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.
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.
- 310-B, Title XIX XXI Behavioral Health Service Benefit
- 310-C, Breast Reconstruction After Mastectomy
- 310-D1, Dental Services for Members 21 Years of Age and Older
- 310-D2, Arizona Long Term Care System Adult Dental Services
- 310-F, Emergency Medical Services
- 310-I, Home Health Services
- 310-J, Hospice Services
- 310-K, Hospital Inpatient Services
- 310-L, Hysterectomy
- 310-M, Immunizations
- 310-N, Laboratory Services
- 310-P - Medical Equipment, Medical Appliances and Medical Supplies
- 310-R, Nursing Facility Services
- 310-S, Observation Services
- 310-V, Prescription Medications-Pharmacy Services
- Attachment A, Informed Consent-Assent for Psychotropic Medication Treatment
- Attachment B, 5-Day Supply Limit of Short-Acting Opioid and Long-Acting Opioid Medication Exclusion Specifications
- Attachment C, ICD-10 Case Managment Diagnosis Codes
- 310-X, Occupational, Physical, and Speech Therapies
- 310-BB, Transportation
- 310-DD, Covered Transplants and Related Immunosuppressant Medications
- 310-FF, Monitoring Controlled and Non-Controlled Medication Utilization
- 310-GG, Nutritional Therapy, Metabolic Foods, and Total Parenteral Nutrition
- 310-HH, End of Life Care and Advance Care Planning
- 310-II, Genetic Testing
- 310-JJ, Orthotic and Prosthetic Devices
- Attachment A,Serious Mental Illness Determination
- Attachment B, Serious Mental Illness Qualifying Diagnosis
- Attachment C, Administrative SMI Decert Form
- Attachment A, Application for Voluntary Evaluation
- Attachment B, Substance Abuse Prevention Program Evaluation and Consent
- Attachment A, Charitable Choice - Anti-Discrimination Notice to Individuals Receiving Substance Use Disorder Treatment Services
- Attachment B, Serious Emotional Disturbance (SED) Program Status Report - MHBG SED Grant
- Attachment C, First Episode Psychosis Program Status Report (Annually)
- Attachment C-1, First Episode Psychosis Program Status Report (Quarterly)
- Attachment D, ICR Peer Review Member Charts
- Attachment E, Substance Abuse Block Grant (SABG) HIV Activity Report
- Attachment F, Substance Abuse Block Grant (SABG) HIV Site Visit Report
- Attachment F-1, Oxford House Financial Reports
- Attachment G, Substance Abuse Block Grant (SABG) Agreements Report
- Attachment H, Oxford House Model Report
- Attachment I, Substance Abuse Block Grant (SABG) Priority Population Waitlist Report
- Attachment J, SABG Capacity Management Report
- Attachment K, Substance Abuse Block Grant (SABG), Prevention, Mental Health Block Grant (MHBG) Plan
- 410, Maternity Care Services
- Attachment A, Semiannual Report of Number of Pregnant Women Who are HIV-AIDS Positive
- Attachment B, AHCCCS Request for Stillbirth Supplement
- Attachment C, AHCCCS Certificate of Necessity for Pregnancy Termination
- Attachment D, AHCCCS Verification of Diagnosis by Contractor for a Pregnancy Termination
- Attachment E, AHCCCS Monthly Pregnancy Termination Report
- 411, Women's Preventative Care Services
- 420, Family Planning
- Attachment A, Consent to Sterilization
- Attachment B, AHCCCS Sterilization Reporting Form for Members Under 21 Years of Age
- 430, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
- Attachment A, AHCCCS EPSDT Periodicity Schedule
- Attachment B, AHCCCS Cert. of Medical Necessity for Comm. Oral Nutritional Supplements
- Attachment C, Procedures for the Coordination of Services Under EPSDT and Early Intervention
- Attachment D, Arizona Early Intervention Program (AzEIP) AHCCCS Member Service Request
- Attachment E, AHCCCS EPSDT Tracking Forms
- Attachment F, EPSDT Plan and Evaluation Checklist
- 431, Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members
- 440, KidsCare Title XXI
- 450, Out-Of-State Placement for Behavioral Health Treatment
- 510, Primary Care Providers
- 520, Member Transitions
- Attachment A, Enrollment Transition Information (ETI) Form
- Attachment B, Out of Service Area Placement Request
- 530 - Member Transfers Between Facilities
- 541, Coordination of Care with other Government Agencies
- 550, Member Records and Confidentiality
- 560, Children's Rehabilitative Services Care Coordination and Service Plan Management
- 580, Behavioral Health Referral and Intake Process
- 610 - AHCCCS Provider Qualifications
- 630, Medical Record Requirements
- 640, Advance Directives
- 650 - Behavioral Health Provider Requirements for Assisting Individuals with Eligibility Verification and Screening, Application for Public Health Benefits
- 660, Opioid Treatment Program Mid-Level Exemption
- Attachment A, Arizona Opioid Treatment Program - Exemption Request and Record of Justification
- Attachment B, Arizona Opioid Treatment Program - Exemption Renewal and Record of Justification
- 670, Federally Qualified Healthcare Centers (FQHC) and Rural Health Clinics (RHC) Reimbursement
- 680, Federally Mandated Programs for Nursing Facilities
- 910, Quality Management-Performance Improvement QM-PI Program Scope
- Attachment A, AHCCCS Contractor Services-Service Site Monitoring
