Patient Referrals

Arizona Foundation for Medical Care is a preferred provider organization. As such, plan members who go to in-network providers receive higher “in-network” benefit levels than they would by seeking medical services from out-of-network providers.

We ask AFMC providers to refer these plan members to in-network providers to minimize their out-of-pocket expenses, especially for lab services, pathology groups and DME providers. You can find other in-network providers by using the AFMC Provider Search Tool. If it is necessary to refer a member out-of-network, please remember to inform your patients of that referral before the service is provided. AFMC members should be aware of any and all out-of-network (out-of-pocket) expenses they could incur by using out-of-network providers or facilities.

Member Eligibility and Claims Submission

AFMC does not maintain benefit or eligibility information for members. Providers should contact the administrator indicated on the patient’s identification card for benefit and eligibility information.

AFMC recommends that providers verify benefits for all services rendered to AFMC members. Verifying benefits allows the provider to collect any co-payment, co-insurance, deductible, etc. at the time of service.

The following organizations currently have health plan members with access to AFMC’s Network: AFMC’s Listing of Administrators

AFMC also offers providers on-line patient enrollment verification. This information DOES NOT guarantee coverage or payment, but rather indicates that the specified patient has access to AFMC for the date of service, according to enrollment records. To verify benefits and eligibility, you MUST contact the Administrator listed on the enrollment screen or from the patient’s health plan member ID card.

Precertification Review

Medical necessity is certified for all inpatient stays, either through AFMC Medical Management or a payor’s designated Medical Management Organization. Please refer to your patient’s ID card for full instructions. Below are some points to remember when precertification is necessary:

  • Determine the Patient’s Plan: PPO, POS, SELECT, etc. Check the patient’s insurance ID card for this information.
  • Be certain to use a hospital, ambulatory surgery center and other providers that participate in your patient’s plan. Verify enrollment status.
  • Insurance plans that use AFMC’s Medical Management Services require that before a patient can be admitted to a hospital for elective procedures, the activity must be certified in advance. This is required for any scheduled elective treatment. If an elective or planned medical admission is not precertified, healthcare benefits may be reduced or lost.

For more information on AFMC’s Pre-certification Policy and Procedures, refer to the AFMC Provider Reference Guide, Section 7.2

Concurrent Review

Insurance plans require that a patient’s progress be monitored after admission. Nurse Coordinators work with the admitting physician, hospital and medical advisors to evaluate the patient’s progress. Based on this evaluation, the number of certified days may be adjusted. In addition, Nurse Coordinators are also prepared to assist with discharge planning requirements.

Emergency Admission

In the case of an emergency or urgent admission, call AFMC or the payor’s Medical Management organization within 24-48 hours of an emergency admission. Follow the instructions listed on your patient’s ID card, and refer to AFMC’s Provider Reference Guide, Section 7 – Medical Management for more information.