Provider Manual
Learn How to Become a Participating Provider
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Phoenix Health Plan (PHP) provides the following Provider Manual to its participating providers and their office staff.
- Background
- Departmental Structure
- Phone and Fax Numbers
- Website
- Registration for Website Secured Access
Section B - Provider Responsibilities
- AHCCCS Identification Number
- PCP as Gatekeeper
- Specialty Care Provider Role
- Eligibility Verification
- Appointment Availability and Standards
- Patient Care Responsibilities
- Emergency Department Utilization
- Administrative Responsibilities
- Transportation
- Credentialing and Recredentialing Process
- Complaints
- Compliance Program/Fraud and Abuse
- False Claims Act (Deficit Reduction Act (DRA) Public Law 109-171)
- Compliance Issue Reporting Form
Section C - Culturally Competent Patient Care
- Non-Discrimination Policy
- Culturally Competent Care
- Translation Services
- Culturally Competent Patient Care
Section D - Eligibility and Enrollment
- AHCCCS Eligibility
- Rate Codes
- Selecting a Primary Care Provider
- Member Identification Cards
- Co-Payments
- Member Reassignment
- Member Rights
- Member Grievances
- Member Responsibilities
- Advance Directives
- Advanced Directives Resource List
- Covered Services
- Durable Medical Equipment
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
- Family Planning Services
- Foot and Ankle Services
- Home Health
- Hospice
- Hospital
- Hospital Concurrent Review
- Laboratory Services
- Long Term Care
- Nutrition
- Orthotics and Prosthetics
- Outpatient Rehab Services
- Practice Guidelines
- Prescription Medications and Pharmacy
- Prenatal Care
- Qualified Medicare Beneficiaries
- Radiology Services
- Surgery Services
- Transplants
- Transportation
- Vision
- Non-Covered Services
- AHCCCS Certificate of Medical Necessity for Oral Supplements
Section F - Referral and Prior Authorization Process
- Standard Authorization Requests
- Expedited Authorization Requests
- Coordination of Benefits
- Pharmacy Prior Authorization and Formulary Exception Process
- Referral Process from PCP to Specialist
- Referral From Specialist to Specialist
- Referral Process for Ancillary Care Providers
- Hospital Admissions
- Maternal Child Health (MCH)
- Family Planning Services (Rate Code 55xx)
- Medically Necessary Abortions
- Maternity Care
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
- Children's Rehabilitative Services (CRS)
- Outreach and Educational Programs
- Dental Periodicity Schedule Recommendations
- Dental Claims Address
- Dental Guidelines/Pre-Determination Requirements
- AHCCCS Dental Periodicity Table
Section I - Billing and Claims
- Claims Payment Methods
- Claims Status
- Claim Submission Information
- HCFA 1500 Claim Form
- UB-92 Claim Form
- Hospital Outpatient Billing
- Immunization Vaccine for Children (VFC) Program & Other Injectables
- Modifiers
- PEDS Tool
- Third Party Liability
- Claims Resubmission Policy
- Duplicate or Erroneous Payments
- Explanation of Remittance Advice
- Medical Review of Claims
- Reimbursement
- Claims Submitted for Family Planning Services
- Claims Submitted for SOBRA Family Planning Services (Rate Code 55xx)
- Surgery Claims
- Claims Submitted by Inpatient Facilities
- Outlier Claims
- Outpatient Hospital Facilities
- Ancillary Claims
- Emergency Transportation
- General Information
Section J - Quality Management/Quality Improvement
- Quality Management/Quality Improvement Overview
- Quality Improvement Committee (CSQIC)
- Peer Review
- Medical Record Audit
- Confidential Exchange of Member Information
- Clinical Practice Guidelines
- Formulary Overview
- Pharmacy and Therapeutics Committee
- Pharmacy Prior Authorization and Formulary Exception Process
- Formulary Changes and Updates
- Exclusions
- Limitations
- Provider Claim Disputes
- Member Appeals
- Claim Dispute Form
- Behavioral Health Practice Guidelines
- Behavioral Health Referral Guidelines
- ADHS Department of Behavioral Health Services Referral Form