R9-22-714. Payments to Providers

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. B. Provider reimbursement. The Administration or a contractor shall reimburse a provider for a service furnished to a member only if: 1. The provider personally furnishes the service to a specific member. For purposes of this Section, services personally furnished by a provider include: a. Services provided by medical residents or dental students in a teaching environment; or 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. 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. The service contributes directly to the diagnosis or treatment of the member; and 4. The service ordinarily requires performance by the type of provider seeking reimbursement. C. The Administration or a contractor may make a payment for covered services only: 1. To the provider; 2. To anyone specified in a reassignment from the provider to a government agency or reassignment by a court order; 3. To a business agent, if the agent’s compensation for the service is: a. Related to the cost of processing the billing; b. Not related on a percentage or other basis to the amount that is billed or collected; and c. Not dependent upon collection of the payment; 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. 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. 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. 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. 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. A surgical pathology service; 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. A clinical consultation service that: a. Is requested by the member’s attending physician or primary care physician, 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, c. Results in a written narrative report included in the member’s medical record, d. Requires the exercise of medical judgment by the consultant pathologist, and e. Is listed in the capped fee-for-service schedule; or 4. A clinical laboratory interpretative service that: a. Is requested by the member’s attending physician or primary care physician, b. Results in a written narrative report included in the member’s medical record, c. Requires the exercise of medical judgment by the consultant pathologist, and d. Is listed in the capped fee-for-service schedule.