Current through Register Vol. 30, No. 38, September 20, 2024
A. For the
purposes of this Article, the following definitions apply:
1. "Authorization" means written, verbal, or
electronic 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
physical and behavioral health services as specified in Articles 2 and
12.
7. The Administration or a
contractor shall provide services under the Section 1115 Waiver as defined in
A.R.S. §
36-2901.
8. An AHCCCS registered provider shall
provide covered services within the provider's scope of practice.
9. 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.
10. Medical or behavioral health
services are not covered services if provided to:
a. An inmate of a public institution;
or
b. A person who is in residence
at an institution for the treatment of tuberculosis.
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 provide prior authorization for
services unless the provider submits documentation of the medical necessity of
the treatment along with the prior authorization request.
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 or during the prior quarter 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.
I. The
Administration shall determine the circumstances under which a FFS member may
receive services, other than emergency services, from service providers outside
the member's county of residence or outside the state. Criteria considered by
the Administration in making this determination shall include availability and
accessibility of appropriate care and cost effectiveness.
J. The restrictions, limitations, and
exclusions in this Article do not apply to a contractor electing to provide
non-covered services.
1. The Administration
shall not consider the costs of providing a noncovered service to a member in
the development or negotiation of a capitation rate.
2. A contractor shall pay for noncovered
services from administrative revenue or other contractor funds that are
unrelated to the provision of services under this Chapter.
3. If a member requests a service that is not
covered or is not authorized by a contractor, or the Administration, an
AHCCCS-registered service provider may provide the service according to
R9-22-702.
K. Subject to
CMS approval, the restrictions, limitations, and exclusions specified in the
following subsections do not apply to American Indians receiving services
through IHS or a tribal health program operating under P.L. 93-638 when those
services are eligible for 100 percent federal financial participation:
1. R9-22-205(A)(8),
2.
R9-22-206,
3.
R9-22-207,
4.
R9-22-212(C),
5.
R9-22-212(D),
6.
R9-22-212(E)(8),
7.
R9-22-215(C)
(5), (C)(6), and
8.
R9-22-215(C)(4).
