Exhibit 300-1, AHCCCS Covered Services Acute Care
Services / TitleXIX / Title XXI
<21 / >21<19 / <19
Audiology / X / XX / X[1]
BehavioralHealth / SEEEXHIBIT300-2A and 300-2B[2]
BreastReconstructionAfterMastectomy / X / X / X
ChiropracticServices / X / X
CochlearImplants / X / X
Diagnostic Testing / X / X / X
EmergencyDentalServices / X / X[3] / X
PreventiveTherapeuticDentalServices *See AMPM Policy 310-D2 for ALTCS Dental Services / X / X[4] / X[5]
LimitedMedicalandSurgicalServicesbyaDentist(forMembersAge21andolder) / X / X[6]
Dialysis / X / X / X
EmergencyServices-Medical / X / X / X
Emergency EyeExam / X / X[7] / X
VisionExam/PrescriptiveLenses / X / X[8] / X
LensPostCataractSurgery / X / X / X
TreatmentforMedicalConditionsoftheEye / X / X / X[9]
HealthRiskAssessment ScreeningTests(forMembersAge21andOlder) / X[10] / X[11] / X
PreventiveExaminationsintheAbsenceofany KnownDiseaseorSymptom / X / X / X
HIV/AIDSAntiretroviralTherapy / X / X / X
High Frequency Chest Wall Oscillation Therapy / X / X / X[12]
HomeHealthServices / X / X / X
Hospice / X / X / X
HospitalInpatientMedical / X / X / X
HospitalObservation / X / X / X
HospitalOutpatientMedical / X / X / X
Hysterectomy(medicallynecessary) / X / X / X
Immunizations / X / X / X
Laboratory / X / X / X
MaternityServices / X / X / X
FamilyPlanning / X / X[13] / X
EarlyandPeriodicScreening,DiagnosisandTreatment(MedicalServices) / X / X
OtherEarlyandPeriodicScreening,DiagnosisandTreatmentServicesCoveredByTitleXIX / X / X[14] / X
MedicalFoods / X / X / X
Durable [15]MedicalEquipment / X / X / X
MedicalSupplies / X / X / X
Prosthetic / X / X[16] / X
OrthoticDevices / X / X / X
Negative Pressure Wound Therapy / X / X / X[17]
NursingFacilities (upto90days) / X / X / X
Non-PhysicianFirstSurgicalAssistant / X / X / X
PhysicianServices / X / X[18] / X
FootandAnkleServices / X / X / X
PrescriptionDrugs / X / X / X
Primary CareProviderServices / X / X / X
Privateduty nursing / X / X / X
RadiologyandMedicalImaging / X / X / X
OccupationalTherapy–Inpatient / X / X / X
OccupationalTherapy–Outpatient / X / X[19] / X
PhysicalTherapy–Inpatient / X / X / X
PhysicalTherapy–Outpatient(SeePolicy RegardingVisitLimitations) / X / X / X
Sleep Studies (Polysomnography) / X / X / X[20]
SpeechTherapy –Inpatient / X / X / X
SpeechTherapy–Outpatient / X / X
RespiratoryTherapy / X / X / X
TotalOutpatientParenteralNutrition / X / X / X
Non-ExperimentaltransplantsapprovedforTitleXIXreimbursement(SeePolicyRegardingSpecificTransplantCoverage) / X / X / X
TransplantRelatedimmunosuppressantdrugs / X / X / X
Transportation–Emergency / X / X / X
Transportation-Non-emergency / X / X / X
Triage / X / X / X
SeeAMPM Chapter300, Section 310[21]forageandservicedeliverysiterestrictions,scopeandtimelimitations,providerspecialtyrequirementandeligibilitylimitations.
SeeAMPM Policy 410[22]Chapter 400 forMaternalandChildHealthServicerestrictionsandlimitations.
SeeAMPM Policy 820[23] Chapter 800 forFFS/PArequirements.
SeeAMPM Chapter1100forcoveredservicesfortheEmergencyServicesProgram(ESP).
SeeArizonaAdministrativeCode,Title9,Chapter22, 28and31regardingAHCCCScoveredservices.
Exhibit 300-1 - Page1 of 2
Effective Dates: 10/01/17
Revision Dates:01/01/01, 10/01/01,10/01/07,10/01/09,10/01/10,11/01/11,09/01/16,08/24/17
[1] Adding as a covered service for this population
[2] Adding additional location of Behavioral Health Exhibit
[3] Adding as a covered service for this population
[4] Removing as a covered service for this population
[5] Adding as a covered service for this population
[6] Removing as a covered service for this population
[7] Adding as a covered service for this population
[8] Removing as a covered service for this population
[9] Adding as a covered service for this population
[10] Adding as a covered service for this population
[11] Adding as a covered service for this population
[12] Adding to the list as a covered service for all populations
[13] Adding as a covered service for this population
[14] Removing as a covered service for this population
[15] POST APC CHANGE: Uniform term used is Medical Equipment
[16] Adding as a covered service for this population
[17] Adding to the list as a covered service for all populations
[18] Adding as a covered service for this population
[19] Adding as a covered service for this population
[20] Adding to the list as a covered service for all populations
[21] Adding Section information is found in
[22] Adding exact Policy
[23] Adding Exact Policy