Medicaid Arizona

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On the General tab:

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Type – K (Medicaid)

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Mode – R (Regular)

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State – AZ (Arizona)

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Form – CMS-1500

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On the NPI tab:

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In the IDs to include in EMC files section, select National Provider IDs (NPI).

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In the IDs to include in Paper Claims section, select Legacy IDs and National Provider IDs (NPI).

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On the Liability/ Spend Down tab, make no selection because Arizona Medicaid captures this information from the local representatives and it must not be reported on the claim.

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On the Print Variations tab, select the following print variations.

Form Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Complete all required areas of the CMS-1500 (08/05) claim form.

Use only the original CMS-1500 (08/05) claim forms with the red drop-out ink or file electronically.

When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

The value for all check boxes on the form is X. If a field is empty, the items must be left blank on the form. Do not complete the numeric fields with zeros; they must be left blank unless specified.

Select the following print variations:

Claims must be itemized based on the Revenue/HCPC Code.

FL 1

Health Insurance Box

Select the appropriate health insurance if other than Medicaid.

FL 9–9d

Other Insured's Name

If a patient has insurance primary to Medicaid, report in these locators.

Enter the other insured's information in Patient>General>Claim Constants or Claims>Process>Annotate Claims. If other insured is the recipient, enter Same.

FL 10a

Is Patient's Condition Related to Current or Previous Employment

If the patient's condition is related to the current or previous employment, enter Y in the Value field in Patient>General>Claim Constants.

FL 10b

Is Patient's Condition Related to Auto Accident

If the patient's condition is related to an auto accident, enter Y in the Value field in Patient>General>Claim Constants.

FL 10c

Is Patient's Condition Related to Other Accident

If the patient's condition is related to another accident, enter Y in the Value field in Patient>General>Claim Constants.

FL 11

Insured's Policy Group or FECA Number

Select the Print the Insurance ID print variation.

FL 17

Name of Referring Provider or Other

Source

Select the Print the Referral Source print variation.

FL 17b

NPI Number

Enter the referring physician's NPI in Claims>General>Claim Constants.

FL 19

Reserved for Local Use

When billing for the EPD waiver services, enter the 03 special program code in Patient>General>Claim Constants.

FL 24d

Procedures, Services, or Supplies

Select the Print shift modifiers based on start time of visits. Note: Requires Shift Modifiers to be set up in Billing Ratesprint variation.

FL 24j

Rendering Provider ID (shaded area)

Select the Print rendering provider's NPI print variation.

FL 30

Balance Due

Select the Suppress printing the Balance Due print variation.

FL 31

Signature of Physician or Supplier

Select the Print Authorized Signature and date print variation.

FL 32

Name/Address of Facility

Select the Print facility where services rendered print variation.

FL 33

Billing Provider Information and Physician Number

Select the Print the agency name, address and phone number print variation.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Patient Sign (Patient Signature Code)

If the Rel Infor (Release of Information) field in Patient>General>Payers>HIPAA is set to Y, select the appropriate patient signature code, if different from the default code of B (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

Program (Special Program Code)

In Patient>General>Payers>Pay Source>HIPAA, select 01 (EPSDT) if the services are provided under the EPSDT problem.

Medicare Assign (Medicare Assignment Code)

If the code other than the default A (Assigned) is selected in the Medicare Assign field in Patient>General>Payers>HIPAA, then C (Not Assigned) will print to the claim file.

Carrier Codes

Select the appropriate code identifying the type of insurance policy within a specific insurance program in the Insurance Type Code field in Administration>Financial>Insurance Codes>Carrier Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician or referring physician, enter either the doctor's federal tax ID or Social Security Number.

Enter the attending physician's provider number in the License No field.

Arizona Medicaid requires two zeros at the beginning before the provider number followed by the 2-digit location code. This value must be entered for each physician in the License No field. For example, if the license number is AAAAAA and the location code is LL, the provider will populate the License No field for the physician as follows: 00AAAAAALL.

These fields are located in Resource>General>Roles.

Provider ID

Enter the provider ID in the Provider ID field in Administration>Financial>Insurance Codes>General.

Arizona Medicaid requires two zeros at the beginning before the provider number followed by the 2-digit location code. This value must be entered for each physician in the Provider ID field. For example, if the license number is PPPPPP and the location code is LL, the provider will populate the License No field for the physician as follows: 00PPPPPPLL.

Receiver ID (File Recipient)

Enter the patient's AHCCCS recipient ID in the Insurance ID field Patient>General>Payers.

Receiver ID (Payer)

Enter the 5-digit Electronic Supplier Number assigned by the AHCCCS in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter AHCCCS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the 5-digit submitter ID assigned by AHCCCS in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Field

Description

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Patient Sign (Patient Signature Code)

If the Rel Infor (Release of Information) field in Patient>General>Payers>HIPAA is set to Y, select the appropriate patient signature code, if different from the default code of B (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

Program (Special Program Code)

In Patient>General>Payers>Pay Source>HIPAA, select 01 (EPSDT) if the services are provided under the EPSDT problem.

Medicare Assign (Medicare Assignment Code)

If the code other than the default A (Assigned) is selected in the Medicare Assign field in Patient>General>Payers>HIPAA, then C (Not Assigned) will print to the claim file.

Carrier Codes

Select the appropriate code identifying the type of insurance policy within a specific insurance program in the Insurance Type Code field in Administration>Financial>Insurance Codes>Carrier Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician or referring physician, enter either the doctor's federal tax ID or Social Security Number.

Enter the attending physician's provider number in the License No field.

