Provider Manual

Provider Manual
Chapter 1 Introduction to BCBSAZ Health Choice
Exhibit 1-1 Provider Escalation Notice
Chapter 2 Member Eligibility and Member Services
Member ID Card – Medicare Only
Member ID Card – AHCCCS Only
Member ID Card – Dual
Chapter 3 Provider Responsibility
Exhibit 3.5.1 Missed Medical Appointment Log
Exhibit 3.5.2 Missed Dental Appointment Log
Exhibit 3.7 EPSDT Tracking Form Order Sheet
Exhibit 3.38.1 BHH Corporate Compliance Evaluation Form
Exhibit 3.38.2 Corporate Compliance Training Certification Form
Exhibit 3.38.3 Performance of Exclusion Checks Attestation Form
Chapter 4 Cultural Competency
Chapter 5 Quality Management
Exhibit 5.1 Care Management Referral Form
Chapter 6 Medical Authorizations and Notifications
Exhibit 6.2 Medical Services and Behavioral Health Prior Authorization Form
PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities
BHIF, BHRF, TFC Prior Authorization and Continued Stay Request Form
Notification of Admission, Transfer and Discharge for Out of Home Placements
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
Exhibit 13.1 Medical Remittance Advice
Exhibit 13.2 Dental Remittance Advice
Exhibit 13.3 Remittance Denial Codes
Chapter 14 Medicare and Other Insurance Liability
Chapter 15 Claim Disputes, Member Appeals, and Member Grievances
Chapter 16 Family Planning, Maternal Health, and Children’s Services
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 – English
Exhibit 16.5 Hysterectomy Consent Form – Spanish
Exhibit 16.8 Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
Exhibit 16.10 Maternal Risk Assessment
Chapter 17 Pharmacy and Drug Formulary
Exhibit 17.1 Formulary Addition Request Form
Exhibit 17.2 Pharmacy Services Prior Authorization Form
Exhibit 17.3 Psychotropic Medication Monitoring Program
Exhibit 17.4 ePrescribing Information
Exhibit 17.5 HIE eRX Information
Chapter 18 Behavioral Health Services
PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities
BHIF, BHRF, TFC Prior Authorization and Continued Stay Request Form
Notification of Admission, Transfer and Discharge for Out of Home Placements
Northern AZ ED Reporting
Chapter 19 Hospital Services
Chapter 20 Oral Health Services
Exhibit 20.1 Dental Specialty Request form
Exhibit 20.2 Dental Matrix – Under 21
Exhibit 20.3 Dental Matrix – Over 21
Chapter 21
Financial Reporting Guide
Exhibit 21.1 SABG and MHBG Expenditure Form
Chapter 22 Care Management
* Exhibit 430-4 AzEIP AHCCCS Member Service Request Form
Exhibit 430-A AHCCCS EPSDT Periodicity Schedule
* Exhibit 431-A AHCCCS Dental Periodicity Schedule

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