL PROBLEMS Heart Lung Kidneys Diabetes Asthma High Blood Pressure Other Previous Surgeries: Any previous HIV exposure or history? Has HIV status been confirmed with lab work? Any History of STD s? Received prenatal care prior to filling out this form? If yes, from whom? Hospital for delivery: CARE 1ST HEALTH PLAN ARIZONA USE ONLY Authorization #: From: Completed By: To: Dates Submit the Pregnancy Risk Assessment Form within thirty (30) days from the initial visit. If not submitted timely, authorization may be considered for visits only. Please complete the form in its entirety. If you have questions, call our Maternal Child Health (MCH) Team at x The risk assessment form is used by Case Management for assessment of member needs and risks. Updated

50 Credentialing Alliance PRACTITIONER DATA FORM PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner. New providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee if applicable). To: Return To: Fax: Phone: Fax: Phone: DIRECTIONS: Please type or print this form clearly and return the completed form with attachments Certification in your requested specialty or documentation of your examination date is required in order to successfully complete the contracting process Post the following items (as applicable) to CAQH - Check box to indicate items posted: IRS 941 coupon or accurate W9 Documentation of board certification or scheduled exam date Medicaid required insurance certificates as applicable (see page 3 for requirements) Fluoride Varnish Application Training Certificate (PCPs only) Developmental Screening Tool Training Certificate-PEDS/ASQ/M-CHAT (PCPs only) General Anesthesia Permit, Conscious Sedation Permit and/or Oral Conscious Sedation Permit (Dental providers only) CAQH Registration is required ( - for assistance please contact CAQH HELP DESK ) CAQH # Please ensure your application and attestation is up to date and that each health plan you are requesting participation in is authorized to access your data. Practitioner s Name & Degree: (Last) (First) (M.I.) (Degree) Female Male Practitioner s Effective Date w/practice: DOB: 1099 Registered Name (Required): Tax ID #: Group Practice Name (DBA) if applicable: Are you associated with any of the following: IPA PHO N/A If IPA or PHO marked please provide Name: Group Type (check all that apply): PCP OBGYN Dentist Specialist Lines of Business: Medicaid Individual NPI#: Organizational NPI#: Malpractice Policy #: Medicare Commercial SSN: DEA #: State: Exp. Date: License #: State: Exp. Date: Is provider a Medication Assisted Treatment (MAT) prescriber? Yes No (if yes): XDEA #: State: Exp. Date: Is provider a Medicare participating provider? Yes No AHCCCS I.D.#: Board Certification: Yes No New Graduate 1 : Yes No Primary Practicing Specialty: Date of Exam: Graduation/Completion Date: Board Certification: Yes No Dental Hygienist Affiliated Dentist Name: Secondary Practicing Specialty: Date of Exam: Want Contract as PCP? Yes No Accepting New Patients? Yes No Patient Age Range: Patient Gender: M F B Do you provide services to individuals with special needs/chronic conditions (check all that Physician Assistant Supervising Physician Name: apply)? Physical Developmental Behavioral Emotional None Do you provide services/accommodations to individuals who have difficulty communicating or cooperating (i.e. those with autism or intellectual disabilities)? Yes No Do you provide services to individuals with mobility limitations (i.e. wheelchair bound)? Yes No Do you treat any of the following diagnoses (check all that apply)? Anxiety ADHD Depression HIV None PCPs & OBs ONLY: Do you provide any of the following services (check all that apply)? EPSDT OB None Do you participate in VFC (Vaccines for Children)? Yes No (PCPs seeing AHCCCS members 18 & < must participate) VFC PIN Code: Is Practice/Practitioner FQHC or RHC? FQHC RHC N/A Do you E-Prescribe? Yes No Hospitals & Ambulatory Surgery Center(s) where practitioner has privileges: Names of Practitioners in Call Group (Must be contracted with plan): 1 licensed to practice medicine or dentistry for the first time in your career and or completed post-graduate training for the first time within the last 6 months Revised Page 1 of 5 SEE PAGE 5 FOR FAX AND PHONE INFORMATION

