Claims information

Claims information

Claims Submission

As a Participating Provider with Magellan Complete Care of Arizona (MCC of AZ), providers have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered health care services unless otherwise specified under the provider’s Participating Agreement. The rates established in the provider’s Participating Agreement is considered full payment for covered services provided. Accordingly, MCC of AZ members may not be balanced billed for any remaining amounts and/or differences between what is billed and the provider’s negotiated reimbursement rate defined in the rate exhibit of the provider’s Participating Agreement.

Procedure for Reimbursement of Covered Services

As a Participating Provider, each provider agrees to bill all covered services provided to MCC of AZ members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500, UB04 and/or CMS 1450 to be considered for adjudication and/or payment. Providers may visit the Centers for Medicare and Medicaid Services (CMS) website at www.cms.hhs.gov to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.

Any claims requiring authorization should include the medical authorization number in the appropriate field of the CMS 1500, UB04 or CMS 1450 to assist with appropriate claims processing and timely claims payment. For a list of services requiring prior authorization, please visit our provider tools and resources on www.MCCofAZ.com, or as indicated, please reference Section 9: Medical Management of the provider handbook.

Paper Claims

MCC of AZ Participating Providers are strongly encouraged to submit their claims electronically. However, paper claims can be accepted. When paper claims are submitted, they must be on properly completed original red UB04, CMS-1450 or CMS-1500 (02-12) claim form and laser-printed or typed. Mail paper claims to:

Magellan Complete Care of Arizona

Claims Service Center

P.O. Box 956

Elk Grove, IL 60009-0956

Electronic Claims and Electronic Data Interchange (EDI)

MCC of AZ has the ability to accept provider claims electronically. Providers submit their claims electronically to experience the cost-saving benefits, administrative simplification as well as ease of submission and claims payment. MCC of AZ works with many claim clearinghouses. To check if MCC of AZ has a relationship with a provider’s clearinghouse, the provider may call Customer Service at 1-800- 424-5891.

MCC01 will be our Payer ID for Change Health, Ability and WCEDI.

Change Healthcare link:

https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-eft-enrollment-forms

Timely Filing

Claims for services provided to MCC of AZ members should be submitted within six months (180 days) of the date of service unless otherwise agreed upon in the Participating Provider Agreement. If not otherwise defined in the Participating Agreement and/or in the case of a Non-Participating Provider who provides covered services to an MCC of AZ member, claims must be received within 12 months (365 calendar days) to be considered for processing and payment.

Timely Filing Exception Considerations

  1. Coordination of Benefits - When a member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.
  2. Member with Retroactive Eligibility – When a member becomes eligible for an AHCCCS Complete Care program after the date of service but their coverage is backdated to include the date of service, the time frame for timely filing begins on the date MCC of AZ receives notification from the enrollment broker of the member’s enrollment.
  3. Other (Good Cause) – MCC of AZ will consider exceptions on a case by case basis for other causes of filing delays, such as incorrect information provided by official sources.

Clean Claim

A claim is considered clean when the service is billed on the appropriate CMS form (CMS-1500, 1450 or UB04), with current coding standards in the required form field and any required attachment or supporting documentation necessary to properly process and adjudicate the claim(s).

By definition, a “clean” claim is a claim that will not require MCC of AZ to investigate or update in order to apply proper adjudication and payment. Clean claims must contain all of the basic information necessary as follows:

  • Current industry standard data coding
  • Attachments appropriate for submission and procedural circumstance
  • Completed data elements field required for the CMS-1500, CMS- 1450 or UB04

A claim is considered “unclean” if one or more of the following conditions exist due to a good faith determination and/or dispute regarding:

  • The standards or format used in the completion or submission of the form
  • The eligibility of the person listed for coverage
  • The responsibility of another payer for all or part of the claim
  • The amount of the claim or the amount currently due under the claim
  • The benefits covered
  • The manner in which services were accessed or provided
  • The claim was submitted fraudulently

Correct Form

MCC of AZ requires claims for professional services to be submitted using the CMS-1500 form. Claims for hospital/facility services (or other ancillary services) should be submitted using the CMS-1450 or UB04.

Provider-Specific Billing Instructions and Manuals

MCC of AZ follows AHCCCS guidance regarding Billing and Reimbursement. AHCCCS-specific provider billing instructions and manuals as well as other coding instruction resources are available on the AHCCCS website at: https://www.azahcccs.gov/Shared/Downloads/ACOM/PolicyFiles/200/203v2.pdf

https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/FFS_Chap04GeneralBillingR ules.pdf

Please visit www.MCCofAZ.com/Provider/ for provider-specific resources and trainings.

