Section R9-22-703. Payments by the Administration

A.      General requirements. A provider shall enter into a provider agreement with the Administration that meets the require- ments of A.R.S. § 36-2904 and 42 CFR 431.107(b) as of Octo- ber 1, 2012, which is incorporated by reference and on file with the Administration, and available from the U.S. Govern- ment Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC, 20401. This incorporation by reference contains no future editions or amendments.

B.       Timely submission of claims.

1.        Under A.R.S. § 36-2904, the Administration shall deem a paper or electronic claim to be submitted on the date that it is received by the Administration. The Administration shall do one or more of the following for each claim it receives:

a.         Place a date stamp on the face of the claim,

b.        Assign a system-generated claim reference number, or

c.         Assign a system-generated date-specific number.

2.        Unless a shorter time period is specified in contract, the Administration shall not pay a claim for a covered service unless the claim is initially submitted within one of the following time limits, whichever is later:

a.         Six months from the date of service or for an inpa- tient hospital claim, six months from the date of dis- charge; or

b.        Six months from the date of eligibility posting.

3.        Unless a shorter time period is specified in contract, the Administration shall not pay a clean claim for a covered service unless the claim is submitted within one of the following time limits, whichever is later:

a.         Twelve months from the date of service or for an inpatient hospital claim, 12 months from the date of discharge; or

b.        Twelve months from the date of eligibility posting.

4.        Unless a shorter time period is specified in contract, the Administration shall not pay a claim submitted by an IHS or tribal facility for a covered service unless the claim is initially submitted within 12 months from the date of ser- vice, date of discharge, or eligibility posting, whichever is later.

C.      Claims processing.

1.        The Administration shall notify the AHCCCS-registered provider with a remittance advice when a claim is pro- cessed for payment.

2.        The Administration shall reimburse a hospital for inpa- tient hospital admissions and outpatient hospital services rendered on or after March 1, 1993, as follows and in the manner and at the rate described in A.R.S. § 36-2903.01:

a.         If the hospital bill is paid within 30 days from the date of receipt, the claim is paid at 99 percent of the rate.

Arizona Health Care Cost Containment System - Administration

b.        If the hospital bill is paid between 30 and 60 days from the date of receipt, the claim is paid at 100 per- cent of the rate.

c.         If the hospital bill is paid after 60 days from the date of receipt, the claim is paid at 100 percent of the rate plus a fee of one percent per month for each month or portion of a month following the 60th day of receipt of the bill until date of payment.

3.        A claim is paid on the date indicated on the disbursement check.

4.        A claim is denied as of the date of the remittance advice.

5.        The Administration shall process a hospital claim under this Article.

D.      Prior authorization.

1.        An AHCCCS-registered provider shall:

a.         Obtain prior authorization from the Administration for non-emergency hospital admissions, covered ser- vices as specified in Articles 2 and 12 of this Chap- ter, and for administrative days as described in R9- 22-712.75,

b.        Notify  the  Administration  of  hospital  admissions under Article 2 of this Chapter, and

c.         Make records available for review by the Adminis- tration upon request.

2.        The Administration may deny a claim if the provider fails to comply with subsection (D)(1).

3.        If the Administration issues prior authorization for an inpatient hospital admission, a specific service, or level of care but subsequent medical review indicates that the admission, the service, or level of care was not medically appropriate, the Administration shall adjust the claim payment.

E.       Review of claims and coverage for hospital supplies.

1.        The Administration may conduct prepayment and post- payment review of any claims, including but not limited to hospital claims.

2.        Personal care items supplied by a hospital, including but not limited to the following, are not covered services:

a.         Patient care kit,

b.        Toothbrush,

c.         Toothpaste,

d.        Petroleum jelly,

e.         Deodorant,

f.         Septi soap,

g.        Razor or disposable razor,

h.        Shaving cream,

i.         Slippers,

j.         Mouthwash,

k.        Shampoo,

l.         Powder,

m.       Lotion,

n.        Comb, and

o.        Patient gown.

