016.06.02 Ark. Code R. § 009 - State Plan Transmittal #2001-033 and Developmental Rehabilitation Services Provider Manual
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
CATEGORICALLY NEEDY
Developmental Rehabilitation Services may be provided in the recipient?s home, in the community, or in a clinical setting. These services require prior authorization.
Extension of the benefit limit will be provided if medically necessary.
Developmental Rehabilitation Services are early intervention services for eligible Medicaid recipients under three years of age that have been identified as medically necessary and recommended by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law. This program covers two basic services:
This service provides a diagnostic process necessary for the purpose of determining a child?s initial and continuing eligibility, developmental status and need for medically necessary developmental services. This includes:
parent/family to promote acquisition of skills in developmental areas (cognitive, motor, adaptive, communication). These rehabilitative services include:
Developmental Rehabilitation Services are early intervention services for eligible Medicaid recipients under three years of age that have been identified as medically necessary and recommended by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law. This program covers two basic services:
This service provides a diagnostic process necessary for the purpose of determining a child?s initial and continuing eligibility, developmental status and need for medically necessary developmental services. This includes:
to promote acquisition of skills in developmental areas (cognitive, motor, adaptive, communication). These rehabilitative services include:
who holds a minimum of a high school diploma and has two years experience working with children with disabilities. The Developmental Therapy Assistant must complete an initial 24 hour training course and pass a competency based assessment with a minimum score of 80%. The Assistant must work under the supervision of the Developmental Therapist and must be supervised 10% of the time spent in direct interaction with the recipient. A Developmental Therapy Assistant may provide only Therapeutic Activities services.
Developmental Rehabilitation Services may be provided in the recipient?s home, in the community, or in a clinical setting. These services require prior authorization.
Extension of the benefit limit will be provided if medically necessary.
Physicians' services, whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere
The benefit limit will be considered in conjunction with the benefit limit established for rural health clinic services, medical services furnished by a dentist, office medical services furnished by an optometrist and certified nurse midwife services. Recipients will be allowed twelve (12) visits per State Fiscal Year for physicians' services, medical services provided by a dentist, rural health clinic services, office medical services furnished by an optometrist, certified nurse midwife services or a combination of the five. For physicians? services, medical services provided by a dentist, office medical services furnished by an optometrist, certified nurse midwife services or rural health clinic core services beyond the 12 visit limit, extensions will be provided if medically necessary. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
The extension of benefits described above will be handled in the following manner:
The following diagnoses are considered to be categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm (code range 140.0 through 208.91); HIV infection (code range 042.0 through 044.9) and renal failure (code range 584.5 through 586). All other diagnoses are subject to prior authorization before benefits can be extended.
Medical and surgical services furnished by a dentist (in accordance with Section 1905 (a)(5)(B) of the Act).
Medical services furnished by a dentist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for recipients age 21 and older.
The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, rural health clinic services, office medical services furnished by an optometrist and certified nurse midwife services. Recipients will be allowed twelve (12) visits per State Fiscal Year for medical services furnished by a dentist, physicians' services, rural health clinic services, office medical services furnished by an optometrist, certified nurse midwife services or a combination of the five. For physician services, medical services provided by a dentist, office medical services furnished by an optometrist, certified nurse midwife services or rural health clinic core services beyond the 12 visit limit, extensions will be provided if medically necessary. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
Surgical services furnished by a dentist are not benefit limited.
Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum charge allowed. The Title XIX maximum for these services is based on the Child Health Management (CHMS) reimbursement methodology.
ARKANSAS MEDICAID PROGRAM
DEVELOPMENTAL
REHABILITATION SERVICES
PROVIDER MANUAL
DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL SERVICES
GENERAL INFORMATION
The purpose of Section I is to explain the role the provider plays in the Arkansas Medicaid Program. The information conveyed will provide the users with an understanding of Medicaid program policy. It also contains information the provider may need to answer questions that individuals often ask about the Medicaid Program.
When fully utilized, this manual will be an effective tool for the provider office personnel. For instance, it may serve as a tool for training billing clerks by providing them with a basic knowledge of the Medicaid Program, covered and non-covered services, special billing procedures and detailed instructions for accurate completion of claims. Proper use of this manual will result in a reduction of errors in claim filing, thus expediting payment.
The manual will be an effective tool if it is properly maintained. The fiscal agent, EDS, will mail each provider all manual updates when produced. These updates should be promptly filed in the manual according to the procedures discussed in Section 101.100. Information that has not yet been incorporated into this manual is issued via Official Notices and Remittance Advice (RA) messages. Official Notices and RAs are filed in the back of this manual.
All manuals, Official Notices and RAs are also available for downloading, without charge, from the Medicaid Home Page Web Site at www.medicaid.state.ar.us. These documents are maintained in separate folders on the Web Site. Downloading all three sets of documents for the program in question will ensure the provider of having the most current policy information available.
Three major areas are covered in Section I.
The manual is designed to accommodate new pages as further interpretations of the law and changes in policy and procedures are made. These changes are released to the provider in the form of a manual update, an Official Notice or an RA (remittance advice) message. The fiscal agent, EDS, will issue these changes as directed by the Division of Medical Services (DMS). Periodically, all changes made to Medicaid policy will be promulgated and incorporated into each Medicaid provider manual as policy.
An update transmittal letter will accompany each update to this manual. Updates will have sequential identification numbers assigned, e.g., Update Transmittal #1. The transmittal letter identifies the new page numbers to be added and/or the pages to be replaced and provides any other information about the update being made. An Update Control Log has been provided in the back of the manual to record updates received. When an update package is received, the updated manual pages should be filed in the provider manual, removing the pages being revised. The effective date should be entered on the Update Control Log opposite the appropriate update number. When the update is complete, the transmittal letter should be filed immediately after the update control log in ascending sequence by update number.
Effective for dates of service on or after July 1, 1999, extra copies of paper manuals, manual updates and official notices may be purchased through EDS. EDS will charge $32.50 per manual. There will be an annual charge of $35.00 for manual updates and official notices. The cost for a provider manual with updates/official notices will be $67.50. Requests for manuals, updates and official notices may be sent to EDS, Manual Order, PO Box 8036, Little Rock, AR 72203-8036.
All manuals, manual updates, Official Notices and RAs are available for downloading, without charge, from the Arkansas Medicaid Home Page Web Site at www.medicaid.state.ar.us.
Section 7 of Act 280 of 1939 and Act 416 of 1977 gave authority to the State of Arkansas, the Division of Social Services, now referred to as the Department of Human Services, to establish and maintain a medical care program for the indigent. It also gave authority to the Commissioner of Social Services, now called the Director of the Department of Human Services, to set forth and administer the rules and regulations necessary to carry out such a program. Out of this legislation, the Arkansas Medical Assistance Program was formed.Title XIX of the Social Security Act provides for federal grants to the states for their medical assistance programs. Originally enacted by the Social Security Amendments of 1965 and Public Law 89-97, Title XIX was approved on July 30, 1965. Although officially entitled ?Grants to States for Medical Assistance Programs,? this title is popularly called ?Medicaid.? The stated purpose of Title XIX is to enable the states to furnish the following:
Thus, the Medicaid Program is a joint federal-state program that provides necessary medical services to eligible persons who would not be able to pay for such services.
In Arkansas, the Division of Medical Services administers the program and is responsible for all parts of the program. Within the Division, the Office of Long Term Care is responsible for nursing homes.
The Arkansas Medicaid Program provides, with limitations, the following services:
Federally Mandated Services
* Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for Persons
Under Age 21 (Child Health Services)
* Family Planning Services
* Federally Qualified Health Center (FQHC) Services
* Home Health Services
* Inpatient Hospital Services
* Laboratory and X-Ray Services
* Nurse-Midwife Services
* Nurse Practitioner Services
* Nursing Facility Services for Individuals Age 21 or Older who are categorically eligible (e.g., Aid to the Aged, Blind or Disabled)
* Outpatient Hospital Services
* Physician Services
* Rural Health Clinic Services
Optional Services
* Ambulatory Surgical Center Services
* Audiological Services (Arkansas Medicaid limits this service to persons under 21
in the Child Health Services (EPSDT) Program) * Targeted Case Management for Pregnant Women
* Targeted Case Management Services for Adults with a Developmental Disability
* Targeted Case Management Services for Recipients Age 60 and Older
* Certified Registered Nurse Anesthetist (CRNA)
* Child Health Management Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program) * Chiropractic Services
* Dental Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program) * Developmental Day Treatment Clinic Services (DDTCS)
* Domiciliary Care Services
* Durable Medical Equipment
Optional Services
* End-Stage Renal Disease (ESRD) Facility Services
* Hyperalimentation Services
* Hospice Services
* Inpatient Psychiatric Services for Individuals Under Age 21
* Inpatient Rehabilitative Hospital Services
* Intermediate Care Facility Services for Mentally Retarded
* Medical Supplies
* Nursing Facility Services for patients under 21 years of age
* Occupational, Physical, Speech Therapy Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Personal Care Services
* Podiatrist Services
* Portable X-Ray Services
* Private Duty Nursing Services (for Ventilator-Dependent of all ages and High-
Technology Non-Ventilator Dependent for persons under 21 in the Child Health Services (EPSDT) Program)
* Prescription Drugs
* Psychologist Services (Arkansas Medicaid limits this service to persons under 21
in the Child Health Services (EPSDT) Program)
* Rehabilitative Services for Persons with Mental Illness (RSPMI)
* Rehabilitative Services for Persons with Physical Disabilities (RSPD)
* Transportation Services (Ambulance, Non-Public)
* Ventilator Equipment
* Visual Services
The following Medicaid covered services are available for recipients under age 21 through the Child Health Services (EPSDT) Program:
* Eye Prostheses
* Repairs and Replacements of Eyeglasses
* Hearing Aid Services
Medical Clearance
Audiological Exam
Purchase of Hearing Aid * Immunizations
* Allergy/Desensitization Injections and Antigens
* Child Health Management Services
* Inpatient Psychiatric Care
* Cochlear Implantation
* Durable Medical Equipment (DME), e.g. specialized wheelchairs
* Psychology Services
* Chiropractic Services
* Occupational, Physical, Speech Therapy Services
Additional services may be covered if determined to be medically necessary as a result of a Child Health Services (EPSDT) screening/referral. These services include, but are not limited to:
* Targeted Case Management Services for Recipients Under the Age of 21
* Orthotic Appliances
* Prosthetic Devices
* Respiratory Care Services
The Division of Medical Services (DMS) encourages all Medicaid providers to participate in providing Child Health Services (EPSDT) screening services to eligible Medicaid recipients. DMS provides patient outreach, including assistance in scheduling screening appointments and providing transportation for the recipients to all providers? offices. Except in certain counties that require a primary care physician (PCP) referral, recipients have freedom of choice in selecting a provider for screening services. To make certain this occurs, all local county offices will be given lists of providers who have agreed to accept referrals and provide Child Health Services (EPSDT) screenings. This list will be updated as additions, deletions and address and/or telephone number changes occur. Information regarding PCP referrals is located in Sections 180 through 187. The list of counties requiring a PCP referral is located in Section 184.
A complete screening package includes the following components as appropriate for the age and sex of the child:
All of the components listed above are required for a complete Child Health Services (EPSDT) medical screen. The tests and procedures used in screening are intended to be quick, inexpensive and easy to administer. They are not necessarily intended to provide conclusive proof of a problem or abnormality, only the indication that one may exist.
Cases, in which problems or abnormalities are indicated, should be referred for diagnosis. If the child is receiving care from a participating Child Health Services (EPSDT) Medicaid provider, then screening, diagnosis and treatment may be provided by that same practitioner.
Providers billing Medicaid for diagnosis or treatment must certify that their services result from a Child Health Services (EPSDT) screening or referral. The certification is a matter of entering ?Y? in the ?EPSDT Indicator? field in the AEVCS format. Field numbers (#s) and valid values for each claim type/provider type are:
Individuals interested in providing Child Health Services (EPSDT) screening services or receiving more information, may call (501) 682-8297 or 1-800-482 -1141.
The following services are available for eligible recipients through Medicaid Home and Community Based 2176 Waivers:
ElderChoices has been designed for individuals age 65 and over, who, without the services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain Medicaid eligible individuals at home in order to preclude or postpone institutionalization.
ElderChoices eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
More detailed information may be found in the ElderChoices manual.
The Developmental Disability Services Alternative Community Services (DDS-ACS) waiver has been designed for individuals who, without the services, would require institutionalization and could not otherwise reside in the community. Individuals eligible for the services must not be residents of a hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).
DDS-ACS eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
Services supplied through this program are:
More detailed information may be found in the DDS-ACS manual.
The Alternatives for Adults with Physical Disabilities (APD) Waiver has been designed for disabled individuals age 21 through 64, who receive Supplemental Security Income, or are Medicaid eligible by virtue of their disability and who, without the provision of the services, would require a nursing facility level of care.
APD eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
The services offered through the waiver are:
More detailed information may be found in the APD manual.
The following services are available for eligible recipients through Medicaid 1915(b) waivers:
In the Primary Care Physician Managed Care Program, a Medicaid recipient chooses a physician or single-entity provider who is responsible for the management of the recipient?s total health care. The primary care physician provides primary care services, health education and referrals to other needed medical services when necessary. The PCP also coordinates and monitors prescribed medical and rehabilitation services on behalf of the recipient.
More detailed information, including exemptions in the PCP Program, may be found in Sections 180 through 187 of this manual.
The Medicaid Non-Emergency Transportation (NET) Waiver Services for Medicaid recipients have been established statewide. The program requires Medicaid recipients to contact a local transportation broker to obtain non-emergency transportation for appointments to Medicaid covered services. Transportation brokers are individuals who have contracted with the Division of Medical Services (DMS) to supply the non-emergency transportation (NET) services. The NET broker must provide transportation to and from medical providers for Medicaid covered services.
Transportation providers for the Developmentally Disabled (DD) population may choose to provide services for the Developmentally Disabled population as a fee-for-service provider for transportation to and from a Developmental Day Treatment Clinic Service (DDTCS) facility or contract with the transportation broker in their region to provide non-emergency transportation services. The broker must provide transportation to and from medical providers for Medicaid covered services. Active Children?s Medical Services (CMS) recipients may still use CMS vans for transportation.
The Arkansas Medicaid Non-Emergency Transportation Waiver Program does not include I services for Nursing Facility residents, Intermediate Care Facilities for Mentally Retarded (ICF-MR) residents, Qualified Medicare Beneficiaries (QMBs), Special Low Income Qualified I Medicare Beneficiaries (SMBs), Qualifying Individuals-1s and 2s (QI-1s and 2s), ARKids First participants or Family Planning Waiver recipients.
More detailed information may be found in the Transportation manual and on the Arkansas ' Medicaid Home Page at www.medicaid.state.ar.us.
Programs
The following services are available for eligible individuals through 1115 Research and Demonstration Waiver Programs:
ARKids First was designed to integrate uninsured children, age 18 and under, into the health care system. ARKids First benefits are comparable to those of State employees/Teachers insurance program.
ARKids First providers must be enrolled in the Arkansas Medicaid Program.
Eligibility criteria for ARKids First are:
ARKids First participants are required to select a Primary Care Physician at the time of application.
For more information, refer to the ARKids First provider manual and to the Arkansas Medicaid Home Page at www.medicaid.state.ar.us.
The Arkansas Department of Human Services, in collaboration with the Arkansas Department of Health, established the Family Planning demonstration Waiver Program (Category 69). Eligibility for the program is limited to women of childbearing age who are not currently certified in any other Medicaid category. The target population is women age 14 to age 44, but all women at risk of unintended pregnancy will be allowed to apply for the program. The family income must be at or below 133% of the Federal Poverty Level.
Recipients are not required to have a photo Medicaid identification card. Their Medicaid coverage entitles them to only family planning services with the provider of their choice. They are not required to select a Primary Care Physician (PCP).
Eligible Family Planning Waiver Services recipients remain Medicaid-eligible for the duration of the five year waiver, implemented September 1, 1997, with no reevaluation or change-in-status reporting requirements. Loss of eligibility will occur only when a woman moves from the state, becomes Medicaid eligible in another aid category, becomes pregnant, or requests that her case be closed.
The Utilization Review Section of the Arkansas Medicaid Program has the responsibility for assuring quality medical care for its recipients along with protecting the integrity of both state and federal funds supporting the Medical Assistance Program. The tasks of the Utilization Review Section are mandated by federal regulations. To realize completion of the tasks assigned, a system has been developed which retrospectively evaluates medical practice patterns by comparing each provider's pattern to norms and limits set by all providers of the same specialty. This system utilizes the information that appears on the Medicaid claim. Utilization Review reports are then printed for all providers who exceed the norms or limits established by their peers. The staff evaluating these computerized reports are experienced medical review analysts who work under the direction of the Medicaid Program's Medical Director, and who have access to the expertise of a Peer Review Committee plus a full complement of specialty consultants on an as-needed basis.
