Docstoc

Arizona Administrative Code Title 9_ Ch. 22 Arizona Health Care

Document Sample
Arizona Administrative Code Title 9_ Ch. 22 Arizona Health Care Powered By Docstoc
					                                                      Arizona Administrative Code                                        Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

                                                    TITLE 9. HEALTH SERVICES
                            CHAPTER 22. ARIZO A HEALTH CARE COST CO TAI ME T SYSTEM
                                                 ADMI ISTRATIO
    Editor’s ote: The Office of the Secretary of State prints all Code Chapters on white paper (Supp 01-3).
     Editor’s ote: This Chapter contains rules which were adopted or amended under an exemption from the Arizona Administrative
Procedure Act (A.R.S. Title 41, Chapter 6), pursuant to Laws 1992, Ch. 301, § 61 and Ch. 302, § 13, and Laws 1993, Ch. 6, § 34. Exemp-
tion from A.R.S. Title 41, Chapter 6 means that AHCCCS did not submit notice of this rulemaking to the Secretary of State’s Office for
publication in the Arizona Administrative Register; the Governor’s Regulatory Review Council did not review these rules; AHCCCS was
not required to hold public hearings on these rules; and the Attorney General did not certify these rules. Because this Chapter contains
rules which are exempt from the regular rulemaking process, the Chapter is printed on blue paper.
                   ARTICLE 1. DEFI ITIO S                             R9-22-216.    NF, Alternative HCBS Setting, or HCBS
                                                                      R9-22-217.    Services Included in the Federal Emergency Ser-
        ew Article 1, consisting of Sections R9-22-101 through R9-
                                                                                    vices Program
22-103, R9-22-105, and R9-22-106 through R9-22-112 adopted
                                                                      R9-22-218.    Repealed
effective December 8, 1997 (Supp. 97-4).
                                                                                         ARTICLE 3. REPEALED
     Former Article 1, consisting of Section R9-22-101, repealed
effective December 8, 1997 (Supp. 97-4).                                  Article 3, consisting of Sections R9-22-301 through R9-22-319
                                                                      and R9-22-321 through R9-22-344, repealed by final rulemaking at
Section
                                                                      5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1). Section R9-
R9-22-101.      Location of Definitions
                                                                      22-320 repealed December 13, 1993 (Supp. 93-4).
R9-22-102.      Repealed
R9-22-103.      Repealed                                                                 ARTICLE 4. REPEALED
R9-22-104.      Reserved
                                                                      Section
R9-22-105.      Repealed
                                                                      R9-22-401.    Repealed
R9-22-106.      Repealed
                                                                      R9-22-402.    Repealed
R9-22-107.      Repealed
                                                                      R9-22-403.    Repealed
R9-22-108.      Repealed
                                                                      R9-22-404.    Repealed
R9-22-109.      Repealed
                                                                      R9-22-405.    Repealed
R9-22-110.      Repealed
                                                                      R9-22-406.    Repealed
R9-22-111.      Reserved
R9-22-112.      Repealed                                                  ARTICLE 5. GE ERAL PROVISIO S A D STA DARDS
R9-22-113.      Reserved
                                                                      Section
R9-22-114.      Repealed
                                                                      R9-22-501.    General Provisions and Standards – Related Defini-
R9-22-115.      Repealed
                                                                                    tions
R9-22-116.      Repealed
                                                                      R9-22-502.    Pre-existing Conditions
R9-22-117.      Repealed
                                                                      R9-22-503.    Provider Requirements Regarding Records
R9-22-118.      Reserved
                                                                      R9-22-504.    Marketing; Prohibition Against Inducements; Mis-
R9-22-119.      Reserved
                                                                                    representations; Discrimination; Sanctions
R9-22-120.      Repealed
                                                                      R9-22-505.    Standards, Licensure, and Certification for Providers
             ARTICLE 2. SCOPE OF SERVICES                                           of Hospital and Medical Services
                                                                      R9-22-506.    Repealed
Section
                                                                      R9-22-507.    Repealed
R9-22-201.    Scope of Services-related Definitions
                                                                      R9-22-508.    Repealed
R9-22-202.    General Requirements
                                                                      R9-22-509.    Transition and Coordination of Member Care
R9-22-203.    Experimental Services
                                                                      R9-22-510.    Repealed
R9-22-204.    Inpatient General Hospital Services
                                                                      R9-22-511.    Repealed
R9-22-205.    Attending Physician, Practitioner, and Primary Care
                                                                      R9-22-512.    Release of Safeguarded Information
              Provider Services
                                                                      R9-22-513.    Repealed
R9-22-206. Organ and Tissue Transplant Services
                                                                      R9-22-514.    Repealed
R9-22-207. Dental Services
                                                                      R9-22-515.    Repealed
R9-22-208. Laboratory, Radiology, and Medical Imaging Ser-
                                                                      R9-22-516.    Renumbered
              vices
                                                                      R9-22-517.    Renumbered
R9-22-209. Pharmaceutical Services
                                                                      R9-22-518.    Information to Enrolled Members
R9-22-210. Emergency Medical Services for Non-FES Mem-
                                                                      R9-22-519.    Repealed
              bers
                                                                      R9-22-520.    Expired
R9-22-210.01. Emergency Behavioral Health Services for Non-
                                                                      R9-22-521.    Program Compliance Audits
              FES Members
                                                                      R9-22-522.    Quality Management/Utilization Management (QM/
R9-22-211. Transportation Services
                                                                                    UM) Requirements
R9-22-212. Durable Medical Equipment, Orthotic and Pros-
                                                                      R9-22-523.    Expired
              thetic Devices, and Medical Supplies
                                                                      R9-22-524.    Repealed
R9-22-213. Early and Periodic Screening, Diagnosis, and Treat-
                                                                      R9-22-525.    Repealed
              ment Services (E.P.S.D.T.)
                                                                      R9-22-526.    Renumbered
R9-22-214. Repealed
                                                                      R9-22-527.    Renumbered
R9-22-215. Other Medical Professional Services
                                                                      R9-22-528.    Renumbered


June 30, 2011                                                    Page 1                                                       Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

R9-22-529.        Renumbered                                               R9-22-712.15. Outpatient Hospital Reimbursement: Affected Hos-
                                                                                         pitals
       ARTICLE 6. RFP A D CO TRACT PROCESS
                                                                           R9-22-712.16. Reserved
     Article 6, consisting of Sections R9-22-601 through R9-22-            R9-22-712.17. Reserved
604, adopted by final rulemaking at 5 A.A.R. 607, effective Febru-         R9-22-712.18. Reserved
ary 5, 1999 (Supp. 99-1).                                                  R9-22-712.19. Reserved
                                                                           R9-22-712.20. Outpatient Hospital Reimbursement: Methodology
     Article 6, consisting of Sections R9-22-601 through R9-22-
                                                                                         for the AHCCCS Outpatient Capped Fee-For-Ser-
605, repealed by final rulemaking at 5 A.A.R. 607, effective Febru-
                                                                                         vice Schedule
ary 5, 1999 (Supp. 99-1).
                                                                           R9-22-712.21. Reserved
     Article 6, consisting of Sections R9-22-601 through R9-22-            R9-22-712.22. Reserved
604, adopted effective July 16, 1985.                                      R9-22-712.23. Reserved
                                                                           R9-22-712.24. Reserved
    Former Article 6, consisting of Sections R9-22-601 through
                                                                           R9-22-712.25. Outpatient Hospital Fee Schedule Calculations:
R9-22-603, repealed effective October 1, 1983.
                                                                                         Associated Service Costs for ER and Surgery Ser-
Section                                                                                  vices
R9-22-601.        General Provisions                                       R9-22-712.26. Reserved
R9-22-602.        RFP                                                      R9-22-712.27. Reserved
R9-22-603.        Contract Award                                           R9-22-712.28. Reserved
R9-22-604.        Contract or Proposal Protests; Appeals                   R9-22-712.29. Reserved
R9-22-605.        Waiver of Contractor’s Subcontract with Hospitals        R9-22-712.30. Outpatient Hospital Reimbursement: Payment for a
R9-22-606.        Contract Compliance Sanction                                           Service Not Listed in the AHCCCS Outpatient
                                                                                         Capped Fee-For Service Schedule
        ARTICLE 7. STA DARDS FOR PAYME TS
                                                                           R9-22-712.31. Reserved
Section                                                                    R9-22-712.32. Reserved
R9-22-701. Standard for Payments Related Definitions                       R9-22-712.33. Reserved
R9-22-701.01. Reserved                                                     R9-22-712.34. Reserved
R9-22-701.02. Reserved                                                     R9-22-712.35. Outpatient Hospital Reimbursement: Adjustments to
R9-22-701.03. Reserved                                                                   Fees
R9-22-701.04. Reserved                                                     R9-22-712.36. Reserved
R9-22-701.05. Reserved                                                     R9-22-712.37. Reserved
R9-22-701.06. Reserved                                                     R9-22-712.38. Reserved
R9-22-701.07. Reserved                                                     R9-22-712.39. Reserved
R9-22-701.08. Reserved                                                     R9-22-712.40. Outpatient Hospital Reimbursement: Annual and
R9-22-701.09. Reserved                                                                   Periodic Update
R9-22-701.10. Scope of the Administration’s and Contractor’s Lia-          R9-22-712.41. Reserved
              bility                                                       R9-22-712.42. Reserved
R9-22-702. Charges to Members                                              R9-22-712.43. Reserved
R9-22-703. Payments by the Administration                                  R9-22-712.44. Reserved
R9-22-704. Repealed                                                        R9-22-712.45. Outpatient Hospital Reimbursement: Outpatient
R9-22-705. Payments by Contractors                                                       Payment Restrictions
R9-22-706. Repealed                                                        R9-22-712.46. Reserved
R9-22-707. Repealed                                                        R9-22-712.47. Reserved
R9-22-708. Payments for Services Provided to Eligible Native               R9-22-712.48. Reserved
              Americans                                                    R9-22-712.49. Reserved
R9-22-709. Contractor’s Liability to Hospitals for the Provision           R9-22-712.50. Outpatient Hospital Reimbursement: Billing
              of Emergency and Post-stabilization Care                     R9-22-713. Overpayment and Recovery of Indebtedness
R9-22-710. Payments for Non-hospital Services                              R9-22-714. Payments to Providers
R9-22-711. Copayments                                                      R9-22-715. Hospital Rate Negotiations
R9-22-712. Reimbursement: General                                          R9-22-716. Repealed
R9-22-712.01. Inpatient Hospital Reimbursement                             R9-22-717. Repealed
R9-22-712.02. Reserved                                                     R9-22-718. Urban Hospital Inpatient Reimbursement Program
R9-22-712.03. Reserved                                                     R9-22-719. Contractor Performance Measure Outcomes
R9-22-712.04. Reserved                                                     R9-22-720. Reinsurance
R9-22-712.05. Graduate Medical Education Fund Allocation
                                                                                               ARTICLE 8. REPEALED
R9-22-712.06. Reserved
R9-22-712.07. Rural Hospital Inpatient Fund Allocation                           Article 8, consisting of Sections R9-22-801 through R9-22-804
 Exhibit 1.   Pool Example                                                 and Exhibit A, repealed by final rulemaking at 10 A.A.R. 808, effec-
R9-22-712.08. Reserved                                                     tive April 3, 2004. The subject matter of Article 8 is now in 9 A.A.C.
R9-22-712.09. Hierarchy For Tier Assignment                                34 (Supp. 04-1).
R9-22-712.10. Outpatient Hospital Reimbursement: General
                                                                           Section
R9-22-712.11. Reserved
                                                                           R9-22-801.     Repealed
R9-22-712.12. Reserved
                                                                           R9-22-802.     Repealed
R9-22-712.13. Reserved
                                                                           R9-22-803.     Repealed
R9-22-712.14. Reserved
                                                                           R9-22-804.     Repealed
                                                                            Exhibit A.    Repealed


Supp. 11-2                                                            Page 2                                                      June 30, 2011
                                                    Arizona Administrative Code                                          Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

R9-22-805.      Repealed                                                  ARTICLE 12. BEHAVIORAL HEALTH SERVICES
                    ARTICLE 9. REPEALED                                   Article 12, consisting of Sections R9-22-1201 through R9-22-
                                                                     1208, repealed; new Article 12, consisting of Sections R9-22-1201
     Article 22, consisting of Sections R9-22-901 through R9-22-
                                                                     through R9-22-1208 adopted by final rulemaking at 6 A.A.R. 179,
909, repealed by final rulemaking at 12 A.A.R. 4484, January 6,
                                                                     effective December 13, 1999 (Supp. 99-4).
2007 (Supp. 06-4).
                                                                     Section
     Article 22, consisting of Sections R9-22-901 through R9-22-
                                                                     R9-22-1201. General Requirements
908, adopted effective August 29, 1985.
                                                                     R9-22-1202. ADHS and Contractor Responsibilities
     Former Article 22, consisting of Section R9-22-901, repealed    R9-22-1203. Eligibility for Covered Services
effective October 1, 1983.                                           R9-22-1204. General Service Requirements
                                                                     R9-22-1205. Scope and Coverage of Behavioral Health Services
Section
                                                                     R9-22-1206. General Provisions and Standards for Service Pro-
R9-22-901.      Repealed
                                                                                 viders
R9-22-902.      Repealed
                                                                     R9-22-1207. General Provisions for Payment
R9-22-903.      Repealed
                                                                     R9-22-1208. Repealed
R9-22-904.      Repealed
R9-22-905.      Repealed                                                                ARTICLE 13. REPEALED
R9-22-906.      Repealed
                                                                          Article 13, consisting of Sections R9-22-1301 through R9-22-
R9-22-907.      Repealed
                                                                     1309, repealed by final rulemaking at 10 A.A.R. 808, effective April
R9-22-908.      Repealed
                                                                     3, 2004. The subject matter of Article 13 is now in 9 A.A.C. 34
R9-22-909.      Repealed
                                                                     (Supp. 04-1).
ARTICLE 10. FIRST- A D THIRD-PARTY LIABILITY A D
                                                                         Article 13, consisting of Sections R9-22-1301 through R9-22-
                    RECOVERIES
                                                                     1309, adopted effective September 9, 1998 (Supp. 98-3).
    Article 10, consisting of Section R9-22-1001 through R9-22-
                                                                     Section
1002, adopted effective ovember 7, 1997 (Supp. 97-4).
                                                                     R9-22-1301.    Repealed
    Article 10, consisting of Section R9-22-1001 through R9-22-      R9-22-1302.    Repealed
1002, repealed effective ovember 7, 1997 (Supp. 97-4).               R9-22-1303.    Repealed
                                                                     R9-22-1304.    Repealed
    Article 10 consisting of Sections R9-22-1001 and R9-22-1002
                                                                     R9-22-1305.    Repealed
adopted effective October 1, 1985.
                                                                     R9-22-1306.    Repealed
Section                                                              R9-22-1307.    Repealed
R9-22-1001. Definitions                                              R9-22-1308.    Repealed
R9-22-1002. General Provisions                                       R9-22-1309.    Repealed
R9-22-1003. Cost Avoidance
                                                                         ARTICLE 14. AHCCCS MEDICAL COVERAGE FOR
R9-22-1004. Member Participation
                                                                                 FAMILIES A D I DIVIDUALS
R9-22-1005. Collections
R9-22-1006. AHCCCS Monitoring Responsibilities                            Article 14, consisting of Sections R9-22-1401 through R9-22-
R9-22-1007. Notification for Perfection, Recording, and Assign-      1436, repealed; new Article 14, consisting of Sections R9-22-1401
            ment of AHCCCS Liens                                     through R9-22-1433 made by exempt rulemaking at 7 A.A.R. 4593,
R9-22-1008. Notification Information for Liens                       effective October 1, 2001 (Supp. 01-3).
R9-22-1009. Notification of Health Insurance Information
                                                                          Article 14, consisting of Sections R9-22-1401 through R9-22-
    ARTICLE 11. CIVIL MO ETARY PE ALTIES A D                         1436, adopted by final rulemaking at 5 A.A.R. 294, effective Janu-
                   ASSESSME TS                                       ary 8, 1999 (Supp. 99-1).
    Article 11 consisting of Sections R9-22-1101 through R9-22-      Section
1104 adopted effective October 1, 1986.                              R9-22-1401.    General Information
                                                                     R9-22-1402.    Ineligible Person
Section
                                                                     R9-22-1403.    Agency Responsible for Determining Eligibility
R9-22-1101. Basis for Civil Monetary Penalties and Assessments
                                                                     R9-22-1404.    Assignment of Rights Under Operation of Law
            for Fraudulent Claims; Definitions
                                                                     R9-22-1405.    Confidentiality and Safeguarding of Information
R9-22-1102. Determining the Amount of a Penalty
                                                                     R9-22-1406.    Application Process
R9-22-1103. Determining the Amount of an Assessment
                                                                     R9-22-1407.    Deceased Applicants
R9-22-1104. Mitigating Circumstances
                                                                     R9-22-1408.    Applicant and Member Responsibility
R9-22-1105. Aggravating Circumstances
                                                                     R9-22-1409.    Withdrawal of Application
R9-22-1106. Notice of Intent
                                                                     R9-22-1410.    Department Responsibilities
R9-22-1107. Reserved
                                                                     R9-22-1411.    Withdrawal from AHCCCS Medical Coverage
R9-22-1108. Request for a Compromise
                                                                     R9-22-1412.    Verification of Eligibility Information
R9-22 1109. Failure to Respond to the Notice of Intent
                                                                     R9-22-1413.    Time-frames, Approval, Discontinuance, or Denial
R9-22-1110. Request for State Fair Hearing
                                                                                    of an Application
R9-22-1111. Issues and Burden of Proof
                                                                     R9-22-1414.    Review of Eligibility
R9-22-1112. Withdrawal and Continuances
                                                                     R9-22-1415.    Notice of Adverse Action
                                                                     R9-22-1416.    Effective Date of Eligibility
                                                                     R9-22-1417.    Social Security Number
                                                                     R9-22-1418.    State Residency


June 30, 2011                                                   Page 3                                                        Supp. 11-2
Title 9, Ch. 22                                         Arizona Administrative Code
                                        Arizona Health Care Cost Containment System – Administration

R9-22-1419. Citizenship and Immigrant Status                              R9-22-1601.    General Information
R9-22-1419.01. Repealed                                                   R9-22-1602.    Ineligible Person
R9-22-1419.02. Repealed                                                   R9-22-1603.    Definitions
R9-22-1419.03. Repealed                                                   R9-22-1604.    Effective Date of Eligibility for Services
R9-22-1419.04. Repealed                                                   R9-22-1605.    Services
R9-22-1420. Income Eligibility Criteria                                   R9-22-1606.    Application Process
R9-22-1421. Income Eligibility                                            R9-22-1607.    Withdrawal
R9-22-1422. Methods for Calculating Monthly Income                        R9-22-1608.    Assignment of Rights Under Operation of Law
R9-22-1423. Calculations and Use of Methods Listed in R9-22-              R9-22-1609.    General Eligibility Criteria
             1422 Based on Frequency of Income                            R9-22-1610.    Changes/Redetermination
R9-22-1424. Use of Methods Listed in R9-22-1423 Based on                  R9-22-1611.    Copayments
             Type of Income                                               R9-22-1612.    Resources
R9-22-1425. Sponsor Deemed Income                                         R9-22-1613.    Repealed
R9-22-1426. Exemptions from Sponsor Deemed Income                         R9-22-1614.    Confidentiality and Safeguarding of Information
R9-22-1427. Eligibility for a Family                                      R9-22-1615.    Notice Requirements
R9-22-1428. Eligibility for a Person Not Eligible as a Family             R9-22-1616.    Calculating the Monthly Income for Determining
R9-22-1429. Eligibility for a Newborn                                                    the Premium Amount
R9-22-1430. Extended Medical Coverage for a Pregnant Woman                R9-22-1617.    Repealed
R9-22-1431. Family Planning Services Extension Program                    R9-22-1618.    General Provisions Related to Premiums
             (FPEP)                                                       R9-22-1619.    Request for Hearing Process
R9-22-1432. Young Adult Transitional Insurance                            R9-22-1620.    Repealed
R9-22-1433. Special Groups for Children                                   R9-22-1621.    Reserved
R9-22-1434. Repealed                                                      R9-22-1622.    Repealed
R9-22-1435. Eligibility for a Person With Medical Expenses                R9-22-1623.    Repealed
             Whose Income is Over 100 Percent FPL                         R9-22-1624.    Repealed
R9-22-1436. MED Family Unit                                               R9-22-1625.    Repealed
R9-22-1437. MED Income Eligibility Requirements                           R9-22-1626.    Repealed
R9-22-1438. MED Resource Eligibility Requirements                         R9-22-1627.    Repealed
R9-22-1439. MED Effective Date of Eligibility                             R9-22-1628.    Repealed
R9-22-1440. MED Eligibility Period                                        R9-22-1629.    Repealed
R9-22-1441. Eligibility Appeals                                           R9-22-1630.    Repealed
R9-22-1442. Cessation of MED Coverage                                     R9-22-1631.    Repealed
                                                                          R9-22-1632.    Reserved
   ARTICLE 15. AHCCCS MEDICAL COVERAGE FOR
                                                                          R9-22-1633.    Repealed
   PEOPLE WHO ARE AGED, BLI D, OR DISABLED
                                                                          R9-22-1634.    Repealed
     Article 15, consisting of Sections R9-22-1501 through R9-22-         R9-22-1635.    Reserved
1508, repealed; new Article 15, consisting of Sections R9-22-1501         R9-22-1636.    Repealed
through R9-22-1505 made by exempt rulemaking at 7 A.A.R. 4593,
                                                                                          ARTICLE 17. E ROLLME T
effective October 1, 2001 (Supp. 01-3).
                                                                               Article 17, consisting of Sections R9-22-1701 through R9-22-
     Article 15, consisting of Sections R9-22-1501 through R9-22-
                                                                          1704, adopted by final rulemaking at 5 A.A.R. 294, effective Janu-
1508, adopted by final rulemaking at 5 A.A.R. 294, effective Janu-
                                                                          ary 8, 1999 (Supp. 99-1).
ary 8, 1999 (Supp. 99-1).
                                                                          Section
Section
                                                                          R9-22-1701. Enrollment-Related Definitions
R9-22-1501.       General Information
                                                                          R9-22-1702. Enrollment of a Member with an AHCCCS Contrac-
R9-22-1502.       General Eligibility Criteria
                                                                                      tor
R9-22-1503.       Financial Eligibility Criteria
                                                                          R9-22-1703. Effective Date of Enrollment with a Contractor
R9-22-1504.       Eligibility For A Person Who Is Aged, Blind, or Dis-
                                                                          R9-22-1704. Newborn Enrollment
                  abled
                                                                          R9-22-1705. Guaranteed Enrollment Period
R9-22-1505.       Eligibility for Special Groups
R9-22-1506.       Repealed                                                                  ARTICLE 18. RESERVED
R9-22-1507.       Repealed
                                                                                        ARTICLE 19. FREEDOM TO WORK
R9-22-1508.       Repealed
                                                                               Article 19, consisting of Sections R9-22-1901 through R9-22-
     ARTICLE 16. SOCIAL SECURITY DISABILITY
                                                                          1922, made by exempt rulemaking at 9 A.A.R. 95, effective January
   I SURA CE - TEMPORARY MEDICAL COVERAGE
                                                                          1, 2003 (Supp. 02-4).
    Article 16, consisting of Sections R9-22-1601 through R9-22-
                                                                          Section
1636, repealed by exempt rulemaking at 7 A.A.R. 4593, effective
                                                                          R9-22-1901. General Freedom to Work Requirements
October 1, 2001 (Supp. 01-3).
                                                                          R9-22-1902. General Administration Requirements
      Article 16, consisting of Sections R9-22-1601 through R9-22-        R9-22-1903. Application for Coverage
1613, R9-22-1615 through R9-22-1620, R9-22-1622 through R9-               R9-22-1904. Notice of Approval or Denial
22-1631, R9-22-1633, R9-22-1634, and R9-22-1636, adopted by               R9-22-1905. Reporting and Verifying Changes
final rulemaking at 5 A.A.R. 294, effective January 8, 1999 (Supp.        R9-22-1906. Actions that Result from a Redetermination or
99-1).                                                                                Change
                                                                          R9-22-1907. Notice of Adverse Action Requirements
Section
                                                                          R9-22-1908. Request for Hearing


Supp. 11-2                                                           Page 4                                                   June 30, 2011
                                                      Arizona Administrative Code                                          Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

R9-22-1909.     Conditions of Eligibility                                   “Assessment”                                       R9-22-1101
R9-22-1910.     Repealed                                                    “Assignment”                                        R9-22-101
R9-22-1911.     Repealed                                                    “Attending physician”                               R9-22-101
R9-22-1912.     Repealed                                                    “Authorized representative”                         R9-22-101
R9-22-1913.     Premium Requirements                                        “Authorization”                                     R9-22-201
                                                                            “Auto-assignment algorithm”                        R9-22-1701
R9-22-1914.     Repealed                                                    “AZ-NBCCEDP”                                       R9-22-2001
R9-22-1915.     Institutionalized Person                                    “Baby Arizona”                                     R9-22-1401
R9-22-1916.     Repealed                                                    “Behavior management services”                     R9-22-1201
R9-22-1917.     Repealed                                                    “Behavioral health adult therapeutic home”         R9-22-1201
R9-22-1918.     Additional Eligibility Criteria for the Basic Cover-        “Behavioral health therapeutic home care
                age Group                                                   services”                                          R9-22-1201
R9-22-1919.     Additional Eligibility Criteria for the Medically           “Behavioral health evaluation”                     R9-22-1201
                Improved Group                                              “Behavioral health medical practitioner”           R9-22-1201
R9-22-1920.     Repealed                                                    “Behavioral health professional”            A.A.C. R9-20-1201
                                                                            “Behavioral health recipient”                       R9-22-201
R9-22-1921.     Enrollment                                                  “Behavioral health service”                        R9-22-1201
R9-22-1922.     Redetermination of Eligibility                              “Behavioral health technician”              A.A.C. R9-20-1201
     ARTICLE 20. BREAST A D CERVICAL CA CER                                 “BHS”                                              R9-22-1401
              TREATME T PROGRAM                                             “Billed charges”                                    R9-22-701
                                                                            “Blind”                                            R9-22-1501
Section                                                                     “Burial plot”                                      R9-22-1401
R9-22-2001. Breast and Cervical Cancer Treatment Program                    “Business agent”                      R9-22-701 and R9-22-704
            Related Definitions                                             “Calculated inpatient costs”                     R9-22-712.07
R9-22-2002. General Requirements                                            “Capital costs”                                     R9-22-701
                                                                            “Capped fee-for-service”                            R9-22-101
R9-22-2003. Eligibility Criteria                                            “Caretaker relative”                               R9-22-1401
R9-22-2004. Treatment                                                       “Case management”                                  R9-22-1201
R9-22-2005. Application Process                                             “Case record”                                       R9-22-101
R9-22-2006. Approval, Denial, or Discontinuance of Eligibility              “Case review”                                       R9-22-101
R9-22-2007. Effective and End Date of Eligibility                           “Cash assistance”                                  R9-22-1401
R9-22-2008. Redetermination of Eligibility                                  “Categorically eligible”                            R9-22-101
                                                                            “CCR”                                               R9-22-712
  ARTICLE 21. TRAUMA A D EMERGE CY SERVICES                                 “Certified psychiatric nurse practitioner”         R9-22-1201
                     FU D                                                   “Charge master”                                     R9-22-712
                                                                            “Child”                           R9-22-1503 and R9-22-1603
     Article 21, consisting of Sections R9-22-2101 through R9-22-           “Children’s Rehabilitative Services” or “CRS”       R9-22-201
2103, made by exempt rulemaking at 9 A.A.R. 4001, effective Octo-           “Claim”                                            R9-22-1101
ber 19, 2003 (Supp. 03-3).                                                  “Claims paid amount”                             R9-22-712.07
Section                                                                     “Clean claim”                                 A.R.S. § 36-2904
                                                                            “Clinical supervision”                              R9-22-201
R9-22-2101. General Provisions                                              “CMDP”                                             R9-22-1701
R9-22-2102. Distribution of Trauma and Emergency Services                   “CMS”                                               R9-22-101
            Fund: Level I Trauma Centers                                    “Continuous stay”                                   R9-22-101
R9-22-2103. Distribution of Trauma and Emergency Services                   “Contract”                                          R9-22-101
            Fund: Emergency Services                                        “Contract year”                                     R9-22-101
                                                                            “Contractor”                                  A.R.S. § 36-2901
                   ARTICLE 1. DEFI ITIO S                                   “Copayment”            R9-22-701, R9-22-711 and R9-22-1603
R9-22-101. Location of Definitions                                          “Cost avoid”                                       R9-22-1201
A. Location of definitions. Definitions applicable to this Chapter          “Cost-To-Charge Ratio”                              R9-22-701
                                                                            “Covered charges”                                   R9-22-701
    are found in the following:                                             “Covered services”                                  R9-22-101
    Definition                                 Section or Citation          “CPT”                                               R9-22-701
    “Accommodation”                                     R9-22-701           “Creditable coverage”      R9-22-2003 and 42 U.S.C. 300gg(c)
    “Act”                                               R9-22-101           “Critical Access Hospital”                          R9-22-701
    “ADHS”                                              R9-22-101           “CRS”                                              R9-22-1401
    “Administration”                            A.R.S. § 36-2901            “Cryotherapy”                                      R9-22-2001
    “Adverse action”                                    R9-22-101           “Customized DME”                                    R9-22-212
    “Affiliated corporate organization”                 R9-22-101           “Day”                               R9-22-101 and R9-22-1101
    “Aged”               42 U.S.C. 1382c(a)(1)(A) and R9-22-1501            “Date of the Notice of Adverse Action”             R9-22-1441
    “Aggregate”                                         R9-22-701           “DBHS”                                              R9-22-201
    “AHCCCS”                                            R9-22-101           “DCSE”                                             R9-22-1401
    “AHCCCS inpatient hospital day or days of care” R9-22-701               “De novo hearing”                              42 CFR 431.201
    “AHCCCS registered provider”                        R9-22-101           “Dentures” and “Denture services”                   R9-22-201
    “Ambulance”                                 A.R.S. § 36-2201            “Department”                                  A.R.S. § 36-2901
    “Ancillary department”                              R9-22-701           “Dependent child”                              A.R.S. § 46-101
    “Ancillary service”                                 R9-22-701           “DES”                                               R9-22-101
    “Anticipatory guidance”                             R9-22-201           “Diagnostic services”                               R9-22-101
    “Annual enrollment choice”                        R9-22-1701            “Director”                                          R9-22-101
    “APC”                                               R9-22-701           “Disabled”                                         R9-22-1501
    “Appellant”                                         R9-22-101           “Discussion”                                        R9-22-101
    “Applicant”                                         R9-22-101           “Disenrollment”                                    R9-22-1701
    “Application”                                       R9-22-101           “DME”                                               R9-22-101


June 30, 2011                                                      Page 5                                                      Supp. 11-2
Title 9, Ch. 22                                     Arizona Administrative Code
                                    Arizona Health Care Cost Containment System – Administration

     “DRI inflation factor”                             R9-22-701         “Medical education costs”                           R9-22-701
     “E.P.S.D.T. services”                       42 CFR 440.40(b)         “Medical expense deduction” or “MED”              R9-22-1401
     “Eligibility posting”                              R9-22-701         “Medical record”                                    R9-22-101
     “Eligible person”                            A.R.S. § 36-2901        “Medical review”                                    R9-22-701
     “Emergency behavioral health condition                               “Medical services”                            A.R.S. § 36-401
     for the non-FES member”                            R9-22-201         “Medical supplies”                                  R9-22-201
     “Emergency behavioral health services for the                        “Medical support”                                 R9-22-1401
     non-FES member”                                    R9-22-201         “Medically necessary”                               R9-22-101
     “Emergency medical condition for the non-FES                         “Medicare claim”                                    R9-22-101
     member”                                            R9-22-201         “Medicare HMO”                                      R9-22-101
     “Emergency medical services for the non-FES                          “Member”                                     A.R.S. § 36-2901
     member”                                            R9-22-201         “Mental disorder”                             A.R.S. § 36-501
     “Emergency medical or behavioral health                              “Milliman study”                                R9-22-712.07
     condition for a FES member”                        R9-22-217         “Monthly equivalent”              R9-22-1421 and R9-22-1603
     “Emergency services costs”                A.R.S. § 36-2903.07        “Monthly income”                  R9-22-1421 and R9-22-1603
     “Encounter”                                        R9-22-701         “National Standard code sets”                       R9-22-701
     “Enrollment”                                      R9-22-1701         “New hospital”                                      R9-22-701
     “Enumeration”                                      R9-22-101         “NICU”                                              R9-22-701
     “Equity”                                           R9-22-101         “Noncontracted Hospital”                            R9-22-718
     “Experimental services”                            R9-22-203         “Noncontracting provider”                    A.R.S. § 36-2901
     “Existing outpatient service”                      R9-22-701         “Non-FES member”                                    R9-22-201
     “Expansion funds”                                  R9-22-701         “Non-IHS Acute Hospital”                            R9-22-701
     “FAA”                                             R9-22-1401         “Nonparent caretaker relative”                    R9-22-1401
     “Facility”                                         R9-22-101         “Notice of Findings”                                R9-22-109
     “Factor”                         R9-22-701 and 42 CFR 447.10         “Nursing facility” or “NF”                 42 U.S.C. 1396r(a)
     “FBR”                                              R9-22-101         “OBHL”                                            R9-22-1201
     “Federal financial participation” or “FFP”    42 CFR 400.203         “Observation day”                                   R9-22-701
     “Federal poverty level” or “FPL”             A.R.S. § 36-2981        “Occupational therapy”                              R9-22-201
     “Fee-For-Service” or “FFS”                         R9-22-101         “Offeror”                                           R9-22-101
     “FES member”                                       R9-22-101         “Operating costs”                                   R9-22-701
     “FESP”                                             R9-22-101         “Organized health care delivery system”             R9-22-701
     “First-party liability”                           R9-22-1001         “Outlier”                                           R9-22-701
     “File”                                            R9-22-1101         “Outpatient hospital service”                       R9-22-701
     “Fiscal agent”                                     R9-22-210         “Ownership change”                                  R9-22-701
     “Fiscal intermediary”                              R9-22-701         “Ownership interest”                          42 CFR 455.101
     “Foster care maintenance payment”         42 U.S.C. 675(4)(A)        “Parent”                                          R9-22-1603
     “FQHC”                                             R9-22-101         “Partial Care”                                    R9-22-1201
     “Free Standing Children’s Hospital”                R9-22-701         “Participating institution”                         R9-22-701
     “Fund”                                          R9-22-712.07         “Peer group”                                        R9-22-701
     “Graduate medical education (GME) program”         R9-22-701         “Peer-reviewed study”                             R9-22-2001
     “Grievance”                                 A.A.C. R9-34-202         “Penalty”                                         R9-22-1101
     “GSA”                                              R9-22-101         “Pharmaceutical service”                            R9-22-201
     “HCPCS”                                            R9-22-701         “Physical therapy”                                  R9-22-201
     “Health care practitioner”                        R9-22-1201         “Physician”                                         R9-22-101
     “Hearing aid”                                      R9-22-201         “Physician assistant”                             R9-22-1201
     “HIPAA”                                            R9-22-701         “Post-stabilization services” R9-22-201 or 42 CFR 422.113
     “Home health services”                             R9-22-201         “PPC”                                               R9-22-701
     “Homebound”                                       R9-22-1401         “PPS bed”                                           R9-22-701
     “Hospital”                                         R9-22-101         “Practitioner”                                      R9-22-101
     “In-kind income”                                  R9-22-1420         “Pre-enrollment process”                          R9-22-1401
     “Insured entity”                                   R9-22-720         “Premium”                                         R9-22-1603
     “Intermediate Care Facility for                                      “Prescription”                                      R9-22-101
     the Mentally Retarded” or “ICF-MR”         42 U.S.C. 1396d(d)        “Primary care provider” or “PCP”                    R9-22-101
     “ICU”                                              R9-22-701         “Primary care provider services”                    R9-22-201
     “IHS”                                              R9-22-101         “Prior authorization”                               R9-22-101
     “IHS enrolled” or “enrolled with IHS”              R9-22-708         “Prior period coverage” or “PPC”                    R9-22-701
     “IMD” or “Institution for Mental                                     “Procedure code”                                    R9-22-701
     Diseases”                     42 CFR 435.1010 and R9-22-201          “Proposal”                                          R9-22-101
     “Income”                          R9-22-1401 and R9-22-1603          “Prospective rates”                                 R9-22-701
     “Indigent”                                        R9-22-1401         “Psychiatrist”                                    R9-22-1201
     “Individual”                                        R9-22-211        “Psychologist”                                    R9-22-1201
     “Inmate of a public institution”             42 CFR 435.1010         “Psychosocial rehabilitation services”              R9-22-201
     “Inpatient covered charges”                     R9-22-712.07         “Public hospital”                                   R9-22-701
     “Interested party”                                 R9-22-101         “Qualified alien”                         A.R.S. § 36-2903.03
     “Intermediate Care Facility for the                                  “Qualified behavioral health service provider”    R9-22-1201
     Mentally Retarded” or “ICF-MR”             42 U.S.C. 1396d(d)        “Quality management”                                R9-22-501
     “Intern and Resident Information System”           R9-22-701         “Radiology”                                         R9-22-101
     “LEEP”                                            R9-22-2001         “RBHA” or “Regional Behavioral Health
     “Legal representative”                             R9-22-101         Authority”                                          R9-22-201
     “Level I trauma center”                           R9-22-2101         “Reason to know”                                  R9-22-1101
     “License” or “licensure”                           R9-22-101         “Rebase”                                            R9-22-701
     “Licensee”                                        R9-22-1201         “Referral”                                          R9-22-101
     “Liquid assets”                                   R9-22-1401         “Rehabilitation services”                           R9-22-101
     “Mailing date”                                     R9-22-101         “Reinsurance”                                       R9-22-701


Supp. 11-2                                                       Page 6                                                  June 30, 2011
                                                    Arizona Administrative Code                                           Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

     “Remittance advice”                               R9-22-701          “AHCCCS” means the Arizona Health Care Cost Containment
     “Resident”                                        R9-22-701          System, which is composed of the Administration, contractors,
     “Residual functional deficit”                     R9-22-201          and other arrangements through which health care services are
     “Resources”                                      R9-22-1401          provided to a member.
     “Respiratory therapy”                             R9-22-201
     “Respite”                                        R9-22-1201          “AHCCCS registered provider” means a provider or noncon-
     “Responsible offeror”                             R9-22-101          tracting provider who:
     “Responsive offeror”                              R9-22-101
     “Revenue Code”                                    R9-22-701               Enters into a provider agreement with the Administration
     “Review”                                          R9-22-101               under R9-22-703(A), and
     “Review month”                                    R9-22-101               Meets license or certification requirements to provide
     “RFP”                                             R9-22-101               covered services.
     “Rural Contractor”                                R9-22-718
     “Rural Hospital”                 R9-22-712.07 and R9-22-718          “Appellant” means an applicant or member who is appealing
     “Scope of services”                               R9-22-201          an adverse action by the Department or Administration.
     “Section 1115 Waiver”                       A.R.S. § 36-2901         “Applicant” means a person who submits or whose authorized
     “Service location”                                R9-22-101          representative submits a written, signed, and dated application
     “Service site”                                    R9-22-101          for AHCCCS benefits.
     “SOBRA”                                           R9-22-101
     “Specialist”                                      R9-22-101          “Application” means an official request for AHCCCS medical
     “Specialty facility”                              R9-22-701          coverage made under this Chapter.
     “Speech therapy”                                  R9-22-201
     “Spendthrift restriction”                        R9-22-1401          “Assignment” means enrollment of a member with a contrac-
     “Sponsor”                                        R9-22-1401          tor by the Administration.
     “Sponsor deemed income”                          R9-22-1401
     “Sponsoring institution”                          R9-22-701          “Attending physician” means a licensed allopathic or osteo-
     “Spouse”                                          R9-22-101          pathic doctor of medicine who has primary responsibility for
     “SSA”                                        42 CFR 1000.10          providing or directing preventive and treatment services for a
     “SSDI Temporary Medical Coverage”                R9-22-1603          Fee-For-Service member.
     “SSI”                                          42 CFR 435.4
     “SSN”                                             R9-22-101          “Authorized representative” means a person who is authorized
     “Stabilize”                                 42 U.S.C. 1395dd         to apply for medical assistance or act on behalf of another per-
     “Standard of care”                                R9-22-101          son.
     “Sterilization”                                   R9-22-201          “Capped fee-for-service” means the payment mechanism by
     “Subcontract”                                     R9-22-101
     “Submitted”                                 A.R.S. § 36-2904         which a provider of care is reimbursed upon submission of a
     “Substance abuse”                                 R9-22-201          valid claim for a specific covered service or equipment pro-
     “SVES”                                           R9-22-1401          vided to a member. A payment is made in accordance with an
     “Therapeutic foster care services”               R9-22-1201          upper or capped limit established by the Director. This capped
     “Third-party”                                    R9-22-1001          limit can either be a specific dollar amount or a percentage of
     “Third-party liability”                          R9-22-1001          billed charges.
     “Tier”                                            R9-22-701
     “Tiered per diem”                                 R9-22-701          “Case record” means an individual or family file retained by
     “Title IV-D”                                     R9-22-1401          the Department that contains all pertinent eligibility informa-
     “Title IV-E”                                     R9-22-1401          tion, including electronically stored data.
     “Total Inpatient payments”                      R9-22-712.07
     “Trauma and Emergency Services Fund” A.R.S. § 36-2903.07             “Case review” means the Administration’s evaluation of an
     “TRBHA” or “Tribal Regional Behavioral Health                        individual’s or family’s circumstances and case record in a
     Authority”                                       R9-22-1201          review month.
     “Treatment”                                      R9-22-2004
     “Tribal Facility”                           A.R.S. § 36-2981         “Categorically eligible” means a person who is eligible under
     “Unrecovered trauma center readiness costs”      R9-22-2101          A.R.S. §§ 36-2901(6)(a)(i), (ii), or (iii) or 36-2934.
     “Urban Contractor”                                R9-22-718          “CMS” means the Centers for Medicare and Medicaid Ser-
     “Urban Hospital”                                  R9-22-718          vices.
     “USCIS”                                          R9-22-1401
     “Utilization management”                          R9-22-501          “Continuous stay” means a period during which a member
     “WWHP”                                           R9-22-2001          receives inpatient hospital services without interruption begin-
B.   General definitions. In addition to definitions contained in         ning with the date of admission and ending with the date of
     A.R.S. § 36-2901, the words and phrases in this Chapter have         discharge or date of death.
     the following meanings unless the context explicitly requires
     another meaning:                                                     “Contract” means a written agreement entered into between a
                                                                          person, an organization, or other entity and the Administration
     “Act” means the Social Security Act.                                 to provide health care services to a member under A.R.S. Title
     “ADHS” means the Arizona Department of Health Services.              36, Chapter 29, and this Chapter.
     “Adverse action” means an action taken by the Department or          “Contract year” means the period beginning on October 1 of a
     Administration to deny, discontinue, or reduce medical assis-        year and continuing until September 30 of the following year.
     tance.                                                               “Covered services” means the health and medical services
     “Affiliated corporate organization” means any organization           described in Articles 2 and 12 of this Chapter as being eligible
     that has ownership or control interests as defined in 42 CFR         for reimbursement by AHCCCS.
     455.101, and includes a parent and subsidiary corporation.           “Day” means a calendar day unless otherwise specified.


June 30, 2011                                                    Page 7                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     “DES” means the Department of Economic Security.                         state or a county regulatory agency or board and allows a
                                                                              health care provider to lawfully render a health care service.
     “Diagnostic services” means services provided for the purpose
     of determining the nature and cause of a condition, illness, or          “Mailing date” when used in reference to a document sent first
     injury.                                                                  class, postage prepaid, through the United States mail, means
                                                                              the date:
     “Director” means the Director of the Administration or the
                                                                                   Shown on the postmark;
     Director’s designee.
                                                                                   Shown on the postage meter mark of the envelope, if no
     “Discussion” means an oral or written exchange of informa-
                                                                                   postmark; or
     tion or any form of negotiation.
                                                                                   Entered as the date on the document, if there is no legible
     “DME” means durable medical equipment, which is an item or
                                                                                   postmark or postage meter mark.
     appliance that can withstand repeated use, is designed to serve
     a medical purpose, and is not generally useful to a person in            “Medical record” means a document that relates to medical or
     the absence of a medical condition, illness, or injury.                  behavioral health services provided to a member by a physi-
                                                                              cian or other licensed practitioner of the healing arts and that is
     “Enumeration” means the assignment of a nine-digit identifi-
                                                                              kept at the site of the provider.
     cation number to a person by the Social Security Administra-
     tion.                                                                    “Medically necessary” means a covered service is provided by
                                                                              a physician or other licensed practitioner of the healing arts
     “Equity” means the county assessor full cash value or market
                                                                              within the scope of practice under state law to prevent disease,
     value of a resource minus valid liens, encumbrances, or both.
                                                                              disability, or other adverse health conditions or their progres-
     “Facility” means a building or portion of a building licensed or         sion, or to prolong life.
     certified by the Arizona Department of Health Services as a
                                                                              “Medicare claim” means a claim for Medicare-covered ser-
     health care institution under A.R.S. Title 36, Chapter 4, to pro-
                                                                              vices for a member with Medicare coverage.
     vide a medical service, a nursing service, or other health care
     or health-related service.                                               “Medicare HMO” means a health maintenance organization
                                                                              that has a current contract with Centers for Medicare and Med-
     “FBR” means Federal Benefit Rate, the maximum monthly
                                                                              icaid Services for participation in the Medicare program under
     Supplemental Security Income payment rate for a member or a
                                                                              42 CFR 417(L).
     married couple.
                                                                              “Offeror” means an individual or entity that submits a pro-
     “Fee-For-Service” or “FFS” means a method of payment by
                                                                              posal to the Administration in response to an RFP.
     the AHCCCS Administration to a registered provider on an
     amount-per-service basis for a member not enrolled with a                “Physician” means a person licensed as an allopathic or osteo-
     contractor.                                                              pathic physician under A.R.S. Title 32, Chapter 13 or Chapter
                                                                              17.
     “FES member” means a person who is eligible to receive
     emergency medical and behavioral health services through the             “Practitioner” means a physician assistant licensed under
     FESP under R9-22-217.                                                    A.R.S. Title 32, Chapter 25, or a registered nurse practitioner
                                                                              certified under A.R.S. Title 32, Chapter 15.
     “FESP” means the federal emergency services program under
     R9-22-217 which covers services to treat an emergency medi-              “Prescription” means an order to provide covered services that
     cal or behavioral health condition for a member who is deter-            is signed or transmitted by a provider authorized to prescribe
     mined eligible under A.R.S. § 36-2903.03(D).                             the services.
     “FQHC” means federally qualified health center.                          “Primary care provider” or “PCP” means an individual who
                                                                              meets the requirements of A.R.S. § 36-2901(12) or (13), and
     “GSA” means a geographical service area designated by the
                                                                              who is responsible for the management of a member’s health
     Administration within which a contractor provides, directly or
                                                                              care.
     through a subcontract, a covered health care service to a mem-
     ber enrolled with the contractor.                                        “Prior authorization” means the process by which the Admin-
                                                                              istration or contractor, whichever is applicable, authorizes, in
     “Hospital” means a health care institution that is licensed as a
                                                                              advance, the delivery of covered services contingent on the
     hospital by the Arizona Department of Health Services under
                                                                              medical necessity of the services.
     A.R.S. Title 36, Chapter 4, Article 2, and certified as a pro-
     vider under Title XVIII of the Social Security Act, as                   “Prior period coverage” means the period prior to the mem-
     amended, or is currently determined, by the Arizona Depart-              ber’s enrollment during which a member is eligible for cov-
     ment of Health Services as the CMS designee, to meet the                 ered services. PPC begins on the first day of the month of
     requirements of certification.                                           application or the first eligible month, whichever is later, and
                                                                              continues until the day the member is enrolled with a contrac-
     “IHS” means Indian Health Service.
                                                                              tor.
     “Interested party” means an actual or prospective offeror
                                                                              “Proposal” means all documents, including best and final
     whose economic interest may be directly affected by the issu-
                                                                              offers, submitted by an offeror in response to an RFP by the
     ance of an RFP, the award of a contract, or by the failure to
                                                                              Administration.
     award a contract.
                                                                              “Radiology” means professional and technical services ren-
     “Legal representative” means a custodial parent of a child
                                                                              dered to provide medical imaging, radiation oncology, and
     under 18, a guardian, or a conservator.
                                                                              radioisotope services.
     “License” or “licensure” means a nontransferable authoriza-
     tion that is granted based on established standards in law by a


Supp. 11-2                                                           Page 8                                                       June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

    “Referral” means the process by which a member is directed                3). Former Section R9-22-101 adopted as an emergency
    by a primary care provider or an attending physician to another           now adopted and amended as a permanent rule effective
    appropriate provider or resource for diagnosis or treatment.                August 30, 1982 (Supp. 82-4). Former Section R9-22-
                                                                             101 repealed, former Sections R9-22-102 and R9-22-301
    “Rehabilitation services” means physical, occupational, and
                                                                             renumbered as Section R9-22-101 and amended effective
    speech therapies, and items to assist in improving or restoring
                                                                              October 1, 1983 (Supp. 83-5). Adopted as an emergency
    a person’s functional level.
                                                                                effective May 18, 1984, pursuant to A.R.S. § 41-1003,
    “Responsible offeror” means an individual or entity that has                  valid for only 90 days (Supp. 84-3). Amended as an
    the capability to perform the requirements of a contract and             emergency by adding new paragraphs (24), (46), (84) and
    that ensures good faith performance.                                       (91) and renumbering accordingly effective August 16,
                                                                                1984, pursuant to A.R.S. § 41-1003, valid for only 90
    “Responsive offeror” means an individual or entity that sub-
                                                                              days (Supp. 84-4). Amended as an emergency by adding
    mits a proposal that conforms in all material respects to an
                                                                                new paragraphs (2) and (15) and renumbering accord-
    RFP.
                                                                             ingly effective October 25, 1984, pursuant to A.R.S. § 41-
    “Review” means a review of all factors affecting a member’s                 1003, valid for only 90 days (Supp. 84-5). Emergency
    eligibility.                                                             expired. Permanent amendment added paragraphs (2) and
                                                                               (15) and renumbered accordingly effective February 1,
    “Review month” means the month in which the individual’s or
    family’s circumstances and case record are reviewed.                       1985 (Supp. 85-1). Amended effective October 1, 1985
                                                                               (Supp. 85-5). Amended paragraphs (10) and (15) effec-
    “RFP” means Request for Proposals, including all documents,                 tive October 1, 1986 (Supp. 86-5). Amended effective
    whether attached or incorporated by reference, that are used by           January 1, 1987, filed December 31, 1986 (Supp. 86-6).
    the Administration for soliciting a proposal under 9 A.A.C. 22,            Amended effective October 1, 1987; amended effective
    Article 6.                                                                 December 22, 1987 (Supp. 87-4). Amended by deleting
    “Service location” means a location at which a member                      paragraphs (39) and (62) and renumbering accordingly
    obtains a covered service provided by a physician or other                 effective July 1, 1988 (Supp. 88-3). Amended effective
    licensed practitioner of the healing arts under the terms of a           May 30, 1989 (Supp. 89-2). Amended effective April 13,
    contract.                                                                   1990 (Supp. 90-2). Amended effective September 29,
                                                                               1992 (Supp. 92-3). Amended under an exemption from
    “Service site” means a location designated by a contractor as                 the provisions of the Administrative Procedure Act,
    the location at which a member is to receive covered services.           effective March 1, 1993 (Supp. 93-1). Amended under an
    “S.O.B.R.A.” means Section 9401 of the Sixth Omnibus Bud-                exemption from the provisions of the Administrative Pro-
    get Reconciliation Act, 1986, amended by the Medicare Cata-              cedure Act, effective July 1, 1993 (Supp. 93-3). Amended
    strophic   Coverage      Act    of     1988,  42    U.S.C.                under an exemption from the provisions of the Adminis-
    1396a(a)(10)(A)(i)(IV), 42 U.S.C. 1396a(a)(10)(A)(i)(VI),                 trative Procedure Act, effective October 26, 1993 (Supp.
    and 42 U.S.C. 1396a(a)(10)(A)(i)(VII).                                   93-4). Amended effective December 13, 1993 (Supp. 93-
                                                                                4). Amended effective January 14, 1997 (Supp. 97-1).
    “Specialist” means a Board-eligible or certified physician who            Section repealed; new Section adopted effective Decem-
    declares himself or herself as a specialist and practices a spe-          ber 8, 1997 (Supp. 97-4). Section repealed, new Section
    cific medical specialty. For the purposes of this definition,              adopted by final rulemaking at 5 A.A.R. 294, effective
    Board-eligible means a physician who meets all the require-                 January 8, 1999 (Supp. 99-1). Amended by final rule-
    ments for certification but has not tested for or has not been                making at 5 A.A.R. 607, effective February 5, 1999
    issued certification.                                                     (Supp. 99-1). Amended by final rulemaking at 5 A.A.R.
    “Spouse” means a person who has entered into a contract of                867, effective March 4, 1999 (Supp. 99-1). Amended by
    marriage recognized as valid by this state.                                final rulemaking at 5 A.A.R. 4061, effective October 8,
                                                                                1999 (Supp. 99-4). Amended by final rulemaking at 6
    “SSN” means Social Security number.                                        A.A.R. 179, effective December 13, 1999 (Supp. 99-4).
    “Standard of care” means a medical procedure or process that             Amended by final rulemaking at 6 A.A.R. 2435, effective
    is accepted as treatment for a specific illness, injury, or medi-        June 9, 2000 (Supp. 00-2). Amended by final rulemaking
    cal condition through custom, peer review, or consensus by the           at 6 A.A.R. 3317, effective August 7, 2000 (Supp. 00-3).
    professional medical community.                                          Amended by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                              tive October 1, 2001 (Supp. 01-3). Amended by exempt
    “Subcontract” means an agreement entered into by a contrac-              rulemaking at 7 A.A.R. 5701, effective December 1, 2001
    tor with any of the following:                                            (Supp. 01-4). Amended by final rulemaking at 7 A.A.R.
         A provider of health care services who agrees to furnish                   5814, effective December 6, 2001 (Supp. 01-4).
         covered services to a member,                                        Amended by final rulemaking at 8 A.A.R. 424, effective
                                                                               January 10, 2002 (Supp. 02-1). Amended by final rule-
         A marketing organization, or                                          making at 8 A.A.R. 2325, effective May 9, 2002 (Supp.
         Any other organization or person that agrees to perform               02-2). Amended by final rulemaking at 8 A.A.R. 3317,
         any administrative function or service for the contractor                 effective July 15, 2002 (Supp. 02-3). Amended by
         specifically related to securing or fulfilling the contrac-           exempt rulemaking at 9 A.A.R. 4001, effective October
         tor’s obligation to the Administration under the terms of a          19, 2003 (Supp. 03-3). Amended by exempt rulemaking
         contract.                                                           at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-
                                                                                 4). Amended by final rulemaking at 11 A.A.R. 3830,
                         Historical ote                                       effective November 12, 2005 (Supp. 05-3). Amended by
    Adopted as an emergency effective May 20, 1982 pursu-                     final rulemaking at 11 A.A.R. 5467, effective December
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-               6, 2005 (Supp. 05-4). Amended by final rulemaking at 13


June 30, 2011                                                       Page 9                                                       Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

          A.A.R. 836, effective May 5, 2007 (Supp. 07-1).                     rulemaking at 10 A.A.R. 808, effective April 3, 2004
      Amended by final rulemaking at 13 A.A.R. 3351, effec-                                      (Supp. 04-1).
     tive November 10, 2007 (Supp. 07-3). Amended by final
                                                                       R9-22-109.     Repealed
      rulemaking at 14 A.A.R. 1598, effective May 31, 2008
        (Supp. 08-2). Amended by exempt rulemaking at 16                                        Historical ote
       A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).                    Adopted effective December 8, 1997 (Supp. 97-4).
                                                                            Amended by final rulemaking at 5 A.A.R. 4061, effective
R9-22-102.        Repealed
                                                                            October 8, 1999 (Supp. 99-4). Amended by exempt rule-
                           Historical ote                                     making at 7 A.A.R. 4593, effective October 1, 2001
     Adopted as an emergency effective May 20, 1982, pursu-                 (Supp. 01-3). Section repealed by final rulemaking at 12
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-              A.A.R. effective 4484, effective January 6, 2007 (Supp.
      3). Former Section R9-22-102 adopted as an emergency                                            06-4).
      now adopted and amended as a permanent rule effective
                                                                       R9-22-110.     Repealed
       August 30, 1092 (Supp. 82-4). Former Section R9-22-
     102 renumbered together with former Section R9-22-301                                      Historical ote
      as Section R9-22-101 and amended effective October 1,                    Adopted effective December 8, 1997 (Supp. 97-4).
         1983 (Supp. 83-5). New Section adopted effective                   Amended by final rulemaking at 6 A.A.R. 2435, effective
        December 8, 1997 (Supp. 97-4). Amended by exempt                    June 9, 2000 (Supp. 00-2). Section repealed by final rule-
     rulemaking at 7 A.A.R. 5701, effective December 1, 2001                making at 10 A.A.R. 1146, effective May 1, 2004 (Supp.
      (Supp. 01-4). Amended by final rulemaking at 8 A.A.R.                                          04-1).
      2325, effective May 9, 2002 (Supp. 02-2). Amended by
                                                                       R9-22-111.     Reserved
      final rulemaking at 11 A.A.R. 5467, effective December
     6, 2005 (Supp. 05-4). Amended by final rulemaking at 13           R9-22-112.     Repealed
     A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Section
                                                                                                 Historical ote
     repealed by final rulemaking at 13 A.A.R. 3351, effective
                                                                             Adopted effective December 8, 1997 (Supp. 97-4). Sec-
                 November 10, 2007 (Supp. 07-3).
                                                                            tion repealed; new Section adopted by final rulemaking at
R9-22-103.        Repealed                                                  6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4).
                                                                            Amended by exempt rulemaking at 7 A.A.R. 4593, effec-
                          Historical ote
                                                                            tive October 1, 2001 (Supp. 01-3). Repealed by final rule-
      Adopted effective December 8, 1997 (Supp. 97-4). Sec-
                                                                             making at 13 A.A.R. 836, effective May 5, 2007 (Supp.
     tion repealed by final rulemaking at 5 A.A.R. 294, effec-
                                                                                                      07-1).
                 tive January 8, 1999 (Supp. 99-1).
                                                                       R9-22-113.     Reserved
R9-22-104.        Reserved
                                                                       R9-22-114.     Repealed
R9-22-105.        Repealed
                                                                                                 Historical ote
                         Historical ote
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
        Adopted effective December 8, 1997 (Supp. 97-4).
                                                                            294, effective January 8, 1999 (Supp. 99-1). Amended by
     Amended by final rulemaking at 6 A.A.R. 2435, effective
                                                                            final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
     June 9, 2000 (Supp. 00-2). Section repealed by final rule-
                                                                               (Supp. 00-2). Amended by exempt rulemaking at 7
      making at 11 A.A.R. 4277, effective December 5, 2005
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                          (Supp. 05-4).
                                                                             Section repealed by final rulemaking at 11 A.A.R. 5467,
R9-22-106.        Repealed                                                           effective December 6, 2005 (Supp. 05-4).
                         Historical ote                                R9-22-115.     Repealed
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                                                Historical ote
     607, effective February 5, 1999 (Supp. 99-1). Amended
                                                                            Final Section adopted at 5 A.A.R. 294, effective January
      by final rulemaking at 6 A.A.R. 2435, effective June 9,
                                                                            8, 1999 (Supp. 99-1). Amended by exempt rulemaking at
     2000 (Supp. 00-2). Section repealed by final rulemaking
                                                                             7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
      at 11 A.A.R. 5467, effective December 6, 2005 (Supp.
                                                                            Section repealed by final rulemaking at 11 A.A.R. 5467,
                               05-4).
                                                                                    effective December 6, 2005 (Supp. 05-4).
R9-22-107.        Repealed
                                                                       R9-22-116.     Repealed
                         Historical ote
                                                                                                 Historical ote
       Adopted effective December 8, 1997 (Supp. 97-4).
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
     Amended by final rulemaking at 8 A.A.R. 424, effective
                                                                            294, effective January 8, 1999 (Supp. 99-1). Amended by
     January 10, 2002 (Supp. 02-1). Amended by final rule-
                                                                            final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
     making at 8 A.A.R. 3317, effective July 15, 2002 (Supp.
                                                                            (Supp. 00-2). Section repealed by exempt rulemaking at 7
       02-3). Section repealed by exempt rulemaking at 11
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
        A.A.R. 2297, effective July 1, 2005 (Supp. 05-2).
                                                                       R9-22-117.     Repealed
R9-22-108.        Repealed
                                                                                                Historical ote
                        Historical ote
                                                                            New Section adopted by final rulemaking at 5 A.A.R. 294,
       Adopted effective December 8, 1997 (Supp. 97-4).
                                                                              effective January 8, 1999 (Supp. 99-1). Amended by
     Amended by final rulemaking at 6 A.A.R. 3317, effective
                                                                            exempt rulemaking at 7 A.A.R. 4593, effective October 1,
      August 7, 2000 (Supp. 00-3). Section repealed by final



Supp. 11-2                                                        Page 10                                                    June 30, 2011
                                                      Arizona Administrative Code                                              Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

     2001 (Supp. 01-3). Section repealed by final rulemaking at              “Hearing aid” means an instrument or device designed for, or
       14 A.A.R. 1598, effective May 31, 2008 (Supp. 08-2).                  represented by the supplier as aiding or compensating for
                                                                             impaired or defective human hearing, and includes any parts,
R9-22-118.      Reserved
                                                                             attachments, or accessories of the instrument or device.
R9-22-119.      Reserved
R9-22-120.      Repealed                                                     “Home health services” means services and supplies that are
                                                                             provided by a home health agency that coordinates in-home
                           Historical ote                                    intermittent services for curative, habilitative care, including
     New Section made by final rulemaking at 7 A.A.R. 5814,                  home-health aide services, licensed nurse services, and medi-
         effective December 6, 2001 (Supp. 01-4). Section                    cal supplies, equipment, and appliances.
     repealed by final rulemaking at 12 A.A.R. 4488, effective
                   January 6, 2007 (Supp. 06-4).                             “IMD” or “Institution for Mental Diseases” means an Institu-
                                                                             tion for Mental Diseases as described in 42 CFR 435.1010 and
              ARTICLE 2. SCOPE OF SERVICES                                   licensed by ADHS.
R9-22-201. Scope of Services-related Definitions                             “Medical supplies” means consumable items that are designed
In addition to definitions contained in A.R.S. § 36-2901, the words          specifically to meet a medical purpose.
and phrases in this Chapter have the following meanings unless the           “Non-FES member” means an eligible person who is entitled
context explicitly requires another meaning:                                 to full AHCCCS services.
     “Anticipatory guidance” means a person responsible for a
                                                                             “Occupational therapy” means medically prescribed treatment
     child receives information and guidance of what the person
                                                                             provided by or under the supervision of a licensed occupa-
     should expect of the child’s development and how to help the
                                                                             tional therapist, to restore or improve an individual’s ability to
     child stay healthy.
                                                                             perform tasks required for independent functioning.
     “Behavioral health recipient” means a Title XIX or Title XXI
                                                                             “Pharmaceutical service” means medically necessary medica-
     acute care member who is eligible for, and is receiving, behav-
                                                                             tions that are prescribed by a physician, practitioner, or dentist
     ioral health services through ADHS/DBHS.
                                                                             under R9-22-209.
     “Children’s Rehabilitative Services” or “CRS” means the pro-
                                                                             “Physical therapy” means treatment services to restore or
     gram within ADHS that provides covered medical services
                                                                             improve muscle tone, joint mobility, or physical function pro-
     and covered support services in accordance with A.R.S. § 36-
                                                                             vided by or under the supervision of a registered physical ther-
     261.
                                                                             apist.
     “Clinical supervision” means a Clinical Supervisor under 9
                                                                             “Post-stabilization services” means covered services related to
     A.A.C. 20, Article 2 reviews the skills and knowledge of the
                                                                             an emergency medical or behavioral health condition provided
     individual supervised and provides guidance in improving or
                                                                             after the condition is stabilized.
     developing the skills and knowledge.
                                                                             “Primary care provider services” means healthcare services
     “DBHS” means the Division of Behavioral Health Services
                                                                             provided by and within the scope of practice, as defined by
     within the Arizona Department of Health Services.
                                                                             law, of a licensed physician, certified nurse practitioner, or
     “Emergency behavioral health condition for the non-FES                  licensed physician assistant.
     member” means a condition manifesting itself by acute symp-
                                                                             “Psychosocial rehabilitation services” means services that pro-
     toms of sufficient severity, including severe pain, such that a
                                                                             vide education, coaching, and training to address or prevent
     prudent layperson who possesses an average knowledge of
                                                                             residual functional deficits and may include services that may
     health and medicine could reasonably expect the absence of
                                                                             assist a member to secure and maintain employment. Psycho-
     immediate medical attention to result in:
                                                                             social rehabilitation services may include:
           Placing the health of the person, including mental health,
                                                                                   Living skills training,
           in serious jeopardy;
                                                                                   Cognitive rehabilitation,
           Serious impairment to bodily functions;
                                                                                   Health promotion,
           Serious dysfunction of any bodily organ or part; or
                                                                                   Supported employment, and
           Serious physical harm to another person.
                                                                                   Other services that increase social and communication
     “Emergency behavioral health services for the non-FES mem-
                                                                                   skills to maximize a member’s ability to participate in the
     ber” means those behavioral health services provided for the
                                                                                   community and function independently.
     treatment of an emergency behavioral health condition.
                                                                             “RBHA” or “Regional Behavioral Health Authority” means
     “Emergency medical condition for the non-FES member”
                                                                             the same as in A.R.S. § 36-3401.
     means treatment for a medical condition, including labor and
     delivery, that manifests itself by acute symptoms of sufficient         “Residual functional deficit” means a member’s inability to
     severity, including severe pain, such that a prudent layperson          return to a previous level of functioning, usually after experi-
     who possesses an average knowledge of health and medicine,              encing a severe psychotic break or state of decompensation.
     could reasonably expect the absence of immediate medical                “Respiratory therapy” means treatment services to restore,
     attention to result in:                                                 maintain, or improve respiratory functions that are provided
           Placing the member’s health in serious jeopardy,                  by, or under the supervision of, a respiratory therapist licensed
                                                                             according to A.R.S. Title 32, Chapter 35.
           Serious impairment to bodily functions, or
                                                                             “Scope of services” means the covered, limited, and excluded
           Serious dysfunction of any bodily organ or part.
                                                                             services under Articles 2 and 12 of this Chapter.
     “Emergency medical services for the non-FES member”
                                                                             “Speech therapy” means medically prescribed diagnostic and
     means services provided for the treatment of an emergency
                                                                             treatment services provided by or under the supervision of a
     medical condition.
                                                                             certified speech therapist.


June 30, 2011                                                      Page 11                                                         Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     “Sterilization” means a medically necessary procedure, not for              ers within the contractor’s network without a referral
     the purpose of family planning, to render an eligible person or             from a primary care provider.
     member barren in order to:                                            6. A member may receive behavioral health evaluation ser-
          Prevent the progression of disease, disability, or adverse             vices without a referral from a primary care provider. A
          health conditions; or                                                  member may receive behavioral health treatment services
                                                                                 only under referral from the primary care provider or
          Prolong life and promote physical health.                              upon authorization by the contractor or the contractor’s
     “Substance abuse” means the chronic, habitual, or compulsive                designee.
     use of any chemical matter that, when introduced into the             7. AHCCCS or a contractor shall provide services under the
     body, is capable of altering human behavior or mental func-                 Section 1115 Waiver as defined in A.R.S. § 36-2901.
     tioning and, with extended use, may cause psychological               8. An AHCCCS registered provider shall provide covered
     dependence and impaired mental, social or educational func-                 services within the provider’s scope of practice.
     tioning. Nicotine addiction is not considered substance abuse         9. In addition to the specific exclusions and limitations oth-
     for adults who are 21 years of age or older.                                erwise specified under this Article, the following are not
                           Historical ote                                        covered:
     Adopted as an emergency effective May 20, 1982 pursu-                       a. A service that is determined by the AHCCCS Chief
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-                       Medical Officer to be experimental or provided pri-
      3). Former Section R9-22-201 adopted as an emergency                            marily for the purpose of research;
      now adopted and amended as a permanent rule effective                      b. Services or items furnished gratuitously, and
      August 30, 1982 (Supp. 82-4). Amended effective Octo-                      c. Personal care items except as specified under R9-22-
     ber 1, 1985 (Supp. 85-5). Amended subsection (B) effec-                          212.
         tive May 30, 1989 (Supp. 89-2). Amended under an                  10. Medical or behavioral health services are not covered ser-
     exemption from the provisions of the Administrative Pro-                    vices if provided to:
      cedure Act, effective July 1, 1993 (Supp. 93-3). Section                   a. An inmate of a public institution;
       repealed, new Section adopted effective September 22,                     b. A person who is in residence at an institution for the
      1997 (Supp. 97-3). Amended by exempt rulemaking at 7                            treatment of tuberculosis; or
        A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                     c. A person age 21 through 64 who is in an IMD,
     Amended by final rulemaking at 8 A.A.R. 2325, effective                          unless the service is covered under Article 12 of this
     May 9, 2002 (Supp. 02-2). Amended by exempt rulemak-                             Chapter.
     ing at 10 A.A.R. 4588, effective October 12, 2004 (Supp.           C. The Administration or a contractor may deny payment of non-
      04-4). Amended by final rulemaking at 11 A.A.R. 3217,                emergency services if prior authorization is not obtained as
     effective October 1, 2005 (Supp. 05-3). Section repealed;             specified in this Article and Article 7 of this Chapter. The
         new Section made by final rulemaking at 13 A.A.R.                 Administration or a contractor shall not reimburse services
                 3351, effective November 10, 2007                         that require prior authorization unless the provider documents
        (Supp. 07-3). Amended by exempt rulemaking at 16                   the diagnosis and treatment.
        A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).            D. Services under A.R.S. § 36-2908 provided during the prior
                                                                           period coverage do not require prior authorization.
R9-22-202. General Requirements                                         E. Prior authorization is not required for services necessary to
A. For the purposes of this Article, the following definitions             evaluate and stabilize an emergency medical condition. The
    apply:                                                                 Administration or a contractor shall not reimburse services
    1. “Authorization” means written or verbal authorization               that require prior authorization unless the provider documents
         by:                                                               the diagnosis and treatment.
         a. The Administration for services rendered to a fee-          F. A service is not a covered service if provided outside the GSA
               for-service member, or                                      unless one of the following applies:
         b. The contractor for services rendered to a prepaid              1. A member is referred by a primary care provider for med-
               capitated member.                                                 ical specialty care outside the GSA. If a member is
    2. Use of the phrase “attending physician” applies only to                   referred outside the GSA to receive an authorized medi-
         the fee-for-service population.                                         cally necessary service, the contractor shall also provide
B. In addition to other requirements and limitations specified in                all other medically necessary covered services for the
    this Chapter, the following general requirements apply:                      member;
    1. Only medically necessary, cost effective, and federally-            2. There is a net savings in service delivery costs as a result
         reimbursable and state-reimbursable services are covered                of going outside the GSA that does not require undue
         services.                                                               travel time or hardship for a member or the member’s
    2. Covered services for the federal emergency services pro-                  family;
         gram (FESP) are under R9-22-217.                                  3. The contractor authorizes placement in a nursing facility
    3. The Administration or a contractor may waive the cov-                     located out of the GSA; or
         ered services referral requirements of this Article.              4. Services are provided during prior period coverage.
    4. Except as authorized by the Administration or a contrac-         G. If a member is traveling or temporarily residing outside of the
         tor, a primary care provider, attending physician, practi-        GSA, covered services are restricted to emergency care ser-
         tioner, or a dentist shall provide or direct the member’s         vices, unless otherwise authorized by the contractor.
         covered services. Delegation of the provision of care to a     H. A contractor shall provide at a minimum, directly or through
         practitioner does not diminish the role or responsibility of      subcontracts, the covered services specified in this Chapter
         the primary care provider.                                        and in contract.
    5. A contractor shall offer a female member direct access to        I. The Administration shall determine the circumstances under
         preventive and routine services from gynecology provid-           which a FFS member may receive services, other than emer-
                                                                           gency services, from service providers outside the member’s


Supp. 11-2                                                         Page 12                                                    June 30, 2011
                                                     Arizona Administrative Code                                              Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

   county of residence or outside the state. Criteria considered by               and effective for the condition for which it is intended or
   the Administration in making this determination shall include                  used based on the weight of the evidence in peer-
   availability and accessibility of appropriate care and cost                    reviewed articles in medical journals published in the
   effectiveness.                                                                 United States.
J. The restrictions, limitations, and exclusions in this Article do          3. The service does not meet the standard in subsection
   not apply to the following:                                                    (A)(2) because the condition for which the service is
   1. Public and private employers selecting AHCCCS as a                          intended or used is rare, but the service has been demon-
         health care option for their employees according to 9                    strated to be safe and effective for the condition for which
         A.A.C. 27; and                                                           it is intended or used based on the weight of opinions
   2. A contractor electing to provide noncovered services.                       from specialists who provide the service or related ser-
         a. The Administration shall not consider the costs of                    vices.
              providing a noncovered service to a member in the         B.   The following factors shall be considered when evaluating the
              development or negotiation of a capitation rate.               weight of peer-reviewed articles or the opinions of specialists:
         b. A contractor shall pay for noncovered services from              1. The mortality rate and survival rate of the service as com-
              administrative revenue or other contractor funds that               pared to the rates for alternative non-experimental ser-
              are unrelated to the provision of services under this               vices.
              Chapter.                                                       2. The types, severity, and frequency of complications asso-
K. Subject to CMS approval, the restrictions, limitations, and                    ciated with the services as compared with the complica-
   exclusions specified in the following subsections do not apply                 tions associated with alternative non-experimental
   to American Indians receiving services through IHS or a tribal                 services.
   health program operating under P.L. 93-638 when those ser-                3. The frequency with which the service has been performed
   vices are eligible for 100 percent federal financial participa-                in the past.
   tion:                                                                     4. Whether there is sufficient historical information regard-
   1. R9-22-205(A)(8),                                                            ing the service to provide reliable data regarding risks and
   2. R9-22-205(B)(4)(f),                                                         benefits.
   3. R9-22-206,                                                             5. The reputation and experience of the authors and/or spe-
   4. R9-22-207,                                                                  cialists and their record in related areas.
   5. R9-22-212(C),                                                          6. The extent to which medical science in the area develops
   6. R9-22-212(D),                                                               rapidly and the probability that more definite data will be
   7. R9-22-212(E)(8),                                                            available in the foreseeable future.
   8. R9-22-215(C)(2),                                                       7. Whether the peer reviewed article describes a random
   9. R9-22-215(C)(5).                                                            controlled trial or an anecdotal clinical case study.
                          Historical ote                                                          Historical ote
     Adopted as an emergency effective May 20, 1982 pursu-                   Adopted as an emergency effective May 20, 1982 pursu-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
     3). Former Section R9-22-202 adopted as an emergency                     3). Former Section R9-22-203 adopted as an emergency
     now adopted and amended as a permanent rule effective                    now adopted and amended as a permanent rule effective
     August 30, 1982 (Supp. 82-4). Amended effective Octo-                    August 30, 1982 (Supp. 82-4). Amended effective Octo-
     ber 1, 1985 (Supp. 85-5). Amended effective October 1,                   ber 1, 1985 (Supp. 85-5). Amended effective October 1,
     1987; amended effective December 22, 1987 (Supp. 87-                     1987; amended effective December 22, 1987 (Supp. 87-
        4). Amended effective May 30, 1989 (Supp. 89-2).                         4). Amended effective May 30, 1989 (Supp. 89-2).
         Amended effective April 13, 1990 (Supp. 90-2).                           Amended effective April 13, 1990 (Supp. 90-2).
       Amended effective December 13, 1993 (Supp. 93-4).                       Amended effective September 29, 1992 (Supp. 92-3).
       Amended effective July 1, 1995, under an exemption                    Amended under an exemption from the provisions of the
     from A.R.S. Title 41, Chapter 6, pursuant to Laws 1994,                 Administrative Procedure Act effective March 22, 1993;
      Ch. 322, § 21; filed with the Office of the Secretary of               received in the Office of the Secretary of State March 24,
    State June 22, 1995 (Supp. 95-3). Amended effective Jan-                   1993 (Supp. 93-1). Amended effective December 13,
      uary 1, 1996, under an exemption from A.R.S. Title 41,                 1993 (Supp. 93-4). Section repealed effective September
    Chapter 6, pursuant to Laws 1995, Third Special Session,                   22, 1997 (Supp. 97-3). New Section made by exempt
     Ch. 1, § 5; filed with the Office of the Secretary of State             rulemaking at 16 A.A.R. 1638, effective October 1, 2010
    December 28, 1995 (Supp. 95-4). Section repealed effec-                                         (Supp. 10-3).
    tive September 22, 1997 (Supp. 97-3). New Section made
                                                                        R9-22-204. Inpatient General Hospital Services
    by final rulemaking at 13 A.A.R. 3351, effective Novem-
                                                                        A. A contractor, fee-for-service provider or noncontracting pro-
    ber 10, 2007 (Supp. 07-3). Amended by exempt rulemak-
                                                                            vider shall render inpatient general hospital services including:
     ing at 16 A.A.R. 1638, effective October 1, 2010 (Supp.
                                                                            1. Hospital accommodations and appropriate staffing, sup-
                                10-3).
                                                                                 plies, equipment, and services for:
R9-22-203. Experimental Services                                                 a. Maternity care, including labor, delivery, and recov-
A. Experimental services are not covered. A service is not experi-                    ery room, birthing center, and newborn nursery;
    mental if:                                                                   b. Neonatal intensive care unit (NICU);
    1. It is generally and widely accepted as a standard of care                 c. Intensive care unit (ICU);
        in the practice of medicine in the United States and is a                d. Surgery, including surgery room and recovery room;
        safe and effective treatment for the condition for which it              e. Nursery and related services;
        is intended or used.                                                     f. Routine care; and
    2. The service does not meet the standard in subsection
        (A)(1), but the service has been demonstrated to be safe


June 30, 2011                                                      Page 13                                                        Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          g.    Emergency behavioral health services provided                3.   Medically necessary treatment;
                under Article 12 of this Chapter for a member eligi-         4.   Prescriptions for medication and medically necessary
                ble under A.R.S. § 36-2901(6)(a).                                 supplies and equipment;
     2. Ancillary services as specified by the Director and                  5. Referral to a specialist or other health care professional if
          included in contract:                                                   medically necessary;
          a. Laboratory services;                                            6. Patient education;
          b. Radiological and medical imaging services;                      7. Home visits if medically necessary; and
          c. Anesthesiology services;                                        8. Except as provided in subsection (B), preventive health
          d. Rehabilitation services;                                             services, such as, immunizations, colonoscopies, mam-
          e. Pharmaceutical services and prescription drugs;                      mograms and PAP smears.
          f. Respiratory therapy;                                       B.   The following limitations and exclusions apply to attending
          g. Blood and blood derivatives; and                                physician and practitioner services and primary care provider
          h. Central supply items, appliances, and equipment that            services:
                are not ordinarily furnished to all patients and cus-        1. Specialty care and other services provided to a member
                tomarily reimbursed as ancillary services.                        upon referral from a primary care provider, or to a mem-
B.   The following limitations apply to inpatient general hospital                ber upon referral from the attending physician or practi-
     services that are provided by FFS providers.                                 tioner are limited to the service or condition for which the
      1. Providers shall obtain prior authorization from the                      referral is made, or for which authorization is given by
          Administration for the following inpatient hospital ser-                the Administration or a contractor.
          vices:                                                             2. A member’s physical examination is not covered if the
          a. Nonemergency and elective admission, including                       sole purpose is to obtain documentation for one or more
                psychiatric hospitalization;                                      of the following:
          b. Elective surgery, excluding a voluntary sterilization                a. Qualification for insurance,
                procedure. Voluntary sterilization procedure does                 b. Pre-employment physical evaluation,
                not require prior authorization; and                              c. Qualification for sports or physical exercise activi-
          c. Services or items provided to cosmetically recon-                          ties,
                struct or improve personal appearance after an ill-               d. Pilot’s examination for the Federal Aviation Admin-
                ness or injury.                                                         istration,
     2. The Administration may perform concurrent review for                      e. Disability certification to establish any kind of peri-
          hospitalizations to determine whether there is medical                        odic payments,
          necessity for the hospitalization.                                      f. Evaluation to establish third-party liabilities, or
          a. A provider shall notify the Administration no later                  g. Physical ability to perform functions that have no
                than the fourth day of hospitalization after an emer-                   relationship to primary objectives of the services
                gency admission or no later than the second day                         listed in subsection (A).
                after an intensive care unit admission so that the           3. Orthognathic surgery is covered only for a member who
                Administration may initiate concurrent review of the              is less than 21 years of age;
                hospitalization.                                             4. The following services are excluded from AHCCCS cov-
          b. Failure of the provider to obtain prior authorization                erage:
                is cause for denial of a claim.                                   a. Infertility services, reversal of surgically induced
                                                                                        infertility (sterilization), and gender reassignment
                          Historical ote
                                                                                        surgeries;
      Adopted as an emergency effective May 20, 1982 pursu-
                                                                                  b. Pregnancy termination counseling services;
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                  c. Pregnancy terminations, unless required by state or
      3). Former Section R9-22-204 adopted as an emergency
                                                                                        federal law.
      now adopted and amended as a permanent rule effective
                                                                                  d. Services or items furnished solely for cosmetic pur-
      August 30, 1982 (Supp. 82-4). Amended effective Octo-
                                                                                        poses;
     ber 1, 1985 (Supp. 85-5). Amended subsection (A) effec-
                                                                                  e. Hysterectomies unless determined medically neces-
     tive December 22, 1987 (Supp. 87-4). Amended effective
                                                                                        sary; and
      December 13, 1993 (Supp. 93-4). Section repealed, new
                                                                                  f. Preventive services not covered are well exams,
     Section adopted effective September 22, 1997 (Supp. 97-
                                                                                        meaning physical examinations in the absence of
     3). Amended by final rulemaking at 6 A.A.R. 179, effec-
                                                                                        any known disease or symptom or any specific med-
      tive December 13, 1999 (Supp. 99-4). Amended by final
                                                                                        ical complaint by the patient precipitating the exam-
         rulemaking at 6 A.A.R. 2435, effective June 9, 2000
                                                                                        ination.
          (Supp. 00-2). Amended by exempt rulemaking at 7
        A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                                       Historical ote
     Amended by final rulemaking at 8 A.A.R. 2325, effective                 Adopted as an emergency effective May 20, 1982 pursu-
                      May 9, 2002 (Supp. 02-2).                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                              3). Former Section R9-22-205 adopted as an emergency
R9-22-205. Attending Physician, Practitioner, and Primary
                                                                              now adopted and amended as a permanent rule effective
Care Provider Services
                                                                              August 30, 1982 (Supp. 82-4). Amended effective Octo-
A. A primary care provider, attending physician, or practitioner
                                                                             ber 1, 1985 (Supp. 85-5). Amended subsection (A), para-
    shall provide primary care provider services within the pro-
                                                                             graph (15) and added paragraph (20) effective December
    vider’s scope of practice under A.R.S. Title 32. A member
                                                                             22, 1987 (Supp. 87-4). Amended subsection (C)(2) effec-
    may receive primary care provider services in an inpatient or
                                                                                tive May 30, 1989 (Supp. 89-2). Amended under an
    outpatient setting including at a minimum:
                                                                             exemption from the provisions of the Administrative Pro-
    1. Periodic health examination and assessment;
                                                                                cedure Act effective March 22, 1993; received in the
    2. Evaluation and diagnostic workup;
                                                                               Office of the Secretary of State March 24, 1993 (Supp.


