Frequently Asked Questions (FAQs) Regarding Coronavirus Disease 2019 (COVID-19) Updated 1/30/2023
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As a result of changes made in response to the COVID-19 emergency, information presented in the CMS-approved flexibilities and FAQs may not align with various provisions set forth in the AHCCCS Medical Policy Manual (AMPM), the AHCCCS Contractor Operation Manual (ACOM) Policies; the AHCCCS billing requirements; and/or other AHCCCS directives. In these instances, the CMS-approved flexibilities and FAQs take precedence and are controlling.
On March 17, 2020 and March 24, 2020, AHCCCS submitted requests to the Centers for Medicare and Medicaid Services (CMS) to waive certain Medicaid and KidsCare requirements in order to ensure ongoing access to care over the course of the COVID-19 outbreak.
BILLING & CLAIMS
- 1. (updated 1/6/21) Question: Does AHCCCS have a centralized resource for medical coding resources related to COVID-19?
- Answer: Yes, the AHCCCS Medical Coding Resources web page includes a COVID-19 Medical Coding Information section and COVID-19 Emergency Medical Coding guidance.
- 2. (added 3/19/20) Question: Will AHCCCS issue guidance regarding prior authorization expectations related to COVID-19 testing and treatment?
- Answer: Prior authorization is not permitted for COVID-19 testing or treatment.
- 3. (added 3/20/20) Question: Is there a claims modifier for services related to the COVID-19 emergency?
- Answer: Yes, AHCCCS has designated the CR modifier to be used on all claims for services provided as a result of, or related to COVID-19. It is imperative that providers begin utilizing this modifier immediately in all appropriate instances in order for AHCCCS to identify the costs of services attributable to this emergency. All other guidance regarding use of modifiers continues to be applicable.
- 4. (updated 1/6/21) Question: How should hospitals that are reimbursed by APR-DRG bill for inpatient services related to the new ICD-10 diagnosis code for COVID-19?
- Answer: AHCCCS was notified that the 3M software did not recognize the new ICD-10 diagnosis code for COVID-19 prior to April 1, 2020. Until the April 1, 2020 software release, hospitals were instructed to bill for other related conditions such as:
- Acute Bronchitis
- Lower Respiratory Infection
- ARDS - Acute respiratory distress syndrome
The April 1, 2020 release of 3M softwarerecognizes the defined ICD-10 diagnosis code, U07.1, which is mapped to an existing APR-DRG.
- 5. (added 4/22/20) Question: Is IHS required to report CPT and modifiers on UB-04 claims (pertaining to COVID-19)?
- Answer: IHS facilities are not required to report CPT/HCPCS and modifiers on UB-04 claim forms when billing the All Inclusive Rate (AIR).
- 6. (updated 7/19/21) Question: Does AHCCCS reimburse IHS and 638 providers for services rendered at an Alternate Care Site (ACS)?
- Answer: Per the COVID-19 Emergency Declaration Blanket Waivers & Flexibilities for Health Care Providers document released by CMS, AHCCCS will reimburse for services provided at or through an ACS, with a retroactive effective date of March 1, 2020 through the end of the emergency declaration. Such services shall be reimbursable, so long as those services performed are administered to a Title XIX or Title XXI eligible AHCCCS member, and are medically necessary, cost-effective, federally and state reimbursable, provided by an AHCCCS-registered provider.
To qualify for reimbursement, services must be performed by an ACS that is operated by a hospital, FQHC, rural health clinic, owned or operated by the Indian Health Service, or tribes or tribal organizations with a 638 agreement. For additional information about ACS reimbursement, including fee for service billing guidelines, please refer to the Division of Fee-for-Service Management (DFSM) Alternate Care Site Memo.
- 1. (updated 10/20/22) Question: Does AHCCCS have guidance about Prior Authorization (PA) and Concurrent Review procedures during the COVID-19 emergency?
- Answer: Please see the MCO AHCCCS October 20, 2022 memo. This guidance does not apply to AHCCCS Fee for Service Programs. Fee for Service guidance, in coordination with tribal stakeholders, is available in this August 2, 2022 Fee for Service memo.
- 2. (updated 8/10/21) Question: Is AHCCCS willing to suspend medical record review audits and behavioral health chart audit review processes at this time?
- Answer: The formal medical record review (MRR) audits and behavioral health audits remain suspended at this time; however, some auditing efforts are being implemented, such as those tied to implementation of the HCBS Rules and Person-Centered Planning. Those audit functions may require a review of medical, behavioral health, and/or other member records but those are not considered the formal MRR or behavioral health audits.
- 3. (added 3/27/20) Question: Will AHCCCS consider relaxing the timeframe for issuing Notice of Adverse Benefit Determination (NOABD) letters for non-urgent prior authorization requests? Due to the need to print securely we have been unable to deploy these staff home while complying with this AHCCCS requirement.
- Answer: No, AHCCCS will not be extending the timeframe for Notice of Adverse Benefit Determination (NOABD) letters for non-urgent prior authorization requests.
- 1. (added 9/4/20) Question: Will all pharmacies be allowed to bill for flu vaccine regardless of whether they are in the prescription pharmacy network of the MCO?
- Answer: No, AHCCCS’ requirements regarding in-network providers are not lifted and still apply. All AHCCCS registered pharmacies can serve members enrolled with a Fee-for-Service Program, including the American Indian Health Program and Tribal Arizona Long Term Care System.
- 2. (added 9/4/20) Question: For children ages 3-18, are the pharmacies to bill VFC or do they bill the MCOs directly through the pharmacy system at point of sale?
- Answer: For children ages 3 through 18, the pharmacies are to submit claims for the flu vaccine to the MCO’s PBM. The MCO’s PBM is to reimburse the pharmacy for the cost of the flu vaccine (in addition to the administration of the vaccine).
- 3. (added 9/4/20) Question: For FQHCs/RHCs providing influenza vaccines should there be a % increase to their PPS rate that equates to a 10% vaccine/admin bump when they bill for a qualifying visit with administration of influenza vaccine? Or should there be an additional 10% vaccine/admin bump outside of the PPS rate when they bill for a qualifying visit with administration of influenza vaccine?
- Answer: No. There is no change to the PPS rate for FQHCs/RHCs or reimbursement outside of the PPS rate for this purpose.
- 4. (added 9/4/20) Question: Can you provide all of the MCO reimbursement rates for vaccines?
- Answer: AHCCCS is unable to provide MCOs’ reimbursement rates. For the AHCCCS Fee-For-Service rates, please see the fee schedule at: https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/.
- 5. (updated 9/14/20) Question: For Indian Health Service (IHS) and Tribal (638) facilities that provide influenza vaccines, will there be a percent increase to the All Inclusive Rate (AIR) that equates to a 10% vaccine/administration increase when they bill for a qualifying visit with administration of influenza vaccine? Or will there be an additional 10% vaccine/administration increase outside of the AIR rate when they bill for a qualifying visit with administration of influenza vaccine?
- Answer: No. There is no change to the AIR for IHS/638 pharmacy reimbursement or reimbursement outside of the AIR for this purpose. Pharmacies should be aware that the “four-walls” provision is applicable. Please see the Flu Vaccine Memo on this web page for more information on flu vaccinations and billing for IHS/638 pharmacies.
- 6. (added 10/1/20) Question: Will AHCCCS allow encounter overrides for duplicates (for same dates of service, same member, same provider) when the same vaccine admin codes are billed with different modifiers (e.g. SY, SL) for multiple vaccines on the same day?
- Answer: No, AHCCCS will not allow encounter overrides for duplicates in the example as described. Vaccine admin codes should not be billed with two different modifiers. They should be billed with either the SY (for adults, or for children for vaccines not covered by VFC) or the SL modifier (for children for vaccines covered by VFC).
- 7. (added 9/30/21) Question: Are children ages 3 years and older required to obtain vaccines from the Vaccines for Children program?
- Answer: Children ages 3 years and above can obtain their flu vaccine from VFC providers or from pharmacies outside of the VFC program.
GENERAL COVID-19 QUESTIONS
- 1. (updated 7/19/21) Question: Where can I get information and updates about the coronavirus and COVID-19?
- Answer: Information about COVID-19 is available from the Centers for Disease Control (CDC) and the Arizona Department of Health Services. Additionally, the general public in Arizona can call the Arizona Poison Control System at 1-844-542-8201 or the statewide COVID-19 Hotline, available 8 a.m. to 8 p.m. daily, in English and Spanish, by dialing 2-1-1 in Arizona. The COVID-19 hotline is administered by 2-1-1 Arizona and Solari, Inc., and can address questions about how to prepare for and prevent COVID-19 spread; testing information for COVID-19; at-risk populations; what to do if an individual gets sick; COVID-19 and animals; and other resources for accurate, reliable, and up-to-date information.
