Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.20 - Outpatient Hospital Reimbursement: Methodology for the AHCCCS Outpatient Capped Fee-for-service Schedule

Current through Register Vol. 30, No. 28, July 12, 2024
A. To establish the AHCCCS Outpatient Capped
				Fee-for-service Schedule for all claims with a begin date of service on or
				before September 30, 2011, AHCCCS shall:
1.
				Define the dataset of claims and encounters that shall be used to establish the
				AHCCCS Outpatient Capped Fee-for-service Schedule.
2. Identify all the claims and encounters
				from non-IHS acute hospitals located in Arizona for services to be paid under
				the AHCCCS Outpatient Capped Fee-for-service Schedule.
3. Match the revenue code on each detail of
				each claim and encounter to the ancillary line item CCR as reported on
				hospital-specific mapping documents and hospital-specific Medicare Cost Report
				for those hospitals that have submitted Medicare Cost Reports FYE
				2002.
4. Multiply the line item CCR
				from subsection (A)(3) by the covered billed charge for that revenue code to
				establish the cost for the service.
5. Inflate the cost for the service from
				subsection (A)(4) using Global Insight Health-care Cost Review inflation
				factors from date of service month to the midpoint of the rate year in which
				the fees are initially effective.
6. Include associated costs under
				R9-22-712.25 to calculate the rates for emergency room and surgery
				services.
7. Combine data from all
				Arizona hospitals identified in subsection (A)(3) for each procedure code to
				establish the statewide median cost for each procedure.
8. Group procedure codes according to the
				Ambulatory Payment Classification (APC) System groups as listed in 69 FR 65682,
				November 15, 2004, and establish a statewide median cost for each APC. Multiply
				each statewide median APC cost by 116 percent to establish the AHCCCS-based fee
				for each procedure in that specific APC group. AHCCCS shall assign each
				procedure in the group the same fee.
9. For those procedure codes that are not
				grouped into any APC, establish a procedure-specific fee using either:
a. The AHCCCS Non-hospital Capped
				Fee-for-service Fee Schedule,
b.
				116 percent of the procedure-specific median cost AHCCCS-based fee,
				or
c. The Medicare Clinical
				Laboratory Fee Schedule for laboratory services.
10. Compare the AHCCCS-based fee established
				in subsections (A)(8) and (9) against the comparable Medicare fee established
				for the Medicare APC group as listed in the 69 FR 65682, November 15, 2004. The
				fee for each procedure shall be the greater of the AHCCCS-based fee or the
				Medicare fee but no more than 150 percent of the AHCCCS-based fee; however, for
				those laboratory services for which a limit is established in the Medicare
				Clinical Laboratory Fee Schedule, the fee shall not exceed that
				limit.
11. Assign the 2005 Medicare
				fee in the AHCCCS Outpatient Capped Fee-for-service Schedule for those
				procedures for which there are fewer than 20 occurrences of the procedure code
				in the dataset, either independently, or, if applicable, for all procedure
				codes within an APC Group.