Rates & Codes

This section contains information of interest to AHCCCS health plans and providers.

• Capitation Rates
• Enrollment Rate Codes and Values
• Fee-for-Service Rates
• 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 01-01-07 [ZIP (PDF, Excel)]
  Outpatient Fee Schedule Effective 10-01-06 [ZIP (PDF, Excel)]
  Outpatient Fee Schedule Effective 07-01-05 [ZIP (PDF, Excel)]
• Outpatient Hospital Cost-to-Charge Ratio
• Inpatient Hospital Codes & Values
• Inpatient Hospital Cost-to-Charge Ratio
• Frequently Asked Question

These schedules are not intended to be an all-inclusive list of procedure and service codes.

Capitation Rates

Acute Care Capitation Rates

• Rates Effective October 1, 2007 [PDF, 15KB]
• Rates Effective October 1, 2006 [PDF, 14KB]
• Acute Care Capitation Rates Archive
• Statewide Average Acute Care Capitation Rates [PDF, 13KB]
  (Updated September, 2007)

ALTCS Capitation Rates

• Rates Effective October 1, 2008 [PDF, 8KB]
• Rates Effective October 1, 2007
• Rates Effective October 1, 2006

Behavioral Health Capitation Rates

• Rates Effective July 1, 2008 [PDF, 7KB]
• Rates Effective July 1, 2007 [PDF, 8KB]
• Rates Effective July 1, 2006 [PDF, 10KB]

Children's Rehabilitative Services (CRS)

• Rates Effective October 1, 2008 [PDF, 8KB]
• Rates Effective July 1, 2007 [PDF, 7KB]
• Rates Effective July 1, 2006 [PDF, 7KB]

Comprehensive Medical and Dental Program (CMDP)

• Rates Effective January 1, 2008 [PDF, 7KB]
• Rates Effective January 1, 2007 [PDF, 7KB]
• Rates Effective January 1, 2006 [PDF, 7KB]

Enrollment Rate Codes and Values

Enrollment Rate Codes and Values [PDF, 23 Kb]
(Posted August 1, 2002)
This PDF document contains Enrollment codes and values. This document also includes RP145 and RP160 codes and descriptions.

Fee-For-Service Rates (AHCCCS)

Search Fee-For-Service (FFS) Rates Fee Schedules

• Physician Fee Schedules 2007
  (Updated January, 2008)
  Note: for CYE 2007 and 2006 transportation rates, please see the Transportation Rates link below.
• Physician Fee Schedules 2006
• Physician Fee Schedules 2005
• Physician Fee Schedules 2004
• Physician Fee Schedules 2003
• Physician Fee Schedules 2002
• Physician Fee Schedules 2001
• Physician Fee Schedules 2000

Transportation Rates

NOTICE: BR = By Report. Beginning 10/1/2002, the capped fee-for-service rate for services described as BR is 65% of the covered billed charges, with the exception of ground ambulance services for which the rate is 80% of the covered billed charges.

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.

• Transportation Rates: Effective October 1, 2007 [PDF, 29.79 Kb]
  (Posted September 18, 2007)
• Transportation Rates: Effective October 1, 2006 [PDF, 42.83 Kb]
  (Posted August 10, 2006)

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.

• Effective July 1, 2003 through September 30, 2008
• Effective October 1, 2002
• Effective October 1, 2001
• Effective January 1, 2001
• Effective February 15, 2000

Dental

• 2007-2008 Dental Procedure Codes and Rates (10/01/2007 - 09/30/2008)
• 2007 Dental Procedure Codes and Rates (01/01/2007 - 09/30/2007)
• 2006 Dental Procedure Codes and Rates
• 2004 and 2005 Dental Procedure Codes and Rates

Dialysis

• Effective October 1, 2006
  (Posted September, 2006)
• Effective May 1, 2005

Hemophilia Factor

NOTE: Rates Subject to change quarterly.

2008

• 2nd Quarter 2008 Rates
  Effective 04/1/2008 through 06/30/2008
• 1st Quarter 2008 Rates
  Effective 01/1/2008 through 03/31/2008

Previous Years

• 2007
• 2006
• 2005

Home and Community Based Services

• October 1, 2007, through September 30, 2008
  (Updated September, 2007)
• October 1, 2006, through September 30, 2007
  
• October 1, 2005, through September 30, 2006
• October 1, 2004, through September 30, 2005
• October 1, 2002, through September 30, 2003
• October 1, 2001, through September 30, 2002  
• October 1, 2000, through September 30, 2001
• October 1, 1999, through September 30, 2000

Hospice

• October 1, 2007 through September 30, 2008
  (Updated October, 2007)
• October 1, 2006 through September 30, 2007
  
• October 1, 2005 through September 30, 2006
• October 1, 2004 through September 30, 2005
• Effective October 1, 2003 through September 30, 2004 (Adjusted 04/04)
• October 1, 2002 through September 30, 2003
• October 1, 2001 through September 30, 2002  
• April 1, 2001, through September 30, 2001
• October 1, 2000, through March 31, 2001

Inpatient Hospital

• October 1, 2007 through September 30, 2008 [PDF]
• October 1, 2006 through September 30, 2007 [PDF]
• October 1, 2005 through September 30, 2006 [PDF]
• October 1, 2004 through September 30, 2005 [PDF]

Nursing Facility

• October 1, 2007, through September 30, 2008
  (Updated September, 2007)
• October 1, 2006, through September 30, 2007
  
• October 1, 2005, through September 30, 2006
• October 1, 2004, through September 30, 2005
• February 1, 2004, through September 30, 2004
• October 1, 2002, through January 31, 2004
• October 1, 2001, through September 30, 2002
• October 1, 2000, through September 30, 2001
• October 1, 1999, through September 30, 2000

Transplant

• Transplant Type Overview Sheet with Rates [PDF, 11.5 Kb]
  (Posted January, 2008)
• Transplant Rates - All Transplants [ZIP (Excel) 19.6 Kb]
  (Posted January, 2008)

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.

Inpatient Hospital Codes & Values

• Excluded Surgical Procedures [PDF, 17 Kb]
• Maternity/Psychiatric Diagnosis [PDF, 9 Kb]

Inpatient Hospital Cost-to-Charge Ratio

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.

Frequently Asked Question

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.

Have a question about our annual update of the fee schedule section of the AHCCCS web site? Email us at FFSRates@azahcccs.gov

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