AHCCCS Medical Policy Manual (AMPM)
The AMPM provides guidance to contractors and their delegated subcontractors, along with providers regarding services covered under the AHCCCS Program. It applies to Managed Care Organization (MCO) Contractors, their delegated subcontractors, and Fee-For-Service (FFS) Programs including: American Indian Health Program (AIHP), DDD Tribal Health Program (DDD THP), Tribal ALTCS, TRBHA, and all FFS populations. Additionally, it includes details for the Federal Emergency Services Program (FESP).
The AMPM operates with authority in conjunction with federal and state regulations, other agency guides and manuals, and applicable contracts.
AHCCCS Contract and Policy Dictionary
The AHCCCS Contract and Policy Dictionary offers a centralized location for definitions found within the various AHCCCS Contractor Operations Manual (ACOM) and AHCCCS Medical Policy Manual (AMPM) policies.
Feedback on Policies Currently Under Review at AHCCCS
Stakeholders are able to view all policies currently under review for potential updates or changes by AHCCCS staff and provide feedback. AHCCCS also invites the public the opportunity to provide general comments to all policies found in the AHCCCS Contractor Operations Manual (ACOM) and AHCCCS Medical Policy Manual (AMPM). The general public, stakeholders, and tribal members are encouraged to submit comments on any policies found within the ACOM and AMPM at any time.
Your input is valued and appreciated.
Submitting Public Comment on Policy Changes
AHCCCS provides up to a 45-day public comment period prior to publishing AHCCCS Contractor Operations Manual (ACOM) and AHCCCS Medical Policy Manual (AMPM) policies that have a substantial change. Should an expedited time period be required, the expedited time period will not be less than two weeks. Tribal members, stakeholders, and the general public are able to review and submit comments regarding changes being presented.
To review policies currently posted for public comment, please visit the Public Comment page
2024
2023
2022
2021
2020
- November 03, 2020
- October 30, 2020
- October 05, 2020
- September 30, 2020
- September 11, 2020
- September 01, 2020
- August 14, 2020, Updated March 31, 2021
- August 03, 2020
- July 09, 2020
- July 01, 2020
- June 03, 2020
- May 26, 2020
- May 08, 2020
- April 23, 2020
- April 10, 2020
- March 02, 2020
- February 12, 2020
- February 01, 2020
- January 09, 2020
2019
- December 16, 2019
- December 6, 2019
- November 27, 2019
- October 31, 2019
- October 18, 2019
- October 18, 2019 - AMPM Policy 320-I, Telehealth Notification
- September 25, 2019
- September 24, 2019 - AMPM Policy 320-S, Applied Behavior Analysis Notification
- September 13, 2019 - AMPM Policy 310-BB, Transportation Notification
- September 04, 2019
- August 07, 2019
- July 22, 2019
- July 05, 2019
- May 07, 2019
- April 26, 2019
- April 18, 2019
- April 16, 2019
- April 03, 2019
- March 14, 2019
- February 08, 2019
- January 25, 2019
2018
2017
2016
2015
- Exhibit 300-1 - AHCCCS Covered Services with Special Circumstances
- Exhibit 300-2A - AHCCCS Covered Services Behavioral Health
- Exhibit 300-2B - AHCCCS Covered Non-Title XIX XXI Behavioral Health Services
- Exhibit 300-3 – AHCCCS Integrated System of Care Structure, Values, and Principles
- 310-B, Title XIX XXI Behavioral Health Service Benefit
- 310-C, Breast Reconstruction After Mastectomy
- 310-D1, Dental Services for Members 21 Years of Age and Older
- 310-D2, Arizona Long Term Care System Adult Dental Services
- 310-F, Emergency Medical Services
- 310-I - Home Health Services
- 310-J, Hospice Services
- 310-K – Hospital Inpatient General Services
- 310-L, Hysterectomy
- 310-M, Immunizations
- 310-N, Laboratory Services
- 310-P, Medical Equipment, Medical Appliances, and Medical Supplies
- 310-R, Nursing Facility Services
- 310-S, Observation Services
- 310-V - Prescription Medications-Pharmacy Services
- Attachment A - Informed Consent - Assent For Psychotropic Medication Treatment
- Attachment B - 5-Day Supply Limit of Short-Acting Opioid and Long-Acting Opioid Medication Exclusion Specifications
- Attachment C - ICD-10 Case Management Diagnosis Codes
- 310-W, Community Health Worker-Community Health Representative
- 310-X, Occupational, Physical, and Speech Therapies
- 310-BB - Transportation
- 310-DD, Covered Transplants and Related Immunosuppressant Medications
- Attachment A - Extended Eligibility Process-Procedure for Covered Solid Organ and Tissue Transplants
- 310-FF, Monitoring Controlled and Non-Controlled Medication Utilization
- 310-GG, Nutritional Therapy, Metabolic Foods, and Total Parenteral Nutrition
- 310-HH, End of Life Care and Advance Care Planning
- 310-II, Genetic Testing
- 310-JJ, Orthotic and Prosthetic Devices