- Attachment B, Contractor Monitoring of Direct Care Worker (DCW) Training and Testing Standards
- 920, Quality Management/Performance Improvement Program Administrative Requirements
- Attachment A, QM-PI Program Annual Plan Submission Checklist
- Attachment B, Integrated Health Care Report Checklist
- Attachment C, AHCCCS Quality Improvement CAP Contractor Checklist
- 940, Medical Records and Communication of Clinical Information
- 950, Credentialing and Recredentialing Processes
- 960, Tracking and Trending of Member and Provider Issues
- Attachment A, AHCCCS Contractor Quarterly Quality Management Report
- Attachment B, Health Care Acquired Conditions (HCAC) Other Provider Preventable Conditions (OPPC) Reporting Tool
- Attachment C, Health and Safety Update Immediate Jeopardy Form
- 962, Reporting and Monitoring of Seclusion and Restraint
- Attachment A, Seclusion and Restraint Individual Reporting Form
- Attachment B, Seclusion and Restraint Monthly Report
- Attachment C, Seclusion and Restraint Redacted Monthly Report
- 963, Peer Recovery Support Training, Credentialing and Supervision Requirements
- Attachment A- Peer Recovery Support Specialist Involvement in Service Delivery-ACC Report
- Attachment B- Peer Recovery Support Specialist Involvement in Service Delivery-ALTCS Report
- Attachment C- Peer Recovery Support Specialist Involvement in Service Delivery-RBHA Report
- Attachment D- Development References
- Attachment E- Peer Recovery Support Specialist Involvement in Service Delivery-DDD Report
- 964, Credentialed Parent Family Support Requirements
- Attachment A- Credentialed Parent Family Support Specialist Involvement In Service Delivery-ACC Report
- Attachment B- Credentialed Parent Family Support Specialist Involvement In Service Delivery -ALTCS Report
- Attachment C- Credentialed Parent Family Support Specialist Involvement In Service Delivery RBHA Report
- Attachment D- Credentialed Parent Family Support Specialist Involvement In Service Delivery DDD Report
- 965, Community Service Agencies
- Attachment A, Initial Application and Credentialing Amendment Request
- Attachment B, Documentation Submission Standards
- Attachment C, Criminal History Affidavit
- Attachment D, Self Declaration of Criminal History
- 970, Performance Measures
- 980, Performance Improvement Projects
- 1010 - Medical Management Administrative Requirements
- 1020 - Medical Management Scope and Components
- Attachment A, Psychiatric Security Review Board GEI Conditional Release Monthly Report
- Attachment B, AHCCCS Adult and Children's Emergency Department Wait Time Report
- Attachment C, Justice Reach-In Template
- Attachment D, SHCN Reporting Template
- Attachment E, Pharmacy and Prescriber Report Template
- Attachment F, ED Diversion Report
- Attachment G, HNHC Member List
- Attachment H, Medical Management (MM) Plan Checklist
- Attachment I, Medical Management (MM) Work Plan Guide and Template
- Attachment J, AzSH Admissions-Discharges Deliverable Template
- 1040 - Outreach, Engagement, Re-Engagement and Closure for Behavioral Health
- 1240-A, Direct Care Services
- 1240-B, Adult Day Health Care Services
- 1240-C, Community Transition Services
- 1240-D, Emergency Alert System
- 1240-E, Habilitation Services
- 1240-F, Home Delivered Meals
- 1240-G, Home Health Services
- Attachment A, Medical Supplies Included in FFS Home Health Nursing Visits
- Attachment B, Home Health Skilled Nursing Services
- 1240-I, Home Modifications
- Exhibit 1300-1, Agency with Choice Service Codes and Applicable Units of Service
- Exhibit 1300-2, Agency of Choice Co-Employment Agreement
- Exhibit 1300-3, Arizona Health Care Cost Containment System Agency with Choice Individual Representative Form
- Exhibit 1300-4, Self Directed Attendant Care Service Codes and Applicable Units of Service
- Appendix A, EPSDT and Adult Quarterly Monitoring Report Instructions & Templates
- CYE2019 ACC EPSDT and Adult Quarterly Monitoring Report
- CYE2019 ACC Specific Reporting Instructions
- CYE2019 ALTCS EPSDT and Adult Quarterly Monitoring Report
- CYE2019 ALTCS Specific Reporting Instructions
- CYE2019 CMDP EPSDT and Adult Quarterly Monitoring Report
- CYE2019 CMDP Specific Reporting Instructions
- CYE2019 DDD EPSDT and Adult Quarterly Monitoring Report
- CYE2019 DDD Specific Reporting Instructions
- CYE2019 RBHA EPSDT and Adult Quarterly Monitoring Report
- CYE2019 RBHA Specific Reporting Instructions
- Appendix C, Medical Management (MM) Plan Checklist
- Appendix G, Medical Management (MM) Work Plan Guide and Template
- Appendix H, Policy for Management of Acute Behavioral Health Situations (NFS with No BH Units)
2019
- December 16, 2019
- December 6, 2019
- November 27, 2019
- October 31, 2019
- October 18, 2019
- October 18, 2019 - AMPM Policy 320-I, Telehealth Notification
- September 25, 2019
- September 24, 2019 - AMPM Policy 320-S, Applied Behavior Analysis Notification
- September 13, 2019 - AMPM Policy 310-BB, Transportation Notification
- September 04, 2019
- August 07, 2019
- July 22, 2019
- July 05, 2019
- May 07, 2019
- April 26, 2019
- April 18, 2019
- April 16, 2019
- April 03, 2019
- March 14, 2019
- February 08, 2019
- January 25, 2019