Ariz. Admin. Code § 9-22-1205

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-22-1205 - Scope and Coverage of Behavioral Health Services

A. Inpatient behavioral health services. The following inpatient services are covered subject to the limitations and exclusions in this Article and Article 2.

1. Covered inpatient behavioral health services include all behavioral health services, medical detoxification, accommodations and staffing, supplies, and equipment, if the service is provided under the direction of a physician in a Medicare-certified:

a. General acute care hospital,

b. Inpatient psychiatric unit in a general acute care hospital, or

c. Behavioral health hospital.

2. Inpatient service limitations:

a. Inpatient services, other than emergency services specified in this Section, are not covered unless prior authorization is obtained.

b. Inpatient services and room and board are reimbursed on a per diem basis. The per diem rate includes all services, except the following licensed or certified providers may bill independently for services:

i. A licensed psychiatrist,

ii. A certified psychiatric nurse practitioner,

iii. A licensed physician assistant,

iv. A licensed psychologist,

v. A licensed clinical social worker,

vi. A licensed marriage and family therapist,

vii. A licensed professional counselor,

viii. A licensed independent substance abuse counselor, and

ix. A medical practitioner.

B. Behavioral Health Inpatient facility for children. Services provided in a Behavioral Health Inpatient facility for children as defined in 9. A.A.C. 10, Article 3 are covered subject to the limitations and exclusions under this Article.

1. Behavioral Health Inpatient facility for children services are not covered unless provided under the direction of a licensed physician in a licensed Behavioral Health Inpatient facility for children accredited by an AHCCCS-approved accrediting body as specified in contract.

2. Covered Behavioral Health Inpatient facility for children services include room and board and treatment services for behavioral health and substance abuse conditions.

3. Inpatient Behavioral Health Inpatient facility for children service limitations.

a. Services are not covered unless prior authorized, except for emergency services as specified in this Section.

b. Services are reimbursed on a per diem basis. The per diem rate includes all services, except the following licensed or certified providers may bill independently for services:

i. A licensed psychiatrist,

ii. A certified psychiatric nurse practitioner,

iii. A licensed physician assistant,

iv. A licensed psychologist,

v. A licensed clinical social worker,

vi. A licensed marriage and family therapist,

vii. A licensed professional counselor,

viii. A licensed independent substance abuse counselor, and

ix. A medical practitioner.

4. The following may be billed independently if prescribed by a provider as specified in this Section who is operating within the scope of practice:

a. Laboratory services, and

b. Radiology services.

.

C. Covered Inpatient sub-acute agency services. Services provided in a inpatient sub-acute facility as defined in 9 A.A.C. 10, Article 1 are covered subject to the limitations and exclusions under this Article.

1. Inpatient sub-acute facility services are not covered unless provided under the direction of a licensed physician in a licensed inpatient sub-acute facility that is accredited by an AHCCCS-approved accrediting body .

2. Covered Inpatient sub-acute facility services include room and board and treatment services for behavioral health and substance abuse conditions.

3. Services are reimbursed on a per diem basis. The per diem rate includes all services, except the following licensed or certified providers may bill independently for services:

a. A licensed psychiatrist,

b. A certified psychiatric nurse practitioner,

c. A licensed physician assistant,

d. A licensed psychologist,

e. A licensed clinical social worker,

f. A licensed marriage and family therapist,

g. A licensed professional counselor,

h. A licensed independent substance abuse counselor, and

i. A medical practitioner.

4. The following may be billed independently if prescribed by a provider specified in this Section who is operating within the scope of practice:

a. Laboratory services, and

b. Radiology services.

.

D.

Behavioral health residential facility services. Services provided in a licensed behavioral health residential facility as defined in 9 A.A.C. 10, Article 1 are covered subject to the limitations and exclusions under this Article.

1. Behavioral health residential facility services are not covered unless provided by a licensed behavioral health residential facility.

2. Covered services include all non-prescription drugs as defined in A.R.S. § 32-1901, non-customized medical supplies, and clinical oversight or direct supervision of the behavioral health residential facility staff whichever is applicable. Room and board are not covered services.

