Fillable Printable Ffs Chap02 Eligibility
Fillable Printable Ffs Chap02 Eligibility
Ffs Chap02 Eligibility
AHCCCS Fee-For-Service Provider Manual
December 2013
Updated: 12/12/2013
Chapter 2
Eligibility
December 2013
AHCCCS Fee-For-Service Provider Manual
Updated: 12/12/2013
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A. OVERVIEW
All Arizona residents can apply for AHCCCS services or the Arizona Long Term Care
System (ALTCS) program. There are many programs that individuals may qualify for in
order to receive AHCCCS medical services or ALTCS coverage.
The programs have a number of different financial and non-financial requirements that
applicants must meet, including, but not limited to:
1. Proof of Arizona residency at the time of application
2. Proof of U.S. citizenship and identity or proof of qualified alien status
If a non-citizen does not meet the qualified alien status requirements for full services,
but meets all other requirements for the Caretaker Relative, SOBRA Child, SOBRA
Pregnant Woman, Young Adult Transitional Insurance (YATI), Adult, or SSI-MAO
category, the individual is eligible to receive Federal Emergency Services (FES)
only.
3. An income test that requires applicants to identify all individual and/or family earned
and unearned income and provide documentation if needed
4. A resource test that requires applicants to identify resources (e.g., homes, other
property, liquid assets, vehicles, and any other item of value) and provide
documentation of their value
NOTE: A resource test is only required for the ALTCS program.
5. Other requirements
Each program has certain non-financial and/or financial requirements, that are unique
to the program, and are aimed at serving specific groups of people.
Refer to http://www.azahcccs.gov/applicants/default.aspx for additional information.
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B. ELIGIBILITY
Eligibility determination is not performed under one roof, but by various agencies,
depending on the eligibility category.
For example, pregnant women, caretaker relatives, children, and single individuals enter
AHCCCS by way of the Department of Economic Security. The blind, aged or disabled
who receive Supplemental Security Income enter through the Social Security
Administration. Eligibility for categories such as ALTCS, SSI – Medical Assistance Only
(aged, blind and disabled who do not qualify for Supplemental Security Income cash
payment), KidsCare, Freedom to Work, Breast and Cervical Cancer Treatment Program
and Medicare Cost Sharing programs are handled directly by the AHCCCS
Administration.
Each eligibility category has its own eligibility criteria. This information is also available
in a booklet on the AHCCCS website:
http://www.ahcccs.gov/community/Downloads/resources/Description_of_AHCCCS_Pro
grams.pdf
1. Coverage for parents and caretaker relatives is provided under Caretaker Relatives
2. Coverage for children is provided under the following eligibility categories:
a. ALTCS
b. KidsCare
i. KidsCare is Arizona’s version of the Title XXI State Children’s Health
Insurance Program
ii. It covers low-income children under age 19 if the family income is less than
200 per cent of Federal Poverty Level (FPL).
c. Child group
d. SSI Cash (Title XVI) or SSI MAO
e. Young Adult Transitional Insurance (YATI) for former foster care children aged
18 to 26
f. Foster care children
g. Adoption Subsidy children
h. Newborns
All babies born to AHCCCS-eligible mothers are also deemed to be AHCCCS
eligible and may remain eligible for up to one year if the newborn continues to
reside in Arizona.
i. Newborns born to mothers receiving Federal Emergency Services also are
eligible up to one year of age. While the mother will be covered on a fee-for-
service basis under FESP, the newborn will be enrolled with a health plan.
ii. Newborns born to mothers enrolled in KidsCare will be approved for KidsCare
beginning with the newborn’s date of birth unless the child is Medicaid eligible.
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iii. Newborns receive separate AHCCCS ID numbers, and services for them must be
billed separately using the newborn's ID. Services for a newborn that are included
on the mother's claim will be denied.
3. Coverage for single individuals and couples is provided under the following eligibility
categories:
a. ALTCS
b. Breast and Cervical Cancer Treatment Program
c. Family Planning Services (FPS) provides family planning services only for up to
24 months to SOBRA pregnant women after a 60-day post partum period
d. SOBRA Pregnant Women
e. SSI Cash (Title XVI) or SSI MAO
f. Adults
g. Freedom to Work
h. Transplants
i. Medicare Cost Sharing
Various Medicare Savings Programs help recipients pay Medicare Part A & B premiums,
deductibles, and coinsurance.
