A world full of terms and acronyms can be hard to navigate. Take a look at our list of most commonly used terms and acronyms to familiarize yourself with common industry terminology, or use the list as a reference when you need it.
AAPPD - Arizona Association of Providers for People with Disabilities
ABA - Applied Behavioral Analysis
ABILITY ONE - Formerly Javits Wagner O’Day Act that provides set aside contract opportunities with the Federal Government that employ people who are blind or severely handicapped.
Absent Parent - An individual who is absent from the home and is legally responsible for providing financial and/or medical support for a dependent child, as specified by A.A.C. R9-22-1001.
Abuse - The infliction of, or allowing another person to inflict, or cause, physical pain or injury, impairment of bodily function, disfigurement or serious emotional damage which may be evidenced by severe anxiety, depression, withdrawal, or untoward aggressive behavior. Such abuse may be caused by acts or omissions of an individual having responsiblity for the care, custody or control of a client receiving behavioral health services or community services. Abuse shall also include sexual misconducut, assault, molestation, incest, or prostitution of, or with, a client under the care of personnel of a mental health agency. A.A.C. R9-21-101(B).
Abuse - of a Child - The infliction or allowing of physical injury, impairment of bodily function or disfigurement or the infliction of or allowing another person to cause serious emotional damage as evidenced by severe anxiety, depression, withdrawal, or untoward aggressive behavior and which emotional damage is diagnosed by a medical doctor or psychologist and is caused by the acts or omissions of an individual who has the care, custody, and control of a child. As specified in A.R.S.§ 8-201(2), abuse includes:
1. Inflicting or allowing sexual abuse, sexual conduct with a minor, sexual assault, molestation of a child, commercial sexual exploitation of a minor, sexual exploitation of a minor, incest, or child sex trafficking as those acts are described in the A.R.S. Title 13, Chapter 14.
2. Physical injury that results from permitting a child to enter or remain in any structure or vehicle in which volatile, toxic, or flammable chemicals are found or equipment is possessed by any person for the purpose of manufacturing a dangerous drug as specified in A.R.S.§ 13-3401.
3. Unreasonable confinement of a child.
Abuse of a Vulnerable Adult - The intentional infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, or sexual abuse or sexual assault as specified in A.R.S. § 46-451(A)(1).
Abuse - of Member - Abuse of a Vulnerable Adult or the Abuse of a Child who is a member as specified in A.R.S. § 46-451(A)(1), A.R.S. § 8-201(2), and A.R.S. § 46-451(A)(9).
Abuse - of the AHCCCS Program - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care, noncompliance with licensure standards, misuse of billing numbers, or misuse or abuse of billing privileges. It also includes beneficiary practices that result in unnecessary cost to the AHCCCS Program [42 CFR 455.2].
Access - The timely use of services to achieve optimal outcomes, as evidenced by managed care plans successfully demonstrating and reporting on outcome information for the availability and timeliness elements specified in 42 CFR 438.68, 42 CFR 438.206, and 42 CFR 438.320.
Access to Professional Service Initiative (APSI) - A program to preserve and promote access to medical services through a uniform percentage increase to the Contractor’s rates for professional services provided by qualified physicians and non-physician professionals affiliated with designated hospitals as specified in Contract and Policy. Federal regulation mandates that these payments be prior approved by Centers for Medicare and Medicaid Services (CMS) before they shall be implemented.
ACDL - Arizona Center for Disability Law
Action - The denial or limited authorization of a requested behavioral health service. This includes:
1. Type or level of service.
2. Reduction, suspension, or termination of a previously authorized service.
3. Denial, in whole or in part, of payment for a service.
4. Failure to provide covered services in a timely manner.
5. Failure to act within established timeframes for resolving an Appeal or complaint and providing notice to affected parties, and
6. Denial of the Title XIX/XXI eligible person's request to obtain covered services outside the network.
Active Treatment - A current need for treatment. The treatment is identified on the member’s service plan to treat a serious and chronic physical, developmental, or behavioral condition requiring medically necessary services of a type or amount beyond that generally required by members that lasts, or is expected to last one year or longer, and requires ongoing care not generally provided by a primary care provider.
Active Treatment - Children's Rehabilitation Services (CRS) - A current need for treatment of the CRS qualifying condition(s) or it is anticipated that treatment or evaluation for continuing treatment of the CRS qualifying condition(s) will be needed within the next 18 months from the last date of service for treatment of any CRS qualifying condition as specified in A.A.C. R9-22-1301.
Activities of Daily Living - Activities a member shall perform daily for the member’s regular day-to-day necessities, including but not limited to mobility, transferring, bathing, dressing, grooming, eating, and toileting.
Actual Acquisition Cost - The purchase price of a drug paid by a pharmacy net of all discounts, rebates, chargebacks, and other adjustments to the price of the drug, not including professional fees.
Actuary - An individual who meets the qualification standards established by the American Academy of Actuaries for an actuary and follows the practice standards established by the Actuarial Standards Board. An actuary develops and certifies the capitation rates as specified in 42 CFR 438.2.
Acute - Symptoms that are characterized by sharpness or severity, have a sudden onset, have arisen quickly, and are short-lived.
Acute Care Hospital - A general hospital that provides surgical services and emergency services.
Adjudicated Claim - A claim that has been received and processed by the Contractor which resulted in a payment or denial of payment.
