AdSS Operations Policy Manual Chapter 5000 - for Public ...

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Division of Developmental Disabilities AdSS Operations Policy Manual

Chapter 5000 Reinsurance

1 5000 REINSURANCE POLICY CYE 2022

2 EFFECTIVE DATE: XXX XX, 2021 (TBD) 3 REFERENCES: A.R.S.§ 8-512; Title XIX/XXI; 9 A.A.C.22; AMPM policy 1620-I; DDD Medical 4 Policy Manual, Policy 310-DD; AdSS Operations Manual, Policy 414; AMPM Chapter 300, 5 Policy 310 Attachments A and B

6 INTRODUCTION

7 Reinsurance is a stop-loss program provided by the Division o f Developmental Disabilities 8 (Division) to the AdSS for the partial reimbursement of covered medical services incurred for 9 a member beyond an annual deductible level. The Division is self-insured for the reinsurance

10 program, which is characterized by an initial deductible level and a subsequent coinsurance 11 percentage. This risk-sharing program is available when the provisions delineated in this 12 policy, the AHCCCS Medical Policy Manual (AMPM) and the contract are met. Failure to 13 comply with any of the provisions in the contract, this policy, or other program materials 14 may result in denial of reinsurance reimbursement.

15 All due dates denote on or before 5:00 p .m. on the due date indicated. If the due date lands 16 on a weekend or State-recognized holiday, then the due d ate i s the ne xt business day, on or 17 before 5:00 PM.

18 PURPOSE

19 The purpose of this policy is to provide general information r egarding the AdSS 20 responsibilities to the Division reinsurance program, including the requirements for eligibility, 21 determination of benefits, and deductible rate.

22 The primary objective of this policy is to establish c onsistency and uniformity in the 23 processing of reinsurance. Not every pr ocess step can be included in this policy. As a result, 24 several tools have been developed to assist i n processing reinsurance. For reference there is 25 a separate policy (DDD Operations Manual – Policy 5000) for the Division responsibilities to 26 AHCCCS reinsurance program.

27 DEFINITIONS & ACRONYMS

28 A. ACOM – AHCCCS Contractor Operations Manual, which provides information regarding 29 covered services and is available on the AHCCCS website.

30 B. ADHS – Arizona Department of Health Services

31 C. AdSS - Administrative Services Subcontractors

32 D. AHCCCS – Arizona Health Care Cost Containment System

33 E. ALTCS – Arizona Long Term Care System

34 F. AMPM – AHCCCS Medical Policy Manual provides information regarding covered 35 healthcare services and is available on the AHCCCS website.

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36 G. BHS - Behavioral Health – Behavioral Health S ervices: the assessment, diagnosis 37 and/or treatment of an individual’s behavioral health issue(s) and includes services 38 for both mental health and substance abuse conditions.

39 H. Biologic Drugs – Biologics is the term used for biological or products produced by 40 biotechnology. These drugs are also referred to as biologicals, biologic drugs, 41 biological drugs, or biopharmaceuticals.

42 I. Case – A record for a member that is comprised of one or more adjudicated 43 encounters.

44 J. Case Type - A description o f the type of reinsurance being paid to the Division based 45 on t he member’s medical condition and eligibility. PMMIS Screen RF776 lists case 46 types.

47 K. Clean Claim Status/Clean Encounter – A c laim/encounter that may be processed in 48 PMMIS without obtaining additional information from the Contractor of service or from 49 a third party and has passed all of the Encounter and Reinsurance edits within the 15-50 month timely-filing deadline. This does not include claims being appealed or claims 51 that are the subject of a grievance, under investigation for fraud or abuse, or claims 52 under review for medical necessity.

53 L. Coinsurance – The percentage rate at which AHCCCS will reimburse the Division for 54 covered services above the deductible.

55 M. Contractor – Also referred to as the AdSS, a n organization or entity that has a prepaid 56 capitated contract with the Division to provide goods and services to members, either 57 directly or through subcontracts with providers, in conformance with contractual 58 requirements, AHCCCS Statutes and Rules, and Federal law and regulations.

59 N. Contract Year – The contract year for reinsurance is the twelve-month period 60 beginning on October 1st t hrough and including September 30th. The contract year 61 may not correspond with the term of a contract as specified in Section A of an 62 entity’s contract with AHCCCS.

63 O. CRS – Children’s Rehabilitative Services: a designation for Title XIX and Title XXI 64 children i n need of medical treatment, rehabilitation, and related support who have 65 completed the CRS application and have met the eligibility criteria to receive CRS-66 related services as specified in 9 A.A.C.22.

67 P. Deductible: The a nnual amount of reinsurance-covered services that must be paid 68 and encountered by the AdSS f or each individual member before the AdSS re ceives 69 reinsurance payments from the Division.

70 Q. DHCM – Division of Health Care M anagement

71 R. DOS – Date of Service

72 S. Encounter – A re cord of health care related service that is a mirror image of a claim 73 and is rendered by a provider or providers registered with AHCCCS to a member who 74 is enrolled with the Division on the date of service.


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Division o f Developmental Disabilities AdSS Operations Policy Manual


75 T. Gaucher’s Disease – An inherited metabolic disorder in which harmful quantities of a 76 fatty substance called glucocerebroside accumulates in the spleen, liver, bone marrow 77 and, i n rare cases, the brain.

78 U. General Mental Health (GMH) – A classification o f diagnoses that is not Seriously 79 Mentally Ill; these diagnoses are not so severe t hat people c annot function without 80 intense services and medication(s).

81 V. Hemophilia – This is a group of hereditary genetic disorders that impair the body's 82 ability to control blood clotting or coagulation. There are three types of hemophilia - 83 A, B, and C. The severity of hemophilia is related to the amount of clotting factor in 84 the blood.

85 W. IMD – Institution for Mental Disease

86 X. MM – AHCCCS Medical Management

87 Y. PMMIS - Prepaid Medical Management Information System, the AHCCCS m ainframe 88 pricing system of record.

89 Z. PPC – Prior Period Coverage is the period of time prior to the member’s enrollment, 90 during which a member is eligible for covered services. The timeframe is from the 91 effective date of eligibility to the day a member is enrolled with the Division.

92 AA. Prospective – The period of time from when the AdSS receives notification the 93 member has been assigned to their plan and they a re prospectively c apitated for the 94 member.

95 BB. PT – Provider Type

96 CC. RAR – Reinsurance Action Request, also RARF - Reinsurance Action Request Form

97 DD. RI – Reinsurance

98 EE. RTC – Residential Treatment Center

99 FF. Substance Ab use (SA) – As s pecified in A.A.C. R9-10-101, a n in dividual’s misuse of 100 alcohol or another drug or chemical that:

101 1. Alters the individual’s behavior or mental functioning;

102 2. Has the potential to cause the individual to be psychologically or 103 physiologically dependent on alcohol or another drug or chemical; and

104 3. Impairs, reduces, or destroys the individual’s social or economic functioning.

105 GG. Skilled Nursing Facility (SNF) - A nursing facility for those members who need nursing 106 care 24 hours a day, but who do not require hospital care under the daily direction of 107 a physician.

108 HH. Substance Ab use (SA) – S ubstance Abuse is the use of illegal s ubstances like illegal 109 drugs and prescription drugs; it also includes using substances in ways other than 110 intended like gasoline, household chemicals, etc.



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111 II. Title XIX Member – Members include those members eligible under 1931 p rovisions of 112 the Social Security Act (previously AFDC), Sixth O mnibus Budget Reconciliation Act 113 (SOBRA), Supplemental Security Income (SSI), or SSI-related groups, Medicare Cost 114 Sharing groups, Title XIX Waiver groups, Breast and Cervical Cancer Treatment 115 program, Title IV-E Foster Care and Adoption Subsidy, Young Adult Transitional 116 Insurance, and Freedom to Work. The funding source is different from a Title XXI 117 member therefore the payments are accounted for separately by AHCCCS.

118 JJ. Title XXI Member – Member eligible to receive services under Title XXI of the Social 119 Security Act. The funding source is different from a Title X IX member; therefore, the 120 payments are accounted for separately by AHCCCS.

