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

Behavioral Health

Dental

Dialysis

Hemophilia Factor

NOTE:  Rates Subject to change quarterly.

2008

Archived Hemophilia Factor Rates  

Home and Community Based Services

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 for payment outlier 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 and rural inpatient cost-to-charge ratios for payment of outlier are:

10/01/2007 - 9/30/2008 - urban : 3737. rural : .4143.
10/01/2008 - 9/30/2009 - urban : 3405. rural : .4145.

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." the inpatient cost-to-charge ratio for out-of-state hospitals is:

10/01/2007 - 9/30/2008 : 3060.
10/01/2008 - 9/30/2009 : 3070.

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 9/30/2009, the inpatient cost-to-charge ratio is:

10/01/2007 - 9/30/2008 - urban : 3060. rural : .4280.
10/01/2008 - 9/30/2009 - urban : 3070. rural : .4180.

Nursing Facility

Outpatient Hospital

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?

  • 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.

  • Behavioral health fees are adjusted July 1st.

  • 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.

  • Long-term care rates - nursing facilities, home & community based services, and hospice - are updated annually October 1st.

  • 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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