- 310-KK - Biomarkers Testing
- 320-B - Member Participation in Experimental Services and Clinical Trials
- 320-C, Breast and Cervical Cancer Treatment Program
- 320-G, Lung Volume Reduction Surgery
- 320-I - Telehealth
- 320-M, Medical Marijuana
- 320-O, Behavioral Health Assessments and Treatment Service Planning
- 320-P, Eligibility Determinations for Individuals with Serious Emotional Disturbance and Serious Mental Illness
- 320-Q, General and Informed Consent
- 320-R – Special Assistance for Members with Serious Mental Illness
- 320-S, Behavior Analysis Services
- 320-T1 - Block Grants and Discretionary Grants
- 320-T2 - Non-Title XIX XXI Services and Funding (Excluding Block Grants and Discretionary)
- 320-U – Pre-Petition screening, Court Ordered Evaluation, and Court Ordered Treatment
- 320-V – Behavioral Health Residential Facilities
- 320-W - Therapeutic Foster Care for Children
- 320-X - Adult Behavioral Health Therapeutic Homes
- 320-Z - Members on Conditional Release
- Exhibit 400-2A, Maternity and Family Planning Services and Supplies Plan Checklist – Reserved
- Exhibit 400-3, AHCCCS Maternal Child Health-EPSDT Member Outreach
- 410 - Maternity Care Services
- Attachment A - Semiannual Report of Number of Pregnant Women Who are HIV-AIDS Positive
- Attachment B - AHCCCS Request for Stillbirth Supplement
- Attachment C - AHCCCS Certificate of Necessity for Pregnancy Termination
- Attachment D - AHCCCS Verification of Diagnosis by Contractor for a Pregnancy Termination
- Attachment E - AHCCCS Pregnancy Termination Report
- 411, Women's Preventive Care Services
- 420, Family Planning Services and Supplies
- Attachment A - Consent to Sterilization
- Attachment B - AHCCCS Sterilization Reporting Form for Members Under 21 Years of Age
- 430 - Early and Periodic Screening, Diagnostic, and Treatment Services
- Attachment A - AHCCCS Early and Periodic Screening, Diagnostic and Treatment Periodicity Schedule
- Attachment B - AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements
- Attachment C - Procedures for the Coordination of Services Under Early and Periodic Screening, Diagnostic and Treatment and Early Intervention
- Attachment D - Arizona Early Intervention Program AHCCCS Member Service Request Form
- Attachment E - AHCCCS Early and Periodic Screening, Diagnostic and Treatment Clinical Sample Templates
- Attachment F - Early and Periodic Screening, Diagnostic, and Treatment Program Plan Checklist – Reserved
- 431, Oral Health Care for Early and Periodic Screening, Diagnosis and Treatment Aged Members
- Attachment A - AHCCCS Dental Periodicity Schedule
- Attachment B - Dental Program Plan Checklist - Reserved
- 440, KidsCare Title XXI
- 450, Out-Of-State Placement for Behavioral Health Treatment
- 510, Primary Care Providers
- 520, Member Transitions
- Attachment A - Enrollment Transition Information (ETI) Form
- Attachment B - Out-of-Service Area Placement
- 530 - Member Transfers Between Facilities
- 540, Electronic Visit Verification
- Attachment A - Electronic Visit Verification Designee Attestation
- Attachment B - Paper Timesheet Attestation
- Attachment C - AHCCCS Electronic Visit Verification Paper Timesheet
- Attachment D - EVV Member Contingency Back-Up Plan
- 541 - Coordination of Care with other Government Agencies
- 560, Children's Rehabilitative Services Care Coordination and Service Plan Management
- 570 - Provider Case Management
- 580 - Child and Family Team
- Attachment A - Strengths, Needs, and Culture Discovery Domains
- Attachment B - CALOCUS Implementation Guidelines for CFT Practice Nine Essential Activities
- Attachment C - Child and Family Supervision Tool
- Attachment D - Arizona Child and Family Teams Supervision Tool Users Guide
- Attachment E - Implementation of 12 Principles for Children's Behavioral Health Service Delivery
- 581 – Working with the Birth Through Five Population
- Attachment A – Child's Adjustment to Out-of-Home Placement Template
- Attachment B – Background and Evidence
- Attachment C – Initial Engagement Session Template
- Attachment D – Population Recommended Resources
- 582 – Support And Rehabilitation Services for Children, Youth, And Young Adults
- 583 - Family Involvement in The Children’s Behavioral Health System
- 584 - Youth Involvement in The Children’s Behavioral Health System
- 585 – The Unique Needs of Children, Youth, And Families Involved with Department of Child Safety (DCS)
- 586 – Children’s Out of Home Services
- 587 – Transition To Adulthood
- 590 - Behavioral Health Crisis Services and Care Coordination
- 610 - AHCCCS Provider Qualifications
- Attachment A – AHCCCS Provider Types – Reserved
- Attachment B – AHCCCS Provider Types Screening Tool – Reserved
- 620 - Children's Rehabilitative Services Multi-Specialty Care Model
