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Non Payable RBHA Services and Modifier and Place of Service Requirements for BH Services

Date: 08/17/20

Regional Behavioral Health Authority (RBHA) Payable Services

Arizona Complete Health-Complete Care Plan (AzCH-CCP) identified a benefit configuration issue leading to periodic payments for non-covered benefits for RBHA members. As a result, effective for dates of service August 24, 2020 and forward we have updated the benefit configuration for our RBHA members to align with AHCCCS requirements.

Services not considered behavioral health are not payable by the RBHA.  You will see them processed with a denial code EXMP (DENY: PLEASE RESUBMIT TO THE MEDICAL PLAN FOR CONSIDERATION). 

The following services are not considered behavioral health and therefore are not payable by the RBHA:

  • Services billed with a physical health, i.e. non-behavioral health diagnosis 
  • Services not found on the Behavioral Health Services Matrix (Formerly called the B2 Matrix) found on the Medical Coding Resources page on the AHCCCS website: https://www.azahcccs.gov/PlansProviders/MedicalCodingResources.html
  • Emergency Room facility claims are not covered for RBHA members regardless of the diagnosis code. They are the responsibility of the Physical Health plan. This is outlined in Chapter 19 of the AHCCCS Fee-For-Service Billing Manual p. 6:  https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/FFS_Chap19BehavioralHealth.pdf
    • Emergency Department Payment Responsibility – Facility Claims: Payment of a facility claim for an emergency department visit, not resulting in an inpatient admission, is the responsibility of the enrolled health plan regardless of the principal diagnosis on the facility claim
    • Definition of Enrolled Health Plan:  For members enrolled with different entities for their physical and behavioral health services, the Enrolled Health Plan is the entity which provides physical health services

Modifiers Billed with Behavior Health Services

It’s important to make certain behavioral health services are billed with the correct modifier in position 1 

Example:  T1016 is billed with modifier HN or HO in position 1

If correct modifier is not billed in position 1, the service must be denied EXIM (DENY: RESUBMIT WITH MODIFIER SPECIFIED BY STATE FOR PROPER PAYMENT)

Place of Service Billed with Behavioral Health Services

Always confirm the place of service is one allowed by AHCCCS for the particular service being billed

Example:  T1016 may be billed with the following places of service 02, 03, 05, 06, 07, 08, 09, 11, 12, 15, 19, 20, 22, 23, 34, 49, 50, 53, 54, 71, 72, or 99.  Other places of service will be denied, e.g. 21

If a noncovered place of service is billed, the service must be denied EXLO (DENY: CPT & LOCATION ARE NOT COMPATIBLE, PLEASE RESUBMIT)

 

Questions

If there are any questions regarding this communication please reach out to your assigned Provider Engagement Specialist or email AzCHProviderEngagement@azcompletehealth.com.

References:

AHCCCS Medical Policy Manual (AMPM). See General Requirements for Coding/Billing

https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/310B.pdf

https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320T.pdf