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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyArizona AHCCCS Admin Days Prior Auth | OpenPayer
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    CurrentArizona Health Care Cost Containment SystemPolicy N/A

    Behavioral Health Administrative Days Guidance

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    Clarifies reimbursement, billing, and prior authorization requirements for behavioral health administrative days and distinguishes them from traditional acute-care administrative days.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyBehavioral Health Administrative Days Guidance
    Policy CodePolicy N/A
    Change TypeClarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization for behavioral health administrative days and follow established administrative-day billing procedures.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    $816.39Diagnosis-based behavioral health administrative day rate
    1Rate across revenue codes
    RequiredPrior authorization
    AppliesDifferential Adjusted Payment

    Behavioral Health Administrative Day Reimbursement Conditions

    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.

    Behavioral Health Administrative Day Reimbursement Conditions

    The newly established behavioral health (BH) administrative day applies to eligible provider type 02 claims with a BH primary diagnosis and discharge dates on or after 10/1/18. It does not apply to the traditional administrative day for an acute-care inpatient admission that does not meet acute inpatient criteria.

    ALL of the following

    • The claim is for a provider type 02 inpatient BH stay with a BH primary diagnosis.

      For discharge dates on or after 10/1/18, AHCCCS reimburses eligible claims under the newly established BH administrative day methodology rather than the DRG amount.

    • The claim is being submitted as a BH administrative day claim and follows the established processes and procedures for billing administrative day claims.
    • Prior authorization has been obtained for the BH administrative days.

      Prior authorization is required.

    • The applicable payer arrangement is ONE of the following

      • AHCCCS or an ACC MCO uses the AHCCCS BH administrative day rate: the diagnosis-based daily rate is $816.39, loaded as a provider-specific rate in PR050, without regard to revenue code.

        The rate is found on the Inpatient Behavioral Health Capped Fee-For-Service Schedule under the service description “Psychiatric Hospital”; effective 10/1/19, the description is revised to “Psychiatric Stay.” The rate is not differentiated by revenue code.

      • The provider and MCO have negotiated a contracted rate that differs from the AHCCCS fee schedule.

        An MCO and provider may negotiate a different contracted rate.

      • The claim is paid by an RBHA.

        RBHAs continue to pay provider type 02 claims with a BH primary diagnosis under the rates in effect on 9/30/18, including per diem rates differentiated by revenue code. RBHA claims do not follow this BH administrative day rate policy.

    Applicable reimbursement requirements

    • For AHCCCS or an ACC MCO using AHCCCS rates, reimbursement is at a single BH administrative day rate for all revenue codes.

      The daily rate is driven by diagnosis code and is not differentiated by revenue code.

    • The Differential Adjusted Payment (DAP) contractual requirement is applied to the BH administrative day rate.

      If BH administrative day claims were reimbursed without the DAP, the MCO must reprocess the claims and must not require resubmission.

    Rate and Applicable Claim Profile

    Behavioral health administrative day rate
    Daily rate$816.39 diagnosis-based daily rate
    Revenue code treatmentPaid regardless of revenue code; the rate is not differentiated by revenue code
    Payment basisReimbursed at a daily rate rather than the DRG amount
    Applicable claim profile
    Provider typeProvider type 02 claim
    Primary diagnosisBehavioral health must be the primary diagnosis
    Applicable discharge datesDischarge dates on or after October 1, 2018
    Reimbursement methodAHCCCS reimburses at a daily rate rather than the DRG amount

    Authorization, Billing, and Reimbursement Actions

    Prior Authorization

    Prior Authorization and Administrative Day Billing

    Prior authorization is required for behavioral health administrative days. Follow the established processes and procedures for billing administrative day claims.

    Billing Rule

    Apply Differential Adjusted Payment

    Apply the Differential Adjusted Payment (DAP) contractual requirement to reimbursement for behavioral health administrative days. If claims were paid without DAP, the MCO should reprocess them without requiring the provider to resubmit the claims.

    Billing Rule

    Apply Payer-Specific Reimbursement Rules

    Apply the payer-specific behavioral health administrative day reimbursement rules to applicable provider type 02 claims with a behavioral health primary diagnosis and discharge dates on or after October 1, 2018. For AHCCCS and ACC MCOs using AHCCCS rates, reimburse at the diagnosis-based daily administrative day rate of $816.39, loaded as a provider-specific rate in PR050, regardless of revenue code; RBHAs continue their existing per diem, revenue-code-dependent reimbursement and do not follow this administrative day/rate policy.

    • The administrative day rate is based on the Inpatient Behavioral Health Capped Fee-for-Service Schedule service description “Psychiatric Hospital,” revised to “Psychiatric Stay” effective October 1, 2019.
    • The daily rate is not differentiated by revenue code. An MCO and provider may negotiate a contracted rate that differs from the AHCCCS fee schedule.
    • This guidance applies to the newly established behavioral health administrative day and does not apply to the traditional administrative day for an inpatient acute care hospital stay that does not meet acute inpatient criteria.

    Administrative Day Terminology

    Behavioral health administrative day
    DefinitionA newly established administrative day for behavioral health inpatient stays
    Payment contextAddresses reimbursement for behavioral health inpatient stays that would normally fall under the DRG payment methodology
    Policy distinctionThe term administrative day in this guidance refers only to the newly established behavioral health administrative day
    Traditional administrative day
    DefinitionAn administrative day involving admission as an inpatient to an acute-care hospital when the member does not meet the criteria for an acute inpatient stay
    Care settingAcute-care hospital inpatient admission
    Guidance applicabilityThis guidance does not apply to the traditional administrative day
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyBehavioral Health Administrative Days Guidance
    Policy CodePolicy N/A
    Change TypeClarification
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization for behavioral health administrative days and follow established administrative-day billing procedures.
    SourceLink
    On This Page
    Behavioral Health Administrative Day Reimbursement ConditionsRate and Applicable Claim ProfileAuthorization, Billing, and Reimbursement ActionsAdministrative Day Terminology