Ariz. Admin. Code § 9-22-712.90

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

Section R9-22-712.90 - Reimbursement of Hospital-based Freestanding Emergency Departments

A. "Hospital-based freestanding emergency department" (hospital-based FSED) means an outpatient treatment center, as defined in R9-10-101, that:

(1) provides emergency room services under R9-10-1019,

(2) is subject to the requirements of 42 C.F.R. 489.24, and

(3) shares an ownership interest with a hospital, regardless of whether the outpatient treatment center operates under a hospital's single group license as described in A.R.S. § 36-422.

B. A hospital-based FSED shall register with the Administration separately from the hospital with which an ownership interest is shared and shall obtain a separate provider identification number. The Administration shall not charge a separate provider enrollment fee for registration of a hospital-based FSED. The Administration shall accept a hospital's compliance with the provider screening and enrollment requirements of 42 CFR Part 455 as compliance by the hospital-based FSED.

C. For dates of service on and after March 1, 2017, and except as provided in subsection (D), services provided by a hospital-based FSED for evaluation and management CPT codes 99281 through 99285 shall be reimbursed at the following percentages of the amounts otherwise reimbursable under R9-22-712.20 through R9-22-712.30. All other covered codes shall be reimbursed in accordance with R9-22-712.20 through R9- 22-712.30 without a percentage reduction.

1. 60 percent for a level 1 emergency department visit as indicated by CPT 99281.

2. 80 percent for a level 2 emergency department visit as indicated by CPT 99282.

3. 90 percent for a level 3 emergency department visit as indicated by CPT 99283.

4. 100 percent for a level 4 or 5 emergency department visit as indicated by CPT codes 99284 and 99285.

D. A hospital-based FSED located in a city or town in a county with less than 500,000 residents, where the only hospital in the city or town operating an emergency department closed on or after January 1, 2015, shall be reimbursed under R9-22-712.20 through R9-22-712.35 using the adjustment in R9-22-712.35 associated with the nearest hospital with which the freestanding emergency department shares an ownership interest.

E. Services provided by an outpatient treatment center that provides emergency room services under R9-10-1019 but does not otherwise meet the criteria in subsection A, shall be reimbursed based on the non-hospital AHCCCS capped fee-for- service schedule under R9-22-710.

F. The Administration shall not reimburse a hospital for services provided at a hospital-based FSED if the member is admitted directly from a hospital-based FSED to a hospital with an ownership interest in the hospital-based FSED. As provided in R9-22-712.60(B), payments made for the inpatient stay using the DRG methodology shall be the sole reimbursement.

G. For dates of service from October 1, 2023 through September 30, 2024 (CYE 2024), the payment otherwise required for hospitalbased FSED services provided by qualifying hospital-based FSEDs shall be increased by a percentage established by the Administration and shall be applied to the payment methodology as described in subsection (C). The percentage is published on the Administration's public website as part of its fee schedule, subsequent to the public notice published no later than September 1, 2023. A hospitalbased FSED will qualify for an increase if it meets the criteria specified below. If a hospital-based FSED receives a DAP for CYE 2024 but fails to meet all of the requirements in subsection (G), the hospital-based FSED shall be disqualified from participating in a DAP for dates of service October 1, 2024 through September 30, 2025 (CYE 2025), if a DAP would be available at that time.

H. an outpatient treatment center designated by the Arizona Department of Health Services Division of Licensing Services as type: hospital-based freestanding emergency department will qualify for an increase if it meets the criteria in subsection (H)(1):

1. No later than April 30, 2023, the hospital-based FSED must submit a Letter of Intent (LOI) to AHCCCS to the following email address: AHCCCSDAP@azahcccs.gov, indicating that they will participate in the Naloxone Distribution Program (NDP).

2. The LOI must contain each hospital-based FSED, including AHCCCS ID(s) and corresponding NPI(s), that the hospital requests to participate in the DAP.

a. No later than November 30, 2023, develop and submit a hospital-based FSED policy that meets AHCCCS/ADHS standards for a NDP.

b. No later than January 1, 2024, begin distribution of Naloxone to individuals at risk of overdose as identified through the hospital-based FSEDs' policy.

I. For dates of service from October 1, 2024 through September 30, 2025 (CYE 2025), the payment otherwise required for hospitalbased FSED services provided by qualifying hospital-based FSEDs shall be increased by a percentage established by the Administration and shall be applied to the payment methodology as described in subsection (C). The percentage is published on the Administration's public website as part of its fee schedule, subsequent to the public notice published no later than September 1, 2024. A hospitalbased FSED can and will qualify for an increase if it meets the criteria specified below for any of the applicable hospital-based FSED subtypes. If a hospital-based FSED receives a DAP for CYE 2025 but fails to meet all of the requirements in subsection (G), the hospital-based FSED shall be disqualified from participating in a DAP for dates of service October 1, 2025 through September 30, 2026 (CYE 2026), if a DAP would be available at that time.

J. A outpatient treatment center designated by the Arizona Department of Health Services Division of Licensing Services as type: hospital-based freestanding emergency department will qualify for an increase if it meets the criteria in subsection (1)(a) or (b):

1. Hospitals with an Emergency Department that participated in the NDP DAP in CYE 2024.

a. No later than April 1, 2024, the hospital must submit a Letter of Intent (LOI) to AHCCCS to the following email address: AHCCCSDAP@azahcccs.gov, indicating that they will participate in the Naloxone Distribution Program (NDP). The LOI must contain each facility, including AHCCCS ID(s) and corresponding National Provider Identifier(s) (NPI), that the hospital requests to participate in the DAP.

b. No later than November 30, 2024, the hospital must develop and submit a facility policy that ensures hospitals are purchasing Naloxone through standard routine pharmacy ordering.

c. No later than February 28, 2025, the hospital must submit a Naloxone Distribution Program Attestation to AHCCCS to the following email address: AHCCCSDAP@azahcccs.gov.

2. Hospitals with an Emergency Department that have not participated in the NDP DAP in CYE 2024.

b. No later than November 30, 2024, the hospital must develop and submit a facility policy that meets AHCCCS/ADHS standards for a NDP.

c. No later than January 1, 2025, the hospital must begin distribution of Naloxone to individuals at risk of overdose as identified through the facilities' policy.

d. No later than February 28, 2025, the hospital must submit a Naloxone Distribution Program Attestation to AHCCCS to the following email address: AHCCCSDAP@azahcccs.gov.

Ariz. Admin. Code § R9-22-712.90

Adopted by final rulemaking at 23 A.A.R. 22, effective 2/11/2017. Amended by final rulemaking at 29 A.A.R. 3394, effective 10/4/2023. Amended by final rulemaking at 30 A.A.R. 3103, effective 10/1/2024.