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 - Standards for Payments Related Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
In addition to definitions contained in A.R.S. §
									36-2901,
				  the words and phrases in this Article have the following meanings unless the
				  context explicitly requires another meaning:
"Accommodation" means room and board services provided to a
				  patient during an inpatient hospital stay and includes all staffing, supplies,
				  and equipment. The accommodation is semi-private except when the member must be
				  isolated for medical reasons. Types of accommodation include hospital routine
				  medical/surgical units, intensive care units, and any other specialty care unit
				  in which room and board are provided.
"Aggregate" means the combined amount of hospital payments
				  for covered services provided within and outside the GSA.
"AHCCCS inpatient hospital day or days of care" means each
				  day of an inpatient stay for a member beginning with the day of admission and
				  including the day of death, if applicable, but excluding the day of discharge,
				  provided that all eligibility, medical necessity, and medical review
				  requirements are met.
"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).
"APC" means the Ambulatory Payment Classification system
				  under
				  42
				  CFR 419.31 used by Medicare for grouping
				  clinically and resource-similar procedures and services.
"Billed charges" means charges for services provided to a
				  member that a hospital includes on a claim consistent with the rates and
				  charges filed by the hospital with Arizona Department of Health Services
				  (ADHS).
"Business agent" means a company such as a billing service or
				  accounting firm that renders billing statements and receives payment in the
				  name of a provider.
"Capital costs" means costs as reported by the hospital to
				  CMS as required by
				  42 CFR
				  413.20.
"Copayment" means a monetary amount, specified by the
				  Director, that a member pays directly to a contractor or provider at the time
				  covered services are rendered.
" Cost-to-charge ratio" (CCR) means a hospital's costs for
				  providing covered services divided by the hospital's charges for the same
				  services. The CCR is the percentage derived from the cost and charge data for
				  each revenue code provided to AHCCCS by each hospital.
"Covered charges" means billed charges that represent
				  medically necessary, reasonable, and customary items of expense for covered
				  services that meet medical review criteria of AHCCCS or a contractor.
"CHC" means a Community Health Center, which includes both
				  Federally Qualified Health Centers and Rural Health Clinics.
"CPT" means Current Procedural Terminology, published, and
				  updated by the American Medical Association. CPT is a nationally-accepted
				  listing of descriptive terms and identifying codes for reporting medical
				  services and procedures performed by physicians that provide a uniform language
				  to accurately designate medical, surgical, and diagnostic services.
"Critical Access Hospital" is a hospital certified by
				  Medicare under 42 CFR 485 Subpart F and
				  42
				  CFR 440.170(g).
"Direct graduate medical education costs" or "direct program
				  costs" means the costs that are incurred for the education activities of an
				  approved graduate medical education program that are the proximate result of
				  training medical residents in the hospital, including resident salaries and
				  fringe benefits, the portion of teaching physician salaries and fringe benefits
				  that are related to the time spent in teaching and supervision of residents,
				  and other related GME overhead costs.
"DRI inflation factor" means Global Insights Prospective
				  Hospital Market Basket.
"Eligibility posting" means the date a member's eligibility
				  information is entered into the AHCCCS Pre-paid Medical Management Information
				  System (PMMIS).
"Encounter" means a record of a medically-related service
				  rendered by an AHCCCS-registered provider to a member enrolled with a
				  contractor on the date of service.
"Existing outpatient service" means a service provided by a
				  hospital before the hospital files an increase in its charge master as defined
				  in
				  R9-22-712(G),
				  regardless of whether the service was explicitly described in the hospital
				  charge master before filing the increase or how the service was described in
				  the charge master before filing the increase.
"Expansion funds" means funds appropriated to support GME
				  program expansions as described under A.R.S. § 36- 2903.01(G)(9)(b) and
				  (c)(i).
"Factor" means a person or an organization, such as a
				  collection agency or service bureau, that advances money to a provider for
				  accounts receivable that the provider has assigned, sold, or transferred to the
				  organization for an added fee or a deduction of a portion of the accounts
				  receivable. Factor does not include a business agent.
"Fiscal intermediary" means an organization authorized by CMS
				  to make determinations and payments for Part A and Part B provider services for
				  a given region.
"Freestanding Children's Hospital" means a separately
				  standing hospital with at least 120 pediatric beds that is dedicated to
				  providing the majority of the hospital's services to children.
