Current through Register Vol. 30, No. 38, September 20, 2024
A. Provider
agreement. The Administration or a contractor shall not reimburse a covered
service provided to a member unless the provider has signed a provider
agreement with the Administration that establishes the terms and conditions of
participation and payment under A.R.S. §
36-2904.
B. Provider reimbursement. The Administration
or a contractor shall reimburse a provider for a service furnished to a member
only if:
1. The provider personally furnishes
the service to a specific member. For purposes of this Section, services
personally furnished by a provider include:
a.
Services provided by medical residents or dental students in a teaching
environment; or
b. Services
provided by a licensed or certified assistant under the general supervision of
a licensed practitioner in accordance with 4 A.A.C. 24, 9 A.A.C. 16, 4 A.A.C.
43, or 4 A.A.C. 45;
2.
The provider verifies that individuals who have provided services described in
subsection (B)(1) have not been placed on the List of Excluded
Individuals/Entities (LEIE) maintained by the United States Department of
Health and Human Services Office of the Inspector General (OIG), located at
OIG's web site;
3. The service
contributes directly to the diagnosis or treatment of the member; and
4. The service ordinarily requires
performance by the type of provider seeking reimbursement.
C. The Administration or a contractor may
make a payment for covered services only:
1.
To the provider;
2. To anyone
specified in a reassignment from the provider to a government agency or
reassignment by a court order;
3.
To a business agent, if the agent's compensation for the service is:
a. Related to the cost of processing the
billing;
b. Not related on a
percentage or other basis to the amount that is billed or collected;
and
c. Not dependent upon
collection of the payment;
4. To the employer of the provider, if the
provider is required as a condition of employment to turn over the provider's
fees to the employer;
5. To the
inpatient facility in which the service is provided, if the provider has a
contract under which the inpatient facility submits the claim; or
6. To a foundation, plan, or similar
organization operating an organized health care delivery system, if the
provider has a contract under which the foundation, plan or similar
organization submits the claim.
D. The Administration or a contractor shall
not make a payment to or through a factor, either directly or by power of
attorney, for a covered service furnished to a member by a provider.
E. Reimbursement for a pathology service.
Unless otherwise specified in a contract, the Administration or a contractor
shall reimburse a pathologist for a pathology service furnished to a member
only if the other requirements in this Section are met and the service is:
1. A surgical pathology service;
2. A specific cytopathology, hematology, or
blood banking pathology service that requires performance by a physician and is
listed in the capped fee-for-service schedule;
3. A clinical consultation service that:
a. Is requested by the member's attending
physician or primary care physician,
b. Is related to a test result that is
outside the clinically significant normal or expected range in view of the
condition of the member,
c. Results
in a written narrative report included in the member's medical
record,
d. Requires the exercise of
medical judgment by the consultant pathologist, and
e. Is listed in the capped fee-for-service
schedule; or
4. A
clinical laboratory interpretative service that:
a. Is requested by the member's attending
physician or primary care physician,
b. Results in a written narrative report
included in the member's medical record,
c. Requires the exercise of medical judgment
by the consultant pathologist, and
d. Is listed in the capped fee-for-service
schedule.
The following Section was amended under an exemption from
the provisions of the Administrative Procedure Act which means that this rule
was not reviewed by the Governor's Regulatory Review Council; the agency did
not submit notice of proposed rulemaking to the Secretary of State for
publication in the Arizona Administrative Register; the agency was not required
to hold public hearings on the rules; and the Attorney General did not certify
this rule. This Section was subsequently amended through the regular rulemaking
process.
