R9-22-1101. Basis for Civil Monetary Penalties and Assessments for Fraudulent Claims; Definitions

A. Scope. This Article applies to prohibited acts as described under A.R.S. § 36-2918(A), and submissions of encounters to the Administration. The Administration considers a person who aids and abets a prohibited act affecting any of the AHC- CCS programs or Health Care Group to be engaging in a prohibited act under A.R.S. § 36-2918(A). B. Purpose. This Article describes the circumstances AHCCCS considers and the process that AHCCCS uses to determine the amount of a penalty, assessment, or penalty and assessment as required under A.R.S. § 36-2918. This Article includes the process and time-frames used by a person to request a State Fair Hearing. C. Definitions. The following definitions apply to this Article: 1. “Assessment” means a monetary amount that does not exceed twice the dollar amount claimed by the person for each service. 2. “Claim” means a request for payment submitted by a person for payment for a service or line item of service, including a submission of an encounter. 3. “Day” means calendar day unless otherwise specified. 4. “File” means the date that AHCCCS receives a written acceptance, request for compromise, request for a counter proposal, or a request for a State Fair Hearing as established by a date stamp on the written document or other record of receipt. 5. “Penalty” means a monetary amount, based on the number of items of service claimed or reported, that does not exceed $2,000 times the number of line items of service. 6. “Person” means an individual or entity as described under A.R.S. § 1-215. 7. “Reason to know” or “had reason to know” means that a person, acts in deliberate ignorance of the truth or falsity of, or with reckless disregard of the truth or falsity of information. No proof of specific intent to defraud is required.