Prior authorization must be obtained before the services are rendered or the services will not be eligible for reimbursement. Pregnancy termination services are covered when one of the following occurs:. For pregnant Members younger than 18 years of age, or those 18 or older and considered incapacitated, providers must secure a dated signature of the pregnant Member's parent or legal guardian or a certified copy of a court order indicating approval of the pregnancy termination procedure.
In addition, if the pregnancy termination is requested as a result of incest or rape, providers must include identification of the proper authority to which the incident was reported. This must include the name of the agency, the report number, and the date that the report was filed. Mifepristone also known as Mifeprex or RU is not a post-coital emergency oral contraceptive. When it is administered, the following documentation is also required: duration of pregnancy in days, the date Intrauterine Device IUD was removed if the Member had one, the date Mifepristone was give, , and documentation that pregnancy termination occurred.
Prior authorization is required for sterilization of Members under the age of 21 or pregnancy termination. To obtain authorization for pregnancy termination, except in cases of medical emergencies, the provider shall obtain a Prior Authorization from The Health Plan Medical Director. The Health Plan Medical Director or designee will review the Prior Authorization request and supporting documentation and expeditiously authorize the procedure, if the documentation meets the criteria for justification of pregnancy termination.
In cases of medical emergency, the provider must submit all documentation of medical necessity to The Health Plan within two working days of the date on which the pregnancy termination procedure was performed. An annual well-person preventative care visit is a covered benefit for members to obtain the recommended preventive services, including preconception counseling.
Providers are responsible for having a process to inform members about preventative health services annually and within 30 days of enrollment for newly enrolled members. Refer to the CDC website at www. The VFC program must be used for members under 19 years of age. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid members in effectively utilizing these resources.
EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health conditions for AHCCCS members under 21 years of age. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.
The provider is responsible for providing these services to pregnant Members under the age of 21, unless the Member has selected an Obstetrics OB provider to serve as both the OB and Primary Care Provider. EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, naturopathic services; nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical equipment; medical appliances; and medical supplies, orthotics, prosthetic devices, eyeglasses, transportation, and family planning services.
EPSDT also including a comprehensive history, developmental and behavioral health screenings, comprehensive unclothed physical examination, appropriate vision testing, hearing testing, laboratory tests, dental screenings and immunizations. However, EPSDT services do not include services that are experimental, that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions or treatments.
Primary care providers PCPs must be trained in the use and scoring of developmental screening tools. Training resources may be found at Arizona Department of Health Services website at www. The following developmental screening tools are available for members at their 9-, and month EPSDT visit:.
Fluoride varnish can be applied as often as every three months between the ages of 6 months and 2 years of age, after the eruption of the first tooth. Providers are expected to follow up with members who miss or no-show their EPSDT appointments and notify the health plan when a member has missed or cancelled three or more visits. Providers are encouraged to use the recall system in order to reduce the number of missed or cancelled appointments.
If the evaluation report indicates that the child does not have a 50 percent developmental delay, the EPSDT Specialist continues to coordinate medically necessary care and services for the child. The Provider shall notify the Health Plan when a child is potentially in need of services related to CRS qualifying conditions, as specified in A. R Article , and A. The notification requirements described above are applicable only to members under 21 years of age. The Provider shall consider members with a CRS qualifying condition as members with special health care needs.
For these children, CRS Providers must provide health care service delivery that involves multiple clinicians, covering the entire continuum of care. In addition to a primary care provider, these children may receive services from subspecialists who manage care related to their condition s and coordinate with other specialty services including but not limited to behavioral health, pharmacy, medical equipment and appliances, therapies, diagnostic services, and telemedicine visits.
Comprehensive care includes a multi-disciplinary team made up of subspecialists and caregivers such as pulmonologists, cardiologists, nutritionists, psychologists, and therapists. Because of the complexity of the needs of these children requiring multiple surgeries, hospitalization, and clinical care it is imperative that there be integrated health information and care coordination for the member.
Services shall be provided using an integrated family-centered, culturally competent, multi-specialty, interdisciplinary approach that includes the following elements:. Providers shall ensure that members with special health care needs that are determined through assessment to need a course of treatment or regular care monitoring have an individualized physical and behavioral treatment or service plan.
