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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAHCCCS Financial Responsibility Update | OpenPayer
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    ModifiedArizona Health Care Cost Containment SystemPolicy 432

    Matrix of Financial Responsibility by Responsible Party

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    Assigns financial responsibility for specified services among AHCCCS enrolled entities based on service type, principal diagnosis, member status, setting, admission status, and applicable conditions.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyMatrix of Financial Responsibility by Responsible Party
    Policy CodePolicy 432
    Change TypeModified
    Effective DateOctober 1, 2018
    Next Review DateNot specified
    Key ActionAssign responsibility for transportation to the member's initial behavioral health appointment according to the responsibility matrix.
    SourceLink
    POLICY UPDATE CHANGES

    Several responsible-party columns were removed because they were no longer applicable effective October 1, 2018.

    The distinction in the responsibility matrix was eliminated and the change was applied to all applicable entries.

    A responsible-party column was removed because it was no longer applicable.

    A distinction in the responsibility matrix was eliminated because it was no longer necessary.

    11Responsible-party categories
    6Service-responsibility rules
    3

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Communication-disorder code groups
    1Emergency-department facility rule
    7Medication-assisted treatment parties
    5Behavioral health transportation parties

    Financial Responsibility by Service Type

    Matrix-Based Reimbursement Responsibility

    Determine financial responsibility by matching the service or claim type to the member’s enrolled entity, principal diagnosis, care setting, and any applicable member or condition exception. An “X” below identifies an entity marked responsible in the matrix; qualifying notes limit the rule where stated.

    ROUTE EACH CLAIM USING ALL APPLICABLE FACTORS

    • SERVICE OR CLAIM TYPE

      • Initial transportation to a behavioral health appointment: responsibility follows the matrix entries for the member’s enrolled entity, regardless of whether the enrolled entity or behavioral health entity scheduled the appointment.
      • Emergent transportation to an acute-care hospital emergency department, including an inter-facility transfer to the emergency department: responsibility follows the matrix entries for the member’s enrolled entity.
      • Communication-disorder claims with behavioral health principal diagnoses and procedure codes 92507, 92508, 92521–92524, or 92550–92597 are treated as physical health services because they are furnished by speech therapists or other physical health providers.
      • Occupational therapy claims are the responsibility of the marked enrolled entities regardless of principal diagnosis.
      • Facility services, including triage and diagnostic tests, provided in an emergency department without admission are assigned according to the emergency-department matrix rule, regardless of principal diagnosis.
      • Professional fees, inpatient facility services, medication-assisted treatment, behavioral health professional fees, and behavioral health transportation are assigned under their specific matrix rules below.

    • MEMBER, DIAGNOSIS, SETTING, AND CONDITION MODIFIERS

      • For RBHA or TRBHA entries, apply the stated limitation for members determined to have serious mental illness (SMI) who are integrated, when present.
      • For CRS entries, apply the stated CRS-related-condition limitation when present.
      • For behavioral health professional fees, apply the primary-care-provider exception for depression, anxiety, or attention deficit hyperactivity disorder treatment furnished by a PCP.
      • For AIHP members assigned to a RBHA or TRBHA, apply the special AHCCCS FFS transportation rule when the claim diagnosis is unspecified.

    MATRIX-IDENTIFIED RESPONSIBLE ENTITIES

    • The matrix identifies responsibility by enrolled entity: Acute Care Contract, RBHA, TRBHA, CRS Fully Integrated, CRS Partially Integrated BH, CRS Partially Integrated Acute, CRS Only, DDD, CMDP, and AIHP.
    • A marked entry may be limited by the accompanying note, including integrated SMI status, a CRS-related condition, GMH/SA Adult Duals status, the service setting, or the claim’s principal diagnosis.

    Physical Health Professional Fees

    The enrolled entity is responsible for professional fees when the claim has a physical health principal diagnosis, regardless of the setting.

    MARKED RESPONSIBLE ENTITIES

    • Acute Care Contract.
    • RBHA for members determined to have SMI who are integrated.
    • CRS Fully Integrated.
    • CRS Partially Integrated BH for a CRS-related condition.
    • CRS Partially Integrated Acute.
    • CRS Only for a CRS-related condition.

    Inpatient Facility Services

    The enrolled entity is responsible for inpatient facility services to hospitalized members when the applicable principal-diagnosis rule is met. Responsibility is unrelated to the bed or floor where the member is placed.

    INPATIENT FACILITY CLAIM

    • The member is hospitalized and the claim is for inpatient facility services.

