Section R9-22-1003. Cost Avoidance

A.      The Administration’s reimbursement responsibility.

1.        The Administration shall pay no more than the difference between the Capped Fee-For-Service schedule and the amount of the third-party liability, unless Medicare is the third-party.

2.        If Medicare is the third-party that is liable, the Adminis- tration shall pay the Medicare copayment, coinsurance, and deductible regardless of the Capped Fee-For-Service Schedule, as described under 9 A.A.C. 29, Article 3.

B.       The Contractor’s reimbursement responsibility.

1.        If the contract between the contractor and the provider does not state otherwise, a contractor shall pay no more than the difference between the contracted rate and the amount of the third-party liability.

2.        If the provider does not have a contract with the contrac- tor, a contractor shall pay no more than the difference between the Capped Fee-For-Service rate and the amount of the third-party liability.

C.      The following parties shall take reasonable measures to iden- tify potentially legally liable first- or third-party sources:

1.        AHCCCS, the Administration, or a contractor;

2.        A provider;

3.        A noncontracting provider; and

4.        A member.

D.      Except as specified under subsection (E), the Administration or a contractor shall cost avoid a claim for AHCCCS covered services under Article 2 if the Administration or a contractor has established the probable existence of a liable party at the time the claim is filed. Establishing liability takes place when the Administration or the contractor receives confirmation that another party is legally responsible for payment of a health care service under Article 2.

E.       The Administration or contractor shall pay the full amount of the claim according to the Capped-Fee-For-Service Schedule or the contracted rate as described under subsection (B), and then seek reimbursement from any liable parties if the claim is for:

1.        Prenatal care for pregnant women,

2.        Preventive pediatric services, including E.P.S.D.T. and administration of vaccines to children under the Vaccines for Children (VFC) program; or

3.        Services covered by third-party liability that is derived from an absent parent whose obligation to pay support is being enforced by the Division of Child Support Enforce- ment.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 1146, effective May 1, 2004 (Supp. 04-1). Amended by final rulemaking at 10 A.A.R. 3012, effective September

11, 2004 (Supp. 04-3). Amended by final rulemaking at

15 A.A.R. 179, effective March 7, 2009 (Supp. 09-1). Amended by final rulemaking at 21 A.A.R. 1237, effec- tive July 7, 2015 (Supp. 15-3).