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Rates & Codes
This section contains information of interest to AHCCCS health plans and providers.
These schedules are not intended to be an all-inclusive list of procedure and service codes.
Capitation Rates
Acute Care Capitation Rates
ALTCS Capitation Rates
Behavioral Health Capitation Rates
Children's Rehabilitative Services (CRS)
Statewide Rates
(Updated July, 2006)
Comprehensive Medical and Dental Program (CMDP)
Enrollment Rate Codes and Values
Enrollment Rate Codes and Values
[PDF, 23 Kb]
(Updated February 25, 2008)
This PDF document contains Enrollment codes and values. This document
also includes RP145 and RP160 codes and descriptions.
Fee-For-Service Rates (AHCCCS)
The appearance on this website of a code and rate is not an indication of
coverage, nor a guarantee of payment. AHCCCS covered procedures can be
viewed in the
AHCCCS Medical Policy Manual (AMPM). AHCCCS covered services can differ
based upon enrollment.
Ambulatory Surgical Center
NOTICE: Although CMS
is changing its Ambulatory Surgery Center (ASC) payment methodology and
adding codes for services that may be performed in, and eligible for
payment at, ASCs effective January 1, 2008, AHCCCS will not be making
those changes for January 1. AHCCCS is currently in the process of
analyzing ASC payment structures and the operational impact of opening
the new codes for payment. AHCCCS will not be making changes to ASC
allowed codes or payments until mid-to-late 2008. Questions may be
addressed to Jean Ellen Schulik at
JeanEllen.Schulik@azahcccs.gov.
NOTE: Additional allowable codes for ASCs are listed in the
Provider Type Profile that is sent to Health Plans each week.
Copies of this are available from AHCCCS Provider Registration.
Behavioral Health
Dental
Dialysis
Hemophilia Factor
NOTE: Rates
Subject to change quarterly.
2008
Archived Hemophilia Factor Rates
Home and Community Based Services
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October 1, 2008, through September 30, 2009
(Updated August, 2008)
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October 1, 2007, through September 30, 2008
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October 1, 2006, through September 30, 2007
Hospice
Inpatient Hospital
Pursuant to R9-22-712.01 Section 2, subsection c., “For dates of service prior to October 1, 2007,
the statewide inpatient hospital
cost-to-charge ratio is used for payment of outliers, as described in subsections
(4), (5), and (6), and out-of-state hospitals, as described in R9-22-712(B).”
The Inpatient cost-to-charge ratio is .4075.
Pursuant to R9-22-712.01 Section 6, subsection c, “AHCCCS shall
phase in the use of the Medicare Urban or Rural Cost-to-Charge Ratios for outlier
determination, threshold calculation, and outlier payment calculation. The three
year phase-in does not apply to out of state or new hospitals.”
The urban inpatient cost-to-charge ratio between
10/01/2007 and 9/30/2008 is .3737. The rural inpatient cost-to-charge
ratio between 10/01/2007 and 9/30/2008 is .4143.
Pursuant to R9-22-712.01 Section 11, “Outliers for out-of-state
hospitals will be calculated using the Medicare urban cost-to-charge ratio times
covered charges. If the resulting cost is equal to or above the urban outlier threshold,
the claim will be paid at the Medicare Urban Cost-to-Charge Ratio times covered
charges." For dates
between 10/01/2007 and 9/30/2008, the inpatient cost-to-charge ratio for out-of-state
hospitals is .3060.
Pursuant to R9-22-712.01 Section 11, "Outliers for new hospitals
will be calculated using the Medicare Urban or Rural Cost-to-Charge Ratio times
covered charges. If the resulting cost is equal to or above the cost threshold,
the claim will be paid at the Medicare Urban or Rural Cost-to-charge ratio.”
For new hospitals
who become AHCCCS eligible between 10-01-2007 and 9/30/2008, the inpatient cost-to-charge
ratio for urban hospitals
is .3060 and for rural hospitals .4280.
Nursing Facility
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October 1, 2008, through September 30, 2009
(Updated August, 2008)
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October 1, 2007, through September 30, 2008
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October 1, 2006, through September 30, 2007
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October 1, 2005, through September 30, 2006
Outpatient Hospital
- Outpatient Fee Schedule Effective 10-01-07 [ZIP (PDF, Excel)
New codes effective on 4/1/2008 are added (Updated March, 2008)
- Outpatient Fee Schedule Effective 10-01-06 [ZIP (PDF, Excel)]
New codes effective on 1/1/2007 are added
(Updated January, 2007)
- Outpatient Hospital Cost-to-Charge Ratio
Pursuant to ARS 36-2903.01(H)(3) as amended by the Laws of 2004 Chapter 279,
any covered outpatient hospital service with dates of service on or after July 1,
2005 that does not have a rate listed on the outpatient hospital capped fee-for-service
schedule shall be reimbursed by applying the statewide cost-to-charge ratio of .3192.
Physician Fee Schedule
Transplant
Transportation
Frequently Asked Questions
How often and when do you update your fee schedule each year?
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Physician fees schedules are updated annually, on or near April 1st of each year.
Quarterly adjustments July 1, October 1, and January 1 made be made to accommodate
new codes or rate adjustments.
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Behavioral health fees are adjusted July 1st.
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Hospital rates are adjusted October 1st; however, this year we moved to a fee schedule
for outpatient rates July 1, 2005. the next adjustment will be October 1, 2006.
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Long-term care rates - nursing facilities, home & community based services,
and hospice - are updated annually October 1st.
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Other rates, such as transportation, are based on analysis and updated when needed.
We post a "NEW" flag on these rates and date them on our web site when they have
been updated.
Are the 51X (clinic) range of revenue codes covered under OPFS?
Yes. 51X (clinic) revenue codes are covered under OPFS for all Providers (both I.H.S.
and non-I.H.S.) This coverage has been in effect since 5/1/2004 when the Physicians
Fee Schedule structure was changed to include place-of-service based rates where
applicable, consistent with Medicare rate structures (i.e. fees for applicable professional
services differ for facility vs. non-facility). The aforementioned change eliminates
the concerns associated with duplication of payments to the facility and practitioner
for facility based services.
What does BR indicate on the fee schedule?
By Report. On the Physician Fee Schedules, BR is 65% of the
covered billed charges. For ground ambulance services, the
rate is 80% of the covered billed charges.
Have a question about AHCCCS Fee-for-Service reimbursement rates?
Email us at
FFSRates@azahcccs.gov
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