Supp. 11-2                                                         Page 14                                                     June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

    93-1). Amended effective December 13, 1993 (Supp. 93-                   June 9, 2000 (Supp. 00-2). Amended by exempt rulemak-
    4). Section repealed, new Section adopted effective Sep-                ing at 7 A.A.R. 5701, effective December 1, 2001 (Supp.
      tember 22, 1997 (Supp. 97-3). Amended by final rule-                    01-4). Amended by exempt rulemaking at 10 A.A.R.
     making at 6 A.A.R. 2435, effective June 9, 2000 (Supp.                 4588, effective October 12, 2004 (Supp. 04-4). Amended
     00-2). Amended by final rulemaking at 8 A.A.R. 2325,                    by exempt rulemaking at 16 A.A.R. 1386, effective July
    effective May 9, 2002 (Supp. 02-2). Amended by exempt                   15, 2010 (Supp. 10-3). Amended by exempt rulemaking at
       rulemaking at 10 A.A.R. 4588, effective October 12,                   16 A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).
    2004 (Supp. 04-4). Amended by exempt rulemaking at 16                   Amended by exempt rulemaking at 17 A.A.R. 1122, April
       A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).                                   1, 2011 (Supp. 11-2).
     Editor’s ote: The following Section was renumbered and a          R9-22-207. Dental Services
new Section adopted under an exemption from the provisions of          A. The Administration or a contractor shall cover dental services
the Administrative Procedure Act which means that this rule was            for a member less than 21 years of age under R9-22-213.
not published as a proposed rule in the Arizona Administrative         B. For individuals age 21 years of age or older, the Administra-
Register; the rule was not reviewed or approved by the Gover-              tion or a contractor shall cover medical and surgical services
nor’s Regulatory Review Council; and the agency was not                    furnished by a dentist only to the extent such services may be
required to hold public hearings on the rule. This Section was             performed under state law either by a physician or by a dentist
subsequently amended through the regular rulemaking process.               and such services would be considered a physician service if
                                                                           furnished by a physician.
R9-22-206. Organ and Tissue Transplant Services
                                                                           1. Except as specified in subsection (C), such services must
A. Organ and tissue transplant services are covered for a member
                                                                                 be related to the treatment of a medical condition such as
    if prior authorized and coordinated with the member’s contrac-
                                                                                 acute pain, infection, or fracture of the jaw. Covered den-
    tor, or the Administration. Only the following transplants are
                                                                                 tal services include examination of the oral cavity, radio-
    covered for individuals 21 years of age or older:
                                                                                 graphs, complex oral surgical procedures such as
    1. Heart, including transplants for the treatment of non-
                                                                                 treatment of maxillofacial fractures, administration of an
          ischemic cardiomyopathy;
                                                                                 appropriate level of anesthesia and the prescription of
    2. Liver, including transplants for patients with hepatitis C;
                                                                                 pain medication and antibiotics.
    3. Kidney (cadaveric and live donor),
                                                                           2. Such services do not include services that physicians are
    4. Simultaneous Pancreas/Kidney (SPK),
                                                                                 not generally competent to perform such as dental clean-
    5. Autologous and Allogeneic related and unrelated
                                                                                 ings, routine dental examinations, dental restorations
          Hematopoietic Cell transplants;
                                                                                 including crowns and fillings, extractions, pulpotomies,
    6. Cornea;
                                                                                 root canals, and the construction or delivery of complete
    7. Bone;
                                                                                 or partial dentures. Diagnosis and treatment of temporo-
    8. Lung; and
                                                                                 mandibular joint dysfunction are not covered except for
    9. Pancreas after a kidney transplant (PAK).
                                                                                 the reduction of trauma.
B. The following transplants are not covered for members 21
                                                                       C. For the purposes of this subsection, simple restorations means
    years of age or older:
                                                                           silver amalgam or composite resin fillings, stainless steel
    1. Pancreas only transplants if it is not performed simulta-
                                                                           crowns or preformed crowns. In addition, dental services for
          neously with or following a kidney transplant. Partial
                                                                           an individual 21 years of age or older include:
          pancreas transplants and autologous and allogeneic pan-
                                                                           1. The elimination of oral infections and the treatment of
          creas islet cell transplants are not covered even if per-
                                                                                 oral disease, which includes dental cleanings, treatment
          formed simultaneously with or following a kidney
                                                                                 of periodontal disease, medically necessary extractions
          transplant,
                                                                                 and the provision of simple restorations as a medically
    2. Intestine transplants, and
                                                                                 necessary pre-requisite to covered transplantation; and
    3. Any other type of transplant not specifically listed in sub-
                                                                           2. Prophylactic extraction of teeth in preparation for cov-
          section (A).
                                                                                 ered radiation treatment of cancer of the jaw, neck or
C. When there is a transplant of multiple organs, reimbursement
                                                                                 head.
    will only be made for those covered.
D. Organ and tissue transplant services are not covered for non-                                  Historical ote
    qualified aliens or noncitizens members of FESP under A.R.S.            Adopted as an emergency effective May 20, 1982 pursu-
    § 36-2903.03(D).                                                        ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                             3). Former Section R9-22-207 adopted as an emergency
                          Historical ote
                                                                             now adopted and amended as a permanent rule effective
     Adopted as an emergency effective May 20, 1982 pursu-
                                                                              August 30, 1982 (Supp. 82-4). Former Section R9-22-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                             207 repealed, new Section R9-22-207 adopted effective
     3). Former Section R9-22-206 adopted as an emergency
                                                                            October 1, 1985 (Supp. 85-5). Section repealed, new Sec-
     now adopted and amended as a permanent rule effective
                                                                             tion adopted effective September 22, 1997 (Supp. 97-3).
     August 30, 1982 (Supp. 82-4). Amended effective Octo-
                                                                            Amended by final rulemaking at 8 A.A.R. 2325, effective
     ber 1, 1985 (Supp. 85-5). Amended effective December
                                                                            May 9, 2002 (Supp. 02-2). Amended by exempt rulemak-
    13, 1993 (Supp. 93-4). Former Section R9-22-206 renum-
                                                                             ing at 16 A.A.R. 1638, effective October 1, 2010 (Supp.
       bered to R9-22-218, new Section R9-22-206 adopted
                                                                                                      10-3).
        effective January 1, 1996, under an exemption from
    A.R.S. Title 41, Chapter 6, pursuant to Laws 1995, Third           R9-22-208. Laboratory, Radiology, and Medical Imaging
      Special Session, Ch. 1, § 5; filed with the Office of the        Services
        Secretary of State December 28, 1995 (Supp. 95-4).             Laboratory, radiology, and medical imaging services are covered
      Amended effective September 22, 1997 (Supp. 97-3).               services if:
    Amended by final rulemaking at 6 A.A.R. 2435, effective



June 30, 2011                                                     Page 15                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     1.   Prescribed by the member’s attending physician, practi-             who requires a continuing or complex regimen of pharmaceu-
          tioner, primary care provider or a dentist, or prescribed by        tical treatment to restore, improve, or maintain physical well
          a physician or practitioner upon referral from the primary          being.
          care provider or dentist.
                                                                                                    Historical ote
     2.   Provided by licensed health care providers in a:
                                                                              Adopted as an emergency effective May 20, 1982 pursu-
          a. Hospital,
                                                                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
          b. Clinic,
                                                                               3). Former Section R9-22-209 adopted as an emergency
          c. Physician’s office, or
                                                                               now adopted and amended as a permanent rule effective
          d. Other health care facility.
                                                                               August 30, 1982 (Supp. 82-4). Amended effective Octo-
                          Historical ote                                       ber 1, 1985 (Supp. 85-5). Amended effective September
     Adopted as an emergency effective May 20, 1982 pursu-                    24, 1986 (Supp. 86-5). Amended subsections (A) and (C)
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-                  effective December 22, 1987 (Supp. 87-4). Amended
      3). Former Section R9-22-208 adopted as an emergency                     subsection (C)(3), effective May 30, 1989 (Supp. 89-2).
      now adopted and amended as a permanent rule effective                    Amended under an exemption from the Administrative
       August 30, 1982 (Supp. 82-4). Former Section R9-22-                     Procedure Act effective March 22, 1993; received in the
      208 repealed, new Section R9-22-208 adopted effective                     Office of the Secretary of State March 24, 1993 (Supp.
      October 1, 1985 (Supp. 85-5). Amended subsection (C)                    93-1). Amended effective December 13, 1993 (Supp. 93-
       effective December 22, 1987 (Supp. 87-4). Amended                      4). Section repealed, new Section adopted effective Sep-
         effective December 13, 1993 (Supp. 93-4). Section                      tember 22, 1997 (Supp. 97-3). Amended by final rule-
      repealed, new Section adopted effective September 22,                    making at 6 A.A.R. 2435, effective June 9, 2000 (Supp.
       1997 (Supp. 97-3). Amended by final rulemaking at 8                     00-2). Amended by final rulemaking at 8 A.A.R. 2325,
          A.A.R. 2325, effective May 9, 2002 (Supp. 02-2).                                effective May 9, 2002 (Supp. 02-2).
R9-22-209. Pharmaceutical Services                                       R9-22-210. Emergency Medical Services for on-FES Mem-
A. An inpatient or outpatient provider, including a hospital,            bers
    clinic, other appropriately licensed health care facility, and       A. General provisions.
    pharmacy may provide covered pharmaceutical services.                     1. Applicability. This Section applies to emergency medical
B. The Administration or a contractor shall require a provider to                services for non-FES members. Provisions regarding
    make pharmaceutical services:                                                emergency behavioral health services for non-FES mem-
    1. Available during customary business hours, and                            bers are in R9-22-210.01. Provisions regarding emer-
    2. Located within reasonable travel distance of a member’s                   gency medical and behavioral health services for FES
          residence.                                                             members are in R9-22-217.
C. Pharmaceutical services are covered if:                                    2. Definitions.
    1. Prescribed for a member by the member’s primary care                      a. For the purposes of this Section, contractor has the
          provider, attending physician, practitioner, or dentist;                    same meaning as in A.R.S. § 36-2901. Contractor
    2. Prescribed by a specialist upon referral from the primary                      does not include ADHS/DBHS, or a subcontractor
          care provider or attending physician; or                                    of ADHS/DBHS, or Children’s Rehabilitative Ser-
    3. The contractor or its designee authorizes the service.                         vices.
D. The following limitations apply to pharmaceutical services:                   b. For the purposes of this Section and R9-22-210.01,
    1. A medication personally dispensed by a physician, den-                         fiscal agent means a person who bills and accepts
          tist, or a practitioner within the individual’s scope of                    payment for a hospital or emergency room provider.
          practice is not covered, except in geographically remote            3. Verification. A provider of emergency medical services
          areas where there is no participating pharmacy or if                   shall verify a person’s eligibility status with AHCCCS,
          accessible pharmacies are closed.                                      and if eligible, determine whether the person is enrolled
    2. A prescription or refill in excess of 100-unit doses is not               with AHCCCS as non-FES FFS or is enrolled with a con-
          covered. A prescription or refill in excess of a 30 day sup-           tractor.
          ply is not covered unless specified in subsection (D)(3).           4. Prior authorization.
    3. A prescription or refill in excess of a 30-day supply is                  a. Emergency medical services. Prior authorization is
          covered if:                                                                 not required for emergency medical services for
          a. The medication is prescribed for chronic illness and                     non-FES members.
                the prescription is limited to no more than a 100-day            b. Non-emergency medical services. If a non-FES
                supply or 100-unit doses, whichever is greater.                       member’s medical condition does not require emer-
          b. The member will be out of the provider’s service                         gency medical services, the provider shall obtain
                area for an extended period of time and the prescrip-                 prior authorization as required by the terms of the
                tion is limited to the extended time period, not to                   provider agreement under R9-22-714(A) or the pro-
                exceed 100 day supply or 100-unit doses, whichever                    vider’s subcontract with the contractor, whichever is
                is greater.                                                           applicable.
          c. The medication is prescribed for contraception and               5. Prohibition against denial of payment. The Administra-
                the prescription is limited to no more than a 100-day            tion and a contractor shall not limit or deny payment for
                supply.                                                          emergency medical services for the following reasons:
    4. An over-the-counter medication, in place of a covered                     a. On the basis of lists of diagnoses or symptoms,
          prescription medication, is covered only if the over-the-              b. Prior authorization was not obtained, or
          counter medication is appropriate, equally effective, safe,            c. The provider does not have a subcontract.
          and less costly than the covered prescription medication.           6. Grounds for denial. The Administration and a contractor
E. A contractor shall monitor and ensure sufficient services to                  may deny payment for emergency medical services for
    prevent any gap in the pharmaceutical regimen of a member                    reasons including but not limited to:


Supp. 11-2                                                          Page 16                                                    June 30, 2011
                                                       Arizona Administrative Code                                            Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

          a.    The claim was not a clean claim;                                         ii.  A contractor physician assumes responsibility
          b.    The claim was not submitted timely; and                                       for the member’s care through transfer;
          c.    The provider failed to provide timely notification                      iii. The contractor’s representative and the treating
                under subsection (B)(4) to the contractor or the                              physician reach agreement concerning the
                Administration, as appropriate, and the contractor                            member’s care; or
                does not have actual notice from any other source                       iv. The member is discharged.
                that the member has presented for services.                    5. Transfer or discharge. The attending physician or practi-
B.   Additional requirements for emergency medical services for                    tioner actually treating the member for the emergency
     non-FES members enrolled with a contractor.                                   medical condition shall determine when the member is
     1. Responsible entity. A contractor is responsible for the                    sufficiently stabilized for transfer or discharge and that
          provision of all emergency medical services to non-FES                   decision shall be binding on the contractor.
          members enrolled with the contractor.                           D.   Additional requirements for FFS members.
     2. Prohibition against denial of payment. A contractor shall              1. Responsible entity. The Administration is responsible for
          not limit or deny payment for emergency medical ser-                     the provision of all emergency medical services to non-
          vices when an employee of the contractor instructs the                   FES FFS members.
          member to obtain emergency medical services.                         2. Grounds for denial. The Administration may deny pay-
     3. Notification. A contractor shall not deny payment to a                     ment for emergency medical services if a provider fails to
          hospital, emergency room provider, or fiscal agent for an                provide timely notice to the Administration.
          emergency medical service rendered to a non-FES mem-                 3. Notification. A provider shall notify the Administration
          ber based on the failure of the hospital, emergency room                 no later than 72 hours after a FFS member receiving
          provider, or fiscal agent to notify the member’s contractor              emergency medical services presents to a hospital for
          within 10 days from the day that the member presented                    inpatient services. The Administration may deny pay-
          for the emergency medical service.                                       ment for failure to provide timely notice.
     4. Contractor notification. A hospital, emergency room pro-
                                                                                                     Historical ote
          vider, or fiscal agent shall notify the contractor no later
                                                                               Adopted as an emergency effective May 20, 1982 pursu-
          than the 11th day after presentation of the non-FES mem-
                                                                               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
          ber for emergency inpatient medical services. A contrac-
                                                                                3). Former Section R9-22-210 adopted as an emergency
          tor may deny payment for a hospital’s, emergency room
                                                                                now adopted and amended as a permanent rule effective
          provider’s, or fiscal agent’s failure to provide timely
                                                                                 August 30, 1982 (Supp. 82-4). Former Section R9-22-
          notice.
                                                                                210 repealed, new Section R9-22-210 adopted effective
C.   Post-stabilization services for non-FES members enrolled with
                                                                                October 1, 1983 (Supp. 83-5). Amended effective Octo-
     a contractor.
                                                                               ber 1, 1985 (Supp. 85-5). Amended subsection (B), para-
     1. After the emergency medical condition of a member
                                                                                    graph (1) effective October 1, 1987 (Supp. 87-4).
          enrolled with a contractor is stabilized, a provider shall
                                                                                 Amended effective December 13, 1993 (Supp. 93-4).
          request prior authorization from the contractor for post-
                                                                                 Amended effective September 22, 1997 (Supp. 97-3).
          stabilization services.
                                                                                Amended by final rulemaking at 5 A.A.R. 867, effective
     2. The contractor is financially responsible for medical post-
                                                                               March 4, 1999 (Supp. 99-1). Amended by final rulemak-
          stabilization services obtained within or outside the net-
                                                                               ing at 6 A.A.R. 179, effective December 13, 1999 (Supp.
          work that have been prior authorized by the contractor.
                                                                               99-4). Amended by exempt rulemaking at 7 A.A.R. 4593,
     3. The contractor is financially responsible for medical post-
                                                                               effective October 1, 2001 (Supp. 01-3). Amended by final
          stabilization services obtained within or outside the net-
                                                                                  rulemaking at 8 A.A.R. 2325, effective May 9, 2002
          work that are not prior authorized by the contractor, but
                                                                               (Supp. 02-2). Amended by final rulemaking at 11 A.A.R.
          are administered to maintain the member’s stabilized
                                                                                     5480, effective December 6, 2005 (Supp. 05-4).
          condition within one hour of a request to the contractor
          for prior authorization of further post-stabilization ser-      R9-22-210.01. Emergency Behavioral Health Services for on-
          vices;                                                          FES Members
     4. The contractor is financially responsible for medical post-       A. General provisions.
          stabilization services obtained within or outside the net-          1. Applicability. This Section applies to emergency behav-
          work that are not prior authorized by the contractor, but               ioral health services for non-FES members. Provisions
          are administered to maintain, improve, or resolve the                   regarding emergency medical services for non-FES mem-
          member’s stabilized condition if:                                       bers are in R9-22-210. Provisions regarding emergency
          a. The contractor does not respond to a request for                     medical and behavioral health services for FES members
                prior authorization within one hour;                              are in R9-22-217.
          b. The contractor authorized to give the prior authori-             2. Definition. For the purposes of this Section, contractor
                zation cannot be contacted; or                                    has the same meaning as in A.R.S. § 36-2901. Contractor
          c. The contractor representative and the treating physi-                does not include ADHS/DBHS, a subcontractor of
                cian cannot reach an agreement concerning the                     ADHS/DBHS, or Children’s Rehabilitative Services.
                member’s care and the contractor physician is not             3. Responsible entity for inpatient emergency behavioral
                available for consultation. In this situation, the con-           health services.
                tractor shall give the treating physician the opportu-            a. Members enrolled with a contractor.
                nity to consult with a contractor physician. The                        i. ADHS/DBHS. ADHS/DBHS or a subcontrac-
                treating physician may continue with care of the                            tor of ADHS/DBHS is responsible for provid-
                member until the contractor physician is reached or:                        ing all inpatient emergency behavioral health
                i. A contractor physician with privileges at the                            services to non-FES members with psychiatric
                      treating hospital assumes responsibility for the                      or substance abuse diagnoses who are enrolled
                      member’s care;


June 30, 2011                                                        Page 17                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

                      with the contractor, from one of the following               c.   The provider failed to provide timely notification to
                      time periods, whichever comes first:                              the contractor, ADHS/DBHS, or a subcontractor of
                      (1) The date on which the member becomes a                        ADHS/DBHS.
                            behavioral health recipient; or                   9. Notification. A hospital, emergency room provider, or
                      (2) The seventy-third hour after admission for               fiscal agent shall notify a contractor, ADHS/DBHS, or a
                            inpatient emergency behavioral health ser-             subcontractor of ADHS/DBHS, whichever is appropriate,
                            vices.                                                 no later than the 11th day from presentation of the non-
                ii. Contractors. Contractors are responsible for                   FES member for emergency inpatient behavioral health
                      providing inpatient emergency behavioral                     services.
                      health services to non-FES members with psy-            10. Behavioral health evaluation. An emergency behavioral
                      chiatric or substance abuse diagnoses who are                health evaluation is covered as an emergency behavioral
                      enrolled with a contractor and are not behav-                health service for a non-FES member under this Section
                      ioral health recipients, for the first 72 hours              if:
                      after admission.                                             a. Required to evaluate or stabilize an acute episode of
          b. FFS members. ADHS/DBHS or a subcontractor of                               mental disorder or substance abuse; and
                ADHS/DBHS is responsible for providing all inpa-                   b. Provided by a qualified provider who is:
                tient emergency behavioral health services for non-                     i. A behavioral health medical practitioner as
                FES FFS members with psychiatric or substance                                 defined in R9-22-112, including a licensed psy-
                abuse diagnoses.                                                              chologist, a licensed clinical social worker, a
     4.   Responsible entity for non-inpatient emergency behav-                               licensed professional counselor, a licensed mar-
          ioral health services for non-FES members. ADHS/                                    riage and family therapist; or
          DBHS or a subcontractor of ADHS/DBHS is responsible                           ii. An ADHS/DBHS-contracted provider.
          for providing all non-inpatient emergency behavioral                11. Transfer or discharge. The attending physician or the pro-
          health services for non-FES members.                                     vider actually treating the non-FES member for the emer-
     5.   Verification. A provider of emergency behavioral health                  gency behavioral health condition shall determine when
          services shall verify a person’s eligibility status with                 the member is sufficiently stabilized for transfer or dis-
          AHCCCS, and if eligible, determine whether the person                    charge and that decision shall be binding on the contrac-
          is a member enrolled with AHCCCS as non-FES FFS or                       tor and ADHS/DBHS or a subcontractor of ADHS/
          is enrolled with a contractor, and determine whether the                 DBHS.
          member is a behavioral health recipient as defined in R9-      B.   Post-stabilization requirements for non-FES members.
          22-102.                                                             1. A contractor, ADHS/DBHS, or a subcontractor of ADHS/
     6.   Prior authorization.                                                     DBHS, as appropriate, is financially responsible for
          a. Emergency behavioral health services. Emergency                       behavioral health post-stabilization services obtained
                behavioral health services do not require prior                    within or outside the network that have been prior autho-
                authorization.                                                     rized by the contractor, ADHS/DBHS, or a subcontractor
          b. Non-emergency behavioral health services. When a                      of ADHS/DBHS.
                non-FES member’s behavioral health condition is               2. The contractor, ADHS/DBHS, or a subcontractor of
                determined by the provider not to require emergency                ADHS/DBHS, as appropriate, is financially responsible
                behavioral health services, the provider shall follow              for behavioral health post-stabilization services obtained
                the prior authorization requirements of a contractor               within or outside the network that are not prior authorized
                and ADHS/DBHS or a subcontractor of ADHS/                          by the contractor, ADHS/DBHS, or a subcontractor of
                DBHS.                                                              ADHS/DBHS, but are administered to maintain the mem-
     7.   Prohibition against denial of payment. A contractor,                     ber’s stabilized condition within one hour of a request to
          ADHS/DBHS, or a subcontractor of ADHS/DBHS shall                         the contractor, ADHS/DBHS, or a subcontractor for prior
          not limit or deny payment to an emergency behavioral                     authorization of further post-stabilization services;
          health provider for emergency behavioral health services            3. The contractor, ADHS/DBHS, or a subcontractor of
          to a non-FES member for the following reasons:                           ADHS/DBHS, as appropriate, is financially responsible
          a. On the basis of lists of diagnoses or symptoms;                       for behavioral health post-stabilization services obtained
          b.     Prior authorization was not obtained;                             within or outside the network that are not prior authorized
          c. The provider does not have a contract;                                by the contractor, ADHS/DBHS, or a subcontractor of
          d. An employee of the contractor, ADHS/DBHS, or a                        ADHS/DBHS, but are administered to maintain,
                subcontractor of ADHS/DBHS instructs the member                    improve, or resolve the member’s stabilized condition if:
                to obtain emergency behavioral health services; or                 a. The contractor, ADHS/DBHS, or a subcontractor of
          e. The failure of a hospital, emergency room provider,                        ADHS/DBHS, does not respond to a request for
                or fiscal agent to notify the member’s contractor,                      prior authorization within one hour;
                ADHS/DBHS, or a subcontractor of ADHS/DBHS                         b. The contractor, ADHS/DBHS, or a subcontractor of
                within 10 days from the day the member presented                        ADHS/DBHS authorized to give the prior authoriza-
                for the emergency service.                                              tion cannot be contacted; or
     8.   Grounds for denial. A contractor, ADHS/DBHS, or a sub-                   c. The representative of the contractor, ADHS/DBHS,
          contractor of ADHS/DBHS may deny payment for emer-                            or the subcontractor and the treating physician can-
          gency behavioral health services for reasons including                        not reach an agreement concerning the member’s
          but not limited to the following:                                             care and the contractor’s, ADHS/DBHS’ or the sub-
          a. The claim was not a clean claim,                                           contractor’s physician, is not available for consulta-
          b. The claim was not submitted timely, or                                     tion. The treating physician may continue with care
                                                                                        of the member until ADHS/DBHS’, the contractor’s,
                                                                                        or the subcontractor’s physician is reached, or:


Supp. 11-2                                                          Page 18                                                    June 30, 2011
                                                      Arizona Administrative Code                                            Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

                i.   A contractor physician with privileges at the                 b.   Ground ambulance service will not suffice for the
                     treating hospital assumes responsibility for the                   factors listed in subsection (B)(2).
                     member’s care;                                      C. Medically necessary nonemergency transportation is limited to
                ii. ADHS/DBHS’, a contractor’s, or a subcontrac-            the cost of transporting the member to an appropriate provider
                     tor’s physician assumes responsibility for the         capable of meeting the member’s medical needs.
                     member’s care through transfer;                        1. As specified in contract, a contractor shall arrange or pro-
                iii. A representative of the contractor, ADHS/                    vide medically necessary nonemergency transportation
                     DBHS, or the subcontractor and the treating                  services for a member who is unable to arrange transpor-
                     physician reach agreement concerning the                     tation to a service site or location.
                     member’s care; or                                      2. For a fee-for-service member, the Administration shall
                iv. The member is discharged.                                     authorize medically necessary nonemergency transporta-
                                                                                  tion for a member who is unable to arrange transportation
                        Historical ote
                                                                                  to a service site or location.
       New Section made by final rulemaking at 11 A.A.R.
                                                                         D. For the purposes of this subsection, an individual means a per-
        5480, effective December 6, 2005 (Supp. 05-4).
                                                                            son who is not in the business of providing transportation ser-
R9-22-211. Transportation Services                                          vices such as a family or household member, friend, or
A. Emergency ambulance services.                                            neighbor. The Administration or a contractor shall cover
    1. A member shall receive medically necessary emergency                 expenses for transportation in traveling to and returning from
          transportation in a ground or air ambulance:                      an approved and prior authorized health care service site pro-
          a. To the nearest appropriate provider or medical facil-          vided by an individual if:
                ity capable of meeting the member’s medical needs;          1. The transportation services are authorized by the Admin-
                and                                                               istration or the member’s contractor or designee;
          b. If no other appropriate means of transportation is             2. The individual is an AHCCCS registered provider; and
                available.                                                  3. No other means of appropriate transportation is available.
    2. The Administration or a member’s contractor shall reim-           E. The Administration or a contractor shall cover expenses for
          burse a ground or air ambulance transport that originates         meals, lodging, and transportation for a member traveling to
          in response to a 911 call or other emergency response sys-        and returning from an approved and prior authorized health
          tem:                                                              care service site outside of the member’s service area or
          a. If the member’s medical condition justifies the med-           county of residence.
                ical necessity of the type of ambulance transporta-      F. The Administration or a contractor shall cover the expense of
                tion received,                                              meals, lodging, and transportation for:
          b. The transport is to the nearest appropriate provider           1. A family member accompanying a member if:
                or medical facility capable of meeting the member’s               a. The member is traveling to or returning from an
                medical needs, and                                                      approved and prior authorized health care service
          c. No prior authorization is required for reimbursement                       site outside of the member’s service area or county
                of these transports.                                                    of residence; and
    3. The member’s medical condition at the time of transport                    b. The meals, lodging, and transportation services are
          determines whether the transport is medically necessary.                      authorized by the Administration or the member’s
    4. A ground or air ambulance provider furnishing transport                          contractor or designee.
          in response to a 911 call or other emergency response sys-        2. An escort who is not a family member as follows:
          tem shall notify the member’s contractor within 10 work-                a. If the member is travelling to or returning from an
          ing days from the date of transport. Failure of the                           approved and prior authorized health care service
          provider to obtain prior authorization is cause for denial.                   site, including an inpatient facility, outside of the
    5. Notification to the Administration of emergency trans-                           member’s service area or county of residence; and
          portation provided to a FFS member is not required, but                 b. If the escort services are authorized by the Adminis-
          the provider shall submit documentation with the claim                        tration or the member’s contractor or designee.
          which justifies the service.                                            c. Wage paid to an escort as reimbursement shall not
B. The Administration or a contractor covers air ambulance ser-                         exceed the federal minimum wage.
    vices only if one or more of the criteria in subsection (B)(1),      G. A provider shall obtain prior authorization from the Adminis-
    (2), or (3) is met. The criteria are:                                   tration for transportation services provided for a member for
    1. The air ambulance transport is initiated at the request of:          the following:
          a. An emergency response unit;                                    1. Medically necessary nonemergency transportation ser-
          b. A law enforcement official;                                          vices not originated through a 911 call or other emer-
          c. A clinic or hospital medical staff member; or                        gency response system; and
          d. A physician or practitioner; and                               2. All meals, lodging, and services of an escort accompany-
    2. The point of pickup:                                                       ing the member under this Section.
          a. Is inaccessible by ground ambulance; or                     H. A charitable organization routinely providing transportation
          b. Is a great distance from the nearest hospital or other         service at no cost to an ambulatory or chairbound person shall
                provider with appropriate facilities to treat the mem-      not charge or seek reimbursement from the Administration or
                ber’s condition; or                                         a contractor for the provision of the service to a member but
    3. The medical condition of the member requires immedi-                 may enter into a subcontract with a contractor for medically
          ate:                                                              necessary transportation services provided to a member.
          a. Intervention from emergency ambulance personnel
                                                                                                   Historical ote
                or providers with the appropriate facilities to treat
                                                                              Adopted as an emergency effective May 20, 1982 pursu-
                the member’s condition, or
                                                                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-



June 30, 2011                                                       Page 19                                                       Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

      3). Former Section R9-22-211 adopted as an emergency                     5.   Except for incontinence briefs for persons over 3 years
      now adopted and amended as a permanent rule effective                         old and under 21 years old as provided in subsection
     August 30, 1982 (Supp. 82-4). Amended effective Octo-                          (E)(6), personal care items including items for personal
     ber 1, 1985 (Supp. 85-5). Amended subsection (A) effec-                        cleanliness, body hygiene, and grooming are not covered
       tive October 1, 1986 (Supp. 86-5). Amended effective                         unless needed to treat a medical condition. Personal care
        December 13, 1993 (Supp. 93-4). Amended effective                           items are not covered services if used solely for preven-
     September 22, 1997 (Supp. 97-3). Amended by final rule-                        tive purposes.
      making at 8 A.A.R. 2325, effective May 9, 2002 (Supp.                    6. Incontinence briefs, including pull-ups are covered to
                               02-2).                                               prevent skin breakdown and enable participation in
                                                                                    social, community, therapeutic and educational activities
R9-22-212. Durable Medical Equipment, Orthotic and Pros-
                                                                                    under the following circumstances:
thetic Devices, and Medical Supplies
                                                                                    a. The member is over 3 years old and under 21 years
A. Durable medical equipment, orthotic and prosthetic devices,
                                                                                          old;
     and medical supplies, including incontinence briefs as speci-
                                                                                    b. The member is incontinent due to a documented dis-
     fied in subsection (E), are covered services to the extent per-
                                                                                          ability that causes incontinence of bowel or bladder,
     mitted in this Section if provided in compliance with
                                                                                          or both;
     requirements of this Chapter; and
                                                                                    c. The PCP or attending physician has issued a pre-
     1. Prescribed by the primary care provider, attending physi-
                                                                                          scription ordering the incontinence briefs;
           cian, or practitioner; or
                                                                                    d. Incontinence briefs do not exceed 240 briefs per
     2. Prescribed by a specialist upon referral from the primary
                                                                                          month unless the prescribing physician presents evi-
           care provider, attending physician, or practitioner; and
                                                                                          dence of medical necessity for more than 240 briefs
     3. Authorized as required by the Administration, contractor,
                                                                                          per month for a member diagnosed with chronic
           or contractor’s designee.
                                                                                          diarrhea or spastic bladder;
B. Covered medical supplies are consumable items that are
                                                                                    e. The member obtains incontinence briefs from pro-
     designed specifically to meet a medical purpose, are dispos-
                                                                                          viders in the contractor’s network;
     able, and are essential for the member’s health.
                                                                                    f. Prior authorization has been obtained as required by
C. Covered DME is any item, appliance, or piece of equipment
                                                                                          the Administration, contractor, or contractor’s desig-
     that is not a prosthetic or orthotic; and
                                                                                          nee. Contractors may require a new prior authoriza-
     1. Is designed for a medical purpose, and is generally not
                                                                                          tion to be issued no more frequently than every 12
           useful to a person in the absence of an illness or injury,
                                                                                          months. Prior authorization for a renewal of an
           and
                                                                                          existing prescription may be provided by the physi-
     2. Can withstand repeated use, and
                                                                                          cian through telephone contact with the member
     3. Is generally reusable by others.
                                                                                          rather than an in-person physician visit. Prior autho-
D. Prosthetics are devices prescribed by a physician or other
                                                                                          rization will be permitted to ascertain that:
     licensed practitioner to artificially replace missing, deformed
                                                                                          i. The member is over age 3 and under age 21;
     or malfunctioning portion of the body. Only those prosthetics
                                                                                          ii. The member has a disability that causes incon-
     that are medically necessary for rehabilitation are covered,
                                                                                                tinence of bladder or bowel, or both;
     except as otherwise provided in R9-22-215.
                                                                                          iii. A physician has prescribed incontinence briefs
E. The following limitations on coverage apply:
                                                                                                as medically necessary. A physician prescrip-
     1. The DME is furnished on a rental or purchase basis,
                                                                                                tion supporting medical necessity may be
           whichever is less expensive. The total expense of renting
                                                                                                required for specialty briefs or for briefs differ-
           the DME does not exceed the cost of the DME if pur-
                                                                                                ent from the standard briefs supplied by the
           chased.
                                                                                                contractor; and
     2. Reasonable repair or adjustment of purchased DME is
                                                                                          iv. The prescription is for 240 briefs or fewer per
           covered if necessary to make the DME serviceable and if
                                                                                                month, unless evidence of medical necessity
           the cost of repair or adjustment is less than the cost of
                                                                                                for over 240 briefs is provided.
           renting or purchasing another unit.
                                                                               7. First aid supplies are not covered unless they are provided
     3. A change in, or addition to, an original order for DME is
                                                                                    in accordance with a prescription.
           covered if approved by the prescriber in subsection (A),
                                                                               8. The following services are not covered for individuals 21
           or prior authorized by the Administration or contractor,
                                                                                    years of age or older:
           and the change or addition is indicated clearly on the
                                                                                    a. Hearing aids;
           order and initialed by the vendor. No change or addition
                                                                                    b. Prescriptive lenses unless they are the sole visual
           to the original order for DME may be made after a claim
                                                                                          prosthetic device used by the member after a cata-
           for services is submitted to the member’s contractor, or
                                                                                          ract extraction;
           the Administration, without prior written notification of
                                                                                    c. Bone Anchor Hearing Aid (BAHA);
           the change or addition to the Administration or the con-
                                                                                    d. Cochlear implant;
           tractor.
                                                                                    e. Percussive vest;
     4. Reimbursement for rental fees shall terminate:
                                                                                    f. Insulin pump;
           a. No later than the end of the month in which the pre-
                                                                                    g. Microprocesser-controlled lower limbs or micropro-
                scriber in subsection (A) certifies that the member
                                                                                          cessor-controlled joints for lower limbs; and
                no longer needs the DME;
                                                                                    h. Orthotics, which are defined as devices that are pre-
           b. If the member is no longer eligible for AHCCCS
                                                                                          scribed by a physician or other licensed practitioner
                services; or
                                                                                          of the healing arts to support a weak or deformed
           c. If the member is no longer enrolled with a contrac-
                                                                                          portion of the body.
                tor, with the exception of transitions of care as spec-
                                                                          F.   Liability and ownership.
                ified in R9-22-509.



Supp. 11-2                                                           Page 20                                                       June 30, 2011
                                                       Arizona Administrative Code                                            Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

     1.   Purchased DME that is provided to a member and no                    7.    Behavioral health services under 9 A.A.C. 22, Article 12;
          longer needed by the member may be disposed of in                    8.    Hospice services as follows:
          accordance with each contractor’s policy.                                  a. Hospice services are covered only for a member
     2.   The Administration shall retain title to purchased DME                          who is in the final stages of a terminal illness and
          provided to a member who becomes ineligible or no                               has a prognosis of death within six months;
          longer requires use of the DME.                                            b. Services available to a member receiving hospice
     3.   If customized DME is purchased by the Administration                            care are limited to those allowable under 42 CFR
          or contractor for a member, the equipment shall remain                          418.202, October 1, 2006, incorporated by reference
          with the person during times of transition to a different                       and on file with the Administration. This incorpora-
          contractor, or upon loss of eligibility. For purposes of this                   tion by reference contains no future editions or
          subsection, customized DME refers to equipment that is                          amendments.
          altered or built to specifications unique to a member’s                    c. Hospice services do not include:
          medical needs and that, most likely, cannot be used or                          i. Medical services provided that are not related
          reused to meet the needs of another individual.                                      to the terminal illness; or
     4.   A member shall return DME obtained fraudulently to the                          ii. Home-delivered meals; and
          Administration or the contractor.                                          d. Hospice services that are provided and covered
                                                                                          through Medicare are not covered by AHCCCS;
                          Historical ote
                                                                               9. Incontinence briefs as specified under R9-22-212; and
     Adopted as an emergency effective May 20, 1982 pursu-
                                                                               10. Other necessary health care, diagnostic services, treat-
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                     ment, and measures required by 42 U.S.C. 1396d(r)(5).
      3). Former Section R9-22-212 adopted as an emergency
                                                                          B.   Providers of E.P.S.D.T. services shall meet the following stan-
      now adopted and amended as a permanent rule effective
                                                                               dards:
       August 30, 1982 (Supp. 82-4). Former Section R9-22-
                                                                               1. Ensure that services are provided by or under the direc-
      212 repealed, new Section R9-22-212 adopted effective
                                                                                     tion of the member’s primary care provider, attending
      October 1, 1983 (Supp. 83-5). Amended effective Octo-
                                                                                     physician, practitioner, or dentist.
     ber 1, 1985 (Supp. 85-5). Amended subsection (B), para-
                                                                               2. Perform tests and examinations under 42 CFR 441 Sub-
     graph (2), and deleted subsection (C) effective October 1,
                                                                                     part B, October 1, 2006, which is incorporated by refer-
          1986 (Supp. 86-5). Section repealed, new Section
                                                                                     ence and on file with the Administration. This
        adopted effective September 22, 1997 (Supp. 97-3).
                                                                                     incorporation by reference contains no future editions or
     Amended by final rulemaking at 8 A.A.R. 2325, effective
                                                                                     amendments.
     May 9, 2002 (Supp. 02-2). Amended by final rulemaking
                                                                               3. Refer a member as necessary for dental diagnosis and
          at 13 A.A.R. 3272, effective September 11, 2007
                                                                                     treatment and necessary specialty care.
        (Supp. 07-3). Amended by exempt rulemaking at 16
                                                                               4. Refer a member as necessary for behavioral health evalu-
       A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).
                                                                                     ation and treatment services.
R9-22-213. Early and Periodic Screening, Diagnosis, and                   C.   Contractors shall meet other E.P.S.D.T. requirements as speci-
Treatment Services (E.P.S.D.T.)                                                fied in contract.
A. The following E.P.S.D.T. services are covered for a member             D.   A primary care provider, attending physician, or practitioner
    less than 21 years of age:                                                 shall refer a member with special health care needs under R9-
    1. Screening services including:                                           7-301 to CRS.
          a. Comprehensive health and developmental history;
                                                                                                    Historical ote
          b. Comprehensive unclothed physical examination;
                                                                               Adopted as an emergency effective May 20, 1982 pursu-
          c. Appropriate immunizations according to age and
                                                                               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                health history;
                                                                                3). Former Section R9-22-213 adopted as an emergency
          d. Laboratory tests; and
                                                                                now adopted and amended as a permanent rule effective
          e. Health education, including anticipatory guidance;
                                                                                 August 30, 1982 (Supp. 82-4). Former Section R9-22-
    2. Vision services including:
                                                                                213 repealed, new Section R9-22-213 adopted effective
          a. Diagnosis and treatment for defects in vision;
                                                                                October 1, 1983 (Supp. 83-5). Amended effective Octo-
          b. Eye examinations for the provision of prescriptive
                                                                                ber 1, 1985 (Supp. 85-5). Amended effective December
                lenses; and
                                                                               13, 1993 (Supp. 93-4). Amended effective September 22,
          c. Prescriptive lenses;
                                                                                 1997 (Supp. 97-3). Amended by final rulemaking at 6
    3. Hearing services including:
                                                                                    A.A.R. 2435, effective June 9, 2000 (Supp. 00-2).
          a. Diagnosis and treatment for defects in hearing;
                                                                               Amended by final rulemaking at 8 A.A.R. 2325, effective
          b. Testing to determine hearing impairment; and
                                                                               May 9, 2002 (Supp. 02-2). Amended by final rulemaking
          c. Hearing aids;
                                                                                    at 13 A.A.R. 3272, effective September 11, 2007
    4. Dental services including:
                                                                                                     (Supp. 07-3).
          a. Emergency dental services as specified in R9-22-
                207;                                                      R9-22-214.     Repealed
          b. Preventive services including screening, diagnosis,
                                                                                                    Historical ote
                and treatment of dental disease; and
                                                                               Adopted as an emergency effective May 20, 1982 pursu-
          c. Therapeutic dental services including fillings,
                                                                               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                crowns, dentures, and other prosthetic devices;
                                                                                3). Former Section R9-22-214 adopted as an emergency
    5. Orthognathic surgery;
                                                                                now adopted and amended as a permanent rule effective
    6. Nutritional assessment and nutritional therapy as speci-
                                                                                 August 30, 1982 (Supp. 82-4). Former Section R9-22-
          fied in contract to provide complete daily dietary require-
                                                                                214 repealed, new Section R9-22-214 adopted effective
          ments or supplement a member’s daily nutritional and
                                                                                October 1, 1983 (Supp. 83-5). Amended effective Octo-
          caloric intake;


June 30, 2011                                                        Page 21                                                       Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

     ber 1, 1985 (Supp. 85-5). Amended subsection (B), para-                 making at 8 A.A.R. 2325, effective May 9, 2002 (Supp.
         graph (4) and added subsection (C), paragraph (2)                    02-2). Amended by exempt rulemaking at 16 A.A.R.
       effective October 1, 1986 (Supp. 86-5). Correction to                     1638, effective October 1, 2010 (Supp. 10-3).
        subsection (C), paragraph (2) (Supp. 87-4). Section
                                                                       R9-22-216.        F, Alternative HCBS Setting, or HCBS
       repealed effective September 22, 1997 (Supp. 97-3).
                                                                       A. Services provided in a NF, including room and board, an alter-
R9-22-215. Other Medical Professional Services                             native HCBS setting as defined in R9-28-101, or a HCBS as
A. The following medical professional services are covered ser-            defined in A.R.S. § 36-2939 are covered for a maximum of 90
    vices if a member receives these services in an inpatient, out-        days per contract year if the member’s medical condition
    patient, or office setting as follows:                                 would otherwise require hospitalization.
    1. Dialysis;                                                       B. Except as otherwise provided in 9 A.A.C. 28, the following
    2. The following family planning services if provided to               services are not itemized for separate billing if provided in a
         delay or prevent pregnancy:                                       NF, alternative HCBS setting, or HCBS:
         a. Medications,                                                   1. Nursing services, including:
         b. Supplies,                                                            a. Administering medication;
         c. Devices, and                                                         b. Tube feedings;
         d. Surgical procedures.                                                 c. Personal care services, including but not limited to
    3. Family planning services are limited to:                                       assistance with bathing and grooming;
         a. Contraceptive counseling, medications, supplies,                     d. Routine testing of vital signs; and
               and associated medical and laboratory examinations,               e. Maintenance of a catheter;
               including HIV blood screening as part of a package          2. Basic patient care equipment and sickroom supplies,
               of sexually transmitted disease tests provided with a             including:
               family planning service;                                          a. First aid supplies such as bandages, tape, ointments,
         b. Sterilization; and                                                        peroxide, alcohol, and over-the-counter remedies;
         c. Natural family planning education or referral;                       b. Bathing and grooming supplies;
    4. Midwifery services provided by a certified nurse practi-                  c. Identification device;
         tioner in midwifery;                                                    d. Skin lotion;
    5. Midwifery services for low-risk pregnancies and home                      e. Medication cup;
         deliveries provided by a licensed midwife;                              f. Alcohol wipes, cotton balls, and cotton rolls;
    6. Respiratory therapy;                                                      g. Rubber gloves (non-sterile);
    7. Ambulatory and outpatient surgery facilities services;                    h. Laxatives;
    8. Home health services under A.R.S. § 36-2907(D);                           i. Bed and accessories;
    9. Private or special duty nursing services when medically                   j. Thermometer;
         necessary and prior authorized;                                         k. Ice bags;
    10. Rehabilitation services including physical therapy, occu-                l. Rubber sheeting;
         pational therapy, speech therapy, and audiology within                  m. Passive restraints;
         limitations in subsection (C);                                          n. Glycerin swabs;
    11. Total parenteral nutrition services, which are the provi-                o. Facial tissue;
         sion of total caloric needs by intravenous route for indi-              p. Enemas;
         viduals with severe pathology of the alimentary tract;                  q. Heating pad; and
    12. Inpatient chemotherapy; and                                              r. Incontinence briefs.
    13. Outpatient chemotherapy.                                           3. Dietary services including preparation and administration
B. Prior authorization from the Administration for a member is                   of special diets, and adaptive tools for eating;
    required for services listed in subsections (A)(4) through (11).       4. Any service that is included in a NF’s room and board
C. The following services are excluded as covered services:                      charge or a service that is required of the NF to meet a
    1. Occupational and speech therapies provided on an outpa-                   federal or state licensure standard or county certification
         tient basis for a member age 21 or older;                               requirement;
    2. Physical therapy provided only as a maintenance regi-               5. Physician visits made solely for the purpose of meeting
         men;                                                                    state licensure standards or county certification require-
    3. Abortion counseling;                                                      ments;
    4. Services or items furnished solely for cosmetic purposes;           6. Physical therapy prescribed only as a maintenance regi-
    5. Services provided by a podiatrist; or                                     men; and
    6. More than 15 outpatient physical therapy visits per con-            7. Assistive devices and non-customized durable medical
         tract year with the exception of the required Medicare                  equipment.
         coinsurance and deductible payment as described in 9          C. A provider shall obtain prior authorization from the Adminis-
         A.A.C. 29, Article 3.                                             tration for a NF admission for a FFS member.
                          Historical ote                                                         Historical ote
     Adopted as an emergency effective May 20, 1982 pursu-                  Adopted effective October 1, 1985 (Supp. 85-5). Section
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-              repealed, new Section adopted effective September 22,
      3). Former Section R9-22-215 adopted as an emergency                    1997 (Supp. 97-3). Amended by final rulemaking at 6
      now adopted and amended as a permanent rule effective                  A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Sub-
      August 30, 1982 (Supp. 82-4). Amended effective Octo-                    section (C) amended to correct a typographical error
      ber 1, 1985 (Supp. 85-5). Section repealed, new Section               (Supp. 00-4). Amended by final rulemaking at 8 A.A.R.
        adopted effective September 22, 1997 (Supp. 97-3).                   2325, effective May 9, 2002 (Supp. 02-2). Amended by
      Amended by final rulemaking at 6 A.A.R. 179, effective                final rulemaking at 13 A.A.R. 3272, effective September
     December 13, 1999 (Supp. 99-4). Amended by final rule-                  11, 2007 (Supp. 07-3). Amended by final rulemaking at


Supp. 11-2                                                        Page 22                                                    June 30, 2011
                                                       Arizona Administrative Code                                               Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

      13 A.A.R. 4122, effective November 6, 2007 (Supp. 07-                     (Supp. 05-4). Amended by final rulemaking at 13 A.A.R.
                                4).                                                3351, effective November 10, 2007 (Supp. 07-3).
      Editor’s ote: The following Section was adopted and                  R9-22-218.     Repealed
amended under an exemption from the provisions of the Adminis-
                                                                                                       Historical ote
trative Procedure Act which means that this rule was not reviewed
                                                                                Section R9-22-218 renumbered from R9-22-206 effective
by the Governor’s Regulatory Review Council; the agency did not
                                                                                 January 1, 1996, under an exemption from A.R.S. Title
submit notice of proposed rulemaking to the Secretary of State for
                                                                                41, Chapter 6, pursuant to Laws 1995, Third Special Ses-
publication in the Arizona Administrative Register; the agency
                                                                                 sion, Ch. 1, § 5; filed with the Office of the Secretary of
was not required to hold public hearings on the rules; and the
                                                                                State December 28, 1995 (Supp. 95-4). Section repealed
Attorney General has not certified this rule. This Section was sub-
                                                                                        effective September 22, 1997 (Supp. 97-3).
sequently repealed and a new Section adopted under the regular
rulemaking process.                                                                            ARTICLE 3. REPEALED
R9-22-217. Services Included in the Federal Emergency Ser-                 R9-22-301.     Repealed
vices Program
                                                                                                      Historical ote
A. Definition. For the purposes of this Section, an emergency
                                                                                 Adopted effective August 30, 1982 (Supp. 82-4). Former
     medical or behavioral health condition for a FES member
                                                                                Section R9-22-301 renumbered together with former Sec-
     means a medical condition or a behavioral health condition,
                                                                                tion R9-22-102 as Section R9-22-101 and amended effec-
     including labor and delivery, manifesting itself by acute symp-
                                                                                  tive October 1, 1983 (Supp. 83-5). New Section R9-22-
     toms of sufficient severity, including severe pain, such that the
                                                                                 301 adopted effective November 20, 1984 (Supp. 84-6).
     absence of immediate medical attention could reasonably be
                                                                                     Amended effective October 1, 1985 (Supp. 85-5).
     expected to result in:
                                                                                 Amended subsection (B), paragraph (8), subsection (E),
     1. Placing the member’s health in serious jeopardy,
                                                                                 paragraph (3), and subsection (J), paragraph (5) effective
     2. Serious impairment to bodily functions,
                                                                                 October 1, 1986 (Supp. 86-5). Amended subsections (C)
     3. Serious dysfunction of any bodily organ or part, or
                                                                                   and (E) effective January 1, 1987, filed December 31,
     4. Serious physical harm to another person.
                                                                                   1986 (Supp. 86-6). Amended subsections (B) and (C)
B. Services. Emergency services for a FES member mean those
                                                                                effective October 1, 1987; amended subsection (D) effec-
     medical or behavioral health services provided for the treat-
                                                                                tive December 22, 1987 (Supp. 87-4). Amended effective
     ment of an emergency condition. Emergency services include
                                                                                May 30, 1989 (Supp. 89-2). Amended effective September
     outpatient dialysis services for an FES member with End Stage
                                                                                 29, 1992 (Supp. 92-3). Amended effective December 13,
     Renal Disease (ESRD) where a treating physician has certified
                                                                                1993 (Supp. 93-4). Section repealed by final rulemaking at
     that in his opinion the absence of receiving dialysis at least
                                                                                   5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
     three times per week would reasonably be expected to result
     in:                                                                   R9-22-302.     Repealed
     1. Placing the patient’s health in serious jeopardy, or
                                                                                                     Historical ote
     2. Serious impairment of bodily function, or
                                                                                Adopted effective August 30, 1982 (Supp. 82-4). Former
     3. Serious dysfunction of a bodily organ or part.
                                                                                   Section R9-22-302 repealed, new Section R9-22-302
C. Covered services. Services are considered emergency services
                                                                                   adopted effective November 20, 1984 (Supp. 84-6).
     if all of the criteria specified in subsection (A) are satisfied at
                                                                                Amended effective January 1, 1987, filed December 31,
     the time the services are rendered and timely notification as
                                                                                  1986 (Supp. 86-6). Amended effective September 29,
     specified in subsection (E) is given. The Administration shall
                                                                                 1992 (Supp. 92-3). Amended under an exemption from
     determine whether an emergency condition exists on a case-
                                                                                   the provisions of the Administrative Procedure Act,
     by-case basis.
                                                                                effective July 1, 1993 (Supp. 93-3). Section repealed by
D. Prior authorization. A provider is not required to obtain prior
                                                                                  final rulemaking at 5 A.A.R. 294, effective January 8,
     authorization for emergency services for FES members. Prior
                                                                                                    1999 (Supp. 99-1).
     authorization for outpatient dialysis services is met when the
     treating physician has completed and signed a monthly certifi-        R9-22-303.     Repealed
     cation as described in subsection (B).
                                                                                                     Historical ote
E. Notification. A provider shall notify the Administration no
                                                                                Adopted effective August 30, 1982 (Supp. 82-4). Former
     later than 72 hours after a FES member receiving emergency
                                                                                  Section R9-22-303 repealed, new Section R9-22-303
     medical or behavioral health services presents to a hospital for
                                                                                   adopted effective November 20, 1984 (Supp. 84-6).
     inpatient services. The Administration may deny payment for
                                                                                    Amended effective October 1, 1985 (Supp. 85-5).
     failure to provide timely notice.
                                                                                 Amended effective January 1, 1987, filed December 31,
                         Historical ote                                           1986 (Supp. 86-6). Amended subsection (A) effective
      Adopted under an exemption from the provisions of the                     February 26, 1988 (Supp. 88-1). Section repealed by final
        Administrative Procedure Act, effective July 1, 1993                     rulemaking at 5 A.A.R. 294, effective January 8, 1999
     (Supp. 93-3). Amended under an exemption from the pro-                                           (Supp. 99-1).
       visions of the Administrative Procedure Act, effective
                                                                           R9-22-304.     Repealed
       October 26, 1993 (Supp. 93-4). Section repealed, new
     Section adopted effective September 22, 1997 (Supp. 97-                                        Historical ote
       3). Amended by exempt rulemaking at 7 A.A.R. 5701,                       Adopted effective August 30, 1982 (Supp. 82-4). Former
      effective December 1, 2001 (Supp. 01-4). Amended by                        Section R9-22-304 repealed, new Section R9-22-304
     exempt rulemaking at 10 A.A.R. 4588, effective October                       adopted effective November 20, 1984 (Supp. 84-6).
      12, 2004 (Supp. 04-4). Amended by final rulemaking at                     Amended effective October 1, 1985 (Supp. 85-5). Section
            11 A.A.R. 5480, effective December 6, 2005



June 30, 2011                                                         Page 23                                                        Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

      repealed by final rulemaking at 5 A.A.R. 294, effective         R9-22-308.     Repealed
                   January 8, 1999 (Supp. 99-1).
                                                                                                  Historical ote
R9-22-305.        Repealed                                                       Adopted effective August 30, 1982 (Supp. 82-4).
                                                                                 Amended effective October 1, 1983 (Supp. 83-5).
                          Historical ote
                                                                             Amended by adding subsection (C) effective March 2,
     Adopted effective August 30, 1982 (Supp. 82-4). Former
                                                                            1984 (Supp. 84-2). Former Section R9-22-308 repealed,
       Section R9-22-305 repealed, new Section R9-22-305
                                                                            new Section R9-22-308 adopted effective November 20,
        adopted effective November 20, 1984 (Supp. 84-6).
                                                                             1984 (Supp. 84-6). Amended effective October 1, 1985
     Amended subsection (A) effective January 1, 1987, filed
                                                                           (Supp. 85-5). Amended effective October 1, 1986 (Supp.
      December 31, 1986 (Supp. 86-6). Amended subsection
                                                                           86-5). Change in heading only effective January 1, 1987,
       (A) effective February 26, 1988 (Supp. 88-1). Section
                                                                            filed December 31, 1986 (Supp. 86-6). Amended effec-
      repealed by final rulemaking at 5 A.A.R. 294, effective
                                                                           tive May 30, 1989 (Supp. 89-2). Amended effective April
                   January 8, 1999 (Supp. 99-1).
                                                                              13, 1990 (Supp. 90-2). Amended under an exemption
R9-22-306.        Repealed                                                 from the provisions of the Administrative Procedure Act,
                                                                             effective July 1, 1993 (Supp. 93-3). Amended under an
                           Historical ote
                                                                           exemption from the provisions of the Administrative Pro-
     Adopted effective August 30, 1982 (Supp. 82-4). Former
                                                                           cedure Act, effective October 26, 1993 (Supp. 93-4). Sec-
         Section R9-22-306 repealed, new Section R9-22-306
                                                                                tion repealed by final rulemaking at 5 A.A.R. 294,
         adopted effective November 20, 1984 (Supp. 84-6).
                                                                                      effective January 8, 1999 (Supp. 99-1).
          Amended effective October 1, 1985 (Supp. 85-5).
     Amended subsection (B), paragraphs (1) and (6) effective         R9-22-309.     Repealed
      October 1, 1986 (Supp. 86-5). Amended subsection (B),
                                                                                                 Historical ote
       paragraph (1) and added a new subsection (N) effective
                                                                                Adopted effective August 30, 1984 (Supp. 82-4).
      January 1, 1987, filed December 31, 1986 (Supp. 86-6).
                                                                           Amended (D)(1)(d) effective October 1, 1983 (Supp. 83-
         Amended subsection (B) effective October 1, 1987;
                                                                           5). Former Section R9-22-309 repealed, new Section R9-
        amended subsection (N) effective December 22, 1987
                                                                           22-309 adopted effective November 20, 1984 (Supp. 84-
       (Supp. 87-4). Amended effective April 13, 1990 (Supp.
                                                                             6). Amended effective October 1, 1985 (Supp. 85-5).
     90-2). Amended effective September 29, 1992 (Supp. 92-
                                                                               Amended effective October 1, 1986 (Supp. 86-5).
      3). Amended under an exemption from the provisions of
                                                                           Amended subsection (F) effective January 1, 1987, filed
      the Administrative Procedure Act, effective July 1, 1993
                                                                            December 31, 1986 (Supp. 86-6). Amended subsections
     (Supp. 93-3). Amended under an exemption from the pro-
                                                                           (A), (B) and (C) effective October 1, 1987 (Supp. 87-4).
        visions of the Administrative Procedure Act, effective
                                                                           Amended effective May 30, 1989 (Supp. 89-2). Amended
     October 26, 1993 (Supp. 93-4). Section repealed by final
                                                                           effective May 30, 1989 (Supp. 89-2). Amended effective
        rulemaking at 5 A.A.R. 294, effective January 8, 1999
                                                                           April 13, 1990 (Supp. 90-2). Amended under an exemp-
                            (Supp. 99-1).
                                                                           tion from the provisions of the Administrative Procedure
R9-22-307.        Repealed                                                 Act, effective July 1, 1993 (Supp. 93-3). Section repealed
                                                                           by final rulemaking at 5 A.A.R. 294, effective January 8,
                           Historical ote
                                                                                               1999 (Supp. 99-1).
          Adopted effective August 30, 1982 (Supp. 82-4).
     Amended subsections (A) and (C), added subsection (G)            R9-22-310.     Repealed
      and (H) effective October 1, 1983 (Supp. 83-5). Former
                                                                                                 Historical ote
        Section R9-22-307 repealed, new Section R9-22-307
                                                                                Adopted effective August 30, 1982 (Supp. 82-4).
        adopted effective November 20, 1984 (Supp. 84-6).
                                                                               Amended (B)(7) and added subsections (C) and (D)
          Amended effective October 1, 1985 (Supp. 85-5).
                                                                            effective October 1, 1983 (Supp. 83-5). Former Section
         Amended subsection (A) as an emergency effective
                                                                              R9-22-310 repealed, new Section R9-22-310 adopted
       December 4, 1985 pursuant to A.R.S. § 41-1003, valid
                                                                              effective November 20, 1984 (Supp. 84-6). Amended
      for only 90 days (Supp. 85-6). Permanent amendment to
                                                                           effective October 1, 1985 (Supp. 85-5). Amended subsec-
      subsection (A) effective February 5, 1986 (Supp. 86-1).
                                                                            tion (B) and deleted subsection (C) effective October 1,
       Amended subsections (E) and (F) effective October 1,
                                                                            1986 (Supp. 86-5). Amended subsection (B), paragraph
      1986 (Supp. 86-5). Amended effective January 1, 1987,
                                                                             (7) effective January 1, 1987, filed December 31, 1986
     filed December 31, 1986 (Supp. 86-6). Amended subsec-
                                                                           (Supp. 86-6). Amended subsection (B) effective May 30,
         tion (A) effective February 26, 1988 (Supp. 88-1).
                                                                              1989 (Supp. 89-2). Amended effective April 13, 1990
     Amended effective May 30, 1989 (Supp. 89-2). Amended
                                                                              (Supp. 90-2). Amended effective December 13, 1993
     effective April 13, 1990 (Supp. 90-2). Amended effective
                                                                            (Supp. 93-4). Section repealed by final rulemaking at 5
       September 29, 1992 (Supp. 92-3). Amended under an
                                                                               A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
     exemption from the provisions of the Administrative Pro-
     cedure Act, effective July 1, 1993 (Supp. 93-3). Amended         R9-22-311.     Repealed
     under an exemption from the provisions of the Adminis-
                                                                                                Historical ote
     trative Procedure Act, effective October 26, 1993 (Supp.
                                                                           Adopted effective August 30, 1982 (Supp. 82-4). Former
     93-4). Amended under an exemption from the provisions
                                                                              Section R9-22-311 repealed, new Section R9-22-311
     of the Administrative Procedure Act, effective October 8,
                                                                              adopted effective November 20, 1984 (Supp. 84-6).
         1996; filed with the Office of the Secretary of State
                                                                           Amended effective October 1, 1985 (Supp. 85-5). Change
        November 6, 1996 (Supp. 96-4). Section repealed by
                                                                            in heading only effective January 1, 1987, filed Decem-
       final rulemaking at 5 A.A.R. 294, effective January 8,
                                                                           ber 31, 1986 (Supp. 86-6). Amended effective April 13,
                          1999 (Supp. 99-1).
                                                                            1990 (Supp. 90-2). Amended under an exemption from
                                                                              the provisions of the Administrative Procedure Act,


Supp. 11-2                                                       Page 24                                                    June 30, 2011
                                                    Arizona Administrative Code                                           Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

     effective July 1, 1993 (Supp. 93-3). Section repealed by              Amended effective January 1, 1987, filed December 31,
      final rulemaking at 5 A.A.R. 294, effective January 8,                1986 (Supp. 86-6). Amended effective May 30, 1989
                         1999 (Supp. 99-1).                                 (Supp. 89-2). Amended effective September 29, 1992
                                                                           (Supp. 92-3). Section repealed by final rulemaking at 5
R9-22-312.      Repealed
                                                                             A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
                          Historical ote
                                                                      R9-22-315.    Repealed
          Adopted effective August 30, 1982 (Supp. 82-4).
     Amended subsections (A) and (B), added subsection (D)                                      Historical ote
      effective October 1, 1983 (Supp. 83-5). Former Section               Adopted effective August 30, 1982 (Supp. 82-4). Former
       R9-22-312 repealed, new Section R9-22-312 adopted                      Section R9-22-315 repealed, new Section R9-22-315
       effective November 20, 1984 (Supp. 84-6). Amended                      adopted effective November 20, 1984 (Supp. 84-6).
    effective October 1, 1985 (Supp. 85-5). Amended subsec-                 Repealed effective October 1, 1985 (Supp. 85-5). New
     tion (A) effective October 1, 1986 (Supp. 86-5). Change                 Section R9-22-315 adopted effective February 5, 1986
     in heading only effective January 1, 1987, filed Decem-                  (Supp. 86-1). Amended effective February 26, 1988
        ber 31, 1986 (Supp. 86-6). Amended subsection (A)                   (Supp. 88-1). Amended effective April 13, 1990 (Supp.
     effective October 1, 1987 (Supp. 87-4). Amended effec-                90-2). Amended under an exemption from the provisions
    tive April 13, 1990 (Supp. 90-2). Amended effective Sep-                 of the Administrative Procedure Act, effective July 1,
         tember 29, 1992 (Supp. 92-3). Amended under an                    1993 (Supp. 93-3). Section repealed by final rulemaking
    exemption from the provisions of the Administrative Pro-               at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
     cedure Act, effective July 1, 1993 (Supp. 93-3). Section
                                                                      R9-22-316.    Repealed
      repealed by final rulemaking at 5 A.A.R. 294, effective
                   January 8, 1999 (Supp. 99-1).                                                 Historical ote
                                                                           Adopted effective August 30, 1982 (Supp. 82-4). Former
R9-22-313.      Repealed
                                                                              Section R9-22-316 repealed, new Section R9-22-316
                          Historical ote                                   adopted as an emergency effective February 9, 1983, pur-
          Adopted effective August 30, 1982 (Supp. 82-4).                   suant to A.R.S. § 41-1003, valid for only 90 days (Supp.
          Amended effective October 1, 1983 (Supp. 83-5).                   83-1). Former Section R9-22-316 repealed, new Section
    Amended subsections (C) and (D) as an emergency effec-                 R9-22-316 adopted as a permanent rule effective May 16,
    tive May 18, 1984, pursuant to A.R.S. § 41-1003, valid for              1983; text of permanent rule identical to the emergency
    only 90 days (Supp. 84-3). Amended subsections (D) and                 (Supp. 83-3). Amended effective October 1, 1983 (Supp.
     (E) as an emergency effective August 16, 1984, pursuant               83-5). Correction subsection (A), paragraph (1) amended
     to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-4).              effective October 1, 1983, (Supp. 83-6). Amended as an
     Emergency expired. Former Section R9-22-313 repealed,                 emergency effective May 18, 1984, pursuant to A.R.S. §
     new Section R9-22-313 adopted effective November 20,                   41-1003, valid for only 90 days (Supp. 84-3). Amended
      1984 (Supp. 84-6). Amended effective October 1, 1985                  as an emergency effective August 16, 1984, pursuant to
     (Supp. 85-5). Amended effective October 1, 1986 (Supp.                  A.R.S. § 41-1003, valid for only 90 days (Supp. 84-4).
      86-5). Amended subsections (B), (C), (E) and (G) effec-              Emergency expired. Former Section R9-22-316 repealed,
    tive January 1, 1987, filed December 31, 1986 (Supp. 86-               new Section R9-22-316 adopted effective November 20,
    6). Amended subsections (B) and (C) effective December                   1984 (Supp. 84-6). Amended effective October 1, 1985
     22, 1987 (Supp. 87-4). Amended effective May 30, 1989                 (Supp. 85-5). Amended subsection (C) effective October
      (Supp. 89-2). Amended effective April 13, 1990 (Supp.                1986 (Supp. 86-5). Change in heading only effective Jan-
    90-2). Amended effective September 29, 1992 (Supp. 92-                    uary 1, 1987, filed December 31, 1986 (Supp. 86-6).
      3). Amended under an exemption from the provisions of                 Amended effective April 13, 1990 (Supp. 90-2). Section
     the Administrative Procedure Act, effective July 1, 1993                repealed by final rulemaking at 5 A.A.R. 294, effective
    (Supp. 93-3). Amended under an exemption from the pro-                                January 8, 1999 (Supp. 99-1).
       visions of the Administrative Procedure Act, effective
                                                                      R9-22-317.    Repealed
         October 26, 1993 (Supp. 93-4). Amended effective
       December 13, 1993 (Supp. 93-4). Amended under an                                         Historical ote
    exemption from the provisions of the Administrative Pro-               Adopted effective August 30, 1982 (Supp. 82-4). Former
        cedure Act, effective October 8, 1996; filed with the                Section R9-22-317 repealed, new Section R9-22-317
    Office of the Secretary of State November 6, 1996 (Supp.                  adopted effective November 20, 1984 (Supp. 84-6).
      96-4). Section repealed by final rulemaking at 5 A.A.R.              Amended effective October 1, 1986 (Supp. 86-5). Section
            294, effective January 8, 1999 (Supp. 99-1).                    repealed by final rulemaking at 5 A.A.R. 294, effective
                                                                                         January 8, 1999 (Supp. 99-1).
R9-22-314.      Repealed
                                                                      R9-22-318.    Repealed
                        Historical ote
        Adopted effective August 30, 1982 (Supp. 82-4).                                        Historical ote
    Amended subsection (A) and added subsection (F) as an                      Adopted effective August 30, 1982 (Supp. 82-4).
      emergency effective February 28, 1983, pursuant to                       Amended effective October 1, 1983 (Supp. 83-5).
     A.R.S. § 41-1003, valid for only 90 days (Supp. 83-1).                Amended as an emergency effective May 18, 1984, pur-
     Amended subsection (A) and added subsection (F) as a                  suant to A.R.S. § 41-1003, valid for only 90 days (Supp.
       permanent rule effective May 16, 1983; text of the                   84-3). Amended as an emergency effective August 16,
     amended rule identical to the emergency (Supp. 83-3).                   1984, pursuant to A.R.S. § 41-1003, valid for only 90
    Former Section R9-22-314 repealed, new Section R9-22-                   days (Supp. 84-4). Emergency expired. Former Section
    314 adopted effective November 20, 1984 (Supp. 84-6).                    R9-22-318 repealed, new Section R9-22-318 adopted
       Amended effective October 1, 1985 (Supp. 85-5).                       effective November 20, 1984 (Supp. 84-6). Amended


June 30, 2011                                                    Page 25                                                      Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

     effective October 1, 1985 (Supp. 85-5). Amended subsec-                ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 83-
       tion (A) and added subsection (C) effective October 1,               3). Former Section R9-22-322 repealed, new Section R9-
        1986 (Supp. 86-5). Amended subsection (A) effective                  22-322 adopted effective October 1, 1983 (Supp. 83-5).
      January 1, 1987, filed December 31, 1986 (Supp. 86-6).                Amended as an emergency effective May 18, 1984 pursu-
         Amended subsection (B) effective October 1, 1987;                  ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-
       amended subsection (A) effective December 22, 1987                   3). Amended as an emergency effective August 16, 1984,
       (Supp. 87-4). Amended effective May 30, 1989 (Supp.                     pursuant to A.R.S. § 41-1003, valid for only 90 days
       89-2). Amended effective April 13, 1990 (Supp. 90-2).                (Supp. 84-4). Emergency expired. Former Section R9-22-
        Amended effective September 29, 1992 (Supp. 92-3).                   322 repealed, new Section R9-22-322 adopted effective
     Amended under an exemption from the provisions of the                    November 20, 1984 (Supp. 84-6). Amended effective
        Administrative Procedure Act, effective July 1, 1993                  October 1, 1985 (Supp. 85-5). Change in heading only
        (Supp. 93-3). Amended effective December 13, 1993                       effective January 1, 1987, filed December 31, 1986
     (Supp. 93-4). Amended under an exemption from the pro-                   (Supp. 86-6). Amended effective September 29, 1992
       visions of the Administrative Procedure Act, effective               (Supp. 92-3). Amended December 13, 1993 (Supp. 93-4).
     October 8, 1996; filed with the Office of the Secretary of               Section repealed by final rulemaking at 5 A.A.R. 294,
      State November 6, 1996 (Supp. 96-4). Section repealed                            effective January 8, 1999 (Supp. 99-1).
     by final rulemaking at 5 A.A.R. 294, effective January 8,
                                                                       R9-22-323.     Repealed
                         1999 (Supp. 99-1).
                                                                                                 Historical ote
R9-22-319.        Repealed
                                                                             Adopted effective August 30, 1982 (Supp. 82-4). Former
                          Historical ote                                       Section R9-22-323 repealed, new Section R9-22-323
          Adopted effective August 30, 1982 (Supp. 82-4).                   adopted effective October 1, 1983 (Supp. 83-5). Amended
     Amended as an emergency effective May 18, 1984, pur-                      as an emergency effective May 18, 1984, pursuant to
     suant to A.R.S. § 41-1003, valid for only 90 days (Supp.                 A.R.S. § 41-1003, valid for only 90 days (Supp. 84-3).
      84-3). Amended as an emergency effective August 16,                     Amended as an emergency effective August 16, 1984,
       1984, pursuant to A.R.S. § 41-1003, valid for only 90                   pursuant to A.R.S. § 41-1003, valid for only 90 days
      days (Supp. 84-4). Emergency expired. Former Section                  (Supp. 84-4). Emergency expired. Former Section R9-22-
       R9-22-319 repealed, new Section R9-22-319 adopted                     323 repealed, new Section R9-22-323 adopted effective
       effective November 20, 1984 (Supp. 84-6). Amended                       November 20, 1984 Supp. 84-6). Amended effective
     effective May 30, 1989 (Supp. 89-2). Amended effective                  October 1, 1985 (Supp. 85-5). Amended subsections (B)
       December 13, 1993 (Supp. 93-4). Section repealed by                      through (D) effective October 1, 1986 (Supp. 86-5).
       final rulemaking at 5 A.A.R. 294, effective January 8,                Amended subsections (A), (B) and (D) effective January
                        1999 (Supp. 99-1).                                  1, 1987, filed December 31, 1986 (Supp. 86-6). Amended
                                                                              subsections (B), (D) and (E) effective October 1, 1987
R9-22-320.        Repealed
                                                                            (Supp. 87-4). Amended subsections (B) and (D) effective
                         Historical ote                                     May 30, 1989 (Supp. 89-2). Amended effective April 13,
     Adopted effective August 30, 1982 (Supp. 82-4). Former                   1990 (Supp. 90-2). Amended effective September 29,
      Section R9-22-320 repealed, new Section R9-22-320                        1992 (Supp. 92-3). Amended effective December 13,
       adopted effective November 20, 1984 (Supp. 84-6).                     1993 (Supp. 93-4). Section repealed by final rulemaking
        Amended effective April 13, 1990 (Supp. 90-2).                       at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
      Repealed effective December 13, 1993 (Supp. 93-4).
                                                                       R9-22-324.     Repealed
R9-22-321.        Repealed
                                                                                                 Historical ote
                           Historical ote                                   Adopted as an emergency effective July 27, 1983, pursu-
     Adopted effective August 30, 1982 (Supp. 82-4). Former                 ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 83-
       Section R9-22-321 repealed, new Section R9-22-321                     4). Former Section R9-22-324 adopted as an emergency
        adopted effective November 20, 1984 (Supp. 84-6).                    renumbered as Section R9-22-327. New Section R9-22-
         Amended effective October 1, 1985 (Supp. 85-5).                       324 adopted effective October 1, 1983 (Supp. 83-5).
      Amended subsections (B) through (E) effective October                 Former Section R9-22-324 repealed, former Section R9-
        1, 1986 (Supp. 86-5). Amended effective January 1,                  22-323 renumbered as Section R9-22-324 and adopted as
      1987, filed December 31, 1986 (Supp. 86-6). Amended                   an emergency effective May 18, 1984, pursuant to A.R.S.
     effective October 1, 1987 (Supp. 87-4). Amended subsec-                  § 41-1003, valid for only 90 days (Supp. 84-3). Former
      tions (B) and (D) effective May 30, 1989 (Supp. 89-2).                   Section R9-22-324 repealed, new Section R9-22-324
          Amended effective April 13, 1990 (Supp. 90-2).                    adopted as an emergency effective August 16, 1984, pur-
       Amended effective September 29, 1992 (Supp. 92-3).                    suant to A.R.S. § 41-1003, valid for only 90 days (Supp.
     Amended under an exemption from the provisions of the                    84-4). Emergency expired. Former Section R9-22-324
        Administrative Procedure Act, effective July 1, 1993                    repealed, new Section R9-22-324 adopted effective
     (Supp. 93-3). Amended December 13, 1993 (Supp. 93-4).                     November 20, 1984 (Supp. 84-6). Change in heading
       Section repealed by final rulemaking at 5 A.A.R. 294,                  only effective October 1, 1987 (Supp. 87-4). Amended
               effective January 8, 1999 (Supp. 99-1).                      effective May 30, 1989 (Supp. 89-2). Amended effective
                                                                            April 13, 1990 (Supp. 90-2). Amended effective Septem-
R9-22-322.        Repealed
                                                                            ber 29, 1992 (Supp. 92-3). Section repealed by final rule-
                       Historical ote                                       making at 5 A.A.R. 294, effective January 8, 1999 (Supp.
       Adopted effective August 30, 1982 (Supp. 82-4).                                                 99-1).
     Amended as an emergency effective May 27, 1983 pursu-



Supp. 11-2                                                        Page 26                                                    June 30, 2011
                                                    Arizona Administrative Code                                           Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

R9-22-325.      Repealed                                              R9-22-329.     Repealed
                         Historical ote                                                         Historical ote
    Adopted effective October 1, 1983 (Supp. 83-5). Former                 Adopted as an emergency effective May 18, 1984, pursu-
      Section R9-22-325 repealed, new Section R9-22-325                    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 84-
       adopted effective November 20, 1984 (Supp. 84-6).                    3). Adopted as an emergency effective August 16, 1984,
        Amended effective October 1, 1987 (Supp. 87-4).                       pursuant to A.R.S. § 41-1003, valid for only 90 days
    Amended effective December 13, 1993 (Sup. 93-4). Sec-                   (Supp. 84-4). Emergency expired. New Section R9-22-
    tion repealed by final rulemaking at 5 A.A.R. 294, effec-               329 adopted effective November 20, 1984 (Supp. 84-6).
                tive January 8, 1999 (Supp. 99-1).                              Amended effective October 1, 1985 (Supp. 85-5).
                                                                           Amended subsection (B) effective January 1, 1987, filed
R9-22-326.      Repealed
                                                                             December 31, 1986 (Supp. 86-6). Section repealed by
                          Historical ote                                     final rulemaking at 5 A.A.R. 294, effective January 8,
    Adopted effective October 1, 1983 (Supp. 83-5). Former                                     1999 (Supp. 99-1).
      Section R9-22-326 repealed, new Section R9-22-326
                                                                      R9-22-330.     Repealed
       adopted effective November 20, 1984 (Supp. 84-6).
        Amended effective October 1, 1985 (Supp. 85-5).                                         Historical ote
        Amended subsection (A) effective October 1, 1986                   Adopted as an emergency effective August 16, 1984, pur-
    (Supp. 86-5). Amended subsection (A) effective January                 suant to A.R.S. § 41-1003, valid for only 90 days (Supp.
     1, 1987, filed December 31, 1986 (Supp. 86-6). Change                    84-4). Emergency expired. New Section R9-22-330
     in heading only effective October 1, 1987 (Supp. 87-4).                  adopted effective November 20, 1984 (Supp. 84-6).
    Amended subsection (A) effective May 30, 1989 (Supp.                       Amended effective October 1, 1985 (Supp. 85-5).
    89-2). Amended effective December 13, 1993 (Supp. 93-                      Amended subsection (A) effective October 1, 1986
    4). Section repealed by final rulemaking at 5 A.A.R. 294,               (Supp. 86-5). Amended effective January 1, 1987, filed
              effective January 8, 1999 (Supp. 99-1).                       December 31, 1986 (Supp. 86-6). Amended subsection
                                                                             (A) effective October 1, 1987 (Supp. 87-4). Amended
R9-22-327.      Repealed
                                                                              subsection (A) effective May 30, 1989 (Supp. 89-2).
                           Historical ote                                  Amended effective April 13, 1990 (Supp. 90-2). Section
       Former Section R9-22-324 adopted as an emergency                     repealed by final rulemaking at 5 A.A.R. 294, effective
      effective July 27, 1983, pursuant to A.R.S. § 41-1003,                             January 8, 1999 (Supp. 99-1).
    valid for only 90 days renumbered as Section R9-22-327
                                                                      R9-22-331.     Repealed
       and adopted as a permanent rule effective October 1,
     1983 (Supp. 83-5). Former Section R9-22-327 repealed,                                    Historical ote
     new Section R9-22-327 adopted effective November 20,                   Adopted effective November 20, 1984 (Supp. 84-6).
     1984 (Supp. 84-6). Amended effective October 1, 1985                     Amended effective October 1 1985 (Supp. 85-5).
      (Supp. 85-5). Amended subsections (A), (D), (E), (G),                   Amended effective October 1, 1986 (Supp. 86-5).
        (H), and (I) effective October 1, 1986 (Supp. 86-5).               Amended effective January 1, 1987, filed December 31,
    Amended subsection (D) and added a new subsection (J)                  1986 (Supp. 86-6). Amended effective October 1, 1987
        effective January 1, 1987, filed December 31, 1986                  (Supp. 87-4). Amended effective December 13, 1993
    (Supp. 86-6). Amended subsections (A) and (E) effective                (Supp. 93-4). Section repealed by final rulemaking at 5
      October 1, 1987 (Supp. 87-4). Amended effective May                    A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
    30, 1989 (Supp. 89-2). Amended effective April 13, 1990
                                                                      R9-22-332.     Repealed
      (Supp. 90-2). Amended effective September 29, 1992
    (Supp. 92-3). Amended under an exemption from the pro-                                     Historical ote
      visions of the Administrative Procedure Act, effective                 Adopted effective November 20, 1984 (Supp. 84-6).
    July 1, 1993 (Supp. 93-3). Section repealed by final rule-                Amended effective October 1,1985 (Supp. 85-5).
    making at 5 A.A.R. 294, effective January 8, 1999 (Supp.                  Amended effective April 13, 1990 (Supp. 90-2).
                                99-1).                                      Amended effective September 29, 1992 (Supp. 92-3).
                                                                            Section repealed by final rulemaking at 5 A.A.R. 294,
R9-22-328.      Repealed
                                                                                   effective January 8, 1999 (Supp. 99-1).
                         Historical ote
                                                                      R9-22-333.     Repealed
    Adopted as an emergency effective October 6, 1983, pur-
    suant to A.R.S. § 41-1003, valid for only 90 days (Supp.                                    Historical ote
      83-5). Emergency Expired. New Section R9-22-328                        Adopted effective November 20, 1984 (Supp. 84-6).
      adopted effective November 20, 1984 (Supp. 84-6).                       Amended effective October 1, 1985 (Supp. 85-5).
       Amended effective October 1, 1985 (Supp. 85-5).                     Amended effective January 1, 1987, filed December 31,
     Amended subsections (A) and (E) effective January 1,                  1986 (Supp. 86-6). Amended under an exemption from
     1987, filed December 31, 1986 (Supp. 86-6). Amended                     the provisions of the Administrative Procedure Act,
     subsection (D) effective October 1, 1987 (Supp. 87-4).                effective July 1, 1993 (Supp. 93-3). Section repealed by
    Amended subsection (D) effective May 30, 1989 (Supp.                    final rulemaking at 5 A.A.R. 294, effective January 8,
     89-2). Amended effective April 13, 1990 (Supp. 90-2).                                    1999 (Supp. 99-1).
     Section repealed by final rulemaking at 5 A.A.R. 294,
                                                                      R9-22-334.     Repealed
             effective January 8, 1999 (Supp. 99-1).
                                                                                              Historical ote
                                                                             Adopted effective November 20, 1984 (Supp. 84-6).
                                                                              Amended effective October 1, 1985 (Supp. 85-5).



