AHCCCS Contractor Operations Manual (ACOM)

Policies with Changes that include revisions due to CMDP Integration of Behavioral Health Services

Pursuant to Laws 2019, 1st Regular Session, Chapter 305, behavioral health services for children in DCS custody were anticipated to transition from the RBHA Contractors to DCS/ CMDP effective October 1, 2020. However, this implementation has been delayed. Revisions that have already been completed for ACOM and AMPM Policies and Attachment(s), related to this anticipated integration [listed in document provided below], will remain in the impacted policies but will not be applicable until such time that CMDP behavioral health service integration is implemented. Revisions unrelated to the integration of behavioral health services for CMDP members; will continue to be effective October 1, 2020.

POLICIES WITH CHANGES THAT INCLUDE REVISIONS DUE TO CMDP INTEGRATION OF BEHAVIORAL HEALTH SERVICES

• 103 - Fraud, Waste and Abuse
• Attachment A - Representations and Certifications of Contractor
• Attachment A-1 - Disclosure Information - Disclosure of Ownership and Control
• Attachment B - Corporate Compliance Work Plan-Sample
• Attachment C - External Audit Plan Template
• 110 - Mental Health Parity
• Attachment A - AZ Parity Summary Report
• Attachment B - Mental Health Parity Attestation
• Attachment C -NQTL Summary
• 317 - Change in Contractor Organizational Structure
• 404 - Contractor Website and Member Information
• Attachment A - Organizations Recognized by AHCCCS
• Attachment B - Contractor Website Certification Checklist
• Attachment C - Member Information Attestation Statement
• 406 - Member Handbook and Provider Directory
• Attachment A - Member Handbook Checklist
• Attachment B - Definitions for AHCCCS Members Pursuant to 42 CFR 438.10
• 415 - Provider Network Development and Management Plan
• Attachment A - Network Attestation Statement
• Attachment B - Network Plan Checklist
• Attachment C - ALTCS EPD Contractor Supplement
• Attachment D - Provider Changes Due to Rates Report
• Attachment E - HCBS Service Delivery Standard Report
• Attachment F - Reserved with new location of Attachment
• Attachment G - Facility and Member Placement Report
• 416 - Provider Information
• 417 - Appointment Availability, Transportation Timeliness, Monitoring, and Reporting
• Attachment A - Appointment Availability and Transportation Timeliness Review
• 429 - Direct Care Worker and Testing Program the Policy
• 432 - Benefit Coordination and Fiscal Responsibility for Behavioral Health Services and Physical Health Services
• Attachment A - Matrix of Financial Responsibility by Responsible Party
• 433 - Member Identification Cards
• Attachment A - Table of Requirements
• 436 - Network Standards
• Attachment A - Minimum Network Requirements Verification Template
• 438 - Administrative Services Subcontractor Evaluation
• Attachment A - Administrative Services Subcontract Checklist
• Attachment B - Administrative Services Subcontractor Evaluation Report Template
• 449 - Behavioral Health Services for Children in Department of Child Safety Custody and Adopted Children
• Attachment A - DCS and Adopted Children Services Reporting Access to Services
• Attachment B - Administrative Services Subcontractor Evaluation Report Template
• 447 - Employment
• Attachment C Psychiatric Rehab Progress Report Specs for RBHA ACC

• 100 - AHCCCS Contractor Operations Manual Overview
• 101 - Marketing
• Attachment A - Marketing Attestation Statement
• Attachment B - Marketing Activities Report
• 103 - Fraud, Waste and Abuse
• Attachment A - Representations and Certifications of Contractor
• Attachment A-1 - Disclosure Information - Disclosure of Ownership and Control
• Attachment B - Corporate Compliance Work Plan-Sample
• Attachment C - External Audit Plan Template
• 104 - Continuity of Operations and Recovery Plan
• Attachment A - Continuity of Operations and Recovery Plan Checklist
• 106 - Certification of MAOs Serving Dual Eligible Members
• Attachment A, Sample CMS State Certification
• 107 - State-Contracted MAO Dual Eligible Special Needs Plans
• 108 - AHCCCS Security Rule Compliance
  • Attachment A - AHCCCS Security Rule Compliance Summary Checklist
• 109 - Institution for Mental Disease 15 Day Limit
  • Attachment A - IMD Placement Exceeding 15 Days
• 110 - Mental Health Parity
  • Attachment A - Benefit Package Mapping 2016-2017
  • Attachment B - Mental Health Parity Attestation
  • Attachment C - Mental Health Parity Analysis Summary
• 111 - AHCCCS Pharmacy and Therapeutics Committee
• Attachment A - Conflict of Interest Disclosure Form

• 201 - Medicare Cost Sharing for Members Covered by Medicare and Medicaid
  • Attachment A - Notification to Waive Medicare Part D Co-Payment
• 203 - Claims Processing
• 205 - Ground Ambulance Transportation Reimbursement Requirements for Non-Contracted Providers

