The Handbook for Members of the American Indian Health Program (AIHP) and/or the Tribal Regional Behavioral Health Authorities (TRBHA)
August 2026
AIHP/TRBHA Member Handbook
Table of Contents Advance Directives................................................................................................................................25 Am I Covered Outside of Arizona..........................................................................................................10 American Indian Medical Home (AIMH).................................................................................................9 Behavioral Health Services...............................................................................................................22-23 Behavioral Health and Crisis Hotlines..................................................................................................5-7 Children / Services for Children............................................................................................................17 Community Resources......................................................................................................................28-30 Covered Services (AHCCCS)..............................................................................................................14-15 Dental Services......................................................................................................................................20 Dialysis Services....................................................................................................................................20 Emergency Care....................................................................................................................................15 Emergency Transportation...............................................................................................................15-16 Enrollment Options.................................................................................................................................7 Family Planning Services..................................................................................................................18-19 Fraud and Abuse..............................................................................................................................25-26 Grievances and Appeals...................................................................................................................11-14 Hospital (Inpatient Services)..................................................................................................................18 Hospital (Outpatient Services)...............................................................................................................18 Hysterectomy Services.....................................................................................................................19-20 ID Cards for Members.............................................................................................................................4 Immunizations..................................................................................................................................17-18 Lodging and Meals...........................................................................................................................23-24 Medicines..............................................................................................................................................23 Notice of Non-Discrimination...........................................................................................................26-27 Office Visits...........................................................................................................................................16 Other Insurance....................................................................................................................................25
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Table of Contents Continued Phone Numbers / Crisis Hotlines.........................................................................................................5-6 Podiatry Services...................................................................................................................................20 Prenatal Services...................................................................................................................................19 Preventative Care..................................................................................................................................16 Prior Authorization (PA)..........................................................................................................................9 Provider Directory...................................................................................................................................8 Rehabilitation Services..........................................................................................................................21 Rights and Responsibilities as a Member.........................................................................................10-11 Tribal Long Term Care Services (ALTCS).................................................................................................24 Tribal Regional Behavioral Health Authority (TRBHA)...........................................................................7-8 Transportation / Non-Emergency Medical Transportation (NEMT)..................................................21-22 Transportation from a Hospital to another Facility................................................................................22 Vision Services......................................................................................................................................21 Where Can I Get Services........................................................................................................................8
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AIHP/TRBHA Member Handbook
Personal Information My AHCCCS ID number: __________________________________________ My Doctor: ____________________________________________________ My Doctor’s phone number: ______________________________________ My Pharmacy: _________________________________________________ My Pharmacy’s phone number: ___________________________________ My Pharmacy’s address:__________________________________________ My Behavior Health Provider: _____________________________________ My Behavior Health phone number: ________________________________
Welcome to AHCCCS Founded in 1982, the Arizona Health Care Cost Containment System (written as AHCCCS and pronounced 'access') is Arizona's Medicaid program. Our mission is to reach across Arizona to provide comprehensive, quality health care to those in need. Thank you for choosing the American Indian Health Program, we will collaborate with you to help you stay healthy. Please keep this Member Handbook in a place where you can find it easily.
Welcome to Gila River Behavioral Health Services Gila River Behavioral Health Services provides behavioral health services to Native Americans and others who live on the Gila River Indian reservation. We also serve Gila River Indian Community members who live outside the reservation. The program provides mental health care. We also help people with drug and alcohol problems. Additional information about services provided through Gila River Behavioral Health Services is available on our Web site at grhc.org/bhs. Gila River Behavioral Health Services is also known as a Tribal Regional Behavioral Health Authority (TRBHA). As such, we provide behavioral health services to a tribal geographic service area (GSA) – The Gila River Indian Community. If you would like more information about the information in this Member Handbook, please call Gila River Behavioral Health Services at (602) 528-7100, (520) 562-3321 # 7010 or 1-888-484-8526, and for hearing impaired, also use TTY services at 711 or 1-800-367-8939. 4
AIHP/TRBHA Member Handbook
ID Cards for Members When you become a member of the AHCCCS American Indian Health Program (AIHP) you will receive an ID card from AHCCCS. Always carry your ID card with you. You will need to show this card when you get medical care. When you get your card, make sure your information is correct. If there is a problem with your card or if you lose your card, please call the AHCCCS Division of Member and Provider Services (DMPS). When ordering a new AIHP ID card you will first speak with the AHCCCS Virtual Assistant (AVA). AVA (the virtual assistant) helps customers via web/chat or voice/telephonic and provides 24/7 service. To request your card, you must speak to an agent. Phone: 602-417-7000 (Maricopa County) or 1-800-962-6690 (Outside Maricopa County) or visit AHCCCS online at: https://www.azahcccs.gov/
These steps will get you to the call queue for an available agent as quickly as possible: 1. Call AHCCCS at the number mentioned above, AVA (the virtual assistant) will greet you, 2. Tell AVA (the virtual assistant) immediately, “I want to speak to an agent,” 3. AVA (the virtual assistant) will ask if there is anything else she can help you with before the call transfers to an agent, you can say “No, I want to speak to an agent,” and 4. Your call will then be placed in a queue for the next available representative 5. Once you are connected to a representative, you may request a copy of your AIHP ID card. NOTE: It is crucial that you do not allow anyone else to use your Member ID Card. This is considered fraudulent. If you think someone has used your card or your information you should report it to the Office of the Inspector General (OIG) by calling: In Arizona: 602-417-4193 Toll Free Outside of Arizona Only: 888-ITS-NOT-OK or 888-487-6686 Or by emailing AHCCCSFraud@azahcccs.gov
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AIHP/TRBHA Member Handbook
Phone Numbers AHCCCS Customer Service In Arizona (Maricopa County): 602-417-7000 or toll free: 1-800-962-6690 AHCCCS Division of Member and Provider Services (DMPS) 800-962-6690 In Maricopa County 602-4174000 If you need emergency care visit the nearest Emergency Room (ER) or Dial 911.
National 24-Hour Crisis Hotlines Crisis services are available to any Arizona residents, regardless of health insurance coverage. If you or someone you know is experiencing a Behavioral Health crisis, please use one of these resources.
