You must try arranging your own transportation to and from your medical appointments. You must try to use your own car, take the bus, or have a family member or friend give you a ride. If you cannot drive yourself or cannot afford to take a bus or taxi, Health Choice will arrange one for you. (NOTE: SOBRA Family Planning members are not covered for any type of transportation services).
If you have an urgent appointment due to an immediate health condition, please contact Member Services at 1-800-322-8670 (TTY 711).
Important Information for Members
A prior authorization is a request to your health plan asking for you to have specific services from your doctor. A prior authorization is not a promise that Health Choice will cover the cost of the service. A prior authorization is also commonly called, “PA.”
A PA request is a form that your doctor fills out and sends to Health Choice. Our prior authorization department will review a standard request and make a decision within 14 calendar days. Your doctor will be notified if the service is approved or denied. If you would like to see a list of services that require your doctor to send in a PA request you can view the lists below:
- Health Choice Arizona Prior Authorization Grid
- Health Choice Arizona Medication Prior Authorization Criteria
If you have questions about prior authorizations, you can call us at 1-800-322-8670.
Quality Management Performance Measures tell Health Choice Arizona how well we are achieving goals set by AHCCCS in the areas of preventive health services such as well care visits, dental visits, breast cancer screening and many more.
AHCCCS used Healthcare Effectiveness Data and Information Set (HEDIS®) 2007 specifications to collect and report results of these measures. Developed and maintained by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry.
Health Choice Arizona continuously checks our quality management performance measures to identify areas for improvement and apply interventions to help more of our members use preventive services so that they can stay healthy!
There may be a time when you are so sick that you cannot make a decision about your own health care. You, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6].
An Advance Directive is a paper that protects your right to refuse health care you do not want. It may also tell people about care that you do want.
There are four types of Advance Directives:
- Living Will (End of life care)
- Medical Power of Attorney
- Mental Healthcare Power of Attorney
- Pre-Hospital Medical Directive (Do Not Resuscitate)
Health Choice Arizona respects your right to make decisions about your health care and thinks that it is important for you to have one or more of these papers.
A Living Will is a piece of paper that tells doctors what types of services you do or do not want if you become very sick and near death and may not be able to make health care decisions or give consent for yourself. For example, in your Living Will you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.
A Medical Power of Attorney is a paper that lets you choose a person to make decisions about your health care when you cannot do it yourself.
A Mental Healthcare Power of Attorney names a person to make decisions about your mental health care if it is found that you cannot.
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. You must complete a special orange form. You can get a free copy of this form by calling the Bureau of Emergency Medical Services at 602-364-3150.
You should get help writing your Living Will and Medical Power of Attorney. Ask your doctor for help if you are not sure who to call.
Making Your Advance Directives Legal
For both a Living Will and a Medical Power of Attorney, you must choose someone who will make decisions about your health care if you cannot. This person can be a family member or a close friend and is called your agent.
To make an Advance Directive legal, you must:
- Sign and date it in front of another person, who also signs it.
This person cannot:
- Be related to you by blood, marriage or adoption;
- Have a right to receive any of your personal and private property upon death;
- Be appointed as your agent; or
- Be your healthcare provider.
- Sign and date it in front of a Notary Public. The Notary Public cannot be your agent or any person involved with the paying of your health care.
If you are too sick to sign your Medical Power of Attorney, you may have another person sign for you.
After you Complete your Advance Directives
- Keep your original signed papers in a safe place.
- Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become involved in your health care. Talk to these people about your wishes concerning your health care.
- If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already had a copy of the old one.
- Be aware that your directives may not be effective in a medical emergency.
- Source of Additional Information and Forms
The following organization provides health care directive forms and information:
Division of Aging and Adult Services
State of Arizona
1789 W. Jefferson, Site Code 950A Phoenix, AZ 85007
Phone: (602) 542-4446
Your local Area Aging and Senior Center may also have forms and information.