301 - ALTCS EPD Program Tiered Reconciliation

• Attachment A - ALTCS EPD Tiered Reconciliation Example

301 CYE 18 - ALTCS EPD Program Prospective Reconciliation

• Attachment A - ALTCS EPD Program Prospective Reconciliation example

302 CYE 14 through 18, PPC Reconciliation-Acute Care and CMDP Contractors

• Attachment A – Health Plan Prior Period Coverage Reconciliation - example

302A CYE 11 through 18 - PPC Reconciliation - ALTCS EPD Contractors

• Attachment A - PPC Reconciliation CYE 11 Sample
• Attachment B - PPC Reconciliation CYE XX Sample

303 - Home and Community Based Services Reconciliation- ALTCS

304 - Premium Tax Reporting

• Attachment A - Matrix of Managed Care Payments Included for Premium Tax

305 - Performance Bond and Equity Per Member Requirements

• Attachment A - Performance Bond Annual Attestation Statement
• Attachment B - Performance Bond Form
• Attachment C - Instructions for Wire ACH Transfers of Funds to AHCCCS via Arizona State Treasurer

306 - Alternative Payment Model Initiative - Withhold and Quality Measure Performance Incentive

• Attachment A - Alternative Payment Model (APM) Quality Management Performance Measure Standards
• Attachment B - Alternative Payment Model (APM) Quality Performance Measure Scores
• Attachment C - Federal Limit Test

307 - Alternative Payment Model Initiative - Strategies and Performance-Based Payments Incentive

• Attachment A - Learning Action Network - Alternative Payment Model Framework Strategies
• Attachment B - Alternative Payment Model Strategies and Performance-Based Payments Incentive Certification

308 - Reconciliation of Title XIX Behavioral Health Prior Period Coverage Expenses for RBHAs

• Attachment A - RBHA Title XIX Behavioral Health Prior Period Coverage GMH-SU and Non-CMDP Child Reconciliation Example

310 - Delivery Supplement Payment

311 - AHCCCS Complete Care (ACC) Program Tiered Reconciliation

• Attachment A - ACC Program Tiered Reconciliation Example

311 CYE 14-18 - Acute Program Tiered Prospective Reconciliation

• Attachment A - Acute Program Tiered Prospective Reconciliation Example

312 CYE 14 through 18 - Children's Rehabilitative Services Program Tiered Reconciliation

• Attachment A – Health Plan CRS Program Reconciliation - Example

314 - Auto-Assignment Algorithm

317 - Change in Contractor Organizational Structure

320 - Health Insurance Provider Fee

• Attachment A - Health Insurance Provider Fee Liability Reporting Template

321 - Payment Reform E-Prescribing

323 - Regional Behavioral Health Authorities Title XIX/XXI Reconciliation and Non-Title XIX/XXI Profit Limit

• Attachment A - Maricopa County & Greater AZ Contractor Title XIX XXI Reconciliation Example CYE 16
• Attachment B - Maricopa County Contractor Title XIX XXI Reconciliation Example CYE 17
• Attachment C - Greater AZ Contractor Title XIX XXI Reconciliation Example CYE 17
• Attachment D - Maricopa County and Greater AZ Contractors Title XIX XXI Reconciliation Example CYE 18
• Attachment E - Maricopa County & Greater AZ Contractors Title XIX XXI Reconciliation Example CYE XX
• Attachment F - Non-Title XIX XXI Profit Limit Example CYE XX

324 - Targeted Investments Program

325 - Access to Professional Services Initiative and Reconciliation

• Attachment A - Health Plan Access to Professional Services Initiative (APSI) - Reconciliation Sample

326 - Fixed Administrative Cost Component Reconciliation for AHCCCS Complete Care

• Attachment A - Admin-Member Month Reconciliation Example

327 - Pediatric Services Initiative

330 - Access to Professional Services Initiative

• Attachment A - Access to Professional Services Initiative (APSI) Example of Final Payment Calculation