June 30, 2011                                                    Page 27                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     Amended effective January 1, 1987, filed December 31,             R9-22-341.     Repealed
       1986 (Supp. 86-6). Amended effective December 13,
                                                                                                Historical ote
     1993 (Supp. 93-4). Section repealed by final rulemaking
                                                                             Adopted effective March 1, 1987, filed December 31,
     at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
                                                                            1986 (Supp. 86-6). Section repealed by final rulemaking
R9-22-335.        Repealed                                                  at 5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
                         Historical ote                                R9-22-342.     Repealed
       Adopted effective November 20, 1984 (Supp. 84-6).
                                                                                                Historical ote
        Amended effective October 1, 1985 (Supp. 85-5).
                                                                              Adopted effective September 29, 1992 (Supp. 92-3).
     Amended by adding subsection (C) effective October 1,
                                                                             Amended effective September 22, 1997 (Supp. 97-3).
      1986 (Supp. 86-5). Amended subsection (B) effective
                                                                             Section repealed by final rulemaking at 5 A.A.R. 294,
     January 1, 1987, filed December 31, 1986 (Supp. 86-6).
                                                                                    effective January 8, 1999 (Supp. 99-1).
      Section repealed by final rulemaking at 5 A.A.R. 294,
             effective January 8, 1999 (Supp. 99-1).                   R9-22-343.     Repealed
R9-22-336.        Repealed                                                                      Historical ote
                                                                             Adopted under an exemption from the provisions of the
                         Historical ote
                                                                               Administrative Procedure Act, effective July 1, 1993
        Adopted effective November 20, 1984 (Supp. 84-6).
                                                                            (Supp. 93-3). Amended under an exemption from the pro-
         Amended effective October 1, 1985 (Supp. 85-5).
                                                                              visions of the Administrative Procedure Act, effective
     Amended by adding subsection (C) effective September 16,
                                                                            October 26, 1993 (Supp. 93-4). Section repealed by final
       1987 (Supp. 87-3). Amended subsection (A) effective
                                                                              rulemaking at 5 A.A.R. 294, effective January 8, 1999
     October 1, 1987 (Supp. 87-4). Amended effective April 13,
                                                                                                  (Supp. 99-1).
     1990 (Supp. 90-2). Section repealed by final rulemaking at
       5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).           R9-22-344.     Repealed
R9-22-337.        Repealed                                                                         Historical ote
                                                                              Adopted under an exemption from the provisions of the
                          Historical ote
                                                                             Administrative Procedure Act, effective October 8, 1996;
       Adopted effective November 20, 1984 (Supp. 84-6).
                                                                            filed with the Office of the Secretary of State November 6,
         Amended effective October 1, 1985 (Supp. 85-5).
                                                                            1996 (Supp. 96-4). Section repealed by final rulemaking at
         Amended effective October 1, 1986 (Supp 86-5).
                                                                               5 A.A.R. 294, effective January 8, 1999 (Supp. 99-1).
      Amended effective January 1, 1987, filed December 31,
      1986 (Supp. 86-6). Correction to subsection (B), para-                               ARTICLE 4. REPEALED
     graph (1) (Supp. 87-3). Amended subsection (C) effective
      December 22, 1987 (Supp. 87-4). Amended subsection               R9-22-401.     Repealed
     (C) effective December 22, 1987 (Supp. 87-4). Amended                                       Historical ote
      effective April 13, 1990 (Supp. 90-2). Section repealed               Adopted as an emergency effective May 20, 1982 pursu-
     by final rulemaking at 5 A.A.R. 294, effective January 8,              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                         1999 (Supp. 99-1).                                  3). Former Section R9-22-401 adopted as an emergency
R9-22-338.        Repealed                                                    now adopted as a permanent rule effective August 30,
                                                                             1982 (Supp. 82-4). Amended effective January 31, 1986
                         Historical ote                                     (Supp. 86-1). Amended effective January 31, 1997 (Supp.
       Adopted effective November 20, 1984 (Supp. 84-6).                      97-1). Amended by final rulemaking at 5 A.A.R. 867,
     Heading changed effective October 1, 1985 (Supp. 85-5).                 effective March 4, 1999 (Supp. 99-1). Section repealed
      Change in heading only effective January 1, 1987, filed                 by final rulemaking at 8 A.A.R. 424, effective January
      December 31, 1986 (Supp. 86-6). Section repealed by                                     10, 2002 (Supp. 02-1).
      final rulemaking at 5 A.A.R. 294, effective January 8,
                       1999 (Supp. 99-1).                              R9-22-402.     Repealed

R9-22-339.        Repealed                                                                       Historical ote
                                                                            Adopted as an emergency effective May 20, 1982, pursu-
                          Historical ote                                    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
         Adopted effective October 1, 1985 (Supp. 85-5).                     3). Former Section R9-22-402 adopted as an emergency
         Amended effective October 1, 1986 (Supp. 86-5).                     now adopted and amended as a permanent rule effective
        Amended subsection (B) effective October 1, 1987                     August 30, 1982 (Supp. 82-4). Amended effective Janu-
     (Supp. 87-4). Amended effective January 14, 1997 (Supp.                  ary 31, 1986 (Supp. 86-1). Amended effective January
      97-1). Section repealed by final rulemaking at 5 A.A.R.               14, 1997 (Supp. 97-1). Amended by final rulemaking at 6
            294, effective January 8, 1999 (Supp. 99-1).                    A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Section
R9-22-340.        Repealed                                                   repealed by final rulemaking at 8 A.A.R. 424, effective
                                                                                          January 10, 2002 (Supp. 02-1).
                         Historical ote
     Adopted effective October 1, 1986 (Supp. 86-5). Section           R9-22-403.     Repealed
     repealed by final rulemaking at 5 A.A.R. 294, effective                                     Historical ote
                  January 8, 1999 (Supp. 99-1).                             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 R9-22-403 adopted as an emergency
                                                                              now adopted as a permanent rule effective August 30,
                                                                             1982 (Supp. 82-4). Amended effective January 31, 1986


Supp. 11-2                                                        Page 28                                                     June 30, 2011
                                                     Arizona Administrative Code                                           Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

     (Supp. 86-1). Amended by adding subsection (C) effec-                 “Quality Improvement” means a process designed to achieve,
       tive October 1, 1987 (Supp. 87-4). Amended effective                through ongoing measurements and intervention, significant
     January 14, 1997 (Supp. 97-1). Section repealed by final              improvement that is sustained over time, in the areas of clini-
      rulemaking at 8 A.A.R. 424, effective January 10, 2002               cal care and non-clinical care and is expected to have a favor-
                           (Supp. 02-1).                                   able effect on health outcomes and member satisfaction.
                                                                           Quality Improvement includes focusing organizational efforts
R9-22-404.      Repealed
                                                                           on improving performance and utilizing data to develop inter-
                         Historical ote                                    vention strategies to improve performance and outcomes.
    Adopted as an emergency effective May 20, 1982, pursu-                 “Utilization management/review” means a methodology used
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-             by professional health personnel to assess the medical indica-
     3). Former Section R9-22-404 adopted as an emergency                  tions, appropriateness, and efficiency of care provided. Utili-
     now adopted and amended as a permanent rule effective                 zation management applies to a contractor’s process to
     August 30, 1982 (Supp. 82-4). Amended effective Janu-                 evaluate and approve or deny the medical necessity, appropri-
      ary 31, 1986 (Supp. 86-1). Amended effective January                 ateness, efficacy and efficiency of health care services, proce-
    14, 1997 (Supp. 97-1). Section repealed by final rulemak-              dures, or settings. Utilization review includes processes for
      ing at 8 A.A.R. 424, effective January 10, 2002 (Supp.               prior authorization, concurrent review, retrospective review,
                               02-1).                                      and case management.
R9-22-405.      Repealed                                                                         Historical ote
                          Historical ote                                   Adopted as an emergency effective May 20, 1982, pursu-
    Adopted as an emergency effective May 20, 1982 pursu-                  ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-              3). Former Section R9-22-501 adopted as an emergency
     3). Former Section R9-22-405 adopted as an emergency                    now adopted as a permanent rule effective August 30,
     now adopted and amended as a permanent rule effective                  1982 (Supp. 82-4). Former Section R9-22-501 repealed,
    August 30, 1982 (Supp. 82-4). Amended as an emergency                  former Section R9-22-502 renumbered and adopted with-
       effective February 23, 1983 pursuant to A.R.S. § 41-                  out change as Section R9-22-501 effective October 1,
    1003, valid for only 90 days (Supp. 83-1). Amended as a                 1983 (Supp. 83-5). Former Section R9-22-501 repealed,
        permanent rule effective May 16, 1983; text of the                  former Section R9-22-526 renumbered and amended as
       amended rule similar to the emergency (Supp. 83-3).                  Section R9-22-501 effective October 1, 1985 (Supp. 85-
        Amended effective January 31, 1986 (Supp. 86-1).                    5). Amended effective December 8, 1997 (Supp. 97-4).
     Amended effective January 14, 1997 (Supp. 97-1). Sec-                  Section repealed; new Section made by final rulemaking
    tion repealed by final rulemaking at 8 A.A.R. 424, effec-                    at 11 A.A.R. 4277, effective December 5, 2005
                tive January 10, 2002 (Supp. 02-1).                        (Supp. 05-4). Amended by final rulemaking at 14 A.A.R.
                                                                                  4330, effective January 3, 2009 (Supp. 08-4).
R9-22-406.      Repealed
                                                                      R9-22-502. Pre-existing Conditions
                          Historical ote                              A. Except as otherwise provided in Article 2 of this Chapter, a
    Adopted as an emergency effective May 20, 1982, pursu-                contractor shall be responsible for providing the full scope of
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-            covered services to each member from the effective date of eli-
     3). Former Section R9-22-406 adopted as an emergency                 gibility until the termination of enrollment or transfer of the
     now adopted and amended as a permanent rule effective                member to another contractor. A contractor shall not impose a
      August 30, 1982 (Supp. 82-4). Former Section R9-22-                 pre-existing condition exclusion with respect to covered ser-
       406 repealed, new Section R9-22-406 adopted as an                  vices.
       emergency effective February 23, 1983, pursuant to             B. A contractor or subcontractor shall not adopt or use any proce-
      A.R.S. § 41-1003, valid for only 90 days (Supp. 83-1).              dure to identify a person who has an existing or anticipated
    Former Section R9-22-316 repealed, new Section R9-22-                 medical or psychiatric condition in order to discourage or
    316 adopted as a permanent rule effective May 16, 1983;               exclude the person from enrolling in the contractor’s health
    text of the Section identical to the emergency (Supp. 83-             plan or encourage the person to enroll in another health plan.
      3). Amended effective January 31, 1986 (Supp. 86-1).
     Amended effective January 14, 1997 (Supp. 97-1). Sec-                                       Historical ote
    tion repealed by final rulemaking at 8 A.A.R. 424, effec-              Adopted as an emergency effective May 20, 1982, pursu-
                tive January 10, 2002 (Supp. 02-1).                        ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                            3). Former Section R9-22-502 adopted as an emergency
 ARTICLE 5. GE ERAL PROVISIO S A D STA DARDS                                 now adopted as a permanent rule effective August 30,
R9-22-501. General Provisions and Standards – Related Def-                   1982 (Supp. 82-4). Former Section R9-22-502 renum-
initions                                                                   bered without change as Section R9-22-501, former Sec-
In addition to definitions contained in A.R.S. § 36-2901, the words        tion R9-22-503 renumbered and amended as Section R9-
and phrases in this Chapter have the following meanings unless the          22-502 effective October 1, 1983 (Supp. 83-5). Former
context explicitly requires another meaning:                                  Section R9-22-502 repealed, new Section R9-22-502
      “Quality management” means a process used by professional                  adopted effective October 1, 1985 (Supp. 85-5).
      health personnel through a formal program involving multiple         Amended effective December 8, 1997 (Supp. 97-4). Sec-
      organizational components and committees to:                          tion repealed; new Section made by final rulemaking at
                                                                            11 A.A.R. 4277, effective December 5, 2005 (Supp. 05-
           Assess the degree to which services provided conform to
                                                                              4). Amended by final rulemaking at 14 A.A.R. 4330,
           desired medical standards and practices; and
                                                                                     effective January 3, 2009 (Supp. 08-4).
           Quality improvement or maintenance of care and ser-
           vices.


June 30, 2011                                                    Page 29                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

R9-22-503. Provider Requirements Regarding Records                            because of race, creed, age, color, sex, religion, national ori-
The provider shall maintain records that meet uniform accounting              gin, ancestry, marital status, sexual preference, physical or
standards and generally accepted practices for maintenance of med-            mental disability, or health status.
ical records, including detailed specification of all patient services   D.   The Administration shall hold a contractor responsible for a
delivered, the rationale for delivery, and the service date. A pro-           violation of this Section resulting from the performance of any
vider shall maintain and upon request, make available to a contrac-           marketing representative, subcontractor, agent, program, or
tor and to the Administration, financial and medical records relating         process under the contractor’s employ or direction and shall
to payment for not less than five years from the date of final pay-           impose contract sanctions on the contractor as specified in
ment, or for records relating to costs and expenses to which the              contract.
Administration has taken exception, five years after the date of final   E.   A contractor shall produce and distribute informational materi-
disposition or resolution of the exception. Providers shall provide           als that are approved by the Administration to each enrolled
one copy of a medical record at no cost if requested by the member.           member or designated representative after the contractor
                                                                              receives notification of enrollment from the Administration.
                            Historical ote
                                                                              The contractor shall ensure that the informational materials
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                              include, at a minimum:
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                              1. A description of all covered services as specified in con-
      3). Former Section R9-22-503 adopted as an emergency
                                                                                   tract;
        now adopted as a permanent rule effective August 30,
                                                                              2. An explanation of service limitations and exclusions;
       1982 (Supp. 82-4). Former Section R9-22-503 renum-
                                                                              3. An explanation of the procedure for obtaining services;
       bered and amended as Section R9-22-502, new Section
                                                                              4. An explanation of the procedure for obtaining emergency
      R9-22-503 adopted effective October 1, 1983 (Supp. 83-
                                                                                   services;
        5). Amended effective October 1, 1985 (Supp. 85-5).
                                                                              5. An explanation of the procedure for filing a grievance
     Amended effective May 30, 1986 (Supp. 86-3). Amended
                                                                                   and appeal; and
     subsection (D) effective January 1, 1987, filed December
                                                                              6. An explanation of when plan changes may occur as spec-
     31, 1986 (Supp. 86-6). Amended subsections (F) and (G)
                                                                                   ified in contract.
        effective December 22, 1987 (Supp. 87-4). Amended
         subsection (I) effective May 30, 1989 (Supp. 89-2).                                        Historical ote
           Amended effective April 13, 1990 (Supp. 90-2).                     Adopted as an emergency effective May 20, 1982, pursu-
        Amended effective September 29, 1992 (Supp. 92-3).                    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
     Amended effective December 8, 1997 (Supp. 97-4). Sec-                     3). Former Section R9-22-504 adopted as an emergency
     tion repealed by final rulemaking at 8 A.A.R. 3317, effec-                now adopted and amended as a permanent rule effective
       tive July 15, 2002 (Supp. 02-3). New Section made by                     August 30, 1982 (Supp. 82-4). Former Section R9-22-
      final rulemaking at 11 A.A.R. 4277, effective December                  504 repealed, former Section R9-22-505 renumbered and
     5, 2005 (Supp. 05-4). Amended by final rulemaking at 14                   adopted without change as Section R9-22-504 effective
        A.A.R. 4330, effective January 3, 2009 (Supp. 08-4).                  October 1, 1983 (Supp. 83-5). Former Section R9-22-504
                                                                                repealed, former Section R9-22-528 renumbered and
R9-22-504. Marketing; Prohibition Against Inducements;
                                                                              amended as Section R9-22-504 effective October 1, 1985
Misrepresentations; Discrimination; Sanctions
                                                                                 (Supp. 85-5). Amended effective December 8, 1997
A. A contractor or the contractor’s marketing representative shall
                                                                              (Supp. 97-4). Amended by final rulemaking at 11 A.A.R.
    not offer or give any form of compensation or reward, or
                                                                                    4277, effective December 5, 2005 (Supp. 05-4).
    engage in any behavior or activity that may be reasonably con-
                                                                               Amended by final rulemaking at 14 A.A.R. 4330, effec-
    strued as coercive, to induce or procure AHCCCS enrollment
                                                                                           tive January 3, 2009 (Supp. 08-4).
    with the contractor. Any marketing solicitation offering a ben-
    efit, good, or service in excess of the covered services in Arti-    R9-22-505.      Standards, Licensure, and Certification for Pro-
    cle 2 is deemed an inducement.                                       viders of Hospital and Medical Services
B. A marketing representative shall not misrepresent itself, the         A provider shall not provide hospital or medical services to a mem-
    contracting health plan represented, or the AHCCCS program,          ber unless the provider is licensed by the Arizona Department of
    through false advertising, false statements, or in any other         Health Services and meets the requirements in 42 CFR 441 and
    manner to induce a member of another contractor to enroll in         482, as of October 1, 2007, and 42 CFR 456 Subpart C, as of Octo-
    the represented health plan. Violations of this subsection           ber 1, 2007, incorporated by reference, on file with the Administra-
    include, but are not limited to, false or misleading claims,         tion and available from the U.S. Government Printing Office, 732
    inferences, or representations such as:                              N. Capitol St., N.W., Washington, D.C. 20401. This incorporation
    1. A member will lose benefits under the AHCCCS program              contains no future editions or amendments. An Indian Health Ser-
          or lose any other health or welfare benefits to which a        vice (IHS) hospital and a Veterans Administration hospital shall not
          member is legally entitled, if the member does not enroll      provide services to a member unless accredited by the Joint Com-
          in the represented contracting health plan;                    mission on Accreditation of Healthcare Organizations (JCAHO).
    2. Marketing representatives are employees of the state or
                                                                                                   Historical ote
          representatives of the Administration, a county, or any
                                                                              Adopted as an emergency effective May 20, 1982, pursu-
          health plan other than the health plan by which they are
                                                                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
          employed, or by which they are reimbursed; and
                                                                               3). Former Section R9-22-505 adopted as an emergency
    3. The represented health plan is recommended or endorsed
                                                                               expired, former Section R9-22-506 adopted as an emer-
          as superior to its competition by any state or county
                                                                              gency now adopted, amended and renumbered as Section
          agency, or any organization, unless the organization has
                                                                              R9-22-505 as a permanent rule effective August 30, 1982
          certified its endorsement in writing to the health plan and
                                                                                (Supp. 82-4). Former Section R9-22-505 renumbered
          the Administration.
                                                                               without change as Section R9-22-504, new Section R9-
C. A marketing representative shall not engage in any marketing
                                                                               22-505 adopted effective October 1, 1983 (Supp. 83-5).
    or pre-enrollment practice that discriminates against a member
                                                                               Former Section R9-22-505 renumbered and amended as


Supp. 11-2                                                          Page 30                                                    June 30, 2011
                                                     Arizona Administrative Code                                              Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

      Section R9-22-509, former Section R9-22-527 renum-                                requested by the Administration, a contractor shall
    bered and amended as Section R9-22-505 effective Octo-                              submit the policies and procedures regarding transi-
    ber 1, 1985 (Supp. 85-5). Editorial correction, spelling of                         tion of members to the Administration for review
    “paraphernalia” in subsection (A) (Supp. 87-4). Amended                             and approval;
        effective December 8, 1997 (Supp. 97-4). Section                          b. Assist in the referral of transitioned members to
    repealed by final rulemaking at 11 A.A.R. 4277, effective                           other community health agencies or county medical
      December 5, 2005 (Supp. 05-4). New Section made by                                assistance programs for medically necessary ser-
     final rulemaking at 14 A.A.R. 4330, effective January 3,                           vices not covered by the Administration, as appro-
                        2009 (Supp. 08-4).                                              priate; and
                                                                                  c. Develop policies and procedures to be followed
R9-22-506.      Repealed
                                                                                        when transitioning members who have significant
                         Historical ote                                                 medical conditions; are receiving ongoing services;
    Adopted as an emergency effective May 20, 1982, pursu-                              or have, at the time of the transition, received prior
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-                          authorization or approval for undelivered, specific
     3). Former Section R9-22-506 adopted as an emergency                               services.
    adopted, amended and renumbered as Section R9-22-505,                   2. The relinquishing contractor shall notify the receiving
    former Section R9-22-507 adopted as an emergency now                          contractor of relevant information about the member’s
    adopted, amended and renumbered as Section R9-22-506                          medical condition and current treatment regimens within
    as a permanent rule effective August 30, 1982 (Supp. 82-                      the timelines defined in contract;
    4). Former Section R9-22-506 repealed, new Section R9-                  3. The relinquishing contractor shall forward medical
     22-506 adopted effective October 1, 1983 (Supp. 83-5).                       records and other relevant materials to the receiving con-
    Former Section R9-22-506 repealed, new Section R9-22-                         tractor. The relinquishing contractor shall bear the cost of
       506 adopted effective October 1, 1985 (Supp. 85-5).                        reproducing and forwarding medical records and other
         Amended effective October 1, 1986 (Supp. 86-5).                          relevant materials;
      Amended subsection (D) effective December 22, 1987                    4. Within the timelines specified in contract, the receiving
     (Supp. 87-4). Repealed effective April 13, 1990 (Supp.                       contractor shall ensure that the member selects or is
    90-2). New Section adopted effective December 13, 1993                        assigned to a primary care provider, and provide the
       (Supp. 93-4). Repealed effective December 8, 1997                          member with:
                          (Supp. 97-4).                                           a. Information regarding the contractor’s providers,
                                                                                  b. Emergency numbers, and
R9-22-507.      Repealed
                                                                                  c. Instructions about how to obtain services.
                         Historical ote                                B.   A contractor shall not use a county or noncontracting provider
    Adopted as an emergency effective May 20, 1982, pursu-                  health resource alternative to diminish the contractor’s con-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-              tractual responsibility or accountability for providing the full
     3). Former Section R9-22-507 adopted as an emergency                   scope of covered services. The Administration may impose
    adopted, amended and renumbered as Section R9-22-506,                   sanctions as described in contract if a contractor makes refer-
    former Section R9-22-508 adopted as an emergency now                    rals to other agencies or programs to reduce expenses incurred
    adopted, amended and renumbered as Section R9-22-507                    by the contractor on behalf of its members.
    as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                                                 Historical ote
    4). Former Section R9-22-507 repealed, new Section R9-
                                                                            Adopted as an emergency effective May 20, 1982, pursu-
     22-507 adopted effective October 1, 1985 (Supp. 85-5).
                                                                            ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    Amended effective December 8, 1997 (Supp. 97-4). Sec-
                                                                             3). Former Section R9-22-509 adopted as an emergency
      tion repealed by final rulemaking at 11 A.A.R. 4277,
                                                                            adopted, amended and renumbered as Section R9-22-508,
            effective December 5, 2005 (Supp. 05-4).
                                                                            former Section R9-22-510 adopted as an emergency now
R9-22-508.      Repealed                                                     adopted and renumbered as Section R9-22-509 as a per-
                                                                               manent rule effective August 30, 1982 (Supp. 82-4).
                         Historical ote
                                                                            Former Section R9-22-509 repealed, former Section R9-
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                             22-505 renumbered and amended as Section R9-22-509
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                             effective October 1, 1985 (Supp. 85-5). Amended effec-
     3). Former Section R9-22-508 adopted as an emergency
                                                                             tive December 8, 1997 (Supp. 97-4). Amended by final
    adopted, amended and renumbered as Section R9-22-507,
                                                                              rulemaking at 11 A.A.R. 4277, effective December 5,
    former Section R9-22-509 adopted as an emergency now
                                                                             2005 (Supp. 05-4). Amended by final rulemaking at 14
    adopted, amended and renumbered as Section R9-22-508
                                                                               A.A.R. 4330, effective January 3, 2009 (Supp. 08-4).
    as a permanent rule effective August 30, 1982 (Supp. 82-
     4). Amended effective December 8, 1997 (Supp. 97-4).              R9-22-510.     Repealed
     Section repealed by final rulemaking at 11 A.A.R. 4277,
                                                                                                 Historical ote
            effective December 5, 2005 (Supp. 05-4).
                                                                            Adopted as an emergency effective May 20, 1982, pursu-
R9-22-509. Transition and Coordination of Member Care                       ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
A. A contractor shall assist in the transition of members to and             3). Former Section R9-22-510 adopted as an emergency
    from other AHCCCS contractors.                                           adopted and renumbered as Section R9-22-509, former
    1. Both the receiving and relinquishing contractor shall:                    Section R9-22-511 adopted as an emergency now
        a. Coordinate with the other contractor to facilitate and           adopted, amended and renumbered as Section R9-22-510
             schedule appointments for medically necessary ser-             as a permanent rule effective August 30, 1982 (Supp. 82-
             vices for the transitioned member within the Admin-            4). Former Section R9-22-510 repealed, new Section R9-
             istration’s timelines specified in the contract. If             22-510 adopted effective October 1, 1985 (Supp. 85-5).



June 30, 2011                                                     Page 31                                                         Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     Amended effective December 8, 1997 (Supp. 97-4). Sec-                          U.S. Government Printing Office, 732 N. Capitol St.,
      tion repealed by final rulemaking at 11 A.A.R. 4277,                          N.W., Washington, D.C. 20401. This incorporation by
            effective December 5, 2005 (Supp. 05-4).                                reference contains no future editions or amendments.
                                                                         C.   The Administration, contractors, providers, and noncontract-
R9-22-511.        Repealed
                                                                              ing providers shall safeguard identifiable information, pro-
                          Historical ote                                      tected health information as specified in 45 CFR 160, and
     Adopted as an emergency effective May 20, 1982, pursu-                   information obtained in the course of application for or rede-
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-               termination of eligibility concerning an applicant or member,
      3). Former Section R9-22-511 adopted as an emergency                    that includes, but is not limited to the following:
     adopted, amended and renumbered as Section R9-22-510,                    1. Name and address;
     former Section R9-22-512 adopted as an emergency now                     2. Social Security number;
     adopted, amended and renumbered as Section R9-22-511                     3. Social and economic conditions or circumstances;
     as a permanent rule effective August 30, 1982 (Supp. 82-                 4. Agency evaluation of personal information;
     4). Former Section R9-22-511 repealed, new Section R9-                   5. Medical data and information concerning medical ser-
      22-511 adopted effective October 1, 1985 (Supp. 85-5).                        vices received, including diagnosis and history of disease
     Amended effective December 8, 1997 (Supp. 97-4). Sec-                          or disability;
       tion repealed by final rulemaking at 11 A.A.R. 4277,                   6. State Data Exchange (SDX) tapes, and other types of
             effective December 5, 2005 (Supp. 05-4).                               information received from outside sources for the pur-
                                                                                    pose of verifying income eligibility and amount of medi-
R9-22-512. Release of Safeguarded Information
                                                                                    cal assistance payments; and
A. The Administration, contractors, providers, and noncontract-
                                                                              7. Any information received in connection with the identifi-
    ing providers shall limit the release of safeguarded information
                                                                                    cation of legally liable third-party resources.
    to persons or agencies for the following purposes in accor-
                                                                         D.   The restriction upon disclosure of information in this Section
    dance with 45 CFR 160 and 45 CFR 164, October 1, 2004, and
                                                                              does not apply to:
    42 CFR 431.300 through 431.307, October 1, 2004, incorpo-
                                                                              1. De-identified information as described by 45 CFR
    rated by reference, on file with the Administration and avail-
                                                                                    164.514, October 1, 2004, incorporated by reference in
    able from the U.S. Government Printing Office, 732 N.
                                                                                    subsection (A); or
    Capitol St., N.W., Washington, D.C. 20401. This incorporation
                                                                              2. A disclosure, in response to a request for information,
    by reference contains no future editions or amendments:
                                                                                    that complies with 45 CFR 160 and 45 CFR 164, October
    1. Official purposes directly related to the administration of
                                                                                    1, 2004, and 42 CFR 431.300 through 431.307, October
         the AHCCCS program including:
                                                                                    1, 2004, incorporated by reference in subsection (A).
         a. Establishing eligibility and post-eligibility treatment
                                                                         E.   A provider shall furnish records requested by the Administra-
               of income, as applicable;
                                                                              tion or a contractor to the Administration or the contractor at
         b. Determining the amount of medical assistance;
                                                                              no charge.
         c. Providing services for members;
         d. Performing evaluations and analysis of AHCCCS                                          Historical ote
               operations;                                                    Adopted as an emergency effective May 20, 1982, pursu-
         e. Filing liens on property as applicable;                           ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
         f. Filing claims on estates, as applicable; and                       3). Former Section R9-22-512 adopted as an emergency
         g. Filing, negotiating, and settling medical liens and               adopted, amended and renumbered as Section R9-22-511,
               claims.                                                        former Section R9-22-513 adopted as an emergency now
    2. Law enforcement. The Administration may release safe-                   adopted and renumbered as Section R9-22-512 as a per-
         guarded information without the applicant’s or member’s                 manent rule effective August 30, 1982 (Supp. 82-4).
         written or verbal consent, for the purpose of conducting             Former Section R9-22-512 repealed, new Section R9-22-
         or assisting an investigation, prosecution, or criminal or              512 adopted effective October 1, 1985 (Supp. 85-5).
         civil proceeding related to the administration of the AHC-              Amended effective December 13, 1993 (Supp. 93-4).
         CCS program.                                                            Amended effective December 8, 1997 (Supp. 97-4).
    3. The Administration may release safeguarded member                       Amended by final rulemaking at 11 A.A.R. 4277, effec-
         information to a review committee in accordance with the              tive December 5, 2005 (Supp. 05-4). Amended by final
         provisions of A.R.S. § 36-2917, without the consent of               rulemaking at 14 A.A.R. 4330, effective January 3, 2009
         the applicant or member.                                                                    (Supp. 08-4).
B. Except as provided in subsection (A), the Administration, con-
                                                                         R9-22-513.     Repealed
    tractors, providers, and noncontracting providers shall disclose
    safeguarded information only to:                                                                Historical ote
    1. An applicant;                                                          Adopted as an emergency effective May 20, 1982, pursu-
    2. A member;                                                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    3. An unemancipated minor, with written permission of a                    3). Former Section R9-22-513 adopted as an emergency
         parent, custodial relative, or designated representative, if:         adopted and renumbered as Section R9-22-512, former
         a. An Administration employee, authorized representa-                     Section R9-22-514 adopted as an emergency now
               tive, or responsible caseworker is present during the          adopted, amended and renumbered as Section R9-22-513
               examination of the safeguarded information; or                 as a permanent rule effective August 30, 1982 (Supp. 82-
         b. After written notification to the provider, and at a               4). Former Section R9-22-513 repealed, former Section
               reasonable time and place.                                      R9-22-526 renumbered and amended as Section R9-22-
    4. Persons authorized by the applicant or member; or                        513 effective October 1, 1985 (Supp. 85-5). Amended
    5. A court order or subpoena compliant with 45 CFR                             effective December 8, 1997 (Supp. 97-4). Section
         164.512(e), October 1, 2004, incorporated by reference,              repealed by final rulemaking at 11 A.A.R. 4277, effective
         on file with the Administration and available from the                             December 5, 2005 (Supp. 05-4).


Supp. 11-2                                                          Page 32                                                    June 30, 2011
                                                     Arizona Administrative Code                                           Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

R9-22-514.      Repealed                                                                        Historical ote
                                                                           Adopted as an emergency effective May 20, 1982, pursu-
                          Historical ote
                                                                           ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                            3). Former Section R9-22-518 adopted as an emergency
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                           adopted, amended and renumbered as Section R9-22-516,
     3). Former Section R9-22-514 adopted as an emergency
                                                                           former Section R9-22-520 adopted as an emergency now
    adopted, amended and renumbered as Section R9-22-513,
                                                                           adopted, amended and renumbered as Section R9-22-518
    former Section R9-22-515 adopted as an emergency now
                                                                           as a permanent rule effective August 30, 1982 (Supp. 82-
    adopted, amended and renumbered as Section R9-22-514
                                                                           4). Former Section R9-22-518 repealed, new Section R9-
    as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                            22-518 adopted effective October 1, 1985 (Supp. 85-5).
     4). Former Section R9-22-514 repealed, former Section
                                                                              Amended effective December 8, 1997 (Supp. 97-4).
     R9-22-517 renumbered and amended as Section R9-22-
                                                                            Amended by final rulemaking at 11 A.A.R. 4277, effec-
      514 effective October 1, 1985 (Supp. 85-5). Amended
                                                                            tive December 5, 2005 (Supp. 05-4). Amended by final
         effective December 8, 1997 (Supp. 97-4). Section
                                                                           rulemaking at 14 A.A.R. 4330, effective January 3, 2009
    repealed by final rulemaking at 11 A.A.R. 4277, effective
                                                                                                 (Supp. 08-4).
                  December 5, 2005 (Supp. 05-4).
                                                                      R9-22-519.     Repealed
R9-22-515.      Repealed
                                                                                                Historical ote
                         Historical ote
                                                                           Adopted as an emergency effective May 20, 1982, pursu-
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                           ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                            3). Former Section R9-22-519 adopted as an emergency
     3). Former Section R9-22-515 adopted as an emergency
                                                                           adopted, amended and renumbered as Section R9-22-517,
    adopted, amended and renumbered as Section R9-22-514,
                                                                           former Section R9-22-521 adopted as an emergency now
    former Section R9-22-517 adopted as an emergency now
                                                                           adopted, amended and renumbered as Section R9-22-519
    adopted, amended and renumbered as Section R9-22-515
                                                                           as a permanent rule effective August 30, 1982 (Supp. 82-
    as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                           4). Former Section R9-22-519 repealed, new Section R9-
     4). Former Section R9-22-515 repealed, former Section
                                                                            22-519 adopted effective October 1, 1985 (Supp. 85-5).
     R9-22-522 renumbered and amended as Section R9-22-
                                                                              Repealed effective December 8, 1997 (Supp. 97-4).
      515 effective October 1, 1985 (Supp. 85-5). Repealed
            effective December 8, 1997 (Supp. 97-4).                  R9-22-520.     Expired
R9-22-516.      Renumbered                                                                      Historical ote
                                                                           Adopted as an emergency effective May 20, 1982, pursu-
                         Historical ote
                                                                           ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                            3). Former Section R9-22-520 adopted as an emergency
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                           adopted, amended and renumbered as Section R9-22-518,
      3). Former Section R9-22-516 adopted as an emergency
                                                                           former Section R9-22-522 adopted as an emergency now
      expired, former Section R9-22-518 adopted as an emer-
                                                                           adopted, amended and renumbered as Section R9-22-520
     gency now adopted, amended and renumbered as Section
                                                                           as a permanent rule effective August 30, 1982 (Supp. 82-
    R9-22-516 as a permanent rule effective August 30, 1982
                                                                           4). Former Section R9-22-520 repealed, new Section R9-
     (Supp. 82-4). Former Section R9-22-516 renumbered as
                                                                            22-520 adopted effective October 1, 1985 (Supp. 85-5).
    Section R9-22-513 effective October 1, 1985 (Supp. 85-5).
                                                                              Amended effective December 13, 1993 (Supp. 93-4).
R9-22-517.      Renumbered                                                 Amended effective December 8, 1997 (Supp. 97-4). Sec-
                                                                           tion expired under A.R.S. § 41-1056(E) at 8 A.A.R. 4851,
                         Historical ote
                                                                                    effective October 9, 2002 (Supp. 02-4).
    Adopted as an emergency effective May 20, 1982, pursu-
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-        R9-22-521. Program Compliance Audits
     3). Former Section R9-22-517 adopted as an emergency             A. The Administration shall conduct an onsite program compli-
    adopted, amended and renumbered as Section R9-22-515,                 ance audit of a contractor at least once every three years during
    former Section R9-22-519 adopted as an emergency now                  the term of the Administration’s contract with the contractor.
    adopted and renumbered and amended as Section R9-22-                  The Administration may conduct, without prior notice, inspec-
    517 as a permanent rule effective August 30, 1982 (Supp.              tions of contractor facilities or perform other elements of a
        82-4). Former Section R9-22-517 renumbered and                    program compliance audit.
    amended as Section R9-22-514 effective October 1, 1985            B. An audit team may perform any or all of the following proce-
                          (Supp. 85-5).                                   dures:
                                                                          1. Conduct private interviews and group conferences with
R9-22-518. Information to Enrolled Members
                                                                               members, physicians, other health professionals, and
A. Each contractor shall produce and distribute printed informa-
                                                                               members of the contractor’s administrative staff includ-
    tional materials to each member or family unit no later than 10
                                                                               ing, but not limited to, the contractor’s principal manage-
    days of receipt of notification of enrollment from the Adminis-
                                                                               ment persons;
    tration. The contractor shall ensure that the informational
                                                                          2. Examine records, books, reports, and papers of the con-
    materials meet the requirements specified in the contractor’s
                                                                               tractor and any management company, and all providers
    current contract.
                                                                               or subcontractors providing health care and other ser-
B. A contractor shall provide a member with the name, address,
                                                                               vices. The examination may include, but need not be lim-
    and telephone number of the member’s primary care provider
                                                                               ited to: minutes of medical staff meetings, peer review
    no later than 10 days from the date of enrollment. The contrac-
                                                                               and quality of care review records, duty rosters of medi-
    tor shall include information on how the member may change
                                                                               cal personnel, appointment records, written procedures
    primary care providers.


June 30, 2011                                                    Page 33                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          for the internal operation of the health plan, contracts and             b.    Ensure that there are qualified QM/UM personnel
          correspondence with members and with providers of                              and sufficient resources to implement the contrac-
          health care services and other services to the plan, and                       tor’s QM/UM activities; and
          additional documentation deemed necessary by the                    5. Ensure that the QM/UM activities include at least:
          Administration to review the quality of medical care.                    a. Prior authorization for non-emergency or scheduled
                                                                                         hospital admissions;
                          Historical ote
                                                                                   b. Concurrent review of inpatient hospitalization;
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                                   c. Retrospective review of hospital claims;
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                   d. Program and provider audits designed to detect
      3). Former Section R9-22-521 adopted as an emergency
                                                                                         over- or under-utilization, service delivery effective-
     adopted, amended and renumbered as Section R9-22-519,
                                                                                         ness, and outcome;
     former Section R9-22-523 adopted as an emergency now
                                                                                   e. Medical records audits;
     adopted, amended and renumbered as Section R9-22-521
                                                                                   f. Surveys to determine satisfaction of members;
     as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                                   g. Assessment of the adequacy and qualifications of
     4). Former Section R9-22-521 repealed, new Section R9-
                                                                                         the contractor’s provider network;
      22-521 adopted effective October 1, 1985 (Supp. 85-5).
                                                                                   h. Review and analysis of QM/UM data;
        Amended effective December 8, 1997 (Supp. 97-4).
                                                                                   i. Measurement of performance using objective qual-
      Amended by final rulemaking at 11 A.A.R. 4277, effec-
                                                                                         ity indicators;
      tive December 5, 2005 (Supp. 05-4). Amended by final
                                                                                   j. Ensuring individual and systemic quality of care;
     rulemaking at 14 A.A.R. 4330, effective January 3, 2009
                                                                                   k. Integrating quality throughout the organization;
                           (Supp. 08-4).
                                                                                   l. Process improvement;
     Editor’s ote: The following Section was amended under an                      m. Credentialing a provider network;
exemption from the provisions of the Administrative Procedure                      n. Resolving quality of care grievances; and
Act which means that this rule was not reviewed by the Gover-                      o. Quality improvement activities focused on improv-
nor’s Regulatory Review Council; the agency did not submit                               ing the quality of care and the efficient, cost-effec-
notice of proposed rulemaking to the Secretary of State for publi-                       tive delivery and utilization of services.
cation in the Arizona Administrative Register; the agency was            C.   A member’s primary care provider shall maintain medical
not required to hold public hearings on the rules; and the Attor-             records that:
ney General has not certified this rule. This Section was subse-              1. Conform to professional medical standards and practices
quently amended through the regular rulemaking process.                            for documentation of medical diagnostic and treatment
                                                                                   data;
R9-22-522. Quality Management/Utilization Management
                                                                              2. Facilitate follow-up treatment; and
(QM/UM) Requirements
                                                                              3. Permit professional medical review and medical audit
A. A contractor shall comply with Quality Management/Utiliza-
                                                                                   processes.
    tion Management (QM/UM) requirements specified in this
                                                                         D.   Within 30 days following termination of the contract between
    Section and in contract. The contractor shall ensure compli-
                                                                              a subcontractor and a contractor, the subcontractor or the sub-
    ance with QM/UM requirements that are accomplished
                                                                              contractor’s designee shall forward to the primary care pro-
    through delegation or subcontract with another party.
                                                                              vider medical records or copies of medical records of all
B. In addition to any requirements specified in contract, a con-
                                                                              members assigned to the subcontractor or for whom the sub-
    tractor shall:
                                                                              contractor has provided services.
    1. Submit to the Administration a written QM/UM plan that
                                                                         E.   The Administration shall monitor each contractor and the con-
         includes a description of the systems, methodologies,
                                                                              tractor’s providers to ensure compliance with Administration
         protocols, and procedures to be used in:
                                                                              QM/UM requirements and adherence to the contractor’s QM/
         a. Monitoring and evaluating the types of services pro-
                                                                              UM plan.
               vided,
                                                                              1. A contractor and the contractor’s providers shall cooper-
         b. Identifying the numbers and costs of services pro-
                                                                                   ate with the Administration in the performance of the
               vided,
                                                                                   Administration’s QM/UM monitoring activities; and
         c. Assessing and improving the quality and appropri-
                                                                              2. A contractor and the contractor’s providers shall develop
               ateness of care and services,
                                                                                   and implement mechanisms for correcting deficiencies
         d. Evaluating the outcome of care provided to mem-
                                                                                   identified through the Administration’s QM/UM monitor-
               bers, and
                                                                                   ing.
         e. Determining the actions necessary to improve ser-
               vice delivery;                                                                      Historical ote
    2. Submit the QM/UM plan to the Administration on an                      Adopted as an emergency effective May 20, 1982, pursu-
         annual basis within timelines specified in contract. If the          ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
         QM/UM plan is changed during the year, the contractor                 3). Former Section R9-22-522 adopted as an emergency
         shall submit the revised plan to the Administration before           adopted, amended and renumbered as Section R9-22-520,
         implementation;                                                      former Section R9-22-524 adopted as an emergency now
    3. Receive approval from the Administration before imple-                  adopted and renumbered as Section R9-22-522 as a per-
         menting the initial or revised QM/UM plan;                              manent rule effective August 30, 1982 (Supp. 82-4).
    4. Ensure that a QM/UM committee operates under the con-                   Former Section R9-22-522 renumbered and amended as
         trol of the contractor’s medical director and includes rep-             Section R9-22-515, new Section R9-22-522 adopted
         resentation from medical and executive management                     effective October 1, 1985 (Supp. 85-5). Amended under
         personnel. The committee shall:                                       an exemption from the provisions of the Administrative
         a. Oversee the development, revision, and implementa-                  Procedure Act, effective March 1, 1993 (Supp. 93-1).
               tion of the QM/UM plan; and                                      Amended effective December 13, 1993 (Supp. 93-4).
                                                                                 Amended effective December 8, 1997 (Supp. 97-4).


Supp. 11-2                                                          Page 34                                                      June 30, 2011
                                                     Arizona Administrative Code                                           Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

      Amended by final rulemaking at 11 A.A.R. 4277, effec-            R9-22-528.     Renumbered
      tive December 5, 2005 (Supp. 05-4). Amended by final
                                                                                               Historical ote
     rulemaking at 14 A.A.R. 4330, effective January 3, 2009
                                                                            Adopted effective October 1, 1983 (Supp. 83-5). Former
                          (Supp. 08-4).
                                                                            Section R9-22-528 renumbered and amended as Section
R9-22-523.      Expired                                                       R9-22-504 effective October 1, 1985 (Supp. 85-5).
                         Historical ote                                R9-22-529.     Renumbered
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                                                Historical ote
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                            Adopted as Section R9-22-529 effective October 1, 1985,
     3). Former Section R9-22-523 adopted as an emergency
                                                                            then renumbered as Section R9-22-1002 effective Octo-
    adopted, amended and renumbered as Section R9-22-521,
                                                                                           ber 1, 1985 (Supp. 85-5).
    former Section R9-22-525 adopted as an emergency now
    adopted, amended and renumbered as Section R9-22-523                      ARTICLE 6. RFP A D CO TRACT PROCESS
    as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                       R9-22-601. General Provisions
       4). Amended effective October 1, 1985 (Supp. 85-5).
                                                                       A. The Director has full operational authority to adopt rules for
    Amended effective December 8, 1997 (Supp. 97-4). Sec-
                                                                           the RFP process and the award of contracts under A.R.S. § 36-
    tion expired under A.R.S. § 41-1056(E) at 8 A.A.R. 4851,
                                                                           2906.
             effective October 9, 2002 (Supp. 02-4).
                                                                       B. This Article applies to the expenditure of all public monies by
R9-22-524.      Repealed                                                   the Administration for covered services under Articles 2 and
                                                                           12 of this Chapter except as otherwise provided by law. The
                         Historical ote
                                                                           Administration shall establish conflict-of-interest safeguards
    Adopted as an emergency effective May 20, 1982, pursu-
                                                                           for officers and employees of this state with responsibilities
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                           relating to contracts that comply with 42 U.S.C. 1396u-
     3). Former Section R9-22-524 adopted as an emergency
                                                                           2(d)(3).
     adopted and renumbered as Section R9-22-522, former
                                                                       C. The Administration shall award contracts under A.R.S. §§ 36-
         Section R9-22-526 adopted as an emergency now
                                                                           2904 and 36-2906 to provide services under A.R.S. § 36-2907.
    adopted, amended and renumbered as Section R9-22-524
                                                                       D. The Administration is exempt from the procurement code
    as a permanent rule effective August 30, 1982 (Supp. 82-
                                                                           under A.R.S. § 41-2501.
    4). Former Section R9-22-524 repealed, new Section R9-
                                                                       E. The Administration and contractors shall retain all contract
     22-524 adopted effective October 1, 1985 (Supp. 85-4).
                                                                           records for five years under A.R.S. § 36-2903 and dispose of
    Amended effective December 8, 1997 (Supp. 97-4). Sec-
                                                                           the records under A.R.S. § 41-2550.
      tion repealed by final rulemaking at 11 A.A.R. 4277,
             effective December 5, 2005 (Supp. 05-4).                                              Historical ote
                                                                            Adopted as an emergency effective May 20, 1982, pursu-
R9-22-525.      Repealed
                                                                            ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                         Historical ote                                      3). Former Section R9-22-601 adopted as an emergency
    Adopted as an emergency effective May 20, 1982, pursu-                    now adopted as a permanent rule effective August 30,
    ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-               1982 (Supp. 82-4). Repealed effective October 1, 1983
     3). Former Section R9-22-525 adopted as an emergency                   (Supp. 83-5). Adopted effective July 16, 1985 (Supp. 85-
    adopted, amended and renumbered as Section R9-22-523,                   4). Amended effective December 13, 1993 (Supp. 93-4).
    former Section R9-22-527 adopted as an emergency now                    Section repealed, new Section adopted by final rulemak-
    adopted, amended and renumbered as Section R9-22-525                      ing at 5 A.A.R. 607, effective February 5, 1999 (Supp.
    as a permanent rule effective August 30, 1982 (Supp. 82-                   99-1). Amended by final rulemaking at 8 A.A.R. 424,
       4). Repealed effective October 1, 1985 (Supp. 85-5).                           effective January 10, 2002 (Supp. 02-1).
R9-22-526.      Renumbered                                             R9-22-602. RFP
                                                                       A. RFP content. The Administration shall include the following
                          Historical ote
                                                                           items in any RFP under this Article:
     Adopted as an emergency effective February 23, 1983,
                                                                           1. Instructions and information to an offeror concerning the
      pursuant to A.R.S. § 41-1003, valid for only 90 days
                                                                                proposal submission including:
    (Supp. 83-1). Adopted as a permanent rule effective May
                                                                                a. The deadline for submitting a proposal,
    16, 1983; text of the permanent rule identical to the emer-
                                                                                b. The address of the office at which a proposal is to be
    gency (Supp. 83-3). Former Section R9-22-526 repealed,
                                                                                     received,
      new Section R9-22-526 adopted effective October 1,
                                                                                c. The period during which the RFP remains open, and
     1983 (Supp. 83-5). Former Section R9-22-526 renum-
                                                                                d. Any special instructions and information;
    bered and amended as Section R9-22-501 effective Octo-
                                                                           2. The scope of covered services under Article 2 of this
                     ber 1, 1985 (Supp. 85-1).
                                                                                Chapter and A.R.S. §§ 36-2906 and 36-2907, covered
R9-22-527.      Renumbered                                                      populations, geographic coverage, service and perfor-
                                                                                mance requirements, and a delivery or performance
                        Historical ote
                                                                                schedule;
     Adopted effective October 1, 1983 (Supp. 83-5). Former
                                                                           3. The contract terms and conditions, including bonding or
     Section R9-22-527 renumbered and amended as Section
                                                                                other security requirements, if applicable;
       R9-22-505 effective October 1, 1985 (Supp. 85-5).
                                                                           4. The factors used to evaluate a proposal;
                                                                           5. The location and method of obtaining documents that are
                                                                                incorporated by reference in the RFP;




June 30, 2011                                                     Page 35                                                       Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

     6.  A requirement that the offeror acknowledge receipt of all                   reasons for rejection shall be part of the contract file. An
         RFP amendments issued by the Administration;                                offeror shall have no right to damages for any claims
     7. The type of contract to be used and a copy of a proposed                     against the state, the state’s employees, or agents if a pro-
         contract form or provisions;                                                posal is rejected in whole or in part.
     8. The length of the contract service;                               D.   Proposal cancellation. If the Administration determines that it
     9. A requirement for cost or pricing data;                                is in the best interest of the state, the Administration may can-
     10. The minimum RFP requirements; and                                     cel a RFP. The reasons for cancellation shall be part of the con-
     11. A provision requiring an offeror to certify that a submit-            tract file. An offeror shall have no right to damages for any
         ted proposal does not involve collusion or other anti-com-            claims against the state, the state’s employees, or agents if a
         petitive practices.                                                   RFP is cancelled.
B.   Proposal process.
                                                                                                    Historical ote
     1. After the deadline for submitting proposals, the Adminis-
                                                                               Adopted as an emergency effective May 20, 1982, pursu-
         tration may open a proposal publicly and announce and
                                                                               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
         record the name of the offeror. The Administration shall
                                                                                3). Former Section R9-22-602 adopted as an emergency
         keep all other information contained in a proposal confi-
                                                                                 now adopted as a permanent rule effective August 30,
         dential. The Administration shall open a proposal for
                                                                                1982 (Supp. 82-4). Repealed effective October 1, 1983
         public inspection after contract award unless the Admin-
                                                                               (Supp. 83-5). Adopted effective July 16, 1985 (Supp. 85-
         istration determines that disclosure is not in the best inter-
                                                                                4). Section repealed, new Section adopted by final rule-
         est of the state.
                                                                                  making at 5 A.A.R. 607, effective February 5, 1999
     2. The Administration shall evaluate a proposal based on the
                                                                                 (Supp. 99-1). Section repealed; new Section made by
         GSA and the evaluation factors listed in the RFP.
                                                                                final rulemaking at 8 A.A.R. 424, effective January 10,
     3. The Administration may initiate discussions with a
                                                                                                   2002 (Supp. 02-1).
         responsive and responsible offeror to clarify and assure
         full understanding of an offeror’s proposal. The Adminis-        R9-22-603. Contract Award
         tration shall provide an offeror fair treatment with respect     The Administration shall award a contract to the responsible and
         to discussion and revision of a proposal. The Administra-        responsive offeror whose proposal is determined most advanta-
         tion shall not disclose information derived from a pro-          geous to the state under A.R.S. § 36-2906. If the Administration
         posal submitted by a competing offeror.                          determines that multiple contracts are in the best interest of the
     4. The Administration shall allow for the adjustment of cov-         state, the Administration may award multiple contracts. The con-
         ered services by expansion, deletion, segregation, or            tract file shall contain the basis on which the award is made.
         combination in order to secure the most financially
                                                                                                    Historical ote
         advantageous proposals for the state.
                                                                               Adopted as an emergency effective May 20, 1982, pursu-
     5. The Administration may conduct an investigation of a
                                                                               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
         person or organization who has ownership or manage-
                                                                                3). Former Section R9-22-603 adopted as an emergency
         ment interests in corporate offerors or affiliated corporate
                                                                                 now adopted as a permanent rule effective August 30,
         organizations of an offeror.
                                                                                1982 (Supp. 82-4). Repealed effective October 1, 1983
     6. The Administration may issue a written request for best
                                                                               (Supp. 83-5). Adopted effective July 16, 1985 (Supp. 85-
         and final offers. The Administration shall state in the
                                                                                4). Section repealed, new Section adopted by final rule-
         request the date, time, and place for the submission of
                                                                                  making at 5 A.A.R. 607, effective February 5, 1999
         best and final offers.
                                                                                 (Supp. 99-1). Section repealed; new Section made by
     7. The Administration shall not request best and final offers
                                                                                final rulemaking at 8 A.A.R. 424, effective January 10,
         more than once unless the Administration determines that
                                                                                                   2002 (Supp. 02-1).
         it is advantageous to the state to request additional best
         and final offers. The Administration shall state in the          R9-22-604. Contract or Proposal Protests; Appeals
         written request for best and final offers that if the offeror    A. Disputes related to contract performance. This Section does
         does not submit a notice of withdrawal or a best and final           not apply to a dispute related to contract performance. A con-
         offer, the Administration shall take the most recent offer           tract performance dispute is governed by Article 8 of this
         as the offeror’s best and final offer.                               Chapter.
C.   Proposal rejection.                                                  B. Resolution of a proposal protest. The procurement officer issu-
     1. The Administration may reject an offeror’s proposal if                ing a RFP shall have the authority to resolve proposal protests.
         the offeror fails to supply the information requested by             An appeal from the decision of the procurement officer shall
         the Administration.                                                  be made to the Director.
     2. The offeror shall not disclose information pertaining to its      C. Filing of a protest.
         proposal to any other offeror prior to contract award. The           1. A person may file a protest with the procurement officer
         offeror may disclose proposal information to a person                     regarding:
         other than another offeror if the recipient agrees to keep                a. A RFP issued by the Administration,
         the information confidential until contract award. Disclo-                b. A proposed award, or
         sure in violation of this subsection may be grounds for                   c. An award of a contract.
         rejecting a proposal.                                                2. A protester shall submit a written protest and include the
     3. The Administration shall provide written notification to                   following information:
         an offeror whose proposal is rejected. The rejection                      a. The name, address, and telephone number of the
         notice shall be part of the contract file and a public                         protester;
         record.                                                                   b. The signature of the protester or protester’s repre-
     4. If the Administration determines that it is in the best                         sentative;
         interest of the state, the Administration may reject any                  c. Identification of a RFP or contract number;
         and all proposals, in whole or in part, under the RFP. The


Supp. 11-2                                                           Page 36                                                       June 30, 2011
                                                      Arizona Administrative Code                                              Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

          d.  A detailed statement of the legal and factual grounds             d. Extent of performance,
              of the protest including copies of any relevant docu-             e. Costs to the state, and
              ments; and                                                        f. Urgency of the procurement.
        e. The relief requested.                                            3. An appropriate remedy may include one or more of the
D. Time for filing a protest.                                                   following:
   1. A protester filing a protest alleging improprieties in a                  a. Terminating the contract;
        RFP shall file the protest before the due date for receipt of           b. Reissuing the RFP;
        proposals.                                                              c. Issuing a new RFP;
   2. A protester filing a protest alleging improprieties that do               d. Awarding a contract consistent with statutes, rules,
        not exist in the original RFP but are subsequently incor-                     and the terms of the RFP; or
        porated into the RFP before the due date for receipt of                 e. Any relief determined necessary to ensure compli-
        proposals shall file the protest prior to the amended due                     ance with applicable statutes and rules.
        date for receipt of proposals.                                   I. Appeals to the Director.
   3. In cases other than those covered in subsections (D)(1)               1. A person may file an appeal about a procurement
        and (2), a protester shall file a protest within 10 days after          officer’s decision with both the Director and the procure-
        the protester knows or should have known the basis of the               ment officer within five days from the date the decision is
        protest.                                                                received. The date the decision is received shall be deter-
E. Stay of procurement during the protest. If a protester files a               mined under subsection (F)(2).
   protest before the contract award, the procurement officer may           2. The appeal shall contain:
   issue a written stay of the contract award. In considering                   a. The information required in subsection (C)(2),
   whether to issue a written stay of contract, the procurement                 b. A copy of the procurement officer’s decision,
   officer shall consider but is not limited to considering whether:            c. The alleged factual or legal error in the decision of
   1. A reasonable probability exists that the protest will be                        the procurement officer on which the appeal to the
        sustained, and                                                                Director is based, and
   2. The stay of the contract award is in the best interest of the             d. A request for hearing unless the person requests that
        state.                                                                        the Director’s decision be based solely upon the con-
F. Stay of contract award during an appeal to the Director. The                       tract record.
   Director shall automatically continue the stay of a contract          J. Dismissal. The Director shall not schedule a hearing and shall
   award if:                                                                dismiss an appeal with a written determination if:
   1. An appeal is filed before a contract award, and                       1. The appeal does not state a basis for protest,
   2. The procurement officer issues a stay of the contract                 2. The appeal is untimely under subsection (H)(1), or
        award under subsection (E), unless                                  3. The appeal is moot.
   3. The Director issues a written determination that the con-          K. Hearing. Hearings under this Section shall be conducted under
        tract award is necessary to protect the best interest of the        R9-22-802 of this Chapter.
        state.
                                                                                                 Historical ote
G. Decision by the procurement officer.
                                                                               Adopted effective July 16, 1985 (Supp. 85-4). Section
   1. The procurement officer shall issue a written decision
                                                                              repealed, new Section adopted by final rulemaking at 5
        within 14 days after a protest has been filed. The decision
                                                                               A.A.R. 607, effective February 5, 1999 (Supp. 99-1).
        shall contain an explanation of the basis of the decision.
                                                                              Amended by final rulemaking at 8 A.A.R. 424, effective
   2. The procurement officer shall furnish a copy of the deci-
                                                                                          January 10, 2002 (Supp. 02-1).
        sion to the protester by:
        a. Certified mail, return receipt requested; or                  R9-22-605. Waiver of Contractor’s Subcontract with Hospi-
        b. Any other method that provides evidence of receipt.           tals
   3. The Administration may extend, for good cause, the time-           If a contractor is unable to obtain a subcontract with a hospital, the
        limit for decisions in subsection (F)(1) for a time not to       contractor may request in writing a waiver from the Administration
        exceed 30 days. The procurement officer shall notify the         as allowed by A.R.S. § 36-2906. The contractor shall state in the
        protester in writing that the time for the issuance of a         request the reasons a waiver is believed to be necessary and all
        decision has been extended and the date by which a deci-         efforts the contractor has made to secure a subcontract. The Admin-
        sion shall be issued.                                            istration shall consider the following criteria in deciding whether to
   4. If the procurement officer fails to issue a decision within        grant the waiver:
        the time-limits in subsection (F)(1) or (3), the protester             1. The number of hospitals in the GSA,
        may proceed as if the procurement officer issued an                    2. The extent to which the contractor’s physicians have staff
        adverse decision.                                                           privileges at noncontracting hospitals in the service area,
H. Remedies.                                                                   3. The size and population of, and the demographic distribu-
   1. If the procurement officer sustains the protest in whole or                   tion within, the service area,
        in part and determines that the RFP, proposed contract                 4. Patterns of medical practice and care within the service
        award, or contract award does not comply with applicable                    area,
        statutes and rules, the procurement officer shall order an             5. Whether the contractor has diligently attempted to negoti-
        appropriate remedy.                                                         ate a hospital subcontract with local hospitals capable of
   2. In determining an appropriate remedy, the procurement                         serving members in the service area,
        officer shall consider all the circumstances of the pro-               6. Whether the contractor has any subcontracts in adjoining
        curement or proposed procurement, including:                                service areas with hospitals that are reasonably accessible
        a. Seriousness of the procurement deficiency,                               to the contractor’s members in the service area, and
        b. Degree of prejudice to other interested parties or to               7. Whether the contractor’s members can reasonably be
              the integrity of the RFP process,                                     expected to receive all covered services in the absence of
        c. Good faith of the parties,                                               a hospital subcontract.


June 30, 2011                                                       Page 37                                                        Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

                         Historical ote                                      “Billed charges” means charges for services provided to a
        Adopted effective January 31, 1986 (Supp. 86-1).                     member that a hospital includes on a claim consistent with the
      Amended effective December 13, 1993 (Supp. 93-4).                      rates and charges filed by the hospital with Arizona Depart-
      Section repealed by final rulemaking at 5 A.A.R. 607,                  ment of Health Services (ADHS).
      effective February 5, 1999 (Supp. 99-1). New Section                   “Business agent” means a company such as a billing service or
     made by final rulemaking at 8 A.A.R. 424, effective Jan-                accounting firm that renders billing statements and receives
                   uary 10, 2002 (Supp. 02-1).                               payment in the name of a provider.
R9-22-606. Contract Compliance Sanction                                      “Capital costs” means costs as reported by the hospital to CMS
A. The Director may impose one or more of the following sanc-                as required by 42 CFR 413.20.
    tions upon a contractor that violates any provision of this              “Copayment” means a monetary amount, specified by the
    Chapter or of a contract:                                                Director, that a member pays directly to a contractor or pro-
    1. Suspend any or all further member enrollment, by choice               vider at the time covered services are rendered.
         or assignment, for a period of time commensurate with
         the nature, term, and severity of the violation.                    “Cost-to-charge ratio” (CCR) means a hospital’s costs for pro-
    2. Withhold a percentage of the contractor’s capitation pre-             viding covered services divided by the hospital’s charges for
         payment, commensurate with the nature, term, and sever-             the same services. The CCR is the percentage derived from the
         ity of the violation.                                               cost and charge data for each revenue code provided to AHC-
B. The Director shall consider the nature, severity, and length of           CCS by each hospital.
    the violation when determining a sanction.                               “Covered charges” means billed charges that represent medi-
C. The Director shall provide a contractor with written notice               cally necessary, reasonable, and customary items of expense
    specifying grounds for the sanction which are commensurate               for covered services that meet medical review criteria of AHC-
    with the nature, term, and severity of the violation and one or          CCS or a contractor.
    more of the following:                                                   “CPT” means Current Procedural Terminology, published and
    1. Length of suspension,                                                 updated by the American Medical Association. CPT is a
    2. Amount to be forfeited, or                                            nationally-accepted listing of descriptive terms and identifying
    3. Prepayment to be withheld.                                            codes for reporting medical services and procedures per-
D. Nothing contained in this Section shall be construed to prevent           formed by physicians that provide a uniform language to accu-
    the Administration from imposing sanctions as provided in                rately designate medical, surgical, and diagnostic services.
    contract under A.R.S. § 36-2903.
                                                                             “Critical Access Hospital” is a hospital certified by Medicare
                         Historical ote                                      under 42 CFR 485 Subpart F and 42 CFR 440.170(g).
      New Section made by final rulemaking at 8 A.A.R. 424,                  “Direct graduate medical education costs” or “direct program
            effective January 10, 2002 (Supp. 02-1).                         costs” means the costs that are incurred by a hospital for the
         ARTICLE 7. STA DARDS FOR PAYME TS                                   education activities of an approved graduate medical educa-
                                                                             tion program that are the proximate result of training medical
R9-22-701. Standard for Payments Related Definitions                         residents in the hospital, including resident salaries and fringe
In addition to definitions contained in A.R.S. § 36-2901, the words          benefits, the portion of teaching physician salaries and fringe
and phrases in this Article have the following meanings unless the           benefits that are related to the time spent in teaching and
context explicitly requires another meaning:                                 supervision of residents, and other related GME overhead
     “Accommodation” means room and board services provided                  costs.
     to a patient during an inpatient hospital stay and includes all         “DRI inflation factor” means Global Insights Prospective Hos-
     staffing, supplies, and equipment. The accommodation is                 pital Market Basket.
     semi-private except when the member must be isolated for
     medical reasons. Types of accommodation include hospital                “Eligibility posting” means the date a member’s eligibility
     routine medical/surgical units, intensive care units, and any           information is entered into the AHCCCS Pre-paid Medical
     other specialty care unit in which room and board are pro-              Management Information System (PMMIS).
     vided.                                                                  “Encounter” means a record of a medically-related service
     “Aggregate” means the combined amount of hospital pay-                  rendered by an AHCCCS-registered provider to a member
     ments for covered services provided within and outside the              enrolled with a contractor on the date of service.
     GSA.                                                                    “Existing outpatient service” means a service provided by a
     “AHCCCS inpatient hospital day or days of care” means each              hospital before the hospital files an increase in its charge mas-
     day of an inpatient stay for a member beginning with the day            ter as defined in R9-22-712(G), regardless of whether the ser-
     of admission and including the day of death, if applicable, but         vice was explicitly described in the hospital charge master
     excluding the day of discharge, provided that all eligibility,          before filing the increase or how the service was described in
     medical necessity, and medical review requirements are met.             the charge master before filing the increase.
     “Ancillary service” means all hospital services for patient care        “Expansion funds” means funds appropriated to support GME
     other than room and board and nursing services, including but           program expansions as described under A.R.S. § 36-
     not limited to, laboratory, radiology, drugs, delivery room             2903.01(H)(9)(b) and (c)(i).
     (including maternity labor room), operating room (including             “Factor” means a person or an organization, such as a collec-
     postanesthesia and postoperative recovery rooms), and therapy           tion agency or service bureau, that advances money to a pro-
     services (physical, speech, and occupational).                          vider for accounts receivable that the provider has assigned,
     “APC” means the Ambulatory Payment Classification system                sold, or transferred to the organization for an added fee or a
     under 42 CFR 419.31 used by Medicare for grouping clini-                deduction of a portion of the accounts receivable. Factor does
     cally and resource-similar procedures and services.                     not include a business agent.



