reglab/statecodes huggingface dataset:
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-715 - Hospital Rate Negotiations

Current through Register Vol. 30, No. 28, July 12, 2024
A.A
				contractor that negotiates with hospitals for inpatient or outpatient services
				shall reimburse hospitals for services rendered on or after March 1, 1993, as
				described in A.R.S. §
									36-2903.01
				and this Article, or at the negotiated rate that, in the aggregate, does not
				exceed reimbursement levels that would have been paid under A.R.S. §
									36-2903.01,
				and this Article. This subsection does not apply to urban hospitals described
				under
				R9-22-718.
Contractors may engage
				  in rate negotiations with a hospital at any time during the contract
				  period.
B.The Administration may negotiate or
				contract with a hospital on behalf of a contractor for discounted hospital
				rates and may require that the negotiated discounted rates be included in a
				subcontract between the contractor and hospital.
The following Section was amended under an exemption from
					 the provisions of the Administrative Procedure Act which means that this rule
					 was not reviewed by the Governor's Regulatory Review Council; the agency did
					 not submit notice of proposed rulemaking to the Secretary of State for
					 publication in the Arizona Administrative Register; the agency was not required
					 to hold public hearings on the rules; and the Attorney General did not certify
					 this rule. This Section was subsequently amended through the regular rulemaking
					 process.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-717

Current through Register Vol. 30, No. 28, July 12, 2024
The following Section was adopted under an exemption from
					 the provisions of the Administrative Procedure Act which means that this rule
					 was not reviewed by the Governor's Regulatory Review Council. The agency was
					 required to submit notice of proposed rulemaking to the Secretary of State for
					 publication in the Arizona Administrative Register; and was required to hold a
					 public hearing.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-718 - Urban Hospital Inpatient Reimbursement Program

Current through Register Vol. 30, No. 28, July 12, 2024
A. Definitions. The following definitions
				apply to this Section:
1. "Contractor" has the
				same meaning as set forth in Arizona Revised Statutes, section
				36-2901,
				and includes all contractors regardless of whether the GSA's served by the
				contractor includes urban or rural counties.
2. "Noncontracted Hospital" means an urban
				hospital, including psychiatric hospitals, which does not have a contract under
				this Section with a contractor.
3
										. "Urban Hospital" means a hospital that
				is not a rural hospital, as defined in
				R9-22-712.07,
				and that is physically located in Mar-icopa or Pima County.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-719 - Contractor Performance Measure Outcomes

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration may retain a specified percentage of
				  capitation reimbursement to distribute to contractors based on their
				  performance measure outcomes under A.R.S. §
									36-2904.
				  The Administration shall notify contractors 60 days prior to a new contract
				  year if this methodology is implemented. The Administration shall specify the
				  details of the reimbursement methodology in contract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-720 - Reinsurance

Current through Register Vol. 30, No. 28, July 12, 2024
A. Reinsurance is a
				stop-loss program provided by the Administration to a contractor for partial
				reimbursement of the cost of covered services for a member with an acute
				medical condition when the cost of covered services exceeds a pre-determined
				deductible level amount within a contract year. The Administration self-insures
				the reinsurance program through a reduction to capitation rates. The
				reinsurance program also includes a catastrophic reinsurance program for
				members diagnosed with specific medical conditions.
B. The Administration shall specify in
				contract guidelines for claims submission, processing, payment, and the types
				of care and services that are provided to a member whose care is covered by
				reinsurance.
C. When the
				Administration determines that a contractor does not follow the specified
				guidelines for care or services and the care or services could have been
				provided at a lower cost according to the guidelines, the Administration shall
				reimburse the contractor as if the care or services had been provided as
				specified in the guidelines.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-721 - Behavioral Health Inpatient Facilities

Current through Register Vol. 30, No. 28, July 12, 2024
"Behavioral health inpatient facility" means a health care
				  institution, other than Arizona State Hospital, that meets the following
				  requirements:
1. Provides continuous
				treatment to an individual experiencing a behavioral health issue that causes
				the individual to:
a. Have a limited or
				reduced ability to meet the individual's basic physical needs;
b. Suffer harm that significantly impairs the
				individual's judgment, reason, behavior, or capacity to recognize
				reality;
c. Be a danger to
				self;
d. Be a danger to
				others;
e. Be persistently or
				acutely disabled as defined in A.R.S. & §
										36-501;
				or
f. Be gravely disabled;
				and
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-730 - Hospital Assessment Fund - Hospital Assessment

