AHCCCS Fee-For-Service Provider Manual

The Fee-For-Service Provider Manual provides detailed information for those applying for AHCCCS (applicants), members, potential and existing providers. Details of the manual include the following:

• For Applicants: Process/steps to obtain services
• For Potential Providers: Registration process
• For Existing Providers: General billing rules, claim forms, authorization process, information on Medicare and other insurance liability

The manual also offers information on covered services, processing of claims and errors, and remittance advice.

Download Entire Manual [Zip]

• FFS Provider Manual [3.03MB]

Download Individual Chapters [PDF]

• Manual Table of Contents [295KB]
• Chapter 1: Introduction to AHCCCS [36KB]
  • Exhibit 1-1, reserved
  • Exhibit 1-2, reserved
  • Exhibit 1-3, Indian Health Services [IHS] Offices [9KB]
  • Exhibit 1-4, Help Line Directory [20KB]
• Chapter 2: Recipient Eligibility and Enrollment [70KB]
• Chapter 3: Provider Records and Registration [89KB]
• Chapter 4: General Billing Rules [163KB]
• Chapter 5: Billing on the CMS 1500 Claim Form [85KB]
• Chapter 6: Billing on the UB-04 Claim Form [136KB]
• Chapter 7: Billing on the ADA 2002 Claim Form [81KB]
• Chapter 8: Authorization/IHS Referral [72KB]
  • Exhibit 8-1, Sample PA Confirmation Letter
• Chapter 9: Medicare/Other Insurance Liability [171KB]
• Chapter 10: Professional and Technical Services [520KB]
  • Exhibit 10-1, Hysterectomy Consent Form
• Chapter 11: Hospital Services [184KB]
  • Exhibit 11-1, Hierarchy for Processing Claims
  • Exhibit 11-2, deleted
  • Exhibit 11-3, Outlier Calculation Worksheet
• Chapter 12: Pharmacy Services [226KB]
  • Exhibit 12-1, MedImpact Prior Authorization Request [79KB]
• Chapter 13: DME and Supplies [65KB]
• Chapter 14: Transportation Services [221KB]
  • Exhibit 14-1, Daily Trip Report [52KB]
  • Exhibit 14-2, Non-emergency Medical Transport Daily Trip Report Instructions [265KB]
• Chapter 15: Dialysis Services [124KB]
• Chapter 16: Free-Standing Ambulatory Surgery Centers [33KB]
• Chapter 17: Free-Standing Birthing Centers [33KB]
• Chapter 18: Emergency Services Program [34KB]
• Chapter 19: Behavioral Health Services [88KB]
• Chapter 20: Home Health Care Services [40KB]
• Chapter 21: ALTCS Services [101KB]
  • Exhibit 21-1, Sample ALTCS Authorization Letter
  • Exhibit 21-2, ALTCS Offices
• Chapter 22: Nursing Facility Services [40KB]
• Chapter 23: Hospice Services [32KB]
• Chapter 24: Transplants [42KB]
• Chapter 25: Claims Processing [56KB]
• Chapter 26: Correcting Claim Errors [146KB]
  • Exhibit 26-1, Claim Correction Request Form [87KB]
  • Exhibit 26-2, Claim Status Request Form [49KB]
• Chapter 27: Understanding the Remittance Advice [265KB]
  • Exhibit 27-1, Sample Remittance Advice - Address Page [70KB]
  • Exhibit 27-2, Sample Remittance Advice - Financial Summary [80KB]
  • Exhibit 27-3, Sample Remittance Advice - Paid Non-Facility Claims [81KB]
  • Exhibit 27-4, Sample Remittance Advice - Denied Non-Facility Claims [81KB]
  • Exhibit 27-5, Sample Remittance Advice - Adjusted Non-Facility Claims [81KB]
  • Exhibit 27-6, Sample Remittance Advice - Voided Non-Facility Claims [81KB]
  • Exhibit 27-7, Sample Remittance Advice - Non-Facility Claims in Process [80KB]
  • Exhibit 27-8, Sample Remittance Advice - Processing Notes [80KB]
  • Exhibit 27-9, Sample Remittance Advice - Paid Facility Inpatient Claims [81KB]
  • Exhibit 27-10, Sample Remittance Advice - Paid Facility Outpatient Claims [101KB]
  • Exhibit 27-11, Sample Remittance Advice - Denied Facility Claims [80KB]
  • Exhibit 27-12, Sample Remittance Advice - Adjusted Facility Claims [81KB]
  • Exhibit 27-13, Sample Remittance Advice - Voided Facility Claims [80KB]
  • Exhibit 27-14, Sample Remittance Advice - Facility Claims in Process [80KB]
• Chapter 28: Claim Disputes [55KB]