100 - 1 AHCCCS Contractor Operations Manual Overview

AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

100 - 1 AHCCCS CONTRACTOR OPERATIONS MANUAL OVERVIEW

EFFECTIVE DATE: 07/01/05, 10/01/12, 11/01/14, 10/01/15 , 07/01/16 2

REVISION DATE:10/25/06, 06/01/11, 09/12/12, 10/02/14, 12/29/14, 08/24/15 , XX/XX/XX 3

STAFF RESPONSIBLE: DIVISION OF HEALTH CARE MANAGEMENT (DHCM) CONTRACTS AND POLICY

I. PURPOSE

The AHCCCS Contractor Operations Manual (ACOM) applies to the following Contractors:

 Acute Care,  Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS), 4  Arizona Long Term Care System/Elderly and Physical Disability Program (ALTCS/EPD),  Children’s Rehabilitation Services (CRS),  Arizona Department of Child Safety/Comprehensive Medical and Dental Program (ADCS/CMDP).  Arizona Department of Economic Security/Division of Developmental Disabilities (DES/DDD),and  Regional Behavioral Health Authorities (RBHAs)

This manual also applies to subcontractors with delegated responsibilities under a contract. Policies within the manual specify their applicability to specific Contractors and subcontractors. For more information refer to other manuals, guides, or documents, including but not limited to those listed in Section VI, References. 5

The purpose of the ACOM is to set forth the Administrative, Claims, Financial, and Operational Policies and requirements of Contractors, of by the AHCCCS Administration. The ACOM Policies further describe AHCCCS contractual requirements and are incorporated by reference in the Contract.

II. DEFINITIONS

638 TRIBAL FACILITY A facility that is owned and/or operated by a Federally recognized American Indian/Alaskan Native Tribe and that is authorized to provide services pursuant to Public Law 93-638,

1 Giving the Manual Overview a Policy number to include it as part of the ACOM instead of a stand alone document. 2 Effective date of simplification 3 Date Policy was presented to the APC committee 4 .Revised policy applicability from DBHS to the RBHAs (Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the provision of behavioral health services under DBHS in the Department of Health Services is transferred to and shall be administered by the AHCCCS) 5 ACOM policies are not written to the subcontractor they are written to the contractor. Should they pass down the responsibility/delegate the responsibility to a subcontractor they are responsible for ensuring the subcontractor adheres to the correct AHCCCS policies ACOM OVERVIEW Page 1 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

as amended. Also referred to as: tribally owned and/or operated 638 facility, tribally owned and/or operated facility, 638 tribal facility, and tribally-operated 638 program. 6

ACUTE CARE A contracted managed care organization (also known as a CONTRACTOR 7 health plan) that provides acute care physical health services to AHCCCS members in the acute care program who are Title XIX or Title XXI eligible. The Acute Care Contractor is also responsible for providing behavioral health services for its enrolled members who are treated by a Primary Care Provider (PCP) for anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD). Acute Care Contractors are also responsible for providing behavioral health services for dual eligible adult members with General Mental Health and/or Substance Abuse (GMH/SA) needs.

ACUTE CARE SERVICES Medically necessary services that are covered for AHCCCS members and which are provided through contractual agreements with managed Care Contractors or on a Fee-For- Service (FFS) basis through AHCCCS. 8 A contracted managed care organization (also known as a health plan) that provides acute care physical health services to AHCCCS members in the acute care program who are Title XIX or Title XXI eligible. The Acute Care Contractor is also responsible for providing behavioral health services for its enrolled members who are treated by a Primary Care Provider (PCP) for anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD). Effective October 1, 2015, Acute Care Contractors are also responsible for providing behavioral health services for dual eligible adult members with General Mental Health and/or Substance Abuse (GMH/SA) needs. For other acute care populations, behavioral health services are carved out and are provided through Tribal or Regional Behavioral Health Authorities.