Current through Register Vol. 30, No. 28, July 12, 2024
A. For purposes of this Section, the
				following terms are defined as provided below unless the context specifically
				requires another meaning:
1. "2019 Medicare
				Cost Report" means The Medicare Cost Report for the hospital fiscal year ending
				in calendar year 2019 as reported in the CMS Healthcare Provider Cost Reporting
				Information System (HCRIS) release dated October 9, 2020.
2. "2019 Uniform Accounting Report" means the
				Uniform Accounting Report submitted to the Arizona Department of Health
				Services as of December 10, 2020 for the hospital's fiscal year ending in
				calendar year 2019.
3. "Quarter"
				means the three month period beginning January 1, April 1, July 1, and October
				1 of each year.
4. A "new hospital"
				means a licensed hospital that did not hold a license from the Arizona
				Department of Health Services prior to January 2, 2022.
5. "Outpatient Net Patient Revenues" means an
				amount, calculated using data in the hospital's 2019 Uniform Accounting Report,
				that is equal to the hospital's 2019 total net patient revenue multiplied by
				the ratio of the hospital's 2019 gross outpatient revenue to the hospital's
				2019 total gross patient revenue.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-731 - Health Care Investment Fund - Hospital Assessment

Current through Register Vol. 30, No. 28, July 12, 2024
A. For purposes of this Section, terms are
				the same as defined in A.A.C.
				R9-22-730 as provided below unless
				the context specifically requires another meaning:
B. Beginning October 1, 2023, for each
				Arizona licensed hospital not excluded under subsection (I) shall be subject to
				an assessment payable on a quarterly basis. The assessment shall be levied
				against the legal owner of each hospital as of the first day of the quarter,
				and except as otherwise required by subsections (D), (E) and (F). For the
				period beginning October 1, 2023, the assessment for each hospital shall be
				amount equal to the sum of:
(1) the number of
				discharges reported on the hospital's 2021 Medicare Cost Report, excluding
				discharges reported on the Medicare Cost Report as "Other Long Term Care
				Discharges," multiplied by the following rates appropriate to the hospital's
				peer group; and
(2) the amount of
				outpatient net patient revenues multiplied by the following rate appropriate to
				the hospital's peer group:
1. $ 245.50 per
				discharge and 3.5063% of outpatient net patient revenues for hospitals located
				in a county with a population less than 500,000 that are designated as type:
				hospital, subtype: short-term.
2.
				$ 245.50 per discharge and 1.4610% of outpatient net patient revenues for
				hospitals designated as type: hospital, sub type: critical access hospital.
3. $ 61.50 per discharge and
				1.4610% of outpatient net patient revenues for hospitals designated as type:
				hospital, subtype: long term.
4. $
				61.50 per discharge and 1.4610% of outpatient net patient revenues for
				hospitals designated as type: hospital, subtype: psychiatric, that reported
				2,500 or more discharges on the 2021 Medicare Cost Report.
5. $ 196.50 per discharge and 3.7985% of
				outpatient net patient revenues for hospitals designated as type: hospital,
				subtype: short-term with 20% of total licensed beds licensed as pediatric,
				pediatric intensive care and neonatal intensive care as reported in the
				hospital's 2021 Uniform Accounting Report.
6. $ 221.00 per discharge and 4.3829% of
				outpatient net patient revenues for hospitals designated as type: hospital,
				subtype: short- term with at least 10% but less than 20% of total licensed beds
				licensed as pediatric, pediatric intensive care and neonatal intensive care as
				reported in the hospital's 2021 Uniform Accounting Report.
7. $ 49.25 per discharge and 1.1688% of
				outpatient net patient revenues for hospitals designated as type: hospital,
				subtype: children's.
8. $ 245.50
				per discharge and 5.8439% of outpatient net patient revenues for hospitals
				designated as type: hospital, subtype: short- term not included in another peer
				group.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1001 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to the definitions in A.R.S. . §§
									36-2901,
				  36-2923
				  and 9 AA.C. 22, Article 1, the following definitions apply to this
				  Article:
"Absent parent" means an individual who is absent from the
				  home and is legally responsible for providing financial and/or medical support
				  for a dependent child.
"Cost avoid" means to deny a claim and return the claim to
				  the provider for a determination of the amount of first-or third-party
				  liability.
"First-party liability" means the obligation of any insurance
				  plan or other coverage obtained directly or indirectly by a member that
				  provides benefits directly to the member to pay all or part of the expenses for
				  medical services incurred by AHCCCS or a member.
"Third-party" means a person, entity, or program that is, or
				  may be, liable to pay all or part of the medical cost of injury, disease, or
				  disability of an applicant or member.
"Third-party liability" means any individual, entity, or
				  program that is or may be liable to pay all or part of the expenditures for
				  medical assistance furnished to a member under a state plan.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1002 - General Provisions

