REMINDER: Arizona Early Intervention Program (AzEIP) Submissions
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Instructions for providers and AzEIP agencies on submitting completed Arizona Early Intervention Program (AzEIP) documentation to the Contractor's Prior Authorization Department to support EPSDT/Early Intervention service coordination and initiation.
No material clinical or coverage changes in this revision.
AzEIP Submission and Coverage Criteria
AzEIP submission criteria
Submission and documentation criteria for processing AzEIP service requests:
ALL of the following
- Review all AzEIP documentation and determine which services are medically necessary.
- Complete AzEIP AHCCCS Member Service Request Form (AMPM Policy 430, Attachment D).
- Provide a completed Individual Family Service Plan (IFSP) documenting individualized goals and family support services; the IFSP initiation date triggers the service initiation timeframe.
- Include an order for services that contains ICD-10 diagnosis code(s) and description and the CPT code for the requested service.
- Submit the most recent encounter/progress notes and documentation that supports medical necessity.
- Return any requested information to the Health Plan within two business days of the request to ensure services can be initiated within 45 days of a completed IFSP.
- Send the completed AzEIP AHCCCS Member Service Request form, IFSP, clinical notes, and order for services to the Contractor's Prior Authorization Department (fax: 480-760-4993).
Service Coding and Timing Requirements
| ICD-10 | Diagnosis code(s) and description required on order for services |
| CPT | CPT code for the requested service required on order for services |
Provider Submission and Response Requirements
Submit complete AzEIP documentation for prior authorization
Send completed AzEIP documentation to the Contractor's Prior Authorization Department for processing. Completed documentation must include the order for services with ICD-10 diagnosis codes and description, the CPT code for the requested service, the signed AzEIP AHCCCS Member Service Request form (AMPM Policy 430, Attachment D), and the most recent encounter/progress notes. Submit these documents to the Contractor's Prior Authorization Department (fax: 480-760-4993).
- Order for services with ICD-10 codes and description
- CPT code for the requested service
- Signed AzEIP AHCCCS Member Service Request form (AMPM Policy 430, Attachment D)
- Most recent encounter/progress notes
Respond to information requests within two business days
Return requested information to the Health Plan within two business days from the date of the request to ensure medically necessary services are initiated within 45 days of a completed IFSP; this includes providing the signed AzEIP AHCCCS Member Service Request form.
- Respond within two business days to information requests
- Ensure signed AzEIP AHCCCS Member Service Request form accompanies response
- Timely response supports initiation of services within 45 days of a completed IFSP
Required Forms and Plans
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