Supp. 11-2                                                         Page 38                                                     June 30, 2011
                                                      Arizona Administrative Code                                              Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

    “Fiscal intermediary” means an organization authorized by                 “Non-IHS Acute Hospital” means a hospital that is not run by
    CMS to make determinations and payments for Part A and                    Indian Health Services, is not a free-standing psychiatric hos-
    Part B provider services for a given region.                              pital, such as an IMD, and is paid under ADHS rates.
    “Freestanding Children’s Hospital” means a separately stand-              “Observation day” means a physician-ordered evaluation
    ing hospital with at least 120 pediatric beds that is dedicated to        period of less than 24 hours to determine whether a person
    provide the majority of the hospital’s services to children.              needs treatment or needs to be admitted as an inpatient.
    “GME program approved by the Administration” or                           “Operating costs” means AHCCCS-allowable accommodation
    “approved GME program” means a graduate medical educa-                    costs and ancillary department hospital costs excluding capital
    tion program that has been approved by a national organiza-               and medical education costs.
    tion as described in 42 CFR 415.152.                                      “Organized health care delivery system” means a public or pri-
    “Graduate medical education (GME) program” means an                       vate organization that delivers health services. It includes, but
    approved residency program that prepares a physician for                  is not limited to, a clinic, a group practice prepaid capitation
    independent practice of medicine by providing didactic and                plan, and a health maintenance organization.
    clinical education in a medical environment to a medical stu-             “Outlier” means a hospital claim or encounter in which the
    dent who has completed a recognized undergraduate medical                 operating costs per day for an AHCCCS inpatient hospital stay
    education program.                                                        meet the criteria described under this Article and A.R.S. § 36-
    “HCPCS” means the Health Care Procedure Coding System,                    2903.01(H).
    published and updated by Center for Medicare and Medicaid                 “Outpatient hospital service” means a service provided in an
    Services (CMS). HCPCS is a listing of codes and descriptive               outpatient hospital setting that does not result in an admission.
    terminology used for reporting the provision of physician ser-
    vices, other health care services, and substances, equipment,             “Ownership change” means a change in a hospital’s owner,
    supplies or other items used in health care services.                     lessor, or operator under 42 CFR 489.18(a).
    “HIPAA” means the Health Insurance Portability and                        “Participating institution” means an institution at which por-
    Accountability Act of 1996, as specified under 45 CFR 162,                tions of a graduate medical education program are regularly
    that establishes standards and requirements for the electronic            conducted and to which residents rotate for an educational
    transmission of certain health information by defining code               experience for at least one month.
    sets used for encoding data elements, such as tables of terms,            “Peer group” means hospitals that share a common, stable, and
    medical concepts, medical diagnostic codes, or medical proce-             independently definable characteristic or feature that signifi-
    dure codes.                                                               cantly influences the cost of providing hospital services,
    “ICU” means the intensive care unit of a hospital.                        including specialty hospitals that limit the provision of ser-
                                                                              vices to specific patient populations, such as rehabilitative
    “Indirect program costs” means the marginal increase in oper-             patients or children.
    ating costs that a hospital experiences as a result of having an
    approved graduate medical education program and that is not               “PPC” means prior period coverage. PPC is the period of time,
    accounted for by the hospital’s direct program costs.                     prior to the member’s enrollment, during which a member is
                                                                              eligible for covered services. The time-frame is the first day of
    “Intern and Resident Information System” means a software                 the month of application or the first eligible month, whichever
    program used by teaching hospitals and the provider commu-                is later, until the day a member is enrolled with a contractor.
    nity for collecting and reporting information on resident train-
    ing in hospital and non-hospital settings.                                “PPS bed” means Medicare-approved Prospective Payment
                                                                              beds for inpatient services as reported in the Medicare cost
    “Medical education costs” means direct hospital costs for                 reports for the most recent fiscal year for which the Adminis-
    intern and resident salaries, fringe benefits, program costs,             tration has a complete set of Medicare cost reports for every
    nursing school education, and paramedical education, as                   rural hospital as determined as of the first of February of each
    described in the Medicare Provider Reimbursement Manual.                  year.
    “Medical review” means a clinical evaluation of documenta-                “Procedure code” means the numeric or alphanumeric code
    tion conducted by AHCCCS or a contractor for purposes of                  listed in the CPT or HCPCS manual by which a procedure or
    prior authorization, concurrent review, post-payment review,              service is identified.
    or determining medical necessity. The criteria for medical
    review are established by AHCCCS or a contractor based on                 “Prospective rates” means inpatient or outpatient hospital rates
    medical practice standards that are updated periodically to               set by AHCCCS in advance of a payment period and repre-
    reflect changes in medical care.                                          senting full payment for covered services excluding any quick-
                                                                              pay discounts, slow-pay penalties, and first-and third-party
    “Medicare Urban or Rural Cost-to-Charge Ratio (CCR)”                      payments regardless of billed charges or individual hospital
    means statewide average capital cost-to-charge ratio published            costs.
    annually by CMS added to the urban or rural statewide aver-
    age operating cost-to-charge ratio published annually by CMS.             “Public hospital” means a hospital that is owned and operated
                                                                              by county, state, or hospital health care district.
    “National Standard code sets” means codes that are accepted
    nationally in accordance with federal requirements under 45               “Rebase” means the process by which the most currently
    CFR 160 and 45 CFR 164.                                                   available and complete Medicare Cost Report data for a year
                                                                              and AHCCCS claim and encounter data for the same year are
    “New hospital” means a hospital for which Medicare Cost                   collected and analyzed to reset the Inpatient Hospital Tiered
    Report claim and encounter data are not available for the fiscal          per diem rates, or the Outpatient Hospital Capped Fee-For-
    year used for initial rate setting or rebasing.                           Service Schedule.
    “NICU” means the neonatal intensive care unit of a hospital               “Reinsurance” means a risk-sharing program provided by
    that is classified as a Level II or Level III perinatal center by         AHCCCS to contractors for the reimbursement of specified
    the Arizona Perinatal Trust.


June 30, 2011                                                       Page 39                                                        Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     contract service costs incurred by a member beyond a certain        R9-22-701.10 Scope of the Administration’s and Contractor’s
     monetary threshold.                                                 Liability
     “Remittance advice” means an electronic or paper document           The Administration shall bear no liability for providing covered
     submitted to an AHCCCS-registered provider by AHCCCS to             services for any member beyond the date of termination of the
     explain the disposition of a claim.                                 member’s eligibility or during the member’s enrollment with a con-
                                                                         tractor. A contractor has no financial responsibility for services pro-
     “Resident” means a physician engaged in postdoctoral training       vided to a member beyond the last date of enrollment except as
     in an accredited graduate medical education program, includ-        provided in Articles 2 and 5 of this Chapter and as specified in con-
     ing an intern and a physician who has completed the require-        tract.
     ments for the physician’s eligibility for board certification.
     “Revenue code” means a numeric code, that identifies a spe-                                 Historical ote
     cific accommodation, ancillary service, or billing calculation,          New Section made by final rulemaking at 13 A.A.R. 662,
     as defined by the National Uniform Billing committee for UB-                      effective April 7, 2007 (Supp. 07-1).
     92 forms.                                                           R9-22-702. Charges to Members
     “Specialty facility” means a facility where the service pro-        A. Except as provided in subsections (B), (C), and (D), an AHC-
     vided is limited to a specific population, such as rehabilitative       CCS registered provider shall not do either of the following,
     services for children.                                                  unless services are not covered or without first receiving veri-
                                                                             fication from the Administration that the person was not an eli-
     “Sponsoring institution” means the institution or entity that is
                                                                             gible person on the date of service:
     recognized by the GME accrediting organization and desig-
                                                                             1. Charge, submit a claim to, or demand or collect payment
     nated as having ultimate responsibility for the assurance of
                                                                                   from a person claiming to be an eligible person; or
     academic quality and compliance with the terms of accredita-
                                                                             2. Refer or report a person claiming to be an eligible person
     tion.
                                                                                   to a collection agency or credit reporting agency.
     “Tier” means a grouping of inpatient hospital services into lev-    B. An AHCCCS registered provider that submits a claim shall not
     els of care based on diagnosis, procedure, or revenue codes,            charge more than the actual, reasonable cost of providing the
     peer group, NICU classification level, or any combination of            covered service.
     these items.                                                        C. An AHCCCS registered provider may charge, submit a claim
     “Tiered per diem” means an AHCCCS capped fee schedule in                to, or demand or collect payment from a member as follows:
     which payment is made on a per-day basis depending upon the             1. To collect an authorized copayment;
     tier (or tiers) into which an AHCCCS inpatient hospital day of          2. To recover from a member that portion of a payment
     care is assigned.                                                             made by a third party to the member if the payment dupli-
                                                                                   cates AHCCCS-paid benefits and is not assigned to a
                           Historical ote                                          contractor; or
     Adopted as an emergency effective May 20, 1982, pursu-                  3. To obtain payment from a member for medical expenses
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-                    incurred during a period when the member intentionally
      3). Former Section R9-22-701 adopted as an emergency                         withheld information or intentionally provided inaccurate
        now adopted as a permanent rule effective August 30,                       information pertaining to the member’s AHCCCS eligi-
      1982 (Supp. 82-4). Former Section R9-22-701 repealed,                        bility or enrollment that caused payment to the provider
         new Section R9-22-701 adopted effective October 1,                        to be reduced or denied.
      1983 (Supp. 83-5). Amended effective October 1, 1985               D. An AHCCCS registered provider may charge, submit a claim
        (Supp. 85-5). Amended effective September 22, 1997                   to, or demand or collect payment for services from a member
      (Supp. 97-3). Amended by final rulemaking at 8 A.A.R.                  if:
        424, effective January 10, 2002 (Supp. 02-1). Section                1. The member requests the provision of a service that is not
     repealed; new Section made by exempt rulemaking at 11                         covered or not authorized by the contractor or the Admin-
          A.A.R. 2297, effective July 1, 2005 (Supp. 05-2).                        istration; and
      Amended by final rulemaking at 12 A.A.R. 2188, effec-                  2. The provider prepares and provides the member with a
       tive June 6, 2006 (Supp. 06-2). Amended by final rule-                      document describing the overall services and the approxi-
      making at 13 A.A.R. 662, effective April 7, 2007 (Supp.                      mate cost of the services; and
      07-1). Amended by final rulemaking at 13 A.A.R. 1782,                  3. The member signs the document prior to services being
          effective June 30, 2007 (Supp. 07-2). Amended by                         provided, indicating that the member understands and
     exempt rulemaking at 13 A.A.R. 3190, effective October                        accepts responsibility for payment.
     1, 2007 (Supp. 07-3). Amended by exempt rulemaking at               E. Notwithstanding subsection (D), an AHCCCS registered pro-
      13 A.A.R. 4032, effective November 1, 2007 (Supp. 07-                  vider may charge, submit a claim to, or demand or collect pay-
                                  4).                                        ment for services from a member eligible for the FESP if:
R9-22-701.01. Reserved                                                       1. The provider submits a claim to the Administration in the
                                                                                   reasonable belief that the service is for treatment of an
R9-22-701.02. Reserved                                                             emergency medical condition; and
R9-22-701.03. Reserved                                                       2. The Administration denies the claim because the service
R9-22-701.04. Reserved                                                             does not meet the criteria of R9-22-217.
R9-22-701.05. Reserved                                                                             Historical ote
R9-22-701.06. Reserved                                                        Adopted as an emergency effective May 20, 1982, pursu-
                                                                              ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
R9-22-701.07. Reserved                                                         3). Former Section R9-22-702 adopted as an emergency
R9-22-701.08. Reserved                                                         now adopted and amended as a permanent rule effective
R9-22-701.09. Reserved                                                        August 30, 1982 (Supp. 82-4). Amended as an emergency
                                                                                effective February 23, 1983, pursuant to A.R.S. § 41-


Supp. 11-2                                                          Page 40                                                      June 30, 2011
                                                      Arizona Administrative Code                                               Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

     1003, valid for only 90 days (Supp. 83-1). Amended as a                       a.    If the hospital bill is paid within 30 days from the
      permanent rule effective May 16, 1983; text identical to                           date of receipt, the claim is paid at 99 percent of the
      the emergency (Supp. 83-3). Former Section R9-22-702                               rate.
     repealed, new Section R9-22-702 adopted effective Octo-                       b. If the hospital bill is paid between 30 and 60 days
     ber 1, 1983 (Supp. 83-5). Amended by adding subsection                              from the date of receipt, the claim is paid at 100 per-
     (B) effective October 1, 1985 (Supp. 85-5). Amended by                              cent of the rate.
       adding subsection (C) effective October 1, 1987 (Supp.                      c. If the hospital bill is paid after 60 days from the date
       87-4). Amended effective April 13, 1990 (Supp. 90-2).                             of receipt, the claim is paid at 100 percent of the rate
        Amended effective December 13, 1993 (Supp. 93-4).                                plus a fee of one percent per month for each month
        Amended effective September 22, 1997 (Supp. 97-3).                               or portion of a month following the 60th day of
     Amended by final rulemaking at 8 A.A.R. 3317, effective                             receipt of the bill until date of payment.
      July 15, 2002 (Supp. 02-3). Amended by final rulemak-                   3. A claim is paid on the date indicated on the disbursement
      ing at 11 A.A.R. 3217, effective October 1, 2005 (Supp.                      check.
                               05-3).                                         4. A claim is denied as of the date of the remittance advice.
                                                                              5. The Administration shall process a hospital claim under
R9-22-703. Payments by the Administration
                                                                                   this Article.
A. General requirements. A provider shall enter into a provider
                                                                         D.   Prior authorization.
    agreement with the Administration that meets the require-
                                                                              1. An AHCCCS-registered provider shall:
    ments of A.R.S. § 36-2904 and 42 CFR 431.107(b) as of
                                                                                   a. Obtain prior authorization from the Administration
    March 6, 1992, which is incorporated by reference and on file
                                                                                         for non-emergency hospital admissions and covered
    with the Administration, and available from the U.S. Govern-
                                                                                         services as specified in Articles 2 and 12 of this
    ment Printing Office, Mail Stop: IDCC, 732 N. Capitol Street,
                                                                                         Chapter,
    NW, Washington, DC, 20401. This incorporation by reference
                                                                                   b. Notify the Administration of hospital admissions
    contains no future editions or amendments.
                                                                                         under Article 2 of this Chapter, and
B. Timely submission of claims.
                                                                                   c. Make records available for review by the Adminis-
    1. Under A.R.S. § 36-2904, the Administration shall deem a
                                                                                         tration upon request.
         paper or electronic claim to be submitted on the date that
                                                                              2. The Administration shall reduce payment of or deny
         it is received by the Administration. The Administration
                                                                                   claims, if an AHCCCS-registered provider fails to obtain
         shall do one or more of the following for each claim it
                                                                                   prior authorization or notify the Administration under
         receives:
                                                                                   Article 2 of this Chapter and this Article.
         a. Place a date stamp on the face of the claim,
                                                                              3. If the Administration issues prior authorization for a spe-
         b. Assign a system-generated claim reference number,
                                                                                   cific level of care but subsequent medical review indi-
                or
                                                                                   cates that a different level of care was medically
         c. Assign a system-generated date-specific number.
                                                                                   appropriate, the Administration shall adjust the claim to
    2. Unless a shorter time period is specified in contract, the
                                                                                   pay for the cost of the appropriate level of care.
         Administration shall not pay a claim for a covered service
                                                                         E.   Review of claims and coverage for hospital supplies.
         unless the claim is initially submitted within one of the
                                                                              1. The Administration may conduct prepayment and post-
         following time limits, whichever is later:
                                                                                   payment review of any claims, including but not limited
         a. Six months from the date of service or for an inpa-
                                                                                   to hospital claims.
                tient hospital claim, six months from the date of dis-
                                                                              2. Personal care items supplied by a hospital, including but
                charge; or
                                                                                   not limited to the following, are not covered services:
         b. Six months from the date of eligibility posting.
                                                                                   a. Patient care kit,
    3. Unless a shorter time period is specified in contract, the
                                                                                   b. Toothbrush,
         Administration shall not pay a clean claim for a covered
                                                                                   c. Toothpaste,
         service unless the claim is submitted within one of the
                                                                                   d. Petroleum jelly,
         following time limits, whichever is later:
                                                                                   e. Deodorant,
         a. Twelve months from the date of service or for an
                                                                                   f. Septi soap,
                inpatient hospital claim, twelve months from the
                                                                                   g. Razor or disposable razor,
                date of discharge; or
                                                                                   h. Shaving cream,
         b. Twelve months from the date of eligibility posting.
                                                                                   i. Slippers,
    4. Unless a shorter time period is specified in contract, the
                                                                                   j. Mouthwash,
         Administration shall not pay a claim submitted by an IHS
                                                                                   k. Shampoo,
         or tribal facility for a covered service unless the claim is
                                                                                   l. Powder,
         initially submitted within 12 months from the date of ser-
                                                                                   m. Lotion,
         vice, date of discharge, or eligibility posting, whichever is
                                                                                   n. Comb, and
         later.
                                                                                   o. Patient gown.
C. Claims processing.
                                                                              3. The following hospital supplies and equipment, if medi-
    1. The Administration shall notify the AHCCCS-registered
                                                                                   cally necessary and used by the member, are covered ser-
         provider with a remittance advice when a claim is pro-
                                                                                   vices:
         cessed for payment.
                                                                                   a. Arm board,
    2. The Administration shall reimburse a hospital for inpa-
                                                                                   b. Diaper,
         tient hospital admissions and outpatient hospital services
                                                                                   c. Underpad,
         rendered on or after March 1, 1993, as follows and in the
                                                                                   d. Special mattress and special bed,
         manner and at the rate described in A.R.S. § 36-2903.01:
                                                                                   e. Gloves,
                                                                                   f. Wrist restraint,
                                                                                   g. Limb holder,


June 30, 2011                                                       Page 41                                                          Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

         h. Disposable item used instead of a durable item,                 contractor. The contractor is responsible for reimbursing pro-
         i. Universal precaution,                                           viders and coordinating care for services provided to a mem-
         j. Stat charge, and                                                ber. Except as provided in subsection (A)(2), a contractor is
         k. Portable charge.                                                not required to reimburse a noncontracting provider for ser-
     4. The Administration shall determine in a hospital claims             vices rendered to a member enrolled with the contractor.
         review whether services rendered were:                             1. Providers. A provider shall enter into a provider agree-
         a. Covered services as defined in R9-22-102;                            ment with the Administration that meets the requirements
         b. Medically necessary;                                                 of A.R.S. § 36-2904 and 42 CFR 431.107(b) as of March
         c. Provided in the most appropriate, cost-effective, and                6, 1992, which is incorporated by reference and on file
               least restrictive setting; and                                    with the Administration, and available from the U.S.
         d. For claims with dates of admission on and after                      Government Printing Office, Mail Stop: IDCC, 732 N.
               March 1, 1993, substantiated by the minimum docu-                 Capitol Street, NW, Washington, DC, 20401. This incor-
               mentation specified in A.R.S. § 36-2903.01.                       poration by reference contains no future editions or
     5. If the Administration adjudicates a claim, a person may                  amendments.
         file a claim dispute challenging the adjudication under 9          2. A contractor shall reimburse a noncontracting provider
         A.A.C. 34.                                                              for services rendered to a member enrolled with the con-
F.   Overpayment for AHCCCS services.                                            tractor as specified in this Article if:
     1. An AHCCCS-registered provider shall notify the Admin-                    a. The contractor referred the member to the provider
         istration when the provider discovers the Administration                      or authorized the provider to render the services and
         made an overpayment.                                                          the claim is otherwise payable under this Chapter, or
     2. The Administration shall recoup an overpayment from a                    b. The service is emergent under Article 2 of this
         future claim cycle if an AHCCCS-registered provider                           Chapter.
         fails to return the overpaid amount to the Administration.    B.   Timely submission of claims.
     3. The Administration shall document any recoupment of an              1. Under A.R.S. § 36-2904, a contractor shall deem a paper
         overpayment on a remittance advice.                                     or electronic claim as submitted on the date that the claim
     4. An AHCCCS-registered provider may file a claim dis-                      is received by the contractor. The contractor shall do one
         pute under 9 A.A.C. 34 if the AHCCCS-registered pro-                    or more of the following for each claim the contractor
         vider disagrees with a recoupment action.                               receives:
                                                                                 a. Place a date stamp on the face of the claim,
                          Historical ote
                                                                                 b. Assign a system-generated claim reference number,
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                                       or
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                 c. Assign a system-generated date-specific number.
       3). Former Section R-22-703 adopted as an emergency
                                                                            2. Unless a shorter time period is specified in subcontract, a
       now adopted as a permanent rule effective August 30,
                                                                                 contractor shall not pay a claim for a covered service
      1982 (Supp. 82-4). Former Section R9-22-703 repealed,
                                                                                 unless the claim is initially submitted within one of the
        new Section R9-22-703 adopted effective October 1,
                                                                                 following time limits, whichever is later:
      1983 (Supp. 83-5). Amended effective October 1, 1985
                                                                                 a. Six months from the date of service or for an inpa-
     (Supp. 85-5). Amended effective October 1, 1986 (Supp.
                                                                                       tient hospital claim, six months from the date of dis-
      86-5). Amended subsection (B), paragraph (1) effective
                                                                                       charge; or
      January 1, 1987, filed December 31, 1986 (Supp. 86-6).
                                                                                 b. Six months from the date of eligibility posting.
       Amended subsection (A) effective September 16, 1987
                                                                            3. Unless a shorter time period is specified in subcontract, a
       (Supp. 87-3). Amended effective May 30, 1989 (Supp.
                                                                                 contractor shall not pay a clean claim for a covered ser-
     89-2). Amended effective September 29, 1992 (Supp. 92-
                                                                                 vice unless the claim is submitted within one of the fol-
     3). Amended effective September 22, 1997 (Supp. 97-3).
                                                                                 lowing time limits, whichever is later:
     Amended by final rulemaking at 8 A.A.R. 3317, effective
                                                                                 a. Twelve months from the date of service or for an
      July 15, 2002 (Supp. 02-3). Amended by final rulemak-
                                                                                       inpatient hospital claim, 12 months from the date of
      ing at 11 A.A.R. 3222, effective October 1, 2005 (Supp.
                                                                                       discharge; or
       05-3). Amended by final rulemaking at 13 A.A.R. 662,
                                                                                 b. Twelve months from the date of eligibility posting.
                effective April 7, 2007 (Supp. 07-1).
                                                                       C.   Date of claim.
R9-22-704.        Repealed                                                  1. A contractor’s date of receipt of an inpatient or an outpa-
                                                                                 tient hospital claim is the date the claim is received by the
                           Historical ote
                                                                                 contractor as indicated by the date stamp on the claim, the
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                                 system-generated claim reference number, or the system-
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                 generated date-specific number assigned by the contrac-
      3). Former Section R9-22-704 adopted as an emergency
                                                                                 tor.
      now adopted and amended as a permanent rule effective
                                                                            2. A hospital claim is considered paid on the date indicated
      August 30 1982 (Supp. 82-4). Amended effective Octo-
                                                                                 on the disbursement check.
      ber 1, 1983 (Supp. 83-5). Amended subsection A., Para-
                                                                            3. A denied hospital claim is considered adjudicated on the
          graph 2. effective October 1, 1985 (Supp. 85-5).
                                                                                 date of the claim’s denial.
     Amended by final rulemaking at 8 A.A.R. 3317, effective
                                                                            4. For a claim that is pending for additional supporting doc-
       July 15, 2002 (Supp. 02-3). Section repealed by final
                                                                                 umentation specified in A.R.S. § 36-2903.01 or 36-2904,
       rulemaking at 13 A.A.R. 662, effective April 7, 2007
                                                                                 the contractor shall assign a new date of receipt upon
                            (Supp. 07-1).
                                                                                 receipt of the additional documentation.
R9-22-705. Payments by Contractors                                          5. For a claim that is pending for documentation other than
A. General requirements. A contractor shall contract with provid-                the minimum required documentation specified in either
    ers to provide covered services to members enrolled with the


Supp. 11-2                                                        Page 42                                                      June 30, 2011
                                                      Arizona Administrative Code                                               Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

         A.R.S. § 36-2903.01 or 36-2904, the contractor shall not                  the contractor is responsible. If a contractor and a hospital
         assign a new date of receipt.                                             agree to a subcontract, the parties shall abide by the terms
   6. A contractor and a hospital may, through a contract                          of the subcontract regarding utilization control activities.
         approved as specified in R9-22-715, adopt a method for                    A hospital shall cooperate with a contractor’s reasonable
         identifying, tracking, and adjudicating a claim that is dif-              activities necessary to perform concurrent review and
         ferent from the method described in this subsection.                      shall make the hospital’s medical records pertaining to a
D. Payment for in-state inpatient hospital services. A contractor                  member enrolled with a contractor available for review.
   shall reimburse an in-state provider of inpatient hospital ser-            3.   Regardless of prior authorization or concurrent review
   vices rendered with an admission date on or after March 1,                      activities, a contractor may make prepayment or post-
   1993, at either a rate specified by subcontract or, in absence of               payment review of all claims, including but not limited to
   the subcontract, the prospective tiered-per-diem amount in                      a hospital claim. A contractor may recoup an erroneously
   A.R.S. § 36-2903.01 and this Article. Subcontract rates, terms,                 paid claim. If prior authorization was given for a specific
   and conditions are subject to review and approval or disap-                     level of care, but medical review of a claim indicates that
   proval under A.R.S. § 36-2904 and R9-22-715. This subsec-                       a different level of care was medically appropriate, a con-
   tion does not apply to an urban contractor as specified in R9-                  tractor shall adjust the claim to pay for the cost for the
   22-718 and A.R.S. § 36-2905.01.                                                 appropriate level of care. An adjustment in payment for a
E. Payment for in-state outpatient hospital services.                              different level of care is effective on the date when the
   1. A contractor shall reimburse an in-state provider of out-                    different level of care is medically appropriate.
         patient hospital services rendered on or after March 1,              4.   A contractor and a hospital may enter into a subcontract
         1993 through June 30, 2005, at either a rate specified by a               that includes hospital claims review criteria and proce-
         subcontract that complies with R9-22-715(A) or, in                        dures if the subcontract meets the requirements of R9-22-
         absence of a subcontract, as described in R9-22-712 or                    715.
         under A.R.S. § 36-2903.01. Subcontract rates, terms, and             5.   Personal care items supplied by a hospital, including but
         conditions are subject to review and approval or disap-                   not limited to the following, are not covered services:
         proval under A.R.S. § 36-2904 and R9-22-715.                              a. Patient care kit,
   2. A contractor shall reimburse an in-state provider of out-                    b. Toothbrush,
         patient hospital services rendered on or after July 1, 2005,              c. Toothpaste,
         at either a rate specified by a subcontract or, in absence of             d. Petroleum jelly,
         a subcontract, as provided under R9-22-712.10, A.R.S. §                   e. Deodorant,
         36-2903.01 and other sections of this Article. The terms                  f. Septi soap,
         of the subcontract are subject to review and approval or                  g. Razor,
         disapproval under A.R.S. § 36-2904 and R9-22-715.                         h. Shaving cream,
F. Inpatient and outpatient out-of-state hospital payments. In the                 i. Slippers,
   absence of a contract with an out-of-state hospital that speci-                 j. Mouthwash,
   fies payment rates, a contractor shall reimburse out-of-state                   k. Disposable razor,
   hospitals for covered inpatient services by multiplying covered                 l. Shampoo,
   charges by the most recent state-wide urban cost-to-charge                      m. Powder,
   ratio as determined in R9-22-712.01(6)(b). In the absence of a                  n. Lotion,
   contract with an out-of-state hospital that specifies payment                   o. Comb, and
   rates, a contractor shall reimburse out-of-state hospitals for                  p. Patient gown.
   covered outpatient services by applying the methodology                    6.   The following hospital supplies and equipment, if medi-
   described in R9-22-712.10 through R9-22-712.50. If the out-                     cally necessary and used by the member, are covered ser-
   patient procedure is not assigned a fee schedule amount, the                    vices:
   contractor shall pay the claim by multiplying the covered                       a. Arm board,
   charges for the outpatient services by the state-wide outpatient                b. Diaper,
   cost-to-charge ratio.                                                           c. Underpad,
G. Payment for observation days. A contractor shall reimburse a                    d. Special mattress and special bed,
   provider and a noncontracting provider for the provision of                     e. Gloves,
   observation days at either a rate specified by subcontract or, in               f. Wrist restraint,
   the absence of a subcontract, as prescribed under R9-22-712,                    g. Limb holder,
   R9-22-712.10, and R9-22-712.45. An “observation day”                            h. Disposable item used instead of a durable item,
   means a physician-ordered evaluation period of less than 24                     i. Universal precaution,
   hours to determine the need of treatment or the need for admis-                 j. Stat charge, and
   sion as an inpatient.                                                           k. Portable charge.
H. Review of claims and coverage for hospital supplies.                       7.   The contractor shall determine in a hospital claims review
   1. A contractor may conduct a review of any claims submit-                      whether services rendered were:
         ted and recoup any payments made in error.                                a. Covered services as defined in R9-22-102;
   2. A hospital shall obtain prior authorization from the                         b. Medically necessary;
         appropriate contractor for nonemergency admissions.                       c. Provided in the most appropriate, cost-effective, and
         When issuing prior authorization, a contractor shall con-                       least restrictive setting; and
         sider the medical necessity of the service, and the avail-                d. For claims with dates of admission on and after
         ability and cost effectiveness of an alternative treatment.                     March 1, 1993, substantiated by the minimum docu-
         Failure to obtain prior authorization when required is                          mentation specified in A.R.S. § 36-2904.
         cause for nonpayment or denial of a claim. A contractor              8.   If a contractor adjudicates a claim or recoups payment for
         shall not require prior authorization for medically neces-                a claim, a person may file a claim dispute challenging the
         sary services provided during any prior period for which


June 30, 2011                                                       Page 43                                                         Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

         adjudication or recoupment as described under 9 A.A.C.               now adopted and amended as a permanent rule effective
         34.                                                                   August 30, 1982 (Supp. 82-4). Former Section R9-22-
I. Non-hospital claims. A contractor shall pay claims for non-                706 repealed, new Section R9-22-706 adopted effective
   hospital services in accordance with contract, or in the absence          October 1, 1983 (Supp. 83-5). Adopted as an emergency
   of a contract, at a rate not less than the Administration’s                 effective May 18, 1984, pursuant to A.R.S. § 41-1003,
   capped fee-for-service schedule or at a lower rate if negotiated              valid for only 90 days (Supp. 84-3). Amended as an
   between the two parties.                                                  emergency effective August 16, 1984, pursuant to A.R.S.
J. Payments to hospitals. A contractor shall pay for inpatient hos-          § 41-1003, valid for only 90 days (Supp. 84-4). Amended
   pital admissions and outpatient hospital services rendered on             as an emergency effective October 25, 1984, pursuant to
   or after March 1, 1993, as follows and as described in A.R.S. §             A.R.S. § 41-1003, valid for only 90 days (Supp. 84-5).
   36-2904:                                                                     Emergency expired. Permanent amendment adopted
   1. If the hospital bill is paid within 30 days from the date of           effective February 1, 1985 (Supp. 85-1). Amended effec-
         receipt, the claim is paid at 99 percent of the rate.                 tive October 1, 1985 (Supp. 85-5). Amended effective
   2. If the hospital bill is paid between 30 and 60 days from               October 1, 1986 (Supp. 86-5). Amended subsections (A),
         the date of receipt, the claim is paid at 100 percent of the           (D), (E), (F), and (G) effective January 1, 1987, filed
         rate.                                                                December 31, 1986 (Supp. 86-6). Amended subsection
   3. If the hospital bill is paid after 60 days from the date of            (F) effective December 22, 1987 (Supp. 87-4). Amended
         receipt, the claim is paid at 100 percent of the rate plus a          subsections (A) and (F) effective May 30, 1989 (Supp.
         1 percent penalty of the rate for each month or portion of            89-2). Amended effective April 13, 1990 (Supp. 90-2).
         the month following the 60th day of receipt of the bill                Amended effective September 29, 1992 (Supp. 92-3).
         until date of payment.                                                 Amended effective September 22, 1997 (Supp. 97-3).
K. Interest payment. In addition to the requirements in subsection           Section repealed by final rulemaking at 10 A.A.R. 4656,
   (J), a contractor shall pay interest for late claims as defined by                   effective January 1, 2005 (Supp. 04-4).
   contract.
                                                                        R9-22-707.     Repealed
                           Historical ote
                                                                                                   Historical ote
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                             Adopted as an emergency effective May 20, 1982, pursu-
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                             ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
      3). Former Section R9-22-705 adopted as an emergency
                                                                              3). Former Section R9-22-707 adopted as an emergency
      now adopted and amended as a permanent rule effective
                                                                              now adopted and amended as a permanent rule effective
     August 30, 1982 (Supp. 82-4). Amended as an emergency
                                                                             August 30, 1982 (Supp. 82-4). Repealed as an emergency
       effective February 23, 1983, pursuant to A.R.S. § 41-
                                                                                effective February 23, 1983, pursuant to A.R.S. § 41-
     1003, valid for only 90 days (Supp. 83-1). Amended as a
                                                                              1003, valid for only 90 days (Supp. 83-1). Repealed as a
         permanent rule effective May 16, 1983; text of the
                                                                               permanent action effective May 16, 1983 (Supp. 83-3).
         amended rule identical to emergency (Supp. 83-3).
                                                                                New Section R9-22-707 adopted effective October 1,
     Former Section R9-22-705 repealed, new Section R9-22-
                                                                               1983 (Supp. 83-5). Adopted as an emergency effective
        705 adopted effective October 1, 1983 (Supp. 83-5).
                                                                               May 18, 1984, pursuant to A.R.S. § 41-1003, valid for
       Amended as an emergency effective October 25, 1984,
                                                                                only 90 days (Supp. 84-3). Adopted as an emergency
        pursuant to A.R.S. § 41-1003, valid for only 90 days
                                                                             effective August 16, 1984, pursuant to A.R.S. § 41-1003,
     (Supp. 84-5). Emergency expired. Permanent amendment
                                                                              valid for only 90 days (Supp. 84-4). Former Section R9-
          adopted effective February 1, 1985 (Supp. 85-1).
                                                                              22-707 repealed, new Section R9-22-707 adopted effec-
          Amended effective October 1, 1985 (Supp. 85-5).
                                                                               tive October 1, 1985 (Supp. 85-5). Former Section R9-
         Amended subsection (C) effective October 1, 1986
                                                                              22-707 repealed, new Section R9-22-707 adopted effec-
     (Supp. 86-5). Amended subsection (C) effective October
                                                                              tive October 1, 1986 (Supp. 86-5). Amended subsection
     1, 1987; amended subsection (C) effective December 22,
                                                                                (A) effective October 1, 1987 (Supp. 87-4). Amended
       1987 (Supp. 87-4). Amended subsections (A) and (C)
                                                                                effective September 29, 1992 (Supp. 92-3). Amended
     effective May 30, 1989 (Supp. 89-2). Amended effective
                                                                             effective September 22, 1997 (Supp. 97-3). Amended by
      April 13, 1990 (Supp. 90-2). Amended under an exemp-
                                                                                 final rulemaking at 8 A.A.R. 3317, effective July 15,
     tion from the provisions of the Administrative Procedure
                                                                              2002 (Supp. 02-3). Section repealed by final rulemaking
        Act, effective March 1, 1993 (Supp. 93-1). Amended
                                                                               at 13 A.A.R. 856, effective May 5, 2007 (Supp. 07-1).
      under an exemption from the provisions of the Adminis-
      trative Procedure Act, effective July 1, 1993 (Supp. 93-          R9-22-708. Payments for Services Provided to Eligible
     3). Amended effective September 22, 1997 (Supp. 97-3).              ative Americans
      Amended by final rulemaking at 5 A.A.R. 867, effective            A. For purposes of this Article “IHS enrolled” or “enrolled with
     March 4, 1999 (Supp. 99-1). Amended by final rulemak-                  IHS” means a Native American who has elected to receive
     ing at 6 A.A.R. 179, effective December 13, 1999 (Supp.                covered services through IHS instead of a contractor.
      99-4). Amended by final rulemaking at 11 A.A.R. 3222,             B. For a Native American who is enrolled with IHS, AHCCCS
     effective October 1, 2005 (Supp. 05-3). Amended by final               shall pay IHS the most recent all-inclusive inpatient, outpa-
        rulemaking at 13 A.A.R. 662, effective April 7, 2007                tient or ambulatory surgery rates published by Health and
     (Supp. 07-1). Amended by final rulemaking at 14 A.A.R.                 Human Services (HHS) in the Federal Register, or a sepa-
             1439, effective May 31, 2008 (Supp. 08-2).                     rately contracted rate with IHS, for AHCCCS-covered ser-
                                                                            vices provided in an IHS facility. AHCCCS shall reimburse
R9-22-706.        Repealed
                                                                            providers for the Medicare coinsurance and deductible
                          Historical ote                                    amounts required to be paid by the Administration or contrac-
     Adopted as an emergency effective May 20, 1982, pursu-                 tor in Chapter 29, Article 3 of this Title.
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-         C. When IHS refers a Native American enrolled with IHS to a
      3). Former Section R9-22-706 adopted as an emergency                  provider other than an IHS or tribal facility, the provider to


Supp. 11-2                                                         Page 44                                                    June 30, 2011
                                                     Arizona Administrative Code                                              Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

     whom the referral is made shall obtain prior authorization                   vider or noncontracting provider for non-hospital services
     from AHCCCS for services as required under Articles 2, 7 or                  according to the Administration’s capped-fee-for-service
     12 of this Chapter.                                                          schedule.
D.    For a Native American enrolled with a contractor, AHCCCS              2. Procedure codes. The Administration shall maintain a
     shall pay the contractor a monthly capitation payment.                       current copy of the National Standard Code Sets man-
E.   Once a Native American enrolls with a contractor, AHCCCS                     dated under 45 CFR 160 (October 1, 2004) and 45 CFR
     shall not reimburse any provider other than IHS or a Tribal                  162 (October 1, 2004), incorporated by reference and on
     facility.                                                                    file with the Administration and available from the U.S.
                                                                                  Government Printing Office, Mail Stop: IDCC, 732 N.
                          Historical ote
                                                                                  Capitol Street, NW, Washington, DC, 20401. This incor-
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                                  poration by reference contains no future editions or
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                  amendments.
      3). Former Section R9-22-708 adopted as an emergency
                                                                                  a. A person shall submit an electronic claim consistent
      now adopted and amended as a permanent rule effective
                                                                                        with 45 CFR 160 (October 1, 2004) and 45 CFR 162
       August 30, 1982 (Supp. 82-4). Former Section R9-22-
                                                                                        (October 1, 2004).
      708 repealed, new Section R9-22-708 adopted effective
                                                                                  b. A person shall submit a paper claim using the
     October 1, 1983 (Supp. 83-5). Former Section R9-22-708
                                                                                        National Standard Code Sets as described under 45
       renumbered and amended as Section R9-22-709, new
                                                                                        CFR 160 (October 1, 2004) and 45 CFR 162 (Octo-
       Section R9-22-708 adopted effective October 1, 1985
                                                                                        ber 1, 2004).
     (Supp. 85-5). Amended effective October 1, 1986 (Supp.
                                                                                  c. The Administration may deny a claim for failure to
      86-5). Amended by final rulemaking at 10 A.A.R. 4656,
                                                                                        comply with subsection (A)(2)(a) or (b).
              effective January 1, 2005 (Supp. 04-4).
                                                                            3. Fee schedule. The Administration shall pay providers,
R9-22-709. Contractor’s Liability to Hospitals for the Provi-                     including noncontracting providers, at the lesser of billed
sion of Emergency and Post-stabilization Care                                     charges or the capped fee-for-service rates specified in
A contractor is liable for emergency hospitalization and post-stabi-              subsections (A)(3)(a) through (A)(3)(d) unless a different
lization care as described in R9-22-210 and R9-22-210.01.                         fee is specified in a contract between the Administration
                                                                                  and the provider, or is otherwise required by law.
                          Historical ote
                                                                                  a. Physician services. Fee schedules for payment for
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                                        physician services are on file at the central office of
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                                        the Administration for reference use during custom-
      3). Former Section R9-22-709 adopted as an emergency
                                                                                        ary business hours.
      now adopted and amended as a permanent rule effective
                                                                                  b. Dental services. Fee schedules for payment for den-
       August 30, 1982 (Supp. 82-4). Former Section R9-22-
                                                                                        tal services are on file at the central office of the
      709 repealed, new Section R9-22-709 adopted effective
                                                                                        Administration for reference use during customary
     October 1, 1983 (Supp. 83-5). Former Section R9-22-709
                                                                                        business hours.
      renumbered and amended as Section R9-22-713, former
                                                                                  c. Transportation services. Fee schedules for payment
      Section R9-22-708 renumbered and amended as Section
                                                                                        for transportation services are on file at the central
         R9-22-709 effective October 1, 1985 (Supp. 85-5).
                                                                                        office of the Administration for reference use during
     Amended under an exemption from the provisions of the
                                                                                        customary business hours.
       Administrative Procedure Act, effective March 1, 1993
                                                                                  d. Medical supplies and durable medical equipment
        (Supp. 93-1). Amended effective September 22, 1997
                                                                                        (DME). Fee schedules for payment for medical sup-
      (Supp. 97-3). Amended by final rulemaking at 8 A.A.R.
                                                                                        plies and DME are on file at the central office of the
      424, effective January 10, 2002 (Supp. 02-1). Amended
                                                                                        Administration for reference use during customary
       by final rulemaking at 13 A.A.R. 856, effective May 5,
                                                                                        business hours. The Administration shall reimburse
                         2007 (Supp. 07-1).
                                                                                        a provider once for purchase of DME during any
     Editor’s ote: The following Section was amended under an                           two-year period, unless the Administration deter-
exemption from the provisions of the Administrative Procedure                           mines that DME replacement within that period is
Act which means that this rule was not reviewed by the Gover-                           medically necessary for the member. Unless prior
nor’s Regulatory Review Council; the agency did not submit                              authorized by the Administration, no more than one
notice of proposed rulemaking to the Secretary of State for publi-                      repair and adjustment of DME shall be reimbursed
cation in the Arizona Administrative Register; the agency was                           during any two-year period.
not required to hold public hearings on the rules; and the Attor-      B.   Pharmacy services. The Administration shall not reimburse
ney General did not certify this rule. This Section was subse-              pharmacy services unless the services are provided by a con-
quently amended through the regular rulemaking process.                     tracted provider or a provider having a subcontract with a
                                                                            Pharmacy Benefit Manager (PBM) contracted with AHCCCS.
R9-22-710. Payments for on-hospital Services
                                                                            The Administration shall reimburse pharmacy services accord-
A. Capped fee-for-service. The Administration shall provide
                                                                            ing to the terms of the contract.
    notice of changes in methods and standards for setting pay-
    ment rates for services in accordance with 42 CFR 447.205,                                   Historical ote
    December 19, 1983, incorporated by reference and on file with           Adopted as an emergency effective May 20, 1982, pursu-
    the Administration and available from the U.S. Government               ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
    Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,             3). Former Section R9-22-710 adopted as an emergency
    Washington, DC, 20401. This incorporation by reference con-              now adopted and amended as a permanent rule effective
    tains no future editions or amendments.                                 August 30, 1982 (Supp. 82-4). Amended as an emergency
    1. Non-contracted services. In the absence of a contract that             effective February 23, 1983, pursuant to A.R.S. § 41-
         specifies otherwise, a contractor shall reimburse a pro-           1003, valid for only 90 days (Supp. 83-1). Amended as a



June 30, 2011                                                     Page 45                                                          Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

      permanent rule effective May 16, 1983; text of amended                  4.    An individual eligible for Supplemental Security Income
     rule identical to emergency (Supp. 83-3). Former Section                       (SSI);
        R9-22-710 repealed, new Section R9-22-710 adopted                     5. An individual eligible for SSI Medical Assistance Only
      effective October 1, 1983 (Supp. 83-5). Amended effec-                        (SSI/MAO) in R9-22-1500;
      tive October 1, 1985. The capped fee-for-service sched-                 6. An individual eligible for the Freedom to Work program
                                                                                    in A.R.S. § 36-2901(6)(g); and
      ules, deleted from Section R9-22-710, are now on file at                7. An individual eligible for the Breast and Cervical Cancer
        the central office of the Administration (Supp. 85-5).                      Treatment program in A.R.S. § 36-2901.05.
      Amended subsections (B) through (D) effective October                   8. An individual with respect to whom child welfare ser-
      1, 1986 (Supp. 86-5). Amended subsection (B) effective                        vices are made available under Part B of Title IV of the
     July 1, 1988 (Supp. 88-3). Amended subsection (B) effec-                       Social Security Act on the basis of being a child in foster
        tive April 27, 1989 (Supp. 89-2). Amended under an                          care, without regard to age or an individual with respect
     exemption from the provisions of the Administrative Pro-                       to whom adoption or foster care assistance is made avail-
          cedure Act, effective March 1, 1993 (Supp. 93-1).                         able under Part E of Title IV of the Social Security Act,
        Amended effective December 13, 1993 (Supp. 93-4).                           without regard to age.
        Amended effective September 22, 1997 (Supp. 97-3).                    9. Copayment amount per service:
      Amended by final rulemaking at 11 A.A.R. 3830, effec-                         a. $2.30 per prescription drug.
                tive November 12, 2005 (Supp. 05-3).                                b. $3.40 per outpatient visit, excluding an emergency
R9-22-711. Copayments                                                                     room visit, if any of the services rendered during the
A. For purposes of this Article:                                                          visit are coded as evaluation and management ser-
    1. A copayment is a monetary amount that a member pays                                vices or non-emergent surgical procedures according
          directly to a provider at the time a covered service is ren-                    to the National Standard Code Sets. An outpatient
          dered.                                                                          visit includes any setting where these services are
    2. An eligible individual is assigned to a hierarchy estab-                           performed such as a physician’s office, an Ambula-
          lished in subsections (B) through (E), for the purposes of                      tory Surgical Center (ASC), or a clinic.
          establishing a copayment amount.                                          c. $2.30 per visit, if a copayment is not being imposed
    3. No refunds shall be made for a retroactive period if there                         under subsection (D)(9)(b) and any of the services
          is a change in an individual’s status that alters the amount                    rendered during the visit are coded as physical,
          of a copayment.                                                                 occupational or speech therapy services according to
B. The following services are exempt from AHCCCS copay-                                   the National Standard Code Sets.
    ments:                                                               E.   Copayments for individuals eligible for Transitional Medical
    1. Family planning services and supplies are exempt from                  Assistance.
          copayments for all members.                                         1. Unless otherwise listed in subsection (C)(1), (2), (5), (6),
    2. Services related to a pregnancy or any other medical con-                    (7) or (D)(1) through (8), an individual eligible for Tran-
          dition that may complicate the pregnancy, including                       sitional Medical Assistance (TMA) in A.R.S. § 36-2924
          tobacco cessation treatment for a pregnant woman, are                     is required to pay the following copayments:
          exempt from copayments for all members.                                   a. $2.30 per prescription drug.
    3. Emergency services as described in 42 CFR 447.53(b)(4)                       b. $4.00 per outpatient visit, excluding an emergency
          are exempt from copayments for all members.                                     room visit, if any of the services rendered during the
    4. All services paid on a fee-for-service basis are exempt                            visit are coded as evaluation and management ser-
          from copayments for all members.                                                vices according to the National Standard Code Sets.
C. The following individuals are exempt from AHCCCS copay-                                An outpatient visit includes any setting where these
    ments:                                                                                services are performed, such as a physician’s office,
    1. An individual under age 19, including individuals eligible                         an Ambulatory Surgical Center (ASC), or a clinic.
          for the KidsCare Program in A.R.S. § 36-2982;                             c. If a copayment is not being imposed under subsec-
    2. An individual determined to be Seriously Mentally Ill                              tion (E)(1)(b), $3.00 per visit if any of the services
          (SMI) by the Arizona Department of Health Services;                             rendered during the visit are coded as physical,
    3. An individual eligible for the Arizona Long-term Care                              occupational or speech therapy services according to
          Program in A.R.S. § 36-2931;                                                    the National Standard Code Sets.
    4. An individual eligible for Medicare Cost Sharing in 9                        d. If a copayment is not being imposed under subsec-
          A.A.C. 29;                                                                      tion (E)(1)(b) or (c), $3.00 per visit, if any of the ser-
    5. An individual eligible for the Children’s Rehabilitative                           vices rendered during the visit are coded as non-
          Services program under A.R.S. § 36-2906(E);                                     emergent surgical procedures according to the
    6. An institutionalized person under R9-22-216; and                                   National Standard Code Sets when provided in a
    7. An individual receiving hospice care as defined in 42                              physician’s office, an (ASC), or any other outpatient
          U.S.C. 1396d(o).                                                                setting, excluding an emergency room, where these
D. Copayments for non-Transitional Medical Assistance (TMA)                               services are performed.
    individuals covered under the State Plan. Unless otherwise                2. The provider may deny a service if the member does not
    listed in subsection (B) or (C), individuals under subsections                  pay the copayment required by subsection (E)(1), how-
    (D)(1) through (8) are subject to the copayments listed in this                 ever, a provider may choose to reduce or waive copay-
    subsection. A provider shall not deny a service when a mem-                     ments under this subsection on a case-by-case basis.
    ber states to the provider an inability to pay a copayment.          F.   Copayments for individuals covered under Section 1115
    1. A family eligible under Section 1931 of the Act;                       Waiver. Unless otherwise listed in subsection (C), (D), or (E)
    2. An individual eligible for Young Adult Transitional                    the following individuals are required to pay the copayments
          Insurance (YATI) in A.R.S. § 36-2901(6)(iii);                       listed in this subsection. The provider may deny a service if
    3. An individual eligible for State Adoption Assistance in                the member does not pay the required copayment. However, a
          R9-22-1433;


Supp. 11-2                                                          Page 46                                                         June 30, 2011
                                                       Arizona Administrative Code                                            Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

     provider may choose to reduce or waive copayments under              was not required to hold public hearings on the rules; and the
     this subsection on a case-by-case basis.                             Attorney General did not certify this rule. This Section was subse-
     1. An individual whose income is equal to or under 100% of           quently amended through the regular rulemaking process.
           the Federal Poverty Level in A.R.S. § 36-2901.01, or
                                                                          R9-22-712. Reimbursement: General
     2. An individual eligible for the Medical Expense Deduc-
                                                                          A. Inpatient and outpatient discounts and penalties. If a claim is
           tion program in A.R.S. § 36-2901.04.
                                                                              pended for additional documentation required under A.R.S. §
           Covered Services                 Copayment                         36-2903.01(H)(4), the period during which the claim is pended
                                                                              is not used in the calculation of the quick-pay discounts and
           Generic prescriptions or         $4.00 per prescription            slow-pay penalties under A.R.S. § 36-2903.01(H)(5).
           brand name prescriptions if      drug                          B. Inpatient and outpatient out-of-state hospital payments. In the
           generic is not available                                           absence of a contract with an out-of-state hospital that speci-
                                                                              fies payment rates, AHCCCS shall reimburse out-of-state hos-
           Brand name prescriptions         $10.00 per prescription
                                                                              pitals for covered inpatient services by multiplying covered
           when generic is available        drug
                                                                              charges by the most recent state-wide urban cost-to-charge
           Nonemergency use of the          $30.00 per visit                  ratio as determined in R9-22-712.01(6)(b). In the absence of a
           emergency room.                                                    contract with an out-of-state hospital that specifies payment
                                                                              rates, AHCCCS shall reimburse an out-of-state hospital for
           Physician office visit           $5.00 per office visit            covered outpatient services by applying the methodology
                                                                              described in R9-22-712.10 through R9-22-712.50. If the out-
G. A provider is responsible for collecting any copayment                     patient procedure is not assigned a fee schedule amount, the
   imposed under this Section.                                                Administration shall pay the claim by multiplying the covered
H. The total aggregate amount of copayments under subsections                 charges for the outpatient services by the state-wide outpatient
   (D) or (E) may not exceed 5% of the family’s income as                     cost-to-charge ratio.
   applied on a quarterly basis. The member may establish that            C. Access to records. Subcontracting and noncontracting provid-
   the aggregate limit has been met on a quarterly basis by pro-              ers of outpatient or inpatient hospital services shall allow the
   viding the Administration with records of copayments                       Administration access to medical records regarding eligible
   incurred during the quarter. In addition, the Administration               persons and shall in all other ways fully cooperate with the
   shall also use claims and encounters information available to              Administration or the Administration’s designated representa-
   the Administration to establish when a member’s copayment                  tive in performance of the Administration’s utilization control
   obligation has reached 5% of the family’s income.                          activities. The Administration shall deny a claim for failure to
I. Reduction in payments to providers. The Administration shall               cooperate.
   reduce the payment it makes to any provider by the amount of           D. Prior authorization. The Administration shall deny a claim for
   a member’s copayment obligation under subsections (E) and                  failure to obtain prior authorization as required in R9-22-210.
   (F), regardless of whether the provider successfully collects          E. Review of claims. Regardless of prior authorization or concur-
   the copayments described in this Section.                                  rent review activities, the Administration may subject all hos-
                            Historical ote                                    pital claims, including outliers, to prepayment medical review
     Adopted as an emergency effective May 20, 1982, pursu-                   or post-payment review, or both. The Administration shall
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-               conduct post-payment reviews consistent with A.R.S. § 36-
     3). Former Sections R9-22-711 adopted as an emergency                    2903.01 and may recoup erroneously paid claims. If prior
      now adopted and amended as a permanent rule effective                   authorization was given for a specific level of care but medical
     August 30, 1982 (Supp. 82-4). Former Section R9-22-711                   review of the claim indicates that a different level of care was
     repealed, new Section R9-22-711 adopted effective Octo-                  appropriate, the Administration may adjust the claim to reflect
      ber 1, 1983 (Supp. 83-5). Amended effective October 1,                  the more appropriate level of care, effective on the date when
       1985 (Supp. 85-5). Amended under an exemption from                     the different level of care was medically appropriate.
         the provisions of the Administrative Procedure Act,              F. Claim receipt.
       effective July 1, 1993 (Supp. 93-3). Amended under an                  1. The Administration’s date of receipt of inpatient or outpa-
     exemption from the provisions of the Administrative Pro-                       tient hospital claims is the date the claim is received by
         cedure Act, effective October 26, 1993 (Supp. 93-4).                       the Administration as indicated by the date stamp on the
        Amended effective September 22, 1997 (Supp. 97-3).                          claim and the system-generated claim reference number
     Amended by final rulemaking at 6 A.A.R. 2435, effective                        or system-generated date-specific number.
     June 9, 2000 (Supp. 00-2). Amended by final rulemaking                   2. Hospital claims are considered paid on the date indicated
       at 8 A.A.R. 3317, effective July 15, 2002 (Supp. 02-3).                      on disbursement checks.
     Amended by exempt rulemaking at 9 A.A.R. 4557, effec-                    3. A denied claim is considered adjudicated on the date the
      tive October 1, 2003 (Supp. 03-4). Amended by exempt                          claim is denied.
        rulemaking at 10 A.A.R. 2194, effective May 3, 2004                   4. Claims that are denied and are resubmitted are assigned
         (Supp. 04-2). Amended by exempt rulemaking at 10                           new receipt dates.
        A.A.R. 4266, effective October 1, 2004 (Supp. 04-3).                  5. For a claim that is pending for additional supporting doc-
      Amended by final rulemaking at 16 A.A.R. 1449, effec-                         umentation specified in A.R.S. §§ 36-2903.01 or 36-
                  tive October 1, 2010 (Supp. 10-3).                                2904, the Administration shall assign a new date of
                                                                                    receipt upon receipt of the additional documentation.
      Editor’s ote: The following Section was adopted and                     6. For a claim that is pending for documentation other than
amended under an exemption from the provisions of the Adminis-                      the minimum required documentation specified in either
trative Procedure Act which means that this rule was not reviewed                   A.R.S. §§ 36-2903.01 or 36-2904, the Administration
by the Governor’s Regulatory Review Council; the agency did not                     shall not assign a new date of receipt.
submit notice of proposed rulemaking to the Secretary of State for
publication in the Arizona Administrative Register; the agency


June 30, 2011                                                        Page 47                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

G.   Outpatient hospital reimbursement. The Administration shall                   the emergency room, observation area, or other outpatient
     pay for covered outpatient hospital services provided to eligi-               department. Services provided in the emergency room,
     ble persons with dates of service from March 1, 1993 through                  observation area, and other outpatient hospital services
     June 30, 2005, at the AHCCCS outpatient hospital cost-to-                     provided before the hospital admission are included in the
     charge ratio, multiplied by the amount of the covered charges.                tiered per diem payment.
     1. Computation of outpatient hospital reimbursement. The                 5.   Rebasing. The Administration shall rebase the outpatient
          Administration shall compute the cost-to-charge ratio on                 hospital cost-to-charge ratios at least every four years but
          a hospital-specific basis by determining the covered                     no more than once a year using updated Medicare Cost
          charges and costs associated with treating eligible per-                 Reports and claim and encounter data.
          sons in an outpatient setting at each hospital. Outpatient          6.   If a hospital files an increase in its charge master for an
          operating and capital costs are included in the computa-                 existing outpatient service provided on or after July 1,
          tion but outpatient medical education costs that are                     2004, and on or before June 30, 2005, which represents
          included in the inpatient medical education component                    an aggregate increase in charges of more than 4.7 percent,
          are excluded. To calculate the outpatient hospital cost-to-              the Administration shall adjust the hospital-specific cost-
          charge ratio annually for each hospital, the Administra-                 to-charge ratio as calculated under subsection (G)(1)
          tion shall use each hospital’s Medicare Cost Reports and                 through (G)(5) by applying the following formula:
          a database consisting of outpatient hospital claims paid
          and encounters processed by the Administration for each                  CCR*[1.047/(1+ % increase)]
          hospital, subjecting both to the data requirements speci-
          fied in R9-22-712.01. The Administration shall use the                   Where “CCR” means the hospital-specific cost-to-charge
          following methodology to establish the outpatient hospi-                 ratio as calculated under subsection (G)(1) through (G)(5)
          tal cost-to-charge ratios:                                               and “% increase” means the aggregate percentage
          a. Cost-to-charge ratios. The Administration shall cal-                  increase in charges for outpatient services shown on the
                culate the costs of the claims and encounters for out-             hospital charge master.
                patient hospital services by multiplying the ancillary
                line item cost-to-charge ratios by the covered                     “Charge master” means the schedule of rates and charges
                charges for corresponding revenue codes on the                     as described under A.R.S. § 36-436 and the rules that
                claims and encounters. Each hospital shall provide                 relate to those rates and charges that are filed with the
                the Administration with information on how the rev-                Director of the Arizona Department of Health Services.
                enue codes used by the hospital to categorize
                                                                                                    Historical ote
                charges on claims and encounters correspond to the
                                                                                 Adopted as an emergency effective February 23, 1983
                ancillary line items on the hospital’s Medicare Cost
                                                                                 pursuant to A.R.S. § 41-1003, valid for only 90 days
                Report. The Administration shall then compute the
                                                                              (Supp. 83-1). Adopted as a permanent rule effective May
                overall outpatient hospital cost-to-charge ratio for
                                                                                 16, 1983; text of adopted rule identical to emergency
                each hospital by taking the average of the ancillary
                                                                                (Supp. 83-3). Former Section R9-22-712 repealed, new
                line items cost-to-charge ratios for each revenue
                                                                                 Section R9-22-712 adopted effective October 1, 1983
                code weighted by the covered charges.
                                                                              (Supp. 83-5). Former Section R9-22-712 renumbered and
          b. Cost-to-charge limit. To comply with 42 CFR
                                                                                 amended as Section R9-22-1001 effective October 1,
                447.325, the Administration may limit cost-to-
                                                                                  1985 (Supp. 85-5). New Section R9-22-712 adopted
                charge ratios to 1.00 for each ancillary line item
                                                                               under an exemption from the provisions of the Adminis-
                from the Medicare Cost Report. The Administration
                                                                              trative Procedure Act, effective March 1, 1993 (Supp. 93-
                shall remove ancillary line items that are non-cov-
                                                                               1). Amended under an exemption from the provisions of
                ered or not applicable to outpatient hospital services
                                                                               the Administrative Procedure Act, effective July 1, 1993
                from the Medicare Cost Report data for purposes of
                                                                              (Supp. 93-3). Amended effective January 14, 1997 (Supp.
                computing the overall outpatient hospital cost-to-
                                                                                 97-1). Amended by exempt rulemaking at 10 A.A.R.
                charge ratio.
                                                                               3831, effective August 25, 2004 (Supp. 04-3). Amended
     2. New hospitals. The Administration shall reimburse new
                                                                               by exempt rulemaking at 11 A.A.R. 2297, effective July
          hospitals at the weighted statewide average outpatient
                                                                              1, 2005 (Supp. 05-2). Amended by final rulemaking at 11
          hospital cost-to-charge ratio multiplied by covered
                                                                                 A.A.R. 3231, effective October 1, 2005 (Supp. 05-3).
          charges. The Administration shall continue to use the
                                                                               Amended by final rulemaking at 14 A.A.R. 1439, effec-
          statewide average outpatient hospital cost-to-charge ratio
                                                                                           tive May 31, 2008 (Supp. 08-2).
          for a new hospital until the Administration rebases the
          outpatient hospital cost-to-charge ratios and the new hos-     R9-22-712.01.         Inpatient Hospital Reimbursement
          pital has a Medicare Cost Report for the fiscal year being     Inpatient hospital reimbursement. The Administration shall pay for
          used in the rebasing.                                          covered inpatient acute care hospital services provided to eligible
     3. Specialty outpatient services. The Administration may            persons with admissions on and after October 1, 1998, on a pro-
          negotiate, at any time, reimbursement rates for outpatient     spective reimbursement basis. The prospective rates represent pay-
          hospital services in a specialty facility.                     ment in full, excluding quick-pay discounts, slow-pay penalties,
     4. Reimbursement requirements. To receive payment from              and third-party payments for both accommodation and ancillary
          the Administration, a hospital shall submit claims that are    department services. The rates include reimbursement for operating
          legible, accurate, error free, and have a covered charge       and capital costs. The Administration shall make reimbursement for
          greater than 0. The Administration shall not reimburse         direct graduate medical education as described in A.R.S. § 36-
          hospitals for emergency room treatment, observation            2903.01. For payment purposes, the Administration shall classify
          hours or days, or other outpatient hospital services per-      each AHCCCS inpatient hospital day of care into one of several
          formed on an outpatient basis, if the eligible person is       tiers appropriate to the services rendered. The rate for a tier is
          admitted as an inpatient to the same hospital directly from    referred to as the tiered per diem rate of reimbursement. The num-


Supp. 11-2                                                          Page 48                                                     June 30, 2011
                                                       Arizona Administrative Code                                          Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

ber of tiers is seven and the maximum number of tiers payable per                         42 CFR 447.271, the Administration shall limit
continuous stay is two. Payment of outlier claims, transplant                             cost-to-charge ratios to 1.00 for each ancillary
claims, or payment to out-of-state hospitals, freestanding psychiat-                      department.
ric hospitals, and other specialty facilities may differ from the inpa-              ii. Operating cost calculation. To calculate the rate
tient hospital tiered per diem rates of reimbursement described in                        for the operating component, the Administra-
this Section.                                                                             tion shall derive the operating costs from
      1. Tier rate data. The Administration shall base tiered per                         claims and encounters by combining the Medi-
           diem rates effective on and after October 1, 1998 on                           care Cost Report data and the claim and
           Medicare Cost Reports for Arizona hospitals for fiscal                         encounter database for all hospitals. In per-
           years ending in 1996 and a database consisting of inpa-                        forming this calculation, the Administration
           tient hospital claims and encounters for dates of service                      shall match the revenue codes on the claims
           matching each hospital’s 1996 fiscal year end.                                 and encounters to the departments in which the
           a. Medicare Cost Report data. Because Medicare Cost                            line items on the Medicare Cost Reports are
                 Report years are not standard among hospitals and                        grouped. The ancillary department cost-to-
                 were not audited at the time of the rate calculation,                    charge ratios for a particular hospital are multi-
                 the Administration shall inflate all the costs to a                      plied by the covered ancillary department
                 common point in time as described in subsection (2)                      charges on each of the hospital’s claims and
                 for each component of the tiered per diem rates. The                     encounters. The AHCCCS inpatient days of
                 Administration shall not make any changes to the                         care on the particular hospital’s claims and
                 tiered per diem rates if the Medicare Cost Report                        encounters are multiplied by the corresponding
                 data are subsequently updated or adjusted. If a single                   accommodation costs per day from the hospi-
                 Medicare Cost Report is filed for more than one hos-                     tal’s Medicare Cost Report. The ancillary cost-
                 pital, the Administration shall allocate the costs to                    to-charge ratios and accommodation costs per
                 each of the respective hospitals. A hospital shall                       day do not include medical education and capi-
                 submit information to assist the Administration in                       tal costs. The Administration shall inflate the
                 this allocation.                                                         resulting operating costs for the claims and
           b. Claim and encounter data. For the database, the                             encounters of each hospital to a common point
                 Administration shall use only those inpatient hospi-                     in time, December 31, 1996, using the DRI
                 tal claims paid by the Administration and encounters                     inflation factor and shall reduce the operating
                 that were accepted and processed by the Administra-                      costs for the hospital by an audit adjustment
                 tion at the time the database was developed for rates                    factor based on available national data and Ari-
                 effective on and after October 1, 1998. The Admin-                       zona historical experience in adjustments to
                 istration shall subject the claim and encounter data                     Medicare reimbursable costs. The Administra-
                 to a series of data quality, reasonableness, and integ-                  tion shall further inflate operating costs to the
                 rity edits and shall exclude from the database or                        midpoint of the rate year (March 31, 1999).
                 adjust claims and encounters that fail these edits.                 iii. Operating cost tier assignment. After calculat-
                 The Administration shall also exclude from the data-                     ing the operating costs, the Administration
                 base the following claims and encounters:                                shall assign the claims and encounters used in
                 i. Those missing information necessary for the                           the calculation to tiers based on diagnosis, pro-
                       rate calculation,                                                  cedure, or revenue codes, or NICU classifica-
                 ii. Medicare crossovers,                                                 tion level, or a combination of these. For the
                 iii. Those submitted by freestanding psychiatric                         NICU tier, the Administration shall further
                       hospitals, and                                                     assign claims and encounters to NICU Level II
                 iv. Those for transplant services or any other hos-                      or NICU Level III peer groups, based on the
                       pital service that the Administration would pay                    hospital’s certification by the Arizona Perinatal
                       on a basis other than the tiered per diem rate.                    Trust. For the Routine tier, the Administration
      2. Tier rate components. The Administration shall establish                         shall further assign claims and encounters to
           inpatient hospital prospective tiered per diem rates based                     the general acute care hospital or rehabilitation
           on the sum of the operating and capital components. The                        hospital peer groups, based on state licensure
           rate for the operating component is a statewide rate for                       by the Department of Health Services. For
           each tier except for the NICU and Routine tiers, which                         claims and encounters assigned to more than
           are based on peer groups. The rate for the capital compo-                      one tier, the Administration shall allocate ancil-
           nent is a blend of statewide and hospital-specific values,                     lary department costs to the tiers in the same
           as described in A.R.S. § 36-2903.01. The Administration                        proportion as the accommodation costs. Before
           shall use the following methodologies to establish the                         calculating the rate for the operating compo-
           rates for each of these components.                                            nent, the Administration shall identify and
           a. Operating component. Using the Medicare Cost                                exclude any claims and encounters that are out-
                 Reports and the claim and encounter database, the                        liers as defined in subsection (6).
                 Administration shall compute the rate for the operat-               iv. Operating rate calculation. The Administration
                 ing component as follows:                                                shall set the rate for the operating component
                 i. Data preparation. The Administration shall                            for each tier by dividing total statewide or peer
                       identify and group into department categories,                     group hospital costs identified in this subsec-
                       the Medicare Cost Report data that provide                         tion within the tier by the total number of AHC-
                       ancillary department cost-to-charge ratios and                     CCS inpatient hospital days of care reflected in
                       accommodation costs per day. To comply with                        the claim and encounter database for that tier.



June 30, 2011                                                         Page 49                                                   Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

          b.   Capital component. For rates effective October 1,                         i.   Maternity. The Administration shall identify
               1999 the capital component is calculated as                                    the Maternity Tier by a primary diagnosis code.
               described in A.R.S. § 36-2903.01.                                              If a claim has an appropriate primary diagnosis,
          c. Statewide inpatient hospital cost-to-charge ratio. For                           the Administration shall pay the AHCCCS
               dates of service prior to October 1, 2007, the state-                          inpatient hospital days of care on the claim at
               wide inpatient hospital cost-to-charge ratio is used                           the maternity tiered per diem rate.
               for payment of outliers, as described in subsections                      ii. NICU. The Administration shall identify the
               (4), (5), and (6), and out-of-state hospitals, as                              NICU Tier by a revenue code. A hospital does
               described in R9-22-712(B). The Administration                                  not qualify for the NICU tiered per diem rate
               shall calculate the AHCCCS statewide inpatient hos-                            unless the hospital is classified as either a
               pital cost-to-charge ratio by using the Medicare Cost                          NICU Level II or NICU Level III perinatal cen-
               Report data and claim and encounter database                                   ter by the Arizona Perinatal Trust. The Admin-
               described in subsection (1) and used to determine                              istration shall pay AHCCCS inpatient hospital
               the tiered per diem rates. For each hospital, the cov-                         days of care on the claim that meet the medical
               ered inpatient days of care on the claims and                                  review criteria for the NICU tier and have a
               encounters are multiplied by the corresponding                                 NICU revenue code at the NICU tiered per
               accommodation costs per day from the Medicare                                  diem rate. The Administration shall pay any
               Cost Report. Similarly, the covered ancillary depart-                          remaining AHCCCS inpatient hospital day on
               ment charges on the claims and encounters are mul-                             the claim that does not meet NICU Level II or
               tiplied by the ancillary department cost-to-charge                             NICU Level III medical review criteria at the
               ratios. The accommodation costs per day and the                                nursery tiered per diem rate.
               ancillary department cost-to-charge ratios for each                       iii. ICU. The Administration shall identify the ICU
               hospital are determined in the same way described in                           Tier by a revenue code. The Administration
               subsection (2)(a) but include costs for operating and                          shall pay AHCCCS inpatient hospital days of
               capital. The Administration shall then calculate the                           care on the claim that meets the medical review
               statewide inpatient hospital cost-to-charge ratio by                           criteria for the ICU tier and has an ICU revenue
               summing the covered accommodation costs and                                    code at the ICU tiered per diem rate. The
               ancillary department costs from the claims and                                 Administration may classify any AHCCCS
               encounters for all hospitals and dividing by the sum                           inpatient hospital days on the claim without an
               of the total covered charges for these services for all                        ICU revenue code, as surgery, psychiatric, or
               hospitals.                                                                     routine tiers.
          d. Unassigned tiered per diem rates. If a hospital has an                      iv. Surgery. The Administration shall identify the
               insufficient number of claims to set a tiered per diem                         Surgery Tier by a revenue code and a valid sur-
               rate, the Administration shall pay that hospital the                           gical procedure code that is not on the AHC-
               statewide average rate for that tier.                                          CCS excluded surgical procedure list. The
     3.   Tier assignment. The Administration shall assign AHC-                               excluded surgical procedure list identifies
          CCS inpatient hospital days of care to tiers based on                               minor procedures such as sutures that do not
          information submitted on the inpatient hospital claim or                            require the same hospital resources as other
          encounter including diagnosis, procedure, or revenue                                procedures. The Administration shall only split
          codes, peer group, NICU classification level, or a combi-                           a surgery tier with an ICU tier. AHCCCS shall
          nation of these.                                                                    pay at the surgery tier rate only when the sur-
          a. Tier hierarchy. In assigning claims for AHCCCS                                   gery occurs on a date during which the member
               inpatient hospital days of care to a tier, the Adminis-                        is eligible.
               tration shall follow the Hierarchy for Tier Assign-                       v. Psychiatric. The Administration shall identify
               ment in R9-22-712.09. The Administration shall not                             the Psychiatric Tier by either a psychiatric rev-
               pay a claim for inpatient hospital services unless the                         enue code and a psychiatric diagnosis or any
               claim meets medical review criteria and the defini-                            routine revenue code if all diagnosis codes on
               tion of a clean claim. The Administration shall not                            the claim are psychiatric. The Administration
               pay for a hospital stay on the basis of more than two                          shall not split a claim with AHCCCS inpatient
               tiers, regardless of the number of interim claims that                         hospital days of care in the psychiatric tier with
               are submitted by the hospital.                                                 any tier other than the ICU tier.
          b. Tier exclusions. The Administration shall not assign                        vi. Nursery. The Administration shall identify the
               to a tier or pay AHCCCS inpatient hospital days of                             Nursery Tier by a revenue code. The Adminis-
               care that do not occur during a period when the per-                           tration shall not split a claim with AHCCCS
               son is eligible. Except in the case of death, the                              inpatient hospital days of care in the nursery
               Administration shall pay claims in which the day of                            tier with any tier other than the NICU tier.
               admission and the day of discharge are the same,                          vii. Routine. The Administration shall identify the
               termed a same day admit and discharge, including                               Routine Tier by revenue codes. The routine tier
               same day transfers, as an outpatient hospital claim.                           includes AHCCCS inpatient hospital days of
               The Administration shall pay same day admit and                                care that are not classified in another tier or
               discharge claims that qualify for either the maternity                         paid under any other provision of this Section.
               or nursery tiers based on the lesser of the rate for the                       The Administration shall not split the routine
               maternity or nursery tier, or the outpatient hospital                          tier with any tier other than the ICU tier.
               fee schedule.                                                   4.   Annual update. The Administration shall annually update
          c. Seven tiers. The seven tiers are:                                      the inpatient hospital tiered per diem rates in accordance
                                                                                    with A.R.S. § 36-2903.01.


