Inpatient Claims for AHCCCS eligible Inmates
Inmates of a public institution who are held involuntarily are not covered by AHCCCS/ Medicaid. They may be enrolled in Medicaid, but may not receive Medicaid covered services during their incarceration.
AHCCCS is engaged with the Arizona Department of Corrections (ADOC) and most of Arizona’s counties, including Maricopa and Pima, in a data exchange process that suspends AHCCCS enrollment upon incarceration, instead of terminating coverage. This exchange allows ADOC and counties to electronically send discharge dates for AHCCCS members, which simplifies the process of transitioning members directly into care. The inmate coverage exclusion applies to Medicaid services to inmates, except as inpatients in a medical institution.
When a detainee is released from custody temporarily to an inpatient hospital setting, designated staff assists the detainee with completing an application for AHCCCS Health Insurance.
The application is submitted to a special unit that determines AHCCCS eligibility for the specific period of the hospital stay.
When the detainee is determined eligible, the hospital will submit a bill to AHCCCS to pay for the brief hospital stay.
Providers should submit claims for AHCCCS eligible inmate’s for hospital inpatient claims and related inpatient physician services directly to AHCCCS. Inmates enrolled under this process will be given an AHCCCS ID number for the period of time they are eligible.
- Claims submitted for these inmates must have the AHCCCS ID number on each claim in order for the claim to process correctly. Providers should validate the AHCCCS ID number on our website at azahcccs.gov
- Claims should be submitted to AHCCCS only after an AHCCCS ID number has been issued to avoid claim denials.
AHCCCS’ Role
- Process claims on behalf of the contracted DOC agencies
- Each County Contract has its own unique branding (criteria code and recipient exception code)
- DOC agencies are responsible for state share of the costs.
- Claims follow AHCCCS guidelines
Outpatient Services
Arizona Department of Corrections (ADOC) and most of Arizona’s counties have contracted with other entities to process outpatient claims, with the exception of Maricopa county and AZ Department of Juvenile corrections. Please contact the individual department of corrections for billing instructions.
Hospital Inpatient Intergovernmental Agreements (IGA)
AHCCCS has intergovernmental agreements (IGA) in place with the majority of counties in Arizona (including Maricopa and Pima) and ADOC to provide services to people in detention who are admitted temporarily into an inpatient hospital setting. This process includes a determination of eligibility for AHCCCS. When a detainee is released from custody temporarily to an inpatient hospital setting, designated staff assists the detainee with completing an application for AHCCCS Health Insurance. The application is submitted to a special unit that determines AHCCCS eligibility for the specific period of the hospital stay. When the detainee is determined eligible, the hospital will submit a bill to AHCCCS to pay for the brief hospital stay.
Enrollment Suspension & Reinstatement
Federal law prohibits states from using Title 19 Medicaid funding to pay for healthcare for individuals who are incarcerated. State and local funding is utilized during the period of incarceration. In order to reduce disruption of care for individuals exiting incarceration, AHCCCS provides a statewide “enrollment suspense & reinstatement” process for AHCCCS members who become incarcerated. This enrollment suspense & reinstatement process reduces the number of individuals who would otherwise have their AHCCCS eligibility terminated. Through this enrollment suspension & reinstatement process, care can be coordinated by county jails or prisons upon discharge.
For more information, please visit: Justice Initiatives
