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Claims Information/Updates
National Correct Coding Initiatives (NCCI) Edits-Mutually Exclusive Edits
Health Choice will be implementing the NCCI edits into our claims processing system to validate the claims that are billed for services to our members. These edits include Mutually Exclusive codes and Column 1/Column 2 edits. The Mutually Exclusive edits will be put into place for claims with a date of service of February 19, 2009 and later. You may see denials or codes that are bundled for services on future remittance advices that do not comply with these rules. These edits are based on guidelines set forth by CMS. ATTENTION: SURGI CENTERS Effective January 1, 2008, all bilateral procedures are to be billed on one claim line with appropriate modifier and a unit of 1. To ensure your claim is processed correctly, please ensure the following pertinent information is contained within the claim: For the Facility
Health Choice Arizona has defined the documentation requirements for inpatient institutional services. The reduction in required documentation for medical records will streamline claim submission and enhance prompt payment. The documentation requirements are for UB04 and electronic (ANSI 837I) claims. Medical records must be included in the following scenarios to allow for prompt adjudication: • Prior Period Coverage - With the exception of Maternity and Nursery claims that meet the federal guidelines of 2 days for post vaginal and 3 days for post c-section delivery that do not qualify for outlier consideration Failure to submit medical records may result in a denial or delay of payment. HCA reserves the right to request additional documentation. Medical records include, but are not limited to:
Providers who file electronic claims or have received an EOB and want to submit medical records for review to substantiate medical necessity must complete the form below to submit with records.  Response for request of medical records and/or IZ form
HCA reserves the right to request medical records for members who meet the Reinsurance threshold after the claim is adjudicated for addition information. HCA is live with WebMD/Emdeon for Professional and Institutional Claims. Please begin sending all Professional and Institutional Claims electronically using Payer ID Number 62179. If you have any questions, please call our EDI Coordinator at 480-731-3514.
Please be aware of the following AHCCCS billing change
Outpatient Institutional Claims no longer require IZ
Important Information regarding billing for the Administration of Combination Vaccines
Recently there has been discussion between AHCCCS and providers relating to reimbursement for the administration of combination vaccines. There has been concern about the reduction in administration fees paid when combination vaccines are given. Contracted Providers should continue to bill for the administration of vaccine by using the correct Vaccines for Children (VFC) code for the combination antigen, or antigen combination, accompanied by the SL modifier. Providers should be advised that billing for the administration separately for each antigen in a combination vaccine is prohibited. When a combination vaccine is administered only one administration fee should be paid. The Center for Medicare and Medicaid (CMS) interprets the Federal Registrar Notice to say that only one administration fee can be paid for each immunization given, including combination immunizations. CMS will be ensuring that states are not reimbursing on a per antigen basis, possibly through an audit process. If you should have any questions please contact your Network Services representative at the following numbers:
Contact Information for Network Services
Source: AHCCCS memo 9/18/2006
Claims Submission Reminder
Providers, when submitting an EOB from a member's primary insurance to Health Choice Generations, please eliminate other Members Health Information. Only submit information pertaining to the Specific member on the claim. In addition, when submitting claims to Health Choice, a claim may be denied if the diagnosis pointer in box 24E does not relate to the procedure billed. If you have questions on either of these "reminders", please call Health Choice Claims Customer Services at (480) 968-6866 or toll-free 1(800) 322-8670. Unclean Claims returned without processing Providers: Health Choice Arizona is unable to process claims that have missing or incorrect key information. As stated in your Health Choice contract, providers are required to notify Network Services of any practice changes that occur within their office. Practice Changes are categorized as any changes, additions, terminations or deletions on information such as name changes, physical addresses, payee address, tax identification changes and provider additions or removals. Changes should be communicated in writing 30 days prior to the effective date or as soon as your office is aware of the change. In addition, if there is missing or incorrect key information missing on the claim, the claim will not be processed. Some examples of missing or incorrect key information include but are not limited to:
Contact your Network Services Representative immediately and submit the appropriate documentation to update the missing or incorrect key information. The claim(s) must be re-submitted at least 5 business days after notifying Network Services with the updates.
Contact Information for Network Services
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