CurrentArizona Health Care Cost Containment SystemPolicy 426

Children's Rehabilitative Services Referrals, Enrollment, Designation and Coverage

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This policy governs how AHCCCS Contractors and the Division of Member Services process referrals and applications for Children's Rehabilitative Services designation, determine enrollment and coverage types, and coordinate responsibility for CRS-related and other covered services. It applies to Acute Care, AHCCCS Complete Care, CMDP, DDD, and RBHA Contractors.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChildren's Rehabilitative Services Referrals, Enrollment, Designation and Coverage

Policy CodePolicy N/A

Change TypeAdministrative and process clarification

Effective DateOct 1, 2018

Next Review DateN/A

Key ActionSubmit the completed CRS referral or application to DMS using the AHCCCS-required form.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to apply Contractors to CRS designation processes.

The policy clarifies referral discussions with the parent, guardian, or authorized representative and the notice and transition responsibilities associated with CRS enrollment.

The policy clarifies that CRS designation is removed when a member turns 21 unless the member timely elects continued enrollment with the CRS Contractor.

The contractor-responsibility section was revised to apply to Contractors for CRS designation operations.

The separate CRS eligibility appeal section was removed as no longer applicable for CRS designation.

The CRS designation monitoring section was revised to describe notification, active-treatment review, and transition processes.

The policy reference list was removed and applicable references were incorporated into the policy text.

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CurrentArizona Health Care Cost Containment SystemPolicy 426

Children's Rehabilitative Services Referrals, Enrollment, Designation and Coverage

Customize your policy alerts

Sign up for Arizona Health Care Cost Containment System Policy 426 alerts

Get alerted when Policy 426 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChildren's Rehabilitative Services Referrals, Enrollment, Designation and Coverage

Policy CodePolicy N/A

Change TypeAdministrative and process clarification

Effective DateOct 1, 2018

Next Review DateN/A

Key ActionSubmit the completed CRS referral or application to DMS using the AHCCCS-required form.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to apply Contractors to CRS designation processes.

The policy clarifies referral discussions with the parent, guardian, or authorized representative and the notice and transition responsibilities associated with CRS enrollment.

The policy clarifies that CRS designation is removed when a member turns 21 unless the member timely elects continued enrollment with the CRS Contractor.

The contractor-responsibility section was revised to apply to Contractors for CRS designation operations.

The separate CRS eligibility appeal section was removed as no longer applicable for CRS designation.

The CRS designation monitoring section was revised to describe notification, active-treatment review, and transition processes.

The policy reference list was removed and applicable references were incorporated into the policy text.

Under 21Primary age group for CRS enrollment

28 daysNewborn retroactive enrollment period

30 daysAdvance notice before age-21 transition

4CRS coverage types

3 yearsContinuous enrollment before disenrollment option

MonthlyCompleted-treatment reporting frequency

CRS Designation, Enrollment, and Responsibility

CRS Designation and Enrollment

CRS designation and enrollment apply when all required eligibility and medical criteria are met.

CRS designation and enrollment

Member is under age 21.
Member is enrolled in Title XIX or Title XXI; applicants not enrolled in Title XIX/XXI cannot be enrolled in the CRS Program.
A CRS qualifying condition requiring active treatment, as defined by A.A.C. R9-22-1303, is confirmed through medical review by the Division of Member Services (DMS).
DMS approves the member's CRS program designation and processes CRS enrollment referrals and applications.
The member has not opted out of or refused enrollment in the CRS Program.

AHCCCS may request medical documentation at any time to determine continued CRS eligibility or designation.

A member enrolled because of a covered medical condition that is later no longer specified in A.A.C. R9-22-1303 may continue CRS enrollment if the member meets the medical criteria for the covered condition that was the basis for initial enrollment.

CRS Coverage Types

The CRS coverage type determines which services the CRS Contractor provides in addition to services related to the CRS condition.

Common CRS Contractor responsibility

Regardless of coverage type, the CRS Contractor is responsible for care and services related to the CRS condition from the member's CRS enrollment date through disenrollment, including applicable Prior Period Coverage (PPC).
Depending on the coverage type, the CRS Contractor may also be responsible for covered services unrelated to the CRS condition.

ONE applicable CRS coverage type

CRS Fully Integrated: Member receives all services from the CRS Contractor, including acute care, behavioral health, and CRS-related services.
CRS Partially-Integrated—Acute: American Indian member receives all acute care and CRS-related services from the CRS Contractor and behavioral health services from a Tribal Regional Behavioral Health Authority (TRBHA).

