TITLE 9. HEALTH SERVICES

CHAPTER 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
ADMINISTRATION

Editor's Note: The Office of the Secretary of State prints all Code Chapters on white paper (Supp 01-3).

Editor's Note: This Chapter contains rules which were adopted or amended under an exemption from the Arizona Administrative Procedure Act (A.R.S. Title 41, Chapter 6), pursuant to Laws 1992, Ch. 301, § 61 and Ch. 302, § 13, and Laws 1993, Ch. 6, § 34. Exemption from A.R.S. Title 41, Chapter 6 means that AHCCCS did not submit notice of this rulemaking to the Secretary of State's Office for publication in the Arizona Administrative Register; the Governor's Regulatory Review Council did not review these rules; AHCCCS was not required to hold public hearings on these rules; and the Attorney General did not certify these rules. Because this Chapter contains rules which are exempt from the regular rulemaking process, the Chapter is printed on blue paper.

ARTICLE 1. DEFINITIONS

New Article 1, consisting of Sections R9-22-101 through R9-22-103, R9-22-105, and R9-22-106 through R9-22-112 adopted effective December 8, 1997 (Supp. 97-4).

Former Article 1, consisting of Section R9-22-101, repealed effective December 8, 1997 (Supp. 97-4).

Section

R9-22-101. Location of Definitions

R9-22-102. Repealed

R9-22-103. Repealed

R9-22-104. Reserved

R9-22-105. Repealed

R9-22-106. Repealed

R9-22-107. Repealed

R9-22-108. Repealed

R9-22-109. Repealed

R9-22-110. Repealed

R9-22-111. Reserved

R9-22-112. Repealed

R9-22-113. Reserved

R9-22-114. Repealed

R9-22-115. Repealed

R9-22-116. Repealed

R9-22-117. Repealed

R9-22-118. Reserved

R9-22-119. Reserved

R9-22-120. Repealed

ARTICLE 2. SCOPE OF SERVICES

Section

R9-22-201. Scope of Services-related Definitions

R9-22-202. General Requirements

R9-22-203. Repealed

R9-22-204. Inpatient General Hospital Services

R9-22-205. Attending Physician, Practitioner, and Primary Care Provider Services

R9-22-206. Organ and Tissue Transplant Services

R9-22-207. Dental Services

R9-22-208. Laboratory, Radiology, and Medical Imaging Services

R9-22-209. Pharmaceutical Services

R9-22-210. Emergency Medical Services for Non-FES Members

R9-22-210.01. Emergency Behavioral Health Services for Non-FES Members

R9-22-211. Transportation Services

R9-22-212. Durable Medical Equipment, Orthotic and Prosthetic Devices, and Medical Supplies

R9-22-213. Early and Periodic Screening, Diagnosis, and Treatment Services (E.P.S.D.T.)

R9-22-214. Repealed

R9-22-215. Other Medical Professional Services

R9-22-216. NF, Alternative HCBS Setting, or HCBS

R9-22-217. Services Included in the Federal Emergency Services Program

R9-22-218. Repealed

ARTICLE 3. REPEALED

Article 3, consisting of Sections R9-22-301 through R9-22-319 and R9-22-321 through R9-22-344, repealed by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Section R9-22-320 repealed December 13, 1993 (Supp. 93-4).

ARTICLE 4. REPEALED

Section

R9-22-401. Repealed

R9-22-402. Repealed

R9-22-403. Repealed

R9-22-404. Repealed

R9-22-405. Repealed

R9-22-406. Repealed

ARTICLE 5. GENERAL PROVISIONS AND STANDARDS

Section

R9-22-501. General Provisions and Standards - Related Definitions

R9-22-502. Pre-existing Conditions

R9-22-503. Provider Requirements Regarding Records

R9-22-504. Marketing; Prohibition against Inducements; Misrepresentations; Discrimination; Sanctions

R9-22-505. Repealed

R9-22-506. Repealed

R9-22-507. Repealed

R9-22-508. Repealed

R9-22-509. Transition and Coordination of Member Care

R9-22-510. Repealed

R9-22-511. Repealed

R9-22-512. Release of Safeguarded Information

R9-22-513. Repealed

R9-22-514. Repealed

R9-22-515. Repealed

R9-22-516. Renumbered

R9-22-517. Renumbered

R9-22-518. Information to Enrolled Members

R9-22-519. Repealed

R9-22-520. Expired

R9-22-521. Program Compliance Audits

R9-22-522. Quality Management/Utilization Management (QM/UM) Requirements

R9-22-523. Expired

R9-22-524. Repealed

R9-22-525. Repealed

R9-22-526. Renumbered

R9-22-527. Renumbered

R9-22-528. Renumbered

R9-22-529. Renumbered

ARTICLE 6. RFP AND CONTRACT PROCESS

Article 6, consisting of Sections R9-22-601 through R9-22-604, adopted by final rulemaking at 5 A.A.R. 607, effective February 5, 1999 (Supp. 99-1).

Article 6, consisting of Sections R9-22-601 through R9-22-605, repealed by final rulemaking at 5 A.A.R. 607, effective February 5, 1999 (Supp. 99-1).

Article 6, consisting of Sections R9-22-601 through R9-22-604, adopted effective July 16, 1985.

Former Article 6, consisting of Sections R9-22-601 through R9-22-603, repealed effective October 1, 1983.

