CurrentArizona Health Care Cost Containment SystemPolicy 310-K

Chapter 18 Federal Emergency Services

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This policy governs AHCCCS Fee-for-Service reimbursement for emergency medical and behavioral health services provided through the Federal Emergency Services Program (FESP), including emergency-service criteria, billing, documentation, maternity, dialysis, and retrospective-review requirements.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChapter 18 Federal Emergency Services

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective Date04/30/2026

Next Review DateN/A

Key ActionFor outpatient dialysis, submit the signed Initial Dialysis Case Creation Form to AHCCCS and complete the Monthly Certification of Emergency Medical Condition for the month of service.

SourceLink

POLICY UPDATE CHANGES

The April 30, 2026 revision updated layout, branding standards, and links.

The March 22, 2021 revision updated the claim-form field number used to document emergency services.

The January 8, 2018 revision updated documentation requirements, telephone numbers, and formatting.

4Federal emergency-condition outcome criteria

4Permitted FESP labor and delivery CPT codes

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CurrentArizona Health Care Cost Containment SystemPolicy 310-K

Chapter 18 Federal Emergency Services

Customize your policy alerts

Sign up for Arizona Health Care Cost Containment System Policy 310-K alerts

Get alerted when Policy 310-K changes without checking for updates manually.

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Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChapter 18 Federal Emergency Services

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective Date04/30/2026

Next Review DateN/A

Key ActionFor outpatient dialysis, submit the signed Initial Dialysis Case Creation Form to AHCCCS and complete the Monthly Certification of Emergency Medical Condition for the month of service.

SourceLink

POLICY UPDATE CHANGES

The April 30, 2026 revision updated layout, branding standards, and links.

The March 22, 2021 revision updated the claim-form field number used to document emergency services.

The January 8, 2018 revision updated documentation requirements, telephone numbers, and formatting.

4Federal emergency-condition outcome criteria

4Permitted FESP labor and delivery CPT codes

Potential actions after retrospective determination that no emergency existed

3 times/weekMinimum dialysis frequency referenced in the emergency-condition certification

Covered Services and Eligibility Criteria

Federal emergency medical or behavioral health services

Covered only when all of the following emergency-condition elements are met.

Qualifying emergency condition

Serious consequence
- Serious jeopardy: The member's health is placed in serious jeopardy.
- Impairment of bodily functions: There is serious impairment to bodily functions.
- Organ or body-part dysfunction: There is serious dysfunction of any bodily organ or part.
- Behavioral-health physical harm: There is serious physical harm to self or another person.
  Applies to behavioral health conditions.

Outpatient dialysis

Outpatient dialysis coverage requires all of the following.

Dialysis emergency certification

Initial case creation form: The completed and signed Initial Dialysis Case Creation Form is submitted to AHCCCS.
See AMPM Exhibit 1120-1.
Monthly certification: The completed and signed Monthly Certification of Emergency Medical Condition is maintained for the month in which outpatient dialysis is received.
See AMPM Exhibit 1120-2.
Qualifying consequence without dialysis
- Serious jeopardy: The member's health would be placed in serious jeopardy.

Routine prenatal services are not covered under the Federal Emergency Services Program (FESP).

FESP services remain subject to all applicable service exclusions and limitations, including the limitations on inpatient hospital services described in R9-22-204 and AMPM Chapter 300, Policy 310-K, Hospital Inpatient Services.

Services that may be medically necessary but do not fully meet the federal definition of an emergency medical condition are not covered under FESP.

Billing Codes and Claim Requirements

Covered CPT CodesCPTCovered

59409	Vaginal delivery only
59514	Cesarean delivery only
59612	Vaginal delivery only, after previous Cesarean delivery
59620	Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery

Emergency claim identification fieldsmixed

CMS-1500 Field 24C	Emergency box must be checked
UB-04 Field 14	Admit Type must be entered as 1 to identify services billed as an emergency

Outpatient Dialysis Frequency

Required frequencyAt least three times per week

Certification opinionThe treating physician must state that failure to receive dialysis at least three times per week would reasonably be expected to result in a qualifying serious consequence.

Qualifying consequencesSerious jeopardy to health, serious impairment of bodily function, or serious dysfunction of a bodily organ or part.

