A. Payment to ADHS/DBHS. The Administration shall make a
monthly capitation payment to ADHS/DBHS based on the number of acute members at
the beginning of each month. The Administration shall incorporate ADHS'/DBHS'
administrative costs into the capitation payment.
B.A. Claims
submissions.
1. ADHS/DBHS shall require all
service providers to submit clean claims no later than the time-frame specified
in contract with the Administration.
2.1. A provider of
behavioral health services shall submit a claim for non-emergency behavioral
health services provided to a member to the appropriate RBHA.
3.2. A
provider of behavioral health services shall submit a claim for non-inpatient
emergency behavioral health services provided to a member to the appropriate
RBHA
4.3. A provider of
behavioral health services shall submit a claim for non-inpatient emergency
behavioral health services provided to a member enrolled in a TRBHA to the
Administration.
5.4. A provider of
behavioral health services shall submit a claim for non-emergency behavioral
health services provided to a member enrolled in a TRBHA to the
Administration.
6.5. A provider of
emergency behavioral health services, that are the responsibility of ADHS/DBHS
or a contractor, shall submit a claim to the entity responsible for emergency
behavioral health services under
R9-22-210.01(A).
7.6. A
provider shall comply with the time-frames and other payment procedures in
Article 7 of this Chapter, if applicable, and A.R.S. §
36-2904.
8.7.
ADHS/DBHS or a contractor, whichever entity is responsible for covering
behavioral health services, shall cost avoid any behavioral health service
claims if it establishes the existence or probable existence of first-party
liability or third-party liability.
C.B. Prior
authorization. Payment to a provider for behavioral health services or items
requiring prior authorization may be denied if a provider does not obtain prior
authorization from a RBHA, ADHS/DBHS, a TRBHA, the Administration or a
contractor.
Notes
Ariz. Admin. Code §
R9-22-1207
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 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Section repealed; new Section adopted by final rulemaking at 6 A.A.R. 179,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 final rulemaking at 13
A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Amended by final rulemaking at
20
A.A.R. 3098, effective 1/4/2015.