Supp. 11-2                                                           Page 50                                                     June 30, 2011
                                                      Arizona Administrative Code                                              Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

    5.   New hospitals. For rates effective on and after October 1,                          Medicare Urban or Rural Cost-to-Charge Ratio.
         1998, the Administration shall pay new hospitals the                                The adjusted hospital specific inpatient cost-to-
         statewide average rate for each tier, as appropriate. The                           charge ratios shall be used for all calculations
         Administration shall update new hospital tiered per diem                            using the Medicare Urban or Rural Cost-to-
         rates annually under A.R.S. § 36-2903.01.                                           Charge Ratios, including outlier determination,
    6.   Outliers. The Administration shall reimburse hospitals                              and threshold calculation.
         for AHCCCS inpatient hospital days of care identified as                       ii. Medicare Cost-to-Charge Ratio Phase-In calcu-
         outliers under this Section by multiplying the covered                              lation for payment. For payment of outlier
         charges on a claim by the Medicare Urban or Rural Cost-                             claims with dates of service on or after October
         to-Charge Ratio. The Urban cost-to-charge ratio will be                             1, 2007 through September 30, 2008, AHCCCS
         used for hospitals located in a county of 500,000 resi-                             shall adjust the statewide inpatient hospital
         dents or more. The Rural cost-to-charge ratio will be used                          cost-to-charge ratio in effect on September 30,
         for hospitals located in a county of fewer than 500,000                             2007 by subtracting one-third of the difference
         residents.                                                                          between the statewide inpatient hospital cost-
         a. Outlier criteria. For rates effective on and after Octo-                         to-charge ratio and the effective Medicare
              ber 1, 1998, the Administration set the statewide                              urban or rural cost-to-charge ratio. For payment
              outlier cost threshold for each tier at the greater of                         of outlier claims with dates of service on or
              three standard deviations from the statewide mean                              after October 1, 2008 through September 30,
              operating cost per day within the tier, or two stan-                           2009, AHCCCS shall adjust the statewide inpa-
              dard deviations from the statewide mean operating                              tient hospital cost-to-charge ratio in effect on
              cost per day across all the tiers. If the covered costs                        September 30, 2007 by subtracting two-thirds
              per day on a claim exceed the urban or rural cost                              of the difference between the statewide inpa-
              threshold for a tier, the claim is considered an out-                          tient hospital cost-to-charge ratio and the effec-
              lier. Outliers will be paid by multiplying the covered                         tive Medicare urban or rural cost-to-charge
              charges by the applicable Medicare Urban or Rural                              ratio.
              CCR. The resulting amount will be the outlier pay-                        iii. Medicare Cost-to-Charge Ratio for outlier
              ment. If there are two tiers on a claim, the Adminis-                          determination, threshold calculation, and pay-
              tration shall determine whether the claim is an                                ment. For outlier claims with dates of service
              outlier by using a weighted threshold for the two                              on or after October 1, 2009, the full Medicare
              tiers. The weighted threshold is calculated by multi-                          Urban or Rural Cost-to-Charge Ratios shall be
              plying each tier rate by the number of AHCCCS                                  utilized for all outlier calculations.
              inpatient hospital days of care for that tier and divid-        7. Transplants. The Administration shall reimburse hospi-
              ing the product by the total tier days for that hospi-              tals for an AHCCCS inpatient stay in which a covered
              tal. Routine maternity stays shall be excluded from                 transplant as described in R9-22-206 is performed
              outlier reimbursement. A routine maternity is any                   through the terms of the relevant contract. As described
              one-day stay with a delivery of one or two babies. A                in R9-22-716, if the Administration and a hospital that
              routine maternity stay will be paid at tier.                        performs transplant surgery on an eligible person do not
         b. Update. The CCR is updated annually by the                            have a contract for the transplant surgery, the Administra-
              Administration for dates of service beginning Octo-                 tion shall not reimburse the hospital more than what
              ber 1, using the most current Medicare cost-to-                     would have been paid to the contracted hospital for that
              charge ratios published or placed on display by CMS                 same surgery.
              by August 31 of that year. The Administration shall             8. Ownership change. The Administration shall not change
              update the outlier cost thresholds for each hospital as             any of the components of a hospital’s tiered per diem
              described under A.R.S. § 36-2903.01.                                rates upon an ownership change.
         c. Medicare Cost-to-Charge Ratio Phase-In. AHCCCS                    9. Psychiatric hospitals. The Administration shall pay free-
              shall phase in the use of the Medicare Urban or                     standing psychiatric hospitals an all-inclusive per diem
              Rural Cost-to-Charge Ratios for outlier determina-                  rate based on the contracted rates used by the Department
              tion, calculation and payment. The three-year phase-                of Health Services.
              in does not apply to out-of-state or new hospitals.             10. Specialty facilities. The Administration may negotiate, at
              i. Medicare Cost-to-Charge Ratio Phase-In out-                      any time, reimbursement rates for inpatient specialty
                    lier determination and threshold calculation.                 facilities or inpatient hospital services not otherwise
                    For outlier claims with dates of service on or                addressed in this Section as provided by A.R.S. § 36-
                    after October 1, 2007 through September 30,                   2903.01. For purposes of this subsection, “specialty facil-
                    2008, AHCCCS shall adjust each hospital spe-                  ity” means a facility where the service provided is limited
                    cific inpatient cost-to-charge ratio in effect on             to a specific population, such as rehabilitative services for
                    September 30, 2007 by subtracting one-third of                children.
                    the difference between the hospital specific              11. Outliers for out-of-state and new hospitals. Outliers for
                    inpatient cost-to-charge ratio and the effective              out-of-state hospitals will be calculated using the Medi-
                    Medicare Urban or Rural Cost-to-Charge Ratio.                 care urban cost-to-charge ratio times covered charges. If
                    For outlier claims with dates of service on or                the resulting cost is equal to or above the urban outlier
                    after October 1, 2008 through September 30,                   threshold, the claim will be paid at the Medicare Urban
                    2009, AHCCCS shall adjust each hospital spe-                  Cost-to-Charge Ratio times covered charges. Outliers for
                    cific inpatient cost-to-charge ratio in effect on             new hospitals will be calculated using the Medicare
                    September 30, 2007 by subtracting two-thirds                  Urban or Rural Cost-to-Charge Ratio times covered
                    of the difference between the hospital specific               charges. If the resulting cost is equal to or above the cost
                    inpatient cost-to-charge ratio and the effective


June 30, 2011                                                       Page 51                                                        Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

          threshold, the claim will be paid at the Medicare Urban or                     iii. The names of the sponsoring institution and all
          Rural Cost-to-Charge ratio.                                                          participating institutions current as of the date
                                                                                               of reporting;
                           Historical ote
                                                                                         iv. The number of approved resident positions and
       New Section made by final rulemaking at 11 A.A.R.
                                                                                               the number of filled resident positions current
      3231, effective October 1, 2005 (Supp. 05-3). Amended
                                                                                               as of the date of reporting;
     by exempt rulemaking at 13 A.A.R. 3190, effective Octo-
                                                                                         v. For programs established as of October 1,
                      ber 1, 2007 (Supp. 07-3).
                                                                                               1999, the number of resident positions that
R9-22-712.02. Reserved                                                                         were filled as of October 1, 1999, if the pro-
                                                                                               gram has not already provided this information
R9-22-712.03. Reserved
                                                                                               to the Administration;
R9-22-712.04. Reserved                                                              b. A hospital seeking a distribution under subsection
                                                                                         (B) shall provide all of the following that apply:
R9-22-712.05. Graduate Medical Education Fund Allocation
                                                                                         i. If the hospital uses the Intern and Resident
A. Graduate medical education (GME) reimbursement as of Sep-
                                                                                               Information System (IRIS) for tracking and
    tember 30, 1997. Subject to legislative appropriation, the
                                                                                               reporting its resident activity to the fiscal inter-
    Administration shall make a distribution based on direct grad-
                                                                                               mediary, copies of the IRIS master and assign-
    uate medical education costs as described in A.R.S. § 36-
                                                                                               ment files for the hospital’s two most recently
    2903.01(H)(9)(a).
                                                                                               completed Medicare cost reporting years as
B. Subject to available funds and approval by CMS, the Adminis-
                                                                                               filed with the fiscal intermediary;
    tration shall annually distribute monies appropriated for the
                                                                                         ii. If the hospital does not use the IRIS or has less
    expansions of GME programs approved by the Administration
                                                                                               than two cost reporting years available in the
    to hospitals for direct program costs eligible for funding under
                                                                                               form of the IRIS master and assignment files,
    A.R.S. § 36-2903.01(H)(9)(b). A GME program is deemed to
                                                                                               the information normally contained in the IRIS
    be established as of the date of its original accreditation. All
                                                                                               master and assignment files in an alternative
    determinations that are necessary to make distributions
                                                                                               format for the hospital’s two most recently
    described by this subsection shall be made using information
                                                                                               completed Medicare cost reporting years;
    possessed by the Administration as of the date of reporting
                                                                                         iii. At the request of the Administration, a copy of
    under subsection (B)(3).
                                                                                               the hospital’s Medicare Cost Report or any part
    1. Eligible health care facilities. A health care facility is eli-
                                                                                               of the report for the most recently completed
          gible for distributions under subsection (B) if all of the
                                                                                               cost reporting year.
          following apply:
                                                                               4.   Allocation of expansion funds. Annually the Administra-
          a. It is a hospital in Arizona that is the sponsoring insti-
                                                                                    tion shall allocate available funds to each approved GME
                tution of, or a participating institution in, one or
                                                                                    program in the following manner:
                more of the GME programs in Arizona;
                                                                                    a. Information provided by hospitals under subsection
          b. It incurs direct costs for the training of residents in
                                                                                         (B)(3)(b) shall be used to determine the program in
                the GME programs, which costs are or will be
                                                                                         which each eligible resident is enrolled and the num-
                reported on the hospital’s Medicare Cost Report;
                                                                                         ber of days that each eligible resident worked in any
          c. It is not administered by or does not receive its pri-
                                                                                         area of the hospital complex or in a non-hospital set-
                mary funding from an agency of the federal govern-
                                                                                         ting under agreement with the reporting hospital
                ment.
                                                                                         during the period of assignment to that hospital. For
    2. Eligible resident positions. For purposes of determining
                                                                                         this purpose, the Administration shall use data relat-
          program allocation amounts under subsection (B)(4) the
                                                                                         ing to the most recent 12-month period that is com-
          following resident positions are eligible for consideration
                                                                                         mon to all information provided under subsections
          to the extent that the resident training takes place in Ari-
                                                                                         (B)(3)(b)(i) and (ii).
          zona and not at a health care facility made ineligible
                                                                                    b. The number of eligible residents allocated to each
          under subsection (B)(1)(c):
                                                                                         participating institution within each approved GME
          a. Filled resident positions in approved programs
                                                                                         program shall be determined as follows:
                established as of October 1, 1999 at hospitals that
                                                                                         i. Total the number of days determined for each
                receive funding as described in A.R.S. § 36-
                                                                                               participating institution under subsection
                2903.01(H)(9)(a) that are additional to the number
                                                                                               (B)(4)(a) and divide each total by 365.
                of resident positions that were filled as of October 1,
                                                                                         ii. Proportionally adjust the result of subsection
                1999; and
                                                                                               (B)(4)(b)(i) for each participating institution
          b. All filled resident positions in approved programs
                                                                                               within each program according to the number
                other than GME programs described in A.R.S. § 36-
                                                                                               of residents determined to be eligible under
                2903.01(H)(9)(a) that were established before July
                                                                                               subsection (B)(2).
                1, 2006.
                                                                                    c. The number of allocated eligible residents deter-
    3. Annual reporting. By April 1st of each year, each GME
                                                                                         mined under subsection (B)(4)(b)(ii) shall be
          program and each hospital seeking a distribution under
                                                                                         adjusted for Arizona Medicaid utilization using the
          subsection (B) shall provide the applicable information
                                                                                         most recent Medicare Cost Report information on
          listed in this subsection to the Administration:
                                                                                         file with the Administration as of the date of report-
          a. A GME program shall provide all of the following:
                                                                                         ing under subsection (B)(3) and the Administration’s
                i. The program name and number assigned by the
                                                                                         inpatient hospital claims and encounter data for the
                      accrediting organization;
                                                                                         time period corresponding to the Medicare Cost
                ii. The original date of accreditation;
                                                                                         Report information for each hospital. The Adminis-
                                                                                         tration shall use only those inpatient hospital claims


Supp. 11-2                                                           Page 52                                                       June 30, 2011
                                                      Arizona Administrative Code                                                Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

               paid by the Administration and encounters that were                        residents allocated to each hospital within that pro-
               adjudicated by the Administration as of the date of                        gram under subsection (B)(4)(c)(ii).
               reporting under subsection (B)(3). The Medicaid-                      c. If funds are insufficient to cover all distributions
               adjusted eligible residents shall be determined as                         within any priority group described under subsection
               follows:                                                                   (B)(5)(a), the Administration shall adjust the distri-
               i. For each hospital, the total AHCCCS inpatient                           butions proportionally within that priority group.
                    hospital days of care shall be divided by the         C.   Subject to available funds and approval by CMS, the Adminis-
                    total Medicare Cost Report inpatient hospital              tration shall annually distribute monies appropriated for the
                    days, multiplied by 100 and rounded up to the              expansions of GME programs approved by the Administration
                    nearest multiple of 5 percent.                             to hospitals for direct program costs eligible for funding under
               ii. The number of allocated eligible residents                  A.R.S. § 36-2903.01(H)(9)(c)(i). A GME program is deemed
                    determined for each participating hospital                 to be established as of the date of its original accreditation. All
                    under subsection (B)(4)(b)(ii) shall be multi-             determinations that are necessary to make distributions
                    plied by the percentage derived under subsec-              described by this subsection shall be made using information
                    tion (B)(4)(c)(i) for that hospital. The number            possessed by the Administration as of the date of reporting
                    of allocated eligible residents determined under           under subsection (C)(3).
                    subsection (B)(4)(b)(ii) for a participating insti-        1. Eligible health care facilities. A health care facility is eli-
                    tution that is not a hospital and not a health care              gible for distributions under subsection (C) if it meets all
                    facility made ineligible under subsection                        the conditions of subsections (B)(1)(a) through (c).
                    (B)(1)(c) shall be multiplied by the percentage            2. Eligible resident positions. For purposes of determining
                    derived under subsection (B)(4)(c)(i) for the                    program allocation amounts under subsection (C)(4), the
                    program’s sponsoring institution or, if the spon-                following resident positions are eligible for consideration
                    soring institution is not a hospital, the sponsor-               to the extent that the resident training takes place in Ari-
                    ing institution’s affiliated hospital. The number                zona and not at a health care facility made ineligible
                    of allocated eligible residents determined under                 under subsection (B)(1)(c):
                    subsection (B)(4)(b)(ii) for a participating insti-              a. All filled resident positions in approved programs
                    tution that is made ineligible under subsection                       established on or after July 1, 2006; and
                    (B)(1)(c) shall be multiplied by zero percent.                   b. For approved programs established on or after July
         d. The total allocation for each approved program shall                          1, 2006 that have been established for less than one
               be determined by multiplying the Medicaid-adjusted                         year as of the date of reporting under subsection
               eligible residents determined under subsection                             (C)(3) and have not yet filled their first-year resident
               (B)(4)(c)(ii) by the per resident conversion factor                        positions, all prospective residents reasonably
               determined below and totaling the resulting dollar                         expected by the program to be enrolled as a result of
               amounts for all participating institutions in the pro-                     the most recently completed annual resident match.
               gram. The per resident conversion factor shall be               3. Annual reporting. By April 1st of each year, each GME
               determined as follows:                                                program and each hospital seeking a distribution under
               i. Calculate the total direct GME costs from the                      subsection (C) shall provide to the Administration:
                    most recent Medicare Cost Reports on file with                   a. A GME program shall provide all of the following:
                    the Administration for all hospitals that have                        i. The requirements of subsections (B)(3)(a)(i)
                    reported such costs.                                                        through (iv);
               ii. Calculate the total allocated residents deter-                         ii. The academic year rotation schedule on file
                    mined under subsection (B)(4)(b)(i) for those                               with the program current as of the date of
                    hospitals      described      under     subsection                          reporting; and
                    (B)(4)(d)(i).                                                         iii. For programs described under subsection
               iii. Divide the total GME costs calculated under                                 (C)(2)(b), the number of residents expected to
                    subsection (B)(4)(d)(i) by the total allocated                              be enrolled as a result of the most recently com-
                    residents      calculated     under     subsection                          pleted annual resident match.
                    (B)(4)(d)(ii).                                                   b. A hospital seeking a distribution under subsection
    5.   Distribution of expansion funds. On an annual basis sub-                         (C) shall provide the requirements of subsection
         ject to available funds, the Administration shall distribute                     (B)(3)(b).
         the allocated amounts determined under subsection                     4. Allocation of expansion funds. Annually the Administra-
         (B)(4) in the following manner:                                             tion shall allocate available funds to approved GME pro-
         a. The allocated amounts shall be distributed in the fol-                   grams in the following manner:
               lowing order of priority:                                             a. Information provided by hospitals in accordance
               i. To eligible hospitals that do not receive funding                       with subsection (B)(3)(b) shall be used to determine
                    in accordance with A.R.S. § 36-                                       the program in which each eligible resident is
                    2903.01(H)(9)(a) for the direct costs of pro-                         enrolled and the number of days that each eligible
                    grams established before July 1, 2006;                                resident worked in any area of the hospital complex
               ii. To eligible hospitals that receive funding in                          or in a non-hospital setting under agreement with the
                    accordance with A.R.S. § 36-2903.01(H)(9)(a)                          reporting hospital during the period of assignment to
                    for the direct costs of programs established                          that hospital. For this purpose, the Administration
                    before July 1, 2006;                                                  shall use data relating to the most recent 12-month
         b. The allocated amounts shall be distributed to the eli-                        period that is common to all information provided in
               gible hospitals in each approved program in propor-                        accordance with subsections (B)(3)(b)(i) and (ii).
               tion to the number of Medicaid-adjusted eligible                      b. For approved programs whose resident activity is
                                                                                          not represented in the information provided in accor-


June 30, 2011                                                        Page 53                                                          Supp. 11-2
Title 9, Ch. 22                                         Arizona Administrative Code
                                        Arizona Health Care Cost Containment System – Administration

                 dance with subsection (B)(3)(b), information pro-                          one month per year in a county other than Maricopa
                 vided by GME programs under subsection (C)(3)(a)                           or Pima whose population was less than 500,000
                 shall be used to determine the number of days that                         persons at the time the residency rotation was added
                 each eligible resident is expected to work at each                         to the academic year rotation schedule.
                 participating institution.                                      3.   Annual reporting. By April 1st of each year, each GME
           c. The number of eligible residents allocated to each                      program and each hospital seeking a distribution under
                 participating institution for each approved GME                      subsection (D) shall provide to the Administration:
                 program shall be determined by totaling the number                   a. A GME program shall provide all of the following:
                 of days determined under subsections (C)(4)(a) and                         i. The requirements of subsections (B)(3)(a)(i)
                 (b) and dividing the totals by 365.                                             through (iv);
           d. The number of allocated residents determined under                            ii. The academic year rotation schedule on file
                 subsection (C)(4)(c) shall be adjusted for Arizona                              with the program current as of the date of
                 Medicaid utilization in accordance with subsection                              reporting;
                 (B)(4)(c).                                                                 iii. For programs described under subsection
           e. The total allocation for each approved program shall                               (D)(2)(c), the number of residents expected to
                 be determined in accordance with subsection                                     be enrolled as a result of the most recently com-
                 (B)(4)(d).                                                                      pleted annual resident match.
     5. Distribution of expansion funds. On an annual basis sub-                      b. A hospital seeking a distribution under subsection
           ject to available funds, the Administration shall distribute                     (D) shall provide the requirements of subsection
           the allocated amounts determined under subsection                                (B)(3)(b)(iii).
           (C)(4) to the eligible hospitals in each approved program             4.   Allocation of funds for indirect program costs. Annually
           in proportion to the number of Medicaid-adjusted eligible                  the Administration shall allocate available funds to
           residents allocated to each within that program under sub-                 approved GME programs in the following manner:
           section (C)(4)(d).                                                         a. Using the information provided by programs under
D.   Subject to available funds and approval by CMS, the Adminis-                           subsection (D)(3), the Administration shall deter-
     tration shall annually distribute monies appropriated for GME                          mine for each program the number of residents in
     programs approved by the Administration to hospitals for indi-                         the program who are eligible under subsection
     rect program costs eligible for funding under A.R.S. § 36-                             (D)(2) and the number of months per year that each
     2903.01(H)(9)(c)(ii). A GME program is deemed to be estab-                             eligible resident will perform rotations in counties
     lished as of the date of its original accreditation. All determi-                      described by subsection (D)(2), multiply the number
     nations that are necessary to make distributions described by                          of eligible residents by the number of months and
     this subsection shall be made using information possessed by                           multiply the result by the per resident per month
     the Administration as of the date of reporting under subsection                        conversion factor determined under subsection
     (D)(3).                                                                                (D)(4)(b).
     1. Eligible health care facilities. A health care facility is eli-               b. Using the most recent Medicare Cost Reports on file
           gible for distributions under subsection (D) if all of the                       with the Administration for all hospitals that have
           following apply:                                                                 calculated a Medicare indirect medical education
           a. It is a hospital in Arizona that is the sponsoring insti-                     payment, the Administration shall determine a per
                 tution of one or more of the GME programs in Ari-                          resident per month conversion factor as follows:
                 zona or the base hospital for one or more of the                           i. Calculate each hospital’s Medicaid share by
                 GME programs in Arizona whose sponsoring insti-                                 dividing the AHCCCS inpatient hospital days
                 tutions are not hospitals;                                                      of care by the total inpatient hospital days from
           b. It incurs indirect program costs for the training of                               the Medicare Cost Report. For this purpose, the
                 residents in the GME programs;                                                  Administration shall use the information
           c. It is not administered by or does not receive its pri-                             described by subsection (B)(4)(c) for adjusting
                 mary funding from an agency of the federal govern-                              allocated residents for Arizona Medicaid utili-
                 ment.                                                                           zation.
     2. Eligible resident positions. For purposes of determining                            ii. Calculate each hospital’s Medicare share by
           program allocation amounts under subsection (D)(4) the                                dividing the Medicare inpatient days on the
           following resident positions are eligible for consideration                           Medicare Cost Report by the total inpatient
           to the extent that the resident training takes place in Ari-                          hospital days on the Medicare Cost Report.
           zona and not at a health care facility made ineligible                           iii. Divide the Medicaid share by the Medicare
           under subsection (D)(1)(c):                                                           share and multiply the resulting ratio by the
           a. Any filled resident position in an approved program                                indirect medical education payment calculated
                 that includes a rotation of at least one month per year                         on the Medicare Cost Report.
                 in a county other than Maricopa or Pima whose pop-                         iv. Total the results for all hospitals, divide the
                 ulation was less than 500,000 persons at the time the                           result by the total allocated residents deter-
                 residency rotation was added to the academic year                               mined under subsection (B)(4)(b)(i) for these
                 rotation schedule;                                                              hospitals, and divide that result by 12.
           b. For approved programs that have been established                   5.   Distribution of funds for indirect program costs. On an
                 for less than one year as of the date of reporting                   annual basis subject to available funds, the Administra-
                 under subsection (D)(3) and have not yet filled their                tion shall distribute the allocated amounts determined
                 first-year resident positions, all prospective residents             under subsection (D)(4) to the program’s sponsoring hos-
                 reasonably expected by the program to be enrolled                    pital or the program’s base hospital if the sponsoring
                 as a result of the most recently completed annual                    institution is not a hospital, up to but not exceeding:
                 resident match who will perform rotations of at least


Supp. 11-2                                                             Page 54                                                     June 30, 2011
                                                       Arizona Administrative Code                                               Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

          a.    The amount calculated for the hospital at subsection                 Hospital Reimbursement System” prepared by Milliman
                (D)(4)(b)(iii), or                                                   USA for AHCCCS on November 15, 2002. A copy of
           b. The median of all amounts calculated at subsection                     each report is on file with the Administration.
                (D)(4)(b)(iii) if no amount was calculated for the             6. “Rural hospital” means a health care institution that is
                hospital.                                                            licensed as a hospital by the Arizona Department of
E.   Reallocation of funds. If funds appropriated for subsection (B)                 Health Services for the previous state fiscal year and is
     are not allocated by the Administration and funds appropriated                  not a hospital operated by IHS or a special hospital that
     for subsections (C) and (D) are insufficient to cover all distri-               limits the care provided to rehabilitation service and:
     butions under subsections (C)(5) and (D)(5), the funds not                      a. Has 100 or fewer beds and is located in a county
     allocated under subsection (B) shall be allocated under subsec-                       with a population of less than 500,000 persons, or
     tions (C) and (D) to the extent of the calculated distributions.                b. Is designated as a critical access hospital for the
     If funds are insufficient to cover all distributions under subsec-                    majority of the previous state fiscal year.
     tions (C)(5) and (D)(5), the Administration shall adjust the dis-         7. “Total inpatient payments” means the sum of:
     tributions proportionally. If funds appropriated for subsections                a. The claims paid amount,
     (C) and (D) are not allocated by the Administration and funds                   b. Any disproportionate share hospital payments for
     appropriated for subsection (B) are insufficient to cover all                         the previous fiscal year, and
     distributions under subsection (B)(5), the funds not allocated                  c. The inpatient component of any Critical Access
     under subsections (C) and (D) shall be allocated under subsec-                        Hospital payments made to the hospital for the pre-
     tion (B) to the extent of the calculated distributions.                               vious state fiscal year.
F.   The Administration may enter into intergovernmental agree-           B.   Each February, the Administration shall allocate the Fund to
     ments with local, county, and tribal governments wherein                  the following three pools for the fiscal year:
     local, county and tribal governments may transfer funds or                1. Rural hospitals with fewer than 26 PPS beds and all Criti-
     certify public expenditures to the Administration. Such funds                   cal Access Hospitals, regardless of the number of beds in
     or certification, subject to approval by CMS, will be used to                   the Critical Access Hospital;
     qualify for additional federal funds. Those funds will be used            2. Rural hospitals other than Critical Access Hospitals with
     for the purposes of reimbursing hospitals specified by the                      26 to 75 PPS beds; and
     local, county, or tribal government for indirect program costs            3. Rural hospitals other than Critical Access Hospitals with
     other than those reimbursed under subsection (D). Funds                         76 to 100 PPS beds.
     transferred and available under this subsection shall be distrib-    C.   The Administration shall allocate the Fund to each pool
     uted in accordance with subsection (D) except that reimburse-             according to the ratio of total inpatient payments to all hospi-
     ment with such funds is not limited to resident positions or              tals assigned to the pool to total inpatient payments to all rural
     rotations in counties with populations of less than 500,000 per-          hospitals.
     sons.                                                                D.   The Administration shall determine each hospital’s claims
                                                                               paid amount and allocate the funds in each pool to each hospi-
                          Historical ote
                                                                               tal in the pool based on the ratio of each hospital’s claims paid
       New Section made by final rulemaking at 13 A.A.R.
                                                                               amount to the sum of the claims paid amount for all hospitals
     1782, effective June 30, 2007 (Supp. 07-2). Amended by
                                                                               assigned to the pool.
     exempt rulemaking at 13 A.A.R. 4032, effective Novem-
                                                                          E.   The Administration shall not make a Fund payment to a hospi-
                     ber 1, 2007 (Supp. 07-4).
                                                                               tal that will result in the hospital’s total inpatient payments
R9-22-712.06. Reserved                                                         plus that hospital’s Fund payment being greater than that hos-
                                                                               pital’s calculated inpatient costs.
R9-22-712.07. Rural Hospital Inpatient Fund Allocation
                                                                               1. If a hospital’s total inpatient payments plus the hospital’s
A. For purposes of this Section, the following words and phrases
                                                                                     Fund payment would be greater than the hospital’s calcu-
    have the following meanings unless the context specifically
                                                                                     lated inpatient costs, the Administration shall make a
    requires another meaning:
                                                                                     Fund payment to the hospital equal to the difference
    1. “Calculated inpatient costs” means the sum of inpatient
                                                                                     between the hospital’s calculated inpatient costs and the
         covered charges multiplied by the Milliman study’s
                                                                                     hospital’s total inpatient payments.
         implied cost-to-charge ratio of .8959.
                                                                               2. The Administration shall reallocate any portion of a hos-
    2. “Claims paid amount” means the sum of all claims paid
                                                                                     pital’s Fund allocation that is not paid to the hospital due
         by the Administration and contractors, as reported by the
                                                                                     to the reason in subsection (E)(1) to the other eligible
         contractor to the Administration, to a rural hospital for
                                                                                     hospitals in the pool based upon the ratio of the claims
         covered inpatient services rendered during the previous
                                                                                     paid amount for each hospital remaining in the pool to the
         state fiscal year.
                                                                                     sum of the claims paid amount for each hospital remain-
    3. “Fund” means any state funds appropriated by the Legis-
                                                                                     ing in the pool.
         lature for the purposes set forth in A.R.S. § 36-2905.02
                                                                          F.   If funds remain in a pool after allocations to each hospital in
         and any federal funds that are available for matching the
                                                                               the pool under subsections (D) and (E), the Administration
         state funds.
                                                                               shall reallocate the remaining funds to the other pools based
    4. “Inpatient covered charges” means the sum of all covered
                                                                               upon the ratio of each pool’s original allocation of the Fund as
         charges billed by a hospital to the Administration or con-
                                                                               determined under subsection (C) to the sum of the remaining
         tractors, as reported by the contractors to the Administra-
                                                                               pools’ original Fund allocations under subsection (C). The
         tion, for inpatient services rendered during the previous
                                                                               Administration shall allocate remaining funds to the hospitals
         state fiscal year.
                                                                               in the remaining pools under subsection (D) and (E). See
    5. “Milliman study” means the report issued by Milliman
                                                                               Exhibit 1 for an example.
         USA on March 11, 2004, to the Arizona Hospital and
                                                                          G.   Subject to CMS approval of the method and distribution of the
         Healthcare Association that updated a portion of a cost
                                                                               Fund, the administration or its contractors will distribute the
         study entitled “Evaluation of the AHCCCS Inpatient



June 30, 2011                                                        Page 55                                                         Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     Fund as a lump sum allocation to the rural hospitals in either
     one or two installments by the end of each state fiscal year.

Exhibit 1.       Pool Example
Pool A receives $2,000,000. Pool B receives $7,000,000.             Pool C receives $3,000,000.
If all of the funds in Pool B are paid to eligible hospitals and there is $1,000,000 remaining, the remaining funds would be allocated to Pool
A and Pool C based on the ratio of each pool’s original allocation (original allocations of $2,000,000 and $3,000,000) to the total of their
original allocation ($2,000,000 + $3,000,000 = $5,000,000).
Pool A would receive 2/5 of the remaining funds ($400,000) and Pool C would receive 3/5 of the remaining funds ($600,000).

                                                           Historical ote
                      New Section made by final rulemaking at 12 A.A.R. 2188, effective June 6, 2006 (Supp. 06-2).

R9-22-712.08. Reserved
R9-22-712.09. Hierarchy For Tier Assignment                              D.   Hospital Services Subject To Fees. AHCCCS shall reimburse
                          IDE TIFICATIO                ALLOWED                services, in the following outpatient hospital categories under
      TIER                   CRITERIA                   SPLITS                the AHCCCS Outpatient Capped Fee-For-Service Schedule:
                                                                              1. Surgery,
MATERNITY          A primary diagnosis defined as     None                    2. Emergency Department,
                   maternity 640.xx - 643.xx,                                 3. Laboratory,
                   644.2x - 676.xx, v22.xx - v24.xx                           4. Radiology,
                   or v27.xx.                                                 5. Clinic, and
NICU               Revenue Code of 174 and the        Nursery                 6. Other services.
                   provider has a Level II or Level                      E.   Reimbursement. AHCCCS shall reimburse outpatient hospital
                   III NICU.                                                  services by procedure codes, in proper combination with reve-
ICU                Revenue Codes of 200-204, 207-Surgery                      nue codes, as prescribed by AHCCCS.
                   212, or 219.                  Psychiatric                                     Historical ote
                                                 Routine                       New Section made by exempt rulemaking at 11 A.A.R.
SURGERY     Surgery is identified by a revenue ICU                                  2297, effective July 1, 2005 (Supp. 05-2).
            code of 36x. To qualify in this
                                                                         R9-22-712.11. Reserved
            tier, there must be a valid surgical
            procedure code that is not on the                            R9-22-712.12. Reserved
            excluded procedure list.
                                                                         R9-22-712.13. Reserved
PSYCHIATRIC Psychiatric Revenue Codes of         ICU
            114, 124, 134, 144, or 154 AND                               R9-22-712.14. Reserved
            Psychiatric Diagnosis = 290.xx -                             R9-22-712.15. Outpatient Hospital Reimbursement: Affected
            316.xx. If a routine revenue code                            Hospitals
            is present and all diagnoses codes                           Except as provided in R9-22-712(G), the AHCCCS Outpatient
            on the claim are equal to 290.xx -                           Capped Fee-For-Service Schedule shall apply to AHCCCS pay-
            316.xx, classify as a psychiatric                            ments for outpatient services in all non-IHS acute hospitals.
            claim.
                                                                                                 Historical ote
NURSERY     Revenue Code of 17x, not equal NICU                                New Section made by exempt rulemaking at 11 A.A.R.
            to 174.                                                                 2297, effective July 1, 2005 (Supp. 05-2).
ROUTINE     Revenue Codes of 100 - 101,          ICU
            110-113, 116 - 123, 126 - 133,                               R9-22-712.16. Reserved
            136 - 143, 146 - 153, 156 - 159,                             R9-22-712.17. Reserved
            16x, 206, 213, or 214.
                                                                         R9-22-712.18. Reserved
                        Historical ote
                                                                         R9-22-712.19. Reserved
       New Section made by final rulemaking at 11 A.A.R.
         3231, effective October 1, 2005 (Supp. 05-3).                   R9-22-712.20. Outpatient Hospital Reimbursement: Methodol-
                                                                         ogy for the AHCCCS Outpatient Capped Fee-For-Service
R9-22-712.10. Outpatient Hospital Reimbursement: General
                                                                         Schedule
A. Effective rule. The outpatient hospital reimbursement rules
                                                                         To establish the AHCCCS Outpatient Capped Fee-For Service
    apply to dates of service beginning July 1, 2005, subject to
                                                                         Schedule, AHCCCS shall:
    Laws 2004, Ch. 279, § 19.
                                                                             1. Define the dataset of claims and encounters that shall be
B. Basis For Payment. Except as provided under R9-22-712.30,
                                                                                  used to establish the AHCCCS Outpatient Capped Fee-
    AHCCCS shall pay for designated outpatient procedures pro-
                                                                                  For-Service Schedule.
    vided to AHCCCS members according to the AHCCCS Out-
                                                                             2. Identify all the claims and encounters from non-IHS
    patient Capped Fee-For-Service Schedule as defined in R9-22-
                                                                                  acute hospitals located in Arizona for services that shall
    712.20.
                                                                                  be paid under the AHCCCS Outpatient Capped Fee-For-
C. Data. AHCCCS shall use Medicare Cost Report and adjudi-
                                                                                  Service Schedule.
    cated claim and encounter data from non-IHS acute care hos-
                                                                             3. Match the revenue code on each detail of each claim and
    pitals located in the state of Arizona to develop fees for the
                                                                                  encounter to the ancillary line item CCR as reported on
    AHCCCS Outpatient Capped Fee-For-Service Schedule.


Supp. 11-2                                                        Page 56                                                      June 30, 2011
                                                     Arizona Administrative Code                                           Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

        hospital-specific mapping documents and hospital-spe-              Capped Fee-For-Service Schedule on file and online with
        cific Medicare Cost Report for those hospitals that have           AHCCCS.
        submitted Medicare Cost Reports FYE 2002.
                                                                                              Historical ote
    4. Multiply the line item CCR from subsection (3) by the
                                                                            New Section made by exempt rulemaking at 11 A.A.R.
        covered billed charge for that revenue code to establish
                                                                                 2297, effective July 1, 2005 (Supp. 05-2).
        the cost for the service.
    5. Inflate the cost for the service from subsection (4) using     R9-22-712.26. Reserved
        Global Insight Health-Care Cost Review inflation factors
                                                                      R9-22-712.27. Reserved
        from date of service month to the midpoint of the rate
        year in which the fees are initially effective.               R9-22-712.28. Reserved
    6. Include associated costs under R9-22-712.25 to calculate
                                                                      R9-22-712.29. Reserved
        the rates for emergency room and surgery services.
    7. Combine data from all Arizona hospitals identified in          R9-22-712.30. Outpatient Hospital Reimbursement: Payment
        subsection (3) for each procedure code to establish the       for a Service ot Listed in the AHCCCS Outpatient Capped
        statewide median cost for each procedure.                     Fee-For-Service Schedule
    8. Group procedure codes according to the Ambulatory Pay-         A. AHCCCS shall calculate a statewide CCR for a service where
        ment Classification (APC) System groups as listed in 69            a specific fee cannot be determined under R9-22-712.20.
        FR 65682, November 15, 2004, and establish a statewide        B. The statewide CCR shall be calculated based on the costs and
        median cost for each APC. Multiply each statewide                  covered charges associated with a service under subsection
        median APC cost by 116 percent to establish the AHC-               (A) for all Arizona hospitals, using the costing method defined
        CCS-based fee for each procedure in that specific APC              in R9-22-712.20(3).
        group. AHCCCS shall assign each procedure in the group        C. To determine the payment amount for procedures where a spe-
        the same fee.                                                      cific fee is not determined under R9-22-712.20, the statewide
    9. For those procedure codes that are not grouped into any             CCR is multiplied times the covered charges.
        APC, establish a procedure-specific fee using either:
                                                                                              Historical ote
        a. The AHCCCS Non-hospital Capped Fee-For-Ser-
                                                                            New Section made by exempt rulemaking at 11 A.A.R.
              vice Fee Schedule;
                                                                                 2297, effective July 1, 2005 (Supp. 05-2).
        b. 116% of procedure-specific median cost AHCCCS-
              based fee; or                                           R9-22-712.31. Reserved
        c. The Medicare Clinical Laboratory Fee Schedule for
                                                                      R9-22-712.32. Reserved
              laboratory services.
    10. Compare the AHCCCS-based fee established in subsec-           R9-22-712.33. Reserved
        tions (8) and (9) against the comparable Medicare fee
                                                                      R9-22-712.34. Reserved
        established for the Medicare APC group as listed in the
        69 FR 65682, November 15, 2004. The fee for each pro-         R9-22-712.35. Outpatient Hospital Reimbursement: Adjust-
        cedure shall be the greater of the AHCCCS-based fee or        ments to Fees
        the Medicare fee but no more than 150 percent of the          A. AHCCCS shall increase the outpatient capped-fee-schedule
        AHCCCS-based fee; however, for those laboratory ser-              established under R9-22-712.20 (except for laboratory ser-
        vices for which a limit is established in the Medicare            vices and out-of-state hospital services) for the following hos-
        Clinical Laboratory Fee Schedule, the fee shall not               pitals submitting any claims:
        exceed that limit.                                                1. By 48 percent for public hospitals on July 1, 2005, as well
    11. Assign the 2005 Medicare fee in the AHCCCS Outpatient                   as hospitals that were public anytime during the calendar
        Capped Fee-For-Service Schedule for those procedures                    year 2004;
        for which there are fewer than 20 occurrences of the pro-         2. By 45 percent for hospitals in counties other than Mari-
        cedure code in the dataset, either independently, or, if                copa and Pima with more than 100 Medicare PPS beds
        applicable, for all procedure codes within an APC Group.                during the contract year in which the outpatient capped-
                                                                                fee-schedule rates are effective;
                        Historical ote
                                                                          3. By 50 percent for hospitals in counties other than Mari-
      New Section made by exempt rulemaking at 11 A.A.R.
                                                                                copa and Pima with 100 or less Medicare PPS beds dur-
           2297, effective July 1, 2005 (Supp. 05-2).
                                                                                ing the contract year in which the outpatient capped-fee-
R9-22-712.21. Reserved                                                          schedule rates are effective;
                                                                          4. By 115 percent for hospitals designated as Critical
R9-22-712.22. Reserved
                                                                                Access Hospitals, or for hospitals that have not been des-
R9-22-712.23. Reserved                                                          ignated as Critical Access Hospitals, but meet the criteria
                                                                                during the contract year in which the outpatient capped-
R9-22-712.24. Reserved
                                                                                fee-schedule rates are effective;
R9-22-712.25. Outpatient Hospital Fee Schedule Calculations:              5. By 113 percent for a freestanding children’s hospital with
Associated Service Costs for ER and Surgery Services                            at least 110 pediatric beds during the contract year in
A. AHCCCS shall include the costs of associated services, as                    which the outpatient capped-fee-schedule rates are effec-
    defined by revenue codes and procedure codes, when deter-                   tive; or
    mining the specific fees for the outpatient hospital procedures       6. By 14 percent for a University Affiliated Hospital, which
    for emergency department and surgery services.                              is a hospital that has a majority of the members of its
B. A complete listing of the revenue codes and procedure codes                  board of directors appointed by the Board of Regents dur-
    for associated costs included in the payment for emergency                  ing the contract year in which the outpatient capped-fee-
    and surgery services is available with the AHCCCS Outpatient                schedule rates are effective.



June 30, 2011                                                    Page 57                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

B.   In addition to subsection (A), the following outpatient capped-    R9-22-712.41. Reserved
     fee-schedule rate increase shall be established: A 50 percent
                                                                        R9-22-712.42. Reserved
     adjustment for a Level 2 and 3 emergency department proce-
     dures billed by a Level 1 trauma center as defined by R9-22-       R9-22-712.43. Reserved
     2101.
                                                                        R9-22-712.44. Reserved
C.   Fee adjustments made under subsection (A) and (B) are avail-
     able with the AHCCCS Outpatient Capped Fee-For Service             R9-22-712.45. Outpatient Hospital Reimbursement: Outpatient
     Schedule, which is on file with AHCCCS and posted on AHC-          Payment Restrictions
     CCS’ web site.                                                     A. AHCCCS shall not reimburse hospitals for emergency room
                                                                            treatment, observation hours, or other outpatient hospital ser-
                          Historical ote
                                                                            vices performed on an outpatient basis if the member is admit-
      New Section made by exempt rulemaking at 11 A.A.R.
                                                                            ted as an inpatient to the same hospital directly from the
      2297, effective July 1, 2005 (Supp. 05-2). Amended by
                                                                            emergency room, observation, or other outpatient department.
     final rulemaking at 13 A.A.R. 3584, effective October 1,
                                                                        B. AHCCCS shall include payment for the emergency room,
      2007 (Supp. 07-4). Amended by final rulemaking at 14
                                                                            observation, and other outpatient hospital services provided to
        A.A.R. 1439, effective May 31, 2008 (Supp. 08-2).
                                                                            the member before the hospital admission in the AHCCCS
R9-22-712.36. Reserved                                                      Inpatient Tiered Per Diem Capped Fee-For-Service Schedule
                                                                            under Article 7 of this Chapter.
R9-22-712.37. Reserved
                                                                        C. Same day admit and discharge claims that qualify for either
R9-22-712.38. Reserved                                                      the maternity or nursery tiers shall be paid based on the lesser
                                                                            of the rate for the maternity or nursery tier, or the outpatient
R9-22-712.39. Reserved
                                                                            hospital fee schedule.
R9-22-712.40. Outpatient Hospital Reimbursement: Annual
                                                                                                Historical ote
and Periodic Update
                                                                              New Section made by exempt rulemaking at 11 A.A.R.
A. Procedure codes. When procedure codes are issued by CMS
                                                                                   2297, effective July 1, 2005 (Supp. 05-2).
    and added to the Current Procedural Terminology published
    by the American Medical Association, AHCCCS shall add the           R9-22-712.46. Reserved
    new procedure codes for covered outpatient services and shall
                                                                        R9-22-712.47. Reserved
    either assign the default CCR, the Medicare rate, or calculate
    an appropriate fee.                                                 R9-22-712.48. Reserved
B. APC changes. AHCCCS may reassign procedure codes to new
                                                                        R9-22-712.49. Reserved
    or different APC groups when APC groups are revised by
    CMS. AHCCCS may reassign procedure codes to a different             R9-22-712.50. Outpatient Hospital Reimbursement: Billing
    APC group than Medicare. If AHCCCS determines that utili-           To receive appropriate reimbursement, hospitals shall:
    zation of a procedure code within the Medicare program is                1. Bill outpatient hospital services on the CMS approved
    substantially different from utilization of the procedure code in             Uniform Billing Form or in electronic format using the
    the AHCCCS program, AHCCCS may choose not to assign                           appropriate HIPAA transaction.
    the procedure code to any APC group. For procedure codes                 2. Follow the UB Manual Guidelines, as published by the
    not grouped into an APC by Medicare, AHCCCS may assign                        National Uniform Billing Committee, and use the appro-
    the code to an APC group when AHCCCS determines that the                      priate revenue code and procedure code combination as
    cost and resources associated with the non-assigned code are                  prescribed by AHCCCS and on file and online with
    substantially similar to those in the APC group.                              AHCCCS.
C. Annual update for Outpatient Hospital Fee Schedule. Begin-
                                                                                                Historical ote
    ning October 1, 2006, AHCCCS shall adjust outpatient fee
                                                                              New Section made by exempt rulemaking at 11 A.A.R.
    schedule rates:
                                                                                   2297, effective July 1, 2005 (Supp. 05-2).
    1. Annually by multiplying the rates effective during the
         prior year by the Global Insight Prospective Hospital          R9-22-713. Overpayment and Recovery of Indebtedness
         Market Basket Inflation Index; or                              A. If a contractor or a subcontracting provider receives an over-
    2. In a particular year the director may substitute the                 payment from the Administration or otherwise becomes
         increases in subsection (C)(1) by calculating the dollar           indebted to the Administration, the contractor or subcontract-
         value associated with the inflation index in subsection            ing provider shall immediately remit the amount of the indebt-
         (C)(1), and applying the dollar value to adjust rates at           edness or overpayment to the Administration for deposit in the
         varying levels.                                                    AHCCCS fund.
D. Rebase. AHCCCS shall rebase the outpatient fees every five           B. If the funds described in subsection (A) are not remitted, the
    years.                                                                  Administration may recover the funds paid by the Administra-
E. Statewide CCR. The statewide CCR calculated in R9-22-                    tion to a contractor or subcontracting provider through:
    712.30 shall be recalculated at the time of rebasing. When              1. A repayment agreement executed with the Administra-
    rebasing, AHCCCS may consider recalculating the statewide                     tion;
    CCR based on the costs and charges for services excluded                2. Withholding or offsetting against current or future pay-
    from the outpatient hospital fee schedule.                                    ments to be paid to the contractor or subcontracting pro-
                                                                                  vider; or
                          Historical ote
                                                                            3. Enforcement of, or collection against, the performance
      New Section made by exempt rulemaking at 11 A.A.R.
                                                                                  bond, financial reserve, or other financial security under
      2297, effective July 1, 2005 (Supp. 05-2). Amended by
                                                                                  A.R.S. § 36-2903.
     final rulemaking at 13 A.A.R. 3584, effective October 1,
      2007 (Supp. 07-4). Amended by final rulemaking at 14
        A.A.R. 1439, effective May 31, 2008 (Supp. 08-2).


Supp. 11-2                                                         Page 58                                                    June 30, 2011
                                                      Arizona Administrative Code                                               Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

                           Historical ote                                D.   The Administration or a contractor shall not make a payment
       Adopted as an emergency effective February 23, 1983,                   to or through a factor, either directly or by power of attorney,
        pursuant to A.R.S. § 41-1003, valid for only 90 days                  for a covered service furnished to a member by a provider.
     (Supp. 83-1). Adopted as a permanent rule effective May             E.   Reimbursement for a pathology service. Unless otherwise
      16, 1983; text of adopted rule identical to the emergency               specified in a contract, the Administration or a contractor shall
       (Supp. 83-3). Former Section R9-22-713 repealed, new                   reimburse a pathologist for a pathology service furnished to a
        Section R9-22-713 adopted effective October 1, 1983                   member only if the other requirements in this Section are met
     (Supp. 83-5). Former Section R9-22-713 renumbered and                    and the service is:
       amended as Section R9-22-714, former Section R9-22-                    1. A surgical pathology service;
        709 renumbered and amended as Section R9-22-713                       2. A specific cytopathology, hematology, or blood banking
     effective October 1, 1985 (Supp. 85-5). Amended by final                       pathology service that requires performance by a physi-
        rulemaking at 8 A.A.R. 3317, effective July 15, 2002                        cian and is listed in the capped fee-for-service schedule;
     (Supp. 02-3). Amended by final rulemaking at 13 A.A.R.                   3. A clinical consultation service that:
              856, effective May 5, 2007 (Supp. 07-1).                              a. Is requested by the member’s attending physician or
                                                                                         primary care physician,
R9-22-714. Payments to Providers
                                                                                    b. Is related to a test result that is outside the clinically
A. Provider agreement. The Administration or a contractor shall
                                                                                         significant normal or expected range in view of the
    not reimburse a covered service provided to a member unless
                                                                                         condition of the member,
    the provider has signed a provider agreement with the Admin-
                                                                                    c. Results in a written narrative report included in the
    istration that establishes the terms and conditions of participa-
                                                                                         member’s medical record,
    tion and payment under A.R.S. § 36-2904.
                                                                                    d. Requires the exercise of medical judgment by the
B. Provider reimbursement. The Administration or a contractor
                                                                                         consultant pathologist, and
    shall reimburse a provider for a service furnished to a member
                                                                                    e. Is listed in the capped fee-for-service schedule; or
    only if:
                                                                              4. A clinical laboratory interpretative service that:
    1. The provider personally furnishes the service to a specific
                                                                                    a. Is requested by the member’s attending physician or
          member. For purposes of this Section, services personally
                                                                                         primary care physician,
          furnished by a provider include:
                                                                                    b. Results in a written narrative report included in the
          a. Services provided by medical residents or dental stu-
                                                                                         member’s medical record,
                dents in a teaching environment; or
                                                                                    c. Requires the exercise of medical judgment by the
          b. Services provided by a licensed or certified assistant
                                                                                         consultant pathologist, and
                under the general supervision of a licensed practitio-
                                                                                    d. Is listed in the capped fee-for-service schedule.
                ner in accordance with 4 A.A.C. 24, 9 A.A.C. 16, 4
                A.A.C. 43, or 4 A.A.C. 45;                                                         Historical ote
    2. The provider verifies that individuals who have provided                Adopted as an emergency effective February 23, 1983,
          services described in subsection (B)(1) have not been                  pursuant to A.R.S. § 41-1003, valid for only 90 days
          placed on the List of Excluded Individuals/Entities                 (Supp. 83-1). Adopted as a permanent rule effective May
          (LEIE) maintained by the United States Department of                16, 1983; text of adopted rule is similar to the emergency
          Health and Human Services Office of the Inspector Gen-              (Supp. 83-3). Repealed effective October 1, 1983 (Supp.
          eral (OIG), located at OIG’s web site;                                  83-5). Former Section R9-22-713 renumbered and
    3. The service contributes directly to the diagnosis or treat-            amended as Section R9-22-714 effective October 1, 1985
          ment of the member; and                                               (Supp. 85-5). Section repealed; new Section made by
    4. The service ordinarily requires performance by the type                 final rulemaking at 8 A.A.R. 424, effective January 10,
          of provider seeking reimbursement.                                    2002 (Supp. 02-1). Amended by final rulemaking at 9
C. The Administration or a contractor may make a payment for                    A.A.R. 3800, effective October 4, 2003 (Supp. 03-3).
    covered services only:                                                    Amended by final rulemaking at 13 A.A.R. 662, effective
    1. To the provider;                                                                       April 7, 2007 (Supp. 07-1).
    2. To anyone specified in a reassignment from the provider
                                                                              Editor’s ote: The following Section was amended under an
          to a government agency or reassignment by a court order;
                                                                         exemption from the provisions of the Administrative Procedure
    3. To a business agent, if the agent’s compensation for the
                                                                         Act which means that this rule was not reviewed by the Gover-
          service is:
                                                                         nor’s Regulatory Review Council; the agency did not submit
          a. Related to the cost of processing the billing;
                                                                         notice of proposed rulemaking to the Secretary of State for publi-
          b. Not related on a percentage or other basis to the
                                                                         cation in the Arizona Administrative Register; the agency was
                amount that is billed or collected; and
                                                                         not required to hold public hearings on the rules; and the Attor-
          c. Not dependent upon collection of the payment;
                                                                         ney General did not certify this rule. This Section was subse-
    4. To the employer of the provider, if the provider is
                                                                         quently amended through the regular rulemaking process.
          required as a condition of employment to turn over the
          provider’s fees to the employer;                               R9-22-715. Hospital Rate egotiations
    5. To the inpatient facility in which the service is provided,       A. A contractor that negotiates with hospitals for inpatient or out-
          if the provider has a contract under which the inpatient           patient services shall reimburse hospitals for services rendered
          facility submits the claim; or                                     on or after March 1, 1993, as described in A.R.S. § 36-2903.01
    6. To a foundation, plan, or similar organization operating              and this Article, or at the negotiated rate that, in the aggregate,
          an organized health care delivery system, if the provider          does not exceed reimbursement levels that would have been
          has a contract under which the foundation, plan or similar         paid under A.R.S. § 36-2903.01, and this Article. This subsec-
          organization submits the claim.                                    tion does not apply to urban hospitals described under R9-22-
                                                                             718.




June 30, 2011                                                       Page 59                                                          Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     1.   Contractors may engage in rate negotiations with a hospi-          2.    “Rural Contractor” means a contractor or program con-
          tal at any time during the contract period.                              tractor as defined in A.R.S. Title 36, Chapter 29 that does
     2. Within seven days before the effective date of a contract,                 not provide services to members residing in either Mari-
          a contractor shall submit copies of the contractor’s nego-               copa or Pima County.
          tiated rate agreements with hospitals, including all rates,        3. “Urban Contractor” means a contractor or program con-
          terms, and conditions, to the Administration for approval.               tractor as defined in A.R.S. Title 36, Chapter 29, that pro-
B.   The Administration may negotiate or contract with a hospital                  vides services to members residing in Maricopa or Pima
     on behalf of a contractor for discounted hospital rates and may               County and may also provide services to members who
     require that the negotiated discounted rates be included in a                 reside in other counties. An urban contractor does not
     subcontract between the contractor and hospital.                              include BHS, CRS, CMDP, HCG or a Tribal government.
                                                                             4. “Rural Hospital” means a hospital, as defined in Article
                           Historical ote
                                                                                   1, that is physically located in Arizona but in a county
       Adopted as an emergency effective February 23, 1983,
                                                                                   other than Maricopa and Pima County.
        pursuant to A.R.S. § 41-1003, valid for only 90 days
                                                                             5. “Urban Hospital” means a hospital, as defined in Article
     (Supp. 83-1). Adopted as a permanent rule effective May
                                                                                   1, that is physically located in Maricopa or Pima County.
     16, 1983; text of adopted rule identical to the emergency
                                                                        B.   General Provisions.
     (Supp. 83-3). Repealed effective October 1, 1983 (Supp.
                                                                             1. This Section applies to an urban hospital who receives
     83-5). New Section R9-22-715 adopted effective October
                                                                                   payment for inpatient hospital services under A.R.S. §§
     1, 1985 (Supp. 85-5). Amended under an exemption from
                                                                                   36-2903.01 and 36-2904.
         the provisions of the Administrative Procedure Act,
                                                                             2. AHCCCS shall operate an inpatient hospital reimburse-
     effective March 1, 1993 (Supp. 93-1). Amended effective
                                                                                   ment program under A.R.S. § 36-2905.01 and this Sec-
      January 14, 1997 (Supp. 97-1). Amended effective Sep-
                                                                                   tion.
       tember 22, 1997 (Supp. 97-3). Amended by final rule-
                                                                             3. Residency of the member receiving inpatient AHCCCS
        making at 11 A.A.R. 3222, effective October 1, 2005
                                                                                   covered services is not a factor in determining which hos-
                             (Supp. 05-3).
                                                                                   pitals are required to contract with which contractors.
     Editor’s ote: The following Section was amended under an                4. An urban contractor shall enter into a contract for reim-
exemption from the provisions of the Administrative Procedure                      bursement for inpatient AHCCCS covered services with
Act which means that this rule was not reviewed by the Gover-                      one or more urban hospitals located in the same county as
nor’s Regulatory Review Council; the agency did not submit                         the urban contractor.
notice of proposed rulemaking to the Secretary of State for publi-           5. A noncontracted urban hospital shall be reimbursed for
cation in the Arizona Administrative Register; the agency was                      inpatient services by an urban contractor at 95% of the
not required to hold public hearings on the rules; and the Attor-                  amount calculated as defined in A.R.S. § 36-2903.01 and
ney General did not certify this rule. This Section was subse-                     this Article, unless otherwise negotiated by both parties.
quently amended through the regular rulemaking process.                 C.   Contract Begin Date. A contract under this Article shall cover
                                                                             inpatient acute care hospital services for members with hospi-
R9-22-716.        Repealed
                                                                             tal admissions on and after October 1, 2003.
                          Historical ote                                D.   Outpatient urban hospital services. Outpatient urban hospital
          Adopted effective October 1, 1985 (Supp. 85-5).                    services, including observation days and emergency room
     Amended under an exemption from the provisions of the                   treatments that do not result in an admission, shall be reim-
      Administrative Procedure Act, effective March 1, 1993                  bursed either through an urban hospital contract negotiated
     (Supp. 93-1). Amended effective January 14, 1997 (Supp.                 between a contractor and an urban hospital, or the reimburse-
       97-1). Amended by final rulemaking at 8 A.A.R. 424,                   ment rates set forth in A.R.S. § 36-2903.01. Outpatient ser-
     effective January 10, 2002 (Supp. 02-1). Section repealed               vices in an urban hospital that result in an admission shall be
      by final rulemaking at 13 A.A.R. 662, effective April 7,               paid as inpatient services in accordance with this Section.
                        2007 (Supp. 07-1).                              E.   Urban Hospital Contract.
                                                                             1. Provisions of an urban hospital contracts. The urban hos-
R9-22-717.        Repealed
                                                                                   pital contract shall contain but is not limited to the fol-
                           Historical ote                                          lowing provisions:
      Adopted effective July 30, 1993 (Supp. 93-3). Amended                        a. Required provisions as described in the Request for
        effective September 22, 1997 (Supp. 97-3). Section                               Proposals (RFP);
     repealed by final rulemaking at 11 A.A.R. 3222, effective                     b. Dispute settlement procedures. If the AHCCCS
                   October 1, 2005 (Supp. 05-3).                                         Grievance System prescribed in A.R.S. § 36-
                                                                                         2903.01(B) and rule is not used, then arbitration
     Editor’s ote: The following Section was adopted under an
                                                                                         shall be used;
exemption from the provisions of the Administrative Procedure
                                                                                   c. Arbitration procedure. If arbitration is used, the
Act which means that this rule was not reviewed by the Gover-
                                                                                         urban hospital contract shall identify:
nor’s Regulatory Review Council. The agency was required to
                                                                                         i. The parties’ agreement on arbitrating claims
submit notice of proposed rulemaking to the Secretary of State for
                                                                                               arising from the contract,
publication in the Arizona Administrative Register; and was
                                                                                         ii. Whether arbitration is nonbinding or binding,
required to hold a public hearing.
                                                                                         iii. Timeliness of arbitration,
R9-22-718. Urban Hospital Inpatient Reimbursement Pro-                                   iv. What contract provisions may be appealed,
gram                                                                                     v. What rules will govern arbitrations,
A. Definitions. The following definitions apply to this Section:                         vi. The number of arbitrators that shall be used,
    1. “Noncontracted Hospital” means an urban hospital which                            vii. How arbitrators shall be selected, and
        does not have a contract under this Section with an urban                        viii. How arbitrators shall be compensated.
        contractor in the same county.                                             d. Timeliness of claims submission and payment;


Supp. 11-2                                                         Page 60                                                      June 30, 2011
                                                      Arizona Administrative Code                                             Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

          e.   Prior authorization;                                          includes a catastrophic reinsurance program for members
          f.   Concurrent review;                                            diagnosed with specific medical conditions.
          g.   Electronic submission of claims;                         B.   The Administration shall specify in contract guidelines for
          h.   Claims review criteria;                                       claims submission, processing, payment, and the types of care
          i.   Payment of discounts or penalties such as quick-pay           and services that are provided to a member whose care is cov-
               and slow-pay provisions;                                      ered by reinsurance.
         j. Payment of outliers;                                        C.   When the Administration determines that a contractor does not
         k. Claim documentation specifications under A.R.S. §                follow the specified guidelines for care or services and the care
               36-2904.                                                      or services could have been provided at a lower cost according
         l. Treatment and payment of emergency room ser-                     to the guidelines, the Administration shall reimburse the con-
               vices; and                                                    tractor as if the care or services had been provided as specified
         m. Provisions for rate changes and adjustments.                     in the guidelines.
     2. AHCCCS review and approval of urban hospital con-
                                                                                                  Historical ote
         tracts:
                                                                             New Section made by final rulemaking at 8 A.A.R. 3317,
         a. AHCCCS may review, approve, or disapprove the
                                                                              effective July 15, 2002 (Supp. 02-3). Amended by final
               hospital contract rates, terms, conditions, and
                                                                                rulemaking at 13 A.A.R. 856, effective May 5, 2007
               amendments to the contract;
                                                                                                    (Supp. 07-1).
         b. An urban contractor shall submit urban hospital con-
               tracts and amendments as specified in the RFPs for                           ARTICLE 8. REPEALED
               the contract year beginning October 1, 2003, or as
                                                                              Article 8, consisting of Sections R9-22-801 through R9-22-804
               specified in the RFP for a new urban hospital con-
                                                                        and Exhibit A, repealed by final rulemaking at 10 A.A.R. 808, effec-
               tract negotiated after October 1, 2003;
                                                                        tive April 3, 2004. The subject matter of Article 8 is now in 9 A.A.C.
         c. The AHCCCS evaluation of each urban hospital
                                                                        34 (Supp. 04-1).
               contract shall include but not be limited to the fol-
               lowing areas:                                            R9-22-801.     Repealed
               i. Availability and accessibility of services to
                                                                                                   Historical ote
                     members,
                                                                             Adopted as an emergency effective May 20, 1982, pursu-
               ii. Related party interests,
                                                                             ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
               iii. Inclusion of required terms pursuant to this
                                                                              3). Former Section R9-22-801 adopted as an emergency
                     Section, and
                                                                              adoption now adopted and amended as a permanent rule
               iv. Reasonableness of the rates.
                                                                              effective August 30, 1982 (Supp. 82-4). Former Section
     3. Evaluation of urban contractor’s use of a noncontracted
                                                                                R9-22-801 repealed, new Section R9-22-801 adopted
         hospital. AHCCCS shall evaluate the contractor’s use of a
                                                                              effective October 29, 1985 (Supp. 85-5). Amended sub-
         contracted versus noncontracted hospital.
                                                                               sections (C), (F), (H), (I), and (K) effective October 1,
F.   Quick-Pay/Slow-Pay. A payment made by urban contractor to
                                                                             1986 (Supp. 86-5). Change of heading only effective Jan-
     a noncontracted hospital shall be subject to quick-pay dis-
                                                                                uary 1, 1987, filed December 31, 1986 (Supp. 86-6).
     counts and slow-pay penalties under A.R.S. § 36-2904.
                                                                              Amended subsection (H) effective May 30, 1989 (Supp.
                         Historical ote                                      89-2). Amended effective September 29, 1992 (Supp. 92-
      Adopted under an exemption from the provisions of the                    3). Section heading amended under an exemption from
        Administrative Procedure Act, effective January 29,                      the provisions of the Administrative Procedure Act,
     1997; pursuant to Laws 1996, Ch. 288, § 24 (Supp. 97-1).                  effective July 1, 1993 (Supp. 93-3). Amended under an
     Amended by exempt rulemaking at 10 A.A.R. 500, effec-                   exemption from the provisions of the Administrative Pro-
     tive February 1, 2004 (Supp. 04-1). Amended by exempt                      cedure Act, effective October 26, 1993 (Supp. 93-4).
     rulemaking at 13 A.A.R. 3190, effective October 1, 2007                    Amended effective December 13, 1993 (Supp. 93-4).
                           (Supp. 07-3).                                     Former Section R9-22-801 repealed, new Section R9-22-
                                                                             801 adopted January 14, 1997 (Supp. 97-1). Amended by
R9-22-719. Contractor Performance Measure Outcomes
                                                                               final rulemaking at 6 A.A.R. 3317, effective August 7,
The Administration may retain a specified percentage of capitation
                                                                              2000 (Supp. 00-3). Section repealed by final rulemaking
reimbursement to distribute to contractors based on their perfor-
                                                                               at 10 A.A.R. 808, effective April 3, 2004 (Supp. 04-1).
mance measure outcomes under A.R.S. § 36-2904. The Administra-
tion shall notify contractors 60 days prior to a new contract year if   R9-22-802.     Repealed
this methodology is implemented. The Administration shall specify
                                                                                                  Historical ote
the details of the reimbursement methodology in contract.
                                                                             Adopted as an emergency effective May 20, 1982, pursu-
                        Historical ote                                       ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
     New Section made by final rulemaking at 8 A.A.R. 424,                    3). Former Section R9-22-802 adopted as an emergency
           effective January 10, 2002 (Supp. 02-1).                             adoption now adopted as a permanent rule effective
                                                                              August 30, 1982 (Supp. 82-4). Amended effective Octo-
R9-22-720. Reinsurance
                                                                               ber 29, 1985 (Supp. 85-5). Amended subsections (A),
A. Reinsurance is a stop-loss program provided by the Adminis-
                                                                             (B), (C) and (D) effective October 14, 1988 (Supp. 88-4).
    tration to a contractor for partial reimbursement of the cost of
                                                                               Amended effective September 29, 1992 (Supp. 92-3).
    covered services for a member with an acute medical condi-
                                                                               Amended effective December 13, 1993 (Supp. 93-4).
    tion when the cost of covered services exceeds a pre-deter-
                                                                             Former Section R9-22-802 repealed, new Section R9-22-
    mined deductible level amount within a contract year. The
                                                                               802 adopted effective January 14, 1997 (Supp. 97-1).
    Administration self-insures the reinsurance program through a
                                                                              Section repealed; new Section adopted by final rulemak-
    reduction to capitation rates. The reinsurance program also
                                                                             ing at 6 A.A.R. 3317, effective August 7, 2000 (Supp. 00-



June 30, 2011                                                      Page 61                                                        Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

       3). Section repealed by final rulemaking at 10 A.A.R.                 August 29, 1985 (Supp. 85-4). Amended effective Octo-
             808, effective April 3, 2004 (Supp. 04-1).                        ber 1, 1986 (Supp. 86-5). Amended effective May 30,
                                                                               1989 (Supp. 89-2). Amended effective September 29,
R9-22-803.        Repealed
                                                                              1992 (Supp. 92-3). Amended under an exemption from
                          Historical ote                                        the provisions of the Administrative Procedure Act,
     Adopted as an emergency effective May 20, 1982, pursu-                   effective July 1, 1993 (Supp. 93-3). Amended under an
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-             exemption from the provisions of the Administrative Pro-
      3). Former Section R9-22-803 adopted as an emergency                  cedure Act, effective October 26, 1993 (Supp. 93-4). Sec-
        now adopted as a permanent rule effective August 30,                tion repealed, new Section adopted by final rulemaking at
      1982 (Supp. 82-4). Former Section R9-22-803 repealed,                   5 A.A.R. 4061, effective October 8, 1999 (Supp. 99-4).
         new Section R9-22-803 adopted effective October 1,                 Section repealed; new Section made by exempt rulemak-
        1983 (Supp. 83-5). Former Section R9-22-803 renum-                    ing at 7 A.A.R. 4593, effective October 1, 2001 (Supp.
     bered and amended as Section R9-22-804. Adopted effec-                 01-3). Section repealed by final rulemaking at 12 A.A.R.
       tive January 31, 1986 (Supp. 86-1). Amended effective                       4484, effective January 6, 2007 (Supp. 06-4).
     September 29, 1992 (Supp. 92-3). Former Section R9-22-
                                                                       R9-22-902.     Repealed
       803 repealed, new Section R9-22-803 adopted January
     14, 1997 (Supp. 97-1). Amended by final rulemaking at 6                                      Historical ote
     A.A.R. 3317, effective August 7, 2000 (Supp. 00-3). Sec-               Adopted effective August 29, 1985 (Supp. 85-4). Former
     tion repealed by final rulemaking at 10 A.A.R. 808, effec-              Section R9-22-902 renumbered and amended as Section
                   tive April 3, 2004 (Supp. 04-1).                           R9-22-904, former Section R9-22-903 renumbered and
                                                                            amended as Section R9-22-902 effective October 1, 1986
R9-22-804.        Repealed
                                                                              (Supp. 86-5). Former Section R9-22-902 repealed, new
                          Historical ote                                        Section R9-22-902 adopted effective May 30, 1989
     Adopted as an emergency effective May 20, 1982, pursu-                   (Supp. 89-2). Amended effective April 13, 1990 (Supp.
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-             90-2). Amended effective September 29, 1992 (Supp. 92-
      3). Former Section R9-22-804 adopted as an emergency                   3). Amended under an exemption from the provisions of
         adoption now adopted as a permanent rule effective                  the Administrative Procedure Act, effective July 1, 1993
      August 30, 1982 (Supp. 82-4). Amended effective Octo-                 (Supp. 93-3). Amended under an exemption from the pro-
        ber 1, 1983 (Supp. 83-5). Former Section R9-22-804                     visions of the Administrative Procedure Act, effective
        repealed, former Section R9-22-803 renumbered and                      October 26, 1993 (Supp. 93-4). Section repealed, new
       amended as Section R9-22-804 effective October 29,                     Section adopted by final rulemaking at 5 A.A.R. 4061,
     1985 (Supp. 85-5). Amended effective October 14, 1988                  effective October 8, 1999 (Supp. 99-4). Section repealed;
     (Supp.88-4). Amended subsections (B) and (C) effective                    new Section made by exempt rulemaking at 7 A.A.R.
      May 30, 1989 (Supp. 89-2). Amended effective Septem-                     4593, effective October 1, 2001 (Supp. 01-3). Section
     ber 29, 1992 (Supp. 92-3). Amended effective December                  repealed by final rulemaking at 12 A.A.R. 4484, effective
          13, 1993 (Supp. 93-4). Former Section R9-22-804                                   January 6, 2007 (Supp. 06-4).
     repealed, new Section R9-22-804 adopted effective Janu-
                                                                       R9-22-903.     Repealed
     ary 14, 1997 (Supp. 97-1). Section repealed; new Section
      adopted by final rulemaking at 6 A.A.R. 3317, effective                                     Historical ote
       August 7, 2000 (Supp. 00-3). Section repealed by final               Adopted effective August 29, 1985 (Supp. 85-4). Former
       rulemaking at 10 A.A.R. 808, effective April 3, 2004                  Section R9-22-903 renumbered and amended as Section
                            (Supp. 04-1).                                    R9-22-902, former Section R9-22-904 renumbered and
                                                                            amended as Section R9-22-903 effective October 1, 1986
Exhibit A.        Repealed
                                                                             (Supp. 86-5). Former Section R9-22-903 repealed, new
                          Historical ote                                       Section R9-22-903 adopted effective May 30, 1989
      New Exhibit adopted by final rulemaking at 6 A.A.R.                    (Supp. 89-2). Section repealed by final rulemaking at 5
       3317, effective August 7, 2000 (Supp. 00-3). Exhibit                   A.A.R. 4061, effective October 8, 1999 (Supp. 99-4).
     repealed by final rulemaking at 10 A.A.R. 808, effective                 New Section made by exempt rulemaking at 7 A.A.R.
                    April 3, 2004 (Supp. 04-1).                               4593, effective October 1, 2001 (Supp. 01-3). Section
                                                                            repealed by final rulemaking at 12 A.A.R. 4484, effective
R9-22-805.        Repealed
                                                                                          January 6, 2007 (Supp. 06-4).
                        Historical ote
                                                                       R9-22-904.     Repealed
     Former Section R9-22-805 adopted as an emergency now
        adopted and amended as a permanent rule effective                                        Historical ote
      August 30, 1982 (Supp. 82-4). Repealed effective Janu-                Adopted effective August 29, 1985 (Supp. 85-4). Former
                   ary 31, 1986 (Supp. 86-1).                                Section R9-22-904 renumbered and amended as Section
                                                                              R9-22-903, former Section R9-22-902 renumbered and
                     ARTICLE 9. REPEALED
                                                                            amended as Section R9-22-904 effective October 1, 1986
R9-22-901.        Repealed                                                    (Supp. 86-5). Amended effective May 30, 1989 (Supp.
                                                                             89-2). Section repealed by final rulemaking at 5 A.A.R.
                          Historical ote
                                                                             4061, effective October 8, 1999 (Supp. 99-4). New Sec-
     Adopted as an emergency effective May 20, 1982, pursu-
                                                                            tion made by exempt rulemaking at 7 A.A.R. 4593, effec-
     ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-
                                                                              tive October 1, 2001 (Supp. 01-3). Section repealed by
      3). Former Section R9-22-901 adopted as an emergency
                                                                             final rulemaking at 12 A.A.R. 4484, effective January 6,
      adoption now adopted and amended as a permanent rule
                                                                                                2007 (Supp. 06-4).
      effective August 30, 1982 (Supp. 82-4). Repealed effec-
        tive October 1, 1983 (Supp. 83-5). Adopted effective


Supp. 11-2                                                        Page 62                                                   June 30, 2011
                                                    Arizona Administrative Code                                            Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

R9-22-905.      Repealed                                             ARTICLE 10. FIRST- A D THIRD-PARTY LIABILITY A D
                                                                                         RECOVERIES
                          Historical ote
    Adopted effective August 29, 1985 (Supp. 85-4). Former           R9-22-1001. Definitions
     Section R9-22-905 renumbered without change as Sec-             In addition to the definitions in A.R.S. §§ 36-2901, 36-2923 and 9
     tion R9-22-908, former Section R9-22-907 renumbered             A.A.C. 22, Article 1, the following definitions apply to this Article:
     and amended as Section R9-22-905 effective October 1,                “Cost avoid” means to deny a claim and return the claim to the
       1986 (Supp. 86-5). Amended effective May 30, 1989                  provider for a determination of the amount of first- or third-
     (Supp. 89-2). Section repealed by final rulemaking at 5              party liability.
       A.A.R. 4061, effective October 8, 1999 (Supp. 99-4).
                                                                          “First-party liability” means the obligation of any insurance
      New Section made by exempt rulemaking at 7 A.A.R.
                                                                          plan or other coverage obtained directly or indirectly by a
      4593, effective October 1, 2001 (Supp. 01-3). Section
                                                                          member that provides benefits directly to the member to pay
    repealed by final rulemaking at 12 A.A.R. 4484, effective
                                                                          all or part of the expenses for medical services incurred by
                  January 6, 2007 (Supp. 06-4).
                                                                          AHCCCS or a member.
R9-22-906.      Repealed
                                                                          “Third-party” means a person, entity, or program that is, or
                         Historical ote                                   may be, liable to pay all or part of the medical cost of injury,
        Adopted effective August 29, 1985 (Supp. 85-4).                   disease, or disability of an applicant or member.
        Amended effective October 1, 1986 (Supp. 86-5).
                                                                          “Third-party liability” means any individual, entity, or pro-
        Amended effective October 1, 1987 (Supp. 87-4).
                                                                          gram that is or may be liable to pay all or part of the expendi-
    Amended effective May 30, 1989 (Supp. 89-2). Amended
                                                                          tures for medical assistance furnished to a member under a
       effective September 22, 1997 (Supp. 97-3). Section
                                                                          state plan.
    repealed by final rulemaking at 5 A.A.R. 4061, effective
      October 8, 1999 (Supp. 99-4). New Section made by                                         Historical ote
     exempt rulemaking at 7 A.A.R. 4593, effective October                 Former Section R9-22-712 renumbered and amended as
    1, 2001 (Supp. 01-3). Section repealed by final rulemak-              Section R9-22-1001 effective October 1, 1985 (Supp. 85-
    ing at 12 A.A.R. 4484, effective January 6, 2007 (Supp.               5). Amended subsections (E) through (H) effective Octo-
                             06-4).                                       ber 1, 1986 (Supp. 86-5). Amended subsections (B), (C),
                                                                           (E), and (F) effective December 22, 1987 (Supp. 87-4).
R9-22-907.      Repealed
                                                                          Section repealed; new Section adopted effective Novem-
                         Historical ote                                    ber 7, 1997 (Supp. 97-4). Section repealed; new Section
    Adopted effective August 29, 1985 (Supp. 85-4). Former                  made by final rulemaking at 10 A.A.R. 1146, effective
     Section R9-22-907 renumbered and amended as Section                  May 1, 2004 (Supp. 04-1). Amended by final rulemaking
      R9-22-905, former Section R9-22-908 renumbered and                  at 15 A.A.R. 179, effective March 7, 2009 (Supp. 09-1).
    amended as Section R9-22-907 effective October 1, 1986
                                                                     R9-22-1002. General Provisions
      (Supp. 86-5). Amended effective May 30, 1989 (Supp.
                                                                     AHCCCS is the payor of last resort unless specifically prohibited
     89-2). Section repealed by final rulemaking at 5 A.A.R.
                                                                     by applicable state or federal law. Entities that pay before AHCCCS
     4061, effective October 8, 1999 (Supp. 99-4). New Sec-
                                                                     include but are not limited to:
    tion made by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                          1. Indian Health Services (IHS/638),
      tive October 1, 2001 (Supp. 01-3). Section repealed by
                                                                          2. Title IV-E,
     final rulemaking at 12 A.A.R. 4484, effective January 6,
                                                                          3. Arizona Early Intervention Program (AZEIP), and
                        2007 (Supp. 06-4).
                                                                          4. Contract health.
R9-22-908.      Repealed
                                                                                               Historical ote
                        Historical ote                                     Section R9-22-529 adopted effective October 1, 1985,
    Adopted effective August 29, 1985 (Supp. 85-4). Former                then renumbered as Section R9-22-1002 effective Octo-
    Section R9-22-908 renumbered and amended as Section                   ber 1, 1985 (Supp. 85-5). Amended subsections (C) and
    R9-22-907, former Section R9-22-905 renumbered with-                   (D) effective October 1, 1986 (Supp. 86-5). Amended
     out change as Section R9-22-908 effective October 1,                   effective December 22, 1987 (Supp. 87-4). Amended
    1986 (Supp. 86-5). Former R9-22-908 repealed effective                under an exemption from the provisions of the Adminis-
       May 30, 1989 (Supp. 89-2). New Section made by                     trative Procedure Act, effective July 1, 1993 (Supp. 93-
    exempt rulemaking at 7 A.A.R. 4593, effective October                    3). Section repealed; new Section adopted effective
    1, 2001 (Supp. 01-3). Section repealed by final rulemak-               November 7, 1997 (Supp. 97-4). Section repealed; new
    ing at 12 A.A.R. 4484, effective January 6, 2007 (Supp.                 Section made by final rulemaking at 10 A.A.R. 1146,
                             06-4).                                        effective May 1, 2004 (Supp. 04-1). Amended by final
                                                                           rulemaking at 15 A.A.R. 179, effective March 7, 2009
R9-22-909.      Repealed
                                                                                                (Supp. 09-1).
                          Historical ote
                                                                     R9-22-1003. Cost Avoidance
      New Section made by exempt rulemaking at 7 A.A.R.
                                                                     A. The Administration’s reimbursement responsibility.
      4593, effective October 1, 2001 (Supp. 01-3). Section
                                                                         1. The Administration shall pay no more than the difference
    repealed by final rulemaking at 12 A.A.R. 4484, effective
                                                                             between the Capped Fee-For-Service schedule and the
                  January 6, 2007 (Supp. 06-4).
                                                                             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 and deductible
                                                                             regardless of the Capped Fee-For-Service Schedule.