- 2. (updated 7/21/21) Question: Where can providers find further information about the CARES and Families First Coronavirus Response Acts?
- Answer: See the CARES and FFCR Act guidance and FAQs on Medicaid.gov.
- 3. (updated 5/6/20) Question: Is AHCCCS covering COVID-19 antibody testing?
- Answer: Yes, as outlined in Section 6004 of the Families First Coronavirus Response Act (FFCRA). Further information is available at the CDC and on the ADHS websites.
- 4. (updated 3/19/20) Question: Does AHCCCS have a centralized resource for members who have general questions or are experiencing flu-like symptoms?
- Answer: Yes. AHCCCS has created a web page to address Medicaid-related questions from providers and contractors about COVID-19 at azahcccs.gov/AHCCCS/AboutUs/covid19.
- For ACC Health Plan members experiencing symptoms: Call the 24-hour Nurse Line for your Health Plan. The Health Plans’ 24/7 Nurse Line numbers are posted on the AHCCCS COVID-19 web page.
- For FFS Members, including those enrolled in the American Indian Health Program (AIHP), Tribal ALTCS, or a Tribal Regional Behavioral Health Authority (TRBHA): Please contact the nearest American Indian Medical Home (AIMH) 24-hour Nurse Line, your doctor, or the nearest IHS/638 facility. The AIMH Nurse Line phone numbers are posted on the AHCCCS COVID-19 web page.
- 5. (updated 1/6/21) Question: Should I keep doctor appointments for routine visits?
- Answer: Please contact your health care provider regarding scheduled, routine visits. Many appointments are now being offered via telehealth for appointments that do not require an in-person visit. For appointments that do require an in-person visit, health care providers have implemented a safety protocol to address COVID-19.
- 6. (updated 7/19/21) Question: What is the guidance on well-child visits during the COVID-19 pandemic?
- Answer: Well-child visits and recommended vaccinations are essential and help make sure children stay healthy and are protected. The CDC and the American Academy of Pediatrics (AAP) recommend every child continues to receive recommended vaccinations during the COVID-19 pandemic.
- 7. (updated 1/6/21) Question: Should elective and non-emergency medical procedures be delayed or postponed?
- Answer: Please contact your health care provider regarding the scheduling of elective and non-emergency medical procedures. Many appointments are now being offered via telehealth for appointments that do not require an in-person visit. For appointments that do require an in-person visit, health care providers have implemented a safety protocol to address COVID-19.
- 8. Question: Arizonans are understandably stressed and anxious right now. What mental health resources do you recommend?
- Answer: AHCCCS covers a full array of behavioral health services for members, and crisis services are available to anyone in Arizona, regardless of insurance coverage. In addition, we have added behavioral health resources offered by the CDC and SAMHSA on the COVID-19 webpage.
- 9. (updated 7/22/21) Question: Will members lose coverage during the COVID-19 emergency?
- Answer: No, per the Families First Coronavirus Response Act, AHCCCS will not disenroll members during the emergency (with the exception of death, those who move out of state, those who voluntarily withdraw, those who aged out of the KidsCare program, or those who are no longer Medicaid eligible but are eligible for a Medicare Savings Program).
- 10. (added 7/24/20) Question: Are non-Medicaid members who are covered under state-only funding, also protected from disenrollment?
- Answer: No, members who are not federally funded under Title XIX (for example, members with a Serious Mental Illness determination who do not qualify for Medicaid) are not exempt from disenrollment during the public health emergency.
- 11. (updated 7/22/21) Question: Is AHCCCS continuing to process Medicaid renewals during the COVID-19 emergency? Should providers assist members with their renewals?
- Answer: Yes, while we are not disenrolling members (with the exception of death, those who move out of state, those who voluntarily withdraw, those who aged out of the KidsCare program, or those who are no longer Medicaid eligible but are eligible for a Medicare Savings Program), we are continuing to process annual renewals. Providers are encouraged to continue to assist members with their renewals.
- 12. (added 4/14/20) Question: Will AHCCCS reinstitute Prior Quarter coverage during the declared emergency?
- Answer: Prior Quarter, or retroactive coverage, is currently available to children under age 19, pregnant women and women in a post partum period. For individuals other than children, pregnant women and women in a post partum period, approved applications are effective as of the first day of the month in which the application is submitted. Individuals are encouraged to submit an application immediately if they are experiencing a health issue, become uninsured or experience a change in circumstance that may make them eligible for AHCCCS Medical Assistance. Apply for AHCCCS.
Federal authority to expand Prior Quarter Coverage beyond children under age 19, pregnant women and women in a post partum period is not under consideration. AHCCCS has taken many steps to ensure ongoing access to health care during the emergency period including suspending premium payments and suspending disenrollments.
- 13. (added 4/2/20) Question: During the COVID-19 emergency will AHCCCS members be required to pay premiums?
- Answer: No. For the duration of the COVID-19 emergency, AHCCCS has suspended premium payments for the KidsCare and Freedom to Work programs as well as copayments for the Transitional Medical Assistance (TMA) and Adult populations. Members who have already paid March 2020 premiums will be credited, and individuals who were disenrolled in March will be reinstated for the duration of the emergency.
- 14. (updated 3/1/22) Question: Due to the COVID-19 emergency, CMS is granting State Medicaid programs the flexibility to waive and/or modify certain Medicaid requirements. What flexibilities has AHCCCS requested?
- Answer: AHCCCS has requested various flexibilities to waive and/or modify certain Medicaid requirements under 1135 and 1115 Waivers and State Plan Amendments. CMS has reviewed and granted approval of these requests. A full list of the status and end-date of each flexibility can be found here: Status of AHCCCS Emergency Authority Requests.
- 15. (updated 10/19/22) Question: Are the current flexibilities under Appendix K pertaining to Home and Community Based Services going to extend beyond the original March 12, 2021 expiration date?
- Answer: The Centers for Medicare & Medicaid Services (CMS) has approved Arizona’s request to extend the approval period of certain previously approved Emergency Preparedness and Response Attachment K authorities through the end of the calendar quarter after the PHE ends, with the following two exceptions which expired on March 12, 2021: regarding service providers for home-delivered meals, and regarding extensions for reassessments and reevaluations. Additionally, AHCCCS will be extending the flexibility to allow parents as paid caregivers for minor children through March 31, 2024, and will be permanently extending the flexibility to provide home delivered meals to all ALTCS populations. For more information on parents as paid caregivers, please visit the Parents as Paid Caregivers of Minor Children FAQ.
- 16. (added 8/24/20) Question: Medicaid applicants need to sign the AHCCCS application form. How is a signature captured when an individual applies online or by phone and does not submit a paper application?
- Answer: When an individual applies using the HEAplus.gov online application, the system captures an electronic signature. When an individual applies over the phone, the state employee or community assistor captures a voice signature. During the COVID-19 public health emergency, community assistors are authorized to obtain verbal consent to act on the applicant's behalf and complete the application.
HEALTH PLANS & AHCCCS FEE FOR SERVICE PROGRAMS (AIHP, TRBHAs and TRIBAL ALTCS) GENERAL GUIDANCE
- 1. (updated 3/19/20) Question: Should Health Plans be educating their members and contracted providers about COVID-19?
- Answer: Yes, Health Plans and FFS Programs should be proactively educating members and providers utilizing information from the Centers for Disease Control (CDC), the Arizona Department of Health Services (ADHS), and other applicable entities outlined in the AHCCCS Contractor Operations Manual (ACOM) 404, Attachment A. If the only source of information in member education materials is one of the entities listed in ACOM 404, Attachment A, it does not need to be submitted to AHCCCS for review or approval.
- 2. (updated 3/19/20) Question: Should Health Plans and FFS providers continue routine staff visits to healthcare facilities, provider practices, and members’ homes?
- Answer: We highly recommend that, when feasible, both Health Plans and FFS Programs and providers leverage technological platforms to conduct virtual visits whenever possible. For example, a 180 day case manager visit for an Arizona Long Term Care System (ALTCS) member located at a Skilled Nursing Facility (SNF) can be done via telehealth.
- 3. (updated 12/30/20) Question: Should ALTCS Health Plans and Tribal ALTCS programs continue to conduct in-person case management and support coordination visits with members?
- Answer: Per AMPM 1620-E, case managers (and support coordinators) must conduct in-person visits for members residing in a skilled nursing facility every 180 days and to a member receiving HCBS or acute-only services every 90 days; these timeframes remain in effect during the PHE. AHCCCS will allow MCOs to conduct electronic visits as long as case managers can visually assess the member through electronic means. If there is not a video conference option available, MCOs should conduct an in-person assessment of the member, assuming that the member and/or member representative is comfortable with an in-person visit and appropriate precautions (including PPE, social distancing, and safety protocols) are taken. If a video conference option is not available and a member or member representative declines an in-person visit, that should be documented in the member’s case management file. MCOs are required to make appropriate accommodations in order to support members' engagement in their visits and assessments (e.g. ASL interpreter, closed captioning on the video monitor), regardless of how the visits and assessments are conducted (remote or in-person).