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS is the payor of last resort unless specifically
				  prohibited by applicable state or federal law. AHCCCS is not the payor of last
				  resort when the following entities are the third-party:
1. Indian Health Services (IHS/638), contract
				health
2. Title IV-E,
3. Arizona Early Intervention Program
				(AZEIP), and
4. Local
				educational agencies providing services under the Individuals with Disabilities
				Education Act under 34 CFR Part 300.
5. Entities and contractors of entities
				providing services under grants awarded as part of the HIV Health Care Services
				Program under
				42 USC
				300 ff et seq., and
6. The Arizona Refugee Resettlement Program
				operated under 45 CFR Part 400. Subpart (G).
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1003 - Cost Avoidance

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				Administration's reimbursement responsibility.
1. The Administration shall pay no more than
				the difference between the Capped Fee-For-Service schedule and the amount of
				the third-party liability, unless Medicare is the third-party.
2. If Medicare is the third-party that is
				liable, the Administration shall pay the Medicare copayment. coinsurance, and
				deductible regardless of the Capped Fee-For-Service Schedule, as described
				under 9 AA.C. 29. Article 3.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1004 - Member Participation

Current through Register Vol. 30, No. 28, July 12, 2024
A member shall cooperate in identifying potentially legally
				  liable first- or third-parties and timely assist the Administration and a
				  contractor, provider, or noncontracting provider in pursuing any first- or
				  third-party who may be liable to pay for covered services.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1005 - Collections

Current through Register Vol. 30, No. 28, July 12, 2024
A. Parties that
				notify AHCCCS. A provider or noncontracting provider shall cooperate with
				AHCCCS by identifying all potential sources of first- or third-party liability
				and notify AHCCCS of these sources.
B. Parties that pursue collection or
				reimbursement. AHCCCS, a provider, or noncontracting provider shall pursue
				collection or reimbursement from all potential sources of first- or third-party
				liability.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1006 - Ahcccs Monitoring Responsibilities

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS shall monitor first- or third-party liability payments
				  to a provider or noncontracting provider, which include but are not limited to
				  payments by or for:
1. Private health
				insurance;
2. Employment-related
				disability and health insurance;
3.
				Long-term care insurance;
4. Other
				federal programs not excluded by statute from recovery;
5. Court ordered or non-court ordered medical
				support from an absent parent;
6.
				State worker's compensation;
7.
				Automobile insurance, including underinsured and uninsured motorists
				insurance;
8. Court judgment or
				settlement from a liability insurer including settlement proceeds placed in a
				trust;
9. First-party probate
				estate recovery;
10.
				Adoption-related payment; or
11. A
				tortfeasor.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1007 - Notification for Perfection, Recording, and Assignment of Ahcccs Liens

Current through Register Vol. 30, No. 28, July 12, 2024
A. Hospital
				requirements. A hospital providing medical services to a member for an injury
				or condition resulting from circumstances reflecting the probable liability of
				a first- or third-party shall within 30 days after a member's discharge:
1. Notify AHCCCS via facsimile or mail under
				R9-22-1008, or
2. Mail AHCCCS a
				copy of the lien the hospital proposes to record or has recorded under A.R.S.
				§
										33-932.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1008 - Notification Information for Liens

