reglab/statecodes huggingface dataset:
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-309 - Confidentiality and Safeguarding of Information

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration or its designee shall maintain the
				  confidentiality of an applicant or member's records and limit the release of
				  safeguarded information under
				  R9-22-512
				  and 6 A.A.C. 12, Article 1. In the event of a conflict between
				  R9-22-512
				  and 6 A.A.C. 12, Article 1,
				  R9-22-512
				  prevails.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-310 - Ineligible Person

Current through Register Vol. 30, No. 28, July 12, 2024
A person is not eligible for AHCCCS medical coverage if the
				  person is:
1. An inmate of a public
				institution, or
2. Over age 64 and
				is residing in an Institution for Mental Disease under
				42 CFR
				435.1009 except as allowed in
				42 USC
				1396 d(h) or as allowed under the
				Administration's Section 1115 waiver.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-311 - Assignment of Rights under Operation of Law

Current through Register Vol. 30, No. 28, July 12, 2024
By operation of law and under A.R.S. §
									36-2903,
				  a person determined eligible assigns rights to the system medical benefits to
				  which the person is entitled.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-312 - Member Notices

Current through Register Vol. 30, No. 28, July 12, 2024
A. Contents of
				notice. The Administration or its designee shall issue a notice by mail,
				personal delivery, or electronic means when an action is taken regarding a
				person's eligibility or premiums. The notice shall contain the following
				information:
1. The date of the notice
				issued;
2. A statement of the
				action being taken;
3. The
				effective date of the action;
4.
				The specific reason for the intended action;
5. If eligibility is being discontinued due
				to income in excess of the income standards, the actual figures used in the
				eligibility determination and the amount by which the person exceeds income
				standards;
6. If a premium is
				imposed or increased, the actual figures used in determining the premium
				amount;
7. The specific law or
				regulation that supports the action, or a change in federal or state law that
				requires an action;
8. An
				explanation of the member's rights to an appeal and continued
				benefits.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-313 - Withdrawal of Application

Current through Register Vol. 30, No. 28, July 12, 2024
A. An
				applicant may withdraw an application at any time before the Administration or
				its designee completes an eligibility determination by making an oral or
				written request for withdrawal to the Administration or its designee and
				stating the reason for withdrawal.
B. If an applicant orally requests withdrawal
				of the application, the Administration or its designee shall document the:
1. Date of the request,
2. Name of the applicant for whom the
				withdrawal applies, and
3. Reason
				for the withdrawal.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-314 - Withdrawal from AHCCCS Medical Coverage

Current through Register Vol. 30, No. 28, July 12, 2024
A. A member may withdraw from AHCCCS medical
				coverage at any time by giving oral or written notice of withdrawal to the
				Administration or its designee. The member or the member's legal or authorized
				representative shall provide the Administration or its designee with:
1. The reason for the withdrawal,
2. The date the notice is effective,
				and
3. The name of the member for
				whom AHCCCS medical coverage is being withdrawn.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-315 - Notice of Adverse Action

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Adverse actions. An applicant or member may appeal, as described under Chapter
				34, by requesting a hearing from the Administration or its designee concerning
				any of the following adverse actions:
1.
				Complete or partial denial of eligibility under
				R9-22-307
				and R9-22-313(E);
2. Suspension,
				termination, or reduction of AHCCCS medical coverage under
				R9-22-307,
				R9-22-312 and
				R9-22-314;
3. Delay in the eligibility determination
				beyond the time-frames under this Article;
4. The imposition of or increase in a premium
				or copayment; or
5. The effective
				date of eligibility.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-316 - Exemptions from Sponsor Deemed Income

Current through Register Vol. 30, No. 28, July 12, 2024
A. An applicant shall provide proof to the
				Administration or its designee when claiming an exemption from sponsor deemed
				income.
B. The Administration or
				its designee shall grant an exemption from deeming a sponsor's income for a
				Lawful Permanent Resident applicant if the applicant:
1. Adjusted immigration status to Lawful
				Permanent Resident from status as a refugee or asylee;
2. Is the spouse or dependent child of the
				sponsor and lives with the sponsor;
3. Is indigent as specified in subsection
				(C);
4. Is a victim of domestic
				violence or extreme cruelty as specified in subsection (D); or
5. Has acquired 40 qualified quarters of work
				credit based on earnings as specified in subsection (E).
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 3 - GENERAL ELIGIBILITY REQUIREMENTS › Section R9-22-317 - Sponsor Deemed Income

