Ariz. Admin. Code § 9-31-201

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

Section R9-31-201 - General Requirements

A. The Administration shall administer the Children's Health Insurance Program under A.R.S. § 36-2982.

B. Scope of services for American Indian fee-for-service members is under Article 16 of this Chapter.

C. A contractor or RBHA shall provide behavioral health services under Articles 12 and 16.

D. In addition to other requirements and limitations specified in this Chapter, the following general requirements apply:

1. Only medically necessary, cost effective, and federally- reimbursable and state-reimbursable services are covered services.

2. The Administration or a contractor may waive the covered services referral requirements of this Article.

3. Except as authorized by a contractor, a primary care provider, practitioner, or dentist shall provide or direct the member's covered services. Delegation of the provision of care to a practitioner does not diminish the role or responsibility of the primary care provider.

4. A contractor shall offer a female member direct access to preventive and routine services from gynecology providers within the contractor's network without a referral from a primary care provider.

5. A member may receive behavioral health services as specified in 9 A.A.C. 22, Articles 2 and 12.

6. A member may receive treatment that is considered the standard of care, or that is approved by the AHCCCS Chief Medical Officer after appropriate input from providers who are considered experts in the field by the professional medical community.

7. An AHCCCS registered provider shall provide covered services within the provider's scope of practice.

8. In addition to the specific exclusions and limitations otherwise specified under this Article, the following are not covered:

a. A service that is determined by the AHCCCS Chief Medical Officer to be experimental or provided primarily for the purpose of research;

b. Services or items furnished gratuitously; and

c. Personal care items, except as specified in R9-31-212.

9. Medical or behavioral health services are not covered if provided to:

a. An inmate of a public institution;

b. A person who is a resident of an institution for the treatment of tuberculosis; or

c. A person who is in an IMD at the time of application, unless provided under Article 12 of this Chapter.

E. The Administration or a contractor may deny payment if a provider fails to obtain prior authorization as specified in this Article and Article 7 of this Chapter for non-emergency services. The Administration or a contractor shall not provide prior authorization for services unless the provider submits documentation of the medical necessity of the treatment along with the prior authorization request.

F. Prior authorization is not required for services necessary to evaluate and stabilize an emergency medical condition.

G. Under A.R.S. § 36-2989, a member shall receive covered services outside of the GSA only if one of the following applies:

1. A member is referred by a primary care provider for medical specialty care out of the contractor's area. If the member is referred outside of the GSA to receive an authorized medically necessary service, a contractor shall also provide all other medically necessary covered services for the member;

2. There is a net savings in service delivery costs as a result of going outside the GSA that does not require undue travel time or hardship for a member or the member's family; or

3. The contractor authorizes placement in a nursing facility located outside of the GSA;

H. If a member is traveling or temporarily residing outside of the GSA, covered services are restricted to emergency care services, unless otherwise authorized by the contractor.

I. A contractor shall provide at a minimum, directly or through subcontracts, the covered services specified in this Chapter and in contract.

J. The restrictions, limitations, and exclusions in this Article do not apply to a contractor if the contractor elects to provide noncovered services.

1. The Administration shall not consider the costs of providing a noncovered service to a member in the development or negotiation of a capitation rate.

2. A contractor shall pay for noncovered services from administrative revenue or other contractor funds that are unrelated to the provision of services under this Chapter.

Ariz. Admin. Code § R9-31-201

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by exempt rulemaking at 5 A.A.R. 3670, effective September 10, 1999 (Supp. 99-3). Amended by exempt rulemaking at 7 A.A.R. 4740, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 3246, effective October 1, 2005 (Supp. 05-3). Amended by final rulemaking at 13 A.A.R. 3276, effective September 11, 2007 (Supp. 07-3). Amended by final rulemaking at 17 A.A.R. 1681, effective August 2, 2011 (Supp. 11-3).