Phone 988 Suicide & Crisis Lifeline: 988 National Substance Use and Disorder Issues Referral and Treatment Hotline: 1-800-662-HELP (4357) Text Send a Text to 988 Text the word "HOME" to 741741 Chat 988 Lifeline Chat https://chat.988lifeline.org/ 6
AIHP/TRBHA Member Handbook
Chat with a Solari Crisis Specialist https://crisis.solari-inc.org/start-a-chat/ Videophone Select Deaf/HoH on the 988 Lifeline web page to connect with a 988 Lifeline counselor https://988lifeline.org/deaf-hard-of-hearing-hearing-loss/
Arizona Statewide Crisis Hotline: 1-844-534-HOPE (4673) 4HOPE (44673) (text)
Suicide and Crisis Hotlines by County and Tribal Nation
Apache, Cochise, Graham, Greenlee, La Paz, Pima, Pinal, Santa Cruz, Yuma: Arizona Complete Health – Complete Care Plan 1-866-495-6735 Coconino, Gila, Mohave, Navajo, Yavapai: Health Choice Arizona 1-877-756-4090 Maricopa County: Mercy Care 1-800-631-1314 Ak-chin Indian Community, Gila River Indian Community: Mercy Care 1-800-259-3449 Salt River Pima Maricopa Indian Community: 1-855-331-6432 Tohono O’odham Nation: 1-844-423-8759 Teen Crisis Hotline Teen Lifeline 602-248-TEEN (8336) (call or text)
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AIHP/TRBHA Member Handbook
Veteran Crisis Hotlines
Veterans Crisis Line: 988 (press 1) Be Connected: 1-866-4AZ-VETS (429-8387) Agricultural Communities: AgriStress Helpline: 833-897-2474 (call or text)
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AIHP/TRBHA Member Handbook
Enrollment Options As an American Indian or Alaskan Native (AI/AN) member, you can receive physical and behavioral health services. Your enrollment choice may affect what services are covered and what providers are in your plan’s network. You have the option to choose a health plan and may enroll in either: • The AHCCCS American Indian Health Program (AIHP), or • The AHCCCS Complete Care (ACC) plan of your choice. A list of all ACC plans can be found on the AHCCCS website at: https://www.azahcccs.gov/healthplans You may switch your enrollment between AHCCCS AIHP and an AHCCCS Complete Care plan (ACC). AI/AN members can switch their enrollment between AHCCCS AIHP and an AHCCCS Complete Care (ACC) Health Plan and back again at any time. • To change from American Indian Health Program to a managed care health plan, call 602417-7000 (Maricopa County) or 1-800-962-6690 (Outside Maricopa County). • To change from a health care plan to American Indian Health Program, the https://www.azahcccs.gov/AmericanIndians/Downloads/American_Indian_Health_Plan_Change _Request_Form.pdf must be submitted to AHCCCS. Only AHCCCS registered Indian Health Service (IHS), Tribally owned/and or operated 638 facilities and Urban Indian Health Organizations (receiving Title V funding from IHS) may use this form. NOTE: Health Plan decisions are entirely up to you. Providers are not permitted to promote or influence your decision to change health plans based on their own preferences. This practice is not permitted. All AHCCCS registered providers are required to serve Fee-for-Service (FFS) members, which includes members on AIHP and/or enrolled with a TRBHA. Providers are strictly prohibited from offering any type of payment or incentive, including both monetary and nonmonetary forms, in return for referring you for or providing you services.
Tribal Regional Behavioral Health Authority (TRBHA) You may enroll to have your behavioral health care coordinated through a Tribal Regional Behavioral Health Authority (TRBHA). You may only choose a TRBHA if you live within the geographic service area the TRBHA serves or are affiliated with the Tribe the TRBHA operates under. A list of TRBHAs can be found on the AHCCCS website at: https://www.azahcccs.gov/Members/BehavioralHealthServices/ Refer to your AHCCCS Medical Identification Card to identify your behavioral health coverage.
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AIHP/TRBHA Member Handbook
If you are unsure about your choices or have questions about how your behavioral health services are coordinated, please contact AHCCCS Clinical Resolution Unit at 602-364-4558. *** Members with a Serious Mental Illness (SMI) designation may receive behavioral health care through either a TRBHA, AIHP, or an AHCCCS Complete Care plan with a Regional Behavioral Health Agreement (ACC-RBHA). Additional information regarding SMI determination can be found on pages 13-15.
Where Can I Get Health Care Services? Regardless of health plan enrollment, physical and behavioral health services may be received at any Indian Health Service (IHS) or Tribally owned and/or operated (638) facility. If you are enrolled in the AIHP you may also receive services at any AHCCCS registered provider. If you choose an AHCCCS Complete Care (ACC) plan you are still able to receive physical and behavioral health services from IHS/638 Tribal facilities. In addition, you can receive services from any provider that is a part of your ACC plan’s network. • If you are unsure which providers are in your ACC plan’s network, you can contact your ACC plan https://www.azahcccs.gov/Members/ProgramsAndCoveredServices/availablehealthplans.html
Provider Directory The Provider Directory is a searchable list of AHCCCS registered providers by Specialty. All providers are required to accept AIHP. To search for an AHCCCS registered provider, you can click the drop-down arrow on Specialty to select All or a specific type of Specialty, such as an Audiologist or Pediatric Psychiatrist. When you search, a listing of AHCCCS registered providers will appear and the provider’s Name, Specialty, Address and Phone number will be listed. Providers with multiple office locations will be listed under each location. The searchable online provider directory is available on our website: https://www.azahcccs.gov/Members/ProgramsAndCoveredServices/ProviderListings/ * Search can be narrowed by Provider Name, Specialty, Address, Zip code or city.
