Provider Information

The provider manual provides important information about Health Choice Generations.

Prior Authorization Guidelines

Prior Authorization Guidelines effective for dates of service 1/1/2018
Prior Authorization Guidelines effective for dates of service 4/1/2017 – 12/31/2017
Prior Authorization Guidelines effective for dates of service 1/1/2017 – 3/31/2017
Medical Services Prior Authorization Form

Clinical Guidelines and Recommendations

Centers for Medicare and Medicaid Services – Medicare Coverage Database

Annual Medicare Model of Care Training – 2018
Annual Medicare Model of Care Training – 2017

Health Choice Generations utilizes:

• Inter-Qual
• UpToDate

Adult Hypertention Management Guidelines (NHLBI)

JNC 7 Report on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

Adult Obesity Management Guidelines (NHLBI and NIDDKD)

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults

Asthma & COPD Management Guidelines (NHLBI)

Guidelines for the Diagnosis and Management of Asthma
COPD Guidelines

Cardiac and CVA Care Management (ACC/AACE)

NCEP III Guideline

Chironic Pain Management Guidelines (American Pain Society)

Clinical Practice Guidelines

Diabetes Management Guidelines (ADA)

Clinical Practice Guidelines

General Infections Disease Management Guidelines (IDSA)

Clinical Practice Guidelines

HIV Management Guidelines

CDC/NIH
IDSA

Pediatric Obesity Management Guidelines (NHLBI and NIDDKD

Childhood Obesity

Smoking Cessation Guidelines (NIH)

Tobacco Cessation

Claim Submissions and Coordination of Benefits

Where should Plan Providers send their Claims?

Medical Claims
Health Choice Generations
410 N. 44th Street, Ste. 510
Phoenix, AZ 85008

Which Provider ID # should be used on the Claim Form for Health Choice Generations

Providers may use their Medicare/UPIN number in Box 33 or continue to use the AHCCCS Provider ID as currently used when billing Health Choice.

Effective January 1, 2007, Health Choice will allow the option to submit claims using the National Provider Identifier (NPI), however, effective May 23, 2007, all claims are required to submitted with the NPI. More information on NPI is available at https://www.cms.gov/NationalProvIdentStand.

Providers currently contracted with Health Choice may mail or fax written notification of their NPI number to the Network Services.

Health Choice Arizona Attention:
Network Services
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008

How may I check Claims Status or Claims Inquiry?

Providers can visit the Health Choice Generations Web site to review claims and check member eligibility. Providers must pre-register on-line prior to having access to this confidential information. After you have registered, you will be able to view only your member’s claim information. Should you have difficulty registering you may refer to the Log-in Tutorial.

Providers may also call Health Choice Generations Claims Customer Service or Member Services for eligibility at 1-800-322-8670.

Who is the Primary payor: Health Choice Generations or Health Choice Arizona?

Health Choice Generations (Medicare) is the primary payor and submits the encounter directly to Health Choice Arizona (Medicaid) for processing of the secondary payment. Providers do not have to submit two claims to each Plan. However, Providers will receive two explanation of Benefits (EOB), one EOB reflects the Medicare allowable and the second EOB will show processing of any secondary amount under the Medicaid (AHCCCS) program. If Health Choice Arizona is not the secondary payor, then the primary EOB must be submitted to the secondary payor by the Provider.

Provider Accounts Receivable

Health Choice does not reconcile accounts receivable for provider offices. It is the responsibility of the provider office to ensure that payments are properly posted and that claims are resubmitted with proper/requested information in a timely manner. Enclosed is a Health Choice Generations denial glossary to assist you in reconciling your receivables.

Current Year Supplemental Benefits

Supplemental Benefits
Supplemental Code Set – Dental
Supplemental Code Set- Non Dental
Chiropractic Services Fact Sheet- 2018
Podiatry Services Fact Sheet- 2018

Certain benefits under the Health Choice Generations plan require a referral or prior authorization. PCPs are required to coordinate the member’s care by sending the member to a contracted Health Choice Generations specialist. If a member receives healthcare services from any physician, hospital or other healthcare provider without getting a referral or authorization in advance, the member may have to pay for these services. Please click on the “Find a Doctor” link for a complete listing of Health Choice Generations providers.