• 401 - Change of Contractor: AHCCCS Complete Care Contractors
  • Attachment A - AHCCCS Complete Care Change of Contractor Form
• 402 - Member Transition for Annual Enrollment Choice and Eligibility Changes
• 403 - Enrollment Choice in a County with Choice and Change of Contractor: ALTCS Contractors
• 404 - Contractor Website and Member Information
  • Attachment A - Organizations Recognized by AHCCCS
  • Attachment B - Contractor Website Certification Checklist
  • Attachment C - Member Information Attestation Statement
• 405 - Cultural Competency, Language Access Plan, and Family-Member Centered Care
  • Attachment A - Cultural Competency Plan, Assessment, Language Access Plan, and Family-Member Centered Care Reporting Checklist
• 406 - Member Handbook and Provider Directory
  • Attachment A - Member Handbook Checklist
  • Attachment B - Definitions for AHCCCS Members Pursuant to 42 CFR 438.10
• 407 - Workforce Development
• 408 - Sanctions
• 412 - Claims Recoupment
• 413 - Gap in Critical Services
  • Attachment A - Gap in Critical Services Log and Authorized Critical Hours Log Form Instructions
  • Attachment A -1 and 2 - Gap in Critical Services Log and Authorized Critical Hours Log Form
  • Attachment B - Telephone Survey Instructions and Template
• 414 - Requirements for Service Authorization Decisions and Notices of Adverse Benefit Determination
  • Attachment A - Notice of Adverse Benefit Determination Template
  • Attachment B - Legal Services Program
  • Attachment C - Notice of Extension Template
• 415 - Provider Network Development and Management Plan
  • Attachment A - Network Attestation Statement
  • Attachment B - Network Development and Management Plan Checklist
  • Attachment C - ALTCS EPD Contractor Supplement
  • Attachment D - Provider Changes Due to Rates Report
  • Attachment E - HCBS Service Delivery Standard Report
  • Attachment F - DME Service Delivery Reporting
• 416 - Provider Information
• 417 - Appointment Availability, Monitoring, and Reporting
  • Attachment A - Appointment Availability Provider Report
• 418 - Provider and Affiliate Advances, Equity Distributions, Loans, and Investments
• 421 - Contract Termination Nursing Facilities and Alternative Home and Community Based Settings
• 423 - Financial Responsibility for Court Ordered Treatment for DUI/Domestic Violence or Other Criminal Offenses
• 424 - Verification of Receipt of Paid Services
  • Attachment A - Quarterly Verification of Services Audit Report
• 425 - Social Networking
  • Attachment A - Social Networking Attestation
• 426 - CRS Application, Designation, and Coverage
• 429 - Direct Care Worker Training and Testing Program
• 431 - Copayment
  • Attachment A - AHCCCS Notification to Set Members Copay Flag to Exempt
• 432 - Benefit Coordination and Fiscal Responsibility for Behavioral Health Services and Physical Health Services
• Attachment A - Matrix of Financial Responsibility by Responsible Party
• 433 - Member Identification Cards
• Attachment A - Table of Requirements
• 434 - Coordination of Benefits and Third Party Liability
  • Attachment A - Total Plan Case Settlement Notification Form
  • Attachment B - Trauma Code ICD10 List
• 435 - Telephone Performance Standards and Reporting
  • Attachment A - Telephone Performance Measures Template
• 436 - Network Standards
  • Attachment A - Minimum Network Requirements Verification Template
• 437 - Financial Responsibility for Services after the Completion of Court-Ordered Evaluation
• 438 – Administrative Services Subcontractor Evaluation
  • Attachment A - Administrative Services Subcontract Checklist
  • Attachment B - Administrative Services Subcontractor Evaluation Report Template
• 439 - Material Changes Provider Network and Business Operations
• Attachment A - Provider Network Business Operations Material Change Plan Checklist
• 440 - Managed Care Expiration or Termination of Contract
• 442 - Member with a Serious Mental Illness' Request to Opt Out from a Regional Behavioral Health Authority to an AHCCCS Complete Care Contractor
• 444 - Notice of Appeal Requirements (Serious Mental Illness Appeals)
• Attachment A - AHCCCS Notice of SMI Grievance and Appeal Procedure
• Attachment B - Notice of Legal Rights for Persons with Serious Mental Illness
• Attachment C - Notice of Decision and Right to Appeal (for Individuals with an SMI)
• Attachment D - Notice of Discrimination Prohibited
• 445 - Submission of Request for Hearing
• Attachment A - Submission of Request for Hearing Cover Sheet
• 446 - Grievances and Investigations Concerning Persons with Serious Mental Illness
• Attachment A - AHCCCS Appeal or Serious Mental Illness Grievance Form
• 447 - Employment
• Attachment A - Psychiatric Rehabilitation Progress Report Specifications for RBHA SMI
• Attachment B - Psychiatric Rehabilitation Progress Report Specifications for GMH SU
• 448 - Housing
• Attachment A - AHCCCS Housing Acquisition-Renovation Application
• Attachment B - AHCCCS Housing Acquisition-Renovation Checklist
• Attachment C - AHCCCS Declaration of Covenants, Conditions, and Restrictions (CC & Rs)
• Attachment D - AHCCCS Housing Acquisition and/or Renovation or New Construction Operating and Funding Agreement - Sample
• 449 - Behavioral Health Services for Children in Department of Child Safety (DCS) Custody and Adopted Children
• Attachment A - DCS and Adopted Children Services Reporting- Access to Services
• Attachment B - DCS and Adopted Children Services Reporting- Calls and Emails and Rapid Response Reconciliation

• Revision Memo Archive
  • 2020
  • 2019
  • 2018
  • 2017
  • 2016
  • 2015
  • 2014
  • 2013
  • 2012
  • 2011