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AIHP/TRBHA Member Handbook
American Indian Medical Home As an added benefit to choosing AIHP as your health program, AIHP members may choose to be part of an American Indian Medical Home (AIMH). An AIMH is an AHCCCS registered IHS/638 Tribal facility that provides primary care case management services and can provide you with access to a care team 24 hours a day, 7 days a week. Members may choose any AHCCCS registered IHS/638 Tribal facility that is a registered Medical Home. The list of American Indian Medical Homes can be found on the AHCCCS website: https://www.azahcccs.gov/AmericanIndians/AmericanIndianMedicalHome/ If you choose an AIMH, a nurse case manager or case management team will be assigned to help you coordinate your health care needs. The AIMH program is a voluntary program. AIHP members who choose to participate may leave the program or change enrollment with AIMH sites at any time. AIHP members can sign up at the AIMH facility of their choice or call AHCCCS’ Division of Member and Provider Services (DMPS) to request enrollment.
Prior Authorization To receive some services from an AHCCCS registered provider that are not a part of the IHS or a Tribal facility, you first must have approval from your health plan (this would be AIHP). This is called prior authorization. The need for prior authorization will depend on your health plan and other requirements. If you are enrolled in AIHP, this authorization comes from the AHCCCS administration. If you are in the American Indian Health Program (AIHP) and/or enrolled in a TRBHA, your health care provider should contact AHCCCS before you receive the following services:
• • • • • • • • •
Non-emergency medical or behavioral health inpatient admissions including admission to a Residential Treatment Center for children and adolescents, Admission to a Behavioral Health Residential Facility (all ages), Non-emergency and elective surgeries, Nursing home placements, Home health services, Non-emergency transportation over one hundred miles (one-way or round trip), Medical equipment and medical supplies, Hospice services, and Medically necessary eyeglasses for adults.
Members enrolled in an AHCCCS Complete Care (ACC) plan should contact the ACC plan with questions about prior authorization. Health Plan contact information can be found on the AHCCCS website at: https://www.azahcccs.gov/AmericanIndians/AmericanIndianMedicalHome/
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AIHP/TRBHA Member Handbook
Am I Covered Outside of Arizona As an AIHP and/or TRBHA member you may be covered by AHCCCS if you are temporarily out of the state, but still an Arizona resident. You may receive services if:
• • •
Medical services are needed because of a medical emergency You need treatment that you can only get in another state, or You have a chronic illness, and your condition must be stabilized before returning to Arizona.
Rights & Responsibilities as a Member Members have certain rights and responsibilities. It is important that you understand each one. Your rights as a member are to: • Be treated with respect and with recognition of your dignity and need for privacy, • Not be discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, gender, gender identity, age, behavioral health condition, intellectual or physical disability, sexual orientation, genetic information, or source of payment, • Receive an annual member handbook and provider directory, • Have services provided in a culturally competent manner, • Can choose a Primary Care Provider (PCP), • Have the right to refuse treatment and services, • Participate in decision-making regarding your health care, • Be provided with information about formulating Advance Directives, • Receive information in a language and format that you understand, • Be provided with information regarding grievances, appeals, and requests for hearing, • Have the right to complain about the health plan, TRBHA, and/or provider, • Have access to review your medical records in accordance with applicable Federal and State Laws, • Have the right to request and receive annually, at no cost, a copy of your medical records, • Have the right to amend or correct your medical records, • Have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, and • Have the right to be free from and report any perceived intimidation, manipulation and/or coercion that may have occurred while receiving services from an AHCCCS Provider.
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AIHP/TRBHA Member Handbook Your responsibilities as a member are: • Share information, • Show your member ID card or identify yourself as an AHCCCS member to health care providers before getting services, • Ask your provider to explain if you do not understand your health condition or treatment plan, • Give your health care providers and case managers all the facts about your health problems, past illnesses, hospital stays, all medications, shots, and other health concerns,
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Follow instructions that you and your health care providers have agreed on, including the instructions of nurses and other health care professionals,
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Schedule appointments during office hours, when possible, instead of using urgent or emergency care, and
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Keep appointments and come on time. Call your provider’s office ahead of time when you cannot keep your appointments.
Grievances and Appeals Members enrolled in the American Indian Health Program (AIHP), have the right to file a grievance, make a complaint, or file an appeal. An appeal is a request from an applicant, member, provider, health plan, or other approved entity to reconsider or change a decision, also known as an action. An action includes any denial, reduction, suspension, termination of a service or benefit, or failure to act in a timely manner. An appeal is the formal procedure asking us to review the request again and confirm if our original decision was correct. Examples of actions: • Denial of a request for surgery, • Denial of a request for a wheelchair, • Denial of basic health care services, • Denial or discontinuance of AHCCCS eligibility. Process to File an Appeal All appeals need to be in writing. Appeals related to denials, discontinuances, or reductions in medical services must be sent to the AHCCCS Office of the General Counsel (OGC). To request an appeal, write to the AHCCCS Office of the General Counsel: AHCCCS Office of The General Counsel 150 N 18th Ave., MD-6200 Phoenix, AZ 85007 FAX: 602-253-9115
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AIHP/TRBHA Member Handbook Standard Appeal During the appeal process, you may submit additional supporting documents or information that you believe would support a different outcome and decision. After we review your appeal, we will send you our decision in writing within 30 days of the date we received your appeal request. Request for an Expedited Appeal A request for an expedited appeal can be made if the member or doctor feels that the person's health will be in serious jeopardy (serious harm to life, health, or ability to attain, maintain or regain maximum function) by waiting 30 days for a decision. If the appeal is expedited, AHCCCS should resolve the appeal within three working days, absent an extension. Continuing Services During an Appeal Members currently receiving services or benefits may be able to continue to receive them during the appeal process. If services or benefits were reduced, suspended, or terminated, a request to continue receiving services during the appeal may be made. The appeal must be filed before the day the reduction, suspension or termination is to take effect. If there are less than 10 days between the notice date and the effective date on the notice, the request for continued services must be filed within 10 days from the notice date. If the appeal is denied, the member may have to pay for the services received during the appeal process. Request a Hearing (after an unfavorable appeal) If the AHCCCS decision on the appeal is unfavorable, a hearing referred to as a State Fair Hearing, where the appeal is presented before an administrative law judge, may be requested. A written request for a State Fair Hearing must be filed with the Office of the General Counsel.
