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FQHCs and RHCs T1015 Claims Processing Notice

Date: 08/02/24

Important Notice for FQHCs & RHCs Regarding T1015 Claims Processing Medical Record Review When Multiple T1015 Visits Billed for Same Member on the Same Day

AHCCCS defines a FQHC/RHC visit as a face-to-face encounter with a licensed AHCCCS-registered practitioner during which an  AHCCCS-covered  ambulatory  service  is  provided  when  that  service  is  not  incident  to  another  service.  Multiple encounters with more than one practitioner within the same discipline, i.e., dental, physical, behavioral health, or with the same practitioner and which take place on the same day and at a single location, constitute a single visit unless the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis or treatment. In this circumstance, the subsequent encounter is considered a separate visit. 

Effective 9/01/2024, Arizona Complete Health-Complete Care Plan (AzCH-CCP) and Care1st Health Plan Arizona (Care1st) will implement a pre-payment medical records review process for multiple T1015 visits billed for the same member on same day, within the same discipline, and at a single location to determine if a subsequent T1015 visit qualifies as a separate visit.   

What to expect:

  1. Select claims billed with more than one T1015 visit for the same member on the same day, within the same discipline, and at the same location will be identified for medical records review.
  2. The claim’s remittance advice will include reason code EXU1 “CLAIM CANNOT BE PROCESSED WITHOUT MEDICAL RECORDS.”
  3. You may submit medical records through our provider portal, mail, or via clearing house.
  4. Upon receipt and review of the medical records,
    • If  review  determines  the  subsequent  T1015  visit  is  in  accordance  with  AHCCCS  policy,  the  claim  will  beprocessed as billed.
    • If review determines the subsequent T1015 visit is not in accordance with AHCCCC policy, the claim will be reprocessed with reason code EXb2 “MEDICAL RECORDS SUBMITTED DO NOT SUPPORT THE SERVICE BILLED” and the visit will not be reimbursed.

If you are not in agreement with the determination made following medical record review, refer to our provider manuals for information on how to file a reconsideration or dispute. Provider Manuals are available on our websites. 


As a reminder, as per AHCCCS policy, a service which is provided incident to another service, whether or not on the same day or at the same location, is considered to be part of the visit and is not reimbursed separately.

Resources

AzCH providers and staff:

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com. 

 

Care1st providers and staff:

If you have questions, please call Network Management at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.