51 PLEASE TYPE OR PRINT CLEARLY & COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. This form includes Personally Identifiable Information (PII) such as practitioner name, date of birth and SSN and should be sent in a secure manner. New providers will receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee if applicable). BILLING SERVICE (If applicable) Name: Contact: Address: Phone: City: State: Zip Code: Fax: PAY TO ADDRESS (All payments sent to this address) Address: City: State: Phone: Fax: Zip Code: PRIMARY ADDRESS (Physical location where services are performed) Address: City: Zip Code: Phone: Fax: County: Office Hours: Is Office Accessible to Persons with Disabilities? Yes No List Practitioner in Directories at this Address? Yes No ADDITIONAL OFFICE: (Indicate other additional offices on an separate sheet) Address: City: Zip Code: Phone: Fax: County: Office Hours: Is Office Accessible to Persons with Disabilities? Yes No List Practitioner in Directories at this Address? Yes No Contact Name/Title: Phone: Fax: PRACTICE CONTACT/ MAILING ADDRESS: Address: Website Address: Address: City: Zip Code: Name: Address: CREDENTIALING CONTACT: Address: Phone: City: State: Zip Code: Fax: Languages other than English spoken by PRACTITIONER: N/A Languages other than English spoken by OFFICE STAFF: N/A Any other Name(s) Possible in Records? N/A Describe Your Medical Record Keeping System(s) (i.e. EMR system, Paper, etc.): Describe Your Cost Record Keeping System(s) (i.e. Billing or A/R system): Electronic Claims Submission? Yes No Internet Access? Yes No Is this a minority or female owned business? Yes No Electronic Funds Transfer? Yes No Revised Page 2 of 5 SEE PAGE 5 FOR FAX AND PHONE INFORMATION

52 AHCCCS INSURANCE REQUIREMENTS Required ONLY if requesting to participate in the Plan s Medicaid Line of Business The AHCCCS Minimum Subcontract Provisions include insurance requirements for Acute Care, RBHA, DCS/CMDP, CRS, ALTCS/EPD and DES/DDD Subcontractors. The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability, Worker s Compensation and Employers Liability and Professional Liability. The AHCCCS insurance requirements are outlined below: For the purpose of this Attachment, the following definition applies: Subcontractor means any third party with a contract with the Contractor (AHCCCS Plan) for the provision of any or all services or requirements specified under the Contractor s contract with AHCCCS, or any entity which has a Provider Participation Agreement or Group Biller Agreement with AHCCCS. Your commercial general liability policy and your business automobile policy (if applicable), need to include an endorsement (see letter a. below under Commercial General Liability and letter a. below under Business Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and letter b. below under Business Automobile Liability) in the Description field of your policy. Your worker s compensation and employers liability policy requires only the waiver of subrogation language (see letter a. below under Worker s Compensation and Employers Liability). For Subcontractors providing direct services to children and/or vulnerable adults (as defined by A.R.S (A)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM coverage may be sublimited to no less than $500,000. The SAM limits may be included within the General Liability limit, provided by separate endorsement with its own limits. If you are unable to obtain SAM coverage under your General Liability because the insurance market will not support it, it should it be included with the Professional Liability. SAM coverage must be noted with the following statement on the Certificate(s) of Insurance: Sexual Abuse and Molestation coverage is included or Sexual Abuse and Molestation coverage is not excluded. A. MINIMUM SCOPE AND LIMITS OF INSURANCE: Subcontractor shall provide coverage with limits of liability not less than those stated below as applicable in accordance with the services provided by the Subcontractor. 1. Commercial General Liability (CGL) Occurrence Form Policy shall include bodily injury, property damage, and broad form contractual liability coverage. General Aggregate $2,000,000 Products Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Damage to Rented Premises $ 50,000 Each Occurrence $1,000,000 a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor. b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. c. For Subcontractors providing direct services to children and/or vulnerable adults (as defined by A.R.S (A)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM coverage may be sub-limited to no less than $500,000. The limits may be included within the General Liability limit, provided by separate endorsement with its own limits. If you are unable to obtain SAM coverage under your General Liability because the insurance market will not support it, it should it be included with the Professional Liability. d. The following statement must be included on the Certificate(s) of Insurance: Sexual Abuse and Molestation coverage is included or Sexual Abuse and Molestation coverage is not excluded. 2. Business Automobile Liability Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance of the services under contract. Combined Single Limit (CSL) $1,000,000 a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor involving automobiles owned, leased, hired and/or non-owned by the Subcontractor. Revised Page 3 of 5 SEE PAGE 5 FOR FAX AND PHONE INFORMATION

