Section R9-22-205. Attending Physician, Practitioner, and Primary Care Provider Services

A.      A primary care provider, attending physician, or practitioner shall provide primary care provider services within the pro- vider’s scope of practice under A.R.S. Title 32. A member may receive primary care provider services in an inpatient or outpatient setting including at a minimum:

1.        Periodic health examination and assessment;

2.        Evaluation and diagnostic workup;

3.        Medically necessary treatment;

4.        Prescriptions for medication and medically necessary supplies and equipment;

5.        Referral to a specialist or other health care professional if medically necessary;

6.        Patient education;

7.        Home visits if medically necessary; and

8.        Preventive health services, such as, well visits, immuni- zations, colonoscopies, mammograms and PAP smears.

B.       The following limitations and exclusions apply to attending physician and practitioner services and primary care provider services:

1.        Specialty care and other services provided to a member upon referral from a primary care provider, or to a mem- ber upon referral from the attending physician or practi- tioner are limited to the service or condition for which the referral is made, or for which authorization is given by the Administration or a contractor.

2.        A member’s physical examination is not covered if the sole purpose is to obtain documentation for one or more of the following:

a.         Qualification for insurance,

b.        Pre-employment physical evaluation,

c.         Qualification for sports or physical exercise activi- ties,

d.        Pilot’s examination for the Federal Aviation Admin- istration,

e.         Disability certification to establish any kind of peri- odic payments,

f.         Evaluation to establish third-party liabilities, or

g.        Physical ability to perform functions that have no relationship to primary objectives of the services listed in subsection (A).

3.        Orthognathic surgery is covered only for a member who is less than 21 years of age;

4.        The following services are excluded from AHCCCS cov- erage:

a.         Infertility services, reversal of  surgically induced infertility (sterilization), and gender reassignment surgeries;

b.        Pregnancy termination counseling services;

c.         Pregnancy terminations, unless required by state or federal law.

d.        Services or items furnished solely for cosmetic pur- poses; and

Arizona Health Care Cost Containment System - Administration

e.         Hysterectomies unless determined medically neces- sary.

Historical Note

Adopted as an emergency effective May 20, 1982 pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-205 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective Octo-

ber 1, 1985 (Supp. 85-5). Amended subsection (A), para- graph (15) and added paragraph (20) effective December 22, 1987 (Supp. 87-4). Amended subsection (C)(2) effec-

tive May 30, 1989 (Supp. 89-2). Amended under an exemption from the provisions of the Administrative Pro- cedure Act effective March 22, 1993; received in the Office of the Secretary of State March 24, 1993 (Supp.

93-1). Amended effective December 13, 1993 (Supp. 93- 4). Section repealed, new Section adopted effective Sep- tember 22, 1997 (Supp. 97-3). Amended by final

rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by exempt rulemaking

at 16 A.A.R. 1638, effective October 1, 2010 (Supp. 10-

3). Amended by final rulemaking at 20 A.A.R. 1949,

effective September 6, 2014 (Supp. 14-3).

Note

Editor’s Note: The following Section was renumbered and a new Section adopted under an exemption from the provisions of the Administrative Procedure Act which means that this rule was not published as a proposed rule in the Arizona Administrative Register; the rule was not reviewed or approved by the Governor’s Regulatory Review Council; and the agency was not required to hold public hearings on the rule. This Section was subsequently amended through the regular rulemaking process.