Fillable Printable 432A
Fillable Printable 432A
432A
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 1 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
1.
Reimbursement of
transportation for the
member to the initial
behavioral health
appointment regardless of
whether the Enrolled
Entity or the Behavioral
Health Entity scheduled
that appointment.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
X
X
X
2.
Reimbursement of
transportation for the
member to the emergency
department of an acute
care hospital when the
transport is emergent,
including inter-facility
transfers to the emergency
department.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 2 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
3.
Reimbursement of claims
with behavioral health
principal diagnoses that
are related to
communication disorders
usually diagnosed in
infancy, childhood or
adolescence. The claim
must be accompanied by
procedure codes ranging
from -92507, 92508,
92521-92524, and 92550-
92597.
These behavioral health
conditions require
services from non-
behavioral health provider
types such as speech
therapists or other
physical health providers,
and are therefore
considered physical health
services.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 3 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
4.
Reimbursement of all
facility services,
including triage and
diagnostic tests,
regardless of principal
diagnosis when provided
in an emergency
department and there is
no admission to the
facility.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
For a
CRS
related
condition
X
X
For a
CRS
related
condition
X
X
X
5.
Reimbursement of
professional fees with a
physical health principal
diagnosis, regardless of
setting.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
For a
CRS
related
condition
X
X
For a
CRS
related
condition
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 4 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
6.
Reimbursement of
services associated with a
PCP visit for diagnosis
and treatment of
depression, anxiety and/or
attention deficit
hyperactive disorder
including professional
fees, related prescriptions,
laboratory and other
diagnostic tests. For
purposes of medication
management, it is not
required that the PCP be
the member’s assigned
PCP.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 5 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
7.
Reimbursement of
inpatient facility services
to hospitalized members
with a principal physical
health diagnosis.
Reimbursement is
unrelated to the bed or
floor where the member
is placed.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
For a
CRS
related
condition
X
X
For a
CRS
related
condition
X
X
X
8.
Reimbursement of
outpatient observation
services with a principal
physical health
diagnosis.
X
X
For
members
determine
d to have
SMI who
are
integrated
X
X
For a
CRS
related
condition
X
X
For a
CRS
related
condition
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 6 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTR
ACTOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DDD
CMDP
AIHP
THE ENROLLED ENTITY IS
RESPONSIBLE FOR:
9.
When the enrolled entity
is AHCCCS FFS for
AIHP members assigned
to a RBHA or TRBHA,
payment of medically
necessary transportation
services (emergent and
non-emergent) when the
diagnosis code on the
claim is unspecified
(799.9 or its replacement
code under ICD-10).
X
[END OF ENROLLED ENTITY RESPONSIBLE PARTY SECTION]
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 7 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTRAC
TOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DD
D
CMD
P
AIH
P
THE BEHAVIORAL HEALTH
ENTITY IS RESPONSIBLE FOR:
10.
Reimbursement of
inpatient facility
services to hospitalized
members with a
behavioral health
principal diagnosis.
Reimbursement is
unrelated to the bed
or floor where the
member is placed.
X
For
GMH/SA
Adult
Duals
X
X
X
X
11.
Reimbursement of
outpatient observation
services with a
principal behavioral
health diagnosis.
X
For
GMH/SA
Adult
Duals
X
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 8 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTRAC
TOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DD
D
CMD
P
AIH
P
THE BEHAVIORAL HEALTH
ENTITY IS RESPONSIBLE FOR:
12.
Reimbursement of
professional fees with a
behavioral health
principal diagnosis,
regardless of setting
including, but not
limited to, diagnosis
and treatment of
depression, anxiety
and/or attention deficit
hyperactive disorder.
X
For
GMH/SA
Adult
Duals
X
X
X
X
AHCCCS CONTRACTOR OPERATIONS MANUAL
ACOM POLICY 432, ATTACHMENT A,
MATRIX OF FINANCIAL RESPONSIBILITY BY RESPONSIBLE PARTY
432, Attachment A - Page 9 of 9
Effective Dates: 04/01/15, 10/01/15, 07/01/16, 09/20/17
Revision Date: 06/28/17
SERVICE/RESPONSIBILITY
ACUTE
CARE
CONTRAC
TOR
RBHA
TRBHA
CRS FULLY
INTEGRATED
CRS
PARTIALLY
INTEGRATED
BH
CRS
PARTIALLY
INTEGRATED
ACUTE
CRS
ONLY
DD
D
CMD
P
AIH
P
THE BEHAVIORAL HEALTH
ENTITY IS RESPONSIBLE FOR:
13.
Reimbursement of
medically necessary
transportation when
transferring a member
from an Acute Hospital,
including an
Emergency
Department, to a
Behavioral Health
setting including but
not limited to, a
Residential Treatment
Center (RTC),
Outpatient Clinic or a
Residential Facility.
X
For
GMH/SA
Adult
Duals
X
X
X
X
[END OF BEHAVIORAL HEALTH ENTITY RESPONSIBLE PARTY SECTION]
