Division of Managed Care (DMC)

The Division of Managed Care (DMC) at AHCCCS is responsible for overseeing the performance and compliance of Managed Care Organizations (MCOs), ensuring they deliver high-quality, medically necessary services to members. DMC manages 11 contracts across 8 MCOs and supports initiatives like care coordination, provider incentives, workforce development, and grievance resolution. It works collaboratively with internal divisions, leadership, and external stakeholders to improve member outcomes and system performance.

Key Units within DMC:

• Administration: Oversees operational, clinical, and ALTCS program areas, led by an Assistant Director and three Deputies.
• Behavioral Health Grievances and Appeals (BHGA): Manages the SMI grievance and appeals system, conducts audits, and invesigates serious incidents.
• Clinical Resolution Unit: Supports members with behavioral health access, Jacob’s Law issues, and SMI eligibility concerns.
• Maternal Child Health (MCH)/EPSDT: Monitors preventive and maternal health programs, collaborating with state and community partnrs.
• Medical Coding: Maintains coding systems and resolves provider disputes.
• Medical Management (MM): Ensures MCO compliance with medical management standards and oversees operational reviews and complex care requests.

ALTCS Program Management:

Focused on the Arizona Long Term Care System (ALTCS), this area ensures quality, compliance, and innovation in long-term care services for eligible members.

Key Units and Functions:

• Case Management: Provides oversight and training for ALTCS case management services and manages the PASRR program.
• Program Initiatives Team: Leads efforts in Whole Person Care, Social Determinants of Health, Workforce Development, and manages systems like EVV and the Closed Loop Referral System.
• Compliance: Oversees contractor compliance and handles escalated member/provider issues.
• Contract and Policy Unit: Manages MCO contracts, RFPs, and policy development for ACOM and AMPM.
• Data Validation: Conducts audits to ensure accuracy of MCO encounter data.
• Network: Ensures MCOs maintain adequate provider networks for timely member access.
• Targeted Investments (TI): Manages $250M incentive programs (TI 1.0 and TI 2.0) to improve care coordination and reduce health disparities.