If you have complaints about your right to make health care decisions, you may contact the Health Choice Arizona Member Services Department at 1-800-322-8670.
It is very important for you to decide what treatment you do or do not want.
- Give copies of your Living Will and/or Medical Power of Attorney to your doctor, hospital and any other people involved with your health care.
- You should get help writing your Living Will/or Medical Power of Attorney. Ask your doctor for help if you are not sure whom to call.
- If you change any part of your Living Will or Medical Power of Attorney, you should make sure you give a copy of the new one to all the people who already had a copy of the old one.
As a Health Choice Arizona Member, you have the following rights:
- You have the right to be treated with respect and dignity.
- You have the right to privacy and confidentiality concerning your health care and your medical records and other member information. All information about your health is private except when the release is allowed by law.
- You have the right to not be discriminated against in the delivery of health care services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
- You have the right to have services provided in a culturally competent manner with consideration for your ability to read and understand English, your cultural or ethnic background, or if you have visual or hearing limitations. Options include access to a language interpreter, a person who can perform sign language if you have a hearing impairment, and written materials available in Braille for visual impairments, or in different formats, as appropriate. You have the right to know about providers who speak languages other than English.
- You have the right to choose a Primary Care Provider (PCP), within the limits of the Health Choice Arizona provider network, and choose other providers as needed from among those affiliated with the network. This also includes the right to refuse care from specified providers.
- You have the right to take part in decision-making about your health care and/or have someone, chosen by you, to make choices for you if you are too sick to make health care decisions. This includes the right to refuse treatment.
- You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- You have the right to be provided with information so that you can put together advance directives; you, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6]. This is a plan that tells your health care providers what kind of treatment you do or do not want if you become too sick to make you own health care decisions.
- You have the right to receive information in a language and format that you understand regarding your rights and responsibilities the amount, duration, and scope of all services and benefits, service providers, services included and excluded as a condition of enrollment, and other information including:
- Provisions for after-hours and emergency health care services. You have the right to access emergency health care services from contracting or non-contracting providers without prior authorization, consistent with your determination of the need for such services as a prudent layperson.
- Information about available treatment options (including the option of no treatment) or alternative courses of care.
- How to obtain services, including authorization requirements and any special procedures for obtaining mental health and substance abuse services, or referrals for specialty services not furnished by your PCP.
- Procedures for obtaining services outside the geographic service area of Health Choice Arizona and how to obtain Medicaid covered services that are not offered or available through the health plan.
- The right to obtain family planning services from an appropriate State Medicaid registered provider.
- A description of how the organization evaluates new technology for inclusion as a covered benefit.
- You have the right to be provided with information regarding grievances, appeals, and requests for hearing.
- You have the right to complain about your managed care organization.
- You have the right to review your medical records in accordance with applicable Federal and State laws; and/or: the right to request annually and at no cost and receive a receive a copy of you medical records as allowed by law (in Title 45 of the Code of Federal Regulations (CFR) 164.524): Your right to access medical records may be denied if the information is:
- Psychotherapy notes.
- Compiled for, or in reasonable anticipation of a civil, criminal or administrative action.
- Protected health information that is subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2).
What this means is that we may use, share or deny sharing health information with you or a legal agency if told to by law which may be in the form of a subpoena, warrant or court order. This may be as a result of a legal matter such as civil, criminal or administrative action.
- You may be denied access to read or receive a copy of the medical record information without a chance for review as allowed by law in 45 CFR Part 164 if:
- The information meets the criteria stated above.
- The provider is a correctional institution or acting under the direction of a correctional institution as defined in 45 CFR 164.501.
- The information is obtained during the course of current research that includes treatment and you agreed to suspend access to the information during the course of research when consenting to participate in the research.
- The information was compiled during a review of quality of care for the purpose of improving the overall provision of care and services.
- The denial of access meets the requirements of the Privacy Act, 5 United States Code (5 U.S. C.) 552a.
- The information was obtained from someone other than a health care provider, under the protection of confidentiality, and access would be reasonably likely to reveal the source of the information.
