Arizona Medicaid: Understanding claims-based member assignments and capitated payments

How medical history and other factors determine PCP assignments

To help keep health care consistent for our UnitedHealthcare Community Plan members, we assign them a primary care provider (PCP). The assignment process is based on whether the member is newly enrolled or already on their plan, as well as their:

Geographic location
PCP preference
Claims history

How assignments work

We manage these assignments through automation, which means you don’t need to inform us when members change PCPs. Your capitation report will reflect the changes for claims-based members in the following UnitedHealthcare Community Plans:

Arizona Health Care Costs Containment System (AHCCCS)
Arizona Long-Term Care System/Elderly & Physically Disabled (ALTCS EPD)
Division of Developmental Disabilities (DDD)
Dual Special Needs Plan (D-SNP)

New members

Our system automatically assigns new members to PCPs based primarily on demographics. Members may also self-select a PCP upon enrollment. ALTCS EPD members are an exception to this process. Rather than assign PCPs automatically, we ask ALTCS EPD members to select a PCP during their initial visit with their case manager.

Existing members

Every quarter, our system reviews claim history data based on the provider group tax identification numbers (TINs). The system automatically updates members’ PCP assignments to align with their recent utilization data. Members may also request a PCP change at any time while in their current plan. Their choice is prioritized over auto-assignment logic and claims-based PCP attribution.