"GME program approved by the Administration" or "approved GME
				  program" means a graduate medical education program that has been approved by a
				  national organization as described in
				  42
				  CFR 415.152.
"Graduate medical education (GME) program" means an approved
				  residency or fellowship program that prepares a physician for independent
				  practice of medicine by providing didactic and clinical education in a medical
				  environment to a medical student who has completed a recognized undergraduate
				  medical education program.
"HCAC" means a health care acquired condition described under
				  42 CFR
				  447.26 but does not include Deep Vein
				  Thrombosis (DVT)/ Pulmonary Embolism (PE) as related to total knee replacement
				  or hip replacement surgery in pediatric and obstetric patients.
"HCPCS" means the Health Care Procedure Coding System,
				  published, and updated by Center for Medicare and Medicaid Services (CMS).
				  HCPCS is a listing of codes and descriptive terminology used for reporting the
				  provision of physician services, other health care services, and substances,
				  equipment, supplies, or other items used in health care services.
"HIPAA" means the Health Insurance Portability and
				  Accountability Act of 1996, as specified under 45 CFR 162, that establishes
				  standards and requirements for the electronic transmission of certain health
				  information by defining code sets used for encoding data elements, such as
				  tables of terms, medical concepts, medical diagnostic codes, or medical
				  procedure codes.
"ICU" means the intensive care unit of a hospital.
"Indirect program costs" means the marginal increase in
				  operating costs that a provider experiences as a result of having an approved
				  graduate medical education program and that is not accounted for by the direct
				  program costs.
"Intern and Resident Information System" means a software
				  program used by teaching providers and the provider community for collecting
				  and reporting information on resident training in hospital and non-hospital
				  settings.
"Medical education costs" means direct costs for intern and
				  resident salaries, fringe benefits, program costs, nursing school education,
				  and paramedical education, as described in the Medicare Provider Reimbursement
				  Manual.
"Medical review" means a clinical evaluation of documentation
				  conducted by AHCCCS or a contractor for purposes of prior authorization,
				  concurrent review, post-payment review, or determining medical necessity. The
				  criteria for medical review are established by AHCCCS or a contractor based on
				  medical practice standards that are updated periodically to reflect changes in
				  medical care.
"Medicare Urban or Rural Cost-to-Charge Ratio (CCR)" means
				  statewide average capital cost-to-charge ratio published annually by CMS added
				  to the urban or rural statewide average operating cost-to-charge ratio
				  published annually by CMS.
"National Standard code sets" means codes that are accepted
				  nationally in accordance with federal requirements under 45 CFR 160 and 45 CFR
				  164.
"New hospital" means a hospital for which Medicare Cost
				  Report claim and encounter data are not available for the fiscal year used for
				  initial rate setting or rebasing.
"NICU" means the neonatal intensive care unit of a hospital
				  that is classified as a Level II or Level III perinatal center by the Arizona
				  Perinatal Trust.
"Non-IHS Acute Hospital" means a hospital that is not run by
				  Indian Health Services, is not a free-standing psychiatric hospital, such as an
				  IMD, and is paid under ADHS rates.
"Observation day" means a physician-ordered evaluation period
				  of less than 24 hours to determine whether a person needs treatment or needs to
				  be admitted as an inpatient. Each observation day consists of a period of 24
				  hours or less.
"Operating costs" means AHCCCS-allowable accommodation costs
				  and ancillary department hospital costs excluding capital and medical education
				  costs.
"OPPC" means an Other Provider Preventable Condition that is:
(1) a wrong surgical or other invasive procedure performed on
				  a patient, (2) a surgical or other invasive procedure performed on the wrong
				  body part, or (3) a surgical or other invasive procedure performed on the wrong
				  patient.
"Organized health care delivery system" means a public or
				  private organization that delivers health services. It includes, but is not
				  limited to, a clinic, a group practice prepaid capitation plan, and a health
				  maintenance organization.
"Outlier" means a hospital claim or encounter in which the
				  operating costs per day for an AHCCCS inpatient hospital stay meet the criteria
				  described under this Article and A.R.S. § 36- 2903.01(G).
"Outpatient hospital service" means a service provided in an
				  outpatient hospital setting that does not result in an admission.