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				Administration or its designee shall use income of a USCIS sponsor to determine
				eligibility for a non-citizen applicant, whether or not the income is
				available, to the non-citizen applicant unless exempt under
				R9-22-316.
B. Counting the income from a sponsor.
1. This Section applies to non-citizen
				applicants who:
a. Are Lawful Permanent
				Residents under
				8
				CFR 101.3;
b. Applied for Lawful Permanent Resident
				Status on or after December 19, 1997;
c. Are sponsored by an individual who signed
				a USCIS I-864 Affidavit of Support; and
d. Are eligible for full AHCCCS medical
				coverage.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-401 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
Definitions. The following definitions apply specifically to
				  terms used within this Article:
"Amounts incurred by the system" include capitation payments,
				  costs incurred by any contractor in excess of capitation, reinsurance, and
				  other administrative, legal or investigative costs associated with a person who
				  obtained eligibility contrary to A.R.S. §
									36-2905.04
				  and/or A.R.S. §
									36-2991.
"Application for eligibility" means any request for benefits
				  administered by AHCCCS under the authority of A.R.S. Title 36, Chapter 29,
				  including applications for presumptive eligibility submitted to hospitals as
				  described under Article 16 of this Chapter.
"Penalty" means an amount not to exceed the amounts incurred
				  by the system during any time period that the person would have been ineligible
				  for benefits but for the false or fraudulent information provided on the
				  application for eligibility. A penalty does not include, and does not need to
				  be reduced by, the amount of any overpayments that AHCCCS may be entitled to
				  recoup from a person who violated A.R.S. §
									36-2905.04
				  and/or A.R.S. §
									36-2991.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-402 - Determining the Amount of the Penalty

Current through Register Vol. 30, No. 28, July 12, 2024
A. AHCCCS shall determine the amount of a
				penalty according to A.R.S. §
									36-2905.04(B)
				 or A.R.S. §
									36-2991(B),
				whichever is applicable, and this Article.
B. In addition to any penalty imposed
				pursuant to ARS §
									36-2905.04
				or
				36-2991,
				and this Article, the Administration may also recoup from the person the
				amounts incurred by the system as a part of the notice and appeal process
				described in this Article.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-403 - Mitigating and Aggravating Circumstances

Current through Register Vol. 30, No. 28, July 12, 2024
A. AHCCCS shall consider any of the following
				to be mitigating circumstances when determining the amount of a penalty for
				obtaining eligibility by fraud.
1. Degree of
				culpability. The degree of culpability of a person is a mitigating circumstance
				if the person did not intend to provide or cause to be provided false
				information on the application for eligibility but was negligent as to the
				truthfulness of the information provided.
2. Prior Offenses. At the time of the
				submittal of the application the person:
a.
				Did not have any prior criminal convictions; and
b. Had not been held civilly liable for
				defrauding a public assistance program.
3. Financial condition. The financial
				condition of a person who violates A.R.S. §
										36-2905.04
				or
				36-2991
				is a mitigating circumstance if the imposition of a penalty without reduction
				will render the person incapable of obtaining necessities of life such as food,
				clothing, and shelter. AHCCCS may consider the resources available to the
				person when determining the amount of the penalty.
4. Other matters as justice may require.
				AHCCCS shall take into account other circumstances of a mitigating nature, if
				in the interest of justice; the circumstances require a reduction of the
				penalty.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-404 - Notice of Intent

Current through Register Vol. 30, No. 28, July 12, 2024
A. If AHCCCS
				imposes a penalty pursuant to this Article, 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.
B. The Notice of Intent shall include:
1. The legal and factual basis for AHCCCS'
				determination that there has been a violation of A.R.S §
										36-2905.04
				and/or 36-2991;
2. The
				penalty;
3. The amounts incurred by
				the system as a result of the violation of A.R.S. §
										36-2905.04
				and/or 36-2991, if AHC-CCS intends to recoup those amounts through this
				process; and
4. The procedure for
				requesting a State Fair Hearing.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-405 - Failure to Respond to the Notice of Intent