53 b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. 3. Worker's Compensation and Employers' Liability Workers' Compensation Statutory Employers' Liability Each Accident $ 1,000,000 Disease Each Employee $ 1,000,000 Disease Policy Limit $ 1,000,000 a. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. 4. Professional Liability (Errors and Omissions Liability) Each Claim $1,000,000 Annual Aggregate $3,000,000 a. In the event that the professional liability insurance required by this Subcontract is written on a claims-made basis, Provider warrants that any retroactive date under the policy shall precede the effective date of the contract and the Subcontract; and that either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under the contract or the Subcontract is completed, whichever is later. b. The policy shall cover professional misconduct or wrongful acts for those positions defined in the Scope of Work of the contract or Subcontract. B. NOTICE OF CANCELLATION: Applicable to all insurance policies required within the Insurance Requirements of this Contract or the Subcontract, Subcontractor s insurance shall not be permitted to expire, be suspended, be canceled, or be materially changed for any reason without thirty (30) days prior written notice the Prime Contractor. C. ACCEPTABILITY OF INSURERS: Subcontractor s insurance shall be placed with companies licensed in the State of Arizona or hold approved non-admitted status on the Arizona Department of Insurance List of Qualified Unauthorized Insurers. Insurers shall have an A.M. Best rating of not less than A- VII. The State of Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect the Contractor or Subcontractor from potential insurer insolvency. If the Subcontractor utilizes the Social Service Contractors Indemnity Pool ( SSCIP ) or other approved insurance pool for insurance coverage, SSCIP or the other approved insurance pool is exempt from the A.M. Best's rating requirements listed in this section. If the Subcontractor chooses to use SSCIP or another approved insurance pool as its insurance provider, the Subcontract would be considered in full compliance with insurance requirements relating to the A.M. Best rating requirements. Revised Page 4 of 5 SEE PAGE 5 FOR FAX AND PHONE INFORMATION

54 The fax number and phone number for each participating plan is listed in the table below. If your intent is to apply for participation in a Health Plan network, please send only to the Plan(s) you are interested in joining. NOT ALL Plans provide services in every county. Please contact the Plan directly to verify that they provide services in your county and that they are accepting new providers. If you are adding a practitioner under an existing Health Plan contract, please only send to the Plan(s) you are contracted with. HEALTH PLAN PHONE FAX/ WEBSITE Care1st Health Plan Arizona (602) (options in order 5, 7) Comprehensive Medical and Dental Program (CMDP) (602) or (800) (options in order 1, 2, 3) (602) SM_AZ_PNO@care1stAZ.com (602) CMDPProviderServices@azdcs.gov Cenpatico Integrated Care x CAZCREDENTIALING@cenpatico.com m/providers/join-our-network.html Health Choice Arizona (800) (options in order 4, 7) Health Net Access (866) Apache/Coconino/Gila/LaPaz/ Maricopa/Mohave/Navajo/ Yavapai: (602) Cochise/Graham/Greenlee/Pima/PinalSa nta Cruz/Yuma: (520) azproviderdata@centene.com Mercy Care Plan (602) (Express Code 631) (480) (860) Mercy Maricopa (800) (860) United Healthcare Community Plan The University of Arizona Health Plans/Banner University Health Plans (877) (612) (520) or (800) (520) Each plan retains the right to make their own contracting decisions (whether or not to add practitioners to their network) and also will make their own credentialing committee decisions (review of the primary source verification information obtained by Aperture Credentialing, LLC resulting in approval/denial by the plan s committee). You will receive separate communication from each plan regarding the effective date of your credentialing and the effective date of your contract. Revised Page 5 of 5 SEE PAGE 5 FOR FAX AND PHONE INFORMATION

