A. Inpatient behavioral health services. The
following inpatient services are covered subject to the limitations and
exclusions in this Article and Article 2.
1.
Covered inpatient behavioral health services include all behavioral health
services, medical detoxification, accommodations and staffing, supplies, and
equipment, if the service is provided under the direction of a physician in a
Medicare-certified:
a. General acute care
hospital,
b. Inpatient psychiatric
unit in a general acute care hospital, or
c. Behavioral health hospital.
2. Inpatient service limitations:
a. Inpatient services, other than emergency
services specified in this Section, are not covered unless prior authorization
is obtained.
b. Inpatient services
and room and board are reimbursed on a per diem basis. The per diem rate
includes all services, except the following licensed or certified providers may
bill independently for services:
i. A licensed
psychiatrist,
ii. A certified
psychiatric nurse practitioner,
iii. A licensed physician
assistant,
iv. A licensed
psychologist,
v. A licensed
clinical social worker,
vi. A
licensed marriage and family therapist,
vii. A licensed professional
counselor,
viii. A licensed
independent substance abuse counselor, and
ix. A medical practitioner.
c.
A member age 21 through 64 is eligible for
behavioral health services provided in a hospital listed in subsection
(A)(1)(b) that meets the criteria for an IMD up to 30 days per admission and no
more than 60 days per benefit year as allowed under the Administration's
Section 1115 Waiver with CMS.
B. Behavioral Health Inpatient
facility for children. Services provided in a Behavioral Health Inpatient
facility for children as defined in 9. A.A.C. 10, Article 3 are covered subject
to the limitations and exclusions under this Article.
1. Behavioral Health Inpatient facility for
children services are not covered unless provided under the direction of a
licensed physician in a licensed Behavioral Health Inpatient facility for
children accredited by an AHCCCS-approved accrediting body as specified in
contract.
2. Covered Behavioral
Health Inpatient facility for children services include room and board and
treatment services for behavioral health and substance abuse
conditions.
3. Inpatient Behavioral
Health Inpatient facility for children service limitations.
a. Services are not covered unless prior
authorized, except for emergency services as specified in this
Section.
b. Services are reimbursed
on a per diem basis. The per diem rate includes all services, except the
following licensed or certified providers may bill independently for services:
i. A licensed psychiatrist,
ii. A certified psychiatric nurse
practitioner,
iii. A licensed
physician assistant,
iv. A licensed
psychologist,
v. A licensed
clinical social worker,
vi. A
licensed marriage and family therapist,
vii. A licensed professional
counselor,
viii. A licensed
independent substance abuse counselor, and
ix. A medical practitioner.
4. The
following may be billed independently if prescribed by a provider as specified
in this Section who is operating within the scope of practice:
a. Laboratory services, and
b. Radiology services.
c.
Psychotropic medication.
C. Covered Inpatient
sub-acute agency services. Services provided in a inpatient sub-acute facility
as defined in 9 A.A.C.
10, Article 1 are covered subject to the limitations and
exclusions under this Article.
1. Inpatient
sub-acute facility services are not covered unless provided under the direction
of a licensed physician in a licensed inpatient sub-acute facility that is
accredited by an AHCCCS-approved accrediting body.
2. Covered Inpatient sub-acute facility
services include room and board and treatment services for behavioral health
and substance abuse conditions.
3.
Services are reimbursed on a per diem basis. The per diem rate includes all
services, except the following licensed or certified providers may bill
independently for services:
a. A licensed
psychiatrist,
b. A certified
psychiatric nurse practitioner,
c.
A licensed physician assistant,
d.
A licensed psychologist,
e. A
licensed clinical social worker,
f.
A licensed marriage and family therapist,
g. A licensed professional
counselor,
h. A licensed
independent substance abuse counselor, and
i. A medical practitioner.
4. The following may be billed
independently if prescribed by a provider specified in this Section who is
operating within the scope of practice:
a.
Laboratory services, and
b.
Radiology services.
c.
Psychotropic medication.
5.
A member age 21 through 64 is eligible for
behavioral health services provided in a Level 1 sub-acute agency that meets
the criteria for an IMD for up to 30 days per admission and no more than 60
days per benefit year as allowed under the Administration's Section 1115 Waiver
with CMS. These limitations do not apply to a member under age 21 or age 65 or
over.
D.
Level 2
behavioral health residential agency services. Services provided in a Level 2
behavioral health residential agency are covered subject to the limitations and
exclusions in this Article.
1.
Level 2 behavioral health residential agency
services are not covered unless provided by a licensed Level 2 behavioral
health residential agency as defined in A.A.C.
R9-20-101 .
2.
Covered services include all services except room
and board.
3.
The following licensed or certified providers may
bill independently for services:
a.
A licensed psychiatrist,
b.
A certified psychiatric nurse
practitioner,
c.
A licensed physician assistant,
d.
A licensed psychologist,
e.
A licensed clinical social worker,
f.
A licensed marriage and family
therapist,
g.
A licensed professional counselor,
h. A licensed independent
substance abuse counselor, and
i. A behavioral health medical
practitioner.
E.
Behavioral health residential facility services. Services provided in a
licensed behavioral health residential facility as defined in 9 A.A.C. 10,
Article 1 are covered subject to the limitations and exclusions under this
Article.
1. Behavioral health
residential facility services are not covered unless provided by a licensed
behavioral health residential facility.