- 4. Question: Are Health Plans permitted to conduct targeted outreach to members at risk to ensure they know the warning signs, understand precautions, and are prepared to take appropriate action should they become ill?
- Answer: Yes, AHCCCS encourages health plans to conduct targeted outreach to at risk members. We highly recommend that Health Plans leverage technological platforms to conduct virtual visits whenever possible.
- 5. (added 3/30/20) Question: Is the newborn notification requirement continuing during the COVID19 emergency?
- Answer: The Newborn notification requirements have NOT changed and remain in place.
- 6. (added 4/17/20) Question: Will AHCCCS release rules that allow SNF-based dialysis instead of only free standing dialysis centers?
- Answer: AHCCCS is adopting CMS guidance for dialysis treatment for the duration of the COVID emergency. CMS is waiving the requirement that dialysis facilities have to provide services directly on its main premises or on other premises that are contiguous with the main premises. Dialysis facilities may enter nursing home/skilled nursing home facilities to provide dialysis service to its patients in those settings in order to limit community exposure. CMS continues to require that services provided to these nursing home residents are under the direction of the same governing body and professional staff as the resident’s usual Medicare-certified dialysis facility. Further, in order to ensure that care is safe, effective and is provided by trained and qualified personnel, CMS requires that the dialysis facility staff: furnish all dialysis care and services, provide all equipment and supplies necessary, maintain equipment and supplies in the nursing home, and complete all equipment maintenance, cleaning and disinfection using appropriate infection control procedures and manufacturer’s instructions for use. Dialysis services delivered in a nursing home or skilled nursing facility should continue to be billed to Medicare as appropriate for dual eligible members.
- 7. (updated 10/19/22) Question: Can parents of minor children provide and receive reimbursement for direct care services during the COVID-19 emergency period?
- Answer: For members who are eligible for home and community based services, CMS has approved payment by health plans and the AHCCCS Fee-for-Service Program for direct care services provided by parents or legally responsible individuals of minor children. The parent or legally responsible individual must be employed/contracted by an AHCCCS registered Direct Care Service agency. More information regarding Direct Care Services can be found in AHCCCS Medical Policy 1240-A - Direct Care Services, and in the Parents as Paid Caregivers of Minor Children FAQdocument. For more information about this request and others that have been approved for the duration of the public health emergency, see the “Status of AHCCCS Emergency Authority Requests” document on the COVID-19 Federal Emergency Authorities Request web page.
- 8. (added 2/17/21) Question: Can spouses who are employed or contracted with a Direct Care Service Agency provide more than 40 hours of attendant care (or similar services) each week during the public health emergency?
- Answer: For members who are eligible for home and community based services, CMS has approved payment by health plans and the AHCCCS Fee-for-Service Program for spouses who are employed/contracted by an AHCCCS Registered Direct Care Service agency to provide more than 40 hours of personal care or similar services in a week. This authority is extended for the duration of federally-declared public health emergency. More information can be found in AHCCCS Medical Policy 1240-A, Direct Care Services.
- 9. (added 2/17/21) Question: Has the annual limit for payment of bed hold days been increased during the COVID-19 emergency period?
- Answer: During the COVID-19 emergency, payment for a reserved bed may be made if the absence does not exceed 30 cumulative days per contract year. This change does not affect the therapeutic leave policy, which remains at 9 cumulative days per contract year.
HEALTH PLAN REQUIREMENTS & DELIVERABLES
- 1. (updated 1/6/21) Question: Will AHCCCS consider waiving or suspending certain deliverables to allow greater flexibility to MCOs considering much of our workforce is telecommuting and focused on member care?
- Answer: Yes, AHCCCS has provided flexibility on deliverables where possible. If an MCO has a specific request, please send it to your AHCCCS Operations/Compliance Officer.
- 2. Question: Do the Health Plans need to request and review COOP documents from providers?
- Answer: During the MCO-AHCCCS Weekly COVID-19 call on 3/16, Director Snyder conveyed the message that AHCCCS expects the health plans to check in with critical provider types to ensure these providers, such as Mobile Crisis providers, Stabilization Crisis providers, Long Term Care facilities, and Outpatient Treatment Program (OTP) providers have Continuity of Operations Plans (COOP) and have reviewed them with staff. This expectation to check in does not mean that the health plans need to request copies of providers’ COOP documents.
- 3. (updated 1/6/21) Question: Is AHCCCS willing to halt hybrid performance measure efforts in light of COVID-19?
- Answer: AHCCCS is reinstituting medical record reviews for select measures. Additionally, MCOs will be starting their HEDIS efforts with providers. AHCCCS does not have concerns about these activities; however, if a provider requests more time due to COVID-related concerns, MCOs should offer as much flexibility as feasible.
- 4. (added 3/20/20) Question: Are there any changes to timeframes for behavioral health service delivery during the COVID-19 emergency for members in DCS custody?
- Answer: No, there are no changes to behavioral health response timeframes for children in DCS custody. For example, the Rapid Response is still required within 72 hours after referral from DCS. Please refer to ACOM 417 and ACOM 449 for additional information on AHCCCS timeframe requirements for children in DCS custody.
- 5. (added 3/24/20) Question: Will AHCCCS consider relaxing the mandatory 72-hour turnaround time for Behavioral Health Residential Facility (BHRF) prior authorization (PA) determinations due to high volume and possible capacity issues?
- Answer: No, as there are concerns that expanding the 72-hour turnaround time on BHRF determinations could impact the continuity of care between inpatient facilities and transitions into the community.
- Answer: Yes, AHCCCS has suspended the Program Integrity Corporate Compliance Audits until the end of the public health emergency.
- 6. (added 4/1/20) Question: Can MCOs delay sending Quality of Care (QOC) Concern acknowledgement and closing letters to the member when a QOC concern is being processed based on the member’s grievance/request?
- Answer: The MCOs must still comply with this requirement; however, electronic signatures shall be permitted. MCOs must maintain a process for printing and mailing letters in a timely manner. Alternatively, if a concern originated via electronic means (e.g. an email), an email response may be sent to the member in lieu of a hard copy mailed letter. If an email is sent, it should be documented in the QOC file.
- 7. (added 4/1/20) Question: Can MCOs delay or suspend redaction of the Seclusion and Restraint reports or Incident, Accident, Death (IAD) report/Quality of Care (QOC) Concern report documentation?
- Answer: AHCCCS will not suspend or delay the redaction requirement. This must be maintained in order to ensure timely submission to the Independent Oversight Committees for review.
- 8. (added 9/25/2020) Question: Can attendant care services be provided to members by attendant care providers during inpatient or short-term skilled nursing stays? Do all members who receive attendant care services maintain those services if they happen to go into the hospital?
- i. Yes, AHCCCS has received flexibility to allow for both services to be provided simultaneously as determined to be medically necessary, which supports members who may need additional care as well as hospitals and other acute/sub-acute care providers that have resource limitations due to the COVID-19 emergency. The services need to be approved and on the member’s care plan.
- ii. Member-specific needs will be assessed and the decision will be specific to the hospital/facility capacity as well as the acuity of the need. Anyone who is currently receiving attendant care services is potentially eligible for simultaneous supports.
PHARMACY & SUPPLIES
- 1. (updated 7/28/21) Question: Will AHCCCS relax refill requirements for medications?
- Answer: The relaxation of refill requirements and 90-day prescription supplies ended June 14, 2021 at midnight. The AHCCCS Fee-For-Service Program and each Managed Care contractor may determine which chronic medications may be filled for a 90-day supply.
- 2. (updated 7/28/21) Question: Will AHCCCS allow a 30-day prescription for a Controlled Substance to be filled early?
- Answer: As of June 15, 2021, controlled substances were subject to the standard utilization health plan requirements. For example, a controlled substance prescription may be refilled after 85% or greater of the prescription's days' supply has been calculated as being utilized by the member. A prescribing clinician may request an early refill of a controlled substance through the member's pharmacy benefit manager's prior authorization process.
- 3. (updated 7/28/21) Question: Are pharmacy supplies and durable medical equipment (DME) supplies available for 90-day fills?
- Answer: As of June 15, 2021, the AHCCCS Fee-For-Service program and each Managed Care contractor may determine the days supply of devices and supplies available for a 90-day fill.
PLANNING FOR THE END OF THE PUBLIC HEALTH EMERGENCY (PHE)
- 1. (added 10/7/21) Question: What is the public health emergency and how does it affect members?