Current through Register Vol. 30, No. 28, July 12, 2024
If a person fails to respond to the Notice of Intent within
				  the timeframe described in A.A.C. §
									R9-22-406(A),
				  AHCCCS shall uphold the penalty and recoupment amounts described in the Notice
				  of Intent.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-406 - Request for State Fair Hearing

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				To dispute the agency action described in the Notice of Intent, the person
				shall file a written Request for State Fair Hearing with AHCCCS within sixty
				(60) days from the date of receipt of the Notice of Intent.
B. If AHCCCS receives a timely request for a
				State Fair Hearing from the person, AHCCCS shall mail a Notice of Hearing
				pursuant to the Uniform Administrative Hearing Procedures described in A.R.S.
				Title 41, Chapter 6, Article 10.
C.
				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 the Uniform Administrative Hearing Procedures
				described in A.R.S. Title 41, Chapter 6, Article 10.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-407 - Burden of Proof

Current through Register Vol. 30, No. 28, July 12, 2024
A. In any State
				Fair Hearing conducted under this Article, AHCCCS shall prove a violation of
				A.R.S. §
									36-2905.04
				and/ or 36-2991, and any aggravating circumstances by a preponderance of the
				evidence.
B. AHCCCS does not have
				to prove any specific intent to defraud.
C. A person shall bear the burden of
				producing and proving by a preponderance of the evidence any affirmative
				defense or any circumstance that would justify reducing the amount of the
				penalty.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 4 - PENALTY FOR OBTAINING ELIGIBILITY BY FRAUD › Section R9-22-408 - Rescission of the Notice of Intent

Current through Register Vol. 30, No. 28, July 12, 2024
AHCCCS may rescind the Notice of Intent at any time prior to
				  the State Fair Hearing without prejudice.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-501 - General Provisions and Standards - 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 Chapter have the following meanings unless the
				  context explicitly requires another meaning:
"Quality management" means a process used by professional
				  health personnel through a formal program involving multiple organizational
				  components and committees to:
Assess the degree to which services provided conform to
				  desired medical standards and practices; and
Quality improvement or maintenance of care and
				  services.
"Quality Improvement" means a process designed to achieve,
				  through ongoing measurements and intervention, significant improvement that is
				  sustained over time, in the areas of clinical care and non-clinical care and is
				  expected to have a favorable effect on health outcomes and member satisfaction.
				  Quality Improvement includes focusing organizational efforts on improving
				  performance and utilizing data to develop intervention strategies to improve
				  performance and outcomes.
"Utilization management/review" means a methodology used by
				  professional health personnel to assess the medical indications,
				  appropriateness, and efficiency of care provided. Utilization management
				  applies to a contractor's process to evaluate and approve or deny the medical
				  necessity, appropriateness, efficacy and efficiency of health care services,
				  procedures, or settings. Utilization review includes processes for prior
				  authorization, concurrent review, retrospective review, and case
				  management.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-502 - Pre-existing Conditions

Current through Register Vol. 30, No. 28, July 12, 2024
A A
				contractor shall not impose a pre-existing condition exclusion with respect to
				covered services.
B. A contractor
				or subcontractor shall not adopt or use any procedure to identify a person who
				has an existing or anticipated medical or psychiatric condition in order to
				discourage or exclude the person from enrolling in the contractor's health plan
				or encourage the person to enroll in another health plan.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-503 - Provider Requirements Regarding Records

Current through Register Vol. 30, No. 28, July 12, 2024
The provider shall maintain records that meet uniform
				  accounting standards and generally accepted practices for maintenance of
				  medical records, including detailed specification of all patient services
				  delivered, the rationale for delivery, and the service date. A provider shall
				  maintain and upon request, make available to a contractor and to the
				  Administration, financial and medical records relating to payment for not less
				  than five years from the date of final payment, or for records relating to
				  costs and expenses to which the Administration has taken exception, five years
				  after the date of final disposition or resolution of the exception. Providers
				  shall provide one copy of a medical record at no cost if requested by the
				  member.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-504 - Marketing; Prohibition against Inducements; Misrepresentations; Discrimination; Sanctions

