REFERENCES, DEFINITIONS, AND ACRONYMS

AHCCCS Definitions as set forth in the current AHCCCS ACC-RBHA, and NTXIX contracts and amendments, ACOM and AMPM policies, AHCCCS Contract and Policy Dictionary, and relevant AHCCCS manuals as periodically amended and published by AHCCCS at the links below.

AHCCCS Contracts

https://azahcccs.gov/Resources/OversightOfHealthPlans/SolicitationsAndContracts/contracts.html

Guides, Manuals, Policies

https://azahcccs.gov/PlansProviders/GuidesManualsPolicies/index.html

AHCCCS Contract and Policy Dictionary

ContractAndPolicyDictionary.pdf (azahcccs.gov)

AHCCCS Related Acronyms

https://www.azahcccs.gov/shared/acronyms.html  

ADULT RECOVERY TEAM ("ART") A defined group of individuals that includes, at a minimum, the member, their family, a behavioral health representative, and any individuals important in the member’s life that are identified and invited to participate by the member. This may include system partners such as extended family members, friends, family support partners, healthcare providers, community resource providers, representatives from churches, synagogues or mosques, agents from other service systems like Probation or the Administrative Office of the Courts (AOC). The size, scope, and intensity of involvement of the team members are determined by the objectives established for the adult, the needs of the family in providing for the adult, and by which individuals are needed to develop an effective service plan and can therefore expand and contract as necessary to be successful on behalf of the adult should this be needed or required.

ADVERSE BENEFIT DETERMINATION (1) the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (2) the reduction, suspension, or termination of a previously authorized service; (3) the denial, in whole or in part, of payment for a service; (4) the failure to provide services in a timely manner; (5) the failure of the Health Plan to act within the established timeframes regarding the standard resolution of grievances and appeals; (6) the denial of a member's request to obtain services outside the network; and/or (7) the denial of a member's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial liabilities.

AFFILIATE A person or entity controlling, controlled by, or under common control with AzCH - Arizona Complete Care.

AHCCCS REGISTERED PROVIDER A provider that enters into an agreement with AHCCCS under A.A.C. R9-22-703(A) and meets licensing or certification requirements to provide covered services.

ARIZONA DEPARTMENT OF ECONOMIC SECURITY ("ADES") The State agency that has the powers and duties set forth in A.R.S. § 41-1951, et seq.

ASSESSMENT INTERVENTION CENTER (“AIC”) A time-limited, intensive program serving children and families that delivers services in an ADHS-licensed BHRF (Provider Type B8). The program’s focus is on thorough psychiatric, psychological, and family systems evaluations, a comprehensive behavioral analysis; and development of targeted interventions individualized for each member and family. The program is designed for up to a thirty (30) day treatment period. The initial fourteen (14) days of service do not require prior authorization. Additional services require a concurrent authorization on or before the fourteenth (14th) day of service. The maximum length of stay is thirty (30) days. The goal of the program is to answer the question “What supports and interventions are needed for this member to live successfully in the community?”

BEST PRACTICES Evidence-based practices, promising practices, or emerging practices.

BRIEF INTERVENTION PROGRAM (BIP) Is a time-limited, intensive crisis intervention program, currently for AzCH members, which delivers services in an ADHS licensed BHRF (Provider Type B8) to help persons live successfully in the community. The program includes crisis, supportive and treatment services. No prior authorization is needed for the first 5 days. A CFT or ART meeting must be conducted within three (3) business days of a member’s admission to the program. If an extension in the stay is needed to further stabilize after the initial 5 days, an authorization is required for an extension of 5 additional days. The clinical documentation must be submitted to support medical necessity. The maximum length of stay is ten (10) days. There are limited beds in the community designed as discharge BIP beds for members who do not qualify for medical necessity in a behavioral health level 1 facility but the member needs stabilization prior to returning to their previous living arrangements.

AzCH – ARIZONA COMPLETE CARE PROVIDER MANUAL Provider Manual including any amendments, appendices, modifications, supplements, bulletins, or notices related to the AzCH - Arizona Complete Care Provider Manual that may be made from time to time and available on AzCH - Complete Health Plan’s website. AzCH - Complete Health Plan shall use its reasonable efforts to give Subcontractor advance notice of any amendment or modification of the AzCH –Complete Health Plan Provider Manual that materially affects Subcontractor's.

CLAIM A service billed under a fee-for-service arrangement.

COMMUNITY SERVICE AGENCY ("CSA") An agency that is contracted directly by the Health Plan and registered with AHCCCS to provide rehabilitation and support services consistent with the staff qualifications and training. Refer to the AHCCCS Covered Behavioral Health Services Guide for details, AHCCCS AMPM 965 - COMMUNITY SERVICE AGENCIES. https://www.azahcccs.gov/shared/MedicalPolicyManual/.