Review analysts may, from time to time, contact a provider to supply the provider with information from these reports as well as to request additional information regarding their medical practice. The provider's cooperation in responding to these contacts will allow for greater accuracy in evaluation.
The Utilization Review Section is also responsible for conducting on-site medical audits for the purpose of verifying the nature and extent of services paid for by the Medicaid Program. This section is responsible for researching all inquiries from recipients in response to the Explanation of Medicaid Benefits (EOMB) and for approving requests for procedures requiring prior authorization.
Providers to be reviewed on-site are selected based on Surveillance and Utilization Review Subsystem (SURS) exceptions (the peer weighted computerized program), random sample selection and community referrals. Providers selected for an on-site audit wiU not be notified in advance.
Providers are reminded that pertinent records concerning the provision of Medicaid covered health care services are to be made available during regular business hours to all Division of Medical Services staff acting within the scope and course of their employment. Pertinent records are also to be made available to the Division's contractual review organization, i.e. Arkansas Foundation for Medical Care, Inc. /Professional Review Organization (AFMC/PRO). All Medicaid providers are required to keep and maintain records that fully disclose the fype and extent of services provided to an Arkansas Medicaid recipient. The nature of the reviews will be to primarily review documentation for services provided, but wiU, at certain times, be used to evaluate the medical necessity of the delivered services in the view of the professional staff and consultants of the Medicaid Program.
When records are stored off-premise or in active use, the audited provider may certify, in writing, that the records in question are in active use or off-premise storage and set a date and hour within three (3) working days, at which time the records will be available. However, the audited provider wiU not be allowed to delay production for matters of convenience, including availability of personnel.
The Utilization Review Section is responsible for recovering Medicaid funds from providers when necessary. Situations resulting in recoupment include, but are not limited to, the following:
When recoupment is deemed appropriate, Utilization Review forwards an Explanation of Recoupment to the provider. This explanation includes the name(s) of the patient(s), date(s) of service, date(s) of payment and the reason for the repayment request. Upon receipt of this notice, the provider has thirty days to forward a check for the refund amount or advise the Utilization Review Section of their wish to appeal the recoupment action. Failure to respond to the recoupment notice will result in the recoupment amount being deducted from future Medicaid reimbursement.
Upon receipt of an Explanation of Recoupment, the provider has thirty (30) days in which to supply written notice of appeal. The appeal process is fully explained in the letter that accompanies the Explanation of Recoupment. In brief, the process is as follows:
The purposes of the recipient lock-in rule are to better enable physicians and pharmacists to provide quality care and to assure that the Medicaid Program does not unintentionally facilitate recipient drug abuse or injury from overmedication or drug interaction. An eligible recipient, when correctly identified by application of a utilization algorithm and clinical review to have utilized Medicaid pharmacy services at a frequency or amount not medically necessary, will be required to select one provider of pharmacy services and will be informed that Medicaid will deny claims for pharmacy services submitted by any provider other than the provider selected by the recipient.
At least 30 days before implementing a recipient lock-in, the Division of Medical Services (DMS) or its agents will mail a notice to the recipient at the address listed on the recipient?s eligibility records stating the reasons for the intended action. This notice will state the process for reconsideration by the recipient. If, upon reconsideration by DMS or its agent, the recipient is not satisfied with the decision to be locked in to one pharmacy provider, the recipient will be notified by the State of the process to appeal in accordance with the Department of Human Services Appeal Procedures.
Within 10 days of receiving the notice of the decision to be locked in, the recipient must select one pharmacy provider.
In cases of provider restriction, the provider selected will be notified prior to the actual ?lock-in,? so adequate time is allowed for selection of another provider should the first provider find he cannot provide the needed services. If a recipient fails or refuses to choose one provider, a list of providers used by the recipient will be reviewed and a provider will be chosen.
When a recipient is involved in restriction, the eligibility verification transaction will reflect ?lock-in to other provider.? The restriction will be removed after demonstration by the recipient that the abusive situation has been corrected.
Application of this rule will not result in the denial, suspension, termination, reduction or delay of medical assistance to any recipient.
The cooperation of all providers is necessary to assure that recipients receive notice upon the implementation of any provider restriction. Any provider who believes a particular recipient should be considered for recipient lock-in should notify the Pharmacy Unit/Utilization Review Section, Division of Medical Services, by calling (501) 683-4120/(501) 682-8334.
SOURCES OF INFORMATION
Any questions regarding provider enrollment, participation requirements and/or contracts should be directed to this unit. Their office may be contacted at (501) 682-8502 or 1-800-482 -1141 (In-State WATS).
EDS, a contractor, performs provider relations and the processing of Medicaid claims. EDS Provider Representatives are available to assist providers with detailed billing or policy questions and to schedule on-site technical assistance with AEVCS and NECS software. To contact a representative, providers may call the Provider Assistance Center at 1-800-457 -4454 (In-State WATS) or (501) 376-2211 (local or out-of-state). Representatives can be reached directly by calling (501) 374-6609.
Children?s Medical Services (CMS) assists providers with questions regarding prior authorization of services for individuals under age 21 in several programs. The programs involved are Targeted Case Management, Personal Care, Private Duty Nursing and Occupational, Physical and Speech Therapy and for certain prosthetic items in the Prosthetics program. They assist providers with questions regarding extension of benefits for the Prosthetics program, the Personal Care and Private Duty Nursing programs and with supplies in the Home Health program. The community based CMS nurse is responsible for prior authorizations. Providers may call (501) 682-2277, (501) 682-2270 or 1-800-482 -5850, extension 22277. Extension 22270 may be utilized to obtain the telephone number for the community based organization for a specific child. CMS Central Office may be contacted by FAX at (501) 682-8247 or (501) 682-1779.
The Utilization Review Section of the Division of Medical Services is available to assist providers with questions regarding extension of benefits and prior authorization of services for individuals age 21 and over, and for specified services for individuals under age 21, with the exception of prescription drug prior authorizations. Utilization Review may be contacted directly by calling (501) 682-8340. Providers may call 1-800-482 -1141 (toll free within Arkansas) and leave a message. The call will be returned as soon as possible. The Personal Care, Inpatient Psychiatric and Home Health Units are sections within Utilization Review. The Arkansas Foundation for Medical Care, Inc. performs medical/surgical prior authorizations. AFMC?s telephone numbers are: (501) 649-8501 for general questions, for procedure precertification and length of stay review (MUMP), 1-800-426 -2234 for In-State and Out-of-State, and (501) 649-0715 in the Fort Smith area.
Customer Assistance, a Section of the Division of County Operations, investigates recipient inquiries regarding Medicaid eligibility and I.D. card inquiries. Recipients may call 1-800-482 -8988 toll free, or TDD 1-501-682 -8275.
Any materials needed in an alternate format, such as large print, can be obtained by contacting the Americans with Disabilities Act Coordinator at (501) 682-8365 (voice) or (501) 682-6789 (TDD).
This unit responds to Medicaid recipient inquiries regarding Medicaid coverage and benefits, assists out-of-state providers with claim filing procedures, verifies recipient eligibility, and maintains recipient correspondence files. Recipients may contact this unit at 1-800-482 -5431 (In-State WATS) or (501) 682-8502. Providers may contact this unit at (501) 682-8502, 1-800-482 -1141 (In-State WATS) or 1-800-482 -5850, extension 28502 (Out-of-State WATS).
The Dental Coordinator assists providers with questions regarding dental services. The Dental Coordinator may be contacted directly by calling (501) 682-8336, (501) 682-8332 or (501) 682-8502.
The Visual Care Coordinator assists providers with questions regarding visual care services. The Visual Care Coordinator may be contacted directly by calling (501) 682-8342 or (501) 682-8502.
Providers may also reach the Dental and Visual Care Units by calling In-State WATS 1-800-482 -1141 or Out-of-State WATS 1-800-482 -5850, Ext. 28502.
EDS, the fiscal agent, has a Provider Assistance Center that is available for billing questions and can be reached at (501) 376-2211 or In-State WATS 1-800-457 -4454 between the hours of 8:00 AM and 4:30 PM, Monday through Friday except for the following holidays:
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New Year?s Day |
Labor Day |
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Good Friday |
Thanksgiving Day and Friday after |
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Memorial Day |
Christmas Eve and Christmas Day |
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Independence Day |
The State?s Program Communications Unit is available to answer providers? questions and direct their telephone calls at (501) 682-8502, In-State WATS 1-800-482 -1141 or Out-of-State WATS 1-800-482 -5850, ext. 28502, Monday through Friday from 8:00 AM through 4:30 PM, except for the following holidays:
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New Year?s Day |
Labor Day |
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Martin Luther King, Jr. Day |
Veterans Day |
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President?s Day |
Thanksgiving Day (and Friday after*) |
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Memorial Day |
Christmas Eve and Christmas Day |
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Independence Day |
* given at the Governor?s discretion |
RECIPIENT ELIGIBILITY
The Department of Human Services (DHS) County Office or the District Social Security Office determines recipient eligibility certification. The category of aid each office is responsible for is described below.
Family Support Specialists in the DHS County Offices have the responsibility of evaluating the circumstances of an individual or family to determine the proper category through which aid should be received. The Medicaid recipient aid categories are listed in Section 136 of this manual.
After evaluation, the DHS County Office establishes Medicaid eligibility dates in accordance with State and Federal policy and regulations.
Social Security Representatives have the responsibility of evaluating an individual?s circumstances to determine eligibility for the Supplementary Security Income (SSI) program administered by the Social Security Administration. The following are SSI aid categories:
SSI entitlement also establishes Medicaid eligibility.
Recipient eligibility in the Arkansas Medicaid Program is date specific. Medicaid eligibility may begin or end on any day of a month. An AEVCS eligibility verification transaction response displays the current eligibility period through the date of the inquiry.
Medicaid recipients may be eligible for Medicaid benefits for the three-month period prior to the date of application when eligibility requirements for that three-month period are met. The DHS County Office establishes retroactive eligibility.
MEDICAID ID CARD
Medicaid recipients are issued a magnetic identification card similar to a credit card. Each identification card displays a hologram, and for most Medicaid categories, a picture of the recipient. Children under the age of five and nursing home/waiver recipients are not pictured. New recipients of the Family Planning Wavier (Category 69) are not pictured unless they were certified using an existing case number and have a previously issued photo ID card. The Division of County Operations issues the Medicaid identification card to Medicaid recipients.
THE MEDICAID IDENTIFICATION CARD DOES NOT GUARANTEE ELIGIBILITY FOR A RECIPIENT. Payment is subject to verification of recipient eligibility at the time services are provided. The eligibility transaction is accomplished at the point-of-sale (POS) device by swiping the card and performing a few simple keystrokes. If the recipient does not have a Medicaid ID card, the Medicaid identification number can be typed in. This will require a point-of-sale (POS) device, EDS supplied software for a personal computer (PC) or an office management system modified to process an eligibility verification transaction. Refer to Section 133 for verification of recipient eligibility procedures, and to Section 301 for additional POS device information.
The following is an explanation of information contained on a Medicaid ID card:
Click here to view image
NOTE: ARKids First identification cards have a different appearance than the Medicaid identification card. See pages I-3 and I-4 of the ARKids First Manual for more information.
When recipients report non-receipt or loss of a Medicaid card, refer the recipients to the local DHS County Office or the Division of County Operations, Customer Assistance, at its toll free number 1-800-482 -8988 or TDD 1-501-682 -8275. To receive a photo ID, the recipient must go to the Revenue Office or DHS County Office two days after approval notification by the DHS County Office.
The Division of Medical Services has implemented the Automated Eligibility Verification and Claims Submission (AEVCS) technology. With AEVCS, Medicaid providers are able to verify a patient?s Medicaid eligibility for a specific date or range of dates, including retroactive eligibility for the past year. Providers may obtain other useful information, such as the status of benefits used during the current fiscal year, other insurance or Medicare coverage, etc. See Section III of this manual for further information on AEVCS.
EDS and the Division of Medical Services (DMS) will verify Medicaid eligibility by telephone only for ?Limited Services Providers? (see Section II) in non-bordering states and in the case of retroactive eligibility with dates of service one year prior to card issuance.
When a provider suspects misuse of a Medicaid Identification Card, the provider should contact the Utilization Review Section of Arkansas Division of Medical Services by calling 1-800-482 -1141 toll free or (501) 682-8218. An investigation will then be made.
MEDICAID RECIPIENT AID CATEGORIES
The following is a list of recipient aid categories. As categories of eligibility are added or deleted, providers will be notified.
|
Category |
Description |
|
|
01 AK |
ARKids First |
AK-No Grant |
|
11 AA |
Aid to the Aged |
AA-No Grant |
|
13 AI |
Aged SSI Individual |
AA-Grant |
|
14 AS |
Aged SSI Spouse |
AA-Grant |
|
16 AA-EC |
Aged Exceptional Category |
AA-MN |
|
17 AA-SD |
Aged Spend Down |
AA-MN |
|
18 AA-QMB |
Aged Qualified Medicare Beneficiary (QMB) |
AA-No Grant |
|
20 TEA |
Transitional Employment Assistance Grant |
TEA-Grant |
|
and/or Medicaid |
TEA-No Grant |
|
|
25 TM |
Transitional Medicaid |
AFDC-No Grant |
|
26 AFDC-EC |
AFDC Exceptional Category |
AFDC-MN |
|
27 AFDC-SD |
AFDC Spend Down |
AFDC-MN |
|
31 AB |
Aid to the Blind |
AB-No Grant |
|
33 BI |
Blind SSI Individual |
AB-Grant |
|
34 BS |
Blind SSI Spouse |
AB-Grant |
|
35 BC |
Blind SSI Child |
AB-Grant |
|
36 AB-EC |
Blind Exceptional Category |
AB-MN |
|
37 AB-SD |
Blind Spend Down |
AB-MN |
|
38 AB-QMB |
Blind Qualified Medicare Beneficiary (QMB) |
AA-No Grant |
|
41 AD |
Aid to the Disabled |
AD-No Grant |
|
43 DI |
Disabled SSI Individual |
AD-Grant |
|
44 DS |
Disabled SSI Spouse |
AD-Grant |
|
45 DC |
Disabled SSI Child |
AD-Grant |
|
46 AD-EC |
Disabled Exceptional Category |
AD-MN |
|
47 AD-SD |
Disabled Spend Down |
AD-MN |
|
48 AD-QMB |
Disabled Qualified Medicare Beneficiary (QMB) |
AD-No Grant |
|
49 TEFRA |
Disabled TEFRA Child |
AD-No Grant |
|
51 U-18 |
Under Age 18 No Grant |
U-18-No Grant |
|
52 NB |
Newborn |
NB-No Grant |
|
56 U-18 EC |
Under Age 18 Exceptional Category |
U-18-MN |
|
57 U-18 SD |
Under Age 18 Spend Down |
U-18-MN |
|
58 QI-1 |
Qualifying Individual - 1 |
QI-1 |
|
61 PW-PL |
Pregnant Women Infants & Children Poverty Level (SOBRA) |
PW-No Grant |
|
62 PW-PE |
Pregnant Women Presumptive Eligibility |
PW-No Grant |
|
63 PW-NB |
SOBRA Newborn |
PW-No Grant |
|
65 PW-NG |
Pregnant Women No Grant |
PW-No Grant |
|
66 PW-EC |
Pregnant Women Exceptional Category |
PW-MN |
|
67 PW-SD |
Pregnant Women Spend Down |
PW-MN |
|
69 FP |
Family Planning Waiver |
FP-W |
|
76 UP-EC |
Unemployed Parent Exceptional Category |
UP-MN |
|
77 UP-SD |
Unemployed Parent Spend Down |
UP-MN |
|
78 QI-2 |
Qualifying Individual - 2 |
QI-2 |
|
80 RRP-GR |
Refugee Resettlement Grant |
RRP-Grant |
|
81 RRP-NG |
Refugee Resettlement No Grant |
RRP-No Grant |
|
86 RRP-EC |
Refugee Resettlement Exceptional Category |
RRP-MN |
|
87 RRP-SD |
Refugee Resettlement Spend Down |
RRP-MN |
|
88 SMB |
Specified Low Income Qualified Medicare Beneficiary (SMB) |
SMB |
|
91 FC |
Foster Care |
FC-No Grant |
|
92 IV-E-FC |
IV-E Foster Care |
FC-No Grant |
|
96 FC-EC |
Foster Care Exceptional Category |
FC-MN |
|
97 FC-SD |
Foster Care Spend Down |
FC-MN |
The Health Care Financing Administration (HCFA) permits states to cover a number of home and community-based services to individuals who would otherwise reside in nursing homes. To allow this coverage, HCFA waives the regulation requiring actual residence in a nursing facility as a prerequisite for Medicaid eligibility. The Medicaid Program refers to these home and community-based programs as ?waiver? programs. There are a number of waivers available to states, each with its own guidelines and restrictions and each having special recipient eligibility restrictions for services.