Section

R9-22-601. General Provisions

R9-22-602. RFP

R9-22-603. Contract Award

R9-22-604. Contract or Proposal Protests; Appeals

R9-22-605. Waiver of Contractor's Subcontract with Hospitals

R9-22-606. Contract Compliance Sanction

ARTICLE 7. STANDARDS FOR PAYMENTS

Section

R9-22-701. Standard for Payments Related Definitions

R9-22-701.10. Scope of the Administration's and Contractor's Liability

R9-22-702. Charges to Members

R9-22-703. Payments by the Administration

R9-22-704. Repealed

R9-22-705. Payments by Contractors

R9-22-706. Repealed

R9-22-707. Repealed

R9-22-708. Payments for Services Provided to Eligible Native Americans

R9-22-709. Contractor's Liability to Hospitals for the Provision of Emergency and Post-stabilization Care

R9-22-710. Payments for Non-hospital Services

R9-22-711. Copayments

R9-22-712. Reimbursement: General

R9-22-712.01. Inpatient Hospital Reimbursement

R9-22-712.02. Reserved

R9-22-712.03. Reserved

R9-22-712.04. Reserved

R9-22-712.05. Graduate Medical Education Fund Allocation

R9-22-712.06. Reserved

R9-22-712.07. Rural Hospital Inpatient Fund Allocation

R9-22-712.08. Reserved

R9-22-712.09. Hierarchy For Tier Assignment

R9-22-712.10. Outpatient Hospital Reimbursement: General

R9-22-712.11. Reserved

R9-22-712.12. Reserved

R9-22-712.13. Reserved

R9-22-712.14. Reserved

R9-22-712.15. Outpatient Hospital Reimbursement: Affected Hospitals

R9-22-712.16. Reserved

R9-22-712.17. Reserved

R9-22-712.18. Reserved

R9-22-712.19. Reserved

R9-22-712.20. Outpatient Hospital Reimbursement: Methodology for the AHCCCS Outpatient Capped Fee-For-Service Schedule

R9-22-712.21. Reserved

R9-22-712.22. Reserved

R9-22-712.23. Reserved

R9-22-712.24. Reserved

R9-22-712.25. Outpatient Hospital Fee Schedule Calculations: Associated Service Costs for ER and Surgery Services

R9-22-712.26. Reserved

R9-22-712.27. Reserved

R9-22-712.28. Reserved

R9-22-712.29. Reserved

R9-22-712.30. Outpatient Hospital Reimbursement: Payment for a Service Not Listed in the AHCCCS Outpatient Capped Fee-For Service Schedule

R9-22-712.31. Reserved

R9-22-712.32. Reserved

R9-22-712.33. Reserved

R9-22-712.34. Reserved

R9-22-712.35. Outpatient Hospital Reimbursement: Adjustments to Fees

R9-22-712.36. Reserved

R9-22-712.37. Reserved

R9-22-712.38. Reserved

R9-22-712.39. Reserved

R9-22-712.40. Outpatient Hospital Reimbursement: Annual and Periodic Update

R9-22-712.41. Reserved

R9-22-712.42. Reserved

R9-22-712.43. Reserved

R9-22-712.44. Reserved

R9-22-712.45. Outpatient Hospital Reimbursement: Outpatient Payment Restrictions

R9-22-712.46. Reserved

R9-22-712.47. Reserved

R9-22-712.48. Reserved

R9-22-712.49. Reserved

R9-22-712.50. Outpatient Hospital Reimbursement: Billing

R9-22-713. Overpayment and Recovery of Indebtedness

R9-22-714. Payments to Providers

R9-22-715. Hospital Rate Negotiations

R9-22-716. Repealed

R9-22-717. Repealed

R9-22-718. Urban Hospital Inpatient Reimbursement Program

R9-22-719. Contractor Performance Measure Outcomes

R9-22-720. Reinsurance

ARTICLE 8. REPEALED

Article 8, consisting of Sections R9-22-801 through R9-22-804 and Exhibit A, repealed by final rulemaking at 10 A.A.R. 808, effective April 3, 2004. The subject matter of Article 8 is now in 9 A.A.C. 34 (Supp. 04-1).

Section

R9-22-801. Repealed

R9-22-802. Repealed

R9-22-803. Repealed

R9-22-804. Repealed

Exhibit A. Repealed

R9-22-805. Repealed

ARTICLE 9. REPEALED

Article 22, consisting of Sections R9-22-901 through R9-22-909, repealed by final rulemaking at 12 A.A.R. 4484, January 6, 2007 (Supp. 06-4).

Article 22, consisting of Sections R9-22-901 through R9-22-908, adopted effective August 29, 1985.

Former Article 22, consisting of Section R9-22-901, repealed effective October 1, 1983.

Section

R9-22-901. Repealed

R9-22-902. Repealed

R9-22-903. Repealed

R9-22-904. Repealed

R9-22-905. Repealed

R9-22-906. Repealed

R9-22-907. Repealed

R9-22-908. Repealed

R9-22-909. Repealed

ARTICLE 10. FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES

Article 10, consisting of Section R9-22-1001 through R9-22-1002, adopted effective November 7, 1997 (Supp. 97-4).

Article 10, consisting of Section R9-22-1001 through R9-22-1002, repealed effective November 7, 1997 (Supp. 97-4).

Article 10 consisting of Sections R9-22-1001 and R9-22-1002 adopted effective October 1, 1985.

