Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-710 - Payments for Non-hospital Services

Current through Register Vol. 30, No. 28, July 12, 2024
A. Capped fee-for-service. The Administration
				shall provide notice of changes in methods and standards for setting payment
				rates for services in accordance with
				42
				CFR 447.205, December 19, 1983, incorporated
				by reference and on file with the Administration and available from the U.S.
				Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,
				Washington, DC, 20401. This incorporation by reference contains no future
				editions or amendments.
1. Non-contracted
				services. In the absence of a contract that specifies otherwise, a contractor
				shall reimburse a provider or noncontracting provider for non-hospital services
				according to the Administration's capped-fee-for-service schedule.
2. Procedure codes. The Administration shall
				maintain a current copy of the National Standard Code Sets mandated under 45
				CFR 160 (October 1, 2004) and 45 CFR 162 (October 1, 2004), incorporated by
				reference and on file with the Administration and available from the U.S.
				Government Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,
				Washington, DC, 20401. This incorporation by reference contains no future
				editions or amendments.
a. A person shall
				submit an electronic claim consistent with 45 CFR 160 (October 1, 2004) and 45
				CFR 162 (October 1, 2004).
b. A
				person shall submit a paper claim using the National Standard Code Sets as
				described under 45 CFR 160 (October 1, 2004) and 45 CFR 162 (October 1,
				2004).
c. The Administration may
				deny a claim for failure to comply with subsection (A)(2)(a) or (b).
3. Fee schedule. The
				Administration shall pay providers, including noncontracting providers, at the
				lesser of billed charges or the capped fee-for-service rates specified in
				subsections (A)(3)(a) through (d) unless a different fee is specified in a
				contract between the Administration and the provider, or is otherwise required
				by law.
a. Physician services. Fee schedules
				for payment for physician services are on file at the central office of the
				Administration for reference use during customary business hours.
b. Dental services. Fee schedules for payment
				for dental services are on file at the central office of the Administration for
				reference use during customary business hours.
c. Transportation services. Fee schedules for
				payment for transportation services are on file at the central office of the
				Administration for reference use during customary business hours. For dates of
				service beginning October 1, 2012, through September 30, 2013, the
				Administration and its contractors shall reimburse ambulance services at 68.59
				percent of the ADHS rates that are in effect as of August 2, 2012.
d. Medical supplies and durable medical
				equipment (DME). Fee schedules for payment for medical supplies and DME are on
				file at the central office of the Administration for reference use during
				customary business hours. The Administration shall reimburse a provider once
				for purchase of DME during any two-year period, unless the Administration
				determines that DME replacement within that period is medically necessary for
				the member. Unless prior authorized by the Administration, no more than one
				repair and adjustment of DME shall be reimbursed during any two-year
				period.