Contractor Payment Responsibility

Payment responsibility depends on CRS enrollment, third-party coverage, the member's election, and age.

Member is enrolled with the CRS Contractor

The CRS Contractor is responsible for payment for covered services provided to enrolled members under the applicable CRS coverage type.
Third-party coverage status
- Private insurance or Medicare pays for a CRS-covered condition: the CRS Contractor is the secondary payer for applicable deductibles and copayments and performs required coordination-of-benefits activities under ACOM Policies 201 and 434.
- Private insurance or Medicare expires, does not cover the CRS condition, is exhausted for CRS-covered conditions, or reaches an annual or lifetime limit: the CRS Contractor is responsible for all covered CRS services provided through its network.

Member opts out of or refuses CRS enrollment and is under age 21

CRS Coverage and Operational Responsibility Criteria

CRS operational responsibility continues or changes based on enrollment status, eligibility, treatment status, age, third-party coverage, and member election.

While CRS designation and enrollment are active

The CRS Contractor is responsible for CRS-condition services from enrollment through disenrollment and during applicable PPC, subject to the member's CRS coverage type and third-party-payment rules.
The CRS Contractor must notify AHCCCS when a member under age 21 with a CRS designation no longer requires active treatment, including when medical records show treatment is complete.
The CRS Contractor must transmit a Members with Completed Treatment Report to AHCCCS at least monthly for CRS members who have completed treatment, in the format and manner specified in Contract Section F, Attachment F3, Contractor Chart of Deliverables.

Grounds for termination of CRS enrollment or designation

Member loses Title XIX/XXI eligibility.

Operational Thresholds and Timeframes

CRS Enrollment Age

CRS enrollment ageUnder 21 years of age

Enrollment requirementThe presence of a CRS condition requiring active treatment must be confirmed through medical review by DMS.

Program eligibilityApplicants must be enrolled in Title XIX or XXI to enroll in the CRS Program.

Newborn Retroactive Enrollment

Retroactive enrollmentNewborns may be enrolled retroactively to the date of birth.

Application deadlineThe CRS application must be received within 28 days of birth.

Enrollment authority

Contractor and Provider Responsibilities

Documentation Required

Submit the CRS Referral/Application

Submit the completed Application for Enrollment into AHCCCS CRS form to DMS for a medical eligibility determination. The form may be faxed, mailed, or delivered in person as directed on the AHCCCS website.

Use the required CRS referral/application form and current submission instructions available on the AHCCCS website.

Documentation Required

Provide Supporting Medical Documentation

Include supporting medical documentation with the CRS referral/application. Documentation must establish the diagnosis and the need for treatment.

Statement from the diagnosing specialist identifying the individual's diagnosis and need for treatment.
Diagnostic testing results supporting the medical diagnosis.

Key CRS Terms

Active Treatment

DefinitionActive Treatment means there is a current need for treatment of a CRS qualifying condition or it is anticipated that treatment or evaluation for continuing treatment will be needed within the next 18 months.

Qualifying conditionThe treatment or evaluation must concern a CRS qualifying condition.

Measurement pointThe 18-month period is measured from the last date of service for treatment of any CRS qualifying condition.

CRS Condition Redetermination

Decision makerCRS Condition Redetermination is a decision made by AHCCCS DMS.

Decision purposeThe decision determines whether a member continues to meet the requirements for CRS eligibility.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChildren's Rehabilitative Services Referrals, Enrollment, Designation and Coverage

Policy CodePolicy N/A

Change TypeAdministrative and process clarification

Effective DateOct 1, 2018

Next Review DateN/A

Key ActionSubmit the completed CRS referral or application to DMS using the AHCCCS-required form.

SourceLink

On This Page

CRS Partially-Integrated—Behavioral Health: CMDP or DDD member receives all behavioral health and CRS-related services from the CRS Contractor and acute care services from the primary program of enrollment.

CRS Only: Member receives all CRS-related services from the CRS Contractor, acute care from the primary program of enrollment, and behavioral health services from the applicable source: CMDP and DDD American Indian members from a TRBHA; American Indian Health Program members from a TRBHA; and ALTCS Tribal Program members from Fee-for-Service (FFS).

The member is enrolled with another AHCCCS Contractor for acute care services.

Third-party coverage status

Private insurance or Medicare pays for treatment of the CRS condition: the acute-care AHCCCS Contractor pays applicable deductibles and copayments remaining after third-party payment.
Private insurance or Medicare does not pay, terminates, or is exhausted for the CRS condition: the acute-care AHCCCS Contractor has no responsibility for CRS-condition services, must refer the member to DMS for CRS eligibility evaluation upon receiving termination or exhaustion information, and the provider may bill the member as authorized by A.A.C. R9-22-702.

