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.
A T T E N T I O N
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. PLEASE CLICK ON THE FOLLOWING LINK:
TRIBAL CONSULTATION NOTIFICATION/PUBLIC COMMENT
TO RECEIVE A NOTIFICATION WHEN POLICIES ARE AVAILABLE FOR PUBLIC COMMENT, PUBLISHED TO AHCCCS.GOV, AND WHEN REVISION MEMOS ARE POSTED, PLEASE SIGN UP FOR CONSTANT CONTACT EMAIL NOTIFICATION BY CLICKING THE SUBSCRIBE TO AMPM BUTTON BELOW.
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.
- Chapter 900
- Chapter 1000
- Appendices
- Exhibit 300-1, AHCCCS Covered Services Acute Care
- Exhibit 300-2A, AHCCCS Covered Services Behavioral Health
- Exhibit 300-2B, AHCCCS Covered Services Behavioral Health Non -Title XIX-XXI Persons
- Exhibit 300-3, Reserved
- Exhibit 300-3A Application of Physical Therapy Visit Outpatient Limit Acute & ALTCS Members 21 Years of Age and Older
- Exhibit 300-3B Inpatient Limit Member & Contractor Responsibility Acute & ALTCS Members 21 Years of Age and Older
- Attachment C, AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements for Members 21 Years of Age or Greater - INitial or Ongoing Request
- Exhibit 310-1, A.A.C. AHCCCS Rule Emergency Medical and Behavioral Health Services for Non-FES Members
- 310-A, Audiology
- 310-B, Behavioral Health Services
- 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-E, Dialysis
- 310-F, Emergency Medical Services
- 310-G, Eye Examinations-Optometry Services
- 310-H, Health Risk Assessment and Screening Tests
- 310-I, Home Health Services
- 310-J, Hospice Services
- 310-K, Hospital Inpatient Services
- 310-L, Hysterectomy
- 310-M, Immunizations
- 310-N, Laboratory
- 310-O, Maternal and Child Health Services
- 310-P, Medical Equipment, Medical Appliances, and Medical Supplies
- 310-Q, Non-Physician Surgical First Assistant Services
- 310-R, Nursing Facility Services
- 310-S, Observation Services
- 310-T, Physician Services
- 310-U, Reserved
- 310-V, Prescription Medications-Pharmacy Services
- Attachment A, Informed Consent-Assent for Psychotropic Medication Treatment
- Attachment B, 5-Day Supply Limit of Short-Acting Opiod and Long-Acting Opioid Medication Exclusion Specifications
- Attachment C, ICD-10-CM Diagnosis Code Description
- 310-W, Radiology and Medical Imaging
- 310-X, Occupational, Physical, and Speech Therapies
- 310-Y, Respiratory Therapy
- 310-Z, Reserved
- 310-AA, Total Parenteral Nutrition
- 310-BB, Transportation
- 310-CC, Triage-Screening and Evaluation of Emergency Medical Conditions
- 310-DD, Covered Transplants and Related Immunosuppressant Medications
- 310-EE, Reserved
- 310-FF, Monitoring Controlled and Non-Controlled Medication Utilization
- 310-GG, Nutritional Assessments and Nutritional Therapy
- Attachment C, AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements for Members 21 Years of Age or Greater - INitial or Ongoing Request
- 310-HH, End of Life Care and Advance Care Planning
- 310-JJ Orthotic and Prosthetic Devices
- Exhibit 320-P-1 Serious Mental Illness Determination
- Exhibit 320-P-2 Serious Mental Illness Qualifying Diagnosis
- Exhibit 320-P-3 Administrative SMI Decert Form
- Exhibit 320-Q-1 Application for Voluntary Evaluation
- Exhibit 320-Q-2 Substance Abuse Prevention Program Eval and Consent
- Exhibit 320-U-1, Application for Involuntary Evaluation
- Exhibit 320-U-2, Application for Emergency Admission for Evaluation
- Exhibit 320-U-3, Petition for Court-Ordered Evaluation
- Exhibit 320-U-4, Petition for Court-Ordered Treatment Gravely Disabled Person
- Exhibit 320-U-5, Affidavit
- Exhibit 320-U-6, A.R.S. 12-136, Flow Chart Recognition of Tribal Court Order Process
- Exhibit 320-U-7, Application for Voluntary Evaluation
- 410, Maternity Care Services
- Attachment A, Semiannual Report of Number of Pregnant Women Who are HIV-AIDS Positive
- Attachment B, 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 Request
- Attachment E, Monthly Pregnancy Termination Report
- Exhibit 410-2, Reserved
- 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, EPSDT Services
- Exhibit 430-1, AHCCCS EPSDT Periodicity Schedule
- Exhibit 430-2, AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements (EPSDT Aged Members - Initial or Ongoing Request)