- Except as provided above, you will be informed of the right to seek review if your request to inspect or obtain a copy of the medical record information is denied when:
- A licensed health care professional has determined the access requested would reasonably be likely to endanger the life or physical safety of you or another person.
- The protected health information makes reference to another person and access would reasonably be likely to cause substantial harm to you or another person.
- The health plan must respond within 30 days to your request for a copy of the records. The response may be the copy of the record, or if necessary to deny the request, the written denial must include the basis for the denial and written information about how to seek review of the denial in accordance with 45 CFR Part 164.
- You have the right to amend or correct your medical records as allowed by law in 45 CFR 164.526:
- The health plan may require the request to be in writing.
- If the health plan agrees to amend information in the your medical record, in whole or in part, at a minimum, the health plan must:
- Identify the information in the record that is affected, and attach or link to the amended information.
- Inform you, in a timely manner, of the amendment.
- Obtain your agreement to allow the health plan to notify relevant persons with whom the amendment needs to be shared.
- The health plan must make reasonable efforts to inform and provide the amendment, within a reasonable time, to: (i) Persons identified by you as having received protected health information and who need the amendment, and, (ii) Persons, including business associates, that are known to the health plan as having your information affected by the amendment and who have relied on or may in the future rely on the original information which might be to your detriment.
- The health plan may deny the request for the amendment or correction if the information:
- Would not be available for review, as noted above.
- Was not created by the health plan, or one of its providers, unless the individual provide a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment.
- Is not part of the member’s medical record.
- Is already accurate and complete.
- If the request is denied, in whole or in part, the health plan must provide you with a written denial within 60 days that includes:
- The basis for the denial.
- Your right to submit a written statement disagreeing with the denial, and how to file the statement.
- A statement that, if you do not submit a statement of disagreement, you may request that the health plan provide your request for amendment and the denial with any future disclosures of the protected health information that is related to the amendment.
- A description of how you may seek review of the denial in accordance with 45 CFR Part 164.
- You have the right to ask for information about the Health Plan’s Physician Incentive Program and the ways that the health plan pays our providers. You may also ask if stop-loss insurance is required, and you may ask for a summary of the member survey results for the health plan.
- Health plan members are free to exercise his/or her rights and that the exercising of those rights will not adversely affect the treatment of the member by the health plan or its providers.
As a Health Choice Arizona Member, you have the following responsibilities:
- To know the name of your assigned doctor known as your Primary Care Provider (PCP).
- To provide, to the extent possible, information needed by the professional staff who is taking care of you (tell your doctor about your health history and/or any medical problems that you have so that you can get the best possible care).
- To follow the advice given by your health care provider (doctor), take your medicine as prescribed, talk with your doctor about your medical care, and get the proper PCP approval, as needed.
- To make appointments during office hours whenever possible instead of using urgent care facilities and/or emergency rooms.
- To get to your appointment on time or to call your doctor ahead of time if you cannot make your appointment.
- To bring shot records to every appointment for your children who are 18 years of age or younger.
Members are in charge of taking care of their AHCCCS ID card. Using the card in a way that is wrong, such as loaning, selling, or giving it to someone else could result in the loss of eligibility and/or legal action as applied by Federal or State law (42 CFR 455.2). If you witness any misuse of any ID card or any other type of fraud or abuse please contact Member Services immediately at 480-968-6866.
FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).
ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the DWS program; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the DWS program (42 CFR 455.2).
What if I know of or think there may be Medicaid fraud?
Medicaid PROVIDER Fraud: If you think a Medicaid provider is involved with fraud, please contact Member Services immediately at 480-968-6866 (Maricopa County) or toll-free at 1-800-322-8670, Monday through Friday 6 a.m. – 6 p.m.
Medicaid CLIENT Fraud: If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Payment Error Prevention Unit
If you have questions or concerns about your health care, doctors, covered services, or care you are receiving please call Member Services at 1-800-322-8670.