This section contains general information related to The Health Plan’s billing rules and requirements for Claims or Encounters.
Payment responsibilities for AHCCCS covered physical and behavioral health services provided to AHCCCS members are pursuant to and clarified in AHCCCS ACOM Policy 432. This policy includes general requirements regarding the payment responsibility of:
- Physical and behavioral health services;
- Physical health services that are provided to members that are also receiving behavioral health services;
- Specific circumstances regarding payment for behavioral health services; and
- Specific circumstances regarding payment for physical health services at the Arizona State Hospital.
A Claim is a detailed invoice that providers must submit to The Health Plan to illustrate what services were rendered to our members. Claims have a dollar amounts tied to them as cash value typically under Fee For Service (FFS payment methodologies).
Encounters have zero cash value as they are used as proof of monies earned through different contracting means such as block purchase, per member per month (PMPM) agreements, grant funds, or otherwise alternate payment methodologies as required.
Claims or Encounters that are not legible or not submitted on the correct form type or not submitted in conformance with the Health Insurance Portability and Accountability Act (HIPAA) transactions requirements, National Uniform Claim Committee Edits (NUCC) and 5010 Standards, will be returned to providers without being processed. This is known as a claim or encounter rejection.
Rejected Claims or Encounters do not count as a clean initial submission. Timely filing guidelines are not considered for rejected claims.
Applicable form types for claim or encounter submissions are as follows:
- HIPAA Format 837P or HCFA 1500 is used to bill or encounter non-facility services, including professional services, transportation, housing and independent laboratories.
- HIPAA Format 837I or UB04 Forms is used to bill or encounter hospital inpatient, outpatient, emergency room, hospital-based clinics and Behavioral Health Inpatient Facility services.
- HIPAA Format NCPDP is used by pharmacies to bill or encounter pharmacy services using NDC codes.
- HIPAA Format 837D or the ADA Dental Claim Form is used by dental providers to bill or claims or encounters for dental service.
Paper Claims are to be mailed, Arizona Complete Health-Complete Care Plan PO Box 9010, Farmington, MO 63640. Paper claims or copies that contain highlighter or color marks, copy overexposure marks, or dark edges or are handwritten are not considered legible submissions claim submission. Liquid paper correction fluid (“White Out”) may not be used. If the claim or encounter is submitted in this manner, the claim will be rejected and returned to the provider.
When submitting claims please ensure that the printed information is aligned correctly with the appropriate section/box on the form. If a claim is not aligned correctly, it may cause the (Optical Character Recognition (OCR) system to read the data incorrectly and the claim will reject.
Payor ID for Submission of 837I or 837P is 68069
Providers also have the option to enroll for access to our Provider Portal to direct key entry claims and supporting supplemental documents. Providers can request access to the Provider Portal by going to The Health Plan website at www.azcompletehealth.com
Select the option “For Providers” then select “Provider Portal” then Create an Account.
In accordance with AHCCCS Requirements, claim and encounter services provided to The Health Plan members must be received in a timely manner. The Health Plan timely filing guidelines are as follows:
- Claims or Encounters must be accepted as a clean claim within 120 days from the end date service or from the date of eligibility posting whichever is later, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
- A retro-eligibility claim is a claim where no eligibility was entered in the AHCCCS system for the date(s) of service, but at a later date eligibility was posted retroactively to cover the date(s) of service. Timely filing time frames are as follows:
- The initial claim must be received no later than 120 days from the AHCCCS date of eligibility posting.
- Retro-eligibility claims must obtain clean claim status no later than 365 days from the AHCCCS date of eligibility posting.
- This time limit does not apply to adjustments.
- Claim or Encounter Resubmissions: Claims or Encounters must be accepted as a clean claim within 365 days from the date of provision of the covered service or eligibility posting deadline, whichever is later.
- If the member has primary insurance (i.e. insurance in addition to The Health Plan), claims or encounters must be submitted to The Health Plan within 180 days from the date of service or 120 days from the date of the primary payer’s EOP, whichever one is later. Secondary claims that are not received within 180 days from the date of service or 120 days from the date of the primary payer’s EOP will be denied for timely filing.
Claims reimbursement is based on contractual agreements that utilize AHCCCS pricing methodologies. These are inclusive of, but are not limited to:
- All patient refined diagnosis related group (APR-DRG)
- Tiered per diem payment structure.
- Outpatient Hospital Fee Schedule (OPFS) for outpatient facilities.
- AHCCCS fee schedules and negotiated rates.
- Arizona Department of Health Services (ADHS) rates.
7.5.1 CMS-1500 Claim Form
AHCCCS identification (ID) number (paper claims only):
- Member’s name, gender and date of birth;
- Diagnosis code number (ICD-10) - enter at least one ICD-10 diagnosis code to describe the member’s condition. Up to 12 ICD-10 codes may be entered. The codes must be entered in the A, B, C format order indicated on the claim form. Behavioral health providers must not use DSM-4 or DSM-5 diagnosis codes;
- Medicaid resubmission code (box 22 on the CMS- 1500), if applicable - enter the appropriate code (7 to indicate a replaced or corrected claim or 8 to indicate a void of a previous claim), along with the applicable claim identification number;
- date(s) of service - enter the beginning and ending service dates;
- place of service emergency indicator, if applicable - enter a check mark, X or Y if the service was an emergency service;
- procedures, services and supplies - enter the CPT or HCPCS procedure code that identifies the service provided;
- diagnosis code pointer;
- billed amount for each service line;
- service units;
- rendering provider NPI (box 24J);
- billing provider tax ID number;
- patient account number, if applicable;
- total charges for the claim;
- amount previously paid, if applicable - enter the total payment amount the provider receivd for this claim from all sources other than The Health Plan;
- signature and date - the provider or their representative must sign and date the claim;
- service facility location information, NPI and AHCCCS ID number, if applicable; and
- billing provider’s name, address, telephone number, and NPI.
7.5.2 UB-04 Claim Form
- name, address and telephone number of the provider rendering service;
- patient control number, if applicable;
- bill type;
- facility’s federal tax ID number;
- statement covers period - enter the beginning and ending dates of the billing period;
- patient name, address, date of birth and gender;
- admission/start of care date;
- admission hour, if applicable;
- type of admission;
- point of origin for admission or visit;
- discharge hour;
- patient discharge status;
- condition codes, if applicable;
- occurrence codes, if applicable;
- responsible party name and address, if applicable;
- value codes and amounts, if applicable;
- revenue code(s);
- revenue code description/NDC code, if applicable;
- HCPCS/rates - enter the inpatient accommodation rate and the appropriate CPT or HCPCS code;
- service date and service units;
- total charges for each revenue code;
- non-covered charges, if applicable;
- payer - enter the name and identification number, if available, of each payer who may have full or partial responsibility for the charges incurred;
- billing provider’s NPI;
- diagnosis and procedure code qualifier;
- principle diagnosis code, admitting diagnosis code;
- other diagnosis codes, if applicable;
- principle procedure code and dates, if applicable;
- attending provider name and identifiers, if applicable;
- operating physician and identifiers, if applicable; and
- other procedure codes, if applicable.
Detailed instructions on how to fill out the claim forms can be found on the AHCCCS website.
7.5.3 Clean Submission Guidelines
As defined by Arizona Revised Statutes (ARS) §36-2904 (G)(1) a “clean claim” is a claim that may be processed without obtaining additional information from the provider of service or from a third party, but does not include claims under investigation for fraud or abuse or claims under review for medical necessity.
A claim is considered “clean” when the following conditions are met:
- All required information has been received by The Health Plan;
- The claim meets all Arizona Health Care Cost Containment System (AHCCCS) submission requirements;
- The only acceptable claim forms are those printed in Flint OCR Red, J6983 or exact match ink;
- Any errors in the data provided have been corrected; and
- All medical documentation required for medical review has been provided.