Individuals eligible for Medicaid under a waiver program have in their Medicaid eligibility file a waiver indicator. The indicator appears on the AEVCS eligibility verification transaction response after the words ?WAIVER ELIGIBLE.? When a recipient?s eligibility file contains a waiver indicator, denoting participation in a home and community-based waiver, that recipient is eligible for only the Medicaid-covered services listed in their plan of care. A nurse or other professional manages the recipient?s case and maintains their plan of care. The case manager lists in the plan of care all medical services the client is to receive, whether or not Medicaid covers the services.
A written individual plan of care for each participating recipient is an absolute requirement of a home and community-based waiver. The plan of care must include an assessment of the patient to determine the services necessary to prevent institutionalization. It must also list the medical and other services the patient will require, as well as the frequency of each service and the type of provider to furnish the service. The patient may choose the provider of each service from among those available.
When a Medicaid recipient participates in a home and community-based waiver program, Medicaid reimburses providers for only those Medicaid-covered services listed in the participant?s plan of care. Medicaid providers must document in the waiver program participant?s record that all services rendered are part of the participant?s plan of care. Medicaid will recoup payments for services not listed in the plan of care.
Medicaid requires waiver program clients to choose a primary care physician (PCP). See Section 180 for complete information regarding the Primary Care Physician Managed Care Program.
ELIGIBILITY VERIFICATION TRANSACTION FORMAT
The following shows the descriptions and values for each of the fields associated with an eligibility verification request transaction.
|
Field # |
Field Name |
Values/Comments |
Required Field |
|
EVS0010 |
Transaction Code |
Code associated with type of transaction. AREV? |
Yes |
|
EVS0020 |
Software Version |
?00? |
Yes |
|
EVS0030 |
Terminal ID |
Number that identifies the user?s terminal. EDS will assign this number at the time of testing and certification. |
Yes |
|
EVS0040 |
Filler |
Not Used |
|
|
EVS0050 |
Filler |
Not Used |
|
|
EVS0060 |
Transaction Type |
Number to identify the type of transaction sent. 00? = Eligibility Verification |
|
|
EVS0070 |
Filler |
Not Used |
|
|
EVS0080 |
Pay To Provider Number |
Provider?s Medicaid ID Number 9 digit numeric i.e., 100000001. |
Yes |
|
EVS0090 |
Filler |
Not Used |
|
|
EVS0100 |
Recipient ID |
Recipient?s Medicaid ID Number. 10 digit numeric, ID i.e., 0100000101 |
Yes |
|
EVS0110 |
Filler |
Not Used |
|
|
EVS0120 |
Filler |
Not Used |
|
|
EVS0130 |
Filler |
Not Used |
|
|
EVS0140 |
Filler |
Not Used |
|
|
EVS0150 |
Filler |
Not Used |
|
|
EVS0160 |
Filler |
Not Used |
|
|
EVS0170 |
Filler |
Not Used |
|
|
EVS0180 |
?From? Date of Service |
?From? date of service. Format = CCYYMMDD |
Yes |
|
EVS0190 |
?To? Date of Service |
?To? date of service. Format = CCYYMMDD |
Yes |
|
EVS0200 |
Screen Type |
Type of EPSDT screening information being requested. ?M? = Medical ?V? = Vision ?D? = Dental ?H? = Hearing Blank = None |
Yes |
RECIPIENT ELIGIBLE RESPONSE FORMAT NON-NURSING HOME
The following shows the descriptions and values for each of the fields associated with an eligibility verification response transaction when the recipient is eligible.
|
Field # |
Field Name |
Values/Comments |
|
EVA0010 |
POS Return |
If non-zero, a system error has occurred. |
|
EVA0020 |
Filler |
Not Used |
|
EVA0030 |
Transaction ID |
Number to identify the type of transaction reviewed. ?00? = Eligibility Verification |
|
EVA0040 |
Return Code |
Code assigned by the OLTP to identify the status. ?E? = Eligible ?R? = Rejected |
|
EVA0050 |
Authorization Code |
Code given by the OLTP for an accepted eligibility transaction. Used internally by EDS. |
|
EVA0060 |
Filler |
Not Used |
|
EVA0070 |
Full First Name |
Recipient?s full first name. |
|
EVA0080 |
Full Last Name |
Recipient?s full last name. |
|
EVA0090 |
Sex |
Indicates whether the recipient is male or female. M? = Male ?F? = Female |
|
EVA0100 |
Screen Type |
Indicates the type of screening information the provider has requested. ?V? = Vision ?D? = Dental ?H? = Hearing ?M? = Medical Blank = None |
|
EVA0110 |
Screen Date |
Indicates the date of the last screening for the screen type requested by the provider. Format = CCYYMMDD |
|
EVA0120 |
Buy-In Code |
Indicates whether the recipient has Medicare buy-in segments. ?A? = Part-A ?B? = Part-B ?X? = Both ?N? = None ?C? = Call for additional information |
|
EVA0130 |
Third Party/Absent Parent |
Indicates whether the recipient has other insurance through an absent parent. Y? = Yes ?N? = No |
|
Eligibility Segment |
Occurs 4 times. |
|
|
EVA0140 |
Aid Category |
Indicates the aid category for the recipient?s eligibility segment. 62? = PW/PE ?18?, ?38? or ?48? = QMB |
|
EVA0150 |
Eligibility Begin Date |
Indicates the begin date of the eligibility segment. Format = CCYYMMDD |
|
EVA0160 |
Eligibility End Date |
Indicates the end date of the eligibility segment. Format = CCYYMMDD |
|
EVA0170 |
County and District |
Indicates county (first two digits) and district (last digit) of residence for the recipient. County codes are found on page I-24 of this manual. |
|
EVA0180 |
Additional Eligibility |
Indicates if the recipient has additional eligibility segments. Y? = Yes ?N? = No |
|
EVA0190 |
Lock-In |
Indicates if a recipient is locked into a specific provider. ?O? = Another provider ?Y? = You ?N? = Not a Lock-in ?C? = Call for additional information (Multiple Lock-in segments or locked-in for part of dates) |
|
EVA0200 |
Waiver Indicator |
Indicates if recipient is Waiver Eligible. ?N? = Not eligible ?Y? = Yes ?C? = Call for additional information ?B? = Both W1 and W2 (Eligible for specific waiver type) |
|
EVA0210 |
Waiver Type |
Indicates the type of waiver service the recipient has. W1? =W1 Waiver ?W2? =W2 Waiver |
|
EVA0220 |
Waiver Amount |
Not Used |
|
EVA0230 |
Spenddown |
Indicates if recipient has spenddown. ?N? = None ?Y? = Yes ?C? = Call for additional information (More spenddown information exists) |
|
EVA0240 |
Spenddown Amount |
Indicates the amount of spenddown the recipient has. |
|
EVA0250 |
Spenddown End Date |
Indicates the end date for the spenddown segment. Format = CCYYMMDD |
|
The following fields are unique for each provider type |
||
|
Pharmacy (07) |
||
|
EVA0260 |
Prescriptions Used |
Number of prescriptions the recipient has used in a month. |
|
EVA0270 |
LTC Indicator |
Indicates if the recipient has Long Term Care benefits. ?N? = None ?Y? = Yes ?C? = Call for additional information (Eligible for part of dates) |
|
EVA0280 |
Filler |
Not Used |
|
Physician (01, 02, 03, 04) |
||
|
EVA0290 |
Outpatient Visits Used |
Number of outpatient visits the recipient has used towards the benefit limit as of the last cycle. |
|
EVA0300 |
Physician Visits Used |
Number of physician visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0310 |
Hospital Days Used |
Number of hospital days the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0320 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0330 |
Consultations Used |
Number of consultations used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
Hospital (05) |
||
|
EVA0340 |
Outpatient Visits Used |
Number of outpatient visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0350 |
Physician Visits Used |
Number of physician visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0360 |
Hospital Days Used |
Number of hospital days the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0370 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0380 |
Consultations Used |
Number of consultations used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
Independent Lab and Radiology (09, 10) |
||
|
EVA0390 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0400 |
Filler |
Not Used |
|
Optometrist/Optician (22) |
||
|
EVA0410 |
Vision Exam |
Indicates the date of the recipient?s last vision examination. Format = CCYYMMDD |
|
EVA0420 |
Filler |
Not Used |
|
Other |
||
|
EVA0430 |
Filler |
Not Used |
|
EVA0440 |
TPL Count |
Number of TPL segments that this recipient has. |
|
TPL Segments |
Occurs 0-3 times |
|
|
EVA0450 |
TPL Company Code |
Code assigned to identify the specific third party carrier. |
|
EVA0460 |
TPL Company Name |
Name of the third party carrier. |
|
EVA0470 |
TPL Address |
Street address of the third party carrier. |
|
EVA0480 |
TPL City |
City of the third party carrier. |
|
EVA0490 |
TPL State |
State of the third party carrier. |
|
EVA0500 |
TPL Zip |
Zip code of the third party carrier. |
|
EVA0510 |
TPL Policy |
Policy number with the third party carrier. |
|
EVA0520 |
TPL Group Policy |
Group policy number with third party carrier. |
|
EVA0530 |
TPL Group Name |
Name of the third party group. |
|
EVA0540 |
TPL Subscriber Number |
Subscriber?s ID number. |
|
EVA0550 |
TPL Subscriber Name |
Subscriber?s name. |
|
EVA0560 |
TPL Relation Code |
Recipient?s relationship to the subscriber. |
|
EVA0570 |
TPL Begin Date |
Date the third party coverage began. Format = CCYYMMDD |
|
EVA0580 |
TPL End Date |
Date the third party coverage ended. Format = CCYYMMDD |
|
EVA0590 |
TPL Coverage Code1 |
Identifies the type of services covered by the third party carrier. |
|
EVA0600 |
TPL Coverage Code2 |
Identifies the type of services covered by the third party carrier. |
|
EVA0610 |
TPL Coverage Code3 |
Identifies the type of services covered by the third party carrier. |
The following shows the descriptions and values for each of the fields associated with an eligibility verification response transaction when the recipient is ineligible.
|
Field # |
Field Name |
Values/Comments |
|
EVR0010 |
POS Return |
If non-zero, a system error has occurred. |
|
EVR0020 |
Filler |
Not Used |
|
EVR0030 |
Transaction Type |
Number to identify the type of transaction received. ?00? = Eligibility Verification |
|
EVR0040 |
Return Code |
Code assigned by the OLTP to identify the status. ?R? = Rejected |
|
EVR0050 |
Error Count |
Number of errors to follow. |
|
Error Segments |
Occurs 1-9 times |
|
|
EVR0060 |
Error Code |
Code associated with the errors found on this transaction. |
|
EVR0070 |
Detail Number |
Location on the transaction where the error has occurred. 00? = Header |
PROVIDER PARTICIPATION
Any provider of services must be enrolled in the Arkansas Medicaid Program prior to reimbursement being made for any services provided to Arkansas Medicaid recipients.
All providers must complete an application and a provider contract and return them to the Division of Medical Services within 30 days from the date they were sent from the Enrollment Unit. Please review Section II of this manual relative to provider participation requirements.
Upon receipt and approval of the above information by the Enrollment Unit, a provider number will be assigned to each approved provider. This number must be used on all claims and correspondence submitted to Arkansas Medicaid.
Provider eligibility will be retroactive 6 months from the date the provider agreement was received by the Division of Medical Services, the effective date of the provider?s license or certification, or the date the service became a part of the Arkansas Medicaid Program, whichever date is the most current.
Instructions for billing and specific details concerning the Arkansas Medicaid Program are contained within this manual. Please read all sections of the manual before signing the contract. The manual is an extension of your Medicaid contract and must be complied with in order to participate in the Arkansas Medicaid Program.
On the following pages, you will find a copy of the provider application and contract and instructions for completing these forms.
All providers must sign an Arkansas Medicaid Provider Contract. The signature must be an original signature of the individual provider. The contract for a group practice, hospital, other institution or agency must be signed by the authorized representative of the provider.
DIVISION OF MEDICAL SERVICES
MEDICAL ASSISTANCE PROGRAM
PROVIDER APPLICATION
As a condition for entering into or renewing a provider agreement all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.
Whenever changes in this information occur, please submit the change in writing to:
Division of Medical Services Provider Enrollment Unit P. O. Box 1437, Slot 1101 Little Rock, AR 72203-1437
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the applicant:
Section I - All providers
Section II - Facilities Only
Section III - Pharmacists/Registered Respiratory Therapist Only
Section IV - Provider Group Affiliations
Electronic Fund Transfer
Managed Care Agreement - Primary Care Physician
W-9 Tax Form - All Providers
Contract - All Providers
Click here to view image
* NOTE: IF THE TAX FORM IS NOT ATTACHED THE APPLICATION WILL BE DENIED
Click here to view image
Click here to view image
|
County |
County Code |
|
Arkansas |
01 |
|
Ashley |
02 |
|
Baxter |
03 |
|
Benton |
04 |
|
Boone |
05 |
|
Bradley |
06 |
|
Calhoun |
07 |
|
Carroll |
08 |
|
Chicot |
09 |
|
Clark |
10 |
|
Clay |
11 |
|
Cleburne |
12 |
|
Cleveland |
13 |
|
Columbia |
14 |
|
Conway |
15 |
|
Craighead |
16 |
|
Crawford |
17 |
|
Crittenden |
18 |
|
Cross |
19 |
|
Dallas |
20 |
|
Desha |
21 |
|
Drew |
22 |
|
Faulkner |
23 |
|
Franklin |
24 |
|
Fulton |
25 |
|
Garland |
26 |
|
Grant |
27 |
|
Greene |
28 |
|
Hempstead |
29 |
|
Hot Spring |
30 |
|
Howard |
31 |
|
Independence |
32 |
|
Izard |
33 |
|
Jackson |
34 |
|
Jefferson |
35 |
|
Johnson |
36 |
|
Lafayette |
37 |
|
Lawrence |
38 |
|
Lee |
39 |
|
Lincoln |
40 |
|
Little River |
41 |
|
Logan |
42 |
|
Lonoke |
43 |
|
Madison |
44 |
|
Marion |
45 |
|
Miller |
46 |
|
Mississippi |
47 |
|
Monroe |
48 |
|
Montgomery |
49 |
|
Nevada |
50 |
|
Newton |
51 |
|
Ouachita |
52 |
|
Perry |
53 |
|
Phillips |
54 |
|
Pike |
55 |
|
Poinsett |
56 |
|
Polk |
57 |
|
Pope |
58 |
|
Prairie |
59 |
|
Pulaski |
60 |
|
Randolph |
61 |
|
Saline |
62 |
|
Scott |
63 |
|
Searcy |
64 |
|
Sebastian |
65 |
|
Sevier |
66 |
|
Sharp |
67 |
|
St. Francis |
68 |
|
Stone |
69 |
|
Union |
70 |
|
Van Buren |
71 |
|
Washington |
72 |
|
White |
73 |
|
Woodruff |
74 |
|
Yell |
75 |
|
State |
County Code |
|
Louisiana |
91 |
|
Missouri |
92 |
|
Mississippi |
93 |
|
Oklahoma |
94 |
|
Tennessee |
95 |
|
Texas |
96 |
|
All other states |
97 |
Enter the two-digit highlighted code, from the following list, which identifies the services the applicant will be providing.