1. Qualified Medicare Beneficiary (QMB)
2. Qualified Individual 1 (QI-1)
3. Specified Low Income Medicare Beneficiary (SLMB)
C. COVERAGE OUT OF STATE
A recipient who is temporarily out of the state but still a resident of Arizona is entitled to
receive AHCCCS benefits under any of the following conditions:
1. Medical services are required because of a medical emergency.
Documentation of the emergency must be submitted with the claim to AHCCCS.
2. The recipient requires a particular treatment that can only be obtained in another state.
3. The recipient has a chronic illness necessitating treatment during a temporary absence
from the state or the recipient’s condition must be stabilized before returning to the
state.
Services furnished to AHCCCS members outside the United States are not covered.
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D. ELIGIBILITY EFFECTIVE DATES
The following general guidelines apply to eligibility effective dates:
1. For most recipients, eligibility is effective from the first day of the month of
application or the first day of the month in which the recipient meets the
qualifications for the program or the date of birth whichever is later.
2. For KidsCare recipients, if the eligibility determination is completed by the 25th day
of the month, eligibility begins on the first day of the following month. For eligibility
determinations completed after the 25th day of the month, eligibility begins on the
first day of the second month following the determination of eligibility.
3. For a move into state or release from prison, the begin date is no sooner than that
date.
E. ENROLLMENT
AHCCCS pre-enrolls most acute care recipients with contractors of their choice when
they apply for eligibility through DES and the Social Security Administration. Each
recipient who applies at a DES or SSA office receives information about the contractors
available to him or her.
ALTCS applicants in Maricopa County and all SSI-MAO applicants also have the
opportunity to select a contractor during the application process.
KidsCare applicants may choose a contractor prior to approval of their application.
Because the recipient can select a contractor while the eligibility decision is pending, he
or she is enrolled on the same day he or she is determined eligible. A recipient who does
not choose a contractor is auto-assigned to a contractor on the same day that his or her
eligibility is posted in the AHCCCS system. The person then has 30 days to enroll with a
different contractor if they wish.
A person who is in the Address Confidentiality Program (ACP) has a pre-assigned
address in Maricopa County regardless of where the individual lives. If the person is not
currently enrolled in an AHCCCS contractor, AHCCCS enrolls the person in Fee-for-
Service until a choice is obtained. If the person is currently enrolled in an AHCCCS
contractor they will remain with that contractor unless the person is in another county and
qualifies for a plan change.
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Contractors are responsible for reimbursing providers for covered services rendered to
recipients during the Prior Period Coverage (PPC) time frame. The PPC is the period
between the recipient’s starting date of AHCCCS eligibility and the date of enrollment
with a contractor.
Example
05/12
Recipient applies at DES and indicates their choice of health plan
which is sent to AHCCCS.
06/18
DES approves application and sends transaction to AHCCCS.
06/19
Eligibility is posted by AHCCCS with an effective date of 05/01 and
enrollment is added back to 5/01.
The recipient is enrolled in his or her pre-selected plan. If the recipient did not make a
pre-enrollment choice, AHCCCS follows re-enrollment rules and family continuity rules
before auto-assigning the recipient to a plan.
The health plan is responsible for prior period coverage from 05/01 (start of eligibility)
through 06/18 (day before the enrollment is being processed). The plan is capitated at the
appropriate PPC rate for this period. Starting 06/19, the plan is capitated under the
appropriate on-going rate.
The eligibility begin date may be different than the Program Contractor enrollment date if
the member is acute care eligible. The member will remain enrolled in the acute care
health plan until the day of ALTCS approval.
AHCCCS acute care recipients who maintain eligibility may change plans once a year
during their enrollment anniversary month. The enrollment anniversary is the month in
which a recipient was first enrolled with an AHCCCS contractor. Native Americans may
change between American Indian Health Plan (AIHP) and an AHCCCS contractor at any
time.
If more than one person in a household/case is on AHCCCS, that household’s anniversary
is the month in which enrollment occurred for the recipient who has been an AHCCCS
recipient continuously for the longest period of time. Any member of the household who
wants to change plans may do so at the same time.
Two months prior to their anniversary date, recipients are reminded of their opportunity
to change plans. Those who wish to change contractors have two months to notify
AHCCCS of their decision.
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The month following the choice is the transitional month during which time AHCCCS
notifies both the former plan and new plan of the enrollment changes. This allows the
plans adequate time to transfer records and welcome new members.
