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 R9-22-712.08 - Federally Qualified Health Center and Rural Health Clinic Graduate Medical Education Program

Current through Register Vol. 30, No. 28, July 12, 2024
A. Subject to
				available funds and approval by CMS, the Administration shall annually
				distribute monies appropriated for primary care GME programs approved by the
				Administration to Federally Qualified Health Centers (FQHC) and Rural Health
				Clinics (RHC) for direct and indirect program costs eligible for funding under
				A.R.S. §
									36-2907.06(I).
1. 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 (D).
2. For
				purposes of this subsection, the term "FQHC" includes Federally Qualified
				Health Center Look-Alikes.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.09 - Hierarchy for Tier Assignment through September 30, 2014

Current through Register Vol. 30, No. 28, July 12, 2024
TIER
IDENTIFICATION CRITERIA
ALLOWED SPLITS
MATERNITY
A primary diagnosis defined as maternity 640.xx -
						  643.xx, 644.2x - 676.xx, v22.xx - v24.xx or v27.xx.
None
NICU
Revenue Code of 174 and the provider has a Level II or
						  Level III NICU.
Nursery
ICU
Revenue Codes of 200-204, 207-212, or 219.
Surgery Psychiatric Routine
SURGERY
Surgery is identified by a revenue code of 36x. To
						  qualify in this tier, there must be a valid surgical procedure code that is not
						  on the excluded procedure list.
ICU
PSYCHIATRIC
Psychiatric Revenue Codes of 114, 124, 134, 144, or 154
						  AND primary Psychiatric Diagnosis = 290.xx - 316.xx. If a routine revenue code
						  is present and all diagnoses codes on the claim are equal to 290.xx - 316.xx,
						  classify as a psychiatric claim.
ICU
NURSERY
Revenue Code of 17x, not equal to 174.
NICU
ROUTINE
Revenue Codes of 100 - 101, 110-113, 116 - 123, 126 -
						  133, 136 - 143, 146 - 153, 156 - 159, 16x, 206, 213, or 214.
ICU
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.10 - Outpatient Hospital Reimbursement: General

Current through Register Vol. 30, No. 28, July 12, 2024
A. Effective rule. The outpatient hospital
				reimbursement rules apply to dates of service beginning July 1, 2005, subject
				to Laws 2004, Ch. 279, § 19.
B. Basis For Payment. Except as provided
				under
				R9-22-712.30,
				AHCCCS shall pay for designated outpatient procedures provided to AHCCCS
				members according to the AHCCCS Outpatient Capped Fee-For-Service Schedule as
				defined in R9-22-712.20.
C. Data.
				AHCCCS shall use Medicare Cost Report and adjudicated claim and encounter data
				from non-IHS acute care hospitals located in the state of Arizona to develop
				fees for the AHCCCS Outpatient Capped Fee-For-Service Schedule.
D. Hospital Services Subject To Fees. AHCCCS
				shall reimburse services, in the following outpatient hospital categories under
				the AHCCCS Outpatient Capped Fee-For-Service Schedule:
1. Surgery,
2. Emergency Department,
3. Laboratory,
4. Radiology,
5. Clinic, and
6. Other services.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.15 - Outpatient Hospital Reimbursement: Affected Hospitals

Current through Register Vol. 30, No. 28, July 12, 2024
Except as provided in
				  R9-22-712(G),
				  the AHCCCS Outpatient Capped Fee-For-Service Schedule shall apply to AHCCCS
				  payments for outpatient services in all non-IHS acute hospitals.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.25 - Outpatient Hospital Fee Schedule Calculations: Associated Service Costs

Current through Register Vol. 30, No. 28, July 12, 2024
A. AHCCCS shall
				include the costs of associated services, as defined by revenue codes and
				procedure codes, when determining the specific fees for the outpatient hospital
				procedures for emergency department and surgery services.
B. Payment made under subsection (A) or
				R9-22-712.20(B)(2) is inclusive of all services on the claim regardless of
				whether the services are provided on one or more days.
C. A complete listing of the revenue codes
				and procedure codes for associated costs included in the payment for emergency
				and surgery services including the effective date of any changes to the listing
				are on file and posted on AHCCCS' web site.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.30 - Outpatient Hospital Reimbursement: Payment for a Service Not Listed in the Ahcccs Outpatient Capped Fee-for-service Schedule