Section

R9-22-1001. Definitions

R9-22-1002. General Provisions

R9-22-1003. Cost Avoidance

R9-22-1004. Member Participation

R9-22-1005. Collections

R9-22-1006. AHCCCS Monitoring Responsibilities

R9-22-1007. Notification for Perfection, Recording, and Assignment of AHCCCS Liens

R9-22-1008. Notification Information for Liens

R9-22-1009. Notification of Health Insurance Information

ARTICLE 11. CIVIL MONETARY PENALTIES AND ASSESSMENTS

Article 11 consisting of Sections R9-22-1101 through R9-22-1104 adopted effective October 1, 1986.

Section

R9-22-1101. Basis for Civil Monetary Penalties and Assessments for Fraudulent Claims; Definitions

R9-22-1102. Determining the Amount of a Penalty

R9-22-1103. Determining the Amount of an Assessment

R9-22-1104. Mitigating Circumstances

R9-22-1105. Aggravating Circumstances

R9-22-1106. Notice of Intent

R9-22-1107. Reserved

R9-22-1108. Request for a Compromise

R9-22 1109. Failure to Respond to the Notice of Intent

R9-22-1110. Request for State Fair Hearing

R9-22-1111. Issues and Burden of Proof

R9-22-1112. Withdrawal and Continuances

ARTICLE 12. BEHAVIORAL HEALTH SERVICES

Article 12, consisting of Sections R9-22-1201 through R9-22-1208, repealed; new Article 12, consisting of Sections R9-22-1201 through R9-22-1208 adopted by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4).

Section

R9-22-1201. General Requirements

R9-22-1202. ADHS and Contractor Responsibilities

R9-22-1203. Eligibility for Covered Services

R9-22-1204. General Service Requirements

R9-22-1205. Scope and Coverage of Behavioral Health Services

R9-22-1206. General Provisions and Standards for Service Providers

R9-22-1207. General Provisions for Payment

R9-22-1208. Repealed

ARTICLE 13. REPEALED

Article 13, consisting of Sections R9-22-1301 through R9-22-1309, repealed by final rulemaking at 10 A.A.R. 808, effective April 3, 2004. The subject matter of Article 13 is now in 9 A.A.C. 34 (Supp. 04-1).

Article 13, consisting of Sections R9-22-1301 through R9-22-1309, adopted effective September 9, 1998 (Supp. 98-3).

Section

R9-22-1301. Repealed

R9-22-1302. Repealed

R9-22-1303. Repealed

R9-22-1304. Repealed

R9-22-1305. Repealed

R9-22-1306. Repealed

R9-22-1307. Repealed

R9-22-1308. Repealed

R9-22-1309. Repealed

ARTICLE 14. AHCCCS MEDICAL COVERAGE FOR FAMILIES AND INDIVIDUALS

Article 14, consisting of Sections R9-22-1401 through R9-22-1436, repealed; new Article 14, consisting of Sections R9-22-1401 through R9-22-1433 made by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).

Article 14, consisting of Sections R9-22-1401 through R9-22-1436, adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).

Section

R9-22-1401. General Information

R9-22-1402. Ineligible Person

R9-22-1403. Agency Responsible for Determining Eligibility

R9-22-1404. Assignment of Rights Under Operation of Law

R9-22-1405. Confidentiality and Safeguarding of Information

R9-22-1406. Application Process

R9-22-1407. Deceased Applicants

R9-22-1408. Applicant and Member Responsibility

R9-22-1409. Withdrawal of Application

R9-22-1410. Department Responsibilities

R9-22-1411. Withdrawal from AHCCCS Medical Coverage

R9-22-1412. Verification of Eligibility Information

R9-22-1413. Time-frames, Approval, Discontinuance, or Denial of an Application

R9-22-1414. Review of Eligibility

R9-22-1415. Notice of Adverse Action

R9-22-1416. Effective Date of Eligibility

R9-22-1417. Social Security Number

R9-22-1418. State Residency

R9-22-1419. Citizenship and Immigrant Status

R9-22-1419.01. Repealed

R9-22-1419.02. Repealed

R9-22-1419.03. Repealed

R9-22-1419.04. Repealed

R9-22-1420. Income Eligibility Criteria

R9-22-1421. Income Eligibility

R9-22-1422. Methods for Calculating Monthly Income

R9-22-1423. Calculations and Use of Methods Listed in R9-22-1422 Based on Frequency of Income

R9-22-1424. Use of Methods Listed in R9-22-1423 Based on Type of Income

R9-22-1425. Sponsor Deemed Income

R9-22-1426. Exemptions from Sponsor Deemed Income

R9-22-1427. Eligibility for a Family

R9-22-1428. Eligibility for a Person Not Eligible as a Family

R9-22-1429. Eligibility for a Newborn

R9-22-1430. Extended Medical Coverage for a Pregnant Woman

R9-22-1431. Family Planning Services Extension Program (FPEP)

R9-22-1432. Young Adult Transitional Insurance

R9-22-1433. Special Groups for Children

R9-22-1434. Repealed

R9-22-1435. Eligibility for a Person With Medical Expenses Whose Income is Over 100 Percent FPL

R9-22-1436. MED Family Unit

R9-22-1437. MED Income Eligibility Requirements

R9-22-1438. MED Resource Eligibility Requirements

R9-22-1439. MED Effective Date of Eligibility

R9-22-1440. MED Eligibility Period

R9-22-1441. Eligibility Appeals

ARTICLE 15. AHCCCS MEDICAL COVERAGE FOR PEOPLE WHO ARE AGED, BLIND, OR DISABLED

Article 15, consisting of Sections R9-22-1501 through R9-22-1508, repealed; new Article 15, consisting of Sections R9-22-1501 through R9-22-1505 made by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).

