Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 1 - DEFINITIONS › Section R9-22-101 - Location of Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
A. Location
				of definitions. Definitions applicable to this Chapter are found in the
				following:
Definition
Section or Citation
"Accommodation"
R9-22-701
"Active treatment"
R9-22-1301
"ADHS"
R9-22-101
"Administration"
A.R.S. §
														36-2901
"Adult behavioral health therapeutic home"
9 A.A.C. 10, Article 1
"Adverse action"
R9-22-101
"Affiliated corporate organization"
R9-22-101
"Aged"
42 U.S.C.
							 1382 c(a)(1)(A) and R9-22-1501
"Agency"
R9-22-1201
"Aggregate"
R9-22-701
"AHCCCS"
R9-22-101
"AHCCCS inpatient hospital day or days of
							 care"
R9-22-701
"AHCCCS registered provider"
R9-22-101
"Ambulance"
A.R.S. §
														36-2201
"Ancillary service"
R9-22-101
"Anticipatory guidance"
R9-22-201
"Annual enrollment choice"
R9-22-1701
"APC"
R9-22-701
"Applicant"
R9-22-101
							 or
							 R9-22-301
"Application"
R9-22-101
"Assessment"
R9-22-1101 or R9-22-1201
"Assignment"
R9-22-101
"Attending physician"
R9-22-101
							 or R9-22-202
"Authorized representative"
R9-22-101
"Authorization"
R9-22-202
"Auto-assignment algorithm"
R9-22-1701
"AZ-NBCCEDP"
R9-22-2001
"Behavior management services"
R9-22-1201
"Behavioral health therapeutic home care
							 services"
R9-22-1201
"Behavioral health paraprofessional"
R9-22-101
"Behavioral health professional"
R9-22-101
"Behavioral health recipient"
R9-22-201
"Behavioral health services"
R9-22-1201
"Behavioral health technician"
R9-22-1201
"Benefit year"
R9-22-201
"BHS"
R9-22-301
"Billed charges"
R9-22-701
"Blind"
R9-22-1501
"Burial plot"
R9-22-1401
"Business agent"
R9-22-701
"Calculated inpatient costs"
R9-22-712.07
"Capital costs"
R9-22-701
"Capped fee-for-service"
R9-22-101
"Caretaker relative"
R9-22-1401
"Case management"
R9-22-1201
"Case record"
R9-22-101
"Cash assistance"
R9-22-1401
"Certified psychiatric nurse practitioner"
R9-22-1201
"Charge master"
R9-22-712
"Child"
R9-22-1503
"Children's Rehabilitative Services" or "CRS"
R9-22-101
							 or
							 R9-22-301
"Chronic"
R9-22-1301
"Claim"
R9-22-1101
"Claims paid amount"
R9-22-712.07
"Clean claim"
A.R.S. §
														36-2904
"Clinical oversight"
9 A.A.C. 10
"CMDP"
R9-22-1701
"CMS"
R9-22-101
"Continuous stay"
R9-22-101
"Contract"
R9-22-101
"Contract year"
R9-22-101
"Contractor"
A.R.S. §
														36-2901 or
							 R9-22-210.01
"Copayment"
R9-22-701
"Cost avoid"
R9-22-1201
"Cost-To-Charge Ratio" or "CCR"
R9-22-701 or R9-22-712
"Court-ordered evaluation"
R9-22-1201
"Court-ordered pre-petition screening"
R9-22-1201
"Court-ordered treatment"
R9-22-1201
"Covered charges"
R9-22-701
"Covered services"
R9-22-101
"CPT"
R9-22-701
"Creditable coverage"
