Ariz. Admin. Code § 9-31-205

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-31-205 - Attending Physician, Practitioner, and Primary Care Provider Services

A. A primary care provider shall provide primary care provider services within the provider's scope of practice under A.R.S. Title 32. A member may receive primary care provider services in an inpatient or outpatient setting including at a minimum:

1. Periodic health examination and assessment,

2. Evaluation and diagnostic workup,

3. Medically necessary treatment,

4. Prescriptions for medication and medically necessary supplies or equipment,

5. Referral to a specialist or other health care professional if medically necessary as specified in A.R.S. § 36-2989,

6. Patient education,

7. Home visits if medically necessary,

8. Covered immunizations, and

9. Covered preventive health services.

B. As specified in A.R.S. § 36-2989, a second opinion procedure may be required to determine coverage for surgery. Under this procedure, documentation must be provided by at least two physicians as to the need for the proposed surgery for the member.

C. The following limitations and exclusions apply to physician and practitioner services and primary care provider services:

1. Specialty care and other services provided to a member upon referral from a primary care provider are limited to the services or conditions for which the referral is made, or for which authorization is given by the contractor;

2. A member's physical examination is not a covered service if the physical examination is to obtain one or more of the following:

a. Qualification for insurance,

b. Pre-employment physical evaluation,

c. Qualification for sports or physical exercise activities,

d. Pilot's examination (Federal Aviation Administration),

e. Disability certification to establish any kind of periodic payments,

f. Evaluation to establish third-party liabilities, or

g. Physical ability to perform functions that have no relationship to primary objectives of the services listed in subsection (A).

3. The following services are excluded from AHCCCS coverage:

a. Infertility services, reversal of surgically induced infertility (sterilization), and gender reassignment surgery;

b. Pregnancy termination counseling services;

c. A pregnancy termination, unless authorized under federal law;

d. A service or item furnished solely for cosmetic purposes;

e. A hysterectomy, unless determined to be medically necessary; and

f. Licensed midwife services for prenatal care and home birth.

Ariz. Admin. Code § R9-31-205

Adopted under an exemption from A.R.S. Title 41, Chapter 6, pursuant to Laws 1998, Ch. 4, § 11, 4th Special Session, effective October 23, 1998 (Supp. 98-4). Amended by final rulemaking at 8 A.A.R. 2365, effective May 9, 2002 (Supp. 02-2).