Reasons for claim denial include, but are not limited to, the following:
- Duplicate submission;
- Member is not eligible for date of service;
- Incomplete data;
- Non-covered services;
- Provider of service is not registered with AHCCCS on the date of service; and
- Information from the primary carrier is required.
7.5.4 Corrected Claim Submission
Providers must correct and resubmit claims to The Health Plan within the 365 days resubmission time frame. When resubmitting a claim, the resubmission indicator (7 for replacement or 8 to void a prior claim) must be indicated in Box 22 along with the original claim number from the remittance advice (RA). The Health Plan utilizes this information to identify the claim as a resubmission. . If the original claim number is missing, the claim may be entered as a new claim and denied for past timely filling or as a duplicate.
Corrected claims must be appropriately marked as such and submitted to the appropriate claims mailing address.
The Health Plan will prepare remittance advice or the appropriate responses that describes its payments, denials or reject reason which will include:
- A description of the rejection, denial or adjustments;
- The reasons for the rejection, denial and adjustments;
- The amount billed;
- The amount paid if applicable;
- Application of coordination of benefits and copays if applicable; and
- Provider rights to assert a claim dispute only in the case the claim was processed.
The Health Plan will submit the related remittance advice with the payment, unless the payment is made by Electronic Funds Transfer (EFT), in which case the remittance will be mailed, or otherwise sent to the provider, no later than the date of the EFT.
Upon request by a provider, an electronic Health Care Claim Payment/Advice 835 transaction will be provided to a provider in accordance with HIPAA requirements if the provider submits an 837I or 837P.
The Health Plan contracts with Capario, Change Health Care (formerly Emdeon (WebMD)) and Ability Network (formerly MD On-Line) to provide claims clearinghouse services for The Health Plan electronic claim submission.
The benefits of electronic claim submission includes:
- Reduction and elimination of costs associated with printing and mailing paper claims;
- Improvement of data integrity through the use of clearinghouse edits;
- Faster receipt of claims by The Health Plan resulting in reduced processing time and faster payment;
- Confirmation of receipt of claims by the clearinghouse; and
- Availability of reports when electronic claims are rejected and ability to track electronic claims, resulting in greater accountability.
For successful electronic data interchange (EDI) claim submission, participating providers must utilize the electronic reporting made available by their vendor or clearinghouse. There may be several levels of electronic reporting:
- Acceptance/rejection reports from EDI vendor
- Acceptance/rejection reports from EDI clearinghouse
- Acceptance/rejection reports from The Health Plan
Providers are encouraged to contact their vendor/ clearinghouse to see how these reports can be accessed/ viewed. All electronic claims that have been rejected must be corrected and resubmitted. Rejected claims may be resubmitted electronically.
Providers may also check the status of paper and electronic claims online at 866-796-0542
For questions regarding electronic claims submission, contact your Provider Engagement Specialist at 866-796-0542.
The Health Plan encourages the electronic filing of claims whenever possible. When submitting claims, it is important to accurately provide all required information as described in Claim Submission Requirements.
Claims submitted with missing data may result in a delay in processing or a denial of the claim. The Health Plan requires that all facility claims be submitted on a UB-04 claim form. Professional fees must be submitted on an original (red) CMS-1500 claim form. Copies of claim forms are not accepted. Participating providers receive a Remittance Advice (RA) each time a claim is processed. When The Health Plan is the primary payer, claims must be submitted no later than 120 days from the date of service or the date of eligibility posting (whichever is later). For inpatient hospital claims, the date of service is considered to be the date of discharge. Initial claims submitted more than 120 days after the date of service are denied.
When The Health Plan is the secondary payer, claims must be submitted within 180 days from the date of service even if payment from Medicare or other insurance has not been received. A copy of the primary carrier’s Explanation of Benefits (EOB) must be attached to the claim form. Following the initial claim submission, The Health Plan allows submission of the secondary claim for up to 120 days from the primary EOB date. The submission must include the primary carrier’s EOB.
If payment is denied based on a provider’s failure to comply with timely filing requirements, the claim is treated as non-reimbursable and cannot be billed to the member.
Acceptable proof of timely filing includes:
- EOB from another insurance carrier dated within The Health Plan’s timely filing limits.
- Denial letter from another insurance carrier, printed on its letterhead and dated within The Health Plan’s timely filing limits;
- Electronic data interchange (EDI) rejection report from clearinghouse which indicates claim was forwarded and accepted by The Health Plan (showing date received versus date of service) that reflects the claim was submitted within The Health Plan’s timely filing limits. Claims that were rejected must be corrected and resubmitted in a timely manner.
Unacceptable proof of timely filing includes:
- Screen-print of claim invoice;
- Billing ledger;
- Copy of original claim;
- Denial letter from another insurance carrier without a date and not on letterhead;
- Record of billing stored in an Excel spreadsheet.
7.9.1 Interest Calculation
The following information applies to interest rate calculations and turnaround times for Medicaid claims.
22.214.171.124 Non-Hospital Claim Turnaround Times
Non-hospital claims for both participating and non- participating providers must be processed within 45 calendar days unless otherwise indicated by contract.
126.96.36.199 Claim Payment Standards
The Health Plan Access insures that 95 percent of all clean claims are adjudicated within 30 calendar days of receipt of the clean claim, and 99 percent are adjudicated within 60 calendar days of receipt of the clean claim.
For hospital clean claims, The Health Plan is required to pay interest on payments made after 60 day of receipt of the clean claim, unless otherwise specified in the contract. Interest shall be paid at the rate of 1% per month for each month or portion of a month from the 61st day until the date of payment (A.R.S. §36-2903.01)
For non-hospital clean claims The Health Plan is required to pay interest on payments made after 45 days of receipt of the clean claim, unless otherwise specified in the contract. Interest shall be paid at the rate of 10% per annum (prorated daily) from the 46th day until the date of payment.
For authorized services submitted by a licensed skilled nursing facility, an assisted living ALTCS provider, or a home and community based ALTCS provider, The Health Plan is required to pay interest on payments made after 30 days of receipt of the clean claim. Interest shall be paid at the rate of 1% per month (prorated on a daily basis) from the date the clean claim is received until the date of payment (A.R.S. §36- 2943.D).
188.8.131.52 Obstetrical Services
The global obstetrical (OB) package includes all antepartum visits, delivery, postpartum visits, and all services associated with admission to and discharge from a hospital.
- Only services not included in the global OB care CPT code (59400 or 59510) may be billed separately.
- A minimum of 5 antepartum visits during an eligible period are required for OB package reimbursement
- While there is not a separate reimbursement for the evaluation and management services that are provided during the prenatal and postpartum care periods, AHCCCS requires that the codes and individual dates of services be included in the global OB service billing.
- Claims for ineligible services are denied when billed in addition to the global OB code.
Services not included in the global OB package and may be billed separately include:
- special screening tests for genetic conditions;
- visits for unrelated conditions.
Refer to the Maternity Care and Delivery section of the CPT code book for details regarding the appropriate coding to use for obstetrical services.
The Health Plan makes every attempt to identify a claim overpayment and indicate the correct processing of the claim on the provider’s remittance advice (RA). An automatic system offset, where applicable, might occur in accordance with the reprocessing of the claim for the overpayment, or on subsequent check runs.
In the event that a provider independently identifies an overpayment from The Health Plan (such as a credit balance), the provider must take the following steps:
- Send a check made payable to Arizona Complete Health-Complete Care Plan
Include a copy of the RA that accompanied the overpayment to expedite The Health Plans’ adjustment of the provider’s account. If the RA is not available, the following information must be provided: The Health Plan member name, date of service, payment amount, The Health Plan member identification (ID) number, vendor name, provider tax ID number, provider number, vendor number, and reason for the overpayment refund. If the RA is not available, it takes longer for The Health Plan to process the overpayment refund.
