Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

 

Section 6.1 Submitting Tribal Fee for Service Claims to AHCCCS

6.1.1 Introduction
6.1.2 References
6.1.3 Scope
6.1.4 Did you know…?
6.1.5 Definitions
6.1.6 Objectives
6.1.7 Procedures
6.1.7-A. What general requirements apply to Tribal Fee-for-Service providers when submitting claims?
6.1.7-B. What requirements apply to Tribal Fee-for-Service providers when submitting claims?


6.1.1 Introduction
Upon rendering a covered behavioral health service, billing information is submitted by behavioral health providers as a "claim" or as an "encounter."  Some behavioral health providers are reimbursed on a fee-for-service basis (these providers submit “claims”) and others are paid on a capitated basis or contract under a block purchase arrangement (these providers submit “encounters”).

The intent of this section is to:

  • Identify general requirements for submitting claims data to AHCCCS;
  • Identify procedures and standardized forms for submitting claims data to AHCCCS;
  • 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.
     

  • 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.
     

  • When crisis services are billed, these services must be identified as such. (see DBHS Policy Attachment 501.1, Billing Instructions Used to Identify Crisis Services).

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6.1.5 Definitions
Claim

Clean Claim

Encounter

Fee-for-Service

Integrated RBHA

Retro-eligibility Claim

Sanction


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. (For additional information related to claim submission, see DBHS Policy Attachment 501.2 Where to Submit Claimes and Encounters).

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 the 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: 10/1/2014
Effective Date: 10/1/2014

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