A) __________________ B) ________________ C) ________________
|
Cod |
e Category Description |
|
03 |
Allergy/Immunology |
|
A8 |
Alternatives for Adults with Physical Disabilities (Alternative) - Environmental Adaptations |
|
A9 |
Alternatives for Adults with Physical Disabilities (Alternative) - Attendant Care Services |
|
A4 |
Ambulatory Surgical Center |
|
AA |
Adolescent Medicine |
|
05 |
Anesthesiology |
|
64 |
Audiologist |
|
06 |
Cardiovascular Disease |
|
C4 |
Child Health Management Services |
|
35 |
Chiropractor |
|
C3 |
CRNA |
|
HA |
DDS ACS Waiver Physical Adaptations |
|
HB |
DDS ACS Waiver Specialized Medical Supplies |
|
HC |
DDS ACS Waiver Case Management Services |
|
HE |
DDS ACS Waiver Supported Employment |
|
H7 |
DDS ACS Waiver Integrated Support |
|
H8 |
DDS ACS Waiver Crisis Abatement Services |
|
H9 |
DDS ACS Waiver Consultation Services |
|
HF |
DDS ACS Waiver Organized HealthCare |
|
V2 |
Dental |
|
X5 |
Dental - Oral Surgeon |
|
V6 |
Dental - Orthodontia |
|
07 |
Dermatology |
|
V3 |
Developmental Day Treatment Center |
|
V5 |
Domiciliary Care |
|
E4 |
ElderChoices H&CB 2176 Waiver - Chore services |
|
E5 |
ElderChoices H&CB 2176 Waiver - Adult foster care |
|
E6 |
ElderChoices H&CB 2176 Waiver - Home maker |
|
E7 |
ElderChoices H&CB 2176 Waiver - Home delivered hot meals |
|
EC |
ElderChoices H&CB 2176 Waiver - Home delivered frozen meals |
|
E8 |
ElderChoices H&CB 2176 Waiver - Personal emergency response systems |
|
E9 |
ElderChoices H&CB 2176 Waiver - Adult day care |
|
EA |
ElderChoices H&CB 2176 Waiver - Adult day health care |
|
EB |
ElderChoices H&CB 2176 Waiver - Respite care |
|
E1 |
Emergency Medicine |
|
E2 |
Endocrinology |
|
E3 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) |
|
F1 |
Family Planning |
|
08 |
Family Practice |
|
F2 |
Federally Qualified Health Center |
|
10 |
Gastroenterology |
|
01 |
General Practice |
|
38 |
Geriatrics |
|
16 |
Gynecology - Obstetrics |
|
H1 |
Hearing Aid Dealer |
|
H2 |
Hematology |
|
H5 |
Hemodialysis |
|
H3 |
Home Health |
|
H6 |
Hospice |
|
A5 |
Hospital - AR State Operating Teaching Hospital |
|
W6 |
Hospital - Inpatient |
|
W7 |
Hospital - Outpatient |
|
CH |
Hospital ? Critical Access |
|
P7 |
Hospital - Pediatric Inpatient |
|
R7 |
Hospital - Rural Inpatient |
|
H4 |
Hyperalimentation |
|
V8 |
Immunization (Health Dept. Only) |
|
69 |
Independent Lab |
|
55 |
Infectious Diseases |
|
W3 |
Inpatient Psychiatric - under 21 |
|
WA |
Inpatient Psychiatric - Residential Treatment Unit within Inpatient Psychiatric Hospital |
|
WB |
Inpatient Psychiatric - Residential Treatment Center |
|
WC |
Inpatient Psychiatric - Sexual Offenders Program |
|
W4 |
Intermediate Care Facility |
|
W5 |
Intermediate Care Facility - Mentally Retarded |
|
11 |
Internal Medicine |
|
L1 |
Larynology |
|
M1 |
Maternity Clinic (Health Dept. Only) |
|
M4 |
Medicare/Medicaid Crossover Only |
|
WI |
Mental Health Practitioner ? Licensed Certified Social Worker |
|
W2 |
Mental Health Practitioner ? Licensed Professional Counselor |
|
R5 |
Mental Health Practitioner ? Licensed Marriage and Family Therapist |
|
62 |
Mental Health Practitioner - Psychologist |
|
N1 |
Neonatology |
|
39 |
Nephrology |
|
13 |
Neurology |
|
N2 |
Nurse Midwife |
|
N3 |
Nurse Practitioner |
|
N4 |
Nurse Practitioner - OB/GYN |
|
RK |
Offsite Intervention Service - Outpatient Mental and Behavioral Health (ARKids ONLY) |
|
X1 |
Oncology |
|
18 |
Ophthalmology |
|
X4 |
Optometrist |
|
X6 |
Orthopedic |
|
12 |
Osteopathy - Manipulative Therapy |
|
X7 |
Osteopathy - Radiation Therapy |
|
X8 |
Otology |
|
X9 |
Otorhinolaryngology |
|
22 |
Pathology |
|
37 |
Pediatrics |
|
P1 |
Personal Care Services |
|
PA |
Personal Care Services / Area Agency on Aging |
|
PD |
Personal Care Services / Developmental Disability Services |
|
PE |
Personal Care Services / Week-end |
|
R3 |
Personal Care Services / Residential Care Facility |
|
P2 |
Pharmacy |
|
P3 |
Physical Medicine |
|
48 |
Podiatrist |
|
63 |
Portable X-ray Equipment |
|
P6 |
Private Duty Nursing |
|
28 |
Proctology |
|
P4 |
Prosthetic Devices |
|
V4 |
Prosthetic - Durable Medical Equipment/Oxygen |
|
Z1 |
Prosthetic - Orthotic Appliances |
|
26 |
Psychiatry |
|
P5 |
Psychiatry - Child |
|
29 |
Pulmonary Diseases |
|
R9 |
Radiation Therapy - Complete |
|
RA |
Radiation Therapy - Technical |
|
30 |
Radiology - Diagnostic |
|
31 |
Radiology - Therapeutic |
|
R6 |
Rehabilitative Services for Persons with Mental Illness |
|
RC |
Rehabilitative Services for Persons with Physical Disabilities |
|
R1 |
Rehabilitative Hospital |
|
RH |
Rehabilitative Hospital-extended Services |
|
R4 |
Rheumatology |
|
R2 |
Rural Health Clinic - Provider Based |
|
R8 |
Rural Health Clinic - Independent Freestanding |
|
S7 |
School Based Health Clinic - Child Health Services |
|
S8 |
School Based Health Clinic - Hearing Screener |
|
S9 |
School Based Health Clinic - Vision Screener |
|
SA |
School Based Health clinic - Vision & Hearing Screener |
|
VV |
School Based Mental Health Clinic |
|
S5 |
Skilled Nursing Facility |
|
S6 |
SNF Hospital Distinct Part Bed |
|
S1 |
Surgery - Cardio |
|
S2 |
Surgery - Colon & Rectal |
|
O2 |
Surgery - General |
|
14 |
Surgery - Neurological |
|
20 |
Surgery - Orthopedic |
|
53 |
Surgery - Pediatric |
|
54 |
Surgery - Oncology |
|
24 |
Surgery - Plastic & Reconstructive |
|
33 |
Surgery - Thoracic |
|
S4 |
Surgery - Vascular |
|
C5 |
Targeted Case Management - Ages 60 and Older |
|
C6 |
Targeted Case Management - Ages 00 - 20 |
|
C7 |
Targeted Case Management - Ages 21 - 59 |
|
T6 |
Therapy - Occupational |
|
T1 |
Therapy - Physical |
|
T2 |
Therapy - Speech Pathologist |
|
TO |
Therapy - Occupational Assistant |
|
TP |
Therapy - Physical Assistant |
|
TS |
Therapy - Speech Pathologist Assistant |
|
A1 |
Transportation - Ambulance, Emergency |
|
A2 |
Transportation - Ambulance, Non-emergency |
|
A6 |
Transportation - Advanced Life Support with EKG |
|
A7 |
Transportation - Advanced Life Support without EKG |
|
TA |
Transportation - Air Ambulance/Helicopter |
|
TB |
Transportation - Air Ambulance/Fixed Wing |
|
TC |
Transportation - Non-Emergency |
|
T5 |
Transportation - Non-Public |
|
T7 |
Transportation - Transportation Intra State Authority |
|
T8 |
Transportation - Transportation Accessible Van, Intra City |
|
T9 |
Transportation - Transportation ? Accessible Van, Intra State Authority |
|
34 |
Urology |
|
V7 |
Ventilator Equipment |
|
ZZ |
Other |
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Dear Provider:
Providers are encouraged to utilize Electronic Fund Transfer (EFT). EFT allows your Medicaid payments to be directly deposited into your bank account. You will notice a difference in your cash flow with EFT because it makes your money available sooner than the actual clearance date of paper checks. Your Medicaid Remittance Advice (RA) will continue to be mailed to the mailing address listed on your enrollment application.
If you wish to have your Medicaid payment automatically deposited, please complete the Authorization for Automatic Deposit and attach a VOIDED CHECK OR DEPOSIT SLIP.
If you choose not to enroll in EFT, your checks along with your Medicaid RA will be mailed to you. Please note that since EFT is available, checks will not be available for pick-up at the EDS office.
If you have any further questions concerning this letter, please contact the EDS Provider Assistance at (501) - 376-2211 (local or out-of-state) or 1-800-457 -4454 (in-state WATS).
Sincerely,
Arkansas Department of Human Services
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MANAGED CARE PROGRAM PRIMARY CARE PHYSICIAN
Family Practitioner
General Practitioner (including osteopath)
* Internal Medicine
* Obstetrician
* Gynecologist Pediatrician
If your specialty of practice is listed above, you MUST complete the Primary Care Physician Participation Agreement and the EPSDT Agreement to participate in the Arkansas Medicaid Program. Please refer to Section I of your Arkansas Medicaid Provider manual for information concerning the Primary Care Physician Program.
* NOTE * Providers whose specialty is either Internal Medicine or Obstetrician/Gynecology have the option of enrolling in the Child Health Services (EPSDT) program, please review the Primary Care Physicians policy.
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County Codes
|
County |
County Code |
|
Arkansas |
01 |
|
Ashley |
02 |
|
Baxter |
03 |
|
Benton |
04 |
|
Boone |
05 |
|
Bradley |
06 |
|
Calhoun |
07 |
|
Carroll |
08 |
|
Chicot |
09 |
|
Clark |
10 |
|
Clay |
11 |
|
Cleburne |
12 |
|
Cleveland |
13 |
|
Columbia |
14 |
|
Conway |
15 |
|
Craighead |
16 |
|
Crawford |
17 |
|
Crittenden |
18 |
|
Cross |
19 |
|
Dallas |
20 |
|
Desha |
21 |
|
Drew |
22 |
|
Faulkner |
23 |
|
Franklin |
24 |
|
Fulton |
25 |
|
Garland |
26 |
|
Grant |
27 |
|
Greene |
28 |
|
Hempstead |
29 |
|
Hot Spring |
30 |
|
Howard |
31 |
|
Independence |
32 |
|
Izard |
33 |
|
Jackson |
34 |
|
Jefferson |
35 |
|
Johnson |
36 |
|
Lafayette |
37 |
|
Lawrence |
38 |
|
Lee |
39 |
|
Lincoln |
40 |
|
Little River |
41 |
|
Logan |
42 |
|
Lonoke |
43 |
|
Madison |
44 |
|
Marion |
45 |
|
Miller |
46 |
|
Mississippi |
47 |
|
Monroe |
48 |
|
Montgomery |
49 |
|
Nevada |
50 |
|
Newton |
51 |
|
Ouachita |
52 |
|
Perry |
53 |
|
Phillips |
54 |
|
Pike |
55 |
|
Poinsett |
56 |
|
Polk |
57 |
|
Pope |
58 |
|
Prairie |
59 |
|
Pulaski |
60 |
|
Randolph |
61 |
|
Saline |
62 |
|
Scott |
63 |
|
Searcy |
64 |
|
Sebastian |
65 |
|
Sevier |
66 |
|
Sharp |
67 |
|
St. Francis |
68 |
|
Stone |
69 |
|
Union |
70 |
|
Van Buren |
71 |
|
Washington |
72 |
|
White |
73 |
|
Woodruff |
74 |
|
Yell |
75 |
|
State |
County Code |
|
Louisiana |
91 |
|
Missouri |
92 |
|
Mississippi |
93 |
|
Oklahoma |
94 |
|
Tennessee |
95 |
|
Texas |
96 |
Please note: Per Section I, page 84, subsection 185.12, item 2 of the Arkansas Medicaid Physicians provider manual, A PCP must be physically located in the State of Arkansas, or in a bordering state trade-area city. The trade-area cities are:
? Monroe and Shreveport, Louisiana
? Clarksdale and Greenville, Mississippi
? Poplar Bluff, Missouri
? Poteau and Salisaw, Oklahoma
? Memphis, Tennessee
? Texarkana, Texas
FORM W-9
REQUEST FOR TAXPAYER
IDENTIFICATION NUMBER AND CERTIFICATION
The Department of Finance and Administration and the Department of Human Services have mandated that an IRS form W-9 be completed by all vendors doing business with the Department of Human Services.
NOTE:
TO ENSURE CORRECT PROCESSING OF THE 1099 --- PLEASE REVIEW THE
FOLLOWING: WHEN BILLING FOR SERVICES UNDER CLINIC NAME AND IRS NUMBER, THE CLINIC AND EACH INDIVIDUAL PROVIDER (i.e., physician, therapist, dentist, etc.) MUST ENROLL BY COMPLETING A SEPARATE APPLICATION AND CONTRACT. A CLINIC MEDICAID NUMBER WILL BE ISSUED AND LINKED WITH EACH INDIVIDUAL?S MEDICAID NUMBER WITHIN THAT GROUP. THE CLINIC MEDICAID NUMBER MUST BE PLACED IN THE PAY TO FIELD AND THE INDIVIDUAL PROVIDER NUMBER MUST BE PLACED IN THE PERFORMING FIELD. THIS WILL ENSURE THAT THE 1099 REFLECTS THE CORRECT TAX NUMBER. PLEASE REFER TO YOUR PROVIDER MANUAL FOR CLAIMS PROCESSING INSTRUCTIONS.
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CONTRACT
TO PARTICIPATE IN THE ARKANSAS MEDICAL ASSISTANCE
PROGRAM ADMINISTERED BY THE DIVISION OF MEDICAL SERVICES UNDER TITLE XIX (MEDICAID)
INSTRUCTIONS
Please ensure that the Provider name on the front page of the contract is identical to that listed in item #2 or item #3 of the application.
If these two names do not match, your enrollment will be denied and the enrollment packet will be returned.
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PROVIDER PARTICIPATION
Providers enrolled in the Arkansas Medicaid Program must agree to the following conditions of participation:
The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare claims for ?physician? services furnished to individuals who are eligible for Medicare and Medicaid, including those eligible as Qualified Medicare Beneficiaries (QMB?s). According to Medicare regulations, ?physician? services, for the purpose of this policy, are services furnished by physicians, dentists, optometrists, chiropractors and podiatrists.
As described above, ?physician? services furnished to an individual enrolled under Medicare who is also eligible for Medicaid, including Qualified Medicare Beneficiaries, may only be made on an assignment related basis.
RESPONSIBILITIES OF THE MEDICAID RECIPIENT
Section 1902 (a) (14) of the Social Security Act permits States to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments or similar cost sharing charges.
If an individual who makes payment at the time of service is later found to be Medicaid eligible and Medicaid is filed, the individual must be refunded the full amount of his/her payment for covered services. If it is agreeable with the individual, these funds may be credited against unpaid non-covered services that are the responsibility of the recipient.
Information relating to cost sharing follows in Sections 143.210 through 143.240.
For inpatient admissions on and before October 31, 2001, the coinsurance charge per admission for Medicaid recipients is 22% of the hospital?s per diem amount, applied on the first Medicaid covered day.
Example:
A Medicaid recipient is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1890.00, the recipient will pay $110.00 (22% Medicaid coinsurance rate).
For inpatient admissions on or after November 1, 2001, the coinsurance charge per admission for Medicaid recipients is 10% of the hospital?s per diem amount, applied on the first Medicaid covered day.
Example:
A Medicaid recipient is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00; the recipient will pay $50.00 (10% Medicaid coinsurance rate).
Recipients
For inpatient admissions on or before October 31, 2001, the coinsurance charge per admission for Medicaid recipients who are also Medicare Part A beneficiaries, is 22% of the hospital?s Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.
Example:
A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.
If, on a subsequent admission, Medicare Part A assesses coinsurance; Medicaid will deduct from the Medicaid payment, an amount equal to 22% of one day?s Medicaid per diem, for inpatient admissions through October 31, 2001. The patient will be responsible for that amount.
Effective for dates of service on or after November 1, 2001, the coinsurance charge per admission for Medicaid recipients who are also Medicare Part A beneficiaries, is 10% of the hospital?s Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.
Example:
A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.
If, on a subsequent admission, Medicare Part A assesses coinsurance; Medicaid will deduct from the Medicaid payment, an amount equal to 10% of one day?s Medicaid per diem. The patient will be responsible for that amount.
Arkansas Medicaid has a recipient copayment policy in the Pharmacy Program. The copayment amount for the Pharmacy Program is applied per prescription. The recipient is responsible for paying the provider a copayment amount based on the following table:
|
Medicaid Maximum Amount |
Recipient Copay |
|
$10.00 or less |
$0.50 |
|
$10.01 to $25.00 |
$1.00 |
|
$25.01 to $50.00 |
$2.00 |
|
$50.01 or more |
$3.00 |
As required by 42 CFR 447.53(b), the following services are excluded from the recipient cost sharing coinsurance/copayment policy:
The fact that a recipient is a resident of a nursing facility does not on its own exclude the Medicaid services provided to the recipient from the cost sharing policy. Unless a Medicaid recipient has applied for long term care assistance through the Arkansas Medicaid Program, been found eligible and Medicaid is making a vendor payment to the nursing facility (NF or ICF/MR) for the recipient, the Medicaid services are not excluded from the cost sharing policy.
The provider must maintain sufficient documentation in the recipient?s medical record which substantiates the exclusion from the recipient cost sharing policy.
