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Arizona School-Based Medicaid Program Overview

Background

PCG was founded in 1986 as a privately held consulting firm serving state and local health and human services programs.  Today, with more 700 professionals in 28 offices around the U.S. and in Montreal, Quebec, we offer a wide range of management consulting and technology solutions to help public sector clients achieve their performance goals and better serve populations  in need. PCG continuously updates its knowledge of industry best practices and maximizes partnerships and investments to deliver the leading consulting approaches and technologies to the marketplace.  The firm is committed to providing proven solutions and outstanding customer service to clients in each of our four practice areas.

PCG is a national leader in school based Medicaid engagements.  Since, 1992, the firm has recovered more than $1.5 billion in federal Medicaid funds for school districts clients across the U.S. – more than any other vendor in the country.  PCG works with over 1,000 clients, ranging from statewide engagements and large urban to small rural districts.

Arizona participates in two Medicaid reimbursement programs for school based services, the Direct Service Claiming (DSC) program and the Medicaid Administrative Claiming (MAC) program.  These two school-based programs assist participating school districts, referred to as Local Education Agencies (LEAs), including charter schools and the Arizona School for the Deaf and Blind (ASDB), by reimbursing them for Medicaid covered services they provide to eligible and qualified students. The purpose of the DSC Program is to allow LEAs to receive reimbursement for Medicaid covered medical services provided to Title XIX eligible students. The purpose of the MAC program is to allow LEAs to receive reimbursement for Medicaid administrative outreach activities that are done routinely within the school setting. 

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that oversees these two school-based programs.  In Arizona, these programs are overseen by the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency.  AHCCCS contracts with a Third Party Administrator (TPA), PCG, to administer both the DSC and MAC programs.

The requirements for both programs are a blended result of federal laws and requirements from CMS, state laws and program requirements from AHCCCS, and administrative requirements from PCG.  Significant changes in either program will typically require some level of approval from all three organizations (CMS, AHCCCS and PCG). 

In 2003, CMS required that a LEA participating in the MAC program must also claim in the DSC program.  A LEA can, however, participate in the DSC program alone.

Role of AHCCCS

AHCCCS is Arizona’s Managed Care Medicaid Program that was developed as a result of Title XIX of the Social Security Act. While AHCCCS also administers other state and federal health care programs, only Title XIX members are eligible for the DSC Program.  The Medicaid Administrative Claiming (MAC) program is one of the two federally funded programs endorsed by the Arizona Department of Education (ADE) and AHCCCS.  AHCCCS is the agency that develops the policies and administers the Medicaid School Based Claiming Program through PCG and in collaboration with the ADE.

Handbooks for the DSC and MAC programs are available under http://web.pcgus.com/azschools/downloads.html and provide the information necessary to successfully participate in both programs.  AHCCCS policies relating to the DSC and MAC Programs can be found on the AHCCCS website at http://www.azahcccs.gov/ under Plans, Providers, Contractors, Provider Billing Resources and Rates, AHCCCS Provider Manuals, AHCCCS Medical Policy Manual (AMPM), Chapter 700.

Role of Public Consulting Group

PCG was assigned the contract by AHCCCS to act as a third party administrator for the DSC and MAC programs in February 2009.  The contract effective date was February 1, 2009.  PCG provides a full spectrum of services under this contract including:

• Training required preparing all LEAs to participate in the Programs.
• Maintaining copies of the signed  “Agreement Between Participating Local Education Agency (LEA) and PCG, Inc.” for each participating LEA
• Processing claims and submitting them through the AHCCCS system.
• Providing the Information Services (IS) system required to administer the Programs. 
• The PCG data processing system houses the Program membership, contracted providers and needed reference materials.
• The system receives claims, edits and processes them and forwards them to AHCCCS for final approval.
• The system assists with distributing payments to each LEA or their Biller, providing a remittance advice that identifies the claims and the amount paid, as well as a list of any denied claims, pended claims and the reason codes.
• Conducting periodic compliance reviews of participating LEAs.
• During the reviews, staff assesses all documentation related to the program, including provider records and student records.
• PCG works closely with participants throughout this process to ensure compliance with all AHCCCS and CMS requirements.

The DSC and MAC Programs are administered by PCG in Phoenix, Arizona, with a staff that is dedicated to the Programs.  LEAs are assigned to individual Account Managers, who are available to answer questions, help resolve problems, provide a specific contracted provider list to their LEAs and perform other related support services.

Contracting with Public Consulting Group (PCG)

In order to become contracted with PCG, a LEA must:

• Be an Arizona public school district or an Arizona charter school
• Have students eligible under the Individuals with Disability Education Act (IDEA)
• Provide one or more of the Medicaid covered services on site
• Sign an agreement with PCG

The agreement details the responsibilities and rights of both PCG and the participating LEA and the services to be provided to the LEA.  The completed contract allows the LEA to participate in the Medicaid School Based Program administered by PCG.  On receipt of the signed contract, PCG will work with the LEA to implement the Medicaid claiming processes.

Contact Information

Local Office:
Public Consulting Group
101 North First Ave, Suite 1800   
Phoenix, AZ  85003 

Phone number:         (602) 324-5090   
Toll Free number:     1-(877)-877-8011
Fax number:              (602) 324-5091  

Email:   AZMAC@PCGUS.COM         for the MAC Program
            AZDIRECT@PCGUS.COM     for the DSC Program
            AZAUDIT@PCGUS.COM      for DSC and MAC Compliance Reviews

About Public Consulting Group

PCG was founded in 1986 as a privately held consulting firm serving state and local health and human services programs. Today, with more than 700 professionals in 30 offices around the U.S., Canada and Poland, we offer a wide range of management consulting and technology solutions to help public sector clients achieve their performance goals and better serve populations in need. PCG continuously updates its knowledge of industry best practices and maximizes partnerships and investments to deliver the leading consulting approaches and technologies to the marketplace.

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