Contractors are not responsible for Medicare Part D drug deductibles or copayments.

Member is age 21 or older and elects to disenroll from the CRS Contractor

The AHCCCS Contractor with which the member is enrolled for acute care services is responsible for payment of services related to the CRS condition regardless of private insurance or Medicare coverage.
That AHCCCS Contractor is the payor of last resort except as provided by state and federal law.

DMS determines that the member no longer meets CRS medical eligibility requirements.

DMS determines that the member has completed treatment for the CRS condition or conditions.

Member or authorized representative requests opt-out or termination; the member, parent, legal guardian, or representative, as applicable, must sign an acknowledgment that the member accepts payment responsibility for CRS-related services.

Member transitions to an ALTCS/EPD Contractor, excluding members enrolled with an ALTCS Tribal Program Contractor.

Re-enrollment after loss of Title XIX/XXI eligibility

Eligibility is regained
- Eligibility is regained within 12 months: the member is re-enrolled with the CRS Contractor without a new referral or application; PPC with the CRS Contractor occurs only in this circumstance for a Title XIX CRS-enrolled member.
- Eligibility is regained after 12 months: a new CRS referral or application is required.

Optional disenrollment after no CRS services

Beginning in CYE15, during an AHCCCS-designated annual period, the member is continuously enrolled as CRS Fully Integrated and has received no services for the CRS condition for three years.
AHCCCS offers the member an option to disenroll and select an available acute-care Contractor in the member's area.
If the member later needs care for a CRS condition, a CRS referral or application must be submitted to DMS for medical-eligibility evaluation.

AHCCCS monitoring determination

If AHCCCS determines that the member is no longer medically eligible for CRS, AHCCCS removes the CRS designation and provides the member or authorized representative written notice that enrollment will transition to another AHCCCS Contractor under A.A.C. R9-22-1306.
The member may appeal the determination under A.A.C. 9-34.

DMS enrolls or designates the applicant into the CRS Program by coverage type.

Notice Before Age 21 Transition

Required noticeWritten notice must be sent at least 30 days prior to the month the member turns 21.

Member choicesThe notice informs the member about the opportunity to continue enrollment with the CRS Contractor or enroll with another AHCCCS Contractor.

Notice contentThe notice explains the process and time period for informing the AHCCCS CRS Enrollment Unit.

Active Treatment Period

Current treatment needThere is a current need for treatment of a CRS qualifying condition.

Anticipated treatment or evaluationTreatment or evaluation for continuing treatment is anticipated to be needed within the next 18 months.

Reference dateThe 18-month period is measured from the last date of service for treatment of any CRS qualifying condition.

Note

Discuss the Referral and Possible Plan Change

Before submitting the completed CRS referral/application, discuss the referral and possible health-plan change with the parent, guardian, or authorized representative. Explain that the child will be referred to a specialist for evaluation of the CRS condition.

Documentation Required

Support the DMS Eligibility Determination

Support DMS processing of the CRS eligibility determination. DMS verifies Title XIX/XXI enrollment and may contact the appropriate parties when additional information is needed.

Applicants who are not enrolled in Title XIX/XXI cannot be enrolled in the CRS Program.
Respond to DMS requests for information needed to determine medical eligibility.

Billing Rule

Provide CRS Covered Services

Provide covered services to members under age 21 who have a confirmed CRS condition requiring active treatment and who have been approved for a CRS designation by DMS.

The CRS Contractor is responsible for care and services related to the CRS condition from CRS enrollment through disenrollment, including applicable Prior Period Coverage.
Depending on the CRS Coverage Type, responsibility may also include services unrelated to the CRS condition.

Billing Rule

Coordinate CRS Payment Responsibility

Pay for services provided to enrolled members as required by the applicable CRS Coverage Type. Regardless of coverage type, the CRS Contractor is responsible for covered services related to the CRS condition during enrollment and applicable Prior Period Coverage.

Apply the CRS Coverage Type rules to determine responsibility for services unrelated to the CRS condition.

Billing Rule

Handle Third-Party Coverage After CRS Opt-Out

When a member declines or refuses CRS enrollment and uses private insurance or Medicare for treatment of a CRS-covered condition, the acute-care AHCCCS Contractor is responsible for applicable deductibles and copayments remaining after the third party pays.

The member who opts out or refuses CRS enrollment is enrolled with another AHCCCS Contractor.
The acute-care Contractor is not otherwise responsible for CRS-condition services except as specified for third-party coverage.