In the absence of knowledge or indication to the contrary, the provider may accept the recipient?s assertion that he/she can not afford to pay the cost sharing coinsurance/copayment amount. The provider may not deny services to any eligible individual due to the individual?s inability to pay the cost of the coinsurance/copayment amount. However, the individual?s inability to pay does not eliminate his/her liability for the coinsurance/copayment charge. The recipient?s inability to pay the coinsurance/copayment amount will not alter the Medicaid reimbursement amount for the claim. Unless the recipient or service is excluded from the coinsurance/copayment policy as listed in Section 143.230, the Medicaid reimbursement amount will be calculated according to current reimbursement methodology minus the appropriate coinsurance amount or appropriate copayment amount.
The method of collecting the coinsurance/copayment amount from the recipient is the responsibility of the provider. In cases of claim adjustments, the responsibility of refunding or collecting additional cost sharing coinsurance/copayment from the recipient will remain the responsibility of the provider.
QUALIFIED MEDICARE BENEFICIARY PROGRAM
The Qualified Medicare Beneficiary (QMB) program was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low income Medicare beneficiaries. If a person is eligible for the QMB program, Medicaid will pay the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance on other medical services. Medicaid will also pay the Medicare Part A premium, the Medicare Part A hospital deductible and the Medicare Part A coinsurance.
To be eligible, the individuals must be age 65 or older, blind or disabled and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal, but cannot exceed the Federal Poverty Level (FPL).
Countable resources may equal but cannot exceed twice the current Supplemental Security Income (SSI) resource limitations.
With the exception of medically needy spend-down categories, individuals may not be certified in a QMB category and in another Medicaid category for simultaneous periods. QMBs do not receive the full range of Medicaid benefits.
For a QMB eligible, Medicaid pays only Medicare covered services.
Qualified Medicare Beneficiaries do not receive prescription drug benefits through the Medicaid program, however, individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the AEVCS eligibility display to verify the QMB category of service. The category of service for a QMB will reflect AA-QMB, AB-QMB or AD-QMB. QMB eligibles are limited to cost sharing of Medicare services. The AEVCS system will display the current eligibility.
Not all providers are mandated to accept Medicare assignment on QMB eligibles (See Section 142.1). However, if a non-physician desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he/she must accept assignment on that claim and enter the information required by Medicare on assigned claims.
When treated by a provider who must accept Medicare assignment according to Section 142, Conditions of Participation, the recipient is not responsible for the difference between the billed charges and the Medicare allowable amount.
Interested individuals may apply for the QMB program at their local Department of Human Services (DHS) county office.
The Specified Low Income Medicare Beneficiaries Program (SMB) was mandated by Section 4501 of the Omnibus Budget Reconciliation Act of 1990, effective January 1, 1993.
Individuals eligible as SMBs are not eligible for the full range of Medicaid benefits. They are eligible for only the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do not receive a Medicaid card.
Eligibility criteria for the SMB program are similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and receiving Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Their countable income must be greater than, but not equal to 100% of the current Federal Poverty Level, and less than, but not equal to 120% of the current Federal Poverty Level.
The resource limit may be equal to but cannot exceed twice the current SSI resource limitations.
Interested individuals may apply for services at their local Department of Human Services (DHS) county office.
The Balanced Budget Act of 1997, Section 4732, (
Public
Law
Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Countable income must be at least 120%, but less than 135% of the current Federal Poverty Level.
Countable resources may equal but cannot exceed twice the current SSI resource limitations.
Individuals interested in the program may apply for services at their local DHS county office.
Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) created the Qualifying Individuals-2 (QI-2) program. Individuals eligible as QI-2 are not eligible for Medicaid benefits. They are eligible for payment for only a portion of the Medicare Part B premium. No other Medicare cost sharing charges will be covered. Individuals eligible for QI-2 will not receive a Medicaid card, and, unlike QMBs and SMBs, may not be certified in another Medicaid category for simultaneous periods. Individuals who are eligible for both QI-2 and spend down will have to choose which coverage is wanted for a particular period of time.
Eligibility for the QI-2 program includes the following criteria: The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Countable income must be at least 135% but less than 175% of the Federal Poverty Level.
Countable resources may equal but cannot exceed twice the current SSI resource limitations.
Individuals interested in the program may apply for services at their local DHS county office.
RECIPIENT NOTIFICATION OF DENIED MEDICAID CLAIM
Due to a Federal court ruling, the Division of Medical Services is required to notify Medicaid recipients when a claim for Medicaid payment is denied. A letter is forwarded to recipients each time a medical claim for payment is denied by the Medicaid Program. The notice includes the recipient?s name, provider?s name, date of service, explanation of service and reason for denial. The notice includes recipient responsibility regarding payment of the denied Medicaid claim.
If the letter indicates the recipient is not responsible for the unpaid amount, the provider may not request payment from the recipient. If the letter indicates the recipient is responsible for the unpaid amount, the provider is responsible for contacting the recipient for payment. For program information regarding responsibilities of the recipient, please refer to Section 143 of this manual. Please refer to Page I-57 of this manual for an example of the recipient notification of denied Medicaid claim.
If the recipient disagrees with the decision made on the Medicaid claim, he/she may file for a fair hearing with the Department of Human Services.
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ADMINISTRATIVE REMEDIES & SANCTIONS
The following sanctions may be invoked against providers based on the grounds specified in the following sections:
Sanctions may be imposed by the Director against a provider for any one or more of the following reasons:
licensure).
Boards or the State Nursing Home Advisory Council.
FORMAL HEARINGS
Should the Division of Medical Services have information that indicates that a provider may have submitted bills and/or has been practicing in a manner inconsistent with program requirements and/or may have received payment for which he may not be properly entitled, appropriate action will be taken to notify the provider of the discrepancies noted. The notification will be in writing and will set forth:
Where the Agency has notified a provider of a violation pursuant to paragraph 161 of an overpayment, payments may be withheld on pending and subsequent entitlements in an amount reasonably calculated to approximate the amounts in question, or payments may be suspended pending a final determination.
Where the Agency intends to withhold or suspend payments, it shall notify the provider in writing and shall include a statement of the provider?s right to request formal review of such decision, if appropriate.
Within 10 calendar days after notice of the Agency?s intention to sanction, the provider may request a formal hearing. Such request must be in writing. Within 20 calendar days following date of request for hearing, the provider must submit, in writing, a statement and supporting documents setting forth, with particularity, those asserted violations, discrepancies and dollar amounts which the provider contends are in compliance with all rules and regulations and the reasons for such contentions. Suspension or withholding of payments may continue until such time as a final determination is made regarding the appropriateness of the disagreement or amount in question.
Unless a timely and proper request for a formal hearing is received by the Agency, the findings of the Agency shall be considered a final and binding administrative determination.
No formal review will be granted if the basis for termination is a failure to meet standards (including licensure or registration) required by Federal or State law for participation in the Medicaid program.
When a formal hearing is scheduled, the Division of Medical Services shall notify the provider and/or his attorney in writing of the date, time and place of the hearing. Notice shall be mailed not less than 10 calendar days before the scheduled date of the hearing.
Any party may appear and be heard at any proceeding described herein through an attorney-at-law or through a designated representative. All persons appearing in proceedings before the Agency shall conform to the standards of conduct practiced by attorneys before the courts of the States. If a person does not conform to those standards, the hearing officer may decline to permit the person to appear in the proceeding or may exclude the person from the proceeding.
A person appearing in a representative capacity shall file a written notice of appearance on behalf of a provider identifying himself by name, address and telephone number; identifying the party represented and shall have a written authorization to appear on behalf of the provider. The Agency shall notify the provider in writing of the name and telephone number of its representative.
All papers filed in any proceeding shall be typewritten on legal sized white paper using one side of the paper only. They shall bear a caption clearly showing the title of the proceeding in connection with which they are filed together with the docket number, if any.
The party, his authorized representative or attorney shall sign all papers, and all papers shall contain his address and telephone number. At least an original and two copies of all papers shall be filed with the Division of Medical Services.
A party shall arrange for the presence of his witnesses at the hearing.
At any time prior to the completion of the hearing, amendments may be allowed on just and reasonable terms to add any party who ought to have been joined, discontinued as to any party, change the allegations or defenses or add new causes of action of defenses. Where the Agency seeks to add a party or a cause of action or change an allegation, notice shall be given pursuant to Section 161, Notice of Violation, and Section 163.1, Notice, Service and Proof of Service, to the appropriate parties except that the provisions of Section 161.2, Right to Review, and Section 161.3, Notice of Formal Hearings, shall not apply. Where a party other than the Division of Medical Services seeks to add a party or change a defense, notice shall be given pursuant to Section 163.1, Notice, Service and Proof of Service. The hearing officer shall continue the hearing for such time as he deems appropriate, and notice of the new date shall be given pursuant to Section 166, Continuances or Further Hearings.
except that when a continuance or further hearing is ordered following a hearing, oral notice of the time and place of the hearing may be given to each party present at the hearing.
A complete record of the proceedings shall be made. The testimony shall be transcribed, and copies of other documentary evidence shall be reproduced when directed by the hearing officer. The record will also be transcribed and reproduced at the request of a party to the hearing provided he bears the cost thereof.
On December 1, 1991, the requirements for advance directives in
the Patient Self Determination Act of 1990, Sections 4206 and 4751 of the
Omnibus Budget Reconciliation Act 1990,
P.L.
Medicaid certified hospitals, nursing facilities, hospices, home health agencies and personal care agencies must conform to the requirements imposed by the Health Care Financing Administration. The federal requirements mandate conformity to current State law. Accordingly, providers must:
* Provide all adult patients (not just Medicaid patients) with written information about their rights under State law to make health care decisions, including the right to accept or refuse medical or surgical treatment and the right to execute advance directives. This information must be provided:
* Maintain written policies, procedures and materials concerning advance directives to ensure compliance with the law.
* Inform all patients and residents about the provider?s policy on implementing advance directives.
* Document in each patient?s medical record whether the patient has received information regarding advance directives. Providers must also document whether patients have signed an advance directive and must record the terms of the advance directive.
ADVANCE DIRECTIVES
* Not discriminate against an individual based on whether they have executed an advance directive. All parties responsible for the patient?s care are obligated to honor the patient?s wishes as stated in the patient?s advance directive. A provider who objects to a patient?s advance directive on moral grounds must, as promptly as practicable, take all reasonable steps to transfer care to another provider.
* Educate staff and the community on advance directives.
* Tell patients if they wish to complete a health care declaration, the health care provider will provide them with information and a health care declaration form. Providers should acquire a supply of the declaration forms and become familiar with the form.
* Tell patients they have a right to reaffirm advance directives, to change the advance directive or to revoke the advance directive at any time and in any manner, including an oral statement to the attending physician or other health care provider.
On the following pages are a sample form describing advance directives and a sample declaration form which meets the requirements of law. A description of advance directive must be distributed to each patient.
HEALTH CARE DECLARATIONS IN ARKANSAS
OVERVIEW
Under Arkansas Law*, if you are a competent adult age 18 or older, you have the right to participate in making your own medical treatment decisions, including the right to accept or refuse specific forms of health care. As one means of exercising this right, the law allows you to complete written declarations containing instructions as to the kinds of health care decisions you wish to have made on your behalf if you become terminally ill or permanently unconscious and unable to make such decisions on your own. These declarations serve much the same purpose under Arkansas law as ?living wills? serve in other states.
SUGGESTED FORMS OF DECLARATION
Arkansas law specifies two standard forms of declaration, one dealing with the possibility of terminal illness, the other dealing with the possibility of permanent unconsciousness. If you wish to make a declaration, you are free to use either or both of these suggested forms, and you are also free to use different wording. You may obtain the standard forms or information on where to obtain them from your physician or other health care provider or from your attorney.
You should be aware that the standard forms do not necessarily address all of the choices you may have the legal right to make. For example, you may wish to insert more detailed instructions concerning your care, such as whether you do or do not wish to have water and food given to you through artificial means if you become terminally ill or permanently unconscious. If you have questions that your physician or health care provider is unable to answer, or if you wish to modify the standard forms by adding special instructions, you may wish to consult with a lawyer or other qualified professional.
CHOICES CONTAINED IN THE STANDARD FORMS OF DECLARATION
Each of the standard forms of declaration allows you to choose one of the following approaches:
STEPS FOR COMPLETING A DECLARATION
To be effective, your declaration(s) must be signed by you or by someone else acting at your direction and must be witnessed by two individuals. A declaration becomes effective when both of the following have occurred:
IF YOU WISH TO REVOKE YOUR DECLARATION(s)
If you have completed a health care declaration and later wish to revoke it, you may do so at any time and in any manner, without regard to your mental or physical condition at the time you wish to revoke. A revocation becomes effective when it is communicated to the attending physician or other health care provider by the person who is revoking, or by someone who is a witness to the revocation. Methods of revocation include, for example, a clear written or oral expression of your wish to revoke or physical destruction of the original and any copies of the declaration.
COMPLETING A HEALTH CARE DECLARATION FOR ANOTHER PERSON
In the case of minors and adults who are no longer able to make health care decisions, a declaration may be executed by another person acting on their behalf. Arkansas law establishes the following order of priority and provides that a declaration may be executed by the first of the following individuals, or category of individuals, who exists and is reasonably available for consultation:
SAFEGUARDS
In addition, Arkansas law affords the following protections:
* A.C.A. 20-17-201, et seq. Other rights of minors are covered in A.C.A. 20-17-214.
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Source: ARC 20-17-202
THE ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM
The Arkansas Medicaid Primary Care Physician Managed Care Program is a statewide program. Medicaid recipients must select a primary care physician (PCP). The PCP will provide primary care services and health education, and referral to specialty physicians, hospital care, or other services when necessary. The PCP is to assess the recipient?s medical condition and to initiate or recommend treatment or therapy as needed. The PCP must assist the recipient in locating needed medical services. The PCP will also coordinate and monitor, on behalf of the recipient, prescribed medical and rehabilitation services. Recipients participating in the PCP Managed Care Program may receive services only from their PCP unless the PCP refers them to another provider, or unless they access a service not requiring a PCP referral. See Section 184 for services not requiring a PCP referral.
Medicaid recipient participation in the program is mandatory except for:
* Recipients who have Medicare as their primary insurance.
* Recipients who are Children?s Medical Services (CMS) clients.
* Recipients who reside in a nursing facility (nursing home).
* Recipients who reside in an intermediate care facility for the mentally retarded
(ICF/MR).
* Recipients with Medically Needy-Spend Down categories of eligibility. MN
means ?Medically Needy.? The second digit of the numeric Recipient Aid Category is always 7 for Spend-Down categories. See Section 136 of any Arkansas Medicaid provider manual for aid category information.
* Recipients with a retroactive eligibility period. Medicaid will not require PCP
enrollment for the period between the beginning of the retroactive eligibility segment and the date of the eligibility authorization. If eligibility extends beyond the authorization date, Medicaid will require enrollment with a PCP unless the recipient is otherwise exempt from PCP program requirements.
* Recipients who are temporarily outside the State of Arkansas. Medicaid will not require PCP enrollment during the recipient?s absence from the state.
To ensure the availability of their choice, recipients must select three primary care physicians (PCPs). They must list their choices in the order of their preference. They may choose from among the following types of providers.
* Family practitioner
* General practitioner
* Internal medicine
* Obstetrician/gynecologist
* Pediatrician
* Single-Entity Primary Care Physician Providers
Medicaid recipients wishing to receive primary health care through a single-entity PCP need not enroll with a specific physician. They may choose an FQHC or one of the designated clinics as their PCP.
If a recipient?s first choice is a PCP who already has a maximum Medicaid recipient caseload, the recipient?s next selection will be effective. Every individual family member eligible for Medicaid must choose a PCP. The PCP may be the same or different for each family member.
Recipients must choose a PCP who provides primary care services in the same geographical area as the recipient?s residence. Medicaid defines the recipient?s geographical area inside the State of Arkansas as the recipient?s county of residence, counties adjacent to the county of residence and counties which adjoin the counties adjacent to the county of residence. Recipients whose county of residence is an Arkansas county bordering another state may select a PCP in specific cities (see Section 185.12) in the state bordering their county of residence.
DHS county office staff will give each Medicaid applicant a written and oral explanation of the PCP program. Applicants must complete form DMS-2609, Primary Care Physician Selection and Change Form, while in the DHS office, indicating the first, second and third choices of each Medicaid-eligible family member. Applicants may request and receive a copy of the completed form. The county office must retain a copy of the form in the applicant?s file. The DHS office will access the Voice Response System (VRS) and enter the PCP?s Medicaid provider number into the Automated Eligibility Verification and Claims Submission (AEVCS) system.
AEVCS will display, on an eligibility verification transaction, the name of the recipient?s PCP and the beginning date of the recipient?s current enrollment with the PCP. Medicaid will not reimburse providers for PCP-restricted services unless AEVCS displays the PCP name. Medicaid providers who are not PCPs should advise recipients with no PCP that Medicaid will not pay the provider?s charges until the recipient selects a PCP and obtains a referral for the service.
