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Provider Manual

Phoenix Health Plan (PHP) provides the following Provider Manual to its participating providers and their office staff.

Section A - Introduction

  • 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

Section E - Covered Services

  • 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

Section G - Medical Services

  • 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

Section H - Dental Services

  • 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

Section L - Formulary

  • 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

Section N - Case Management

  • 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

Forms and Attachments

  • 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

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