R9-22-2003 and
							 42 U.S.C.
							 300 gg(c)
"Crisis services"
R9-22-1201
"Critical Access Hospital"
R9-22-701
"CRS application"
R9-22-1301
"CRS condition"
R9-22-1301
"CRS provider"
R9-22-1301
"Cryotherapy"
R9-22-2001
"Customized DME"
R9-22-212
"Day"
R9-22-101
							 and R9-22-1101
"Date of the Notice of Adverse Action"
R9-22-1441
"DBHS"
R9-22-101
"DCSS"
R9-22-301
"Department"
A.R.S. §
														36-2901
"Dependent child"
A.R.S. §
														46-101 or
							 R9-22-1401
"DES"
R9-22-101
"Diagnostic services"
R9-22-101
"Direct graduate medical education costs" or "direct
							 program costs"
R9-22-701
"Direct supervision"
R9-22-1201
"Director"
R9-22-101
"Disabled"
R9-22-1501
"Discussion"
R9-22-101
"Disenrollment"
R9-22-1701
"DME"
R9-22-101
"DRI inflation factor"
R9-22-701
"E.P.S.D.T. services"
42
							 CFR 440.40(b)
"Eligibility posting"
R9-22-701
"Eligible person"
A.R.S. §
														36-2901
"Emergency behavioral health condition for a non-FES
							 member"
R9-22-201
"Emergency behavioral health services for a non-FES
							 member"
R9-22-201
"Emergency medical condition for a non-FES
							 member"
R9-22-201
"Emergency medical services for a non-FES
							 member"
R9-22-201
"Emergency medical services provider"
R9-22-1201
"Emergency medical or behavioral health condition for
							 a FES membe
r"
							 R9-22-217
"Emergency services costs"
A.R.S. §
														36-2903.07
"Emergency services for a FES member"
R9-22-217
"Encounter"
R9-22-701
"Enrollment"
R9-22-1701
"Equity"
R9-22-101
"Experimental services"
R9-22-203
"Existing outpatient service"
R9-22-701
"Expansion funds"
R9-22-701
"FAA"
R9-22-301
"Facility"
R9-22-101
"Factor"
R9-22-701 and
							 42 CFR
							 447.10
"FBR"
R9-22-101
"Federal financial participation" or "FFP"
42 CFR
							 400.203
"Federal poverty level" or "FPL"
A.R.S. §
														36-2981
"Fee-For-Service" or "FFS"
R9-22-101
"FES member"
R9-22-101
"FESP"
R9-22-101
"First-party liability"
R9-22-1001
"File"
R9-22-1101
"Fiscal agent"
R9-22-210
"Fiscal intermediary"
R9-22-701
"Foster care maintenance payment"
42
							 U.S.C. 675(4)(A)
"FQHC"
R9-22-101
"Freestanding Children's Hospital"
R9-22-701
"Functionally limiting"
R9-22-1301
"Fund"
R9-22-712.07
"Graduate medical education (GME) program"
R9-22-701
"GME program approved by the Administration" or
							 "approved GME program"
R9-22-701
"Grievance"
A.A.C. Chapter 34
"GSA"
R9-22-101
"HCAC"
R9-22-701
"HCPCS"
R9-22-701
"Health care institution"
A.R.S. §
														36-401
"Health care practitioner"
R9-22-1201
"Hearing aid"
R9-22-201
"HIPAA"
R9-22-701
"Home health services"
R9-22-201
"Hospital"
R9-22-101
"ICU"
R9-22-701
"IHS"
R9-22-101
"IHS enrolled" or "enrolled with IHS"
R9-22-708
"IMD" or "Institution for Mental Diseases"
42 CFR
							 435.1010 and
							 R9-22-101
"Income"
R9-22-301
"Indirect program costs"
R9-22-701
"Individual"
R9-22-211
"In-kind income"
R9-22-1420
"Inmate of a public institution"
42 CFR
							 435.1010
"Inpatient covered charges"
R9-22-712.07
"Intermediate Care Facility for the Mentally
							 Retarded" or "ICF-MR"
