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SDOH Code Reminder For Claims Submissions

SDOH Code Reminder for Claims Submissions

Many of you are now regularly billing Social Determinants of Health diagnoses codes. THANK YOU!


Social Determinants of Health are the conditions in which a person is born into, grows, lives, works and ages into that impact their health. Social Determinants of Health take into account factors such as the member’s education, employment, physical environment, socioeconomic status, and social support network.


AHCCCS began monitoring for the presence of Social Determinants of Health ICD-10 codes on April 1, 2018 and to request that providers submit identified Social Determinant of Health ICD-10 diagnosis codes on Medicaid claims in order to comply with state and federal coding requirements.


AHCCCS has provided guidance that Social Determinants of Health codes are NOT to be used as primary ICD-10 diagnosis codes. Social Determinants of Health codes should instead be listed secondary, tertiary, etc., ICD-10 codes. Heath plans that submit encounters to AHCCCS for claims where a Social Determinant of Health diagnosis is in the primary position will receive a sanctionable encounter pend.


As a result, effective immediately, if a Social Determinant of Health ICD-10 code is listed as the primary diagnosis code on a claim, we will deny the claim with the denial code EXEC, which is defined as Diagnosis Cannot be Used as a Primary Diagnosis, Please Resubmit. In addition, for claims that have already been adjudicated with the Social Determinants of Health Code in the primary position and that claim has pended with AHCCCS, AzCH-CCP will begin to reverse and recoup the claims in order to resolve these sanctionable pends.


If you receive a recoup or a denial, please resubmit a corrected claim with the corresponding ICD-10 diagnosis code in the primary position and the Social Determinant of Health code(s) listed in subsequent positions.


For more information on Social Determinants of Health please refer to the following resources on the AHCCCS website:


June 2021 AHCCC Provider Education on Social Determinants of Health


https://azahcccs.gov/Resources/Downloads/DFMSTraining/2021/SocialDeterminantsofHealth.pdf


FFS Provider Billing Manual-Ch. 4-General Billing Rules Exhibit 4-1 Social Determinants of Health ICD-10 List


https://www.azahcccs.gov/PlansProviders/Downloads/FFSProviderManual/Exhibit_4-1SocialDeterminantsHealthICD-10List.pdf


Thank you for following the AHCCCS guidance regarding submission of these very important codes. We appreciate everything you do to care for our members.


If you have questions regarding the information contained in this update, please contact our Provider Customer Service Center at (866) 796-0542. If you need your assigned Provider Engagement Specialist contact information, please email us atAzCHProviderEngagement@azcompletehealth.com

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