The Health Choice Generations Summary of Benefits and Evidence of Coverage list the benefits which are covered by our plan. Chapter four in the Evidence of Coverage lists covered services that need prior authorization.

There are many services a member may obtain on their own, without prior approval from a provider or Health Choice Generations.

The following services are covered as Preventive Care and do not require prior authorization.

• Colorectal Screenings
• Mammography screenings
• Pap Smears, Pelvic Exams and Clinical Breast Exam
• Prostate Cancer Screening exams
• Cardiovascular Disease Testing
• Physical exams
• Outpatient substance abuse services
• Emergency services
• Urgently needed care
• Physician services, including doctor office visits
• Flu shots and pneumonia vaccinations
• Renal dialysis services that are obtained when a member is temporarily outside the plan’s service area and for the first Renal Dialysis visit so the Health Choice Case Management department is aware of the member’s dialysis needs and can coordinate follow-up care (along with the provider). Ongoing dialysis treatment does not require additional authorization(s).

In addition to any exclusions or limitations described in the HC Generations Evidence of Coverage and Summary of Benefits, the following items in the list below are NOT covered except as indicated by Health Choice Generations.

They include but are not limited to:

• Services that are not covered under Original Medicare, unless such services are specifically listed as covered in Section 4.
• Services that you get from non-plan providers, except for care for a medical emergency and urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan’s service area, and care from non-plan providers that is arranged or approved by a plan provider. See other parts of this booklet (especially Sections 2 and 3) for information about using plan providers and the exceptions that apply.
• Services that you get without a referral from your PCP, when a referral from your PCP is required for getting that service.
• Services that you get without prior authorization, when prior authorization is required for getting that service. (Section 4 gives a definition of prior authorization and tells which services require prior authorization.)
• Services that is not reasonable and necessary according to the standards of original Medicare unless these services are otherwise listed by Health Choice Generations as a covered service. As noted in Section 4, we provide all covered services according to Medicare guidelines.
• Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency. (See Section 3 for more information about getting care for a medical emergency).
• Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or unless services covered under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Choice and Original Medicare that are not generally accepted by the medical community. See Section 7 for information about participation in clinical trials while you are a member of Health Choice Generations.
• Surgical treatment of morbid obesity unless medically necessary and covered under Original Medicare.
• Private room in a hospital, unless medically necessary.
• Private duty nurses.




• Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
• Nursing care on a full-time basis in your home.
• Custodial care is not covered by Health Choice Generations unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
• Homemaker services.
• Charges imposed by immediate relatives or members of your household.
• Meals delivered to your home.
• Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary
• Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery is covered for all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast.
• Routine dental care (such as cleanings, fillings, or dentures) or other dental services. Certain dental services that you get when you are in the hospital will be covered.
• Chiropractic care is generally not covered under the plan, (with the exception of manual manipulation of the spine, as outlined in Section 4) and is limited according to Medicare guidelines.
• Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
• Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
• Supportive devices for the feet. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
• Hearing aids and routine hearing examinations.




• Routine eye examinations and eyeglasses (except after cataract surgery), radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
• Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
• Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices. (Medically necessary services for infertility are covered according to Original Medicare guidelines.)
• Acupuncture.
• Naturopath services.
• Services provided to veterans in Veteran’s Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the cost sharing required under Health Choice Generations, we will reimburse veterans for the difference. Members are still responsible for the Health Choice Generations cost sharing amount.

Please see the Health Choice Generations Prior Authorization list for more information on what services are covered and not covered by the Health Choice Generations plan.

This is not all-inclusive therefore Providers must verify both eligibility and covered benefits prior to rendering services at (480) 968-6866 and (800) 322-8670.