Current through Register Vol. 30, No. 28, July 12, 2024
A. A
				contractor or the contractor's marketing representative shall not offer or give
				any form of compensation or reward, or engage in any behavior or activity that
				may be reasonably construed as coercive, to induce or procure AHCCCS enrollment
				with the contractor. Any marketing solicitation offering a benefit, good, or
				service in excess of the covered services in Article 2 is deemed an
				inducement.
B. A marketing
				representative shall not misrepresent itself, the contracting health plan
				represented, or the AHCCCS program, through false advertising, false
				statements, or in any other manner to induce a member of another contractor to
				enroll in the represented health plan. Violations of this subsection include,
				but are not limited to, false or misleading claims, inferences, or
				representations such as:
1. A member will lose
				benefits under the AHCCCS program or lose any other health or welfare benefits
				to which a member is legally entitled, if the member does not enroll in the
				represented contracting health plan;
2. Marketing representatives are employees of
				the state or representatives of the Administration, a county, or any health
				plan other than the health plan by which they are employed, or by which they
				are reimbursed; and
3. The
				represented health plan is recommended or endorsed as superior to its
				competition by any state or county agency, or any organization, unless the
				organization has certified its endorsement in writing to the health plan and
				the Administration.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-505 - Standards, Licensure, and Certification for Providers of Hospital and Medical Services

Current through Register Vol. 30, No. 28, July 12, 2024
A provider shall not provide hospital or medical services to
				  a member unless the provider is licensed by the Arizona Department of Health
				  Services and meets the requirements in 42 CFR 441 and 482, as of October 1,
				  2007, and 42 CFR 456 Subpart C, as of October 1, 2007, incorporated by
				  reference, on file with the Administration and available from the U.S.
				  Government Printing Office, 732 N. Capitol St., N.W., Washington, D.C. 20401.
				  This incorporation contains no future editions or amendments. An Indian Health
				  Service (IHS) hospital and a Veterans Administration hospital shall not provide
				  services to a member unless accredited by the Joint Commission on Accreditation
				  of Healthcare Organizations (JCAHO).
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-509 - Transition and Coordination of Member Care

Current through Register Vol. 30, No. 28, July 12, 2024
A. A contractor shall assist in the
				transition of members to and from other AHCCCS contractors.
1. Both the receiving and relinquishing
				contractor shall:
a. Coordinate with the other
				contractor to facilitate and schedule appointments for medically necessary
				services for the transitioned member within the Administration's timelines
				specified in the contract. If requested by the Administration, a contractor
				shall submit the policies and procedures regarding transition of members to the
				Administration for review and approval;
b. Assist in the referral of transitioned
				members to other community health agencies or county medical assistance
				programs for medically necessary services not covered by the Administration, as
				appropriate; and
c. Develop
				policies and procedures to be followed when transitioning members who have
				significant medical conditions; are receiving ongoing services; or have, at the
				time of the transition, received prior authorization or approval for
				undelivered, specific services.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-512 - Release of Safeguarded Information

Current through Register Vol. 30, No. 28, July 12, 2024
A. The Administration, contractors,
				providers, and noncontracting providers shall limit the release of safeguarded
				information to persons or agencies for the following purposes in accordance
				with 45 CFR 160 and 45 CFR 164, October 1, 2004, and
				42 CFR 431.300
				through
				431.307,
				October 1, 2004, incorporated by reference, on file with the Administration and
				available from the U.S. Government Printing Office, 732 N. Capitol St., N.W.,
				Washington, D.C. 20401. This incorporation by reference contains no future
				editions or amendments:
1. Official purposes
				directly related to the administration of the AHCCCS program including:
a. Establishing eligibility and
				post-eligibility treatment of income, as applicable;
b. Determining the amount of medical
				assistance;
c. Providing services
				for members;
d. Performing
				evaluations and analysis of AHCCCS operations;
e. Filing liens on property as
				applicable;
f. Filing claims on
				estates, as applicable; and
g.
				Filing, negotiating, and settling medical liens and claims.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-518 - Information to Enrolled Members

