Ariz. Admin. Code § R21-1-203 - Exceptions, Limitations, and Exclusions

1. The cost of any medical or dental service that:

a. Is not medically necessary for prevention, diagnosis, or treatment of a condition, illness, or injury; or

b. Any health or medical service that is not eligible for reimbursement by AHCCCS in 9 A.A.C. 22, Article 2, and includes cosmetic procedures, experimental treatment, and personal care items.

2. The portion of the cost of any covered service that exceeds the charges set by the current and approved AHCCCS fee schedule. A medical, dental, or other health provider shall not submit a claim for charges that exceed the AHCCCS fee schedule to any party, including:

a. The Department, its representatives, or any fiscal intermediary the Department may contract with to administer this program;

b. The CMDP Member;

c. The CMDP Member's;

i. Guardian,

ii. Custodian,

iii. Estate,

iv. Foster parent, or

v. Birth parent.

A. DCS CHP shall not pay for:

1. Non-medically necessary health services.

2. Any health service that is not eligible for reimbursement by AHCCCS in 9 A.A.C. Chapter 22, Article 2, including cosmetic procedures, experimental treatment, and personal care items.

3. The cost of care and services payable through any federal, state, county, or municipal program to which a DCS CHP Member may be entitled, except for the cost of care and services in excess of any such program.

4. The cost of care and services payable through an insurance carrier that provides coverage for the DCS CHP Member under A.R.S. § 8-512, except for the cost of care and services in excess of any such insurance benefits.

5. Any admission, service, item, or otherwise uncovered service identified in A.R.S. Title 36, Chapter 29, Article 1, or the approved Medicaid State Plan.

6. The cost of care and services provided to a behavioral health recipient received through Medicaid behavioral health contractors.

B. A health provider shall not submit a bill to or seek payment from the following for any covered services:

1. DCS CHP Member; or

2. DCS CHP Member's:

a. Guardian,

b. Custodian,

c. Estate,

d. Foster parent, or

e. Birth parent.

Notes

Ariz. Admin. Code § R21-1-203

Adopted by exempt rulemaking at 21 A.A.R. 2554, effective 11/30/2015. Amended by final rulemaking at 27 A.A.R. 2518, effective 10/5/2021.