Current through Register Vol. 30, No. 28, July 12, 2024
A. AHCCCS shall calculate a statewide CCR for
				a service where a specific fee cannot be determined under
				R9-22-712.20.
B. For claims with a
				begin date of service on or before September 30, 2011, the statewide CCR shall
				be calculated based on the costs and covered charges associated with a service
				under subsection (A) for all Arizona hospitals, using the method specified in
				R9-22-712.20(A)(3).
C. For all
				claims with a begin date of service on or after October 1, 2011, the statewide
				CCR calculation shall equal either the CMS Medicare Outpatient Urban
				Cost-to-charge Ratio or the CMS Medicare Outpatient Rural Cost-to-charge Ratio
				published by CMS for the state of Arizona. AHCCCS shall use the urban
				cost-to-charge ratio for hospitals located in a county of 500,000 residents or
				more and for out-of-state hospitals. AHCCCS shall use the rural cost-to-charge
				ratio for hospitals located in a county of fewer than 500,000 residents. On
				October 1st of each year, AHCCCS shall adjust urban and rural CCRs to the CCRs
				as published by CMS in the Federal Register on or before August 1st of that
				year.
D. To determine the payment
				amount for procedures where a specific fee is not determined under
				R9-22-712.20, the statewide CCR is multiplied by the covered charges.
EReductions to payments for outpatient
				hospital services not listed in the AHCCCS Outpatient Capped Fee-For-Service
				Schedule. Outpatient hospital services not listed in the AHCCCS Outpatient
				Capped Fee-For-Service Schedule with dates of service on or after October 1,
				2011, shall be reimbursed at 95 percent of the rate published by CMS pursuant
				to subsection (C) of this Section.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.35 - Outpatient Hospital Reimbursement: Adjustments to Fees

Current through Register Vol. 30, No. 28, July 12, 2024
A. For all claims with a begin date of
				service on or before September 30, 2011, AHCCCS shall increase the Outpatient
				Capped Fee-for-service Schedule established under
				R9-22-712.20 (except for laboratory
				services and out-of-state hospital services) for the following hospitals
				submitting any claims:
1. By 48 percent for
				public hospitals on July 1, 2005, and hospitals that were public anytime during
				the calendar year 2004;
2. By 45
				percent for hospitals in counties other than Maricopa and Pima with more than
				100 Medicare PPS beds during the contract year in which the Outpatient Capped
				Fee-for-service Schedule rates are effective;
3. By 50 percent for hospitals in counties
				other than Maricopa and Pima with 100 or less Medicare PPS beds during the
				contract year in which the Outpatient Capped Fee-for-service Schedule rates are
				effective;
4. By 115 percent for
				hospitals designated as Critical Access Hospitals or hospitals that have not
				been designated as Critical Access Hospitals but meet the criteria during the
				contract year in which the Outpatient Capped Fee-for-service Schedule rates are
				effective;
5. By 113 percent for a
				Freestanding Children's Hospital with at least 110 pediatric beds during the
				contract year in which the Outpatient Capped Fee-for-service Schedule rates are
				effective; or
6. By 14 percent for
				a University Affiliated Hospital which is a hospital that has a majority of the
				members of its board of directors appointed by the Board of Regents during the
				contract year in which the Outpatient Capped Fee-for-service Schedule rates are
				effective.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.40 - Outpatient Hospital Reimbursement: Annual and Periodic Update

Current through Register Vol. 30, No. 28, July 12, 2024
A.Procedure codes.
				When procedure codes are issued by CMS and added to the Current Procedural
				Terminology published by the American Medical Association, AHCCCS shall add to
				the Outpatient Capped Fee-for-Service Schedule the new procedure codes for
				covered outpatient services and shall either assign the default CCR under
				R9-22-712.40(F)(2), the Medicare rate, or calculate an appropriate
				fee.
B.APC changes. AHCCCS may
				reassign procedure codes to new or different APC groups when APC groups are
				revised by CMS. AHCCCS may reassign procedure codes to a different APC group
				than Medicare. If AHCCCS determines that utilization of a procedure code within
				the Medicare program is substantially different from utilization of the
				procedure code in the AHCCCS program, AHCCCS may choose not to assign the
				procedure code to any APC group. For procedure codes not grouped into an APC by
				Medicare, AHCCCS may assign the code to an APC group when AHCCCS determines
				that the cost and resources associated with the non-assigned code are
				substantially similar to those in the APC group.
C.Annual update for Outpatient Hospital Fee
				Schedule. Beginning October 1, 2006, through September 30, 2011, AHCCCS shall
				adjust outpatient fee schedule rates:
1.
				Annually by multiplying the rates effective during the prior year by the Global
				Insight Prospective Hospital Market Basket Inflation Index; or
2. In a particular year the director may
				substitute the increases in subsection (C)(1) by calculating the dollar value
				associated with the inflation index in subsection (C)(1), and applying the
				dollar value to adjust rates at varying levels.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.45 - Outpatient Hospital Reimbursement: Outpatient Payment Restrictions

