Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 2 - SCOPE OF SERVICES › Section R9-22-210.01 - Emergency Behavioral Health Services for Non-FES Members

Current through Register Vol. 30, No. 28, July 12, 2024
A. General provisions
1. Applicability. This Section applies to
				emergency behavioral health services for non-FES members. Provisions regarding
				emergency medical services for non-FES members are in
				R9-22-210.
				Provisions regarding emergency medical and behavioral health services for FES
				members are in
				R9-22-217.
2. Definition. For the purposes of this
				Section, "contractor" has the same meaning as in A.R.S. §
										36-2901.
				Contractor does not include ADHS/DBHS, a subcontractor of ADHS/DBHS, or
				Children's Rehabilitative Services.
3. Responsible entity for inpatient emergency
				behavioral health services.
a. Members
				enrolled with a contractor.
ADHS/DBHS. ADHS/DBHS
				  or a subcontractor of ADHS/DBHS is responsible for providing all inpatient
				  emergency behavioral health services to non-FES members with psychiatric or
				  substance abuse diagnoses who are enrolled with the contractor.
b. FFS members. ADHS/DBHS or a subcontractor
				of ADHS/DBHS is responsible for providing all inpatient emergency behavioral
				health services for non-FES FFS members with psychiatric or substance abuse
				diagnoses unless services are provided in an IHS or tribally operated 638
				facility.
4. Responsible
				entity for non-inpatient emergency behavioral health services for non-FES
				members. ADHS/DBHS or a subcontractor of ADHS/DBHS is responsible for providing
				all non-inpatient emergency behavioral health services for non-FES
				members.
5. Verification. A
				provider of emergency behavioral health services shall verify a person's
				eligibility status with AHC-CCS, and if eligible, determine whether the person
				is a member enrolled with AHCCCS as non-FES FFS or is enrolled with a
				contractor, and determine whether the member is a behavioral health recipient
				as defined in
				R9-22-201.
6. Prior authorization.
a. Emergency behavioral health services. A
				provider is not required to obtain prior authorization for emergency behavioral
				health services.
b. Non-emergency
				behavioral health services. When a non-FES member's behavioral health condition
				is determined by the provider not to require emergency behavioral health
				services, the provider shall follow the prior authorization requirements of a
				contractor and ADHS/DBHS or a subcontractor of ADHS/DBHS.
7. Prohibition against limitation or denial
				of payment. A contractor, TRBHA, the Administration, ADHS/DBHS, or a
				subcontractor of ADHS/DBHS shall not limit or deny payment to an emergency
				behavioral health provider for emergency behavioral health services to a
				non-FES member for the following reasons:
a.
				On the basis of lists of diagnoses or symptoms;
b. Prior authorization was not
				obtained;
c. The provider does not
				have a contract;
d. An employee of
				the contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS instructs the member
				to obtain emergency behavioral health services; or
e. The failure of a hospital, emergency room
				provider, or fiscal agent to notify the member's contractor, ADHS/ DBHS, or a
				subcontractor of ADHS/DBHS within 10 days from the day the member presented for
				the emergency service.
8. Grounds for denial. A contractor, the
				Administration, ADHS/DBHS, or a subcontractor of ADHS/DBHS may deny payment for
				emergency behavioral health. services for reasons including but not limited to
				the following:
a. The claim was not a clean
				claim;
b. The claim was not
				submitted timely; or
c. The
				provider failed to provide timely notification under subsection (A)(9) to the
				contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS or the
				Administration.
9.
				Notification.
a. A hospital, emergency room
				provider, or fiscal agent shall notify a contractor, ADHS/DBHS, or a
				subcontractor of ADHS/DBHS, whichever is appropriate, no later than the 11th
				day from presentation of the non-FES member for emergency inpatient behavioral
				health services.
b. A hospital,
				emergency room provider, or fiscal agent shall notify the Administration no
				later than 72 hours after a FFS member receiving emergency behavioral health
				services presents to a hospital for inpatient services.
10.
										Transfer or discharge. The attending physician
				or the provider actually treating the non-FES member for the emergency
				behavioral health condition shall determine when the member is sufficiently
				stabilized for transfer or discharge and that decision shall be binding on the
				contractor and ADHS/DBHS or a subcontractor of ADHS/DBHS.