Chapter 22. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION

A member shall cooperate in identifying potentially legally liable first- or third-parties and timely assist the Administration and a contractor, provider, or noncontracting provider in pursuing any first- or third-party who may be liable to pay for covered services. Notes Ariz. …

A. Parties that notify AHCCCS. A provider or noncontracting provider shall cooperate with AHCCCS by identifying all potential sources of first- or third-party liability and notify AHCCCS of these sources. B. Parties that pursue collection or reimbursement. AHCCCS, a provider, or …

AHCCCS shall monitor first- or third-party liability payments to a provider or noncontracting provider, which include but are not limited to payments by or for: 1. Private health insurance; 2. Employment-related disability and health insurance; 3. Long-term care insurance; 4. Oth…

A. Hospital requirements. A hospital providing medical services to a member for an injury or condition resulting from circumstances reflecting the probable liability of a first- or third-party shall within 30 days after a member's discharge: 1. Notify AHCCCS via facsimile or mail…

A. Except as provided in subsection (B), a hospital, provider, and noncontracting provider identified in R9-22-1007 shall provide the following information to AHCCCS in writing: 1. Name of the hospital, provider or noncontracting provider; 2. Address of the hospital, provider or …

A provider or noncontracting provider shall notify AHCCCS, in writing, of the following health insurance information within 10 days of receipt of the health insurance information: 1. Name of member, 2. Member's Social Security Number or AHCCCS identification number, 3. Insurance …

A. Location of definitions. Definitions applicable to this Chapter are found in the following: Definition Section or Citation "Accommodation" R9-22-701 "Active treatment" R9-22-1301 "ADHS" R9-22-101 "Administration" A.R.S. § 36-2901 "Adult behavioral health therapeutic home" 9 A.…

Notes Ariz. Admin. Code § R9-22-104

A. Scope. This Article applies to prohibited acts as described under A.R.S. § 36-2918(A), and submissions of encounters to the Administration. The Administration considers a person who aids and abets a prohibited act affecting any of the AHCCCS programs or Health Care Group to be…

A. AHCCCS shall determine the amount of a penalty and assessment according to A.R.S. § 36-2918(B) and (C), R9-22-1104, and R9-22-1105. B. AHCCCS shall include in the amount of the penalty and assessment the cost incurred by AHCCCS for conducting the following;1. An investigation,…

AHCCCS shall consider any of the following to be mitigating circumstances when determining the amount of penalties and assessments. 1. The following are mitigating circumstances: a. All the services are of the same type, b. All the dates of services occurred within six months or …

AHCCCS shall consider any of the following to be aggravating circumstances when determining the amount of a penalty, assessment, or penalty and assessment. 1. The nature and circumstances of each claim and the circumstances under which the claim is presented or caused to be prese…

If AHCCCS imposes a penalty, assessment, or a penalty and assessment, AHCCCS shall hand deliver or send by certified mail return receipt requested or Federal Express to the person, a written Notice of Intent to impose a penalty, assessment, or a penalty and assessment. The Notice…

Notes Ariz. Admin. Code § R9-22-1107

A. To request a compromise, the person shall file a written request with AHCCCS within 30 days from the date of receipt of the Notice of Intent. The written request for compromise shall contain the person's reasons for the reduction or modification of the penalty, assessment, or …

If a person fails to respond timely to the Notice of Intent, AHCCCS shall uphold the original penalty, assessment, or penalty and assessment. Notes Ariz. Admin. Code § R9-22-1109 New Section made by final rulemaking at 10 A.A.R. 3056, effective September 11, 2004 (Supp. 04-3). Am…

Notes Ariz. Admin. Code § R9-22-111

A. To request a State Fair Hearing regarding a dispute concerning a penalty, assessment, or penalty and assessment, the person shall file a written request for a State Fair Hearing with AHCCCS within 60 days from the date of the receipt of the Notice of Intent under R9-22-1106 or…

A. Preponderance of evidence. In any State Fair Hearing conducted under R9-22-1110, AHCCCS shall prove by a preponderance of the evidence that a person presented or caused to be presented each claim in violation of this Article and any aggravating circumstances under R9-22-1105 .…

AHCCCS may withdraw the Notice of Intent at any time. Prior to referring a matter to the Office of Administrative Hearings the parties may mutually agree to a continuance. Notes Ariz. Admin. Code § R9-22-1112 New Section made by final rulemaking at 10 A.A.R. 3056, effective Septe…

Notes Ariz. Admin. Code § R9-22-113

Notes Ariz. Admin. Code § R9-22-118

Notes Ariz. Admin. Code § R9-22-119

1. Administration. The program shall be administered as specified in A.R.S. § 36-2903 . 2. Provision of services. Behavioral health services shall be provided as specified in A.R.S. § 36-2907 and this Chapter. 3. Definitions. The following definitions apply to this Article: "Adul…

A. ADHS responsibilities. ADHS is responsible for payment of behavioral health services provided to members, except as specified under subsection (D). ADHS' responsibility for payment of behavioral health services includes claims for inpatient hospital services, which may include…

