Youth H2014 and H2017 Claims Processing Notification
Date: 01/03/25
Effective 2/1/2025 Pre-Payment Medical Records Review Required for H2014 & H2017 Medicaid Claims for Children Under 18
Pre-Payment medical record review will be required for Medicaid claims processed 2/1/2025 and after for members under the age of 18, when more than 8 units are billed for the same member, on the same day, by a single provider
AHCCCS defines the following services in the AHCCCS Covered Behavioral Health Services Guide (CBHSG) (updated 12/23/2024) as follows:
Rehabilitation Services teach independent living, social, and communication skills to persons (or their families) to promote the maximum reduction of behavioral health symptoms and/or restoration of an individual to their best age-appropriate functional level for the purpose of maximizing the person’s ability to live independently and function in the community.
Skills Training and Development: Teaching independent living, social, and communication skills to persons and/or their families in order to maximize the person’s ability to live independently, participate in the community, and manage their behavioral health needs. Examples of areas that may be addressed include self- care, household management, appropriate social engagement, friendships and relationships, avoidance of exploitation, budgeting, recreation, development of social support networks and use of community resources. Services may be provided to a person, a group of individuals and/or their families with the person(s) present.
Psychosocial Rehabilitation: Psychosocial Rehabilitation Services help individuals to compensate for or to eliminate functional deficits and environmental and interpersonal barriers associated with mental illness. The goal of the service is to help individuals achieve the fullest possible integration as an active and productive member of their family and community with the least possible ongoing professional intervention. This is a face-to-face intervention, and the services may be provided in a group or an individual setting. Skills training and development and psychosocial rehabilitation living skills training services must be provided by individuals who are qualified behavioral health professionals, behavioral health technicians or behavioral health paraprofessionals as defined in 9 A.A.C. 10 and AMPM Policy 310-B.
HCPCS Codes:
• H2014 - Skills training and development, per 15 minutes
• H2017 - Psychosocial rehabilitation services, per 15 minutes
A pre-payment medical record review process will be performed on Medicaid claims billed with H2014 or H2017 processed 2/1/2025 and after when the member is under the age of 18, and more than 8 units of H2014 and/or H2017 are billed for the same member on the same day by a single provider (at the TIN level).
Please note: If AHCCCS makes further changes to the CBHSG and/or Disallowance Table AzCH-CCP will determine if additional review processes will be required.
What to expect:
1. Medicaid claims billed for members under the age of 18, with more than 8 units for H2014 and/or H2017 for the same member on the same day, by a single provider (at the TIN level) will undergo pre-payment medical records review.
2. The claim remittance advice will include reason code EXU1 “CLAIM CANNOT BE PROCESSED WITHOUT MEDICAL RECORDS.”
3. You may:
a. Submit the medical records along with your electronic claim submission
OR
b. Upon receipt of the remittance advice submit medical records via our secure provider portal (per Provider Manual Section 8 “Finance/Billing” providers have up to 60 days from receipt of the remittance advice to submit medical records to support the original claim).
4. Upon receipt and review of the medical records:
a. If review determines the claim meets medical necessity criteria in accordance with AHCCCS policy, the claim will be processed as billed.
b. If review determines the claim does not meet medical necessity and services were not provided in accordance with AHCCCS policy, the claim will be reprocessed with reason code EXb2 “MEDICAL RECORDS SUBMITTED DO NOT SUPPORT THE SERVICE BILLED” and the service will not be reimbursed.
If you are not in agreement with the determination made following medical record review, refer to the AzCH-CCP Provider Manual for information on how to file a reconsideration or dispute.
Resources
• Medical Records Submission: AzCH > For Providers > Provider Resources > Claims and Payment
• Provider Manual: www.azcompletehealth.com > For Providers > Provider Resources > Manuals and Forms
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.