Updates to Billing Requirements for Behavioral Health Outpatient Claims

July 14, 2023

Important Provider Billing News!

AHCCCS Fee-for-Service Claim Instructions:

This change is applicable to claims submitted through the Electronically Data Interchange 837P (EDI), paper submissions and via the AHCCCS Online Provider Portal.

Providers are reminded to bill procedures with the correct modifier combinations, units of service provided and correct code combinations.

If a FFS provider submits multiple claims for the same member on the same date of service, the provider will be required to submit documentation for all services provided on all claims submitted moving forward. All of the claims from the provider will require review before payment is authorized.

Prior authorization or medical review of services does not guarantee payment of a claim. Payment is contingent upon eligibility, available benefits, contractual terms, provision of a service that meets coverage criteria limitations, exclusions, coordination of benefits, submission of a clean claim, submission of all required documentation, and other terms and conditions set forth by the program.

New Additions - HCPCS Codes Which Now Require Documentation for Claims Submitted In Any Unit Quantity

New Additions - HCPCS Codes Which Now Require Documentation When Claims Are Submitted In Excess Of 2 Hourly Units Or 4 Fifteen Minute Units

Effective with claims submitted on and after July 17, 2023, Fee-For-Service providers billing more than 2 units of hourly codes or 4 units of 15 minutes codes in the following list of HCPCS codes, on a single date of service, are required to provide the following documentation with the submission of the claim:

Comprehensive assessment:

The member’s most recent comprehensive behavioral health assessment,

Treatment care plan:

The treatment plan for the services billed,

Consent to treat form:

A signed copy of the member’s consent to treatment for the services billed, and

Records / Documentation:

Medical record documentation for each claim line billed on the service date(s).

Billing Codes (claims submitted on or after July 17, 2023 will be affected)

HCPCS Codes Now Requiring Documentation When Billing More Than 8 Units

HCPCS Codes Now Requiring Documentation When Billing More Than 4 Units

Additionally, the documentation requirement on the following codes has changed when providers are submitting claims for more than 4 units on or after July 17, 2023.

Behavioral health outpatient claims may be denied due to any of the following:

Submission of poor quality documentation (i.e., no letterhead, required and/or valid signatures not present, mismatch between documented services provided and services billed, etc.) will result in denial of the claim. See AMPM Chapter 940 Medical Records and Communication of Clinical Information for documentation requirements.

Providers shall submit all required documentation with the claim. Claims received without the required documentation will be denied after 7 calendar days unless the provider submits the required documents within that time frame. Failure to submit all of the required documentation for each date of service billed will result in denial.

A claim line with multiple dates of services on a single line is not allowed and will result in a denial of the claim. When billing behavioral health claims, each service must be billed on a single line to include the:
Date of service,
CPT/HCPCS code and, a
Applicable number of units.

Some billing codes may be denied when inappropriately billed on the same date of service as a per diem service.

H0030 Behavioral Health Hotline Services can only be utilized by a provider that is part of the state crisis system and claims cannot be submitted to DFSM. This code will be denied if billed to DFSM.

A claim submitted with a substance use disorder (SUD) diagnosis for a child 12 years of age or younger will be denied if it is not submitted with documentation.

If a FFS Provider submits a behavioral health outpatient claim to DFSM that is then denied for lack of documentation, and then resubmits a claim with a lesser number of units or a different diagnosis, the provider will be required to submit documentation for all services provided. Documentation will need to be reviewed before payment is authorized for any claim submitted by the provider.

If a FFS provider is found to be submitting multiple claims for the same member on the same service day, the provider will be required to submit documentation for all services provided on any claim submitted. All of the claims from the provider will require documentation that will require review before payment is authorized.

If you have any questions about this communication, please reach out to [email protected]

Thank you,