Documentation, Certification, and Denial Risks

Documentation Required

Outpatient Dialysis Form Requirements

For outpatient dialysis, prior authorization is met when the treating physician submits the completed and signed Initial Dialysis Case Creation Form to AHCCCS and the treating provider completes and signs the Monthly Certification of Emergency Medical Condition for the month in which services are received. Use AMPM Exhibit 1120-1 for the initial form and Exhibit 1120-2 for the monthly certification form.

Submit the completed and signed Initial Dialysis Case Creation Form to AHCCCS.
Complete and sign the Monthly Certification of Emergency Medical Condition for each month outpatient dialysis services are received.

Documentation Required

Support the Emergent Nature of Services

Submit claims with documentation supporting the emergent nature of the services, or ensure AHCCCS has remote access to the medical records. Documentation must verify the medical emergency under the federal criteria; do not attach the entire medical record.

Examples include emergency room records, physician progress notes, operative reports, OB triage records, and discharge summaries.

Federal Emergency Services Program Overview

The Federal Emergency Services Program (FESP) covers only services that meet the federal definition of an emergency medical or behavioral health condition. The condition must involve acute symptoms of sufficient severity, including extreme pain, such that the absence of immediate medical attention could reasonably be expected to place the member’s health in serious jeopardy, cause serious impairment of bodily functions, cause serious dysfunction of an organ or body part, or— for behavioral health conditions—cause serious physical harm to the member or another person.

Key Definitions

Acute

Acute symptomsSymptoms that have arisen quickly.

DurationAcute symptoms are short-lived.

Policy definitionAcute means symptoms that have arisen quickly and which are short-lived.

Chronic

DefinitionA health-related state that is not acute.

Relationship to acuteChronic describes a health-related state that does not meet the definition of acute.

Policy wordingChronic means a health-related state that is not acute.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyChapter 18 Federal Emergency Services

Policy CodePolicy N/A

Change TypeAdministrative updateno material clinical or coverage change

Effective Date04/30/2026

Next Review DateN/A

Key ActionFor outpatient dialysis, submit the signed Initial Dialysis Case Creation Form to AHCCCS and complete the Monthly Certification of Emergency Medical Condition for the month of service.

SourceLink

On This Page

Serious impairment: There would be serious impairment of bodily function.

Serious dysfunction: There would be serious dysfunction of a bodily organ or part.

CMS-1500 billers must check the emergency box in Field 24C; UB-04 billers must enter “1” in Admit Type, Field 14.

Claims are reviewed case by case by AHCCCS Administration on a fee-for-service basis.

Documentation Required

Retain and Complete the Monthly Dialysis Certification

The treating physician must retain the signed monthly certification in the member’s records. The certification must state the physician’s opinion that failure to receive dialysis at least three times per week would reasonably be expected to cause a qualifying serious health consequence.

The opinion must identify at least one expected consequence: placing the member’s health in serious jeopardy; serious impairment to bodily function; or serious dysfunction of a bodily organ or part.

Denial Risk

Failure to Establish a Qualifying Emergency

Every FESP emergency service is subject to retrospective review, and each claim must meet the federal definition of an emergency medical or behavioral health condition. Services may be medically necessary but still fail to qualify as an FESP emergency; claims submitted without supporting documentation may be denied because AHCCCS cannot verify the emergency nature of the service.

AHCCCS may deny or recoup payment when the service did not meet the emergency definition.
AHCCCS may provide provider feedback and education.
A pattern of inappropriate billing may be referred for investigation.
Emergency services must meet the applicable federal criteria at the time of service; prior authorization cannot be required for emergency services.

Billing Rule

Noncovered Prenatal and Improperly Billed Maternity Services

Routine prenatal services are not covered under the FES Program. For FESP members, providers should bill only the designated delivery-only codes for labor and delivery; global delivery-code claims are systematically reduced to the delivery-only reimbursement rate.

59409 — vaginal delivery only.
59514 — cesarean delivery only.
59612 — vaginal delivery only, after previous cesarean delivery.
59620 — cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.
Claims using global delivery codes are reduced to the delivery-only reimbursement rate.

Emergency Medical or Behavioral Health Condition

Condition typeA medical condition, including labor and delivery, or a behavioral health condition.

SymptomsThe condition manifests acute symptoms of sufficient severity, including extreme pain.

Immediate-care standardThe absence of immediate medical attention could reasonably be expected to result in a qualifying serious consequence.

Qualifying consequencesSerious jeopardy to the member’s health; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or serious physical harm to self or another person for behavioral health conditions.