AHCCCS Medical Policy Manual (AMPM)

The AHCCCS Medical Policy Manual (AMPM) provides information to Contractors and Providers regarding services that are covered within the AHCCCS program. The AMPM is applicable to both Managed Care and Fee-for-Service members.

The AMPM should be referenced in conjunction with State and Federal regulations, other Agency manuals [AHCCCS Contractors' Operations Manual (ACOM) and the AHCCCS Fee-for-Service Manual], and applicable contracts.


 How to Submit Public Comments


ACOM and AMPM Policies and related materials that have been opened for review/revisions and will serve to provide Tribal Consultation Notification/Public Comment can be found at the below location. This location allows stakeholders to review and submit comments regarding proposed revisions. The Policies will be open for comment for not more than 45 days unless otherwise stipulated. Should an expedited time period be utilized, the expedited time period will not be less than two weeks. The comment deadline will be specified on each document.

Tribal Consultation Notification/Public Comment

To view AMPM Policies, select Policy from the AMPM Table of Contents below.

The policies below are policies that have been approved by AHCCCS but have not yet reached their implementation date. Changes to these policies may occur up to the date of official publication to the AHCCCS Medical Policy Manual (AMPM).

When the policy reaches its implementation date, it will be removed from the list below and published to the AMPM. Any changes that may have occurred after publishing to this site will be indicated in the final Revision Memo upon official publication to the AMPM.


  • 320-A, Affiliated Practice Dental Hygienist
  • 320-B, AHCCCS Member Participation In Experimental Services
  • 320-C, Breast and Cervical Cancer Treatment Program
  • 320-D, Reserved
  • 320-E, Reserved
  • 320-F, HIV-AIDS Treatment Services
  • 320-G, Lung Volume Reduction Surgery
  • 320-I, Telehealth and Telemedicine
  • 320-J, Reserved
  • 320-K, Tobacco Cessation Product
  • 320-L, Reserved
  • 320-M, Medical Marijuana
  • 320-N, Hepatitis C (HCV) Prior Authorization Requirements for Direct Acting Antiviral Medication Treatment
  • 320-O, Behavioral Health Assessments and Treatment Service Planning
  • 320-P, Serious Mental Illness Eligibility Determination
  • 320-Q, General and Informed Consent
  • 320-R, Special Assistance for Persons Determined to Have a Serious Mental Illness
  • 320-S, Reserved
  • 320-T, Non-Discretionary Federal Grants
  • 320-U, Pre-Petition Screening, Court Ordered Evaluation and Court Ordered Treatment
    • None at this time.
  • 1620-A, Initial Contact Visit Standard
  • 1620-B, Needs Assessment Care Planning Standard
  • 1620-C, Cost Effectiveness Study Standards
  • 1620-D, Placement Service Planning Standard
  • 1620-E, Service Plan Monitoring and Reassessment Standard
  • 1620-F,Tribal Fee-For-Service Standard
  • 1620-G, Behavioral Health Standards
  • 1620-H, Transitional Program Standard
  • 1620-I, High Cost Behavioral Health Reinsurance Standard
  • 1620-J, Out-Of-State Placement Standard
  • 1620-K, Skilled Nurising Need Standard
  • 1620-L, Case File Documentation Standard
  • 1620-M, Contractor Change Standard
  • 1620-N, Service Closure Standard
  • 1620-O, Abuse, Neglect, and Exploitation Reporting Standard
  • Exhibit 1620-1, Case Management (CM) Timeframes
  • Exhibit 1620-2, ALTCS Member Change Report
  • Exhibit 1620-3, Uniform Assessment Tool and Guidelines
  • Exhibit 1620-4, Acute Care Only -D- Placement Guidelines
  • Exhibit 1620-5, Reserved
  • Exhibit 1620-6, High Cost Behavioral Health Reinsurance Form
  • Exhibit 1620-7, Fee-For-Service (FFS) Out-of-State Nursing Facility Placement Request Form
  • Exhibit 1620-8, Program Contractor Change Request Form
  • Exhibit 1620-9, ALTCS Enrollment Transition Information (ETI) Form
  • Exhibit 1620-10, Reserved
  • Exhibit 1620-11, Reserved
  • Exhibit 1620-12, Spouse Attendant Care Acknowledgement of Understanding
  • Exhibit 1620-13, ALTCS Member Service Plan
  • Exhibit 1620-14, ALTCS Member Contingency Back-Up Plan
  • Exhibit 1620-15, Assisted Living Facility (ALF) Residency Agreement
  • Exhibit 1620-16, Assisted Living Facility (ALF) Financial Change Agreement
  • Exhibit 1620-17, Instructions
  • Exhibit 1620-17, HCBS Member Needs Assessment
  • Exhibit 1620-18, ALTCS Member Service Options - Decision Tree
  • Exhibit 1620-19, Services included in High Cost Behavioral Health Reinsurance Calculation