Administrative Appeal - An appeal to AHCCCS of a decision made by a contractor as the result of a grievance.
Administrative Office Of the Courts (AOC) - The Arizona Constitution authorizes an administrative director and staff to assist the Chief Justice with administrative duties. Under the direction of the Chief Justice, the administrative director, and the staff of the Administrative Office of the Courts (AOC) provide the necessary support for the supervision and administration of all State courts.
Administrative Services Subcontract/Subcontractor - An agreement that delegates any of the requirements of the Contract with AHCCCS, including, but not limited to the following:
1. Claims processing, including pharmacy claims.
2. Pharmacy Benefit Manager (PMB).
3. Dental Benefit Manager.
4. Credentialing, including those for only primary source verification (i.e., Credential Verification Organization).
5. Management Service Agreements.
6. Medicaid Accountable Care Organization (ACO).
7. Service Level Agreements with any Division or Subsidiary of a corporate parent owner, and
8. CHP and DDD Subcontracted Health Plan.
A person (individual or entity) who holds an Administrative Services Subcontract is an Administrative Services Subcontractor. Providers are not Administrative Services Subcontractors.
Adoptive Parent(s) - Any adult(s) who is a resident of Arizona, whether married, unmarried, divorced or legally separated, who has adopted a child who is eligible under Title XIX or Title XXI of the Social Security Act.
Adult - An individual 18 years of age or older, unless the term is given a different definition by statute, rule, or policies adopted by AHCCCS.
Adult Day Health Services - A program that provides planned care, supervision and activities, personal care, personal living skills training, meals, and health monitoring in a group setting during a portion of a continuous 24 hour period. Adult day health services may also include preventive, therapeutic and restorative health-related services that do not include behavioral health services as specified in A.R.S. § 36-401.
Adult Developmental Home (ADH) - An Alternative Home and Community Based Services (HCBS) Setting for adults (18 or older) with Developmental Disabilities (DD) which is licensed by Department of Economic Securities (DES) to provide room, board, supervision and coordination of habilitation and treatment for up to three residents as specified in A.R.S. § 36-551.
Adult Foster Care (AFC) Home - An Alternative Home and Community Based Services (HCBS) Setting that provides room and board, supervision, and coordination of necessary adult foster care services within a family type environment for at least one and no more than four adult residents who are ALTCS members.
Adult Group Above 106 Percent Federal Poverty Level (Adults > 106 Percent) - Adults aged 19-64, without Medicare, with income above 106 percent through 133 percent of the Federal Poverty Level (FPL).
Adult Group at or Below 106 Percent Federal Poverty Level (AdultsAdults aged 19-64, without Medicare, with income at or below 106 percent of the Federal Poverty Level (FPL).
Adult Protective Services (APS) - A Program within the Arizona Department of Economic Security (DES) that investigates allegations and provides service referrals to protect vulnerable adults from abuse, neglect, or exploitation.
Adult Recovery Team (ART) - A group of individuals that, following the Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems, work in collaboration and are actively involved in a member's assessment, service planning, and service delivery. At a minimum, the team consists of the member, member’s Health Care Decision Maker (HCDM) (if applicable), advocates (if assigned), and a qualified behavioral health representative. The team may also include the member's family, physical health, behavioral health or social service providers, other agencies serving the member, professionals representing various areas of expertise related to the member's needs, or other individuals identified by the member.
Advance - Includes but is not limited to payment to a provider or affiliate by a Contractor which is based on an estimate of Received But Unpaid Claims (RBUCs), an estimate of the value of erroneous claim denials (including underpayments), a loan, or as otherwise defined by the Contractor.
Advance Care Planning - A part of the End of Life care concept and is a billable service that is a voluntary face-to-face ongoing discussion between a qualified health care professional and the member/ Health Care Decision Maker (HCDM) to:
1. Educate the member/HCDM and Designated Representative (DR) about the member’s illness and the health care options that are available to them.
2. Develop a written plan of care that identifies the member/HCDMs choices for treatment, and
3. Share the member/HCDMs wishes with family, friends, and his or her physicians.
Advance Directive - A document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.
Advanced Life Support (ALS) - Refer to the term Transportation - Advanced Life Support.
Adverse Benefit Determination - The denial or limited authorization of a service request, or the reduction, suspension, or termination of a previously approved service.
Adverse Drug Event (ADE) - An injury resulting from medical intervention related to a drug including harms that occur during medical care that are directly caused by the drug including but not limited to medication errors, adverse drug reactions, allergic reactions, and overdose.
Affiliate (Related Party) Transactions - Transactions with a party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by the Contractor. Control, for purposes of this definition, means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of an enterprise through ownership, by contract, or otherwise. “Related parties” or “Affiliates” include, but are not limited to, agents, managing employees, individuals with an ownership or controlling interest in the disclosing entity, and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and other entities controlled or managed by any such entities or individuals.
Affiliate (Related Party) - A party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by a Contractor. "Related parties" include, but are not limited to, agents, managing employees, individuals with an ownership or controlling interest in the Contractor and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and other entities controlled or managed by any such entities or individuals.
Affiliated Organization - A party that, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with an entity.