- Send the overpayment refund and applicable details to The Health Plan Overpayment Recovery Department at:
Arizona Complete Health-Complete Care Plan
P.O. Box 301000
Los Angeles, CA 90030-1000
Attn: Overpayment Recovery Department
If a provider is contacted by a third-party overpayment recovery vendor acting on behalf of The Health Plan, the provider must follow the overpayment refund instructions provided by the vendor.
If a provider believes they have received a The Health Plan check in error and the provider has not cashed the check, they should return the check to The Health Plan Overpayment Recovery Department with the applicable RA and a cover letter indicating why the check is being returned.
Prior period coverage refers to the time frame from the effective date of eligibility to the day the member is enrolled with The Health Plan. The Health Plan is responsible for payment of all claims for medically necessary covered services, including behavioral health services provided on or after October 1, 2015 to dual- eligible members with General Mental Health/Substance Abuse (GMH/SA) needs, during prior period coverage.
The Health Plan claim processing includes programs that support editing related to National Correct Coding Initiatives (NCCI), bundling/unbundling, multiple procedure/surgical reductions and global E&M bundling standards. The source logic is obtained through various resources such as the Centers for Medicare & Medicaid.
Services (CMS), the American Medical Association (AMA) and other specialty academies. The Health Plan has the ability to apply advanced contextual processing for application of The Health Plan edit logic.
The Health Plan remittance advice (RA) contains important information about claims submissions and cash receipts for overpayments. The RA should be reviewed upon receipt and reconciled against billing records. The RA includes The Health Plan member names and dollar amounts paid for all claims processed during the course of a week.
Processing claims and adjustments results in one of the following remittance situations:
- Positive remittance - A remittance that totals to a positive amount and results in a payment to the provider. The total at the bottom of the RA agrees with the check or electronic payment the provider receives.
- Negative remittance - A remittance produced when the adjusted dollars exceed the total amount of payment on the remittance. The total at the bottom of the RA is negative, and does not result in a check or electronic payment to the provider
The Health Plan makes every attempt to identify a claim overpayment and indicate the correct processing of the claim on the provider’s RA. An automatic system offset, where applicable, might occur in accordance with the reprocessing of the claim for the overpayment, or on immediate subsequent check runs.
Providers are encouraged to register to receive The Health Plan Electronic RA (ERA) and Electronic Funds Transfer (EFT) through PaySpan. Providers can sign up for PaySpan via their website at www.PaySpanHealth.com or providers can contact PaySpan provider support at 1-877-331-7154.
To register for ERA or EFT, contact the Provider Engagement Specialist at 866-796-0542.
The following are billing requirements for specific services and procedures.
Anesthesia - Anesthesia services (except epidurals) require the continuous physical presence of the anesthesiologist or certified nurse anesthetist (CRNA). Anesthesiologists and CRNAs must enter the approved American Society of Anesthesiologists (ASA) code in field 24D and the total number of minutes in field 24G of the CMS 1500 claim form.
Assistant Surgeon - Include the name of the surgeon in box 17 of the CMS-1500 form. Use the appropriate modifiers to reflect the assistant surgeon provider type (80/AS) as well as any services subject to multiple surgery guidelines.
Billing by Report - Include the operative report or chart notes for “by report” procedures, including high level examinations or consultations.
Multiple Surgeons - Include the appropriate modifiers to ensure proper payment of claims. Use modifier 80/AS for assistant surgeon, modifier 62 for co-surgeons and modifier 66 for surgical team.
Newborn Billing - The Health Plan’s Newborn Data Collection Unit must be notified of all newborn admissions. Identification of the admitting pediatrician must be provided when calling in the notification. Notification must be given no later than three days after the birth in order to ensure proper enrollment of the newborn with the Arizona Health Care Cost Containment System (AHCCCS) and The Health Plan.
Newborns whose childbearing members are The Health Plan members are eligible for The Health Plan from the time of delivery. Newborns receive separate The Health Plan identification (ID) numbers, and services for a newborn must be billed separately using the newborn’s ID number.
Arizona Health Care Cost Containment System (AHCCCS) providers who have registered for the Vaccines for Children (VFC) program must submit claims to The Health Plan for the VFC program supplied immunizations in order to receive reimbursement for the administration. The vaccines must be on the VFC listing and must be billed as follows:
For each immunization administered, the claim must include:
- Vaccine CPT code with the modifier SL (indicating a state-supplied vaccine).
- No charge
- Applicable administration CPT code with the modifier SL (indicating a state supplied vaccine) and unit value equal to the code description and number of vaccines provided.
- Usual and customary charge.
Providers must submit administration and vaccine codes on one claim form. Multiple claims should not be submitted.
Providers submitting multiple CMS-1500 for successor forms must staple the completed forms together and number the pages appropriately.
Use of modifier SL sufficiently identifies the claim as a state-supplied vaccine for which the billed vaccine charge is not reimbursed. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration fee and the vaccination is included in performance measurements.
These billing procedures are designed to standardize billing practices and eliminate erroneous payments for state-supplied vaccines, which necessitate collection of overpayments from providers. The Health Plan may seek reimbursement of amounts that were paid inappropriately.
Failure to bill VFC claims in accordance with the billing procedures noted above results in denials for both the vaccine and the associated administration.
7.16.1 Basic Coding Guidelines
Current ICD-10-CM codes, CPT codes, HCPCS codes, and modifiers reflective of the date of service are required on all The Health Plan claims.
These codes should be used in basic accordance with the publishers’ stated guidelines. Three major publications, the American Medical Association’s (AMA) CPT-4 codebook, the Centers for Medicare & Medicaid Services (CMS) HCPCS code book and the ICD-10-CM, represent the basic standard of service code documentation and reference required by The Health Plan .
Valid ICD-10-CM diagnosis codes are required on all claims. The first diagnosis on the claim form is reserved for the primary diagnosis. Up to four diagnoses may be reported.
Code each diagnosis to the highest level of specificity (fourth or seventh digit when available).
Valid AMA CPT-4 and Level II HCPCS procedure codes are required on all claims. A three-month grace period for submitting deleted codes is allowed. After three months, deleted codes are denied.
Procedure codes should be chosen based on the publishers’ definitions and be appropriate for the age and gender of the patient.
Procedure code modifiers are to be used only when the service meets the definition of the modifier and are to be linked only to procedure codes intended for their use.
If a deleted code and its current replacement code are submitted on the same date of service, the last code submitted is denied as a duplicate.
The Health Plan does not require documentation at the time of claim submission; however, in the event the claim is audited, documentation may be required.
- AMA CPT code book
- CMS national policy
- Health Insurance Portability and Accountability Act of 1996 (HIPAA)
7.16.2 Global Surgery
The global surgical package includes all necessary services normally provided by the surgeon before, during and after the surgical procedure. The global surgical package applies to minor procedures that have a zero or 10-day post-operative period and major procedures that have a 90-day post-operative period as defined by the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule.
The global surgical package policy applies to all places of service.
184.108.40.206 Services Included in the Global Package
The following services are included in the global surgical package and, therefore, are not eligible for separate payment:
- Preoperative evaluation and management (E&M) services that are performed one day prior to major surgery or on the same day as a minor or major procedure;
- Exception: New patient visits (CPT codes 99201- 99205) on the same day as a minor surgery are not included in the global package.
- Intraoperative services that are a usual and necessary part of the surgical procedure;
- Anesthesia provided by the surgeon;
- All additional medical or surgical services required of the surgeon during the post-operative period because of complications, which do not require additional trips to the operating room;
- Post-operative E&M services that are related to the surgery;
- Post-operative pain management by the surgeon; and
- Dressing changes, local incision care, removal of operative packs, removal of cutaneous sutures, staples, lines, wires, tubes, drains, and splints, insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes, and change and removal of tracheostomy tubes.
