AHCCCS Technical Interface Guidelines (TIG)

Introduction

Reference File 01 (Refer01.zip) informational records include:

• H1 - Procedure Demographics – basic procedure code information including maximum and minimum age limitations (RF113)
• H2 – FFS and CMDP Max Allowed Charge – provides the AHCCCS Fee For Service maximum allowable charge (MAC) by county for procedure codes for Date of Service (DOS) and Place of service (POS) (RF112)
• H3 - AHCCCS Coverage – indicates AHCCCS coverage parameters for a procedure code. (RF123) (see Coverage code listing Chapter 7-4)
• H4 - AHCCCS Medical Category of Service – provides date sensitive revenue code, UB Bill Type, HCPCS code and NDC codes to COS. Indexed by service type code. (RF769)
• H5 – AHCCCS Revenue Code to Bill Type – used for relational editing between Revenue codes and UB bill type codes
• H6 – Revenue Code to Procedure Code – provides valid, date sensitive revenue code to procedure code relationships. (RF773)
• H7 – Status Code B - Separate payments for services designated with Status Code "B" on the Medicare Physician Fee Schedule for which payment should not be made when other services are provided by the same service provider, for the same recipient, on the same date of service. While these services are appropriately reported for utilization, these services are not separately paid under the AHCCCS fee schedule. All Contractors were required to implement logic to identify these services and disallowance of the separate payment beginning January 1, 2012. (RFC25)
• H8 – Benefit Package Limits – provides service benefit limitations on services such as inpatient days, physical therapy visits and respite hours by effective plan year. (RFC31)
• H9 - Benefit Package Limit exceptions - TABLE NOT CURRENTLY USED - provides the criteria for benefit limit exceptions. (RFC32)
• N1 - Multiple Surgery – (RF724) Extract of HCPCS codes to which multiple procedure discounting rule applies
• N2 - PCP Specialty Rates - New PCP Parity rate table providing special rates for applicable effective dates by Place of Service (POS) for qualified providers (RF144)
• N3 - PCP Special Modifier Rate - provides valid modifier rates, as applicable, for Parity eligible codes with the SL modifier for vaccine administration codes. (RF147)
• N4 – BHS or SDH Data - extract of HCPCS codes that includes BHS and SDoH record data (RF724)

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer01.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 01 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 01

Introduction

Reference File 02 (Refer02.zip) informational records include:

• M1 - Procedure - procedure code specific indicators and values e.g. family planning, TPL applicable, sterilization indicator,min-max age, etc…(RF113)
• M2 – FFS valid modifiers – provides valid procedure code to modifier code relationships for RF112 FFS and CMDP rates includes modifier payment indicator-Amount=A or Percentage=P to be used as multiplier (RF122)
• M3 - NDC with Family Planning indicator = “Y” – extract of NDC-National Drug Codes that are to be considered as family planning related.
• M4 – ICD-9 with Family Planning indicator = “Y” – extract of ICD-9 procedure and diagnosis codes indicated as Family Planning related.
• M5 – Pharmacy Procedure codes – lists CPT/HCPCS codes that require an NDC code when billed on HCFA or UB. (RF326)
• M6- ICD-10 with family Planning indicator = “Y” – extract of ICD-10 procedure and diagnosis codes indicated as Family Planning related.
• M7- AzEIP Payment Rate Schedule - extract of pricing information related to procedures for the AzEIP population.