Affordable Care Act (ACA) - Federal statute signed into law in March 2010 as part of comprehensive health insurance reforms that will, in part, expand health coverage, expand Medicaid eligibility, establish health insurance exchanges, and prohibit health insurers from denying coverage due to pre-existing conditions. The Affordable Care Act is also referred to as the Patient Protection and Affordable Care Act (ACA).
Agency With Choice (AWC) - An option offered to ALTCS members who reside in his/her own home. This option is elective as a member or the member’s Individual Representative (IR) may choose to participate in AWC. Under the AWC option, the provider agency and the member/IR enter into a partnership agreement. The provider agency serves as the legal employer of the Direct Care Worker (DCW) and the member/IR serves as the day-to-day managing employer of the DCW.
Agent - Any individual who has been delegated the authority to obligate or act on behalf of a provider as specified in 42 CFR 455.101.
Aggregate Lifetime Dollar Limit - A dollar limitation on the total amount of specified benefits that may be paid under a Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PIHP), or Prepaid Ambulatory Health Plan (PAHP).
AHCCCS Claims Dashboard Reporting Guide - A document designed to assist the Contractor in submitting a monthly report to address claim requirements, including billing rules and documentation requirements, and submit a report to AHCCCS that will include the rationale for specific requirements.
AHCCCS Contractor Operations Manual (ACOM) - Policies to consolidate and provide ease of access to the Administrative, Claims, Financial, and Operational Policies of the AHCCCS Administration.
AHCCCS Drug List - A list of federally and state reimbursable behavioral health and physical health care medications that is to be used by AHCCCS Fee-For-Service (FFS) Programs and all Contractors responsible for the administration of acute and long-term care pharmacy benefits. This drug list identifies specific federally and state reimbursable medications and related products, which are supported by current evidence-based medicine. The AHCCCS Drug List includes preferred drugs and was developed to encourage the use of safe, effective, clinically appropriate, and the most cost-effective medications.
AHCCCS Eligibility Determination - The process of determining, through an application and required verification, whether an applicant meets the criteria for Title XIX/XXI funded services.
AHCCCS Fee-For-Service (FFS) Program - An AHCCCS program administered by the AHCCCS/Division of Fee-For-Service Management (DFSM) using the original Medicaid payment model, where a fee is paid for each medically necessary service provided (e.g., office visit, test, procedure). Members enrolled in an FFS program may receive AHCCCS-covered services from any AHCCCS-registered provider. Note: Providers do not need to separately contract with any FFS program to render and bill for Medicaid Title XIX/XXI services provided to FFS members. Providers can bill FFS after they enter into a provider participation agreement with AHCCCS Provider Registration. Providers with active registration with AHCCCS Provider Registration serve as the FFS provider network.
AHCCCS Grievance and Appeal System Guide - A document that provides instructions to the Contractors on how to complete the Grievance System Report for submission to and review by the Division of Health Care Management (DHCM), as required by contract.
AHCCCS Housing Acquisition, Construction, and/or Renovation Programs - A housing program that provides state funding (including the Serious Mental Illness (SMI) Housing Trust Fund per A.R.S. § 41-3955.01) for the acquisition, construction and/or renovation of properties (house, condominium, duplex, apartment, new construction etc.) to provide permanent supportive housing for persons designated SMI. The property is held for use of AHCCCS eligible members for an extended period of time through the use of filed Covenants, Conditions, and Restrictions (CC&Rs).
AHCCCS Medical Policy Manual (AMPM) - Provides information to Contractors and Providers regarding services that are covered within the AHCCCS program.
AHCCCS Policy Committee (APC) - A group of individuals comprised of Agency Management and Subject Matter Experts (SME)s within AHCCCS along with external stakeholder and tribal representatives who review and approve new and revised Policies found in both the AHCCCS Contractor Operations Manual (ACOM) and AHCCCS Medical Policy Manual (AMPM).
AHCCCS/Office of the Inspector General (OG) - The AHCCCS Office of Inspector General (AHCCCS-OIG) is the division of AHCCCS that has the authority to conduct preliminary and full investigations relating to fraud, waste, and abuse involving the programs administered by AHCCCS.
AHCCCS/Division of Community Advocacy and Intergovernmental Relations (DCAIR) - The division responsible for community advocacy and Intergovernmental Relations that interface with members, family members and other stakeholders ensuring the voice of the community is heard.
AHCCCS/Division of Fee-For-Service Management (DFSM) - The division responsible for the clinical, administrative and claims functions of the Fee-For-Service (FFS) members. This includes American Indians enrolled in the American Indian Health Program (AIHP) for acute care, members enrolled with the Tribal Regional Behavioral Health Authorities for behavioral health services and Tribal long term care programs, and individuals in the Federal Emergency Service population (FES). DFSM pays FFS provider claims, prior authorizes certain medical and behavioral health services, provides ongoing training, completes clinical claims reviews, provides customer services to FFS providers, and completes care coordination activities for the FFS population. DFSM also acts as the Third Party Administrator for the School Based Claiming program.
AHCCCS/Division of Fee-For-Service Management (DFSM) Quality Management (QM) - A unit within the AHCCCS Division of Fee-For-Service Management (DFSM) that oversees Fee-For-Service (FFS) Quality Management (QM) activities, including but not limited to, Quality of Care (QOC) investigations and Health and Safety inspections.
