Fillable Printable Form 432
Fillable Printable Form 432
Form 432
AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 - OPERATIONS
432 –Page 1 of 7
432 - BENEFIT COORDINATION AND FISCAL RESPONSIBILITY FOR
BEHAVIORAL HEALTH SERVICES AND PHYSICAL HEALTH SERVICES
EFFECTIVE DATES: 07/01/12, 04/01/15, 10/01/15, 07/01/16, 09/20/17
REVISION DATES: 10/11/12, 04/02/15, 05/21/15, 07/30/15, 05/19/16, 06/28/17
I. PURPOSE
This Policy applies to Acute Care, CRS, DCS/CMDP (CMDP), DES/DDD (DDD), and
RBHA Contractors for the purposes of benefit coordination and delineating financial
responsibility for AHCCCS covered behavioral health services provided to AHCCCS
members. This Policy also prescribes payment responsibility for physical health
services that are provided to members who are also receiving behavioral health services.
This Policy does not apply to services provided through Indian Health Services (IHS) or
Tribally owned and/or operated facilities.
II. DEFINITIONS
ACUTE CARE
CONTRACTOR
A contracted managed care organization (also known as a
health plan) that provides acute care physical health
services to AHCCCS members in the acute care program
who are Title XIX or Title XXI eligible. The Acute Care
Contractor is also responsible for providing behavioral
health services for its enrolled members who are treated by
a Primary Care Provider (PCP) for anxiety, depression, and
Attention Deficit Hyperactivity Disorder (ADHD). Acute
Care Contractors are also responsible for providing
behavioral health services for dual eligible adult members
with General Mental Health and/or Substance Abuse
(GMH/SA) needs.
ACUTE CARE HOSPITAL
A general hospital that provides surgical services and
emergency services.
AMERICAN INDIAN
HEALTH PROGRAM
(AIHP)
An acute care Fee-For-Service (FFS) program
administered by AHCCCS for eligible American Indians
which reimburses for services provided by and through the
Indian Health Service (IHS), tribal health programs
operated under 638 or any other AHCCCS registered
provider. AIHP was formerly known as AHCCCS IHS.
BEHAVIORAL HEALTH
DIAGNOSIS
Diagnoses listed in the Standard Service Set in AHCCCS
Reference File (RF) 724.
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BEHAVIORAL HEALTH
ENTITY
A Contractor or subcontractor to which the member is
assigned for the provision of Behavioral Health services.
Behavioral Health Entities are one of the following:
Acute Care Contractor for adult members dually
enrolled in Medicaid and Medicare with General
Mental Health and Substance Abuse needs except for
members who elect a TRBHA for behavioral health
services;
Regional Behavioral Health Authority (RBHA);
Tribal Regional Behavioral Health Authority
(TRBHA);
Children’s Rehabilitative Services (CRS) Fully
Integrated; and
CRS Partially Integrated Behavioral Health
CRS FULLY
INTEGRATED
A coverage type which includes members who receive all
services from the CRS Contractor including acute health,
behavioral health and CRS-related services.
CRS ONLY
A coverage type which includes members who receive all
CRS-related services from the CRS Contractor, who
receive acute health services from the primary program of
enrollment, and who receive behavioral health services as
follows:
CMDP and DDD American Indian (AI) members from
a Tribal RBHA
AIHP members from a T/RBHA
CRS Only also includes ALTCS/EPD AI Fee-For-Service
(FFS) members.
CRS PARTIALLY-
INTEGRATED-ACUTE
A coverage type which includes American Indian members
who receive all acute health and CRS-related services from
the CRS Contractor and who receive behavioral health
services from a Tribal RBHA.
CRS PARTIALLY-
INTEGRATED
BEHAVIORAL HEALTH
(BH)
A coverage type which includes CMDP or DDD members
who receive all behavioral health and CRS-related services
from the CRS Contractor and who receive acute health
services from the primary program of enrollment.
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CHAPTER 400 - OPERATIONS
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ENROLLED
ENTITY
The entity, which may be a Contractor or AHCCCS FFS,
with which the member is enrolled for the provision of
acute care services.
For members enrolled in Acute Care, the Enrolled
Entity is the Acute Care Contractor.
For members enrolled in DDD, with or without CRS
coverage and/or BH coverage, the Enrolled Entity is
DDD.
For members enrolled in CMDP, with or without CRS
coverage and/or BH coverage, the Enrolled Entity is
CMDP.
For members with CRS coverage, whether or not they
have a Serious Mental Illness, who do not elect the
American Indian Health Program, the Enrolled Entity is
CRS under the CRS Fully Integrated coverage type.