Recipients who do not want to change plans will remain enrolled with their current plan
as long as the eligibility remains open.
This same process applies to ALTCS recipients in Maricopa and Pima Counties, where a
choice of contractors is available. Only one ALTCS contractor is available in other
counties
F. EFFECTIVE 1/1/2014 PRIOR QUARTER COVERAGE ELIGIBILITY
Beginning January 1, 2014, AHCCCS will be required to expand the time period
AHCCCS pays for covered services for an eligible individual, to include the three months
prior to the month the individual applied for AHCCCS, if the individual met AHCCCS
eligibility requirements during the month in which the Medicaid covered service was
provided.
Federal requirements provide that an applicant may be eligible for covered services durig
any of the three months prior to the Medicaid application date if the applicant:
1. received one or more AHCCCS covered services during the month and
2. would have qualified for AHCCCS at the time services were received if the
person had applied for AHCCCS.
If the applicant is determined to qualify for AHCCCS during any one or more of the three
months prior to the month of Medicaid application, then the individual will be determined
to have “Prior Quarter Coverage” eligibility during those months.
As stated above, Prior Quarter Coverage eligibility will begin January 1, 2014 which
means that individuals applying for AHCCCS in February 2014 may be determined to
qualify for prior quarter coverage during the month of January 2014. Persons applying in
March 2014 may qualify for prior quarter coverage in January and February. Persons
who apply on or after April 1, 2014 may qualify for prior quarter coverage for up to the
full 3 months prior to the month of the Medicaid application.
AHCCCS will not institute prior quarter coverage eligibility before January 1, 2014.
The AHCCCS Administration will determine whether or not an applicant meets prior
quarter coverage criteria. If so, the providers will be required to bill AHCCCS for
services provided during a prior quarter eligibility period upon verification of eligibility
or upon notification from the recipient of prior quarter coverage eligibility.
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Refer to Chapter 4 General Billing Rules for submitting prior quarter claims.
G. VERIFYING AHCCCS ELIGIBILITY AND ENROLLMENT
Even if a recipient presents an AHCCCS ID card or a decision letter from an eligibility
agency, the provider must always verify the recipient’s eligibility and enrollment status.
Effective dates of eligibility can only be verified through the AHCCCS system and may
change as information is updated in the system. Eligibility categories also may change or
be overridden by other eligibility categories. Recipients also may change their choice of
contractors.
Although there are no Prior Authorization (PA) requirements during the PPC time frame,
once prospective enrollment begins, the contractors may impose PA requirements. These
requirements may differ from those established by AHCCCS for fee-for-service
recipients.
Providers may use any one of several verification processes to obtain eligibility,
enrollment, and Medicare/TPL information (if available).
1. AHCCCS encourages verifications through a batch process (270/271) in which the
provider sends a file of individuals which AHCCCS returns with information the
following day, Information on that process can be obtained by calling the AHCCCS
Help Desk at (602) 417-4451.
2. AHCCCS has developed a Web application that allows providers to verify eligibility
and enrollment using the Internet. Providers also can obtain Medicare/TPL
information for a recipient.
a. To create an account and begin using the application, providers must go to
https://azweb.statemedicaid.us.
b. For technical support when creating an account, providers should call (602) 417-
4451.
3. The Medical Electronic Verification System (MEVS) uses a variety of applications to
provide member information to providers.
For information on MEVS, contact EMDEON at http://www.emdeon.com/contactus/
4. The Interactive Voice Response system (IVR) allows an unlimited number of
verifications by entering information on a touch-tone telephone.
5. Providers may call IVR at:
Phoenix: (602) 417-7200
All others: 1-800-331-5090
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6. In Maricopa County only, providers can request faxed documentation.
Medifax EDI 1-800-444-4336
7. If a provider cannot use the AHCCCS batch or web processes, IVR or EMDEON, for
verification of eligibility or enrollment, the provider may call the AHCCCS
Verification Unit.
The unit is staffed from 8:00 a.m. to 5:00 p.m., Monday through Friday
Providers should be prepared to give the operator the following information:
a. Provider NPI (if applicable) or the AHCCCS Provider Registration
number
b. Recipient’s name, date of birth, and AHCCCS ID number or Social
Security number
c. Date(s) of service
NOTE: Rate Codes can be referenced on the AHCCCS website