AHCCCS/Division of Grants Administration (DGA) - A division within AHCCCS that is the point of contact related to the pursuit, implementation and oversight of grants administered by the agency. DGA is inclusive of both programmatic and financial teams. Together, the teams work closely with each other to ensure the effective communication, oversight, and implementation of all Grant management for the agency.
AHCCCS/Division of Healthcare Management (DHCM) - The division responsible for Contractor oversight regarding AHCCCS Contractor operations, quality, maternal and child health, behavioral health, medical management, case management, rate setting, encounters, and financial/operational oversight.
AHCCCS/Division of Health Care Management (DHCM), Quality Improvement (QI) Team - AHCCCS staff who evaluates Contractor Quality Management/Performance Improvement (QM/PI) Programs; monitors compliance with required Quality/Performance Improvement Standards, Contractor Corrective Action Plans (CAPs) and Performance Improvement Projects (PIPs); and provides technical assistance for QM/PI related matters.
AHCCCS/Division of Health Care Management (DHCM), Quality Managment Team - AHCCCS staff who researches and evaluates Quality of Care (QOC) concerns; provides oversight of contractor credentialing and delegation processes; monitors compliance with required quality standards and Contractor Corrective Action Plans (CAPs); and provides technical assistance for Quality Management (QM) related matters.
AHCCCS Registered Provider - A contracted provider or non-contracting provider who enters into a provider agreement with AHCCCS and meets licensing or certification requirements to provide AHCCCS-covered services.
Air Ambulance - Refer to the term Transportation - Air Ambulance
ALIS Online - The Internet service provided by the legislature to make available to the general public most of the paperwork of the legislature. The ALIS Online address is http://www.azleg.state.az.us
Allocation Letter - Communication provided by AHCCCS to identify funding not otherwise included in the "Original" Allocation Schedule and specific terms and conditions for receipt of Non-Title XIX/XXI funding.
Allocation Scheduled - The schedule prepared by AHCCCS that specifies the Non-Title XIX/XXI non-capitated funding sources by program including Mental Health Block Grant (MHBG) and Substance Abuse Block Grant (SABG) Federal Block Grant funds, discretionary grant funds, State General Fund appropriations, county, and other funds, which are used for services not covered by Title XIX/XXI funding and for populations not otherwise covered by Title XIX/XXI funding.
Alternate Electronic Visit Verification (EVV) System - Refer to the term Electronic Visit Verification (EVV) System – Alternate.
Alternative Home and Community Based Services (HCBS) Setting - A living arrangement where a member may reside and receive HCBS. The setting shall be approved by the director, and either (1) licensed or certified by a regulatory agency of the state, or (2) operated by the IHS, an Indian tribe or tribal organization, or an urban Indian organization, and has met all the applicable standards for state licensure, regardless of whether it has actually obtained the license (A.A.C. R9-28-101). The possible types of settings include:
1. For an individual with a developmental disability:
a. Community residential setting,
b. Group home,
c. State-operated group homes,
d. Group foster homes,
e. Adult behavioral health therapeutic homes,
f. Behavioral health residential facilities,
g. Behavioral health respite homes, and
h. Substance abuse transitional facilities.
2. For an individual who is Elderly and Physically Disabled (E/PD):
a. Adult foster care homes,
b. Assisted living homes or assisted living centers, units only,
c. Adult behavioral health therapeutic homes,
d. Behavioral health residential facilities,
e. Behavioral health respite homes, and
f. Substance abuse transitional facilities.
Ambulance - Refer to the term Transportation – Ambulance
Ambulatory Care - Preventive, diagnostic, and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and/or other health care providers.
Ambulatory Transportation - Refer to the term Transportation – Ambulatory.
American Indian Health Program (AIHP) - A Fee-For-Service program administered by AHCCCS for Title XIX/XXI eligible American Indians which reimburses for physical and behavioral health services provided by and through the Indian Health Service (IHS), tribal health programs operated under 638 or any other AHCCCS registered provider.
Americans with Disabilities Act (ADA) - The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities transportation, and telecommunications as specified in the Americans with Disabilities Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C. 5.
Anniversary Date - The anniversary date is 12 months from the date the member is enrolled with the Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date the member was given an opportunity to change.
Annual Dollar Limit - Total amount of specified benefits that may be paid in a fiscal year 12-month period under a Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PIHP), or Prepaid Ambulatory Health Plan (PAHP).
Annual Enrollment Choice (AEC) - The opportunity for an individual to change Contractors every 12 months.
Appeal - The request for review of an adverse benefit determination.
Appeal Resolution - The written determination by the Contractor concerning an appeal.
Appeal - Serious Mental Illness (SMI) - A request for review of an adverse decision by a Contractor or AHCCCS.
Applicant - 1. Submits an application for behavioral health services as specified in A.A.C. Title 9, Chapter 21, or on whose behalf an application has been submitted, or
2. Is referred for a determination of eligibility for behavioral health services, as specified in A.A.C. R9-21-101.
Appointment - A scheduled day and time for an individual to be evaluated, treated, or receive a service by a healthcare professional or service provider by within their scope of practice.
Approved Direct Care Worker (DCW) Training and Testing Program (Approved Program or Program) - Any entity that is approved by AHCCCS to provide training and testing of Direct Care Workers (DCWs. These Approved Programs can be an AHCCCS registered agency that provides Direct Care Services, a private vocational program, or an educational institution (e.g., high school, college, or university).
