Current through Register Vol. 30, No. 38, September 20, 2024
AFor purposes
of this subsection, the term "member" includes the member's financially
responsible representative as described under A.R.S. §
36-2903.01.
BRegistered providers must accept payment
from the Administration or a contractor as payment in full.
CExcept as provided in subsection (D) a
registered provider shall not request or collect payment from, refer to a
collection agency, or report to a credit reporting agency an eligible person or
a person claiming to be an eligible person.
DAn AHCCCS registered provider may charge,
submit a claim to, or demand or collect payment from a member:
1 To collect the copayment described in
R9-22-711;
2 To recover from a member that portion of a
payment made by a third party to the member for an AHCCCS covered service if
the member has not transferred the payment to the Administration or the
contractor as required by the statutory assignment of rights to
AHCCCS;
3 To obtain payment from a
member for medical expenses incurred during a period when the member
intentionally withheld information or intentionally provided inaccurate
information pertaining to the member's AHCCCS eligibility or enrollment that
caused payment to the provider to be reduced or denied;
4 For a service that is excluded by statute
or rule, or provided in an amount that exceeds a limitation in statute or rule,
if the member signs a document in advance of receiving the service stating that
the member understands the service is excluded or is subject to a limit and
that the member will be financially responsible for payment for the excluded
service or for the services in excess of the limit;
5 When the contractor or the Administration
has denied authorization for a service if the member signs a document in
advance of receiving the service stating that the member understands that
authorization has been denied and that the member will be financially
responsible for payment for the service;
6 For services requested for a member
enrolled with a contractor, and rendered by a noncontracting provider under
circumstances where the member's contractor is not responsible for payment of
"out of network" services under
R9-22-705(A),
if the member signs a document in advance of receiving the service stating that
the member understands the provider is out of network, that the member's
contractor is not responsible for payment, and that the member will be
financially responsible for payment for the excluded service;
7 For services rendered to a person eligible
for the FESP if the provider submits a claim to the Administration in the
reasonable belief that the service is for treatment of an emergency medical
condition and the Administration denies the claim because the service does not
meet the criteria of
R9-22-217;
or
8 If the provider has received
verification from the Administration that the person was not an eligible person
on the date of service.
EThe signature requirement of subsections
(D)(4), (D)(5), and (D)(6) do not apply if:
1
The member is unable or incompetent to sign such a document, or
2 When services are rendered for the purpose
of treating an emergency medical condition as defined in
R9-22-217
and a delay in providing treatment to obtain a signature would have a
significant adverse affect on the member's health.
FExcept as provided for in this Section,
registered providers shall not bill a member when the provider could have
received reimbursement from the Administration or a contractor but for the
provider's failure to file a claim in accordance with the requirements of
AHCCCS statutes, rules, the provider agreement, or contract, such as, but not
limited to, requirements to request and obtain prior authorization, timely
filing, and clean claim requirements.