220.127.116.11 Services Not Included in the Global Surgery Package
The following services are not included in the global surgical package and are eligible for separate payment:
- E&M service that was significant and separately identifiable from the minor surgical procedure performed on the same day. Modifier -25 should be added to the E&M code;
- E&M service performed the day prior to or on the same day of surgery that resulted in the decision for a major surgical procedure. Modifier -57 should be added to the E&M code;
- E&M services that occur during the post-operative period that are unrelated to the surgery. Modifier-24 should be added to the E&M code;
- Critical care when billed for serious injuries or burns;
- Services of other physicians not in the same provider group of the physician that performed the surgery, except where a formal transfer of care occurs;
- Diagnostic tests and procedures, including diagnostic radiological procedures;
- Clearly distinct surgical procedures during the post-operative period that are not re-operations or treatment for complications. Modifiers -58 (staged procedure) or -79 (unrelated procedure or service performed by a physician during the post-operative period) should be added to the surgical procedure code;
- Treatment of post-operative complications that require a trip to the operating room. Modifier -78 should be added to the surgical procedure code; and
- Immunosuppressive therapy for organ transplants. Modifier -24 should be added to the E&M code.
Note: An E&M service that was significant and separately identifiable from the minor surgical procedure performed on the same day that falls within a global period of a previous service but is not related to the previous service requires both a modifier -25 and a modifier -24.
The Health Plan does not require documentation at the time of claim submission unless the service is listed as by report; however, in the event the claim is audited, documentation may be required.
CMS national policy
7.16.3 Multiple Procedure Reduction
When multiple procedures are performed by the same provider at the same session, they are typically subject to the multiple procedure reduction. The primary procedure code is reported as listed and is reimbursed at the full allowed amount. The additional procedure code(s) is reported with a modifier -51 and is reimbursed at a reduced amount. Add- on codes and American Medical Association (AMA) CPT modifier -51 exempt codes should not be reported with modifier -51 as they are excluded from multiple procedure reduction.
The Health Plan applies the multiple procedure reduction to the list of codes on the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule that are subject to multiple surgery guidelines with the exception of the AMA CPT modifier -51 exempt codes on the list. These codes are not subject to multiple procedure reduction. Final adjudication is based on information presented in the Arizona Health Care Cost Containment System (AHCCCS) reference files. If there is a conflict, the AHCCCS reference files will be the guideline utilized, but a request for review can be initiated with supporting documentation.
The Health Plan reimburses multiple procedures using a 100 percent, 50 percent, 50 percent methodology. The procedure with the highest reimbursement value is paid at 100 percent of the allowed amount. Subsequent procedures are paid at 50 percent of the allowed amount.
All procedures should be billed together on one claim to avoid subsequent retractions and adjustments that may occur when procedures are billed separately.
The Health Plan does not require documentation at the time of claim submission other than for by report procedures; however, if the claim is audited, documentation may be required.
- CMS national policy
- AMA CPT code book
- AHCCCS reference files
7.16.4 Provider Preventable Conditions
Section 2702 of the Patient Protection and Affordable Care Act reduces or prohibits payments to health care providers for Medicaid services rendered as a result of certain preventable health care acquired illnesses or injuries.
The Health Plan processes medical claims utilizing the list of Provider Preventable Conditions (PPCs) and surgical errors and reduces or prohibits payments for PPCs.
The Centers for Medicare & Medicaid Services (CMS) issued a final rule implementing section 2702, which reduces or prohibits payments related to PPCs. This rule was built on Medicare’s strategies that already reduces or prohibits hospital payments for preventable conditions, and also improved alignment between Medicare and Medicaid payment policies. Although the new rule gives states the flexibility to expand the list of other provider preventable conditions (OPPCs), Arizona currently employs only the Medicare National Coverage Determinations (NCDs) list as described in the Other Provider-Preventable Conditions definition below.
PPCs are defined as either of the following:
- Health Care-Acquired Condition (HCAC) - Applies only to Medicaid inpatient hospital settings and are included in the following Medicare list of hospital- acquired conditions (HACs):
- Retained foreign object following surgical procedures;
- Air embolism;
- Blood incompatibility;
- Stage III and IV pressure ulcers;
- Injuries resulting from falls and trauma;
- Catheter-associated urinary tract infections;
- Vascular catheter-associated infections;
- Manifestations for poor glycemic control;
- Mediastinitis following coronary artery bypass graft (CABG) procedures;
- Surgical site infections following orthopedic surgery procedures involving spinal column fusion or re-fusion, arthrodesis of the shoulder or elbow, or other procedures on the shoulder or elbow;
- Surgical site infections following bariatric surgery procedures; and
- Deep vein thrombosis or pulmonary embolism following total hip or knee procedures, except in pediatric or obstetrical patients.
- Other Provider-Preventable Condition (OPPC) - Applies to Medicaid inpatient or outpatient health care settings and includes any of the three Medicare NCDs:
- Surgery on the wrong patient;
- Wrong surgery on a patient;
- Surgery on the wrong site.
18.104.22.168 Reporting Requirements
The Health Plan requires providers to both report to the proper Arizona authorities and to The Health Plan incidents of abuse, neglect, as well as any injury (such as falls and fractures), exploitation, HCAC, and/ or unexpected death as soon as the providers are aware of the incident. In turn, The Health Plan reports all incidents of abuse, neglect, injury, exploitation, HCAC, and unexpected deaths to the Arizona Health Care Cost Containment System (AHCCCS) Clinical Quality Management Unit.
Arizona Revised Statue 36-2903.01(K) prohibits providers from billing AHCCCS recipients including Qualified Medicare Beneficiary (QMB) recipients for covered services or be reported to a collection agency for any covered service provided. Providers may not charge members for services that are denied or reduced due to the provider’s failure to comply with billing requirements, such as timely filing, lack of authorization or lack of clean claim status.
Upon oral or written notice from the member that the patient feels the claim or encounter can be covered by The Health Plan, a contracted or non-contracted provider shall not do either of the following unless the provider has verified through The Health Plan that the member has been determined ineligible, has not yet been determined eligible or was not eligible at the time services were rendered:
- Charge, submit a claim to or demand to collect payment from the member; and
Refer or report a member who has been determined as eligible to a collection agency or credit reporting agency for the failure of the member or person who has been determined eligible to pay charges for services covered.
The Health Plan Claim and Encounter Adjudication will deny claims with errors that are identified during the editing process. These errors will be reported to Providers on their Remittance Advice. Provider should correct claims error and resubmit the correction to The Health Plan within 365 days from the date of provision.
When resubmitting a denied claim or encounter, providers must submit a new claim form containing all previously submitted lines. The original claim reference number must be included on the claim or encounter to enable The Health Plan system to identify the claim being resubmitted. Otherwise the claim will be entered as a new claim and may be denied for being received beyond the initial submission time frame.
Submitted encounters or claims for services delivered to Non-Title XIX/XXI enrolled persons must be submitted in the same manner and timeframes as described in the sections above.
Pseudo identification numbers are only applicable to providers under contract with The Health Plan.