42 U.S.C.
							 1396 d(d)
"Intern and Resident Information System"
R9-22-701
"LEEP"
R9-22-2001
"Legal representative"
R9-22-101
"Level I trauma center"
R9-22-2101
"License" or "licensure"
R9-22-101
"Licensee"
R9-22-1201
"MAGI-based income"
R9-22-1401
"Mailing date"
R9-22-101
"Medical education costs"
R9-22-701
"Medical expense deduction" or "MED"
R9-22-1401
"Medical practitioner"
R9-22-1201
"Medical record"
R9-22-101
"Medical review"
R9-22-701
"Medical services"
A.R.S. §
														36-401
"Medical supplies"
R9-22-101
"Medical support"
R9-22-301
"Medically eligible"
R9-22-1301
"Medically necessary"
R9-22-101
"Medicare claim"
R9-22-101
"Medicare Urban or Rural Cost-to-Charge Ratio
							 (CCR)"
R9-22-701
"Member"
A.R.S. § 36-2901 or
							 R9-22-301
"Mental disorder"
A.R.S. § 36-501
"Milliman study"
R9-22-712.07
"Monthly equivalent"
R9-22-1401,
"Monthly income"
R9-22-1401,
"National Standard code sets"
R9-22-701
"New hospital"
R9-22-701
"NICU"
R9-22-701
"Noncontracted Hospital"
R9-22-718
"Noncontracting provider"
A.R.S. §
														36-2901
"Non-FES member"
R9-22-101
"Non-IHS Acute Hospital"
R9-22-701
"Nursing facility" or "NF"
42 U.S.C.
							 1396 r(a)
"Observation day"
R9-22-701
"Occupational therapy"
R9-22-201
"Offeror"
R9-22-101
"Operating costs"
R9-22-701
"OPPC"
R9-22-701
"Organized health care delivery system"
R9-22-701
"Outlier"
R9-22-701
"Outpatient hospital service"
R9-22-701
"Ownership change"
R9-22-701
"Ownership interest"
42
							 CFR 455.101
"Partial Care"
R9-22-1201
"Participating institution"
R9-22-701
"Peer group"
R9-22-701
"Peer-reviewed study"
R9-22-2001
"Penalty"
R9-22-1101
"Person"
R9-22-1101
"Pharmaceutical service"
R9-22-201
"Physical therapy"
R9-22-201
"Physician"
R9-22-101
"Physician assistant"
R9-22-1201
"Post-stabilization services"
R9-22-201 or
							 42
							 CFR 422.113
"PPS bed"
R9-22-701
"Practitioner"
R9-22-101
"Pre-enrollment process"
R9-22-301
"Prescription"
R9-22-101
"Primary care provider" or "PCP"
R9-22-101
"Primary care provider services"
R9-22-201
"Prior authorization"
R9-22-101
"Prior period coverage" or "PPC"
R9-22-101
"Procedure code"
R9-22-701
"Procurement file"
R9-22-601
"Proposal"
R9-22-101
"Prospective rates"
R9-22-701
"Psychiatrist"
R9-22-1201
"Psychologist"
R9-22-1201
"Psychosocial rehabilitation services"
R9-22-201
"Public hospital"
R9-22-701
"Qualified alien"
A.R.S. §
														36-2903.03
"Qualified behavioral health service provider"
R9-22-1201
"Quality management"
R9-22-501
"Radiology"
R9-22-101
"RBHA" or "Regional Behavioral Health
							 Authority"
R9-22-201
"Reason to know" or "had reason to know"
R9-22-1101
"Rebase"
R9-22-701
"Redetermination"
R9-22-1301
"Referral"
R9-22-101
"Rehabilitation services"
R9-22-101
"Reinsurance"
R9-22-701
"Remittance advice"
R9-22-701
"Resident"
R9-22-701
"Residual functional deficit"
R9-22-201
"Resources"
R9-22-301
"Respiratory therapy"
R9-22-201
"Respite"
R9-22-1201
"Responsible offeror"
R9-22-101
"Responsive offeror"
R9-22-101
"Revenue Code"
R9-22-701
"Review"
R9-22-101
"Review month"
R9-22-101
"RFP"
R9-22-101
"Rural Contractor"
R9-22-718
"Rural Hospital"
R9-22-712.07 and R9-22-718
"Scope of services"
R9-22-201
"Section 1115 Waiver"
A.R.S. §
														36-2901
"Service location"
R9-22-101
"Service site"
R9-22-101
"SOBRA"
R9-22-101
"Specialist"
R9-22-101
"Specialty facility"
R9-22-701
"Speech therapy"
R9-22-201
"Spendthrift restriction"
R9-22-1401
"Sponsor"
R9-22-301
"Sponsor deemed income"
R9-22-301
"Sponsoring institution"
R9-22-701
"Spouse"
R9-22-101
"SSA"
42 CFR
							 1000.10
"SSI"
42 CFR
							 435.4
"SSN"
R9-22-101
"Stabilize"