COMPLEX NEEDS The presence of significant behavioral challenges that impact the safety of a member, facility personnel, and/or other members for which additional staff support is needed to address and successfully treat the member’s behavioral challenges in the facility.

CONFLICT OF INTEREST ("COI") Any situation in which the Subcontractor or an individual employed or retained by the Subcontractor is in a position to exploit a contractual, professional, or official capacity in some way for personal or organizational benefit that otherwise would not exist.

CONTRACT YEAR ("CY") The time period that corresponds to the federal fiscal year, October 1 through September 30 used for financial reporting purposes.

CULTURAL COMPETENCY A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals which enables that system, agency, or those professionals to work effectively in cross-cultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities.

DEDICATED HEALTH CARE COORDINATOR The job title used by AzCH - Arizona Complete Care to describe the role Subcontractor employees perform related to assisting a High Needs member and family in achieving recovery. These duties include all duties formerly assigned to the role of the Case Manager and include intensive case management services, management of care, coordination of services, employment support, health promotion, motivational interviewing, assisting with service planning and other similar services to support recovery.

DELIVERABLES The reports and other deliverables the Subcontractor are required to provide to AzCH - Arizona Complete Care pursuant to the AzCH - Arizona Complete Care Provider Manual.

DIRECT CARE STAFF In the case where a Subcontractor is a health care entity, a person or entity who is employed by or otherwise engaged by Subcontractor to provide Covered Services to members.

FISCAL YEAR ("FY") The State budget year: July 1 through June 30. This is to be distinguished from the Contract Year, as defined above.

FORMULARY A list of covered medications available for treatment of members.

FREEDOM TO WORK (also referred to as TICKET TO WORK) Eligible individuals under the Title XIX program that extends eligibility to individuals 16 through 64 years old who meet SSI disability criteria, and whose earned income after allowable deductions is at or below 250% of the FPL, and who are not eligible for any other Medicaid program. These members must pay a premium to AHCCCS, depending on income.

HEALTH CARE COORDINATOR Health Care Coordinator is the job title used by AzCH - Arizona Complete Care to describe the required duties performed by Subcontractor (Provider) employees related to coordinating physical health, behavioral health, and social services in a member-focused manner with the goals of improving whole person health outcomes, and more effective and efficient use of resources. Health Care Coordinators, often referred to as Health Care Coordinators, Case Managers, Integrated Care Managers, or Care Coordinators; provide accessible, comprehensive, and continuous coordination of care based on effective working relationships with members and accumulated knowledge over time of members’ health care challenges and strengths. Health Care Coordinators build on members’ strengths to promote wellness, recovery, and resiliency.

MAY Something is permissive.

MEDICAL EXPENSE DEDUCTION Title XIX waiver member whose family income exceeds the limits of all other Title XIX categories (except ALTCS) and has family medical expenses that reduce income to or below 40% of the Federal Poverty Level. Medical Expense Deduction members may or may not have a categorical link to Title XIX.

MEDICAL INSTITUTION An acute care hospital, rehabilitation hospital, nursing facility, psychiatric hospital, long-term acute care hospital, or other institution, as defined in A.A.C. R9-22-206.

MEMBER An individual enrolled with the Contractor for AHCCCS covered services as specified in this Contract.

MULTIDISCIPLINARY TEAM ("MDT") A team that is composed of behavioral health representatives and is intended to identify the member’s needs and treatment plan in an organized manner for persons with a Serious Mental Illness.

PROVIDER Subcontracted agency that provides Covered Services.

PROVIDER MANUAL AzCH’s Provider Manual.

SERIOUS MENTAL ILLNESS ("SMI") The designation given to adults, 18 years of age and older, with a diagnosable mental disorder as defined in A.R.S. § 36-550, which results in functional impairment which substantially interferes with or limits one or more major life activities.

SERVICE PLAN A written description of all covered health services and other informal supports which includes the member’s family and any other people important to the member needed to achieve service goals as defined by the member. A comprehensive service plan addresses the member’s needs, strengths, interests, and goals with measurable objectives. The Service Plan serves as a guide for the member and anyone involved in assisting with service delivery. The Service Plan is based on the results of a comprehensive assessment.

SUBCONTRACTOR Any person or entity who contracts with AzCH – Arizona Complete Care directly to provide covered services to members.

SUBCONTRACTOR HEALTH CARE COORDINATOR Health Care Coordinator employed by a subcontractor.

WRAP AROUND SERVICES A broad range of supports and services delivered within the Child and Family Team ("CFT") process that meet the needs of the child and family and includes non-traditional supports provided in school, home, and community settings. It is an approach and philosophy of care planning that is family-driven, strengths-based, needs-driven, and culturally competent. It is highly individualized and addresses family needs from multiple life domains, including school, home, and the community.