Arizona - National Breast and Cervical Cancer Early Detection Program (AZ - NBCCEDP) - An Arizona program that provides breast and cervical cancer screening and diagnosis as specified in A.A.C. R9-22-2001.
Arizona Adminsitrative Code (A.A.C.) - The official pubication of Arizona's codified Rules and published by the Administrative Rules Division.
Arizona Association of Health Plans (AzAHP) - AzAHP is an organization dedicated to working with elected officials, AHCCCS Health Care Plans, health care providers, and consumers to keep quality health care available and affordable for all Arizonans. AzAHP is involved in administration of the chart audit process for physical health plan sites and they collaborate with the Contractors with regard to the behavioral health chart audit process.
Arizona Department of Child Safety (DCS) - DCS was established pursuant to A.R.S. § 8-451 et. Seq. to protect children and perform the following:
1. Investigate reports of abuse and neglect.
2. Assess, promote, and support the safety of a child in a safe and stable family or other appropriate placement in response to allegations of abuse or neglect.
3. Work cooperatively with law enforcement regarding reports that include criminal conduct allegations.
4. Without compromising child safety, coordinate services to achieve and maintain permanency on behalf of the child, strengthen the family, and provide prevention, intervention, and treatment services pursuant to this chapter.
Arizona Department of Health Services (ADHS) - The State agency that has the powers and duties set forth in A.R.S. § 36-104 and A.R.S. Title 36, Chapters 5 and 34.
Arizona Department of Juvenile Correction (ADJC) - The State agency responsible for all juveniles adjudicated as delinquent and committed to its jurisdiction by the county juvenile courts.
Arizona Health Care Cost Containment System (AHCCCS) - Arizona’s Medicaid Program, approved by the Centers for Medicare and Medicaid Services as a Section 1115 Waiver Demonstration Program and described in A.R.S. Title 36, Chapter 29.
Arizona Long Term Care System Elderly and/or Phyiscal Disabilities (ALTCS E/PD) - An AHCCCS program which delivers long-term, acute, behavioral health and case management services as authorized by A.R.S. § 36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with developmental disabilities, through contractual agreements and other arrangements.
Arizona Long Term Care Services (ALTCS) Local Office - The Arizona Long Term Care System (ALTCS) local office currently responsible for the member’s financial eligibility case record.
Arizona Long Term Care Services (ALTCS) Transitional Program - A program available for eligible Arizona Long Term Care System (ALTCS) members who, at the time of medical reassessment, have improved either medically, functionally, or both, to the extent that they no longer need institutional care, but who still need significant Long-Term Services and Supports (LTSS). The eligible member will continue to require some LTSS, but at a lower level of care. The ALTCS Transitional program allows those members who meet the lower level of care, as determined by the Pre-Admission Screening (PAS), to continue to receive all ALTCS covered services that are medically necessary. Refer to 9 A.A.C. 28, Article 3.
Arizona Revised Statutes (A.R.S.) - The laws of Arizona. The set of books which contains the Constitution and laws enacted by the Legislature to govern the state. These are updated each legislative session. http://www.azleg.gov/ArizonaRevisedStatutes.asp
Arizona State Hospital (AZSH) - Provides long-term inpatient psychiatric care to Arizonans with mental illnesses who are under court order for treatment.
Arizona State Plan - The written agreements between the State and Centers for Medicare and Medicaid Services (CMS), which describes how the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children's Health Insurance Program (CHIP).
Assessment - An analysis of a patient’s needs for physical health services or behavioral health services to determine which services a health care institution shall provide to the patient as specified in A.A.C. R9-10-101.
Assessment - Behavioral Health - The ongoing collection and analysis of an individual’s medical, psychological, psychiatric, and social conditions in order to initially determine if a health disorder exists, if there is a need for behavioral health services, and on an ongoing basis ensure that the individual’s service plan is designed to meet the individual’s (and family’s) current needs and long term goals.
Assisted Living Center (ALC) - A facility that provides resident rooms or residential units, supervision, and coordination of necessary services to 11 or more residents as specified in A.R.S. § 36-401. Members residing in an ALC shall be provided the choice of single occupancy.
Assisted Living Facility (AHF) - A residential care institution that provides supervisory care services, personal care services or directed care services on a continuing basis. All approved residential settings in this category are required to meet Arizona Department of Health Services (ADHS) licensing criteria as specified in A.A.C. R9-10 Article 8.
Assisted Living Home (ALH) - An Alternative Home and Community Based Services (HCBS) Setting that provides room and board, supervision, and coordination of necessary services to 10 or fewer residents.
ATC - Attendant Care
Authorized Representative - An individual who is authorized to apply for medical assistance or act on behalf of another individual as specified in A.A.C. R9- 22-101, A.A.C. R9-28-401.
Auto-Assignment - The process by which members who do not exercise their right to choose a Contractor, and members who are not assigned a Contractor based on family continuity rules are assigned to a Contractor through an auto-assignment algorithm. The algorithm is a mathematical formula used to assign members to the various Contractors in a manner that is predictable and consistent with AHCCCS goals. Members who do not exercise their right to choose a Contractor and those who are not assigned a Contractor based on family continuity rules are assigned to a Contractor through an auto-assignment algorithm.