Adherence to provider and service-specific billing instructions as defined ensures that the required MCC of AZ encounter data will be accepted by AHCCCS and/or the state’s encounter data warehouse.

Coordination of Benefits

MCC of AZ is the payer of last resort. When the member has commercial insurance coverage, providers must bill the commercial insurance first. This includes children’s early intervention services, with the exception of:

  • Services federally required to be provided at public expense, as is the case for:
    • Assessment/Evaluation
    • Development or review of the Individual Family Service Plan (IFSP)
    • Targeted case management/service coordination
  • Developmental services
  • Any covered early intervention services where the family has declined access to their private health/medical insurance

Coordination of benefits is not applicable to Arizona Vaccines for Children (AVFC) claims submitted by AVFC providers. MCC of AZ will pay these claims.

Balance Billing

Members must not be held responsible for any charges for Medicaid covered services. This includes those circumstances where the provider fails to obtain necessary referrals, prior authorization, or fails to perform other required administrative functions.

Providers may not balance bill MCC of AZ members for coinsurance, copayments, deductibles, financial penalties, or any other amount. Refer to Section 4: Provider Roles and Responsibilities in the provider handbook.

For non-covered services, Participating Providers must inform an MCC of AZ member that a service is not covered by MCC of AZ prior to rendering the service.

Provider Overpayment Refunds

If a provider identifies that a payment by MCC of AZ results in an overpayment, it is the responsibility of the provider to reimburse MCC of AZ for the overpaid amount within the designated time frame dictated in the Participating Provider Agreement and/or overpayment notice. The provider should return the overpayment with a copy of the Remittance Advice (RA) and a cover letter explaining why the payment is being refunded.

Overpayments should be mailed to:

Magellan Complete Care of Arizona

Attention: Network Department

4801 E. Washington St., Suite 225

Phoenix, AZ 85034

Explanation of Remittance Advice

A Provider RA is the MCC of AZ notification to providers upon each claim payment processed during the payment cycle. A separate remit is provided for each line of business in which a provider participates. The RA informs providers of our handling of a claim payment. Providers may elect to receive a claim payment (check) through the mail or electronically.

MCC of AZ generates checks each week. Claims processed during a payment cycle will appear on the RA form as paid, denied or reversed. Adjustments to incorrectly paid claims may reduce the check amount or cause a check to not be issued.

Information contained on the RA may include, but not be limited to, the following:

  • Claims adjudicated by MCC of AZ, including claims paid, denied, reversed, adjusted or voided
  • Summary of amount processed for this payment cycle
  • An action code that describes in more detail the results of the claim determination
  • Remit date
  • Processed amount is the total amount processed for each claim represented on the remit
  • Claims disputes rights
  • Billing provider ID number
  • AHCCCS ID number
  • Check date
  • Member/Patient Name
  • Birthdate
  • Account number
  • Check date
  • Provider Name
  • Claim status
  • Claim number
  • Service code
  • Quantity billed
  • Amount billed
  • Excluded and non‐allowed amounts
  • Allowed amount
  • Amount of other payer’s payment
  • Member co‐pay/deductible/coinsurance
  • Adjustment/denial code

Pursuant to the Provider Agreement and the provider handbook, providers are urged to carefully review the RA and compare to prior remits to ensure proper tracking and posting of adjustments as providers remain responsible for reconciling their accounts.

Providers have the ability to direct funds to a designated bank account directly through electronic funds transfer (EFT). MCC of AZ encourages providers to take advantage of EFT. Since EFT allows funds to be deposited directly into your bank account, you will receive payment sooner than waiting for a mailed check. You may enroll in EFT by submitting an EFT application form, available on our provider portal.

Providers who have questions about claims payment, information contained on the RA or about resubmitting a claim should contact MCC of AZ Claims Resolution Services Unit at 1‐800-424-5891.

Reimbursement Under the Vaccines for Children (VFC) Program

The national Vaccines for Children (VFC) program was established to help raise childhood immunization rates in the United States and to keep children up to age 19 in their medical home. The entitlement program is associated with each state’s Medicaid plan. Children who are eligible for the VFC program are entitled to receive pediatric vaccines that are recommended by the Advisory Committee on Immunization Practices.

PCPs who administer childhood immunizations should be enrolled in the AVFC program, administered by the Arizona Department of Health Services, and participate in the statewide immunization registry database. For more information and to register, contact the Arizona Department of Health Services at 602-364-3676.

Behavioral Health Service Claim Information

Information on submitting a behavioral health service claim can be found here.