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Division of Healthcare Management
The Division of Health Care Management (DHCM) is responsible for procuring contracts and monitoring the ongoing performance of contracted managed care organizations (MCOs) that serve more than 2 million members with expenditures exceeding $10 billion annually. DHCM oversees 15 MCO contractors who purchase services from more than 90 Arizona hospitals and 90,000+ AHCCCS-registered providers.
DHCM is the only division within AHCCCS to be led by two Assistant Directors (ADs), one to oversee the Financial and Data Units, and a second AD to oversee the Operational and Clinical Units.
Staff Administration & Human Resources Partners
Staff administration consists of five administrative assistants who provide administrative support to DHCM directors, managers and staff and assist with the day-to-day administrative functions including coordinating meetings,tracking reports, and assisting in special projects/events. The Business Partnership area oversees DCHM’s recruitment, time management, travel, and facility and equipment needs. They also work in partnership with other divisions regarding budget, vendor contracts, task orders, and employee relations.
Actuarial Unit and Actuarial Analysis Unit
The Actuarial Unit is responsible for calculating actuarially sound capitation rates for all contractors, considering trends in utilization and unit costs of various health care services, shifts in enrollment or demographics of various programs, and changes to covered benefits or provider reimbursements. The unit also provides the Center for Medicare and Medicaid Services (CMS) with legally-required certifications of actuarial soundness for capitation rate updates and other capitation payments, performs advanced analyses based on executive and legislative requests, and demonstrates calculation methods and assumptions to sister agencies or contractors as needed.
The Actuarial Analysis Unit prepares analyses of policy changes,summarizes capitation rate change impacts, and assists with quality control on capitation rates. The unit does various ad hoc analyses, with a specialty in pharmaceutical finance issues, and is responsible for value-based purchasing strategy and implementation.
AHCCCS Office of Data Analytics
The AODA is charged with evaluation and documentation of data, as well as understanding/using data to provide a clear picture of where the agency has been, where the agency is today, and where we need to go in the future.
The AHCCCS Office of Data Analytics has a management team as well as five units to perform these functions:
AODA Management oversees AODA projects and work products, participates in technical and data-related projects and initiatives.
Information Management & Data Analytics Unit (IMDAU)
MDAU conducts data mining and focused analysis, participates in data stewardship/data governance, prepares data-related deliverables, supports report and data extract developments, and oversees the DUGless portal.
Technical Reporting Unit (TRU)
TRU provides operational, grant, and ad hoc reporting and data validation technical support.
Technical Coordination Unit (TCU)
The TCU oversees system requirements; user acceptance testing, review, and execution; external trading partner testing development, tracking and coordination; external security coordination; and member data updates and referrals.
Business Intelligence (BI)
The BI unit develops reports, dashboard reporting packages, Cognos user training, and technical support for the Data Warehouse.
Data Governance maintains data stewardship, data domain projects, and oversight of data -related documentation.
Finance & Reinsurance Unit
The Finance and Reinsurance Unit oversees the financial condition of all contractors via review of quarterly and annual financial reports and assists the Actuarial Unit with financial information and inquiries necessary for capitation rate development. The Unit is also responsible for analyzing, auditing, and processing reinsurance payments to contractors
Incentive Programs Unit
The Incentive Unit determines eligibility of, and calculates payments for, provider incentive programs like the Promoting Interoperability Program, a federally-funded program that promotes the use of electronic health records systems by providers, and the Targeted Investments Program, a five-year program that incentivizes providers to integrate physical and behavioral health services.
The Reimbursement Unit is responsible for establishing fee-for-service reimbursement rates for over 80,000 clinical services on more than two dozen distinct fee schedules; calculating supplemental payments to Arizona hospitals; calculating assessments on hospitals and nursing facilities; performing reimbursement reconciliations for certain providers; determining eligibility and approving payments for Differential Adjusted Payments; reviewing and adjusting payment methodologies periodically to improve cost-effectiveness and equity; and performing fiscal impact analyses.
Contract & Policy Unit
The Contract and Policy Unit manages revisions to Managed Care Organization contracts, facilitates the AHCCCS Policy Committee revision process for the AHCCCS Contractor Operations Manual and AHCCCS Medical Policy Manual policies. IX. Program Initiatives Team.
The Program Initiatives Team works to improve the member experience, access to care, and health outcomes by monitoring contractor compliance with employment, criminal justice, housing social determinants of health, workforce development, and credentialing requirements . The Team also manages Arizona Long Term Care System (ALTCS) policy changes and program initiatives.
The Operations Unit oversees operations of AHCCCS Complete Care contractors, Regional Behavioral Health Authorities, and long-term care contractors. The Unit also conducts policy oversight to ensure accordance with AHCCCS policies and state and federal mandates; reviews and approves contractually-required deliverables; and leads annual contract amendments and periodic Request for Proposals (RFP) to solicit new contractors.
The Compliance team oversees the general compliance of the managed care contractors, including network requirements and Medicare requirements, and also assists with escalated member and provider inquiries.
Encounter Processing provides encounter receipt and processing oversite; Managed Care Organization/Regional Behavioral Health Authority (RBHA) technical assistance; and encounter training/manual maintenance.
Data Validation oversees annual data validation and focused data audits.
Integrated Care/System of Care
The Integrated Care/System of Care unit is responsible for policy development and practice review across the adult and children's systems of care, including implementation of improvement activities related to the Arizona Vision and Guiding Principles. The Integrated Care/System of Care unit is also responsible for developing, implementing, and monitoring initiatives to further integrate physical and behavioral health services through Managed Care Organizations.
The Clinical Unit teams perform clinical development and oversight functions:
The Quality Management team manages and oversees Managed Care Organization (MCO) efforts around member and systemic Quality of Care concerns. The team also performs Quality Management functions for the AHCCCS Fee-for-Service population and is responsible for direct investigations and oversees contractor efforts related to credentialing and monitoring of health care acquired conditions and other provider preventable conditions.
Medical Management oversees contractors’ medical management functions including: prior authorization, concurrent/retrospective/utilization review, chronic care/disease management programs, auditing and advising on member rights in relation to adverse decisions and appeals; coordinating and case managing American Indian Health Program (AIHP) transplants; monitoring specialty contracts and reinsurance for certain medical conditions and transplants; and oversight of case management programs of the long- term care MCOs .
Maternal Child Health (MCH)/ Early and Periodic Screening Diagnosis and Treatment (EPSDT)
The Maternal Child Health (MCH)/ Early and Periodic Screening Diagnosis and Treatment team monitors EPSDT, preventive health, maternity, sterilization, and family planning programs including special needs populations and maternal health programs. This area also collaborates with state and local health and social service agencies as well as community and private health care organizations and providers.
Clinical Resolution Unit
The Clinical Resolution Unit (CRU) assists members who need immediate help accessing physical or behavioral health services. CRU also works with contractors, stakeholders, and other divisions to resolve issues involving service delivery and to ensure complaints are resolved by contractors as required by regulation and policy. CRU is the designated contact for issues involving Jacob’s Law (timely access to behavioral health services for children/youth who are adopted or in foster care) and oversees the SMI opt-out and decertification processes.
The AHCCCS Quality Improvement (QI) team oversees contractor activities meant to improve clinical and non-clinical performance. Primary functions of the QI Team include performance measures, performance improvement projects, member satisfaction surveys, and other Quality Improvement associated efforts.
Medical Coding oversees and maintains all medical coding needs and medical coding technical assistance.