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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".
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AFMC's Web site - An Important Tool for any Provider
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Did you know you can perform the following functions in the Provider Area on the AFMC Web site?
* Check claim re-pricing status.
* Submit a pre-cert.
* Submit a claims appeal.
* Download a copy of the AFMC Administrator Listing to assist you with eligibility and benefit questions.
In addition to the information listed above, AFMC contact numbers and fax numbers can also be found on AFMC's Web site. Please note: Your personal on-line account will deactivate if not used for 30 days and a company account if not used for 90 days. To reactivate your account, call AFMC at 602-252-4042 or 800-624-4277. |
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Do You Know What Administrators Work with AFMC?
| It's easy to find out!
Simply visit the AFMC Web site and click on the "Get Administrator Listing" under the "Provider" link or click here.
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| Important Information for AFMC Contracted Providers | |
On January 1, 2012, AFMC became the Medical Management vendor providing pre-certification services for the City of Mesa. If you have a patient who obtains health benefits through City of Mesa, please be sure to note the new contact information on the back of the ID card.
AFMC Pre-cert number: 602-252-4042 or 800-624-4277
AFMC Pre-cert Fax number: 602-254-3086
AFMC is NOT the network of providers for The City of Mesa.
Please contact the City of Mesa Employee Benefits Administration at 480-644-2299 or benefits.info@mesaaz.gov for questions or to obtain a list of services requiring pre-certification. Additional information is available on the City of Mesa Web site: http://www.mesaaz.gov |
| How to Help PCIP Patients with Pre-authorization | Many new enrollees in the federally administered Pre-Existing Condition Insurance Plan (PCIP) administered by GEHA (utilizing AFMC's network in Arizona) require treatment and services very quickly once their effective date arrives. Often, they will schedule appointments, surgeries or other services before they fully understand their benefits. As a result, many new enrollees are not obtaining pre-authorization for services that require this action and end up paying more than they need.
To ensure current and future PCIP patients receive the most appropriate medical treatment with the lowest out-of-pocket expense, listed below is a snap shot of the PCIP categories that require pre-authorization; in addition to a telephone list of precertification phone numbers.
If you have patients who are interested in PCIP coverage, please let them know about their Web site (www.pciplan.com). Or they can call (800) 220-7898 between 7 am and 5:30 pm Central time, Monday through Friday (except holidays). |
| Problematic Claim Status Issues | AFMC's Member Services 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. The Team will contact the appropriate claim administrator and obtain the status of your claim. |
| Situations that Require Notification to AFMC | There are several circumstances a provider must notify AFMC, in writing, within five (5) days of the occurrence of any of the following:
- License to practice medicine in Arizona is lost, restricted or suspended.
- Hospital privileges are lost, restricted or they have been suspended for a cumulative total of 30 days or more for any 12-month period.
- Any other situation arising, which might materially affect the ability to carry out duties or obligations under your agreement with AFMC.
- Professional liability insurance is canceled or reduced for any reason.
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.
Questions? Contact AFMC by calling 800-624-4277. |
| HHS Plans Database on EHR Incentive Program Participants | HHS plans to create a national database that will contain information about office-based healthcare providers participating in federally funded electronic health-record system incentive payment programs.
Goals of the proposed new system are to create a tool to evaluate those incentive programs and to check up on the work of a national system of regional health information technology extension centers.
Both the incentive programs and the regional extension centers were created under the American Recovery and Reinvestment Act of 2009.According to a notice published in the Federal Register, the database will be linked to a data "dashboard" that will provide access to the record-keeping system for both researchers and the public. In accordance with federal privacy provisions, provider data that is publicly accessible through the dashboard will be aggregated and not individually identifiable. Read more... |
| How States are Keeping Doctors from Moving Out | Widespread concerns about physician shortages have many states working to keep doctors trained in medical schools and residency programs there from crossing state lines to practice medicine.
Nationwide, there were 258.7 active physicians per 100,000 people in 2010, according to new statistics from the Assn. of American Medical Colleges. In individual states, ratios range from a high of 415.5 physicians per 100,000 people in Massachusetts to a low of 176.4 per 100,000 in Mississippi.
On average, only 39% of U.S. physicians practice in the same state where they went to medical school. Forty-eight percent practice in the state where they completed graduate medical education, said the report, released Dec. 2 by the AAMC Center for Workforce Studies.
As a result, medical schools, hospitals, medical societies and state legislatures increasingly are taking a practical approach to retain the physicians and doctors-in-training they already have, said Christiane Mitchell, AAMC director of federal affairs. Read more... |
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