A recipient without a PCP may make their selection at the PCP?s office. The PCP?s office staff will enter the selection via the VRS. The enrollment will be effective immediately upon entry, and its effective date will be the date of entry.
Individuals covered by Medicaid because they are recipients of Supplemental Security Income (SSI) do not choose a PCP when they apply for SSI. When they become eligible for Medicaid, they must choose a PCP at the DHS office in their county of residence or at the office of their chosen PCP. Recipients will document their PCP choice on the Selection and Change Form. Medicaid provider office staff will copy, for their patient?s use, form DMS-2609 from page I-79 of any Medicaid provider manual. The PCP office will access the VRS and enter the PCP?s Medicaid provider number. The telephone number of the VRS is 1-800-805 -1512. The recipient may request and receive a copy of the completed selection form. The PCP office must retain a copy of the form in the recipient?s file.
Effective July 1, 1996, staff at participating acute care hospitals may facilitate PCP selection. Medicaid will cover only approved emergency services for recipients with no PCP. A Medicaid recipient with no PCP, seeking non-emergency services, must complete a selection form. Hospital personnel will enter the PCP selection via the VRS. The enrollment will be effective immediately upon entry, and its effective date will be the date of entry. The recipient may request and receive a copy of the completed selection form. The hospital staff must forward a copy of the selection form to the PCP entered on the VRS.
Only DHS county offices may change PCP selection per recipient or PCP request. Recipients and PCPs requesting a change of PCP selection must submit written requests to the DHS office in the recipient?s county of residence.
The recipient will complete a Selection and Change Form. County office staff will access the VRS to change the PCP. The recipient may request and receive a copy of the completed selection form. The county office must retain a copy of the form in the recipient?s file.
PCPs must submit their change requests by letter to the county DHS office. The county office will forward to the recipient, a Selection and Change form by which to indicate their new selection. The PCP must also give the recipient written notice, 30 days in advance of the effective date of the termination, that the PCP has requested removal of the recipient from the PCP?s caseload and that the recipient must select another PCP (see Conditions of Participation, Section 185.12).
* It is important to note that county office staff cannot remove a PCP from the computer file; they can only replace a PCP?s provider number with that of another PCP. When DHS or a Medicaid provider enrolls a recipient with a PCP, the recipient remains enrolled with that PCP until the recipient?s current eligibility ends, until the provider no longer participates, or until a DHS county office enters a different PCP provider number into the VRS.
The recipient or the PCP may change the PCP selection for access purposes.
The recipient, the PCP or the State may change the PCP selection for cause.
Medicaid defines the expression ?for cause,? in this context, to mean: ?substantive and verifiable reasons other than those regarding recipient access to physician primary care services.?
The recipient may request a change of PCP for cause no more often than every 6 months. The recipient may change their selection of a PCP because their arrangement with the PCP is not acceptable to the recipient. Examples of an unacceptable arrangement include, but are not limited to:
The PCP may request that the recipient change their selection of a PCP because the arrangement with the recipient is not acceptable to the PCP. Examples of an unacceptable arrangement include, but are not limited to:
The PCP must request the change in writing, forwarding a copy to the recipient and to the DHS office in the recipient?s county of residence.
The PCP may request a PCP change for cause no sooner than 6 months after the last requested PCP change for the same recipient. For example, if the physician requests that a patient change PCPs, and subsequently agrees to reenroll them as a PCP Managed Care Program patient, the physician may not request another PCP change for cause until 6 months have elapsed since the date of the previous change request for cause.
It is possible for a Medicaid recipient to enroll or reenroll as a managed care patient with a PCP who has previously dismissed them for cause. If this occurs and the PCP wishes not to renew the relationship, the PCP must again submit a written request to the DHS county office and give the recipient 30 days notice to select another PCP. The 6-month waiting period will not apply to properly documented cases of this nature.
The State may initiate a PCP change request as often as necessary. Examples of reasons the State would ask recipients to change PCPs include, but are not limited to:
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Medicaid services not generally performed by the PCP require a PCP referral. The services listed below are exempt from this requirement.
EPSDT Screens Require PCP Referral for Residents of these Counties:
|
Benton |
Craighead |
Grant |
Marion |
Pulaski |
|
Boone |
Crawford |
Johnson |
Ouachita |
Randolph |
|
Carroll |
Faulkner |
Lawrence |
Perry |
Saline |
|
Clark |
Franklin |
Lonoke |
Poinsett |
Sebastian |
|
Clay |
Garland |
Madison |
Pope |
Washington |
(ICF/MR) services.
Recipients eligible for Medicaid under the guidelines of the waiver programs specified in Section 184 need no PCP referral for waiver services only. When accessing any other Medicaid services, participants in those waiver programs are subject to all requirements of the PCP Managed Care Program. In addition, case managers of waiver program recipients must list in the recipient's plan of care, all services the recipient receives. Waiver program recipients are not eligible for State Plan services unless those services are part of their plan of care and unless the recipient obtains the necessary referrals and otherwise meets all Medicaid Program requirements.
Only those physicians and clinics listed in Section 182.10 may qualify as PCPs. Physicians whose specialty is emergency care or who practice exclusively in hospital emergency departments may not enroll as PCPs. Practitioners in the physician specialties listed in Section 182.10 must enroll as PCPs or DMS will terminate their enrollment in the Arkansas Medicaid Physician Program. Of the specialties eligible to enroll as PCPs, only obstetricians and gynecologists are exempt from mandatory PCP enrollment.
A PCP may have up to 1000 Medicaid recipients on their caseload at one time. The State may, at its discretion, raise the recipient limit per PCP in areas the federal government has designated as medically underserved. The State may, at its discretion, raise the recipient limit for an individual PCP, at that PCP?s request, if the limit creates hardship on the PCP?s practice.
Each PCP may determine their Medicaid caseload limit up to 1000 recipients. In no instance will DMS require a PCP to accept more recipients on their caseload than the PCP has designated as their limit.
PCPs may increase or decrease their caseload limit by no fewer than 10 slots at a time. A PCP must submit a written request to the Division of Medical Services, Provider Enrollment Unit, to change the size of their caseload.
Internal medicine practitioners, obstetricians and gynecologists are exempt from mandatory Child Health Services (EPSDT) enrollment. Area Health Education Centers (AHECs), and the family practice and internal medicine clinics at the University of Arkansas Medical Sciences campus, are the only physician group providers that may enroll as single-entity primary care physician providers.
* A pediatrician may refuse to accept a recipient on their caseload if the recipient is 14 years of age or older. * An obstetrician/gynecologist may refuse to accept on their caseload a male recipient. * An obstetrician/gynecologist may refuse to accept on their caseload a female under the age of 12 years. * An internal medicine practitioner may refuse to accept on their caseload a recipient 16 years of age or younger.
A PCP will make available 24 hour, 7 days per week access to service for the recipients in their caseload. Each physician will follow the standards of community practice for the county in which they practice.
In counties with adequate physician coverage, PCPs will provide for the after-hours care of their patients. Presently, the following counties have adequate physician coverage: Benton, Craighead, Faulkner, Garland, Jefferson, Miller, Pulaski, Saline, Sebastian, Union, Washington and White. In those counties, when Medicaid recipients present to the emergency department for non-emergency care, hospital staff must remind them to contact their PCP, the PCP?s designated substitute or the physician on call for their PCP, regardless of the day or the time of day. Please refer to Sections 185.51, 185.52 and 185.53 for policy information regarding physician substitutes in the PCP Managed Care Program.
* The PCP?s documentation must state the nature of the patient?s complaint and the hospital medical staff?s diagnosis and treatment, including pertinent comments and recommendations, such as suggestions that the patient follow up with a visit to their PCP.
* Documentation by the PCP?s office and the hospital must include the date and the time hospital staff contacts the PCP.
If a recipient has no PCP, hospital staff will offer to enroll them with a PCP. Medicaid will provide participating hospitals with current listings of local area PCPs. Hospital personnel will enter the recipient?s selection via the Voice Response System (VRS), and the enrollment will be effective immediately.
?Inadequate physician coverage? means there are not enough physicians in an area to provide one another with after hours support, and local physicians must refer their patients to the hospital emergency department after their regular office hours. In some such counties, local physicians staff the emergency department part-time or they are on call for one another part-time. The fact remains, however, that in those areas, local physicians are not able to provide full-time coverage among themselves.
* The PCP?s documentation must state the nature of the patient?s complaint and the hospital medical staff?s diagnosis and treatment, including pertinent comments and recommendations, such as suggestions that the patient follow up with a visit to their PCP.
* Documentation by the PCP?s office and the hospital must include the date and the time hospital staff contacts the PCP.
If a recipient has no PCP, hospital staff will offer to enroll them with a PCP. Medicaid will provide participating hospitals with current listings of local area PCPs. Hospital personnel will enter the recipient?s selection via the Voice Response System, and the enrollment will be effective immediately.
A PCP agrees to provide primary care services and health education; and to refer patients to specialty physicians, hospital care, or other services when necessary. The PCP will assess the recipient?s medical condition and initiate or recommend treatment or therapy as needed. The PCP must assist the recipient in locating needed medical services. The PCP will also coordinate and monitor, on behalf of the recipient, prescribed medical and rehabilitation services.
Recipients participating in the PCP Managed Care Program may receive services only from their PCP unless the PCP refers them to another provider, or unless they access a service not requiring a PCP referral. A PCP may refer a recipient to a specific, named provider only if they name more than one provider and allow the recipient to choose. If the recipient elects to see a provider without a referral, the recipient will be responsible for the charges incurred. With respect to the quality and appropriateness of services, PCPs must accept co-responsibility for the ongoing care of referred patients. Services requiring a PCP referral may not begin until the PCP makes the referral. The PCP must renew, at least every 6 months, any referral for ongoing care. Medicaid defers to the physician?s professional judgment in this regard and does not require that the PCP see the patient before making or renewing a referral.
Medicaid provides an optional referral form, the DMS-2610, located on page I-88 that the PCP may use to facilitate referrals. A PCP may also make a referral orally or by note or letter. Medicaid requires documentation of the referral in the recipient?s medical record, regardless of the means by which the PCP makes the referral. Medicaid requires the provider receiving the referral to document it also, and to correspond with the PCP regarding the case when appropriate and when the PCP so requests.
Medicaid permits physicians to substitute for PCPs in some situations. The 3 requirements immediately following apply to all PCP substitutions by physicians.
Physicians affiliated with a Rural Health Clinic or enrolled in a Medicaid-enrolled physician group may substitute for a recipient?s PCP if the PCP is unavailable. Acceptable reasons for a PCP not to be available are: the PCP?s schedule is full because of an unusual number of urgent or time-consuming cases; recipients require services outside the PCP?s normal working hours; or the PCP is ill, on vacation or other leave of absence, or in surgery. Habitual overscheduling of patients is not an acceptable reason for a PCP?s use of a substitute. PCPs and substitutes must fully document each substitution as a PCP referral.
Individual practitioners must designate a substitute physician to take telephone calls, see recipients and make appropriate referrals when the PCP is unavailable. Acceptable reasons for a PCP not to be available are: recipients require services outside the PCP?s normal working hours; or the PCP is ill, on vacation or other leave of absence, or in surgery. Habitual overscheduling or having too great a caseload are not acceptable reasons for a PCP?s use of a substitute. PCPs and substitutes must fully document each substitution as a PCP referral.
Licensed nurse practitioners or licensed physician assistants, employed by a Medicaid-enrolled Rural Health Clinic (RHC) provider, may not function as PCP substitutes. However, they may provide primary care for the PCP?s recipients, with certain restrictions.
PCPs will continue to bill Medicaid on a fee for service basis. Additionally, Medicaid will pay the PCP a monthly management fee. Medicaid will pay a set amount per month, for each recipient enrolled with the PCP on the last day of the month, regardless of the duration of the recipient?s enrollment with the PCP. The PCP will receive the payments quarterly; in October, January, April and July. An accompanying Remittance Advice and Status Report (RA) will itemize the payments, by recipient and enrollment month. The RA will list each PCP?s managed care patients alphabetically, and will include each recipient?s Medicaid identification number and address.
The PCP only refers recipients for access to a specific type of medical service. The PCP may refer recipients to a specific, named provider as long as more than one choice is given to the recipient. However, if the recipient elects to go to a non-referred-to provider, the recipient will then be responsible for the charges incurred. The PCP does not authorize any Medicaid service provision. The PCP program does not modify any Medicaid provider policy. All providers still must follow all Medicaid policy regulating the specific Medicaid services they are providing, such as medical necessity requirements, prior authorization, care plan development, etc. It remains the responsibility of the referred-to/billing provider, who renders service, to document that all Medicaid program requirements are met.
Except for the excluded services listed in Section 184, provider claims for services not authorized by the PCP will be denied. Providers, who have received a referral from a PCP, must indicate authorization by the PCP on the Medicaid claim to assure the appropriateness of the referral. This authorization is the PCP?s Medicaid physician provider number which will be indicated on the Referral Form or verbally given to the provider referred to by the PCP. The provider must have documentation of the referral in the recipient?s medical record via the referral form or notation of verbal referral.
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(Reserved)
(Reserved)
GENERAL INFORMATION
Rehabilitation Services
Providers of Developmental Rehabilitation Services must meet the following criteria to be eligible to participate in the Arkansas Medicaid Program:
States
Only providers of developmental rehabilitation services in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined above.
Routine service providers may furnish and claim reimbursement for developmental rehabilitation services covered by Arkansas Medicaid. Services are subject to benefit limitations and coverage restrictions set forth in this manual. Claims must be filed according to Section III of this manual.
PROGRAM COVERAGE
The Medical Assistance (Medicaid) Program is designed to assist eligible Medicaid recipients in obtaining medical care within the guidelines specified in Section I of this manual. All Medicaid benefits are based upon medical necessity. See the Glossary (Section IV) of this manual for ?medical necessity? definition.
Part C of the Individuals with Disabilities Education Act (IDEA) requires each state to provide mandated early intervention services. The Arkansas Department of Human Services Division of Developmental Disabilities Services (DDS) is the lead agency for the Part C early intervention program in Arkansas. First Connections is the name of the early intervention program.
Arkansas Medicaid?s Developmental Rehabilitation Services Program provides coverage for the following First Connections early intervention services that are medically necessary for Medicaid eligible recipients under three years of age:
The following services are excluded from coverage in this program.
Coverage of Developmental Rehabilitation Services is limited to two basic services for Medicaid eligible recipients who meet the eligibility requirements. Refer to section 214.100 for recipient eligibility criteria and sections 214.200 through 214.220 for information on the services covered.
Recipients eligible for these services must meet the following criteria:
AND
AND
or
The recipient must have a diagnosed physical or mental condition that has a high probability of developmental delay. These diagnosed conditions may include but are not limited to:
Developmental rehabilitation services are early intervention services. This program covers two basic services: developmental testing and therapeutic activities. The DDS certified provider must ensure that an individual providing developmental testing services and therapeutic activities services meets the qualifications as outlined in Part C of IDEA and the DDS First Connections services guidelines.
Developmental rehabilitation services may be provided in the recipient?s home, in the community or in a clinical setting.
Refer to Section III of this manual for billing instructions and procedure codes for services covered in this program.
Developmental testing is a battery of diagnostic tests for the purpose of determining a child?s developmental status and need for early intervention services. This may include, but is not limited to, psychological and behavioral developmental profiles. The profiles are required to determine a person?s eligibility for services and the development of the Individualized Family Service Plan (IFSP).
Developmental testing includes two instruments and a narrative report with interpretation.
Developmental testing is not covered through Developmental Rehabilitation Services if developmental testing has been provided and covered through a DDTCS program or a CHMS program within the last six months.
Therapeutic activities are services that provide direct instruction to a child, or both the parent or caregiver and the child, to promote the child?s acquisition of skills in a variety of developmental areas.
IFSP and must be the direct result of the level of delay(s) determined by the inter-disciplinary assessment.
Benefit limits are the limits on the quantity of covered services Medicaid eligible recipients may receive.
Providers may request benefit extensions for medically necessary services by submitting appropriate DDS First Connections forms for a benefit extension along with supporting documentation to:
First Connections Infant & Toddler Program Developmental Disabilities Services
P. O. Box 1437, Slot N503 Little Rock, Arkansas 72203-1437
DDS First Connections Infant & Toddler Program staff is responsible for approval or denial of benefit extension requests. The requesting provider will be notified of approval or denial of the request. The approval notification will list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service authorized.
Providers are to file the claims electronically, entering the assigned control number in the Prior Authorization (PA) number field of the HCFA-1500 claim format. Subsequent benefit extension requests will be necessary only when the extension expires or when a recipient?s need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Providers may obtain the appropriate forms for requesting benefit extensions from the DDS First Connections Service Coordinator or from the First Connections Program in the DDS central office as listed above.