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer02.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 02 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 02

Introduction

Reference File 03 (Refer03.zip) informational records include various table information related to AHCCCS specific Outpatient Fee Schedule Pricing rules: for more information on the entire AHCCCS Outpatient Fee Schedule pricing methodology see:

https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/outpatientfees.html

• N1 - Procedure OPFS (Outpatient Fee Schedule) Indicators and Values - OPFS procedure code specific indicators and values e.g. family planning, TPL applicable, EPSDT, sterilization indicator, min-max age,etc… (RF127)
• N2 – OPFS Price – provides procedure code specific price for OPFS services (RF126)
• N3 – OPFS Bundled Driver – provides procedure code values and value ranges for services that drive bundled OPFS pricing (RF797)
• N4 – Bundled Revenue Codes – provides a listing of Revenue codes that are subject to bundled payment for OPFS (RF796)
• N5 - CCI codes – lists Correct Coding relationships that indicate bundled and unbundled services editing required by AHCCCS. Note: CCI editing is not limited to OPFS (RF128)
• N6 - Multiple Surgery Exemption Table – Lists procedure codes that are exempted from the OPFS Multiple surgery pricing rules (RF789)
• N7 – Limit Override Modifiers - indicating the relationship of modifier values to action codes that allow override of various types of edit rules, like value 02-frequency limitation on service codes Note: editing is not limited to OPFS (RF723)
• N8 – Override Action Codes - the 2 digit code values for modifier override of various rules (RF725)
• N9 - Valid OPFS procedure Modifiers - provides relationship of procedure code to valid OPFS modifiers indicating amount (A) or percent (P) payment values (RF121)
• P1 - Limit Override Procedures - lists relationship of procedures to override action codes that allow override of various types of edit rules (see override action code table above) (RF739)
• P2 - MUE Units of Service - A Medically Unlikely Edit (MUE) is a claim edit applied to a procedure code for services rendered by one provider/supplier to one patient on one day. MUE are designed to limit fraud and/or coding errors. They represent an upper limit that unquestionably requires further documentation to support MUE is part of the National Correct Coding Initiative (NCCI) to address coding methodologies. Note: not limited to OPFS only. (RF129)
• P3 - NCCI Associated Modifiers - lists modifier values that are valid for National Correct Coding Initiative (NCCI) editing. (RF131)
• P4 - Procedure OPFS Clinic Price RCF - lists statewide pricing values for procedure codes related to Outpatient Clinic charges, these values recognize this pricing is for facility component only of the clinic procedure code. (RF133)
• P5 - Secondary OPFS Bundled Rate Driver Codes OBS - lists 2 codes G0378 and G0379 as additional bundled rate drivers for OPFS pricing as defined in the OPFS pricing flow. (RFC97)

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer03.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 03 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 03

Introduction

• TA – Medicare Covered Part B Therapeutic Classes - Medicare Part B covered drug classification using a therapeutic class grouper. (RF350)
• TB – EVV Procedure Code XReference – indicates the HCPCS/CPT Procedure Code, Provider Type, POS and MOD cross reference data (RF7C3)
• T2 – Link Multiple Service Types – indicates types of coding relationships between service code types like add on codes for HCPCS indicates that codes may or must be used in conjunction with one another. (RF771)
• T3 – VFC Procedure Codes – Date sensitive pricing for toxoids and their administration when covered under Vaccine for Children’s Program (VFC). NOTE-Plans have no liability for VFC covered toxoids. (RF729)
• T4 – Medicare Primary Payer Error Bypass – lists encounter pend codes where related encounter editing is bypassed when Medicaid secondary claims are submitted to AHCCCS as encounters. (RF799)
• T5 – Medicaid Covered Therapeutic Classes – Lists Therapeutic Class Codes not covered by Medicare Part D or B. .(RF347)
• T6 – ASC Rate Schedule – Statewide date sensitive ASC rates.
• T7 – Dental Procedures– provides indicators by dental code related to tooth number, surface and quadrant reporting requirements. (RF103)
• T8 - Procedure Place of service - provides valid, date sensitive procedure code to Place of Service (POS) relationships (RF115)

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer04.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 04 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 04

Introduction

Reference File 05 contains the maximum allowed charge and modifier records similar to those found in the Reference 01 and 02 files. This file contains the Long Term Care MCO Capped Fee Schedule.

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer05.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 05 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 05

Introduction

Reference File 06 contains the maximum allowed charge and modifier records similar to those found in the Reference 01 and 02 files. This file contains the Acute Care MCO Capped Fee Schedule.