ADMINISTRATIVE SERVICES An agreement that delegates any of the requirements of the SUBCONTRACTS 9 contract with AHCCCS, including, but not limited to the following: a. Claims processing, including pharmacy claims, b. Credentialing, including those for only primary source verification (i.e. Credential Verification Organization), c. Management Service Agreements, d. Service Level Agreements with any Division or Subsidiary of a corporate parent owner, e. DDD acute care subcontractors. f. Providers are not Administrative Services Subcontractors. AHCCCS CONTRACTOR The ACOM provides information related to AHCCCS OPERATIONS MANUAL Contractor operations and is available on the AHCCCS website (ACOM) at www.azahcccs.gov www.azahcccs.gov. 10

6 Not applicable to MCO Contractors Operations 7 Added additional definitions that mirror Contract definition throughout Policy 8 Updated to mirror Contract definition 9 Added additional definitions that mirror Contract definition throughout Policy ACOM OVERVIEW Page 2 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

AHCCCS MEDICAL The AMPM provides information regarding covered health care POLICY MANUAL (AMPM) services and is available on the AHCCCS website at 11 www.azahcccs.gov www.azahcccs.gov. 12

AHCCCS DIVISION OF The Division responsible for oversight and processing of Fee- FEE-FOR-SERVICE For-Service (FFS) Claims, prior authorization and management MANAGEMENT for services provided to American Indian Health Plan (AHCCCS/DFSM) 13 (AIHP)/FFS, Tribal ALTCS, and Federal Emergency Services (FES) members.

AHCCCS DIVISION OF The Division responsible for Contractor oversight regarding HEALTH CARE AHCCCS Contractor operations, quality, maternal and child MANAGEMENT health, behavioral health, medical management, case (AHCCCS/DHCM) 14 management, rate setting, encounters, and financial/ operational oversight.

AHCCCS DIVISION OF The Division responsible for management of eligibility and MEMBER SERVICES enrollment of members. ( AHCCCS/ DMS) 15

AHCCCS OFFICE OF The office responsible for the collaborative development of MEDICAL POLICY (OMP) AHCCCS medical policy and maintenance of the AHCCCS Medical Policy Manual.

AHCCCS POLICY A committee comprised of Agency Management and subject COMMITTEE (APC) matter experts within AHCCCS and stakeholder representatives that review new and revised Policies.

AHCCCS REGISTERED A contracted provider or non-contracting provider who enters PROVIDER into a provider agreement with AHCCCS and meets licensing or certification requirements to provide AHCCCS covered services to members.

10 Updating the link to the new AHCCCS website for ACOM 11 Updating the link to the new AHCCCS website for AMPM 12 Updated with the current web address 13 Removing Division definitions within AHCCCS 14 Removing Division definitions within AHCCCS 15 Removing Division definitions within AHCCCS ACOM OVERVIEW Page 3 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

AMERICANS WITH The ADA prohibits discrimination on the basis of disability and DISABILITIES ACT (ADA) ensures equal opportunity for persons with disabilities in employment, state and local government services, public accommodations, commercial facilities, transportation, and telecommunications. Refer to the Americans with Disabilities Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C. 5.

ARIZONA ADMINISTRATIVE State regulations established pursuant to relevant statutes. CODE (A.A.C.) Referred to in Contract as “Rules.” AHCCCS Rules are State regulations which have been promulgated by the AHCCCS Administration and published by the Arizona Secretary of State.

ARIZONA DEPARTMENT OF The department established pursuant to A.R.S. §8-451 to CHILD SAFETY (DCS) protect children and to perform the following: 1. Investigate reports of abuse and neglect. 2. Assess, promote and support the safety of a child in a safe and stable family or other appropriate placement in response to allegations of abuse or neglect. 3. Work cooperatively with law enforcement regarding reports that include criminal conduct allegations. 4. Without compromising child safety, coordinate services to achieve and maintain permanency on behalf of the child, strengthen the family and provide prevention, intervention and treatment services pursuant to this chapter.

ARIZONA DEPARTMENT OF The Division of a State agency, as defined in A.R.S. Title 36, ECONOMIC SECURITY, Chapter 5.1, which is responsible for licensure/certification of DIVISION OF facilities that specifically serve individuals with a DEVELOPMENTAL developmental/intellectual disability, contracting with providers DISABILITIES ( A DES/DDD) that serve individuals with developmental disabilities, and providing services for eligible Arizona residents with a developmental/ intellectual disability. AHCCCS contracts with ADES to serve eligible individuals with a developmental/ intellectual disability.