- Answer: At the beginning of the COVID-19 pandemic, the federal government declared a public health emergency (PHE). During the PHE, Medicaid agencies are required to continue health care coverage for members, even if someone's eligibility changes. As a result, most AHCCCS and KidsCare members have kept and will continue to keep their health care coverage during the PHE, regardless of eligibility status.
- 2. (added 10/7/21) Question: How long will the PHE last?
- Answer: The end date of the PHE is uncertain at this time. The federal government can extend the PHE 90 days at a time, and has done so multiple times since March, 2020.
- 3. (added 9/21/21) Question: If an AHCCCS member is disenrolled from Medicaid after the Public Health Emergency ends, what are the other health care coverage options?
- Answer: Arizonans who are no longer eligible for Medicaid or the Children’s Health Insurance Program (CHIP, known as KidsCare in Arizona) following the end of the PHE may be eligible for coverage through the health insurance marketplace.
- 4. (added 9/21/21) Question: How will AHCCCS work with its partners to ensure enrollment accuracy after the PHE ends?
- Answer: Once the PHE ends, AHCCCS will work closely with our state agency partner, the Department of Economic Security, to re-determine members' eligibility and disenroll only those individuals who are no longer eligible for Medicaid coverage. Members whose eligibility ends or changes after the end of PHE will receive written notice about what’s changing and how they can appeal determinations if they wish. AHCCCS will continue to work closely with the health insurance marketplace to connect Arizonans to other health coverage options.
PROVIDER ENROLLMENT & REQUIREMENTS
- 1. (updated 7/11/22) Question: Do providers still need to conduct in-person supervisory visits of Direct Care Workers?
- Answer: Per AMPM 1240a (Direct Care Services), Direct Care Worker (DCW) agencies are required to perform periodic supervisory/monitoring visits to assess the DCW’s competency in performing the assigned duties in accordance with member’s individualized service needs and preferences. As of June 1, 2022, AHCCCS is requiring all in-person supervisory visits, reviews of case notes/charts, and supervisory engagement with staff to resume. However, member choice must be considered; if members (or their family members) are not yet comfortable with in-person visits, supervisory visits shall continue to be conducted electronically through the end of the federal Public Health Emergency.
- 2. (updated 5/5/22) Question: Are quality monitoring requirements at facilities reinstated?
- Answer: As of June 1, 2022, AHCCCS is reinstating the requirements for quality monitoring visits, including desk-based audits.
- 3. (added 3/24/20) Question: Will AHCCCS consider temporary changes to the Direct Care Worker (DCW) requirements for family members who reside with a member over age 18 to streamline hiring of family members in cases where there is no provider or where there are concerns of exposure due to providers coming into the home?
- Answer: The 90-day training requirement has been suspended, which allows DCWs to provide care while receiving training. The DCW agencies should consider remote learning opportunities to support DCWs, with evaluation of in-person skills and completion of required training following the conclusion of the COVID-19 emergency.
- 4. (added 3/19/20) Question: Will AHCCCS relax the requirement for NEMT drivers to collect a passenger’s signature, whether on paper or electronically?
- Answer: Yes, this requirement has been waived.
- 5. (added 4/22/20) Question: In areas where there are Stay at Home Orders and curfews for the closure of businesses on tribal lands, are NEMT providers exempt?
- Answer: Providers should defer to local guidance issued by the tribes.
- 6. (added 3/24/20) Question: Can CPR/First Aid classes be completed online?
- Answer: CPR/First Aid classes can be completed via a credible online/virtual format sponsored by a nationally-recognized organization with in-person evaluation occurring following the conclusion of the COVID-19 emergency.
- 7. (updated 4/8/20) Question: Should providers continue to conduct supervision of staff work, such as LPNs providing home health nursing services or BHTs providing behavioral health care?
- Answer: AHCCCS policies AMPM 1240-G (Home Health Services) and AMPM 320-O (BH Services and Treatment/Service Planning) outline requirements for care and service delivery by LPNs or BHTs, which includes supervision by appropriate professional staff. Clinical professionals as well as technical-level staff should check with their licensing entities on current requirements and/or specific questions regarding professional-level supervision.
- 8. (added 4/3/20) Question: Should health plans make exceptions for providers not registered with AHCCCS for payment of a claim?
- Answer: No. Providers (in-state and out-of-state) need to be registered with AHCCCS in order to receive payment.
- 9. (added 4/3/20) Question: Will AHCCCS permit providers located out of state to offer both emergency and non-emergency care to Arizona Medicaid and CHIP enrollees?
- Answer: Yes. AHCCCS has created a “short-form” for out-of-state providers in order to streamline the provider enrollment and approval processes for the duration of the emergency. The form, called the Out-of-State Packet, is posted on the AHCCCS Provider Enrollment web page.
- 10. (added 4/3/20) Question: Will AHCCCS streamline provider enrollment requirements for out-of-state providers?
- Answer: Yes. AHCCCS will provisionally and temporarily enroll out-of-state providers for the duration of the public health emergency and in order to accommodate members who were displaced by the emergency. Approved out-of-state providers will be terminated from AHCCCS enrollment at the end of the COVID-19 national emergency; no extensions will be granted beyond the duration of the public health emergency. The out of state provider must be a certified provider enrolled in Medicare or with another State’s Medicaid program and be in good standing.
- 11. (added 4/7/20) Question: Due to restricted contact at inpatient facilities related to the COVID-19 emergency, what if the providers or outpatient clinics do not have all of the discharge documents when the member comes in for their follow up appointment post discharge?
- Answer: Inpatient facilities must provide discharge documents to the providers and outpatient clinics to ensure coordination of care. In the event that not all discharge documents are available, the providers and outpatient clinics are required to conduct the follow up appointment based on the available information to determine additional care and next steps for the patient’s recovery. The Health Information Exchange (HIE) or secure electronic means should be used to share documents. Facilities and providers are encouraged to contact Health Current to enroll in the HIE if they have not done so.
- 12. (added 4/10/20) Question: Can a provider other than a physician order home health services for members during the COVID emergency?
- Answer: Yes, providers whose licensure enables them to practice independently in Arizona, who are not licensed physicians, are able to order home health services, provided they are able to assess and certify the medical necessity of such services within their scope of practice. For example, a Nurse Practitioner practicing independently in the state of Arizona may order home health services for a member within their care. The ordering provider must provide any necessary attestations, and adhere to any Prior Authorization requirements that are relevant for initiating and continuing home health care services to a member.
- 13. (added 4/10/20) Question: What is the process for the second newborn screening?
- Answer: The AZ Dept. of Health Service Office of Newborn Screening advises that newborn screening guidelines have not changed due to COVID-19. Certain conditions are often identified on the second screen after a normal first screen, and if the second screen is not completed, these conditions can be missed or identified late, causing irreversible damage. To limit exposure of COVID-19 to newborns and families, providers are encouraged to collect the second screen during the first well check in-office instead of sending out to a lab. The Office of Newborn Screening can help providers who require supplies to collect in-office tests and provide a free FedEx account for timely transport of newborn screening samples. Contact email@example.com or (602) 364-0128 for more information.
- 14. (updated 4/22/20) Question: Can fingerprint clearance card requirements be waived to help streamline the onboarding process for new employees of provider agencies in an effort to address workforce shortages?
- Answer: No. The provider agencies required to comply with Fingerprint Clearance Card requirements as specified in A.R.S. Title 41, Chapter 12, Article 3.1 must maintain compliance with the law during the COVID-19 state of emergency. If provider agencies are having challenges in finding open locations for professional fingerprinting services, they may want to consider a local police department or professional fingerprinting services that offer online or mobile service options.
- 1. (updated 5/5/20) Question: What are the AHCCCS fee for service (FFS) rates for the COVID-19 testing codes?
- Answer: Effective February 4, 2020, the rate for code U0001 is $35.91 and the rate for code U0002 is $51.31. Effective March 1, 2020, the rate for code G2023 is $23.46 and the rate for code G2024 is $25.46. Effective March 13, 2020, the rate for code 87635 is $51.31. Effective March 18, 2020, the rates for codes U0003 and U0004 are $100.00.
- 2. (updated 7/20/21) Question: Does AHCCCS have any update on retainer payments for providers?
- Answer: CMS has approved retainer (also referred to as retention) payments for HCBS providers of personal care services. As such, AHCCCS is making retention payments to providers serving members enrolled in the ALTCS Elderly and Physical Disabilities (EPD) program, including both Attendant Care and Personal Care services.
- At this time, CMS’ approval is limited to 30 days of retention payments for participating providers. Consecutive billing days are defined as follows:
- If a service is provided on a daily basis 7 days a week, then 30 consecutive billing days is 30 calendar days.
- If a service is provided 5 days a week, then 30 consecutive billing days corresponds to 6 weeks of services (5x6=30).