Complaints, Grievances and Appeals for Members with an SMI Determination If you have been determined to have a Serious Mental Illness (SMI) and have concerns about your care in Arizona’s public behavioral health system, you have different ways to speak up. The best option depends on what the problem is, what outcome you want, and how much time you can spend on it. Informal Complaint: This is the simplest way to speak about a problem. You can talk to the staff member involved or their supervisor to try to fix the issue. You can ask for a meeting in person, by phone, or in writing. This may not be the best option if the problem keeps happening or if staff aren’t willing to help. 14
AIHP/TRBHA Member Handbook SMI Grievance Process This process involves an investigation to explore an alleged violation of rights or a condition that is dangerous, illegal, or inhumane per A.A.C. R9-21-402. If you believe your rights were violated or you were treated in a dangerous, illegal, or inhumane way, you can file a grievance. How to File a Grievance: File within 1 year of the incident (generally). You can file by phone or in writing (written is best). If you file in writing, use the SMI grievance form and keep a copy for your records). By Mail: AHCCCS Office of the General Counsel (OGC) 150 N. 18th Ave., MD 15013 Phoenix, AZ 85007 By Phone: In Arizona (Maricopa County): 602-417-4232 or toll free (Statewide): 1-800-654-8713 ext. 74232 What Happens Next: • An investigator is assigned (if necessary) • They will interview you and others involved, and review related records • A decision is made based on the evidence • If a violation is found, a plan is created to fix it • You have the right to appeal the decision if you disagree Grievance Timeline: • Grievance filed within one year of incident (unless just cause applies) • Grievance confirmation receipt after 5 days • Resolve without investigation after 7 days • If an investigation is necessary, assigned to the investigator and appointment notification confirmed within 7 days • An interview with the filer will take place 10 days after the investigator is assigned 1. Interview with grievance source will take place 15 days after the investigator is assigned and after the conference occurs 2. Written report will be sent to the filer 10-30 days after all interviews 3. Decision letter sent 5 days after written report is sent 4. (if rejected by OGA, 10 additional days will be added to timeline) When filing an appeal or a grievance/request for investigation, it is strongly recommended that you use the AHCCCS Appeal or Serious Mental Illness Grievance Form (the form is attachment A to ACOM 446).
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Formal Complaint: You can file a complaint by speaking or writing to the Customer Service Department of your TRBHA or contractor. They have up to 60 days to respond, though it’s usually faster. If you’re not happy with the result, there’s no official next step—but you can ask the AHCCCS Clinical Resolutions Unit to review it by calling 602-364-4558. SMI Appeal Process An appeal is how you challenge a decision about your mental health services that you may not agree with. You can appeal: • Denied, reduced, or stopped services • Service or discharge plans • Fees or denied fee waivers • Grievance results How to file: • File within 60 days of the decision (generally) • Appeals can be expedited upon request with good cause • Submit by phone or in writing (written appeals are best—use the appeal form and keep a copy) What happens: 1. Informal meeting with your provider (within 7 days) 2. If not resolved, a second meeting with AHCCCS (within 15 days) can be scheduled 3. If it is still not resolved, you can request a hearing to present your case During the appeal: Your services continue unless a clinician says it is unsafe, or you agree to changes. Appeal Timeline: 1. Appeal submitted within 60 days of incident 2. Acknowledged by DFSM or the TRBHA within 5 days 3. First Informal Conference within 7 days (3 days to forward to the next level of informal conference) 4. Second Informal Conference within 15 days (3 days to forward to OAH) Expedited appeal request – 1 day to acknowledge and 2 days to have the IC (see ACOM policy 404 for more information on expedited appeals)
AHCCCS Covered Services AHCCCS covers medically necessary preventative, acute and behavioral health care when it is provided by an AHCCCS registered provider. AHCCCS also offers limited coverage of rehabilitative services, home health care, and long-term care services. Additional covered services are available for 16
AIHP/TRBHA Member Handbook members under the age of 21 under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. If you have questions about whether a service is covered, please check with your health care provider. Your health care provider can contact AHCCCS to verify whether a service is covered. https://www.azahcccs.gov/Members/AlreadyCovered/coveredservices.html Members, age 21 and under, with a Children’s Rehabilitative Services (CRS) designation have their physical and behavioral health services covered under AIHP and the TRBHAs. Members may choose to receive care through the Multi-Specialty Interdisciplinary Clinic (MSIC), IHS/638 Tribal facilities or Urban Indian Health Programs (ITUs) or other AHCCCS registered providers. Members who qualify for a CRS designation and are NOT enrolled with DES/DDD may be enrolled with an AHCCCS Complete Care (ACC) or an AHCCCS Complete Care Plan with a Regional Behavioral Health Agreement (ACC-RBHA) in their service area. The ACC and ACC-RBHA plans manage care for all services (including CRS, other non-CRS physical health services, and all covered behavioral health services). For a comprehensive list of all AHCCCS covered services, please visit the website: https://www.azahcccs.gov/Members/AlreadyCovered/coveredservices.html For questions regarding AHCCCS membership and covered healthcare services, visit AHCCCS online at https://www.azahcccs.gov/ or contact AHCCCS Division of Member and Provider Services (DMPS) at 1-800-962-6690.
Emergency Care AHCCCS provides coverage for emergency medical care 24 hours a day, 7 days a week—both within Arizona and when you're out of state. An emergency is a sudden and serious medical condition that requires immediate treatment to avoid severe harm to your health. Examples of emergencies may include (but are not limited to): • • • • •
Severe chest pain or pressure Trouble breathing Heavy or uncontrolled bleeding Sudden confusion or loss of consciousness Serious injuries from accidents
If you need emergency care, visit the nearest Emergency Room (ER) or Dial 911. Emergencies can lead to disability or death if not treated, so seek care immediately. Prior authorization (PA) is not required for emergency care.
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Emergency Transportation Emergency transportation to the nearest appropriate medical facility is covered by AHCCCS 24 hours a day, 7 days a week. If you are experiencing a medical emergency, call 911 immediately. This includes emergency ground and air ambulance services that are required to manage an emergency medical condition, both at an emergency scene and in transport to the nearest appropriate facility. No prior authorization (PA) is required for emergency transportation. Determination of whether a transport is an emergency is not based on the call to the provider, but upon the member's medical condition at the time of transport.