June 30, 2011                                                   Page 63                                                        Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

B.   The Contractor’s reimbursement responsibility.                            4.  Other federal programs not excluded by statute from
     1. If the contract between the contractor and the provider                    recovery;
           does not state otherwise, a contractor shall pay no more            5. Court ordered or non-court ordered medical support from
           than the difference between the contracted rate and the                 an absent parent;
           amount of the third-party liability.                                6. State worker’s compensation;
     2. If the provider does not have a contract with the contrac-             7. Automobile insurance, including underinsured and unin-
           tor, a contractor shall pay no more than the difference                 sured motorists insurance;
           between the Capped Fee-For-Service rate and the amount              8. Court judgment or settlement from a liability insurer
           of the third-party liability.                                           including settlement proceeds placed in a trust;
C.   The requirement to cost avoid applies to all AHCCCS-covered               9. First-party probate estate recovery;
     services under Article 2 of this Chapter, unless otherwise spec-          10. Adoption-related payment; or
     ified in this Section. The following parties shall take reason-           11. A tortfeasor.
     able measures to identify potentially legally liable first- or
                                                                                                     Historical ote
     third-party sources:
                                                                                    New Section made by final rulemaking at 10 A.A.R.
     1. AHCCCS, the Administration, or a contractor;
                                                                                        1146, effective May 1, 2004 (Supp. 04-1).
     2. A provider;
     3. A noncontracting provider; and                                    R9-22-1007.       otification for Perfection, Recording, and
     4. A member.                                                         Assignment of AHCCCS Liens
D.   When the Administration or a contractor determines that a            A. Hospital requirements. A hospital providing medical services
     third party may be liable for services provided, the Adminis-            to a member for an injury or condition resulting from circum-
     tration or contractor shall pay the full amount of the claim             stances reflecting the probable liability of a first- or third-party
     according to the Capped-Fee-For-Service Schedule and then                shall within 30 days after a member’s discharge:
     seek reimbursement, when:                                                1. Notify AHCCCS via facsimile or mail under R9-22-
     1. The claim is for labor and delivery and postpartum care;                    1008, or
           or                                                                 2. Mail AHCCCS a copy of the lien the hospital proposes to
     2. The liability is from an absent parent, and the claim is for                record or has recorded under A.R.S. § 33-932.
           prenatal care or EPSDT services.                               B. Provider and noncontracting provider requirements. A pro-
                                                                              vider or noncontracting provider, other than a hospital, render-
                          Historical ote
                                                                              ing medical services to a member for an injury or condition
       New Section made by final rulemaking at 10 A.A.R.
                                                                              resulting from circumstances reflecting the probable liability
      1146, effective May 1, 2004 (Supp. 04-1). Amended by
                                                                              of a first- or third-party shall notify AHCCCS via facsimile or
     final rulemaking at 10 A.A.R. 3012, effective September
                                                                              mail under R9-22-1008 within 30 days after providing the ser-
      11, 2004 (Supp. 04-3). Amended by final rulemaking at
                                                                              vice.
       15 A.A.R. 179, effective March 7, 2009 (Supp. 09-1).
                                                                                                    Historical ote
R9-22-1004. Member Participation
                                                                                  New Section made by final rulemaking at 10 A.A.R.
A member shall cooperate in identifying potentially legally liable
                                                                                1146, effective May 1, 2004 (Supp. 04-1). Amended by
first- or third-parties and timely assist the Administration and a con-
                                                                                 final rulemaking at 15 A.A.R. 179, effective March 7,
tractor, provider, or noncontracting provider in pursuing any first-
                                                                                                  2009 (Supp. 09-1).
or third-party who may be liable to pay for covered services.
                                                                          R9-22-1008.      otification Information for Liens
                          Historical ote
                                                                          A. Except as provided in subsection (B), a hospital, provider, and
        New Section made by final rulemaking at 10 A.A.R.
                                                                              noncontracting provider identified in R9-22-1007 shall pro-
      1146, effective May 1, 2004 (Supp. 04-1). Amended by
                                                                              vide the following information to AHCCCS in writing:
       final rulemaking at 15 A.A.R. 179, effective March 7,
                                                                              1. Name of the hospital, provider or noncontracting pro-
                        2009 (Supp. 09-1).
                                                                                    vider;
R9-22-1005. Collections                                                       2. Address of the hospital, provider or noncontracting pro-
A. Parties that notify AHCCCS. A provider or noncontracting                         vider;
    provider shall cooperate with AHCCCS by identifying all                   3. Name of member;
    potential sources of first- or third-party liability and notify           4. Member’s Social Security Number or AHCCCS identifi-
    AHCCCS of these sources.                                                        cation number;
B. Parties that pursue collection or reimbursement. AHCCCS, a                 5. Address of member;
    provider, or noncontracting provider shall pursue collection or           6. Date of member’s admission or date service is provided;
    reimbursement from all potential sources of first- or third-              7. Amount estimated to be due for care of member;
    party liability.                                                          8. Date of discharge, if member has been discharged;
                                                                              9. Name of county in which injuries were sustained; and
                        Historical ote
                                                                              10. Name and address of all persons, firms, and corporations
       New Section made by final rulemaking at 10 A.A.R.
                                                                                    and their insurance carriers identified by the member or
           1146, effective May 1, 2004 (Supp. 04-1).
                                                                                    legal representative as being liable for damages.
R9-22-1006. AHCCCS Monitoring Responsibilities                            B. If the date of discharge is not known at the time the informa-
AHCCCS shall monitor first- or third-party liability payments to a            tion in subsection (A) is provided, a party identified in subsec-
provider or noncontracting provider, which include but are not lim-           tion (A) shall notify AHCCCS of the date of discharge within
ited to payments by or for:                                                   30 days after the member has been discharged.
      1. Private health insurance;
                                                                                                   Historical ote
      2. Employment-related disability and health insurance;
                                                                                 New Section made by final rulemaking at 10 A.A.R.
      3. Long-term care insurance;
                                                                                1146, effective May 1, 2004 (Supp. 04-1). Amended by



Supp. 11-2                                                           Page 64                                                       June 30, 2011
                                                      Arizona Administrative Code                                             Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

       final rulemaking at 15 A.A.R. 179, effective March 7,             R9-22-1102. Determining the Amount of a Penalty
                        2009 (Supp. 09-1).                               A. AHCCCS shall determine the amount of a penalty according
                                                                             to A.R.S. § 36-2918(B) and (C), R9-22-1104, and R9-22-1105.
R9-22-1009.      otification of Health Insurance Information
                                                                         B. AHCCCS shall include in the amount of the penalty the cost
A provider or noncontracting provider shall notify AHCCCS, in
                                                                             for conducting the following;
writing, of the following health insurance information within 10
                                                                             1. An investigation,
days of receipt of the health insurance information:
                                                                             2. Audit, or
     1. Name of member,
                                                                             3. Inquiry.
     2. Member’s Social Security Number or AHCCCS identifi-
          cation number,                                                                          Historical ote
     3. Insurance carrier name,                                                   Adopted effective October 1, 1986 (Supp. 86-5).
     4. Insurance carrier address,                                              Amended effective December 13, 1993 (Supp. 93-4).
     5. Policy number or insurance holder’s Social Security                    Amended effective June 9, 1998 (Supp. 98-2). Section
          Number,                                                              repealed; new Section made by final rulemaking at 10
     6. Policy begin and end dates, and                                       A.A.R. 3056, effective September 11, 2004 (Supp. 04-3).
     7. Insurance holder’s name.
                                                                         R9-22-1103. Determining the Amount of an Assessment
                        Historical ote                                   A. AHCCCS shall determine the amount of an assessment
       New Section made by final rulemaking at 10 A.A.R.                     according to A.R.S. § 36-2918(B) and (C), R9-22-1104, and
           1146, effective May 1, 2004 (Supp. 04-1).                         R9-22-1105.
                                                                         B. AHCCCS shall include in the amount of the assessment the
    ARTICLE 11. CIVIL MO ETARY PE ALTIES A D
                                                                             cost incurred by AHCCCS for conducting the following:
                   ASSESSME TS
                                                                             1. An investigation,
R9-22-1101. Basis for Civil Monetary Penalties and Assess-                   2. Audit, or
ments for Fraudulent Claims; Definitions                                     3. Inquiry.
A. Scope. This Article applies to a provider or non-contracting
                                                                                                  Historical ote
    provider who meets the conditions under this Article and who
                                                                                  Adopted effective October 1, 1986 (Supp. 86-5).
    submits a claim under Medicaid (Title XIX of the Social Secu-
                                                                                Amended effective December 13, 1993 (Supp. 93-4).
    rity Act), KidsCare (Title XXI of the Social Security Act), or
                                                                               Amended effective June 9, 1998 (Supp. 98-2). Section
    the Health Care Group (A.R.S. § 36-2912).
                                                                               repealed; new Section made by final rulemaking at 10
B. Purpose. This Article describes the circumstances AHCCCS
                                                                              A.A.R. 3056, effective September 11, 2004 (Supp. 04-3).
    considers and the process that AHCCCS uses to determine the
    amount of a penalty, assessment, or penalty and assessment as        R9-22-1104. Mitigating Circumstances
    required under A.R.S. § 36-2918. This Article includes the           AHCCCS shall consider any of the following to be mitigating cir-
    process and time-frames used by a provider or non-contracting        cumstances when determining the amount of a penalty, assessment,
    provider to request a State Fair Hearing.                            or penalty and assessment.
C. Definitions. The following definitions apply to this Article:              1. Nature and circumstances of a claim. The following are
    1. “Assessment” means a monetary amount that does not                          mitigating circumstances:
         exceed twice the dollar amount claimed by the provider                    a. All the services are of the same type,
         or non-contracting provider for each service.                             b. All the dates of services occurred within six months
    2. “Claim” means a request for payment submitted by a pro-                          or less,
         vider or non-contracted provider for payment for a ser-                   c. The services listed in subsection (1)(b) total less
         vice or line item of service.                                                  than 25,
    3. “Day” means calendar day unless otherwise specified.                        d. The nature and circumstances do not indicate a pat-
    4. “File” means the date that AHCCCS receives a written                             tern of inappropriate claims for the services, and
         acceptance, request for compromise, request for a counter                 e. The total amount claimed for the services is less than
         proposal, or a request for a State Fair Hearing as estab-                      $1,000.
         lished by a date stamp on the written document or other              2. Degree of culpability. The degree of culpability of a pro-
         record of receipt.                                                        vider or non-contracting provider who presents or causes
    5. “Penalty” means a monetary amount, based on the num-                        to present a claim is a mitigating circumstance if:
         ber of items of service claimed, that does not exceed two                 a. Each service is the result of an unintentional and
         thousand dollars times the number of line items of ser-                        unrecognized error in the process that the provider
         vice.                                                                          or non-contracting provider followed in presenting
    6. “Reason to know” or “had reason to know” means that a                            or in causing to present the service,
         provider or non-contracting provider, acts in deliberate                  b. Corrective steps were taken promptly by the pro-
         ignorance of the truth or falsity of, or with reckless disre-                  vider or non-contracting provider after the error was
         gard of the truth or falsity of information. No proof of                       discovered, and
         specific intent to defraud is required.                                   c. The provider or non-contracting provider had a
                                                                                        fraud and abuse control plan that was operating
                         Historical ote
                                                                                        effectively at the time each claim was presented or
         Adopted effective October 1, 1986 (Supp. 86-5).
                                                                                        caused to be presented.
      Amended subsection A. effective May 30, 1989 (Supp.
                                                                              3. Financial condition. The financial condition of a provider
     89-2). Amended effective September 29, 1992 (Supp. 92-
                                                                                   or non-contracting provider who presents or causes to
         3). Amended effective June 9, 1998 (Supp. 98-2).
                                                                                   present a claim is a mitigating circumstance if the imposi-
      Amended by final rulemaking at 10 A.A.R. 3056, effec-
                                                                                   tion of a penalty, assessment, or penalty and assessment
              tive September 11, 2004 (Supp. 04-3).
                                                                                   without reduction jeopardizes the ability of the provider
                                                                                   or non-contracting provider to continue as a health care


June 30, 2011                                                       Page 65                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          provider. AHCCCS shall consider the resources available            4.     Effect on patient care. The adverse effect on patient care
          to the provider or non-contracting provider when deter-                   that resulted, or could have resulted, from the failure of a
          mining the amount of the penalty, assessment, or penalty                  provider or non-contracting provider who presents or
          and assessment.                                                           causes to present a claim to provide medically necessary
     4.   Other matters as justice may require. AHCCCS shall take                   care.
          into account other circumstances of a mitigating nature, if        5.     Other matters as justice may require. AHCCCS shall take
          in the interest of justice, the circumstances require a                   into account other circumstances of an aggravating
          reduction of the penalty, assessment, or penalty and                      nature, if in the interest of justice, the circumstances
          assessment.                                                               require an increase of the penalty, assessment, or penalty
                                                                                    and assessment.
                         Historical ote
         Adopted effective October 1, 1986 (Supp. 86-5).                                            Historical ote
      Amended effective June 9, 1998 (Supp. 98-2). Section                        New Section made by final rulemaking at 10 A.A.R.
      repealed; new Section made by final rulemaking at 10                         3056, effective September 11, 2004 (Supp. 04-3).
     A.A.R. 3056, effective September 11, 2004 (Supp. 04-3).
                                                                        R9-22-1106.      otice of Intent
R9-22-1105. Aggravating Circumstances                                   If AHCCCS imposes a penalty, assessment, or a penalty and assess-
AHCCCS shall consider any of the following to be aggravating cir-       ment, AHCCCS shall hand deliver or send by certified mail return
cumstances when determining the amount of a penalty, assessment,        receipt requested or Federal Express to the provider or non-con-
or penalty and assessment.                                              tracting provider, a written Notice of Intent to impose a penalty,
     1. Nature and circumstances of each claim. The nature and          assessment, or a penalty and assessment. The Notice of Intent shall
          circumstances of each claim and the circumstances under       include:
          which the claim is presented or caused to be presented are          1. The statutory basis for the penalty, assessment, or the
          aggravating circumstances if:                                           penalty and assessment;
          a. A provider or non-contracting provider has forged,               2. Identification of the state or federal regulation and state
               altered, recreated, or destroyed records;                          or federal law that AHCCCS alleges has been violated;
          b. The provider or non-contracting provider refuses to              3. The factual basis for AHCCCS’ determination that the
               provide pertinent documentation to AHCCCS for a                    penalty, assessment, or the penalty and assessment should
               claim or refuses to cooperate with investigators for               be imposed;
               other than constitutional reasons;                             4. The amount of the penalty, assessment, or penalty and
          c. The services are of several types;                                   assessment;
          d. All the dates of services did not occur within six               5. The process for the provider or non-contracting provider
               months or less;                                                    to accept or request a compromise of the penalty, assess-
          e. The services rendered in subsection (1)(d) are                       ment, or penalty and assessment; and
               greater than 25;                                               6. The process for requesting a State Fair Hearing.
          f. The nature and circumstances indicate a pattern of
                                                                                                    Historical ote
               inappropriate claims for the services; and
                                                                                  New Section made by final rulemaking at 10 A.A.R.
          g. The total amount claimed for the services is $5,000
                                                                                   3056, effective September 11, 2004 (Supp. 04-3).
               or greater.
     2. Degree of culpability. The degree of culpability of a pro-      R9-22-1107. Reserved
          vider or non-contracting provider who presents or causes
                                                                        R9-22-1108. Request for a Compromise
          to present each claim is an aggravating circumstance if:
                                                                        A. To request a compromise, the provider or non-contracting pro-
          a. The provider or non-contracting provider knows or
                                                                            vider shall file a written request with AHCCCS within 30 days
               had reason to know that each service was not pro-
                                                                            from the date of receipt of the Notice of Intent. The written
               vided as claimed,
                                                                            request for compromise shall contain the provider or non-con-
          b. The provider or non-contracting provider knows or
                                                                            tracting provider’s reasons for the reduction or modification of
               had reason to know that no payment could be made
                                                                            the penalty, assessment, or penalty and assessment.
               because the provider or non-contracting provider
                                                                        B. Within 30 days from the date of receipt of the request for com-
               had been excluded from reimbursement by AHC-
                                                                            promise from the provider or non-contracting provider, AHC-
               CCS, or
                                                                            CCS shall send a Notice of Compromise Decision and accept,
          c. The provider or non-contracting provider knows or
                                                                            deny, or offer a counter proposal to the provider or non-con-
               had reason to know that the payment would violate
                                                                            tracting provider’s request for compromise. If AHCCCS offers
               the terms of an agreement between the provider or
                                                                            a counter proposal the amount of the counter proposal shall
               non-contracting provider and AHCCCS system.
                                                                            represent the penalty, assessment, or penalty and assessment.
     3. Prior offenses. The prior offenses of a provider or non-
                                                                            1. If AHCCCS does not withdraw the Notice of Intent under
          contracting provider who presents or causes to present
                                                                                  R9-22-1112 or denies the request for compromise the
          each claim are an aggravating circumstance if:
                                                                                  original penalty, assessment, or penalty and assessment is
          a. At any time before the submittal of the claim the
                                                                                  upheld.
               provider or non-contracting provider was held crimi-
                                                                            2. To dispute the Compromise Decision, the provider or
               nally or civilly liable for any act; or
                                                                                  non-contracting provider shall file a request for a State
          b. The provider or non-contracting provider had
                                                                                  Fair Hearing under R9-22-1110 within 30 days from the
               received an administrative sanction in connection
                                                                                  date of receipt of the Notice of Compromise Decision.
               with:
               i. A Medicaid program,                                                               Historical ote
               ii. A Medicare program, or                                         New Section made by final rulemaking at 10 A.A.R.
               iii. Any other public or private program of reim-                   3056, effective September 11, 2004 (Supp. 04-3).
                     bursement for medical services.


Supp. 11-2                                                         Page 66                                                       June 30, 2011
                                                     Arizona Administrative Code                                              Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

R9-22-1109. Failure to Respond to the otice of Intent                  R9-22-1112. Withdrawal and Continuances
If a provider or non-contracting provider fails to respond timely to   AHCCCS may withdraw the Notice of Intent at any time. Prior to
the Notice of Intent, AHCCCS shall uphold the original penalty,        referring a matter to the Office of Administrative Hearings the par-
assessment, or penalty and assessment.                                 ties may mutually agree to a continuance.
                         Historical ote                                                         Historical ote
       New Section made by final rulemaking at 10 A.A.R.                      New Section made by final rulemaking at 10 A.A.R.
        3056, effective September 11, 2004 (Supp. 04-3).                       3056, effective September 11, 2004 (Supp. 04-3).
R9-22-1110. Request for State Fair Hearing                                  ARTICLE 12. BEHAVIORAL HEALTH SERVICES
A. To request a State Fair Hearing regarding a dispute concerning
                                                                       R9-22-1201. General Requirements
    a penalty, assessment, or penalty and assessment, the provider
                                                                       General requirements. The following general requirements apply to
    or non-contracting provider shall file a written request for a
                                                                       behavioral health services provided under this Article, subject to all
    State Fair Hearing with AHCCCS within 60 days from the
                                                                       exclusions and limitations specified in this Article.
    date of the receipt of the Notice of Intent under R9-22-1106 or
                                                                            1. Administration. The program shall be administered as
    within 30 days from the date of receipt of the Notice of Com-
                                                                                 specified in A.R.S. § 36-2903.
    promise Decision under R9-22-1108, if applicable.
                                                                            2. Provision of services. Behavioral health services shall be
B. AHCCCS shall mail a Notice of Hearing under A.R.S. § 41-
                                                                                 provided as specified in A.R.S. § 36-2907 and this Chap-
    1092.05 if AHCCCS receives a timely request for a State Fair
                                                                                 ter.
    Hearing from the provider or non-contracting provider.
                                                                            3. Definitions. The following definitions apply to this Arti-
C. AHCCCS shall mail a Director’s Decision to the provider or
                                                                                 cle:
    non-contracting provider no later than 30 days after the date
                                                                                 a. “Agency” for the purposes of this Article means the
    the Administrative Law Judge sends the decision of the Office
                                                                                      same as in A.A.C. R9-20-101.
    of Administrative Hearings (OAH) to AHCCCS.
                                                                                 b. “Behavior management services” means services
D. AHCCCS shall accept a written request for withdrawal of a
                                                                                      that assist the member in carrying out daily living
    hearing request if the written request for withdrawal is
                                                                                      tasks and other activities essential for living in the
    received from the provider or non-contracting provider before
                                                                                      community, including personal care services.
    AHCCCS mails a Notice of Hearing under A.R.S. § 41-1092
                                                                                 c. “Behavioral health adult therapeutic home” means a
    et seq. If AHCCCS mailed a Notice of Hearing under A.R.S. §
                                                                                      licensed behavioral health service agency that is the
    41-1092 et seq., a provider or non-contracting provider may
                                                                                      licensee’s residence where behavioral health adult
    withdraw the hearing request only by sending a written request
                                                                                      therapeutic home care services are provided to at
    for withdrawal to OAH.
                                                                                      least one, but no more than three individuals, who
                         Historical ote                                               reside at the residence, have been diagnosed with
       New Section made by final rulemaking at 10 A.A.R.                              behavioral health issues, and are provided with food
        3056, effective September 11, 2004 (Supp. 04-3).                              and are integrated into the licensee’s family.
                                                                                 d. “Behavioral health therapeutic home care services”
R9-22-1111. Issues and Burden of Proof
                                                                                      means interactions that teach the client living, social,
A. Preponderance of evidence. In any State Fair Hearing con-
                                                                                      and communication skills to maximize the client’s
    ducted under R9-22-1110, AHCCCS shall prove by a prepon-
                                                                                      ability to live and participate in the community and
    derance of the evidence that a provider or non-contracting
                                                                                      to function independently, including assistance in
    provider presented or caused to be presented each claim in vio-
                                                                                      the self-administration of medication and any ancil-
    lation of this Article and any aggravating circumstances under
                                                                                      lary services indicated by the client’s treatment plan,
    R9-22-1105. A provider or non-contracting provider shall bear
                                                                                      as appropriate.
    the burden of producing and proving by a preponderance of
                                                                                 e. “Behavioral health evaluation” means the assess-
    the evidence any circumstance that would justify reducing the
                                                                                      ment of a member’s medical, psychological, psychi-
    amount of the penalty, assessment, or penalty and assessment.
                                                                                      atric, or social condition to determine if a behavioral
B. Statistical sampling.
                                                                                      health disorder exists and, if so, to establish a treat-
    1. In meeting the burden of proof described in subsection
                                                                                      ment plan for all medically necessary services.
         (A), AHCCCS may introduce the results of a statistical
                                                                                 f. “Behavioral health medical practitioner” means a
         sampling study as evidence of the number and amount of
                                                                                      health care practitioner with at least one year of full-
         claims that were presented or caused to be presented by
                                                                                      time behavioral health work experience.
         the provider or non-contracting provider A statistical
                                                                                 g. “Behavioral health professional” means the same as
         sampling study constitutes prima facie evidence of the
                                                                                      in A.A.C. R9-20-101.
         number and amount of claims if based upon an appropri-
                                                                                 h. “Behavioral health service” means a service pro-
         ate sampling and computed by valid statistical methods.
                                                                                      vided for the evaluation and diagnosis of a mental
    2. The burden of proof shall shift to the provider or non-
                                                                                      health or substance abuse condition and the planned
         contracting provider to produce evidence reasonably cal-
                                                                                      care, treatment, and rehabilitation of the member.
         culated to rebut the findings of the statistical sampling
                                                                                 i. “Behavioral health technician” means the same as in
         study once AHCCCS has made a prima facie case as
                                                                                      A.A.C. R9-20-101.
         described in subsection (B)(1). AHCCCS shall be given
                                                                                 j    “Case management” for the purposes of this Article,
         the opportunity to rebut this evidence.
                                                                                      means services and activities that enhance treatment,
                         Historical ote                                               compliance, and effectiveness of treatment.
       New Section made by final rulemaking at 10 A.A.R.                         k. “Certified psychiatric nurse practitioner” means a
        3056, effective September 11, 2004 (Supp. 04-3).                              registered nurse practitioner who meets the psychiat-
                                                                                      ric specialty area requirements under A.A.C. R4-19-
                                                                                      505(C).



June 30, 2011                                                     Page 67                                                         Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

          l. “Client” for the purposes of this rule means the same     R9-22-1202. ADHS and Contractor Responsibilities
             as in A.A.C. R9-22-101.                                   A. ADHS responsibilities. Except as provided in subsection (B),
          m. “Cost avoid” means to avoid payment of a third-               behavioral health services shall be provided by a RBHA
             party liability claim when the probable existence of          through a contract with ADHS/DBHS. ADHS/DBHS shall:
             third-party liability has been established under 42           1. Be responsible for providing all inpatient emergency
             CFR 433.139(b).                                                    behavioral health services for a non-FES member with a
          n. “Health care practitioner” means a:                                psychiatric or substance abuse diagnosis who is enrolled
             Physician;                                                         with a contractor in accordance with R9-22-
             Physician assistant;                                               210.01(A)(3);
             Nurse practitioner; or                                        2. Be responsible for providing all inpatient emergency
             Other individual licensed and authorized by law to                 behavioral health services for a FFS member with a psy-
             use and prescribe medication and devices, as defined               chiatric or substance abuse diagnosis who is not enrolled
             in A.R.S. § 32-1901.                                               with a contractor in accordance with R9-22-
          o  “Licensee” means the same as in A.A.C. R9-20-101.                  210.01(A)(3);
          p. “OBHL” means the same as in A.A.C. R9-20-101.                 3. Be responsible for providing all non-inpatient emergency
          q. “Partial care” means a day program of services pro-                behavioral health services for a non-FES member in
             vided to individual members or groups that is                      accordance with R9-22-210.01;
             designed to improve the ability of a person to func-          4. Be responsible for providing all non-emergency behav-
             tion in a community, and includes basic, therapeutic,              ioral health services for a non-FES member;
             and medical day programs.                                     5. Contract with a RBHA for the provision of behavioral
          r. “Physician assistant” means the same as in A.R.S. §                health services in R9-22-1205 for all Title XIX members
             32-2501 except that when providing a behavioral                    under A.R.S. § 36-2907. ADHS/DBHS shall ensure that a
             health service, the physician assistant shall be super-            RBHA provides behavioral health services to members
             vised by an AHCCCS-registered psychiatrist.                        directly, or through subcontracts, with qualified service
          s. “Psychiatrist” means a physician who meets the                     providers who meet the qualifications specified in R9-22-
             licensing requirements under A.R.S. § 32-1401 or a                 1206. If behavioral health services are unavailable within
             doctor of osteopathy who meets the licensing                       a RBHA’s GSA, ADHS/DBHS shall ensure that a RBHA
             requirements under A.R.S. § 32-1800, and meets the                 provides behavioral health services to a Title XIX mem-
             additional requirements of a psychiatrist under                    ber outside the RBHA’s GSA;
             A.R.S. § 36-501.                                              6. Ensure that a member’s behavioral health service is pro-
          t. “Psychologist” means a person who meets the                        vided in collaboration with a member’s primary care pro-
             licensing requirements under A.R.S. §§ 32-2061 and                 vider; and
             36-501.                                                       7. Coordinate the transition of care and medical records,
          u. “Qualified behavioral health service provider”                     under A.R.S. §§ 36-2903, 36-509, R9-22-512, and in con-
             means a behavioral health service provider that                    tract, when a member transitions from:
             meets the requirements of R9-22-1206.                              a. A behavioral health provider to another behavioral
          v. “Respite” means a period of care and supervision of                      health provider,
             a member to provide rest or relief to a family mem-                b. A RBHA to another RBHA,
             ber or other person caring for the member. Respite                 c. A RBHA to a contractor,
             provides activities and services to meet the social,               d. A contractor to a RBHA, or
             emotional, and physical needs of the member during                 e. A contractor to another contractor.
             respite.                                                  B. ADHS/DBHS may contract with a TRBHA for the provision
          w. “TRBHA” or “Tribal Regional Behavioral Health                 of behavioral health services for Native American members.
             Authority” means a Native American tribe under                Native American members may receive covered behavioral
             contract with ADHS/DBHS to coordinate the deliv-              health services:
             ery of behavioral health services to eligible and             1. From an IHS facility,
             enrolled members of the federally-recognized tribal           2. From a TRBHA, or
             nation.                                                       3. From a RBHA.
                                                                       C. Contractor responsibilities. A contractor shall:
                           Historical ote
                                                                           1. Refer a member to an a RBHA under the contract terms;
     Adopted under an exemption from A.R.S. Title 41, Ch. 6,
                                                                           2. Provide EPSDT developmental and behavioral health
     pursuant to Laws 1992, Ch. 301, § 61, effective Novem-
                                                                                screening as specified in R9-22-213;
       ber 1, 1992; received in the Office of the Secretary of
                                                                           3. Provide inpatient emergency behavioral health services
      State November 25, 1992 (Supp. 92-4). Amended under
                                                                                as specified in R9-22-1205 and R9-22-210.01 for a mem-
       an exemption from A.R.S. Title 41, Ch. 6, pursuant to
                                                                                ber not yet enrolled with a RBHA or TRBHA and all
     Laws 1992, Ch. 301, § 61, effective September 30, 1993
                                                                                behavioral health services as specified in contract;
     (Supp. 93-3). Amended under an exemption from A.R.S.
                                                                           4. Provide psychotropic medication services for a member,
       Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,
                                                                                in consultation with the member’s RBHA as needed, for
       effective October 1, 1995; filed with the Secretary of
                                                                                behavioral health conditions specified in contract and
     State September 29, 1995 (Supp. 95-4). Section repealed;
                                                                                within the primary care provider’s scope of practice; and
       new Section adopted by final rulemaking at 6 A.A.R.
                                                                           5. Coordinate a member’s transition of care and medical
          179, effective December 13, 1999 (Supp. 99-4).
                                                                                records under subsection (A)(7).
     Amended by exempt rulemaking at 7 A.A.R. 4593, effec-
       tive October 1, 2001 (Supp. 01-3). Amended by final                                      Historical ote
        rulemaking at 13 A.A.R. 836, effective May 5, 2007                  Adopted under an exemption from A.R.S. Title 41, Ch. 6,
                            (Supp. 07-1).                                   pursuant to Laws 1992, Ch. 301, § 61, effective Novem-
                                                                             ber 1, 1992; received in the Office of the Secretary of


Supp. 11-2                                                        Page 68                                                   June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

      State November 25, 1992 (Supp. 92-4). Amended under               E. Experimental services. Experimental services and services that
        an exemption from A.R.S. Title 41, Ch. 6, pursuant to              are provided primarily for the purpose of research are not cov-
      Laws 1992, Ch. 301, § 61, effective September 30, 1993               ered.
     (Supp. 93-3). Amended under an exemption from A.R.S.               F. Gratuities. A service or an item, if furnished gratuitously to a
        Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,             member, is not covered and payment to a provider shall be
        effective October 1, 1995; filed with the Secretary of             denied.
     State September 29, 1995 (Supp. 95-4). Section repealed;           G. GSA. Behavioral health services rendered to a member shall
        new Section adopted by final rulemaking at 6 A.A.R.                be provided within the RBHA’s GSA except when:
           179, effective December 13, 1999 (Supp. 99-4).                  1. A contractor’s primary care provider refers a member to
     Amended by exempt rulemaking at 7 A.A.R. 4593, effec-                       another area for medical specialty care,
       tive October 1, 2001 (Supp. 01-3). Amended to correct               2. A member’s medically necessary covered service is not
      typographical errors, filed in the Office of the Secretary                 available within the GSA, or
        of State October 30, 2001 (Supp. 01-4). Amended by                 3. A net savings in behavioral health service delivery costs
     final rulemaking at 13 A.A.R. 836, effective May 5, 2007                    is documented by the RBHA for a member. Undue travel
                             (Supp. 07-1).                                       time or hardship for a member or a member’s family is
                                                                                 considered for a member or a member’s family in deter-
R9-22-1203. Eligibility for Covered Services
                                                                                 mining whether there is a net savings.
A. Title XIX members. A member determined eligible under
                                                                        H. Travel. If a member travels or temporarily resides outside of a
    A.R.S. § 36-2901(6)(a), shall receive medically necessary cov-
                                                                           behavioral health service area, covered services are restricted
    ered services under R9-22-1205 and R9-22-201.
                                                                           to emergency behavioral health care, unless otherwise autho-
B. FES members. A person who would be eligible under A.R.S. §
                                                                           rized by the member’s RBHA or TRBHA.
    36-2901(6)(a)(i), A.R.S. § 36-2901(6)(a)(ii), or A.R.S. § 36-
                                                                        I. Non-covered services. If a member requests a behavioral
    2901(6)(a)(iii) except for the failure to meet the U.S. citizen-
                                                                           health service that is not covered or is not authorized by a
    ship or qualified alien status requirements under A.R.S. § 36-
                                                                           RBHA or TRBHA, an AHCCCS-registered behavioral health
    2903.03(A) and A.R.S. § 36-2903.03(B) is eligible for emer-
                                                                           service provider may provide the service according to R9-22-
    gency services only.
                                                                           702.
                           Historical ote                               J. Referral. If a member is referred outside of a RBHA’s or
     Adopted under an exemption from A.R.S. Title 41, Ch. 6,               TRBHA’s service area to receive authorized, medically neces-
     pursuant to Laws 1992, Ch. 301, § 61, effective Novem-                sary behavioral health services, the TRBHA or RBHA is
       ber 1, 1992; received in the Office of the Secretary of             responsible for reimbursement if the claim is otherwise pay-
      State November 25, 1992 (Supp. 92-4). Amended under                  able under this Chapter.
       an exemption from A.R.S. Title 41, Ch. 6, pursuant to            K. Restrictions and limitations.
     Laws 1992, Ch. 301, § 61, effective September 30, 1993                1. The restrictions, limitations, and exclusions in this Article
     (Supp. 93-3). Amended under an exemption from A.R.S.                        do not apply to a contractor, ADHS/DBHS, or a RBHA
       Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,                    when electing to provide a noncovered service.
       effective October 1, 1995; filed with the Secretary of              2. Room and board is not a covered service unless provided
     State September 29, 1995 (Supp. 95-4). Section repealed,                    in an inpatient, Level 1 sub-acute, or residential facility
       new Section adopted by final rulemaking at 6 A.A.R.                       under R9-22-1205.
          179, effective December 13, 1999 (Supp. 99-4).
                                                                                                   Historical ote
     Amended by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                             Adopted under an exemption from A.R.S. Title 41, Ch. 6,
       tive October 1, 2001 (Supp. 01-3). Amended by final
                                                                             pursuant to Laws 1992, Ch. 301, § 61, effective Novem-
        rulemaking at 13 A.A.R. 836, effective May 5, 2007
                                                                               ber 1, 1992; received in the Office of the Secretary of
                            (Supp. 07-1).
                                                                              State November 25, 1992 (Supp. 92-4). Amended under
R9-22-1204. General Service Requirements                                       an exemption from A.R.S. Title 41, Ch. 6, pursuant to
A. Services. Behavioral health services include both mental                  Laws 1992, Ch. 301, § 61, effective September 30, 1993
    health and substance abuse services.                                     (Supp. 93-3). Amended under an exemption from A.R.S.
B. Medical necessity. A service shall be medically necessary as                Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,
    provide under R9-22-201.                                                   effective October 1, 1995; filed with the Secretary of
C. Prior authorization. A service shall be provided to a member              State September 29, 1995 (Supp. 95-4). Amended under
    under Title 36, Chapter 29, Article 1, by a contractor, subcon-            an exemption from A.R.S. Title 41, Ch. 6, pursuant to
    tractor, or provider consistent with the prior authorization             Laws 1995, Ch. 204, § 11, effective January 1, 1996; filed
    requirements in contract and the following:                              with the Secretary of State December 22, 1995 (Supp. 95-
    1. Emergency behavioral health services. A provider is not                4). Section repealed; new Section adopted by final rule-
         required to obtain prior authorization for emergency                  making at 6 A.A.R. 179, effective December 13, 1999
         behavioral health services.                                            (Supp. 99-4). Amended by exempt rulemaking at 7
    2. Non-emergency behavioral health services. When a                        A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
         member’s behavioral health condition is determined by               Amended by final rulemaking at 13 A.A.R. 836, effective
         the provider not to require emergency behavioral health                             May 5, 2007 (Supp. 07-1).
         services, the provider shall follow the prior authorization
                                                                        R9-22-1205. Scope and Coverage of Behavioral Health Ser-
         requirements of ADHS/DBHS or the RBHA/TRBHA.
                                                                        vices
D. EPSDT. For Title XIX members under age 21, EPSDT ser-
                                                                        A. Inpatient behavioral health services. The following inpatient
    vices include all medically necessary covered behavioral
                                                                             services are covered subject to the limitations and exclusions
    health services.
                                                                             in this Article.
                                                                             1. Covered inpatient behavioral health services include all
                                                                                   behavioral health services, medical detoxification,


June 30, 2011                                                      Page 69                                                       Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

          accommodations and staffing, supplies, and equipment, if        C.   Covered Level 1 sub-acute agency services. Services provided
          the service is provided under the direction of a physician           in a Level 1 sub-acute agency as defined in A.A.C. R9-20-101
          in a Medicare-certified:                                             are covered subject to the limitations and exclusions under this
          a. General acute care hospital, or                                   Article.
          b. Inpatient psychiatric hospital.                                   1. Level 1 sub-acute agency services are not covered unless
     2. Inpatient service limitations:                                               provided under the direction of a licensed physician in a
          a. Inpatient services, other than emergency services                       licensed Level 1 sub-acute agency that is accredited by an
                specified in this Section, are not covered unless prior              AHCCCS-approved accrediting body as specified in con-
                authorized.                                                          tract.
          b. Inpatient services and room and board are reim-                   2. Covered level 1 sub-acute agency services include room
                bursed on a per diem basis. The per diem rate                        and board and treatment services for behavioral health
                includes all services, except the following licensed                 and substance abuse conditions.
                or certified providers may bill independently for ser-         3. Services are reimbursed on a per diem basis. The per
                vices:                                                               diem rate includes all services, except the following
                i. A licensed psychiatrist,                                          licensed or certified providers may bill independently for
                ii. A certified psychiatric nurse practitioner,                      services:
                iii. A licensed physician assistant,                                 a. A licensed psychiatrist,
                iv. A licensed psychologist,                                         b. A certified psychiatric nurse practitioner,
                v. A licensed clinical social worker,                                c. A licensed physician assistant,
                vi. A licensed marriage and family therapist,                        d. A licensed psychologist,
                vii. A licensed professional counselor,                              e. A licensed clinical social worker,
                viii. A licensed independent substance abuse coun-                   f. A licensed marriage and family therapist,
                      selor, and                                                     g. A licensed professional counselor,
                ix. A behavioral health medical practitioner.                        h. A licensed independent substance abuse counselor,
          c. A member age 21 through 64 is eligible for behav-                             and
                ioral health services provided in a hospital listed in               i. A behavioral health medical practitioner.
                subsection (A)(1)(b) that meets the criteria for an            4. The following may be billed independently if prescribed
                IMD up to 30 days per admission and no more than                     by a provider specified in this Section who is operating
                60 days per contract year as allowed under the                       within the scope of practice:
                Administration’s Section 1115 Waiver with CMS.                       a. Laboratory services,
B.   Level 1 residential treatment center services. Services pro-                    b. Radiology services, and
     vided in a Level 1 residential treatment center as defined in                   c. Psychotropic medication.
     A.A.C. R9-20-101 are covered subject to the limitations and               5. A member age 21 through 64 is eligible for behavioral
     exclusions under this Article.                                                  health services provided in a level 1 sub-acute agency
     1. Level 1 residential treatment center services are not cov-                   that meets the criteria for an IMD for up to 30 days per
          ered unless provided under the direction of a licensed                     admission and no more than 60 days per contract year as
          physician in a licensed Level 1 residential treatment cen-                 allowed under the Administration’s Section 1115 Waiver
          ter accredited by an AHCCCS-approved accrediting body                      with CMS. These limitations do not apply to a member
          as specified in contract.                                                  under age 21 or age 65 or over.
     2. Covered residential treatment center services include             D.   Level 2 behavioral health residential agency services. Services
          room and board and treatment services for behavioral                 provided in a level 2 behavioral health residential agency are
          health and substance abuse conditions.                               covered subject to the limitations and exclusions in this Arti-
     3. Residential treatment center service limitations.                      cle.
          a. Services are not covered unless prior authorized,                 1. Level 2 behavioral health residential agency services are
                except for emergency services as specified in this                   not covered unless provided by a licensed Level 2 behav-
                Section.                                                             ioral health residential agency as defined in A.A.C. R9-
          b. Services are reimbursed on a per diem basis. The per                    20-101.
                diem rate includes all services, except the following          2. Covered services include all services except room and
                licensed or certified providers may bill indepen-                    board.
                dently for services:                                           3. The following licensed or certified providers may bill
                i. A licensed psychiatrist,                                          independently for services:
                ii. A certified psychiatric nurse practitioner,                      a. A licensed psychiatrist,
                iii. A licensed physician assistant,                                 b. A certified psychiatric nurse practitioner,
                iv. A licensed psychologist,                                         c. A licensed physician assistant,
                v. A licensed clinical social worker,                                d. A licensed psychologist,
                vi. A licensed marriage and family therapist,                        e. A licensed clinical social worker,
                vii. A licensed professional counselor,                              f. A licensed marriage and family therapist,
                viii. A licensed independent substance abuse coun-                   g. A licensed professional counselor,
                      selor, and                                                     h. A licensed independent substance abuse counselor,
                ix. A behavioral health medical practitioner.                              and
     4. The following may be billed independently if prescribed                      i. A behavioral health medical practitioner.
          by a provider as specified in this Section who is operating     E.   Level 3 behavioral health residential agency services. Services
          within the scope of practice:                                        provided in a licensed Level 3 behavioral health residential
          a. Laboratory services,                                              agency as defined in A.A.C. R9-20-101 are covered subject to
          b. Radiology services, and                                           the limitations and exclusions under this Article.
          c. Psychotropic medication.


Supp. 11-2                                                           Page 70                                                    June 30, 2011
                                                       Arizona Administrative Code                                               Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

     1.    Level 3 behavioral health residential agency services are                b.   A behavioral health practitioner not specified in sub-
           not covered unless provided by a licensed Level 3 behav-                      section (G)(2)(a)(i) through (G)(2)(a)(x), who is
           ioral health residential agency.                                              contracted with or employed by an AHCCCS-regis-
     2. Covered services include all non-prescription drugs as                           tered behavioral health agency shall not bill inde-
           defined in A.R.S. § 32-1901, non-customized medical                           pendently.
           supplies, and clinical supervision of the level 3 behav-       H. Emergency behavioral health services are covered subject to
           ioral health residential agency staff. Room and board are         the limitations and exclusions under this Article. In order to be
           not covered services.                                             covered, behavioral health services shall be provided by quali-
     3. The following licensed and certified providers may bill              fied service providers under R9-22-1206. ADHS/DBHS shall
           independently for services:                                       ensure that emergency behavioral health services are available
           a. A licensed psychiatrist,                                       24 hours per day, seven days per week in each GSA for an
           b. A certified psychiatric nurse practitioner,                    emergency behavioral health condition for a non-FES member
           c. A licensed physician assistant,                                as defined in R9-22-102.
           d. A licensed psychologist,                                    I. Other covered behavioral health services. Other covered
           e. A licensed clinical social worker,                             behavioral health services include:
           f. A licensed marriage and family therapist,                      1. Case management as defined in R9-22-1201;
           g. A licensed professional counselor,                             2. Laboratory and radiology services for behavioral health
           h. A licensed independent substance abuse counselor,                    diagnosis and medication management;
                 and                                                         3. Psychotropic medication and related medication;
           i. A behavioral health medical practitioner.                      4. Monitoring, administration, and adjustment for psycho-
F.   Partial care. Partial care services are covered subject to the                tropic medication and related medications;
     limitations and exclusions in this Article.                             5. Respite care;
     1. Partial care services are not covered unless provided by a           6. Behavioral health therapeutic home care services pro-
           licensed and AHCCCS-registered behavioral health                        vided by a RBHA in a professional foster home defined
           agency that provides a regularly scheduled day program                  in 6 A.A.C. 5, Article 58 or in a behavioral health adult
           of individual member, group, or family activities that are              therapeutic home as defined in 9 A.A.C. 20, Article 1;
           designed to improve the ability of the member to function         7. Personal care services, including assistance with daily
           in the community. Partial care services include basic,                  living skills and tasks, homemaking, bathing, dressing,
           therapeutic, and medical day programs.                                  food preparation, oral hygiene, self-administration of
     2. Partial care services. Educational services that are thera-                medications, and monitoring of the behavioral health
           peutic and are included in the member’s behavioral health               recipient’s condition and functioning level provided by a
           treatment plan are included in per diem reimbursement                   licensed and AHCCCS-registered behavioral health
           for partial care services.                                              agency or a behavioral health professional, behavioral
G.   Outpatient services. Outpatient services are covered subject to               health technician, or behavioral health paraprofessional
     the limitations and exclusions in this Article.                               as defined in 9 A.A.C. 20, Article 1; and
     1. Outpatient services include the following:                           8. Other support services to maintain or increase the mem-
           a. Screening provided by a behavioral health profes-                    ber’s self-sufficiency and ability to live outside an institu-
                 sional or a behavioral health technician as defined in            tion.
                 R9-22-1201;                                              J. Transportation services. Transportation services are covered
           b. A behavioral health evaluation provided by a behav-            under R9-22-211.
                 ioral health professional or a behavioral health tech-
                                                                                                     Historical ote
                 nician;
                                                                               Adopted under an exemption from A.R.S. Title 41, Ch. 6,
           c. Counseling including individual therapy, group, and
                                                                               pursuant to Laws 1992, Ch. 301, § 61, effective Novem-
                 family therapy provided by a behavioral health pro-
                                                                                 ber 1, 1992; received in the Office of the Secretary of
                 fessional or a behavioral health technician;
                                                                                State November 25, 1992 (Supp. 92-4). Amended under
           d. Behavior management services as defined in R9-22-
                                                                                 an exemption from A.R.S. Title 41, Ch. 6, pursuant to
                 1201; and
                                                                               Laws 1992, Ch. 301, § 61, effective September 30, 1993
           e. Psychosocial rehabilitation services as defined in
                                                                               (Supp. 93-3). Amended under an exemption from A.R.S.
                 R9-22-102.
                                                                                 Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,
     2. Outpatient service limitations.
                                                                                 effective October 1, 1995; filed with the Secretary of
           a. The following licensed or certified providers may
                                                                               State September 29, 1995 (Supp. 95-4). Section repealed,
                 bill independently for outpatient services:
                                                                                 new Section adopted by final rulemaking at 6 A.A.R.
                 i. A licensed psychiatrist,
                                                                                    179, effective December 13, 1999 (Supp. 99-4).
                 ii. A certified psychiatric nurse practitioner,
                                                                               Amended by exempt rulemaking at 7 A.A.R. 4593, effec-
                 iii. A licensed physician assistant as defined in R9-
                                                                                 tive October 1, 2001 (Supp. 01-3). Amended by final
                       22-1201,
                                                                                 rulemaking at 11 A.A.R. 5480, effective December 6,
                 iv. A licensed psychologist,
                                                                                2005 (Supp. 05-4). Amended by final rulemaking at 13
                 v. A licensed clinical social worker,
                                                                                    A.A.R. 836, effective May 5, 2007 (Supp. 07-1).
                 vi. A licensed professional counselor,
                 vii. A licensed marriage and family therapist,           R9-22-1206. General Provisions and Standards for Service
                 viii. A licensed independent substance abuse coun-       Providers
                       selor,                                             A. Qualified service provider. A qualified behavioral health ser-
                 ix. A behavioral health medical practitioner and             vice provider shall:
                 x. An outpatient clinic or a Level IV transitional           1. Have all applicable state licenses or certifications, or
                       agency licensed under 9 A.A.C. 20, Article 1,               comply with alternative requirements established by the
                       that is an AHCCCS-registered provider.                      Administration;


June 30, 2011                                                        Page 71                                                         Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

     2.  Register with the Administration as a service provider;                 shall submit a claim to the entity responsible for emer-
     3.  Comply with all requirements under Article 5 and this                   gency behavioral health services under R9-22-210.01(A).
         Article.                                                           7. A provider shall comply with the time-frames and other
     4. Register with ADHS/DBHS as a behavioral health ser-                      payment procedures in Article 7 of this Chapter, if appli-
         vice provider, and                                                      cable, and A.R.S. § 36-2904.
     5.   Contract with the appropriate RBHA/TRBHA.                         8. ADHS/DBHS or a contractor, whichever entity is respon-
B.   Quality and utilization management.                                         sible for covering behavioral health services, shall cost
     1. Service providers shall cooperate with the quality and uti-              avoid any behavioral health service claims if it estab-
         lization management programs of a RBHA, a TRBHA, a                      lishes the existence or probable existence of first-party
         contractor, ADHS/DBHS, and the Administration as                        liability or third-party liability.
         specified in this Chapter and in contract.                    C.   Prior authorization. Payment to a provider for behavioral
     2. Service providers shall comply with applicable proce-               health services or items requiring prior authorization may be
         dures under 42 CFR 456, as of October 1, 2006, incorpo-            denied if a provider does not obtain prior authorization from a
         rated by reference, on file with the Administration and            RBHA, ADHS/DBHS, a TRBHA, or a contractor.
         available from the U.S. Government Printing Office, Mail
                                                                                                   Historical ote
         Stop: IDCC, 732 N. Capitol St., NW, Washington, DC
                                                                            Adopted under an exemption from A.R.S. Title 41, Ch. 6,
         20401. This incorporation contains no future editions or
                                                                             pursuant to Laws 1992, Ch. 301, § 61, effective Novem-
         amendments.
                                                                               ber 1, 1992; received in the Office of the Secretary of
                           Historical ote                                    State November 25, 1992 (Supp. 92-4). Amended under
     Adopted under an exemption from A.R.S. Title 41, Ch. 6,                   an exemption from A.R.S. Title 41, Ch. 6, pursuant to
     pursuant to Laws 1992, Ch. 301, § 61, effective Novem-                    Laws 1995, Ch. 204, § 11, effective October 1, 1995;
       ber 1, 1992; received in the Office of the Secretary of                  filed with the Secretary of State September 29, 1995
      State November 25, 1992 (Supp. 92-4). Amended under                    (Supp. 95-4). Section repealed; new Section adopted by
       an exemption from A.R.S. Title 41, Ch. 6, pursuant to                final rulemaking at 6 A.A.R. 179, effective December 13,
     Laws 1992, Ch. 301, § 61, effective September 30, 1993                   1999 (Supp. 99-4). Amended by final rulemaking at 13
     (Supp. 93-3). Amended under an exemption from A.R.S.                         A.A.R. 836, effective May 5, 2007 (Supp. 07-1).
       Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, § 11,
                                                                       R9-22-1208. Repealed
       effective October 1, 1995; filed with the Secretary of
     State September 29, 1995 (Supp. 95-4). Section repealed,                                   Historical ote
       new Section adopted by final rulemaking at 6 A.A.R.                   New Section adopted by final rulemaking at 6 A.A.R.
          179, effective December 13, 1999 (Supp. 99-4).                        179, effective December 13, 1999 (Supp. 99-4).
     Amended by exempt rulemaking at 7 A.A.R. 4593, effec-                  Amended by final rulemaking at 6 A.A.R. 3317, effective
       tive October 1, 2001 (Supp. 01-3). Amended by final                   August 7, 2000 (Supp. 00-3). Section repealed by final
        rulemaking at 13 A.A.R. 836, effective May 5, 2007                   rulemaking at 11 A.A.R. 5480, effective December 6,
                            (Supp. 07-1).                                                      2005 (Supp. 05-4).
R9-22-1207. General Provisions for Payment                                                ARTICLE 13. REPEALED
A. Payment to ADHS/DBHS. The Administration shall make a
                                                                            Article 13, consisting of Sections R9-22-1301 through R9-22-
    monthly capitation payment to ADHS/DBHS based on the
                                                                       1309, repealed by final rulemaking at 10 A.A.R. 808, effective April
    number of acute members at the beginning of each month. The
                                                                       3, 2004. The subject matter of Article 13 is now in 9 A.A.C. 34
    Administration shall incorporate ADHS’/DBHS’ administra-
                                                                       (Supp. 04-1).
    tive costs into the capitation payment.
B. Claims submissions.                                                 R9-22-1301. Repealed
    1. ADHS/DBHS shall require all service providers to sub-
                                                                                               Historical ote
          mit clean claims no later than the time-frame specified in
                                                                              Adopted effective September 9, 1998 (Supp. 98-3).
          ADHS/DBHS’ contract with the Administration.
                                                                            Amended by final rulemaking at 6 A.A.R. 3317, effective
    2. A provider of behavioral health services shall submit a
                                                                             August 7, 2000 (Supp. 00-3). Section repealed by final
          claim for non-emergency behavioral health services pro-
                                                                             rulemaking at 10 A.A.R. 808, effective April 3, 2004
          vided to a member enrolled in a RBHA to the appropriate
                                                                                                 (Supp. 04-1).
          RBHA, and if not enrolled in a RBHA, to ADHS/DBHS.
    3. A provider of behavioral health services shall submit a         R9-22-1302. Repealed
          claim for non-inpatient emergency behavioral health ser-
                                                                                               Historical ote
          vices provided to a member enrolled in a RBHA to the
                                                                              Adopted effective September 9, 1998 (Supp. 98-3).
          appropriate RBHA, and if not enrolled in a RBHA, to
                                                                            Amended by final rulemaking at 6 A.A.R. 3317, effective
          ADHS/DBHS.
                                                                             August 7, 2000 (Supp. 00-3). Section repealed by final
    4. A provider of behavioral health services shall submit a
                                                                             rulemaking at 10 A.A.R. 808, effective April 3, 2004
          claim for non-inpatient emergency behavioral health ser-
                                                                                                 (Supp. 04-1).
          vices provided to a member enrolled in a TRBHA to the
          Administration.                                              R9-22-1303. Repealed
    5. A provider of behavioral health services shall submit a
                                                                                               Historical ote
          claim for non-emergency behavioral health services pro-
                                                                              Adopted effective September 9, 1998 (Supp. 98-3).
          vided to a member enrolled in a TRBHA to the Adminis-
                                                                            Amended by final rulemaking at 6 A.A.R. 3317, effective
          tration.
                                                                             August 7, 2000 (Supp. 00-3). Section repealed by final
    6. A provider of emergency behavioral health services, that
                                                                             rulemaking at 10 A.A.R. 808, effective April 3, 2004
          are the responsibility of ADHS/DBHS or a contractor,
                                                                                                 (Supp. 04-1).



Supp. 11-2                                                        Page 72                                                    June 30, 2011
                                                    Arizona Administrative Code                                           Title 9, Ch. 22
                                    Arizona Health Care Cost Containment System – Administration

R9-22-1304. Repealed                                                         “Burial plot” means a space reserved in a cemetery, crypt,
                                                                             vault, or mausoleum for the remains of a deceased per-
                       Historical ote
                                                                             son.
      Adopted effective September 9, 1998 (Supp. 98-3).
    Amended by final rulemaking at 6 A.A.R. 3317, effective                  “Caretaker relative” means a parent who maintains a fam-
     August 7, 2000 (Supp. 00-3). Section repealed by final                  ily setting for a dependent child and who exercises
     rulemaking at 10 A.A.R. 808, effective April 3, 2004                    responsibility for the day-to-day physical care, guidance,
                         (Supp. 04-1).                                       and support of that child.
R9-22-1305. Repealed                                                         “Cash assistance” means a program administered by the
                                                                             Department that provides assistance to needy families
                       Historical ote                                        with dependent children under 42 U.S.C. 601 et seq.
      Adopted effective September 9, 1998 (Supp. 98-3).                      “CRS” means the program within ADHS that provides
    Amended by final rulemaking at 6 A.A.R. 3317, effective                  covered medical services and covered support services in
     August 7, 2000 (Supp. 00-3). Section repealed by final                  accordance with A.R.S. 36-261.
     rulemaking at 10 A.A.R. 808, effective April 3, 2004
                         (Supp. 04-1).                                       “DCSE” means the Division of Child Support Enforce-
                                                                             ment, which is the division within the Department that
R9-22-1306. Repealed                                                         administers the Title IV-D program and includes a con-
                         Historical ote                                      tract agent operating a child support enforcement pro-
     Adopted effective September 9, 1998 (Supp. 98-3). Sec-                  gram on behalf of the Department.
    tion repealed by final rulemaking at 10 A.A.R. 808, effec-               “FAA” means the Family Assistance Administration, the
                 tive April 3, 2004 (Supp. 04-1).                            administration within the Department’s Division of Bene-
                                                                             fits and Medical Eligibility with responsibility for provid-
R9-22-1307. Repealed
                                                                             ing cash and food stamp assistance to a member and for
                       Historical ote                                        determining eligibility for AHCCCS medical coverage.
      Adopted effective September 9, 1998 (Supp. 98-3).                      “Homebound” means a person who is confined to home
    Amended by final rulemaking at 6 A.A.R. 3317, effective                  because of physical or mental incapacity.
     August 7, 2000 (Supp. 00-3). Section repealed by final
     rulemaking at 10 A.A.R. 808, effective April 3, 2004                    “Income” means combined earned and unearned income.
                         (Supp. 04-1).                                       “Indigent” means an applicant’s total income, including
                                                                             sponsor deemed income actually received, is less than or
R9-22-1308. Repealed                                                         equal to 100% of the federal poverty level for the size of
                       Historical ote                                        the income group under R9-22-1425.
      Adopted effective September 9, 1998 (Supp. 98-3).                      “Liquid assets” means those assets in the form of cash or
    Amended by final rulemaking at 6 A.A.R. 3317, effective                  other financial instruments, that are convertible to cash
     August 7, 2000 (Supp. 00-3). Section repealed by final                  and include:
     rulemaking at 10 A.A.R. 808, effective April 3, 2004                          Savings accounts;
                         (Supp. 04-1).                                             Checking accounts;
R9-22-1309. Repealed                                                               Stocks and bonds;
                                                                                   Mutual fund shares;
                       Historical ote                                              Promissory notes;
      Adopted effective September 9, 1998 (Supp. 98-3).                            Cash value of insurance policies; and
    Amended by final rulemaking at 6 A.A.R. 3317, effective                        Similar assets.
     August 7, 2000 (Supp. 00-3). Section repealed by final                  “Medical expense deduction” or “MED” means the cost
     rulemaking at 10 A.A.R. 808, effective April 3, 2004                    of the following expenses if incurred in the United States:
                         (Supp. 04-1).
                                                                                   A medical service or supply that would be covered if
   ARTICLE 14. AHCCCS MEDICAL COVERAGE FOR                                         provided to an AHCCCS member of any age under
           FAMILIES A D I DIVIDUALS                                                Articles 2 and 12 of this Chapter;
R9-22-1401. General Information                                                    A medical service or supply that would be covered if
A. Scope. This Article contains eligibility criteria to determine                  provided to an Arizona Long-term Care System
    whether a family or individual is eligible for AHCCCS medi-                    member under 9 A.A.C. 28, Articles 2 and 11;
    cal coverage.                                                                  Other necessary medical services provided by a
B. Definitions. In addition to definitions contained in R9-22-101                  licensed practitioner or physician;
    and A.R.S. § 36-2901, the words and phrases in this Article                    Assistance with daily living if the assistance is docu-
    and Article 15 have the following meanings unless the context                  mented in an individual plan of care by a nurse,
    explicitly requires another meaning:                                           social service worker, registered therapist, or dieti-
         “Baby Arizona” means the public or private partnership                    tian under the supervision of a physician except
         program that provides a pregnant woman an opportunity                     when provided by the spouse of an applicant or the
         to apply for AHCCCS medical coverage at a Baby Ari-                       parent of a minor child;
         zona provider’s office through a streamlined eligibility
         process.                                                                  Medical services provided in a licensed nursing
                                                                                   home or in an alternative HCBS setting under R9-
         “BHS” means the division of Behavioral Health Services                    28-101;
         within the Arizona Department of Health Services.




June 30, 2011                                                    Page 73                                                      Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

               Purchasing and maintaining an animal guide or ser-                                Historical ote
               vice animal for the assistance of a member of the              New Section adopted by final rulemaking at 5 A.A.R.
               MED family unit under R9-22-1436; and                           294, effective January 8, 1999 (Supp. 99-1). Section
               Health insurance premiums, deductibles, and coin-             repealed; new Section made by exempt rulemaking at 7
               surance, if the insured is a member of the MED fam-            A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
               ily unit.                                                     Amended by final rulemaking at 11 A.A.R. 4942, effec-
                                                                                      tive December 31, 2005 (Supp. 05-4).
          “Medical support” means to provide health care coverage
          in the form of health insurance or court-ordered payment      R9-22-1403. Agency Responsible for Determining Eligibility
          for medical care.                                             The Department shall determine eligibility under the provisions of
          “Nonparent caretaker relative” means a person, other          this Article. The Department shall not discriminate against an appli-
          than a parent, who is related by blood, marriage, or lawful   cant or member because of race, color, creed, religion, ancestry,
          adoption to a dependent child and who:                        national origin, age, sex, or physical or mental disability.
               Maintains a family setting for the dependent child,                               Historical ote
               and                                                            New Section adopted by final rulemaking at 5 A.A.R.
               Exercises responsibility for the day-to-day physical            294, effective January 8, 1999 (Supp. 99-1). Section
               care, guidance, and support of the dependent child.           repealed; new Section made by exempt rulemaking at 7
          “Pre-enrollment process” means the process that provides            A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          an applicant the opportunity to choose an AHCCCS                   Amended by final rulemaking at 11 A.A.R. 4942, effec-
          health plan before the determination of eligibility is com-                 tive December 31, 2005 (Supp. 05-4).
          pleted.                                                       R9-22-1404. Assignment of Rights Under Operation of Law
          “Resources” means real and personal property, including       By operation of law and under A.R.S. § 36-2903, a person deter-
          liquid assets.                                                mined eligible assigns rights to the system and the county all types
          “Spendthrift restriction” means a legal restriction on the    of medical benefits to which the person is entitled.
          use of a resource that prevents a payee or beneficiary                                 Historical ote
          from alienating the resource.                                       New Section adopted by final rulemaking at 5 A.A.R.
          “Sponsor” means an individual who signs the USCIS I-                 294, effective January 8, 1999 (Supp. 99-1). Section
          864 Affidavit of Support agreeing to support a non-citi-           repealed; new Section made by exempt rulemaking at 7
          zen as a condition of the non-citizen’s admission for per-          A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          manent residence in the United States.                             Section repealed; new Section made by final rulemaking
          “Sponsor deemed income” means the unearned income                      at 11 A.A.R. 4942, effective December 31, 2005
          for an applicant named on the USCIS I-864 Affidavit of                                   (Supp. 05-4).
          Support who is applying for AHCCCS medical coverage.          R9-22-1405. Confidentiality and Safeguarding of Information
          “SVES” means the State Verification and Exchange Sys-         The Administration and Department shall maintain the confidenti-
          tem, a system through which the Department exchanges          ality of an applicant or member’s records and limit the release of
          income and benefit information with the Internal Reve-        safeguarded information under R9-22-512 and 6 A.A.C. 12, Article
          nue Service, Social Security Administration, and State        1. In the event of a conflict between R9-22-512 and 6 A.A.C. 12,
          Wage and Unemployment Insurance Benefit data files.           Article 1, R9-22-512 prevails.
          “Title IV-D” means Title IV-D of the Social Security Act,                               Historical ote
          42 U.S.C. 651-669, the statutes establishing the child sup-           New Section adopted by final rulemaking at 5 A.A.R.
          port enforcement and paternity program.                               294, effective January 8, 1999 (Supp. 99-1). Section
          “Title IV-E” means Title IV-E of the Social Security Act            repealed; new Section made by exempt rulemaking at 7
          42 U.S.C. 670-679, the statutes establishing the foster               A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          care and adoption assistance programs.                             Amended by final rulemaking at 9 A.A.R. 5123, effective
                                                                             January 3, 2004 (Supp. 03-4). Section repealed; new Sec-
          “USCIS” means the United States Citizen and Immigra-                tion made by final rulemaking at 11 A.A.R. 4942, effec-
          tion Services.                                                               tive December 31, 2005 (Supp. 05-4).
                         Historical ote                                 R9-22-1406. Application Process
      New Section adopted by final rulemaking at 5 A.A.R.               A. Right to apply. A person may apply for AHCCCS medical
       294, effective January 8, 1999 (Supp. 99-1). Section                 coverage by submitting an Administration-approved written
     repealed; new Section made by exempt rulemaking at 7                   application to the Administration, an FAA office, or one of the
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                  following outstation locations:
     Amended by final rulemaking at 11 A.A.R. 4942, effec-                  1. A BHS site;
              tive December 31, 2005 (Supp. 05-4).                          2. A facility contracted with CRS Administration;
R9-22-1402. Ineligible Person                                               3. A Baby Arizona-approved provider’s office, if the appli-
A person is not eligible for AHCCCS medical coverage if the per-                  cant is a pregnant woman;
son is:                                                                     4. A Federally Qualified Health Center or disproportionate
     1. An inmate of a public institution, or                                     share hospital under 42 U.S.C. 1396r-4; or
     2. Age 21 through age 64 and is residing in an Institution for         5. Any other site, including a hospital, approved by the
         Mental Disease under 42 CFR 435.1009 except if                           Department or the Administration.
         allowed under the Administration’s Section 1115 waiver.        B. Written application. To initiate the application process, any
                                                                            person may apply by submitting a written application under 42
                                                                            CFR 435.907 with the appropriate signatures to one of the
                                                                            sites listed in subsection (A).


Supp. 11-2                                                         Page 74                                                    June 30, 2011
                                                       Arizona Administrative Code                                                Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

     1.   A written application is one that contains the:                       6.    If the application is incomplete, the Administration or the
          a. Applicant’s legible name,                                                Administration’s designee shall do at least one of the fol-
          b. Address or location where the applicant can be                           lowing:
                reached,                                                              a. Contact an applicant or an applicant’s representative
          c. Signature of the person listed in subsection (D)(2) or                         by telephone or electronic medium to obtain the
                (D)(3),                                                                     missing information required for an eligibility deter-
          d. Date the application was signed.                                               mination;
     2. The Administration or Administration’s designee shall                         b. Mail a request for additional information to an appli-
          require that a third party witness the signing and attest by                      cant or an applicant’s representative, allowing 10
          signing the application if the individual signing the appli-                      days from the date of the request to provide the
          cation signs with a mark.                                                         required additional information; or
     3. The Administration or Administration’s designee shall                         c. Meet with the applicant, representative, or house-
          accept an application for a person who is incapacitated                           hold member.
          and whose name and address are unknown.                          E.   Assistance with application. The Administration or Adminis-
C.   Date of application. The date of application is the date a writ-           tration’s designee shall allow a person of the applicant’s choice
     ten application is received by the Administration or its desig-            to accompany, assist, and represent the applicant in the appli-
     nee at a location listed in subsection (A).                                cation process.
D.   Complete application form.
                                                                                                     Historical ote
     1. The Administration shall consider an application com-
                                                                                 New Section adopted by final rulemaking at 5 A.A.R.
          plete when:
                                                                                  294, effective January 8, 1999 (Supp. 99-1). Section
          a. All questions are answered; and
                                                                                repealed; new Section made by exempt rulemaking at 7
          b. All necessary verification is provided by an appli-
                                                                                 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                cant or an applicant’s representative.
                                                                                Section repealed; new Section made by final rulemaking
     2. The Administration or Administration’s designee shall
                                                                                at 11 A.A.R. 4942, effective December 31, 2005 (Supp.
          not approve an application unless the applicant’s legal
                                                                                05-4). Amended by final rulemaking at 14 A.A.R. 1598,
          representative, if one exists, signs the declarations on the
                                                                                          effective May 31, 2008 (Supp. 08-2).
          application relating to the applicant’s eligibility, under
          penalty of perjury.                                              R9-22-1407. Deceased Applicants
     3. If there is no legal representative, or the legal representa-      A. If an applicant dies while an application is pending, the
          tive is incapacitated, one of the following shall sign the           Administration or Administration’s designee shall complete an
          declarations on the application relating to the applicant’s          eligibility determination for all applicants listed on the appli-
          eligibility, under penalty of perjury:                               cation, including the deceased applicant.
          a. The applicant, if age 18 or older;                            B. The Administration or Administration’s designee shall com-
          b. The applicant, if less than 18 years old and married              plete an eligibility determination on an application filed on
                or not living with a parent;                                   behalf of a deceased applicant, if the application is filed in the
          c. The applicant’s spouse if the applicant and spouse                same month as the applicant’s death.
                are not legally separated;
                                                                                                    Historical ote
          d. An adult who lives with an applicant, if the applicant
                                                                                 New Section adopted by final rulemaking at 5 A.A.R.
                is less than 18 years old or age 18 and a student;
                                                                                  294, effective January 8, 1999 (Supp. 99-1). Section
          e. One of the unmarried partners if living together with
                                                                                repealed; new Section made by exempt rulemaking at 7
                a child in common, if the child is the applicant;
                                                                                 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          f. Another party, if the applicant is incapacitated and
                                                                                Section repealed; new Section made by final rulemaking
                no one listed in subsections (D)(3)(a) through (e) is
                                                                                    at 11 A.A.R. 4942, effective December 31, 2005
                available to sign the application on the applicant’s
                                                                                                      (Supp. 05-4).
                behalf. The Administration shall require incapacity
                to be verified by written documentation signed by a        R9-22-1408. Applicant and Member Responsibility
                licensed physician or by one of the following:             A. An applicant and a member shall authorize the Department to
                i. A physician assistant,                                      obtain verification for initial eligibility or continuation of eli-
                ii. A nurse practitioner, or                                   gibility.
                iii. A registered nurse under the direction of a           B. As a condition of eligibility, an applicant or a member shall:
                      licensed physician; or                                   1. Provide the Department with complete and truthful infor-
          g. A person authorized verbally in the presence of an                      mation. The Department may deny an application or dis-
                employee of the Administration or the Administra-                    continue eligibility if:
                tion’s designee or in writing, by a person listed in                 a. The applicant or member fails to provide informa-
                subsection (D)(2) or (D)(3)(a) through (c), to repre-                     tion necessary for initial or continuing eligibility;
                sent the applicant in the application process. The                   b. The applicant or member fails to provide the Depart-
                authorized representative may sign the declaration                        ment with written authorization to permit the
                on the application relating to the applicant’s eligibil-                  Department to obtain necessary initial or continuing
                ity, under penalty or perjury.                                            eligibility verification;
     4. Unmarried adults not applying for a child in common                          c. The applicant or member fails to provide verifica-
          shall each sign the application if using the same applica-                      tion under R9-22-1412 after the Department made
          tion form.                                                                      an effort to obtain the necessary verification but has
     5. The application shall be witnessed and signed by a third                          not obtained the necessary information; or
          party if the individual signing the application signs with a               d. The applicant or member does not assist the Depart-
          mark.                                                                           ment in resolving incomplete, inconsistent, or



June 30, 2011                                                         Page 75                                                         Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

                 unclear information that is necessary for initial or     F.   As a condition of eligibility of a child whose parent, legal rep-
                 continuing eligibility;                                       resentative, or other legally responsible adult applies for AHC-
     2. Cooperate with the Division of Child Support Enforce-                  CCS medical coverage on behalf of the child, the individual
           ment (DCSE) in establishing paternity and enforcing                 who applies for the child shall cooperate with the Department
           medical support obligations when requested unless good              to establish paternity and obtain medical support or other pay-
           cause exists for not cooperating under 42 CFR 433.147 as            ments as provided in A.R.S. § 46-292(C). However, a pregnant
           of October 1, 2006, which is incorporated by reference,             woman under A.R.S. § 36-2901(6)(a)(ii) is not required to pro-
           on file with the Administration, and available from the             vide the Department with information regarding paternity or
           U.S. Government Printing Office, Mail Stop: IDCC, 732               medical support from a father of a child born out of wedlock.
           N. Capitol St., NW, Washington, DC, 20401. This incor-
                                                                                                    Historical ote
           poration by reference contains no future editions or
                                                                                New Section adopted by final rulemaking at 5 A.A.R.
           amendments. The Department shall not deny AHCCCS
                                                                                 294, effective January 8, 1999 (Supp. 99-1). Section
           eligibility to an applicant who would otherwise be eligi-
                                                                               repealed; new Section made by exempt rulemaking at 7
           ble, is a minor child, and whose parent or legal represen-
                                                                                A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
           tative does not cooperate with the medical support
                                                                               Section repealed; new Section made by final rulemaking
           requirements under subsection (E) or first- and third-
                                                                               at 11 A.A.R. 4942, effective December 31, 2005 (Supp.
           party liability requirements under Article 10 of this Chap-
                                                                               05-4). Amended by final rulemaking at 14 A.A.R. 1598,
           ter; and
                                                                                         effective May 31, 2008 (Supp. 08-2).
     3. Provide the following information concerning third-party
           coverage for medical care:                                     R9-22-1409. Withdrawal of Application
           a. Name of policyholder,                                       A. An applicant may withdraw an application at any time before
           b. Policyholder’s relationship to the applicant or mem-            the Department completes an eligibility determination by mak-
                 ber,                                                         ing an oral or written request for withdrawal to the Department
           c. SSN of the policy holder,                                       and stating the reason for withdrawal.
           d. Name and address of the insurance company, and              B. If an applicant orally requests withdrawal of the application,
           e. Policy number.                                                  the Department shall document the:
C.   A member or an applicant shall:                                          1. Date of the request,
     1. Send to the Department any medical support payments                   2. Name of the applicant for whom the withdrawal applies,
           received while the member is eligible that result from a                 and
           medical support order;                                             3. Reason for the withdrawal.
     2. Cooperate with the Administration or Administration’s             C. An applicant may withdraw an application in writing by:
           designee regarding any issues arising as a result of Eligi-        1. Completing a Department-approved voluntary with-
           bility Quality Control described under A.R.S. § 36-                      drawal form; or
           2903.01; and                                                       2. Submitting a written, signed, and dated request to with-
     3. Inform the Department of the following changes within                       draw the application.
           10 days from the date the applicant or member knows of a       D. The effective date of the withdrawal is the date of the applica-
           change:                                                            tion.
           a. In address;                                                 E. If an applicant requests to withdraw an application, the
           b. In the household’s composition;                                 Department shall:
           c. In income;                                                      1. Deny the application, and
           d. In resources, when required under R9-22-1438 for                2. Notify the applicant of the denial following the notice
                 the Medical Expense Deduction (MED) program;                       requirements under R9-22-1413.
           e. In Arizona state residency;
                                                                                                   Historical ote
           f. In citizenship or immigrant status;
                                                                                New Section adopted by final rulemaking at 5 A.A.R.
           g. In first- or third-party liability that may contribute to
                                                                                 294, effective January 8, 1999 (Supp. 99-1). Section
                 the payment of all or a portion of the person’s medi-
                                                                               repealed; new Section made by exempt rulemaking at 7
                 cal costs; or
                                                                                A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
           h. That may affect the member’s or applicant’s eligibil-
                                                                               Section repealed; new Section made by final rulemaking
                 ity, including a change in a woman’s pregnancy sta-
                                                                                   at 11 A.A.R. 4942, effective December 31, 2005
                 tus.
                                                                                                     (Supp. 05-4).
D.   As a condition of eligibility, an applicant or a member shall
     apply for other benefits as required under 42 CFR 435.608 as         R9-22-1410. Department Responsibilities
     of October 1, 2006, which is incorporated by reference, on file      A. The Department shall provide during the application process
     with the Administration, and available from the U.S. Govern-             to the applicant or member information explaining the require-
     ment Printing Office, Mail Stop: IDCC, 732 N. Capitol St.,               ments to:
     NW, Washington, DC, 20401. This incorporation by reference               1. Cooperate with DCSE in establishing paternity and
     contains no future editions or amendments.                                    enforcing medical support, except in circumstances when
E.   As a condition of eligibility, an applicant or a member shall                 good cause under 42 CFR 433.147 exists for not cooper-
     cooperate with the assignment of rights under R9-22-1404. If                  ating;
     the applicant or member receives medical care and services for           2. If applicable, establish good cause for not cooperating
     which a first or third party is or may be liable, the applicant or            with DCSE in establishing paternity and enforcing medi-
     member shall cooperate with the Department and the Adminis-                   cal support;
     tration in identifying and providing information to assist the           3. Report a change listed in R9-22-1408(C)(3) no later than
     Department and the Administration in pursuing any first or                    10 days from the date the applicant or member knows of
     third party who is or may be liable to pay for medical care and               the change;
     services.