ARIZONA DEPARTMENT OF The state agency mandated to provide behavioral health HEALTH SERVICES, services to Title XIX and Title XXI Acute care members who DIVISION OF BEHAVIORAL are eligible for behavioral health services. Services are HEALTH (ADHS/DBHS) 16 provided through the ADHS Division of Behavioral Health and its Contractors. ARIZONA HEALTH CARE Arizona’s Medicaid Program, approved by the Centers for COST CONTAINMENT Medicare and Medicaid Services as a Section 1115 Waiver SYSTEM (AHCCCS) Demonstration Program and described in A.R.S. Title 36, Chapter 29.

16 Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the provision of behavioral health services under DBHS in the Department of Health Services is transferred to and shall be administered by the AHCCCS. ACOM OVERVIEW Page 4 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

ARIZONA LONG TERM An AHCCCS Program which delivers long-term, acute, CARE SYSTEM (ALTCS) behavioral health care and case management services, as authorized by A.R.S. §36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with Developmental Disabilities (DD), through contractual agreements and other arrangements.

ARIZONA REVISED The Laws of the State of Arizona. STATUTES (A.R.S.)

ALTCS MEMBER CHANGE A user guide that provides a tutorial for the process of reporting REPORT USER GUIDE to AHCCCS when a change needs to be made on a long term care member’s eligibility or enrollment record via the electronic Member Change Report (eMCR).

BEHAVIORAL HEALTH Refers to a behavioral health inpatient facility, a behavioral FACILITY health residential facility, a substance abuse transitional facility, a behavioral health specialized transitional facility, an outpatient treatment center that provides only behavioral health services, or a behavioral health supportive home as outlined in A.A.C. R9-10. Including but not limited to; Services provided to managed care Title XIX members (including members who receive behavioral health services through an Integrated Regional Behavioral Health Authority [Integrated RBHA], Regional Behavioral Health Authority [RBHA], or Tribal Regional Behavioral Authority [TRBHA]) may be reimbursed in any behavioral health setting, regardless of age, under the Federal Provision, 42 C.F.R. 438.6(e), when approved for managed care contracts by CMS.

BEHAVIORAL HEALTH A health care institution that provides continuous treatment to INPATIENT FACILITY an individual experiencing a behavioral health issue that causes the individual to: 1. Have a limited or reduced ability to meet the individual’s basic physical needs, 2. Suffer harm that significantly impairs the individual’s judgment, reason, behavior, or capacity to recognize reality, 3. Be a danger to self, 4. Be a danger to others, 5. Be persistently, acutely, or gravely disabled as outlined in A.R.S. §36-501, or 6. Be gravely disabled.

ACOM OVERVIEW Page 5 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

BEHAVIORAL HEALTH As specified in A.A.C. R9-10-101, an individual licensed under PROFESSIONAL A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual to: a. Independently engage in the practice of behavioral health as defined in A.R.S. §32-3251; or b. Except for a licensed substance abuse technician, engage in the practice of behavioral health as defined in A.R.S. §32- 3251 under direct supervision as defined in A.A.C. R4-6- 101.; c. A psychiatrist as defined in A.R.S. §36-501; d. A psychologist as defined in A.R.S. §32-2061; e. A psychiatrist as defined in A.R.S. §36-501; f. A psychiatrist as defined in A.R.S. §36-501; A psychologist as defined in A.R.S. §32-2061; g. A physician; h. A registered nurse i. A registered nurse practitioner licensed as an adult psychiatric and mental health nurse; or j. A behavior analyst as defined in A.R.S. §32-2091; or k. A registered nurse.

C ARE MANAGEMENT A group of activities performed by the Contractor to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost, and help achieve better health care outcomes. Distinct from case management, care management does not include the day-to-day duties of service delivery.

C ASE MANAGEMENT A collaborative process which assess, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.

