Section R9-22-718. Urban Hospital Inpatient Reimbursement Pro- gram

A.      Definitions. The following definitions apply to this Section:

1.        “Noncontracted Hospital” means an urban hospital which does not have a contract under this Section with an urban contractor in the same county.

2.        “Rural Contractor” means a contractor or program con- tractor as defined in A.R.S. Title 36, Chapter 29 that does not provide services to members residing in either Mar- icopa or Pima County.

3.        “Urban Contractor” means a contractor or program con- tractor as defined in A.R.S. Title 36, Chapter 29, that pro- vides services to members residing in Maricopa or Pima County and may also provide services to members who reside in other counties. An urban contractor does not include ADHS/BHS, or a TRBHA.

4.        “Rural Hospital” means a hospital, as defined in R9-22- 712.07, that is physically located in Arizona but in a county other than Maricopa and Pima County.

5.        “Urban Hospital” means a hospital that is not a rural hos- pital and is physically located in Maricopa or Pima County.

B.       General Provisions.

1.        This Section applies to an urban hospital who receives payment for inpatient hospital services under A.R.S. §§ 36-2903.01 and 36-2904.

2.        AHCCCS shall operate an inpatient hospital reimburse- ment program under A.R.S. § 36-2905.01 and this Sec- tion.

3.        Residency of the member receiving inpatient AHCCCS covered services is not a factor in determining which hos- pitals are required to contract with which contractors.

4.        An urban contractor shall enter into a contract for reim- bursement for inpatient AHCCCS covered services with one or more urban hospitals located in the same county as the urban contractor.

5.        A noncontracted urban hospital shall be reimbursed for inpatient services by an urban contractor at 95% of the amount calculated as defined in A.R.S. § 36-2903.01 and this Article, unless otherwise negotiated by both parties.

C.      Contract Begin Date. A contract under this Article shall cover inpatient acute care hospital services for members with hospi- tal admissions on and after October 1, 2003.

D.      Outpatient urban hospital services. Outpatient urban hospital services, including observation days and emergency room treatments that do not result in an admission, shall be reim- bursed either through an urban hospital contract negotiated between a contractor and an urban hospital, or the reimburse- ment rates set forth in A.R.S. § 36-2903.01. Outpatient ser- vices in an urban hospital that result in an admission shall be paid as inpatient services in accordance with this Section.

E.       Urban Hospital Contract.

1.        Provisions of an urban hospital contracts. The urban hos- pital contract shall contain but is not limited to the fol- lowing provisions:

a.         Required provisions as described in the Request for Proposals (RFP);

b.        Dispute settlement procedures. If the AHCCCS Grievance System prescribed in A.R.S. § 36- 2903.01(B) and rule is not used, then arbitration shall be used;

c.         Arbitration  procedure.  If  arbitration   is  used,  the urban hospital contract shall identify:

i.         The parties’ agreement on arbitrating claims arising from the contract,

ii.        Whether arbitration is nonbinding or binding,

iii.      Timeliness of arbitration,

iv.       What contract provisions may be appealed,

v.        What rules will govern arbitrations,

vi.       The number of arbitrators that shall be used,

vii.     How arbitrators shall be selected, and

viii.    How arbitrators shall be compensated.

d.        Timeliness of claims submission and payment;

e.         Prior authorization;

f.         Concurrent review;

g.        Electronic submission of claims;

h.        Claims review criteria;

i.         Payment of discounts or penalties such as quick-pay and slow-pay provisions;

j.         Payment of outliers;

k.        Claim documentation specifications under A.R.S. § 36-2904.

l.         Treatment  and  payment  of  emergency   room  ser- vices; and

m.       Provisions for rate changes and adjustments.

2.        AHCCCS review and approval of urban hospital con- tracts:

a.         AHCCCS may review, approve, or disapprove the hospital contract rates, terms, conditions, and amendments to the contract;

b.        The AHCCCS evaluation of each urban hospital contract shall include but not be limited to the fol- lowing areas:

i.         Availability  and  accessibility  of  services  to members,

ii.        Related party interests,

iii.      Inclusion  of  required  terms  pursuant  to  this Section, and

iv.       Reasonableness of the rates.

F.       Quick-Pay/Slow-Pay. A payment made by urban contractor to a noncontracted hospital shall be subject to quick-pay dis- counts and slow-pay penalties under A.R.S. § 36-2904.

Historical Note

Adopted under an exemption from the provisions of the Administrative Procedure Act, effective January 29, 1997; pursuant to Laws 1996, Ch. 288, § 24 (Supp. 97-1).

Amended by exempt rulemaking at 10 A.A.R. 500, effec- tive February 1, 2004 (Supp. 04-1). Amended by exempt

rulemaking at 13 A.A.R. 3190, effective October 1, 2007 (Supp. 07-3). Amended by final rulemaking at 20 A.A.R.

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