AHCCCS Fee-For-Service Provider Billing Manual

The Fee-For-Service Provider Billing 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

The Fee-For-Service (FFS) Provider Billing Manual is intended to outline billing requirements for providers who are billing the AHCCCS FFS unit for reimbursement.

This is a Master PDF that contains all chapters of the FFS Provider Billing Manual and its corresponding exhibits.

• FFS Provider Billing Manual - Master PDF
  * Master pdf is currently undergoing revisions - please see individual chapters for more accurate and up to date information

Download Individual Chapters

• Manual Table of Contents 
• Chapter 1: Introduction to AHCCCS
  • Exhibit 1-1, reserved
  • Exhibit 1-2, reserved
  • Exhibit 1-3  Indian Health Services [IHS] Offices
  • Exhibit 1-4  Help Line Directory
• Chapter 2:  Eligibility
• Chapter 3:  Provider Records and Registration
• Chapter 4:  General Billing Rules
• Chapter 5:  Billing on the CMS 1500 Claim Form
• Chapter 6:  Billing on the UB-04 Claim Form
• Chapter 7:  Billing on the ADA 2012 Claim Form
• Chapter 8:  Prior Authorizations
• Chapter 9:  Medicare/Other Insurance Liability
• Chapter 10:  Individual Practitioner Services
• Exhibit 10-1, Participating Provider
• Chapter 10: Addendum FQHC/RHC
• Chapter 11:  Hospital Services
  • Exhibit 11-2, Fee-for Service Outlier Exclusion List
  • Exhibit 11-4, Outlier Record Request
• Chapter 11:  Addendum AHCCCS APR-DRG Payment System Design Payment Policies
• Chapter 12:  Pharmacy Services
  • Exhibit 12-1,  OptumRx Prior Authorization Request
• Chapter 13:  DME, Orthotics, Prosthetics, Medical Supplies
• Chapter 14:  Transportation Services
  • Exhibit 14-1,  Daily Trip Report (PDF)
  • Exhibit 14-1,  Daily Trip Report (Excel File)
  • Exhibit 14-2, Non-emergency Medical Transport Daily Trip Report Instructions
  • Exhibit 14-3, Tribal Contact Information
  • Exhibit 14-4, Public Transportation Pass Form
• Chapter 15:  Dialysis Services
• Chapter 16:  Free-Standing Ambulatory Surgery Centers
• Chapter 17:  Free Standing Birthing Centers
• Chapter 18:  Federal Emergency Services Program
• Chapter 19:  Behavioral Health Services
• Chapter 20:  Home Health Care Services
• Exhibit 20-1, Medical Supplies Included in FFS Home Health Nursing Visits
• Exhibit 20-2, Home Health Skilled Nursing Services
• Chapter 21:  ALTCS Services
  • Exhibit 21-1, Sample ALTCS Authorization Letter
  • Exhibit 21-2, ALTCS Offices
• Chapter 22:  Nursing Facility Services
• Exhibit 22-1, Durable Medical Equipment Included in the Nursing Facility and Intermediate Care Facility FFS Per Diem Rate
• Exhibit 22-2, Medical Supplies Included in the Nursing Facility FFS Per Diem Rate
• Chapter 23:  Hospice Services
• Chapter 24:  Transplants
• Chapter 25:  Claims Processing
• Chapter 26:  Correcting Claim Errors
• Chapter 27:  Understanding the Remittance Advice
  • Exhibit 27-1,  Sample Remittance Advice - Address Page
  • Exhibit 27-2,  Sample Remittance Advice - Financial Summary
  • Exhibit 27-3,  Sample Remittance Advice - Paid Non-Facility Claims
  • Exhibit 27-4,  Sample Remittance Advice - Denied Non-Facility Claims
  • Exhibit 27-5,  Sample Remittance Advice - Adjusted Non-Facility Claims
  • Exhibit 27-6,  Sample Remittance Advice - Voided Non-Facility Claims
  • Exhibit 27-7,  Sample Remittance Advice - Non-Facility Claims in Process
  • Exhibit 27-8,  Sample Remittance Advice - Processing Notes
  • Exhibit 27-9,  Sample Remittance Advice - Paid Facility Inpatient Claims
  • Exhibit 27-10,  Sample Remittance Advice - Paid Facility Outpatient Claims
  • Exhibit 27-11,  Sample Remittance Advice - Denied Facility Claims
  • Exhibit 27-12,  Sample Remittance Advice - Adjusted Facility Claims
  • Exhibit 27-13,  Sample Remittance Advice - Voided Facility Claims
  • Exhibit 27-14,  Sample Remittance Advice - Facility Claims in Process
• Chapter 28:  Claim Disputes
• Chapter 29:  Housing and Health Opportunities (H2O) Services