Provider Manual

Provider Manual
Chapter 1 Introduction to Health Choice Arizona
Chapter 2 Member Eligibility and Member Services
Chapter 3 Provider Responsibility
Chapter 4 Cultural Competency
Chapter 5 Quality Management
Chapter 6 Medical Authorizations and Notifications
Chapter 7 General Billing Rules
Chapter 8 Billing on the CMS 1500 Claim Form
Chapter 9 Billing on the UB Claim Form
Chapter 10 Billing on the ADA Claim Form
Chapter 11 Claims Processing
Chapter 12 Correcting Claim Errors
Chapter 13 Understanding the Remittance Advice
Chapter 14 Medicare and Other Insurance Liability
Chapter 15 Claim Disputes, Member Appeals, and Member Grievances
Chapter 16 Women and Children’s Services
Chapter 17 Pharmacy and Drug Formulary
Chapter 18 Behavioral Health Services
Chapter 19 Hospital Services
Chapter 20 Oral Health Services
Exhibits
 Exhibit 1.1 Provider Escalation Notice
Exhibit 3.2 EPSDT and Dental Periodicity Schedule
Exhibit 3.5.1 Missed Medical Appointment Log
Exhibit 3.5.2  Missed Dental Appointment Log
Exhibit 3.6.12  Maternal Risk Assessment
 Exhibit 3.7 EPSDT Tracking Form Order Sheet
Exhibit 4.1 Interpreter Services
 Exhibit 5.1 Case Management Referral Form
Exhibit 6.2  Medical Services Prior Authorization Form
Exhibit 6.9A  CRS Qualifying Medical Conditions
Exhibit 13.1  Medical Remittance Advice
Exhibit 13.2 Dental Remittance Advice
Exhibit 13.3 Remittance Denial Codes
Exhibit 16.1  CRS Application – English
Exhibit 16.2 CRS Application – Spanish
Exhibit 16.3  Federal Sterilization Consent Form
Exhibit 16.4  Newborn Reporting Form
 Exhibit 16.5 Hysterectomy Consent Form
Exhibit 16.8 Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
Exhibit 17.1 Formulary Addition Request Form
Exhibit 17.2  Pharmacy Services Prior Authorization Form
Exhibit 17.3 Controlled Substances Prescription Monitoring Program
Exhibit 17.4 ePrescribing Information
Exhibit 20.1  Dental Specialty Request form
Exhibit 20.2  Dental Matrix – Under 21
Exhibit 20.3 Dental Matrix – Over 21
 Exhibit 430-4 AzEIP AHCCCS Member Service Request Form
 Exhibit 431-1A  AHCCCS Dental Periodicity Schedule