On very rare occasions, usually following a crisis episode, basic information about a Member may not be available. When the identity of a Member is unknown, a provider may use a pseudo identification number to register an unidentified person. This allows an encounter to be submitted to AHCCCS, allowing The Health Plan and the provider to be reimbursed for delivering certain covered services. Covered services that can be encountered/billed using pseudo identification numbers are limited to:
- Crisis Intervention Services (Mobile);
- Case Management; and
Pseudo identification numbers must only be used as a last option when other means to obtain the needed information have been exhausted. Inappropriate use of a pseudo identification number may be considered a fraudulent act. The Health Plan’s pseudo identification number for the South GSA in Greater Arizona is [AHCCCS ID FOR SOUTH ARIZONA GSA – NR010126M0 for service dates after 10/1/2015]
42 CFR Section 447.26 prohibits payment for services related to Provider-Preventable Conditions. A Provider-Preventable Condition is a condition that meets the definition of a Health Care-Acquired Condition (HCAC) or an Other Provider-Preventable Condition (OPPC) as defined in Section 22.214.171.124 above.
A Member’s health status may be compromised by hospital conditions and/or medical personnel in ways that are sometimes diagnosed as a “complication”. If it is determined that the complication resulted from an HCAC or OPPC, any additional hospital days or other additional charges resulting from the HCAC or OPPC will not be reimbursed. If it is determined that the HCAC or OPPC was a result of mistake or error by a hospital or medical professional, The Health Plan will conduct a quality of care investigation and report the occurrence and results of the investigation to the AHCCCS Clinical Quality Management Unit.
7.21.1 Fraud, Waste and Abuse (FWA) Claim or Encounter Edits
As part of our Contract Requirement, claims and encounters are cycled through our editing software which is based on National Correct Coding Initiatives (NCCI). NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The “National Correct Coding Initiative Policy Manual for Medicare Services” is updated annually. The PTP code pair edits, MUE tables, and NCCI manual are accessed through the National Correct Coding Initiative Edits webpage at cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html on the CMS website.
Providers can request formal reconsideration of these denials by sending a written reconsideration letter with medical records to:
Arizona Complete Health Complete Care Plan
PO Box 9010
Farmington MO 63640.
Providers should reference the Control Reference Number in their cover letter. Actual copies of the claim or encounter is not needed.
A copayment is a monetary amount that a Member pays directly to a provider at the time covered services are rendered. This section covers AHCCCS copayments for the Title XIX/XXI (Medicaid)/XXI (KidsCare) population and also covers the AHCCCS copayments for the Non-Title XIX /XXI population. Although persons may be exempt from AHCCCS copayments, these individuals may still be subject to Medicare copayments. Most Medicaid eligible Members remain exempt from copayments, such as SMI Members and Members under the age of nineteen (19), while others are subject to an optional and mandatory copayment.
Prior to billing and before attempting to collect copayments from a Member, providers are required to verify the Member is not exempt or eligible to be exempt from being charged for copayments. Furthermore, providers must apply copayments for Members in conformance with the AHCCCS Policy on copayments and AAC R9-22-711 (PDF).
7.22.2 AHCCCS Copayments for Non-Title XIX/XXI Eligible Persons with a Serious Mental Illness (SMI)
- For individuals who are Non-Title XIX/XXI eligible persons with SMI, AHCCCS has established a copayment to be charged to these Members for covered services (A.R.S. 36-3409).
- Copayment requirements are not applicable to services funded by the Substance Abuse Block Grant (SABG), Mental Health Block Grant (MHBG) or Project for Assistance in Transition from Homelessness (PATH) federal block grant.
- Copayments are not assessed for crisis services or collected at the time crisis services are provided.
- Persons with SMI must be informed prior to the provision of services of any fees associated with the services (R9-21-202(A) (8)), and providers must document such notification to the person in their comprehensive clinical record.
- Copayments assessed for Non-Title XIX/XXI persons with SMI are intended to be payments by the Member for all covered health services, but copayments are only collected at the time of the psychiatric assessment and psychiatric follow up appointments.
- Copayments are:
- A fixed dollar amount of $3;
- Applied to in-network services; and
- Collected at the time services are rendered.
- Providers will be responsible for collecting copayments. Any copayments collected are reported in the encounter. Providers will:
- Assess the fixed dollar amount per service received, regardless of the number of units encountered. Collect the $3 copayment at the time of the psychiatric assessment or the psychiatric follow up appointment;
- Take reasonable steps to collect on delinquent accounts, as necessary;
- Collect copayments as an administrative process, and not in conjunction with a person’s health treatment;
- Clearly document in the person’s comprehensive clinical record all efforts to resolve non-payment issues, as they occur; and
- Not refuse to provide or terminate services when an individual states they are unable to pay copayments described in this section. The Health Plan encourages a collaborative approach to resolve non-payment issues, which may include the following:
- Engage in informal discussions and avoid confrontational situations;
- Re-screen the person for AHCCCS eligibility; and
- Present other payment options, such as payment plans or payment deferrals, and discuss additional payment options as requested by the person.
7.22.3 AHCCCS Copayments for Title XIX/XXI Members
Persons who are Title XIX/XXI eligible will be assessed a copayment in accordance with AAC R9-22-711. Certain populations and certain services are exempt from copayments. AHCCCS copayments are not charged to the following persons for any service:
- Persons under age 19;
- Persons that are Seriously Mentally Ill (SMI);
- Individuals up through age 20 eligible for the Children’s Rehabilitative Services Program (CRS);
- Acute care members who are placed in nursing facilities or residential facilities such as an Assisted Living Home when such placement is made as an alternative to hospitalization. The exemption from copayments for these members is limited to 90 days in a contract year.
- Persons who are enrolled in the Arizona Long Term Care System (ALTCS);
- People who are eligible for Qualified Medicare Beneficiary (QMB) A.A.C. Title 9, Chapter 29
- Persons receiving hospice care;
- American Indian Members who are active or previous users of the Indian Health Service, tribal health programs operated under a tribal 638 facility, or urban Indian health programs;
- Individuals in the Breast and Cervical Cancer Treatment Program;
- Adults eligible under AAC R9-22-1427(E) (PDF). These individuals are known as the Adult Group. Persons in the Adult Group are individuals 19-64, who are not pregnant, do not have Medicare, and are not eligible in any other eligibility category and whose income does not exceed 133% of the federal poverty level (FPL). The adult group includes individuals who were previously eligible under the AHCCCS Care program with income that did not exceed 100% of the FPL, as well as other adults described in R9-22-1427(E) with income above 100% FPL, but not greater than 133% FPL;
- Individuals receiving child welfare services under Part B Title IV of the Social Security Act, on the basis of being a child in foster care without regard to age;
- Individuals receiving adoption or foster care assistance under Part E of Title IV of the Social Security Act without regard to age; and
- Individuals who are pregnant through the postpartum period.
Copayments are not charged for the following services:
- Emergency Services
- Family Planning services and supplies
- Pregnancy related health care and health care for any other medical condition that may complicate the pregnancy, including tobacco cessation treatment for pregnant members
- Services paid on a Fee-For-Services basis
- Preventive services, such as well visits, immunizations, pap smear, colonoscopies and mammograms and
- Provider preventable services
7.22.4 Non-Mandatory (Nominal/Optional) Copayments
Individuals eligible for AHCCCS through any of the populations listed below may have nominal (optional) copayments for certain services. Nominal copayments are also referred to as optional copayments (see Table 1 below). Providers are prohibited from refusing services to Members who have nominal (optional) copayments if the Member states they are unable to pay the copayment.
Persons with nominal (optional) copayments are:
- Caretaker relatives eligible under AAC R9-22-1427(A) (PDF) (also known as AHCCCS for Families with Children under section 1931 of the Social Security Act);
- Individuals eligible under the Young Adult Transitional Insurance (YATI) for young adults who were in foster care;
- Individuals eligible for the State Adoption Assistance for Special Needs Children who are being adopted;
- Individuals receiving Supplemental Security Income (SSI) through Social Security Administration for people who are age 65 or older, blind or disabled;
- Individuals receiving SSI Medical Assistance Only (SSI MAO) who are age 65 or older, blind or disabled; and
- Individuals in the Freedom to Work (FTW) program.
