Ariz. Admin. Code § 9-22-204

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

Section R9-22-204 - Inpatient General Hospital Services

A. The following limitations apply to inpatient general hospital services that are provided by FFS providers.

1. Providers shall obtain prior authorization from the Administration for the following inpatient hospital services:

a. Nonemergency and elective admission, including psychiatric hospitalization;

b. Elective surgery; and

c. Services or items provided to cosmetically reconstruct or improve personal appearance after an illness or injury.

2. The Administration or a contractor may deny a claim if a provider fails to obtain prior authorization.

3. Providers are not required to obtain prior authorization from the Administration for the following inpatient hospital services:

a. Voluntary sterilization,

b. Dialysis shunt placement,

c. Arteriovenous graft placement for dialysis,

d. Angioplasties or thrombectomies of dialysis shunts,

e. Angioplasties or thrombectomies of arteriovenous graft for dialysis,

f. Hospitalization for vaginal delivery that does not exceed 48 hours,

g. Hospitalization for cesarean section delivery that does not exceed 96 hours, and

h. Other services identified by the Administration through the Provider Participation Agreement.

4. The Administration may perform concurrent review for hospitalizations of non-FES members to determine whether there is medical necessity for the hospitalization. A provider shall notify the Administration no later than 72 hours after an emergency admission.

B. Coverage of in-state and out-of-state inpatient hospital services is limited to 25 days per benefit year for members age 21 and older for claims with discharge dates on or before September 30, 2014. The limit applies for all inpatient hospital services with dates of service during the benefit year regardless of whether the member is enrolled in Fee for Service, is enrolled with one or more contractors, or both, during the benefit year.

1. For purposes of calculating the limit:

a. Inpatient days are counted towards the limit if paid by the Administration or a contractor;

b. Inpatient days will be counted toward the limit in the order of the adjudication date of a paid claim;

c. Paid inpatient days are allocated to the benefit year in which the date of service occurs;

d. Each 24 hours of paid observation services is counted as one inpatient day if the patient is not admitted to the same hospital directly following the observation services;

e. Observation services, which are directly followed by an inpatient admission to the same hospital are not counted towards the inpatient limit; and

f. After 25 days of inpatient hospital services have been paid as provided for in this Section:

i. Outpatient services that are directly followed by an inpatient admission to the same hospital, including observation services, are not covered.

ii. Continuous periods of observation services of less than 24 hours that are not directly followed by an inpa-tient admission to the same hospital are covered.

iii. For continuous periods of observation services of 24 hours or more that are not directly followed by an inpa-tient admission to the same hospital, 23 hours of observations services are covered.

2. The following inpatient days are not included in the inpatient hospital limitation described in this Section:

a. Days reimbursed under specialty contracts between AHCCCS and a transplant facility that are included within the component pricing referred to in the contract;

b. Days related to Behavioral Health:

i. Inpatient days that qualify for the psychiatric tier under R9-22-712.09 and reimbursed by the Administration or its contractors, or

ii. Inpatient days with a primary psychiatric diagnosis code reimbursed by the Administration or its contractors, or

iii. Inpatient days paid by the Arizona Department of Health Services Division of Behavioral Health Services or a RBHA or TRBHA.

c. Days related to treatment for burns and burn late effects at an American College of Surgeons verified burn center;

d. Same Day Admit Discharge services are excluded from the 25 day limit; and

e. Subject to approval by CMS, days for which the state claims 100% FFP, such as payments for days provided by IHS or 638 facilities.

Ariz. Admin. Code § R9-22-204

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-204 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended subsection (A) effective December 22, 1987 (Supp. 87-4). Amended effective December 13, 1993 (Supp. 93-4). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 179, effective December 13, 1999 (Supp. 99-4). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by exempt rulemaking at 7 A.A.R. 4593, effective October 1, 2001 (Supp. 01-3). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 17 A.A.R. 1658, effective August 2, 2011 (Supp. 11-3). Amended by exempt rulemaking at 17 A.A.R. 1707, effective October 1, 2011 (Supp. 11-3). Amended by exempt rulemaking at 18 A.A.R. 1745, effective October 1, 2012 (Supp. 12-2). Amended by final rulemaking at 19 A.A.R. 2747, effective October 8, 2013. Amended by final rulemaking at 20 A.A.R. 1949, effective 9/6/2014.