Federal Emergency Services Program

Claims Documentation Requirements

To qualify for payment rendered to persons covered under the Emergency Services Program, all of the following conditions must be met:

1. Verify the person is eligible for AHCCCS Emergency Services Program on the date of service, and

2. Be sure the medical record accurately documents the emergency and meets the federal guidelines for an emergency, and

3. Be sure to check the “emergency” box on the HCFA 1500 claim form (field 24-I) or on the UB92 identify admit type 1 for both inpatient and outpatient claims (field 19), and

4. ALL PROVIDERS billing on a HCFA 1500 form or a UB92 form should attach supporting documentation* to the claim form. Additional instructions can be obtained in the AHCCCS Fee-for-Service Provider Manual or from the AHCCCS Claims Customer Service Unit.

* Examples of the documentation can be an operative report, progress note, or summary letter, etc. It is expected that this documentation will verify the medical emergency as defined in the federal guideline. Do not attach the entire medical record.

The Federal Definition for Emergency Services:

Emergency services are services that:

1. Are medically necessary, and
2. Result from the sudden onset of a health condition with acute symptoms, and
3. Which, in the absence of immediate medical attention,
4. Is reasonably likely to result in at least one of the following:

• Placing the individual's health in serious jeopardy, or

• Serious impairment to bodily functions, or

• Serious dysfunction of any bodily organ or part.

Based on the patient's particular circumstances at the time the service is rendered, the service must fully meet all the federal requirements for treatment of an emergency medical condition as defined above to be considered for payment.

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