Current through Register Vol. 30, No. 38, September 20, 2024
A.General
requirements. A contractor shall contract with providers to provide covered
services to members enrolled with the contractor. The contractor is responsible
for reimbursing providers and coordinating care for services provided to a
member. Except as provided in subsection (A)(2), a contractor is not required
to reimburse a noncontracting provider for services rendered to a member
enrolled with the contractor.
1. Providers. 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 March 6,
1992, 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.
2. A contractor shall reimburse a
noncontracting provider for services rendered to a member enrolled with the
contractor as specified in this Article if:
a.
The contractor referred the member to the provider or authorized the provider
to render the services and the claim is otherwise payable under this Chapter,
or
b. The service is emergent under
Article 2 of this Chapter.
B.Timely submission of claims.
1. Under A.R.S. §
36-2904,
a contractor shall deem a paper or electronic claim as submitted on the date
that the claim is received by the contractor. The contractor shall do one or
more of the following for each claim the contractor 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 subcontract, a contractor 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 subcontract, a contractor 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.
C.Date of claim.
1. A contractor's date of receipt of an
inpatient or an outpatient hospital claim is the date the claim is received by
the contractor as indicated by the date stamp on the claim, the
system-generated claim reference number, or the system-generated date-specific
number assigned by the contractor.
2. A hospital claim is considered paid on the
date indicated on the disbursement check.
3. A denied hospital claim is considered
adjudicated on the date of the claim's denial.
4. For a claim that is pending for additional
supporting documentation specified in A.R.S. §
36-2903.01
or
36-2904,
the contractor shall assign a new date of receipt upon receipt of the
additional documentation.
5. For a
claim that is pending for documentation other than the minimum required
documentation specified in either A.R.S. §
36-2903.01
or
36-2904,
the contractor shall not assign a new date of receipt.
6. A contractor and a hospital may, through a
contract approved as specified in
R9-22-715,
adopt a method for identifying, tracking, and adjudicating a claim that is
different from the method described in this subsection.
D.Payment for in-state inpatient hospital
services for claims with discharge dates on or before September 30, 2014. A
contractor shall reimburse an in-state provider of inpatient hospital services
rendered with a discharge date on or before September 30, 2014 , at either a
rate specified by subcontract or, in absence of the subcontract, the
prospective tiered-per-diem amount in A.R.S. §
36-2903.01
and this Article. Subcontract rates, terms, and conditions are subject to
review and approval or disapproval under A.R.S. § 36-2904 and
R9-22-715.
This subsection does not apply to an urban contractor as specified in
R9-22-718
and A.R.S. §
36-2905.01.
E.Payment for Inpatient out-of-state hospital
payments for claims with discharge dates on or before September 30, 2014. In
the absence of a contract with an out-of-state hospital that specifies payment
rates, a contractor shall reimburse out-of-state hospitals 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).
F.Payment for inpatient hospital services for
claims with discharge dates on and after October 1, 2014 regardless of
admission date. Subject to
R9-22-718
and A.R.S. §
36-2905.01
regarding urban hospitals, a contractor shall reimburse an instate or
out-of-state provider of inpatient hospital services, at either a rate
specified by subcontract or, in absence of a subcontract, the DRG rate
established by the Administration and this Article. Subcontract rates, terms,
and conditions are subject to review and approval or disapproval under A.R.S.
§ 36-2904 and
R9-22-715.
G.Payment for in-state outpatient hospital services.
A contractor shall
reimburse an in-state provider of outpatient hospital services rendered on or
after July 1, 2005, at either a rate specified by a subcontract or, in absence
of a subcontract, as provided under
R9-22-712.10,
A.R.S. §
36-2903.01
and other sections of this Article. The terms of the subcontract are subject to
review and approval or disapproval under A.R.S. § 36-2904 and
R9-22-715.
H.Outpatient out-of-state hospital
payments. In the absence of a contract with an out-of-state hospital that
specifies payment rates, a contractor shall reimburse out-of-state hospitals
for covered outpatient services by applying the methodology described in
R9-22-712.10
through R9-22-712.50. If the outpatient procedure is not assigned a fee
schedule amount, the contractor shall pay the claim by multiplying the covered
charges for the outpatient services by the statewide outpatient cost-to-charge
ratio.
I.Payment for observation days. A contractor shall
reimburse a provider and a noncontracting provider for the provision of
observation days at either a rate specified by subcontract or, in the absence
of a subcontract, as prescribed under R9-22-712,
R9-22-712.10,
and R9-22-712.45.
J.Review of claims and coverage for hospital supplies.
1. A contractor may conduct a review of any
claims submitted and recoup any payments made in error.
2. A hospital shall obtain prior
authorization from the appropriate contractor for nonemergency admissions. When
issuing prior authorization, a contractor shall consider the medical necessity
of the service, and the availability and cost effectiveness of an alternative
treatment. Failure to obtain prior authorization when required is cause for
nonpayment or denial of a claim. A contractor shall not require prior
authorization for medically necessary services provided during any prior period
for which the contractor is responsible. If a contractor and a hospital agree
to a subcontract, the parties shall abide by the terms of the subcontract
regarding utilization control activities. A hospital shall cooperate with a
contractor's reasonable activities necessary to perform concurrent review and
shall make the hospital's medical records pertaining to a member enrolled with
a contractor available for review.
3. Regardless of prior authorization or
concurrent review activities, a contractor may make prepayment or post-payment
review of all claims, including but not limited to a hospital claim. A
contractor may recoup an erroneously paid claim.
If prior authorization was given 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 contractor shall adjust the claim payment.
4. A contractor and a hospital may enter into
a subcontract that includes hospital claims review criteria and procedures if
the subcontract meets the requirements of
R9-22-715.
5. 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,
h. Shaving cream,
i. Slippers,
j. Mouthwash,
k. Disposable razor,
l. Shampoo,
m. Powder,
n. Lotion,
o. Comb, and
p. Patient gown.
6. 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.
7. The contractor shall determine
in a hospital claims review whether services rendered were:
a. Covered services as defined in
R9-22-201;
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. §
36-2904.
8. If a contractor adjudicates a
claim or recoups payment for a claim, a person may file a claim dispute
challenging the adjudication or recoupment as described under 9 A.A.C.
34.
K.Non-hospital claims. A contractor shall pay claims
for non-hospital services in accordance with contract, or in the absence of a
contract, at a rate not less than the Administration's capped fee-for-service
schedule or at a lower rate if negotiated between the two parties.
L.Payments to hospitals. A contractor shall pay for
inpatient hospital admissions and outpatient hospital services rendered on or
after March 1, 1993, as follows and as described in A.R.S. §
36-2904:
1. If the hospital bill is paid within 30
days from the date of receipt, the claim is paid at 99 percent of the
rate.
2. 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.
3. 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 1 percent penalty of the rate for each month
or portion of the month following the 60th day of receipt of the bill until
date of payment.
M.Interest payment. In
addition to the requirements in subsection (L), a contractor shall pay interest
for late claims as defined by contract.
N.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.