55 Credentialing Alliance ORGANIZATIONAL DATA FORM PLEASE COMPLETE THIS FORM IN ITS ENTIRETY INCLUDING ATTACHMENTS SO THAT WE MAY PROCESS YOUR REQUEST. New providers receive written confirmation of their effective date with the health plan. Members may not be seen until the provider receives written confirmation that a request or change is approved and completed (this includes approval by the Credentialing Committee if applicable). Please Type or Print Clearly. Please type or print this form clearly and return the completed form with attachments (attachments will need to be scanned if submitted electronically) Please complete a separate Organizational Data Form for entities with different AHCCCS ID # s and/or License # s. Attach the following: IRS 941 coupon or accurate W9 Copy of all accreditation certificates (including Medicare) Liability insurance face/certificate Medicaid required insurance certificates as applicable (see page 2 for requirements) NON-ACCREDITED FACILITIES: Copy of most recent State and/or Medicare Survey Audit List of practitioners providing services at each location (See AzAHP Ancillary Provider Roster) (if applicable) 1099 Registered Name (Required): Tax ID #: Facility Name/DBA (if applicable): Lines of Business: Medicaid Medicare Commercial License #: State: Exp. Date: Is provider a Medicare participating provider? Yes No AHCCCS I.D.#: Organizational NPI#: Facility Type (check all that apply): Acute Rehab Family Planning O&P Transportation Assisted Living Center ASC Home Health PT/OT/ST Urgent Care Assisted Living Home Dialysis Hospice Radiology Vision FQHC DME/Infusion Hospital Sleep Center Wound Care Outpatient Medical Rehab Center Enteral Lab SNF Behavioral Health Other BILLING SERVICE (If applicable) Name: Contact: Address: Phone: City: State: Zip Code: Fax: PAY TO ADDRESS (All payments sent to this address) Address: City: Zip Code: Phone: Fax: Zip Code: PRIMARY ADDRESS (Physical location where services are performed) *Attach additional locations Address: City: Zip Code: Phone: Fax: County: Modalities: Hours: Is Office Accessible to Persons with Disabilities? Yes No List this Address in Directories? Yes No Contact Name/Title: Phone: Fax: FACILITY CONTACT/ MAILING ADDRESS: Address: Website Address: Address: City: Zip Code: CREDENTIALING CONTACT: Name: Address: Address: Phone: City: State: Zip Code: Fax: Describe Your Medical Record Keeping System(s) (i.e. EMR, Paper, etc.): Describe Your Cost Record Keeping System(s) (i.e. Billing or A/R system): Electronic Claims Submission? Yes No Internet Access? Yes No Is this a minority or female owned business? Yes No Electronic Funds Transfer? Yes No Page 1 of 4