For members with CRS coverage, whether or not they
have a Serious Mental Illness, who elect a TRBHA for
behavioral health services, the Enrolled Entity is CRS
under the CRS partially Integrated-Acute coverage
type.
For members with Serious Mental Illness without CRS
coverage who do not elect the American Indian Health
Program, the Enrolled Entity is a RBHA.
For members with Serious Mental Illness without CRS
coverage who elect a TRBHA for behavioral health
services, the Enrolled Entity is either the Acute Care
Contractor or AIHP.
For members who elect the American Indian Health
Program, the Enrolled Entity is AIHP.
For members receiving all services from the CRS
Contractor including acute health, behavioral health
and CRS-related services, the Enrolled Entity is CRS
under the Fully Integrated CRS coverage type.
For American Indian members receiving all acute
health and CRS-related services from the CRS
Contractor and receiving behavioral health services
from a TRBHA, the Enrolled Entity is CRS under the
CRS partially Integrated-Acute coverage type.
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PRIMARY CARE PROVIDER
(PCP)
An individual who meets the requirements of A.R.S. §36-
2901, and who is responsible for the management of the
member’s health care. A PCP may be a physician defined
as a person licensed as an allopathic or osteopathic
physician according to A.R.S. Title 32, Chapter 13 or
Chapter 17, or a practitioner defined as a physician
assistant licensed under A.R.S. Title 32, Chapter 25, or a
certified nurse practitioner licensed under A.R.S. Title 32,
Chapter 15. The PCP must be an individual, not a group or
association of persons, such as a clinic.
PRINCIPAL DIAGNOSIS
The condition established after study to be chiefly
responsible for occasioning the admission or care for the
member, (as indicated by the Principal Diagnosis on a UB
claim form from a facility or the first-listed diagnosis on a
CMS 1500 claim line).
The Principal Diagnosis should not be confused with the
admitting diagnosis or any other diagnoses on the claim.
Neither the admitting diagnosis nor any other diagnoses on
the claim should be used in the assignment of payment
responsibility.
REGIONAL BEHAVIORAL
HEALTH AUTHORITY
(RBHA)
A Managed Care Organization that has a contract with the
administration, the primary purpose of which is to
coordinate the delivery of comprehensive mental health
services to all eligible persons assigned by the
administration to the managed care organization.
Additionally the Managed Care Organization shall
coordinate the delivery of comprehensive physical health
services to all eligible persons with a serious mental illness
enrolled by the administration to the managed care
organization.
SERIOUS MENTAL ILLNESS
(SMI)
A condition as defined in A.R.S. §36-550 diagnosed in
persons 18 years and older.
TRIBAL REGIONAL
BEHAVIORAL HEALTH
AUTHORITY (TRBHA)
A tribal entity that has an intergovernmental agreement
with the administration, the primary purpose of which is to
coordinate the delivery of comprehensive behavioral
health services to all eligible persons assigned by the
administration to the tribal entity. Tribal governments,
through an agreement with the State, may operate a Tribal
Regional Behavioral Health Authority for the provision of
behavioral health services to American Indian members.
Refer to A.R.S. §36-3401, §36-3407.
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CHAPTER 400 - OPERATIONS
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III. POLICY
The purpose of this Policy is to clarify payment responsibility of AHCCCS Contractors
for physical and behavioral health services for specific circumstances. Payment for
AHCCCS covered behavioral health and physical health services is determined by the
Principal Diagnosis appearing on a claim, except in limited circumstances as described
in Attachment A, Matrix of Financial Responsibility by Responsible Party.
As this policy is not intended to address all scenarios involving payment responsibility,
refer to Contract for additional information regarding covered services.
A. GENERAL REQUIREMENTS REGARDING PAYMENT FOR PHYSICAL AND
BEHAVIORAL HEALTH SERVICES
1. Regardless of setting, if physical health services are listed on a claim with a
Principal Diagnosis of behavioral health, the Behavioral Health Entity is
responsible for payment of covered physical health services as well as behavioral
health services.
2. Regardless of setting, if behavioral health services are listed on a claim with a
Principal Diagnosis of physical health, the Enrolled Entity is responsible for
payment of covered behavioral health services as well as physical health
services.
3. Payment responsibility for professional services associated with an inpatient stay
is determined by the Principal Diagnosis on the professional claim. Payment
responsibility for the inpatient facility claim and payment responsibility for the
associated professional services is not necessarily the same entity. Payment of
the professional claim shall not be denied by the responsible entity due to lack of
authorization/notification of the inpatient stay regardless of the entity which
authorized the inpatient stay.