Preventative Care AIHP covers medically necessary services for health assessments, screening tests, immunizations, and health education such as, but not limited to:
• • • • • • • • • • • • •
Well Exams and Physical Exams Laboratory Tests Cancer screenings Breast (mammogram) Cervical (Pap tests) Colon (colonoscopy) Prostate (PSA test) Heart Disease screenings High blood pressure screening Cholesterol screening Other Diseases HIV screening and/or other sexually transmitted infections screening Tuberculosis screening
The following services are not covered under the AIHP program: Physical exams needed by outside public or private agencies such as:
• • • • • •
Exams for insurance purposes, Pre-employment physical examinations, Sports exams or exams for exercise programs for members over age 21 Pilot examinations, Disability exams, or Evaluation for lawsuits.
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Office Visits AIHP covers medically necessary physician office visits and/or specialty office visits for the purpose of diagnosis and/or treatment of illness and injury. Office visits and specialty visits do not require Prior Authorization (PA).
Services for Children AIHP provides health care coverage for enrolled members under the age of 21 through wellness visits offered by the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT ensures that children and young adults receive regular checkups, screenings, and any necessary follow-up care to support healthy development. The purpose of EPSDT is to ensure the availability and accessibility of health care resources and assist the member/Health Care Decision Maker (HCDM), Designated Representative (DR) in effectively utilizing these resources. Enrolled members should be seen by their AHCCCS registered healthcare provider for routine wellness visits and dental checkups. Wellness visits include: • • • • • •
Health, nutrition, and developmental history, Screening for immunizations, Laboratory tests, Vision, speech, and hearing screening, Dental screening, and Behavioral health screening.
The EPSDT Periodicity Schedule is intended to meet reasonable and prevailing standards of medical and dental practice and specify screening services at each stage of the child's life. The service intervals represent minimum requirements. Any services determined by a Primary Care Provider (PCP) to be medically necessary shall be provided, regardless of the interval. More information along with the Periodicity Schedule can be found on the AHCCCS website under the AMPM Policy 430 – Early and Periodic Screening, Diagnostic and Treatment Services.
Immunizations AIHP covers recommended immunizations for enrolled members, both adults and children under age 19. As recommended by the CDC and ACIP, covered immunizations include, but are not limited to: • • • •
Diphtheria-Tetanus-Pertussis (DTP), Influenza, Coronavirus Disease 2019 (COVID-19) Pneumococcus, 19
AIHP/TRBHA Member Handbook • • • • • • • •
Rubella, Measles, Hepatitis A, Hepatitis B, Pertussis, Zoster “Shingles” vaccine, for members 50 and older, HPV vaccine, for females and males between the ages 9 to 26 years, and All child and adolescent immunizations, as recommended by the CDC childhood immunization schedules.
All members under age 19 are eligible to receive immunizations under the Vaccines for Children Program (VFC). AHCCCS registered providers shall be enrolled in the VFC program and use VFC supplied vaccines. The VFC program is a federally funded program that provides free vaccines to children.
Inpatient Hospital Services AIHP covers medically necessary inpatient hospital care in AHCCCS registered hospitals. This can also include IHS/638 Tribal facilities. Covered services include, but are not limited to: • Routine (regular) hospital care, • Intensive care, • Intensive care for newborns, • Maternity care, including labor and delivery, recovery rooms, and birthing centers, • Nursery for newborns and infants, • Surgery, including anesthesiology, and • Emergency services.
Outpatient Hospital Services AIHP covers medically necessary outpatient preventative treatment, diagnostic services such as labs or x-rays, rehabilitative services such as physical therapy (PT), occupational therapy (OT), or speech therapy (ST), palliative services and surgeries for all members. Your AHCCCS registered health care provider may need to obtain approval (prior authorization or PA) from AHCCCS before services are rendered. All services submitted for reimbursement are subject to review by AHCCCS.
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Family Planning Services AIHP offers Family planning services (FPS) to eligible members who voluntarily choose to delay or prevent pregnancy that include covered medical, surgical, pharmacological and laboratory benefits. Family planning services (FPS) include the provision of accurate information and counseling to allow members to make informed decisions about the specific family planning methods available. AHCCCS covered services: Contraceptive (birth control) counseling, exams, medications, and supplies such as: • Oral Contraceptives (daily birth control pills), Depo-Provera Shots, Diaphragms, Intrauterine Devices (IUDs), long-acting reversable contraceptives (LARC), Condoms and Foams. • Voluntary permanent sterilization (male and female), • Associated medical and laboratory exams and/or radiological procedures, including ultrasounds related to Family planning services (FPS), • Treatment of complications resulting from contraceptive use, including emergency treatment, • Natural family planning education or referrals to qualified health care professionals. AHCCCS uncovered services: • Infertility diagnosis or treatment, or • Pregnancy Termination or related counseling, unless: a. Pregnancy termination is medically necessary to protect the life of the mother according to the medical judgement of an AHCCCS registered and licensed physician, and/or b. Pregnancy termination is medically necessary to prevent a serious physical or mental health problem for the mother, or c. The pregnancy was a result of rape or incest.
Prenatal Services If you think you may be pregnant, make an appointment with an AHCCCS registered primary care physician (PCP), obstetrician (OB) or an AHCCCS registered midwife to ensure timely and appropriate maternity care. Your AHCCCS registered provider will help develop a prenatal care plan, which includes regular visits to monitor the health of both the mother and baby. The provider may talk about: • Eating healthy foods, taking vitamins, and what to avoid during pregnancy, • What to expect • What tests will ensure both you and the baby are healthy.
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Hysterectomy Services AIHP covers medically necessary hysterectomy services. The medical necessity is determined and carefully diagnosed by your AHCCCS registered provider. A hysterectomy is defined as “a medical procedure or operation for the purpose of removing the uterus.” Your healthcare provider will explain what the procedure is, after-care services, and will require you to sign the hysterectomy consent form. The form must be signed and dated by the member, the physician who performs the hysterectomy, the person who obtains the member’s consent, and, if applicable, an interpreter.
