1. A. A primary care provider, attending physician, or practitioner shall provide primary care provider services within the provider’s scope of practice under A.R.S. Title 32. A member may receive primary care provider services in an inpatient or outpatient setting including at a minimum:

   1. 1. Periodic health examination and assessment;
   2. 2. Evaluation and diagnostic workup;
   3. 3. Medically necessary treatment;
   4. 4. Prescriptions for medication and medically necessary supplies and equipment;
   5. 5. Referral to a specialist or other health care professional if medically necessary;
   6. 6. Patient education;
   7. 7. Home visits if medically necessary; and
   8. 8. Preventive health services, such as, well visits, immunizations, colonoscopies, mammograms and PAP smears.

2. B. The following limitations and exclusions apply to attending physician and practitioner services and primary care provider services:

   1. 1. Specialty care and other services provided to a member upon referral from a primary care provider, or to a member upon referral from the attending physician or practitioner are limited to the service or condition for which the referral is made, or for which authorization is given by the Administration or a contractor.

   2. 2. A member’s physical examination is not covered if the sole purpose is to obtain documentation for one or more of the following:

      1. a. Qualification for insurance,
      2. b. Pre-employment physical evaluation,
      3. c. Qualification for sports or physical exercise activities,
      4. d. Pilot’s examination for the Federal Aviation Administration,
      5. e. Disability certification to establish any kind of periodic payments,
      6. f. Evaluation to establish third-party liabilities, or
      7. g. Physical ability to perform functions that have no relationship to primary objectives of the services listed in subsection (A).
   3. 3. Orthognathic surgery is covered only for a member who is less than 21 years of age;

   4. 4. The following services are excluded from AHCCCS coverage:

      1. a. Infertility services, reversal of surgically induced infertility (sterilization), and gender reassignment surgeries;
      2. b. Pregnancy termination counseling services;
      3. c. Pregnancy terminations, unless required by state or federal law.
      4. d. Services or items furnished solely for cosmetic purposes; and
      5. e. Hysterectomies unless determined medically necessary.

Historical Note

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-205 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended subsection (A), paragraph (15) and added paragraph (20) effective December 22, 1987 (Supp. 87-4). Amended subsection (C)(2) effective May 30, 1989 (Supp. 89-2). Amended under an exemption from the provisions of the Administrative Procedure Act effective March 22, 1993; received in the Office of the Secretary of State March 24, 1993 (Supp. 93-1). Amended effective December 13, 1993 (Supp. 93-4). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 6 A.A.R. 2435, effective June 9, 2000 (Supp. 00-2). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by exempt rulemaking at 10 A.A.R. 4588, effective October 12, 2004 (Supp. 04-4). Amended by exempt rulemaking at 16 A.A.R. 1638, effective October 1, 2010 (Supp. 10-3). Amended by final rulemaking at 20 A.A.R. 1949, effective September 6, 2014 (Supp. 14-3).

Editor’s Note: The following Section was renumbered and a new Section adopted under an exemption from the provisions of the Administrative Procedure Act which means that this rule was not published as a proposed rule in the Arizona Administrative Register; the rule was not reviewed or approved by the Governor’s Regulatory Review Council; and the agency was not required to hold public hearings on the rule. This Section was subsequently amended through the regular rulemaking process.