1. A. Provider agreement. The Administration or a contractor shall not reimburse a covered service provided to a member unless the provider has signed a provider agreement with the Administration that establishes the terms and conditions of participation and payment under A.R.S. § 36-2904.

2. B. Provider reimbursement. The Administration or a contractor shall reimburse a provider for a service furnished to a member only if:

   1. 1. The provider personally furnishes the service to a specific member. For purposes of this Section, services personally furnished by a provider include:

      1. a. Services provided by medical residents or dental students in a teaching environment; or
      2. b. Services provided by a licensed or certified assistant under the general supervision of a licensed practitioner in accordance with 4 A.A.C. 24, 9 A.A.C. 16, 4 A.A.C. 43, or 4 A.A.C. 45;
   2. 2. The provider verifies that individuals who have provided services described in subsection (B)(1) have not been placed on the List of Excluded Individuals/Entities (LEIE) maintained by the United States Department of Health and Human Services Office of the Inspector General (OIG), located at OIG’s web site;
   3. 3. The service contributes directly to the diagnosis or treatment of the member; and
   4. 4. The service ordinarily requires performance by the type of provider seeking reimbursement.

3. C. The Administration or a contractor may make a payment for covered services only:

   1. 1. To the provider;
   2. 2. To anyone specified in a reassignment from the provider to a government agency or reassignment by a court order;

   3. 3. To a business agent, if the agent’s compensation for the service is:

      1. a. Related to the cost of processing the billing;
      2. b. Not related on a percentage or other basis to the amount that is billed or collected; and
      3. c. Not dependent upon collection of the payment;
   4. 4. To the employer of the provider, if the provider is required as a condition of employment to turn over the provider’s fees to the employer;
   5. 5. To the inpatient facility in which the service is provided, if the provider has a contract under which the inpatient facility submits the claim; or
   6. 6. To a foundation, plan, or similar organization operating an organized health care delivery system, if the provider has a contract under which the foundation, plan or similar organization submits the claim.
4. D. The Administration or a contractor shall not make a payment to or through a factor, either directly or by power of attorney, for a covered service furnished to a member by a provider.

5. E. Reimbursement for a pathology service. Unless otherwise specified in a contract, the Administration or a contractor shall reimburse a pathologist for a pathology service furnished to a member only if the other requirements in this Section are met and the service is:

   1. 1. A surgical pathology service;
   2. 2. A specific cytopathology, hematology, or blood banking pathology service that requires performance by a physician and is listed in the capped fee-for-service schedule;

   3. 3. A clinical consultation service that:

      1. a. Is requested by the member’s attending physician or primary care physician,
      2. b. Is related to a test result that is outside the clinically significant normal or expected range in view of the condition of the member,
      3. c. Results in a written narrative report included in the member’s medical record,
      4. d. Requires the exercise of medical judgment by the consultant pathologist, and
      5. e. Is listed in the capped fee-for-service schedule; or

   4. 4. A clinical laboratory interpretative service that:

      1. a. Is requested by the member’s attending physician or primary care physician,
      2. b. Results in a written narrative report included in the member’s medical record,
      3. c. Requires the exercise of medical judgment by the consultant pathologist, and
      4. d. Is listed in the capped fee-for-service schedule.

Historical Note

Adopted as an emergency effective February 23, 1983, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 83-1). Adopted as a permanent rule effective May 16, 1983; text of adopted rule is similar to the emergency (Supp. 83-3). Repealed effective October 1, 1983 (Supp. 83-5). Former Section R9-22-713 renumbered and amended as Section R9-22-714 effective October 1, 1985 (Supp. 85-5). Section repealed; new Section made by final rulemaking at 8 A.A.R. 424, effective January 10, 2002 (Supp. 02-1). Amended by final rulemaking at 9 A.A.R. 3800, effective October 4, 2003 (Supp. 03-3). Amended by final rulemaking at 13 A.A.R. 662, effective April 7, 2007 (Supp. 07-1).

Editor’s Note: The following Section was amended under an exemption from the provisions of the Administrative Procedure Act which means that this rule was not reviewed by the Governor’s Regulatory Review Council; the agency did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; the agency was not required to hold public hearings on the rules; and the Attorney General did not certify this rule. This Section was subsequently amended through the regular rulemaking process.