Overview

Section 1902(a)(42)(B) of the Social Security Act requires that states establish a Medicaid Recovery Audit Contractor Program (RAC Program) as a mechanism to monitor the integrity of payments made to Medicaid providers. The Arizona Health Care Cost Containment System (“AHCCCS”) AHCCCS has retained Health Management Systems, Inc. (HMS), a Gainwell Technologies company, as it’s RAC contractor to conduct periodic reviews of claims paid by AHCCCS for health care services rendered to Medicaid members. The objective of the RAC program is to identify and recover payments made to Medicaid providers that do not meet state and federal requirements. RAC audits, include coding validation, payment accuracy, compliance with state and federal regulations, policies, contractual requirements and utilization standards.

This website provides information relevant to the work to be completed by HMS on behalf of AHCCCS for the RAC Program. It is intended to support AHCCCS in achieving its mission to reduce improper Medicaid payments and to support providers with education and resources.

For state and federal statutes and regulations, refer to the following links and citations which further outline AHCCCS’s authority and provider responsibilities with regards to service delivery, billing and reimbursement in the Arizona Medicaid Program:

Arizona Program Rules:

AHCCCS Program Rules

Code of Federal Regulations:

42 CFR Part 455, Subpart F

eCFR :: 42 CFR Part 455 -- Program Integrity: Medicaid

Policy References

Place of Service

AHCCS Medical Policy Manual: AHCCCS Medical Policy Manual (AMPM) (azahcccs.gov)

310-K Hospital Inpatient Services: 310-S.pdf (azahcccs.gov)

310-K Hospital Inpatient Services: 310-K.pdf (azahcccs.gov)

810 Fee-For-Service Utilization Management: AMPM Policy 810 (azahcccs.gov)

820: Fee-For-Service prior authorization requirements: AMPM Policy 820 (azahcccs.gov)

1020: Utilization Management: AMPM POLICY 1020 (azahcccs.gov)

AHCCS Provider Guides and Manuals: GUIDES AND MANUALS FOR HEALTH PLANS AND PROVIDERS (azahcccs.gov)

Ariz. Admin. Code § 9-22-202: Section R9-22-202 - General Requirements, Ariz. Admin. Code § 9-22-202 | Casetext Search + Citator

Prior Authorization Information: https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/priorauthorizationforms.html

Ariz. Admin. Code § 9-22-204: Section R9-22-204 - Inpatient General Hospital Services, Ariz. Admin. Code § 9-22-204 | Casetext Search + Citator

Place of Service

AHCCS Fee-For-Service Provider Billing Manual: AHCCCS Fee-For-Service Provider Billing Manual (azahcccs.gov)

AHCCCS APR-DRG Payment System Design Payment Policies: FFS_Chap11_Addendum.pdf (azahcccs.gov)

Inpatient Hospital APR-DRG Reimbursement Values: Fee-For-Service (azahcccs.gov)

Ariz. Admin. Code § 9-22-701 Standard for Payments : Arizona Administrative Code | Article 7 - STANDARDS FOR PAYMENTS | Casetext

Medical Coding Resources: Medical Coding Resources (azahcccs.gov)

Resources

Upon access to the HMS Provider Portal, a Training Guide will be available

Arizona RAC Informational Documentation:

Arizona RAC Overview Presentation

HMS & AHCCCS RAC Audit Program Webinar Deck
RAC Overview Presentation (PowerPoint)
RAC Overview Presentation (Pre-recorded Webinar)
Arizona RAC FAQs
HMS Provider Portal—New Users Click Here
Record Limit Tier Information

Size Class	Annual IP Claim Spend	Provider Limit
Extra Small	Less than 1M	20 Records/Mo
Small	1M to 5 M	40 Records/Mo
Medium	5M to 10M	80 Records/Mo
Large	10M to 50M	120 Records/Mo
Extra Large	50M to 100M	175 Records/Mo
Apex	Greater than 100M	200 Records/Mo

Rebuttal Process

Providers may request a rebuttal in writing
Rebuttals must be received within thirty (30) calendar days of the date in the Preliminary Finding Letter
Submission Options:

- Electronic (preferred method)
  - HMS Provider Portal
  - Secure File Transfer Protocol (SFTP)
    - For instructions to set up SFTP, GoGreen@hms.com or call 833-712-7888
- Mail Hardcopy:

HMS

5615 Highpoint Dr.

Mail Stop #200 – AZ

Irving, TX 75038

You will receive a Follow-Up Preliminary Finding if you were unresponsive to the initial notification. The RAC will allow an additional thirty (30) days to submit additional documents and request a Rebuttal Review. The RAC will review additional documents within thirty (30) calendar days of receipt.

Medical Record Submission

Electronic Submission

HMS prefers medical records be submitted electronically through the Provider Portal.

Mailing in Medical Records

Providers may mail in hard copies of medical records.
HMS prefers medical records be submitted electronically through the Provider Portal.
Please mail records or CDs or DVDs to the address below:

HMS

5615 Highpoint Dr.

Mail Stop #200 - AZ

Irving, TX 75038

For password, protected DVD or CDs to ensure proper processing email the password to az_support@gainwelltechnologies.com. Please include the following in the email:

- Letter Reference number and/or Internal Control Number (ICN) from the Medical Records Request Letter
- The password
- Any CD label information
- Tracking information to include the carrier and tracking ID
HMS recommends that preferred provider point(s) of contact are loaded into the HMS Provider Portal. In the event of a damaged CD or incomplete record, HMS will attempt to contact the provider. Please see the Provider Portal training for information on how to add/update provider contacts.

SFTP

Providers may also request a Secure File Transfer Protocol (SFTP) be set up for delivering electronic medical records. Please contact HMS Provider Relations with any SFTP requests at 855-287-1682.

Contact Information

HMS Provider Services is available Monday -Friday 8:00 a.m. to 5 p.m. Mountain Time: 1- 833-712-7888

Inquiry Type	Appropriate Contact	Contact Information
Questions about HMS Provider Portal	HMS Provider Services	1- 833-712-7888
Address updates in HMS Provider Portal	HMS Provider Services	1- 833-712-7888
Claim/Review Status Questions	HMS Provider Services	1- 833-712-7888
Providing a Password for a CD or DVD	HMS Provider Services	az_support@gainwelltechnologies.com
Medical Records Address	HMS	HMS – Arizona Recovery Audit Services HMS 5615 Highpoint Dr. Mail Stop #200 - AZ Irving, Texas 75038
Rebuttal Request	HMS	HMS – Arizona Recovery Audit Services HMS 5615 Highpoint Dr. Mail Stop #200 - AZ Irving, Texas 75038