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 R9-22-1008 - Notification Information for Liens
Universal Citation: AZ Admin Code R 9-22-1008
Current through Register Vol. 30, No. 38, September 20, 2024
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 noncontracting provider;
3. Name of member;
4. Member's Social Security Number or AHCCCS
identification number;
5. Address
of member;
6. Date of member's
admission or date service is provided;
7. Amount estimated to be due for care of
member;
8. Date of discharge, if
member has been discharged;
9. Name
of county in which injuries were sustained; and
10. Name and address of all persons, firms,
and corporations and their insurance carriers identified by the member or legal
representative as being liable for damages.
B. If the date of discharge is not known at the time the information in subsection (A) is provided, a party identified in subsection (A) shall notify AHCCCS of the date of discharge within 30 days after the member has been discharged.
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