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer06.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 06 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 06

Introduction

Reference File 07 (Refer07.zip) informational record.

• M1 – Co-pay to service - Date sensitive data related to recipient copay requirements for service codes, includes other information relevant to the service type and copay amount e.g. POS, provider type, age etc. (RF7A7)
• M2 – Reinsurance Transplant Contracts - provides Reinsurance Transplant data for contract year and amount. (RI315)
• M3 – Specialty Drug Rate - extract of NDC-Specialty Drug Codes and AHC Rate. (RF325)
• M4 – Provider Tax ID Special Processing - List of Providers by Tax ID which indicates the special processing code from RF680, they are associated to for processing of claims and encounters and reporting purposed. (RF681)
• M5 – Provider ID Special Processing - List of Providers by provider ID which indicates the special processing code from RF680, they are associated to for processing of claims and encounters and reporting purposed. (RF682)
• M6 – Special Population Diagnosis – provide the ICD-10 Diagnosis codes that are associated with special populations. (RF260)
  
  • The special populations identified to date are:
    • Severely Emotionally Disturbed (SED)
    • Neonatal Abstinence Syndrome (NAS)
    • Severe Combined Immunodeficiency (SCI)
    • Autism or At Risk (AUT)
• M7 – Eval and MGMT Proc Codes - Date sensitive data related to recipient copay requirements for service codes, includes other information relevant to the service type and copay amount e.g. POS, provider type, age etc. (RF7A7)
• M8 – DAP Special Processing Code(s)/Amount(s) - List of amounts and percentages that are associated with differential adjusted payments (DAP). (RF684)
• M9 – DAP Special Processing Code(s) - List of special processing codes for special pricing and reporting purposes. (RF680)
• D1 - Provider Type(s)/Special Processing Code(s)/DAP Amount(s) - DAP percentage(s)/amount(s) that associated with provider types and special processing codes, (RF687)
• Form Types I, O,L are informational only
• DAP rate is within the rates on PR050

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer07.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 07 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 07

Introduction

Reference 08 file contains data related ICD10 procedure and diagnosis codes.

The Refer08 extract includes records L1, L2, L3, and L4
Record L1 includes all Active Records (STA-CD = 'A') from RF161 (R-ICD10-PROC).
Record L2 includes all Active Records (STA-CD = 'A') from RF163 (RF-ICD10-CVG)
Record L3 includes all Active Records (STA-CD = 'A') from RF223 (RF-ICD10-DIAG)
Record L4 includes all Active Records (STA-CD ='A') from RF221 (RF-I10-DIAG-CVG)

Schedules

The file will be extracted quarterly on the 1st of the first month of each quarter: 1/1; 4/1; 7/1; 10/1.

Media

The file is name is Refer08.zip and is in the \ftp\shareinfo\reference\prod\out\ folder.

Testing

Reference 08 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 08

Introduction

Reference File 09 (Refer09.zip) informational records include:

• C1 – Electronic Visit Verification (EVV) Provider Key Contact Data – This file is intended for optional reference by MCO's as needed and no specific processing use is defined. (RF686)
• S1 – School CTDS Information – provides a new claims and encounters reporting requirements and an edit related to services provided in a school based place of service. (RF7C4)
• R1 - ROPA Exceptions - provides the MCO’s with the necessary data for the ROPA providers that are not registered with AHCCCS because they are not registerable provider types

Schedules

The file will be extracted on the 1st and 15th of the month.

Media

The file is name is Refer09.zip and is in the \ftp\shareinfo\reference\prod\out\ folder. File size 320 bites.

Testing

Reference 09 file transmissions must be tested in coordination with the AHCCCSA ISD operations staff prior to production implementation of a new Health Plan or change in service bureau, or as a result of changes. Typical testing of file transmission takes approximately one week and must be completed prior to implementation of any new processing arrangement.

Reference Documents (File Layout)

Link to Provider Interface TIG File Layouts.Reference File 09