Please refer to Section III of this manual for a listing of the procedure codes.
PRIOR AUTHORIZATION
First Connections Infant & Toddler Program
Developmental Disabilities Services
P. O. Box 1437, Slot N503
Little Rock, AR 72203-1437
Providers may obtain the Prior Authorization (PA) forms from the First Connections program staff.
control number will be assigned and the PA number will be entered into the Medicaid system.
The First Connections Program staff will review PA requests for 10% of the total number of children on each service coordinator?s caseload. The IFSP will be reviewed and the parent or legal guardian will be contacted to assess successful outcomes for the child and family.
When coverage of services or a prior authorization request for services is denied, the recipient may request a fair hearing of the denial of services from the Department of Human Services.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services, within thirty (30) days of the date of the denial notification.
Submit appeal requests to:
Department of Human Services
Appeals and Hearings Section
P. O. Box 1437, Slot N401
Little Rock, Arkansas 72203-1437
REIMBURSEMENT
The reimbursement methodology for Developmental Rehabilitation Services is a ?fee schedule? methodology. Under the fee schedule methodology, reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowed for each procedure. The maximum allowable fee for a procedure is the same for all Developmental Rehabilitation Services providers.
A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision the provider will be afforded the opportunity for a conference, if he/she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services, is unsatisfactory, the provider may then appeal the question to the standing Rate Review Panel established by the Director of the Division of Medical Services. This panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services Management Staff who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
GENERAL INFORMATION
The purpose of Section III of the Arkansas Medicaid Manual is to explain the procedures for billing in the Arkansas Medicaid Program.
Three major areas are covered in this section:
The Automated Eligibility Verification and Claims Submission (AEVCS) System is the method of submitting Medicaid claims electronically. Medicaid requires AEVCS submission of the following claim types: UB-92, HCFA-1500, Vision, Dental, EPSDT and Pharmacy.
Providers have several choices of AEVCS submission methods: personal computer (PC)-based software, point of sale (POS) devices, or adapting their current office management system to submit claims in the proper format to AEVCS.
Provider Electronic Solution Application software is available for any provider who submits Medicaid claims. The software requires, at a minimum, 486/66 processor with 8 MB RAM, 25 MB free space, CD-ROM drive, and Windows 95. We strongly recommend running the software on a Pentium 100 (or greater) processor with 16 MB RAM, 25 MB free space, CD-ROM drive and Windows 95, Windows 98, or Windows NT 4.0 or higher. Claims can be transmitted for processing by almost any Hayes-compatible modem, with the exception of the US Robotics Voice Modem and Hewlett-Packard?s HP ?Pavillion?. Eligibility verifications are part of the base software system. The software supports the following claim types: HCFA-1500, UB-92, Dental, EPSDT, Pharmacy and Vision.
EDS has a staff of representatives available during regular business hours from 8:00 a.m. to 4:30 p.m. (see section 119 of this manual for EDS holiday closings) to assist with any needs concerning POS devices. Please call the AEVCS Help Desk at (501) 375-1025 (locally and out-of-state), or 1-800-457 -4275 (within Arkansas) for help with questions regarding software or POS devices.
EDS maintains a Provider Assistance Center to assist Medicaid providers during regular business hours from 8:00 a.m. to 4:30 p.m. (CST). See section 119 of this manual for EDS holiday closings. Should you have any questions concerning claims payment, please contact the Provider Assistance Center at 1-800-457 -4454 (Toll Free) within Arkansas or locally and out-of-state at (501) 376-2211.
EDS has a full time staff of Provider Representatives available for consultation regarding billing problems that cannot be resolved through the Provider Assistance Center. Provider Representatives are available to visit your office to provide training on billing.
The Code of Federal Regulations (42 CFR), at 447.45 (d) (1), states ?The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.? The 12 month filing deadline applies to all claims, including:
There are no exceptions to the 12 month filing deadline policy. However, the definitions and additional federal regulations below will permit some flexibility for those who adhere closely to them.
Federal regulations dictate that providers must file the Medicaid portion of claims for dually eligible beneficiaries within 12 months of the beginning date of service. The Medicare claim will establish timely filing for Medicaid, if the provider files with Medicare during the 12 month Medicaid filing deadline. Medicaid may then consider payment of Medicare deductible and/or coinsurance, even if the Medicare intermediary or carrier crosses the claim to Medicaid after more than a year has passed since the date of service. Medicaid may also consider such a claim for payment if Medicare notifies only the provider and does not electronically forward the claim to Medicaid. Federal regulations permit Medicaid to pay its portion of the claim within 6 months after the Medicaid ?agency or the provider receives notice of the disposition of the Medicare claim.?
Providers may not electronically transmit to EDS any claims for dates of service over 12 months in the past. To submit a Medicare/Medicaid crossover claim meeting the timely filing conditions in the first paragraph above, please refer to Patients with Joint Medicare/Medicaid Coverage, section 342.000, of this manual. In addition to following the billing procedures explained in section 342.000, enclose a signed cover memo or Claim Inquiry Form requesting payment for the Medicaid portion of a Medicare claim which was filed to Medicare within 12 months of the date of service, and which Medicare adjudicated more than 12 months after the date of service.
The definitions of the terms, clean claim and new claim, help to determine which claims and adjustments Medicaid may consider for payment, when more than 12 months have passed since the beginning date of service.
42 CFR, at 447.45 (b), defines a clean claim as a claim that Medicaid can process ??without obtaining additional information from the provider of the service or from a third party.? The definition ??includes a claim with errors originating in a State?s claims system.?
A claim that denies for omitted or incorrect data, or for missing attachments, is not a clean claim. A claim filed more than 12 months after the beginning date of service is not a clean claim, except under the special circumstances described below.
A new claim is a claim that is unique, differing from all other claims in at least one material fact. It is very important to note that identical claims, received by Medicaid on different days, differ in the material fact of their receipt date, and are both new claims, unless defined otherwise in the next paragraph.
Sometimes a clean claim pays incorrectly or denies incorrectly. When a provider files an adjustment request for such a claim, or refiles the claim after 12 months have passed from the beginning date of service, the submission is not necessarily a new claim. The adjustment or claim may be within the filing deadline. For Medicaid to consider that the submission is not a new claim and, therefore, is within the filing deadline, the adjustment or claim must meet two requirements:
Retroactive eligibility does not constitute an exception to the filing deadline policy. If an appeal or other administrative action delays an eligibility determination, the provider must submit the claim within the 12-month filing deadline. If the claim denies for recipient ineligibility, the provider may resubmit the claim when the patient becomes eligible for the retroactive date(s) of service. Medicaid may then consider the claim for payment because the provider submitted the initial claim within the 12-month filing deadline, and the denial was not the result of an error by the provider.
To submit a claim for services rendered to a patient who is not yet eligible for Medicaid, enter, on the claim form or on the electronic format, a pseudo Medicaid recipient identification number, 9999999999. Medicaid will deny the claim. Retain the denial or rejection for proof of timely filing, if eligibility determination occurs more than 12 months after the date of service.
Occasionally, the state Medicaid agency or a federal agency, such as the Social Security Administration, is unable to complete a Medicaid eligibility determination in time for service providers to file timely claims. Arkansas Medicaid?s claims processing system is unable to accept a claim for services rendered to an ineligible individual, and to suspend that claim until the individual is retroactively eligible for the claim dates of service. To resolve this dilemma, Arkansas Medicaid considers the pseudo recipient identification number 9999999999 to represent, an ??error originating within (the) State?s claims system.? Therefore, a claim containing that number is a clean claim if it contains all other information necessary for correct processing. By defining the initial claim as a clean claim, denied by processing error, we may allow the provider to refile the claim when the government agency completes the eligibility determination. The provider must submit with the claim, proof of the initial filing and a letter or other documentation sufficient to explain that administrative processes (such as determination of SSI eligibility) prevented the resubmittal before the filing deadline.
When it is necessary to submit an adjustment or resubmit a claim to Medicaid, after 12 months have passed since the beginning date of service, the procedures below must be followed.
If the fiscal agent has incorrectly paid a clean claim, and the error has made it impossible to adjust the payment before 12 months have passed since the beginning date of service, a completed Adjustment Request Form (Form EDS-AR-004, page III-60 of this manual) must be submitted to the address specified on the form. Attach the documentation necessary to explain why the error has prevented refiling the claim until more than 12 months have passed after the beginning date of service.
Submit a paper claim to the address below, attaching:
Send these materials to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
Submit a paper claim to the address below, attaching:
Send these materials to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
To solve some of the billing problems associated with differing interpretations of procedure code descriptions, EDS implemented the ClaimCheck® enhancement to the Arkansas MMIS system in February 1997. This software analyzes procedure codes and compares them to nationally accepted published standards to recommend more accurate billing. Most ClaimCheck® edits are simply automated versions of Medicaid edits already in place, so claims are resolved much more quickly. In some cases of denied claims, ClaimCheck® can recommend the appropriate procedure code or combination of codes to ensure payment.
ClaimCheck® developers based the software?s edits on the guidelines contained in the Physicians? Current Procedural Terminology (CPT) book, and Arkansas Medicaid customized it for local policy and procedure codes. ClaimCheck® bases its editing decisions on the individual payee?s own established policy, and recommends appropriate actions to the payee?s claims processing system.
Please note that ClaimCheck® implementation does not affect Medicaid policy. If there are questions regarding the function of ClaimCheck® edits, the Provider Assistance Center (PAC) may be called at (501) 376-2211 (local and out-of-state) or 1-800-457 -4454 (in-state WATS).
The Arkansas Medicaid Program distributes a weekly Remittance and Status Report (RA) to each provider with claims paid, denied or pending, as of the previous weekend processing cycle. (Sections 320 through 324.800 of this manual contain information for a complete explanation of the RA). Use the RA to verify claim receipt and to track claims through the system. Claims transmitted through the Automated Eligibility Verification and Claims Submission (AEVCS) system will appear on the RA within 2 weeks of transmission. Paper claims and adjustments may take as long as six weeks to appear on the RA.
If a claim does not appear on the RA within the amount of time appropriate for its method of submission, contact the EDS Provider Assistance Center. A Provider Assistance Center Representative can explain what system activity, if any, regarding the submission, has occurred since EDS printed and mailed the last RA. If the transaction on the RA cannot be understood, or is in error, the representative can explain its current status and suggest remedies when appropriate. If there is no record of the transaction, the representative will suggest that the claim be resubmitted.
When a written response to a claim inquiry is preferred, EDS provides a Medicaid Claim Inquiry Form, EDS-CI-003. The form in this manual may be copied, or a supply may be requested from EDS. A separate form for each claim in question must be used. EDS is required to respond in writing only if they can determine the nature of the questions. The Medicaid Claim Inquiry Form is for use in locating a claim transaction and understanding its disposition. If help is needed with an incorrect claim payment, refer to section 330 of this manual for the Adjustment Request Form and information regarding adjustments.
To inquire about a claim, the following items on the Medicaid Claim Inquiry Form must be completed. A copy of this form follows these instructions. In order to answer your inquiry as quickly and accurately as possible, please follow these instructions:
|
Field Name and Number |
Instructions for Completion |
|
1. Provider Number |
Enter the 9-digit Arkansas Medicaid provider number assigned. If requesting information regarding a clinic billing, indicate the clinic provider number. |
|
2. Provider Name and Address |
Enter the name and address of the provider as shown on the claim in question. |
|
3. Recipient Name (First, Last) |
Enter the patient?s name as shown on the claim in question. |
|
4. Recipient ID |
Enter the 10-digit Medicaid identification number assigned to the patient. |
|
5. Billed Amount |
Enter the amount the Medicaid Program was billed for the service. |
|
6. Remittance Advice Date |
Enter the date of the Medicaid RA on which the claim most recently appeared. |
|
7. Date(s) of Service |
Enter the month, day and year of the earliest date of service on the claim in question. |
|
8. ICN (Claim Number) |
Enter the 13-digit claim control number assigned to the claim by Medicaid. If the claim being questioned is shown on a Medicaid RA, this number will appear under the heading ?Claim Number.? |
|
9. Provider Message/Reason for Inquiry |
State the specific description of the problem and any remarks which may be helpful to the person answering the inquiry. |
|
10. Signature, Phone and Date |
The provider of service or designated authorized individual inquiring must sign and date the form. |
NOTE: The lower section of the form is reserved for the response to your inquiry.
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To order EDS-supplied forms, please use the Medicaid Form Request, Form EDS-MFR-001. An example of the form appears on page III-14. EDS supplies the following forms:
|
Acknowledgement of Hysterectomy Information |
(DMS-2606) |
|
Adjustment Request Form - Medicaid XIX |
(EDS-AR-004) |
|
CHMS Benefit Extension for Occupational, Physical and Speech Therapy Services |
(DMS-629) |
|
Certification Statement for Abortion |
(DMS-2698) |
|
Consent for Release of Information |
(DMS-619) |
|
DDTCS Transportation Survey |
(DMS-632) |
|
EPSDT |
(DMS-694) |
|
Explanation of Check Refund |
(EDS-CR-002) |
|
Hospice/INH Claim Form |
(DHS-754) |
|
Hospital/Physician/Certified Nurse Midwife Referral for Newborn Infant Medicaid Coverage |
(DCO-645) |
|
Medicaid Claim Inquiry Form |
(EDS-CI-003) |
|
Medicaid Form Request |
(EDS-MFR-001) |
|
Medicaid Prior Authorization and Extension of Benefits Request |
(DMS-2694) |
|
Medical Equipment Request for Prior Authorization & Prescription |
(DMS-679) |
|
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC |
(DMS-633) |
|
Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 Prescription/Referral |
(DMS-640) |
|
Parent Agreement for Private Duty Nursing for Recipients Under 21 |
(DMS-610) |
|
Personal Care Assessment and Service Plan |
(DMS-618) |
|
Primary Care Physician Selection and Change Form |
(DMS-2609) |
|
Prior Authorization and Prescription for Medical Equipment for Medicaid Recipients Under Age 21 |
(DMS-609) |
|
Referral for Medical Assistance |
(DMS-630) |
|
Request for Extension of Benefits |
(DMS-699) |
|
Request for Extension of Benefits for Medical Supplies for Medicaid Recipients Under Age 21 |
(DMS-602) |
|
Request for Prior Authorization and Prescription for Hyperalimentation |
(DMS-2615) |
|
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification |
(DMS-2692) |
|
Request for Targeted Case Management Prior Authorization for Recipients Under Age 21 |
(DMS-601) |
|
Sterilization Consent Form |
(DMS-615) |
|
Sterilization Consent Form - Information for Men |
(PUB-020) |
|
Sterilization Consent Form - Information for Women |
(PUB-019) |
|
Verification of Medical Services |
(DMS-2618) |
|
Visual Care |
(DMS-26-V) |
Complete the Medicaid Form Request and indicate the quantity needed of each form.
Mail your request to: EDS
Provider Assistance Center
P. O. Box 8036
Little Rock, AR 72203-8036
The Medicaid Program does not provide copies of the HCFA-1500 claim form. The provider may request a copy of this claim form from any available vendor. An available vendor is:
Superintendent of Documents U.S. Government Printing Office Public Documents Department N.W. Washington, DC 20402
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BILLING PROCEDURES
Developmental Rehabilitation Services providers use the HCFA-1500 format to bill the Arkansas Medicaid Program for services provided to eligible Medicaid recipients. Each claim may contain charges for only one recipient.
Providers submitting claims electronically, must maintain a daily electronic claim transaction summary, signed by an authorized individual. Refer to the Provider Contract (Form DMS-653).
The Automated Eligibility Verification and Claims Submission (AEVCS) system is the electronic method for verifying a recipient?s eligibility and filing claims for payment. A provider may file a claim immediately after providing a service. AEVCS will edit the claim for billing errors and advise of the claim?s acceptance into the processing system for adjudication. If AEVCS rejects the claim, it will list up to 9 reasons for the rejection and permit the claim to be corrected and resubmitted.
EDS processes each week?s accumulation of claims during the weekend cycle. The deadline for each weekend cycle is 12:00 midnight Friday.
Section 301.000 of this manual contains information on available AEVCS options.
The following table lists the values/comments for each of the fields associated with a HCFA-1500 claim transaction. The last column provides a cross-reference to section 311.400 of this manual for specific field requirements and instructions.