Out-patient services for physical, occupational and speech therapy
Doctor or other provider outpatient office visits for evaluation and management of your care. This excludes emergency room/emergency department visits
7.22.5 Mandatory Copayments for Certain AHCCCS Members
Persons with higher income who are determined eligible for AHCCCS through the Transitional Medical Assistance (TMA) program will have mandatory copayments for some medical services (see Table 2 below). TMA Members are described in AAC R9-22-1427(B) (PDF).
When a Member has a mandatory copayment, a provider can refuse to provide a service to a Member who does not pay the mandatory copayment. A provider may choose to waive or reduce any copayment under this section.
Doctor or other provider outpatient office visits for evaluation and management of your care. This excludes emergency room/emergency department visits.
Physical, Occupational and Speech Therapies
Outpatient Non-emergency or voluntary surgical procedures. This excludes emergency room/emergency department visits.
7.22.6 Copayment Limits
Members subject to copays will not be required to pay additional copayments once the total amount of copayments made is more than 5% of the gross family income (before taxes and deductions) during a calendar quarter (January through March, April through June, July through September, and October through December).
The Health Plan will track each member’s specific copayment levels by service type to identify those members who have reached the 5% copayment limit. With the exception of prescription drugs (where a copay is charged for each drug received), only one copay may be assessed for services received during a visit. If the coding for the visit falls within more than one copayment category, the member is responsible for the highest copayment amount.
Third party liability refers to situations in which persons enrolled in the public health care system also have health care service coverage through another health insurance plan, or “third party”. The third party can be liable or responsible for covering some or all the services a person receives, including medications. Providers are responsible for determining and verifying if a person has third party health insurance before using other sources of payment such as Medicaid (Title XIX), KidsCare (Title XXI) or State appropriated health care funds. Pursuant to federal and State law, Medicaid is the payer of last resort except under limited situations, meaning that Medicaid funds shall be used as a source of payment for covered services only after all other
Sources of payment have been exhausted.
The intent of this section is to describe the requirements for providers to:
- Determine if a person has third party health insurance coverage before using federal or State funds;
- Coordinate services and assign benefit coverage to third party payers when information regarding the existence of third party coverage is available; and
- Submit billing information that includes documentation that third party payers were assigned coverage for any covered services that were rendered to the enrolled person.
- Coordinate benefits for persons enrolled with Medicare Part A, Part B, and/or Part D.
- Coordinate benefits for persons enrolled in a qualified health plan through the federal health insurance exchange.
7.23.1 Additional Information
- If third party information becomes available to the provider at any time for Title XIX/XXI eligible persons, that information must be reported to the AHCCCS Administration within 10 days from the date of discovery.
- An online Medical Insurance Referral should be completed and submitted to AHCCCS through the Health Management Systems (HMS) website whenever an AHCCCS Member is discovered to have other medical insurance, or whenever other medical insurance has terminated or changed. HMS has launched a new Third Party Liability (“TPL”) Referral Web Portal. The site to gain this access is https://www.azahcccs.gov/PlansProviders/HealthPlans/tpl.html
- AHCCCS has also established a process for The Health Plan to report third party information for Title XIX/XXI eligible persons daily to the AHCCCS on a Third Party Leads submission file. After submitting the file to AHCCCS for verification of the information, The Health Plan will receive notification of updated information on the TPL files. The Health Plan makes third party payer information available to all providers involved with the person receiving services.
- Third parties include, but are not limited to, private health insurance, Medicare, employment related health insurance, medical support from non-custodial parents, court judgments or settlements from a liability insurer, state worker’s compensation, first party probate-estate recoveries, long term care insurance and other federal programs.
- For those Medicare Part A and Part B services that are also covered under Title XIX, there is no cost sharing obligation if The Health Plan has a contract with the Medicare provider and the provider’s subcontracted rate includes Medicare cost sharing as specified in the contract.
- As of January 1, 2006, Medicare Part D Prescription Drug coverage became available to all Medicare eligible persons. Medicare is considered third party liability and must be billed prior to use of Title XIX/XXI or state funds.
- Children who qualify for Adoption Subsidy will be eligible for Title XIX/XXI benefits. In addition, their families may also have private insurance. Simultaneous use of the private insurance and Title XIX/XXI coverage may occur through the coordination of benefits. Following an intake and assessment, providers must determine the services and supports needed. Any necessary services that are not covered through the private insurance, including copayments and deductibles, may be covered under Title XIX.
7.23.2 Identifying Other Health Insurance
Providers are responsible for determining and verifying if a person has third party health insurance before using other sources of payment such as Medicaid (Title XIX), Title XXI or State appropriated health funds.
- Providers must identify the existence of potentially liable parties through the use of trauma code edits, utilizing diagnostic codes 800 to 999.9 (excluding code 994.6), external causes of injury codes E000 through E999, and other procedures.
- If third party information becomes available to the provider at any time for Title XIX/XXI eligible persons, that information must be reported to the AHCCCS Administration within 10 days from the date of discovery.
- Providers must report third party information via the following website: https://www.azahcccs.gov/PlansProviders/HealthPlans/tpl.html . From this link, you can navigate to Health Management Systems (HMS), where you can enter a Member’s TPL information.
The Health Plan will receive notification of updated information on the TPL files. The Health Plan makes third party payer information available to all providers involved with the person receiving services.
Providers must inquire about a person’s other health insurance coverage during the initial appointment or intake process. When providers attempt to verify a person’s Title XIX/XXI eligibility, information regarding the existence of any third party coverage is provided through AHCCCS’s automated eligibility verification systems. If a person is not eligible for Title XIX/XXI benefits, they will not have any information to verify through the automated systems. Therefore, the existence of third party payers must be explored with the person during the screening and application process for AHCCCS health insurance.
7.23.3 Services Covered by Other Health Insurance Party
Third party health insurance coverage may cover all or a portion of the health services rendered to a person. Providers must contact the third party directly to determine what coverage is available to the person. At times, The Health Plan may incur the cost of copayments or deductibles for a Title XIX/XXI eligible person or person with SMI, while the cost of the covered service is reimbursed through the third party payer. However, payments by another State agency are not considered third party and in this circumstance, AHCCCS and The Health Plan are not the payer of last resort.
- In an emergency situation, the provider must first provide any medically necessary covered services, and then coordinate payment with any potential third party payers.
- When coverage from a third party payer has been verified, there are two methods used in the coordination of benefits:
- Cost avoidance - Providers must cost avoid all claims or services that are subject to third-party payment. The Health Plan may deny payment to a provider if a provider is aware or unaware of third party liability and submits a claim or encounter to The Health Plan. In emergencies, providers must provide the necessary services and then coordinate payment with the third party payer; or
- Post-payment recovery is necessary in cases where a health provider has not established the probable existence of third party coverage at the time services were rendered or paid for, or was unable to cost avoid.
If a third-party insurer requires a person to pay a copayment, coinsurance or deductible, The Health Plan is responsible for covering those costs for Title XIX/XXI eligible persons if the third party payer is not another State agency. AHCCCS and The Health Plan are required to be the payers of last resort for Title XIX/XXI and Non-Title XIX/XXI covered services. Payment by another State agency is not considered third party and, in this circumstance, AHCCCS and The Health Plan are not the payer of last resort.
Upon determination that a person has third party coverage, a provider must submit proper documentation to demonstrate that the third party has been assigned responsibility for the covered services provided to the person. An Explanation of Payments (EOP) and an Explanation of Benefits (EOB) are the only suitable documents that can be submitted for coordination of benefits.
Initial third party claims received after 6 months from date of service or 90 days from the primary payer’s EOP will be denied for Past Filing Deadline (PFD) regardless of primary insurance coverage.