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Each contractor shall produce and distribute printed informational materials to
				each member or family unit no later than 10 days of receipt of notification of
				enrollment from the Administration. The contractor shall ensure that the
				informational materials meet the requirements specified in the contractor's
				current contract.
B. A contractor
				shall provide a member with the name, address, and telephone number of the
				member's primary care provider no later than 10 days from the date of
				enrollment. The contractor shall include information on how the member may
				change primary care providers.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-521 - Program Compliance Audits

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				The Administration shall conduct an onsite program compliance audit of a
				contractor at least once every three years during the term of the
				Administration's contract with the contractor. The Administration may conduct,
				without prior notice, inspections of contractor facilities or perform other
				elements of a program compliance audit.
B. An audit team may perform any or all of
				the following procedures:
1. Conduct private
				interviews and group conferences with members, physicians, other health
				professionals, and members of the contractor's administrative staff including,
				but not limited to, the contractor's principal management persons;
2. Examine records, books, reports, and
				papers of the contractor and any management company, and all providers or
				subcontractors providing health care and other services. The examination may
				include, but need not be limited to: minutes of medical staff meetings, peer
				review and quality of care review records, duty rosters of medical personnel,
				appointment records, written procedures for the internal operation of the
				health plan, contracts and correspondence with members and with providers of
				health care services and other services to the plan, and additional
				documentation deemed necessary by the Administration to review the quality of
				medical care.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 5 - GENERAL PROVISIONS AND STANDARDS › Section R9-22-522 - Quality Management/Utilization Management (QM/UM) Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
A. A contractor
				shall comply with Quality Management/Utilization Management (QM/UM)
				requirements specified in this Section and in contract. The contractor shall
				ensure compliance with QM/UM requirements that are accomplished through
				delegation or subcontract with another party.
B. In addition to any requirements specified
				in contract, a contractor shall:
1. Submit to
				the Administration a written QM/UM plan that includes a description of the
				systems, methodologies, protocols, and procedures to be used in:
a. Monitoring and evaluating the types of
				services provided,
b. Identifying
				the numbers and costs of services provided,
c. Assessing and improving the quality and
				appropriateness of care and services,
d. Evaluating the outcome of care provided to
				members, and
e. Determining the
				actions necessary to improve service delivery;
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-601 - General Provisions

Current through Register Vol. 30, No. 28, July 12, 2024
A. The
				Director has full operational authority to adopt rules for the RFP process and
				the award of contracts under A.R.S. §
									36-2906.
B. This Article applies to the award of
				contracts under A.R.S. §§
									36-2904
				and
				36-2906
				to provide services under A.R.S. §
									36-2907
				and the expenditure of public monies by the Administration pertaining to
				covered services when the procurement so states. The Administration shall
				establish conflict-of-interest safeguards for officers and employees of this
				state with responsibilities relating to contracts that comply with
				42 U.S.C.
				1396 u - 2(d)(3).
C. The Administration is exempt from the
				procurement code under A.R.S. §
									41-2501.
D. The Administration and contractors shall
				retain all contract records for five years under A.R.S. §
									36-2903
				and dispose of the records under A.R.S. §
									41-2550.
E. The following terms are defined as related
				to this Article:
"Procurement file" means the official records file of the
				  Director whether located in the Office of the Director or at the public
				  procurement unit. The procurement file shall include in electronic or paper
				  form a list of notified vendors, final solicitation, solicitation amendments,
				  bids/offers, final proposal revisions, clarifications, and final evaluation
				  report.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-602 - RFP

Current through Register Vol. 30, No. 28, July 12, 2024
A. RFP content. The
				Administration shall include the following items in any RFP under this Article:
1. Instructions and information to an offeror
				concerning the proposal submission including:
a. The deadline for submitting a
				proposal,
b. The address of the
				office at which a proposal is to be received,
c. The period during which the RFP remains
				open, and
d. Any special
				instructions and information;
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-603 - Contract Award

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration shall award a contract to the responsible
				  and responsive offeror whose proposal is determined most advantageous to the
				  state under A.R.S. §
									36-2906.
				  If the Administration determines that multiple contracts are in the best
				  interest of the state, the Administration may award multiple contracts. The
				  contract file shall contain the basis on which the award is made.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-604 - Contract or Proposal Protests; Appeals

