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Medicaid Odering Provider Requirement & Denial Code "EX7M - Denied Does Not Meet AHCCCS Encounter Requirements"

Date: 12/06/21

Dear Providers and Billing Staff:

We wrote you in early October to tell you effective 9/21/21 we began enforcing an AHCCCS billing requirement for Ordering providers outlined in Chapter 10 of the AHCCCS Fee for Service Billing Manual for service categories outlined below. We made that change with the understanding it was necessary to align with AHCCCS Encounter requirements. We communicated that claims submitted without the ordering provider for the services below had to be denied EX7M - DENIED-DOES NOT MEET AHCCCS ENCOUNTER REQUIREMENTS, and noted if you receive one of these denials, you could submit a corrected claim with the applicable ordering provider information for re-adjudication.  

We also noted the change was not related to Referring, Ordering, Prescribing, and Attending (ROPA) soft editing that we’ve sent multiple reminders about.

Based on the volume of claim denials we further reviewed, discussed, researched, and agreed we could safely remove the requirement without creating significant encounter pends or other data issues. In addition to removing the edit, we also have begun to reprocess claims denied for the requirement regardless of the service billed.

The services noted as requiring the submission of an ordering provider were:

  • Laboratory (8000 series CPT codes)
  • Radiology (7000 series CPT codes)
  • Medical and Surgical Supplies
  • Enteral and Parenteral Therapy
  • Drugs (J-codes)
  • Temporary (K and Q codes)
  • Orthotics
  • Prosthetics
  • Respiratory DME
  • Vision codes (V-codes)
  • 97001-97546

In the same communication we also noted ordering providers could only be one of the following provider types:

  • Physician (MD or DO)
  • Optometrist
  • Physician Assistant
  • Registered Nurse Practitioner
  • Dentist
  • Podiatrist
  • Psychologist
  • Certified Nurse Midwife

If you have questions, please contact our Provider Customer Service Center 866-796-0542 or contact your Provider Engagement Specialist. If you need contact information for your assigned Provider Engagement Specialist, please email us at: AzchProviderEngagement@azcompletehealth.com.