Current through Register Vol. 30, No. 28, July 12, 2024
A.AHCCCS shall not
				reimburse hospitals for emergency room treatment, observation hours, or other
				outpatient hospital services performed on an outpatient basis if the member is
				admitted as an inpatient to the same hospital directly from the emergency room,
				observation, or other outpatient department.
B.AHCCCS shall include payment for the
				emergency room, observation, and other outpatient hospital services provided to
				the member before the hospital admission in the AHCCCS Inpatient Tiered Per
				Diem Capped Fee-For-Service Schedule under Article 7 of this Chapter.
C.Same day admit and discharge.
1. For discharges before September 30, 2014.
				Same day admit and discharge claims that qualify for either the maternity or
				nursery tiers shall be paid based on the lesser of the rate for the maternity
				or nursery tier, or the outpatient hospital fee schedule.
2. For discharge dates on and after October
				1, 2014. Same day admit and discharge claims are paid for through the
				outpatient fee schedule.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.50 - Outpatient Hospital Reimbursement: Billing

Current through Register Vol. 30, No. 28, July 12, 2024
To receive appropriate reimbursement, hospitals shall:
1. Bill outpatient hospital services on the
				CMS approved Uniform Billing Form or in electronic format using the appropriate
				HIPAA transaction.
2. Follow the UB
				Manual Guidelines, as published by the National Uniform Billing Committee, and
				use the appropriate revenue code and procedure code combination as prescribed
				by AHCCCS and on file and online with AHCCCS.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.60 - Diagnosis Related Group Payments

Current through Register Vol. 30, No. 28, July 12, 2024
A. Inpatient hospital services with discharge
				dates on or after October 1, 2014, shall be reimbursed using the diagnosis
				related group (DRG) payment methodology described in this section and sections
				R9-22-712.61
				through
				R9-22-712.81.
B. Payments made using the DRG methodology
				shall be the sole reimbursement to the hospital for all inpatient hospital
				services and related supplies provided by the hospital. Services provided in
				the emergency room, observation area, or other outpatient departments that are
				directly followed by an inpatient admission to the same hospital are not
				reimbursed separately. Are reimbursed through the DRG methodology and not
				reimbursed separately.
C. Each
				claim for an inpatient hospital stay shall be assigned a DRG code and a DRG
				relative weight based on the All Patient Refined Diagnosis Related Group
				(APR-DRG) classification system established by 3M Health Information Systems.
				The applicable version of the APR-DRG classification system shall be available
				on the agency's website.
D.
				Payments for inpatient hospital services reimbursed using the DRG payment
				methodology are subject to quick pay discounts and slow pay penalties under
				A.R.S.
				36-2904.
E. Payments for inpatient hospital services
				reimbursed using the DRG payment methodology are subject to the Urban Hospital
				Reimbursement Program under R9-22-718.
F. For purposes of this section and sections
				R9-22-712.61 through R9-22-712.81:
1. "DRG
				National Average length of stay" means the national arithmetic mean length of
				stay published in the All Patient Refined Diagnosis Related Group (APR-DRG)
				classification established by 3M Health Information Systems.
2. "Length of stay" means the total number of
				calendar days of an inpatient stay beginning with the date of admission through
				discharge, but not including the date of discharge (including the date of a
				discharge to another hospital, i.e., a transfer) unless the member
				expires.
3. "Medicare" means Title
				XVIII of the Social Security Act,
				42 U.S.C.
				1395
et seq
.
4. "Medicare labor share" means a hospital's
				labor costs as a percentage of its total costs as determined by CMS for
				purposes of the Medicare Inpatient Prospective Payment System.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.61 - DRG Payments: Exceptions