Supp. 11-2                                                           Page 76                                                     June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

     4.   Send to the Department any medical support payments                Department. The member or the member’s legal or authorized
          received through a Title IV-D court order; and                     representative shall provide the Department with:
     5. Cooperate with the Department’s and Administration’s                 1. The reason for the withdrawal,
          assignment of rights and securing payments received                2. The date the notice is effective, and
          from any liable party for a member’s medical care.                 3. The name of the member for whom AHCCCS medical
B.   At initial application or eligibility review a Department repre-             coverage is being withdrawn.
     sentative shall:                                                   B.   The Department shall discontinue eligibility for AHCCCS
     1. Offer to help the applicant or member to complete the                medical coverage for all family members if the notice of with-
          application form and to obtain required verification;              drawal does not identify a specific person.
     2. Provide the applicant or member with information                C.   The Department shall notify the member of the discontinuance
          explaining:                                                        as required by R9-22-1415.
          a. The eligibility and verification requirements for
                                                                                                 Historical ote
                AHCCCS medical coverage,
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
          b. The requirement that the applicant or member obtain
                                                                               294, effective January 8, 1999 (Supp. 99-1). Section
                and provide a SSN to the Department,
                                                                             repealed; new Section made by exempt rulemaking at 7
          c. How the Department uses the SSN,
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          d. The Department’s practice of exchanging eligibility
                                                                             Section repealed; new Section made by final rulemaking
                and income information through the State Verifica-
                                                                                 at 11 A.A.R. 4942, effective December 31, 2005
                tion and Exchange System (SVES),
                                                                                                   (Supp. 05-4).
          e. The applicant and member’s right to appeal an
                adverse action under R9-22-1441,                        R9-22-1412. Verification of Eligibility Information
          f. The assignment of rights under operation of law as         A. An applicant or a member has the primary responsibility to
                provided in A.R.S. § 36-2903,                               provide the Department with information necessary to verify
          g. That the Department will use any information pro-              eligibility and complete the determination of eligibility at the
                vided by the member to complete data matches with           time of initial application, when a change in circumstances
                potentially liable parties,                                 occurs that may affect eligibility, or at the eligibility review
          h. The eligibility review process,                                under R9-22-1414. With the exception of subsection (B), the
          i. The program coverage and the types of services                 applicant or member shall use the following types of docu-
                available under each program,                               ments, in the following order, to verify information:
          j. The AHCCCS pre-enrollment process,                             1. First, hard copy verification: written evidence originating
          k. Availability of continued AHCCCS medical cover-                     from an agency, organization, or an individual with actual
                age under R9-22-1427,                                            knowledge of the information;
          l. That the Department will use the Systematic Alien              2. Second, a written record of a collateral contact: a verbal
                Verification for Entitlements (SAVE) process to ver-             statement from a representative of an agency or organiza-
                ify eligible alien status, and                                   tion, or an individual with actual knowledge of the infor-
          m. That the Department will help the applicant or mem-                 mation; and
                ber obtain necessary verification if the applicant or       3. Third, the applicant’s or member’s written statement, to
                member asks for help;                                            be used only if:
     3. Provide information regarding the penalties for perjury                  a. Verification under subsections (A)(1) and (A)(2) is
          and fraud printed on the application;                                        not available, and
     4. Review any verification items provided by the applicant                  b. The statement is not inconsistent with other informa-
          or member and inform the member of any additional ver-                       tion.
          ification items and time-frames within which the appli-       B. The Department shall not accept any form of verification other
          cant or member shall provide information to the                   than hard copy verification for:
          Department;                                                       1. SSN;
     5. Explain to the applicant or member the applicant’s and              2. Legal alien status;
          member’s responsibilities under R9-22-1408;                       3. Proof of alien sponsor under R9-22-1425, if applicable;
     6. Provide information regarding all reporting requirements            4. Relationship, when questionable; and
          and explain to the applicant or member that the applicant         5. Citizenship, when questionable.
          or member may lose the earned income disregards under         C. The Department shall only accept hard copy verification or a
          R9-22-1420 if the applicant or member fails to timely             collateral contact for verification of pregnancy and amounts
          report earned income changes.                                     billed for the care of a dependent child or incapacitated adult.
                                                                        D. The Department shall provide an applicant or member at least
                          Historical ote
                                                                            10 days from the date of a written request for information to
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                            provide required verification. The Department may deny the
        294, effective January 8, 1999 (Supp. 99-1). Section
                                                                            application or discontinue eligibility if an applicant or a mem-
     repealed; new Section made by exempt rulemaking at 7
                                                                            ber does not provide the required information timely.
       A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
     Section repealed; new Section made by final rulemaking                                       Historical ote
          at 11 A.A.R. 4942, effective December 31, 2005                       New Section adopted by final rulemaking at 5 A.A.R.
       (Supp. 05-4). Section repealed; new Section made by                      294, effective January 8, 1999 (Supp. 99-1). Section
      final rulemaking at 14 A.A.R. 1598, effective May 31,                   repealed; new Section made by exempt rulemaking at 7
                         2008 (Supp. 08-2).                                    A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                             Amended by exempt rulemaking at 10 A.A.R. 23, effec-
R9-22-1411. Withdrawal from AHCCCS Medical Coverage
                                                                                 tive December 9, 2003 (Supp. 03-4). Amended by
A. A member may withdraw from AHCCCS medical coverage at
                                                                             exempt rulemaking at 10 A.A.R. 4588, effective October
    any time by giving oral or written notice of withdrawal to the


June 30, 2011                                                      Page 77                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

      12, 2004 (Supp. 04-4). Section repealed; new Section                    Section repealed; new Section made by final rulemaking
      made by final rulemaking at 11 A.A.R. 4942, effective                       at 11 A.A.R. 4942, effective December 31, 2005
                December 31, 2005 (Supp. 05-4).                               (Supp. 05-4). Amended by final rulemaking at 14 A.A.R.
                                                                                     1598, effective May 31, 2008 (Supp. 08-2).
R9-22-1413. Time-frames, Approval, Discontinuance, or
Denial of an Application                                                 R9-22-1414. Review of Eligibility
A. Application processing time. The Department shall complete            A. Except as provided in subsection (B), the Department shall
    an eligibility determination under 42 CFR 435.911 within 45              complete a review of each member’s continued eligibility for
    days after the application date under R9-22-1406 unless:                 AHCCCS medical coverage at least once every 12 months.
    1. The applicant is pregnant. The Department shall com-              B. The Department shall complete a review of eligibility for a:
          plete an eligibility determination for a pregnant woman            1. Pregnant woman determined eligible under R9-22-
          within 20 days after the application date unless additional             1428(2) following the termination of her pregnancy,
          information is required to determine eligibility; or               2. Non-pregnant member approved only for Federal Emer-
    2. The applicant is in a hospital as an inpatient at the time of              gency Services at least once in a six-month period,
          application. Within seven days of the Department’s                 3. Member approved for the MED program under R9-22-
          receipt of a signed application the Department shall com-               1435 through R9-22-1440 before the end of the six-
          plete an eligibility determination if the Department does               month eligibility period,
          not need additional information or verification to deter-          4. Any time there is a change in a member’s circumstance
          mine eligibility.                                                       that may affect eligibility.
B. Approval. If the applicant meets all the eligibility require-         C. If a member continues to meet all eligibility requirements and
    ments and conditions of eligibility of this Article, the Depart-         conditions of eligibility, the Department shall authorize con-
    ment shall approve the application and provide the applicant             tinued eligibility and notify the member of continued eligibil-
    with an approval notice. The approval notice shall contain:              ity. If the member continues to be eligible for Federal
    1. The name of each approved applicant,                                  Emergency Services, the notice shall state that the continued
    2. The effective date of eligibility as defined in R9-22-1416            eligibility is for Federal Emergency Services only.
          for each approved applicant,                                   D. The Department shall discontinue eligibility and notify the
    3. The reason and the legal citations if a member is                     member of the discontinuance under R9-22-1415 if the mem-
          approved for only emergency medical services, and                  ber:
    4. The applicant’s right to appeal the decision under R9-22-             1. Fails to comply with the review of eligibility,
          1441(A).                                                           2. Fails to comply with the requirements and conditions of
C. Denial. If an applicant fails to meet the eligibility requirements             eligibility under this Article without good cause under 42
    or conditions of eligibility of this Article, the Department shall            CFR 433.148, or
    deny the application and provide the applicant with a denial             3. Does not meet the eligibility requirements.
    notice. The denial notice shall contain:
                                                                                                  Historical ote
    1. The name of each ineligible applicant,
                                                                               New Section adopted by final rulemaking at 5 A.A.R.
    2. The specific reason why the applicant is ineligible,
                                                                                294, effective January 8, 1999 (Supp. 99-1). Section
    3. The income and resource calculations for the applicant
                                                                              repealed; new Section made by exempt rulemaking at 7
          compared to the income or resource standards for eligibil-
                                                                               A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          ity when the reason for the denial is due to the applicant’s
                                                                              Section repealed; new Section made by final rulemaking
          income or resources exceeding the applicable standard,
                                                                                  at 11 A.A.R. 4942, effective December 31, 2005
    4. The legal citations supporting the reason for the ineligi-
                                                                                                    (Supp. 05-4).
          bility,
    5. The location where the applicant can review the legal             R9-22-1415.      otice of Adverse Action
          citations,                                                     A. Notice requirement. If a member fails to meet an eligibility
    6. The date of the application being denied; and                         requirement or condition of eligibility under this Chapter, the
    7. The applicant’s right to appeal the decision and request a            Department shall provide the member a Notice of Adverse
          hearing.                                                           Action no later than 10 days before the effective date of the
D. The Department shall reopen an application or reinstate eligi-            suspension, reduction, or discontinuance.
    bility of a member when any of the following conditions are          B. The Department shall mail a Notice of Adverse Action to a
    met:                                                                     member to discontinue eligibility no later than the effective
    1. The denial or discontinuance of eligibility was due to an             date of action if the Department:
          administrative error,                                              1. Receives a request to withdraw under R9-22-1411,
    2. The discontinuance of eligibility was due to noncompli-               2. Receives verification that the member is ineligible under
          ance with a condition of eligibility and the applicant or               R9-22-1402,
          member complies prior to the effective date of the discon-         3. Has documented information confirming the death of a
          tinuance,                                                               member,
    3. The member informs the Department of a change of cir-                 4. Receives returned mail with no forwarding address from
          cumstances prior to the effective date of the discontinu-               the post office and the member’s whereabouts are
          ance, that would allow for continued eligibility, or                    unknown, or
    4. Following a discontinuance the member requests and is                 5. Verifies that the member has been approved for Medicaid
          eligible for continuation of medical coverage pending an                by another state.
          appeal under R9-22-1441.                                       C. The Department shall ensure that the Notice of Adverse
                          Historical ote                                     Action contains:
       New Section adopted by final rulemaking at 5 A.A.R.                   1. The name of each ineligible member,
        294, effective January 8, 1999 (Supp. 99-1). Section                 2. The specific reason why the member is ineligible,
      repealed; new Section made by exempt rulemaking at 7                   3. The income and resource calculations compared to the
       A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                       income or resource standards when the reason for the dis-


Supp. 11-2                                                          Page 78                                                   June 30, 2011
                                                       Arizona Administrative Code                                              Title 9, Ch. 22
                                       Arizona Health Care Cost Containment System – Administration

          continuance is due to the member’s income or resources           Washington, DC, 20401. This incorporation by reference contains
          exceeding the applicable standard,                               no future editions or amendments. The Department shall not con-
     4.   The legal citations supporting the reason for ineligibility,     sider an alien who does not have immigrant status under 8 U.S.C.
     5.   The location where the member can review the legal cita-         1101(a)(15) to be a resident.
          tions,
                                                                                                    Historical ote
     6.   The date the discontinuance is effective, and
                                                                                 New Section adopted by final rulemaking at 5 A.A.R.
     7.   The member’s appeal rights and right to continued medi-
                                                                                  294, effective January 8, 1999 (Supp. 99-1). Section
          cal coverage pending appeal under R9-22-1441.
                                                                                repealed; new Section made by exempt rulemaking at 7
                         Historical ote                                          A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
      New Section adopted by final rulemaking at 5 A.A.R.                       Section repealed; new Section made by final rulemaking
       294, effective January 8, 1999 (Supp. 99-1). Section                         at 11 A.A.R. 4942, effective December 31, 2005
     repealed; new Section made by exempt rulemaking at 7                                             (Supp. 05-4).
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                           R9-22-1419. Citizenship and Immigrant Status
     Section repealed; new Section made by final rulemaking
                                                                           A. An applicant or a member is not eligible for full services under
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                               Article 2 of this Chapter, unless the applicant or member is a
                           (Supp. 05-4).
                                                                               citizen of the United States or is a qualified alien under A.R.S.
R9-22-1416. Effective Date of Eligibility                                      § 36-2903.03(B) or meets the requirements of A.R.S. § 36-
A. Except as provided in subsections (B) and (C), the effective                2903.03(C).
    date of eligibility is the first day of the month that the applicant   B. The Department shall use the Systematic Alien Verification for
    files an application if the applicant is eligible that month, or           Entitlements (SAVE) process to verify legal alien status.
    the first day of the first eligible month following the applica-       C. An applicant or member is eligible for emergency medical ser-
    tion month except for:                                                     vices under R9-22-217 if the applicant or member is either a
    1. The MED program under R9-22-1439, and                                   qualified alien or noncitizen and:
    2. Eligibility for a newborn under R9-22-1429.                             1. Meets all other eligibility requirements except those in
B. The effective date of eligibility for an applicant who moves                      subsection (A), and
    into Arizona during the month of application is the date Ari-              2. Is eligible under A.R.S. § 36-2901(6)(a)(i), (ii), or (iii).
    zona residency is established.
                                                                                                     Historical ote
C. The effective date of eligibility for an inmate applying for
                                                                                   New Section adopted by final rulemaking at 5 A.A.R.
    medical coverage is the date the applicant no longer meets the
                                                                                   294, effective January 8, 1999 (Supp. 99-1). Section
    definition of an inmate of a public institution.
                                                                                 repealed; new Section made by exempt rulemaking at 7
                         Historical ote                                            A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
      New Section adopted by final rulemaking at 5 A.A.R.                       Amended by final rulemaking at 9 A.A.R. 5123, effective
       294, effective January 8, 1999 (Supp. 99-1). Section                     January 3, 2004 (Supp. 03-4). Section repealed; new Sec-
     repealed; new Section made by exempt rulemaking at 7                        tion made by final rulemaking at 11 A.A.R. 4942, effec-
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                                tive December 31, 2005 (Supp. 05-4).
     Section repealed; new Section made by final rulemaking
                                                                           R9-22-1419.01.      Repealed
         at 11 A.A.R. 4942, effective December 31, 2005
                           (Supp. 05-4).                                                             Historical ote
                                                                                New Section made by final rulemaking at 9 A.A.R. 5123,
R9-22-1417. Social Security umber
                                                                                effective January 3, 2004 (Supp. 03-4). Section repealed
A. As a condition of eligibility, an applicant or a member shall
                                                                                by final rulemaking at 11 A.A.R. 4942, effective Decem-
    furnish a SSN under 42 CFR 435.910 and 435.920.
                                                                                               ber 31, 2005 (Supp. 05-4).
B. A person who is not able to legally obtain a SSN is not
    required to furnish a SSN.                                             R9-22-1419.02.      Repealed
C. The Department shall grant an applicant until the first review
                                                                                                     Historical ote
    of eligibility to provide a SSN if the applicant is cooperating
                                                                                New Section made by final rulemaking at 9 A.A.R. 5123,
    with the Department to obtain a SSN.
                                                                                effective January 3, 2004 (Supp. 03-4). Section repealed
D. If an applicant cannot recall the applicant’s SSN or has not
                                                                                by final rulemaking at 11 A.A.R. 4942, effective Decem-
    been issued a SSN, the Department shall assist in obtaining or
                                                                                               ber 31, 2005 (Supp. 05-4).
    verifying the applicant’s SSN under 42 CFR 435.910.
                                                                           R9-22-1419.03.      Repealed
                         Historical ote
      New Section adopted by final rulemaking at 5 A.A.R.                                            Historical ote
       294, effective January 8, 1999 (Supp. 99-1). Section                     New Section made by final rulemaking at 9 A.A.R. 5123,
     repealed; new Section made by exempt rulemaking at 7                       effective January 3, 2004 (Supp. 03-4). Section repealed
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                      by final rulemaking at 11 A.A.R. 4942, effective Decem-
     Section repealed; new Section made by final rulemaking                                    ber 31, 2005 (Supp. 05-4).
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                           R9-22-1419.04.      Repealed
                           (Supp. 05-4).
                                                                                                     Historical ote
R9-22-1418. State Residency
                                                                                New Section made by final rulemaking at 9 A.A.R. 5123,
An applicant or a member is not eligible unless the applicant or
                                                                                effective January 3, 2004 (Supp. 03-4). Section repealed
member is a resident of Arizona under 42 CFR 435.403 as of
                                                                                by final rulemaking at 11 A.A.R. 4942, effective Decem-
November 21, 1990, which is incorporated by reference and on file
                                                                                               ber 31, 2005 (Supp. 05-4).
with the Administration, and available from the U.S. Government
Printing Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,


June 30, 2011                                                         Page 79                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

R9-22-1420. Income Eligibility Criteria                                       8.   Earnings from high school on-the-job training programs;
A. Evaluation of income. In determining eligibility, the Depart-              9.   Earned income of a dependent child who is a student
    ment shall evaluate the following types of income received by                  enrolled and attending school at least half-time as defined
    a person identified in subsection (B):                                         by the institution;
    1. Earned income, including in-kind income, before any                    10. Fair Labor Standard Act supplemental payment;
         deductions. For purposes of this Section, in-kind income             11. Food stamp benefits;
         means room, board, or provision for other needs in                   12. Foster care maintenance payments intended for a child
         exchange for work performed. The person identified in                     who is not included in the family or Medical Expense
         subsection (B) shall ensure that the provider of the in-                  Deduction (MED) unit;
         kind income establishes and verifies the monetary value              13. Funds set aside in an Individual Development Account
         of the item provided. The provider may be, but is not lim-                under A.A.C. R6-12-404;
         ited to:                                                             14. Governmental rent and housing subsidies;
         a. A landlord who provides all or a portion of rent or               15. Income tax refunds, including any earned income tax
               utilities in exchange for services;                                 credit;
         b. A store owner who gives goods such as groceries,                  16. Loans from a private person or a commercial or educa-
               clothes, or furniture in exchange for services; or                  tional institution if there is a written agreement for repay-
         c. An individual who trades goods such as a car, tools,                   ment of the loan;
               trailer, building material, or gasoline in exchange for        17. Nonrecurring cash gifts that do not exceed $30 per person
               services;                                                           in any calendar quarter;
    2. Self-employment income under R9-22-1424, including                     18. Payments made from a fund established by the Susan
         gross business receipts minus business expenses; and                      Walker v. Bayer Corporation class action lawsuit or the
    3. Unearned income, including deemed income under R9-                          Ricky Ray Hemophilia Relief Fund Act of 1998;
         22-1425 from the sponsor of a non-citizen applicant.                 19. Radiation exposure compensation payments;
B. A person whose income is counted. The Department shall                     20. Reimbursement for work-related expenses that do not
    include the income of the following persons under Section                      exceed the actual expense amount;
    1902(a)(17) of the Act if living with the applicant unless the            21. Reimbursement for Job Opportunities and Basic Skills
    person is a SSI cash recipient:                                                (JOBS) Program training-related expenses;
    1. Applicant;                                                             22. Reparation and restitution payments under Section
    2. Applicant’s parent if the applicant is an unmarried depen-                  1902(r) of the Act;
         dent child who is less than 18 years old;                            23. SSI designated account and interest earned on the
    3. Applicant’s spouse;                                                         account;
    4. A sponsor under 8 CFR 213a.1 of a person meeting the                   24. Temporary Assistance for Needy Families (TANF) or SSI
         qualified alien requirements under A.R.S. § 36-2903.03                    cash assistance payment;
         and the sponsor’s spouse; and                                        25. Vendor payment made by an organization or person who
    5. A non-parent caretaker relative and spouse, as allowed                      is not a member of the family or MED unit, to a third
         under R9-22-1427, and their unmarried minor children if                   party to cover family expenses;
         applying as a family, including a dependent child living             26. Volunteers In Service To America (VISTA) income that
         with a caretaker relative.                                                does not exceed the state or federal minimum wage;
C. Income exclusions. The Department shall not count the fol-                 27. Vocational rehabilitation program payments made as
    lowing income:                                                                 reimbursement for training-related expenses, subsistence
    1. Agent Orange settlement fund payments;                                      and maintenance allowances, and incentive payments that
    2. AmeriCorps Network Program benefits;                                        are not intended as wages;
    3. Burial benefits dispersed solely for burial expenses;                  28. Women, Infants, and Children (WIC) benefits; or
    4. Cash contributions from agencies or organizations other                29. Any other income specifically excluded under 20 CFR
         than the Department or the Administration if the contri-                  416 Appendix to Subpart K, as of June 6, 1997, which is
         butions are not intended to cover the following items:                    incorporated by reference and on file with the Adminis-
         a. Food;                                                                  tration, and available from the U.S. Government Printing
         b. Rent or mortgage payments for shelter;                                 Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,
         c. Utilities;                                                             Washington, DC, 20401. This incorporation by reference
         d. Household supplies such as bedding, towels, laun-                      contains no future editions or amendments.
               dry, cleaning, and paper supplies;                        D.   Special income provision for child support. The Administra-
         e. Public transportation fares for personal use;                     tion or Administration’s designee shall consider child support
         f. Basic clothing or diapers; or                                     to be income of the child for whom the support is intended and
         g. Personal care and hygiene items, such as soap,                    count the child support income received after deducting $50
               toothpaste, shaving cream, and deodorant;                      per child receiving child support income from the monthly
    5. Disaster assistance provided under the Federal Disaster                amount.
         Relief Act, disaster assistance organizations, or compara-      E.   Determining income for a month.
         ble assistance provided by state or local governments;               1. Calculating monthly income. The Administration or
    6. Educational grants or scholarships funded by the United                     Administration’s designee shall calculate monthly
         States Department of Education or from a Veterans Edu-                    income under R9-22-1421 through R9-22-1426,
         cation assistance program or the Bureau of Indian Affairs            2. The Administration or Administration’s designee shall
         student assistance program;                                               deduct the applicable disregards and deductions to which
    7. Energy assistance that is provided:                                         a person is entitled for the month.
         a. Either in cash or in-kind by a government agency or          F.   Earned income disregards.
               municipal utility, or                                          1. General. The Department shall apply the earned income
         b. In-kind by a private nonprofit organization;                           disregards to each employed person’s gross earnings.


Supp. 11-2                                                          Page 80                                                      June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

    2.   Disregards. The Department shall apply the following                 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
         method to calculate the amount of the countable earned              Section repealed; new Section made by final rulemaking
         income under subsection (A):                                            at 11 A.A.R. 4942, effective December 31, 2005
         a. Subtract a $90 cost of employment (COE) allowance                                     (Supp. 05-4).
              from the gross amount of earned income for each
                                                                        R9-22-1422. Methods for Calculating Monthly Income
              person whose earned income is counted;
                                                                        A. Projecting income.
         b. Subtract an amount billed for the care of each depen-
                                                                            1. Description. Projecting income is a method of determin-
              dent child or incapacitated adult member who is the
                                                                                ing the amount of income that a person will receive.
              responsibility of the person whose income is
                                                                            2. Calculation. The Department shall project income by:
              counted, if the care is for the purpose of allowing the
                                                                                a. Converting income to a monthly equivalent,
              person to work. If more than one person in the
                                                                                b. Using unconverted income, or
              household is responsible for and billed for the care
                                                                                c. Prorating income to determine a monthly equivalent.
              of a dependent child the disregard may be split
                                                                            3. Exclusion. When calculating projected monthly income,
              between the wage earners to the benefit of the fam-
                                                                                the Administration or Administration’s designee shall
              ily, but shall not exceed the maximum disregards as
                                                                                exclude an unusual variation in income under R9-22-
              follows:
                                                                                1424(E), except for a month in which the variation is
              i. A maximum of $200 for each child under age
                                                                                anticipated to occur.
                    two and $175 for each other dependent for a
                                                                        B. Averaged income.
                    wage-earner employed full-time (86 or more
                                                                            1. Description. Averaging income proportionally distributes
                    hours per month); and
                                                                                the person’s income received on a regular basis.
              ii. A maximum of $100 for each child under age
                                                                            2. Calculation. To average income, the Administration or
                    two, and $88 for each other dependent for a
                                                                                Administration’s designee shall add the amount of the
                    wage earner employed part-time (less than 86
                                                                                income and divide by the total number of pay periods. If
                    hours a month).
                                                                                the amount of income received per pay period fluctuates,
    3.   Loss of disregards. The Department shall not apply the
                                                                                and the fluctuation is expected to continue, the Adminis-
         earned income disregards if the member fails to report to
                                                                                tration or designee shall:
         the Department a change in earned income within 10 days
                                                                                a. Use the averaged weekly or bi-weekly amounts to
         from the date the change becomes known to the member.
                                                                                      convert weekly or bi-weekly income to a monthly
         The change report to the Department shall be postmarked
                                                                                      equivalent;
         no later than the 10th day from the date the change
                                                                                b. Use the averaged monthly or semi-monthly amounts
         becomes known.
                                                                                      to project monthly income; and
                         Historical ote                                         c. Use the averaged hours worked and multiply the
      New Section adopted by final rulemaking at 5 A.A.R.                             average by the current rate of pay. If there is a
       294, effective January 8, 1999 (Supp. 99-1). Section                           change in the rate of pay, use the new rate of pay
     repealed; new Section made by exempt rulemaking at 7                             when calculating projected income under subsection
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                            (A).
     Section repealed; new Section made by final rulemaking             C. Prorated income.
         at 11 A.A.R. 4942, effective December 31, 2005                     1. Description. Prorated income evenly distributes a per-
                           (Supp. 05-4).                                        son’s income over the period the income is intended to
                                                                                cover to calculate a monthly equivalent.
R9-22-1421. Income Eligibility
                                                                            2. Calculation. To prorate income, the Administration or
A. A person is eligible under this Article unless the person’s
                                                                                designee shall divide the total amount of the person’s
    monthly income exceeds the appropriate Federal Poverty
                                                                                income received during the period by the number of
    Level (FPL) listed in R9-22-1427 and R9-22-1428. A person
                                                                                months that the income is intended to cover.
    is eligible under R9-22-1437 unless the person’s income dur-
                                                                        D. Converted income.
    ing the period defined in R9-22-1437(C) exceeds the FPL
                                                                            1. Description. Converted income is income received
    under R9-22-1437(B).
                                                                                weekly or biweekly that is changed to a monthly equiva-
B. The Administration or Administration’s designee shall con-
                                                                                lent.
    sider the following factors when determining the income
                                                                            2. Calculation.
    period to use to determine monthly income:
                                                                                a. The Administration or designee shall average the
    1. Type of income,
                                                                                      weekly or bi-weekly income amounts before con-
    2. Frequency of income,
                                                                                      verting to the monthly equivalent if the person’s past
    3. If source of income is new or terminated, or
                                                                                      income fluctuates and the fluctuation is expected to
    4. Income fluctuation
                                                                                      recur.
C. Definitions.
                                                                                b. To convert income paid weekly to a monthly equiva-
    1. “Monthly income” means the gross countable income
                                                                                      lent, the Administration or designee shall multiply
          received or projected to be received during the month or
                                                                                      the weekly average by 4.3 weeks.
          the monthly equivalent.
                                                                                c. To convert income paid bi-weekly to a monthly
    2. “Monthly equivalent” means a monthly countable income
                                                                                      equivalent, the Administration or designee shall
          amount established by averaging, prorating, or converting
                                                                                      multiply the bi-weekly average by 2.15 weeks.
          a person’s income.
                                                                        E. Unconverted income.
                         Historical ote                                     1. Description. Unconverted income is the actual amount of
      New Section adopted by final rulemaking at 5 A.A.R.                       income received or projected to be received during a
       294, effective January 8, 1999 (Supp. 99-1). Section                     month.
     repealed; new Section made by exempt rulemaking at 7



June 30, 2011                                                      Page 81                                                       Supp. 11-2
Title 9, Ch. 22                                     Arizona Administrative Code
                                    Arizona Health Care Cost Containment System – Administration

     2.   Calculation. The Administration or designee shall sum           1.   Description. Terminated income is income received dur-
          the actual amount of income received or projected to be              ing the last calendar month that income is received from a
          received during a month.                                             source when no more income is expected to be received
                                                                               from the source.
                         Historical ote
                                                                          2. Calculating monthly income.
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                               a. If a full month’s income is received, the Administra-
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                     tion or Administration’s designee shall use the
     repealed; new Section made by exempt rulemaking at 7
                                                                                     appropriate method described in R9-22-1423 to cal-
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                                     culate the monthly income.
     Section repealed; new Section made by final rulemaking
                                                                               b. If less than a full month’s income is received, the
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                                     Administration or Administration’s designee shall
                           (Supp. 05-4).
                                                                                     use the unconverted method to calculate the monthly
R9-22-1423. Calculations and Use of Methods Listed in R9-22-                         income.
1422 Based on Frequency of Income                                    C.   Break in income.
A. Monthly income. If income is received monthly or in a lump             1. Description. A break in income is a break in established
    sum, the Administration or designee shall use the unconverted              frequency of income of one calendar month or more.
    method for calculating monthly income.                                2. Calculating monthly income.
    1. Lump sum means a nonrecurring payment that serves as a                  a. If a full month’s income is received, the Administra-
          complete payment.                                                          tion or Administration’s designee shall use the
    2. Lump sum payments include but are not limited to:                             appropriate method described in R9-22-1423 to cal-
          rebates or credits; inheritances; insurance settlements;                   culate the monthly income.
          and payments for prior months from such sources as                   b. If less than a full month’s income is received, the
          Social Security, Veterans Administration, Railroad                         Administration or Administration’s designee shall
          Retirement, child support arrearages, or other benefits.                   use the unconverted method to calculate the monthly
    3. A lump sum payment may include a portion intended for                         income.
          the current month.                                         D.   Contract income.
B. Weekly income. If income is received weekly, the Administra-           1. Description. Contract income is income a person earns
    tion or designee shall convert the income to a monthly equiva-             under a contract or other legal document that specifies a
    lent under R9-22-1422(D).                                                  length of time the contract or legal document covers, the
C. Bi-weekly income. If income is received bi-weekly, the                      amount of income to be paid, and the frequency of pay-
    Administration or designee shall convert the income to a                   ment.
    monthly equivalent under R9-22-1422(D).                               2. Calculating monthly income.
D. Semi-monthly or daily income. If income is received semi-                   a. The Administration or designee shall calculate the
    monthly or daily, the Administration or designee shall use the                   monthly income based on the frequency of payment
    unconverted method for calculating monthly income under                          if income is paid more frequently than monthly.
    R9-22-1422(E).                                                             b. The Administration or designee shall prorate over
E. Bimonthly, quarterly, semi-annual, or annual income. If                           the period of time specified by the contract if income
    income is received bimonthly, quarterly, semi-annually, or                       is paid monthly or less frequently.
    annually, the Administration or designee shall prorate the       E.   Unusual variation in the amount of income.
    income received or projected to be received under R9-22-              1. Description. Unusual variation is an amount of income
    1422(C).                                                                   that is different from the established amount received and
                                                                               is not projected to continue or recur.
                         Historical ote
                                                                          2. Calculating monthly income.
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                               a. When calculating income for the month in which an
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                     unusual variation in income occurs, the Administra-
     repealed; new Section made by exempt rulemaking at 7
                                                                                     tion or designee shall include the unusual variation
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                                     in the income calculation.
     Section repealed; new Section made by final rulemaking
                                                                               b. When an unusual variation in income occurs during
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                                     the month, the Administration or Administration’s
                           (Supp. 05-4).
                                                                                     designee shall use the converted method for calcu-
R9-22-1424. Use of Methods Listed in R9-22-1423 Based on                             lating monthly income if income is received weekly
Type of Income                                                                       or bi-weekly.
A. New income.                                                                 c. When projecting income for the months following
    1. Description. New income is income received from a new                         the month in which the unusual variation occurs, the
         source during the first calendar month that the income is                   Administration or designee shall exclude the
         received from the source.                                                   unusual variation in income from the income calcu-
    2. Calculating monthly income.                                                   lation.
         a. If a full month’s income is received, the Administra-    F.   Self-employment income.
              tion or Administration’s designee shall use the             1. Description. Self-employment income is income a person
              appropriate method described in R9-22-1423 to cal-               earns from the person’s own trade or business less allow-
              culate the monthly income.                                       able expenses.
         b. If less than a full month’s income is received, the           2. Calculating monthly income. The Administration or
              Administration or Administration’s designee shall                Administration’s designee shall use the following meth-
              use the unconverted method to calculate the monthly              ods in the following order:
              income.                                                          a. When the self-employed person filed a tax return for
B. Terminated income.                                                                the prior year and the person states that the current
                                                                                     income is the same, the Administration or Adminis-


Supp. 11-2                                                      Page 82                                                     June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

                tration’s designee shall prorate the income under R9-             b. The sponsor’s dependent children, and
                22-1422.                                                          c. The sponsor’s spouse’s dependent children;
          b.    When the self-employed person did not file a tax             2.   The Department shall subtract the total gross income
                return for the prior year or states that the current              from 100% of the FPL for the sponsor’s family size; and
                income is not the same, the Administration or                3.   The amount calculated under subsections (D)(1) and
                Administration’s designee shall:                                  (D)(2) represents the remaining amount deemed to the
                i. Use the person’s business ledger or other                      applicant from the sponsor.
                      records to verify the current income received,
                                                                                                 Historical ote
                      less allowable expenses; and
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
                ii. Use the appropriate method described in R9-
                                                                               294, effective January 8, 1999 (Supp. 99-1). Section
                      22-1423 to calculate the monthly income.
                                                                             repealed; new Section made by exempt rulemaking at 7
          c.    When the self-employed person did not file a tax
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                return or keep business records of the income
                                                                             Section repealed; new Section made by final rulemaking
                received and expense incurred during the income
                                                                                 at 11 A.A.R. 4942, effective December 31, 2005
                period, the Administration or Administration’s des-
                                                                                                   (Supp. 05-4).
                ignee:
                i. Shall use the person’s written statement to ver-     R9-22-1426. Exemptions from Sponsor Deemed Income
                      ify income received,                              A. An applicant shall provide proof to the Administration or des-
                ii. Shall not deduct incurred expenses from the             ignee when claiming an exemption from sponsor deemed
                      income without hard-copy verification of the          income.
                      expense, and                                      B. The Administration or designee shall grant an exemption from
                iii. Shall use the appropriate method described in          using a sponsor’s income for a Lawful Permanent Resident
                      R9-22-1423 to calculate the monthly income.           applicant if the applicant:
                                                                            1. Entered the U.S. or applied for a visa or adjustment of
                         Historical ote
                                                                                  status before December 19, 1997;
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                            2. Adjusted immigration status to Lawful Permanent Resi-
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                  dent from status as a refugee or asylee;
     repealed; new Section made by exempt rulemaking at 7
                                                                            3. Qualifies only for Federal Emergency Services;
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                            4. Has a sponsor who signed an Affidavit of Support other
     Section repealed; new Section made by final rulemaking
                                                                                  than the USCIS Form I-864;
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                            5. Is the spouse or child of the sponsor and lives with the
                           (Supp. 05-4).
                                                                                  sponsor;
R9-22-1425. Sponsor Deemed Income                                           6. Is indigent as specified in subsection (C);
A. The Administration or Administration’s designee shall use                7. Is a victim of domestic violence or extreme cruelty as
    income of a USCIS sponsor to determine eligibility for a non-                 specified in subsection (D); or
    citizen applicant, whether or not the income is available, to the       8. Has acquired 40 qualified quarters of work credit based
    non-citizen applicant unless exempt under R9-22-1426.                         on earnings as specified in subsection (E).
B. Counting the income from a sponsor.                                  C. The Administration or designee shall grant an exemption from
    1. This Section applies to non-citizens applicants who:                 sponsor deemed income for indigent applicants for a period of
          a. Are Lawful Permanent Residents under 8 CFR                     12 months beginning with the application month. The Admin-
               101.3;                                                       istration or designee shall redetermine indigent status at each
          b. Applied for Lawful Permanent Resident Status on or             eligibility renewal.
               after December 19, 1997;                                     1. An applicant is indigent if all of the following are met:
          c. Are sponsored by an individual who signed a USCIS                    a. The applicant does not reside with the applicant’s
               I-864 Affidavit of Support; and                                         sponsor;
          d. Are eligible for full AHCCCS medical coverage.                       b. The applicant does not receive free room and board;
    2. Sponsor deemed income shall be considered the income                            and
          of the non-citizen applicant only.                                      c. The applicant’s total gross income including monies
    3. The Administration shall not use the provisions of this                         received from the sponsor and the value of any ven-
          Section and R9-22-1426 when:                                                 dor payments received for food, utilities, or shelter
          a. The applicant becomes a naturalized U.S. citizen;                         does not exceed 100% of the FPL.
          b. The applicant qualifies for an exemption listed in             2. The Administration shall send a notice to the Department
               R9-22-1426; or                                                     of Homeland Security when approving an applicant who
          c. The sponsor dies.                                                    is exempt from sponsor deemed income due to indigency.
C. Determining income from a sponsor.                                   D. The Administration shall grant an exemption from sponsor
    1. For an applicant who is exempt under R9-22-1426(C) and               deemed income for an applicant who is a victim of domestic
          (D), only cash contributions actually received from the           violence or extreme cruelty under 8 CFR 204.2 for a period of
          sponsor are countable income to the applicant.                    12 months beginning with the application month. The Admin-
    2. For an applicant to whom the sponsor’s income is                     istration shall redetermine the exemption status at each
          deemed, the Department shall exclude any cash contribu-           renewal.
          tions received from the sponsor.                                  1. The Administration considers an applicant to be a victim
D. Calculation of income from a sponsor.                                          of domestic violence or extreme cruelty when all of the
    1. The Department shall include the total gross income of                     following are met:
          the sponsor and the following individuals who live in the               a. The applicant is the victim, the parent of a child vic-
          sponsor’s household:                                                         tim, or the child of a parent victim;
          a. The sponsor’s spouse,


June 30, 2011                                                      Page 83                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          b.   The perpetrator of the domestic violence or extreme            2.   A dependent child who is age 18 and:
               cruelty was the spouse or parent of the victim or                   a. A full-time student at a secondary school or attend-
               other family member related by blood, marriage or                         ing a vocational or technical training school that
               adoption to the victim;                                                   includes shop practicum for at least 30 hours per
          c. The perpetrator was residing in the same household                          week or does not include shop practicum and atten-
               as the victim when the abuse occurred;                                    dance is at least 25 hours per week, and
          d. The abuse occurred in the United States;                              b. Reasonably expected to complete the education or
          e. The applicant did not participate in the domestic vio-                      training before age 19; and
               lence or cruelty; and                                          3. A natural or adoptive parent of a dependent child.
          f. The victim does not currently live with the perpetra-       C.   The Department shall include in the family unit, the spouse of
               tor.                                                           the dependent child’s parent if the spouse wants to apply for
     2. The applicant shall provide proof that the applicant or the           AHCCCS medical coverage. The Department shall include the
          applicant’s child is a victim of domestic violence or               spouse of the non-parent caretaker relative if:
          extreme cruelty by presenting one of the following:                 1. The non-parent caretaker relative applies and is eligible,
          a. USCIS form I-360 Petition for Ameriasian, Widow,                      and
               or Special Immigrant;                                          2. The non-parent caretaker relative applies for the spouse.
          b. USCIS form I-797 USCIS approval of the I-360                D.   The Department shall include in the family unit, a dependent
               petition;                                                      child’s non-parent caretaker relative if the non-parent care-
          c. Reports or affidavits concerning the domestic vio-               taker relative wants to apply for AHCCCS medical coverage
               lence or cruelty from police, judges, or other court           and:
               officials, medical personnel, school officials, clergy,        1. Provides the dependent child with:
               social workers, counseling or mental health person-                 a. Physical care,
               nel, or other social service agency personnel;                      b. Support,
          d. Legal documentation, such as an order of protection                   c. Guidance, and
               against the perpetrator or an order convicting the                  d. Control; and
               perpetrator of committing an act of domestic vio-              2. The parent of a dependent child:
               lence or extreme cruelty that chronicles the exist-                 a. Does not live in the non-parent caretaker relative’s
               ence of domestic violence or extreme cruelty;                             home;
          e. Evidence that indicates that the applicant sought safe                b. Lives with the non-parent caretaker relative but is
               haven in a battered women’s shelter or similar ref-                       also a dependent child; or
               uge because of the domestic violence or extreme                     c. Lives with the non-parent caretaker relative but can-
               cruelty against the applicant or the applicant’s child;                   not function as a parent due to physical or mental
               or                                                                        impairment.
          f. Photographs of the applicant or applicant’s child           E.   The Department shall not include a SSI-cash recipient in the
               showing visible injury.                                        family unit.
E.   The Administration shall grant an exemption from sponsor            F.   A child is considered a deprived dependent if deprived of
     deemed income for an applicant who has reached 40 qualify-               parental support and care by:
     ing quarters of work credit.                                             1. Continued absence of a parent;
     1. The Administration or Administration’s designee shall                 2. Death of a parent;
          not count quarters credited after January 1, 1997 that              3. Disability of a parent, as determined by a healthcare prac-
          were earned while the applicant was receiving any federal                titioner;
          means-tested benefits.                                              4. Unemployment or under-employment of a parent in a
     2. The Administration shall not count the 40 qualifying                       two-parent assistance unit under subsection (I).
          quarters of work credit unless the credited quarters are:      G.   Continued absence of a parent.
          a. Quarters that the applicant worked;                              1. Continued absence under subsection (F) is established:
          b. Quarters worked by the applicant’s spouse or                          a. When absence of the parent from the home either
               deceased spouse during their marriage; or                                 interrupts or terminates the parent’s functioning as a
          c. Quarters worked by the applicant’s parents when the                         provider of support, physical care, or guidance for
               applicant was under age 18.                                               the child;
                                                                                   b. When absence of the parent from the house for a
                         Historical ote
                                                                                         known or indefinite duration precludes relying on
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                                         the parent for the present support or care of the
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                         child; or
     repealed; new Section made by exempt rulemaking at 7
                                                                                   c. When the parent’s absence from the home is for a
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                                         period of 30 days or more and for any reason other
     Section repealed; new Section made by final rulemaking
                                                                                         than those listed in subsection (G)(2).
         at 11 A.A.R. 4942, effective December 31, 2005
                                                                              2. The Department shall not consider the following to be
                           (Supp. 05-4).
                                                                                   continued absence:
R9-22-1427. Eligibility for a Family                                               a. The parent is voluntarily absent to visit friends or
A. A family unit with an eligible deprived dependent child is eli-                       relatives, to seek employment or maintain a job, or
    gible for AHCCCS medical coverage when the requirements                              to attend school or training if the parent in the home
    of this Section are met. A woman in her third trimester of                           and the absent parent are not separated;
    pregnancy with no other dependent children is considered a                     b. The parent is absent due to active military duty;
    family unit with a dependent child.                                            c. The parents live in separate dwellings and the dwell-
B. A family unit includes the following when living together:                            ings are considered part of a single home; or
    1. A natural or adopted dependent child under age 18,


Supp. 11-2                                                          Page 84                                                     June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

          d.  One parent is absent from the home in order to allow          (K)(3)(a) and up to four months if eligible under subsection
              the remaining family members to qualify for medi-             (K)(3)(b) if the family unit’s income exceeds 100 percent of
              cal assistance.                                               the FPL and the following conditions are met:
H. Disability of a parent, as determined by a healthcare practitio-         1. The family continues to include a dependent child;
   ner.                                                                     2. The family received AHCCCS medical coverage under
   1. Disability is established if the parent or applicant pro-                  this Section for three calendar months out of the most
        vides a medical statement from a healthcare practitioner                 recent six months; and
        that includes:                                                      3. The loss of AHCCCS coverage under this Section is due
        a. A diagnosis of the parent’s medical condition,                        to:
        b. A finding that the parent has a physical or mental                    a. Increased earned income of the caretaker relative
              condition that prevents the parent from working, and                    and the person is a member of the family unit in
        c. An opinion concerning the duration of unemploy-                            accordance with 42 U.S.C. 1396a(e)(1) and 42
              ability or a date for re-evaluation of unemployabil-                    U.S.C. 1396r-6, or
              ity.                                                               b. Increased spousal or child support and the family
   2. Disability is established without further medical verifica-                     unit member meets requirements under 42 CFR
        tion if the parent or applicant provides evidence that:                       435.115(f).
        a. The Social Security Administration (SSA) has deter-         L.   An applicant may be added to the continued medical coverage
              mined that the parent is eligible for Retirement, Sur-        of a family unit, under subsection (K)(3)(a), if the applicant
              vivors, Disability Insurance (RSDI) benefits due to           did not reside with the family unit at the time continued medi-
              blindness or disability;                                      cal coverage under this Section was determined and the appli-
        b. The SSA has determined that the parent is eligible               cant is:
              for Supplemental Security Income (SSI) due to                 1. The spouse or dependent child of the family unit receiv-
              blindness or disability;                                           ing continued medical coverage, or
        c. The Veteran’s Administration has determined that                 2. The parent of a dependent child who is a member of the
              the parent has a 100% disability;                                  family unit receiving continued medical coverage.
        d. The parent’s healthcare practitioner has released the
                                                                                                Historical ote
              parent from the hospital and imposed work restric-
                                                                             New Section adopted by final rulemaking at 5 A.A.R.
              tions for a specified recuperation period;
                                                                              294, effective January 8, 1999 (Supp. 99-1). Section
        e. The parent’s employer or physician has required the
                                                                            repealed; new Section made by exempt rulemaking at 7
              parent to terminate employment due to the onset of a
                                                                             A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
              disability and the healthcare practitioner has speci-
                                                                            Section repealed; new Section made by final rulemaking
              fied a recuperation period;
                                                                                at 11 A.A.R. 4942, effective December 31, 2005
        f. The parent’s healthcare practitioner has determined
                                                                                                  (Supp. 05-4).
              that the parent is capable of employment only in a
              sheltered workshop under 26 U.S.C. 151(c)(5)(B),         R9-22-1428. Eligibility for a Person ot Eligible as a Family
              for a specified period of time, and the parent is so     Income standards. A person who is not approved in a family unit
              employed; or                                             under R9-22-1427 but meets all the eligibility requirements in the
        g. A prior certification of the parent’s disability by a       Article is eligible for AHCCCS medical coverage if countable
              healthcare practitioner is in the applicant’s case       income does not exceed the following percentage of the FPL:
              record as maintained by the Department and is still           1. 150 percent for a pregnant woman,
              valid to cover the period in which assistance is              2. 140 percent for a child under one year of age,
              requested and will be received.                               3. 133 percent for a child age one through five years of age,
I. Unemployment or under-employment of a parent in a two-par-                    or
   ent assistance unit.                                                     4. 100 percent for all other persons.
   1. A child is deprived if the primary wage earning parent is
                                                                                                  Historical ote
        unemployed or underemployed and the two-parent assis-
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
        tance unit meets the following requirements:
                                                                               294, effective January 8, 1999 (Supp. 99-1). Section
        a. The child’s natural or adoptive mother and father
                                                                             repealed; new Section made by exempt rulemaking at 7
              both reside with the child, and
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
        b. Neither parent meets the provisions of subsection
                                                                            Section repealed; new Section made by final rulemaking
              (F)(3).
                                                                                 at 11 A.A.R. 4942, effective December 31, 2005
   2. “Underemployment” means the parent’s earned income
                                                                            (Supp. 05-4). Amended by final rulemaking at 14 A.A.R.
        combined with the assistance unit’s other countable
                                                                                    1598, effective May 31, 2008 (Supp. 08-2).
        income does not exceed the income standards provided in
        subsection (J).                                                R9-22-1429. Eligibility for a ewborn
   3. “Primary wage earner” means the parent in a two-parent           A child born to a mother eligible for and receiving medical cover-
        assistance unit who earned the greater amount of income        age under this Article, Article 15 of the Chapter, or 9 A.A.C. 28, is
        in the 24-month period immediately preceding the month         automatically eligible for AHCCCS medical coverage for a period
        in which an application for assistance is submitted.           not to exceed 12 months if the child continuously lives with the
J. Income standard. A family unit is not eligible if the family        mother in the state of Arizona. Automatic eligibility begins on the
   unit’s countable income exceeds 100 percent of the FPL              child’s date of birth and ends with the last day of the month in
   adjusted annually for the family unit.                              which the child turns age one. The Department shall conduct an
K. Continued medical coverage. An eligible member of the fam-          informal review when the child is six months old to ensure the child
   ily unit under this Section is entitled to continued AHCCCS         resides with the mother in Arizona.
   coverage for up to 12 months if eligible under subsection



June 30, 2011                                                     Page 85                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

                         Historical ote                                      8.   Becomes eligible under 9 A.A.C. 22, 9 A.A.C. 28, or 9
      New Section adopted by final rulemaking at 5 A.A.R.                         A.A.C. 31 for full services under Article 2 of this Chap-
       294, effective January 8, 1999 (Supp. 99-1). Section                       ter;
     repealed; new Section made by exempt rulemaking at 7                    9. Becomes sterile; or
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                   10. Dies.
     Section repealed; new Section made by final rulemaking             E.   The Administration or its designee shall not reinstate eligibil-
         at 11 A.A.R. 4942, effective December 31, 2005                      ity under this Section after the effective date of a discontinu-
                           (Supp. 05-4).                                     ance of eligibility unless the discontinuance is overturned on
                                                                             appeal or resulted from an administrative error.
R9-22-1430. Extended Medical Coverage for a Pregnant
Woman                                                                                              Historical ote
A. A pregnant woman who applies for and is determined eligible                 New Section adopted by final rulemaking at 5 A.A.R.
    for AHCCCS medical coverage during the pregnancy remains                    294, effective January 8, 1999 (Supp. 99-1). Section
    eligible throughout the postpartum period.                                repealed; new Section made by exempt rulemaking at 7
B. The postpartum period begins the day the pregnancy termi-                    A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
    nates and ends the last day of the month in which the 60th day           Section repealed; new Section made by final rulemaking
    following pregnancy termination.                                              at 11 A.A.R. 4942, effective December 31, 2005
                                                                             (Supp. 05-4). Amended by final rulemaking at 13 A.A.R.
                         Historical ote
                                                                              2633, effective July 10, 2007 (Supp. 07-3). Amended by
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                               final rulemaking at 14 A.A.R. 1598, effective May 31,
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                                 2008 (Supp. 08-2).
     repealed; new Section made by exempt rulemaking at 7
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).              R9-22-1432. Young Adult Transitional Insurance
     Section repealed; new Section made by final rulemaking             A person under the age of 21 who was in the custody of the Depart-
         at 11 A.A.R. 4942, effective December 31, 2005                 ment of Economic Security under A.R.S. Title 8, Chapter 5 or
                           (Supp. 05-4).                                Chapter 10 on the person’s 18th birthday is eligible for AHCCCS
                                                                        medical coverage under A.R.S. § 36-2901(6)(a)(iii).
R9-22-1431. Family Planning Services Extension Program
(FPEP)                                                                                           Historical ote
A. A member who loses eligibility for AHCCCS medical cover-                   New Section adopted by final rulemaking at 5 A.A.R.
    age under R9-22-1430 due to the postpartum period ending                   294, effective January 8, 1999 (Supp. 99-1). Section
    and who has no other creditable coverage, as specified in 42             repealed; new Section made by exempt rulemaking at 7
    U.S.C. 300gg(c), may receive up to 24 months of family plan-              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
    ning services as provided in this Section and A.R.S. § 36-               Section repealed; new Section made by final rulemaking
    2907.04.                                                                     at 11 A.A.R. 4942, effective December 31, 2005
B. Review of eligibility.                                                                          (Supp. 05-4).
    1. The Department shall complete a review of each mem-
                                                                        R9-22-1433. Special Groups for Children
          ber’s continued eligibility for FPEP at least once every 12
                                                                        The Administration shall provide AHCCCS medical coverage to
          months.
                                                                        children eligible for Title IV-E adoption subsidy or Title IV-E foster
    2. If a member continues to meet all eligibility require-
                                                                        care under 42 CFR 435.145 and children eligible for state adoption
          ments, the Department shall authorize continued eligibil-
                                                                        subsidy under 42 CFR 435.227.
          ity for the FPEP and notify the member of continued
          eligibility.                                                                           Historical ote
    3. The Department shall discontinue eligibility and notify                New Section adopted by final rulemaking at 5 A.A.R.
          the member of the discontinuance under R9-22-1415 if                 294, effective January 8, 1999 (Supp. 99-1). Section
          the member:                                                        repealed; new Section made by exempt rulemaking at 7
          a. Has income that exceeds 150 percent of the FPL at                A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                the time of the 12-month review,                             Section repealed; new Section made by final rulemaking
          b. Fails to comply with a review of eligibility under                  at 11 A.A.R. 4942, effective December 31, 2005
                this subsection, or                                                                (Supp. 05-4).
          c. Meets any of the criteria under subsection (D).
                                                                        R9-22-1434. Repealed
C. Changes in the member’s income after the initial or review eli-
    gibility determination shall not impact the member’s eligibility                              Historical ote
    during the following 12-month period.                                      New Section adopted by final rulemaking at 5 A.A.R.
D. The Administration or its designee shall deny or terminate a                 294, effective January 8, 1999 (Supp. 99-1). Section
    member from FPEP under this Section if the member:                        repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
    1. Voluntarily withdraws from the program;                               tive October 1, 2001 (Supp. 01-3). New Section made by
    2. Has whereabouts that are unknown;                                     exempt rulemaking at 7 A.A.R. 5701, effective December
    3. Fails to provide information to the Administration or the               1, 2001 (Supp. 01-4). Section repealed by exempt rule-
          Administration’s designee;                                           making at 10 A.A.R. 4588, effective October 12, 2004
    4. Becomes an inmate of a public institution;                                                   (Supp. 04-4).
    5. Moves out-of-state;
                                                                        R9-22-1435. Eligibility for a Person With Medical Expenses
    6. Has creditable coverage under 42 U.S.C. 300gg(c);
                                                                        Whose Income is Over 100 Percent FPL
    7. Fails to meet the documentation requirements for U.S.
                                                                        An applicant who is not eligible for AHCCCS medical coverage
          citizenship or legal alien status under A.R.S. § 36-
                                                                        due to excess income may become AHCCCS eligible by deducting
          2903.03;
                                                                        medical expenses from the applicant’s income. This coverage is
                                                                        called Medical Expense Deduction (MED).


Supp. 11-2                                                         Page 86                                                     June 30, 2011
                                                     Arizona Administrative Code                                              Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

                          Historical ote                                   2.   Disregard from the remaining earned income an amount
        New Section adopted by final rulemaking at 5 A.A.R.                     billed by the provider for the care of each dependent child
        294, effective January 8, 1999 (Supp. 99-1). Section                    under age 18 or incapacitated adult member of the MED
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                    family unit if the care is for the purpose of allowing the
     tive October 1, 2001 (Supp. 01-3). New Section made by                     person to work. If more than one person in the household
      final rulemaking at 11 A.A.R. 4942, effective December                    is responsible for and billed for the care of a dependent
                       31, 2005 (Supp. 05-4).                                   child, the disregard may be split between the wage earn-
                                                                                ers if splitting the disregard is to the benefit of the family,
R9-22-1436. MED Family Unit
                                                                                but shall not exceed the maximum disregards as follows:
A. For the purpose of this Section, a child is an unmarried person
                                                                                a. A maximum of $200 for a child under age two and
    under age 18.
                                                                                      $175 for other dependents for a wage-earner
B. The Department shall consider each of the following to be a
                                                                                      employed full-time (86 or more hours per month);
    family when living together:
                                                                                      and
    1. A parent and the parent’s children;
                                                                                b. A maximum of $100 for a child under age two, and
    2. A married couple without children;
                                                                                      $88 for other dependents for a wage earner
    3. A married couple and the children of either or both
                                                                                      employed part-time (less than 86 hours a month);
         spouses;
                                                                           3. Add the remaining earned income for each MED family
    4. Unmarried parents who live with at least one child in
                                                                                member to the unearned income of all MED family mem-
         common, and the parents’ other children, whether in
                                                                                bers;
         common or not; and
                                                                           4. Compare the MED family’s unit countable income
    5. A person without children.
                                                                                amount to the income standard in subsection (B). The dif-
C. If an applicant is pregnant, the family unit includes the number
                                                                                ference is the amount of medical expenses the family
    of unborn children.
                                                                                shall incur during the medical expense deduction period
D. A child of the children included in subsections (B)(1), (B)(3),
                                                                                to become eligible;
    or (B)(4) is considered part of the family unit when living
                                                                           5. Subtract allowable medical expense deductions that were
    together.
                                                                                incurred by:
E. The Department shall not include a SSI-cash recipient in the
                                                                                a. A member of the MED family unit;
    MED family unit even if the SSI-cash recipient is a parent,
                                                                                b. A deceased spouse or minor child of a MED family
    spouse, or child.
                                                                                      unit if this person would have been a member of the
                          Historical ote                                              MED unit during the MED expense deduction
        New Section adopted by final rulemaking at 5 A.A.R.                           period;
        294, effective January 8, 1999 (Supp. 99-1). Section                    c. A person who was a minor child of a MED family
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                          unit member when the expense was incurred but
     tive October 1, 2001 (Supp. 01-3). New Section made by                           who is no longer a minor child; or
      final rulemaking at 11 A.A.R. 4942, effective December                    d. A minor child, including a child who is a runaway,
                       31, 2005 (Supp. 05-4).                                         who left home before the date of application to live
                                                                                      with someone other than a parent; and
R9-22-1437. MED Income Eligibility Requirements
                                                                           6. Compare the net MED family income to the income stan-
A. Income exclusions. The exclusions in R9-22-1420(C) apply to
                                                                                dard listed in subsection (B).
    the MED family unit.
                                                                      F.   The family is eligible if the net income in subsection (E)(6)
B. Income standard.
                                                                           does not exceed the income standard in subsection (B).
    1. The Department shall divide the annual FPL for the MED
         family unit that is in effect during each month of the                                  Historical ote
         income period by 12 to determine the monthly FPL.                      New Section made by final rulemaking at 11 A.A.R.
    2. The Department shall add the monthly FPLs for the                         4942, effective December 31, 2005 (Supp. 05-4).
         income period and multiply the resulting amount by 40
                                                                      R9-22-1438. MED Resource Eligibility Requirements
         percent.
                                                                      A. Including countable resources. The Department shall include
    3. Changes to the annual FPL are implemented in April of
                                                                          the resources not excluded that belong to and are available to
         each year.
                                                                          members of the family of a qualified alien under A.R.S. § 36-
C. Income period. The income period is the month of application
                                                                          2903.03 and the sponsor and sponsor’s spouse of a person who
    and the next two months. The Department shall add together
                                                                          is a qualified alien.
    the three months’ income to establish the MED family unit’s
                                                                      B. Ownership and availability. The Department shall evaluate the
    income amount.
                                                                          ownership of resources to determine the availability of
D. Medical expense deduction period. The medical expense
                                                                          resources to a person listed in subsection (A).
    deduction period is a three-month period consisting of:
                                                                          1. Jointly owned resources with ownership records contain-
    1. For a new application, the month before the application
                                                                                ing the words “and” or “and/or” between the owners’
         month, the month of application, and month following the
                                                                                names are available to each owner except if one of the
         application month; or
                                                                                owners refuses to sell. A consent to sale is not required if
    2. For a MED eligibility review, the last month of the prior
                                                                                all owners are members of the MED family unit.
         MED eligibility period and the following two months.
                                                                          2. Jointly owned resources with ownership records contain-
E. The Department shall calculate the amount of countable
                                                                                ing the word “or” between the owners’ names are pre-
    monthly income as follows:
                                                                                sumed to be available in full to each owner. The applicant
    1. Subtract a $90 cost of employment allowance from the
                                                                                or member may rebut the presumption by providing clear
         gross amount of earned income for each person whose
                                                                                and convincing evidence of intent to establish a different
         earned income is counted;
                                                                                type of ownership. If the presumption is rebutted, the
                                                                                resource is available to the owners:


June 30, 2011                                                    Page 87                                                           Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

          a.    Consistent with the intent of the owners, or                   3.   Not assign an equity value to a resource that is less than
          b.    Based on each owner’s proportionate net contribu-                   zero; and
                tion if there is not clear and convincing evidence of a        4. Determine the MED family unit’s resources by adding the
                different allocation.                                               totals determined in subsections (1) and (2).
     3. The Department shall establish availability of a trust            F.   Resource standard to be eligible for MED. A person is not eli-
           under 42 U.S.C. 1396p(d)(4)(A) or (C).                              gible for MED if the resources determined in subsection (E)
C.   Unavailability. The Department shall consider the following               exceed $100,000 or if more than $5,000 are liquid resources.
     resources unavailable:
                                                                                                     Historical ote
     1. Property subject to spendthrift restriction, such as:
                                                                                    New Section made by final rulemaking at 11 A.A.R.
           a. Accounts established by the SSA, Veteran’s Admin-
                                                                                     4942, effective December 31, 2005 (Supp. 05-4).
                istration, or similar sources that mandate that the
                funds in the account be used for the benefit of a per-    R9-22-1439. MED Effective Date of Eligibility
                son not residing with the MED family unit; or             A. A MED family unit is eligible on the day the income and
           b. Trusts established by a will or funded solely by the            resource eligibility requirements are met but no earlier than the
                income and resources of someone other than a mem-             first day of the month of application. If the family unit meets
                ber of the MED family unit.                                   the income requirements in the application month but does not
     2. A resource being disputed in a divorce proceeding or pro-             meet the resource limit until the following month, the family
           bate matter;                                                       unit’s effective date of eligibility is the first day of the month
     3. Real property located on a Native American reservation;               following the month of application.
     4. A resource held by a conservator to the extent court-             B. The Department shall adjust the effective date of eligibility
           imposed restrictions make the resource unavailable to the          under subsection (A) to an earlier date if:
           applicant, member, or member of the family unit for:               1. A member presents verification of additional allowable
           a. Medical care,                                                         medical expenses incurred on an earlier date during the
           b. Food,                                                                 medical expense deduction period that allow the member
           c. Clothing, or                                                          to meet the income requirements, and
           d. Shelter.                                                        2. The member presents the verification within 60 days of
D.   Resource exclusion. The Department shall exclude the follow-                   approval of eligibility under this Section.
     ing resources from the calculation of resources under subsec-        C. The Department shall not adjust an effective date of eligibility
     tion (E):                                                                more than one time per application.
     1. One burial plot for each person listed in R9-22-1436;             D. The Department shall adjust the effective date no later than 30
     2. Household furnishings and personal items that are neces-              days after the end of the 60-day period under subsection
           sary for day-to-day living;                                        (B)(2).
     3. Up to $1500 of the value of one prepaid funeral plan for          E. The Department shall deny an application and provide the
           each person listed in R9-22-1436 that specifically covers          applicant a denial notice when the applicant does not meet the
           only funeral-related expenses as evidenced by a written            MED requirements under this Article during the month of
           contract;                                                          application or the month following the month of application.
     4. The value of one motor vehicle regularly used for trans-
                                                                                                     Historical ote
           portation. If the MED family unit owns more than one
                                                                                    New Section made by final rulemaking at 11 A.A.R.
           vehicle, the exclusion is applied to the vehicle with the
                                                                                     4942, effective December 31, 2005 (Supp. 05-4).
           highest equity value;
     5. The value of a vehicle used to earn income and not used           R9-22-1440. MED Eligibility Period
           simply for transportation to and from employment;              The Department shall approve eligibility for six months. Changes
     6. The value of a vehicle in which a SSI-cash recipient has          in circumstances do not affect eligibility for the first three months.
           an ownership interest; and
                                                                                                     Historical ote
     7. The value of any vehicle used for medical treatment,
                                                                                    New Section made by final rulemaking at 11 A.A.R.
           employment, or transportation of a SSI-cash disabled
                                                                                     4942, effective December 31, 2005 (Supp. 05-4).
           child, and that is excluded by SSI for that reason.
     8. Funds set aside in an Individual Development Account              R9-22-1441. Eligibility Appeals
           under 6 A.A.C. 12, Article 4; and                              A. Adverse actions. An applicant or member may appeal by
     9. Any other resource specifically excluded by federal law.              requesting a hearing from the Department concerning any of
E.   Calculation of resources. The Department shall determine the             the following adverse actions:
     value of all household resources as follows:                             1. Complete or partial denial of eligibility under R9-22-
     1. Calculate the total amount of countable liquid resources;                   1413;
     2. Calculate the equity value of each countable non-liquid               2. Suspension, termination, or reduction of AHCCCS medi-
           resource. The Department shall determine the equity                      cal coverage under R9-22-1415;
           value of a countable non-liquid resource by subtracting            3. Delay in the eligibility determination beyond the time-
           the amount of valid encumbrances on that resource from:                  frames under this Article;
           a. The market value of real property if there is no                4. The imposition of or increase in a premium or copay-
                assessor’s evaluation of the property,                              ment; or
           b. The market value of real property if the assessor’s             5. The effective date of eligibility.
                value of the real property does not include the value     B. Notice of Adverse Action. The Department shall personally
                of permanent structures on that property,                     deliver or send, by regular mail, a Notice of Adverse Action to
           c. The assessor’s full cash value if subsections                   the person affected by the action. For the purpose of this Sec-
                (E)(2)(a) and (E)(2)(b) do not apply, and                     tion, the date of the Notice of Adverse Action shall be the date
           d. The market value of a non-liquid resource that is not           of personal delivery to the applicant or the postmark date, if
                real property;                                                mailed.


Supp. 11-2                                                           Page 88                                                     June 30, 2011
                                                     Arizona Administrative Code                                                Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

C.   Automatic change and hearing rights.                                   5.    Except as provided in 42 CFR 435.911, the Administra-
     1. An applicant or a member is not entitled to a hearing if                  tion shall determine eligibility within 90 days for an
         the sole issue is a federal or state law requiring an auto-              applicant applying on the basis of disability and 45 days
         matic change adversely affecting some or all recipients.                 for all other applicants.
     2. An applicant or a member is entitled to a hearing if a fed-         6. If an applicant dies while an application is pending, the
         eral or state law requires an automatic change and the                   Administration shall complete an eligibility determina-
         applicant or member timely files an appeal that alleges a                tion for the deceased applicant.
         misapplication of the facts to the law.                            7. The Administration shall complete an eligibility determi-
                                                                                  nation on an application filed on behalf of a deceased
                        Historical ote
                                                                                  applicant, if the application is filed in the month of the
       New Section made by final rulemaking at 11 A.A.R.
                                                                                  applicant’s death.
        4942, effective December 31, 2005 (Supp. 05-4).
                                                                       E.   Redetermination of eligibility for a person terminated from the
R9-22-1442. Cessation of MED Coverage                                       SSI cash program.
The Department shall not approve any individual or family who has           1. Continuation of AHCCCS medical coverage. The
applied on or after May 1, 2011 as eligible for MED coverage. With                Administration shall continue AHCCCS medical cover-
respect to any applications that are pending as of May 1, 2011, the               age for a person terminated from the SSI cash program
Department shall not approve any individual or family as eligible                 until a redetermination of eligibility under subsection
for MED coverage who has not met all eligibility requirements                     (E)(2) is completed.
prior to May 1, 2011.                                                       2. Coverage group screening. The Administration shall
                                                                                  screen a person for eligibility under any coverage group
                        Historical ote
                                                                                  under A.R.S. §§ 36-2901(6)(a)(i), (ii), (iii), (iv), and (v)
      New Section made by exempt rulemaking at 17 A.A.R.
                                                                                  and 36-2934.
           1028, effective May 1, 2011 (Supp. 11-2).
                                                                                  a. If a person files an application for Arizona Long-
     ARTICLE 15. AHCCCS MEDICAL COVERAGE FOR                                            Term Care System (ALTCS) coverage, the Adminis-
     PEOPLE WHO ARE AGED, BLI D, OR DISABLED                                            tration shall determine eligibility under 9 A.A.C. 28,
                                                                                        Article 4.
R9-22-1501. General Information
                                                                                  b. If an applicant or member is aged, blind, or disabled,
A. General. The Administration shall determine eligibility for
                                                                                        but not in need of long-term care services, the
    AHCCCS medical coverage for the following applicants or
                                                                                        Administration shall determine eligibility under this
    members using the eligibility criteria and requirements in this
                                                                                        Article.
    Article:
                                                                                  c. For all other persons, the Administration shall refer
    1. A person who is aged, blind, or disabled and does not
                                                                                        the applicant’s case to the Department for an eligi-
         receive SSI cash; and
                                                                                        bility decision under Article 14.
    2. A person terminated from the SSI cash program under
                                                                            3. Eligibility decision.
         R9-22-1505.
                                                                                  a. If a person is eligible under this Article or 9 A.A.C.
B. Definitions. In addition to definitions contained in A.R.S. §
                                                                                        28, Article 4, the Administration shall send a notice
    36-2901, the words and phrases in this Chapter have the fol-
                                                                                        as under subsection (G) informing the applicant that
    lowing meanings unless the context explicitly requires another
                                                                                        AHCCCS medical coverage is approved.
    meaning:
                                                                                  b. If a person is ineligible, the Administration shall
         “Aged” means a person who is 65 years of age or older as
                                                                                        send a notice as under subsection (G) to deny AHC-
         specified in 42 U.S.C. 1382c(a)(1)(A).
                                                                                        CCS medical coverage.
         “Blind” means a person who has been determined blind
                                                                       F.   Eligibility effective date. Eligibility is effective on the first day
         by the Department of Economic Security, Disability
                                                                            of the month that all eligibility requirements are met, but no
         Determination Services Administration, under 42 U.S.C.
                                                                            earlier than the month of application.
         1382c(a)(2).
                                                                       G.   Notice for approval or denial. The Administration shall send
         “Disabled” means a person who has been determined dis-
                                                                            an applicant a written notice of the decision regarding the
         abled by the Department of Economic Security, Disabil-
                                                                            application. This notice shall include a statement of the
         ity Determination Services Administration, under 42
                                                                            intended action, and:
         U.S.C. 1382c(a)(3)(A) through (E).
                                                                            1. If approved, the notice shall contain the effective date of
C. Confidentiality. The Administration shall maintain the confi-
                                                                                  eligibility.
    dentiality of an applicant’s or member’s records and limit the
                                                                            2. If approved under FESP, the notice shall also contain:
    release of safeguarded information under R9-22-512.
                                                                                  a. The emergency services certification end date,
D. Application process.
                                                                                  b. A statement detailing the reason for the denial of full
    1. A person may apply for AHCCCS medical coverage by
                                                                                        services,
         submitting a signed application to any Administration
                                                                                  c. The legal authority supporting the decision,
         office or outstation location under R9-22-1406.
                                                                                  d. Where the legal authority supporting the decision
    2. The provisions in R9-22-1406(B), (C), and (E) apply to
                                                                                        can be found,
         this Section.
                                                                                  e. An explanation of the right to request a hearing, and
    3. The application date is the date a signed application is
                                                                                  f. The date by which a request for hearing shall be
         received at any Administration office or outstation loca-
                                                                                        received by the Administration.
         tion approved by the Director.
                                                                            3. If denied, the notice shall contain:
    4. An applicant who files an application may withdraw the
                                                                                  a. The effective date of the denial;
         application, either orally or in writing. If an applicant
                                                                                  b. The reason for the denial, including specific finan-
         withdraws an application, the Administration shall send
                                                                                        cial calculations and the financial eligibility stan-
         the applicant a denial notice under subsection (G).
                                                                                        dard, if applicable;
                                                                                  c. Legal authority supporting the decision;


June 30, 2011                                                     Page 89                                                           Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          d.   Where the legal authority supporting the decision                  c.  The reason for the discontinuance, including spe-
               can be found;                                                          cific financial calculations and the financial eligibil-
         e. An explanation of the right to request a hearing; and                     ity standard if applicable;
         f. The date by which a request for hearing shall be                     d. The legal authority that supports the action proposed
               received by the Administration.                                        by the Administration;
H. Reporting and verifying changes.                                              e. Where the legal authority supporting the decision
   1. An applicant or a member shall report to the Administra-                        can be found;
         tion the following changes for the applicant or member,                 f. An explanation of the right to request a hearing; and
         the applicant’s or member’s spouse, and the applicant or                g. The date by which a hearing request shall be
         member’s dependent children:                                                 received by the Administration and the right to con-
         a. Change of address;                                                        tinue medical coverage pending appeal.
         b. Change in the household’s members;                             2. Advance notice of changes in eligibility. Advance notice
         c. Change in income;                                                    means a notice of proposed action that is issued to the
         d. Death;                                                               member at least 10 days before the effective date of the
         e. Change in marital status;                                            proposed action. Except under subsection (K)(3), the
         f. Change in school attendance;                                         Administration shall issue an advance notice when an
         g. Change in Arizona state residency; and                               adverse action is taken to suspend, reduce or discontinue
         h. Any other change that may affect the member’s or                     eligibility.
               applicant’s eligibility.                                    3. Exceptions from advance notice. The Administration
   2. A member shall report to the Administration the follow-                    shall issue a notice to a member to discontinue eligibility
         ing changes:                                                            no later than the effective date of the action if:
         a. Admission to a penal institution,                                    a. The member provides to the Administration a
         b. Change in U.S. citizenship or immigrant status,                           clearly written statement, signed by that member,
         c. Receipt of a Social Security number, and                                  that:
         d. Change in first- or third-party liability that may con-                   i. Services are no longer wanted; or
               tribute to the payment of all or a portion of the per-                 ii. Gives information that requires a discontinu-
               son’s medical costs.                                                          ance or reduction of services and indicates that
   3. A person other than a member or an applicant who                                       the member understands that this is the result of
         reports a change to the Administration either orally or in                          supplying the information;
         writing shall include the:                                              b. The member provides information to the Adminis-
         a. Name of the affected applicant or member;                                 tration that requires a discontinuance of eligibility
         b. Description of the change;                                                and a member signs a written statement waiving
         c. Date the change occurred;                                                 advance notice;
         d. Name of the person reporting the change; and                         c. The member cannot be located and mail sent to the
         e. Social Security or case number of the applicant or                        member’s last known address has been returned as
               member, if known.                                                      undeliverable under 42 CFR 431.213(d) subject to
   4. An applicant or a member shall provide verification of                          reinstatement of discontinued eligibility;
         changes if requested by the Administration.                             d. The member has been admitted to a public institu-
   5. An applicant or a member shall report anticipated                               tion where a member is ineligible for coverage;
         changes in eligibility to the Administration as soon as the             e. The member has been approved for Medicaid in
         person knows that the change will occur.                                     another state; or
   6. An applicant or a member shall report an unanticipated                     f. The Administration receives information confirming
         change to the Administration within 10 days following                        the death of the member.
         the date the change occurred.                                  L. Request for hearing. An applicant or member may request a
I. Processing of changes and redeterminations. If a member                 hearing under Chapter 34 for any of the following adverse
   receives AHCCCS medical coverage under subsection (A), the              actions:
   Administration shall redetermine the member’s eligibility at            1. Complete or partial denial of eligibility,
   least once every 12 months or more frequently when changes              2. Discontinuance or reduction of AHCCCS medical cover-
   occur that may affect eligibility.                                            age, or
J. Actions that may result from a redetermination or change. In            3. Delay in the eligibility determination beyond the time-
   processing a redetermination or change, the Administration                    frames listed in R9-22-1501(D).
   shall determine whether there should be:                             M. Assignment of rights. A person determined eligible assigns
   1. No change in eligibility,                                            rights to all types of medical benefits to which the person is
   2. Discontinuance of eligibility if a condition of eligibility is       entitled under operation of law under A.R.S. § 36-2903.
         no longer met, or
                                                                                                  Historical ote
   3. A change in the program under which a person receives
                                                                               New Section adopted by final rulemaking at 5 A.A.R.
         AHCCCS medical coverage.
                                                                                294, effective January 8, 1999 (Supp. 99-1). Section
K. Notice of discontinuance.
                                                                              repealed; new Section made by exempt rulemaking at 7
   1. Contents of notice. The Administration shall issue a
                                                                               A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
         notice when it takes action to discontinue a member’s eli-
                                                                             Amended by final rulemaking at 9 A.A.R. 5123, effective
         gibility. The notice shall contain the following informa-
                                                                             January 3, 2004 (Supp. 03-4). Amended by exempt rule-
         tion:
                                                                               making at 10 A.A.R. 23, effective December 9, 2003
         a. A statement of the action that is being taken;
                                                                                (Supp. 03-4). Amended by exempt rulemaking at 10
         b. The effective date of the action;
                                                                               A.A.R. 4588, effective October 12, 2004 (Supp. 04-4).
                                                                             Amended by final rulemaking at 11 A.A.R. 4942, effec-
                                                                                       tive December 31, 2005 (Supp. 05-4).