In addition, the Provider shall conduct multi-disciplinary staffings for members with challenging behaviors or health care needs [42 CFR The Provider shall coordinate care for members that includes allowing members with a CRS designation turning 21 the choice to continue being served by an MSIC that is able to provide services and coordinate care for adults with special healthcare needs.
Members with a CRS qualifying condition are currently exempt from mandatory and optional copayments. BMI is used to assess underweight, overweight and those at risk for overweight. BMI for children is sex and age specific. The following established percentile cutoff points are used to identify underweight and overweight in children:. Primary care providers PCPs should calculate the growth of children under 2 years of age by using the World Health Organization WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the U.
The Health Plan covers the following for members with a medical condition described in the section above:. Nutritional assessments and nutritional therapy is provided for members whose health status may improve with nutrition intervention. Nutritional assessments and nutritional therapy are covered benefits for members ages 21 and older when all of the following apply:. Nutritional assessments are conducted to assist members whose health status may improve with nutritional intervention.
This includes members who are under or overweight. A PCP may perform the nutritional assessment or may refer the member to a registered dietician. Prior authorization is always required for nutritional therapy. Providers must submit all clinically relevant information for medical necessity review and prior authorization requests. Prior authorization is required for commercial oral supplemental nutritional feedings, including specialty infant formulas, unless the member is also currently receiving nutrition through enteral or parenteral feedings.
Prior authorization is not required for the first 30 days if the member requires commercial oral nutritional supplements on a temporary basis due to an emergent condition. An example of a nutritional supplement is an amino acid-based formula used by a member for eosinophilic gastrointestinal disorder.
The primary care physician PCP or attending physician must determine medical necessity on an individual basis for commercial oral nutritional supplements. The PCP or attending physician must have documentation that nutritional counseling was provided as part of the Early and Periodic Screening, Diagnosis and Treatment EPSDT program and specify alternatives that were tried in an effort to boost caloric intake and change food consistencies before considering commercially available nutritional supplements for oral feedings, or to supplement feedings.
The PCP or attending physician must complete the Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form and indicate on the form which criteria were met when assessing medical necessity of providing commercial oral nutritional supplements.
The Health Plan has a comprehensive dental network for members. Dental Providers must submit claims and prior authorizations to Envolve Dental , or by phone at Eligible EPSDT Members under the age of 21 years old have comprehensive dental service benefits which include preventive, therapeutic and emergency dental services. If a member does not qualify under their dental eligibility and a medical condition is present, medical necessity is determined by the health plan. Medical documentation is required and must be submitted directly to the health plan for review and prior authorization determination.
A screening is intended to identify gross dental or oral lesions, but is not a thorough clinical examination and does not involve making a clinical diagnosis resulting in a treatment plan. Depending on the results of the oral health screening, referral to a dentist must be made as outlined in the Contract:.
EPSDT Members may select a dentist within the health plans contracted network and receive preventive dental services without a referral. Physicians who have completed the AHCCCS required training may be reimbursed for fluoride varnish applications completed at the EPSDT Well Child Visit as often as every three months between the ages of 6 months and 2 years of age, after the eruption of the first tooth.
Refer to Training Module 6 that covers caries risk assessment, fluoride varnish and counseling. Upon completion of the required training, providers should upload a copy of their certificate to the Council for Affordable Quality Healthcare CAQH site.
This certificate is used in the credentialing process to verify completion of training necessary for reimbursement. An oral health screening must be part of an EPSDT screening conducted by a PCP; however, it does not substitute for examination through direct referral to a dentist.
Orthodontic treatment and extraction of non-symptomatic teeth are generally not covered services. This includes third molars. Medically necessary emergency dental care and extractions are covered for persons age 21 years and older who meet the criteria for a dental emergency. AHCCCS covers the following dental services provided by a licensed dentist for members who are 21 years of age or older:. Maxillofacial dental services provided by a dentist are not covered except to the extent prescribed for the reduction of trauma, including reconstruction of regions of the maxilla and mandible.
Diagnosis and treatment of temporomandibular joint dysfunction TMD or TMJ is not covered except for the reduction of trauma. Routine restorative procedures and routine root canal therapy are not emergency dental services and are not covered. Treatment for the prevention of pulpal death and imminent tooth loss is limited to non-cast fillings, crowns constructed from pre-formed stainless steel, pulp caps, and pulpotomies only for the tooth causing pain or in the presences of active infection.
