Ariz. Admin. Code § 9-22-1105

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-22-1105 - Aggravating Circumstances

AHCCCS shall consider any of the following to be aggravating circumstances when determining the amount of a penalty, assessment, or penalty and assessment.

1. The nature and circumstances of each claim and the circumstances under which the claim is presented or caused to be presented are aggravating circumstances if:

a. A person has forged, altered, recreated, destroyed, or failed to maintain records;

b. The person refuses to provide pertinent documentation to AHCCCS for a claim or refuses to cooperate with investigators;

c. The services are of several billing code types;

d. All the dates of services occurred within six months or greater;

e. The number of claims submitted is greater than 25;

f. The nature and circumstances indicate a pattern of inappropriate claims for the services; and

g. The total amount claimed for the services is $5,000 or greater.

2. The degree of culpability of a person who presents or causes to present each claim is an aggravating circumstance, including but not limited to, if:

a. The person knows or had reason to know that each service was not provided as claimed,

b. The person knows or had reason to know that no payment could be made because the person had been excluded from reimbursement by AHCCCS, or

c. The person knows or had reason to know that the payment would violate the terms of an agreement between the person and AHCCCS system.

d. The person knows or had reason to know that the payment would violate state or federal law.

3. The prior offenses of a person who presents or causes to present each claim are an aggravating circumstance if:

a. At any time before the submittal of the claim the person was held criminally or civilly liable for any act, or

b. The person had received an administrative sanction in connection with:

i. A Medicaid program,

ii. A Medicare program, or

iii. Any other public or private program of reimbursement for medical services.

4. The adverse effect on patient care that resulted, or could have resulted, from the failure to provide medically necessary care by a person in connection with a claim.

5. AHCCCS shall take into account other circumstances of an aggravating nature, if in the interest of justice, the circumstances require an increase of the penalty, assessment, or penalty and assessment.

Ariz. Admin. Code § R9-22-1105

New Section made by final rulemaking at 10 A.A.R. 3056, effective September 11, 2004 (Supp. 04-3). Amended by final rulemaking at 17 A.A.R. 2615, effective February 4, 2012 (Supp. 11-4). Amended by final rulemaking at 30 A.A.R. 925, effective 4/25/2024.