The following guidelines must be adhered to by health providers regarding third party payers:
- Providers must bill claims for any covered services to any third party payer when information on that third party payer is available. Documentation that such billing has occurred must accompany the claim when submitted for payment. Such documentation includes a copy of the Explanation of Payment or Explanation of Benefits (EOB) from the third party payer. The only exceptions to this billing requirement are:
- When it is determined that the person had relevant third party coverage after services were rendered or reimbursed;
- When a Member eligible for both Medicaid and Medicare (dual eligible) receives services in a Behavioral Health Inpatient facility that is not Medicare certified. Non-Medicare certified facilities may be utilized for dual eligible members when a Medicare certified facility is not available; or
- When a Member is receiving covered services from a preferred provider (i.e., the provider is close to person’s home) and the provider is unable to bill the person’s third party payer.
- The Health Plan may deny payment to a provider if a provider is aware of third party liability and submits a claim to The Health Plan. However, if the provider knows that the third party payer will not pay for or provide a medically necessary covered service, the provider must not decline to render the service to the member.
- If the provider does not know whether a particular medically necessary covered service is covered by the third party payer, the provider must contact the third party payer rather than requiring the person receiving services to do so.
- Providers may not employ cost avoidance strategies that limit or deny a person eligible for services from receiving timely, clinically appropriate, accessible, medically necessary covered services.
7.23.5 Discovery of Third Party Liability After Services Were Rendered or Reimbursed
If it is determined that a person has third party liability after services were rendered or reimbursed, providers must identify all potentially liable third party payers and pursue reimbursement from them. In instances of post-payment recovery, the provider must submit an adjustment to the original claim, including a copy of the Explanation of Payment (EOP) or the Explanation of Benefits (EOB). Providers shall not pursue recovery in the following circumstances, unless the case has been referred to The Health Plan and the provider by AHCCCS or AHCCCS’s authorized representative:
- Uninsured/underinsured motorist insurance;
- Restitution Recovery;
- First- and third-party liability insurance;
- Worker’s Compensation;
- Tortfeasors, including casualty;
- Estate Recovery; or
- Special Treatment Trust Recovery.
The provider must report any cases involving the above circumstances to The Health Plan, which will then report such cases to AHCCCS’s authorize representative for determination of a “total plan” case. Providers may be asked to cooperate with AHCCCS and/or AHCCCS in third party collection efforts.
7.23.6 Copayments, Premiums, Coinsurance and Deductibles for Non-Title XIX/XXI Persons with SMI for Which There Is Third Party Liability
The copayment assessed for Non-Title XIX/XXI persons with SMI is intended to be paid by the Member for services covered in the medication only benefit (e.g., psychiatric assessments, medication management, medications), but copayments are only collected at the time of the psychiatric assessment and psychiatric follow up appointments.
Non-Title XIX/XXI persons with SMI may be assessed the AHCCCS copayment in accordance with Section 8.11 - Copayments, or may be assessed copayments, premiums, coinsurance and/or deductibles for services covered by the third party insurer. When a Non-Title XIX/XXI person with SMI is assessed for the AHCCCS copayment, they will pay the AHCCCS copayment or the copayment required by the third party insurer, whichever is less (see AHCCCS Report Third Party Liability (TPL) at https://www.azahcccs.gov/PlansProviders/HealthPlans/tpl.html
Additionally, when a Non-Title XIX/XXI person with SMI is assessed a copayment for a generic medication that is also on the AHCCCS Non-Title XIX/XXI Formulary, they will pay the AHCCCS copayment or the copayment required by the third party insurer, whichever is less. The Health Plan is responsible for covering the difference between the AHCCCS copayment and the third party copayment when the third party copayment is greater than the AHCCCS copayment.
Members are responsible for third party copayments for services that are not services that the AHCCCS covers (see AHCCCS Guidelines to the RBHA/MCO/Health Plans and Providers for Services to Non-Title XIX/XXI Members with a Serious Mental Illness) and third party premiums, coinsurance and deductibles, if applicable.
When Non-Title XIX/XXI persons with SMI have difficulty paying copayments, the provider must re-screen the individual for Title XIX/XXI eligibility.
7.23.7 Medicaid Eligible Persons with Medicare Part A and Part B
Providers are responsible for identifying whether Members are enrolled in Medicare Part A or Medicare Part B and covering services accordingly. For Medicaid eligible persons with Medicare Part A, Part B, and/or Part D:
- Title XIX/XXI eligible person may receive coverage under both Medicaid (AHCCCS) and Medicare. These persons are sometimes referred to as “dual eligibles” or “Duals”. In most cases, providers are responsible for payment of Medicare Part A and Part B coinsurance and/or deductibles for covered services provided to dual eligible persons. However, there are different cost sharing responsibilities that apply to dual eligible persons for a variety of situations. Unless prior approval is obtained from AHCCCS or The Health Plan, providers must limit their cost sharing responsibility according to ACOM Policy 201 and Policy 202. Providers shall have no cost sharing obligation if the Medicare payment exceeds what the provider would have paid for the same service of a non-Medicare Member.
- Some dual eligible AHCCCS Members may have Medicare Part B only. As these Members do not have Medicare Part A, Medicaid is the primary payer for services which generally would be covered under Part A including hospitalizations, skilled nursing facilities, and hospice. A claim should not be denied for a lack of Medicare Explanation of Payment (EOP) when the Member is not enrolled in Medicare Part A;
- In the same way, if Members have Medicare Part A only, Medicaid is the primary payer for services which are generally covered under Part B including physician visits and durable medical equipment; and
- In the event that a Title XIX/XXI eligible person also has coverage through Medicare, providers must ensure adherence with the requirements described in this subsection.
Qualified Medicare Beneficiary (QMB) Duals are entitled to all AHCCCS and Medicare Part A and B covered services. The Health Plan is responsible for payment of Medicare cost sharing for all Medicare covered services regardless of whether the services are covered by AHCCCS. The Health Plan only has responsibility to make payments to providers registered with AHCCCS to provide services to AHCCCS eligible Members. The payment of Medicare cost sharing must be provided regardless of whether the provider is in The Health Plan network or prior authorization has been obtained.
The Health Plan Responsibility
Out of Network
Medicare Only—not covered by AHCCCS
Cost sharing responsibility only
AHCCCS Only—not covered by Medicare, including pharmacy and other prescribed services
Reimbursement for all medically necessary services
AHCCCS and Medicare covered Service (except for emergent)
Cost sharing responsibility only
Cost sharing responsibility only
*Subject to The Health Plan Policy
The Health Plan is responsible for the payment of the Medicare cost sharing for AHCCCS covered services for Non-QMB Duals that are rendered by a Medicare provider within The Health Plan network.
The Health Plan Responsibility
Out of Network
Medicare Only—not covered by AHCCCS
No cost sharing responsibility
AHCCCS Only—not covered by Medicare, including pharmacy and other prescribed services
Reimbursement for all medically necessary services
AHCCCS and Medicare covered Service (except for emergent)
Cost sharing responsibility only
Cost sharing responsibility only
126.96.36.199 Limits on Cost Sharing:
The Health Plan shall have no cost sharing obligation if the Medicare payment exceeds The Health Plan contracted rate for the services. The Health Plan liability for cost sharing plus the amount of Medicare’s payment shall not exceed The Health Plan contracted rate for the service. There is no cost sharing obligation if The Health Plan has a contract with the provider, and the provider’s contracted rate includes Medicare cost sharing.
The exception to these limits on payments as noted above is that The Health Plan The Health Plan shall pay 100% of the Member copayment amount for any Medicare Part a Skilled Nursing Facility (SNF) days (21 through 100) even if The Health Plan has a Medicaid Nursing Facility rate less than the amount paid by Medicare for a Part a SNF day.