Billing Rule

Coordinate CRS Payment and Benefits

When an enrolled CRS member uses private insurance or Medicare for a CRS-covered condition, the CRS Contractor is the secondary payer for applicable deductibles and copayments and must perform appropriate coordination-of-benefits activities.

Follow the coordination-of-benefits requirements in ACOM Policies 201 and 434.

Denial Risk

Apply Third-Party Coverage and Opt-Out Rules

If a member who opted out of CRS has private insurance or Medicare that does not pay for the CRS condition, terminates, or is exhausted for the CRS-covered condition, the acute-care AHCCCS Contractor has no responsibility for services related to that condition.

Upon learning that third-party coverage has terminated or been exhausted, refer the member to DMS for evaluation of CRS eligibility.
When the acute-care Contractor is not responsible, the provider may bill the member as authorized by A.A.C. R9-22-702.

Denial Risk

Limit Acute-Care Contractor Responsibility

Do not assign responsibility for Medicare Part D drug deductibles or copayments to the Contractor. When private insurance or Medicare does not pay, terminates, or is exhausted for a CRS-covered condition after CRS opt-out, the acute-care Contractor remains not responsible for related services.

Contractors are not responsible for Medicare Part D drug deductibles or copayments.
A member may be billed as authorized by A.A.C. R9-22-702 when the acute-care Contractor has no payment responsibility.

Billing Rule

Pay for CRS Services After Age 21

For members age 21 or older who elect to disenroll from the CRS Contractor, the AHCCCS Contractor responsible for acute-care enrollment must pay for services related to the CRS condition, regardless of private insurance or Medicare coverage.

The acute-care AHCCCS Contractor is the payor of last resort except as provided by state and federal law.

Documentation Required

Document CRS Opt-Out Acknowledgment

Obtain the required acknowledgment when a member or, when applicable, the member's parent, legal guardian, or representative requests CRS opt-out or termination. DMS must explain that another AHCCCS Contractor generally will not cover CRS-related services except as specified in this policy.

The member or authorized representative must acknowledge understanding and agreement to accept payment responsibility for CRS-related services.
If private insurance or Medicare pays for the CRS condition, the acute-care Contractor pays applicable copayments and deductibles as specified in the policy.

Note

Manage CRS Designation Termination and Re-Enrollment

Process CRS designation termination and re-enrollment when eligibility or medical circumstances change. DMS may terminate the designation when Title XIX/XXI eligibility is lost, medical eligibility is no longer met, treatment is completed, the member opts out, or the member transitions to an ALTCS/EPD Contractor, subject to the policy exceptions.

If Title XIX/XXI eligibility is regained within 12 months, re-enroll the member without a new referral/application; after 12 months, require a new referral/application.
Prior Period Coverage applies when a Title XIX CRS member loses and regains eligibility within 12 months and is re-enrolled.
A member who again needs CRS care after designation termination must be referred to DMS for a new medical-eligibility evaluation.

Note

Offer Disenrollment After Three Years Without CRS Services

During the designated annual timeframe, offer eligible CRS Fully Integrated members an option to disenroll when they have been continuously enrolled in CRS for three years without receiving services for their CRS condition.

Allow the member to choose an available Acute Care Contractor in the member's area.
If CRS care is later needed, submit a CRS referral/application to DMS for medical-eligibility evaluation.

Note

Provide Disenrollment Notice and Appeal Information

Ensure that DMS sends written notice of CRS disenrollment or removal of the CRS designation to the member or authorized representative. The notice must describe hearing rights and provide information about the hearing process.

AHCCCS must notify the member or authorized representative when it removes the CRS designation and transitions enrollment to another AHCCCS Contractor under A.A.C. R9-22-1306.
The member may appeal the determination under A.A.C. R9-34.

Documentation Required

Report Completed Treatment

Notify AHCCCS when a CRS member under age 21 with a CRS designation no longer requires active treatment for the qualifying condition, including by providing medical records showing treatment is complete.

Transmit the Members with Completed Treatment Report at least monthly for each CRS member who has completed treatment.
Send the report as specified in Contract Section F, Attachment F3, Contractor Chart of Deliverables.

Applicable ruleThe determination is made under A.A.C. R9-22-1305.

CRS Qualifying Condition

DefinitionA CRS qualifying condition is a covered medical condition that is medically disabling or potentially disabling.

Eligibility significanceThe condition qualifies for CRS medical eligibility.

Applicable ruleCRS medical eligibility is specified in A.A.C. R9-22-1303.