2014 Arizona Revised Statutes
Title 36 - Public Health and Safety
§ 36-264 Coordination of benefits; third party payments; definition

36-264. Coordination of benefits; third party payments; definition

A. The administration shall establish a benefit recovery program for state funded services to persons who receive services pursuant to this article that are covered in whole or in part by a first party health insurance medical benefit. The administration shall coordinate benefits provided pursuant to this article so that any costs for services payable by the administration are costs avoided or recovered from any available provider of first party health insurance medical benefits, subject to the specific scope of benefits of the provider of first party medical insurance benefits. The administration may require that health care service providers are responsible for the coordination of benefits provided pursuant to this article. The administration shall act as a payor of last resort unless this is specifically prohibited by federal law.

B. The director shall require each parent or legal guardian of a child receiving services pursuant to this article to assign to the administration rights that the person or the person's parents or guardian has to first party health insurance medical benefits to which the person is entitled and that relate to the specific services that the person has received or will receive pursuant to this program. This state has a right to subrogation against a provider of first party health insurance medical benefits to enforce the assignment of first party health insurance medical benefits for services provided pursuant to this article.

C. The provisions of this section are controlling over the provisions of a first party health insurance medical benefits policy issued after the September 30, 1992. If the policy provisions exclude or limit coverage on the basis of a child's eligibility for services under this article, the administration shall monitor payments from providers of first party health insurance medical benefits that are collected by providers of medical care.

D. This section applies to a health care services organization subject to title 20, chapter 4, article 9 in which a child is enrolled and who is receiving services pursuant to this article. If a child enrolled in a health care services organization requires services under this article and if the benefits for the services are contractually available through the health care services organization, the health care services organization may require the enrolled child to receive the services through the health care services organization's contracted provider network up to the coverage limits set forth in the health care services organization's evidence of coverage. If the health care services organization elects not to provide the covered services either directly or through its contracted provider network or is unable to provide the covered services directly or through its contracted provider network and the services are covered benefits as set forth in the health care services organization's evidence of coverage, then the health care services organization shall reimburse the administration for the services provided through the administration for the enrolled child. The health care services organization is not required to reimburse the administration for services beyond the coverage limits set forth in the health care services organization's evidence of coverage for the enrolled child. The amount of reimbursement paid by a health care services organization to the administration shall not be greater than the level of compensation the health care services organization pays to its contracted provider network. A health care services organization may impose prior authorization, referral and other utilization review requirements in providing or paying for services to an enrolled child under this section.

E. For the purposes of this section, " first party health insurance medical benefits" includes benefits payable from a hospital, medical, dental and optometric service corporation subject to title 20, chapter 4, article 3, a health care services organization subject to title 20, chapter 4, article 9, an insurer providing disability insurance subject to title 20, chapter 6, article 4, an insurer providing group disability insurance subject to title 20, chapter 6, article 5, and any other available first party health insurance medical benefits, but does not include monies available under a social services block grant or an optional state supplemental payment program if federal monies are available.