121 KK. TPL – Third Party Liability

122 LL. Von Willebrand’s – An in herited blood disorder characterized by prolonged bleeding 123 time. It is the most common h ereditary bleeding disorder in humans.

124 POLICY

125 I. Regular Reinsurance

126 A. Eligibility AdSS DDD Regular Reinsurance

127 Regular reinsurance (DES case type) is available to partially reimburse the Division 128 participating in the Developmentally Disabled (DD) Services Program for covered 129 inpatient facility services as described in contract, the AMPM, and this policy, when 130 the cost of care for a member exceeds an annual deductible amount. Except as 131 described below, m embers who are enrolled with the AdSS on a capitated basis and 132 meet the appropriate deductible amount may qualify for Reinsurance reimbursement. 133 The coinsurance percentage is the rate at which T he Division w ill reimburse the AdSS 134 for covered inpatient facility services incurred above the deductible.

135 B. Determination of Reinsurance B enefits

136 Services that are covered under Regular Reinsurance (DES) are specified in the 137 AHCCCS Reinsurance System on the R I325 screen entitled “RI Covered Services.”

138 C. Deductibles

139 The deductible level is a set a mount o f $50,000, established as of October 1st o f each 140 contract year, with 75% coinsurance.

141 II. Catastrophic Reinsurance

142 A. Eligibility

143 Catastrophic reinsurance is available to partially reimburse the AdSS for the cost of 144 care associated with certain medical conditions, specific drugs, pregnancy 145 terminations, and High Cost Behavioral Health, as described below and in the AMPM.

146 Catastrophic reinsurance is obtained by submitting a request a nd medical 147 documentation fo r new cases to the Division within 30 days of the identification of the


Case Type Deductible Coinsurance

Hemophilia $0 85%

Von Willebrand’s $0 85%

Gaucher’s Disease $0 85%

Biologic /

High Cost Specialty Drugs

$0 85%

State Only Terminations

$0 100%

Behavioral Health $0 75%


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148 catastrophic case. Catastrophic reinsurance will be retrospectively provided for a 149 maximum of 30 days from the date the request is received by AHCCCS.

150 B. Determination of Benefits

151 For members diagnosed with Hemophilia, v on Willebrand's Disease, or Gaucher's 152 Disease, or members receiving one of the covered biological and/or High Cost 153 Specialty drugs, the AdSS’s clinical staff must review the medical documentation to 154 ensure the member’s condition meets the criteria for catastrophic reinsurance. If the 155 criteria are met, the AdSS must submit a letter requesting reinsurance to the Division 156 within thirty (30) days of:

157 a. Initial diagnosis,

158 b. Enrollment with the AdSS,

159 c. When the AdSS becomes aware of the condition, and/or

160 d. Beginning of each contract year.

161 C. Catastrophic Reinsurance Deductibles

162

163

164 D. Process for Requesting Reinsurance Ca se C reation

165 The AdSS must submit the “Request for Catastrophic Reinsurance Form Letter”, 166 located on the AHCCCS website, to the Division in order to secure catastrophic 167 reinsurance.

168 For newly-diagnosed or newly-enrolled members with the Division, the AdSS must 169 submit the Request for Catastrophic Reinsurance Form Letter and the medical 170 documentation within 3 0 days of the initial diagnosis or enrollment with the Division. 171 The request will be reviewed by the Division’s Medical Director. Upon a pproval, the




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172 Division will submit the letter and documentation to the AHCCCS MMU for review, 173 approval and case activation.

174 E. Hemophilia

175 For members diagnosed with hemophilia, all medically-necessary covered services 176 provided during the contract y ear shall be eligible for reimbursement. Adjudicated 177 encounters for services provided to enrolled members with a diagnosis of hemophilia 178 will be used to determine reinsurance reimbursement.

179 For continuation of previously approved catastrophic reinsurance, the AdSS m ust 180 submit the Request for Catastrophic Reinsurance letter to the Division within 3 0 days 181 of the start of the contract year, which will be reviewed by the Division’s Medical 182 Director. Upon approval, the Division will submit the letter to the AHCCCS, who will 183 use the previously submitted medical information as proof of diagnosis.

184 Catastrophic reinsurance coverage is available for all members diagnosed with 185 Hemophilia. AHCCCS holds a specialty contract for anti-hemophilic agents and related 186 services for Hemophilia. The AdSS shall exclusively utilize the AHCCCS contract for 187 Hemophilia Factor and Blood Disorders as the authorizing payor. As such, the AdSS 188 will provide prior authorization, care coordination, and reimbursement for all 189 components covered under the contract for their members. The AdSS will comply 190 with the terms and conditions of the Division contract. Reinsurance coverage for anti-191 hemophilic blood factors will be limited to 85% of the Division contracted amount or 192 the AdSS’s paid amount, whichever is lower.

193 F. Von Willebrand’s Disease

194 For members diagnosed with von Willebrand’s Disease, all medically-necessary 195 covered services provided during the contract year shall be eligible for 196 reimbursement. Adjudicated encounters for services provided to enrolled members 197 with a diagnosis of von Willebrand’s Disease will be used to determine reinsurance 198 reimbursement. Von Willebrand’s Disease reinsurance coverage is based on the 199 following:

200 ● Type 1 and Type 2A must n ot r espond to desmopressin (DDAVP);

201 ● Type 2B, Type 2M and Type 2N are eligible based on t he diagnoses only;

202 ● Type 3 is eligible based on the diagnosis only.

203 The AdSS must conduct a review of clinical records to determine the member’s type 204 of von Willebrand’s Disease and whether or not the member has responded to a 205 DDAVP medication prior to requesting catastrophic reinsurance.

206 G. Gaucher’s Disease

207 All medically n ecessary covered services provided during the contract year shall be 208 eligible for reimbursement for all members with a diagnosis of Gaucher’s Disease 209 Type I. Timely adjudicated encounters for services provided to these enrolled 210 members will be used to determine reinsurance reimbursement.




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211 Members with Gaucher’s Disease Type 2 and Type 3 are not eligible for catastrophic 212 reinsurance reimbursement due to the limited effect of the enzyme replacement 213 infusions.

214 H. Biological/High C ost Specialty Drugs

215 Catastrophic reinsurance is available to cover the cost of certain biological and/or 216 High Cost S pecialty drugs when determined to be medically necessary.

217 Catastrophic reinsurance for biological and/or High Cost Specialty drug coverage is 218 only available for the costs of the following drugs:

•Aldurazyme • Kynamro • Acthar Gel • Ceprotin • Syprine • Kuvan • Fabryzyme • Spinraza • Orfadin • Lumizyme • Soliris • Kalydeco • Myozyme • Zolgensma • Evrysdi • Juxtapid • Revcovi • Vyondys • Cinryze • Trikafta • Viltepso • Exondys • Symdeko • Oxlumo • Firazyr • Orkambi • Luxturna • Elaprase • Ruconest • Amondys 45

219

220 When a biosimilar (generic equivalent) of a biologic drug is available and AHCCCS has 221 determined that the biosimilar is more cost effective than the brand-name product, 222 the Division will reimburse 85% o f the lesser of the biological cost or its biosimilar 223 equivalent for Reinsurance purposes unless the biosimilar equivalent i s contra-224 indicated for a specific member. I f the AHCCCS Pharmacy and Therapeutics 225 Committee mandates the utilization o f the only brand-name biologic product r ather 226 than the biosimilar, the Division will reimburse at 85% of the amount of the branded 227 biologic drug.

228 In t he instances in which A HCCCS has specialty contracts, or legislation a nd/or policy 229 limits the allowable reimbursement, the amount to be used in the computation o f 230 reinsurance will be the lesser of the AHCCCS contracted/mandated amount or the 231 AdSS paid amount.