- Exhibit 430-3, Procedures for the Coordination of Services Under EPSDT and Early Intervention
- Exhibit 430-4, Arizona Early Intervention Program (AzEIP) AHCCCS Member Service Request
- 431, Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members
- 440, KidsCare Services
- 450 Out-Of-State Placement for Children or Young Adults 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
- 540 - Reserved
- 541 - Coordination of Children's Care with other Government Agencies
- 550, Member Records and Confidentiality
- 560, CRS Care Coordination and Service Plan Management
- 570, Community Collaborative Care Teams
- 580, Behavioral Health Referral and Intake Process
- 900 Chapter Overview
- 910, Quality Management-Performance Improvement Program Administrative Requirements
- 920, Quality Management-Performance Improvement Program Scope
- Exhibit 920-1, Health Care Acquired Conditions Other Provider Preventable Conditions Reporting Tool
- Exhibit 920-2, Health and Safety Update-Immediate Jeopardy-Immediate Care Need Form
- Exhibit 920-3, Organization Providers Approved-Not Approved Direct Care Worker Training and Testing Programs
- 930, Member Rights and Responsibilities
- 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
- 961, Peer, Family, and CSA Training, Credentialing, and Oversight Requirements
- Exhibit-1, Community Service Agency Application
- Exhibit-2, Community Service Agency, Direct Service Staff-Contractor Reference Form
- Exhibit-3, Community Service Agency, Criminal History Affidavit
- Exhibit-4, Community Service Agency, Self Declaration of Criminal History
- Exhibit-7, Community Service Agency, Intent to Contract Form
- 962 - Reporting and Monitoring of Seclusion and Restraint
- Attachment A, Seclusion and Restraint Individual Reporting Form
- Attachment B, Seclusion and Restraint Monthly Report
- 970, Performance Measures
- 980, Performance Improvement Projects
- Attachment 980-A, Protocol for Conducting Performance Improvement Projects
- Attachment 980-B, Performance Improvement Project (PIP) Report
- 990, Reporting Requirements
- 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
- 1030 - Reserved
- 1040 - Outreach, Engagement, Re-Engagement and Closure for Behavioral Health
- 1050 - Coordination of Care with other Government Entities for Behavioral Health Services
- 1060 - Training Requirements for RBHAs and Behavioral Health Providers
- 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 Private Duty Nursing Services
- 1240-H, Reserved
- 1240-I, Home Modifications
- 1240-J, Reserved
- 1250-A, Reserved
- 1250-B, Reserved
- 1250-C, Acute Care Services
- 1250-D, Respite Care
- 1250-E, Rehabilitative Therapies
- 1250-F, Reserved
- 1250-G, Nutritional Assessments and Nutritional Therapy
- 1250-H, Transportation
- 1250, Attachment B, AHCCCS/ALTCS Services, Service Codes and Applicable Units of Service Transportation
- 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
- Appendices Table of Contents
- Appendix A, EPSDT and Adult Quarterly Monitoring Report Instructions & Templates
- CYE 2018 Acute Performance Measures Template
- CYE 2018 Acute Specific Reporting Instructions
- CYE 2018 ALTCS EPD Acute Performance Measures Template
- CYE 2018 ALTCS EPD Specific Reporting Instructions
- CYE 2018 DCS/CMDP Performance Measures Template
- CYE 2018 DCS/CMDP Specific Reporting Instructions
- CYE 2018 CRS Performance Measures Template
- CYE 2018 CRS Specific Reporting Instructions
- CYE 2018 DES/DDD Performance Measures Template
- CYE 2018 DES/DDD Specific Reporting Instructions
- CYE 2018 RBHA GMHSA Performance Measures Template
- CYE 2018 RBHA GMHSA Specific Reporting Instructions
- CYE 2018 RBHA SMI Performance Measures Template
- CYE 2018 RBHA SMI Specific Reporting Instructions
- Appendix B, EPSDT Tracking Forms
- Appendix C, Medical Management (MM) Plan Checklist
- Appendix D, Reserved
- Appendix E, Childhood and Adolescent Behavioral Health Tool Kits
- Appendix F, Adult Behavioral Health Tool Kits
- 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)
- Appendix I, Reserved
- Appendix J, FFS Mileage Reimbursement Form
- Appendix K, Reserved