AHCCCS DFSM Claims Clues - July 2026

REQUIREMENTS: 1. IMMEDIATELY: Billing team must verify system configuration for case management (T1016) billing. Ensure T1016 claims are submitted at the capped fee-for-service rate (NOT at FQHC/RHC all-inclusive per visit PPS rate). Confirm only qualified behavioral health technicians (BHT) or behavioral health paraprofessionals (BHPP) are billing this code. Update internal billing guidelines. 2. IMMEDIATELY: No action needed for denial reason code L243.1. Do NOT resubmit previously denied claims under this code. AHCCCS will automatically reprocess affected claims. Flag any pending L243.1 denials in your system for monitoring. 3. BEFORE ALL FUTURE SUBMISSIONS: Update claim submission protocols for behavioral health claims. When reporting Participating Provider details in the 'Additional Information' field, remove all descriptions of the behavioral health service code. The CPT/HCPCS code alone identifies the service. Train all billing staff to eliminate service descriptions to reduce claim denials and processing delays. 4. BY NEXT PRIOR AUTH REQUEST CYCLE: Revise prior authorization submission procedures. If a prior authorization request is in pending status and the 6-month claim filing deadline is approaching, submit the claim anyway to meet the initial timely filing window. This does NOT supersede the requirement to submit timely prior auth requests—do both. Communicate this dual-submission requirement to providers and front-office staff. 5. ONGOING: Verify providers understand that prior authorization approval does NOT guarantee payment. Claims must still include medical necessity documentation, meet clean claim criteria, and comply with timely filing (12-month resubmission window). Update billing system validation to reject incomplete prior auth requests lacking required clinical notes, lab results, and diagnostic codes. 6. ONGOING: Train billing team to identify which services require prior authorization BEFORE submitting requests. Do NOT submit prior auth for services that never require authorization (office visits, laboratory, x-rays, E&M codes). Reference the Fee For Service Prior Authorization Guidelines.xlsx when in doubt. CONSEQUENCES: Claims lacking proper prior authorization will be denied. Claims submitted after 6-month deadline will not be reprocessable. Unnecessary service descriptions in participating provider fields will cause claim denials and processing delays. Claims without medical necessity documentation will be denied even with prior auth approval.