A. Title XIX members. A member determined eligible under A.R.S. § 36-2901(6)(a) or (g) except for the failure to meet U.S. citizenship or qualified alien status requirements, shall receive medically necessary covered services under Article 12 and Article 2. B. FES members. A pers…

A. Services. Behavioral health services include mental health, substance abuse, and physical services. Medically necessary services shall be covered and service requirements met as described under Article 2 and Article 5. B. Medical necessity. A service shall be medically necessa…

A. Inpatient behavioral health services. The following inpatient services are covered subject to the limitations and exclusions in this Article and Article 2. 1. Covered inpatient behavioral health services include all behavioral health services, medical detoxification, accommoda…

A. Payment to ADHS/DBHS. The Administration shall make a monthly capitation payment to ADHS/DBHS based on the number of acute members at the beginning of each month. The Administration shall incorporate ADHS'/DBHS' administrative costs into the capitation payment. B.A. Claims sub…

In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Article have the following meanings unless the context explicitly requires another meaning: "Active treatment" means there is a current need for treatment of the CRS qualifying condition(s) or…

Beginning October 1, 2013, an AHCCCS member who needs active treatment for one or more of the qualifying medical condition(s) in R9-22-1303 shall be given a CRS Designation. An American Indian member can choose to receive CRS services through an American Indian Health Plan or a c…

The following lists identify those medical condition(s) that do qualify for CRS services as well as those that do not qualify for CRS services. The list of condition(s) that qualify for a CRS Designation is all inclusive. The list of condition(s) that do not qualify for a CRS Des…

A.To refer an individual for a CRS medical eligibility determination a person shall submit to the Administration the following information: 1. CRS application, 2. Documentation from a specialist who diagnosed the individual, stating the individual's diagnosis, 3. Diagnostic test …

A. Continued eligibility for CRS services shall be redetermined by verifying active treatment status of the CRS qualifying medical condition(s) as follows: 1. The Ccontractor is responsible for notifying the AHCCCS Administration of the date when a member with a CRS Designation i…

The Administration will cover medically necessary services as described within Article 2 unless otherwise specified in contract. Notes Ariz. Admin. Code § R9-22-1307 Adopted effective September 9, 1998 (Supp. 98-3). Amended by final rulemaking at 6 A.A.R. 3317, effective August 7…

A. Scope. This Article contains eligibility criteria to determine whether a household or individual is eligible for AHC-CCS medical coverage. Eligibility criteria described under Article 3 applies to this Article. B. Definitions. In addition to definitions contained in R9-22-101 …

The Administration or its designee shall determine eligibility under the provisions of this Article. The Administration or its designee shall not discriminate against an applicant or member because of race, color, creed, religion, ancestry, national origin, age, sex, or physical …

A. The Administration or its designee shall complete an eligibility determination under R9-22-306(A)(1) unless:1. The applicant is pregnant. The Administration or its designee shall complete an eligibility determination for a pregnant woman within 20 days after the application da…

A. Except as provided in R9-22-303 and subsections (B), (C) and (D), the effective date of eligibility is the first day of the month that the applicant files an application if the applicant is eligible that month, or the first day of the first eligible month following the applica…

A. Evaluation of income. In determining eligibility, the Administration or its designee shall evaluate the following types of income received by a person identified in subsection (B): 1. Earned income, including in-kind income, before any deductions. For purposes of this Section,…

A. In determining eligibility, if an individual would otherwise be ineligible under this Article due to excess income, the Administration or its designee shall subtract an amount equivalent to five percentage points of the Federal Poverty Level (FPL) from the household income. B.…

A. Projecting income. 1. Description. Projecting income is a method of determining the amount of income that a person will receive. 2. Calculation. The Administration or its designee shall project income by: a. Converting income to a monthly equivalent, b. Using unconverted incom…

A. Monthly income. If otherwise countable income is received monthly or in a lump sum, the Administration or its designee shall use the unconverted method for calculating monthly income.1. Lump sum means a nonrecurring payment that serves as a complete payment. 2. Lump sum paymen…

A. New income. 1. Description. New income is income received from a new source during the first calendar month that the income is received from the source. 2. Calculating monthly income.a. If a full month's income is received, the Administration or its designee shall use the appr…

A. Caretaker Relatives. An individual is eligible for AHCCCS medical coverage as a Caretaker Relative when the individual meets the following requirements: 1. Is a caretaker relative as defined in R9-22-1401. 2. The total countable income under R9-1420(B) does not exceed 106 perc…

A. Eligibility for 12-months postpartum coverage. Individuals who applied and were determined eligible while pregnant, including prior quarter months under R9-22-303(A), remain eligible through the last day of the month in which a 12-month postpartum period, beginning on the last…

A child born to a mother eligible for and receiving medical coverage under this Article, Article 15 of the Chapter, or 9 A.A.C. 28, is automatically eligible for AHCCCS medical coverage for a period not to exceed 12 months . Automatic eligibility begins on the child's date of bir…