AHCCCS Contractor Operations Manual (ACOM)

• 429 - Direct Care Worker and Testing Program

• 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
• 207 CYE 13 through 17 - Primary Care Enhanced Payments
  • Attachment A - AHCCCS Encounter Flow

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

315 CYE 16 and CYE 17 - Acute Program Value-Based Purchasing Initiative

• Attachment A - Acute Care Program (VBP) Strategies
• Attachment B - Acute Care Contractor (VBP) Quality Management Performance Measure Standards
• Attachment C - Acute Care Program (VBP) Quality Distribution Example
• Attachment D - Acute Care Program (VBP) Reconciliation Example
• Attachment E - Acute Care Program (VBP) Strategies Certification

316 CYE 14 through CYE 17, Adult Group Above 106 Federal Poverty Level Reconciliation

• Attachment A - Health Plan Adult Group Above 106% Federal Poverty Level Reconciliation Example

317 - Change in Contractor Organizational Structure

318 CYE 16 and CYE 17 - Arizona Long Term Care System (ALTCS) Elderly and Physical Disability (EPD) Program Value-Based Purchasing Initiative

• Attachment A - ALTCS EPD Program (VBP) Strategies
• Attachment B - ALTCS EPD Contractor (VBP) Quality Management Performance Measure Standards
• Attachment C - ALTCS EPD Program (VBP) Quality Distribution Example
• Attachment D - ALTCS EPD Program (VBP) Reconciliation Example
• Attachment E - ALTCS EPD Program (VBP) Strategies Certification

319 CYE16 and CYE17, Children's Rehabilitative Services Value-Based Purchasing Initiative

• Attachment A - CRS (VBP) Strategies
• Attachment B - CRS (VBP) Strategies Certification

320 - Health Insurance Provider Fee

• Attachment A - Health Insurance Provider Fee Liability Reporting Template

321 - Payment Reform E-Prescribing

322 CYE16 and CYE17, Regional Behavioral Health Authority Value-Based Purchasing Initiative

• Attachment A - RBHA (VBP) Strategies
• Attachment B - RBHA (VBP) Strategies Certification

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

• 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-1 - Notice of Adverse Benefit Determination Not Involving Medications Template
  • Attachment A-2 - Notice of Adverse Benefit Determination Involving Medications Template
  • Attachment B - Legal Services Program
  • Attachment C - Guide to Language in Notices of Adverse Benefit Determination
  • Attachment D - 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 DCS Custody and Adopted Children
• Attachment A - Children In Out-of-Home Placement and in the Legal Custody of DCS and Adopted Children Services Reporting Access to Services
• Attachment B - Children in Out-of-Home Placement and in the Legal Custody of DCS and Adopted Children Services Reporting-Calls and Emails

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