- If a service is provided 3 days a week, then 30 consecutive billing days corresponds to 10 weeks of services (3x10=30).
- AHCCCS has established guidelines for provider qualifications to receive retention payments. Among those guidelines is a requirement that providers not lay off staff and maintain staff salary and wages at pre-COVID-19 levels. Please see the COVID-19 Retention Payment Guidelines.
- The Department of Economic Security, Division of Developmental Disabilities (DES/DDD) has established COVID-19 Value Based Payments for HCBS providers serving members enrolled in the ALTCS DD program. See more details here regarding this DES/DDD VBP initiative.
- 3. (added 4/23/20) Question: How can EMS providers assist with reducing ambulance transports to, and non-emergency use of, hospital emergency rooms during this COVID-19 crisis?
- Answer: EMS providers are able to participate in a joint Arizona Department of Health Services (ADHS) and AHCCCS program called Treat and Refer. The Treat and Refer program addresses the situation when an individual calls 911, but whose illness or injury does not require ambulance transport to a hospital emergency department.
- In order to receive reimbursement for Treat and Refer services for AHCCCS members, EMS agencies must first submit an application to ADHS (click here for more information on the application process). Of note, ADHS revised the requirements for the Treat and Refer program in January 2020 in order to streamline the application process and increase participation. Once approved, ADHS will connect EMS providers to AHCCCS to complete the AHCCCS provider application process in order to receive reimbursement for Treat and Refer services. AHCCCS and ADHS will expedite application processing due to the COVID-19 emergency.
- AHCCCS is reimbursing Treat and Refer providers for A0998 Ambulance response and treatment, no transport, conducted in-person as well as via telemedicine (interactive audio and video communications). When conducting via telemedicine, the GT modifier must be used. Please refer to the AHCCCS Medical Coding webpage for additional information.
- In addition, during the COVID-19 public health emergency, EMS agencies can perform the clinical Treat and Refer activities, with the COVID-19 guidelines as approved by their administrative medical director, without submitting an application to ADHS for Treat and Refer recognition. However, under this pathway, these EMS agencies cannot bill AHCCCS for reimbursement.
- 4. (added 4/22/20) Question: For providers who are paid by RBHAs under block payment arrangements, and who have a payable due now or during the COVID-19 emergency period to the RBHA for submitting encounters below the required threshold for block for periods prior to the COVID-19 emergency declaration, will AHCCCS provide any financial assistance for these payables?
- Answer: AHCCCS is directing the RBHAs to delay collection of payments owed by providers (that are due now or during the COVID-19 emergency period) due to the provider submitting encounters below required thresholds for all periods prior to the start of the emergency declaration on March 13, 2020. This delay shall be in place for three months after the end of the month in which the emergency period is officially ended. RBHA’s are allowed to inform block providers of their encounter shortfall/overage to block funding so that providers can appropriately record necessary accounting entries, i.e., payables/receivables. Providers that desire to pay for encounter shortfalls prior to the RBHAs collecting overpayments three months after the end of the month in which the emergency period is officially ended shall be allowed to make those payments.
- 5. (added 4/22/20) Question: When the emergency period is over and the future reconciliation of block payments paid during the COVID-19 emergency finds that the provider has a payable, will AHCCCS provide any financial assistance for those payables?
- Answer: AHCCCS shall direct RBHAs to delay future collection of payments, no sooner than three months after the end of the month in which the emergency period is officially ended, for monies owed by providers for the period of under-reporting that occurs during the COVID-19 emergency period.
- AHCCCS does not intend to lower encounter thresholds. Providers are encouraged to continue to deliver medically necessary services to members using telehealth and telephone delivery, which are paid/valued at the same rate as face-to-face delivery, to the greatest extent possible.
- 6. (added 3/11/22) Question: For providers who are paid by RBHAs under block payment arrangements, and who will not be able to meet encounter thresholds for the block during the period of the COVID-19 emergency declaration due to under-utilization of services, will AHCCCS reduce encounter threshold requirements if AHCCCS receives approval from CMS for behavioral health provider retention payments?
- Answer: Reducing encounter thresholds for under-utilization of services during the COVID-19 declaration period is essentially a form of retention payments. Providers paid under block payment arrangements should be treated the same as providers paid under fee for service arrangements who are also experiencing under-utilization of services relative to retention payments. That is, regardless of how the provider is paid by the RBHA (block or fee for service), many providers are seeing reduced appointments and thus reduced revenue. AHCCCS did not receive CMS approval to implement retention payments for behavioral health providers.
- 7. (updated 3/11/22) Question: What has AHCCCS done to date to supply financial relief to providers impacted by the COVID-19 emergency?
- Answer: In addition to the federal relief that was disseminated directly to providers through the CARES Act and the Paycheck Protection Program and Health Care Enhancement Act, AHCCCS has taken many actions to provide financial relief to Arizona Medicaid providers, including:
- Offered $5.3 million in additional payments to Critical Access Hospitals (CAHs) using the temporary Federal Medical Assistance Percentage (FMAP) increase of 6.2% included in the Families First Coronavirus Response Act (FFCRA). The temporary increase allowed AHCCCS to recalculate supplemental payments to CAHs to reflect an increase of approximately 64%.
- Accelerated $50 million in payments to hospitals which participated in the Graduate Medical Education (GME) program in 2019, including $2.5 million to trauma hospitals.
- Implemented $270 million in interim payments to hospitals participating in the GME program in 2020.
- Advanced supplemental payments to three hard-hit NFs facilities by one month, allowing payments to be made in April rather than May 2020.
- Made one-time payments totaling approximately $18 million to nursing facilities (NFs), approximately $6.5 million to assisted living facilities (ALF), and $17 million for Home and Community Based Services (HCBS) providers.
- Initiated the provision of retention payments (payments aimed at covering the cost of revenue declines stemming from decreased utilization) to ALTCS providers who serve individuals who are elderly or have physical disabilities (ALTCS-EPD) and offer attendant care and/or personal care services. AHCCCS has released operational guidelines to ALTCS-EPD providers and Managed Care Organizations (MCOs), allowing for the initiation of such payments.
- Accelerating $41.3 million in interim payments in early May to participants in the Targeted Investments (TI) Program. Payments are typically made sometime after the close of the contract year which ends on September 30.
Additionally, AHCCCS was awarded a $2.0 million SAMHSA grant to increase the mental health services infrastructure in response to the COVID-19 public health emergency.
TELEHEALTH DELIVERY & BILLING
- 1. (updated 1/4/22) Question: Are telehealth services covered by AHCCCS?
- Answer: Yes, AHCCCS covers all forms of telehealth services including asynchronous (store and forward), remote patient monitoring, teledentistry, telemedicine (interactive audio and video), and audio-only modalities. See the AHCCCS Telehealth web page or more information, including the AHCCCS Medical Policy Manual (AMPM) 320-I Telehealth, the AHCCCS Telehealth Code Set, and other telehealth resources.
- 2. (updated 1/4/22) Question: Will all AHCCCS Health Plans and the AHCCCS Fee-For-Service Programs honor the use of telehealth (including audio-only), as expanded by AHCCCS in response to COVID-19?
- Answer: Yes, regardless of whether a provider is specifically contracted to provide telehealth services, AHCCCS Health Plans and AHCCCS Fee for Service programs will reimburse for services delivered via telehealth modalities as outlined in AHCCCS policy.
- 3. (updated 1/4/22) Question: Is there an AHCCCS Fee Schedule rate difference for services provided “in-person” versus services offered via telehealth (including audio-only)?
- Answer: The rates on the AHCCCS fee schedule for services offered via telehealth and/or telephonically are not lower than the published rates for "in-person" services.
- 4. (updated 1/4/22) Question: Are AHCCCS health plans required to reimburse at the same rate for services provided “in-person” and services provided via telehealth (including audio-only)?
- Answer: Yes, effective March 18, 2020 until the end of the COVID-19 emergency declaration, AHCCCS health plans shall not discount rates for services provided via telehealth as compared to contracted rates for "in-person" services.
- 5. (added 3/19/20) Question: Can Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) offer services via telehealth?
- Answer: On March 18, 2020, CMS issued guidance for Medicaid programs confirming that FQHCs and RHCs can offer services via telehealth, including services via telephone. For more information on the services that can be offered via telehealth/telephone, please see other telehealth questions/answers in this FAQ document.
- 6. (added 3/19/20) Question: What rate will AHCCCS pay an FQHC/RHC for services delivered via telehealth?
- Answer: In accordance with the March 18, 2020 guidance from CMS, for services offered via telehealth within the scope of the FQHC/RHC benefit, health plans and AHCCCS FFS programs will pay the established PPS rate. For services offered via telehealth that are not covered as part of the FQHC/RHC benefit, health plans will reimburse FQHCs/RHCs at contracted rates and AHCCCS FFS programs will reimburse FQHCs/RHCs consistent with the AHCCCS fee schedule.