Current through Register Vol. 30, No. 28, July 12, 2024
A. Disputes related to contract performance.
				This Section does not apply to a dispute related to contract performance. A
				contract performance dispute is governed by 9 A.A.C. 34.
B. Resolution of a proposal protest. The
				procurement officer issuing a RFP shall have the authority to resolve proposal
				protests. An appeal from the decision of the procurement officer shall be made
				to the Director.
C. Filing of a
				protest.
1. A person may file a protest with
				the procurement officer regarding:
a. A RFP
				issued by the Administration,
b. A
				proposed award, or
c. An award of a
				contract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-605 - Waiver of Contractor's Subcontract with Hospitals

Current through Register Vol. 30, No. 28, July 12, 2024
If a contractor is unable to obtain a subcontract with a
				  hospital as contractually required, the contractor may request in writing a
				  waiver from the Administration as allowed by A.R.S. §
									36-2906.
				  The contractor shall state in the request the reasons a waiver is believed to
				  be necessary and all efforts the contractor has made to secure a subcontract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 6 - RFP AND CONTRACT PROCESS › Section R9-22-606 - Contract Compliance Sanction

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				The Director may impose sanctions upon a contractor for violation of any
				provision of this Chapter or of a contract. Sanctions include but are not
				limited to:
1. Suspension of any or all
				further member enrollment, by choice and/or assignment for a period of
				time.
2. Imposition of a monetary
				sanction.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-701.10 - Scope of the Administration's and Contractor's Liability

Current through Register Vol. 30, No. 28, July 12, 2024
The Administration shall bear no liability for providing
				  covered services for any member beyond the date of termination of the member's
				  eligibility or during the member's enrollment with a contractor. A contractor
				  has no financial responsibility for services provided to a member beyond the
				  last date of enrollment except as provided in Articles 2 and 5 of this Chapter
				  and as specified in contract.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-703 - Payments by the Administration

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				General requirements. A provider shall enter into a provider agreement with the
				Administration that meets the requirements of A.R.S. §
									36-2904
				and
				42 CFR
				431.107(b) as of October 1,
				2012, which is incorporated by reference and on file with the Administration,
				and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N.
				Capitol Street, NW, Washington, DC, 20401. This incorporation by reference
				contains no future editions or amendments.
B. Timely submission of claims.
1. Under A.R.S. § 36-2904, the
				Administration shall deem a paper claim to be submitted on the date that it is
				received by the Administration. An electronic claim is deemed received by the
				Administration when the claim enters the information processing system
				designated by the Administration for electronic claims in a form that is
				capable of being processed by the designated information processing system. The
				Administration shall do one or more of the following for each claim it
				receives:
a. Place a date stamp on the face
				of the claim,
b. Assign a
				system-generated claim reference number, or
c. Assign a system-generated date-specific
				number.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-705 - Payments by Contractors

Current through Register Vol. 30, No. 28, July 12, 2024
A.General
				requirements. A contractor shall contract with providers to provide covered
				services to members enrolled with the contractor. The contractor is responsible
				for reimbursing providers and coordinating care for services provided to a
				member. Except as provided in subsection (A)(2), a contractor is not required
				to reimburse a noncontracting provider for services rendered to a member
				enrolled with the contractor.
1. Providers. A
				provider shall enter into a provider agreement with the Administration that
				meets the requirements of A.R.S. § 36-2904 and
				42 CFR
				431.107(b) as of March 6,
				1992, which is incorporated by reference and on file with the Administration,
				and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N.
				Capitol Street, NW, Washington, DC, 20401. This incorporation by reference
				contains no future editions or amendments.
2. A contractor shall reimburse a
				noncontracting provider for services rendered to a member enrolled with the
				contractor as specified in this Article if:
a.
				The contractor referred the member to the provider or authorized the provider
				to render the services and the claim is otherwise payable under this Chapter,
				or
b. The service is emergent under
				Article 2 of this Chapter.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-708 - Payments for Services Provided to Eligible American Indians