CARE PLAN 17 The individualized regimen of care and services that are prepared by the service provider and includes measurable goals and objectives for the outcome of services authorized by an ALTCS member’s case manager. The Care Plan includes specific treatment methodologies and services to be rendered to an ALTCS member in order to meet established goals and objectives.

CENTERS FOR MEDICARE An organization within the United States Department of Health AND MEDICAID SERVICES and Human Services which administers the Medicare and (CMS) Medicaid programs and the State Children’s Health Insurance Program.

17 Term no longer referenced instead using Service Plan ACOM OVERVIEW Page 6 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

CHILDREN’S A program that provides medical treatment, rehabilitation, and REHABILITATIVE SERVICES related support services to Title XIX and Title XXI members (CRS) who have completed the CRS application and have met the eligibility criteria to receive CRS related services as specified in 9 A.A.C.22.

CLAIMS DASHBOARD GUIDE A guide designed to assist the Contractor in submitting a monthly report to address claim requirements, including billing rules and documentation requirements, and submit a report to AHCCCS that will include the rationale for specific requirements.

CODE OF FEDERAL The general and permanent rules published in the Federal REGULATIONS (CFR) Register by the departments and agencies of the Federal Government.

DEPARTMENT OF CHILD A Contractor that is responsible for the provision of covered, SAFETY/ COMPREHENSIVE medically necessary AHCCCS services for foster children in MEDICAL AND DENTAL Arizona. Refer to A.R.S. §8-512. 19 PLAN ( DCS/ CMDP) 18 On May 29, 2014 the Department of Child Safety was established pursuant to A.R.S. §8-451. Under the authority of DCS is CMDP, a Contractor that is responsible for the provisions of covered, medically necessary AHCCCS services for children in foster care in Arizona. CMDP previously existed as a department within the Arizona Department of Economic Security (ADES).

CONTRACTOR An organization, or entity that has a prepaid capitated contract with AHCCCS pursuant to A.R.S. §36-2904, §36-2940, or §36-2944 to provide goods and services to members either directly or through subcontracts with providers, in conformance with contractual requirements, AHCCCS Statute and Rules, and Federal law and regulations.

18 Definition changed to mirror Contract 19 Definition change to mirror Contract ACOM OVERVIEW Page 7 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

EARLY AND PERIODIC A comprehensive child health program of prevention, SCREENING, DIAGNOSIS AND treatment, correction, and improvement of physical and mental TREATMENT (EPSDT) health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical, oral and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 U.S.C. 1396 d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

FEE-FOR-SERVICE (FFS) A method of payment to an AHCCCS registered provider on an amount-per-service basis for services reimbursed directly by AHCCCS for members not enrolled with a managed care Contractor. 20

GRIEVANCE GUIDE A guide that provides instructions to the Contractors on how to complete the Grievance System Report for submission to and review by the Division of Health Care Management (DHCM), as required by contract.

HEALTH INSURANCE The Health Insurance Portability and Accountability Act (P.L. PORTABILITY AND 104-191); also known as the Kennedy-Kassebaum Act, signed ACCOUNTABILITY ACT August 21, 1996 as amended and as reflected in the (HIPAA) implementing regulations at 45 CFR Parts 160, 162, and 164.

HOME AND COMMUNITY Home and community-based services, as defined in BASED SERVICES (HCBS) A.R.S. §36-2931 and §36-2939.

20 Not applicable to MCO Contractors Operations

INTEGRATED REGIONAL An organization that provides behavioral health services to BEHAVIORAL HEALTH AHCCCS members who are Title XIX or Title XXI eligible, AUTHORITY (INTEGRATED other than adult members dually enrolled in Medicaid and RBHA) 21 Medicare with General Mental Health and Substance Abuse needs and American Indians who choose a TRBHA. The Integrated RBHA also provides physical health services for AHCCCS members determined to have a Serious Mental Illness, with the exception of American Indians who choose AIHP.

