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Eligibility and Benefit Information
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AFMC does not maintain benefit or eligibility information for members. Providers should contact the administrator indicated on the patient's identification card for benefit and eligibility information. The claim administrator name and phone number can also be found in AFMC's Listing of Administrators.
AFMC recommends that providers verify benefits for all services rendered to AFMC members. Verifying benefits allows the provider to collect any co-payment, co-insurance, deductible, etc. at the time of service. |
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Provider Reference Guide
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AFMC has created the Provider Reference Guide to assist contracted providers and their office staff in the administration of AFMC's network plans.
Whenever you have a question about any aspect of AFMC's operations as it pertains to your practice and administering of benefits to AFMC members, first check the appropriate section of the Guide. If you don't find the answer to your question, contact us. We are always willing to help.
The updated Provider Reference Guide can be accessed by going to AFMC's Web site, click on "Provider" then "Provider Reference Guide". This is a secure area; you must be a registered AFMC Web site user to access this information.
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What to Know to Appeal an AFMC Claim
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AFMC Call Center agents cannot appeal a claim on your behalf. Should you need to appeal a medical or hospital claim, please utilize AFMC's on-line appeal function by visiting the Web site. Click on the "Provider" link on the right hand side of the page, then the "Claims Appeal" sub-link.
You may also send
your appeal by mail to:
Arizona Foundation for Medical Care
PO Box 2909
Attention: Medical Review
Phoenix, Arizona 85062-2909
If you need to appeal a hospital claim, please mail it to the address above Attention: Hospital Appeals.
If you are submitting an appeal based on pricing, please send it to AFMC. If you are appealing a paid claim, you must send your appeal to the Payor.
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Notify AFMC of Demographic Changes
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Providers must notify AFMC of changes in their demographic information by utilizing AFMC's Provider Change Form.
The Provider Change Form should be used to submit a change in address, Tax ID# or specialty change, etc. A provider may add or delete contracted physicians by notifying AFMC in writing within 30 days of status change.
The Provider Change Form can be downloaded from the AFMC Web site under the Provider link, Admin List/Commonly Used Forms.
Claims for dates of service greater than 30 days prior to notification of physician status change shall be deemed as an out-of-network claim and forwarded to the insureds payor for processing. Balance billing the insured for these claims is prohibited under this agreement.
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Utilize In-Network Providers and/or Facilities
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As stated in your contract with AFMC, providers are required to refer their patients covered under an AFMC-sponsored and/or endorsed healthcare plan to in-network services, especially for lab services, pathology groups, and DME providers.
If it is necessary to refer a member out-of-network, please remember to inform your patients of that referral before the service is provided. The patient should be aware of any, and all, out-of-network (out-of-pocket) expenses they could incur by using out-of-network providers or facilities |
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As an AFMC contracted provider you play a very important role in the delivery of healthcare services to the members of the employer groups we service. As such, it is important to AFMC to keep you informed of policies, procedures, and general reference information, which include minimum standards of care that are required of AFMC providers. We hope this information will help you better understand how AFMC operates.
Should you have any questions about information contained in Chart Notes, please contact our Marketing & Network Management Department or call 800-624-4277.
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Did you know...
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You can check claims status on-line at azfmc.com?
You can request precertification on-line at azfmc.com?
You can request a claims appeal on-line at azfmc.com?
You can download a copy of the AFMC Administrators List to assist you with eligibility and benefit questions from azfmc.com?
AFMC contact numbers and fax numbers can be found on-line?
Your personal on-line account will deactivate if not used for 30 days? Call AFMC Call Center at 602-252-4042 or 800-624-4277 to be reactivated.
Your company on-line account will deactivate if not used for 90 days? Call AFMC Call Center at 602-252-4042 or 800-624-4277 to be reactivated.
CPT code 95165 (Professional services for the supervision of preparation and provision of antigen immunotherapy; single or multiple antigens) has an AFMC maximum annual allowance? If your specialty involves allergy immunotherapy, and you need a fee schedule, please fill out the Fee Schedule Request Form and return to AFMC.
Effective January 1, 2011, all claims billed incorrectly with the new 2011 immunization administration codes (90460 & 90461) will be returned to your office.
For answers to these and any questions you may have, call AFMC Monday - Friday, 8 am - 5 pm at 602-252-4042 or toll-free at 800-624-4277.
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| Fee Schedules - Use the Form! | |
Providers that contract with AFMC agree to follow a pre-determined fee schedule. It is the provider's responsibility to review the maximum reimbursement schedule adopted by AFMC's Independent Reimbursement Committee so they are fully aware of the payments they will receive for covered services rendered to patients insured under AFMC-sponsored and/or endorsed healthcare plans.
The Fee Schedule is directed by the Reimbursement Committee, which meets throughout the year to review, amend and set procedure allowances. The Fee Schedule can change twice a year - January 1 and again July 1.
AFMC contracted providers can request a fee schedule at any time by utilizing the designated form. AFMC's Fee Schedule Request Form is available on the Web site www.azfmc.com in an easy to use interactive pdf format. The form can be found at the bottom of the page under Provider/Administrator List/Commonly Used Forms.
Please note: In order to expedite your request, please send one (1) form with multiple codes; not multiple forms with one code each. Upon receiving the form, AFMC will price your codes accordingly and fax back to your office. Please allow three business days for processing. Please remember to include the required supporting documentation and to sign the form. In addition, it is important that you please remember to request all of your codes at one time. If you have any questions or problems with the form, please contact AFMC's Network Management Department.
AFMC's fee schedule is proprietary and confidential and for reference of AFMC member physicians only. It may not be reproduced without the expressed written permission of AFMC, and is not to be used for billing purposes, or to be disclosed to any other entity. Should you have a question regarding an AFMC allowable, please contact the Network Management Department or call 602-252-4042 or 800-624-4277.
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Prepare for 5010 Today!
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Protect and strengthen your organization's relationship with Arizona Foundation for Medical Care.
On January 1, 2012, a federal mandate requires health plans, clearinghouses and providers to use new standards in electronically conducting certain healthcare administrative transactions at the heart of daily operations, including claims submission, status requests and responses.
The deadline is approaching fast (AFMC's Compliance Deadline was May 1, 2011). Now is the time for effected healthcare organizations to upgrade and test their claims management systems to accomodate 5010 and prevent operational disruptions.
AFMC has prepared a Q & A document to answer your immediate questions and concerns regarding functionality with us: download and print a copy,
in addition to a Companion Guide: download and print a copy.
Several organizations have joined together to sponsor a Web site - GetReady5010.org - to assist providers in becoming 5010 compliant. The site includes Webinars, Handouts and much more. Visit the site today!
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| How to Contact AFMC | |
We want to make it easy for you to communicate with us. Should you or your staff have any questions, concerns, and/or feedback, please contact AFMC's Provider Relations Team in the Marketing & Network Management Department by calling 800-624-4277 or by e-mail.
Contact our Call Center, Provider Unit at 800-624-4277, Monday through Friday from 8 am - 5 pm, Mountain Standard Time to verify provider participation status; request assistance on a claims repricing issue; and ask general administrative questions.
Call the Network Management Department at 800-624-4277 for questions pertaining to a facility or physician contract.
To check the payment status of a claim or to verify benefits and eligibility,
contact the patient's plan administrator; their contact information is located
on the back of the patient's ID card or in AFMC's Listing of Plan Administrators located on the AFMC Web site.
To check precertification status for groups using AFMC medical management services, call AFMC's CHOICE unit at 800-624-4277.
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326 E. Coronado Road · Phoenix, Arizona 85044
www.azfmc.com · networkmanagement@azfmc.com
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