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DATA SYSTEMS/REPORTING REQUIREMENTS

With respect to decisions on enrollment, providers shall defer to AHCCCS, which has exclusive authority to enroll and dis-enroll Medicaid eligible members in accordance with the rules set forth in A.A.C., R9-22, Article 17 and R9-31, Articles 3 and 17. Providers shall also defer to AHCCCS, which has exclusive authority to designate who will be enrolled and dis-enrolled as Non-Medicaid eligible members.

The collection and reporting of accurate, complete, and timely enrollment, and disenrollment data is of vital importance to the successful operation of the AHCCCS health service delivery system. It is necessary for providers to submit specific data on each person who is actively receiving services from the health system. As such, it is important for provider staff (e.g., intake workers, clinicians, data entry staff) to have a thorough understanding of why it is necessary to collect the data, how it can be used and how to accurately label the data. This policy has particular relevance for those providers that conduct assessments, ongoing service planning, and annual updates. This data in turn is used by the AHCCCS to:

  • Monitor and report on outcomes of individuals in active care (e.g., employment/educational status, substance use);
  • Comply with federal and state funding and/or grant requirements;
  • Assist with financial-related activities such as budget development and rate setting;
  • Support quality management and utilization management activities; and
  • Inform stakeholders and community members.

The Health Plan’s Management Information System has the capability to receive and load data from a provider‘s EHR to collect enrollment data for submission to AHCCCS.

Additionally, the Health Plan and AHCCCS shall have access privileges and user-rights to any and all member information within Contractor‘s MIS system, and that of any Management Information System (MIS)/Electronic Health Record (EHR) system operated by a subcontracted provider. At a minimum, the Health Plan and AHCCCS shall be permitted real-time access to client level data, claims and billing, service planning, assessment, and grievance and appeal data.

7.1.1     Enrollment and Disenrollment Transactions

7.1.1.1     General Requirements

Arizona Health Care Cost Containment System (AHCCCS) enrolled individuals are considered enrolled with the Health Plan at the onset of their eligibility. They are provided an AHCCCS identification card listing their assigned Health Plan. This assignment is sent daily from AHCCCS to the Health Plan.

For a Non-Title XIX/XXI eligible person to be enrolled, providers must follow the State Only and “crisis” enrollment processes. All AHCCCS enrolled individuals with a mental health benefit are considered enrolled with the Health Plan at the time of their AHCCCS eligibility.

For a Non-Title XIX/XXI eligible person who receives a covered service, they must be enrolled effective the date of first contact by a provider.

7.1.1.2     When to Collect Enrollment Information

For Non-Title XIX/XXI eligible individuals, information necessary to complete an enrollment is usually collected during the intake and assessment process (see Section 13.6 Assessment and Service Planning).

For AHCCCS enrolled individuals, the 834 information will be provided to the Health Plan by AHCCCS.

7.1.1.3     Other Considerations for Both Non-Title XIX/XXI Eligible and AHCCCS Enrolled Individuals

For an AHCCCS enrolled individual, AHCCCS will notify the Health Plan of changes to the above information.

When a person in active care permanently relocates from one RBHA/MCO/Health Plan’s geographic area to another RBHA/MCO/Health Plan’s geographic area, an Inter-RBHA/MCO transfer must occur (see Section 14.2 – Inter-RBHA/MCO Coordination of Care). The steps that are necessary to facilitate an Inter-RBHA/MCO transfer include the following data submission requirements for Non-Title XIX/XXI individuals:

  • The home T/RBHA/Health Plan must submit a dis-enrollment request to AHCCCS.
  • The receiving T/RBHA/Health Plan must submit an enrollment transaction to AHCCCS after home Health Plan dis-enrolls.
  • AHCCCS will notify the Health Plan when the Health Plan enrolled person is determined eligible for the Arizona Long Term Care System (ALTCS) Elderly and Physically Disabled (EPD) Program. This information will be passed to the Health Plan in a daily file.

 

7.1.2     Member and Clinical Data

7.1.2.1     When Member and Clinical Data is Collected

Member and clinical data shall be collected starting at the first date of service.

Clinical data collected by providers must be reported to AHCCCS via the AHCCCS DUGless portal. The AHCCCS Demographic & Outcomes Data Set User Guide  describes the minimum required data elements that comprise the demographic data set, in part. Providers are required to comply with AHCCCS demographic requirements, submitting demographic data to AHCCCS through the AHCCCS DUGLess portal