The Health Plan can require prior authorization, but if the Medicare provider determines that a service is medically necessary, The Health Plan is responsible for Medicare cost sharing, even if The Health Plan determines otherwise. If Medicare denies a service for lack of medical necessity, The Health Plan will apply its own criteria to determine medical necessity. If criteria support medical necessity, then The Health Plan shall cover the cost of the service.
For QMB Dual Members, The Health Plan has cost sharing responsibility regardless of whether the services were provided by an in or out of network provider. For AHCCCS covered services rendered by an out of network provider to a non-QMB Dual, The Health Plan The Health Plan is not liable for any Medicare cost sharing unless The Health Plan The Health Plan has authorized the Member to obtain services out of network. If a Member has been advised of The Health Plan network, and the Member’s responsibility is delineated in the Member handbook, and the Member elects to go out of network, The Health Plan is not responsible for paying the Medicare cost sharing amount.
7.23.8 Medicare Part D Prescription Drug Coverage
188.8.131.52 Cost sharing and coordination of benefits for persons enrolled in Medicare Part D:
Title XIX/XXI funds are not available to pay any cost sharing of Medicare Part D.
The Health Plan will utilize available Non-Title XIX/XXI funds to cover Medicare Part D copayments for Title XIX and Non-Title XIX persons with SMI, with the following limitations:
- Copayments are to be covered for behavioral health medications on the AHCCCS Preferred Drug List. Copayments are to be covered for medications prescribed by in-network providers. The Health Plan The Health Plan may utilize Non-Title XIX/XXI funds for coverage of medications during the Medicare Part D coverage gap; and
- If a request for an exception has been submitted and denied by the Medicare Part D plan, The Health Plan may utilize Non-Title XIX/XXI funds to cover the cost of the non-covered Part D medication for persons with SMI, regardless of Title XIX/XXI eligibility.
The Health Plan may utilize at its discretion Non-Title XIX/XXI funds for coverage of medications during the Medicare Part D coverage gap. If a request for an exception has been submitted and denied by the Medicare Part D plan, The Health Plan may utilize at its discretion Non-Title XIX/XXI funds to cover the cost of the non-covered Part D medication for persons with SMI, regardless of Title XIX/XXI eligibility.
7.23.9 The Health Plan Providers’ Enrollment Responsibilities
The Health Plan providers must educate and encourage Non-Title XIX/XXI Members with SMI to enroll in a qualified health plan through the federal health insurance exchange and offer assistance for those choosing to enroll during open enrollment periods and qualified life events. The following applies for Members who enroll in a qualified health plan through the federal health insurance exchange:
- Members enrolled in a qualified health plan through the Federal Health Insurance Marketplace continue to be eligible for Non-Title XIX/XXI covered services that are not covered under the exchange plan.
- Non-Title XIX/XXI funds may not be used to cover premiums or copays associated with qualified health plans through the Federal Health Insurance Marketplace or other third party liability premiums or copays other than Medicare Part D for Members with SMI.
- The Health Plan is required issue approval prior to any utilization of Non-Title XIX/XXI funding for services otherwise covered under a qualified plan through the Federal Health Insurance Marketplace.
Providers shall maintain all records in compliance with the noted specifications for record keeping related to transportation services. It is the responsibility of the provider to maintain documentation that supports each transport provided. Transportation providers put themselves at risk of recoupment of payment if the required documentation is not maintained or covered services cannot be verified.
The Health Plan will cover medically necessary non-emergency ground and air transportation to and from a required medical service for most recipients. Non-emergency transportation providers must bill the number of trips and the number of loaded miles as units of service on the CMS 1500 claim form or 837P. Loaded mileage is defined as the distance traveled, measured in statute miles, with a recipient on board the vehicle and being transported to receive medically necessary covered services.
Transportation billing guidelines related to Third Party Liability and Coordination of Benefits are the same. Providers must identify all potentially liable third party payers and pursue reimbursement from them.
Providers must provide and retain fiscal responsibility for transportation for Title XIX/XXI persons in order for the person to receive a covered health service reimbursed by a third party, including Medicare.
Claims will be reviewed and if applicable adjustments will be made to the claim. If a provider chooses to submit a refund as opposed to having Claims Technical Assistance do the review for adjustment, payments should be made to:
Arizona Complete Health - Complete Care Plan
333 E. Wetmore Road
Tucson, AZ 85705
Attn: Overpayment Recovery Department
7.26.1 Health Plan Sanction Authority
Arizona Complete Health-Complete Care Plan may impose financial sanctions for failure to comply with the terms of the Contract (including requirements set forth in documents incorporated by reference and the Health Plan Provider Manual). Health Plan shall determine, at its sole discretion, the amount of any sanction. Sanctions shall be assessed according to the severity of the violation. Sanction amounts may be doubled each month for continued failure to adequately address contract performance challenges.
7.26.2 Administration of Sanction Payments
Any financial sanctions due and owing to Health Plan may be offset by Health Plan against any payments due Provider under the Health Plan Contract until the full amount is paid. Provider and Health Plan each acknowledge that the financial sanctions constitute liquidated damages for the loss of a bargain, are not penalties, and are a reasonable approximation of Health Plan’s damages under the circumstances, as can best be determined as of the date hereof. Health Plan shall have the right to impose such an offset even if Provider contests the financial sanction; provided, however, that if the financial sanction is reduced or eliminated following a provider Claim Dispute, Health Plan shall pay any such sums within thirty (30) days of the final resolution of the dispute process.
7.26.3 Sanctions Imposed by State or Federal Authorities
If any State or federal authority imposes a sanction against Health Plan, for any act or omission that Provider was prohibited or required (respectively) to perform pursuant to the Health Plan Contract, Health Plan may, in addition to any other remedies available under the Health Plan Contract, impose a sanction against Provider in an amount equal to the amount of any such sanction imposed on Health Plan. Provider shall reimburse Health Plan for these sanctions upon demand, or, at Health Plan’s election, the sanctions may be offset against any payments due to Provider under the Health Plan Contract. Health Plan will not levy these sanctions upon Provider until such time as the sanctioning authority actually imposes sanctions upon Health Plan. If any such sanction applies to more than one provider and the sanctioning authority does not delineate individual provider responsibility, Health Plan may apportion sanctions to Provider based on an equitable method that accounts for Provider’s share of responsibility.
7.26.4 Sanction for Failure to Provide Deliverables
Provider has agreed to the time frames for the Deliverables set forth in the Health Plan Provider Manual. In the event Provider fails to provide the Deliverables in accordance with the Health Plan Provider Manual, Provider shall pay a fine for such delay in the amount of five hundred dollars ($500.00) per incident.
7.26.5 Performance Sanctions
Unless explicitly stated otherwise in this Health Plan Provider Manual or documents incorporated by reference, at Health Plan’s discretion, Providers are subject to the following additional sanctions:
- One Thousand dollar ($1,000.00) fine for failure to submit a Corrective Action Plan by the due date specified in a Corrective Action Letter issued by Health Plan.
- One thousand dollar ($1000.00) fine for failure to respond to a concern raised by AHCCCS within the time frame specified by AHCCCS.
- Sanction for failure to provide appropriate coordination of care for a Member, resulting in an untoward event that affects the local community or the Member; amount of sanction determined at the sole discretion of the Health Plan commensurate with the seriousness of the untoward event.
- Three thousand dollar ($3000.00) fine per incident or failure to adhere to contract requirements or Health Plan Provider Manual requirements.
7.26.6 Notice to Cure
Arizona Complete Health-Complete Care Plan may issue a Notice to Cure for substantial non-compliance with a contract requirement or Health Plan Provider Manual expectation. A Notice to Cure may be issued on a particular program or on the contract as a whole. The Notice to Cure will specify the action required to cure the Notice to Cure, the timeline required, and the consequences for failure to cure the deficiency.