Care1st Health Plan Arizona

Provider Manual

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TABLE OF CONTENTS:

SECTION I - INTRODUCTION

  • Welcome
  • Mission Statement
  • Introduction to Care1st
  • Department Organization

SECTION II - QUICK REFERENCE CONTACT LIST

  • Department Contacts
  • Website
  • Contracted Vendors
  • Arizona Health Care Cost Containment System (AHCCCS)
  • Hearing Impaired
  • Translation Services

SECTION III - PROVIDER ROLES AND RESPONSIBILITIES

  • PCP Gatekeeper Role
  • Specialist Responsibility
  • Service Delivery Responsibilities
  • Care Coordination
  • Appointment and Wait Time Standards
  • Provider Network Changes
  • Removal of Member from Panel
  • Provider Inquiries, Complaints, Requests for Information & General Grievances/Disputes
  • Provider Directory
  • Eligibility Verification
  • Cancelled and Missed Appointments
  • AHCCCS Cost Sharing & Co-payments
  • Provision of Covered Services
  • ASIIS
  • Referrals and Prior Authorization
  • Submitting Claims and Encounters
  • Inappropriate Use of the Emergency Room
  • Documentation
  • Data Validation
  • Advance Directives
  • Non-Discrimination Policy
  • Culturally Competent Care

SECTION IV - MEMBER RIGHTS & RESPONSIBILITIES

  • Member Rights
  • Member Responsibilities
  • Grievances
  • Advance Directives

SECTION V - ELIGIBILITY AND ENROLLMENT

  • Eligibility Determination and Enrollment
  • KidsCare
  • DES/DDD
  • Rate Codes
  • Member Identification Cards
  • PCP Assignment
  • Eligibility Verification
  • Newborn Coverage
  • AHCCCS Cost Sharing & Co-Payments

SECTION VI - COVERED SERVICES

  • Covered Services
  • Chiropractic Services
  • Children’s Rehabilitative Services (CRS)
  • Dental
  • Emergency Services
  • EPSDT Services
  • Family Planning Extension Services
  • Family Planning Services
  • Home Health
  • Hearing
  • Laboratory
  • Maternity Care
  • Optometry/Vision
  • Orthotics and Prosthetics
  • Pharmacy
  • Podiatry
  • Radiology
  • Rehabilitation
  • Transportation

SECTION VII - BEHAVIORAL HEALTH SERVICES

  • Overview
  • Psychotropic Medication Prescribing, Adjustment & Monitoring
  • Behavioral Health Crisis Services
  • Behavioral Health Referrals
  • Telephonic Consultation Services through Magellan
  • Face-to-Face Consultation Services through Magellan
  • Coordination of Care
  • Transfer of Care
  • Provider Information

SECTION VIII - CLAIM DISPUTES AND APPEALS

  • Claim Disputes & Appeals Process
  • Member Appeals

SECTION IX - MEDICAL OPERATIONS

  • Overview
  • Prior Authorization and Referral Process
  • Case Management
  • Disease Management
  • Pharmacy Management
  • Concurrent Review
  • Retrospective Review

SECTION X - QUALITY IMPROVEMENT

  • Overview
  • Confidentiality and Conflict of Interest
  • Credentialing
  • Peer Review
  • Medical Record Guidelines

SECTION XI - BILLING, CLAIMS AND ENCOUNTERS

  • Claim Submissions
  • Required ID Numbers
  • Billing for Services Rendered
  • Medical Claims Review

SECTION XII - FRAUD, WASTE AND/OR ABUSE

  • Fraud and Abuse
  • Deficit Reduction Act

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