Current through Register Vol. 30, No. 28, July 12, 2024
A.
				Notwithstanding Section
				R9-22-712.60, claims for inpatient
				services from the following hospitals shall be paid on a per diem basis,
				including provisions for outlier payments, where rates and outlier thresholds
				are included in the capped fee schedule published by the Administration on its
				website and available for inspection during normal business hours at 801 E.
				Jefferson, Phoenix, Arizona. If the covered costs per day on a claim exceed the
				published threshold for a day, the claim is considered an outlier. Outliers
				will be paid by multiplying the covered charges by the outlier CCR. The outlier
				CCR will be the sum of the urban or rural default operating CCR appropriate to
				the location of the hospital and the statewide capital cost-to-charge ratio in
				the data file established as part of the Medicare Inpatient Prospective Payment
				System by CMS. The resulting amount will be the total reimbursement for the
				claim. There is no provision for outlier payments for hospitals described under
				subsection (A)(3).
1. Hospitals designated as
				type: hospital, subtype; rehabilitation in the Provider & Facility Database
				for Arizona Medical Facilities posted by the Arizona Department of Health
				Services Division of Licensing Services on its website in March of each
				year;
2. Hospitals designated as
				type: hospital, subtype: long term in the Provider & Facility Database for
				Arizona Medical Facilities posted by the Arizona Department of Health Services
				Division of Licensing Services on its website for March of each year;
3. Hospitals designated as type: hospital,
				subtype; psychiatric in the Provider & Facility Database for Arizona
				Medical Facilities posted by the Arizona Department of Health Services Division
				of Licensing Services on its website for March of each year;
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.62 - DRG Base Payment

Current through Register Vol. 30, No. 28, July 12, 2024
A. The initial
				DRG base payment is the product of the DRG base rate, the DRG relative weight
				for the post-HCAC DRG code assigned to the claim, and any applicable provider
				and service policy adjustors.
B.
				The DRG base rate for each hospital is the statewide standardized amount of
				which the hospital's labor-related share of that amount is adjusted by the
				hospital's wage index. The hospital's labor share is determined based on the
				labor share for the Medicare inpatient prospective payment system published in
				Volume 85 of the Federal Register at page 59060 and 59061 published September
				18, 2020. The hospital's wage index is determined based on the wage index
				tables reference in Volume 85 of the Federal Register at page 59059 published
				September 18, 2020. The statewide standardized amount is included in the AHCCCS
				capped fee schedule available on the agency's website.
C. Claims shall be assigned both a DRG code
				derived from all diagnosis and surgical procedure codes included on the claim
				(the "pre-HCAC" DRG code) and a DRG code derived excluding diagnosis and
				surgical procedure codes associated with the health care acquired conditions
				that were not present on admission or any other provider-preventable conditions
				(the "post-HCAC" DRG code). The DRG code with the lower relative weight shall
				be used to process claims using the DRG methodology.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.63 - DRG Base Payments Not Based on the Statewide Standardized Amount

Current through Register Vol. 30, No. 28, July 12, 2024
A. Notwithstanding
				Section R9-22-712.62, a select specialty
				hospital standardized amount shall be used in place of the statewide
				standardized amount in subsection
				R9-22-712.62(B) to
				calculate the DRG base rate for the following hospitals:
1. Hospitals located in a city with a
				population greater than one million, which on average have at least 15 percent
				of inpatient days for patients who reside outside of Arizona, and at least 50
				percent of discharges as reported on the 2011 Medicare Cost Report are
				reimbursed by Medicare.
2.
				Hospitals designated as type: hospital, subtype: short term that has a license
				number beginning "SH" in the Provider & Facility Database for Arizona
				Medical Facilities posted by the ADHS Division of Licensing Services on its
				website for March of each year.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.64 - DRG Base Payments and Outlier CCR for Out-of-State Hospitals

Current through Register Vol. 30, No. 28, July 12, 2024
A. DRG Base
				payment:
1. For high volume out-of-state
				hospitals defined in subsection (C), the wage adjusted DRG base payment is
				determined as described in
				R9-22-712.62.
2. Notwithstanding subsection
				R9-22-712.62 the
				wage adjusted DRG base rate for out-of-state hospitals that are not high volume
				hospitals shall be included in the AHCCCS capped fee schedule available on the
				agency's website.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.65 - DRG Provider Policy Adjustor

Current through Register Vol. 30, No. 28, July 12, 2024
A. After calculating the DRG base payment as
				required in sections
				R9-22-712.62,
				R9-22-712.63, or R9-22-712.64, for claims from a high-utilization hospital, the
				product of the DRG base rate and the DRG relative weight for the post-HCAC DRG
				code shall be multiplied by a provider policy adjustor that is included in the
				AHCCCS capped fee schedule available on the agency's website.
B. A hospital is a high-utilization hospital
				if the hospital had:
1. Covered inpatient days
				subject to DRG reimbursement, determined using adjudicated claim and encounter
				data during the fiscal year beginning October 1, 2015, equal to at least four
				hundred percent of the statewide average number of AHCCCS-covered inpatient
				days at all hospitals;
2. A
				Medicaid inpatient utilization rate greater than 30% calculated as the ratio of
				AHCCCS-covered inpatient days to total inpatient days as reported in the
				hospital's Medicare Cost Report for the fiscal year ending 2016; and,
3. Received less than $2 million in add-on
				payment for outliers under
				R9-22-712.68,
				based on adjudicated claims and encounters for fiscal year beginning October 1,
				2015.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.66 - DRG Service Policy Adjustor

