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The intent of
this section is to:
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Identify general requirements for submitting claims data to
AHCCCS;
-
Identify procedures and standardized
forms for submitting claims data to AHCCCS;
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Articulate the timelines for
submitting billing information.
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6.1.2
References
The following citations can serve as additional resources for this
content area:
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6.1.3
Scope
To whom does this apply?
All
behavioral health providers contracted with a Tribal RBHA that
submit claims to AHCCCS.
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6.1.4
Did you know…?
Submission of legible and accurate billing data facilitates timely
reimbursement for fee-for-service providers.
-
Paper claims are not
considered legible if they contain highlighter or color marks,
copy overexposure marks or dark edges.
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Behavioral health
providers must not bill, nor attempt to collect payment directly
or through a collection agency from a person claiming to be
AHCCCS eligible without first receiving verification from AHCCCS
that the person was ineligible for AHCCCS on the date of
service, or that services provided were not Title XIX/XXI
covered services.
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6.1.5
Definitions
Claim
Clean
Claim
Fee-for-Service
Retro-eligibility
Claim
6.1.6 Objectives
To ensure behavioral health providers
submit timely, accurate and complete claims to AHCCCS.
6.1.7
Procedures
6.1.7-A.
What general requirements apply
to Tribal Fee-for-Service providers when submitting claims?
All paper claims must be submitted using the CMS 1500, UB-04 or
the Universal Pharmacy Form. For specific billing instructions, see
AHCCCS Billing Manual for IHS/Tribal Providers.
Providers must
use the following forms to submit paper claims:
-
The CMS 1500 (formerly HCFA
1500) Claim Form is used to bill non-facility services,
including professional services, transportation and independent
laboratories.
-
The UB-04 (formerly HCFA 1450)
Claim Form is used to bill all hospital inpatient, outpatient,
emergency room, hospital-based clinic and residential treatment
center services.
-
The Universal Pharmacy Claim
Form is used by pharmacists to bill pharmacy services using NDC
codes.
All claims
or copies of paper claims:
- Must be legible and submitted on
the correct form.
- May be returned to the provider
without processing if they are illegible, incomplete, or not
submitted on the correct form. HIPAA regulations specify the
format for the submission of all electronic claims submitted to
AHCCCS.
- HIPAA Format 837P is used to
bill non-facility services, including professional services,
transportation and independent laboratories.
- HIPAA Format 837I is used to
bill hospital inpatient, outpatient, emergency room,
hospital-based clinic and residential treatment center services.
- HIPAA Format NCPDC is used by
pharmacists to bill pharmacy services using NDC codes.
If more information is needed
regarding electronic submission of claims to
AHCCCS,
please contact AHCCCS Electronic Claims Submission Unit at (602)
417-7670 #4.
What happens after a claim is
submitted?
Submitted claims for services
delivered to a Title XIX or Title XXI eligible person will result in
one of the following dispositions:
- Denied;
- Pended; or
- Approved.
Denied claims: Claims are typically
denied because of a discrepancy between form field(s) and AHCCCS’
edit tables. A denied claim may be resubmitted as long as the claim
is submitted within 12 months of the date of service. Tribal RBHA
claims will be denied in the event the claim is untimely, illegible
or incomplete.
Pended Claims: A claim may stop
processing and "pend" for internal review when the error detected
concerns data or procedures that may be resolved by AHCCCS.
Internally pended claims are generally processed without further
information from the provider.
Approved claims: Approved claims have
passed the timeliness, accuracy and completeness standards and have
been successfully processed by AHCCCS.
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6.1.7-B.
What requirements apply to
Tribal Fee-for-Service providers when submitting claims?
Behavioral health providers must
submit accurate, timely and complete claims data to AHCCCS for all
covered behavioral health services, either on paper or
electronically.
All paper claims must be mailed to:
AHCCCS Claims
P.O. Box 1700
Phoenix, Arizona 85002-1700
For submitting electronic claims:
Contact the AHCCCS Electronic Claims Submission Unit at (602)
417-7670 #4.
Claim submission timeframes
All initial claims must be received
by AHCCCS no later than six months from the date of service, unless
the behavioral health recipient has retro-eligibility. For hospital
inpatient claims, "date of service" means the date of discharge of
the behavioral health recipient. Claims initially received beyond
the six-month timeframe, except retro-eligibility claims, will be
denied. If a claim is originally received within the six-month
timeframe, the provider has up to 12 months from the date of service
to resubmit the claim in order to achieve clean claim status or to
correct a previously processed claim, unless the claim is a
retro-eligibility claim. If a claim does not achieve clean claim
status or is not corrected within 12 months, AHCCCS is not liable
for payment.
What is a retro-eligibility claim?
A retro-eligibility claim is a claim
where no eligibility was entered in the AHCCCS system on the date(s)
of service but, at a later date, eligibility was posted
retroactively to cover the date(s) of service. Retro-eligibility
fee-for-service claims are considered timely submissions if the
initial claim is received by AHCCCS no later than six months from
the AHCCCS date of eligibility posting. Retro-eligibility claims
must attain clean claim status no later than 12 months from the
AHCCCS date of eligibility posting. Corrections to paid
retro-eligibility claims must be received by AHCCCS no later than 12
months from the AHCCCS date of eligibility posting.
Can a denied claim be resubmitted?
AHCCCS will deny claims with errors
that are identified during the editing process. These errors will be
reported to the provider in the AHCCCS remittance advice. Providers
must correct claim errors and resubmit claims to AHCCCS for
processing within the 12-month clean claim timeframe.
When resubmitting a denied claim, the
provider must submit a new claim form containing all previously
submitted lines. The original AHCCCS claim reference number (CRN)
must be included on the claim to enable the AHCCCS 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 timeframe.
Requirements for Medicare Part A
and B, and Medicare Part D Prescription Drug Plan
Coordination of Benefits for persons
eligible for Medicare Part A, Part B or Part D must follow the
procedures established in Provider Manual Section 3.5, Third Party
Liability and Coordination of Benefits.
For specific billing instructions on
Medicare Part A and B, and Medicare Part D Prescription Drug Plan,
see Client Information System (CIS) File Layout and Specifications
Manual and ADHS/DBHS Office of Program Support Procedures Manual.
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6.1 Submitting Claims
Last Revised: 05/25/2006
Effective Date: 04/15/2008 |