56 AHCCCS INSURANCE REQUIREMENTS Required ONLY if requesting to participate in the Plan s Medicaid Line of Business The AHCCCS Minimum Subcontract Provisions include insurance requirements for Acute Care, RBHA, DCS/CMDP, CRS, ALTCS/EPD and DES/DDD Subcontractors. The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability, Worker s Compensation and Employers Liability and Professional Liability. The AHCCCS insurance requirements are outlined below: For the purpose of this Attachment, the following definition applies: Subcontractor means any third party with a contract with the Contractor (AHCCCS Plan) for the provision of any or all services or requirements specified under the Contractor s contract with AHCCCS, or any entity which has a Provider Participation Agreement or Group Biller Agreement with AHCCCS. Your commercial general liability policy and your business automobile policy (if applicable), need to include an endorsement (see letter a. below under Commercial General Liability and letter a. below under Business Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and letter b. below under Business Automobile Liability) in the Description field of your policy. Your worker s compensation and employers liability policy requires only the waiver of subrogation language (see letter a. below under Worker s Compensation and Employers Liability). For Subcontractors providing direct services to children and/or vulnerable adults (as defined by A.R.S (A)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM coverage may be sub-limited to no less than $500,000. The SAM limits may be included within the General Liability limit, provided by separate endorsement with its own limits. If you are unable to obtain SAM coverage under your General Liability because the insurance market will not support it, it should it be included with the Professional Liability. SAM coverage must be noted with the following statement on the Certificate(s) of Insurance: Sexual Abuse and Molestation coverage is included or Sexual Abuse and Molestation coverage is not excluded. A. MINIMUM SCOPE AND LIMITS OF INSURANCE: Subcontractor shall provide coverage with limits of liability not less than those stated below as applicable in accordance with the services provided by the Subcontractor. 1. Commercial General Liability (CGL) Occurrence Form Policy shall include bodily injury, property damage, and broad form contractual liability coverage. General Aggregate $2,000,000 Products Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Damage to Rented Premises $ 50,000 Each Occurrence $1,000,000 a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor. b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. c. For Subcontractors providing direct services to children and/or vulnerable adults (as defined by A.R.S (A)(9)), the policy shall include coverage for Sexual Abuse and Molestation (SAM). This SAM coverage may be sub-limited to no less than $500,000. The limits may be included within the General Liability limit, provided by separate endorsement with its own limits. If you are unable to obtain SAM coverage under your General Liability because the insurance market will not support it, it should it be included with the Professional Liability. d. The following statement must be included on the Certificate(s) of Insurance: Sexual Abuse and Molestation coverage is included or Sexual Abuse and Molestation coverage is not excluded. 2. Business Automobile Liability Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance of the services under contract. Combined Single Limit (CSL) $1,000, Page 2 of 4

57 a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by the Subcontractor or on behalf of the Subcontractor or Contractor involving automobiles owned, leased, hired and/or non-owned by the Subcontractor. b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. 3. Worker's Compensation and Employers' Liability Workers' Compensation Statutory Employers' Liability Each Accident $ 1,000,000 Disease Each Employee $ 1,000,000 Disease Policy Limit $ 1,000,000 a. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by the Subcontractor or on behalf of the Subcontractor or Contractor. 4. Professional Liability (Errors and Omissions Liability) Each Claim $1,000,000 Annual Aggregate $3,000,000 a. In the event that the professional liability insurance required by this Subcontract is written on a claims-made basis, Provider warrants that any retroactive date under the policy shall precede the effective date of the contract and the Subcontract; and that either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under the contract or the Subcontract is completed, whichever is later. b. The policy shall cover professional misconduct or wrongful acts for those positions defined in the Scope of Work of the contract or Subcontract. B. NOTICE OF CANCELLATION: Applicable to all insurance policies required within the Insurance Requirements of this Contract or the Subcontract, Subcontractor s insurance shall not be permitted to expire, be suspended, be canceled, or be materially changed for any reason without thirty (30) days prior written notice the Prime Contractor. C. ACCEPTABILITY OF INSURERS: Subcontractor s insurance shall be placed with companies licensed in the State of Arizona or hold approved non-admitted status on the Arizona Department of Insurance List of Qualified Unauthorized Insurers. Insurers shall have an A.M. Best rating of not less than A- VII. The State of Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect the Contractor or Subcontractor from potential insurer insolvency. If the Subcontractor utilizes the Social Service Contractors Indemnity Pool ( SSCIP ) or other approved insurance pool for insurance coverage, SSCIP or the other approved insurance pool is exempt from the A.M. Best's rating requirements listed in this section. If the Subcontractor chooses to use SSCIP or another approved insurance pool as its insurance provider, the Subcontract would be considered in full compliance with insurance requirements relating to the A.M. Best rating requirements Page 3 of 4