Dental Services AIHP covers dental services provided by an AHCCCS registered dentist for members under 21 years of age through the Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT), which include, but are not limited to: • Check-ups and sealants (to prevent and treat) • Emergency dental services, and • All medically necessary therapeutic dental services. AHCCCS covers medical and surgical services furnished by a dentist for adults 21 years of age and over only to the extent that such services: • Are emergency dental services up to $1,000 annual limit, or • Are medically necessary treatments prior to a transplant, or • Are medically necessary treatments prior to cancer treatments (cancer of the jaw, neck or head). Medically necessary diagnostic, therapeutic and preventive dental services provided at IHS/638 Tribal facilities are not subject to the $1,000 limit.
Dialysis Services Dialysis services are treatments for members who are diagnosed with ESRD (End-Stage Renal Disease). Dialysis services replace the function of the kidneys and encompass a range of treatments to help keep the blood clean and support individuals. AIHP covers dialysis at AHCCCS registered end stage renal disease (ESRD) facilities. AHCCCS covers all medically necessary services, supplies, and testing (including regular laboratory testing).
Podiatry Services
Podiatry services are covered for adults 21 years of age and older when ordered by the member’s AHCCCS registered primary care provider and services are provided by a licensed podiatrist. Some podiatry services may require Prior Authorization (PA). Talk to your AHCCCS registered provider regarding specific procedures.
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Rehabilitation Services AHCCCS covers physical, occupational, speech, and respiratory (breathing) therapy services as well as audiology (hearing testing). The rehabilitation services must be:
• •
Ordered by an AHCCCS registered provider, and Provided by (or under the direct supervision of) a licensed therapist.
Occupational therapy (OT) and physical therapy (PT) are each subject to a maximum of thirty (30) sessions per benefit year. Limitations and exclusions: • Outpatient speech therapy (ST) services are only covered for children under 21 years of age, and • AHCCCS does not cover physical therapy (PT) services if no improvement is expected.
Vision Services AIHP covers eye and optometric services provided by AHCCCS registered eye care professionals (ophthalmologists and optometrists). There are limits based on the member’s age and eligibility: Vision Services for children under 21 years of age: • Routine, medically necessary eye exams • Eyeglasses are covered, as well as replacements and/or repairs. Vision Services for adults 21 years of age and over: • Treatment of medical conditions of the eye are covered, • Routine eye examinations for prescription lenses are not covered, and • Eyeglasses may be considered medically necessary for adults following cataract surgery.
Transportation for Medical & Behavioral Health Appointments Non-Emergency Medical Transportation (NEMT)
AHCCCS covers non-emergency medical transportation (NEMT) to and from medically necessary medical and behavioral health covered services. This service is available for members who are unable to provide or pay for their own transportation, when free transportation services are not available. 23
AIHP/TRBHA Member Handbook AHCCCS covers NEMT to the nearest IHS/638 Tribal facility or behavioral health facility or to the nearest medical or behavioral health provider capable of meeting the member’s needs. Your AHCCCS registered health care provider may need to obtain approval (prior authorization or PA) from AHCCCS prior to the transport.
Transportation from a Hospital to another Facility Round-trip ground ambulance transportation may be covered by AHCCCS if the member is hospitalized and needs to be taken to the nearest appropriate facility for special services if: • Use of any other type of transportation may be unsafe, or • The member cannot get the services needed at the hospital where they are staying.
Behavioral Health Services AHCCCS covers behavioral health services provided at IHS/638 Tribal facilities, or at an AHCCCS registered provider. AHCCCS covers mental health, substance (drug and alcohol) use treatment, and crisis services. A referral is not needed for behavioral health services. All AHCCCS members have access to behavioral health services, including: • Persons designated with a serious mental illness (SMI), and • Members who are eligible to receive services funded through federal block grants. A member designated with a Serious Mental Illness (SMI) is a person 18 years of age or older with a mental, behavioral, or emotional disorder that severely and negatively affects their daily life. The member may not be able to remain in the community without treatment and/or services. A referral or request can be coordinated with the member’s behavioral health provider or TRBHA to assess and determine if the member is eligible to receive SMI services. AIHP members with an SMI determination may receive assistance with coordination of care and case management from AIHP Care Management in the absence of case management from a TRBHA and/or an AHCCCS registered provider. AHCCCS covers: • Inpatient services in a hospital and other facilities, • Partial care (supervised, treatment or medical day programs), • Individual, group, and/or family counseling and therapy, • Emergency/crisis services, • Behavior management (behavioral health personal assistance, family, and peer support), • Evaluation and diagnosis, • Medicine and monitoring of medicine, • Psychosocial rehabilitation (living skills training, health promotion, pre-job training, education and development, job coaching, and employment support),
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Laboratory and radiology services, Screening, Emergency transportation, Non-emergency transportation, and • Respite care (with limits).
How do I contact my Behavioral Health Case Manager?
Gila River Behavioral Health Services is available to help answer your questions. We can help you: • • • • •
Learn how to become a member and get behavioral health services Learn about the services you can get Find a provider, including providers that provide services after normal business hours; Get answers to your questions Make a complaint or give positive feedback about services.
After the completion of an intake, you will be assigned a clinician (case manager or clinical liaison) who will assist with coordinating your behavioral health services. Your assigned clinician will: • Talk to you about your strengths and needs; • Help you to decide the kinds of services and supports that would help you the most; and • Work with you to make sure that the services and supports you receive continue to meet your needs.
To contact your assigned clinician, call Gila River Behavioral Health Services at (602) 528-7100, (520) 562-3321 ext. 7010 or 1-888-484-8526, and for hearing impaired, also use TTY services at 711 or 1-800-367-8939. Calls are answered between 8:00 a.m. and 5:00 p.m. MondayFriday, excluding holidays. Crisis services are available to any Arizona resident, regardless of health insurance coverage. If you or someone you know is experiencing a behavioral health crisis, please call 988 or one of the national or local crisis lines listed on page 6.