Article 15, consisting of Sections R9-22-1501 through R9-22-1508, adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).

Section

R9-22-1501. General Information

R9-22-1502. General Eligibility Criteria

R9-22-1503. Financial Eligibility Criteria

R9-22-1504. Eligibility For A Person Who Is Aged, Blind, or Disabled

R9-22-1505. Eligibility for Special Groups

R9-22-1506. Repealed

R9-22-1507. Repealed

R9-22-1508. Repealed

ARTICLE 16. SOCIAL SECURITY DISABILITY INSURANCE - TEMPORARY MEDICAL COVERAGE

Article 16, consisting of Sections R9-22-1601 through R9-22-1636, repealed by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).

Article 16, consisting of Sections R9-22-1601 through R9-22-1613, R9-22-1615 through R9-22-1620, R9-22-1622 through R9-22-1631, R9-22-1633, R9-22-1634, and R9-22-1636, adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).

Section

R9-22-1601. General Information

R9-22-1602. Ineligible Person

R9-22-1603. Definitions

R9-22-1604. Effective Date of Eligibility for Services

R9-22-1605. Services

R9-22-1606. Application Process

R9-22-1607. Withdrawal

R9-22-1608. Assignment of Rights Under Operation of Law

R9-22-1609. General Eligibility Criteria

R9-22-1610. Changes/Redetermination

R9-22-1611. Copayments

R9-22-1612. Resources

R9-22-1613. Repealed

R9-22-1614. Confidentiality and Safeguarding of Information

R9-22-1615. Notice Requirements

R9-22-1616. Calculating the Monthly Income for Determining the Premium Amount

R9-22-1617. Repealed

R9-22-1618. General Provisions Related to Premiums

R9-22-1619. Request for Hearing Process

R9-22-1620. Repealed

R9-22-1621. Reserved

R9-22-1622. Repealed

R9-22-1623. Repealed

R9-22-1624. Repealed

R9-22-1625. Repealed

R9-22-1626. Repealed

R9-22-1627. Repealed

R9-22-1628. Repealed

R9-22-1629. Repealed

R9-22-1630. Repealed

R9-22-1631. Repealed

R9-22-1632. Reserved

R9-22-1633. Repealed

R9-22-1634. Repealed

R9-22-1635. Reserved

R9-22-1636. Repealed

ARTICLE 17. ENROLLMENT

Article 17, consisting of Sections R9-22-1701 through R9-22-1704, adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).

Section

R9-22-1701. Enrollment-Related Definitions

R9-22-1702. Enrollment of a Member with an AHCCCS Contractor

R9-22-1703. Effective Date of Enrollment with a Contractor

R9-22-1704. Newborn Enrollment

R9-22-1705. Guaranteed Enrollment Period

ARTICLE 18. RESERVED

ARTICLE 19. FREEDOM TO WORK

Article 19, consisting of Sections R9-22-1901 through R9-22-1922, made by exempt rulemaking at 9 A.A.R. 95, effective January 1, 2003 (Supp. 02-4).

Section

R9-22-1901. General Freedom to Work Requirements

R9-22-1902. General Administration Requirements

R9-22-1903. Application for Coverage

R9-22-1904. Notice of Approval or Denial

R9-22-1905. Reporting and Verifying Changes

R9-22-1906. Actions That Result From a Redetermination or Change

R9-22-1907. Notice of Adverse Action Requirements

R9-22-1908. Request For Hearing

R9-22-1909. Social Security Number

R9-22-1910. State Residency

R9-22-1911. Citizenship and Immigrant Status

R9-22-1912. Age

R9-22-1913. Premium

R9-22-1914. Income

R9-22-1915. Institutionalized Person

R9-22-1916. Non Payment of Premium

R9-22-1917. Applicant and Member Responsibility

R9-22-1918. Additional Eligibility Criteria for the Basic Coverage Group

R9-22-1919. Additional Eligibility Criteria for the Medically Improved Group

R9-22-1920. Premium Amount

R9-22-1921. Enrollment

R9-22-1922. Redetermination of Eligibility

ARTICLE 20. BREAST AND CERVICAL CANCER TREATMENT PROGRAM

Section

R9-22-2001. Breast and Cervical Cancer Treatment Program Related Definitions

R9-22-2002. General Requirements

R9-22-2003. Eligibility Criteria

R9-22-2004. Treatment

R9-22-2005. Application Process

R9-22-2006. Approval, Denial, or Discontinuance of Eligibility

R9-22-2007. Effective and End Date of Eligibility

R9-22-2008. Redetermination of Eligibility

ARTICLE 21. TRAUMA AND EMERGENCY SERVICES FUND

Article 21, consisting of Sections R9-22-2101 through R9-22-2103, made by exempt rulemaking at 9 A.A.R. 4001, effective October 19, 2003 (Supp. 03-3).