- 7. (updated 1/4/22) Question: Are there any AHCCCS restrictions on the AHCCCS provider types that are permitted to provide services via telehealth (including audio-only) modalities?
- Answer: AHCCCS covers telehealth services within the scope of practice of the AHCCCS provider type, and as outlined in AHCCCS Medical Policy Manual (AMPM) 320-I Telehealth and the AHCCCS Telehealth Code Set.
- 8. (updated 1/4/22) Question: Typically providers require in-person visits for controlled substance refills. Can these services be provided via telehealth (including audio-only) during the COVID-19 emergency?
- Answer: AHCCCS has updated its Telehealth Code Set to enable providers to be able to conduct visits via telehealth, including for controlled and non-controlled substance medication refills when clinically appropriate.
- 9. (updated 1/4/22) Question: During the COVID-19 emergency period, how do providers handle the informed consent requirements and treatment plan agreements/signatures that require a member or guardian's written consent, agreement and/or signature if they are providing services via telehealth (including audio-only)?
- Answer: During the COVID-19 emergency, providers delivering services through telehealth can obtain verbal consent and verbal service or treatment plan agreements and document the Member's/Guardian's verbal consent and verbal agreement in the Electronic Medical Record (EMR). It will not be necessary to gather retroactive signatures once the COVID-19 emergency period ends provided the documentation is in the EMR.
- 10. (updated 5/6/20) Question: Can LOCAL EDUCATION AGENCIES (LEAs) receive reimbursement for Medicaid-covered medical services provided to eligible students through telehealth and telephonic means during school closures due to COVID-19?
- Answer: AHCCCS, working in conjunction with the Arizona Department of Education and Public Consulting Group (AHCCCS’ third party administrator for the Medicaid School Based Claiming program), have updated their systems to allow LEAs to bill for telehealth services for the Medicaid in Schools program for Dates of Service (DOS) March 30, 2020 and later.
- 11. (updated 5/6/20) Question: How does an IHS/638 Provider bill telehealth services?
- Answer: For specific billing instructions regarding telehealth and telephonic services, please see Chapter 8 -Individual Practitioner Services of the IHS-Tribal Provider Billing Manual. The Division of Fee-for-Service Management has not changed the way to bill for telehealth services but has expanded what services can be delivered via telehealth.
- 12. (updated 11/23/21) Question: How does the “Four Walls” apply to IHS/638 free-standing clinics?
- Answer: In March 2020, AHCCCS requested flexibility from CMS to reimburse free-standing clinics at the All Inclusive Rate for telehealth and telephonic services during the COVID-19 emergency, even if neither the member nor the clinician was within the “Four Walls” but a clinic visit/facility defined service had been provided. Consistent with guidance from CMS issued on October 04, 2021, DFSM will not review claims pertaining to the "Four Walls" provision until nine months after the COVID-19 PHE ends. More information from CMS can be found in the CIB Informational Bulletin - Four Walls.
- 13. (updated 3/31/20) Question: Can physician interns and residents provide telehealth services to AHCCCS members?
- Answer: AHCCCS reimburses for telehealth services provided to our members by physician interns and residents. Billing parameters remain the same and additional information can be found in the FFS Provider Manual (page 40).
- 14. (updated 6/30/22) Question: Can telehealth be utilized for initial appointments (i.e. when members that have not been seen in-person previously)?
- Answer: Yes, telehealth can be utilized for initial appointments when clinically appropriate. For Medication Assisted Treatment (MAT),SAMHSA guidance has indicated telehealth for initial appointments can only be used for buprenorphine products. Telehealth for initial appointments for methadone is unallowable. For more information see two SAMHSA guidance memos, issued April 21, 2020, and June 28, 2022, on the provision of methadone and buprenorphine for the treatment of Opioid Use Disorder during the COVID-19 public health emergency.
- 15. (updated 1/4/22) Question: Are behavioral health technicians (BHTs) permitted to provide services via telehealth modalities (including audio-only)?
- Answer: Yes, BHTs can utilize telehealth modalities to provide behavioral health services. AMPM 320-O Behavioral Health Assessments and Treatment/Service Planning and 310-B -TITLE XIX/XXI Behavioral Health Service Benefit outline requirements for service delivery by BHTs, including clinical oversight requirements.
- 16. (updated 4/1/20) Question: Is there Federal Guidance for utilizing widely available communications applications for providing telehealth services, such as FaceTime or Skype during the COVID-19 emergency?
Answer: On March 17, 2020 the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced, effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency. More information can be found at HHS Office of Civil Rights and SAMHSA.
- 17. (updated 1/4/22) Question: Can primary care physicians and pediatricians outreach to their patients to provide preventive medicine counseling via telehealth (including audio-only) during the COVID-19 emergency?
Answer: Yes, providers are encouraged to outreach to patients to ensure their care needs are being met during the emergency. Details on what billing codes can be utilized via telehealth for preventive medicine counseling are listed on the AHCCCS Telehealth Code Set.
- 18. (updated 1/4/22) Question: When are the AHCCCS telehealth policy flexibilities offered during the COVID-19 pandemic, including the use of the temporary telephonic code set, due to expire?
Answer: AHCCCS updated its audio-only coverage as of 1/1/22 based on the Arizona Telehealth Advisory Committee recommendations as well as Medicare coverage decisions. This updated coverage can be found on the AHCCCS Telehealth Code Set.
- 19. (updated 1/4/22) Question: By when does AHCCCS plan to finalize its post-pandemic telehealth policy decisions?
Answer: AHCCCS is in the process of updating AHCCCS Medical Policy Manual (AMPM) 320-I Telehealth to incorporate post-pandemic coverage updates. Subscribe here to receive AHCCCS policy notifications on Tribal Consultation Notification and Public Comment and publication updates.
- 1. (updated 1/14/22) Question: Does AHCCCS cover testing for COVID-19?
- Answer: Yes, AHCCCS covers all FDA-approved COVID-19 testing. COVID-19 testing options include:
- Home collection: Tests and collection kits where samples are collected at home and sent to a lab for processing.
- Point-of-care: Tests and rapidly return a result at your doctor's office or other health care setting.
- Multi-analyte: Tests that detect the virus that causes COVID-19 and other viruses like flu.
- At-home: Tests performed at home with a self-collected sample.
- 2. (updated 1/14/22) Question: Where can I find information on COVID-19 testing sites?
- Answer: Please visit the Arizona Department of Health Services (ADHS) COVID-19 Everyone Get Tested website.
- 3. (updated 1/14/22) Question: Is prior authorization required for COVID-19 testing?
- Answer: No. Health plans (including AHCCCS’ Division of Fee-for-Service- Management) are not permitted to prior authorize COVID-19 testing.
- 4. (updated 1/14/22) Question: Do AHCCCS health plans cover COVID-19 testing by out-of-network providers?
- Answer: Yes, AHCCCS health plans must reimburse AHCCCS registered in and out-of-network providers for COVID-19 testing.
- 5. (updated 2/1/22) Question: What is the coverage limit for at-home COVID-19 testing?
- Answer: AHCCCS will cover one at-home COVID-19 testing kit (two tests) per member per month with a prescription by a provider or a pharmacist when filled at a pharmacy.
- 6. (added 2/1/22) Question: Can pharmacists prescribe at home COVID-19 test kits?
- Answer: Yes, pharmacists can prescribe at home COVID-19 test kits.
- 7. (added 1/18/22) Question: How do I order free COVID-19 tests from the federal government?
- Answer: Americans can request free tests at COVIDTests.gov. The initial program will allow four free tests to be requested per residential address. Tests are expected to ship within 7-12 days of being ordered.
COVID-19 Testing for Dual Eligible (members who are enrolled in both Medicare and AHCCCS)
- 8. (updated 4/8/22) Question: Does Medicare cover COVID at-home testing for AHCCCS Dual Eligible members?
- Answer: Beginning April 4, 2022, Medicare will cover up to eight at-home, over-the-counter COVID-19 tests per month at no charge to Dual Eligible members.These at-home test kits are also available to Dual Eligible members enrolled in any Medicare Advantage plan, including a Dual Eligible Special Needs Plan (D-SNP). These at-home test kits will be available until the pandemic ends.
- 9. (added 2/8/22) Question: Which at-home COVID-19 tests will be covered?
- Answer: Medicare will cover COVID-19 over-the-counter tests approved or authorized by the U.S. Food and Drug Administration (FDA).
- 10. (updated 4/8/22) Question: Where will the free tests be available?
- Answer: A list of eligible pharmacies and other health care providers that have committed publicly to participate in this Medicare initiative can be found at Medicare.gov. Because additional eligible pharmacies and health care providers may also participate, people with Medicare should check with their pharmacy or health care provider to find out whether they are participating.
