Current through Register Vol. 30, No. 38, September 20, 2024
A.A primary care
provider, attending physician, or practitioner shall provide primary care
provider services within the provider's scope of practice under A.R.S. Title
32. A member may receive primary care provider services in an inpatient or
outpatient setting including at a minimum:
1.
Periodic health examination and assessment;
2. Evaluation and diagnostic
workup;
3. Medically necessary
treatment;
4. Prescriptions for
medication and medically necessary supplies and equipment;
5. Referral to a specialist or other health
care professional if medically necessary;
6. Patient education;
7. Home visits if medically necessary;
and
8. Preventive health services,
such as, well visits, immunizations, colo-noscopies, mammograms and PAP
smears.
B.The following
limitations and exclusions apply to attending physician and practitioner
services and primary care provider services:
1. Specialty care and other services provided
to a member upon referral from a primary care provider, or to a member upon
referral from the attending physician or practitioner are limited to the
service or condition for which the referral is made, or for which authorization
is given by the Administration or a contractor.
2. A member's physical examination is not
covered if the sole purpose is to obtain documentation for one or more of the
following:
a. Qualification for
insurance,
b. Pre-employment
physical evaluation,
c.
Qualification for sports or physical exercise activities,
d. Pilot's examination for the Federal
Aviation Administration,
e.
Disability certification to establish any kind of periodic payments,
f. Evaluation to establish third-party
liabilities, or
g. Physical ability
to perform functions that have no relationship to primary objectives of the
services listed in subsection (A).
3. Orthognathic surgery is covered only for a
member who is less than 21 years of age;
4. The following services are excluded from
AHCCCS coverage:
a. Infertility services,
reversal of surgically induced infertility (sterilization), and gender
reassignment surgeries;
b.
Pregnancy termination counseling services;
c. Pregnancy terminations, unless required by
state or federal law.
d. Services
or items furnished solely for cosmetic purposes; and
e. Hysterectomies unless determined medically
necessary.
The following Section was renumbered and a new Section
adopted under an exemption from the provisions of the Administrative Procedure
Act which means that this rule was not published as a proposed rule in the
Arizona Administrative Register; the rule was not reviewed or approved by the
Governor's Regulatory Review Council; and the agency was not required to hold
public hearings on the rule. This Section was subsequently amended through the
regular rulemaking process.