KIDSCARE Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare I program offers comprehensive medical, preventive, treatment services, and behavioral health care services statewide to eligible children under the age of 19, in households with income at or below 133% and 200%of the Federal Poverty Level (FPL). The KidsCare II program has the same benefits and premium requirements as KidsCare I, however household income limits cannot be greater than 175% FPL. The KidsCare II program is available May 1, 2012 through January 31, 2014. 22

MANAGED CARE A health care delivery system consisting of affiliated and/or ORGANIZATION (MCO) owned hospitals, physicians and others which provide a wide range of coordinated health services; an umbrella term for health plans that provide health care in return for a predetermined monthly fee and coordinate care through a defined network of physicians and hospitals.

MEDICALLY NECESSARY As defined in A.A.C. R9-22.101. Medically necessary means a covered service provided by a physician or other licensed practitioner of the healing arts within the scope of practice under State law to prevent disease, disability or other adverse conditions or their progression, or prolong life.

MEMBER An eligible person who is enrolled in AHCCCS, as defined in A.R.S. §36-2931, §36-2901, §36-2901.01 and A.R.S. §36- 2981.

NON-TITLE XIX/XXI An individual who needs or may be at risk of needing covered MEMBER OR health-related services, but does not meet federal and State NON-TITLE XIX/XXI requirements for Title XIX or Title XXI eligibility. PERSON

NON-TITLE XIX/XXI SMI A Non-Title XIX/XXI member who has met the criteria to be MEMBER designated as Seriously Mentally Ill.

21 All plans are integrated making no reason for the distinction 22 Kidscare is reinstated as of ACOM OVERVIEW Page 9 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

PROVIDER AFFILIATION Every quarter the Contractors are required to submit TRANSMISSION (PAT) USER information about each individual provider within their network MANUAL as specified in Contract. Each Contractor is responsible for submitting true and valid information.

PREPAID MEDICAL An integrated information infrastructure that supports AHCCCS MANAGEMENT operations, administrative activities and reporting requirements. INFORMATION SYSTEM (PMMIS)

PRIMARY CARE PROVIDER An individual who meets the requirements of A.R.S. §36-2901, (PCP) and who is responsible for the management of the member’s health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15. The PCP must be an individual, not a group or association of persons, such as a clinic.

REGIONAL BEHAVIORAL An organization under contract with the ADHS to administer HEALTH AUTHORITY covered behavioral health services in a geographically specific (RBHA) area of the state. Refer to A.R.S. §36-3401, §36-3407, and A.A.C. R9-22-201.

SERIOUS MENTAL ILLNESS A condition as defined in A.R.S. §36-550 and determined in a (SMI) person 18 years of age or older.

SERVICE PLAN 23 A complete written description of all covered health services and other informal supports which includes individualized goals, family support services, care coordination activities and strategies to assist the member in achieving an improved quality of life.

STATE CHILDREN’S HEALTH State Children’s Health Insurance Program under Title XXI of INSURANCE PROGRAM the Social Security Act (Also known as CHIP). The Arizona (SCHIP) version of CHIP is referred to as “KidsCare.” See also “KIDSCARE.”

23 Definition taken from Contract. Service Plan replaces the term Care Plan ACOM OVERVIEW Page 10 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

SUBCONTRACTOR 1. A provider of health care who agrees to furnish covered services to members. 2. A person, agency or organization with which the Contractor has contracted or delegated some of its management/administrative functions or responsibilities. 3. A person, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies equipment or services provided under the AHCCCS agreement.

TITLE XIX Known as Medicaid, Title XIX of the Social Security Act provides for Federal grants to the states for medical assistance programs. Title XIX enables states to furnish medical assistance to those who have insufficient income and resources to meet the costs of necessary medical services, rehabilitation and other services, to help those families and individuals become or remain independent and able to care for themselves Title XIX of the social security act which is also referred to Members include but are not limited to those eligible under Section 1931 of the Social Security Act, Supplemental Security Income (SSI), SSI-related groups, Medicare cost sharing groups, Breast and Cervical Cancer Treatment Program and Freedom to Work Program. Which include those populations 42 U.S.C. 1396 a (a)(10)(A).

TITLE XXI Title XXI of the Social Security Act provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low income children in an effective and efficient manner that is coordinated with other sources of child health benefits coverage.

