AHCCCS Medical Policy Manual (AMPM)
Information Regarding COVID-19
In response to Medicaid-related questions from providers and contractors arising from the COVID-19 pandemic, AHCCCS has developed a list of Frequently Asked Questions (FAQs) Regarding Coronavirus Disease 2019 (COVID-19) which is updated regularly. It is important to note that there are instances where the information presented in the CMS-approved flexibilities and COVID-19 FAQs does not align with provisions set forth by the AHCCCS Medical Policy Manual (AMPM). In these instances the CMS-approved flexibilities and FAQs take precedence and are controlling.
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 and 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.
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- Chapter 965
- Chapter 1610
- Chapter 1620
- 1620-A - Initial Contact Visit Standard
- 1620-B - Needs Assessment Care Planning Standard
- 1620-D - Placement Service Planning Standard
- 1620-E - Service Plan Monitoring and Reassessment Standard
- Exhibit 1620-10 - AHCCCS Person Centered Service Plan
- Exhibit 1620-13, Reserved
- Exhibit 1620-17 - HCBS Member Needs Assessment Tool Guidelines
- Exhibit 1620-17 - Attachment A - HCBS Needs Assessment
- 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 Exclustion 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 Eligibility Determination Form
- Attachment B, Serious Mental Illness Qualifying Diagnosis
- Attachment C, Administrative Serious Mental Illness Decertification 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 Preventive 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
- 540, Electronic Visit Verification
- Attachment A, Electronic Visit Verification Designee Attestation
- Attachment B, Paper Timesheet Attestation
- Attachment C, AHCCCS Electronic Visit Verification Paper Timesheet
- Attachment D, EVV Member Contingency Back-Up Plan
- 541, Coordination of Care with other Government Agencies
- 560, Children's Rehabilitative Services Care Coordination and Service Plan Management
- 580, Behavioral Health Referral and Intake Process
- 610 - AHCCCS Provider Qualifications
- 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
- 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, Quality Management/Performance Improvement Program Plan Checklist
- Attachment B, AHCCCS Quality Improvement Corrective Action Plan Contractor Checklist
- 940, Medical Records and Communication of Clinical Information
- 950, Credentialing and Recredentialing Processes
- 960, Quality of Care Concerns
- Attachment A, Contractor Quality Management Report
- Attachment B, Health Care Acquired Conditions (HCAC) Other Provider Preventable Conditions (OPPC) Report Template
- Attachment C, Health and Safety Update Immediate Jeopardy Form
- Attachment D, Individuals with Intellectual Disabilities Investigation Training
- 962, Reporting and Monitoring of Seclusion and Restraint
- 963, Peer and Recovery Support Service Provision Requirements
- Attachment A - Peer Recovery Support Specialist Involvement in Service Delivery
- Attachment B - Development References
- Attachment C - Peer Support Employment and Training Graduates
- 964, Credentialed Parent Family Support Requirements
- Attachment A - Credentialed Parent Family Support Specialists Involvement in Service Delivery Report
- Attachment B - Credentialed Parent Family Support Provider Graduates
- 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
- Attachment A, Protocol for Conducting Performance Improvement Projects (PIP)
- Attachment B, Performance Improvement Project (PIP) Report ACC, CMDP, and ALTCS E/PD Specific
- Attachment C, Performance Improvement Project (PIP) Report DDD Specific
- Attachment D, Performance Improvement Project (PIP) Report RBHA Specific
- 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, Pharmacy and Prescriber Report Template
- Attachment E, Emergency Department Diversion Report
- Attachment F, Medical Management Plan Checklist
- Attachment G, Medical Management Work Plan Guide and and Template
- Attachment H, Arizona State Hospital Admission and Discharge 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, Private Duty Nursing Services
- Attachment A, Medical Supplies Included in FFS Home Health Nursing Visits
- Attachment B, Home Health Skilled Nursing Services
- 1240-I, Home Modifications
- 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 B, CYE 2020 Performance Measure Monitoring Report Specific Instructions
- CYE 2020 ACC Performance Measure Monitoring Report Template
- CYE 2020 ALTCS Performance Measure Monitoring Report Template
- CYE 2020 CMDP Performance Measure Monitoring Report Template
- CYE 2020 DDD Performance Measure Monitoring Report Template
- CYE 2020 RBHA Performance Measure Monitoring Report Template
- Appendix H, Policy for Management of Acute Behavioral Health Situations (NFS with No BH Units)
2020
- November 03, 2020
- October 30, 2020
- October 05, 2020
- September 30, 2020
- September 11, 2020
- September 01, 2020
- August 14, 2020
- August 03, 2020
- July 09, 2020
- July 01, 2020
- June 03, 2020
- May 26, 2020
- May 08, 2020
- April 23, 2020
- April 10, 2020
- March 02, 2020
- February 12, 2020
- February 01, 2020
- January 09, 2020
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