232 Requests for new biological drugs will not b e accepted for Reinsurance purposes.

233 I. High Dollar Catastrophic Coverage - $1,000,000+

234 For all reinsurance case types other than tr ansplants, the AdSS will be reimbursed 235 100% for all medically-necessary reinsurance-covered expenses provided in a 236 reinsurance contract year, after the reinsurance case total value meets or exceeds $1 237 million. The $1 million figure represents total health p lan paid amount including the 238 deductible. Once this level is met, the AdSS must notify, via email, the Division 239 Reinsurance point of contact to create the following case type:

240 ● Catastrophic Regular Acute (DDC ) and/or Catastrophic Hemophilia (CHM), 241 Catastrophic Biological/High Cost Specialty Drug (CRB) or

242 ● Catastrophic ALTCS (CLT) ca se and receive enhanced reinsurance 243 reimbursement.

244 Notification m ust include:


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245 ● Request to create t he DDC, CHM, CRB or CLT case a nd

246 ● List of encounters (in numerical order) that are to be transferred on the 247 Catastrophic Request for CRN Transfer Form to the DDC, CHM, CRB or CLT 248 case.

249 Failure t o notify

250 [1] Failure to notify the Division o f a request for another case type or [2] Failure to 251 notify the r einsurance unit of encounters that should be transferred or [3] Failure to 252 adjudicate encounters appropriately within 15 months from the end date of service 253 will d isqualify the related encounters and the entire other catastrophic case for 100% 254 reimbursement.

255 J. Terminations of Pregnancy Involving State-Only Funds

256 The Division c overs pregnancy termination, involving state-only funds, if the 257 pregnancy termination is medically necessary a ccording to an assessment of a 258 licensed physician who attests that continuation o f the pregnancy could reasonably be 259 expected to pose a serious physical or mental health problem for the pregnant 260 member by:

261 a. Creating a serious physical or mental health problem for the pregnant 262 member,

263 b. Seriously impairing a bodily function of the pregnant member,

264 c. Causing dysfunction of a bodily organ or part of the pregnant member,

265 d. Exacerbating a health problem of the pregnant member, or,

266 e. Preventing the pregnant member from obtaining treatment for a health 267 problem.

268 The attending physician m ust attest that a pregnancy termination has been 269 determined medically n ecessary by su bmitting the DDD Medical Policy Manual, 270 Chapter 400, Policy 410 – Medical Policy for Maternal and Child Health.

271 All outpatient medically necessary covered services related to the pregnancy 272 termination, for the date of service only on the day the pregnancy was terminated, 273 will be considered for reinsurance reimbursement at 100% of the lesser of the AdSS’s 274 paid amount or the AHCCCS Fee Schedule amount. Adjudicated encounters for these 275 covered services provided to enrolled members will be used to determine reinsurance 276 benefits.

277 K. High Cost Behavioral Health

278 Expenditures for members enrolled in the High Cost Behavioral Health (BEH) Program 279 will also be considered for catastrophic reinsurance reimbursement. BEH reinsurance 280 only applies to members enrolled in the ALTCS p rogram prior to October 1, 2007. 281 Effective October 1, 2007 the High Cost Behavioral Health Program services were


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282 discontinued under catastrophic coverage unless the case was approved prior to 283 October 1, 2007 and the member was a ctive on September 30, 2007.

284 If the AdSS believes that a member who has been approved for BEH reinsurance 285 continues to require a specialized treatment program and placement, the AdSS must 286 submit a reauthorization request for continued reinsurance reimbursement to the 287 Division. The reauthorization request and supporting documentation (described in 288 AMPM 1620-I) must be submitted to, and received by, the Division no later than 1 0 289 business days prior to the expiration of the current approval. Failure to comply with 290 the 10 business-day timeframe or the documentation requirements will result in a 291 denial of additional reinsurance reimbursement.

292 Authorizations are typically for twelve (12) months but may be authorized for a 293 shorter time period based upon the individual case. The requests must i nclude the 294 supporting documentation as described in AMPM 1620-I.

295 For ALTCS b ehavioral health members, medically-necessary covered services provided 296 during the contract year may be eligible for reimbursement. Adjudicated encounters 297 for covered services provided to enrolled members with significant behavioral 298 management problems will be used to determine reimbursement. Reinsurance 299 coverage will be based on documentation substantiating the member has been placed 300 in the least restrictive treatment setting to safely manage the member’s needs.

301 III. Transplants

302 A. Overview and Eligibility

303 Transplant reinsurance coverage is available to partially reimburse the AdSS for the 304 cost of care for an enrolled member who meets transplant reinsurance criteria 305 specified in the AMPM, Chapter 300, Policy 310-DD – Organ Transplant.

306 In order to be eligible for transplant reinsurance reimbursement, the AdSS must 307 notify the Division within 3 0 days of the first component of the transplant.

308 Reinsurance will be retroactively provided for a maximum of 30 d ays from the date 309 the letter was received by the Division. Upon receipt of the request from the AdSS, 310 the Division’s Medical Director will review. Upon a pproval, the request and 311 documentation w ill b e submitted to the A HCCCS MMU. Upon review and approval, 312 the MMU will activate t he t ransplant reinsurance case.

313 Note: Individuals who qualify for transplant services, but who are later determined 314 ineligible, due to excess income, may qualify for extended eligibility (refer to State 315 Only Transplants Option 1 and Option 2 in Section I V below).

316 In addition, the AdSS must timely submit clean r einsurance claims (i.e. Transplant 317 Invoice Cover Sheet, UB, HCFA 1500, proof of payment and all other supporting 318 documentation as described in Policy 3 10-DD) to the Division no later than 15 m onths 319 from the end date of service for each transplant component in order to receive 320 reinsurance reimbursement. The submission date is the date of receipt by the 321 Division.



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322 Failure to comply with either the notification filing requirement, or the clean c laim 323 submission requirement may result in the denial of reinsurance reimbursement.

324 For all transplant case types, it is critical that the AdSS perform timely and complete 325 evaluations to determine whether a particular transplant is medically necessary, is 326 considered the standard of ca re, and is not co nsidered experimental. If it i s 327 determined by AHCCCS that a transplant does not meet criteria for transplant 328 reinsurance coverage, it will not be covered under regular reinsurance coverage 329 (previously referred to as "inpatient" reinsurance coverage).

330 B. Contract Information

331 The contracted rates are comprised of components (stages) at a fixed price for each 332 component. The AdSS may reference the transplant contract on the AHCCCS website 333 for further details.

334 In general, the components are defined as follows:

335 ● Outpatient transplant evaluation

336 ● Donor search and/or harvesting of the donor cells for stem cell transplants

337 ● Preparation and transplant

338 ● Post-transplant care (Days 1 – 30 and D ays 3 1 – 60)

339 C. Covered Transplants

340 The AHCCCS Administration, as the single State agency, has the authority under 341 Federal law to determine which tr ansplant procedures, if any, will be reimbursed as 342 covered services for Title XIX adults. As with other AHCCCS-covered services, 343 transplants must be medically necessary, cost effective, and Federally and State 344 reimbursable. Arizona State regulations specifically address transplant services.

345 However, the Early and Periodic Screening Diagnostic and Treatment (EPSDT) 346 Program for individuals under age 21 c overs all non-experimental transplants 347 necessary t o correct or ameliorate defects, illnesses and physical conditions whether 348 or not the particular transplant is covered by the AHCCCS State Plan.

349 AHCCCS covers medically necessary transplant services and related 350 immunosuppressant medications in accordance with Federal and State l aw and 351 regulations. Please refer to the A MPM, Chapter 300, Policy 310-DD for a complete 352 list of the AHCCCS covered transplants. The transplant contract rates are updated 353 annually and posted on the AHCCCS website.

354 1.) Process for Transplant Reinsurance Case Creation

355 The Division is responsible for the timely submission of a written r equest for 356 reinsurance approval of a covered organ or stem cell transplantation. MM staff will 357 review the submission, consult with the A HCCCS Medical Director as necessary, and 358 inform the Division’s Medical Director in writing of the approval or denial for 359 transplant reinsurance.



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360 The following steps represent the flow for requesting reinsurance for a transplant 361 case:

362 a. The AdSS receives a request for a transplant. The Division determines if the 363 transplant type is medically necessary and covered under the AHCCCS State 364 Plan in accordance wi th the AMPM Chapter 300-Policy 3 10-DD.