3.        The following hospital supplies and equipment, if medi- cally necessary and used by the member, are covered ser- vices:

a.         Arm board,

b.        Diaper,

c.         Underpad,

d.        Special mattress and special bed,

e.         Gloves,

f.         Wrist restraint,

g.        Limb holder,

h.        Disposable item used instead of a durable item,

i.         Universal precaution,

j.         Stat charge, and

k.        Portable charge.

4.        The Administration shall determine in a hospital claims review whether services rendered were:

a.         Covered services as defined in Article 2;

b.        Medically necessary;

c.         Provided in the most appropriate, cost-effective, and least restrictive setting; and

d.        For claims with dates of admission on and after March 1, 1993, substantiated by the minimum documentation spec- ified in A.R.S. § 36-2903.01.

5.        If the Administration adjudicates a claim, a person may file a claim dispute challenging the adjudication under 9

A.A.C. 34.

F.       Overpayment for AHCCCS services.

1.        An AHCCCS-registered provider shall notify the Admin- istration when the provider discovers the Administration made an overpayment.

2.        The Administration shall recoup an overpayment from a future claim cycle if an AHCCCS-registered provider fails to return the overpaid amount to the Administration.

3.        The Administration shall document any recoupment of an overpayment on a remittance advice.

4.        An AHCCCS-registered provider may file a claim dis- pute under 9 A.A.C. 34 if the AHCCCS-registered pro- vider disagrees with a recoupment action.

G.      For services subject to limitations or exclusions such as the number of hours, days, or visits covered as described in Article 2 of this Chapter, once the limit is reached the Administration will not reimburse the services.

H.      Prior quarter reimbursement. A provider shall:

1.        Bill the Administration for services provided during a prior quarter eligibility period upon verification of eligi- bility or upon notification from a member of AHCCCS eligibility.

2.        Reimburse a member when payment has been received from the Administration for covered services during a prior quarter eligibility period. All funds paid by the member shall be reimbursed.

3.        Accept payment received by the Administration as pay- ment in full.

I.        Payment for in-state inpatient hospital services for claims with discharge dates on or before September 30, 2014. The Admin- istration shall reimburse an in-state provider of inpatient hos- pital services rendered with a discharge date on or before September 30, 2014, the prospective tiered-per-diem amount in A.R.S. § 36-2903.01 and this Article.

J.        Payment for out-of-state inpatient hospital services for claims with discharge dates on or before September 30, 2014. The Administration shall reimburse an out-of-state provider of inpatient hospital services rendered with a discharge date on or before September 30, 2014, for covered inpatient services by multiplying covered charges by the most recent statewide urban cost-to-charge ratio as determined in R9-22- 712.01(6)(b).

K.      Payment for inpatient hospital services for claims with dis- charge dates on and after October 1, 2014 regardless of admis- sion date. The Administration shall reimburse an in-state or out-of-state provider of inpatient hospital services rendered with a discharge date on or after October 1, 2014, the DRG rate established by the Administration.

L.       The Administration may enter into contracts for the provisions of transplant services.

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 R-22-703 adopted as an emergency

now adopted as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22-703 repealed, new Section R9-22-703 adopted effective October 1, 1983 (Supp. 83-5). Amended effective October 1, 1985

(Supp. 85-5). Amended effective October 1, 1986 (Supp. 86-5). Amended subsection (B), paragraph (1) effective January 1, 1987, filed December 31, 1986 (Supp. 86-6). Amended subsection (A) effective September 16, 1987 (Supp. 87-3). Amended effective May 30, 1989 (Supp.

89-2). Amended effective September 29, 1992 (Supp. 92-

3). 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. 3222, effective October 1, 2005 (Supp.

05-3). Amended by final rulemaking at 13 A.A.R. 662,

effective April 7, 2007 (Supp. 07-1). Amended by final

rulemaking at 17 A.A.R. 1658, effective August 2, 2011 (Supp. 11-3). 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, effec-

tive October 8, 2013 (Supp. 13-3). Amended by final

rulemaking at 19 A.A.R. 3309, November 30, 2013 (Supp. 13-4). Amended by final rulemaking at 20 A.A.R.

1956, September 6, 2014 (Supp. 14-3).