TRIBAL/REGIONAL An organization under contract with the State of Arizona that BEHAVIORAL HEALTH administers covered behavioral health services for Title XIX AUTHORITY (T/RBHA) and XXI members. Tribal governments, through an agreement with the State, may operate a Tribal Regional Behavioral Health Authority for the provision of behavioral health services to American Indian Members. Refer to A.R.S. §36-3401, §36- 3407, and R9-22-201. 24

III. POLICY

A. MANUAL CONTENT

The ACOM consists of four chapters, identified below. Each Chapter contains individual Policies and corresponding Policy Attachment(s). The Policy Attachments are considered

24 Not applicable to MCO Contractors Operations

Policy requirements and are provided in the appropriate format (e.g. Microsoft Word, Microsoft Excel, etc.) as necessary for ease of use. and are part of each Policy.

CHAPTER 100 Contains the Manual Overview and 25 policies pertaining ADMINISTRATION to business plan and organization.

CHAPTER 200 Contains policies pertaining to claim adjudication and CLAIMS reimbursement.

CHAPTER 300 Contains policies pertaining to financial information or FINANCIAL data, including reconciliation and reporting.

CHAPTER 400 Contains policies pertaining to Contractor operations OPERATIONS such as; member information, coordination of care, and network management.

The Contractor is responsible for complying with the requirements set forth within the ACOM and is responsible for ensuring that its subcontractors are notified when modifications are made to the ACOM. Upon adoption by AHCCCS, updates to the ACOM are made available to Contractors on the AHCCCS Contractor Operations Manual (ACOM) area of the AHCCCS website.

B. THE DIVISION OF HEALTH CARE MANAGEMENT (DHCM)

DHCM, in conjunction with other divisions within AHCCCS, is responsible for the formu- lation of ACOM policiesPolicies. ACOM Policies are developed and/or revised in order to maintain a consistent, uniform approach and to ensure the following:

1. Consistency with statutes and rules and contractual requirements,;

2. Regular review; ,

3. Timely communication of updates; , and

4. Reduction of duplication and inconsistencies.

New or revised policies Policies can stem from a variety of sources including, but not limited to, federal or state legislation, contractual requirements, internal operational changes, and requests for written guidelines in a particular area. Policy modifications are assessed for a financial impact and the need for input/comments from external parties (e.g. health plans, state agencies, stakeholders, CMS).

C. POLICY APPROVAL AHCCCS POLICY COMMITTEE 26

25 Adding the Manual Over 26 Updating the system to reflect current procedures ACOM OVERVIEW Page 12 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

The AHCCCS Policy Committee (APC) is comprised of AHCCCS management and subject matter experts and stakeholder representation including member, advocate and Tribal representatives.

The AHCCCS Policy Committee (APC) APC reviews policies within the ACOM related to Contractor operations and , the AMPM regarding medical policy. In addition, other policies are reviewed as designated by the Director, Deputy Director, or the head of divisions/offices. Policies are reviewed to ensure they follow compliance with the guidelines set forth by the Centers for Medicare and Medicaid (CMS), Federal and/or State Citations, and are in the best interest of the State. In addition, nNew policies and substantive modifications to existing policies must be and are presented reviewed by to the committee.

In the event of an expedited matterreview request, AHCCCS the Executive Management Team may also approve policy changes. and approved by the AHCCCS Policy Committee (APC) or Executive Management. APC is comprised of Agency Management and subject matter experts.

APC or Executive Management reviews policies related to medical policy, Contractor operations, FFS operations, or other policies as designated by the head of a division/office, Deputy Director, or Director to ensure policies are cost effective and in the best interest of the AHCCCS Program and the State.

Upon approval, the Policy is assigned an effective date and a revision date (which is the date of the approval).