Average Manufacturer Price (AMP) - The average price paid by wholesalers for drugs distributed to the retail class of trade, net of customary prompt pay discounts.
Average Speed of Answer (ASOA) - The average on line wait time in seconds that the member/ provider waits from the moment the call is connected in the Contractor’s phone switch until the call is picked up by a contractor’s representative or Interactive Voice Recognition System (IVR).
AzEIP - Arizona Early Intervention Program
Baseline Data - Data collected at the beginning of a Performance Improvement Project that is used as a starting point for measurement and the basis for comparison with subsequent remeasurement(s) in demonstrating significant and sustained improvement.
Basic Life support (BLS) - Refer to the term Transportation - Basic Life Support (BLS).
BCaBA - Board Certified Assistant Behavior Analyst
BCBA - Board Certified Behavior Analyst
Bed Hold - A 24 hour per day unit of service that is authorized by an ALTCS member’s case manager or the behavioral health case manager or a subcontractor for an acute care member, which may be billed despite the member’s absence from the facility for the purposes of short term hospitalization leave and therapeutic leave as specified in the Arizona Medicaid State Plan, 42 CFR 447.40 and 42 CFR 483.12, 9 A.A.C. 28.
Behavioral Analysis Services - The use of behavior analysis to assist an individual to learn new behavior, increase existing behavior, reduce existing behavior, and emit behavior under precise environmental conditions as specified in A.R.S. § 32-2091.
Behavioral Analysis Trainee - An individual who has met the credentialing requirements of a nationally recognized behavior analyst certification board as a board certified behavior analyst, assistant behavior analyst, or a matriculated graduate student or trainee whose activities are part of a defined behavior analysis program of study, practicum, intensive practicum, or supervised independent fieldwork. The practice under this role requires direct and ongoing supervision consistent with the standards set by a nationally recognized behavior analyst certification board as determined by the Arizona Board of Psychologist Examiners, and as specified in A.R.S. § 32-2091.08.
Behavioral Analyst - An individual who is licensed to practice behavior analysis. As specified in A.R.S § 32-2091.
Behavioral Health Assessment - Refer to the term Assessment - Behavioral Health.
Behavioral Health - Mental health and substance use collectively.
Behavioral Health Condition - Mental, behavioral, or Neurodevelopmental Disorder diagnosis defined by International Classification of Diseases, Tenth Revision, Clinical Modification.
Behavioral Health Diagnosis - Diagnoses listed in the Standard Service Set in AHCCCS Reference File (RF) 724.
Behavioral Health Disorder - Any behavioral, mental health, and/or substance use diagnoses found in the most current version of the Diagnostic and Statistical Manual of Mental Disorders excluding those diagnoses such as intellectual disability, learning disorders and dementia, which are not typically responsive to mental health or substance use treatment.
Behavioral Health Facility - A health care institution, as specified in A.A.C. R9-10-101, that provides continuous treatment to an individual experiencing a behavioral health issue that causes the individual to:
1. Have a limited or reduced ability to meet the individual's basic physical needs.
2. Suffer harm that significantly impairs the individual’s judgement, reason, behavior, or capacity to recognize reality.
3. Be a danger to self.
4. Be a danger to others.
5. Be a person with a persistent or acute disability as specified in A.R.S. § 36-501, or
6. Be a person with a grave disability as specified in A.R.S. § 36-501.
Behavioral Health Inpatient Facilities (BHIF)- A health care institution, as specified in A.A.C. R9-10-101, that provides continuous treatment to an individual experiencing a behavioral health issue that causes that individual to:
1. Have a limited or reduced ability to meet the basic physical needs.
2. Suffer harm that significantly impairs the judgment, reason, behavior, or capacity to recognize reality.
3. Be a danger to self.
4. Be a danger to others.
5. Be persistently or acutely disabled as specified in A.R.S. § 36-501, or
6. Be gravely disabled.
Behavioral Health Out-of-Home Treatment -Highly individualized treatment services and support interventions to meet the needs of each child and his or her family. When community-based services are not effective in maintaining the child in his/her home setting, or safety concerns become critical, the use of out of home treatment services can provide essential behavioral health interventions to stabilize the situation. The primary goal of out of home treatment intervention is to prepare the child and family, as quickly as possible, for the child’s safe return to his/her home and community settings.
Behavioral Health Paraprofessional (BHPP) - As specified in A.A.C. R9-10-101, an individual who is not a Behavioral Health Professional who provides behavioral health services at or for a health care institution according to the health care institution’s policies and procedures that:
1. If the behavioral health services were provided in a setting other than a licensed health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. § 32, Chapter 33, and
2. Are provided under supervision by a Behavioral Health Professional.
Behavioral Health Professional (BHP) -
1. An individual licensed under A.R.S. § 32, Chapter 33, whose scope of practice allows the individual to:
a. Independently engage in the practice of behavioral health as specified in A.R.S. § 32-3251, or
b. Except for a licensed substance abuse technician, engage in the practice of behavioral health as specified in A.R.S. § 32-3251 under direct supervision as specified in A.A.C. R4-6-101.