Current through Register Vol. 30, No. 28, July 12, 2024
A. Except as provided in subsection (B), a
				hospital, provider, and noncontracting provider identified in R9-22-1007 shall
				provide the following information to AHCCCS in writing:
1. Name of the hospital, provider or
				noncontracting provider;
2. Address
				of the hospital, provider or noncontracting provider;
3. Name of member;
4. Member's Social Security Number or AHCCCS
				identification number;
5. Address
				of member;
6. Date of member's
				admission or date service is provided;
7. Amount estimated to be due for care of
				member;
8. Date of discharge, if
				member has been discharged;
9. Name
				of county in which injuries were sustained; and
10. Name and address of all persons, firms,
				and corporations and their insurance carriers identified by the member or legal
				representative as being liable for damages.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES › Section R9-22-1009 - Notification of Health Insurance Information

Current through Register Vol. 30, No. 28, July 12, 2024
A provider or noncontracting provider shall notify AHCCCS, in
				  writing, of the following health insurance information within 10 days of
				  receipt of the health insurance information:
1. Name of member,
2. Member's Social Security Number or AHCCCS
				identification number,
3. Insurance
				carrier name,
4. Insurance carrier
				address,
5. Policy number or
				insurance holder's Social Security Number,
6. Policy begin and end dates, and
7. Insurance holder's name.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1101 - Basis for Civil Monetary Penalties and Assessments for Fraudulent Claims; Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
A. Scope.
				This Article applies to prohibited acts as described under A.R.S. §
									36-2918(A),
				and submissions of encounters to the Administration. The Administration
				considers a person who aids and abets a prohibited act affecting any of the
				AHCCCS programs or Health Care Group to be engaging in a prohibited act under
				A.R.S. §
									36-2918(A).
B. Purpose. This Article describes the
				circumstances AHCCCS considers and the process that AHCCCS uses to determine
				the amount of a penalty, assessment, or penalty and assessment as required
				under A.R.S. §
									36-2918.
				This Article includes the process and time-frames used by a person to request a
				State Fair Hearing.
C. Definitions.
				The following definitions apply to this Article:
1. "Assessment" means a monetary amount that
				does not exceed twice the dollar amount claimed by the person for each
				service.
2. "Claim" means a request
				for payment submitted by a person for payment for a service or line item of
				service, including a submission of an encounter.
3. "Day" means calendar day unless otherwise
				specified.
4. "File" means the date
				that AHCCCS receives a written acceptance, request for compromise, request for
				a counter proposal, or a request for a State Fair Hearing as established by a
				date stamp on the written document or other record of receipt.
5. "Penalty" means a monetary amount, based
				on the number of items of service claimed or reported, that does not exceed
				$2,000 times the number of line items of service.
6. "Person" means an individual or entity as
				described under A.R.S. §
										1-215.
7. "Reason to know" or "had reason to know"
				means that a person, acts in deliberate ignorance of the truth or falsity of,
				or with reckless disregard of the truth or falsity of information. No proof of
				specific intent to defraud is required.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1102 - Determining the Amount of a Penalty and an Assessment

Current through Register Vol. 30, No. 28, July 12, 2024
A. AHCCCS shall determine the amount of a
				penalty and assessment according to A.R.S. §
									36-2918(B)
				and (C), R9-22-1104, and
				R9-22-1105.
B. AHCCCS shall include
				in the amount of the penalty and assessment the cost incurred by AHCCCS for
				conducting the following;
1. An
				investigation,
2. Audit,
				or
3. Inquiry.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1104 - Mitigating Circumstances

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS shall consider any of the following to be mitigating
				  circumstances when determining the amount of penalties and assessments.
1. The following are mitigating
				circumstances:
a. All the services are of the
				same type,
b. All the dates of
				services occurred within six months or less,
c. The number of claims submitted is less
				than 25,
d. The nature and
				circumstances do not indicate a pattern of inappropriate claims for the
				services, and
e. The total amount
				claimed for the services is less than $1,000.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1105 - Aggravating Circumstances

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS shall consider any of the following to be aggravating
				  circumstances when determining the amount of a penalty, assessment, or penalty
				  and assessment.
1. The nature and
				circumstances of each claim and the circumstances under which the claim is
				presented or caused to be presented are aggravating circumstances if:
a. A person has forged, altered, recreated,
				destroyed, or failed to maintain records;
b. The person refuses to provide pertinent
				documentation to AHCCCS for a claim or refuses to cooperate with
				investigators;
c. The services are
				of several billing code types;
d.
				All the dates of services occurred within six months or greater;
e. The number of claims submitted is greater
				than 25;
f. The nature and
				circumstances indicate a pattern of inappropriate claims for the services;
				and
g. The total amount claimed for
				the services is $5,000 or greater.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1106 - Notice of Intent

