A. General provisions
1. Applicability. This Section applies to
emergency behavioral health services for non-FES members. Provisions regarding
emergency medical services for non-FES members are in
R9-22-210 .
Provisions regarding emergency medical and behavioral health services for FES
members are in
R9-22-217.
2. Definition. For the purposes of this
Section, "contractor" has the same meaning as in A.R.S. §
36-2901.
Contractor does not include ADHS/DBHS, a subcontractor of ADHS/DBHS, or
Children's Rehabilitative Services.
3. Responsible entity for inpatient emergency
behavioral health services.
a. Members
enrolled with a contractor.
i. ADHS/DBHS. ADHS/DBHS
or a subcontractor of ADHS/DBHS is responsible for providing all inpatient
emergency behavioral health services to non-FES members with psychiatric or
substance abuse diagnoses who are enrolled with the contractor.
(1)
The date on which the member becomes a behavioral
health recipient, or
(2)
The 73rd hour after admission for inpatient
emergency behavioral health services.
ii. Contractors. Contractors are
responsible for providing inpatient emergency behavioral health services to
non-FES members with psychiatric or substance abuse diagnoses who are enrolled
with a contractor and are not behavioral health recipients, for the first 72
hours after admission.
b. FFS members. ADHS/DBHS or a subcontractor
of ADHS/DBHS is responsible for providing all inpatient emergency behavioral
health services for non-FES FFS members with psychiatric or substance abuse
diagnoses unless services are provided in an IHS or tribally operated 638
facility.
4. Responsible
entity for non-inpatient emergency behavioral health services for non-FES
members. ADHS/DBHS or a subcontractor of ADHS/DBHS is responsible for providing
all non-inpatient emergency behavioral health services for non-FES
members.
5. Verification. A
provider of emergency behavioral health services shall verify a person's
eligibility status with AHC-CCS, and if eligible, determine whether the person
is a member enrolled with AHCCCS as non-FES FFS or is enrolled with a
contractor, and determine whether the member is a behavioral health recipient
as defined in
R9-22-201.
6. Prior authorization.
a. Emergency behavioral health services. A
provider is not required to obtain prior authorization for emergency behavioral
health services.
b. Non-emergency
behavioral health services. When a non-FES member's behavioral health condition
is determined by the provider not to require emergency behavioral health
services, the provider shall follow the prior authorization requirements of a
contractor and ADHS/DBHS or a subcontractor of ADHS/DBHS.
7. Prohibition against limitation or denial
of payment. A contractor, TRBHA, the Administration, ADHS/DBHS, or a
subcontractor of ADHS/DBHS shall not limit or deny payment to an emergency
behavioral health provider for emergency behavioral health services to a
non-FES member for the following reasons:
a.
On the basis of lists of diagnoses or symptoms;
b. Prior authorization was not
obtained;
c. The provider does not
have a contract;
d. An employee of
the contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS instructs the member
to obtain emergency behavioral health services; or
e. The failure of a hospital, emergency room
provider, or fiscal agent to notify the member's contractor, ADHS/ DBHS, or a
subcontractor of ADHS/DBHS within 10 days from the day the member presented for
the emergency service.
8. Grounds for denial. A contractor, the
Administration, ADHS/DBHS, or a subcontractor of ADHS/DBHS may deny payment for
emergency behavioral health. services for reasons including but not limited to
the following:
a. The claim was not a clean
claim;
b. The claim was not
submitted timely; or
c. The
provider failed to provide timely notification under subsection (A)(9) to the
contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS or the
Administration.
9.
Notification.
a. A hospital, emergency room
provider, or fiscal agent shall notify a contractor, ADHS/DBHS, or a
subcontractor of ADHS/DBHS, whichever is appropriate, no later than the 11th
day from presentation of the non-FES member for emergency inpatient behavioral
health services.
b. A hospital,
emergency room provider, or fiscal agent shall notify the Administration no
later than 72 hours after a FFS member receiving emergency behavioral health
services presents to a hospital for inpatient services.
10.
Behavioral health evaluation. An emergency
behavioral health evaluation is covered as an emergency behavioral health
service for a non-FES member under this Section if:
a.
Required to evaluate or stabilize an acute episode
of mental disorder or substance abuse, and
b.
Provided by a qualified provider who
is:
i. A behavioral health medical
practitioner as defined in
R9-22-112, including a
licensed psychologist, a licensed clinical social worker, a licensed
professional counselor, and a licensed marriage and family therapist;
or
ii. An ADHS/DBHS-contracted
provider.
10.
11.Transfer or discharge. The attending physician
or the provider actually treating the non-FES member for the emergency
behavioral health condition shall determine when the member is sufficiently
stabilized for transfer or discharge and that decision shall be binding on the
contractor and ADHS/DBHS or a subcontractor of ADHS/DBHS.
B. Post-stabilization requirements for
non-FES members.
1. A contractor, ADHS/DBHS,
or a subcontractor of ADHS/DBHS, as appropriate, is financially responsible for
behavioral health post-stabilization services obtained within or outside the
network that have been prior authorized by the contractor, ADHS/DBHS, or a
subcontractor of ADHS/DBHS.
2. The
contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS, as appropriate, is
financially responsible for behavioral health post-stabilization services
obtained within or outside the network that are not prior authorized by the
contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS, but are administered to
maintain the member's stabilized condition within one hour of a request to the
contractor, ADHS/DBHS, or a subcontractor for prior authorization of further
post-stabilization services;
3. The
contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS, as appropriate, is
financially responsible for behavioral health post-stabilization services
obtained within or outside the network that are not prior authorized by the
contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS, but are administered to
maintain, improve, or resolve the member's stabilized condition if:
a. The contractor, ADHS/DBHS, or a
subcontractor of ADHS/DBHS, does not respond to a request for prior
authorization within one hour;
b.
The contractor, ADHS/DBHS, or a subcontractor of ADHS/DBHS authorized to give
the prior authorization cannot be contacted; or
c. The representative of the contractor,
ADHS/DBHS, or the subcontractor and the treating physician cannot reach an
agreement concerning the member's care and the contractor's, ADHS/DBHS' or the
subcontractor's physician, is not available for consultation. The treating
physician may continue with care of the member until ADHS/ DBHS', the
contractor's, or the subcontractor's physician is reached, or:
i. A contracted physician with privileges at
the treating hospital assumes responsibility for the member's care;
ii. ADHS/DBHS', a contractor's, or a
subcontractor's physician assumes responsibility for the member's care through
transfer;
iii. A representative of
the contractor, ADHS/DBHS, or the subcontractor and the treating physician
reach agreement concerning the member's care; or
iv. The member is
discharged.
