Provider Manual

Provider Manual	Title
Chapter 1	Introduction to BCBSAZ Health Choice Exhibit 1-1 Provider Escalation Notice
Chapter 2	Member Eligibility and Member Services Member ID Card – Medicare Only Member ID Card – AHCCCS Only Member ID Card – Dual
Chapter 3	Provider Responsibilities Exhibit 3.5.1 Missed Medical Appointment Log Exhibit 3.5.2 Missed Dental Appointment Log Exhibit 3.7 EPSDT Clinical Sample Template Exhibit 3.38 Corporate Compliance Evaluation Form
Chapter 4	Cultural Competency
Chapter 5	Quality Management Exhibit 5.1 Care Management Referral Form
Chapter 6	Authorizations and Notifications Exhibit 6.2 Medical Services and Behavioral Health Prior Authorization Form PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities BHIF, BHRF, TFC, and SUD BHRF Prior Authorization and Continued Stay Request Form Notification of Admission, Transfer and Discharge for Out of Home Placements
Chapter 7	General Billing Rules
Chapter 8	Billing on the CMS 1500 Claim Form
Chapter 9	Billing on the UB Claim Form
Chapter 10	Billing on the ADA Claim Form
Chapter 11	Claims Processing
Chapter 12	Correcting Claim/Encounter Errors
Chapter 13	Understanding the Remittance Advice Exhibit 13.1 Medical Remittance Advice Exhibit 13.2 Dental Remittance Advice Exhibit 13.3 Remittance Denial Codes
Chapter 14	Medicare and Other Insurance Liability
Chapter 15	Claim Disputes, Member Appeals, and Member Grievances
Chapter 16	Family Planning, Maternal Health, and Children’s Services Exhibit 16.1 CRS Application – English Exhibit 16.2 CRS Application – Spanish Exhibit 16.3 Federal Sterilization Consent Form Exhibit 16.4 Newborn Reporting Form Exhibit 16.5 Hysterectomy Consent Form – English Exhibit 16.8 Certificate of Medical Necessity for Commercial Oral Nutritional Supplements Exhibit 16.10 Maternal Risk Assessment
Chapter 17	Pharmacy and Drug Formulary Exhibit 17.1 Formulary Addition Request Form Exhibit 17.2 Pharmacy Services Prior Authorization Form Exhibit 17.3 Psychotropic Medication Monitoring Program Exhibit 17.4 ePrescribing Information Exhibit 17.5 HIE eRX Information
Chapter 18	Behavioral Health Services PA and Continued Stay Review Form for Psychiatric Hospitals and Sub-Acute Facilities BHIF, BHRF, TFC Prior Authorization and Continued Stay Request Form Notification of Admission, Transfer and Discharge for Out of Home Placements Northern AZ ED Reporting
Chapter 19	Hospital Services
Chapter 20	Oral Health Services Exhibit 20.1 Dental Specialty Request form Exhibit 20.2 2024 Dental Matrix – Under 21 Exhibit 20.3 2024 Dental Matrix – Over 21
Chapter 21	RESERVED (NOT IN USE)
Chapter 22	Care Management
*	Exhibit 430-4 AzEIP AHCCCS Member Service Request Form Exhibit 430-A AHCCCS EPSDT Periodicity Schedule
*	Exhibit 431-A AHCCCS Dental Periodicity Schedule

Provider Manual

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