Current through Register Vol. 30, No. 28, July 12, 2024
If AHCCCS imposes a penalty, assessment, or a penalty and
				  assessment, AHCCCS shall hand deliver or send by certified mail return receipt
				  requested or Federal Express to the person, a written Notice of Intent to
				  impose a penalty, assessment, or a penalty and assessment. The Notice of Intent
				  shall include:
1. The statutory basis
				for the penalty, assessment, or the penalty and assessment;
2. Identification of the state or federal
				regulation and state or federal law that AHCCCS alleges has been
				violated;
3. The factual basis for
				AHCCCS' determination that the penalty, assessment, or the penalty and
				assessment should be imposed;
4.
				The amount of the penalty, assessment, or penalty and assessment;
5. The process for the person to accept or
				request a compromise of the penalty, assessment, or penalty and assessment;
				and
6. The process for requesting a
				State Fair Hearing.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1108 - Request for a Compromise

Current through Register Vol. 30, No. 28, July 12, 2024
A. To
				request a compromise, the person shall file a written request with AHCCCS
				within 30 days from the date of receipt of the Notice of Intent. The written
				request for compromise shall contain the person's reasons for the reduction or
				modification of the penalty, assessment, or penalty and assessment.
B. Within 30 days from the date of receipt of
				the request for compromise from the person, AHCCCS shall send a Notice of
				Compromise Decision that accepts, denies, or offers a counter proposal to the
				person's request for compromise. If AHCCCS offers a counter proposal the amount
				of the counter proposal shall represent the penalty, assessment, or penalty and
				assessment.
1. If AHCCCS does not withdraw the
				Notice of Intent under
				R9-22-1112 or denies the request
				for compromise the original penalty, assessment, or penalty and assessment is
				upheld.
2. To dispute the
				Compromise Decision, the person shall file a request for a State Fair Hearing
				under R9-22-1110 within 30 days from the
				date of receipt of the Notice of Compromise Decision. A failure to respond to
				the Notice of Compromise Decision will lead to the decision being
				upheld.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1109 - Failure to Respond to the Notice of Intent

Current through Register Vol. 30, No. 28, July 12, 2024
If a person fails to respond timely to the Notice of Intent,
				  AHCCCS shall uphold the original penalty, assessment, or penalty and
				  assessment.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1110 - Request for State Fair Hearing

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				To request a State Fair Hearing regarding a dispute concerning a penalty,
				assessment, or penalty and assessment, the person shall file a written request
				for a State Fair Hearing with AHCCCS within 60 days from the date of the
				receipt of the Notice of Intent under R9-22-1106 or within 30 days from the
				date of receipt of the Notice of Compromise Decision under R9-22-1108, if
				applicable.
B. AHCCCS shall mail a
				Notice of Hearing under A.R.S. §
									41-1092.05
				if AHCCCS receives a timely request for a State Fair Hearing from the
				person.
C. AHCCCS shall mail a
				Director's Decision to the person no later than 30 days after the date the
				Administrative Law Judge sends the decision of the Office of Administrative
				Hearings (OAH) to AHCCCS.
D. AHCCCS
				shall accept a written request for withdrawal of a hearing request if the
				written request for withdrawal is received from the person before AHCCCS mails
				a Notice of Hearing under A.R.S. §
									41-1092 et
				seq. If AHCCCS mailed a Notice of Hearing under A.R.S. §
									41-1092 et
				seq., a person may withdraw the hearing request only by sending a written
				request for withdrawal to OAH.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1111 - Issues and Burden of Proof