- 11. (updated 4/8/22) Question: How will eligible pharmacies or other participating entities bill for the at-home COVID-19 tests?
- Answer: See CMS’ COVID-19 Over-the-Counter Tests web page for information about who can provide covered tests and how to bill Medicare.
- 12. (added 2/8/22) Question: Is the Dual Eligible member required to pay a copayment or any cost sharing for the at-home COVID-19 tests?
- Answer: No, there is no charge for the tests.
UNINSURED TESTING, TREATMENT, VACCINE ADMINISTRATION
- 1. (updated 4/6/22) Question: Can providers be reimbursed for COVID-19 testing, treatment and vaccine administration for Arizonans who are uninsured?
- Answer: Due to lack of sufficient funds, the US Department of Health and Human Services Health Resources & Services Administration (HRSA) COVID-19 Uninsured Program stopped accepting claims for federal reimbursement for COVID-19 testing, treatment, and vaccine administration for uninsured individuals. Claims for testing and treatment submitted after March 22, and claims for vaccine administration submitted after April 5, will not be adjudicated for payment.
- 1. (updated 7/27/21) Question: Where can I find COVID-19 vaccination locations in Arizona?
- Answer: Vaccine locations throughout the state are posted on the Arizona Department of Health Service’s (DHS) “Find Vaccine” web page. Register for an appointment at https://podvaccine.azdhs.gov/.
- 2. (updated 12/23/20) Question: Will AHCCCS suspend in-network requirements in order for qualified AHCCCS registered providers who are not contracted with an MCO to be reimbursed for administering the COVID-19 vaccine to AHCCCS enrolled members?
- Answer: Yes, AHCCCS will require that all MCOs suspend network requirements and reimburse for the COVID-19 vaccine administered by all qualified providers.
- 3. (updated 7/27/21) Question: How can AHCCCS-registered providers sign up to become a COVID-19 vaccinator?
- Answer: Any AHCCCS-registered provider that would like to obtain COVID-19 vaccines from the distribution of vaccines sent to the Arizona Department of Health Services (ADHS) must register and complete the Provider Onboarding process with the ADHS Arizona Immunization Program Office (AIPO) to become COVID-19 vaccinators using this Provider Onboarding tool developed in the REDCap system. AHCCCS-registered pharmacy providers who are obtaining COVID-19 vaccines directly from the federal government are not required to register with ADHS.
- 4. (updated 12/17/20) Question: Will the Arizona Department of Health Services (ADHS) COVID-19 vaccine onboarded providers receive the COVID-19 vaccine free of charge?
- Answer: Yes. At this time, COVID-19 vaccines have been purchased from the drug manufacturers by the federal government and are free of charge to ADHS-onboarded providers and to the pharmacies obtaining the vaccines directly from the federal government. Providers are not permitted to charge AHCCCS members for the COVID-19 vaccine.
- 5. (updated 12/17/20) Question: How are AHCCCS-registered providers reimbursed for COVID-19 vaccine administration?
- Answer: AHCCCS-registered providers will be reimbursed for the applicable Current Procedural Terminology (CPT) administration code when a COVID-19 vaccine has been administered to eligible AHCCCS members. This applies to providers who are onboarded with the Arizona Department of Health Services and pharmacies obtaining the vaccines directly from the federal government. All providers submitting claims for the administration fee for COVID-19 vaccines must use the CMS 1500 claim form or the 837P format. Please note that COVID-19 vaccines are provided at no charge to states and federal partners from the federal government, therefore, a cost for the vaccine greater than zero shall not be entered on the CMS 1500 claim form nor on the 837P format. Providers are not permitted to charge AHCCCS members for the COVID-19 vaccine.
- 6. (added 12/17/20) Question: Are MCOs required to reimburse AHCCCS-registered providers at the AHCCCS fee schedule rate for COVID-19 vaccine administration?
- Answer: Yes, MCOs are required to reimburse at 100 percent of the AHCCCS Fee-For-Service (FFS) rates and may not apply any discounts. MCOs are also required to follow the AHCCCS FFS rates by reimbursing mid-level practitioners at 100 percent of the FFS rates for COVID-19 vaccine administration only.
- 7. (updated 12/17/20) Question: What are the AHCCCS billing guidelines for COVID-19 vaccine?
- Answer: The AHCCCS billing guidelines are posted on the azahcccs.gov website at COVID-19 Vaccine Administration Billing Guidelines.
- 8. (updated 7/27/21) Question: What is the reimbursement methodology for retail pharmacies administering COVID-19 vaccine?
- Answer: Pharmacies administering COVID-19 vaccines must bill AHCCCS and its contractors using the CMS 1500 claim form or in the 837P format. The NDC of the vaccine is not required because the CPT codes are specific to the specific vaccine and manufacturer. Please see COVID-19 Vaccine Administration Billing Guidelines for more information.
- 9. (updated 9/1/21) Question: What are the AHCCCS fee-for-service reimbursement rates for the COVID-19 vaccine administration?
- Answer: AHCCCS has adopted date-specific payment rates for COVID-19 vaccine administration.
For dates of service through March 14, 2021, AHCCCS adopted the Medicare payment rates as follows:
- The AHCCCS fee-for-service rate for COVID-19 vaccine administration is $28.39 to administer single-dose vaccines.
- For a COVID-19 vaccine requiring a series of two doses, the initial dose administration payment rate is $16.94, and the second dose administration payment rate is $28.39.
For dates of service on and after March 15, 2021:
- The AHCCCS fee-for-service rate for COVID-19 vaccine administration is $40.00 to administer single-dose vaccines.
- For a COVID-19 vaccine requiring a series of two doses, the initial dose administration payment rate is $40.00 and the second dose administration payment rate is $40.00.
For dates of service between March 15, 2021 and August 8, 2021, AHCCCS adopted the Medicare payment rates as follows:
- The AHCCCS fee-for-service rate for COVID-19 vaccine administration is $40.00 to administer single-dose vaccines.
- For a COVID-19 vaccine requiring a series of two doses, the initial dose administration payment rate is $40.00 and the second dose administration payment rate is $40.00.
For dates of service on and after August 9, 2021:
- The AHCCCS fee-for-service rate for COVID-19 vaccine administration is $83.00 to administer single-dose vaccines.
- For a COVID-19 vaccine requiring a series of two doses, the initial dose administration payment rate is $83.00 and the second dose administration payment rate is $83.00.
For dates of service on and after August 12, 2021:
- The AHCCCS fee-for-service rate for third dose COVID-19 vaccine administration is $83.00.
- 10. (updated 12/17/20) Question: Which AHCCCS-registered provider types can be reimbursed for COVID-19 vaccine administration to eligible members?
- Answer: Any AHCCCS-registered provider type whose scope of practice includes vaccine administration may be reimbursed for COVID-19 vaccine administration. The full list of AHCCCS-registered provider types can be found in the AHCCCS Medical Policy Manual, 610 Attachment A.
- 11. (added 12/17/20) Question: Will mid-level practitioners (e.g., nurse practitioners, physician assistants) be reimbursed for the vaccine administration fee at the same rate as physicians?
- Answer: AHCCCS will reimburse all AHCCCS-registered providers whose scope of practice includes vaccine administration and who are COVID-19 vaccine onboarded by ADHS at 100 percent of the AHCCCS capped fee schedule. Given the unprecedented COVID-19 pandemic and associated challenges, including the need to vaccinate AHCCCS members as expeditiously as possible, AHCCCS is waiving the existing reimbursement methodology for COVID-19 vaccine administration only, effective 12/14/2020. In that existing methodology, as per the Fee-For Service (FFS) Provider Billing Manual, Physician Assistants and Nurse Practitioners are reimbursed at 90 percent of the AHCCCS capped fee schedule or billed charges, whichever is less.
- 12. (added 12/3/20) Question: Will AHCCCS reimburse for COVID-19 vaccine administration by medical assistants?
- Answer: Yes, AHCCCS reimburses for vaccine administration performed by medical assistants under the direct supervision of a doctor of medicine, physician assistant or nurse practitioner consistent with A.R.S. 32-1456 and other applicable statutes and rules. The supervising doctor of medicine, physician assistant, or nurse practitioner will need to be COVID-19 vaccine onboarded by ADHS.
- 13. (updated 12/22/20) Question: If I am an AHCCCS-registered provider and wish to become a mass immunizer administering COVID-19 vaccine, do I need to re-register with AHCCCS?
- Answer: No, you do not need to re-register with AHCCCS as long as vaccine administration is part of your scope of service for your provider type. If you are an AHCCCS-registered provider with vaccine administration as part of the scope of service for your AHCCCS provider type and onboarded with the ADHS for COVID-19 vaccine, you are able to bill for COVID-19 vaccine administration as a mass immunizer.