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to subsection
				  R9-22-712.65,
				  for claims with DRG codes in the following categories, the product of the DRG
				  base rate, the DRG relative weight for the post-HCAC DRG code, and the DRG
				  provider policy adjustor shall be multiplied by the service policy adjustor
				  listed in the AHCCCS capped fee schedule, available on the agency's website,
				  corresponding to the following DRG codes:
1. Normal newborn DRG codes
2. Neonates DRG codes
3. Obstetrics DRG codes
4. Psychiatric DRG codes
5. Rehabilitation DRG codes
6. Burn DRG codes.
7. Claims for members
				under age 19 assigned DRG codes other than listed above:
a. For dates of discharge occurring on or
				after October 1, 2014 and ending no later than December 31, 2015 regardless of
				severity of illness level,
b. For
				dates of discharge on or after January 1, 2016, for severity of illness levels
				1 and 2,
c. For dates of discharge
				on or after January 1, 2016 and before January 1, 2017, for severity of illness
				levels 3 and 4.
d. For dates of
				discharge on or after January 1, 2017, and before January 1, 2018 for severity
				of illness levels 3 and 4.
e. For
				dates of discharge on or after January 1, 2018, for severity of illness levels
				3 and 4.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.67 - DRG Reimbursement: Transfers

Current through Register Vol. 30, No. 28, July 12, 2024
A. For purposes of this Section a "transfer"
				means the transfer of a member from a hospital to a short-term general hospital
				for inpatient care, a designated cancer center, children's hospital, or a
				critical access hospital except when a member is moved for the purpose of
				receiving sub-acute services.
B.
				Designated cancer center or children's hospitals are those hospitals identified
				as such in the UB-04 billing manual published by the National Uniform Billing
				Committee.
C. The hospital the
				member is transferred from shall be reimbursed either the initial DRG base
				payment or the transfer DRG base payment, whichever is less.
D. The transfer DRG base payment is an amount
				equal to the initial DRG base payment, as determined after making any provider
				or service policy adjustors, divided by the DRG National Average length of stay
				for the DRG code multiplied by the sum of one plus the length of
				stay.
E. The hospital the member is
				transferred to shall be reimbursed under the DRG payment methodology without a
				reduction due to the transfer.
F.
				Unadjusted DRG base payment. The unadjusted DRG base payment is either the
				initial DRG base payment, as determined after making any provider or service
				policy adjustors, or the transfer DRG base payment, whichever is
				less.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.68 - DRG Reimbursement: Unadjusted Outlier Add-on Payment

Current through Register Vol. 30, No. 28, July 12, 2024
A. Claims for
				inpatient hospital services qualify for an outlier add-on payment if the claim
				cost exceeds the outlier cost threshold.
B. The claim cost is determined by
				multiplying covered charges by an outlier CCR as described by the following
				subsections:
1. For hospitals designated as
				type: hospital, subtype: children's in the Provider & Facility Database for
				Arizona Medical Facilities posted by the ADHS Division of Licensing Services on
				its website for March of each year. The outlier CCR will be calculated by
				dividing the hospital total costs by the total charges using the most recent
				Medicare Cost Report available as of September 1 of that year.
2. For Critical Access Hospitals the outlier
				CCR will be the sum of the statewide rural default operating cost-to-charge
				ratio and the statewide capital cost-to-charge ratio in the data file
				established as part of the Medicare Inpatient Prospective Payment System by
				CMS.
3. For all other hospitals the
				outlier CCR will be the sum of the operating cost-to-charge ratio and the
				capital cost-to-charge ratio established for each hospital in the impact file
				established as part of the Medicare Inpatient Prospective Payment System by
				CMS.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.69 - DRG Reimbursement: Covered Day Adjusted DRG Base Payment and Covered Day Adjusted Outlier Add-on Payment