365 b. If the AdSS receives a request for transplant that is outside of the AMPM 366 criteria, the AdSS may consult an independent re view organization regarding 367 whether or not the requested transplant is considered the standard of care and 368 is medically necessary. If the AdSS determines the transplant request s hould 369 be a uthorized, the AdSS will inform the Division of the pending decision. The 370 AdSS then submits a request for transplant reinsurance approval to the 371 Division which m ust be received within thirty (30) days of the initiation of the 372 first transplant component. The AdSS may initially authorize an evaluation or a 373 search only and the transplant facility may subsequently approve or deny the 374 transplant after completion of t he evaluation. The AdSS is not r equired to send 375 additional notification t o the Division via a second letter. This information will 376 be submitted to the Division on the AdSS’s Quarterly Transplant Log

377 c. If the AdSS denies the transplant b ased on medical necessity o r coverage 378 criteria, the AdSS shall follow the requirements of issuance of a Notices of 379 Adverse Benefits Determinations (NOA) as outlined in the DDD Operations Policy 380 Manual, Chapter 400, Policy 410. Notification to the Division is required prior to 381 issuance of a denial.

382 d. The Division will review the transplant request and issue an approval of 383 reinsurance indicating that t he case has been approved and activated in the 384 PMMIS system.

385 Notwithstanding the denial of reinsurance by the Division, the AdSS is responsible for 386 payment of claims for all services approved by the AdSS.

387 D. Process for Ongoing Case Communication via the Quarterly Transplant Log:

388 1. The transplant log must be submitted to the Division no later than 10 days 389 after the end of each quarter as outlined in the DES/AdSS contract.

390 2. The Transplant Lo g serves the purposes of communicating the AdSSs’ 391 transplant activity on a quarterly basis. The Transplant Log format cannot be 392 altered prior to submission to the Division. If the Transplant Log is password 393 protected or altered in any way, it will be rejected and considered as a non-394 submission.

395 3. The AdSS must highlight in yellow the member’s name and the cell(s) that 396 contain information that has been changed or updated since the p revious 397 submission. The AdSS must complete all cells within the template.

398 Note in the Comments Section general comments, which could include but is 399 not limited to: new activity, transplants that have been d enied, cases that are



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400 closed and rationale, TPL, Medicare where the transplant is not covered or the 401 member has no benefit remaining.

402 4. The Transplant Log is cumulative for the entire contract year. The transplant 403 log submitted to AdSS October 10th, must contain a ll the transplant activity 404 from the previous contract year.

405 5. The Transplant Log created for the new contract year must have all non-active 406 members removed. For example, members who expired, members who were 407 removed from the wait list; members who were transplanted prior to 9/30, or 408 members who terminated with the AdSS m ust be removed from the Transplant 409 Log on the January 10th submission.

410 6. The Transplant Log will only include components that are re-insurable by the 411 Division. For example, do not include Consultations or Kidney transplants on 412 Transplant Lo g submission.

413 E. Transplant Claim Reimbursement:

414 Transplant encounters must be filed with a CN1 code of 09. If encounters are no t 415 submitted with a CN1 code of 09, then the encounter will not associate to the case. 416 The AdSS is required to void and replace the encounter with the correct CN1 code if 417 there is more than 45 days before the 15-month timely filing deadline.

418 If there is less than 45 days, a request may be made to the Division reinsurance to 419 manually associate the CRN\. The AdSS must submit a list of the CRNs by form type 420 and in numerical order that must be transferred on a Reinsurance Action Request 421 Form, prior to the 15-month timely filing deadline. This manual way of associating 422 CRNs can be time-consuming for the analyst and is only to be used as a last resort 423 and should not include all or nearly all of the CRNs for that stage.

424 Reinsurance payments will be linked to transplant encounter submissions. In order to 425 receive reinsurance payment for transplant stages, billed amounts and health plan 426 paid amounts for adjudicated encounter submissions must agree (the billed charges 427 and health plan paid amounts on the PMMIS RI115 screen must equal the billed 428 charges and health plan paid amounts on the hard copy do cuments) with supporting 429 transplant stage claims and/or invoices. Pro-rated calculations are to be applied only 430 when tandem transplants occur or when a member changes Health Plans, (Health 431 Plan Id # changes) in the middle of a transplant stage. The calculation is based on 432 the number of days used during the s tage.

433 Transplant Checklist:

434 Invoice Coversheet available on the AHCCCS website, and a copy of the invoice from 435 the facility. Each s tage must be identified and include the documentation listed 436 below:

437 ● Copy of Invoice from Facility

438 ● Stages identified & included in documentation

439 ● Hospital UB



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440 ● Copy of all appropriate HCFA 1500’s (by DOS) TOTALED for reference

441 ● Contractor’s PAID AMOUNT clearly identified for each component

442 ● Proof of payment to the Facility

443 ● Payments equal to Facility Claims/Invoices:

444 o Transplant Stages

445 o Billed Amounts

446 o Health Plan paid Amount

447 ● Total Billed Charges (PMMIS RI 115) = Copy of Claims/Invoices

448 ● Health Plan Paid Amounts (PMMIS RI 115) = Copy of Claims/Invoices

449 ● List all by [1] Stage and [2] Form Type:

450 o No Pay

451 o Non-Allowed

452 o Denied

453 ● In order to receive reinsurance payment for transplant stages, billed amounts 454 and health plan paid amounts for adjudicated encounters must agree with the 455 transplant facility’s related claims and/or invoices. The total billed charges and 456 health plan paid amounts from the PMMIS R I115 s creen must agree to the 457 totals on the hard copies of the claims/invoices submitted. Timeliness for each 458 stage payment will be calculated based on the latest adjudication date for the 459 complete set of encounters related to the stage.

460 The AdSS shall post information to their Division R einsurance SFTP folder and 461 submit an email indicating the information has been posted.

462 F. Processing Rules for Transplants that Span Contract Years:

463 1. The stage rate that is paid to the facility is the rate based on the end date of 464 the stage.

465 2. It is not necessary to split the encounter between the two contract years; 466 however, the stage must be split between the two contract years based on the 467 actual dates within the two contract years.

468 3. The only exception to number 2 is when a 61+ component exists. If the 469 encounters cross contract years, the stage must be split in order to pay.

470 4. A Reinsurance Action Request Fo rm (RAR or RARF) must be submitted 471 identifying the encounter(s) with any dates of service that s pan contract years. 472 AHCCCS will associate/transfer the encounter(s) to the case/stage based on 473 the end date of the stage.





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474 G. Outlier Threshold Coverage for Transplants:

475 A t ransplant case may qualify for outlier coverage when a specified contractual outlier 476 threshold (listed on the transplant rate sheets) is met or exceeded. When submitting 477 a request for outlier consideration the outlier worksheet must accompany the request. 478 The outlier stage in PMMIS is created by Reinsurance Finance. The worksheet is 479 available on the AHCCCS website. The outpatient evaluation c omponent is not 480 eligible for outlier reimbursement.

481 Outlier Checklist:

482 ● Completed Transplant Outlier Worksheet.

483 ● Copy o f m ock O utlier UB (should this be the process used) f or case dates of 484 service inclusive of the contract year of the transplant case stages currently in 485 PMMIS.

486 ● Identify the A HCCCS UB C RN.

487 ● Outlier claim will reflect a zero pay for the earlier contract year with th e Outlier

488 ● payment reflected on the latest contract year, as reimbursement is based on 489 the end date of the stage.

490 ● Reinsurance Action Request identifies the m ock UB(s) AHCCCS CRN.

491 ● All completed stage invoices.

492 ● Proof of payment to the facility.

493 ● List of all no pay/non allowed and/or non-covered/denied charges totaled by 494 stage and form type.

