Ariz. Admin. Code § R9-28-1104 - General Service Requirements
B.
Prior authorization for emergency behavioral health
services. A provider is not required to obtain prior authorization for
emergency behavioral health services.
C.
Prohibition against denial of payment. A program contractor,
tribal contractor, or the Administration shall not limit or deny payment to an
emergency behavioral health provider for emergency behavioral health services
to a member for the following reasons:
1.
On the basis of lists of diagnoses or
symptoms,
2.
Prior authorization was not obtained,
or
3.
The provider does not have a
contract.
D.
A program contractor or the Administration shall not limit
or deny payment to an emergency behavioral health provider for emergency
behavioral health services provided to a member if the member received those
services as directed by an employee of the program contractor or the
Administration.
E.
Grounds for denial for persons enrolled with a program or
tribal contractor. A program contractor or the Administration may deny payment
to an emergency behavioral health provider for emergency behavioral health
services for reasons including but not limited to the
following:
1.
The claim was not a clean claim,
2.
The claim was not submitted timely,
or
3.
The provider failed to provide timely notification
to the Administration or the program contractor, as applicable.
F.
Notification to program contractor for persons enrolled with
a program contractor. A hospital, emergency room provider, or fiscal agent
shall notify a program contractor no later than the 11th day from presentation
of the member enrolled with a program contractor for emergency inpatient
behavioral health services.
G.
Notification to Administration for Native Americans enrolled
with a tribal contractor. A provider shall notify the Administration no later
than 72 hours after a Native American member enrolled with a tribal contractor
presents to a hospital for inpatient emergency behavioral health
services.
H. Behavioral health evaluation. Subject to A.R.S. §
36-545.06 and
R9-28-903, an
emergency behavioral health evaluation is covered as an emergency service for a
member under this Section if:
1.
Required to evaluate or stabilize an acute episode
of mental disorder or substance abuse; and
2.
Provided by a qualified provider who is a behavioral
health medical practitioner as defined in A.A.C.
R9-22-1201, including
a licensed psychologist, a licensed clinical social worker, a licensed
professional counselor, or a licensed marriage and family
therapist.
I. Post-stabilization requirements for members enrolled with a
program contractor.
1.
A program contractor is financially responsible for
behavioral health post-stabilization services obtained within or outside the
network that have received prior authorization from the program
contractor.
2.
The program contractor is financially responsible
for behavioral health post-stabilization services obtained within or outside
the network that have not received prior authorization from the program
contractor, but are administered to
maintain the member's stabilized condition within one hour
of a request to the program contractor for prior authorization of further
post-stabilization services;
3.
The program contractor is financially responsible
for behavioral health post-stabilization services obtained within or outside
the network that have not received prior authorization from the program
contractor, but are administered to maintain, improve, or resolve the member's
stabilized condition if:
a.
The program contractor does not respond to a request
for prior authorization within one hour;
b.
The program contractor authorized to give the prior
authorization cannot be contacted; or
c.
The representative of the program contractor and the
treating physician cannot reach an agreement concerning the member's care and
the program contractor's physician is not available for consultation. The
treating physician may continue with care of the member until the program
contractor's physician is reached, or:
i. A program contractor's
physician with privileges at the treating hospital assumes responsibility for
the member's care;
ii. A program contractor's
physician assumes responsibility for the member's care through
transfer;
iii. A representative of the
program contractor and the treating physician reach agreement concerning the
member's care; or
iv. The member is
discharged.
4.
Transfer or discharge. The attending physician or
the provider actually treating the 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 program
contractor.
J. Prior authorization for non-emergency behavioral health
services. When a member's behavioral health condition is determined by the
provider not to require emergency behavioral health services, the provider
shall follow the program contractor's or the Administration's prior
authorization requirements.
K. E.P.S.D.T. services. For Title XIX members under age 21,
E.P.S.D.T. services shall include all medically necessary Title XIX-covered
behavioral health services to a member.
L. Experimental services. Experimental services and services
that are provided primarily for the purpose of research are not
covered.
M. Gratuities. A service or an item, if furnished gratuitously
to a member by a provider, is not covered and payment to a provider shall be
denied.
N. GSA. Behavioral health services rendered to a member
enrolled with a program contractor shall be provided within the program
contractor's GSA except when:
1.
A primary care provider refers a member to another
area for medical specialty care;
2.
A member's medically necessary covered service is
not available within the GSA;
3.
A net savings in behavioral health service delivery
costs can be documented by the program contractor for a member. Undue travel
time or hardship shall be considered for a member or a member's family;
or
4.
A member is placed by the program contractor in a NF
or an Alternative HCBS setting located out of the program contractor's GSA, but
remains enrolled with that program contractor.
O. Travel. If a member travels or temporarily resides outside
of a program contractor's GSA, covered services are restricted to emergency
behavioral health care, unless authorized by the member's program
contractor.
P. Non-covered services. If a member requests a behavioral
health service that is not covered or is not authorized by a program
contractor, the tribal contractor, or the Administration, the behavioral health
service may be provided by an AHC-CCS-registered behavioral health service
provider according to A.A.C.
R9-22-702 .
Q. Restrictions and limitations.
1.
The restrictions, limitations, and exclusions in
this Article do not apply to a program contractor that elects to provide a
noncovered service.
2.
Room and board is not a covered service unless
provided by the Administration or a program contractor in a Level 1, inpatient,
sub-acute, or residential center under A.A.C.
R9-22-1205 .
Notes
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