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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAHCCCS FQHC/RHC Reconciliation Update | OpenPayer
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    CurrentArizona Health Care Cost Containment SystemPolicy N/A

    Federally Qualified Health Center and Rural Health Clinic Annual Reconciliation

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    Governs AHCCCS’s annual reconciliation of Medicaid reimbursements for Federally Qualified Health Centers and Rural Health Clinics providing covered services to Medicaid enrollees through Managed Care Organizations, including visit, payment, audit, balance, payment, and recoupment calculations.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyFederally Qualified Health Center and Rural Health Clinic Annual Reconciliation
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2022
    Next Review DateN/A
    Key ActionAfter receiving the Preliminary Reconciliation, notify AHCCCS by email no later than the fourth Friday of September whether the reconciliation is accepted or ARRD/AUP will be submitted.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AnnuallyPreliminary reconciliation cycle
    Oct 1–Sep 30Fiscal-year dates of service included
    Dec 31Payment or recoupment deadline when the preliminary reconciliation is accepted
    Feb 28

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Payment or recoupment deadline for ARRD/AUP reconciliations submitted by January 31
    T1015HCPCS code used to determine qualifying visit counts

    Reconciliation Eligibility and Revenue Rules

    Eligible FQHC/RHC Visit

    A visit is eligible for reconciliation when ALL of the following are met:

    ALL of the following

    • The service is an AHCCCS-covered ambulatory service.
    • The service meets the FQHC/RHC encounter definition and is not merely incident to another service.
    • The service is provided in an outpatient setting, including the patient's residence or an institution used as the patient's home; services provided in a hospital are excluded.
    • The service is not case management, group therapy, group services, or an inpatient service.

    Visit-Count Calculation

    AHCCCS counts qualifying visits from PMMIS data for the fiscal year being reconciled:

    ALL of the following

    • Count all T1015 units from the approved/adjudicated data file.
    • Count T1015 units from the administrative denial file.

    • Exclude when

      • The visit is an ineligible same-day FQHC/RHC duplicate under the same primary diagnosis code.
      • The Alt HP Value paid amount is $0.

    Reconciliation Revenue Rules

    Amounts reported for reconciliation must satisfy ALL of the following requirements:

    ALL of the following

    • Include Alt HP Value, third-party payments for PPS-eligible CPT/HCPCS services, quarterly supplemental payments, and other revenue from all payers associated with reported visits.
    • Do not include claims billed directly to AHCCCS or their associated Fee-for-Service revenue.

    Codes, Dates, and Reconciliation Calculations

    Qualifying visit-count codeHCPCSCovered
    T1015HCPCS code used to count FQHC/RHC qualifying visits, including paid/adjudicated units and eligible administrative-denial units.
    PPS-eligible servicesmixedCovered
    No codes listed
    Excluded or non-PPS-eligible servicesmixedNot Covered
    No codes listed
    Reconciliation Period
    Fiscal-year periodOctober 1 through September 30
    Dates includedAll dates of service in the fiscal year being reconciled
    Reconciliation cycleAHCCCS calculates the Preliminary Reconciliation in September each year
    Qualifying Visit Calculation
    Visit-count basisTotal qualifying HCPCS T1015 units
    Rate appliedPPS rate in effect for the fiscal year being reconciled

    Provider Submission and Response Requirements

    Billing Rule

    Respond to the Preliminary Reconciliation

    Following receipt of the Preliminary Reconciliation, notify AHCCCS by email no later than the fourth Friday of September whether the FQHC/RHC accepts the Preliminary Reconciliation or will submit ARRD/AUP.

    • Choose one response: accept the Preliminary Reconciliation or submit ARRD/AUP.
    • Send the notification by the fourth Friday of September.
    Documentation Required

    Submit ARRD/AUP documentation

    If the FQHC/RHC elects to submit ARRD/AUP, submit all required AUP and ARRD documentation to AHCCCS by the fourth Wednesday in November. Submissions after that date are subject to delayed payment dates specified in the policy.