"Ownership change" means a change in a hospital's owner,
				  lessor, or operator under
				  42 CFR
				  489.18(a).
"Participating institution" means an institution at which
				  portions of a graduate medical education program are regularly conducted and to
				  which residents rotate for an educational experience for at least one
				  month.
"Peer group" means hospitals that share a common, stable, and
				  independently definable characteristic or feature that significantly influences
				  the cost of providing hospital services, including specialty hospitals that
				  limit the provision of services to specific patient populations, such as
				  rehabilitative patients or children.
"PPC" means prior period coverage. PPC is the period of time,
				  prior to the member's enrollment, during which a member is eligible for covered
				  services. The time-frame is the first day of the month of application or the
				  first eligible month, whichever is later, until the day a member is enrolled
				  with a contractor.
"PPS bed" means Medicare-approved Prospective Payment beds
				  for inpatient services as reported in the Medicare cost reports for the most
				  recent fiscal year for which the Administration has a complete set of Medicare
				  cost reports for every rural hospital as determined as of the first of February
				  of each year.
"Primary care GME program" means a graduate medical
				  education program that prepares a physician for the practice of internal
				  medicine, family medicine, pediatrics, obstetrics, geriatrics, or
				  psychiatry.
"Procedure code" means the numeric or alphanumeric code
				  listed in the CPT or HCPCS manual by which a procedure or service is
				  identified.
"Prospective rates" means inpatient or outpatient hospital
				  rates set by AHCCCS in advance of a payment period and representing full
				  payment for covered services excluding any quickpay discounts, slow-pay
				  penalties, and first-and third-party payments regardless of billed charges or
				  individual hospital costs.
"Public hospital" means a hospital that is owned and operated
				  by county, state, or hospital health care district.
"Qualifying health information exchange organization" means a
				  non-profit health information organization as defined in A.R.S. § 363801
				  that provides the statewide exchange of patient health information among
				  disparate health care organizations and providers not owned, operated, or
				  controlled by the health information exchange. A qualifying health information
				  exchange organization must include representation by the administration on its
				  board of directors, and have a significant number of health care participants,
				  including hospitals, laboratories, payers, community physicians and Federally
				  Qualified Health Centers.
"Rebase" means the process by which the most currently
				  available and complete Medicare Cost Report data for a year and AHCCCS claim
				  and encounter data for the same year are collected and analyzed to reset the
				  Inpatient Hospital Tiered per diem rates, or the Outpatient Hospital Capped
				  Fee-For-Service Schedule.
"Reinsurance" means a risk-sharing program provided by AHCCCS
				  to contractors for the reimbursement of specified contract service costs
				  incurred by a member beyond a certain monetary threshold.
"Remittance advice" means an electronic or paper document
				  submitted to an AHCCCS-registered provider by AHCCCS to explain the disposition
				  of a claim.
"Resident" means a physician engaged in postdoctoral training
				  in an accredited graduate medical education program, including an intern and a
				  physician who has completed the requirements for the physician's eligibility
				  for board certification.
"Revenue code" means a numeric code, that identifies a
				  specific accommodation, ancillary service, or billing calculation, as defined
				  by the National Uniform Billing committee for UB04 forms.
"Sub-acute services" means inpatient care for a patient with
				  an acute illness, injury, or exacerbation of a disease process when the patient
				  does not require acute inpatient hospitalization. Sub-acute care is rendered
				  immediately after, or instead of, acute inpatient hospitalization.
"Specialty facility" means a facility where the service
				  provided is limited to a specific population, such as rehabilitative services
				  for children.
"Sponsoring institution" means the institution or entity that
				  is recognized by the GME accrediting organization and designated as having
				  ultimate responsibility for the assurance of academic quality and compliance
				  with the terms of accreditation.
"Tier" means a grouping of inpatient hospital services into
				  levels of care based on diagnosis, procedure, or revenue codes, peer group,
				  NICU classification level, or any combination of these items.
"Tiered per diem" means an AHCCCS capped fee schedule in
				  which payment is made on a per-day basis depending upon the tier (or tiers)
				  into which an AHCCCS inpatient hospital day of care is assigned.
"Trip" means a one-way transport each time a taxi is called.
				  If the taxi waits for the member, then the transport continues to be part of
				  the one-way trip. If the taxi leaves and is called to pick up the member, that
				  is considered a new one-way trip.