Ariz. Admin. Code § R9-34-224 - Continuation of Services While the Contractor Appeal and the State Fair Hearing Are Pending

A. For the purposes of this Section, timely filing means filing on or before the later of the following:

1. Within 10 days after the date that the contractor mails the Notice of Action, or

2. The effective date of the action as indicated in the Notice of Action.

B. The contractor shall continue the enrollee's services if:

1. The enrollee files the appeal timely;

2. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

3. The services were ordered by an authorized provider;

4. The original period covered by the original authorization has not expired; and

5. The enrollee requests continuation of services.

C. If, at the enrollee's request, the contractor continues or reinstates the enrollee's services while the appeal is pending, the contractor shall continue services until one of following occurs:

1. The enrollee withdraws the appeal;

2. Ten days pass after the contractor mails the Notice of Appeal Resolution to the enrollee, unless the enrollee, within the 10-day time-frame, has requested in writing a State Fair Hearing with continuation of benefits until a Director's Decision is reached;

3. AHCCCS mails a Director's Decision adverse to the enrollee; or

4. The time-period or service limits of a previously authorized service have been met.

D. If the Director's Decision upholds the contractor's action, the contractor may recover the cost of the services furnished to the enrollee while the appeal is pending if the services were furnished solely because of the requirements of this Section.

Notes

Ariz. Admin. Code § R9-34-224

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).