58 The fax number and phone number for each participating plan is listed in the table below. If your intent is to apply for participation in a Health Plan network, please send only to the Plan(s) you are interested in joining. NOT ALL Plans provide services in every county. Please contact the Plan directly to verify that they provide services in your county and that they are accepting new providers. If you are adding a location/facility under an existing Health Plan contract, please only send to the Plan(s) you are contracted with. HEALTH PLAN PHONE FAX/ WEBSITE Care1st Health Plan Arizona (602) (options in order 5, 7) Comprehensive Medical and Dental Program (CMDP) (602) or (800) (options in order 1, 2, 3) (602) SM_AZ_PNO@care1stAZ.com (602) CMDPProviderServices@azdcs.gov Cenpatico Integrated Care x CAZCREDENTIALING@cenpatico.com providers/join-our-network.html Health Choice Arizona (800) (options in order 4, 7) (480) Health Net Access (866) Mercy Care Plan (602) (Express Code 631) Apache/Coconino/Gila/LaPaz/ Maricopa/ Mohave/Navajo/ Yavapai: (602) Cochise/Graham/Greenlee/Pima/ Pinal/Santa Cruz/Yuma: (520) azproviderdata@centene.com (860) Mercy Maricopa (800) (860) United Healthcare Community Plan The University of Arizona Health Plans/Banner University Healthy Plans (877) (612) (520) or (800) (520) Each plan retains the right to make their own contracting decisions (whether or not to add organizations to their network) and also will make their own credentialing committee decisions (review of the primary source verification information obtained by Aperture Credentialing, LLC resulting in approval/denial by the plan s committee). You will receive separate communication from each plan regarding the effective date of your credentialing and the effective date of your contract Page 4 of 4

59 Referral for Behavioral Health Services FAX: Date: Time (24-hour clock): Type of Service Requested: Name and Title: Affiliated Agency: Phone: Fax: Type of Service Requested: One time consultation Ongoing Behavioral Health Services Information on Person Making Referral (Check all that apply): Treatment Services: (Choose One) Behavioral Health Counseling and Therapy Assessment, Evaluation and Screening Services Other Professional Behavioral Health Services Requested General description of service(s) requested: (Choose One) Individual Therapy Family Therapy Group Therapy Medication Management Substance Abuse Unknown Rehabilitation Services:(Choose One) Skills Training and Development Cognitive Rehabilitation Behavioral Health Prevention/Promotion Education Psychoeducational Services/Supportive Employment Medical Services: Medication Services (Choose One) Laboratory, Radiology and Medical Imaging Medical Management Electroconvulsive Therapy (ECT) Support Services: (Choose One) Case Management Personal Care Services Home Care Training Family (Family Support) Self-Help/Peer Services (Peer Support) Home Care Training to Home Care Client Unskilled Respite Care Supported Housing Sign Language or Oral Interpretative Services Non-Medically Necessary Covered Services Transportation Behavioral Health Day Programs: (Choose One) Supervised Behavioral Health Treatment and Day Programs Therapeutic Behavioral Health Services and Day Programs Community Psychiatric Supportive Treatment Medical Day Programs ADHS/DBHS Policy Form Last Revision: 12/31/2014 Effective Date: 02/27/2015 Page 1 of 3

60 Referral for Behavioral Health Services FAX: Information on Person Being Referred for Services Last Name: First Name: Gender: Female Male Home Phone: Cell Phone: Primary Language: Address: City: State: Zip: Current Location (if not address above): If female, are you pregnant?: Yes No N/A Intravenous Drug (IV) use: Yes No N/A Parent/ Legal Guardian (if applicable): Parent/ Legal Guardian phone : Identify individual(s) that the member, parent or guardian may wish to be invited to initial appointment with person (Include phone): Person/Parent/Guardian is aware of Referral: Yes No Cultural and Language Considerations: Yes No If yes interpreter needed: Yes No Mobility Assistance: Yes No If yes, identify assistance needed: Visual Assistance: Yes No If yes, identify assistance needed: Hearing Impairment Assistance: Yes No If yes, identify assistance needed: Developmental or Cognitive Impairment: Yes No Accommodation Needs AHCCCS: Yes No AHCCCS ID # (if applicable): Yes No Self-Pay: Yes No Private insurance: Yes No Health Plan: Yes No Medicare: Yes No Block Grant eligible: Yes No Other: Primary Care Physician (PCP): PCP Phone / Fax: Name of Private Insurance and/or Health Plan: Reason for Referral: Payment Source ADHS/DBHS Policy Form Last Revision: 12/31/2014 Effective Date: 02/27/2015 Page 2 of 3