495 H. Claim (Encounter) Documentation and Timeframes for Contracts

496 In order to be considered for reimbursement, the AdSS must submit 497 approved/adjudicated transplant claims for each stage of the solid organ 498 transplantation or hematopoietic cellular therapy with the documentation. Clean 499 claims must be received and adjudicated no later than 1 5 months from the end date 500 of service for each particular transplant stage. In order to be considered a clean 501 claim, the complete set of encounters for the particular stage must be adjudicated 502 and determined payable on or before the 15-month timeframe. Outlier claim 503 components must be submitted no later than fifteen (15) months from the end date 504 of the last completed stage. Approximately forty-five days are necessary for the 505 Division to complete the adjudication p rocess. Therefore, the AdSS is advised to 506 submit the encounter file at l east 45 days prior to the 15-month deadline to ensure 507 that the adjudication m eets the 15-month tim eframe. If the AdSS submits the 508 encounter file to the Division less than 45 days before the 15-month timeframe and 509 the adjudication has not been c ompleted by the 15-month deadline, then the claim 510 will be denied for not having achieved clean claim status within t he required 511 timeframe. Timeliness of the claim submission for each stage of the transplant will be 512 based on the submission date for the complete set of encounters related to the stage.



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513 For example, if the first stage o f a transplant ends on August 15, 2016, the claims for 514 this stage must be received by the Division on o r before November 15, 2017. The 515 complete set o f encounters must be adjudicated on or before November 15, 2017, 516 which means the encounter file should be submitted to the Division - which will then 517 submit it to AHCCCS - no later than noon on October 9, 2017. Timeliness for each 518 stage payment will be calculated based on the latest adjudication date for the 519 complete set of encounters related to the stage.

520 I. 11/61+ Stay:

521 When the p ost-transplant inpatient c are is continuous (from the date of the prep and 522 transplant component) and exceeds 10 days for kidney transplants and 60 days for all 523 other case types, t he following processing rules apply:

524 ● The claim/encounter for the continuous inpatient stay for day 11+ for kidney 525 and day 61+ for all other case types for all members will be reimbursed at 526 75% of the transplant per diem rate less the deductible.

527 ● The claim/encounter for the continuous inpatient stay for day 11+ for kidney 528 transplants and day 61+ for all other case types will be eligible for outlier 529 reimbursement (not to be confused with transplant outlier reimbursement) 530 when the cost t hreshold is met or exceeded.

531 ● All encounters representative of the continuous inpatient stay must be 532 received by the Division prior to adjudication of 11/61+

533 ● Encounters submitted for an 11/61+ stage that spa n contract y ears need to be 534 split.

535 J. Transportation and Lodging:

536 Transportation, room, and board are reimbursable to the AdSS at the Division 537 allowable rates for the transplant candidate/recipient, potential donor/donor and, if 538 needed, on e adult c aregiver.

539 K. Exclusions and Considerations:

540 ● Transplant reinsurance is not available for members who have an alternate 541 payer, e.g. Medicare or TPL.

542 ● Bone grafts and corneal transplants do not qualify for transplant reinsurance 543 coverage.

544 ● Kidney transplants are included within the AdSS’s capitation rate and do not 545 qualify for transplant reinsurance.

546 ● When the types of services listed in t his section d o not qualify for transplant 547 reinsurance, they may qualify under the regular reinsurance program (as 548 described in Chapters 2 and 3 of this policy m anual).



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549 If it is determined by the Division that a transplant, other than th e situations listed 550 above, d oes not m eet the Division criteria for the transplant, it will not be considered 551 for any reinsurance coverage, including regular reinsurance coverage.

552 L. Transplants for Members with Medicare:

553 Transplant Reinsurance is not available for members who have Medicare Part A o r 554 Medicare Part A a nd B.

555 Exceptions: A transplant may be covered under the below circumstances:

556 ● If a member has Medicare Part A a nd has exhausted their Medicare Part A 557 benefit

558 ● (including lifetime reserve days) during a transplant stage, only that stage and 559 subsequent stages may qualify for reinsurance. If the stage(s) qualify, any 560 payments received from Medicare coverage will be deducted from the 561 reinsurance reimbursement.

562 ● If a member has Medicare Part B only, the case may qualify for Transplant 563 Reinsurance and any payments received from Medicare coverage will be 564 deducted from the reinsurance reimbursement.

565 ● In instances where a member qualifies for partial transplant coverage, an EOB 566 with Medicare payments is required and must balance with M edicare payments 567 in PMMIS. In addition, if the member has exhausted Medicare Pa rt A, the EOB 568 must have a statement to that effect.

569 ● If Medicare does not cover a transplant type based on the member’s diagnoses 570 and the transplant type is a Division covered benefit, the case will qualify for 571 transplant reinsurance.

572 Important:

573 If the member chooses not to use their available lifetime reserve days, the stages will 574 not qualify for reinsurance r eimbursement.

575 M. Multi-Organ Transplants that are not covered in the Division Specialty Contracts:

576 The Division may au thorize cases that ov erlap when a second transplant component is 577 started within th e timeframe of an e stablished component. Th erefore, if a member 578 requires a multi-organ transplant the following billing rules apply:

579 Division reinsurance will cover the preparation and transplant components for each 580 organ (when performed separately), and the post-transplant component that p rovides 581 the Division with the h ighest reimbursement and covers the longest period of time.

582 If a second covered organ transplant is performed during the post-transplant p eriods 583 of the first transplant, the Division will prorate the first transplant component and 584 provide reinsurance reimbursement for the surgical component of the second 585 transplant. This component is followed by the initial day 1-30 post-transplant 586 component and the day 31- 60 post-transplant component. For example: If, on day



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587 15 post-transplant of the first transplant, the determination to conduct the prep and 588 transplant of another organ is made, day 15 ends the component phase of days 1-30 589 of the first transplant, and 50% of the 1-30 post-transplant component is paid. Day 590 16 becomes day 1 of the prep and transplant for the second transplant. Remaining 591 transplant components follow. All applicable notification and claims filing requirements 592 apply.

593 N. Multi-sequence transplants:

594 When a transplant case occurs that requires an additional transplant for the same 595 transplant type (i.e. bone marrow), the Division may au thorize cases that ov erlap 596 when an additional transplant sequence is started within the timeframe of an 597 established component. Therefore, if a member requires a second sequence 598 transplant the following billing rules apply:

599 Division reinsurance will cover the initial transplant until the prep and transplant of 600 the additional sequence occurs. If an additional sequence is performed during the 601 post-transplant periods of the previous transplant, the Division will prorate the 602 transplant component that coincides with the prep and transplant of the following 603 sequence.

604 For example: If on day 15 p ost-transplant of the initial sequence, the determination 605 to conduct the prep and transplant of an additional sequence is made, day 15 ends 606 the component phase of days 1-30 of the first initial sequence of the transplant, and 607 50% of the 1-30 post-transplant component is paid for the initial s equence. Day 16 608 becomes day 1 of the prep and transplant for the additional sequence of the 609 transplant. All applicable notification a nd claims filing requirements apply.

610 O. Out of State or Non-Contracted Transplants

611 To qualify for reinsurance, the Division must review and approve all requests for 612 services at non-contracted transplant facilities located outside the state of Arizona or 613 out-of-state contracted facilities for non-contracted types prior to the commencement 614 of services. If the AdSS intends to use an out of state non-contracted transplant 615 facility for a covered transplant and the Division already holds a contract for that 616 transplant type the AdSS must obtain prior approval from the Division Medical 617 Director. If prior approval is not obtained, and the AdSS incurs costs at the out of 618 state facility, those costs will not be eligible for either transplant or regular 619 reinsurance. In addition, those costs will be excluded from any applicable 620 reconciliation calculations.

621 An approved transplant performed out of state at a non-contracted facility will b e 622 reimbursed at 85% of the lesser of 1) the Division transplant contracted rate for the 623 same organ or tissue, if available, or 2) the health plan paid amount. The Division 624 Medical Director must approve, on a case-by-case basis, the AdSS’s use of a non-625 contracted transplant facility or the use of an out-of-state contracted facility for a 626 contract type that is available in s tate. Depending on the unique circumstances of 627 each approved out-of-state transplant, Division Reinsurance unit may consider, on a 628 case-by-case basis, reinsurance coverage at 85% of the AdSS’s paid amount for 629 comparable case/component rates.