3. The following licensed and certified providers may bill independently for services:

a. A licensed psychiatrist,

b. A certified psychiatric nurse practitioner,

c. A licensed physician assistant,

d. A licensed psychologist,

e. A licensed clinical social worker,

f. A licensed marriage and family therapist,

g. A licensed professional counselor,

h. A licensed independent substance abuse counselor, and

E. Partial care. Partial care services are covered subject to the limitations and exclusions in this Article.

1. Partial care services are not covered unless provided by a licensed and AHCCCS-registered behavioral health agency that provides a regularly scheduled day program of individual member, group, or family activities that are designed to improve the ability of the member to function in the community. Partial care services include basic, therapeutic, and medical day programs.

2. Partial care services. Educational services that are therapeutic and are included in the member's behavioral health treatment plan are included in per diem reimbursement for partial care services.

F. Outpatient services. Outpatient services are covered subject to the limitations and exclusions in this Article and Article 2.

1. Outpatient services include the following:

a. Screening provided by a behavioral health professional or a behavioral health technician as defined in R9-22-1201;

b. A behavioral health assessment provided by a behavioral health professional or a behavioral health technician;

c. Counseling including individual therapy, group therapy, and family therapy provided by a behavioral health professional or a behavioral health technician;

d. Behavior management services as defined in R9-22-1201; and

e. Psychosocial rehabilitation services as defined in R9-22-201.

2. Outpatient service limitations.

a. The following licensed or certified providers may bill independently for outpatient services:

i. A licensed psychiatrist;

ii. A certified psychiatric nurse practitioner;

iii. A licensed physician assistant as defined in R9-22-1201;

iv. A licensed psychologist;

v. A licensed clinical social worker;

vi. A licensed professional counselor;

vii. A licensed marriage and family therapist;

viii. A licensed independent substance abuse counselor;

ix. A medical practitioner; and

x. An outpatient treatment center or substance abuse transitional facility licensed under 9 A.A.C. 10, Article 14, that is an AHCCCS-registered provider.

b. A behavioral health practitioner not specified in subsections (F)(2)(a)(i) through (x), who is contracted with or employed by an AHCCCS-registered behavioral health agency shall not bill independently.

G. Emergency behavioral health services are covered subject to the limitations and exclusions under this Article. In order to be covered, behavioral health services shall be provided by qualified service providers under R9-22-1206. ADHS/DBHS shall ensure that emergency behavioral health services are available 24 hours per day, seven days per week in each GSA for an emergency behavioral health condition for a non-FES member as defined in R9-22-201.

H. Other covered behavioral health services. Other covered behavioral health services include:

1. Case management as defined in 9 A.A.C. 10, Article 1;

2. Laboratory and radiology services for behavioral health diagnosis and medication management;

3. Medication;

4. Monitoring, administration, and adjustment for psychotropic medication and related medications;

5. Respite care as described within subsection (J);

6. Behavioral health therapeutic home care services provided by a RBHA in a professional foster home defined in 6 A.A.C. 5, Article 58 or in an adult behavioral health therapeutic home as defined in 9 A.A.C. 10, Article 1;

8. Other support services to maintain or increase the member's self-sufficiency and ability to live outside an institution.

I. Transportation services. Transportation services are covered under R9-22-211.

J. Limited Behavioral Health services. Respite services are limited to no more than 600 hours per benefit year.

Ariz. Admin. Code § R9-22-1205

Adopted under an exemption from A.R.S. Title 41, Ch. 6, pursuant to Laws 1992, Ch. 301, § 61, effective November 1, 1992; received in the Office of the Secretary of State November 25, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Ch. 6, pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Amended under an exemption from A.R.S. Title 41, Ch. 6, pursuant to Laws 1995, Ch. 204, §11, effective October 1, 1995; filed with the Secretary of State September 29, 1995 (Supp. 95-4). Section repealed, new Section adopted by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 11 A.A.R. 5480, effective December 6, 2005 (Supp. 05-4). Amended by final rulemaking at 13 A.A.R. 836, effective May 5, 2007 (Supp. 07-1). Amended by exempt rulemaking at 17 A.A.R. 1870, effective October 1, 2011 (Supp. 11-3). Amended by final rulemaking at 19 A.A.R. 2747, effective October 8, 2013. Amended by final rulemaking at 20 A.A.R. 3098, effective 1/4/2015.