42 U.S.C.
							 1395 dd
"Standard of care"
R9-22-101
"Sterilization"
R9-22-201
"Subcontract"
R9-22-101
"Submitted"
A.R.S. §
														36-2904
"Substance abuse"
R9-22-201
"SVES"
R9-22-301
"Tax dependent"
42 CFR
							 435.4
"Taxi"
A.R.S. §
														28-101(53)
"Taxpayer"
R9-22-1401
"Third-party"
R9-22-1001
"Third-party liability"
R9-22-1001
"Tier"
R9-22-701
"Tiered per diem"
R9-22-701
"Title IV-D"
R9-22-1401
"Title IV-E"
R9-22-1401
"Total Inpatient payments"
R9-22-712.07
"Trauma and Emergency Services Fund"
A.R.S. §
														36-2903.07
"TRBHA" or "Tribal Regional Behavioral Health
							 Authority"
R9-22-1201
"Treatment"
R9-22-2004
"Tribal Facility"
A.R.S. §
														36-2981
"Unrecovered trauma center readiness costs"
R9-22-2101
"Urban Contractor"
R9-22-718
"Urban Hospital"
R9-22-718
"USCIS"
R9-22-301
"Utilization management"
R9-22-501
"WWHP"
R9-22-2001
B.
				General definitions. 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 expli citly requires another meaning:
"ADHS" means the Arizona Department of Health
				  Services.
"Adverse action" means an action taken by the Department or
				  Administration to deny, discontinue, or reduce medical assistance.
"Affiliated corporate organization" means any organization
				  that has ownership or control interests as defined in
				  42
				  CFR 455.101, and includes a parent and
				  subsidiary corporation.
"AHCCCS" means the Arizona Health Care Cost Containment
				  System, which is composed of the Administration, contractors, and other
				  arrangements through which health care services are provided to a
				  member.
"AHCCCS registered provider" means a provider or
				  noncontracting provider who:
Enters into a provider agreement with the Administration
				  under
				  R9-22-703(A),
				  and
Meets license or certification requirements to provide
				  covered services.
"Ancillary service" means all hospital services for patient
				  care other than room and board and nursing services, including but not limited
				  to, laboratory, radiology, drugs, delivery room (including maternity labor
				  room), operating room (including postanesthesia and postoperative recovery
				  rooms), and therapy services (physical, speech, and occupational).
"Applicant" means a person who submits or whose authorized
				  representative submits a written, signed, and dated application for AHCCCS
				  benefits.
"Application" means an official request for AHCCCS medical
				  coverage made under this Chapter.
"Assignment" means enrollment of a member with a contractor
				  by the Administration.
"Attending physician" means a licensed allopathic or
				  osteopathic doctor of medicine who has primary responsibility for providing or
				  directing preventive and treatment services for a Fee-For-Service
				  member.
"Authorized representative" means a person who is authorized
				  to apply for medical assistance or act on behalf of another person.
"Behavioral health paraprofessional" means an individual who
				  is not a behavioral health professional who provides behavioral health services
				  at or for a health care institution according to the health care institution's
				  policies and procedures that:
If the behavioral health services were provided in a setting
				  other than a licensed health care institution,
If the individual would be required to be licensed as a
				  behavioral professional under A.R.S. Title 32, Chapter 33,
If the behavioral health services were provided in a setting
				  other than a licensed health care institution; and Are provided under
				  supervision by a behavioral health professional
				  R9-10-101.
"Behavioral Health Professional" has the same meaning as
				  defined A.A.C.
				  R9-10-101 excluding
				  subsection (g).
"Capped fee-for-service" means the payment mechanism by which
				  a provider of care is reimbursed upon submission of a valid claim for a
				  specific covered service or equipment provided to a member. A payment is made
				  in accordance with an upper or capped limit established by the Director. This
				  capped limit can either be a specific dollar amount or a percentage of billed
				  charges.
"Case record" means an individual or family file retained by
				  the Department that contains all pertinent eligibility information, including
				  electronically stored data.