    • PRINCIPAL DIAGNOSIS / MATRIX CONDITION

      • The hospitalized member’s principal diagnosis is physical health, where the matrix marks the applicable enrolled entity responsible.
      • The hospitalized member’s principal diagnosis otherwise meets the applicable matrix responsibility entry and any stated SMI, integrated-member, or CRS-related-condition limitation.

    MARKED RESPONSIBLE ENTITIES

    Medication-Assisted Treatment

    The enrolled entity is responsible for medication-assisted treatment (MAT) for opioid use disorder and/or attention deficit hyperactivity disorder, including the related professional, prescription, laboratory, and other diagnostic services.

    MAT RESPONSIBILITY

    • The claim is for MAT for opioid use disorder and/or attention deficit hyperactivity disorder.

    • INCLUDED SERVICES

      • Professional fees.
      • Related prescriptions.
      • Laboratory services.
      • Other related diagnostic tests.

    Behavioral Health Professional Fees

    The behavioral health entity is responsible for professional fees with a behavioral health principal diagnosis, regardless of the setting.

    BEHAVIORAL HEALTH PROFESSIONAL FEE

    • The claim is for professional fees and has a behavioral health principal diagnosis, including diagnosis or treatment of depression, anxiety, and/or attention deficit hyperactivity disorder.

    • EXCEPTION

      • Treatment is provided by a primary care provider; depression, anxiety, and/or attention deficit hyperactivity disorder treatment provided by a PCP is excluded from the behavioral health entity’s responsibility.
      • No PCP exception applies.

    MARKED RESPONSIBLE BEHAVIORAL HEALTH ENTITIES

    • Acute Care Contract for GMH/SA Adult Duals.

    Behavioral Health Transportation

    The behavioral health entity is responsible for medically necessary transportation transferring a member from an acute hospital, including an emergency department, to a behavioral health setting.

    TRANSFER TRANSPORTATION

    • The transportation is medically necessary.
    • The member is transferred from an acute hospital, including an emergency department, to a behavioral health setting.

    • BEHAVIORAL HEALTH DESTINATION

      • Residential Treatment Center (RTC).
      • Outpatient clinic.
      • Another behavioral health setting.

    AIHP Transportation Claims

    When AHCCCS FFS is the enrolled entity for specified AIHP members, AHCCCS FFS is responsible for medically necessary transportation claims meeting the diagnosis condition below.

    AIHP TRANSPORTATION CLAIM

    • AHCCCS FFS is the enrolled entity for an AIHP member assigned to a RBHA or TRBHA.
    • The transportation is medically necessary and may be emergent or non-emergent.
    • The diagnosis code on the claim is unspecified: 799.9 or its replacement code under ICD-10.

    Applicable Procedure and Diagnosis Codes

    Communication-disorder procedure codesCPT
    92507Procedure code identified for communication-disorder claims
    92508Procedure code identified for communication-disorder claims
    92521-92524Procedure-code range identified for communication-disorder claims
    92550-92597Procedure-code range identified for communication-disorder claims
    Unspecified diagnosis for transportation claimsICD-10
    799.9Unspecified diagnosis code referenced for medically necessary transportation claims; use its replacement code under ICD-10 where applicable.

    Reimbursement Assignment Rules

    Billing Rule

    Assign responsibility for the initial behavioral health appointment

    Assign responsibility for transportation to the member’s initial behavioral health appointment according to the responsible-party matrix, regardless of whether the enrolled entity or the behavioral health entity scheduled the appointment.

    Billing Rule

    Assign emergent transportation responsibility

    Assign responsibility for emergent transportation to the emergency department of an acute-care hospital according to the responsible-party matrix. This includes inter-facility transfers to the emergency department.

    Billing Rule

    Process communication-disorder claims as physical health services

    Key Responsibility and Service Terms

    Responsible party
    MeaningResponsible-party columns identify the enrolled entity assigned responsibility for reimbursement.
    Matrix categoriesThe matrix includes acute care contract, RBHA, TRBHA, CRS arrangements, DDD, CMDP, and AIHP entities.
    Matrix notationAn X in a responsible-party column indicates that the corresponding enrolled entity is responsible for the listed service or claim.
    Medication-assisted treatment
    Professional servicesProfessional fees related to medication-assisted treatment for opioid use disorder and/or attention deficit hyperactivity disorder.
    PrescriptionsPrescriptions related to medication-assisted treatment.
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyMatrix of Financial Responsibility by Responsible Party
    Policy CodePolicy 432
    Change TypeModified
    Effective DateOctober 1, 2018
    Next Review DateNot specified
    Key ActionAssign responsibility for transportation to the member's initial behavioral health appointment according to the responsibility matrix.
    SourceLink
    On This Page
    Financial Responsibility by Service TypeApplicable Procedure and Diagnosis CodesReimbursement Assignment RulesKey Responsibility and Service Terms
  1. DDD, CMDP, and AIHP.
    2. Acute Care Contract.
  2. RBHA for applicable integrated members.
  3. TRBHA for members determined to have SMI who are integrated.
  4. CRS Fully Integrated.
  5. CRS Partially Integrated BH for a CRS-related condition.
  6. CRS Partially Integrated Acute.
  7. CRS Only for a CRS-related condition.
  8. For medication management, the treating PCP does not have to be the member’s assigned PCP.

