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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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Did You Know???
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You can check claims status on-line at azfmc.com?
You can request precertification and
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.
For answers to these and any other 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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Verifying Participation in AFMC's Network
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In an effort to streamline processes and reduce administrative burdens for our providers, AFMC offers on-line patient enrollment verification. The process is easy:
· Go to the AFMC Web site.
· Click on the "Provider" link.
· Click on the "Enrollment Search" sub-link. Log into the secure area.
· You will be asked to enter your TIN and PIN, then the patient's ID number or last name and date of birth.
This area of the Web site will only show if the patient is able to access AFMC's network. You will need to verify benefits and eligibility with the member's Plan Administrator whose name and phone number will be listed on the Enrollment Search screen, or from the patient's health
plan member ID Card.
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Problematic Claim Status Issues
| AFMC's Payor Service Team is available to assist you with problematic claims. AFMC defines a claim as "problematic" when:
· It has been outstanding more than 60 days from the re-pricing date; and/or
· Your efforts to resolve the issue with the claim administrator have been unsuccessful.
Claims must be less than 18 months from the date of service. If you would like us to assist you with research on a problematic claim, please call the AFMC Call Center at 800-624-4277 for the Payor Unit. Our Payor Service Team will contact the appropriate claim administrator and obtain
the status of your claim. |
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AFMC's Contact Information
| Arizona Foundation for Medical Care
326 E. Coronado Rd.
Phoenix, AZ 85004
800-624-4277
602-252-4042
www.azfmc.com
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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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AFMC Renewal Is Approaching - Fast!
| In the fall of every year, AFMC's membership renewal season starts and continues through the end of December. The membership renewal process is required by all providers that belong to AFMC's network. A few items to note:
Individual Providers: The individual renewal portal should be used if you are an individual physician who is currently active in the AFMC network. AFMC individual providers have three ways to complete their renewal, online; download a renewal form from the AFMC Web site; contact AFMC to request your renewal form.
Group Providers: AFMC Group providers can comple their renewal online using your tax ID number and password PIN. Please make sure to fill out the entire form and pay your dues (if applicable).
Look for a special edition of the AFMC Chart Notes in mid-August. This issue will explain the process and provide you with the information you'll need to complete your renewal. AFMC will also mail a letter to your office/facility in early September.
If there have been any demographic changes in your office - new address, phone, email, web site, etc. - or if you have lost or added providers to your office/practice/facility, please utilize the Provider Change Form |
Changes to the Physicians and Pharmaceutical Fee Schedule for Workers Compensation
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The Industrial Commission of Arizona updated their manual; adding two subsections effective July 25, 2011.
One section of interest to AFMC Providers is the new EOB/EOR requirements for Worker's Comp Payors. A payor's EOR/EOB must contain added effective sufficient information to allow a provider to determine whether the amount of payment is correct and whom to contact regarding any questions related to the payment. The EOR/EOB will include the following:
a. The name of the injured worker;
b. The name of the payer and the name of the third party administrator, if applicable;
c. If applicable, the name, telephone number, and address of all entities that reviewed the medical billing on behalf of the payer;
d. If applicable, the name, telephone number and address of the party that has a written contract signed by the physician that allows the contracting party or other third party to access and pay rates that are different from those provided under this Fee Schedule;
e. The amount billed by the physician;
f. The amount of any reduction due to a written contract with the physician; and
g. The amount of payment.
The Industrial Commission of Arizona is the agency that administers and enforces state laws relating to the protection of life, health, safety and welfare of Arizona's employees. This includes laws relating to workers' compensation, occupational safety and health, payment of wages, and child labor. For more information, visit their Web site.
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Prepare for 5010 Today!
| Six Month Check-in: Act Now for the Version 5010 Transition
The Version 5010 transition is less than six months away for all HIPAA covered entities. This means that to submit transactions electronically, all covered entities must upgrade from Version 4010/4010A to Version 5010. Version 5010, unlike Version 4010, accommodates the new ICD-10 code sets, and is a required preliminary step for the use of the new ICD-10 medical code sets. Before the compliance deadline of January 1, 2012, you should conduct internal and external transactions within your organizations and with your billing partners - including payers, vendors, clearinghouses and providers. External testing should take place now in order to make sure that you are able to send and receive compliant transactions effectively. Testing now will help identify any potential issues that may arise, and allow the necessary time to address them. The CMS ICD-10 Web site has resources to support providers, payers and vendors as they make the transition to Version 5010 and ICD-10. Keep Up to Date on Version 5010 and ICD-10. Please visit www.cms.gov/ICD10 for the latest news and resources to help you prepare. |
Valley Fever Cases in Maricopa County Expected to Rise
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The powerful dust storm that swept across Maricopa County last week likely will produce a large increase in new Valley Fever infections over the next two to three months, an expert at the University of Arizona predicts.
John Galgiani, MD, Director of the Valley Fever Center for Excellence at the University of Arizona College of Medicine, said such an increase in cases occurred following a similar huge blow in California's Central Valley. Years ago, a Santa Ana wind storm blew dust from the Central Valley as far north as the San Francisco Bay Area. Kern County in California, like Maricopa County, is heavily endemic for the fungus that causes Valley Fever. As published in a medical journal, that storm resulted in 120 extra Valley Fever infections in Kern County, mostly in the subsequent two months. (Pappagianis D. "Tempest from Tehachapi takes toll or Coccidioides aloft from afar." Western Journal of Medicine, 129:527-530, 1978).
"Because Maricopa County has ten times the number of people and three times the proportion of the population susceptible to first Valley Fever infections, we should expect 3,600 additional Valley Fever infections in Maricopa County for a total of 5,000 infections in July and August," Dr. Galgiani said.
Public health officials and other medical professionals recently raised the concern that Valley Fever infections would increase as a result of the July 5 wind storm. By using the past experience in California as a guide, Dr. Galgiani points out that we can estimate just how large that increase may be.
"People living in Phoenix and the surrounding areas should know about this risk and seek medical attention if they develop symptoms of pneumonia during that time," Dr. Galgiani said. It would also be important for the medical community to be on heightened alert for the possibility of Valley Fever in their patients with new illnesses. Early diagnosis and management should reduce the overall severity of the infections.
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AFMC's Requirements for Version 5010
| The current compliance date for the version 5010 file format begins January 1, 2012. The 5010 rules require the adoption of new ICD-10 Codes.
As a result, AFMC now requires that all providers submit a zip+4 and one active physical address on any new provider applications, which include the following:
- All addresses must have a full zip code, including zip+4. To find the zip+4 for an address, visit the USPS Zip Code Look-up Web site
- Each physician must have at least one active physical address. Therefore, P.O. Boxes will no longer be accepted as a physician's only active address.
- The billing address also must be a physical address. It cannot be a lock box or PO Box. A provider can have a payment address in the EDI file that is a PO Box or lock box.
For more information about the 5010 standard by visiting the Centers for Medicare & Medicaid Services Web site. |
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