Section

R9-22-2101. General Provisions

R9-22-2102. Distribution of Trauma and Emergency Services Fund: Level I Trauma Centers

R9-22-2103. Distribution of Trauma and Emergency Services Fund: Emergency Services

ARTICLE 1. DEFINITIONS

R9-22-101. Location of Definitions

A. Location of definitions. Definitions applicable to this Chapter are found in the following:

Definition Section or Citation

"Accommodation" R9-22-701

"Act" R9-22-101

"ADHS" R9-22-101

"Administration" A.R.S. § 36-2901

"Adverse action" R9-22-101

"Affiliated corporate organization" R9-22-101

"Aged" 42 U.S.C. 1382c(a)(1)(A) and R9-22-1501

"Aggregate" R9-22-701

"AHCCCS" R9-22-101

"AHCCCS inpatient hospital day or days of care" R9-22-701

"AHCCCS registered provider" R9-22-101

"Ambulance" A.R.S. § 36-2201

"Ancillary department" R9-22-701

"Ancillary service" R9-22-701

"Anticipatory guidance" R9-22-201

"Annual enrollment choice" R9-22-1701

"APC" R9-22-701

"Appellant" R9-22-101

"Applicant" R9-22-101

"Application" R9-22-101

"Assessment" R9-22-1101

"Assignment" R9-22-101

"Attending physician" R9-22-101

"Authorized representative" R9-22-101

"Authorization" R9-22-201

"Auto-assignment algorithm" R9-22-1701

"AZ-NBCCEDP" R9-22-2001

"Baby Arizona" R9-22-1401

"Behavior management services" R9-22-1201

"Behavioral health adult therapeutic home" R9-22-1201

"Behavioral health therapeutic home care
services" R9-22-1201

"Behavioral health evaluation" R9-22-1201

"Behavioral health medical practitioner" R9-22-1201

"Behavioral health professional" R9-20-1201

"Behavioral health recipient" R9-22-201

"Behavioral health service" R9-22-1201

"Behavioral health technician" R9-20-1201

"BHS" R9-22-1401

"Billed charges" R9-22-701

"Blind" R9-22-1501

"Burial plot" R9-22-1401

"Business agent" R9-22-701 and R9-22-704

"Calculated inpatient costs" R9-22-712.07

"Capital costs" R9-22-701

"Capped fee-for-service" R9-22-101

"Caretaker relative" R9-22-1401

"Case management" R9-22-1201

"Case record" R9-22-101

"Case review" R9-22-101

"Cash assistance" R9-22-1401

"Categorically eligible" R9-22-101

"CCR" R9-22-712

"Certified psychiatric nurse practitioner" R9-22-1201

"Charge master" R9-22-712

"Child" R9-22-1503 and R9-22-1603

"Children's Rehabilitative Services" or "CRS" R9-22-201

"Claim" R9-22-1101

"Claims paid amount" R9-22-712.07

"Clean claim" A.R.S. § 36-2904

"Clinical supervision" R9-22-201

"CMDP" R9-22-1701

"CMS" R9-22-101

"Continuous stay" R9-22-101

"Contract" R9-22-101

"Contract year" R9-22-101

"Contractor" A.R.S. § 36-2901

"Copayment" R9-22-701, R9-22-711 and R9-22-1603

"Cost avoid" R9-22-1201

"Cost-To-Charge Ratio" R9-22-701

"Covered charges" R9-22-701

"Covered services" R9-22-101

"CPT" R9-22-701

"Creditable coverage" R9-22-2003 and 42 U.S.C. 300gg(c)

"Critical Access Hospital" R9-22-701

"CRS" R9-22-1401

"Cryotherapy" R9-22-2001

"Customized DME" R9-22-212

"Day" R9-22-101 and R9-22-1101

"Date of the Notice of Adverse Action" R9-22-1441

"DBHS" R9-22-201

"DCSE" R9-22-1401

"De novo hearing" 42 CFR 431.201

"Dentures" and "Denture services" R9-22-201

"Department" A.R.S. § 36-2901

"Dependent child" A.R.S. § 46-101

"DES" R9-22-101

"Diagnostic services" R9-22-101

"Director" R9-22-101

"Disabled" R9-22-1501

"Discussion" R9-22-101

"Disenrollment" R9-22-1701

"DME" R9-22-101

"DRI inflation factor" R9-22-701

"E.P.S.D.T. services" 42 CFR 440.40(b)

"Eligibility posting" R9-22-701

"Eligible person" A.R.S. § 36-2901

"Emergency behavioral health condition
for the non-FES member" R9-22-201

"Emergency behavioral health services for the
non-FES member" R9-22-201

"Emergency medical condition for the non-FES
member" R9-22-201

"Emergency medical services for the non-FES
member" R9-22-201

"Emergency medical or behavioral health
condition for a FES member" R9-22-217

"Emergency services costs" A.R.S. § 36-2903.07

"Encounter" R9-22-701

"Enrollment" R9-22-1701

"Enumeration" R9-22-101

"Equity" R9-22-101

"Experimental services" R9-22-101

"Existing outpatient service" R9-22-701

"Expansion funds" R9-22-701

"FAA" R9-22-1401

"Facility" R9-22-101

"Factor" R9-22-701 and 42 CFR 447.10

"FBR" R9-22-101

"Federal financial participation" or "FFP" 42 CFR 400.203

"Federal poverty level" or "FPL" A.R.S. § 36-2981

"Fee-For-Service" or "FFS" R9-22-101

"FES member" R9-22-101

"FESP" R9-22-101

"First-party liability" R9-22-1001

"File" R9-22-1101

"Fiscal agent" R9-22-210

"Fiscal intermediary" R9-22-701

"Foster care maintenance payment" 42 U.S.C. 675(4)(A)

"FQHC" R9-22-101

"Free Standing Children's Hospital" R9-22-701

"Fund" R9-22-712.07

"Graduate medical education (GME) program" R9-22-701

"Grievance" R9-34-202

"GSA" R9-22-101

"HCPCS" R9-22-701

"Health care practitioner" R9-22-1201

"Hearing aid" R9-22-201

"HIPAA" R9-22-701

"Home health services" R9-22-201

"Homebound" R9-22-1401

"Hospital" R9-22-101

"In-kind income" R9-22-1420

"Insured entity" R9-22-720

"Intermediate Care Facility for

the Mentally Retarded" or "ICF-MR" 42 USC 1396d(d)

"ICU" R9-22-701

"IHS" R9-22-101

"IHS enrolled" or "enrolled with IHS" R9-22-708

"IMD" or "Institution for Mental
Diseases" 42 CFR 435.1010 and R9-22-201

"Income" R9-22-1401 and R9-22-1603

"Indigent" R9-22-1401

"Individual" R9-22-211

"Inmate of a public institution" 42 CFR 435.1010

"Inpatient covered charges" R9-22-712.07

"Interested party" R9-22-101

"Intermediate Care Facility for the
Mentally Retarded" or "ICF-MR" 42 U.S.C. 1396d(d)

"Intern and Resident Information System" R9-22-701

"LEEP" R9-22-2001

"Legal representative" R9-22-101

"Level I trauma center" R9-22-2101

"License" or "licensure" R9-22-101

"Licensee" R9-22-1201

"Liquid assets" R9-22-1401

"Mailing date" R9-22-101

"Medical education costs" R9-22-701

"Medical expense deduction" or "MED" R9-22-1401

"Medical record" R9-22-101

"Medical review" R9-22-701

"Medical services" A.R.S. § 36-401

"Medical supplies" R9-22-201

"Medical support" R9-22-1401

"Medically necessary" R9-22-101

"Medicare claim" R9-22-101

"Medicare HMO" R9-22-101

"Member" A.R.S. § 36-2901

"Mental disorder" A.R.S. § 36-501

"Milliman study" R9-22-712.07

"Monthly equivalent" R9-22-1421 and R9-22-1603

"Monthly income" R9-22-1421 and R9-22-1603

"National Standard code sets" R9-22-701

"New hospital" R9-22-701

"NICU" R9-22-701

"Noncontracted Hospital" R9-22-718

"Noncontracting provider" A.R.S. § 36-2901

"Non-FES member" R9-22-201

"Non-IHS Acute Hospital" R9-22-701

"Nonparent caretaker relative" R9-22-1401

"Notice of Findings" R9-22-109

"Nursing facility" or "NF" 42 U.S.C. 1396r(a)

"OBHL" R9-22-1201

"Observation day" R9-22-701

"Occupational therapy" R9-22-201

"Offeror" R9-22-101

"Operating costs" R9-22-701

"Organized health care delivery system" R9-22-701

"Outlier" R9-22-701

"Outpatient hospital service" R9-22-701

"Ownership change" R9-22-701

"Ownership interest" 42 CFR 455.101

"Parent" R9-22-1603

"Partial Care" R9-22-1201

"Participating institution" R9-22-701

"Peer group" R9-22-701

"Peer-reviewed study" R9-22-2001

"Penalty" R9-22-1101

"Pharmaceutical service" R9-22-201

"Physical therapy" R9-22-201

"Physician" R9-22-101

"Physician assistant" R9-22-1201

"Post-stabilization services" R9-22-201 or 42 CFR 422.113

"PPC" R9-22-701

"PPS bed" R9-22-701

"Practitioner" R9-22-101

"Pre-enrollment process" R9-22-1401

"Premium" R9-22-1603

"Prescription" R9-22-101

"Primary care provider or "PCP" R9-22-101

"Primary care provider services" R9-22-201

"Prior authorization" R9-22-101

"Prior period coverage" or "PPC" R9-22-701

"Procedure code" R9-22-701

"Proposal" R9-22-101

"Prospective rates" R9-22-701

"Psychiatrist" R9-22-1201

"Psychologist" R9-22-1201

"Psychosocial rehabilitation services" R9-22-201

"Public hospital" R9-22-701

"Qualified alien" A.R.S. § 36-2903.03

"Qualified behavioral health service provider" R9-22-1201

"Quality management" R9-22-501

"Radiology" R9-22-101

"RBHA" or "Regional Behavioral Health
Authority" R9-22-201

"Reason to know" R9-22-1101

"Rebase" R9-22-701

"Referral" R9-22-101

"Rehabilitation services" R9-22-101

"Reinsurance" R9-22-701

"Remittance advice" R9-22-701

"Resident" R9-22-701

"Residual functional deficit" R9-22-201

"Resources" R9-22-1401

"Respiratory therapy" R9-22-201

"Respite" R9-22-1201

"Responsible offeror" R9-22-101

"Responsive offeror" R9-22-101

"Revenue Code" R9-22-701

"Review" R9-22-101

"Review month" R9-22-101

"RFP" R9-22-101

"Rural Contractor" R9-22-718

"Rural Hospital" R9-22-712.07 and R9-22-718

"Scope of services" R9-22-201

"Section 1115 Waiver" A.R.S. § 36-2901

"Service location" R9-22-101

"Service site" R9-22-101

"SOBRA" R9-22-101

"Specialist" R9-22-101

"Specialty facility" R9-22-701

"Speech therapy" R9-22-201

"Spendthrift restriction" R9-22-1401

"Sponsor" R9-22-1401

"Sponsor deemed income" R9-22-1401

"Sponsoring institution" R9-22-701

"Spouse" R9-22-101

"SSA" 42 CFR 1000.10

"SSDI Temporary Medical Coverage" R9-22-1603

"SSI" 42 CFR 435.4

"SSN" R9-22-101

"Stabilize" 42 U.S.C. 1395dd

"Standard of care" R9-22-101

"Sterilization" R9-22-201

"Subcontract" R9-22-101

"Submitted" A.R.S. § 36-2904

"Substance abuse" R9-22-201

"SVES" R9-22-1401

"Therapeutic foster care services" R9-22-1201

"Third-party" R9-22-1001

"Third-party liability" R9-22-1001

"Tier" R9-22-701

"Tiered per diem" R9-22-701

"Title IV-D" R9-22-1401

"Title IV-E" R9-22-1401

"Total Inpatient payments" R9-22-712.07

"Trauma and Emergency Services Fund" A.R.S. § 36-2903.07

"TRBHA" or "Tribal Regional Behavioral Health
Authority" R9-22-1201

"Treatment" R9-22-2004

"Tribal Facility" A.R.S. § 36-2981

"Unrecovered trauma center readiness costs" R9-22-2101

"Urban Contractor" R9-22-718

"Urban Hospital" R9-22-718

"USCIS" R9-22-1401

"Utilization management" R9-22-501

"WWHP" R9-22-2001

B. General definitions. In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:

"Act" means the Social Security Act.

"ADHS" means the Arizona Department of Health Services.

"Adverse action" means an action taken by the Department or Administration to deny, discontinue, or reduce medical assistance.

"Affiliated corporate organization" means any organization that has ownership or control interests as defined in 42 CFR 455.101, and includes a parent and subsidiary corporation.

"AHCCCS" means the Arizona Health Care Cost Containment System, which is composed of the Administration, contractors, and other arrangements through which health care services are provided to a member.

"AHCCCS registered provider" means a provider or noncontracting provider who:

Enters into a provider agreement with the Administration under R9-22-703(A), and

Meets license or certification requirements to provide covered services.

"Appellant" means an applicant or member who is appealing an adverse action by the Department or Administration.

"Applicant" means a person who submits or whose authorized representative submits a written, signed, and dated application for AHCCCS benefits.

"Application" means an official request for AHCCCS medical coverage made under this Chapter.

"Assignment" means enrollment of a member with a contractor by the Administration.

"Attending physician" means a licensed allopathic or osteopathic doctor of medicine who has primary responsibility for providing or directing preventive and treatment services for a Fee-For-Service member.

"Authorized representative" means a person who is authorized to apply for medical assistance or act on behalf of another person.

"Capped fee-for-service" means the payment mechanism by which a provider of care is reimbursed upon submission of a valid claim for a specific covered service or equipment provided to a member. A payment is made in accordance with an upper or capped limit established by the Director. This capped limit can either be a specific dollar amount or a percentage of billed charges.

"Case record" means an individual or family file retained by the Department that contains all pertinent eligibility information, including electronically stored data.

"Case review" means the Administration's evaluation of an individual's or family's circumstances and case record in a review month.

"Categorically eligible" means a person who is eligible under A.R.S. §§ 36-2901(6)(a)(i), (ii), or (iii) or 36-2934.

"CMS" means the Centers for Medicare and Medicaid Services.

"Continuous stay" means a period during which a member receives inpatient hospital services without interruption beginning with the date of admission and ending with the date of discharge or date of death.

"Contract" means a written agreement entered into between a person, an organization, or other entity and the Administration to provide health care services to a member under A.R.S. Title 36, Chapter 29, and this Chapter.

"Contract year" means the period beginning on October 1 of a year and continuing until September 30 of the following year.

"Covered services" means the health and medical services described in Articles 2 and 12 of this Chapter as being eligible for reimbursement by AHCCCS.

"Day" means a calendar day unless otherwise specified.

"DES" means the Department of Economic Security.

"Diagnostic services" means services provided for the purpose of determining the nature and cause of a condition, illness, or injury.

"Director" means the Director of the Administration or the Director's designee.

"Discussion" means an oral or written exchange of information or any form of negotiation.

"DME" means durable medical equipment, which is an item or appliance that can withstand repeated use, is designed to serve a medical purpose, and is not generally useful to a person in the absence of a medical condition, illness, or injury.

"Enumeration" means the assignment of a nine-digit identification number to a person by the Social Security Administration.

"Equity" means the county assessor full cash value or market value of a resource minus valid liens, encumbrances, or both.

"Experimental services" means services that are associated with treatment or diagnostic evaluation and that are not generally and widely accepted as a standard of care in the practice of medicine in the United States unless:

The weight of the evidence in peer-reviewed articles in medical journals published in the United States supports the safety and effectiveness of the service; or

In the absence of peer-reviewed articles, for services that are rarely used, novel, or relatively unknown in the general professional medical community, the weight of opinions from specialists who provide the service attests to the safety and effectiveness of the service.

"Facility" means a building or portion of a building licensed or certified by the Arizona Department of Health Services as a health care institution under A.R.S. Title 36, Chapter 4, to provide a medical service, a nursing service, or other health care or health-related service.

"FBR" means Federal Benefit Rate, the maximum monthly Supplemental Security Income payment rate for a member or a married couple.

"Fee-For-Service" or "FFS" means a method of payment by the AHCCCS Administration to a registered provider on an amount-per-service basis for a member not enrolled with a contractor.

"FES member" means a person who is eligible to receive emergency medical and behavioral health services through the FESP under R9-22-217.

"FESP" means the federal emergency services program under R9-22-217 which covers services to treat an emergency medical or behavioral health condition for a member who is determined eligible under A.R.S. § 36-2903.03(D).

"FQHC" means federally qualified health center.

"GSA" means a geographical service area designated by the Administration within which a contractor provides, directly or through a subcontract, a covered health care service to a member enrolled with the contractor.

"Hospital" means a health care institution that is licensed as a hospital by the Arizona Department of Health Services under A.R.S. Title 36, Chapter 4, Article 2, and certified as a provider under Title XVIII of the Social Security Act, as amended, or is currently determined, by the Arizona Department of Health Services as the CMS designee, to meet the requirements of certification.

"IHS" means Indian Health Service.

"Interested party" means an actual or prospective offeror whose economic interest may be directly affected by the issuance of an RFP, the award of a contract, or by the failure to award a contract.

"Legal representative" means a custodial parent of a child under 18, a guardian, or a conservator.

"License" or "licensure" means a nontransferable authorization that is granted based on established standards in law by a state or a county regulatory agency or board and allows a health care provider to lawfully render a health care service.

"Mailing date" when used in reference to a document sent first class, postage prepaid, through the United States mail, means the date:

Shown on the postmark;

Shown on the postage meter mark of the envelope, if no postmark; or

Entered as the date on the document, if there is no legible postmark or postage meter mark.

"Medical record" means a document that relates to medical or behavioral health services provided to a member by a physician or other licensed practitioner of the healing arts and that is kept at the site of the provider.

"Medically necessary" means a covered service is provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, or other adverse health conditions or their progression, or to prolong life.

"Medicare claim" means a claim for Medicare-covered services for a member with Medicare coverage.

"Medicare HMO" means a health maintenance organization that has a current contract with Centers for Medicare and Medicaid Services for participation in the Medicare program under 42 CFR 417(L).

"Offeror" means an individual or entity that submits a proposal to the Administration in response to an RFP.

"Physician" means a person licensed as an allopathic or osteopathic physician under A.R.S. Title 32, Chapter 13 or Chapter 17.

"Practitioner" means a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a registered nurse practitioner certified under A.R.S. Title 32, Chapter 15.

"Prescription" means an order to provide covered services that is signed or transmitted by a provider authorized to prescribe the services.

"Primary care provider" or "PCP" means an individual who meets the requirements of A.R.S. § 36-2901(12) or (13), and who is responsible for the management of a member's health care.

"Prior authorization" means the process by which the Administration or contractor, whichever is applicable, authorizes, in advance, the delivery of covered services contingent on the medical necessity of the services.

"Prior period coverage" means the period prior to the member's enrollment during which a member is eligible for covered services. PPC begins on the first day of the month of application or the first eligible month, whichever is later, and continues until the day the member is enrolled with a contractor.

"Proposal" means all documents, including best and final offers, submitted by an offeror in response to an RFP by the Administration.

"Radiology" means professional and technical services rendered to provide medical imaging, radiation oncology, and radioisotope services.

"Referral" means the process by which a member is directed by a primary care provider or an attending physician to another appropriate provider or resource for diagnosis or treatment.

"Rehabilitation services" means physical, occupational, and speech therapies, and items to assist in improving or restoring a person's functional level.

"Responsible offeror" means an individual or entity that has the capability to perform the requirements of a contract and that ensures good faith performance.

"Responsive offeror" means an individual or entity that submits a proposal that conforms in all material respects to an RFP.

"Review" means a review of all factors affecting a member's eligibility.

"Review month" means the month in which the individual's or family's circumstances and case record are reviewed.

"RFP" means Request for Proposals, including all documents, whether attached or incorporated by reference, that are used by the Administration for soliciting a proposal under 9 A.A.C. 22, Article 6.

"Service location" means a location at which a member obtains a covered service provided by a physician or other licensed practitioner of the healing arts under the terms of a contract.

"Service site" means a location designated by a contractor as the location at which a member is to receive covered services.

"S.O.B.R.A." means Section 9401 of the Sixth Omnibus Budget Reconciliation Act, 1986, amended by the Medicare Catastrophic Coverage Act of 1988, 42 U.S.C. 1396a(a)(10)(A)(i)(IV), 42 U.S.C. 1396a(a)(10)(A)(i)(VI), and 42 U.S.C. 1396a(a)(10)(A)(i)(VII).

"Specialist" means a Board-eligible or certified physician who declares himself or herself as a specialist and practices a specific medical specialty. For the purposes of this definition, Board-eligible means a physician who meets all the requirements for certification but has not tested for or has not been issued certification.

"Spouse" means a person who has entered into a contract of marriage recognized as valid by this state.

"SSN" means Social Security number.

"Standard of care" means a medical procedure or process that is accepted as treatment for a specific illness, injury, or medical condition through custom, peer review, or consensus by the professional medical community.

"Subcontract" means an agreement entered into by a contractor with any of the following:

A provider of health care services who agrees to furnish covered services to a member,

A marketing organization, or

Any other organization or person that agrees to perform any administrative function or service for the contractor specifically related to securing or fulfilling the contractor's obligation to the Administration under the terms of a contract.