Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION
Article 10 - FIRST- AND THIRD-PARTY LIABILITY AND RECOVERIES
Section R9-22-1003 - Cost Avoidance

Universal Citation: AZ Admin Code R 9-22-1003

Current through Register Vol. 30, No. 38, September 20, 2024

A. The Administration's reimbursement responsibility.

1. The Administration shall pay no more than the difference between the Capped Fee-For-Service schedule and the amount of the third-party liability, unless Medicare is the third-party.

2. If Medicare is the third-party that is liable, the Administration shall pay the Medicare copayment. coinsurance, and deductible regardless of the Capped Fee-For-Service Schedule, as described under 9 AA.C. 29. Article 3.

B. The Contractor's reimbursement responsibility.

1. If the contract between the contractor and the provider does not state otherwise, a contractor shall pay no more than the difference between the contracted rate and the amount of the third-party liability.

2. If the provider does not have a contract with the contractor, a contractor shall pay no more than the difference between the Capped Fee-For-Service rate and the amount of the third-party liability.

C. The following parties shall take reasonable measures to identify potentially legally liable first-or third-party sources:

1. AHCCCS, the Administration, or a contractor;

2. A provider;

3. A noncontracting provider; and

4. A member.

D. Except as specified under subsection (E). the Administration or a contractor shall cost avoid a claim for AHCCCS covered services under Article 2 if the Administration or a contractor has established the probable existence of a liable party at the time the claim is filed. Establishing liability takes place when the Administration or the contractor receives confirmation that another party is legally responsible for payment of a health care service under Article 2.

E. The Administration or contractor shall pay the full amount of the claim according to the Capped-Fee-For-Service Schedule or the contracted rate as described under subsection (B). and then seek reimbursement from any liable parties if the claim is for:

1. Prenatal care for pregnant women.

2. Preventive pediatric services, including E.P.S.D.T. and administration of vaccines to children under the Vaccines for Children (VFC) program; or

3. Services covered by third-party liability that is derived from an absent parent whose obligation to pay support is being enforced by the Division of Child Support Enforcement.

Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.