Arizona Medicaid requires two zeros at the beginning before the provider number followed by the 2-digit location code. This value must be entered for each physician in the License No field. For example, if the license number is AAAAAA and the location code is LL, the provider will populate the License No field for the physician as follows: 00AAAAAALL.

These fields are located in Resource>General>Roles.

Provider ID

Enter the provider ID in the Provider ID field in Administration>Financial>Insurance Codes>General.

Arizona Medicaid requires two zeros at the beginning before the provider number followed by the 2-digit location code. This value must be entered for each physician in the Provider ID field. For example, if the license number is PPPPPP and the location code is LL, the provider will populate the License No field for the physician as follows: 00PPPPPPLL.

Receiver Name (Payer)

Enter AHCCCS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the 5-digit submitter ID assigned by AHCCCS in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

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Complete all required areas of the UB-04 claim form.

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Use only original UB-04 claim forms with the red drop-out ink or file electronically.

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When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>

The value for all check boxes on the form is X.

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If a field is not completed, leave the items empty on the form.

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Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

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Claims are split into items based on the Revenue/HCPC Codes.

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Type – K (Medicaid)

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Mode – B (Benefit)

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State – AZ (Arizona)

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Form – UB-04

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In the Room and Board section, select the Do Not Bill the Day of Discharge check box.

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In the Print Rules for Day of Termination section, select the Print Day of Termination as Claim/Service Thru/To Date check box.

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In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

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In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the Make separate claims (with totals) for claims print variation.

FL 8

Patient Name/Identifier

Select the Print the middle initial only print variation.

FL 14–15

Admission Type/Point of Origin

Select the Print '3' and '1' Admission Type/Src print variation.

FL 16

Discharge hour

Enter the discharge hour in Patient>General>Claim Constants.

FL 17

Patient Discharge Status

The application automatically calculates patient status codes of 01 (routine discharge), 41 (expired), and 30 (still a patient). If your agency reports other codes, refer to the NUBC Manual and enter these codes in Patient>General>Claim Constants.

FL 18–28

Condition Code

If needed, enter condition codes in Patient>General>Claim Constants.

FL 29

Accident State

If occurrence code from the range of 01–05 is used, enter the 2-character accident state in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Code

If needed, enter occurrence codes in Patient>General>Claim Constants.

FL 35ab–36ab

Occurrence Span Codes

If needed, enter occurrence span codes in Patient>General>Claim Constants.

FL 42

Revenue Code

Enter the appropriate revenue codes in the Rev Code column in Administration>Financial>Billing Rates>Rates for this insurance. Ensure that 001 is entered in the Total Rev Code field in Administration>Financial>Insurance Codes>General.

FL 42–49

Rules for all Claims

Select the following print variations:

FL 44

HCPCS/Rate/HIPPS Code

If needed, enter HCPCS codes in the HCPCS/HIPPS Code field in Administration>Financial>Billing Rates. Also, include any modifiers in positions 6–7, 8–9, and 10–11 of this field.

FL 55

Estimated Amount Due

Select the Suppress printing estimated amount due print variation.

FL 58

Insured's Name

Select the Print the middle initial only print variation.

FL 59

Patient's Relationship to Insured

Select the Suppress printing of Patient Relationship print variation.

FL 61

Insured's Group Name

Select the Print the Insurance Group Name print variation.

FL 69

Admit Diagnosis

Select the Print the patient's diagnosis code as of the patient's admission date print variation.

FL 80

Remarks

If needed, enter remarks in Patient>General>Claim Constants.

Enter the CRN of a resubmitted, adjusted, or voided claim. For resubmissions of denied claims, enter Resubmission as a remark.

Field

Description

Authorized Signature

Complete the Authorized Signature field in Administration>Financial>Insurance Codes>EMC.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Carrier Code

Enter the appropriate Arizona Medicaid-assigned ID codes for each insurance carrier (including Arizona Medicaid) in Administration>Financial>Insurance Codes>Carrier Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

For the patient's attending physician and referring physician, enter either the physician's federal tax ID or Social Security Number.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Receiver Name (Payer)

Enter AHCCCS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

Make sure the Request for paper EOB check box in Administration>Financial>Insurance Codes>General is clear. 
AHCCCS Medicaid does not provide paper EOBs.

Submitter ID

Enter the submitter ID assigned by Arizona Medicaid in the Submitter ID field in Administration>Financial>Insurance Codes>EMC. This ID must be 6 digits long and consist of 0 at the beginning followed by the 5-digit Electronic Supplier Number.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

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In Administration>Financial>Insurance Codes>Print Variations, select the check box under FL 14–15 to ensure the ANSI 5010 Billing Template compliance.

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Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor(Release of Information) field in Patient>General>Payers>HIPAA.

Field

Description

Authorized Signature

Complete the Authorized Signature field in Administration>Financial>Insurance Codes>EMC.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Yby default for each carrier. Change to N where applicable.

Carrier Code

Enter the appropriate Arizona Medicaid-assigned ID codes for each insurance carrier (including Arizona Medicaid) in Administration>Financial>Insurance Codes>Carrier Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

For the patient's attending physician and referring physician, enter either the physician's federal tax ID or Social Security Number.

Enter the physician's taxonomy code.

These fields are located in Resource>General>Roles.

Receiver Name (Payer)

Enter AHCCCS in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

Make sure the Request for paper EOB check box in Administration>Financial>Insurance Codes>General is clear. 
AHCCCS Medicaid does not provide paper EOBs.

Submitter ID

Enter the submitter ID assigned by Arizona Medicaid in the Submitter ID field in Administration>Financial>Insurance Codes>EMC. This ID must be 6 digits long and consist of 0 at the beginning followed by the 5-digit Electronic Supplier Number.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.