Approved APC determines if the proposed policy changes are substantial and require up to a two week Public Comment review period prior or if it is determined that the changes were not substantial they changes are not substantial and is therefore policy canis Approve the Policy and publishedto final publication. 1. policies are finalized and published to the AHCCCS website and notification is provided to the Contractor. A more detailed account can be found within the publication of the ACOM Revision Memo. 2. 3. Updates to the ACOM website occur as-needed but, are typically published at the beginning of each month. ACOM Revision Memos can be accessed at the following link on the AHCCCS website: ACOM Revision Memos

D. TRIBAL CONSULTATION NOTIFICATION/ PUBLIC COMMENT 27

All Policies and related materials that have been opened for review and revisions will be posted to the AHCCCS Web Site within the AMPM Tribal Consultation Notification/Public Comment location. This page allows for both Tribal members and the general public to review and submit comments regarding changes that are being presented. The policy will be open for not more than 45 days unless otherwise stipulated. Due to extreme circumstances there will be on occasion the need to provide an expedited time

27 Adding new procedure added to the Policy process ACOM OVERVIEW Page 13 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

period that will be not less than two weeks and will be noted if utilized. The comment deadline will be specified on each document. Comments must be limited only to policies that are currently open and listed on the site.

AHCCCS will review all comments submitted; however, will not be responding to any submissions. When the open period has concluded, the Policies will be removed from the page and review of all comments will be done. 28

Tribal members, Contractors and the general public are encouraged to sign up for the Public Comment Listserv (POLICY_PUBLIC_COMMENT-L) in order to receive timely notifications.

Irequires a public comment periodIn order to be notified of policies open for public comment, individuals must subscribe to the Policy-Public-Comment-L. is l,reviews but does not provide responses t to the policyas a result of E. PUBLISHED POLICIES

At the conclusion of the Tribal Consultation Notification/Ppublic cComment period, comments are reviewed and Ppolicies are finalized and published to the AHCCCS website. An overview of changes can be found within the ACOM Revision Memo. AHCCCS has instituted a Listserv to communicate updates regarding the ACOM. In order to be notified of updates it is the Contractor’s responsibility to subscribe to the ACOM Listserv (DHCM-ACOM-L) in order to receive timely updates.

Updates to the ACOM websitewepagewebpage occur as-needed but, are typically published at the beginning of each month.

F. OTHER AHCCCS GUIDES AND MANUALS 29

The ACOM frequently provides reference to other AHCCCS manuals and legal references or documents which provide more detailed information. These include, but are not limited to:

 AHCCCS ALTCS Member Change Report User Guide  AHCCCS Covered Behavioral Health Services Guide  AHCCCS Claims Dashboard Reporting Guide  AHCCCS Contractor Operations Manual (ACOM)  AHCCCS Eligibility Policy Manual  AHCCCS Encounter Manual  AHCCCS Fee-For-Service Provider Manual  AHCCCS Financial Reporting Guides  AHCCCS Grievance and Appeal System Reporting Guide  AHCCCS Guide to Languages in Notices of Action (NOA)  AHCCCS Medical Policy Manual (AMPM)  AHCCCS Minimum Subcontract Provisions  AHCCCS Operations Reporting Guidelines

28 New process surrounding Tribal Consultation Notification/Public Comment procedures and time frames. 29 Updating and adding other AHCCCS Guides and Manuals ACOM OVERVIEW Page 14 of 15 AHCCCS CONTRACTOR OPERATIONS MANUAL MANUAL OVERVIEW CHAPTER 100 - ADMINISTRATION

 AHCCCS Program Integrity Reporting Guide  AHCCCS Provider Affiliation Transmission (PAT) Manual  AHCCCS Public Notices and Opportunities for Public Comment  AHCCCS Reinsurance Policy Manual  AHCCCS State Plan  AHCCCS Technical Interface Guidelines  Arizona Administrative Code (A.A.C.)  Arizona Revised Statutes (A.R.S.)  Arizona Section 1115 Waiver  Code of Federal Regulations (CFR)  Medicare D-SNP Agreements (MIPPA Agreements)

IV. REFERENCES V. VI. VII. Acute Care Contract, Section D VIII.ADHS/DBHS Contract, Section D IX. ALTCS/EPD Contract, Section D X. CRS Contract, Section D XI. DCS/CMDP Contract, Section D XII. DES/DDD Contract, Section D XIII.Contract, Section F, Attachment F3, Contractor Chart of Deliverables 30

30 Removed reference list‐ applicable references are included in the policy

ACOM OVERVIEW Page 15 of 15