Ariz. Admin. Code § R9-22-718 - Urban Hospital Inpatient Reimbursement Program

A. Definitions. The following definitions apply to this Section:

1. "Contractor" has the same meaning as set forth in Arizona Revised Statutes, section 36-2901, and includes all contractors regardless of whether the GSA's served by the contractor includes urban or rural counties.

2. "Noncontracted Hospital" means an urban hospital, including psychiatric hospitals, which does not have a contract under this Section with a contractor.

3. "Urban Contractor" means a contractor or program contractor as defined in A.R.S. Title 36, Chapter 29, that provides services to members residing in Maricopa or Pima County and may also provide services to members who reside in other counties. An urban contractor does not include ADHS/BHS, or a TRBHA.

4. "Rural Hospital" means a hospital, that is physically located in Arizona but in a county other than Maricopa and Pima County.

3 5. "Urban Hospital" means a hospital that is not a rural hospital, as defined in R9-22-712.07, and that is physically located in Mar-icopa or Pima County.

B. General Provisions.

1. This Section applies to an urban hospital who receives payment for inpatient hospital services under A.R.S. §§ 36-2903.01 and 36-2904.

2. AHCCCS shall operate an inpatient hospital reimbursement program under A.R.S. § 36-2905.01 and this Section.

3. Residency of the member receiving inpatient AHCCCS covered services is not a factor in determining which hospitals are required to contract with which contractors.

4. A contractor shall enter into a contract for reimbursement for inpatient AHCCCS covered services with one or more urban hospitals located in the same county as the contractor.

5. A noncontracted urban hospital shall be reimbursed for inpatient services by a contractor at 95% of the amount calculated as defined in A.R.S. § 36-2903.01 and this Article, unless otherwise negotiated by both parties.

C. Contract Begin Date. A contract under this Article shall cover inpatient acute care hospital services for members with hospital admissions on and after October 1, 2003.

D. Outpatient urban hospital services. Outpatient urban hospital services, including observation days and emergency room treatments that do not result in an admission, shall be reimbursed either through an urban hospital contract negotiated between a contractor and an urban hospital, or the reimbursement rates set forth in A.R.S. § 36-2903.01. Outpatient services in an urban hospital that result in an admission shall be paid as inpatient services in accordance with this Section.

E. Urban Hospital Contract.

1. Provisions of an urban hospital contracts. The urban hospital contract shall contain but is not limited to the following provisions:

a. Required provisions as described in the Request for Proposals (RFP);

b. Dispute settlement procedures. If the AHCCCS Grievance System prescribed in A.R.S. § 36-2903.01(B) and rule is not used, then arbitration shall be used;

c. Arbitration procedure. If arbitration is used, the urban hospital contract shall identify:

i. The parties' agreement on arbitrating claims arising from the contract,

ii. Whether arbitration is nonbinding or binding,

iii. Timeliness of arbitration,

iv. What contract provisions may be appealed,

v. What rules will govern arbitrations,

vi. The number of arbitrators that shall be used,

vii. How arbitrators shall be selected, and

viii. How arbitrators shall be compensated.

d. Timeliness of claims submission and payment;

e. Prior authorization;

f. Concurrent review;

g. Electronic submission of claims;

h. Claims review criteria;

i. Payment of discounts or penalties such as quick-pay and slow-pay provisions;

j. Payment of outliers;

k. Claim documentation specifications under A.R.S. § 36-2904.

l. Treatment and payment of emergency room services; and

m. Provisions for rate changes and adjustments.

2. AHCCCS review and approval of urban hospital contracts:

a. AHCCCS may review, approve, or disapprove the hospital contract rates, terms, conditions, and amendments to the contract;

b. The AHCCCS evaluation of each urban hospital contract shall include but not be limited to the following areas:

i. Availability and accessibility of services to members,

ii. Related party interests,

iii. Inclusion of required terms pursuant to this Section, and

iv. Reasonableness of the rates.

F. Quick-Pay/Slow-Pay. A payment made by a contractor to a noncontracted hospital shall be subject to quick-pay discounts and slow-pay penalties under A.R.S. § 36-2904.

Notes

Ariz. Admin. Code § R9-22-718

Adopted under an exemption from the provisions of the Administrative Procedure Act, effective January 29, 1997; pursuant to Laws 1996, Ch. 288, §24 (Supp. 97-1). Amended by exempt rulemaking at 10 A.A.R. 500, effective February 1, 2004 (Supp. 04-1). Amended by exempt rulemaking at 13 A.A.R. 3190, effective October 1, 2007 (Supp. 07-3). Amended by final rulemaking at 20 A.A.R. 1957, effective 9/6/2014. Amended by final rulemaking at 24 A.A.R. 1515, effective 6/30/2018.