AHCCCS Box 19 Billing Requirements Reminder
Date: 09/05/23
Dear Arizona Complete Health-Complete Care Plan (AzCH-CCP), Care1st Providers and Billing Staff:
Integrated Clinics/Behavioral Health Outpatient Clinics/Clinics. For claims with dates of service on and after July 1, 2023, the AHCCCS registered provider types below must report the individual practitioner who rendered services associated with the clinical visit on professional and dental claims in box 19. If the individual practitioner is not reported, the claim must be denied. Exhibit 10-1 of the AHCCCS Fee-For-Service Provider Billing Manual provides billing instructions for box 19 including examples.
• Integrated Clinics (IC) (Provider Type IC),
• Behavioral Health Outpatient Clinics (BHOP) (Provider Type 77), and
• Clinics (Provider Type 05)
Services Rendered in a School Setting Effective March 1, 2022, if the service is rendered in place of service 03 (school), the School Identifier is also required to be submitted in box 19. Chapter 10 and Exhibit 10-1 of the AHCCCS Fee-For-Service Provider Billing Manual includes detailed instructions for the school-based requirement. A listing of the school 9-digit CTDS identifier codes are available on the AHCCCS Medical Coding Resources webpage > Coding Related Exhibits and Policy Reference
References
- AHCCCS FFS Manual
- AHCCCS FFS Manual Exhibit 10
- AHCCCS Participation Provider Training
- AHCCCS Medical Coding Resource
Box 19 Examples:
| AHCCCS Registered provider: | Non AHCCCS Registerable provider (BHT, etc.): | School Identifier: |
| XX1231231234SMITH, JANE | 9999999999SMITH, JOHN | OBNNNNNNNNN |
A comma between last and first name is required
Additional Reminders
- The rendering provider on the claim is the IC, BHOP or Clinic, not the practitioner. The site-specific NPI and/or the IC, BHOP or Clinic entity name is placed in the following fields of the CMS 1500 Claim Form (Paper/Web Claim):
| Medical Paper Claims | Dental Paper Claims | Medical & Dental EDI Claims |
| Box 24J and 32 | Box 54 and 56 | Loop 2310B |
- The participating/performing practitioner information is listed in the following fields of the claim:
| Medical Paper Claims | Dental Paper Claims | Medical & Dental EDI Claims |
| Box 19 | Box 35 | Loop 2300 NTE segment |
- If the service is rendered at a school place of service, the 9-digit State CTDS identifier assigned to the school is listed in the following fields of the claim. School CTDS codes can be obtained on the AHCCCS website.
| Medical Paper Claims | Dental Paper Claims | Medical & Dental EDI Claims |
| Box 19 | Box 35 | Loop 2300 NTE segment |
- When submitting a paper claim, populate box 31 on medical and box 53 on dental claims with ‘Signature on file’.
AzCH-CCP providers and staff:
If you have questions, please contact your AzCH-CCP Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.