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Preponderance of evidence. In any State Fair Hearing conducted under
				R9-22-1110, AHCCCS shall prove by a preponderance of the evidence that a person
				presented or caused to be presented each claim in violation of this Article and
				any aggravating circumstances under R9-22-1105. A person shall bear the burden
				of producing and proving by a preponderance of the evidence any circumstance
				that would justify reducing the amount of the penalty, assessment, or penalty
				and assessment.
B. Statistical
				sampling.
1. In meeting the burden of proof
				described in subsection (A), AHCCCS may introduce the results of a statistical
				sampling study as evidence of the number and amount of claims that were
				presented or caused to be presented by the person. A statistical sampling study
				constitutes prima facie evidence of the number and amount of claims if computed
				by valid statistical methods.
2.
				The burden of proof shall shift to the person to produce evidence reasonably
				calculated to rebut the findings of the statistical sampling study once AHCCCS
				has made a prima facie case as described in subsection (B)(1). AHCCCS shall be
				given the opportunity to rebut this evidence.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 11 - CIVIL MONETARY PENALTIES AND ASSESSMENTS › Section R9-22-1112 - Withdrawal and Continuances

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS may withdraw the Notice of Intent at any time. Prior
				  to referring a matter to the Office of Administrative Hearings the parties may
				  mutually agree to a continuance.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 12 - BEHAVIORAL HEALTH SERVICES › Section R9-22-1202 - ADHS, Contractor, Administration and CRS Responsibilities

Current through Register Vol. 30, No. 28, July 12, 2024
A. ADHS
				responsibilities. ADHS is responsible for payment of behavioral health services
				provided to members, except as specified under subsection (D). ADHS'
				responsibility for payment of behavioral health services includes claims for
				inpatient hospital services, which may include physical health services, when
				the principal diagnosis on the hospital claim is a behavioral health diagnosis.
				Behavioral health diagnoses are identified as "mental disorders" in the latest
				International Classification of Diseases (ICD) code set as required by AHCCCS
				claims and encounters.
B. ADHS/DBHS
				may contract with a TRBHA for the provision of behavioral health services for
				American Indian members. American Indian members may receive covered behavioral
				health services:
1. From an IHS or tribally
				operated 638 facility,
2. From a
				TRBHA, or
3. From a RBHA.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 12 - BEHAVIORAL HEALTH SERVICES › Section R9-22-1203 - Eligibility for Covered Services

Current through Register Vol. 30, No. 28, July 12, 2024
A. Title XIX members. A member determined
				eligible under A.R.S. §
									36-2901(6)(a) or
				(g) except for the failure to meet U.S.
				citizenship or qualified alien status requirements, shall receive medically
				necessary covered services under Article 12 and Article 2.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 12 - BEHAVIORAL HEALTH SERVICES › Section R9-22-1204 - General Service Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
A. Services. Behavioral health services
				include mental health, substance abuse, and physical services. Medically
				necessary services shall be covered and service requirements met as described
				under Article 2 and Article 5.
B.  Notification
				to Administration for American Indians enrolled with a tribal contractor. A
				provider shall notify the Administration no later than 72 hours after an
				American Indian member enrolled with a tribal contractor presents to a
				behavioral health hospital for inpatient emergency behavioral health
				services.
C.
				 Restrictions and limitations.
Room and board is not
				  a covered service unless provided in a behavioral health inpatient facility
				  under
				  R9-22-1205.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 12 - BEHAVIORAL HEALTH SERVICES › Section R9-22-1205 - Scope and Coverage of Behavioral Health Services

Current through Register Vol. 30, No. 28, July 12, 2024
A. Inpatient behavioral health services. The
				following inpatient services are covered subject to the limitations and
				exclusions in this Article and Article 2.
1.
				Covered inpatient behavioral health services include all behavioral health
				services, medical detoxification, accommodations and staffing, supplies, and
				equipment, if the service is provided under the direction of a physician in a
				Medicare-certified:
a. General acute care
				hospital,
b. Inpatient psychiatric
				unit in a general acute care hospital, or
c. Behavioral health hospital.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 12 - BEHAVIORAL HEALTH SERVICES › Section R9-22-1207 - General Provisions for Payment

