A sample of the 18 AHCIP rules in v12, with the denial code or underpayment each one catches and the AHCIP General Rule (GR) reference. The full list is in /how-it-works.
When a procedure and an E/M visit are billed on the same day, the E/M needs a -25 modifier to indicate it's a separately identifiable service. Without it, AHCIP bundles the visit into the procedure and pays $0 for it.
AHCIP reference: General Rule 1.4 (modifier-25 unlock). Denial code: bundled.
A GP performing a procedure same-day as an office visit should declare the CMGP modifier. Without it, the visit line is reduced to 50% under AHCIP GR 4.4.
AHCIP reference: General Rule 4.4. Denial code: 50% visit-line underpayment.
Specialist visit billed but the clinical note mentions a referral. AHCIP denies with 80G if the referring_provider_npi is missing.
AHCIP reference: GR 6.2 (referring provider NPI required for specialist claims). Denial code: 80G.
Service billed to AHCIP that is non-insured (e.g. cosmetic, AWV without proper eligibility, certain travel immunizations). The claim is rejected in full rather than underpaid.
AHCIP reference: Schedule of Medical Benefits, section on non-insured services. Denial code: 05A.
Telehealth visit billed without documented patient consent. AHCIP requires explicit consent for virtual visits.
AHCIP reference: GR 3.3 (telehealth consent). Denial code: 31.
Lab billed without an AHCIP-eligible diagnosis pointer. Common in family medicine where in-house lab is high-volume.
AHCIP reference: Schedule of Medical Benefits, lab section. Denial code: 39 or 39DA.
Line item with no diagnosis pointer. The procedure is medically necessary, but the linkage to a specific diagnosis is missing. Bundling risk.
AHCIP reference: GR 6.1 (diagnosis linkage). Denial code: 37 or 37A.
Patient eligible for a preventive service (AWV, HMV, well-baby) that wasn't billed. Zorva flags when the patient is age-eligible and there's no AWV / HMV code in the last 12 months.
AHCIP reference: AWV and HMV billing rules in the Schedule of Medical Benefits.
Specialist consult billed without prior-referral documentation. AHCIP requires the referring provider's note on file.
AHCIP reference: GR 6.2 (specialist referral). Denial code: 63 or 63A.
Visit billed outside the standard 9–5 window without the after-hours premium code. Common in walk-in components of family-medicine practices.
AHCIP reference: After-hours premium schedule. Denial code: not applicable (underpayment).
Same procedure billed twice in a 30-day window for the same patient. The clinic may not realize one was a duplicate.
AHCIP reference: GR 6.4 (duplicate procedure detection). Denial code: 80G or duplicate-recovery.
Service billed that is age-restricted (e.g. pediatric vaccine on an adult, geriatric screening on a young patient). AHCIP rejects in full.
AHCIP reference: Schedule of Medical Benefits, age-restricted codes. Denial code: 67A.