A. A contractor, fee-for-service provider or noncontracting
provider shall render inpatient general hospital services
including:
1.
Hospital accommodations and appropriate staffing,
supplies, equipment, and services for:
a.
Maternity care, including labor, delivery, and
recovery room, birthing center, and newborn nursery;
b.
Neonatal intensive care unit (NICU);
c.
Intensive care unit (ICU);
d.
Surgery, including surgery room and recovery
room;
e.
Nursery and related services;
f.
Routine care; and
g.
Emergency behavioral health services provided under
Article 12 of this Chapter for a member eligible under A.R.S. §
36-2901(6)(a) .
2.
Ancillary services as specified by the Director and
included in contract:
a.
Laboratory services;
b.
Radiological and medical imaging
services;
c.
Anesthesiology services;
d.
Rehabilitation services;
e.
Pharmaceutical services and prescription
drugs;
f.
Respiratory therapy;
g.
Blood and blood derivatives; and
h. Central supply items, appliances, and equipment that are
not ordinarily furnished to all patients and customarily reimbursed as
ancillary services
B.
A.The following
limitations apply to inpatient general hospital services that are provided by
FFS providers.
1. Providers shall obtain prior
authorization from the Administration for the following inpatient hospital
services:
a. Nonemergency and elective
admission, including psychiatric hospitalization;
b. Elective surgery; and
c. Services or items provided to cosmetically
reconstruct or improve personal appearance after an illness or
injury.
2. The
Administration or a contractor may deny a claim if a provider fails to obtain
prior authorization.
3. Providers
are not required to obtain prior authorization from the Administration for the
following inpatient hospital services:
a.
Voluntary sterilization,
b.
Dialysis shunt placement,
c.
Arteriovenous graft placement for dialysis,
d. Angioplasties or thrombectomies of
dialysis shunts,
e. Angioplasties
or thrombectomies of arteriovenous graft for dialysis,
f. Hospitalization for vaginal delivery that
does not exceed 48 hours,
g.
Hospitalization for cesarean section delivery that does not exceed 96 hours,
and
h. Other services identified by
the Administration through the Provider Participation Agreement.
4. The Administration may perform
concurrent review for hospitalizations of non-FES members to determine whether
there is medical necessity for the hospitalization. A provider shall notify the
Administration no later than 72 hours after an emergency admission.
C.
B.Coverage of in-state and out-of-state inpatient
hospital services is limited to 25 days per benefit year for members age 21 and
older for claims with discharge dates on or before September 30, 2014. The
limit applies for all inpatient hospital services with dates of service during
the benefit year regardless of whether the member is enrolled in Fee for
Service, is enrolled with one or more contractors, or both, during the benefit
year.
1. For purposes of calculating the
limit:
a. Inpatient days are counted towards
the limit if paid by the Administration or a contractor;
b. Inpatient days will be counted toward the
limit in the order of the adjudication date of a paid claim;
c. Paid inpatient days are allocated to the
benefit year in which the date of service occurs;
d. Each 24 hours of paid observation services
is counted as one inpatient day if the patient is not admitted to the same
hospital directly following the observation services;
e. Observation services, which are directly
followed by an inpatient admission to the same hospital are not counted towards
the inpatient limit; and
f. After
25 days of inpatient hospital services have been paid as provided for in this
Section:
i. Outpatient services that are
directly followed by an inpatient admission to the same hospital, including
observation services, are not covered.
ii. Continuous periods of observation
services of less than 24 hours that are not directly followed by an inpa-tient
admission to the same hospital are covered.
iii. For continuous periods of observation
services of 24 hours or more that are not directly followed by an inpa-tient
admission to the same hospital, 23 hours of observations services are
covered.
2.
The following inpatient days are not included in the inpatient hospital
limitation described in this Section:
a. Days
reimbursed under specialty contracts between AHCCCS and a transplant facility
that are included within the component pricing referred to in the
contract;
b. Days related to
Behavioral Health:
i. Inpatient days that
qualify for the psychiatric tier under
R9-22-712.09 and reimbursed by the Administration or its contractors, or
ii. Inpatient days with a primary psychiatric
diagnosis code reimbursed by the Administration or its contractors,
or
iii. Inpatient days paid by the
Arizona Department of Health Services Division of Behavioral Health Services or
a RBHA or TRBHA.
c. Days
related to treatment for burns and burn late effects at an American College of
Surgeons verified burn center;
d.
Same Day Admit Discharge services are excluded from the 25 day limit;
and
e. Subject to approval by CMS,
days for which the state claims 100% FFP, such as payments for days provided by
IHS or 638 facilities.
Notes
Ariz. Admin. Code §
R9-22-204
Adopted as an emergency
effective May 20, 1982 pursuant to A.R.S. §
41-1003,
valid for only 90 days (Supp. 82-3). Former Section R9-22-204 adopted as an
emergency now adopted and amended as a permanent rule effective August 30, 1982
(Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended
subsection (A) effective December 22, 1987 (Supp. 87-4). Amended effective
December 13, 1993 (Supp. 93-4). Section repealed, new Section adopted effective
September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 179,
effective December 13, 1999 (Supp. 99-4). Amended by final rulemaking at 6
A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by exempt rulemaking
at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by final
rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by
final rulemaking at 17 A.A.R. 1658, effective August 2, 2011 (Supp. 11-3).
Amended by exempt rulemaking at 17 A.A.R. 1707, effective October 1, 2011
(Supp. 11-3). Amended by exempt rulemaking at 18 A.A.R. 1745, effective October
1, 2012 (Supp. 12-2). Amended by final rulemaking at 19 A.A.R. 2747, effective
October 8, 2013. Amended by final rulemaking at
20
A.A.R. 1949, effective 9/6/2014.