"Children's Rehabilitative Services" or "CRS" means the
				  program that provides covered medical services and covered support services in
				  accordance with A.R.S. §
										36-261.
"CMS" means the Centers for Medicare and Medicaid
				  Services.
"Continuous stay" means a period during which a member
				  receives inpatient hospital services without interruption beginning with the
				  date of admission and ending with the date of discharge or date of
				  death.
"Contract" means a written agreement entered into between a
				  person, an organization, or other entity and the Administration to provide
				  health care services to a member under A.R.S. Title 36, Chapter 29, and this
				  Chapter.
"Contract year" means the period beginning on October 1 of a
				  year and continuing until September 30 of the following year.
"Covered services" means the health and medical services
				  described in Articles 2 and 12 of this Chapter as being eligible for
				  reimbursement by AHCCCS.
"Day" means a calendar day unless otherwise specified.
"DBHS" means the Division of Behavioral Health Services
				  within the Arizona Department of Health Services.
"DES" means the Department of Economic Security.
"Diagnostic services" means services provided for the purpose
				  of determining the nature and cause of a condition, illness, or injury.
"Director" means the Director of the Administration or the
				  Director's designee.
"Discussion" means an oral or written exchange of information
				  or any form of negotiation.
"DME" means durable medical equipment, which is an item or
				  appliance that can withstand repeated use, is designed to serve a medical
				  purpose, and is not generally useful to a person in the absence of a medical
				  condition, illness, or injury.
"Equity" means the county assessor full cash value or market
				  value of a resource minus valid liens, encumbrances, or both.
"Facility" means a building or portion of a building licensed
				  or certified by the Arizona Department of Health Services as a health care
				  institution under A.R.S. Title 36, Chapter 4, to provide a medical service, a
				  nursing service, or other health care or health-related service.
"FBR" means Federal Benefit Rate, the maximum monthly
				  Supplemental Security Income payment rate for a member or a married
				  couple.
Fee-For-Service" or "FFS" means a method of payment by the
				  AHCCCS Administration to a registered provider on an amount-per-service basis
				  for a member not enrolled with a contractor.
"FES member" means a person who is eligible to receive
				  emergency medical and behavioral health services through the FESP under
				  R9-22-217.
"FESP" means the federal emergency services program under
				  R9-22-217
				  which covers services to treat an emergency medical or behavioral health
				  condition for a member who is determined eligible under A.R.S. §
										36-2903.03(D).
"FQHC" means federally qualified health center.
"GSA" means a geographical service area designated by the
				  Administration within which a contractor provides, directly or through a
				  subcontract, a covered health care service to a member enrolled with the
				  contractor.
"Hospital" means a health care institution that is licensed
				  as a hospital by the Arizona Department of Health Services under A.R.S. Title
				  36, Chapter 4, Article 2, and certified as a provider under Title XVIII of the
				  Social Security Act, as amended, or is currently determined, by the Arizona
				  Department of Health Services as the CMS designee, to meet the requirements of
				  certification.
"IHS" means Indian Health Service.
"IMD" or "Institution for Mental Diseases" means an
				  Institution for Mental Diseases as described in
				  42 CFR
				  435.1010 that is licensed by ADHS.
"Legal representative" means a custodial parent of a child
				  under 18, a guardian, or a conservator.
"License" or "licensure" means a nontransferable
				  authorization that is granted based on established standards in law by a state
				  or a county regulatory agency or board and allows a health care provider to
				  lawfully render a health care service.
"Mailing date" when used in reference to a document sent
				  first class, postage prepaid, through the United States mail, means the
				  date:
Shown on the postmark;
Shown on the postage meter mark of the envelope, if no
				  postmark; or
Entered as the date on the document, if there is no legible
				  postmark or postage meter mark.
"Medical record" means a document that relates to medical or
				  behavioral health services provided to a member by a physician or other
				  licensed practitioner of the healing arts and that is kept at the site of the
				  provider.
"Medical supplies" means consumable items that are designed
				  specifically to meet a medical purpose.
"Medically necessary" means a covered service is provided by
				  a physician or other licensed practitioner of the healing arts within the scope
				  of practice under state law to prevent disease, disability, or other adverse
				  health conditions or their progression, or to prolong life.