    9. MARKED RESPONSIBLE ENTITIES

    • Acute Care Contract.
    • RBHA for members determined to have SMI who are integrated.
    • CRS Fully Integrated.
    • CRS Partially Integrated Acute.
    • DDD, CMDP, and AIHP.
  9. RBHA.
  10. TRBHA.
  11. CRS Fully Integrated.
  12. CRS Partially Integrated BH.

    13. MARKED RESPONSIBLE BEHAVIORAL HEALTH ENTITIES

    • Acute Care Contract for GMH/SA Adult Duals.
    • RBHA.
    • TRBHA.
    • CRS Fully Integrated.
    • CRS Partially Integrated BH.

    Reimburse claims with behavioral health principal diagnoses related to communication disorders when the claim includes the specified speech and communication procedure codes. These claims are treated as physical health services because they are provided by non-behavioral-health provider types, such as speech therapists or other physical health providers.

    • CPT 92507
    • CPT 92508
    • CPT 92521–92524
    • CPT 92550–92597
    Billing Rule

    Assign occupational therapy claim responsibility

    Assign responsibility for reimbursement of occupational therapy claims according to the responsible-party matrix, regardless of the principal diagnosis.

    Billing Rule

    Assign emergency-department facility services

    Assign responsibility for reimbursement of all facility services provided in an emergency department when there is no admission to the facility, regardless of principal diagnosis. This includes triage and diagnostic tests; apply the member-status and CRS-related conditions identified in the matrix.

    • Facility services
    • Triage
    • Diagnostic tests
    Billing Rule

    Assign professional fees with a physical-health diagnosis

    Assign responsibility for reimbursement of professional fees with a physical-health principal diagnosis regardless of the setting. Apply the responsible-party matrix, including its applicable integrated-SMI and CRS-related conditions.

    Billing Rule

    Assign medication-assisted treatment services

    Assign reimbursement for medication-assisted treatment for opioid use disorder and/or attention deficit hyperactivity disorder to the responsible enrolled entity. Include professional fees, related prescriptions, laboratory tests, and other diagnostic tests; for medication management, the PCP does not have to be the member’s assigned PCP.

    • Professional fees
    • Related prescriptions
    • Laboratory tests
    • Other diagnostic tests
    Billing Rule

    Apply the physical-health professional-fee rule

    Assign reimbursement for professional fees with a physical health principal diagnosis according to the marked responsible-party columns, regardless of the setting.

    Billing Rule

    Assign inpatient facility responsibility

    Assign reimbursement for inpatient facility services to the responsible enrolled entity based on the hospitalized member’s principal diagnosis and the marked matrix entries. Responsibility is unrelated to the bed or floor where the member is placed.

    Billing Rule

    Assign behavioral-health professional fees

    Assign reimbursement for professional fees with a behavioral health principal diagnosis to the responsible behavioral health entity regardless of the setting. This includes diagnosis and treatment of depression, anxiety, and/or attention deficit hyperactivity disorder, except when that treatment is provided by a PCP.

    Billing Rule

    Assign transportation to behavioral health settings

    Assign reimbursement for medically necessary transportation when transferring a member from an acute hospital, including an emergency department, to a behavioral health setting. Covered destinations include, but are not limited to, a residential treatment center or outpatient clinic.

    Billing Rule

    Pay specified AIHP transportation claims

    When AHCCCS FFS is the enrolled entity for AIHP members assigned to an RBHA or TRBHA, pay medically necessary emergent and non-emergent transportation when the claim diagnosis is unspecified. Use diagnosis code 799.9 or its replacement code under ICD-10.

    • Applies to medically necessary emergent and non-emergent transportation
    • Use 799.9 or its ICD-10 replacement code when applicable
    Laboratory testsLaboratory tests related to medication-assisted treatment.
    Diagnostic testsOther diagnostic tests related to medication-assisted treatment.
    Behavioral health setting
    ScopeA behavioral health setting is a behavioral health destination to which a member may be transferred from an acute hospital, including an emergency department.
    Residential treatmentResidential Treatment Center (RTC).
    Outpatient careOutpatient clinic.
    Other destinationsOther behavioral health settings are included; the listed examples are not exhaustive.