Current through Register Vol. 30, No. 28, July 12, 2024
A.For purposes of this Article "IHS enrolled"
				or "enrolled with IHS" means an American Indian who has elected to receive
				covered services through IHS instead of a contractor.
B.For an American Indian who is enrolled with
				IHS, AHCCCS shall pay IHS the most recent all-inclusive inpatient, outpatient
				or ambulatory surgery rates published by Health and Human Services (HHS) in the
				Federal Register, or a separately contracted rate with IHS, for AHCCCS-covered
				services provided in an IHS facility. AHCCCS shall reimburse providers for the
				Medicare coinsurance and deductible amounts required to be paid by the
				Administration or contractor in Chapter 29, Article 3 of this Title.
C.When IHS refers an American Indian enrolled
				with IHS to a provider other than an IHS or tribal facility, the provider to
				whom the referral is made shall obtain prior authorization from AHCCCS for
				services as required under Articles 2, 7 or 12 of this Chapter.
D.For an American Indian enrolled with a
				contractor, AHCCCS shall pay the contractor a monthly capitation
				payment.
E.Once an American Indian
				enrolls with a contractor, AHCCCS shall not reimburse any provider other than
				IHS or a Tribal facility.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-709 - Contractor's Liability to Hospitals for the Provision of Emergency and Post-stabilization Care

Current through Register Vol. 30, No. 28, July 12, 2024
A contractor is liable for emergency hospitalization and
				  post-stabilization care as described in
				  R9-22-210
				  and
				  R9-22-210.01.
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 R9-22-711 - Copayments

Current through Register Vol. 30, No. 28, July 12, 2024
A. For purposes of
				this Article:
1. A copayment is a monetary
				amount that a member pays directly to a provider at the time a covered service
				is rendered.
2. An eligible
				individual is assigned to a hierarchy established in subsections (B) through
				(E), for the purposes of establishing a copayment amount.
3. No refunds shall be made for a retroactive
				period if there is a change in an individual's status that alters the amount of
				a copayment.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712 - Reimbursement: General

Current through Register Vol. 30, No. 28, July 12, 2024
A.Inpatient and
				outpatient discounts and penalties. If a claim is pended for additional
				documentation required under A.R.S. §
									36-2903.01(G)(4),
				the period during which the claim is pended is not used in the calculation of
				the quick-pay discounts and slow-pay penalties under A.R.S. §
									36-2903.01(G)(5).
B.Inpatient and outpatient in-state or
				out-of-state hospital payments.
1. Payment
				for inpatient out-of-state hospital services for claims with discharge dates on
				or before September 30, 2014. In the absence of a contract with an out-of-state
				hospital that specifies payment rates, AHCCCS shall reimburse out-of-state
				hospitals for covered inpatient services by multiplying covered charges by the
				most recent statewide urban cost-to-charge ratio as determined in
				R9-22-712.01(6)(d).
2. Payment for inpatient in-state hospital
				services for claims with discharge dates on or before September 30, 2014.
				AHCCCS shall reimburse an in-state provider of inpatient hospital services
				rendered with a discharge date on or before September 30, 2014, at the
				prospective tiered-per-diem amount in A.R.S. §
										36-2903.01
				and this Article.
3. Payment for
				inpatient in-state or out-of-state hospital services for claims with discharge
				dates on and after October 1, 2014 regardless of admission date. Subject to
				R9-22-718
				and A.R.S. §
										36-2905.01
				regarding urban hospitals, a contractor shall reimburse an in-state or
				out-of-state provider of inpatient hospital services, at either a rate
				specified by subcontract or, in the absence of a subcontract, the DRG rate
				established by the Administration and this Article. Subcontract rates, terms,
				and conditions are subject to review and approval or disapproval under A.R.S.
				§ 36-2904 and
				R9-22-715.
4. Outpatient out-of-state hospital payments.
				In the absence of a contract with an out-of-state hospital that specifies
				payment rates, AHCCCS shall reimburse an out-of-state hospital for covered
				outpatient services by applying the methodology described in
				R9-22-712.10
				through
				R9-22-712.50.
				If the outpatient procedure is not assigned a fee schedule amount, the
				Administration shall pay the claim by multiplying the covered charges for the
				outpatient services by the statewide outpatient cost-to-charge ratio.
5. Outpatient in-state hospital payments. A
				contractor shall reimburse an in-state provider of outpatient hospital services
				rendered on or after July 1, 2005, at either a rate specified by a subcontract
				or, in absence of a subcontract, as provided under
				R9-22-712.10,
				A.R.S. §
										36-2903.01
				and other sections of this Article. The terms of the subcontract are subject to
				review and approval or disapproval under A.R.S. § 36-2904 and
				R9-22-715.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.05 - Graduate Medical Education Fund Allocation

