Current through Register Vol. 30, No. 38, September 20, 2024
A.
General requirements. A provider shall enter into a provider agreement with the
Administration that meets the requirements of A.R.S. §
36-2904
and
42 CFR
431.107(b) as of October 1,
2012, which is incorporated by reference and on file with the Administration,
and available from the U.S. Government Printing Office, Mail Stop: IDCC, 732 N.
Capitol Street, NW, Washington, DC, 20401. This incorporation by reference
contains no future editions or amendments.
B. Timely submission of claims.
1. Under A.R.S. § 36-2904, the
Administration shall deem a paper claim to be submitted on the date that it is
received by the Administration. An electronic claim is deemed received by the
Administration when the claim enters the information processing system
designated by the Administration for electronic claims in a form that is
capable of being processed by the designated information processing system. The
Administration shall do one or more of the following for each claim it
receives:
a. Place a date stamp on the face
of the claim,
b. Assign a
system-generated claim reference number, or
c. Assign a system-generated date-specific
number.
2. Unless a
shorter time period is specified in contract, the Administration shall not pay
a claim for a covered service unless the claim is initially submitted within
one of the following time limits, whichever is later:
a. Six months from the date of service or for
an inpatient hospital claim, six months from the date of discharge;
or
b. Six months from the date of
eligibility posting.
3.
Unless a shorter time period is specified in contract, the Administration shall
not pay a clean claim for a covered service unless the claim is submitted
within one of the following time limits, whichever is later:
a. Twelve months from the date of service or
for an inpatient hospital claim, 12 months from the date of discharge;
or
b. Twelve months from the date
of eligibility posting.
4. Unless a shorter time period is specified
in contract, the Administration shall not pay a claim submitted by an HIS or
tribal facility for a covered service unless the claim is initially submitted
within 12 months from the date of service, date of discharge, or eligibility
posting, whichever is later.
C. Claims processing.
1. The Administration shall notify the
AHCCCS-registered provider with a remittance advice when a claim is processed
for payment.
2. The Administration
shall reimburse a hospital for inpatient hospital admissions and outpatient
hospital services rendered on or after March 1, 1993, as follows and in the
manner and at the rate described in A.R.S. §
36-2903.01:
a. If the hospital bill is paid within 30
days from the date of receipt, the claim is paid at 99 percent of the
rate.
b. If the hospital bill is
paid between 30 and 60 days from the date of receipt, the claim is paid at 100
percent of the rate.
c. If the
hospital bill is paid after 60 days from the date of receipt, the claim is paid
at 100 percent of the rate plus a fee of one percent per month for each month
or portion of a month following the 60th day of receipt of the bill until date
of payment.
3. A claim
is paid on the date indicated on the disbursement check.
4. A claim is denied as of the date of the
remittance advice.
5. The
Administration shall process a hospital claim under this Article.
D. Prior authorization.
1. An AHCCCS-registered provider shall:
a. Obtain prior authorization from the
Administration for non-emergency hospital admissions, covered services as
specified in Articles 2 and 12 of this Chapter, and for administrative days as
described in R9- 22-712.75,
b.
Notify the Administration of hospital admissions under Article 2 of this
Chapter, and
c. Make records
available for review by the Administration upon request.
2. The Administration may deny a claim if the
provider fails to comply with subsection (D)(1).
3. If the Administration issues prior
authorization for an inpatient hospital admission, a specific service, or level
of care but subsequent medical review indicates that the admission, the
service, or level of care was not medically appropriate, the Administration
shall adjust the claim payment.
E. Review of claims and coverage for hospital
supplies.
1. The Administration may conduct
prepayment and postpayment review of any claims, including but not limited to
hospital claims.
2. Personal care
items supplied by a hospital, including but not limited to the following, are
not covered services:
a. Patient care
kit,
b. Toothbrush,
c. Toothpaste,
d. Petroleum jelly,
e. Deodorant,
f. Septi soap,
g. Razor or disposable razor,
h. Shaving cream,
i. Slippers,
j. Mouthwash,
k. Shampoo,
l. Powder,
m. Lotion,
n. Comb, and
o. Patient gown.
3. The following hospital supplies and
equipment, if medically necessary and used by the member, are covered services:
a. Arm board,
b. Diaper,
c. Underpad,
d. Special mattress and special
bed,
e. Gloves,
f. Wrist restraint,
g. Limb holder,
h. Disposable item used instead of a durable
item,
i. Universal
precaution,
j. Stat charge,
and
k. Portable charge.
4. The Administration shall
determine in a hospital claims review whether services rendered were:
a. Covered services as defined in Article
2;
b. Medically
necessary;
c. Provided in the most
appropriate, cost-effective, and least restrictive setting; and
d. For claims with dates of admission on and
after March 1, 1993, substantiated by the minimum documentation specified in
A.R.S. §
36-2903.01.
5. If the Administration
adjudicates a claim, a person may file a claim dispute challenging the
adjudication under 9 A.A.C. 34.
F. Overpayment for AHCCCS services.
1. An AHCCCS-registered provider shall notify
the Administration when the provider discovers the Administration made an
overpayment.
2. The Administration
shall recoup an overpayment from a future claim cycle if an AHCCCS-registered
provider fails to return the overpaid amount to the Administration.
3. The Administration shall document any
recoupment of an overpayment on a remittance advice.
4. An AHCCCS-registered provider may file a
claim dispute under 9 A.A.C. 34 if the AHCCCS-registered provider disagrees
with a recoupment action.
G. For services subject to limitations or
exclusions such as the number of hours, days, or visits covered as described in
Article 2 of this Chapter, once the limit is reached the Administration will
not reimburse the services.
H.
Prior quarter reimbursement. A provider shall:
1. Bill the Administration for services
provided during a prior quarter eligibility period upon verification of
eligibility or upon notification from a member of AHCCCS eligibility.
2. Reimburse a member when payment has been
received from the Administration for covered services during a prior quarter
eligibility period. All funds paid by the member shall be reimbursed.
3. Accept payment received by the
Administration as payment in full.
I. Payment for in-state inpatient hospital
services for claims with discharge dates on or before September 30, 2014. The
Administration shall reimburse an in-state provider of inpatient hospital
services rendered with a discharge date on or before September 30, 2014, the
prospective tiered-per-diem amount in A.R.S. §
36-2903.01
and this Article.
J. Payment for
out-of-state inpatient hospital services for claims with discharge dates on or
before September 30, 2014. The Administration shall reimburse an out-of-state
provider of inpatient hospital services rendered with a discharge date on or
before September 30, 2014, for covered inpatient services by multiplying
covered charges by the most recent statewide urban cost-to-charge ratio as
determined in
R9-22-712.01(6)(b).
K. Payment for inpatient hospital services
for claims with discharge dates on and after October 1, 2014 regardless of
admission date. The Administration shall reimburse an in-state or out-of-state
provider of inpatient hospital services rendered with a discharge date on or
after October 1, 2014, the DRG rate established by the
Administration.
L. The
Administration may enter into contracts for the provisions of transplant
services.