4. Payment for an emergency department facility claim of an acute care facility
including triage and diagnostic tests, when there is no admission to the facility,
is the responsibility of the Enrolled Entity regardless of the Principal Diagnosis
on the facility claim. Payment responsibility for professional services associated
with the emergency department visit is determined by the Principal Diagnosis on
the professional claim. Payment responsibility for the emergency department
visit and payment responsibility for the associated professional services is not
necessarily the same entity. Payment of the professional claim shall not be
denied by the responsible entity due to lack of notification of the emergency
department visit.
5. AHCCCS FFS
will be responsible for payment of claims for physical and
behavioral health services that are provided by an IHS or a tribally owned and/or
operated facility to Title XIX members whether enrolled in managed care or
FFS.
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In addition to identifying exceptions, Attachment A, Matrix of Financial
Responsibility by Responsible Party also provides detail and clarification regarding
payment responsibility in specific scenarios.
All AHCCCS services must be medically necessary, cost effective, and federally and
state reimbursable. For specific information on inpatient reimbursement rates refer
to A.A.C. R9-22-712.60 et seq. Enrolled Entities and Behavioral Health Entities
may enter into contracts with providers that delineate other payment terms, including
responsibility for payment.
B. SPECIFIC CIRCUMSTANCES REGARDING PAYMENT FOR BEHAVIORAL HEALTH
SERVICES
The Enrolled Entity is responsible for 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. PCPs who treat members with these behavioral health
conditions may provide medication management services including prescriptions,
laboratory and other diagnostic tests necessary for diagnosis, and treatment. Clinical
tool kits for the treatment of anxiety, depression, and ADHD are available in the
AMPM Policy 310.
The Enrolled Entity is responsible for payment of medication management services
provided by the PCP while the member may simultaneously be receiving counseling
and other medically necessary rehabilitative services from the Behavioral Health
Entity. For purposes of medication management, it is not required that the PCP be
the member’s assigned PCP.
1. The Enrolled Entity must coordinate with the Behavioral Health Entity when
both physical and behavioral health services are rendered during an inpatient stay
and the Enrolled Entity is notified of the stay.
Such coordination shall include, but is not limited to: communication/
collaboration of authorizations, determinations of medical necessity, and
concurrent reviews.
2. When the Principal Diagnosis on an inpatient claim is a behavioral health
diagnosis, the Behavioral Health Entity shall not deny payment of the inpatient
facility claim for lack of authorization or medical necessity when the member’s
Enrolled Entity authorized and/or determined medical necessity of the stay
through concurrent review, such as when the admitting diagnosis is a physical
health diagnosis.
4. When the Enrolled Entity is AHCCCS FFS for AIHP members assigned to a
RBHA or TRBHA, AHCCCS FFS is responsible for payment of medically
necessary transportation services (emergent and non-emergent) when the
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CHAPTER 400 - OPERATIONS
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diagnosis code on the claim is unspecified (799.9 or its replacement code under
ICD-10).
5. Payment of pre-petition screening and court ordered evaluation services is the
fiscal responsibility of a county. For payment responsibility for other court
ordered services refer to ACOM Policy 423 and ACOM Policy 437.
C. SPECIFIC CIRCUMSTANCES REGARDING PAYMENT FOR PHYSICAL HEALTH
SERVICES – ARIZONA STATE HOSPITAL (AZSH)
The payment responsibilities of an Enrolled Entity described below for members
residing in AzSH do not apply to CMDP because CMDP members are under the age
of 18 and members residing in AzSH are 18 years and older.
1. AHCCCS enrolled members who are residing in the AzSH
and who require
physical health services that are not provided by AzSH during their stay, will
receive services at Maricopa Integrated Health Systems (MIHS) clinics and/or
Maricopa Medical Center (MMC).
a. The Enrolled Entity shall provide reimbursement for medically necessary
physical health services under one of the two following arrangements:
i. A contractual agreement with MIHS clinics including MMC and MIHS
physicians, to provide all medically necessary services. MIHS will be
assigned to provide primary care services for all members residing in
AzSH, or
ii. In the absence of a contractual agreement, the enrolled entity shall be
responsible for coordination of care, prior authorization processes, claims
payments, and provider and member issues for all services delivered by
MIHS. The Contractor shall provide a seamless and obstacle free process
for the provision of services and payment.
b. Emergency services for AzSH residents will be provided by the Maricopa
Medical Center and shall be reimbursed by the Enrolled Entity regardless of
prior authorization or notification, and
c. Physical health related pharmacy services for AzSH residents will be provided
by AzSH in consultation with the Enrolled Entity. The Enrolled Entity is
responsible for such payment.