- 640, Advance Directives
- 650 - Behavioral Health Provider Requirements for Assisting Individuals with Eligibility Verification and Screening, Application for Public Health Benefits
- 660 - Opioid Treatment Program
- 670, Federally Qualified Healthcare Centers (FQHC) and Rural Health Clinics (RHC) Reimbursement
- 680, Federally Mandated Programs for Nursing Facilities
- 680-A, Resident Assessment
- 680-B, Nurse Aide Training and Competency Evaluation Program
- 680-C, Pre-Admission Screening and Resident Review (PASRR)
- 910 - Quality Management/Performance Improvement Program Scope
- Attachment A – AHCCCS Contractor Services-Service Site Monitoring
- Attachment B – ALTCS Contractors Monitoring of Direct Care Worker Training and Testing Standards
- 920, Quality Management/Performance Improvement Program Administrative Requirements
- 930 - Implementation and Fidelity Monitoring of SAMHSA Evidence-Based Practices
- 940, Medical Records and Communication of Clinical Information
- 950, Credentialing and Recredentialing Processes
- 960 - Quality of Care Concerns
- Attachment C – Health and Safety Update – Onsite Review Form
- Attachment D – Individuals with Intellectual Disabilities Investigation Training
- 961 - Incident, Accident, and Death Reporting
- 962, Reporting and Monitoring of Seclusion and Restraint
- 963, Peer and Recovery Support Service Provision Requirements
- Attachment A - Peer Recovery Support Specialist Involvement in Service Delivery
- Attachment B – Peer Support Employment Training Program Admission Interview Tool
- Attachment C - Peer Support Employment and Training Graduates
- 964, Credentialed Family Support Partner Requirements
- Attachment A - Credentialed Family Support Partner Involvement in Service Delivery Report
- Attachment B - Credentialed Family Support Partner Graduates
- 965, Community Service Agencies
- Attachment A - Initial Application and Credentialing Amendment Request
- Attachment B - Documentation Submission Standards
- Attachment C - Criminal History Affidavit
- Attachment D - Self Declaration of Criminal History
- 970, Performance Measures
- 980, Performance Improvement Projects
- 1010 - Medical Management Administrative Requirements
- Attachment A – Medical Management Program Plan Checklist
- Attachment B - Medical Management Work Plan Guide
- 1020 - Utilization Management
- 1021 - Contractor Care Management
- Attachment A - Emergency Department Diversion Summary
- Attachment B - 24 Hours Post Medical Clearance Emergency Department Report
- Attachment E - High Cost Behavioral Health Report
- 1022 - Justice System Reach-In Program
- Attachment A - Justice System Reach-In Monitoring Report
- Attachment B - Justice System Reach-In and Reentry Plan (JSRP) Checklist
- 1023 - Disease-Chronic Care Management
- 1024 – Drug Utilization Review
- 1040 – Outreach, Engagement, and Re-Engagement for Behavioral Health
- 1210, Institutional Services and Settings
- 1230-A - Assisted Living Facilities
- 1230-C - Community Residential Settings
- 1240-A, Direct Care Services
- 1240-B, Adult Day Health Care Facilities
- 1240-C, Community Transition Services
- 1240-D, Emergency Alert System
- 1240-E, Habilitation Services
- 1240-F, Home Delivered Meals
- 1240-G – Private Duty Nursing and Licensed Health Aide Services
- Attachment A - Medical Supplies Included in FFS Home Health Nursing Visits
- Attachment B – Intermittent, Continuous Skilled Nursing, and Licensed Health Aide Services
- 1240-I, Home Modifications
- 1240-J – Employment Services
- 1250-D, Respite Care
- 1250-H, Companion Care
- 1610, Guiding Principles and Components of ALTCS Case Management
- 1620-A, Initial Contact Visit Standard
- 1620-B, Needs Assessment Care Planning Standard
- 1620-C, Cost Effectiveness Study Standards
- 1620-D, Placement and Service Planning Standard
- 1620-E, Service Plan Monitoring and Reassessment Standard
- 1620-F, Tribal ALTCS Fee-For-Service Standards
- 1620-G, Behavioral Health Standards
- 1620-H, Transitional Program Standard
- 1620-I, High Cost Behavioral Health Reinsurance Standard
- 1620-J, Out-Of-State Placement Standard
- 1620-K, Skilled Nursing Need Standard
- 1620-L, Case File Documentation Standard
- 1620-M, Contractor Change Standard
- 1620-N, Service Closure Standard
- 1620-O, Abuse, Neglect, and Exploitation Reporting Standard
- 1630, Administrative Standards
- Attachment A, Case Management Plan Checklist
- Attachment B, Person-Centered Service Plan Performance Standards
- 1640 - Targeted Case Management Standards
- 1710 - AHCCCS Housing Program
- Exhibit 1720-1 – Housing and Health Opportunities (H2O) Services
- Exhibit 1720-2 – Housing and Health Opportunities (H2O) Caseload and Contact Requirements
- Exhibit 1720-3 – Housing and Health Opportunities (H2O) Provider Training