Current through Register Vol. 30, No. 28, July 12, 2024
A. Graduate medical education (GME)
				reimbursement as of September 30, 1997. Subject to legislative appropriation,
				the Administration shall make a distribution based on direct graduate medical
				education costs as described in A.R.S. §
									36-2903.01(G)(9)(a).
B. Subject to available funds and approval by
				CMS, the Administration shall annually distribute monies appropriated for the
				expansions of GME programs approved by the Administration to hospitals for
				direct program costs eligible for funding under A.R.S. §
									36-2903.01(G)(9)(b).
				A GME program is deemed to be established as of the date of its original
				accreditation. All determinations that are necessary to make distributions
				described by this subsection shall be made using information possessed by the
				Administration as of the date of reporting under subsection (B)(3).
1. Eligible health care facilities. A health
				care facility is eligible for distributions under subsection (B) if all of the
				following apply:
a. It is a hospital in
				Arizona that is the sponsoring institution of, or a participating institution
				in, one or more of the GME programs in Arizona;
b. It incurs direct costs for the training of
				residents in the GME programs, which costs are or will be reported on the
				hospital's Medicare Cost Report;
c.
				It is not administered by or does not receive its primary funding from an
				agency of the federal government.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.07 - Rural Hospital Inpatient Fund Allocation

Current through Register Vol. 30, No. 28, July 12, 2024
A. For purposes of this Section, the
				following words and phrases have the following meanings unless the context
				specifically requires another meaning:
1.
				"Calculated inpatient costs" means the sum of inpatient covered charges
				multiplied by the Milliman study's implied cost-to-charge ratio of
				.8959.
2. "Claims paid amount"
				means the sum of all claims paid by the Administration and contractors, as
				reported by the contractor to the Administration, to a rural hospital for
				covered inpatient services rendered for dates of service during the previous
				state fiscal year.
3. "Fund" means
				any state funds appropriated by the Legislature for the purposes set forth in
				A.R.S. §
										36-2905.02
				and any federal funds that are available for matching the state
				funds.
4. "Inpatient covered
				charges" means the sum of all covered charges billed by a hospital to the
				Administration or contractors, as reported by the contractors to the
				Administration, for inpatient services rendered during the previous state
				fiscal year.
5. "Milliman study"
				means the report issued by Milliman USA on March 11, 2004, to the Arizona
				Hospital and Healthcare Association that updated a portion of a cost study
				entitled "Evaluation of the AHCCCS Inpatient Hospital Reimbursement System"
				prepared by Milliman USA for AHCCCS on November 15, 2002. A copy of each report
				is on file with the Administration.
6. "Rural hospital" means a health care
				institution that is licensed as an acute care hospital by the Arizona
				Department of Health Services for the previous state fiscal year and is not an
				IHS hospital or a tribally owned or operated facility and:
a. Has 100 or fewer PPS beds, not including
				beds reported as sub provider beds on the hospital's Medicare Cost Report, and
				is located in a county with a population of less than 500,000 persons,
				or
b. Is designated as a critical
				access hospital for the majority of the previous state fiscal year.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Exhibit 1 - Pool Example

Current through Register Vol. 30, No. 28, July 12, 2024
Pool A receives $2,000,000. Pool B receives $7,000,000. Pool
				  C receives $3,000,000. If all of the funds in Pool B are paid to eligible
				  hospitals and there is $1,000,000 remaining, the remaining funds would be
				  allocated to Pool A and Pool C based on the ratio of each pool's original
				  allocation (original allocations of $2,000,000 and $3,000,000) to the total of
				  their original allocation ($2,000,000 + $3,000,000 = $5,000,000).
Pool A would receive 2/5 of the remaining funds ($400,000)
				  and Pool C would receive 3/5 of the remaining funds ($600,000).