Provider Manual
Abrazo Advantage Health Plan (AAHP) provides the following Provider Manual as a source of readily available information regarding the administration of Abrazo advantage Health Plan (HMO) for participating providers and their office staff.
SECTION A:Introduction to Abrazo Advantage Health Plan (AAHP)
- Background of AAHP
- Departmental Structure
- Important Phone Numbers
- Website Information
SECTION B: Provider Responsibilities
- PCP as Gatekeeper
- Specialist Role
- Patient Care Responsibilities
- Emergency Department Utilization
- Administrative Responsibilities
- Important Facts about Dually - Enrolled Members
- Transportation
- Credentialing and Re-credentialing Process
- Compliance Program
- False Claims Act
- Fraud and Abuse
- Grievances
- Deficit Reduction Act (DRA) Public Law 109-171
SECTION C:Culturally Competency Patient Care
- Non-Discrimination Policy
- Culturally Competent Care
- Language Line Services
- Institute for Health Professions Education
Section D: Eligibility and Enrollment
- Medicare Eligibility
- Selecting a Primary Care Provider
- Member Eligibility
- Member Identification Cards
- Member Reassignment
- Member Rights
- Member Appeals, Reconsideration and Grievances
- Member Responsibilities
- Advance Directives
Section E: Covered Services
- Covered Services
- Abrazo Advantage Plus Benefits
- Inpatient Services
- Inpatient Hospital Care
- Inpatient Mental Health Care
- Skilled Nursing Facility Care
- Home Health Care
- Hospice Care
- Outpatient Services
- Physician Services
- Chiropractic Services
- Podiatry
- Outpatient Mental Health Care
- Ambulance Services
- Outpatient Rehabilitation Services
- Durable Medical Equipment
- Prosthetic Devices
- Diabetic Services & Supplies
- Medical Nutrition Therapy
- Outpatient Diagnostic Tests
- Preventative Care and Screening Tests
- Bone Mass Measurements
- Colorectal Screening
- Immunizations
- Mammography Screening
- Pap Smears, Pelvic Exams, and Clinical Breast Exams
- Prostate Cancer Screening
- Cardiovascular Disease Testing
- Physical Exams
- Other Services
- Renal Dialysis
- Prescription Drugs
- Additional Benefits
- Dental Services
- Hearing Services
- Vision Services
- Health and Wellness Education Programs
- Abrazo Advantage Benefits
- Inpatient Services
- Inpatient Hospital Care
- Inpatient Mental Health Care
- Skilled Nursing Facility Care
- Home Health Care
- Hospice Care
- Outpatient Services
- Physician Services
- Chiropractic Services
- Podiatry
- Outpatient Mental Health Care
- Ambulance Services
- Outpatient Rehabilitation Services
- Durable Medical Equipment
- Prosthetic Devices
- Diabetic Services & Supplies
- Outpatient Diagnostic Tests
- Preventative Care and Screening Tests
- Bone Mass Measurements
- Colorectal Screening
- Immunizations
- Mammography Screening
- Pap Smears, Pelvic Exams, and Clinical Breast Exams
- Prostate Cancer Screening
- Cardiovascular Disease Testing
- Physical Exams
- Other Services
- Renal Dialysis
- Prescription Drugs
- Additional Benefits
- Dental Services
- Hearing Services
- Vision Services
- Health and Wellness Education Programs
- Transporation
- Non-Covered Services
Section F: Referral and Prior Authorization Process
- Overview
- Standard Authorization Requests
- Expedited Authorization Requests
- Coordination of Benefits
- Formulary
- Referral Process from PCP to SCP
- Referral Process from SCP to SCP
- Referral Process for Ancillary Providers
- Hospital Admissions
- Member Hospital Transfers
Section G: Billing and Claims
- Claim Submission Information
- CMS 1500 (08/05) Claim Form
- Sample CMS 1500 (08/05) Claim Form
- UB-04 Claim Form
- Sample UB-04 Claim Form
- Modifiers
- Hospital Outpatient Billing
- Third Party Liability
- Explanation of Remittance Advise
- Claims Resubmission Policy
- Duplicate or Erroneous Payments
- Claim Appeals Process
- Medical Review of Claims
- Surgery Claims
- Claims Submitted by Inpatient Facilities
- Outpatient Facilities
- Ancillary Claims
- Emergency Transportation
- General Information
- Sample Provider Reconsideration (Appeal) Form
Section H: Quality Management/Quality Improvement
- Quality Management/Quality Improvement Overview
- Clinical and Service Quality Improvement Committee (CSQIC)
- Peer Review
- Medical Record Audit
- Confidential Exchange of Member Information
- AAHP Clinical Practice Guidelines
Section I: Formulary
- Pharmacy Committee
- Formulary Overview
- Exceptions
- Limitations
- Change Request
Section J: Member & Provider Appeals
- Claims Customer Service
- Appeals
- Appealing on behalf of a member
- Appointment of Representation Form (AOR)
- Sample Provider Reconsideration (Appeal) Form
Section K: Case Management
- Case Management
- Disease Management
- Referral Information
For Appeals Process or Status Questions contact us:
By Phone: (602) 824-3900 or (800) 747-7997 ext. 3735
H5985_246-2013 Pending CMS Approval