Current through Register Vol. 31, No. 12, March 21, 2025
A. The
Administration shall administer the Children's Health Insurance Program under
A.R.S. §
36-2982.
B. Scope of services for American Indian
fee-for-service members is under Article 16 of this Chapter.
C. A contractor or RBHA shall provide
behavioral health services under Articles 12 and 16.
D. In addition to other requirements and
limitations specified in this Chapter, the following general requirements
apply:
1. Only medically necessary, cost
effective, and federally- reimbursable and state-reimbursable services are
covered services.
2. The
Administration or a contractor may waive the covered services referral
requirements of this Article.
3.
Except as authorized by a contractor, a primary care provider, practitioner, or
dentist shall provide or direct the member's covered services. Delegation of
the provision of care to a practitioner does not diminish the role or
responsibility of the primary care provider.
4. A contractor shall offer a female member
direct access to preventive and routine services from gynecology providers
within the contractor's network without a referral from a primary care
provider.
5. A member may receive
behavioral health services as specified in 9 A.A.C. 22, Articles 2 and
12.
6. A member may receive
treatment that is considered the standard of care, or that is approved by the
AHCCCS Chief Medical Officer after appropriate input from providers who are
considered experts in the field by the professional medical
community.
7. An AHCCCS registered
provider shall provide covered services within the provider's scope of
practice.
8. In addition to the
specific exclusions and limitations otherwise specified under this Article, the
following are not covered:
a. A service that
is determined by the AHCCCS Chief Medical Officer to be experimental or
provided primarily for the purpose of research;
b. Services or items furnished gratuitously;
and
c. Personal care items, except
as specified in R9-31-212.
9. Medical or behavioral health services are
not covered if provided to:
a. An inmate of a
public institution;
b. A person who
is a resident of an institution for the treatment of tuberculosis; or
c. A person who is in an IMD at the time of
application, unless provided under Article 12 of this Chapter.
E. The Administration
or a contractor may deny payment if a provider fails to obtain prior
authorization as specified in this Article and Article 7 of this Chapter for
non-emergency services. The Administration or a contractor shall not provide
prior authorization for services unless the provider submits documentation of
the medical necessity of the treatment along with the prior authorization
request.
F. Prior authorization is
not required for services necessary to evaluate and stabilize an emergency
medical condition.
G. Under A.R.S.
§
36-2989,
a member shall receive covered services outside of the GSA only if one of the
following applies:
1. A member is referred by
a primary care provider for medical specialty care out of the contractor's
area. If the member is referred outside of the GSA to receive an authorized
medically necessary service, a contractor shall also provide all other
medically necessary covered services for the member;
2. There is a net savings in service delivery
costs as a result of going outside the GSA that does not require undue travel
time or hardship for a member or the member's family; or
3. The contractor authorizes placement in a
nursing facility located outside of the GSA;
H. If a member is traveling or temporarily
residing outside of the GSA, covered services are restricted to emergency care
services, unless otherwise authorized by the contractor.
I. A contractor shall provide at a minimum,
directly or through subcontracts, the covered services specified in this
Chapter and in contract.
J. The
restrictions, limitations, and exclusions in this Article do not apply to a
contractor if the contractor elects to provide noncovered services.
1. The Administration shall not consider the
costs of providing a noncovered service to a member in the development or
negotiation of a capitation rate.
2. A contractor shall pay for noncovered
services from administrative revenue or other contractor funds that are
unrelated to the provision of services under this Chapter.
