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ARIZONA HOUSE OF REPRESENTATIVES57th Legislature, 2nd Regular Session |
Senate: HHS DPA 7-0-0-0 | Third Read 24-5-1-0 |
SB 1116: AHCCCS; claims review; behavioral health
Sponsor: Senator Werner, LD 4
Committee on Health & Human Services
Overview
Requires that before any claim denial or adverse appeal determination regarding the medical necessity of a behavioral health service covered by the American Indian Health Program (AIHP), the claim and its supporting medical documentation must be reviewed and the denial approved by an individual with at least two years of relevant clinical experience providing the same or similar services.
History
Established in 1981, the Arizona Health Care Cost Containment System (AHCCCS) is Arizona's Medicaid program that oversees contracted health plans for the delivery of health care to individuals and families who qualify for Medicaid and other medical assistance programs. Through contracted health plans across the state, AHCCCS delivers health care to qualifying individuals including low-income adults, their children or people with certain disabilities. Members must meet certain financial and nonfinancial requirements to be eligible for AHCCCS (A.R.S. § 36-2901).
American Indians and Alaska Natives enrolled in AHCCCS or Children's Health Insurance Program may choose to receive their coverage through the AIHP. The AIHP provides medically necessary services for enrolled members, including preventive and behavioral health care services (AIHP).
A capped fee-for-service is a payment method in which a health care provider is reimbursed after submitting a valid claim for a covered service or equipment provided to a member. Payment is made according to an upper limit established by the Director of AHCCCS and may be set as either a fixed dollar amount or a percentage of billed charges. AHCCCS must reimburse both contracting and noncontracting providers at the lesser of the billed charges or the applicable capped fee-for-service rate, unless a different rate is specified in a contract with the provider or otherwise required by law. Fee schedules for covered services are maintained at the AHCCCS central office for public reference during regular business hours and are also available on the AHCCCS website (A.A.C. R9-22-101; R9-22-710; AHCCCS).
Provisions
1. Requires an individual with at least two years of relevant clinical experience providing the same or similar services to review the claim and supporting medical documentation before approving any denial or adverse appeal determination based on the medical necessity of a behavioral health service covered by the AIHP. (Sec. 1)
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5. Initials AG/LK SB 1116
6. 3/4/2026 Page 0 Health & Human Services
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