2. A psychiatrist as specified in A.R.S. § 36-501.
3. A psychologist as specified in A.R.S. § 32-2061.
4. A physician.
5. A behavior analyst as specified in A.R.S. § 32-2091.
6. A registered nurse practitioner licensed as an adult psychiatric and mental health nurse, or
7. A registered nurse:
a. A psychiatric-mental health nursing certification, or
b. One year of experience providing behavioral health services.
Behavioral Health Residential Facility (BHRF) - As specified in A.A.C. R9-10-101, a health care institution that provides treatment to an individual experiencing a behavioral health issue that:
1. Limits the individual’s ability to be independent, or
2. Causes the individual to require treatment to maintain or enhance independence.
Behavioral Health Residential Facility (BHRF) Secured - As specified in A.R.S. § 36-425.06 (B) and A.A.C. R9-10-101 (36), "secure" means premises that limit a patient's egress in the least restrictive manner consistent with the patient's court-ordered treatment plan and is a healthcare institution that provides treatment to an individual experiencing a behavioral health issue that limits the individual's ability to receive treatment in an independent setting.
Behavioral Health Residential Facility (BHRF) Staff - An employee of the behavioral health residential facility agency including but not limited to administrators, behavioral health professionals and behavioral health technicians.
Behavioral Health Services - Physician or practitioner services, nursing services, health-related services, or ancillary services provided to an individual to address the individual's behavioral health issue.
Behavioral Health Technician (BHT) - An individual who is not a Behavioral Health Professional (BHP) who provides the following services to a patient to address the patient's behavioral health issue:
1. With clinical oversight by a BHP, services that, if provided in a setting other than a health care institution, would be required to be provided by an individual licensed as specified in A.R.S. § 32, Chapter 33, and
2. Health-related services.
Benchmark - The process of comparing a practice’s performance with an external standard to motivate engagement in quality improvement efforts and understand where performance falls in comparison to others. Benchmarks may be generated from similar organizations, quality collaboratives, and authoritative bodies.
Benefit Package - All benefits provided to a specific population group or targeted residents (e.g., individuals with a Serious Mental Illness [SMI] designation) regardless of the Health Care Delivery System.
Benefits - Health care services that are intended to maintain or improve the health status of dual eligible members, for which the Medicare Advantage Organization (MAO) incurs a cost or liability under a Centers for Medicare and Medicaid Services (CMS) approved Plan Benefits package offered by the MAO (not solely an administrative processing cost).
Bereavement Counseling - Emotional, psychosocial, and spiritual support and services provided before and after the death of a member to assist the family with issues related to grief, loss, and adjustment.
Biosimilar - A biological drug approved by the Food and Drug Administration (FDA) based on a showing that it is highly similar to an FDA-Approved biological drug, known as the reference product, and has no clinically meaningful differences in terms of safety and effectiveness from the reference product.
Board Certified - An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification and when applicable, requirements for maintenance of certification.
Border Communities - Cities, towns, or municipalities located in Arizona and within a designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding neighboring countries, due to service availability or distance.
Breast and Cervical Cancer Treatment Program (BCCTP) - Eligible individuals under the Title XIX expansion program for women with income up to 250 percent of the Federal Poverty Level (FPL), who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.
Broadcast - Video, Audio, or text transmitted through Social Networking Applications, via internet, cellular or wireless network for display on any device (e.g., comments, podcasts, blogs).
Business Day - Refer to the term Day – Business/Working.
Calendar Day - Includes every day of the week including weekends and holidays.
Care Management - A group of activities performed to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost, and help achieve better health care outcomes. Distinct from case management, care management does not include the day-to-day duties of service delivery.
Care Plan - A documented description of physical health services and behavioral health services expected to be provided to a resident, based on the resident's comprehensive assessment that includes measurable objectives and the methods for meeting the objectives.
Care Giver - A caregiver is an adult who is providing for the physical, emotional, and social needs (i.e., caring for) a child who is under the care, custody, and contractor. Examples of Caregivers can include birth parent(s), foster parent(s), adoptive parent(s), kin or relative(s), group home staff. Caregivers can be licensed or unlicensed.
CARF - Commission on Accreditation of Rehabilitation Facilities
Case Management - A collaborative process, which assess, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.
Case Management Experience - Human service related experience requiring care coordination across service delivery systems and work involving assessing, evaluating, and monitoring services for individuals with special health care needs related but not limited to conditions such as physical and/or intellectual disabilities, aging, physical and/or behavioral health disorders, and substance use disorder.
Case Manager - An individual assigned as responsible for locating, accessing, and monitoring the provision of services to individuals in conjunction with a clinical team as specified in A.A.C. Title 9, Chapter 21 and Chapter 28, and Title 6, Chapter 6.
Case Manager - Assigned - The individual or team assigned by the Contractor who is responsible for locating, accessing, and monitoring the provision of all services as specified in contract for high needs children and members with a Serious Mental Illness (SMI) designation.
Case Management - Provider - An individual assigned as responsible for locating, accessing, and monitoring the provision of services to individuals in conjunction with a clinical team as specified in A.A.C. Title 9, Chapter 21 and Chapter 28, and Title 6, Chapter 6.
CBE - Center Based Employment
Center For Substance Abuse Treatment (CSAT) - Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) center to promote community-based substance abuse treatment and recovery services for individuals and families in every community. CSAT provides national leadership to improve access, reduce barriers, and promote high quality, effective treatment, and recovery services.