    Key Reconciliation Terms

    Administrative Denial
    Administrative denialAn encounter denied for administrative reasons
    Underlying serviceThe claim is for a valid Medicaid-covered service
    Member statusThe service was provided to an eligible member
    Alt HP Value
    Non-capitated arrangementThe amount paid by AHCCCS health plans to the provider
    Sub-capitated arrangementThe AHCCCS-system-generated health plan allowed rate less third-party reimbursement paid on the claim
    Term
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyFederally Qualified Health Center and Rural Health Clinic Annual Reconciliation
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2022
    Next Review DateN/A
    Key ActionAfter receiving the Preliminary Reconciliation, notify AHCCCS by email no later than the fourth Friday of September whether the reconciliation is accepted or ARRD/AUP will be submitted.
    SourceLink
    On This Page
    Reconciliation Eligibility and Revenue RulesCodes, Dates, and Reconciliation CalculationsProvider Submission and Response RequirementsKey Reconciliation Terms
    Calculation
    Total qualifying T1015 units multiplied by the applicable fiscal-year PPS rate
    Preliminary Reconciliation Balance
    Total payable amountThe amount calculated from the total number of qualifying visits multiplied by the applicable PPS rate
    Total amount paidAlt HP Value, applicable third-party payments, and quarterly supplemental payments
    Preliminary balanceTotal payable amount less total amount paid
    • AHCCCS will email AUP and ARRD process instructions by the first Monday in October.
    • A later deadline may apply under the policy.
    Documentation Required

    Meet ARRD/AUP submission deadlines

    ARRD/AUP submissions made no later than January 31 are eligible for payment or recoupment by February 28. AHCCCS may grant an extension when circumstances outside the FQHC/RHC’s control prevent timely submission, provided the clinic submits a written request and explanation before January 31.

    • Without an extension, failure to submit by January 31 results in the Preliminary Reconciliation becoming the final reconciliation.
    • If a deadline falls on a holiday or weekend, it is assumed to fall on the next business day.
    • AHCCCS may adjust subsequent due dates if the Preliminary Reconciliation was delivered after September 30.
    Documentation Required

    Verify reported visit revenue

    Report all revenue received from Medicaid and non-Medicaid payers associated with the reported visits, including applicable payer reimbursements and other revenue. Do not include Fee-for-Service claims revenue, which represents claims billed directly to AHCCCS; the CEO and CFO must certify that the information is true, accurate, and complete.

    • Include revenue from all payors associated with the reported visits.
    • Exclude claims billed directly to AHCCCS and their associated Fee-for-Service revenue.
    • Obtain CEO and CFO signatures and dates on the verification.
    Documentation Required

    Support the AUP review

    For an ARRD/AUP submission, the auditor must reconcile reported visits and reimbursements to supporting patient and payment management system reports, test a statistically significant sample of eligible visits and payments, and submit the complete claims list identifying sampled claims. AUP findings are extrapolated to the total visits and revenue to determine the final reconciliation amount.

    • Verify sampled visits were face-to-face or valid telehealth encounters, occurred in an outpatient setting, involved AHCCCS-enrolled patients, and provided AHCCCS-covered services.
    • Confirm the sample includes no visits billed directly to AHCCCS and that all payments for selected visits are reported.
    • The claims list must include the Claim Number, AHCCCS Health Plan, Medicaid Paid Amount, and Medicare/Other Insurance Paid Amount.
    Alt HP Value
    Encounter or Visit
    Basic definitionA face-to-face encounter with a licensed AHCCCS-registered practitioner during which a covered ambulatory service is provided
    Service limitationThe service must not be incident to another service
    Same-day encountersMultiple encounters with practitioners in the same discipline at the same location generally constitute one visit
    Separate visit exceptionA subsequent encounter is a separate visit when illness or injury requires additional diagnosis or treatment
    Services Incident to a Visit
    Integral supplies and servicesServices and supplies that are an integral, though incidental, part of a physician’s or practitioner’s professional service
    ExamplesMedical supplies, venipuncture, and assistance by auxiliary personnel such as a nurse or medical assistant
    Ancillary servicesOutpatient diagnostic or therapeutic ancillary services provided as an adjunct to basic medical or surgical services
    Examples of ancillary servicesX-ray, medication, and laboratory testing
    Site of Services
    Covered settingsOutpatient settings only
    Included locationsThe patient’s residence, including a skilled nursing facility, nursing facility, or other institution used as the patient’s home
    Excluded settingHospital services are not covered