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630 P. Split Stages when Contractor enrollment changes

631 When a Division transplant r ecipient ch anges subcontractors during a transplant 632 stage, the contracted facility m ust split the stage charges accordingly a nd pro-rate 633 the transplant contracted stage amount to the two separate sub-contractors. This 634 would also be the necessary process for the outlier, should that provision b e allowed 635 by contract as the outlier stage is a total of all services during the transplant dates of 636 service. The Division will be responsible for setting up the stages in PMMIS for the 637 appropriate dates of service they are responsible for.

638 IV. Transplant Extended Eligibility, State On ly Transplants

639 Transplant Extended Eligibility -Option 1 and Option 2: Individuals who are approved 640 and currently on the transplant waiting list and subsequently lose eligibility may be 641 eligible for and select one of two eligibility options. Extended eligibility is authorized 642 only for members who have met all of the f ollowing conditions:

643 1. The individual has been determined ineligible due to excess income, and 644 2. The individual was on the transplant waitlist before AHCCCS eligibility expired.

645 3. The individual entered into a contractual arrangement with the transplant 646 facility to pay the amount of income, which i s in excess of the eligibility income 647 standards (referred to as transplant share of cost).

648 Reinsurance coverage for State Only O ption 1 and Option 2 members (as described in 649 Section D, Paragraph 2, Eligibility Categories) for transplants received at an AHCCCS 650 contracted facility is paid at the lesser of 1) 85% of the AHCCCS c ontract amount for 651 the transplantation services rendered, less the transplant share of cost; or 2) 85% of 652 the Division paid amount, less the transplant share of cost. For transplants received 653 at a facility not contracted with AHCCCS, payment is made at the lesser of 85% of the 654 lowest AHCCCS contracted amount for the transplant services rendered less the 655 transplant share of cost, or the Division paid amount, less the transplant share of 656 cost. All Option 1 and Option 2 transplants are subject to the terms regarding out of 657 State transplants set forth above a nd in the AHCCCS Reinsurance Po licy Manual. The 658 AHCCCS contracted transplant rates may be found on the AHCCCS website. When a 659 member is referred to a transplant facility for an AHCCCS-covered organ transplant 660 under Option 1 or 2, the Division shall notify AHCCCS, DHCM, Medical Management as 661 specified in the AMPM Chapter 300, Policy 310 Attachments A and B.

662 Option 1:

663 Extended eligibility is for one twelve-month continuous period of time. During that 664 time, the member is eligible for all AHCCCS covered services as long as they co ntinue 665 to remain on the transplant waiting list. All medically necessary covered services 666 provided to Option 1 members, unrelated to the transplant, shall be eligible for 667 reimbursement, with no deductible, at 100% o f the Division ’ s paid amount based on 668 adjudicated encounters. If determined medically ineligible for a transplant at any time 669 during the period, eligibility will terminate at the end of the calendar month in which 670 the determination is made.

671 Option 2:



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672 Extended eligibility covers transplant services only. At the time that the transplant is 673 scheduled to be performed, the transplant ca ndidate will reapply and will be re-674 enrolled with her/her previous DDD Contractor to receive all covered transplant 675 services.

676 V. Processing Encounters

677 Encounter Submission

678 The Division is reimbursed for reinsurance claims by submitting encounters that 679 associate to a reinsurance case. All reinsurance-associated encounters except a s 680 provided below for “Disputed Matters”, must reach an adjudicated/approved status 681 within f ifteen m onths from the end date of service, or date of eligibility posting, 682 whichever is later. Encounters should never be manually replaced or voided during 683 the Reinsurance Pa yment Cycle, which runs from t he e vening of the first Wednesday 684 of the month until the morning of the s econd Wednesday of the month. Per AHCCCS, 685 AdSSs voiding or replacing encounters during the Reinsurance Payment C ycle may be 686 subject to Administrative Action per ACOM 408.

687 A. Voids

688 When a void encounter is submitted for a previously paid associated Reinsurance 689 encounter, the reinsurance payment related to the voided encounter will be 690 recouped.

691 B. Replacements

692 When a replacement encounter is submitted timely for a previously-paid associated 693 Reinsurance encounter and the replaced health plan paid amount is less than 694 the original health plan paid amount, the difference will be recouped.

695 When a replacement encounter is submitted timely for a previously-paid associated 696 Reinsurance encounter and the replaced health plan paid amount is greater 697 than the original health plan paid amount, the additional amount will be paid if 698 the replacement encounter was adjudicated and reached approved status (CLM 699 STAT 31) within 15 months from end date of service, or date of eligibility 700 posting, whichever is later.

701 Replacement Encounter 702 703 ● Timely submission 704 ● Health P lan Paid amount is greater than on the original Health Plan Paid 705 amount 706 ● Replacement encounter was Adjudicated - AND - 707 ● Replacement encounter reached Approved Status ( CLM STAT 31)

708 Result: Any additional reinsurance payment due will be paid.

709 When a replacement encounter is submitted timely for a previously-paid associated 710 Reinsurance encounter and the replaced health plan paid amount is greater 711 than the original health plan paid amount, but the replacement encounter was 712 not adjudicated and did not reach approved status (CLM STAT 31) within 15





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713 months from end date of service, or date of eligibility posting, whichever is 714 later within the same encounter cycle, then the original health plan paid 715 amount will be recouped.

716 Replacement Encounter 717 718 ● Timely submission 719 ● Health P lan Paid amount is greater than on the original Health Plan Paid 720 amount 721 ● Replacement encounter was not Adjudicated - AND - 722 ● Replacement encounter did not reach Approved Status (CLM STAT 31) 723 ● Within the SAME E NCOUNTER CYCLE

724 Result: Original Health Plan Paid Amount will be recouped.

725 When a replacement encounter is not submitted in a timely manner, and does not 726 adjudicate to encounter approved status (CLM STAT 31) within 1 5 months 727 from the end date of service, or date of eligibility posting, whichever is later, 728 within the s ame encounter cycle i t was submitted, and any of the following 729 scenarios occur:

730 1. The original encounter was never associated to a Reinsurance case; 731 2. The original encounter associated to a Reinsurance case but never 732 reached pay status (PY); 733 3. The original encounter has a previous reinsurance paid amount of zero 734 ($0.00), 735 736 The replacement encounter is then subject to the reinsurance timely filing limit edits:

737 H583 Reinsurance C laim r eceived more than 15 months after End DOS, or,

738 H584 Reinsurance C laim r eceived more than 15 months after Eligibility Posting.

739 Replacement Encounter 740 741 ● Not submitted in a Timely Manner 742 ● Replacement encounter did not Adjudicated - AND - 743 ● Replacement encounter did not reach Approved Status (CLM STAT 31) 744 ● Within the SAME E NCOUNTER CYCLE 745 ● Original encounter (encounter identified on the 837 & NCPDP) 746 ● Never associated to the case –OR– 747 ● Original encounter (encounter identified on the 837 & NCPDP) 748 ● Never reached “PY” –OR– 749 ● Original encounter (encounter identified on the 837 & NCPDP) 750 ● Reinsurance Paid Amount = $0.

751 Result: Replacement encounter will be subject to:

752 1. Timely Filing Edits





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753 2. Edit H583 -or- Edit H584

754 Replacement Encounter 755 756 ● Not submitted Timely 757 ● Replacement e ncounter did not A djudicate - AND - 758 ● Replacement encounter did not reach Approved Status (CLM STAT 31) 759 ● Within the SAME E NCOUNTER CYCLE 760 ● Original encounter (encounter identified on the 837 & NCPDP) 761 Reinsurance Paid Amount > $0.

762 Result: Original Health Plan Paid Amount will be recouped.

763 The R eplacement Encounter consists of a TWO-STEP Process:

764 1. The O riginal Health Plan Paid Amount will be RECOUPED.

765 2. The Replacement Encounter transaction/process.

766 C. New Day

767 When a new encounter (not a replacement encounter) is submitted for a previously 768 voided encounter, the new encounter is considered a “new day” encounter and 769 subject to the timely filing rules (stated above) when a ssociated to a 770 reinsurance case (i.e. the Reinsurance system will recoup all reinsurance 771 payments made related to the voided encounter. The reinsurance system will 772 then calculate the timely filing limits on the new day encounter of 15 months 773 from end date of service or date of eligibility posting, whichever is later, 774 regardless of when the original encounter was adjudicated).