Center-Based Employment (CBE) - A service that provides a controlled and protected work environment, additional supervision and other supports for individuals engaged in remunerative work either in a work center or in the community.
Centers For Disease Control and Prevention (CDC) - A federal agency under the Department of Health and Human Services, based in Atlanta, Georgia, that provides information and tools to promote health, prevent disease, injury and disability and prepare for new health threats.
Centers For Medicare and Medicaid Services (CMS) - The federal agency within the United States Department of Health and Human Services (HHS), which administers the Medicare (Title XVIII) and Medicaid (Title XIX) programs and the State Children’s Health Insurance Program (Title XXI).
Centers of Excellence (COE) - A facility and/or program that is recognized as providing the highest levels of leadership, quality, and service. Centers of Excellence align physicians and other providers to achieve higher value through greater focus on appropriateness of care, clinical excellence, and patient satisfaction.
Certificate of Partnership - The basic legal instrument filed with a state to form partnership. A Certificate of Partnership is not required to form a partnership in the State of Arizona.
Certified Nurse Midwife (CNM) - An individual certified by the American College of Nursing Midwives (ACNM) on the basis of a national certification examination and licensed to practice in Arizona by the State Board of Nursing. CNMs practice independent management of care for pregnant women and newborns, providing antepartum, intrapartum, postpartum, gynecological, and newborn care, within a health care system that provides for medical consultation, collaborative management, or referral.
Change in Organizational Structure - Any of the following:
b. Change in organizational documents (e.g., Amendments to Articles of Incorporation, Articles of Incorporation, Articles of Organization) or Certificate of Partnership.
c. Change in Ownership.
d. Change of Management Services Agreement (MSA) Subcontractor (to the extent management of all or substantially all plan functions have been delegated to meet AHCCCS contractual requirements).
e. Joint Venture.
h. State Agency reorganization resulting from an act of the Governor of the State of Arizona or the Arizona State Legislature.
i. Other applicable changes which may cause:
i. A change in the Employer Identification Number/Tax Identification Number (EIN/TIN),
ii. Changes in critical member information, including the website, member or provider handbook and member ID card, or
iii. A change in legal entity name.
Change in Ownership - Any change in the possession of ownership interests in equity, capital, stock, profits, or voting rights with respect to a business such that there is a change in the persons or entities having the controlling interest of an organization, such as changes that result from a Merger or Acquisition, or, with respect to nonstock corporations (e.g., non-profit corporations, limited liability companies or partnerships), a change in the members or sponsors of the corporation or in the voting rights of the members, partners, or sponsors of the corporation.
Chemical Restraint - A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Refer to 42 CFR 482.13 (e)(1)(I)(B). Chemical Restraints shall be interpreted and applied in compliance with the Center for Medicaid Services (CMS) State Operations Manual, for further Regulations and Interpretive Guidelines for Hospitals.
Child - An individual under the age of 18, unless the term is given a different definition by statute, rule or policies adopted by AHCCCS.
Child - Kidscare - An individual under the age of 19 years.
Child and Family Team (CTF) - A group of individuals that includes, at a minimum, the child and their family, or Health Care Decision Maker (HCDM). A behavioral health representative, and any individuals important in the child’s life that are identified and invited to participate by the child and family. This may include teachers, extended family members, friends, family support partners, healthcare providers, coaches, and community resource providers, representatives from churches, temples, synagogues, mosques, or other places of worship/faith, agents from other service systems like the Arizona Department of Child Safety (DCS) or the Division of Developmental Disabilities (DDD). The size, scope, and intensity of involvement of the team members are determined by the objectives established for the child, the needs of the family in providing for the child, and by who is needed to develop an effective service plan, and can therefore, expand and contract as necessary to be successful on behalf of the child.
Child Developmental Certified Homes - An Alternative Home and Community Based Services (HCBS) residential setting for members who are under age 18 with developmental disabilities which is licensed by Department of Economic Security (DES) and provide room and board, supervision and coordination of habilitation and treatment for up to three residents as specified in A.R.S. § 36-593.01.
Children's Rehabilitative Services (CRS) - Program that provides covered medical services and covered support services in accordance with A.A.C. R9-22-1303 and A.R.S. § 36-2912.
Children's Rehabilitative Services (CRS) Application - A submitted form with additional documentation required by the AHCCCS/Division of Member and Provider Services (DMPS)in order to make a determination whether an AHCCCS member is medically eligible for a CRS Designation.
Children's Rehabilitative Services (CRS) Condition - Any of the covered medical conditions in A.A.C. R9-22-1303 which are referred to as covered conditions in A.R.S. § 36-2912.
CHIP - Children's Health Insurance Program (Known as KidsCare in Arizona)
Chronic - A health related state that is not acute.
Claim Dispute - A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance.
Clean Claim - A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as specified in A.R.S. § 36-2904.
Client Assessment and Tracking System (CATS) - A component of AHCCCS’ data management information system that supports the Arizona Long Term Care System (ALTCS) and that is designed to provide key information to and receive key information from ALTCS Contractors.
Clinical Breat Exam - A physical examination of the breasts by a health care provider used as a primary diagnostic procedure for early detection of breast cancer.
Clinical Laboratory Improvement Act (CLIA) - A certificate issued on the basis of the laboratory’s accreditation by an organization approved by Centers for Medicare and Medicaid