Section R9-22-702. Charges to Members

A.      For purposes of this subsection, the term “member” includes the member’s financially responsible representative as described under A.R.S. § 36-2903.01.

B.       Registered providers must accept payment from the Adminis- tration or a contractor as payment in full.

C.      Except as provided in subsection (D) a registered provider shall not request or collect payment from, refer to a collection agency, or report to a credit reporting agency an eligible per- son or a person claiming to be an eligible person.

D.      An AHCCCS registered provider may charge, submit a claim to, or demand or collect payment from a member:

1.        To collect the copayment described in R9-22-711;

2.        To recover from a member that portion of a payment made by a third party to the member for an AHCCCS covered service if the member has not transferred the payment to the Administration or the contractor as required by the statutory assignment of rights to AHC- CCS;

3.        To obtain payment from a member for medical expenses incurred during a period when the member intentionally withheld information or intentionally provided inaccurate information pertaining to the member's AHCCCS eligi-

bility or enrollment that caused payment to the provider to be reduced or denied;

4.        For a service that is excluded by statute or rule, or pro- vided in an amount that exceeds a limitation in statute or rule, if the member signs a document in advance of receiving the service stating that the member understands the service is excluded or is subject to a limit and that the member will be financially responsible for payment for the excluded service or for the services in excess of the limit;

5.        When the contractor or the Administration has denied authorization for a service if the member signs a docu- ment in advance of receiving the service stating that the member understands that authorization has been denied and that the member will be financially responsible for payment for the service;

6.        For services requested for a member enrolled with a con- tractor, and rendered by a noncontracting provider under circumstances where the member’s contractor is not responsible for payment of “out of network” services under R9-22-705(A), if the member signs a document in advance of receiving the service stating that the member understands the provider is out of network, that the mem- ber’s contractor is not responsible for payment, and that the member will be financially responsible for payment for the excluded service;

7.        For services rendered to a person eligible for the FESP if the provider submits a claim to the Administration in the reasonable belief that the service is for treatment of an emergency medical condition and the Administration denies the claim because the service does not meet the criteria of R9-22-217; or

8.        If the provider has received verification from the Admin- istration that the person was not an eligible person on the date of service.

E.       The signature requirement of subsections (D)(4), (D)(5), and (D)(6) do not apply if:

1.        The member is unable or incompetent to sign such a doc- ument, or

2.        When services are rendered for the purpose of treating an emergency medical condition as defined in R9-22-217 and a delay in providing treatment to obtain a signature would have a significant adverse affect on the member’s health.

F.       Except as provided for in this Section, registered providers shall not bill a member when the provider could have received reimbursement from the Administration or a contractor but for the provider’s failure to file a claim in accordance with the requirements of AHCCCS statutes, rules, the provider agree- ment, or contract, such as, but not limited to, requirements to request and obtain prior authorization, timely filing, and clean claim requirements.

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 R9-22-702 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended as an emergency

effective February 23, 1983, pursuant to A.R.S. § 41- 1003, valid for only 90 days (Supp. 83-1). Amended as a permanent rule effective May 16, 1983; text identical to the emergency (Supp. 83-3). Former Section R9-22-702 repealed, new Section R9-22-702 adopted effective Octo- ber 1, 1983 (Supp. 83-5). Amended by adding subsection

(B) effective October 1, 1985 (Supp. 85-5). Amended by adding subsection (C) effective October 1, 1987 (Supp. 87-4). Amended effective April 13, 1990 (Supp. 90-2). Amended effective December 13, 1993 (Supp. 93-4). Amended effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 3317, effective July 15, 2002 (Supp. 02-3). Amended by final rulemak- ing at 11 A.A.R. 3217, effective October 1, 2005 (Supp.

05-3). Amended by exempt rulemaking at 17 A.A.R. 1707, effective October 1, 2011 (Supp. 11-3). Amended by final rulemaking at 19 A.A.R. 2747, effective October 8, 2013 (Supp. 13-3).