"Medicare claim" means a claim for Medicare-covered services
				  for a member with Medicare coverage.
Non-FES member" means an eligible person who is entitled to
				  full AHCCCS services.
"Offeror" means an individual or entity that submits a
				  proposal to the Administration in response to an RFP.
"Physician" means a person licensed as an allopathic or
				  osteopathic physician under A.R.S. Title 32, Chapter 13 or Chapter 17.
"Practitioner" means a physician assistant licensed under
				  A.R.S. Title 32, Chapter 25, or a registered nurse practitioner certified under
				  A.R.S. Title 32, Chapter 15.
"Prescription" means an order to provide covered services
				  that is signed or transmitted by a provider authorized to prescribe the
				  services.
"Primary care provider" or "PCP" means an individual who
				  meets the requirements of A.R.S. §
										36-2901
				  (14), and who is responsible for the management of a member's health
				  care.
"Prior authorization" means the process by which the
				  Administration or contractor, whichever is applicable, authorizes, in advance,
				  the delivery of covered services based on factors including but not limited to
				  medical necessity, cost effectiveness, compliance with this Article and any
				  applicable contract provisions. Prior authorization is not a guarantee of
				  payment.
"Prior period coverage" means the period prior to the
				  member's enrollment during which a member is eligible for covered services. PPC
				  begins on the first day of the month of application or the first eligible
				  month, whichever is later, and continues until the day the member is enrolled
				  with a contractor.
"Proposal" means all documents, including best and final
				  offers, submitted by an offeror in response to an RFP by the
				  Administration.
"Radiology" means professional and technical services
				  rendered to provide medical imaging, radiation oncology, and radioisotope
				  services.
"Referral" means the process by which a member is directed by
				  a primary care provider or an attending physician to another appropriate
				  provider or resource for diagnosis or treatment.
"Rehabilitation services" means physical, occupational, and
				  speech therapies, and items to assist in improving or restoring a person's
				  functional level.
"Responsible offeror" means an individual or entity that has
				  the capability to perform the requirements of a contract and that ensures good
				  faith performance.
"Responsive offeror" means an individual or entity that
				  submits a proposal that conforms in all material respects to an RFP.
"Review" means a review of all factors affecting a member's
				  eligibility.
"Review month" means the month in which the individual's or
				  family's circumstances and case record are reviewed.
"RFP" means Request for Proposals, including all documents,
				  whether attached or incorporated by reference, that are used by the
				  Administration for soliciting a proposal under 9 A.A.C. 22, Article 6.
"Service location" means a location at which a member obtains
				  a covered service provided by a physician or other licensed practitioner of the
				  healing arts under the terms of a contract.
"Service site" means a location designated by a contractor as
				  the location at which a member is to receive covered services.
S.O.B.R.A." means Section 9401 of the Sixth Omnibus Budget
				  Reconciliation Act, 1986, amended by the Medicare Catastrophic Coverage Act of
				  1988,
				  42 U.S.C.
				  1396 a(a)(10)(A)(i)(IV),
				  42 U.S.C.
				  1396 a(a)(10)(A)(i)(VI), and
				  42 U.S.C.
				  1396 a(a)(10)(A)(i)(VII).
"Specialist" means a Board-eligible or certified physician
				  who declares himself or herself as a specialist and practices a specific
				  medical specialty. For the purposes of this definition, Board-eligible means a
				  physician who meets all the requirements for certification but has not tested
				  for or has not been issued certification.
"Spouse" means a person who has entered into a contract of
				  marriage recognized as valid by this state.
"SSN" means Social Security number.
"Standard of care" means a medical procedure or process that
				  is accepted as treatment for a specific illness, injury, or medical condition
				  through custom, peer review, or consensus by the professional medical
				  community.
"Subcontract" means an agreement entered into by a contractor
				  with any of the following:
A provider of health care services who agrees to furnish
				  covered services to a member,
A marketing organization, or
Any other organization or person that agrees to perform any
				  administrative function or service for the contractor specifically related to
				  securing or fulfilling the contractor's obligation to the Administration under
				  the terms of a contract.
"Taxi" is as defined in A.R.S. §
										28-101(53).