2. Covered services include all
non-prescription drugs as defined in A.R.S. §
32-1901,
non-customized medical supplies, and clinical oversight or direct supervision
of the behavioral health residential facility staff whichever is applicable.
Room and board are not covered services.
3. The following licensed and certified
providers may bill independently for services:
a. A licensed psychiatrist,
b. A certified psychiatric nurse
practitioner,
c. A licensed
physician assistant,
d. A licensed
psychologist,
e. A licensed
clinical social worker,
f. A
licensed marriage and family therapist,
g. A licensed professional
counselor,
h. A licensed
independent substance abuse counselor, and
i. A behavioral health medical
practitioner.
F.E. Partial
care. Partial care services are covered subject to the limitations and
exclusions in this Article.
1. Partial care
services are not covered unless provided by a licensed and AHCCCS-registered
behavioral health agency that provides a regularly scheduled day program of
individual member, group, or family activities that are designed to improve the
ability of the member to function in the community. Partial care services
include basic, therapeutic, and medical day programs.
2. Partial care services. Educational
services that are therapeutic and are included in the member's behavioral
health treatment plan are included in per diem reimbursement for partial care
services.
G.F. Outpatient services.
Outpatient services are covered subject to the limitations and exclusions in
this Article and Article 2.
1. Outpatient
services include the following:
a. Screening
provided by a behavioral health professional or a behavioral health technician
as defined in
R9-22-1201;
b. A behavioral health assessment provided by
a behavioral health professional or a behavioral health technician;
c. Counseling including individual therapy,
group therapy, and family therapy provided by a behavioral health professional
or a behavioral health technician;
d. Behavior management services as defined in
R9-22-1201;
and
e. Psychosocial rehabilitation
services as defined in
R9-22-201.
2. Outpatient service limitations.
a. The following licensed or certified
providers may bill independently for outpatient services:
i. A licensed psychiatrist;
ii. A certified psychiatric nurse
practitioner;
iii. A licensed
physician assistant as defined in
R9-22-1201;
iv. A licensed psychologist;
v. A licensed clinical social
worker;
vi. A licensed professional
counselor;
vii. A licensed marriage
and family therapist;
viii. A
licensed independent substance abuse counselor;
ix. A medical practitioner; and
x. An outpatient treatment center or
substance abuse transitional facility licensed under 9 A.A.C.
10, Article 14,
that is an AHCCCS-registered provider.
b. A behavioral health practitioner not
specified in subsections (F)(2)(a)(i) through (x), who is contracted with or
employed by an AHCCCS-registered behavioral health agency shall not bill
independently.
H.G. Emergency
behavioral health services are covered subject to the limitations and
exclusions under this Article. In order to be covered, behavioral health
services shall be provided by qualified service providers under
R9-22-1206 . ADHS/DBHS
shall ensure that emergency behavioral health services are available 24 hours
per day, seven days per week in each GSA for an emergency behavioral health
condition for a non-FES member as defined in
R9-22-201.
I.H. Other covered
behavioral health services. Other covered behavioral health services include:
2. Laboratory and
radiology services for behavioral health diagnosis and medication
management;
3.
Medication;
4. Monitoring,
administration, and adjustment for psychotropic medication and related
medications;
5. Respite care as
described within subsection (K)
(J);
6. Behavioral health
therapeutic home care services provided by a RBHA in a professional foster home
defined in 6 A.A.C.
5, Article 58 or in an adult behavioral health therapeutic
home as defined in 9 A.A.C.
10, Article 1;
7.
Personal care services, including assistance with
daily living skills and tasks, homemaking, bathing, dressing, food preparation,
oral hygiene, self-administration of medications, and monitoring of the
behavioral health recipient's condition and functioning level provided by a
licensed and AHCCCS-registered behavioral health agency or a behavioral health
professional, behavioral health technician, or behavioral health
paraprofessional as defined in 9 A.A.C. 20, Article 19 A.A.C. 10, Article 1;
and
8. Other
support services to maintain or increase the member's self-sufficiency and
ability to live outside an institution.
J.I.
Transportation services. Transportation services are covered
under
R9-22-211.
K.J. Limited
Behavioral Health services. Respite services are limited to no more than 600
hours per benefit year.
Notes
Ariz. Admin. Code §
R9-22-1205
Adopted under an
exemption from A.R.S. Title 41, Ch. 6, pursuant to Laws 1992, Ch. 301, §
61, effective November 1, 1992; received in the Office of the Secretary of
State November 25, 1992 (Supp. 92-4). Amended under an exemption from A.R.S.
Title 41, Ch. 6, pursuant to Laws 1992, Ch. 301, § 61, effective September
30, 1993 (Supp. 93-3). Amended under an exemption from A.R.S. Title 41, Ch. 6,
pursuant to Laws 1995, Ch. 204, §11, effective October 1, 1995; filed with
the Secretary of State September 29, 1995 (Supp. 95-4). Section repealed, new
Section adopted by final rulemaking at 6 A.A.R. 179, effective December 13,
1999 (Supp. 99-4). Amended by exempt rulemaking at 7 A.A.R. 4593, effective
October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 11 A.A.R. 5480,
effective December 6, 2005 (Supp. 05-4). Amended by final rulemaking at 13
A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Amended by exempt rulemaking at
17 A.A.R. 1870, effective October 1, 2011 (Supp. 11-3). Amended by final
rulemaking at 19 A.A.R. 2747, effective October 8, 2013. Amended by final
rulemaking at
20
A.A.R. 3098, effective 1/4/2015.