Supp. 11-2                                                         Page 90                                                     June 30, 2011
                                                      Arizona Administrative Code                                             Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

R9-22-1502. General Eligibility Criteria                                          information necessary to complete the determination of
A. Social Security Number.                                                        eligibility.
    1. An applicant applying under R9-22-1501(A)(1) or                       2.   The Administration shall provide an applicant or a mem-
          (A)(2), or R9-22-1505(A) shall furnish a SSN or apply                   ber no less than 10 days following the date of written
          for one, as required under 42 CFR 435.910 and 435.920.                  request for the information to provide required verifica-
    2. An applicant who meets all other eligibility criteria                      tion. If an applicant or member does not provide the
          except the criteria in subsection (C) shall provide a SSN               required information timely, the Administration may
          unless the applicant cannot legally obtain one.                         deny the application or discontinue eligibility.
    3. If an applicant cannot recall or has not been issued a SSN,
                                                                                                  Historical ote
          the Administration shall assist in obtaining or verifying
                                                                               New Section adopted by final rulemaking at 5 A.A.R.
          the applicant’s SSN under 42 CFR 435.910.
                                                                                294, effective January 8, 1999 (Supp. 99-1). Section
B. State residency. A person is not eligible unless the person is a
                                                                              repealed; new Section made by exempt rulemaking at 7
    resident of Arizona under 42 CFR 435.403.
                                                                               A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
C. Citizenship and immigrant status.
                                                                              Amended by final rulemaking at 11 A.A.R. 4942, effec-
    1. An applicant or a member is not eligible for full services
                                                                                       tive December 31, 2005 (Supp. 05-4).
          under Article 2 of this Chapter unless the applicant or
          member is a citizen of the United States or is a qualified    R9-22-1503. Financial Eligibility Criteria
          alien under A.R.S. § 36-2903.03(B) or meets the require-      A. General income eligibility. The Administration shall count the
          ments of A.R.S. § 36-2903.03(C).                                  identified income under 42 U.S.C. 1382a and 20 CFR 416
    2. An applicant or member is eligible for emergency medi-               Subpart K with the exceptions in subsection (B).
          cal services under R9-22-217 if the applicant or member       B. Exceptions.
          is either a qualified alien or noncitizen and:                    1. In-kind support and maintenance under 42 U.S.C.
          a. Meets all other eligibility requirements except those               1382a(a)(2)(A) is excluded.
                in subsection (A); and                                      2. For a person living with a spouse, the Administration cal-
          b. Is eligible under A.R.S. § 36-2901(6)(a)(i), (ii), or               culates net income for an eligible couple under 42 CFR
                (iii).                                                           416.1160 as of June 15, 1999, which is incorporated by
D. Applicant and member responsibility. As a condition of eligi-                 reference and on file with the Administration, and avail-
    bility, an applicant and a member shall:                                     able from the U.S. Government Printing Office, Mail
    1. Authorize the Administration to obtain verification of                    Stop: IDCC, 732 N. Capitol Street, NW, Washington, DC,
          information for initial or continued eligibility;                      20401. This incorporation by reference contains no future
    2. Give the Administration complete and truthful informa-                    editions or amendments, even if the spouse is not eligible
          tion. The Administration may deny an application or dis-               for or applying for SSI or coverage under this Article.
          continue eligibility if:                                          3. In determining the net income of a married couple living
          a. The applicant or member fails to provide informa-                   with a child or the net income of a person who is not liv-
                tion necessary for initial or continuing eligibility;            ing with a spouse but living with a child, a child alloca-
          b. The applicant or member fails to provide the Admin-                 tion is allowed as a deduction from the combined net
                istration with written authorization to permit the               income of the couple for each child regardless of whether
                Administration to obtain necessary verification;                 the child is ineligible or eligible. For the purposes of this
          c. The applicant or member fails to provide verifica-                  Section, a child means a person who is unmarried, natural
                tion after the Administration had made an effort to              or adopted, and under age 18 or under age 22 if a full-
                obtain the necessary verification but has not                    time student. Each child’s allocation deduction is reduced
                obtained the necessary information; or                           by that child’s income, including public income mainte-
          d. The applicant or member does not assist the Admin-                  nance payments, using the methodology under 20 CFR
                istration in resolving incomplete, inconsistent, or              416.1163(b)(1) and (2) as of June 15, 1999, which is
                unclear information that is necessary for initial or             incorporated by reference and on file with the Adminis-
                continuing eligibility;                                          tration, and available from the U.S. Government Printing
    3. Comply with the DCSE under 42 CFR 433.148 in estab-                       Office, Mail Stop: IDCC, 732 N. Capitol Street, NW,
          lishing paternity and enforcing medical support obliga-                Washington, DC, 20401. This incorporation by reference
          tions when requested. The Administration shall not deny                contains no future editions or amendments.
          AHCCCS eligibility to any applicant who would other-              4. In determining the income deemed available to an appli-
          wise be eligible, is a minor child, and whose parent or                cant who is a child from an ineligible parent or parents,
          legal representative does not cooperate with the medical               an allocation for each eligible or ineligible child of the
          support requirements or first- and third-party liability               parent is allowed as a deduction from the parent’s income
          under Article 10;                                                      under 20 CFR 416.1165(b). The child’s allocation is
    4. Provide information concerning third-party coverage for                   reduced by that child’s income, including public income
          medical care; and                                                      maintenance payments.
    5. Take all necessary steps to obtain annuity, pension, retire-         5. In determining the income of a person who receives an
          ment, and disability benefits for which the applicant or               annual Title II Cost of Living Allowance (COLA)
          member may be entitled.                                                increase, the COLA amount is disregarded for the months
E. Inmate of a public institution. An inmate of a public institution             of January through March, but is countable income effec-
    is not eligible to AHCCCS coverage if federal financial partic-              tive in April to correspond with the FPL implementation
    ipation (FFP) is not available.                                              date.
F. Verification of eligibility information.                                 6. Sponsor deemed income. The Administration shall use
    1. The applicant or member has the primary responsibility                    income of a USCIS sponsor to determine eligibility for a
          to provide the Administration with verification of all                 non-citizen applicant under R9-22-1425, whether or not



June 30, 2011                                                      Page 91                                                        Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

          the income is available, unless exempt under R9-22-                     a.   Was determined disabled by the Social Security
          1426.                                                                        Administration before attaining the age of 22 years,
                                                                                  b. Became entitled to or received an increase in child’s
                         Historical ote
                                                                                       insurance benefits under Title II of the Act on the
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                                       basis of blindness or disability,
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                  c. Was terminated from SSI cash benefits due to enti-
     repealed; new Section made by exempt rulemaking at 7
                                                                                       tlement to or an increase in income under Title II of
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                                       the Act,
     Amended by final rulemaking at 11 A.A.R. 4942, effec-
                                                                                  d. Meets the requirements under this Article, and
              tive December 31, 2005 (Supp. 05-4).
                                                                                  e. Is 18 years of age or older;
R9-22-1504. Eligibility For A Person Who is Aged, Blind, or                  4. A disabled widow or widower (DWW) under 42 U.S.C.
Disabled                                                                          1383c(d) who:
A. To be eligible for AHCCCS medical coverage, an applicant                       a. Is blind or disabled,
    shall meet the conditions of eligibility and requirements in this             b. Is ineligible for Medicare Part A benefits,
    Article and:                                                                  c. Received SSI cash benefits the month before Title II
    1. Meet one of the income tests described in subsection (B)                        of the Act benefit payments began, and
         or (C), or                                                               d. Meets the requirements under this Article; and
    2. The special requirements in R9-22-1505.                               5. Under 42 CFR 435.135, a person who:
B. The Administration shall determine whether the applicant’s                     a. Is aged, blind, or disabled;
    countable income, as described in R9-22-1503, is less than or                 b. Receives benefits under Title II of the Act;
    equal to 100 percent of the SSI FBR, as adjusted annually.                    c. Received SSI cash benefits in the past;
C. The Administration shall determine whether the applicant’s                     d. Received SSI cash benefits and Title II of the Social
    countable income, as described in R9-22-1503, without                              Security Act benefits concurrently for at least one
    deducting the amount from earned income under 42 U.S.C.                            month anytime after April 1977;
    1382a(b)(4)(B)(iii), is less than or equal to 100 percent FPL as              e. Became ineligible for SSI cash benefits while
    adjusted annually.                                                                 receiving SSI and benefits under Title II of the Act
                                                                                       concurrently; and
                         Historical ote
                                                                                  f. Meets the requirements under this Article.
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                        B.   Income for special groups.
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                             1. Except as provided in subsection (B)(2), income eligibil-
     repealed; new Section made by exempt rulemaking at 7
                                                                                  ity is determined using the income criteria in R9-22-
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                                  1503(A).
     Amended by final rulemaking at 11 A.A.R. 4942, effec-
                                                                             2. Exceptions to income for special groups.
              tive December 31, 2005 (Supp. 05-4).
                                                                                  a. For a person in the DAC coverage group under sub-
R9-22-1505. Eligibility for Special Groups                                             section (A)(3), the applicant’s Title II of the Act ben-
A. The following are considered special groups:                                        efits are disregarded in determining income
    1. A person meeting the requirements in A.R.S. § 36-                               eligibility under 42 U.S.C. 1383c(c).
        2903.03 who:                                                              b. For a person in the DWW coverage group, under
        a. Is aged, blind, or disabled under 42 CFR 435.520, 42                        subsection (A)(4), the applicant’s Title II of the Act
             CFR 435.530, or 42 CFR 435.540 as of October 1,                           benefits are disregarded in determining income eli-
             2004, which are incorporated by reference and on                          gibility under 42 U.S.C. 1383c(b) and (d).
             file with the Administration, and available from the                 c. For an applicant or member in the coverage group
             U.S. Government Printing Office, Mail Stop: IDCC,                         under subsection (A)(5), the portion of the appli-
             732 N. Capitol Street, NW, Washington, DC, 20401.                         cant’s or member’s Title II of the Act benefits attrib-
             This incorporation by reference contains no future                        uted to cost-of-living adjustments received by the
             editions or amendments.                                                   applicant since the effective date of SSI ineligibility
        b. Received SSI cash or AHCCCS medical coverage                                is disregarded in determining income eligibility
             under this subsection, or subsections (A)(2), (A)(3),                     under 42 CFR 435.135.
             or (A)(4) on or before August 21, 1996;                    C.   100 percent FBR. As a condition of eligibility for all special
        c. Was residing in the United States under color of law              groups, countable income shall be equal to or less than 100
             on or before August 21, 1996; and                               percent of the SSI FBR, as adjusted annually.
        d. Meets the requirements under this Article;
                                                                                                 Historical ote
    2. A disabled child (DC) under 42 U.S.C.
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
        1396a(a)(10)(A)(i)(II). A disabled child is a child who:
                                                                               294, effective January 8, 1999 (Supp. 99-1). Section
        a. Was receiving SSI cash benefits as a disabled child
                                                                             repealed; new Section made by exempt rulemaking at 7
             on August 22, 1996;
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
        b. Lost SSI cash benefits effective July 1, 1997, or
                                                                             Amended by final rulemaking at 11 A.A.R. 4942, effec-
             later, due to a disability determination under Section
                                                                                      tive December 31, 2005 (Supp. 05-4).
             211(d)(2)(B) of Subtitle B of P.L. 104-193;
        c. Continues to meet the disability requirements for a          R9-22-1506. Repealed
             child that were in effect on August 21, 1996; and
                                                                                                 Historical ote
        d. Meets the requirements under this Article;
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
    3. A disabled adult child (DAC), under 42 U.S.C. 1383c(c)
                                                                               294, effective January 8, 1999 (Supp. 99-1). Section
        who:
                                                                             repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                                        tive October 1, 2001 (Supp. 01-3).



Supp. 11-2                                                         Page 92                                                      June 30, 2011
                                                      Arizona Administrative Code                                             Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

R9-22-1507. Repealed                                                          “Income” means the total gross amount of all money received
                                                                              by or directly deposited into a financial account of a member
                         Historical ote
                                                                              of the household income group as specified in R9-22-1616.
      New Section adopted by final rulemaking at 5 A.A.R.
       294, effective January 8, 1999 (Supp. 99-1). Section                   “Monthly equivalent” means a monthly income amount estab-
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                   lished by averaging, prorating, or converting a person's
                tive October 1, 2001 (Supp. 01-3).                            income.
R9-22-1508. Repealed                                                          “Monthly income” means the gross income received or pro-
                                                                              jected to be received during the month or the monthly equiva-
                         Historical ote                                       lent.
      New Section adopted by final rulemaking at 5 A.A.R.                     “Parent” means a biological, adoptive, or step-parent.
       294, effective January 8, 1999 (Supp. 99-1). Section
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                   “Premium” means a monthly payment that an enrolled mem-
                tive October 1, 2001 (Supp. 01-3).                            ber pays to the Administration to remain eligible.
                                                                              “SSDI Temporary Medical Coverage” means Social Security
     ARTICLE 16. SOCIAL SECURITY DISABILITY
                                                                              Disability Insurance Temporary Medical Coverage.
   I SURA CE - TEMPORARY MEDICAL COVERAGE
                                                                                                    Historical ote
R9-22-1601. General Information
                                                                                New Section adopted by final rulemaking at 5 A.A.R.
A. The Administration shall administer the program as specified
                                                                                 294, effective January 8, 1999 (Supp. 99-1). Section
    in A.R.S. § 36-2930.
                                                                               repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
B. Operational Authority. The Director has full operational
                                                                              tive October 1, 2001 (Supp. 01-3). New Section made by
    authority to adopt rules or to use the appropriate rules for the
                                                                              exempt rulemaking at 12 A.A.R. 3892, effective October
    development and management of an eligibility and enrollment
                                                                                                 1, 2006 (Supp. 06-3).
    system as specified in A.R.S. § 36-2930.
C. Expenditure limit and enrollment:                                     R9-22-1604. Effective Date of Eligibility for Services
    1. All applicants must enroll in a capitated health plan as          Effective date of initial enrollment:
         specified in A.R.S. § 36-2930(C).                                    1. For an eligibility determination completed by the 25th
    2. The Administration will accept enrollees subject to the                     day of the month, enrollment shall begin on the first day
         availability of funds. If the Director determines that mon-               of the month following the determination of eligibility.
         ies may be insufficient for the program, the Administra-             2. For an eligibility determination completed after the 25th
         tion shall stop processing applications for the program as                day of the month, enrollment shall begin on the first day
         specified in A.R.S. § 36-2930.                                            of the second month following the determination of eligi-
    3. If the Administration stops processing an application                       bility.
         because the monies are insufficient as specified in this
                                                                                                    Historical ote
         Section, the Administration shall place an applicant on a
                                                                                New Section adopted by final rulemaking at 5 A.A.R.
         waiting list and notify the applicant.
                                                                                 294, effective January 8, 1999 (Supp. 99-1). Section
    4. After the Administration has verified that funding is suf-
                                                                               repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
         ficient, it will resume processing applications as specified
                                                                              tive October 1, 2001 (Supp. 01-3). New Section made by
         in A.R.S. § 36-2930.
                                                                              exempt rulemaking at 12 A.A.R. 3892, effective October
                           Historical ote                                                        1, 2006 (Supp. 06-3).
       New Section adopted by final rulemaking at 5 A.A.R.
                                                                         R9-22-1605. Services
        294, effective January 8, 1999 (Supp. 99-1). Section
                                                                         The Administration shall cover medically necessary services under
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                         9 A.A.C. 22, Article 2, for a member, subject to the limitations and
     tive October 1, 2001 (Supp. 01-3). New Section made by
                                                                         exclusions specified in Article 2, unless otherwise specified in this
     exempt rulemaking at 12 A.A.R. 3892, effective October
                                                                         Chapter.
                        1, 2006 (Supp. 06-3).
                                                                                                    Historical ote
R9-22-1602. Ineligible Person
                                                                                New Section adopted by final rulemaking at 5 A.A.R.
A person is not eligible for coverage under this Article if the person
                                                                                 294, effective January 8, 1999 (Supp. 99-1). Section
is an inmate of a public institution.
                                                                               repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                           Historical ote                                     tive October 1, 2001 (Supp. 01-3). New Section made by
       New Section adopted by final rulemaking at 5 A.A.R.                    exempt rulemaking at 12 A.A.R. 3892, effective October
        294, effective January 8, 1999 (Supp. 99-1). Section                                     1, 2006 (Supp. 06-3).
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                         R9-22-1606. Application Process
     tive October 1, 2001 (Supp. 01-3). New Section made by
                                                                         A. Availability. The Administration shall make available program
     exempt rulemaking at 12 A.A.R. 3892, effective October
                                                                             applications. Any person may request a program application.
                        1, 2006 (Supp. 06-3).
                                                                         B. Who may apply for a person. The provisions in R9-22-
R9-22-1603. Definitions                                                      1406(B) apply to this Article.
In addition to the definitions contained in this Chapter, the words      C. An application is completed and submitted to the Administra-
and phrases in this Article have the following meaning unless the            tion:
context explicitly requires another meaning:                                 1. In person,
     “Child” means a person less than 18 years old or an unborn              2. By mail,
     child.                                                                  3. By fax, or
                                                                             4. By other form approved by the Administration
     “Copayment” means a monetary amount that a member pays
     directly to a provider at the time a covered service is rendered.


June 30, 2011                                                       Page 93                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

D.   Date of application. The date of application is the date the                                   Historical ote
     Administration receives an application that:                               New Section adopted by final rulemaking at 5 A.A.R.
     1. Is signed and dated by the person making the application,             294, effective January 8, 1999 (Supp. 99-1). Amended by
     2. Includes the legible name of the person for whom assis-               final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
          tance is requested, and                                             (Supp. 00-2). Section repealed by exempt rulemaking at 7
     3. Includes the address or location of the person submitting               A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
          the application.                                                     New Section made by exempt rulemaking at 12 A.A.R.
E.   Completed Application.                                                          3892, effective October 1, 2006 (Supp. 06-3).
     1. The provisions in R9-22-1406(E) apply to this Section.
                                                                         R9-22-1609. General Eligibility Criteria
     2. The Administration shall consider an application com-
                                                                         A. To be eligible for this program:
          plete when:
                                                                             1. An applicant must have received Medicaid coverage, pur-
          a. All questions are answered,
                                                                                   suant to A.R.S. §§ 36-2901(6) and 36-2931(5), within the
          b. An enrollment choice is included, and
                                                                                   24-month period prior to application for this program.
          c. All necessary verification is provided by an appli-
                                                                             2. The applicant is not receiving healthcare coverage from
                cant or an applicant’s representative.
                                                                                   Health Care Group pursuant to A.R.S. § 36-2912.
     3. If the application is incomplete, the Administration shall
                                                                             3. The applicant or member must apply for and comply with
          do one or both of the following:
                                                                                   the Title TXIX or Title TXXI programs if an applicant or
          a. Contact an applicant or an applicant’s representative
                                                                                   member screens potentially eligible for any Title TXIX or
                by telephone to obtain the missing information
                                                                                   Title TXXI programs.
                required for an eligibility determination;
                                                                             4. An applicant or member is eligible for SSDI under 42
          b. Mail a request for additional information to an appli-
                                                                                   U.S.C. 423 and is not eligible for Medicare benefits under
                cant or an applicant’s representative, allowing 10
                                                                                   42 U.S.C. 426(b) or 426-1.
                days from the date of the request to provide the
                                                                             5. An applicant or member shall not have creditable cover-
                required additional information;
                                                                                   age as specified in 42 U.S.C. 300gg(c).
          c. An applicant shall provide the Administration with
                                                                         B. Social Security Number. An applicant applying under this
                all requested information within 10 days from the
                                                                             Article shall furnish a SSN or apply for one.
                date of the written request for the information. If an
                                                                         C. State residency. An applicant or member is not eligible unless
                applicant fails to provide the requested information
                                                                             the person is a resident of Arizona as specified under A.R.S. §
                and fails to request an extension of the 10-day period
                                                                             36-2930.
                or the request for extension is denied, the Adminis-
                                                                         D. Citizenship and immigrant status. An applicant or a member is
                tration shall deny eligibility.
                                                                             not eligible for coverage under this Article unless the applicant
F.   Eligibility determination. When an application is complete, the
                                                                             or member is a citizen of the United States or is a qualified
     Administration shall mail notification to the applicant regard-
                                                                             alien under A.R.S. § 36-2903.03(B).
     ing the eligibility determination.
                                                                         E. Applicant and member responsibility. As a condition of eligi-
                           Historical ote                                    bility, an applicant and a member shall:
       New Section adopted by final rulemaking at 5 A.A.R.                   1. Authorize the Administration to obtain verification of
        294, effective January 8, 1999 (Supp. 99-1). Section                       information for initial or continued eligibility;
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                 2. Give the Administration complete and truthful informa-
     tive October 1, 2001 (Supp. 01-3). New Section made by                        tion. The Administration may deny an application or dis-
     exempt rulemaking at 12 A.A.R. 3892, effective October                        continue eligibility if:
                        1, 2006 (Supp. 06-3).                                      a. The applicant or member fails to provide informa-
                                                                                         tion necessary for initial or continuing eligibility;
R9-22-1607. Withdrawal
                                                                                   b. The applicant or member fails to provide the Admin-
A. An applicant or member may withdraw from AHCCCS medi-
                                                                                         istration with written authorization to permit the
    cal coverage at any time by giving oral or written notice of
                                                                                         Administration to obtain necessary verification;
    withdrawal to the Administration. The applicant, member,
                                                                                   c. The applicant or member fails to provide verifica-
    applicant’s legal or authorized representative, or member's
                                                                                         tion after the Administration had made an effort to
    legal or authorized representative shall provide the Adminis-
                                                                                         obtain the necessary verification but has not
    tration with:
                                                                                         obtained the necessary information; or
    1. The reason for the withdrawal,
                                                                                   d. The applicant or member does not assist the Admin-
    2. The date the notice is effective, and
                                                                                         istration in resolving incomplete, inconsistent, or
    3. The name of the applicant or member for whom AHC-
                                                                                         unclear information that is necessary for initial or
          CCS medical coverage is being withdrawn.
                                                                                         continuing eligibility; and
B. The Administration shall notify the applicant or member of the
                                                                             3. Provide information concerning third-party coverage for
    discontinuance as required by R9-22-1615.
                                                                                   medical care.
                           Historical ote                                    4. A member must notify the Administration when the
       New Section adopted by final rulemaking at 5 A.A.R.                         member becomes eligible for Medicare benefits under 42
        294, effective January 8, 1999 (Supp. 99-1). Section                       U.S.C. 426(b) or 426-1. When the member becomes eli-
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                       gible for Medicare benefits, the member is ineligible for
     tive October 1, 2001 (Supp. 01-3). New Section made by                        coverage under this Article.
     exempt rulemaking at 12 A.A.R. 3892, effective October              F. Verification of eligibility information.
                        1, 2006 (Supp. 06-3).                                1. The applicant or member has the primary responsibility
                                                                                   to provide the Administration with verification of all
R9-22-1608. Assignment of Rights Under Operation of Law
                                                                                   information necessary to complete the determination of
A person shall assign rights to the system of all types of medical
                                                                                   eligibility.
benefits to which the person is entitled.


Supp. 11-2                                                          Page 94                                                    June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

     2.   The Administration shall provide an applicant or a mem-                                 Historical ote
          ber no less than 10 days following the date of written              New Section adopted by final rulemaking at 5 A.A.R.
          request for the information to provide required verifica-            294, effective January 8, 1999 (Supp. 99-1). Section
          tion. If an applicant or member does not provide the               repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
          required information timely, the Administration may               tive October 1, 2001 (Supp. 01-3). New Section made by
          deny the application or discontinue eligibility.                  exempt rulemaking at 12 A.A.R. 3892, effective October
                                                                                               1, 2006 (Supp. 06-3).
                           Historical ote
       New Section adopted by final rulemaking at 5 A.A.R.             R9-22-1613. Repealed
     294, effective January 8, 1999 (Supp. 99-1). Amended by
                                                                                                Historical ote
     final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
                                                                             New Section adopted by final rulemaking at 5 A.A.R.
     (Supp. 00-2). Section repealed by exempt rulemaking at 7
                                                                              294, effective January 8, 1999 (Supp. 99-1). Section
       A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                            repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
      New Section made by exempt rulemaking at 12 A.A.R.
                                                                                       tive October 1, 2001 (Supp. 01-3).
            3892, effective October 1, 2006 (Supp. 06-3).
                                                                       R9-22-1614. Confidentiality and Safeguarding of Information
R9-22-1610. Changes/Redetermination
                                                                       The Administration shall maintain the confidentiality of an appli-
A. Reporting Changes. A member or a member’s representative
                                                                       cant's or member's records and limit the release of information as
    shall report the following changes within 10 days to the
                                                                       specified under R9-22-512.
    Administration:
    1. Any change in income that will begin or continue into the                               Historical ote
          following month,                                                   New Section made by exempt rulemaking at 12 A.A.R.
    2. Any change of address,                                                   3892, effective October 1, 2006 (Supp. 06-3).
    3. The addition or departure of a household member,
                                                                       R9-22-1615.        otice Requirements
    4. Creditable health coverage under private or group health
                                                                       A. Upon completion of a determination or redetermination of eli-
          insurance,
                                                                           gibility for an applicant or member, the Administration shall
    5. Receipt of Medicare Benefits, and
                                                                           issue a written notice to an individual who initiated the appli-
    6. Incarceration of a member or placement in a public insti-
                                                                           cation. This notice shall include a statement of the intended
          tution.
                                                                           action, an explanation of a person’s hearing rights as specified
B. Verification. If required verification is needed and requested as
                                                                           in 9 A.A.C. 34, Article 1, and:
    a result of a change specified in subsection (A) of this Section
                                                                           1. If approved, the notice shall contain the name and effec-
    to determine the impact on eligibility and is not received
                                                                                 tive date of eligibility for the approved applicant;
    within 10 days, the Administration shall discontinue eligibility
                                                                           2. If denied, the notice shall contain:
    and send a notice of adverse action to the member.
                                                                                 a. The name of the ineligible applicant,
C. Redetermination. If no change is reported, the Administration
                                                                                 b. The effective date of the denial,
    shall initiate an annual redetermination.
                                                                                 c. The reasons for ineligibility,
D. Termination. If the Administration determines that a member
                                                                                 d. The legal authority supporting the reason for ineligi-
    no longer meets the eligibility or premium criteria, the Admin-
                                                                                       bility, and
    istration shall terminate coverage.
                                                                                 e. The resource or reference materials where the legal
                           Historical ote                                              authority citations are found.
       New Section adopted by final rulemaking at 5 A.A.R.             B. Discontinuance.
     294, effective January 8, 1999 (Supp. 99-1). Amended by               1. When the Administration discontinues a member's eligi-
     final rulemaking at 6 A.A.R. 2435, effective June 9, 2000                   bility, the Administration shall provide a member with:
     (Supp. 00-2). Section repealed by exempt rulemaking at 7                    a. Advance notice at least 10 days before the effective
       A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                            date of the adverse action except as provided in sub-
      New Section made by exempt rulemaking at 12 A.A.R.                               section (B)(1)(b).
            3892, effective October 1, 2006 (Supp. 06-3).                        b. Adequate notice no later than the date of adverse
                                                                                       action when a member:
R9-22-1611. Copayments
                                                                                       i. Voluntarily withdraws and indicates an under-
A. Except for a member receiving behavioral health services or a
                                                                                             standing of the results of the action,
    Native American, a member is subject to the copayments as
                                                                                       ii. Becomes an inmate of a public institution as
    specified in R9-22-711(D).
                                                                                             specified in R9-22-1606(F),
B. The provider shall not deny a service because of the member's
                                                                                       iii. Dies and the Administration has verification of
    inability to pay a copayment.
                                                                                             the death,
                           Historical ote                                              iv. Has whereabouts that are unknown and the
       New Section adopted by final rulemaking at 5 A.A.R.                                   Administration’s loss of contact is confirmed
     294, effective January 8, 1999 (Supp. 99-1). Amended by                                 by returned mail from the post office with no
     final rulemaking at 6 A.A.R. 2435, effective June 9, 2000                               forwarding address,
     (Supp. 00-2). Section repealed by exempt rulemaking at 7                          v. Is approved for Title XIX, Title XXI, or HCG.
       A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).                            vi. Becomes eligible for Medicare benefits.
      New Section made by exempt rulemaking at 12 A.A.R.                   2. In addition to the requirements listed in subsection
            3892, effective October 1, 2006 (Supp. 06-3).                        (A)(2), the termination notice shall include an explana-
                                                                                 tion of a member’s right to continued coverage pending a
R9-22-1612. Resources
                                                                                 request for hearing as provided in 9 A.A.C. 34, Article 1.
There is no resource test for coverage under this Article.
                                                                       C. Premium Change.




June 30, 2011                                                     Page 95                                                       Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

     1.   When the Administration receives information that                           i.    Use the averaged weekly or bi-weekly amounts
          increases a member's premium amount, the Administra-                              to convert weekly or bi-weekly income to a
          tion shall provide the member with:                                               monthly equivalent;
          a. Advance notice at least 10 days before the effective                     ii. Use the averaged monthly or semi-monthly
                date of the adverse action.                                                 amounts to project monthly income; and
          b. The reason for the increase in premium including                         iii. Use the averaged hours worked and multiply
                appropriate income calculations and income stan-                            the average by the current rate of pay. If there is
                dard, and                                                                   a change in the rate of pay, use the new rate of
          c. An explanation of the member's hearing rights as                               pay when calculating projected income under
                specified in 9 A.A.C. 34, Article 1.                                        subsection (D)(1).
     2.   When the Administration receives information that                 3. Prorated income.
          decreases a member's premium amount, the Administra-                  a. Description. Prorated income evenly distributes a
          tion shall provide the member with notice of the decrease.                  person's income over the period the income is
                                                                                      intended to cover to calculate a monthly equivalent.
                           Historical ote
                                                                                b. Calculation. To prorate income, the Administration
       New Section adopted by final rulemaking at 5 A.A.R.
                                                                                      shall divide the total amount of the person's income
        294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                      received during the period by the number of months
      repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                                      that the income is intended to cover.
     tive October 1, 2001 (Supp. 01-3). New Section made by
                                                                            4. Converted income.
     exempt rulemaking at 12 A.A.R. 3892, effective October
                                                                                a. Description. Converted income is income received
                        1, 2006 (Supp. 06-3).
                                                                                      weekly or biweekly that is changed to a monthly
R9-22-1616. Calculating the Monthly Income for Determining                            equivalent.
the Premium Amount                                                              b. Calculation.
A. The Administration shall count gross household income.                             i. The Administration shall average the weekly or
B. The person(s) whose income is counted. The following per-                                bi-weekly income amounts before converting
     sons, when residing together, constitute a household income                            to the monthly equivalent if the person's past
     group whose income is counted:                                                         income fluctuates and the fluctuation is
     1. The applicant;                                                                      expected to recur.
     2. A child of the applicant;                                                     ii. To convert income paid weekly to a monthly
     3. A stepchild of the applicant;                                                       equivalent, the Administration shall multiply
     4. The spouse of the applicant; and                                                    the weekly average by 4.3 weeks.
     5. The other parent of any of the applicant's children.                          iii. To convert income paid bi-weekly to a monthly
C. The Administration shall consider the following factors when                             equivalent, the Administration shall multiply
     determining the income period to use to determine monthly                              the bi-weekly average by 2.15 weeks.
     income:                                                                5. Unconverted income.
     1. Type of income,                                                         a. Description. Unconverted income is the actual
     2. Frequency of income,                                                          amount of income received or projected to be
     3. If source of income is new or terminated, or                                  received during a month.
     4. Income fluctuation.                                                     b. Calculation. The Administration shall sum the actual
D. Methods for Calculating the Monthly Income                                         amount of income received or projected to be
     1. Projecting income.                                                            received during a month.
          a. Description. Projecting income is a method of deter-      E.   Calculations and Use of Methods Listed in subsection (D)
              mining the amount of income that a person will                Based on Frequency of Income
              receive.                                                      1. Monthly income. If income is received monthly or in a
          b. Calculation. The Administration shall project                      lump sum, the Administration shall use the unconverted
              income by:                                                        method for calculating monthly income.
              i. Converting income to a monthly equivalent,                     a. Lump sum means a nonrecurring payment that
              ii. Using unconverted income, or                                        serves as a complete payment.
              iii. Prorating income to determine a monthly                      b. Lump sum payments include but are not limited to:
                    equivalent.                                                       rebates or credits; inheritances; insurance settle-
          c. Exclusion. When calculating projected monthly                            ments; and payments for prior months from such
              income, the Administration shall exclude an unusual                     sources as Social Security, Veterans Administration,
              variation in income under subsection (F)(5), except                     Railroad Retirement, child support arrearages, or
              for a month in which the variation is anticipated to                    other benefits.
              occur.                                                            c. A lump sum payment may include a portion
     2. Averaged income.                                                              intended for the current month.
          a. Description. Averaging income proportionally dis-              2. Weekly income. If income is received weekly, the
              tributes the person's income received on a regular                Administration shall convert the income to a monthly
              basis.                                                            equivalent under subsection (D)(4).
          b. Calculation. To average income, the Administration             3. Bi-weekly income. If income is received bi-weekly, the
              shall add the amount of the income and divide by the              Administration shall convert the income to a monthly
              total number of pay periods. If the amount of income              equivalent under subsection (D)(4).
              received per pay period fluctuates, and the fluctua-          4. Semi-monthly or daily income. If income is received
              tion is expected to continue, the Administration                  semi-monthly or daily, the Administration shall use the
              shall:                                                            unconverted method for calculating monthly income
                                                                                under subsection (D)(5).


Supp. 11-2                                                        Page 96                                                       June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

     5.  Bimonthly, quarterly, semi-annual, or annual income. If                      ii.   When an unusual variation in income occurs
         income is received bimonthly, quarterly, semi-annually,                            during the month, the Administration shall use
         or annually, the Administration shall prorate the income                           the converted method for calculating monthly
         received or projected to be received under subsection                              income if income is received weekly or bi-
         (D)(3).                                                                            weekly.
F.   Use of Methods Listed in subsection (E) Based on Type of                         iii. When projecting income for the months follow-
     Income                                                                                 ing the month in which the unusual variation
     1. New income.                                                                         occurs, the Administration shall exclude the
         a. Description. New income is income received from a                               unusual variation in income from the income
              new source during the first calendar month that the                           calculation.
              income is received from the source.                           6.   Self-employment income.
         b. Calculating monthly income.                                          a. Description. Self-employment income is income a
              i. If a full month's income is received, the Admin-                     person earns from the person's own trade or business
                    istration shall use the appropriate method                        less allowable expenses.
                    described in subsection (E) to calculate the                 b. Calculating monthly income. The Administration
                    monthly income.                                                   shall use the following methods in the following
              ii. If less than a full month's income is received,                     order:
                    the Administration shall use the unconverted                      i. When the self-employed person filed a tax
                    method to calculate the monthly income.                                 return for the prior year and the person states
     2. Terminated income.                                                                  that the current income is the same, the Admin-
         a. Description. Terminated income is income received                               istration shall prorate the income under subsec-
              during the last calendar month that income is                                 tion (D).
              received from a source when no more income is                           ii. When the self-employed person did not file a
              expected to be received from the source.                                      tax return for the prior year or states that the
         b. Calculating monthly income.                                                     current income is not the same, the Administra-
              i. If a full month's income is received, the Admin-                           tion shall use the person's business ledger or
                    istration shall use the appropriate method                              other records to verify the current income
                    described in subsection (E) to calculate the                            received, less allowable expenses and use the
                    monthly income.                                                         appropriate method described in subsection (E)
              ii. If less than a full month's income is received,                           to calculate the monthly income.
                    the Administration shall use the unconverted                      iii. When the self-employed person did not file a
                    method to calculate the monthly income.                                 tax return or keep business records of the
     3. Break in income.                                                                    income received and expense incurred during
         a. Description. A break in income is a break in estab-                             the income period, the Administration shall use
              lished frequency of income of one calendar month or                           the person's written statement to verify income
              more.                                                                         received, shall not deduct incurred expenses
         b. Calculating monthly income.                                                     from the income without hard-copy verification
              i. If a full month's income is received, the Admin-                           of the expense, and shall use the appropriate
                    istration shall use the appropriate method                              method described in subsection (E) to calculate
                    described in subsection (E) to calculate the                            the monthly income.
                    monthly income.
                                                                                                  Historical ote
              ii. If less than a full month's income is received,
                                                                              New Section adopted by final rulemaking at 5 A.A.R.
                    the Administration shall use the unconverted
                                                                            294, effective January 8, 1999 (Supp. 99-1). Amended by
                    method to calculate the monthly income.
                                                                            final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
     4. Contract income.
                                                                            (Supp. 00-2). Section repealed by exempt rulemaking at 7
         a. Description. Contract income is income a person
                                                                              A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
              earns under a contract or other legal document that
                                                                             New Section made by exempt rulemaking at 12 A.A.R.
              specifies a length of time the contract or legal docu-
                                                                                   3892, effective October 1, 2006 (Supp. 06-3).
              ment covers, the amount of income to be paid, and
              the frequency of payment.                                R9-22-1617. Repealed
         b. Calculating monthly income.
                                                                                                Historical ote
              i. The Administration shall calculate the monthly
                                                                             New Section adopted by final rulemaking at 5 A.A.R.
                    income based on the frequency of payment if
                                                                              294, effective January 8, 1999 (Supp. 99-1). Section
                    income is paid more frequently than monthly.
                                                                            repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
              ii. The Administration shall prorate over the
                                                                                       tive October 1, 2001 (Supp. 01-3).
                    period of time specified by the contract if
                    income is paid monthly or less frequently.         R9-22-1618. General Provisions Related to Premiums
     5. Unusual variation in the amount of income.                     A. For the purpose of this Section:
         a. Description. Unusual variation is an amount of                 1. To remain eligible, all members shall pay the premium
              income that is different from the established amount             amounts specified in this Section.
              received and is not projected to continue or recur.          2. Failure to pay two months' premiums by the last working
         b. Calculating monthly income.                                        day of the second month of non-payment shall result in
              i. When calculating income for the month in                      discontinuance of benefits under this Article.
                    which an unusual variation in income occurs,       B. Premiums
                    the Administration shall include the unusual
                    variation in the income calculation.


June 30, 2011                                                     Page 97                                                       Supp. 11-2
Title 9, Ch. 22                                      Arizona Administrative Code
                                     Arizona Health Care Cost Containment System – Administration

     1.  When household income is 100 percent and less than or                  a.    All unpaid premiums and enrollment fees for any
         equal to 150 percent of the FPL, the monthly premium for                     AHCCCS program that the applicant incurred prior
         each eligible member is $60 per month.                                       to becoming eligible, and
   2. When household income is greater than 150 percent of                      b. All unpaid premiums for the applicant's children.
         the FPL and less than or equal to 200 percent of the FPL,         2.   Allocation of Outstanding Payments. All payments
         the monthly premium for each eligible member is $120                   received for eligible members shall first be applied to any
         per month.                                                             past due amounts for prior months owed to the Adminis-
   3. When household income is greater than 200 percent of                      tration. Any remaining amounts shall first be applied to
         the FPL and less than or equal to 250 percent of the FPL,              the amount due for the current month for a person, eligi-
         the monthly premium for each eligible member is $180                   ble under this Article.
         per month.
                                                                                                 Historical ote
   4. When household income is greater than 250 percent of
                                                                             New Section adopted by final rulemaking at 5 A.A.R.
         the FPL and less than or equal to 300 percent of the FPL,
                                                                              294, effective January 8, 1999 (Supp. 99-1). Section
         the monthly premium for each eligible member is $240
                                                                            repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
         per month.
                                                                           tive October 1, 2001 (Supp. 01-3). New Section made by
   5. When household income is greater than 300 percent of
                                                                           exempt rulemaking at 12 A.A.R. 3892, effective October
         the FPL, the monthly premium for each eligible member
                                                                                              1, 2006 (Supp. 06-3).
         is $300 per month.
C. Payment Due Date for Current Month. The monthly premium            R9-22-1619. Request for Hearing Process
   payment is due on the 15th day of the month for coverage of        A. Denial. If the Administration denies a member under R9-22-
   that month. This would be considered a current payment.                1615, a request for hearing process shall be conducted under 9
D. Payment Received Date. A payment is considered received on             A.A.C. 34.
   the date that the Administration receives and credits the pay-     B. Discontinuance. If the Administration discontinues a member
   ment to the member's account.                                          under R9-22-1615, the request for hearing process shall be
E. Past Due Payment                                                       conducted under 9 A.A.C. 34.
   1. Past due payment date. A payment is considered past due         C. Discontinuance for Non-Payment of Premiums. Except as pro-
         if the Administration does not receive the full payment by       vided in this Section, the Administration shall discontinue eli-
         the 15th day of the month in which the payment is due.           gibility on the effective date of the discontinuance if the past
   2. Payment not received. If payment for a month is not                 due amount for at least one prior month is not received by the
         received in full by the last working day of the month in         Administration in full before the effective date of the discon-
         which the payment is due, the Administration shall               tinuance.
         include the past and current due amounts in the next bill-   D. Reinstatement of Coverage. The Administration shall rescind
         ing statement.                                                   the discontinuance and continue eligibility if the past due
F. Payment Type. A premium shall be paid to the Administration            amount for at least one prior month is received by the Admin-
   by a:                                                                  istration in full before the effective date of the discontinuance.
   1. Cashier's check,                                                E. Continuation of Coverage during the request for hearing pro-
   2. Personal check,                                                     cess. To receive coverage from the time a Director's decision is
   3. Money order,                                                        issued, except as specified in subsection (E)(3).
   4. Electronic debit, or                                                1. A member shall:
   5. Other form approved by the Administration.                                a. File a request for hearing prior to the effective date
G. Insufficient Funds. The Administration shall not accept a per-                    of the discontinuance,
   sonal check or electronic debit when the premium has been                    b. Submit the full monthly premium amount to the
   previously paid with a personal check or electronic debit that                    Administration prior to the date of the discontinu-
   was returned to the Administration because of insufficient                        ance, and
   funds.                                                                       c. Continue to timely pay the full monthly premium
H. Payment In Advance. A premium may be paid in advance.                             amount each month during the hearing process.
I. Reimbursement of a Premium                                             2. If the decision is upheld, the Administration shall not
   1. A premium paid in advance is nonrefundable, unless the                    refund any premium amounts that have been paid during
         member is disenrolled at least 15 days prior to the month              the hearing process.
         of coverage.                                                     3. A member must notify the Administration when the
   2. A premium paid during an appeal and request for hearing                   member becomes eligible for Medicare benefits under 42
         process is applied as specified in R9-22-1619.                         U.S.C. 426(b) or 426-1. When the member becomes eli-
J. Change in Premium Amount.                                                    gible for Medicare benefits, the member is ineligible for
   1. When there is a decrease in the amount of the member's                    continuation of coverage.
         premium the decrease is effective the month following        F. Increase in premium amount. To stop the Administration from
         receipt of verification of the income decrease.                  increasing the premium amount from the time request for hear-
   2. When there is an increase in the amount of the member's             ing is filed until a Director's decision is issued:
         premium, the member receives advance notice. The pre-            1. A member shall file a request for hearing prior to the
         mium increase is effective the first month following the               effective date of the action as specified in 9 A.A.C. 34.
         month in which 10 day advance notice is issued.                  2. If the decision to increase the premium is upheld, the
K. Payment of Outstanding Premium and Enrollment Fee owed to                    member shall be responsible for paying the higher pre-
   the Administration.                                                          mium retroactively from the proposed effective date of
   1. As a condition of eligibility, an applicant or member shall               the increase in the premium amount that is being
         pay any unpaid premiums and enrollment fees owed to                    appealed.
         the Administration that were previously incurred. The        G. Method of payment during the hearing process. To continue
         unpaid premiums and enrollment fees consist of:                  coverage a member shall pay the premium by:


Supp. 11-2                                                       Page 98                                                     June 30, 2011
                                                      Arizona Administrative Code                                         Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

    1.      Cashier's check,                                               repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
    2.      Money order, or                                                           tive October 1, 2001 (Supp. 01-3).
    3.      Other form approved by the Administration.
                                                                      R9-22-1629. Repealed
                          Historical ote
                                                                                               Historical ote
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                            New Section adopted by final rulemaking at 5 A.A.R.
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                             294, effective January 8, 1999 (Supp. 99-1). Section
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                                                                           repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
    tive October 1, 2001 (Supp. 01-3). New Section made by
                                                                                      tive October 1, 2001 (Supp. 01-3).
    exempt rulemaking at 12 A.A.R. 3892, effective October
                       1, 2006 (Supp. 06-3).                          R9-22-1630. Repealed
R9-22-1620. Repealed                                                                           Historical ote
                                                                            New Section adopted by final rulemaking at 5 A.A.R.
                         Historical ote
                                                                             294, effective January 8, 1999 (Supp. 99-1). Section
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                           repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                      tive October 1, 2001 (Supp. 01-3).
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                tive October 1, 2001 (Supp. 01-3).                    R9-22-1631. Repealed
R9-22-1621. Reserved                                                                           Historical ote
                                                                            New Section adopted by final rulemaking at 5 A.A.R.
R9-22-1622. Repealed
                                                                             294, effective January 8, 1999 (Supp. 99-1). Section
                         Historical ote                                    repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
      New Section adopted by final rulemaking at 5 A.A.R.                             tive October 1, 2001 (Supp. 01-3).
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                      R9-22-1632. Reserved
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                tive October 1, 2001 (Supp. 01-3).                    R9-22-1633. Repealed
R9-22-1623. Repealed                                                                           Historical ote
                                                                            New Section adopted by final rulemaking at 5 A.A.R.
                         Historical ote
                                                                             294, effective January 8, 1999 (Supp. 99-1). Section
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                           repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                      tive October 1, 2001 (Supp. 01-3).
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                tive October 1, 2001 (Supp. 01-3).                    R9-22-1634. Repealed
R9-22-1624. Repealed                                                                           Historical ote
                                                                            New Section adopted by final rulemaking at 5 A.A.R.
                         Historical ote
                                                                             294, effective January 8, 1999 (Supp. 99-1). Section
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                           repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
       294, effective January 8, 1999 (Supp. 99-1). Section
                                                                                      tive October 1, 2001 (Supp. 01-3).
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                tive October 1, 2001 (Supp. 01-3).                    R9-22-1635. Reserved
R9-22-1625. Repealed                                                  R9-22-1636. Repealed
                         Historical ote                                                        Historical ote
      New Section adopted by final rulemaking at 5 A.A.R.                   New Section adopted by final rulemaking at 5 A.A.R.
       294, effective January 8, 1999 (Supp. 99-1). Section                  294, effective January 8, 1999 (Supp. 99-1). Section
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-                repealed by exempt rulemaking at 7 A.A.R. 4593, effec-
                tive October 1, 2001 (Supp. 01-3).                                    tive October 1, 2001 (Supp. 01-3).
R9-22-1626. Repealed                                                                  ARTICLE 17. E ROLLME T
                         Historical ote                               R9-22-1701. Enrollment-Related Definitions
      New Section adopted by final rulemaking at 5 A.A.R.             In addition to definitions contained in A.R.S. § 36-2901, the words
       294, effective January 8, 1999 (Supp. 99-1). Section           and phrases in this Chapter have the following meanings unless the
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-           context explicitly requires another meaning:
                tive October 1, 2001 (Supp. 01-3).                         “Annual enrollment choice” means the annual opportunity for
                                                                           a person to change contractors.
R9-22-1627. Repealed
                                                                          “Auto-assignment algorithm” or “Algorithm” means a formula
                         Historical ote
                                                                          used by the Administration to assign to a contractor a member
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                          who did not make a timely choice under R9-22-1702.
       294, effective January 8, 1999 (Supp. 99-1). Section
     repealed by exempt rulemaking at 7 A.A.R. 4593, effec-               “CMDP” means Comprehensive Medical and Dental Program.
                tive October 1, 2001 (Supp. 01-3).
                                                                          “Disenrollment” means the discontinuance of a person’s enti-
R9-22-1628. Repealed                                                      tlement to receive covered services from a contractor of
                                                                          record.
                           Historical ote
         New Section adopted by final rulemaking at 5 A.A.R.              “Enrollment” means the process by which an eligible person
         294, effective January 8, 1999 (Supp. 99-1). Section             becomes a member of a contractor’s plan.


June 30, 2011                                                   Page 99                                                       Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

                          Historical ote                                           d. Resides in an area not served by a contractor.
        New Section adopted by final rulemaking at 5 A.A.R.              B.   Fee-for-service coverage. A member not enrolled with a con-
     294, effective January 8, 1999 (Supp. 99-1). Amended by                  tractor under subsection (A)(5) shall obtain covered medical
     final rulemaking at 6 A.A.R. 2435, effective June 9, 2000                services from an AHCCCS-registered provider on a fee-for-
         (Supp. 00-2). Amended by exempt rulemaking at 7                      service basis under Article 7.
        A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).             C.   Foster care child. The Administration shall enroll a member
        Amended to correct a typographical error, filed in the                with CMDP if the member is a foster care child under A.R.S. §
      Office of the Secretary of State October 30, 2001 (Supp.                8-512.
     01-4). Amended by exempt rulemaking at 7 A.A.R. 5701,               D.   Family Planning Services Extension Program. A member eli-
       effective December 1, 2001 (Supp. 01-4). Amended by                    gible for the Family Planning Services Extension Program
     exempt rulemaking at 10 A.A.R. 4588, effective October                   under R9-22-1431, shall remain enrolled with the member’s
        12, 2004 (Supp. 04-4). Section repealed; new Section                  contractor of record or IHS.
       made by final rulemaking at 14 A.A.R. 1598, effective             E.   Contractor or IHS enrollment change for a member.
                     May 31, 2008 (Supp. 08-2).                               1. The Administration shall change a member’s enrollment
                                                                                   if the member requests a change to an available contrac-
R9-22-1702. Enrollment of a Member with an AHCCCS Con-
                                                                                   tor or IHS during an annual enrollment period. A Native
tractor
                                                                                   American may change from an available contractor to
A. General enrollment requirements. The Administration shall
                                                                                   IHS or from IHS to an available contractor at any time.
     enroll a member with a contractor as described in this Section,
                                                                              2. The Administration shall approve a change in enrollment
     unless the member has pre-selected a contractor on the appli-
                                                                                   for any member if the change is a result of the final out-
     cation:
                                                                                   come of a grievance under 9 A.A.C. 34.
     1. Except as provided in subsections (A)(3), (A)(5), and (C),
                                                                              3. A member may choose a different contractor if the mem-
          a member who is determined to be eligible under this
                                                                                   ber moves into a GSA not served by the current contrac-
          Chapter and resides in an area served by more than one
                                                                                   tor or if the contractor is no longer available. If the
          contractor, may choose an available contractor serving
                                                                                   member does not select a contractor, the Administration
          the member’s GSA within 30 days from the date of notice
                                                                                   shall auto-assign the member as provided in subsection
          of enrollment. A Native American member may select
                                                                                   (A)(2).
          IHS or another available contractor.
                                                                              4. The Administration shall provide the member 60-day
     2. If the member does not make a choice under subsection
                                                                                   advance notice of the member’s option to change plans
          (A)(1), the Administration shall immediately auto-assign
                                                                                   by the member’s annual enrollment date.
          the member to:
                                                                              5. A member may disenroll from a plan if:
          a. IHS if the member is a Native American living on a
                                                                                   a. The member moves out of the GSA;
               reservation,
                                                                                   b. The plan does not, because of moral or religious
          b. A contractor based on family continuity, or
                                                                                         objections, cover the service a member seeks; or
          c. A contractor by using the auto-assignment algo-
                                                                                   c. The member needs related services to be performed
               rithm.
                                                                                         at the same time; not all related services are avail-
     3. If the member’s period of ineligibility and disenrollment
                                                                                         able within the network; and the member’s primary
          from the contractor of record is for a period of less than
                                                                                         care provider or another provider determines that
          90 days, the Administration shall enroll the member with
                                                                                         receiving the services separately would subject the
          the member’s most recent contractor of record, if avail-
                                                                                         member to unnecessary risk.
          able, except if:
                                                                              6. For exceptions to this Article, the Administration shall
          a. The member no longer resides in the contractor’s
                                                                                   approve a change for an enrolled member as determined
               GSA;
                                                                                   by the Director.
          b. The contractor’s contract is suspended or termi-
               nated;                                                                              Historical ote
          c. The member was previously enrolled with CMDP                       New Section adopted by final rulemaking at 5 A.A.R.
               but at the time of re-enrollment the member is not a           294, effective January 8, 1999 (Supp. 99-1). Amended by
               foster care child;                                              exempt rulemaking at 7 A.A.R. 4593, effective October
          d. The member chooses another contractor or chooses                   1, 2001 (Supp. 01-3). Section repealed; new Section
               IHS, if available to the member, during the annual              made by final rulemaking at 14 A.A.R. 1598, effective
               enrollment choice period; or                                                   May 31, 2008 (Supp. 08-2).
          e. The member was previously enrolled with a contrac-
                                                                         R9-22-1703. Effective Date of Enrollment with a Contractor
               tor but at the time of re-enrollment the member is a
                                                                         A. Effective date of enrollment. A member’s date of enrollment is
               foster care child.
                                                                             the date enrollment action is taken by the Administration.
     4. When the member’s disenrollment period is more than 90
                                                                             However, if a plan change occurs for an annual enrollment
          days, the member may select a contractor as described in
                                                                             choice, the effective date is the month of the member’s enroll-
          subsection (A)(1).
                                                                             ment anniversary date.
     5. The Administration shall not enroll a member with a con-
                                                                         B. Financial liability of the contractor. The contractor shall be
          tractor if a member:
                                                                             financially liable for an enrolled member’s care as specified in
          a. Is eligible for the FESP under R9-22-1419;
                                                                             contract.
          b. Is eligible for less than 30 days from the date the
               Administration receives notification of a member’s                                  Historical ote
               eligibility, except for a member who is enrolled with            New Section adopted by final rulemaking at 5 A.A.R.
               CMDP or IHS;                                                   294, effective January 8, 1999 (Supp. 99-1). Amended by
          c. Is eligible only for a retroactive period of eligibility,         exempt rulemaking at 7 A.A.R. 4593, effective October
               except for a member who is enrolled with CMDP or                 1, 2001 (Supp. 01-3). Section repealed; new Section
               IHS; or


Supp. 11-2                                                         Page 100                                                    June 30, 2011
                                                     Arizona Administrative Code                                            Title 9, Ch. 22
                                     Arizona Health Care Cost Containment System – Administration

      made by final rulemaking at 14 A.A.R. 1598, effective                5.   The last day of the month in which the Administration
                  May 31, 2008 (Supp. 08-2).                                    receives notification that a member’s adoption proceed-
                                                                                ings are finalized; or
R9-22-1704.      ewborn Enrollment
                                                                           6. The last day of the month in which the Administration
A. General.
                                                                                receives notification that a member’s whereabouts are
    1. The Administration shall enroll a newborn child of an eli-
                                                                                unknown.
          gible mother with an available contractor or IHS, based
                                                                      D.   Retroactive adjustments. The Administration shall adjust the
          on the mother’s enrollment.
                                                                           member’s eligibility and enrollment retroactively under sub-
    2. The Administration shall auto-assign a newborn child of
                                                                           section (C).
          an eligible mother who is not enrolled with a contractor
          or IHS or who is enrolled with CMDP. When a mother                                     Historical ote
          enrolled in CMDP has a newborn and the newborn is sur-                New Section made by final rulemaking at 14 A.A.R.
          rendered to Administration on Children, Youth and Fami-                  1598, effective May 31, 2008 (Supp. 08-2).
          lies (ACYF), the newborn is then enrolled with CMDP.
                                                                                          ARTICLE 18. RESERVED
    3. The Administration shall notify the mother of the right to
          choose a different contractor for her newborn child. The                   ARTICLE 19. FREEDOM TO WORK
          mother may make her choice within 30 days from the
                                                                           Article 19, consisting of Sections R9-22-1901 through R9-22-
          date of notice of enrollment.
                                                                      1922, made by exempt rulemaking at 9 A.A.R. 95, effective January
B. Financial liability for newborns. The contractor shall be finan-
                                                                      1, 2003 (Supp. 02-4).
    cially liable for the medical care of a newborn as specified in
    contract.                                                         R9-22-1901. General Freedom to Work Requirements
                                                                      Under 42 U.S.C. 1396a(a)(10)(A)(ii)(XV) and (XVI), the Adminis-
                         Historical ote
                                                                      tration shall determine eligibility for AHCCCS medical services,
      New Section adopted by final rulemaking at 5 A.A.R.
                                                                      under Article 2 of this Chapter, using the eligibility criteria and
    294, effective January 8, 1999 (Supp. 99-1). Amended by
                                                                      requirements under this Article for an applicant or member who is:
    final rulemaking at 6 A.A.R. 2435, effective June 9, 2000
                                                                            1. At least 16 years of age, but less than 65 years of age,
       (Supp. 00-2). Amended by exempt rulemaking at 7
                                                                            2. Employed, and
      A.A.R. 4593, effective October 1, 2001 (Supp. 01-3).
                                                                            3. Not income eligible under A.R.S. § 36-2901(6)(a).
      Amended to correct a typographical error, filed in the
     Office of the Secretary of State October 30, 2001 (Supp.                                  Historical ote
     01-4). Section repealed; new Section made by final rule-              New Section made by exempt rulemaking at 9 A.A.R. 95,
       making at 14 A.A.R. 1598, effective May 31, 2008                            effective January 1, 2003 (Supp. 02-4).
                           (Supp. 08-2).
                                                                      R9-22-1902. General Administration Requirements
R9-22-1705. Guaranteed Enrollment Period                              The Administration shall comply with the confidentiality rule under
A. General. Except for members enrolled with IHS or CMDP, the         R9-22-512(C).
    Administration shall provide a guaranteed enrollment period
                                                                                                 Historical ote
    for a one-time period that begins on the effective date of the
                                                                           New Section made by exempt rulemaking at 9 A.A.R. 95,
    member’s initial enrollment with a contractor and ends on the
                                                                           effective January 1, 2003 (Supp. 02-4). Amended by final
    last day of the fifth full calendar month after the date of the
                                                                             rulemaking at 15 A.A.R. 220, effective March 7, 2009
    member’s initial enrollment.
                                                                                                  (Supp. 09-1).
B. Exceptions to guaranteed period. The Administration shall not
    grant a guaranteed enrollment period or shall terminate a guar-   R9-22-1903. Application for Coverage
    anteed enrollment period as provided in subsection (C), if the    A. A person may apply by submitting an application to an
    member:                                                               Administration office.
    1. Did not meet the conditions of eligibility when initially      B. The application date is the date the application is received at
          enrolled with the contractor;                                   an Administration office or outstation location approved by
    2. Except as provided in 9 A.A.C. 22, Article 12, is an               the Director as described under R9-22-1406(A).
          inmate of a public institution as defined in 42 CFR         C. The provisions in R9-22-1406(B) and (D) apply to this Sec-
          435.1010;                                                       tion.
    3. Dies;                                                          D. The applicant or representative who files the application may
    4. Moves out-of-state;                                                withdraw the application for coverage either orally or in writ-
    5. Voluntarily withdraws from the AHCCCS program;                     ing. An applicant withdrawing an application shall receive a
    6. Is adopted; or                                                     denial notice under R9-22-1904.
    7. Has whereabouts that are unknown.                              E. Except as provided in 42 CFR 435.911, the Administration
C. Disenrollment effective date. The Administration shall termi-          shall determine eligibility within 45 days.
    nate any guaranteed enrollment period to which the member is
                                                                                                 Historical ote
    not entitled effective on:
                                                                           New Section made by exempt rulemaking at 9 A.A.R. 95,
          1. The date the member is admitted to a public institu-
                                                                           effective January 1, 2003 (Supp. 02-4). Amended by final
               tion under subsection (B);
                                                                            rulemaking at 9 A.A.R. 5123, effective January 3, 2004
          2. The member’s date of death;
                                                                           (Supp. 03-4). Amended by final rulemaking at 15 A.A.R.
          3. The last day of the month in which the Administra-
                                                                                   220, effective March 7, 2009 (Supp. 09-1).
               tion receives notification that a member moved out-
               of-state;                                              R9-22-1904.      otice of Approval or Denial
          4. The date the Administration receives written notifi-     The Administration shall send an applicant a written notice of the
               cation of the member’s voluntary withdrawal from       decision regarding the application. This notice shall include a state-
               the AHCCCS program;                                    ment of the action, and:



June 30, 2011                                                   Page 101                                                        Supp. 11-2
Title 9, Ch. 22                                       Arizona Administrative Code
                                      Arizona Health Care Cost Containment System – Administration

     1.   If approved, the notice shall contain:                               rulemaking at 15 A.A.R. 220, effective March 7, 2009
          a. The effective date of eligibility,                                                   (Supp. 09-1).
          b. The amount the person shall pay, and
                                                                         R9-22-1908. Request for Hearing
          c. An explanation of the person’s hearing rights speci-
                                                                         An applicant or member may request a hearing under 9 A.A.C. 34.
               fied in 9 A.A.C. 34.
     2.   If denied, R9-22-1501(G)(3) applies.                                                      Historical ote
                                                                              New Section made by exempt rulemaking at 9 A.A.R. 95,
                           Historical ote
                                                                              effective January 1, 2003 (Supp. 02-4). Amended by final
     New Section made by exempt rulemaking at 9 A.A.R. 95,
                                                                                rulemaking at 15 A.A.R. 220, effective March 7, 2009
     effective January 1, 2003 (Supp. 02-4). Amended by final
                                                                                                     (Supp. 09-1).
       rulemaking at 15 A.A.R. 220, effective March 7, 2009
                            (Supp. 09-1).                                R9-22-1909. Conditions of Eligibility
                                                                         An applicant or member shall meet the following conditions to
R9-22-1905. Reporting and Verifying Changes
                                                                         qualify for the Freedom to Work program:
An applicant or member shall report and verify changes, as
                                                                              1. Furnish a valid Social Security Number (SSN);
described under R9-22-1501(H), to the Administration.
                                                                              2. Be a resident of Arizona;
                           Historical ote                                     3. Be a citizen of the United States, or meet requirements
     New Section made by exempt rulemaking at 9 A.A.R. 95,                         for a qualified alien under A.R.S. § 36-2903.03(B);
     effective January 1, 2003 (Supp. 02-4). Amended by final                 4. Be at least 16 years of age, but less than 65 years of age;
       rulemaking at 15 A.A.R. 220, effective March 7, 2009                   5. Have countable income that does not exceed 250 percent
                            (Supp. 09-1).                                          of FPL. The Administration shall count the income under
                                                                                   42 U.S.C. 1382a and 20 CFR 416 Subpart K with the fol-
R9-22-1906. Actions that Result from a Redetermination or
                                                                                   lowing exceptions:
Change
                                                                                   a. The unearned income of the applicant or member
The processing of a redetermination or change shall result in one of
                                                                                         shall be disregarded,
the following actions:
                                                                                   b. The income of a spouse or other family member
     1. No change in eligibility or premium,
                                                                                         shall be disregarded, and
     2. Discontinuance of eligibility if a condition of eligibility is
                                                                                   c. The deduction for a minor child shall not apply;
          no longer met,
                                                                              6. Comply with the member responsibility provisions under
     3. A change in premium amount, or
                                                                                   R9-22-1502(D) and (F).
     4. A change in the coverage group under which a person
          receives AHCCCS medical coverage.                                                         Historical ote
                                                                              New Section made by exempt rulemaking at 9 A.A.R. 95,
                         Historical ote
                                                                              effective January 1, 2003 (Supp. 02-4). Amended by final
     New Section made by exempt rulemaking at 9 A.A.R. 95,
                                                                                rulemaking at 15 A.A.R. 220, effective March 7, 2009
             effective January 1, 2003 (Supp. 02-4).
                                                                                 (Supp. 09-1). Section repealed; new Section made by
R9-22-1907.      otice of Adverse Action Requirements                           final rulemaking at 15 A.A.R. 220, effective March 7,
A. The requirements under R9-22-1501(K)(1) apply.                                                 2009 (Supp. 09-1).
B. Advance notice of a change in eligibility or premium amount.
                                                                         R9-22-1910. Repealed
    Advance notice means a notice of proposed action that is
    issued to the member at least 10 days before the effective date                                Historical ote
    of the proposed action. Except under subsection (C), advance              New Section made by exempt rulemaking at 9 A.A.R. 95,
    notice shall be issued whenever an adverse action is taken to             effective January 1, 2003 (Supp. 02-4). Section repealed
    discontinue eligibility, or increase the premium amount.                  by final rulemaking at 15 A.A.R. 220, effective March 7,
C. Exceptions from advance notice. A notice shall be issued to                                   2009 (Supp. 09-1).
    the member to discontinue eligibility no later than the effective
                                                                         R9-22-1911. Repealed
    date of action if:
    1. A member provides a clearly written statement, signed by                                    Historical ote
         that member, that services are no longer wanted.                     New Section made by exempt rulemaking at 9 A.A.R. 95,
    2. A member provides information that requires termination                effective January 1, 2003 (Supp. 02-4). Section repealed
         of eligibility or reduction of services, indicates that the          by final rulemaking at 15 A.A.R. 220, effective March 7,
         member understands that this must be the result of sup-                                 2009 (Supp. 09-1).
         plying that information, and the member signs a written
                                                                         R9-22-1912. Repealed
         statement waiving advance notice;
    3. A member cannot be located and mail sent to the mem-                                        Historical ote
         ber’s last known address has been returned as undeliver-             New Section made by exempt rulemaking at 9 A.A.R. 95,
         able subject to reinstatement of discontinued services               effective January 1, 2003 (Supp. 02-4). Section repealed
         under 42 CFR 431.231(d);                                             by final rulemaking at 15 A.A.R. 220, effective March 7,
    4. A member has been admitted to a public institution where                                  2009 (Supp. 09-1).
         a person is ineligible for coverage;
                                                                         R9-22-1913. Premium Requirements
    5. A member has been approved for Medicaid in another
                                                                         A. As a condition of eligibility, an applicant or member shall:
         state; or
                                                                             1. Pay the premium required under subsection (B).
    6. The Administration receives information confirming the
                                                                             2. Not have any unpaid premiums for more than one
         death of a member.
                                                                                  month’s premium amount.
                           Historical ote                                B. The Administration shall process premiums under 9 A.A.C.
     New Section made by exempt rulemaking at 9 A.A.R. 95,                   31, Article 14 with the following exceptions:
     effective January 1, 2003 (Supp. 02-4). Amended by final                1. A member who has countable income:


Supp. 11-2                                                         Page 102                                                   June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

          a.   Under $500, the monthly premium payment shall be                  rity or Medicare taxes are paid on the applicant or mem-
               $0.                                                               ber’s work.
          b. Over $500 but not greater than $750, the monthly
                                                                                                 Historical ote
               premium payment shall be $10.
                                                                             New Section made by exempt rulemaking at 9 A.A.R. 95,
     2.   The premium for a member shall be increased by $5 for
                                                                                     effective January 1, 2003 (Supp. 02-4).
          each $250 increase in countable income above $750.
                                                                        R9-22-1919. Additional Eligibility Criteria for the Medically
                           Historical ote
                                                                        Improved Group
     New Section made by exempt rulemaking at 9 A.A.R. 95,
                                                                        As a condition of eligibility for the Medically Improved Group, a
     effective January 1, 2003 (Supp. 02-4). Amended by final
                                                                        member shall:
       rulemaking at 15 A.A.R. 220, effective March 7, 2009
                                                                            1. Be employed. Under this Section, employed means an
                            (Supp. 09-1).
                                                                                 individual who:
R9-22-1914. Repealed                                                             a. Earns at least the minimum wage and works at least
                                                                                       40 hours per month, or
                          Historical ote
                                                                                 b. Has gross monthly earnings at least equal to those
     New Section made by exempt rulemaking at 9 A.A.R. 95,
                                                                                       earned by an individual who is earning the minimum
     effective January 1, 2003 (Supp. 02-4). Section repealed
                                                                                       wage working 40 hours per month.
     by final rulemaking at 15 A.A.R. 220, effective March 7,
                                                                            2. Cease to be eligible for medical coverage under R9-22-
                        2009 (Supp. 09-1).
                                                                                 1918 or a similar Basic Coverage Group program admin-
R9-22-1915. Institutionalized Person                                             istered by another state because the member, by reason of
A person is not eligible for AHCCCS medical coverage if the per-                 medical improvement, is determined at the time of a reg-
son is:                                                                          ularly scheduled continuing disability review to no longer
     1. An inmate of a public institution if federal financial par-              be disabled; and
         ticipation (FFP) is not available, or                              3. Continues to have a severe medically determinable
     2. Age 21 through age 64 and is residing in an Institution for              impairment, as determined under Social Security Act sec-
         Mental Disease under 42 CFR 435.1009 except when                        tion 1902(a)(10)(A)(ii)(XVI).
         allowed under the Administration’s Section 1115 IMD
                                                                                                   Historical ote
          waiver or allowed under a managed care contract approved by
                                                                             New Section made by exempt rulemaking at 9 A.A.R. 95,
          CMS.
                                                                             effective January 1, 2003 (Supp. 02-4). Amended by final
                           Historical ote                                      rulemaking at 15 A.A.R. 220, effective March 7, 2009
     New Section made by exempt rulemaking at 9 A.A.R. 95,                                          (Supp. 09-1).
     effective January 1, 2003 (Supp. 02-4). Amended by final
                                                                        R9-22-1920. Repealed
       rulemaking at 15 A.A.R. 220, effective March 7, 2009
                            (Supp. 09-1).                                                         Historical ote
                                                                             New Section made by exempt rulemaking at 9 A.A.R. 95,
R9-22-1916. Repealed
                                                                             effective January 1, 2003 (Supp. 02-4). Section repealed
                          Historical ote                                     by final rulemaking at 15 A.A.R. 220, effective March 7,
     New Section made by exempt rulemaking at 9 A.A.R. 95,                                      2009 (Supp. 09-1).
     effective January 1, 2003 (Supp. 02-4). Section repealed
                                                                        R9-22-1921. Enrollment
     by final rulemaking at 15 A.A.R. 220, effective March 7,
                                                                        The Administration shall enroll members under Article 17 of this
                        2009 (Supp. 09-1).
                                                                        Chapter. If a member has not paid a required premium, the Admin-
R9-22-1917. Repealed                                                    istration shall not grant a guaranteed enrollment period.
                          Historical ote                                                         Historical ote
     New Section made by exempt rulemaking at 9 A.A.R. 95,                   New Section made by exempt rulemaking at 9 A.A.R. 95,
     effective January 1, 2003 (Supp. 02-4). Section repealed                        effective January 1, 2003 (Supp. 02-4).
     by final rulemaking at 15 A.A.R. 220, effective March 7,
                                                                        R9-22-1922. Redetermination of Eligibility
                        2009 (Supp. 09-1).
                                                                        A. Redetermination. Except as provided in subsection (B), the
R9-22-1918. Additional Eligibility Criteria for the Basic Cov-              Administration shall complete a redetermination of eligibility
erage Group                                                                 at least once a year.
An applicant or member shall meet the following eligibility criteria:   B. Change in circumstance. The Administration may complete a
    1. Disabled. As a condition of eligibility, an applicant or             redetermination of eligibility if there is a change in the mem-
         member shall be disabled. Disabled means a person who              ber’s circumstances, including a change in disability or
         has been determined disabled by the Department of Eco-             employment that may affect eligibility.
         nomic Security, Disability Determination Services              C. Medical Improvement. If a member is no longer disabled
         Administration, under 42 U.S.C. 1382c(a)(3)(A) through             under R9-22-1918, the Administration shall determine if the
         (E), except employment activity, earnings, and substantial         member is eligible under other coverage groups including the
         gainful activity shall not be considered in determining            medically improved group.
         whether the individual meets the definition of disability.
                                                                                                 Historical ote
    2. Employed. As a condition of eligibility, an applicant or
                                                                             New Section made by exempt rulemaking at 9 A.A.R. 95,
         member shall be employed. Employed means that an
                                                                                     effective January 1, 2003 (Supp. 02-4).
         applicant or member is paid for working and Social Secu-




June 30, 2011                                                     Page 103                                                      Supp. 11-2
Title 9, Ch. 22                                        Arizona Administrative Code
                                       Arizona Health Care Cost Containment System – Administration

     ARTICLE 20. BREAST A D CERVICAL CA CER                                          ment for breast cancer or cervical cancer, including a pre-
              TREATME T PROGRAM                                                      cancerous cervical lesion, as specified in R9-22-2004;
                                                                               5. Not be covered under creditable coverage as specified in
R9-22-2001. Breast and Cervical Cancer Treatment Program
                                                                                     Section 2701(c) of the Public Health Services Act, 42
Related Definitions
                                                                                     U.S.C. 300gg(c). For purposes of this Article, IHS or
In addition to definitions contained in A.R.S. § 36-2901, the words
                                                                                     Tribal health coverage is not considered creditable cover-
and phrases in this Chapter have the following meaning unless the
                                                                                     age as specified in 42 U.S.C. 1396a(a)(10)(A)(ii), as
context explicitly requires another meaning:
                                                                                     amended by the Native American Breast and Cervical
     “AZ-NBCCEDP” means the Arizona programs of the National
                                                                                     Cancer Treatment Technical Amendment Act of 2002;
     Breast and Cervical Cancer Early Detection Program. AZ-
                                                                                     and
     NBCCEDP provides breast and cervical cancer screening and
                                                                               6. Meet the requirements under R9-22-1417 and R9-22-
     diagnosis in Arizona.
                                                                                     1418.
     “Cryotherapy” means the destruction of abnormal tissue using
                                                                          B.   Ineligible woman. A woman is ineligible under this Article if
     an extremely cold temperature.
                                                                               the woman:
     “LEEP” means the loop electrosurgical excision procedure
                                                                               1. Is an inmate of a public institution and federal financial
     that passes an electric current through a thin wire loop.
                                                                                     participation (FFP) is not available,
     “Peer-reviewed study” means that, prior to publication, a med-
                                                                               2. Is at least age 21 but less than age 65 and resides in an
     ical study has been subjected to the review of medical experts
                                                                                     Institution for Mental Disease (IMD) as defined in R9-
     who:
                                                                                     22-112, except if allowed under the Administration’s Sec-
           Have expertise in the subject matter of the study,
                                                                                     tion 1115 waiver, or
           Evaluate the science and methodology of the study,
                                                                               3. No longer meets an eligibility requirement under this
           Are selected by the editorial staff of the publication, and
                                                                                     Article.
           Review the study without knowledge of the identity or
                                                                          C.   Metastasized cancer. The AHCCCS Chief Medical Officer
           qualifications of the author.
                                                                               may continue a woman’s eligibility under this Article if a
     “WWHP” means the Well Women Healthcheck Program
                                                                               metastasized cancer is found in another part of the woman’s
     administered by the Arizona Department of Health Services.
                                                                               body and that metastasized cancer is a known or a presumed
     The WWHP is one of the programs within AZ-NBCCEDP that
                                                                               complication of the breast or cervical cancer as determined by
     provides breast and cervical cancer screening and diagnosis.
                                                                               the treating physician.
                         Historical ote                                   D.   Reoccurrence of cancer. A woman shall have eligibility rees-
     New Section made by final rulemaking at 7 A.A.R. 5814,                    tablished after eligibility under this Article ends if the woman
        effective December 6, 2001 (Supp. 01-4). Section                       is screened under the AZ-NBCCEDP program and additional
      repealed; new Section made by final rulemaking at 12                     breast cancer or cervical cancer, including a pre-cancerous cer-
       A.A.R. 4488, effective January 6, 2007 (Supp. 06-4).                    vical lesion, is found.
                                                                          E.   Ineligible male. A male is precluded from receiving screening
R9-22-2002. General Requirements
                                                                               and diagnostic services under the AZ-NBCCEDP program and
A. Confidentiality. The Administration shall maintain the confi-
                                                                               is ineligible under this Article.
    dentiality of a woman’s records and shall not disclose a
    woman’s financial, medical, or other confidential information                                  Historical ote
    except as allowed under R9-22-512.                                         New Section made by final rulemaking at 7 A.A.R. 5814,
B. Covered services. A woman who is eligible under this Article                 effective December 6, 2001 (Supp. 01-4). Amended by
    receives all medically necessary services under Articles 2 and             final rulemaking at 12 A.A.R. 4488, effective January 6,
    12 of this Chapter.                                                                           2007 (Supp. 06-4).
C. Choice of health plan. A woman who is eligible under this
                                                                          R9-22-2004. Treatment
    Article shall be enrolled with a contractor under Article 17 of
                                                                          A. Breast cancer. Coverage for treatment for breast cancer under
    this Chapter.
                                                                              this Article shall conclude on the last provider visit for the spe-
D. A Native American woman who receives services through
                                                                              cific treatment of the cancer or at the end of hormonal therapy
    Indian Health Service (IHS) or through a tribal health program
                                                                              for the cancer, whichever is later. For purposes of this subsec-
    qualifies for services provided under this Article if all eligibil-
                                                                              tion treatment means:
    ity requirements are met.
                                                                              1. Lumpectomy or surgical removal of breast cancer;
E. A woman qualified under this Article shall pay co-pays as
                                                                              2. Chemotherapy;
    described in R9-22-711.
                                                                              3. Radiation therapy; and
                         Historical ote                                       4. A treatment for breast cancer that, as determined by the
     New Section made by final rulemaking at 7 A.A.R. 5814,                         AHCCCS Chief Medical Officer, is considered the stan-
        effective December 6, 2001 (Supp. 01-4). Section                            dard of care as supported by a peer-reviewed study pub-
      repealed; new Section made by final rulemaking at 12                          lished in a medical journal.
       A.A.R. 4488, effective January 6, 2007 (Supp. 06-4).               B. Pre-cancerous cervical lesion. Coverage for treatment for a
                                                                              pre-cancerous cervical lesion under this Article, including
R9-22-2003. Eligibility Criteria
                                                                              moderate or severe cervical dysplasia or carcinoma in situ,
A. General. To be eligible under this Article, a woman shall meet
                                                                              shall conclude on the last provider visit for specific treatment
    the requirements of this Article and:
                                                                              for the pre-cancerous lesion. For purposes of this subsection
    1. Be screened for breast and cervical cancer through AZ-
                                                                              treatment means:
         NBCCEDP;
                                                                              1. Conization;
    2. Be less than 65 years of age;
                                                                              2. LEEP;
    3. Be ineligible for Title XIX under Articles 14 and 15 in
                                                                              3. Cryotherapy; and
         this Chapter;
                                                                              4. A treatment for pre-cancerous cervical lesion that, as
    4. Receive a positive screen under subsection (A)(1), a con-
                                                                                    determined by the AHCCCS Chief Medical Officer, is
         firmed diagnosis through AZ-NBCCEDP, and need treat-


Supp. 11-2                                                          Page 104                                                      June 30, 2011
                                                      Arizona Administrative Code                                           Title 9, Ch. 22
                                      Arizona Health Care Cost Containment System – Administration

          considered the standard of care as supported by a peer-                 the Administration shall provide the woman a Notice of
          reviewed study published in a medical journal.                          Action no later than 10 days before the effective date of
C.   Cervical cancer. Coverage for treatment for cervical cancer                  the discontinuance.
     under this Article shall conclude on the last provider visit for        2. The Administration may mail the Notice of Action no
     the specific treatment for the cancer. For purposes of this sub-             later than the effective date of the discontinuance if the
     section treatment means:                                                     Administration:
     1. Surgery;                                                                  a. Receives a written statement from the woman volun-
     2. Radiation therapy;                                                              tarily withdrawing from AHCCCS,
     3. Chemotherapy; and                                                         b. Receives information confirming the death of the
     4. A treatment for cervical cancer that, as determined by the                      woman,
          AHCCCS Chief Medical Officer, is considered the stan-                   c. Receives returned mail with no forwarding address
          dard of care as supported by a peer-reviewed study pub-                       from the post office and the woman’s whereabouts
          lished in a medical journal.                                                  are unknown, or
                                                                                  d. Receives information confirming that the woman
                         Historical ote
                                                                                        has been approved for Title XIX services outside the
     New Section made by final rulemaking at 7 A.A.R. 5814,
                                                                                        state of Arizona.
        effective December 6, 2001 (Supp. 01-4). Section
                                                                             3. The Notice of Action shall contain the:
      repealed; new Section made by final rulemaking at 12
                                                                                  a. Name of the ineligible woman,
       A.A.R. 4488, effective January 6, 2007 (Supp. 06-4).
                                                                                  b. Effective date of the discontinuance,
R9-22-2005. Application Process                                                   c. Specific reason why the woman is discontinued,
A. Application. A woman may apply for eligibility under this                      d. Legal citations supporting the reason for the discon-
    Article by submitting a complete application as specified in                        tinuance,
    R9-22-1406.                                                                   e. Location where the woman can review the legal cita-
B. Submitting the application. The woman may complete and                               tions, and
    submit an application at the time of the AZ-NBCCEDP                           f. Information regarding the woman’s appeal and
    screening. The AZ-NBCCEDP staff may mail or fax the appli-                          request for hearing rights.
    cation directly to the Administration.                              E.   Request for hearing. A woman who is denied, or discontinued
C. Date of application. The date of the application is the date of           for the Breast and Cervical Cancer Treatment Program may
    the diagnostic procedure that results in a positive diagnosis for        request a hearing under Chapter 34.
    breast cancer or cervical cancer, including a pre-cancerous cer-
                                                                                                 Historical ote
    vical lesion.
                                                                             New Section made by final rulemaking at 7 A.A.R. 5814,
D. Responsibility of a woman who is applying or who is a mem-
                                                                                effective December 6, 2001 (Supp. 01-4). Section
    ber. A woman who is applying or who is a member shall:
                                                                              repealed; new Section made by final rulemaking at 12
    1. Provide medical insurance information, including any
                                                                               A.A.R. 4488, effective January 6, 2007 (Supp. 06-4).
         changes in medical insurance; and
    2. Inform the Administration about a change in address, res-        R9-22-2007. Effective and End Date of Eligibility
         idence, and alienage status.                                   A. The effective date of e