775 VI. Coordination of Benefits and Third-Party Elements

776 Pursuant to federal and state law, AHCCCS i s the payer of last resort except under 777 limited situations. This means AHCCCS shall be used as a source of payment for 778 covered services only after all other sources of payment have been exhausted. The 779 Division shall coordinate benefits in accordance with 42 CFR 433. 135 et seq., ARS 36-780 2903, and A.A.C. R9-22-1001 et seq. so that costs for services otherwise payable by 781 the Division are cost-avoided or recovered from a liable party.

782 The two methods used in the coordination of benefits are cost avoidance and post 783 payment recovery. The Division shall use these methods as described in A.A.C. R9-784 22-1001 et seq., federal, and state law.

785 The Division is required to notify AHCCCS or its authorized representative, within t en 786 (10) business days of the identification o f a 1st or 3rd party liability case with known 787 Reinsurance. Failure to comply with the notification r equirements may result in those 788 sanctions specified in the contract. Should AHCCCS or its authorized representative 789 identify third party recovery payments received by the Division that do not comply 790 with t he notification r equirements in t his section, the following actions shall occur:




791 1. For open cases, AHCCCS shall reimburse itself 100% percent o f any duplicate 792 payments by adjusting the Reinsurance case. An a dministrative fee of 15 793 percent of the duplicate payments may be added to t he adjustment.

794 2. For closed cases, AHCCCS or its authorized representative shall bill the 795 Division directly for 100% percent of the duplicate payments. An 796 administrative fee equal to the current TPL Contractor’s contingency fee 797 schedule shall be added to the billing.

798 All Medicare and Third-Party payers should be billed, and the encounter adjudicated 799 through the Contractor’s system prior to submission to AHCCCS. In a ddition, the 800 Medicare Allowed, Medicare Paid, Third Party Payments and Value Code fields, as 801 applicable, must be completed when the encounter is submitted for Reinsurance 802 consideration.

803 VII. Time L imits for Filing Reinsurance Claims

804 A claim for reinsurance may be filed for any encounter of an AHCCCS reinsurance- 805 covered service. In order to qualify for reinsurance consideration, the reinsurance 806 claim must be filed and must reach clean claim status within the submission 807 timeframes described below. An inpatient reinsurance claim consists of valid 808 encounter(s) containing the information s pecified in this manual, policy, and contract.

809 Reinsurance claims for regular reinsurance cases are created automatically by PMMIS 810 once the encounter reaches an adjudicated status through the Encounter System. For 811 all other types of reinsurance claims, however, the Division must file a written request 812 for reinsurance consideration with the DHCM or the D HCM Reinsurance Unit within the 813 required timeframes as described in this policy.

814 Claims for reinsurance must be submitted to the Division and must attain a clean 815 status no later than f ifteen (15) months from the end date of service.

816 Exceptions:

817 Retro Eligibility Encounters

818 An exception for claims submission will be made for retro eligibility encounters; the 819 claim for reinsurance must be submitted to the AHCCCS Administration a nd must 820 attain a clean claim status no later than fifteen (15) months from the date of 821 eligibility posting.

822 EDOS <-> 15 Months

823 Transplant Encounters

824 For transplant reinsurance claims, refer to Transplant reinsurance claims must be 825 submitted in clean claim status no later than 15 months from the end date of the 826 particular transplant stage.

827 EDOStage <-> 15 Months

828 Exception f rom 15-month t imeframe



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829 For encounters which are the subject o f a member appeal, provider claim dispute, 830 grievance or other legal action, including an informal resolution originating from a 831 request for a formal claim dispute or member appeal, the Division has the greater of: 832 1) 90 days from the date of the final decision i n that proceeding/action, or 2) 15 833 months from the end date of service/date of eligibility posting to file the reinsurance 834 claim AND for the reinsurance claim to reach adjudicated/approved status. Therefore, 835 reinsurance encounters for disputed matters will be considered timely if both the 836 decision letter is received and the encounters reach adjudicated/approved status no 837 later than 9 0 days from the date of the final decision in that proceeding/action, even 838 though the 15 month deadline has expired.

839 Date of Final Decision < -> 90 Days

840 Note that an adjudicated/approved claim/encounter is one that has passed all of the 841 Encounter and Reinsurance edits and that can be p rocessed without obtaining 842 additional information from the provider of service, the Division, or from a third party. 843 This does not include claims under investigation for fraud or abuse or claims under 844 review for medical necessity. With respect to hospital/long term care encounters, 845 “date of service” means the date of discharge.

846 VIII. Reimbursement

847 The Division will reimburse the AdSS for costs incurred in excess of the applicable 848 deductible level, subject to coinsurance percentages. Covered amounts in excess of 849 the deductible level shall be reimbursed based upon costs paid by the Division, net of 850 interest, penalties, discounts and coinsurance, unless the costs are paid under a sub-851 capitated arrangement.

852 In sub-capitated arrangements the Division shall base reimbursement of Reinsurance 853 encounters on the lower of the AHCCCS a llowed amount or the reported Health Plan 854 paid amount, net of interest, penalties, discounts and coinsurance. Reimbursement 855 for Regular Reinsurance benefits will be m ade o nce each month, subject to the 856 availability of funds.

857 The following Lessor of Logic has been included to assist in determining the 858 Reinsurance Approved Amount.

859 Any final claims which c ross over contract years will not be eligible for regular 860 reinsurance.

861 AHCCCS will not pay regular reinsurance on interim claims. The final claim submitted 862 by a hospital associated with the full length of the patient stay will be eligible for 863 reinsurance consideration as long as the days of the hospital stay do not cross 864 contract years.

865 Effective 10/1/18, the Division will pay reinsurance on claims containing any Prior 866 Period Coverage (PPC) and Prospective Coverage for regular and catastrophic 867 reinsurance types. Transplant Days 11+/61+ paid at the per diem rate are not 868 subject to the transplant outlier (prep and transplant through day 60) but are subject 869 to outlier pursuant to the transplant Specialty Contract at an established cost


Form Type Type of Medicare Field on Encounter

I Medicare Part A Medicare

Medicare Part B Other Insurance

A Medicare Part A Does Not Apply

Medicare Part B Medicare

O Medicare Part A Other Insurance

Medicare Part B Does Not Apply


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870 threshold. See the Day 11+/61+ Outlier Worksheet and Instructions located on th e 871 AHCCCS website.

872 The fact that an encounter has been approved and adjudicated is separate to whether 873 the encounter qualifies for payment under reinsurance. To qualify for reimbursement 874 under the R einsurance Program, the encounter must independently meet all criteria, 875 including but not limited to, medical necessity of the service, cost effectiveness of the 876 service, non-experimental nature of the service, dollar thresholds, etc.

877 Let’s Talk Medicare

878 Medicare Calculations –

879 The R einsurance system DOES NOT calculate the Medicare fields on the Encounter or 880 837. The d ata on the 837 is translated in the Encounter system. The Reinsurance 881 data is populated and mapped from the fields in the Encounter system. If, there are 882 issues regarding how the Contractor submits Medicare amounts on the 837 and its 883 translation to the Encounter, then the Contractor must address these issues with the 884 AHCCCS Encounter Unit.

885 PMMIS’ view of Medicare –

886 The Encounter System categorizes Medicare as the type of Medicare appropriate for 887 the s tay. Meaning, if the Encounter is Form type I then the Encounter System reads 888 the Medicare Field as Medicare Part A d ollars. If the Encounter is Form type A then 889 the Encounter System reads the Medicare Field as Medicare Part B dollars.

890 Scenario Examples:

891 ● If the member has only Medicare Part B and the encounter is for an inpatient 892 stay, then on the encounter the Medicare Part B dollars should be placed under 893 Other Coverage.

894 ● If the member has only Medicare Part B and the encounter is for a doctor visit, 895 then on the encounter the Medicare Part B dollars should be placed under 896 Medicare Coverage.


897



898 Medicare Lesser of Logic –

899 ● The Medicare copay, coinsurance or deductible, or

900 ● The difference between the Contractor’s contracted rate and the Medicare paid 901 amount.

