Even though you and your staff may have worked with AHCCCS for a long time, there are certain repeat questions that seem to pop up on a regular basis. Here are some of them:
Q: We confirmed a prior authorization with a contracted AHCCCS plan several days before an outpatient surgery but didn’t “notify” on the date of the procedure, or when the patient became an inpatient. Now the plan won’t pay. Can they do that?
Your contract likely has language that says you will follow their policies and procedures and that allows the Plan to deny payment if you don’t notify the plan of the admission. All providers need to stay up to date on the policies imposed by the plans. The AHCCCS plans all have their provider manuals and prior authorization guidelines available on their websites. If the plan denies full payment, you should always try to negotiate a settlement or partial payment, which may require a claim dispute.
Q: We tried to submit a corrected claim after one year, but within 60 days of the last EOB. The plan rejected it. Isn’t that wrong?
The 60-day grace period past a year only applies to claim disputes, not cleaning a claim. If you have to correct a claim and the one year is approaching, you should file the dispute with the corrected claim. It’s also a good practice to simultaneously submit it to the claim department. If the plan issues a decision rejecting the dispute because the claim did not go to the claim department, file a Request for State Fair Hearing. We think these are improper denials and that the plan must consider ALL information submitted with the dispute.
Q: We billed the primary payer and did not submit a timely bill to the AHCCCS plan as secondary. Can the AHCCCS plan deny the claim?
Yes. You must submit your initial claim to the AHCCCS plan within the required timeframes, even if AHCCCS is secondary.
Q: The primary plan authorized and paid for a procedure, but the AHCCCS plan won’t pay for the patient’s cost-share because they did not authorize the service. Can they do that?
Yes. AHCCCS allows the plans to require their own authorization or notification as a condition of paying secondary responsibility on a commercial plan. For Medicare dual members, the AHCCCS plan can require notification, but cannot deny on the basis of medical necessity. All other denial grounds (clean claim, covered benefit) remain in place.
If you have questions about this article, please contact the author Susan L. Watchman.