Current through Register Vol. 30, No. 28, July 12, 2024
A. Claims
				submissions.
1. A provider of
				behavioral health services shall submit a claim for non-emergency behavioral
				health services provided to a member to the appropriate RBHA.
2. A
				provider of behavioral health services shall submit a claim for non-inpatient
				emergency behavioral health services provided to a member to the appropriate
				RBHA
3. A provider of
				behavioral health services shall submit a claim for non-inpatient emergency
				behavioral health services provided to a member enrolled in a TRBHA to the
				Administration.
4. A provider of
				behavioral health services shall submit a claim for non-emergency behavioral
				health services provided to a member enrolled in a TRBHA to the
				Administration.
5. A provider of
				emergency behavioral health services, that are the responsibility of ADHS/DBHS
				or a contractor, shall submit a claim to the entity responsible for emergency
				behavioral health services under
				R9-22-210.01(A).
6. A
				provider shall comply with the time-frames and other payment procedures in
				Article 7 of this Chapter, if applicable, and A.R.S. §
										36-2904.
7.
				ADHS/DBHS or a contractor, whichever entity is responsible for covering
				behavioral health services, shall cost avoid any behavioral health service
				claims if it establishes the existence or probable existence of first-party
				liability or third-party liability.
B. Prior
				authorization. Payment to a provider for behavioral health services or items
				requiring prior authorization may be denied if a provider does not obtain prior
				authorization from a RBHA, ADHS/DBHS, a TRBHA, the Administration or a
				contractor.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1301 - Children's Rehabilitative Services (CRS) related Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to definitions contained in A.R.S. §
									36-2901,
				  the words and phrases in this Article have the following meanings unless the
				  context explicitly requires another meaning:
"Active treatment" means there is a current need for
				  treatment of the CRS qualifying condition(s) or it is anticipated that
				  treatment or evaluation for continuing treatment of the CRS qualifying
				  condition(s) will be needed within the next 18 months from the last date of
				  service for treatment of any CRS qualifying condition.
"CRS application" means a submitted form with any additional
				  documentation required by the Administration to determine whether an individual
				  is medically eligible for CRS.
"CRS condition" means any of the covered medical
				  condition(s) in
				  R9-22-1303.
"Functionally limiting" means a restriction having a
				  significant effect on an individual's ability to perform an activity of daily
				  living as determined by a provider.
"Medically eligible" means meeting the medical eligibility
				  requirements of
				  R9-22-1303.
"Redetermination" means a decision made by the
				  Administration regarding whether a member continues to meet the requirements in
				  R9-22-1302.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1302 - Children's Rehabilitative Services (CRS) Eligibility Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
Beginning October 1, 2013, an AHCCCS member who needs active
				  treatment for one or more of the qualifying medical condition(s) in
				  R9-22-1303
				  shall be given a CRS Designation. An American Indian member can choose to
				  receive CRS services through an American Indian Health Plan or a contractor. A
				  member enrolled in CMDP shall obtain CRS services through CMDP. The contractor
				  shall provide covered services necessary to treat the condition(s) and other
				  services described within the contract. The effective date of the CRS
				  Designation shall be as specified in contract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1303 - Medical Eligibility

Current through Register Vol. 30, No. 28, July 12, 2024
The following lists identify those medical condition(s) that
				  do qualify for CRS services as well as those that do not qualify for CRS
				  services. The list of condition(s) that qualify for a CRS Designation is all
				  inclusive. The list of condition(s) that do not qualify for a CRS Designation
				  is not an all-inclusive list.
1.
				Cardiovascular System
a. CRS condition(s) that
				qualify for CRS medical eligibility:
i.
				Arrhythmia,
ii. Arteriovenous
				fistula,
iii.
				Cardiomyopathy,
iv. Conduction
				defect,
v. Congenital heart defect
				other than isolated small Ventricular Septal Defects (VSD), Patent Ductus
				Arteriosus (PDA), Atrial Septal Defects (ASD),
vi. Coronary artery and aortic
				aneurysm,
vii. Renal vascular
				hypertension,
viii. Rheumatic heart
				disease, and
ix. Valvular
				disorder.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1304 - Referral and Disposition of Crs Medical Eligibility Determination

Current through Register Vol. 30, No. 28, July 12, 2024
A.To refer an
				individual for a CRS medical eligibility determination a person shall submit to
				the Administration the following information:
1. CRS application,
2. Documentation from a specialist who
				diagnosed the individual, stating the individual's diagnosis,
3. Diagnostic test results that support the
				individual's diagnosis, and
4.
				Documentation of the individual's need for specialized treatment of the CRS
				condition through medical, surgical, or therapy modalities.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1305 - CRS Redetermination