- 14. (added 12/17/20) Question: Will AHCCCS members receive the COVID-19 vaccine free of charge?
- Answer: Yes. The COVID-19 vaccine(s) are provided and administered to AHCCCS members at no charge.
- 15. (updated 3/1/22) Question: Who is eligible to receive the COVID vaccine?
- Answer: Please visit the CDC website at www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines.html for the most up-to-date information on the COVID-19 vaccines that are authorized or approved for use in the United States.
- 16. (updated 7/11/22) Question: Can my child receive a COVID-19 vaccine at a pharmacy?
- Answer: Children three years of age and older can receive a COVID-19 vaccine at a pharmacy. Children under three years of age can only receive a COVID-19 vaccine at a PCP’s or pediatrician's office.
- 17. (added 1/28/21) Question: Will AHCCCS accept roster billing during the COVID-19 public health emergency?
- Answer: AHCCCS does not accept roster billing. Individual claims for each member must be submitted.
- 18. (updated 4/13/21) Question: Does COVID-19 vaccine administration qualify for a visit at the all-inclusive per visit rate, also called the Prospective Payment System (PPS), rate?
- Answer: Based on guidance from CMS, FQHC/RHCs (including 638 FQHCs) should bill the all-inclusive, per visit (PPS) rate for COVID-19 vaccine administration performed by FQHC/RHCs’ employees within their scope of practice, including if it is the only service provided at that time. If the COVID-19 vaccine is provided as part of an office visit, the vaccine administration will be considered incidental to that visit and not a separate PPS-eligible visit. FQHC Pharmacy billing will remain under the pharmacy provider type and is not eligible for receiving the all-inclusive, per visit rate.
- 19. (added 2/17/21) Question: Does AHCCCS have a COVID-19 vaccine outreach program?
- Answer: Yes we are actively working to reach AHCCCS members. The AHCCCS website homepage links to a page where members can find more information about vaccines. AHCCCS has posted a 2-minute video with Dr. Sara Salek about the initial vaccine distribution.
Additionally, AHCCCS and our contracted managed care health plans are working together on consistent messaging in their communication to members through all health plans’ channels of communication.
- 20. (updated 1/19/23) Question: Are AHCCCS members able to use Veyo or other Medicaid-funded transportation to get to their vaccine appointment?
- Answer: Non-emergency medical transportation (NEMT) is a covered Medicaid service, available to any AHCCCS member who is unable to provide their own transportation, or find alternative transportation, to a covered Medicaid service appointment. Traditional NEMT (when a member is dropped off for a service and then picked up to return home) will be used for AHCCCS members who need transportation to COVID-19 vaccinations where two trips, a drop-off and pick-up, are appropriate.
- 21. (added 5/3/21) Question: Can an EMT bill for a home visit and for COVID-19 vaccine administration when the vaccine is delivered to a homebound member?
- Answer: Yes. Under certain circumstances, both the home visit and the administration of the vaccine will be allowed to be billed when the COVID-19 vaccine is administered. Please review the guidance published on the Medical Coding Resources web page.
- 22. (updated 11/19/21) Question: Will AHCCCS reimburse Indian Health Service and tribally owned/operated 638 clinics at the All Inclusive Rate (AIR) in cases where the COVID-19 vaccine is administered by an Registered Nurse (RN) when no clinic service has been provided (e.g., RNs providing vaccinations at mass vaccination sites)?
- Answer: Yes. Effective for claims with dates of service on or after 12/14/2020, when the COVID-19 vaccine is administered by a registered nurse without a billable clinic service being provided on the same day, AHCCCS will reimburse IHS/638 clinics (non-FQHC clinics) at the outpatient AIR (four walls provision still applies, please see the four walls FAQ). The claim must be billed with the primary diagnosis code: Z23. An order (individual or standing) is required for vaccine administration and the ordering provider shall be listed in field 76 of the claim. The same billing rules apply to the 1st and 2nd doses of any multi-dose COVID-19 vaccine, and any required boosters.
- 23. (added 9/30/21) Question: Does AHCCCS require members or providers to be vaccinated against COVID-19?
- Answer: AHCCCS does not require its members or providers to be vaccinated against COVID-19.. However, AHCCCS providers must follow all regulations issued by the Centers for Medicare and Medicaid Services that apply to them, including the Medicare Conditions of Participation. See the AHCCCS COVID-19 Vaccine web page for more information about the benefits and risks of the COVID-19 vaccine and where to find it.
- 24. (added 10/7/21) Question: Can an AHCCCS health care provider, like a doctor’s office or a hospital, require patients to be vaccinated as a requirement of receiving services on-site?
- Answer: Yes, health care providers can make their own decisions about whether they require their patients to be vaccinated. AHCCCS members who are unable to see their usual provider should contact their health plan for more information on alternatives.
AMERICAN RESCUE PLAN ACT
- Mandatory coverage of the COVID-19 vaccine and vaccine administration,
- 100 percent federal match for COVID-19 vaccine administration beginning on April 1, 2021,
- State option to extend coverage for pregnant and postpartum women for one year postpartum (current coverage is 60 days postpartum),
- State option to provide and obtain an 85 percent federal match for the provision of community-based mobile crisis services,
- 100 percent federal match for services rendered by Urban Indian Health Organizations,
- Sunset of the limit on the maximum rebate amount for single source drugs and innovator multiple source drugs, and
- Increased federal match of 10 percentage points for the implementation of activities which enhance, expand or strengthen state HCBS programs, effective April 1, 2021.
- 1. (added 5/21/21) Question: What is the ARPA option for Home and Community Based Services (HCBS)?
- Answer: Section 9817 of ARPA provides a 10 percentage point increase in federal matching funds (capped at 95 percent) for Home and Community Based Services (HCBS) to help implement or expand activities to enhance HCBS. States must use the federal funds from the increased FMAP to supplement, not supplant, existing state funds expended for Medicaid HCBS as of April 1, 2021. States must match the federal funds from the increased FMAP with state funds to implement or supplement one or more activities to enhance, expand, or strengthen HCBS under the State’s Medicaid program.
On May 13, 2021, the Centers for Medicare and Medicaid Services (CMS) issued State Medicaid Director Letter #21-003 to clarify the types of services that may be used to draw down enhanced federal funds, how states may reinvest funds in HCBS, and the reporting requirements for expenditures. Specifically, CMS authorizes spending on state plan benefits, waiver services, and related COVID-19 activities but will not allow matching funds for administrative expenses. For more information on ARP Section 9817 and how Arizona plans to reinvest these dollars, please see the ARPA main page.
- 2. (updated 3/3/22) Question: How will AHCCCS spend the funds from the HCBS expenditure enhancement?
- Answer: In July 2021, AHCCCS submitted Arizona's Section 9817 spending plan and narrative to CMS. Activities detailed in the spending plan were based on feedback from internal and external stakeholders, including but not limited to members, providers, and tribes. In February 2022, AHCCCS received conditional approval from CMS for activities listed in the spending plan. AHCCCS is currently in the process of operationalizing and implementing activities detailed in the spending plan. For a full list of proposed activities please review the spending plan document located on AHCCCS' ARPA website. Please note that items detailed in the spending plan are subject to change.
COVID-19 VACCINE MANDATES
- 1. (updated 3/10/22) Question: What guidance does AHCCCS have for providers regarding the CMS Interim Final Rule for Health Care Staff Vaccination?
- Answer: In Guidance for the Interim Rule issued by CMS regarding health care staff vaccination, CMS has clarified compliance dates for States where the vaccine mandate was formerly blocked. For Arizona facilities and providers regulated by the CMS vaccine mandate, the first dose must be received by February 13, 2022, and the second dose, when applicable, must be received by March 15, 2022.
On January 13, 2022, the United States Supreme Court granted the Federal Government's emergency request and allowed the CMS Interim Final Rule (IFR) vaccine requirement for Medicaid and Medicare providers to take effect. Therefore, the CMS vaccine mandate requirements will proceed, pending appeal of the IFR.
The January 13 Supreme Court ruling is not a ruling on the merits of the IFR, and the challenges to the IFR by the States are continuing in the appellate courts.
In the January 13 ruling, the Supreme Court lifted the injunctions which blocked enforcement of the CMS vaccine mandate for the two groups of States challenging the IFR. Arizona was among the many States covered by the injunctions halting the vaccine mandate. CMS is expected to furnish information and guidance which will clarify timeframes for compliance with the IFR vaccine requirements for Arizona and for other States.
In a separate ruling on January 13, the Supreme Court blocked the OSHA rule establishing the large employer vaccine or test mandate.
The American Rescue Plan Act (ARPA) was signed into law by President Biden on March 11, 2021. The ARPA contains several provisions that may impact state Medicaid programs, including: