TITLE 9. HEALTH SERVICES
CHAPTER 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
ADMINISTRATION
Supp. 08-2
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Former Article 1, consisting of Section R9-22-101, repealed effective December 8, 1997 (Supp. 97-4).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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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 Repealed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.
Historical Note
Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-101 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22-101 repealed, former Sections R9-22-102 and R9-22-301 renumbered as Section R9-22-101 and amended effective October 1, 1983 (Supp. 83-5). Adopted as an emergency effective May 18, 1984, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-3). Amended as an emergency by adding new paragraphs (24), (46), (84) and (91) and renumbering accordingly effective August 16, 1984, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-4). Amended as an emergency by adding new paragraphs (2) and (15) and renumbering accordingly effective October 25, 1984, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-5). Emergency expired. Permanent amendment added paragraphs (2) and (15) and renumbered accordingly effective February 1, 1985 (Supp. 85-1). Amended effective October 1, 1985 (Supp. 85-5). Amended paragraphs (10) and (15) effective October 1, 1986 (Supp. 86-5). Amended effective January 1, 1987, filed December 31, 1986 (Supp. 86-6). Amended effective October 1, 1987; amended effective December 22, 1987 (Supp. 87-4). Amended by deleting paragraphs (39) and (62) and renumbering accordingly effective July 1, 1988 (Supp. 88-3). Amended effective May 30, 1989 (Supp. 89-2). Amended effective April 13, 1990 (Supp. 90-2). Amended effective September 29, 1992 (Supp. 92-3). Amended under an exemption from the provisions of the Administrative Procedure Act, effective March 1, 1993 (Supp. 93-1). Amended under an exemption from the provisions of the Administrative Procedure Act, effective July 1, 1993 (Supp. 93-3). Amended under an exemption from the provisions of the Administrative Procedure Act, effective October 26, 1993 (Supp. 93-4). Amended effective December 13, 1993 (Supp. 93-4). Amended effective January 14, 1997 (Supp. 97-1). Section repealed; new Section adopted effective December 8, 1997 (Supp. 97-4). Section repealed, new Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by final rulemaking at 5 A.A.R. 607, effective February 5, 1999 (Supp. 99-1). Amended by final rulemaking at 5 A.A.R. 867, effective March 4, 1999 (Supp. 99-1). Amended by final rulemaking at 5 A.A.R. 4061, effective October 8, 1999 (Supp. 99-4). Amended by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 6 A.A.R. 3317, effective August 7, 2000 (Supp. 00-3). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by exempt rulemaking at 7 A.A.R. 5701, effective December 1, 2001 (Supp. 01-4). Amended by final rulemaking at 7 A.A.R. 5814, effective December 6, 2001 (Supp. 01-4). Amended by final rulemaking at 8 A.A.R. 424, effective January 10, 2002 (Supp. 02-1). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 8 A.A.R. 3317, effective July 15, 2002 (Supp. 02-3). Amended by exempt rulemaking at 9 A.A.R. 4001, effective October 19, 2003 (Supp. 03-3). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by final rulemaking at 11 A.A.R. 3830, effective November 12, 2005 (Supp. 05-3). Amended by final rulemaking at 11 A.A.R. 5467, effective December 6, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Amended by final rulemaking at 13 A.A.R. 3351, effective November 10, 2007 (Supp. 07-3). Amended by final rulemaking at 14 A.A.R. 1598, effective May 31, 2008 (Supp. 08-2).
R9-22-102. Repealed
Historical Note
Adopted as an emergency effective May 20, 1982, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-102 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1092 (Supp. 82-4). Former Section R9-22-102 renumbered together with former Section R9-22-301 as Section R9-22-101 and amended effective October 1, 1983 (Supp. 83-5). New Section adopted effective December 8, 1997 (Supp. 97-4). Amended by exempt rulemaking at 7 A.A.R. 5701, effective December 1, 2001 (Supp. 01-4). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 5467, effective December 6, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Section repealed by final rulemaking at 13 A.A.R. 3351, effective November 10, 2007 (Supp. 07-3).
R9-22-103. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Section repealed by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
R9-22-104. Reserved
R9-22-105. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Section repealed by final rulemaking at 11 A.A.R. 4277, effective December 5, 2005 (Supp. 05-4).
R9-22-106. Repealed
Historical Note
New Section adopted by final rulemaking at 5 A.A.R. 607, effective February 5, 1999 (Supp. 99-1). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Section repealed by final rulemaking at 11 A.A.R. 5467, effective December 6, 2005 (Supp. 05-4).
R9-22-107. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 8 A.A.R. 424, effective January 10, 2002 (Supp. 02-1). Amended by final rulemaking at 8 A.A.R. 3317, effective July 15, 2002 (Supp. 02-3). Section repealed by exempt rulemaking at 11 A.A.R. 2297, effective July 1, 2005 (Supp. 05-2).
R9-22-108. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 3317, effective August 7, 2000 (Supp. 00-3). Section repealed by final rulemaking at 10 A.A.R. 808, effective April 3, 2004 (Supp. 04-1).
R9-22-109. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 5 A.A.R. 4061, effective October 8, 1999 (Supp. 99-4). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Section repealed by final rulemaking at 12 A.A.R. effective 4484, effective January 6, 2007 (Supp. 06-4).
R9-22-110. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Section repealed by final rulemaking at 10 A.A.R. 1146, effective May 1, 2004 (Supp. 04-1).
R9-22-111. Reserved
R9-22-112. Repealed
Historical Note
Adopted effective December 8, 1997 (Supp. 97-4). Section repealed; new Section adopted by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Repealed by final rulemaking at 13 A.A.R. 836, effective May 5, 2007 (Supp. 07-1).
R9-22-113. Reserved
R9-22-114. Repealed
Historical Note
New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Section repealed by final rulemaking at 11 A.A.R. 5467, effective December 6, 2005 (Supp. 05-4).
R9-22-115. Repealed
Historical Note
Final Section adopted at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Section repealed by final rulemaking at 11 A.A.R. 5467, effective December 6, 2005 (Supp. 05-4).
R9-22-116. Repealed
Historical Note
New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Section repealed by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
R9-22-117. Repealed
Historical Note
New Section adopted by final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Section repealed by final rulemaking at 14 A.A.R. 1598, effective May 31, 2008 (Supp. 08-2).
R9-22-120. Repealed
Historical Note
New Section made by final rulemaking at 7 A.A.R. 5814, effective December 6, 2001 (Supp. 01-4). Section repealed by final rulemaking at 12 A.A.R. 4488, effective January 6, 2007 (Supp. 06-4).
ARTICLE 2. SCOPE OF SERVICES
R9-22-201. Scope of Services-related 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:
"Anticipatory guidance" means a person responsible for a child receives information and guidance of what the person should expect of the child's development and how to help the child stay healthy.
"Behavioral health recipient" means a Title XIX or Title XXI acute care member who is eligible for, and is receiving, behavioral health services through ADHS/DBHS.
"Children's Rehabilitative Services" or "CRS" means the program within ADHS that provides covered medical services and covered support services in accordance with A.R.S. § 36-261.
"Clinical supervision" means a Clinical Supervisor under 9 A.A.C. 20, Article 2 reviews the skills and knowledge of the individual supervised and provides guidance in improving or developing the skills and knowledge.
"DBHS" means the Division of Behavioral Health Services within the Arizona Department of Health Services.
"Dentures" and "Denture services" mean a partial or complete set of artificial teeth and related services that are determined to be medically necessary and the primary treatment of choice, or an essential part of an overall treatment plan, and designed to alleviate a medical condition as determined by the primary care provider in consultation with the dental service provider.
"Emergency behavioral health condition for the non-FES member" means a condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
Placing the health of the person, including mental health, in serious jeopardy;
Serious impairment to bodily functions;
Serious dysfunction of any bodily organ or part; or
Serious physical harm to another person.
"Emergency behavioral health services for the non-FES member" means those behavioral health services provided for the treatment of an emergency behavioral health condition.
"Emergency medical condition for the non-FES member" means treatment for a medical condition, including labor and delivery, that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
Placing the member's health in serious jeopardy,
Serious impairment to bodily functions, or
Serious dysfunction of any bodily organ or part.
"Emergency medical services for the non-FES member" means services provided for the treatment of an emergency medical condition.
"Hearing aid" means an instrument or device designed for, or represented by the supplier as aiding or compensating for impaired or defective human hearing, and includes any parts, attachments, or accessories of the instrument or device.
"Home health services" means services and supplies that are provided by a home health agency that coordinates in-home intermittent services for curative, habilitative care, including home-health aide services, licensed nurse services, and medical supplies, equipment, and appliances.
"IMD" or "Institution for Mental Diseases" means an Institution for Mental Diseases as described in 42 CFR 435.1010 and licensed by ADHS.
"Medical supplies" means consumable items that are designed specifically to meet a medical purpose.
"Non-FES member" means an eligible person who is entitled to full AHCCCS services.
"Occupational therapy" means medically prescribed treatment provided by or under the supervision of a licensed occupational therapist, to restore or improve an individual's ability to perform tasks required for independent functioning.
"Pharmaceutical service" means medically necessary medications that are prescribed by a physician, practitioner, or dentist under R9-22-209.
"Physical therapy" means treatment services to restore or improve muscle tone, joint mobility, or physical function provided by or under the supervision of a registered physical therapist.
"Post-stabilization services" means covered services related to an emergency medical or behavioral health condition provided after the condition is stabilized.
"Primary care provider services" means healthcare services provided by and within the scope of practice, as defined by law, of a licensed physician, certified nurse practitioner, or licensed physician assistant.
"Psychosocial rehabilitation services" means services that provide education, coaching, and training to address or prevent residual functional deficits and may include services that may assist a member to secure and maintain employment. Psychosocial rehabilitation services may include:
Living skills training,
Cognitive rehabilitation,
Health promotion,
Supported employment, and
Other services that increase social and communication skills to maximize a member's ability to participate in the community and function independently.
"RBHA" or "Regional Behavioral Health Authority" means the same as in A.R.S. § 36-3401.
"Residual functional deficit" means a member's inability to return to a previous level of functioning, usually after experiencing a severe psychotic break or state of decompensation.
"Respiratory therapy" means treatment services to restore, maintain, or improve respiratory functions that are provided by, or under the supervision of, a respiratory therapist licensed according to A.R.S. Title 32, Chapter 35.
"Scope of services" means the covered, limited, and excluded services under Articles 2 and 12 of this Chapter.
"Speech therapy" means medically prescribed diagnostic and treatment services provided by or under the supervision of a certified speech therapist.
"Sterilization" means a medically necessary procedure, not for the purpose of family planning, to render an eligible person or member barren in order to:
Prevent the progression of disease, disability, or adverse health conditions; or
Prolong life and promote physical health.
"Substance abuse" means the chronic, habitual, or compulsive use of any chemical matter that, when introduced into the body, is capable of altering human behavior or mental functioning and, with extended use, may cause psychological dependence and impaired mental, social or educational functioning. Nicotine addiction is not considered substance abuse for adults who are 21 years of age or older.
Historical Note
Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-201 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended subsection (B) effective May 30, 1989 (Supp. 89-2). Amended under an exemption from the provisions of the Administrative Procedure Act, effective July 1, 1993 (Supp. 93-3). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by final rulemaking at 11 A.A.R. 3217, effective October 1, 2005 (Supp. 05-3). Section repealed; new Section made by final rulemaking at 13 A.A.R. 3351, effective November 10, 2007
(Supp. 07-3).
R9-22-202. General Requirements
A. For the purposes of this Article, the following definitions apply:
1. "Authorization" means written or verbal authorization by:
a. The Administration for services rendered to a fee-for-service member, or
b. The contractor for services rendered to a prepaid capitated member.
2. Use of the phrase "attending physician" applies only to the fee-for-service population.
B. In addition to other requirements and limitations specified in this Chapter, the following general requirements apply:
1. Only medically necessary, cost effective, and federally-reimbursable and state-reimbursable services are covered services.
2. Covered services for the federal emergency services program (FESP) are under R9-22-217.
3. The Administration or a contractor may waive the covered services referral requirements of this Article.
4. Except as authorized by the Administration or a contractor, a primary care provider, attending physician, practitioner, or a dentist shall provide or direct the member's covered services. Delegation of the provision of care to a practitioner does not diminish the role or responsibility of the primary care provider.
5. A contractor shall offer a female member direct access to preventive and routine services from gynecology providers within the contractor's network without a referral from a primary care provider.
6. A member may receive behavioral health evaluation services without a referral from a primary care provider. A member may receive behavioral health treatment services only under referral from the primary care provider or upon authorization by the contractor or the contractor's designee.
7. A member may receive treatment that is considered the standard of care or that is approved by the AHCCCS Chief Medical Officer after appropriate input from providers who are considered experts in the field by the professional medical community.
8. AHCCCS or a contractor shall provide services under the Section 1115 Waiver as defined in A.R.S. § 36-2901.
9. An AHCCCS registered provider shall provide covered services within the provider's scope of practice.
10. In addition to the specific exclusions and limitations otherwise specified under this Article, the following are not covered:
a. A service that is determined by the AHCCCS Chief Medical Officer to be experimental or provided primarily for the purpose of research;
b. Services or items furnished gratuitously, and
c. Personal care items except as specified under R9-22-212.
11. Medical or behavioral health services are not covered services if provided to:
a. An inmate of a public institution;
b. A person who is in residence at an institution for the treatment of tuberculosis; or
c. A person age 21 through 64 who is in an IMD, unless the service is covered under Article 12 of this Chapter.
C. The Administration or a contractor may deny payment of non-emergency services if prior authorization is not obtained as specified in this Article and Article 7 of this Chapter. The Administration or a contractor shall not reimburse services that require prior authorization unless the provider documents the diagnosis and treatment.
D. Services under A.R.S. § 36-2908 provided during the prior period coverage do not require prior authorization.
E. Prior authorization is not required for services necessary to evaluate and stabilize an emergency medical condition. The Administration or a contractor shall not reimburse services that require prior authorization unless the provider documents the diagnosis and treatment.
F. A service is not a covered service if provided outside the GSA unless one of the following applies:
1. A member is referred by a primary care provider for medical specialty care outside the GSA. If a member is referred outside the GSA to receive an authorized medically necessary service, the contractor shall also provide all other medically necessary covered services for the member;
2. There is a net savings in service delivery costs as a result of going outside the GSA that does not require undue travel time or hardship for a member or the member's family;
3. The contractor authorizes placement in a nursing facility located out of the GSA; or
4. Services are provided during prior period coverage.
G. If a member is traveling or temporarily residing outside of the GSA, covered services are restricted to emergency care services, unless otherwise authorized by the contractor.
H. A contractor shall provide at a minimum, directly or through subcontracts, the covered services specified in this Chapter and in contract.