Provider Manual
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
- National Payor Identification Number
- PCP as Gatekeeper
- Specialty Care Provider Role
- Provider and Patient Communication
- Eligibility Verification
- Newborn Notification
- Accommodatin AHCCCS Members
- Appointment Availability Standards
- Advance Directives
- Patient Care Responsibilities
- Emergency Department Utilization
- Administrative Responsibilities
- Record Retention
- Transportation
- Credentialing and Recredentialing Process
- Complaints
- Compliance Program/Fraud and Abuse
Section C - Culturally and Linguistcally Competent Patient Care
- Non-Discrimination Policy
- National Standards for CLAS
- Cultural and Ligngusitc Resources
- Translation Services
- Culturally Competent Patient Care
Section D - Eligibility and Enrollment
- AHCCCS Eligibility
- Selecting a Primary Care Provider
- Member Identification Cards
- Newborns
- Co-Payments
- Member Reassignment
- Member Rights
- Member Responsibilities
- Changing of Health Plan
- MemberAdvance Directives
- Advance Directives Resource List
- Covered Services
- Durable Medical Equipment
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
- Eye Examinations/Optometry Services
- Family Planning Services
- Foot and Ankle Services
- Home Health
- Hospice
- Hospital
- Immunizations
- Laboratory Services
- Long Term Care
- Nutrition
- Orthotics and Prosthetics
- Outpatient Rehab Services
- Practice Guidelines
- Pharmacy and Medications
- Prenatal Care
- Qualified Medicare Beneficiaries
- Radiology Services
- Surgery Services
- Transplants
- Transportation
- Vision
- Non-Covered Services
Section F - Referral and Prior Authorization
- Standard Authorization Requests
- Expedited Authorization Requests
- Coordination of Benefits
- Pharmacy Prior Authorization and Formulary Exception Process
- Referral Process from PCP to Specialist
- Referral Process from Specialist to Specialist
- Referral Process for Ancillary Care Providers
- Hospital Admissions
- Maternal Child Health (MCH)
- Family Planning Services
- Medically Necessary Pregnancy Terminations
- Maternity Care
- Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
- Arizona Early Intervention Program (AzEIP)
- Children's Rehabilitative Services (CRS)
- Outreach and Educational Programs
- Hospital Concurrent Review
- Practice Guidelines
- DentaQuest
- EPSDT Covered Services
- Dental Periodicity Schedule Recommendations
- Adult Members Age 21 and Older Covered Services
Section I - Billing and Claims
- Filing Claims
- Claims Payment Methods
- Claims Status
- Claim Submission Information
- HCFA 1500 Claim Form
- UB-04 Claim Form
- Hospital Outpatient Billing
- Immunization Vaccine for Children (VFC) Program
- Other Injectables
- Service Reprorting Accuracy
- Modifiers
- Developmental Screening Tools
- Oral Health Serivces
- Behavioral Health
- Third Party Liability
- Duplicate or Erroneous Payments
- Cost Sharing with Medicare
- Fiscal Responsibility for Behavioral and Physical Health Services
- Explanation of Remittance Advice
- Medical Review of Claims
- Claims Processing Edits
- Reimbursement
- Claims Submitted for Family Planning Services
- FQHC PPS Rate
- Claims Submitted for EPSDT Services
- Surgery Claims
- Claims Submitted by Inpatient Facilities
- Outlier Claims
- Outpatient Hospital Facilities
- Ancillary Claims
- Emergency Transportation
- General Information
Section J - Claims Resubmissions and Disputes
- Duplicate or Erroneous Payments
- Claims Resubmissions
- Claims Resubmission Mailing Address
- Claims Disputes
Section K - Quality Management/Quality Improvement
- Quality Management/Quality Improvement Overview
- Quality Improvement Committee (QIC)
- 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
- Procedures for Amending the Drug List
- Formulary Changes and Updates
- Exclusions
- Limitations
Section M - Member Grievance and Appeals
- Member Grievances
- Member Appeals
- Appointment of Representation
- Case Management
- Disease Management
- Referral Information
Section O - Behavioral Health - RBHA
- Behavioral Health Services
- Identification of Behavioral Health Needs & Referral Guidelines
- Coordination of Care Guidelines between Medical Providers & RBHA
- RBHA Contact Information
- Behavioral Health Documentation Guidelines for PCPs
- Ongoing Communication with PHP
- Behavioral Health Pharmacy Guidelines and Prescription Services
- Prescribing Psychotropic Medications
- Behavioral Health Tool Kits
- Controlled Substances Prescription Monitoring Program
Section P - Behavioral Health - GMH/SA
- PHP Contact Information
- Eligibility Verification
- Behavioral Health Covered Services
- Appointment Standards and Timeliness of Services
- Referral Process
- Translation Services
- Non-Emergency Transportation
- Prior Authorization Guidelines Services
- Pharmacy Guidelines and Prescription Services
- Prescribing Psychotropic Medications
- Controlled Substances Prescription Monitoring Program (CSPMP)
- Behavioral Health Case Management
- Behavioral Health Crisis Services
- Court Ordered Treatment and Petition Process
- Deficit Reduction Act (DRA)
- FWA Reporting Form
- Appointment of Representation Form
- Consent for Sterilization Form
- Controlled Substances Prescription Monitoring
- EPDST Periodicity Schedule
- EPSDT Dental Periodicity Schedule
- EPSDT Certificate of Medical Necessity – Oral Nutritional
- Certificate of Medical Necessity (Adult) – Oral Nutritional
- RBHA Referral Form
- GMH/SA Referral Form