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ARIZONA STATE SENATE
Fifty-Seventh Legislature, Second Regular Session
AHCCCS; claims review; behavioral health
Purpose
Requires an appeal of a behavioral health claim that is subject to the capped fee-for-service schedule to be reviewed by an individual who has relevant clinical experience.
Background
The Arizona Health Care Cost Containment System (AHCCCS) serves as Arizona's Medicaid agency, which offers qualifying Arizona residents access to healthcare programs, including behavioral health. AHCCCS consists of contracts with contractors for the provision of hospitalization and medical care coverage to members. A contractor is a person or entity that has a prepaid capitated contract with AHCCCS to provide health care to members as prescribed, either directly or through subcontracts with providers (A.R.S. §§ 36-2901 and 36-2903).
A capped
fee-for-service is the payment mechanism by which a provider of care is
reimbursed upon submission of a valid claim for a specific covered service or
equipment provided to a member. A payment is made in accordance with an upper
or capped limit established by the Director of AHCCCS and may either be a
specific dollar amount or a percentage of billed charges. AHCCCS must pay
providers, including both contracting and noncontracting providers, at either
the lesser of billed charges or outlined capped fee-for-service rates, unless a
different fee is specified in a contract between AHCCCS and the provider, or is
otherwise required by law. Fee schedules for payment for various covered
services are on file at the central office of AHCCCS for reference use during
customary business hours and on the AHCCCS website (A.A.C.
R9-22-101 and R9-22-710; AHCCCS).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1.
Requires any appeal of a behavioral health claim that is subject to the AHCCCS
capped
fee-for-service schedule to be reviewed by an individual who has relevant
clinical experience.
2. Becomes effective on the general effective date.
Prepared by Senate Research
January 15, 2026
MM/SDR/hk