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Gila River Indian Community CRISIS HOTLINE: 1-800-259-3449
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Medicines AHCCCS covers medicines prescribed by your provider. There are three places you can go to get your medicines: • IHS facilities, • Tribal 638 facilities, or • Pharmacies that are part of Optum Rx’s network. AIHP FFS Pharmacy Network Please work with your physician, dentist, or other health care provider to get your prescriptions through the appropriate pharmacy. It is best to have your prescriptions filled at the same pharmacy each time. AHCCCS uses a list of preferred medicines. If your provider prescribes a medicine that is not on the preferred list, the pharmacy will work with your provider to change to a preferred medicine. If your provider disagrees with the change, your AHCCCS registered provider may need to request prior authorization for the non-preferred medicine for AHCCCS to pay for it. Medicines filled outside of an IHS/638 pharmacy will have their scripts filled through Optum Rx, AHCCCS’ Pharmacy Benefit Manager (PBM). If you have questions about your prescription benefits, please call 1-855-577-6310. You can get information about prescription benefits 24 hours a day, 7 days a week. Members may also visit our website at: https://www.azahcccs.gov/PlansProviders/Pharmacy/
Lodging and Meals When you require a medically necessary overnight stay near a treating facility located outside the geographical service area where you live, lodging and/or meal provisions can be requested when: • You are unable to arrange and pay for these services on your own and, • Charitable lodging is not available. Your provider can send in a request to cover your lodging and/or meal provisions by emailing the completed AHCCCS FFS Travel Service Request Form to Medical Transportation Management (MTM) at: CMArizonaHealthCareM&L@mtm-inc.net
Requests must be made 7-10 days in advance of the appointment date of service. For urgent requests, that could seriously affect your life or health, your provider can email caremanagers@azahcccs.gov to request an urgent review. If approved, MTM will arrange lodging and meals and will contact you for further information. 27
AIHP/TRBHA Member Handbook You must notify AHCCCS and MTM of any changes that affect the amount and/or duration of lodging/meal services, such as:
• • • • •
Changes in treatment timeframes, Early treatment discontinuation, Home on weekends, Cancellation/Rescheduled appointments/no shows, Unplanned inpatient admission.
For any issues with your travel arrangements, you can contact MTM’s 24-hour phone line for assistance at: 888-889-0296 or by email at CM-ArizonaHealthCareM&L@mtm-inc.net.
Tribal ALTCS – Arizona Long Term Care System The Tribal Arizona Long Term Care System (Tribal ALTCS) Program is a Fee-For-Service integrated health plan that delivers comprehensive patient care through the coordinated efforts of the assigned Tribal ALTCS Case Manager, various healthcare providers, and AHCCCS Division of Fee-For-Service Management (DFSM). This approach aims to provide user-friendly access to care and improve health outcomes. Eligible elderly and/or physically disabled American Indians who live on or lived on a reservation prior to admission into an off-reservation facility will be enrolled in a Tribal ALTCS Program. Members will remain eligible for Tribal ALTCS if they continue to meet Medicaid medical and financial requirements. A complete list of covered services can be found in the Tribal ALTCS member handbook. Members may receive ALTCS services through the Department of Economic Security, Division of Developmental Disabilities (DES/DDD), which is the statewide ALTCS program contractor for people with developmental disabilities. American Indians can choose the DDD Tribal Health Program (DDD THP) to receive their physical health services, behavioral health services and Children's Rehabilitative Services (if eligible) from any AHCCCS authorized fee for service provider statewide.
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Advance Directives There may be a time when you are unable to make medical decisions for yourself. An Advance Directive is a legal document that you sign to protect your right to refuse any health care that you do not want, and to receive any health care you do want. The following are different types of Advance Directives: • A living will tell providers what types of services you do or do not want if you become sick, • A medical power of attorney lets you choose a person to make decisions about your health care when you cannot do it yourself, and • A pre-hospital medical care directive tells providers if you do not want certain lifesaving emergency care that you would get outside a hospital or in a hospital emergency room.
Other Insurance Please be sure to tell your health care provider about all medical insurance that you have. Other insurance may cover some or all of your medical care and is primary to any AHCCCS coverage. This may affect what AHCCCS can cover. If there are any changes to your medical insurance, please submit a change report via Health-e-Arizona Plus at: https://www.healthearizonaplus.gov/Login/Default
Fraud and Abuse Fraud is when someone lies or gives false information with the intent to receive benefits or payments that they are not legally eligible for. Abuse means actions that result in unnecessary cost to AHCCCS. Examples of Member Fraud: • Giving someone else your AHCCCS ID card so that they can get health care services • Using someone else’s ID card to get services • Providing incorrect household composition information • Hiding employment or self-employment information • Misrepresenting medical condition/s or ethnicities Examples of Provider Fraud: • Performing and/or billing medically unnecessary services • Making false statements and false claims • Billing for services and supplies not provided • Double billing, over billing and/or incorrect coding • Committing prescription and/or pharmacy fraud • Paying for and/or receiving kickbacks
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Fraud or abuse of any type is not allowed. If fraud or abuse is suspected, please contact the AHCCCS Office of Inspector General. • (to report Member fraud) In Arizona: 602-417-4193 or Toll-Free outside of Arizona only: 888ITS-NOT-OK (888-487-6686) • (to report Provider fraud) In Arizona: 602-417-4045 or Toll-Free outside of Arizona only: 888ITS-NOT-OK (888-487-6686) Suspected fraud or abuse can also be reported with this online form: https://www.azahcccs.gov/Fraud/ReportFraud/onlineform.aspx If you have questions, contact the AHCCCS Office of Inspector General (OIG) at: AHCCCSFraud@azahcccs.gov. The primary way fraud is discovered is through reports from people like you who report it to AHCCCS. Absolutely anyone can report fraud, abuse or member abuse. There are no restrictions and reports may be anonymous. OIG depends on members, providers and the public to report any suspicious activity.