Current through Register Vol. 30, No. 28, July 12, 2024
Adjustments to the payments are made to account for days not
				  covered by AHCCCS as follows:
1. A
				covered day reduction factor unadjusted is determined if the member is not
				eligible on the first day of the inpatient stay but is eligible for subsequent
				days during the inpatient stay. In this case, a covered day reduction factor
				unadjusted is calculated by dividing the number of AHCCCS covered days by the
				DRG National Average length of stay. The number of AHCCCS covered days is equal
				to the number of days the member is eligible during inpatient stay.
2. A covered day reduction factor unadjusted
				is also determined if the member is eligible on the first day of the inpatient
				stay but is determined ineligible for one or more days prior to the date of
				discharge. In this case, a covered day reduction factor unadjusted is
				calculated by adding one to the number of AHCCCS covered days and dividing the
				result by the DRG National Average length of stay. The number of AHCCCS covered
				days is equal to the number of days the member is eligible during the inpatient
				stay.
3. If the covered day
				reduction factor unadjusted is greater than one, then the covered day reduction
				factor final is one; otherwise, the covered day reduction factor final is equal
				to the covered day reduction factor unadjusted.
4. The covered day adjusted DRG base payment
				is an amount equal to the product of the unadjusted DRG base payment and the
				covered day reduction factor final.
5. The covered day adjusted DRG outlier
				add-on payment is an amount equal to the product of the unadjusted DRG outlier
				add-on payment and the covered day reduction factor final.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.70 - Covered Day Adjusted DRG Base Payment and Covered Day Adjusted Outlier Add-on Payment for FES members

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to the covered day reduction factor in
				  R9-22-712.69,
				  a covered day reduction factor unadjusted is determined for an inpatient stay
				  during which an FES member receives services for the treatment of an emergency
				  medical condition and also receives services once the condition no longer meets
				  the criteria as an emergency medical condition described in
				  R9-22-217.
1. A covered day reduction factor unadjusted
				is calculated by adding one to the AHCCCS covered days and dividing the result
				by the DRG National Average length of stay. The number of AHCCCS covered days
				is equal to the number of inpatient days during which an FES member receives
				services for an emergency medical condition as described in
				R9-22-217.
				For purposes of this adjustment, any portion of a day during which the FES
				member receives treatment for an emergency medical condition is counted as an
				AHCCCS covered day.
2. If the
				covered day reduction factor unadjusted is greater than one, then the covered
				day reduction factor final is one; otherwise, the covered day reduction factor
				final is equal to the covered day reduction factor unadjusted.
3. The covered day adjusted DRG base payment
				is an amount equal to the product of the unadjusted DRG base payment and the
				covered day reduction factor final.
4. The covered day adjusted DRG outlier
				add-on payment is an amount equal to the product of the unadjusted DRG outlier
				add-on payment and the covered day reduction factor final.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.72 - DRG Reimbursement: Enrollment Changes During an Inpatient Stay

Current through Register Vol. 30, No. 28, July 12, 2024
A. If a member's
				enrollment changes during an inpatient stay, including changing enrollment from
				fee-for-service to a contractor, or vice versa, or changing from one contractor
				to another contractor, the contractor with whom the member is enrolled on the
				date of discharge shall be responsible for reimbursing the hospital for the
				entire length of stay under the DRG payment rules in sections
				R9-22-712.60
				through
				R9-22-712.81.
				If the member is eligible but not enrolled with a contractor on the date of
				discharge, then the AHCCCS administration shall be responsible for reimbursing
				the hospital for the entire length of stay under the DRG payment rules in
				sections
				R9-22-712.60
				through
				R9-22-712.81.
B. When a member's enrollment
				changes during an inpatient stay, the hospital shall use the date of enrollment
				with the payer responsible on the date of discharge as the "from" date of
				service on the claim regardless of the date of admission.
C. Interim claims submitted to a payer other
				than the payer responsible on the day of discharge shall be processed in the
				same manner as other interim claims as described in
				R9-22-712.76.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.73 - DRG Reimbursement: Inpatient Stays for Members Eligible for Medicare

Current through Register Vol. 30, No. 28, July 12, 2024
If the hospital receives less than the full Medicare payment
				  for a member eligible for benefits under Part A of Medicare because the member
				  has exceeded the maximum benefit permitted under Part A of Medicare, the
				  hospital shall submit a separate claim for services performed after the date
				  the maximum Medicare Part A benefit is exceeded. The claim may include all
				  diagnosis codes for the entire inpatient stay, but the hospital is only
				  required to include revenue codes, surgical procedure codes, service units, and
				  charges for services performed after the date the Medicare Part A benefit is
				  exceeded. A claim so submitted shall be reimbursed using the DRG payment
				  methodology.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.74 - DRG Reimbursement: Third Party Liability

Current through Register Vol. 30, No. 28, July 12, 2024
DRG payments are subject to reduction based on cost avoidance
				  under section
				  R9-22-1003 and
				  other rules regarding first-and third-party liability under Article 10 of this
				  Chapter including cost avoidance for claims for ancillary services covered
				  under Part B of Medicare.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.75 - DRG Reimbursement: Payment for Administrative Days

