Preventive and clinical practice guidelines are based on the health needs and opportunities for improvement identified as part of the Quality Assurance Program Improvement (QAPI) program. Whenever possible, Care1st adopts preventive and clinical practice guidelines that are published by nationally recognized organizations or government institutions as well as state-wide collaborative and/or a consensus of healthcare professionals in the applicable field.
AHCCCS Behavioral Health Practice Tools
- Working with the Birth through Five Population (PDF)
- Psychiatric and Psychotherapeutic Best Practices for Children Birth through Five Years of Age (PDF)
- Child and Family Team (PDF)
- Support and Rehabilitation Services for Children, Adolescents, and Young Adults (PDF)
- Family Involvement in the Children's Behavioral Health System (PDF)
- Youth Involvement in the Children's Behavioral Health System (PDF)
- The Unique Behavioral Health Services - Needs of Children, Youth, and Families Involved with DCS (PDF)
- Children's Out-of-Home Services (PDF)
- Transition to Adulthood (PDF)
Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.
Care1st Health Plan Arizona utilizes InterQual® criteria for those medical technologies, procedures, or pharmaceutical treatments for which a Care1st Health Plan Arizona clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment, and imaging procedures by logging into the secure provider portal or by calling Care1st Health Plan Arizona. In addition, Care1st Health Plan Arizona may from time-to-time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual criteria is payable by Care1st Health Plan Arizona.
The Policies do not constitute authorization or guarantee of coverage of any procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service, or supply. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine. The health plan reserves the right to amend the Policies without notice to providers or Members.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.
The Clinical Policy Manuals may be accessed through the links below.