The health plan covers these services only after a transplant evaluation determines that the member is an appropriate candidate for organ or tissue transplantation. C R and A. The member must sign the document before receiving the service in order for the provider to bill the member. It is expected that the document contain information describing the type of service to be provided and the charge for the service.
No referral is required for an eligible member to make a dental appointment or receive dental care from one of the contracted health plan dental providers. Prior authorizations may be required for therapeutic services.
Depending on the results of the oral health screening, a referral to a dentist must be made. The American Academy of Pediatric Dentistry AAPD defines the dental home as the ongoing relationship between dentist and the member, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.
The dental home must include:. Dental home providers can request that a covered member be removed from their panel by issuing the person a written notice and allowing up to 60 days for assignment to a new dental home provider. Emergency eye care, which meets the definition of an emergency medical condition, is covered for all Members.
For Members who are 21 years of age or older, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses, are covered. Vision examinations and the provision of prescriptive lenses are covered for Members under the EPSDT program and for adults when medically necessary following cataract removal. Cataract removal is covered for all eligible Members under certain conditions.
Ocular photoscreening is limited to a lifetime coverage limit of one. Automated visual screening, described by CPT code , is for vision screening only, and not recommended for or covered by AHCCCS when used to determine visual acuity for purposes of prescribing glasses or other corrective devices. Get Covered.
Already Covered. Eligibility Policy Manual. Select one of the following for more information: Who Can Receive Services. The applicant may qualify for this program if the applicant: Is an Arizona resident Is pregnant Is a United States citizen or a qualified immigrant If the person is not a U. You pay a premium, but they cover everything. Good luck! And more! Legal advice is dependent upon the specific circumstances of each situation. Pregnant Women. I hope that this helps. This book examines the major US welfare programs affecting children and presents a systematic evaluation of the evidence regarding the effects of welfare programs on the children themselves.
Like most of the women who have already responded. Try medicade because there are different requirements for family planning and pregnancy care issues. Also there are state insurances that varies form state to state and vary in price depending on coverage. I am in a different state but I know here the cheapest if like bucks a month. But I would try medicade.
Good luck and congratulations on your pregnancy! I have been in your situation because we are not married and when I got pregnant with my daughter I was also denied and had to reapply and left out the fact that me and my BF were together because if you are barely over the limit they will deny you. I'm pregnant and have come across and emergency that requires me to go out of town.
Click on another city to see only the Pregnant Women Detox Programs in that city. Would that be something that might work in your favor too?
If I was to go into labor while being in a different state, will ahcccs cover me? Visit AzCourtHelp: Free or reduced fee legal help might be available for those that qualify.
There are also clinics throughout Maricopa County that will see patients without insurance on a sliding fee schedule - go through the Department of Health. You only go to the OB once per month until the last month of your pregnancy. High-risk pregnancy. We had some complications at birth and extra ultrasounds and our total cost was It is a discount insurance.
I don't know if you have found anything yet. It is worth a try. Free or reduced fee legal help might be available for those that qualify. Jordan E. Goodman website. In doing so, Congress exempted If you are approved for emergency services only, you may receive medical services from any provider doctor, hospital, etc.
First of all god has giving you a wonderful blessing, Congrads It's really scary, but we cut back on everything we could and it's just so expensive to have health insurance. Like so many others, my husband makes just a little too much to qualify for assistance.
The youngest son of the artist Ted DeGrazia, his family has lived in Arizona more than years. You will find 'health insurance alternatives'. We just had our third baby with no insuance first two with insurance.
Contact us at or visit us at W. I would really like to go to the doctor sooner than later so I hope this doesn't take to long: I'll keep you all updated on what happens and what I decide to do.
Try clicking on that, or you can even write to him. Coconino 8. Thanks again to everyone!!!! It's not fair that they penalize you if you're married but still don't make enough on one salary. Making a budget and sticking with it was the only way my husband and I were able to make our money stretch to go where it needed to. This insightful book details the principles of the Wraparound approach, which offers families collaborative, individualized, community-based, strengths-focused service.
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That serve Arizona residents i also do n't qualify which you thought anyways member a! Already pregnant, you may receive medical services from any provider doctor, hospital, etc. Judge will recommend a decision to the high cost and am petrified getting!
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