AHCCCS Provider Resubmission and Reconsideration Process

In order to streamline requests for FFS resubmissions and reconsiderations, the Division of Fee for Service Management has developed a new process for providers to submit these claims and prior authorization re-reviews.

Prior Authorization Reconsideration Submission

A reconsideration is a provider’s request for AHCCCS to review a prior authorization that the provider believes was denied in error. A reconsideration may involve a re-review after submitting new documentation or correcting information such as CPT/HCPCS codes, billing units, or dates of service.

What to Include in a Reconsideration Request:

• Any additional documentation needed to support the request.
• A brief written explanation describing why the reconsideration is being requested.

AHCCCS may be unable to reverse a denial if the provider does not clearly explain why the original decision should be reconsidered.

Submission Requirements

• Clearly label each prior authorization reconsideration request with “reconsideration.”
• Reconsideration requests may be submitted through the standard prior authorization submission process. Refer to the Fee for Service Prior Authorization Submission Web Page for more information on PA Submission methods.
• The preferred method is to upload the request and supporting documents to the corresponding Prior Authorization Event in the Provider Portal.

Providers have 12 months from the date of service to request a reconsideration of the claim, so prior authorizations must be updated prior to the submission of a claim resubmission.

For Claims:

Resubmissions

A "Resubmission" is defined as a claim originally denied because of missing documentation, incorrect coding, etc., which is now being resubmitted with the required information.

When filing resubmissions or reconsiderations, please include the following information:

• A corrected claim;
• Cover letter with "RESUBMISSION" written or typed (do not write on the claims);
• A copy of the remittance advice on which the claim was denied or incorrectly paid; and
• Any additional documentation required.

Each claim should be identified clearly with the words "resubmission" or "reconsideration".

Reconsiderations

A "Reconsideration" is defined as a request for review of a claim that a provider feels was incorrectly paid or denied because of processing errors.

When filing reconsiderations, please include the following information:

• A copy of the original claim (reprint or copy is acceptable)
• Cover letter with "RECONSIDERATION" written or typed;
• A copy of the remittance advice on which the claim was denied or incorrectly paid
• Any additional documentation required
• A brief note describing what correction is needed. If the provider is unwilling to justify in writing why a legitimately denied claim deserves reconsideration, it will be difficult for AHCCCS to reverse its decision.

Mail all resubmission and reconsideration requests to:

AHCCCS Claims Department
Attn: Resubmission & Reconsideration
150 N. 18th Ave. MD 8200
Phoenix, AZ 85007

Providers have 12 months from the date of service to request a reconsideration of the claim, so prior authorizations must be updated prior to the submission of a claim resubmission.

A request for review or reconsideration of a claim does not constitute an appeal or Provider Claim Dispute (see Chapter 28 | Rich Text Version in the FFS Provider Manual and Chapter 19 | Rich Text Version in the IHS/Tribal Provider Manual).