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Continued eligibility for CRS services shall be redetermined by verifying
				active treatment status of the CRS qualifying medical condition(s) as follows:
1. The Ccontractor is responsible for
				notifying the AHCCCS Administration of the date when a member with a CRS
				Designation is no longer in active treatment for the qualifying
				condition(s).
2. The Administration
				may request, at any time, that the contractor submit the medical documentation
				to the Administration for a CRS medical redetermination within the specified
				time-frames in contract.
3. The
				Administration shall notify the member or authorized representative of the
				outcome of the redetermination.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 13 - CHILDREN'S REHABILITATIVE SERVICES (CRS) › Section R9-22-1307 - Covered Services

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration will cover medically necessary services as
				  described within Article 2 unless otherwise specified in
				  contract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1403 - Agency Responsible for Determining Eligibility

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration or its designee shall determine
				  eligibility under the provisions of this Article. The Administration or its
				  designee shall not discriminate against an applicant or member because of race,
				  color, creed, religion, ancestry, national origin, age, sex, or physical or
				  mental disability.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1413 - Time-frames, Reinstatement of an Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. The Administration or its designee shall
				complete an eligibility determination under
				R9-22-306(A)(1)
				unless:
1. The applicant is pregnant. The
				Administration or its designee shall complete an eligibility determination for
				a pregnant woman within 20 days after the application date unless additional
				information is required to determine eligibility; or
2. The applicant is in a hospital as an
				inpatient at the time of application. Within seven days of the Administration
				or its designee's receipt of a signed application the Administration or its
				designee shall complete an eligibility determination if the Administration or
				its designee does not need additional information or verification to determine
				eligibility.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1416 - Effective Date of Eligibility

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Except as provided in R9-22-303 and subsections (B), (C) and (D), the effective
				date of eligibility is the first day of the month that the applicant files an
				application if the applicant is eligible that month, or the first day of the
				first eligible month following the application month except for:
1. The MED program under
				R9-22-1439,
				and
2. Eligibility for a newborn
				under
				R9-22-1429.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1420 - Income Eligibility Criteria

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Evaluation of income. In determining eligibility, the Administration or its
				designee shall evaluate the following types of income received by a person
				identified in subsection (B):
1. Earned
				income, including in-kind income, before any deductions. For purposes of this
				Section, in-kind income means room, board, or provision for other needs in
				exchange for work performed. The person identified in subsection (B) shall
				ensure that the provider of the in-kind income establishes and verifies the
				monetary value of the item provided. The provider may be, but is not limited
				to:
a. A landlord who provides all or a
				portion of rent or utilities in exchange for services;
b. A store owner who gives goods such as
				groceries, clothes, or furniture in exchange for services; or
c. An individual who trades goods such as a
				car, tools, trailer, building material, or gasoline in exchange for
				services;
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1421 - Magi Based Income Eligibility

Current through Register Vol. 30, No. 28, July 12, 2024
A. In determining
				eligibility, if an individual would otherwise be ineligible under this Article
				due to excess income, the Administration or its designee shall subtract an
				amount equivalent to five percentage points of the Federal Poverty Level (FPL)
				from the household income.
B. A
				person is eligible under this Article when:
1.
				Subject to subsection (A), the monthly household income does not exceed the
				appropriate FPL;
2. If ineligible
				under (B)(1), the household income determined in accordance with
				26 CFR
				1.36B-1(e) is below 100
				percent FPL; or
3. For eligibility
				under
				R9-22-1437,
				the person's income during the period defined in R9-22-1437(C) does not exceed
				the FPL under
				R9-22-1437(B).
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 14 - AHCCCS MEDICAL COVERAGE FOR HOUSEHOLDS › Section R9-22-1422 - Methods for Calculating Monthly Income

Current through Register Vol. 30, No. 28, July 12, 2024
A. Projecting income.
1. Description. Projecting income is a method
				of determining the amount of income that a person will receive.
2. Calculation. The Administration or its
				designee shall project income by:
a.
				Converting income to a monthly equivalent,
b. Using unconverted income, or
c. Prorating income to determine a monthly
				equivalent.
3.
				Exclusion. When calculating projected monthly income, the Administration or its
				designee shall exclude an unusual variation in income under
				R9-22-1424(E),
				except for a month in which the variation is anticipated to occur.