61 Referral for Behavioral Health Services FAX: Unable to Contact Person Being Referred for Services If the person is taking medications to treat a behavioral health condition, does she/he have an adequate supply for the next 30 days? Yes No If no, when will she/he exhaust the current supply of medication? If currently receiving services will there be any other interruptions that need to be addressed? Outreach Attempts: Type of Outreach and Engagement conducted (check all that apply): Phone Call Number of calls: Face to Face visit attempts Number of attempts: If unsuccessful, state reason why (check all that apply): No answer to phone call Person being referred already enrolled in behavioral health services Telephone disconnected Person being referred refuses behavioral health services Message(s) left with no response Referral Source Notified of Unsuccessful Contact: Yes No If yes, list alternate contact information obtained: ****If Unable to Contact Stop Here**** Information to be Collected by Network Provider Date: Time (24-hour clock): If applicable, name and contact information of the provider that will assume primary responsibility for the person's behavioral health care: Type of Appointment: Immediate Urgent Routine Available Intake Appointment Offered: Yes No If yes, specify date, time, place: ACTION TAKEN Scheduled Intake Appointment: Yes No If yes, specify date, time, place: If not Referred for Appointment specify why: Other Disposition, explain: Outcome (within 30 days) Intake Appointment Kept: Yes No If no, why (Check all that apply) Rescheduled by Provider Rescheduled by Person being referred Cancelled without rescheduling by Person being referred Person being referred was a no show If no show, specify outreach and engagement efforts (including number of attempts and type): Was assessment completed the same day as intake: Yes No If no, date assessment scheduled for: ****Please return form to referral source with Action Taken section completed.**** ADHS/DBHS Policy Form Last Revision: 12/31/2014 Effective Date: 02/27/2015 Page 3 of 3

62 PM FORM3.3.1 Referral for Behavioral Health Services FAX TO: Follow up by phone: I. Fax: Information on Person Making Referral Today s Date Time (24 hour clock) Name and Title: Title Affiliated Agency: Phone: Type of Service Requested: One Time Consultation Ongoing Behavioral Health Services Behavioral Health Services Requested (check all that apply) Treatment Services Rehabilitation Services Medical Services Support Services Behavioral Health Day Programs II. Information on Person Being Referred for Services F M Last Name First Name DOB Gender Marital Status: Single Married Divorced Widowed Primary Language Address City State Zip Telephone Current location (if other than above) Cell Phone: Parent/Legal Guardian (if applicable) Phone: Identify individual(s) the member, parent or guardian may wish to be invited to initial appointment with person (include phone). Person/Parent/Guardian is aware of referral: No Yes Cultural and language considerations? No Yes If yes, specify language/need Accommodation Needed for: Mobility No Yes If yes, identify assistance needed Visual Impairment No Yes If yes, identify assistance needed Hearing Impairment No Yes If yes, identify assistance needed Developmental/Cognitive Impairment No Yes If yes, identify assistance needed Payment Source: AHCCCS ID# Self Pay Medicare Other: Private Insurance Private Insurance/Health Plan Name PCP: Phone: Fax: Check any of the following which pertain to the person being referred: Shows evidence of suicidal or homicidal thoughts or behaviors Was recently D/C from inpatient setting Other potential risk factors, e.g., dehydrated, malnourished, homeless Children in CPS custody Pregnant Woman Has immediate medical needs Pregnant w/substance abuse IV drug user Identified need for psychotropic medication Is currently hospitalized. Reason for Referral: Additional information and contact information. If the person is taking medications to treat a behavioral health condition, does she/he have an adequate supply for the next 30 days? Yes No If no, when will she/he exhaust the current supply of medication? PM Form Page 1 of 2 Last Revised: 2/3/2016 Effective Date: 10/1/2015

