Comprehensive Medical and Dental Program

Reinsurance

Statement/Purpose

DCS Comprehensive Health Plan (DCS CHP) pursues revenue available from the AHCCCS stop-loss program known as reinsurance.

Definitions

Reinsurance: Reinsurance is a stop-loss program provided by AHCCCS to DCS CHP for the partial reimbursement of covered medical services for the Contract Year. The reinsurance Contract Year is the year beginning on October 1 and ending on September 30. Reinsurance is paid for services incurred for a member beyond an annual deductible level.

Policy

DCS CHP participates in the AHCCCS Reinsurance Program and receives reinsurance benefits for partial reimbursement of covered medical services incurred for a member beyond an annual deductible level.

DCS CHP complies with the eligibility requirements, determination of benefits, and deductible rates set forth in the AHCCCS Reinsurance Policy Manual, the AHCCCS Medical Policy Manual (AMPM), and the IGA between DCS CHP and AHCCCS.

Procedure

DCS CHP participates in the AHCCCS Reinsurance Program and receives reinsurance benefits for partial reimbursement of covered medical services incurred for a member beyond an annual deductible level.

DCS CHP complies with the eligibility requirements, determination of benefits, and deductible rates set forth in the AHCCCS Reinsurance Policy Manual, the AHCCCS Medical Policy Manual (AMPM), and the IGA between DCS CHP and AHCCCS.

Reporting

The DCS Finance Unit generates a monthly Potential Reinsurance Cases Report from the DCS Health Information System and updates a monthly reinsurance tracking spreadsheet with new paid claim information. Cases are checked against subsequent AHCCCS Remittance Advice Reports to determine if the potential cases meet the applicable deducible amount, catastrophic disease criteria, or transplant criteria. If the applicable deductible/criteria is met but the member does not appear on the AHCCCS report within 30 days, DCS CHP reviews the status of the related encounters.

Audit and Reporting

The AHCCCS reinsurance remittance is audited against the DCS CHP expected reinsurance recovery and discrepancies are reviewed. If DCS CHP is overpaid on either an open or closed case, DCS CHP notifies the Reinsurance Program Compliance Auditor Supervisor at AHCCCS within 30 days.

DCS CHP and its contracted MCO provides information on transplant or Catastrophic receipts to AHCCCS, as required, for qualifying recipients eligible for reinsurance reimbursements. A transplant may qualify for outlier coverage when a specified contractual deductible is met or exceeded. Before processing, the outlier invoice is reviewed. Only transplant related services are included in the outlier calculations. DCS CHP submits the following information with the outlier request to AHCCCS Reinsurance Unit for review:

• Outlier Worksheet (Supplied by AHCCCS);

• All completed stage invoices;

• Proof of payment to the facility;

• List of all non-covered/denied charges by transplant stage.