Your Right to Choose Your Health Plan As an AHCCCS member, you have the right to choose the health plan that works best for you. Your doctors and other providers should not ask you which plan to pick or try to get you to switch plans based on what works best for them. You are in charge of your health plan decisions, and no one should ask you to change your plan. If you ever feel unsure or need help understanding your options, AHCCCS is here to support you. AHCCCS Customer Service In Arizona (Maricopa County): 602-417-7000 or toll free: 1-800-962-6690
Notice of Non-Discrimination AHCCCS complies with applicable Federal civil rights laws, does not discriminate, and does not treat people differently based on race, color, national origin, age, disability, or sex. If you believe that AHCCCS, or an AHCCCS-registered contractor or provider, failed to provide these services or discriminated in another way based on race, color, national origin, age, disability, or sex, you can file a grievance with the AHCCCS Office of Administrative Legal Services. You can file a grievance in person or by mail, fax, or email. Your grievance must be in writing and must be submitted within 180 days of the date that the person filing the grievance becomes aware of what is believed to be discrimination. 30
AIHP/TRBHA Member Handbook Submit your grievance to: General Counsel, AHCCCS Administration Office of the General Counsel (OIG) 150 N 18th Ave, MD 6200 Phoenix, AZ 85007 Fax: 602-253-9115 Email: EqualAccess@azahcccs.gov You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf Or by mail at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Or by phone at: 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at: https://www.hhs.gov/ocr/complaints/index.html Concerns About the Quality of Care Received AHCCCS is committed to ensuring that all members receive quality health care and can access services. If you or any AHCCCS member have experienced a barrier to getting health care services or have concerns about the quality of services received, please report it to Clinical Quality Management (CQM) by, submitting the form at https://www.azahcccs.gov/ACMS/default.aspx Or by phone: (602) 417-4885 Or by emailing: CQM@azahcccs.gov Submit concerns that include (but are not limited to): • Inability to receive health care services; • Concerns about the quality of care received; • Issues with health care providers or health plans; or Timely access to services.
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Community Resources AHCCCS Office of Individual and Family Affairs (OIFA) OIFA’s mission has been to ensure the voices of those who receive behavioral health services, and their families are heard at every level of Arizona’s public behavioral health system OIFA@azahcccs.gov www.azahcccs.gov/AHCCCS/HealthcareAdvocacy/OIFA.html 2-1-1 Arizona Arizona Information and Referral System is a call center that can help you find many community services. Examples of services include: • Food Banks • Clothes • Shelters • Assistance to pay rent/utilities • Education Programs Dial 2-1-1 within Arizona Dial 877-211-8661 from anywhere Arizona Relay, callers: 7-1-1 or 800-367-8939 and ask for 877-211-8661 https://211arizona.org/ ARIZONA@WORK Provides comprehensive statewide and locally based workforce solutions for job seekers and employers. https://arizonaatwork.com/ Arizona Department of Health Services 150 N. 18th Ave. Phoenix, AZ 85007 602-542-1025 https://www.azdhs.gov/ Arizona Department of Health Services Children and Youth with Special Health Care Needs (CYSHCN) Program 602-542-1860 CYSHCN@azdhs.gov https://www.azdhs.gov/prevention/womens-childrens-health/cyshcn/index.php
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Community Resources Continued Arizona Early Intervention Program (AzEIP) AzEIP helps families of children with disabilities or developmental delays age birth to 3 years. 1789 W. Jefferson St., Fl4NW Phoenix, AZ 85007-3202 602-532-9960 or 1-844-770-9500 (Option 5) Referrals: 1-888-592-0140 https://des.az.gov/azeip Opioid Assistance and Referral Line Confidential advice and services available 24 hours a day, 7 days a week. Staffed by certified nurses and pharmacists. 1-888-688-4222 AZLINKS AzLinks.gov offers assistance and information on aging and disability. Use AzLinks.gov to plan for future needs or handle an immediate need for seniors, people with disabilities, caregivers, friends and family members, and professionals assisting others. 602-542-4446 https://azdaars.getcare.com/consumer/ Dump the Drugs AZ Use this tool to find a convenient disposal location for unneeded or expired prescriptions left in the home. https://www.azdhs.gov/gis/dump-the-drugs-az/ Low Income Housing Services The Housing authority of Maricopa County improves the quality of life of families and strengthen communities by developing and sustaining affordable housing programs Maricopa Housing Authority 8910 N. 78th Ave., Building D Peoria, AZ 85345 602-744-4500 https://maricopahousing.org/ Vocational Rehabilitation The Vocational Rehabilitation program provides a variety of services to persons with disabilities, with the ultimate goal to prepare for, enter into, or retain employment. https://des.az.gov/vr Family-Run Organizations Providing Children’s Services Family-run organizations employ parents who have real life experience in the behavioral, medical and/or Department of Child Safety (DCS) systems. They specialize in providing family support services and can provide one-on-one support to you. 33
AIHP/TRBHA Member Handbook https://www.azahcccs.gov/AHCCCS/Downloads/FamilyRunOrganizationsFlyer.pdf Peer-Run Organizations Peer-run organizations are service providers owned, operated and administrated by persons with lived experiences of mental health and/ or substance use disorders. These organizations are based in the community and provide support services. https://www.azahcccs.gov/AHCCCS/Downloads/PeerRunOrganizationsFlyer.pdf Women, Infants, and Children (WIC) The Arizona Supplemental Nutrition Program for Women, Infants, and Children (WIC) provide nutrition education, breastfeeding support, supplemental nutritious foods and referrals to health and social services. WIC serves pregnant, breastfeeding, and postpartum women, infants, and children under the age of five. WIC (800) 252-5942 https://www.azdhs.gov/prevention/azwic/ 24 Hour Breastfeeding Hotline: 1-800-833-4642 StrongHearts Native Helpline is a 24/7 confidential and anonymous culturally appropriate domestic and sexual violence helpline for Native Americans. 1-844-762-8483 https://strongheartshelpline.org/ https://strongheartshelpline.org/ National Domestic Violence Hotline 1-800-799-SAFE (7233) https://www.thehotline.org/ Office of Human Rights The Office of Human Rights (OHR) is part of AHCCCS, Arizona’s Medicaid program. It helps people with Serious Mental Illness (SMI) get the services they need and protects their rights. OHR makes sure that members who need Special Assistance are quickly identified and assigned a representative. The OHR provides advocacy to individuals with SMI to help them understand, protect and exercise their rights, facilitate self-advocacy through education and obtain access to behavioral health services in the public behavioral health system in Arizona. OHR Main Office 150 N 18th Ave Phoenix, AZ 85007 MD 4200 602-364-4585 or 800-421-2124 (toll free) Email: OHRts@azahcccs.gov https://azahcccs.gov/AHCCCS/HealthcareAdvocacy/ohr.html 34
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