Ariz. Admin. Code § 9-22-1003

Current through Register Vol. 30, No. 43, October 25, 2024

Section R9-22-1003 - Cost Avoidance

A. The Administration's reimbursement responsibility.

1. The Administration shall pay no more than the difference between the Capped Fee-For-Service schedule and the amount of the third-party liability, unless Medicare is the third-party.

2. If Medicare is the third-party that is liable, the Administration shall pay the Medicare copayment. coinsurance, and deductible regardless of the Capped Fee-For-Service Schedule, as described under 9 AA.C. 29. Article 3.

B. The Contractor's reimbursement responsibility.

1. If the contract between the contractor and the provider does not state otherwise, a contractor shall pay no more than the difference between the contracted rate and the amount of the third-party liability.

2. If the provider does not have a contract with the contractor, a contractor shall pay no more than the difference between the Capped Fee-For-Service rate and the amount of the third-party liability.

C. The following parties shall take reasonable measures to identify potentially legally liable first-or third-party sources:

1. AHCCCS, the Administration, or a contractor;

2. A provider;

3. A noncontracting provider; and

4. A member.

D. Except as specified under subsection (E). the Administration or a contractor shall cost avoid a claim for AHCCCS covered services under Article 2 if the Administration or a contractor has established the probable existence of a liable party at the time the claim is filed. Establishing liability takes place when the Administration or the contractor receives confirmation that another party is legally responsible for payment of a health care service under Article 2.

E. The Administration or contractor shall pay the full amount of the claim according to the Capped-Fee-For-Service Schedule or the contracted rate as described under subsection (B). and then seek reimbursement from any liable parties if the claim is for:

1. Prenatal care for pregnant women.

2. Preventive pediatric services, including E.P.S.D.T. and administration of vaccines to children under the Vaccines for Children (VFC) program; or

3. Services covered by third-party liability that is derived from an absent parent whose obligation to pay support is being enforced by the Division of Child Support Enforcement.

Ariz. Admin. Code § R9-22-1003

New Section made by final rulemaking at 10 A.A.R. 1146, effective May 1, 2004 (Supp. 04-1). Amended by final rulemaking at 10 A.A.R. 3012, effective September 11, 2004 (Supp. 04-3). Amended by final rulemaking at 15 A.A.R. 179, effective March 7, 2009 (Supp. 09-1). Amended by final rulemaking at 31 A.A.R. 1237, effective 7/7/2015.