63 PM FORM3.3.1 Referral for Behavioral Health Services FAX TO: Follow up by phone: Referral Received: Last Name: First Name: SSN: Name and Title: Affiliated Agency: Phone: Fax: The following information is to be completed by the Network Provider III. Unable to contact person being referred Number of outreach attempts Type of Outreach and Engagement conducted (check all that apply) Phone Calls Number of Calls Face to face visit attempt Number of attempts If unsuccessful, state reason why (check all that apply) No answer to phone call(s) Person being referred already enrolled in behavioral health services Telephone disconnected Person being referred refuses behavioral health services Message(s) left with no response Referral source notified of unsuccessful contact; if this box checked, list alternate contact information obtained: IF UNABLE TO CONTACT STOP HERE Date Received: Time (24 hour clock) If applicable, name and contact information of the provider that will assume primary responsibility for the person s behavioral health care: Type of appointment: Immediate Urgent Routine Available Intake Appointment Offered (specify date, time, place) IV. Action Taken Scheduled Intake Appointment (specify date, time, place): Not referred for appointment (specify why) Other disposition, explain V. Outcome (within 30 days) Intake appointment kept Yes No If no, why? (check all that apply): Rescheduled by provider Rescheduled by person being referred Cancelled without rescheduling by person being referred Person being referred was a no show Was the assessment done on same day as intake? Yes No If no, date assessment schedule for: Return to Referral Source and AHCCCS Behavioral Health Coordinator with Action Taken Section complete. Fax #s for Health Plan BH Coordinators: American Indian Health Plan: Health Choice: Care 1 st : Mercy Care Plan: DCS/CMDP: University Family Plan: United Healthcare: PM Form Page 1 of 2 Last Revised: 2/3/2016 Effective Date: 10/1/2015

64 ATTACHMENT B ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION FORM Complete appropriate sections below, attach voided check, deposit slip or letter from financial institution and return to Network Management: FAX TO: QUESTIONS: (Options 5, 7) Section I New EFT Setup Change in Account Number Change in Account Type Change in Financial Institution Cancellation Request (complete sections II, III and V only) Section II PAYEE IDENTIFICATION Federal Employer s Identification Number (EIN: - Or Social Security Number (SSN): - - (Disclosure of your Social Security Number is voluntary pursuant to 42 USC 405(c)(2)(C). The State of Arizona will use your SSN or EIN to file required information returns with the Internal Revenue Service) Payee Name (provider) Business Phone Business Fax AHCCCS/Medicare ID# NPI# Address Address City State Zip Code Section III AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION I authorize Care1st to process payments owed to me via Electronic Funds Transfer (EFT) deposits. Care1st shall deposit the electronic payments in the financial institution and account designated below. I certify that I have read and agree to comply with Care1st rules, governing payments and electronic transfers as they exist on this form or as subsequently adopted, amended, or repealed. I certify that I am authorized to initiate electronic funds transfer (EFT) for the entity receiving deposits, pursuant to this agreement, and that all information provided is accurate. Signature (Required) Title Date Section IV FINANCIAL INSTITUTION Bank Name: Bank Address: City State: Zip Code Branch Phone Number: - - Routing transit number: Customer Account Number: Type of Account: Checking Savings Lockbox Attach voided check (checking acct) or deposit slip (savings acct) when submitting. If a voided check is not available, please request a letter from your financial institution on bank letterhead, which reflects the routing and account numbers. Forms presented without a copy of voided check, deposit slip, or bank confirmation will be retuned to the requestor, unprocessed. Confirmation of EFT setup will be faxed once complete. Section V CANCELLATION Reason: Date: FOR INTERNAL USE ONLY: Vendor # EC# Set Up Completed By/Date EFT projected for claims paid the week of Confirmation Sent to Provider via Fax / on by Revised:

65 CARE1ST HEALTH PLAN ARIZONA NO SHOW LOG FAX COMPLETED FORMS TO: PCP/Office Name: PCP/Office Phone#: Member Name Member AHCCCS ID# Member Phone Number Date of Missed Appointment Reason for Appointment ( EPSDT or Sick Visit, etc) Care1st/ONECare will provide education to members about the importance of keeping their appointments and the need to cancel and/or reschedule appointments. C:\Users\dsobrino\Desktop\temp Please report missed appointments on a regular basis.