Current through Register Vol. 30, No. 28, July 12, 2024
A. Categories of Administrative Days.
				Administrative days fall into one of two categories, either (A)(1) or (A)(2).
1. Administrative days due to lack of
				appropriate placement options and not meeting inpatient medical criteria.
				Administrative days are days in which a member is admitted as an inpatient to
				an acute care hospital, does not meet the criteria for an acute inpa-tient
				stay, but is admitted or not discharged because;
(1) an appropriate placement outside the
				hospital is not available,
(2) the
				member cannot be safely discharged or transferred, or
(3) the Administration or the contractor
				failed to provide for the appropriate placement outside the hospital in a
				timely manner.
a. Administrative days may occur prior to an acute
				care episode, for example, when a woman with a high-risk pregnancy is admitted
				to a hospital while awaiting delivery.
b.  Administrative days
				may also occur at the end of an acute care episode, for example, when a member
				is not discharged while awaiting placement in a nursing facility or other
				sub-acute or post-acute setting.
c. Administrative days
				may also include days in a receiving hospital when the member has been
				discharged from one acute care hospital for the purpose of receiving sub-acute
				services at the receiving hospital.
d
.
Administrative days do not include days
				when the member is awaiting appropriate placement or services that are
				currently available but the hospital has not transferred or discharged the
				member because of the hospital's administrative or operational
				delays.
e. Administrative days
				include inpatient claims covered by a RBHA or TRBHA that otherwise meet the
				criteria in subsection (A)(1). 2. Administrative days for claims with the
				principal diagnosis of behavioral health meeting inpatient medical criteria.
				Administrative days are days with dates of discharge on or after October 1,
				2018, in which a member is admitted as an inpatient to an acute care hospital,
				meets the criteria for an acute inpatient stay, and the principal diagnosis on
				the hospital claim is a behavioral health diagnosis. Inpatient claims covered
				by a RBHA or TRBHA are not considered administrative days under subsection
				(A)(2) regardless of the principal diagnosis on the hospital
				claim.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.76 - DRG Reimbursement: Interim Claims

Current through Register Vol. 30, No. 28, July 12, 2024
A.For inpatient stays with a length of stay
				greater than 29 days, a hospital may submit interim claims for each 30 day
				period during the inpatient stay.
B.Hospitals shall be reimbursed for interim
				claims at a per diem rate of $500 per day.
C.Following discharge, the hospital shall
				void all interim claims. In such circumstances, the hospital shall submit a
				claim to the payer with whom the member is enrolled on the date of discharge,
				whether the Administration or a contractor, for the entire inpatient stay for
				which the final claim shall be reimbursed under the DRG payment methodology.
				Interim claims will be recouped.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.77 - DRG Reimbursement: Admissions and Discharges on the Same Day

Current through Register Vol. 30, No. 28, July 12, 2024
A.Except as
				provided for in subsection (B), for any claim for inpatient services with an
				admission date and discharge date that are the same calendar date, the
				contractor or the Administration shall process the claim as an outpatient claim
				and the hospital shall be reimbursed under
				R9-22-712.10
				through R9-22-712.50.
B.Claims with
				an admission date and discharge date that are the same calendar date that also
				indicate that the member expired on the date of discharge shall be reimbursed
				under the DRG methodology.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.78 - DRG Reimbursement: Readmissions

Current through Register Vol. 30, No. 28, July 12, 2024
If a member is readmitted without prior authorization to the
				  same hospital that the member was discharged from within 72 hours and the DRG
				  code assigned to the claim for the prior admission has the same first three
				  digits as the DRG code assigned to the claim for the readmission, then payment
				  for the claim for the readmission will be disallowed only if the readmission
				  could have been prevented by the hospital.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.79 - DRG Reimbursement: Change of Ownership

Current through Register Vol. 30, No. 28, July 12, 2024
The administration shall not change any of the components of
				  the calculation of reimbursement for inpatient services using the DRG
				  methodology based upon a change in the hospital's ownership except to the
				  extent those components would change under the methodology had the hospital not
				  changed ownership (e.g., updating the hospital's cost-to-charge ratio as of
				  September 1 of each year under
				  R9-22-712.68
				  ).
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.80 - DRG Reimbursement: New Hospitals