902 Edit A510 –

903 Medicare Deductible and Coinsurance Exceeds Allowed Amount

904 ● Reinsurance Internal Pend –

905 Approval/Denial of CRN is the decision o f the Reinsurance Compliance Auditor.

906 IX. Claim Dispute/Hearing Director’s Decisions

907 Encounters for reinsurance claims that have p assed the fifteen month deadline a nd 908 are being adjusted due to a grievance or appeal decision must be submitted and pass 909 all encounter and reinsurance edits within 90 calendar days of the date of the final 910 claim dispute decision or hearing decision, or Director’s decision, or other legal 911 action/proceeding whichever is applicable. Failure to submit the encounter and the 912 decision documentation within this timeframe will result in t he loss of any related 913 reinsurance dollars.

914 X. Administrative D ispute P rocess

915 The AdSS must f ollow the Division’s reinsurance submission processes described in 916 the contract, policy and this manual in order for encounters to be reviewed for 917 potential reinsurance payment. If the A dSS has exhausted the reinsurance 918 refiling/reconsideration processes and still disagrees with an action taken regarding a 919 reinsurance claim, the AdSS may file an administrative dispute concerning the 920 payment, denial, or recoupment of a reinsurance claim.

921 In o rder for the administrative dispute to be considered by the Division, the 922 administrative dispute must be TIMELY fil ed by the AdSS. To be timely filed, the 923 administrative dispute must be RECEIVED b y the Division n o later than 60 days from 924 the remit associated with the Reinsurance Case Summary Report containing the 925 original payment, denial, or recoupment of a timely submitted reinsurance claim. 926 Detailed information regarding the individual reinsurance claims may be found in th e 927 monthly Reinsurance Case Summary Report.

928 All administrative disputes must be in writing and must state the factual and legal 929 basis explaining why the AdSS believes the payment, denial, or recoupment to be 930 incorrect. All administrative disputes must be directed to:

931 All claim disputes must be hand-delivered or mailed to:

932 Division o f Developmental Disabilities 933 Office of Administrative Review 934 4000 North Central Avenue, 3rd Floor, #301 935 Mail Drop 2HE5


CN1 DEFINITION SUB CAP DESCRIPTION

Blank 00 ● No sub-capitated payment arrangement ● Services: fee-for-service basis. (FFS) ● Subscriber Exception code is 25 (PMMIS

Screen Ri320), ● Sub-Cap code is 05.

01 DRG 00 ● Full sub-capitation arrangement ● Services: Fully sub-capitated contractual

arrangement. ● Subscriber exception code is 25 (PMMIS

Screen Ri320) ● Sub-Cap code is 05.

02 Per Diem 00 ● Full Sub-Capitation arrangement ● Services: Fully Sub-Capitated contractual



03 Variable

Per Diem

00 ● Full Sub-Capitation arrangement ● Services: Fully Sub-Capitated contractual


Screen Ri320)


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936 Phoenix, Arizona 85012

937 In order for a service and the corresponding encounters to qualify for reinsurance 938 coverage, the service must independently meet criteria for coverage of reinsurance 939 based on consideration of all relevant information and documentation. A Hearing 940 Decision which determines that the AdSS must reimburse a particular medical service 941 does not, in and of itself, establish that the service qualifies for reinsurance coverage, 942 under catastrophic, behavioral health, transplant or regular inpatient reinsurance. 943 Hearing Decisions are based on evidence from the official hearing record which may 944 be limited depending upon t he evidence presented by the parties. In c ontrast, 945 reinsurance coverage determinations are based on evaluation o f all pertinent 946 information and data, whether or not the information was presented at a hearing. The 947 AdSS is prohibited from recouping monies paid to providers for services authorized by 948 the Division, but which have been subsequently denied reinsurance coverage by 949 AHCCCS. 950 951 952 953 Quick Reference 954

CN1 Indicator Crosswalk to Sub Cap Codes


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● Sub-Cap code is 05.

04 Flat 00 ● Full Sub-Capitation arrangement ● Services: Fully Sub-Capitated contractual



05 Capitated 01 ● Full Sub-Capitation arrangement ● Services: Fully Sub-Capitated contractual



06 Percent 00 ● Partial Sub-Capitation arrangement ● Services: Sub-Capitated provider that’s

excluded from the Sub-Capitated payment arrangement.

● Subscriber exception code is 25 (PMMIS Screen Ri320)

● Sub-Cap code is 05.

09 Other 08 ● Negotiated settlement ● Services: Negotiated settlement, for

example grievance settlement ● Subscriber exception code is not 25

(PMMIS Screen Ri320) 09 Other 04 ● Contracted Transplant Service

● Services paid via catastrophic reinsurance ● Subscriber exception code is 25 (PMMIS

Screen Ri320) Identified by

Filename

06 ● Denied claim used to report valid Division services that are denied. For example, if a claim was denied for untimely submission.

955 956 Summary of Reinsurance Coverage 957

Case Type Deductible Co-Ins

RAC-Acute Contractors $35,000 75%

AC-CMDP Contractor $20,000 75%

Catastrophic–Biologics/

High Cost Specialty Drug

n/a 85%


Transplant n/a 85%

Other-High$ n/a 100%

Hemophilia n/a 85%

Von Wilebrand’s n/a 85%

Gaucher’s n/a 85%

State Only Termination n/a 100%

High Cost Behavioral Health n/a 75%

DES - DDD $50,000 75%

RAC-ALTCS – EPD MC PT .A 0-1,999 $10,000 75%

RAC-ALTCS – EPD MC PT .A 2,000+ $20,000 75%

AC-ALTCS – EPD No PT.A 0-1,999 $20,000 75%

RAC-ALTCS – EPD No PT.A 2,000+ $30,000 75%

Reinsurance Contract Year Contract Year Ending

Yr 33 10/01/14 – 9/30/15

Yr 34 10/01/15 – 9/30/16

Yr 35 10/01/16 – 9/30/17

Yr 36 10/01/17 – 9/30/18

Yr 37 10/01/18 – 9/30/19

Yr 38 10/01/19 – 9/30/20

Yr 39 10/01/20 – 9/30/21


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958 959 Reinsurance Reports 960 961 The following reports (available in comma delimited or text format) are available via 962 the Division FTP Server for AdSS’ use and reference: 963 964 RI91L205 - Reinsurance Pend Report 965 This report is a summary of case information for all active cases that have pending 966 reinsurance encounters during that reporting period. It lists the edit codes, edit 967 descriptions, and edit counts. 968 969 RI81L310 - Reinsurance Remittance Advice Report


970 This report is generated after the monthly reinsurance payment cycle and is a 971 summary of all financial activity applied to only those cases that were included in t he 972 payment cycle. Financial activity and reinsurance encounters detailed on the 973 Reinsurance Remittance Advice includes payments, replacements, voids, 974 recoupments and denials. 975 976 RI91L105 - Reinsurance Case Summary Report 977 This report is a summary of case information for all active cases during the monthly 978 reinsurance cycle and lists the status of all reinsurance encounters associated to each 979 reinsurance case. Also included are the case level totals for the allowed amount, 980 liability, deductible, premium tax paid and total paid. 981 982 RI91L100 - Reinsurance Case I nitiation Report 983 This report is a summary of case information created during the previous month’s 984 reinsurance case creation cycle including encounter information for those encounters 985 associated to the cases created in the reporting period. 986 987 RI91L315 - Reinsurance Case Reconciliation Report 988 This report is a summary of case information with a detailed listing of encounters that 989 potentially apply to an active reinsurance case but have not been a ssociated to the 990 case due to pend errors. Also included are those encounters in the edit/audit process 991 to enable reconciliation o f the encounter records with the reinsurance records.


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992 993 994 995 996 997 998 999

1000 1001 1002 1003 1004 1005 1006 1007 1008 1009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1019




1020 1021 Pricing & Lesser of Logic Flowchart

1022 1023 1024




1025 Lesser of Calculation Flowchart 1026

1027




1028 Discount Determination Flowchart 1029

1030


AdSS Operations Policy Manual Chapter 5000 - for Public ...

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