Arizona Court of Appeals Division One holds that A.R.S. § 36-2904(G) does not require an otherwise-timely claim to be error-free for reimbursement of medical services.

A Nevada hospital provided inpatient medical care to a patient insured by an AHCCCS contractor.  The patient stayed in the hospital for six months.  Three months after the patient left the hospital, the hospital submitted three claims for reimbursement to the contractor.  The contractor denied the claims because they were untimely and for failure to properly code the claims.  The hospital appealed the decision of whether the claims were timely to an Administrative Law Judge.  The ALJ granted the contractor’s appeal, but the Director of AHCCCS reversed that decision, denying the hospital’s claim for reimbursement and holding that it was untimely.

The hospital appealed that decision to superior court.  The superior court reversed the decision of the Director, holding that the claims for reimbursement were timely.  The contractor appealed, arguing that the superior court improperly substituted its judgment for the agency and should have deferred to the reasoned decision of the Director.

The Court of Appeals affirmed.  The Court first clarified that, under Arizona law, courts do not defer to agencies on questions of law, and do not give deference to any prior decision of the agency.  The Court then held that, under A.R.S. § 36-2904(G), so long as a hospital submits its claims for reimbursement within six months, substantive errors within that claim for reimbursement such as coding a claim incorrectly do not render it untimely. 

Judge Brown authored the opinion for the Court; Judges Weinzweig and Bailey concurred.

Posted by: John Bullock