Current through Register Vol. 30, No. 28, July 12, 2024
A. DRG base payment for new hospitals. For
				any hospital that does not have a labor share or wage index published by CMS as
				described in section
				R9-22-712.62(B)
				because the hospital was not in operation, the DRG base rate described in
				section
				R9-22-712.62(B)
				shall be calculated as the statewide standardized amount after adjusting that
				amount for the labor-related share and the wage index published by CMS as
				described in section
				R9-22-712.62(B)
				that is appropriate to the location of the hospital published by CMS as
				described in section R9-22-712.62(B).
B. Outlier calculations for new hospitals.
				For any hospital that does not have an operating cost-to-charge ratio listed in
				the impact file described in section R9-22-712.68(B) because the hospital was
				not in operation prior to the publication of the impact file, the statewide
				urban or rural default operating cost-to-charge ratio appropriate to the
				location of the hospital and the statewide capital cost-to-charge ratio shall
				be used to determine the unadjusted outlier add-on payment. The statewide urban
				or rural default operating cost-to-charge ratio and the statewide capital
				cost-to-charge ratio shall be based on the ratios published by CMS and updated
				by the Administration as described in section
				R9-22-712.68(C).
C. In addition to the requirement of this
				section, DRG reimbursement for new hospitals is determined under
				R9-22-712.60
				through
				R9-22-712.79.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.81 - DRG Reimbursement: Updates

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to the other updates provided for in sections
				  R9-22-712.60 through R9-22-712.80, the Administration may update the version of
				  the APR-DRG classification system established by 3M Health Information Systems,
				  adjust the statewide standardized amount in section
				  R9-22-712.62,
				  the base payments in sections
				  R9-22-712.63
				  and
				  R9-22-712.64,
				  the provider policy adjustor in section
				  R9-22-712.65,
				  service policy adjustors section R9-22-712.66, and the fixed loss amounts and
				  marginal cost percentages used to calculate the outlier threshold in section
				  R9-22-712.68
				  to the extent necessary to assure that payments are consistent with efficiency,
				  economy, and quality of care and are sufficient to enlist enough providers so
				  that care and services are available at least to the extent that such care and
				  services are available to the general population in the geographic area. The
				  Administration shall publish any proposed classification system on the agency's
				  website at least 30 days prior to the effective date, to ensure a sufficient
				  period for public comment, as required by
				  42
				  C.F.R. §
										447.205. In addition, the
				  public notice shall be available for inspection during normal business hours at
				  701 E. Jefferson, Phoenix, Arizona. The requirements of
				  42
				  C.F.R. §
										447.205 as of November 2, 2015
				  are incorporated by reference and do not include any later amendments.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.90 - Reimbursement of Hospital-based Freestanding Emergency Departments

Current through Register Vol. 30, No. 28, July 12, 2024
A. "Hospital-based
				freestanding emergency department" (hospital-based FSED) means an outpatient
				treatment center, as defined in
				R9-10-101, that:
(1) provides emergency room services under
				R9-10-1019,
(2) is subject to the requirements of
				42 C.F.R.
				489.24, and
(3) shares an ownership interest with a
				hospital, regardless of whether the outpatient treatment center operates under
				a hospital's single group license as described in A.R.S. §
										36-422.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-713 - Overpayment and Recovery of Indebtedness

Current through Register Vol. 30, No. 28, July 12, 2024
A. If a contractor or a subcontracting
				provider receives an overpayment from the Administration or otherwise becomes
				indebted to the Administration, the contractor or subcontracting provider shall
				immediately remit the amount of the indebtedness or overpayment to the
				Administration for deposit in the AHCCCS fund.
B. If the funds described in subsection (A)
				are not remitted, the Administration may recover the funds paid by the
				Administration to a contractor or subcontracting provider through:
1. A repayment agreement executed with the
				Administration;
2. Withholding or
				offsetting against current or future payments to be paid to the contractor or
				subcontracting provider; or
3.
				Enforcement of, or collection against, the performance bond, financial reserve,
				or other financial security under A.R.S. §
										36-2903.
Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-714 - Payments to Providers

Current through Register Vol. 30, No. 28, July 12, 2024
A. Provider
				agreement. The Administration or a contractor shall not reimburse a covered
				service provided to a member unless the provider has signed a provider
				agreement with the Administration that establishes the terms and conditions of
				participation and payment under A.R.S. §
									36-2904.
B. Provider reimbursement. The Administration
				or a contractor shall reimburse a provider for a service furnished to a member
				only if:
1. The provider personally furnishes
				the service to a specific member. For purposes of this Section, services
				personally furnished by a provider include:
a.
				Services provided by medical residents or dental students in a teaching
				environment; or
b. Services
				provided by a licensed or certified assistant under the general supervision of
				a licensed practitioner in accordance with 4 A.A.C. 24, 9 A.A.C. 16, 4 A.A.C.
				43, or 4 A.A.C. 45;