Current through Register Vol. 30, No. 38, September 20, 2024
A.Inpatient and
outpatient discounts and penalties. If a claim is pended for additional
documentation required under A.R.S. §
36-2903.01(G)(4),
the period during which the claim is pended is not used in the calculation of
the quick-pay discounts and slow-pay penalties under A.R.S. §
36-2903.01(G)(5).
B.Inpatient and outpatient in-state or
out-of-state hospital payments.
1. Payment
for inpatient out-of-state hospital services 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, AHCCCS 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)(d).
2. Payment for inpatient in-state hospital
services for claims with discharge dates on or before September 30, 2014.
AHCCCS shall reimburse an in-state provider of inpatient hospital services
rendered with a discharge date on or before September 30, 2014, at the
prospective tiered-per-diem amount in A.R.S. §
36-2903.01
and this Article.
3. Payment for
inpatient in-state or out-of-state 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 in-state or
out-of-state provider of inpatient hospital services, at either a rate
specified by subcontract or, in the 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.
4. Outpatient out-of-state hospital payments.
In the absence of a contract with an out-of-state hospital that specifies
payment rates, AHCCCS shall reimburse an out-of-state hospital 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
Administration shall pay the claim by multiplying the covered charges for the
outpatient services by the statewide outpatient cost-to-charge ratio.
5. Outpatient in-state hospital payments. 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.
C.Access to records.
Subcontracting and noncontracting providers of outpatient or inpatient hospital
services shall allow the Administration access to medical records regarding
eligible persons and shall in all other ways fully cooperate with the
Administration or the Administration's designated representative in performance
of the Administration's utilization control activities. The Administration
shall deny a claim for failure to cooperate.
D.Prior authorization. The Administration or
contractor may deny a claim if a provider fails to obtain prior authorization
as required under
R9-22-210.
E.Review of claims. Regardless of prior
authorization or concurrent review activities, the Administration may subject
all hospital claims, including outliers, to prepayment medical review or
post-payment review, or both. The Administration shall conduct post-payment
reviews consistent with A.R.S. §
36-2903.01
and may recoup erroneously paid claims.
F.Claim receipt.
1. The Administration's date of receipt of
inpatient or outpatient hospital claims is the date the claim is received by
the Administration as indicated by the date stamp on the claim and the
system-generated claim reference number or system-generated date-specific
number.
2. Hospital claims are
considered paid on the date indicated on disbursement checks.
3. A denied claim is considered adjudicated
on the date the claim is denied.
4.
Claims that are denied and are resubmitted are assigned new receipt
dates.
5. For a claim that is
pending for additional supporting documentation specified in A.R.S. §
36-2903.01
or
36-2904,
the Administration shall assign a new date of receipt upon receipt of the
additional documentation.
6. 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 Administration shall not assign a new date of receipt.
G.Outpatient hospital reimbursement. The
Administration shall pay for covered outpatient hospital services provided to
eligible persons with dates of service from March 1, 1993 through June 30,
2005, at the AHCCCS outpatient hospital cost-to-charge ratio, multiplied by the
amount of the covered charges.
1. Computation
of outpatient hospital reimbursement. The Administration shall compute the
cost-to-charge ratio on a hospital-specific basis by determining the covered
charges and costs associated with treating eligible persons in an outpatient
setting at each hospital. Outpatient operating and capital costs are included
in the computation but outpatient medical education costs that are included in
the inpatient medical education component are excluded. To calculate the
outpatient hospital cost-to-charge ratio annually for each hospital, the
Administration shall use each hospital's Medicare Cost Reports and a database
consisting of outpatient hospital claims paid and encounters processed by the
Administration for each hospital, subjecting both to the data requirements
specified in
R9-22-712.01.
The Administration shall use the following methodology to establish the
outpatient hospital cost-to-charge ratios:
a.
Cost-to-charge ratios. The Administration shall calculate the costs of the
claims and encounters for outpatient hospital services by multiplying the
ancillary line item cost-to-charge ratios by the covered charges for
corresponding revenue codes on the claims and encounters. Each hospital shall
provide the Administration with information on how the revenue codes used by
the hospital to categorize charges on claims and encounters correspond to the
ancillary line items on the hospital's Medicare Cost Report. The Administration
shall then compute the overall outpatient hospital cost-to-charge ratio for
each hospital by taking the average of the ancillary line items cost-to-charge
ratios for each revenue code weighted by the covered charges.
b. Cost-to-charge limit. To comply with
42
CFR 447.325, the Administration may limit
cost-to-charge ratios to 1.00 for each ancillary line item from the Medicare
Cost Report. The Administration shall remove ancillary line items that are
non-covered or not applicable to outpatient hospital services from the Medicare
Cost Report data for purposes of computing the overall outpatient hospital
cost-to-charge ratio.
2.
New hospitals. The Administration shall reimburse new hospitals at the weighted
statewide average outpatient hospital cost-to-charge ratio multiplied by
covered charges. The Administration shall continue to use the statewide average
outpatient hospital cost-to-charge ratio for a new hospital until the
Administration rebases the outpatient hospital cost-to-charge ratios and the
new hospital has a Medicare Cost Report for the fiscal year being used in the
rebasing.
3. Specialty outpatient
services. The Administration may negotiate, at any time, reimbursement rates
for outpatient hospital services in a specialty facility.
4. Reimbursement requirements. To receive
payment from the Administration, a hospital shall submit claims that are
legible, accurate, error free, and have a covered charge greater than zero. The
Administration shall not reimburse hospitals for emergency room treatment,
observation hours or days, or other outpatient hospital services performed on
an outpatient basis, if the eligible person is admitted as an inpatient to the
same hospital directly from the emergency room, observation area, or other
outpatient department. Services provided in the emergency room, observation
area, and other outpatient hospital services provided before the hospital
admission are included in the tiered per diem payment.
5. Rebasing. The Administration shall rebase
the outpatient hospital cost-to-charge ratios at least every four years but no
more than once a year using updated Medicare Cost Reports and claim and
encounter data.
6. If a hospital
files an increase in its charge master for an existing outpatient service
provided on or after July 1, 2004, and on or before June 30, 2005, which
represents an aggregate increase in charges of more than 4.7%, the
Administration shall adjust the hospital-specific cost-to-charge ratio as
calculated under subsection (G)(1) through (5) by applying the following
formula:
CCR*[1.047/(1+% increase)]
Where "CCR" means the hospital-specific cost-to-charge ratio
as calculated under subsection (G)(1) through (5) and "% increase" means the
aggregate percentage increase in charges for outpatient services shown on the
hospital charge master.
"Charge master" means the schedule of rates and charges as
described under A.R.S. §
36-436
and the rules that relate to those rates and charges that are filed with the
Director of the Arizona Department of Health Services.