BILLING PROCEDURES - AEVCS
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
Header 1 Information |
||
|
Provider ID |
Billing provider?s Medicaid ID number. 9 digit numeric. |
Field 33 |
|
Recipient ID |
Recipient?s Medicaid ID number. 10 digit numeric. |
Field 1A |
|
First Name |
First character only of the recipient?s first name. |
Field 2 |
|
Last Name |
First two characters only of the recipients last name. |
Field 2 |
|
Patient Account Number |
Provider can assign an individual number to identify the patient. Default = spaces. |
Field 26 |
|
Prior Authorization Number |
Prior authorization number. 10 digit numeric. Default = spaces. |
Field 23 |
|
Referring Physician ID |
9 digit numeric Medicaid provider number of the referring provider. Default = spaces. |
Field 17A |
|
Header 2 Information |
||
|
Diagnosis 1 |
Primary diagnosis code. Do not type the decimal. |
Field 21 |
|
Diagnosis 2 |
Secondary diagnosis code, if applicable. Do not type the decimal. Default = spaces. |
Field 21 |
|
Diagnosis 3 |
Third diagnosis code, if applicable. Do not type the decimal. Default = spaces. |
Field 21 |
|
Diagnosis 4 |
Fourth diagnosis code, if applicable. Do not type the decimal. Default = spaces. |
Field 21 |
|
Employment Related? |
Not applicable to Developmental Rehabilitation Services. |
Field 10A |
|
Incident Date |
Not applicable to Developmental Rehabilitation Services. |
Field 14 |
|
Accident Related? |
Indicates whether the condition is due to an accident. Y? = Yes ?N? = No. |
Field 10B or 10C |
|
Hospital Admit Date |
Not applicable to Developmental Rehabilitation Services. |
Field 18 |
|
Facility Name |
Name of facility where services were rendered if other than home or office. Default = spaces. |
Field 32 |
|
Facility Address |
Address of facility where services were rendered. Default = spaces. |
Field 32 |
|
Outside Lab Work? |
Not applicable to Developmental Rehabilitation Services. |
Field 20 |
|
Therapy Services Code |
Not applicable to Developmental Rehabilitation Services. |
Field 19 |
|
School District Code |
Local Education Agency (LEA) code that identifies the school district in which therapy services are rendered. |
Field 19 |
|
Other Insurance? |
Indicates whether the recipient has insurance. Y? = Yes ?N? = No. |
N/A |
|
TPL Paid Amount |
Amount paid on this claim by third party carrier. Default = zero. |
Field 29 |
|
TPL Denial Date |
Date the claim was denied by third party carrier. Format = CCYYMMDD. Default = zero. |
N/A |
|
Detail Information |
||
|
From DOS |
?From? date of service. Format = CCYYMMDD. For spanning dates of service, do not include any date on which no service was rendered. |
Field 24A |
|
To DOS |
?To? date of service. Format = CCYYMMDD. For spanning dates of service, do not include any date on which no service was rendered. |
Field 24A |
|
POS |
Place of service code. |
See Section 311.200 |
|
TOS |
Type of service code. |
See Section 311.200 |
|
Procedure |
Procedure code. 5 digit alpha numeric CPT or HCPCS code. |
Field 24D |
|
Modifier |
Not applicable to Developmental Rehabilitation Services. Default = zero. |
Field 24D |
|
Hours |
Not applicable to Developmental Rehabilitation Services. |
Field 24D |
|
Minutes |
Not applicable to Developmental Rehabilitation Services. |
Field 24D |
|
Extreme Age |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Surgical Avoid |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Hypothermia |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Hypotension |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Pressure |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Circulation |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
Units |
Number of units billed on this claim detail. 0? not valid. |
Field 24G |
|
Diagnosis |
Diagnosis code that pertains to this detail. Enter appropriate diagnosis code from Header 2. |
Field 24E |
|
Charges |
Billed amount for this detail. |
Field 24F |
|
Fund Code |
Not applicable to Developmental Rehabilitation Services. |
N/A |
|
EPSDT/Family Planning |
Indicates the services were rendered as a result of EPSDT screening. Enter ?E? if services are a result of EPSDT screening. F? = Family Planning. Default = spaces. |
Field 24H |
|
Performing Provider ID |
Performing provider?s Medicaid ID number if different from billing provider. 9 digit numeric. |
Field 24K |
|
TPL Information |
||
|
Carrier Code |
National code assigned to identify the specific third party carrier. Default = spaces. |
N/A |
|
Policy Number |
Third party carrier insurance policy number. Default = spaces. |
Field 11 |
|
Company Name |
Name of the third party carrier. Default = spaces. |
Field 11C |
|
Address |
Address of the third party carrier. Default = spaces. |
N/A |
|
Second TPL |
Indicates whether the recipient has a second third party insurance. Response required if primary insurance is entered; ?Y? = Yes ?N? = No. |
Field 11D |
|
Carrier Code |
National code assigned to identify the specific third party carrier. Default = spaces. |
N/A |
|
Policy Number |
Secondary third party carrier policy number. Default = spaces. |
Field 9A |
|
Company Name |
Name of the secondary third party carrier. Default = spaces. |
Field 9D |
|
Address |
Address of the secondary third party carrier. Default = spaces. |
N/A |
|
Insured/Other than Recipient |
Enter ?Y? if the insured person is the Medicaid recipient. Enter ?N? if insured person is not the Medicaid recipient. |
N/A |
|
First Name |
First name of the insured person if different from recipient and recipient is covered under the policy. Default = spaces. |
Field 4 |
|
Last Name |
Last name of the insured person if different from recipient and recipient is covered under the policy. Default = spaces. |
Field 4 |
|
Address |
If the insured person?s name is entered, enter the insured person?s address. Default = spaces. |
Field 7 |
|
Employer/ School Name |
Name of the insured person?s employer or school. Default = spaces. |
Field 9C |
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
POS-Return |
If non-zero, system error has occurred. |
N/A |
|
Return Code |
System-assigned code that identifies the status. C? = Claim Captured |
N/A |
|
ICN |
Internal Control Number assigned to the processed claim. |
N/A |
|
Full First Name |
Recipient?s full first name. |
N/A |
|
Full Last Name |
Recipient?s full last name. |
N/A |
|
Diag1 Description |
Description of the primary diagnosis. |
N/A |
|
Diag2 Description |
Description of the secondary diagnosis. |
N/A |
|
Diag3 Description |
Description of the third diagnosis. |
N/A |
|
Diag4 Description |
Description of the fourth diagnosis. |
N/A |
|
Detail Description Count |
Number of response descriptions for this transaction. |
N/A |
|
Detail Description Segments |
Occurs 1-6 times. |
N/A |
|
Diagnosis Description |
Detail diagnosis description. |
N/A |
|
Procedure Description |
Detail procedure description. |
N/A |
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
POS-Return |
If non-zero, a system error has occurred. |
N/A |
|
Return Code |
System-assigned code that identifies the status. R? = Claim Not Captured (error(s) detected) |
N/A |
|
Filler |
Not Used. |
N/A |
|
Filler |
Not Used. |
N/A |
|
Error Count |
Number of errors to follow. |
N/A |
|
Error Segments |
Occurs 1-9 times. |
N/A |
|
Error Code |
Code associated with the errors found on this transaction. |
N/A |
|
Detail Number |
Location on the claim where the error has occurred. 00? = Header ?01? = Detail 1 ?02? = Detail 2 ?03? = Detail 3 ?04? = Detail 4 ?05? = Detail 5 ?06? = Detail 6 |
N/A |
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
Transaction Code |
Code associated with the type of transaction. ARCR? |
N/A |
|
Software Version |
?00? |
N/A |
|
Terminal ID |
Number that identifies the user?s terminal. EDS will assign this number at the time of testing and certification. |
N/A |
|
Provider ID |
Provider?s Medicaid ID number. 9 digit numeric, i.e., 100000001. |
N/A |
|
Recipient ID |
Recipient?s Medicaid ID number. 10 digit numeric, i.e., 0100000101. |
N/A |
|
ICN |
Internal Control Number assigned to the processed claim. |
N/A |
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
POS-Return |
If non-zero, a system error has occurred. |
N/A |
|
ICN |
Internal Control Number assigned to the processed claim. |
N/A |
|
Return Code |
System-assigned code that identifies the status. A? = Claim Reversed. |
N/A |
|
Field Name |
Values/Comments |
Refer to Section 311.400 |
|
POS-Return |
If non-zero, a system error has occurred. |
N/A |
|
Return Code |
System-assigned code that identifies the status. R? = Claim Not Reversed. |
N/A |
|
Error Count |
Number of errors to follow. |
N/A |
|
Error Segments |
Occurs 1-9 times. |
N/A |
|
Error Code |
Code associated with the errors found on this transaction. |
N/A |
|
Detail Number |
Location on the claim where the error has occurred. 00? = Header. |
N/A |
|
Place of Service |
Type of Service |
|
3 ? Office |
Q ? Developmental Rehabilitation Services |
|
4 ? Patient?s Home |
|
|
5 ? DDTCS Clinic/Day Care Facility |
|
|
0 ? Other locations |
EDS offers providers several options for electronic billing. Therefore, claims submitted on paper are paid once a month. The only claims exempt from this process are those which require attachments or manual pricing.
To bill for Developmental Rehabilitation Services, use the HCFA-1500. The numbered items correspond to numbered fields on the claim form. (A sample HCFA-1500 follows these billing instructions.)
The following instructions must be read and carefully adhered to, so that EDS can efficiently process claims. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be forwarded to:
EDS
Claims
P.O. Box 8034
Little Rock, AR 72203
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
|
Field Name and Number |
Instructions for Completion |
|
1. Type of Coverage |
This field is not required for Medicaid. |
|
A. Insured?s I.D. Number |
Enter the patient?s 10-digit Medicaid identification number as it appears on the AEVCS eligibility verification transaction response. |
|
2. Patient?s Name |
Enter the patient?s last name and first name as it appears on the AEVCS eligibility verification transaction response. |
|
3. Patient?s Birth Date |
Enter the patient?s date of birth in MM/DD/YY format as it appears on the Medicaid identification card. |
|
Patient?s Sex |
Check ?M? for male or ?F? for female. |
|
4. Insured?s Name |
Required if there is insurance affecting this claim. Enter the insured?s last name, first name and middle initial. |
|
5. Patient?s Address |
Optional entry. Enter the patient?s full mailing address, including street number and name, (post office box or RFD), city name, state name and zip code. |
|
6. Patient Relationship to Insured |
Check the appropriate box indicating the patient?s relationship to the insured if there is insurance affecting this claim. |
|
7. Insured?s Address |
Required if insured?s address is different from the patient?s address. |
|
8. Patient Status |
This field is not required for Medicaid. |
|
9. Other Insured?s Name |
If patient has other insurance coverage as indicated in Field 11D, enter the other insured?s last name, first name and middle initial. |
|
A. Other Insured?s Policy or Group Number |
Enter the policy or group number of the other insured. |
|
B. Other Insured?s Date of Birth |
This field is not required for Medicaid. |
|
Other Insured?s Sex |
This field is not required for Medicaid. |
|
C. Employer?s Name or School Name |
Enter the employer?s name or school name. |
|
D. Insurance Plan Name or Program Name |
Enter the name of the insurance company. |
|
10. Is Patient?s Condition Related to |
|
|
A. Employment |
Not required for Developmental Rehabilitation Services. |
|
B. Auto Accident |
Check the appropriate box if the patient?s condition was auto accident related. If ?YES,? enter the place (two letter State postal abbreviation) where the accident took place. Check ?NO? if not auto accident related. |
|
C. Other Accident |
Check ?YES? if the patient?s condition was other accident related. Check ?NO? if not other accident related. |
|
D. Reserved for Local Use |
This field is not required for Medicaid. |
|
11. Insured?s Policy Group or FECA Number |
Enter the insured?s policy group or FECA number. |
|
A. Insured?s Date of Birth |
This field is not required for Medicaid. |
|
Insured?s Sex |
This field is not required for Medicaid. |
|
B. Employer?s Name or School Name |
Enter the insured?s employer?s name or school name. |
|
C. Insurance Plan Name or Program Name |
Enter the name of the insurance company. |
|
D. Is There Another Health Benefit Plan? |
Check the appropriate box indicating whether there is another health benefit plan. |
|
12. Patient?s or Authorized Person?s Signature |
This field is not required for Medicaid. |
|
13. Insured?s or Authorized Person?s Signature |
This field is not required for Medicaid. |
|
14. Date of Incident/Accident |
Required only if medical care being billed is related to an accident. Enter the date of the accident. |
|
15. If Patient Has Had Same or Similar Illness, Give First Date. |
This field is not required for Medicaid. |
|
16. Dates Patient Unable to Work in Current Occupation |
This field is not required for Medicaid. |
|
17. Name of Referring Physician or Other Source |
Required, if applicable. Enter the name of the referring physician. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
|
A. I.D. Number of Referring Physician |
Enter the 9-digit Medicaid provider number of the referring physician. |
|
18. Hospitalization Dates Related to Current Services |
For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format. Not required for this program. |
|
19. Therapy Code and/or LEA # |
Enter the appropriate code for occupational, physical and speech therapy services. Not required for this program. |
|
20. Outside Lab Work |
Check ?YES? if laboratory work was performed outside your office. Check ?NO? if laboratory work was performed inside your office. |
|
21. Diagnosis or Nature of Illness or Injury |
Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with HCFA diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service. |
|
22. Medicaid Resubmission Code |
Reserved for future use. |
|
Original Reference Number |
Reserved for future use. |
|
23. Prior Authorization Number |
Enter the prior authorization number, if applicable. |
|
24. A. Date of Service |
Enter the ?from? and ?to? dates of service for each service provided in MM/DD/YY format. A single date of service need not be entered twice on the same line. |
|
Each claim detail line may include dates from only one calendar month. For example, dates of service 06-15-99 through 07-14-99 must be billed on two lines: 06-15-99 to 06-30-99 and 07-01-99 to 07-14-99. For spanning dates of service, do not include any date on which no service was rendered. |
|
|
B. Place of Service |
Enter the appropriate place of service code. See Section 311.200 for codes. |
|
C. Type of Service |
Enter the appropriate type of service code. See Section 311.200 for codes. |
|
D. Procedures, Services or Supplies |
Enter the procedure code that best describes the service. Enter applicable modifiers if available. |
|
A procedure code for a service performed more than once on the same date should be listed as one entry on the claim with multiple units listed in Field 24G. |
|
|
E. Diagnosis Code |
Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number (?1,? ?2,? ?3,? ?4?) from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD- 9-CM. |
|
F. Charges |
Enter the charge for the service. This charge should be the provider?s customary fee to private-pay clients. If more than one unit of service is being billed, enter the charge for the total number of units billed. |
|
G. Days or Units |
Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A. |
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H. EPSDT Screening/Referral and/or Family Planning |
Enter ?E? if services rendered were a result of a Child Health Services (EPSDT) screening/referral. |
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I. Emergency |
This field is not required for Medicaid. |
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J. Coordination of Benefit |
This field is not required for Medicaid. |
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K. Reserved for Local Use |
When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after ?GRP#.? |
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When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter this number in Field 33 after ?GRP#.? |
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25. Federal Tax I.D. Number |
This field is not required for Medicaid. |
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26. Patient?s Account Number |
This is an optional entry that may be used for accounting purposes. Enter the patient?s (recipient?s) account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted. The number will appear on the RA and assist in identifying claims. |
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27. Accept Assignment |
This field is not required for Medicaid. |
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28. Total Charge |
Enter the total of Column 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.) |
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29. Amount Paid |
Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. DO NOT enter any payment by the patient or any amount previously paid by Medicaid. (See NOTE below Field 30.) |
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30. Balance Due |
Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. |
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NOTE: For Fields 28, 29 and 30, up to 26 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due. |
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31. Physician?s or Supplier?s Signature |
The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider?s direction. Provider?s signature? is defined as the provider?s actual signature, a rubber stamp of the provider?s signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
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32. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office) |
If other than home or office, enter the name and address, specifying the street, city, state and zip code of the facility where services were performed. |
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33. Billing Provider |
Enter the billing provider?s name and complete address. Telephone number is requested but not required. |
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Provider I.D. Number |
Enter the 9-digit pay-to provider number in Field 33 after ?GRP#? and the individual practitioner?s number in Field 24K. |
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SPECIAL BILLING PROCEDURES
The following is a listing of Developmental Rehabilitation Services procedure codes. It is imperative that the Medicaid code listed for the services provided be used.
|
Procedure Code |
Description |
Benefit Limit |
|
96111 |
Developmental testing; extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments, eg, Bayley Scales of Infant Development) with interpretation and report, per hour. |
Four (4) one hour units per calendar year |
|
97530 |
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes |
Four 15 minute units per week |
RESERVED
FINANCIAL INFORMATION - REMITTANCE AND STATUS REPORT
The Remittance and Status Report, or Remittance Advice (RA), is a computer generated document showing the status and payment breakdown of all claims submitted to Medicaid for processing. It is designed to simplify accounting by allowing accurate reconciliation of claim submissions.
An RA is mailed each week a provider has claims paid, denied or in process. Once a week, all claims completed in a daily cycle are processed through the financial cycle. The RA is produced at the time checks are issued. Checks are written to providers for payment of their claims. The accompanying RAs are produced explaining each provider?s payment on a claim by claim basis. Only providers who have finalized claims or claims in process (claims that have been through at least one financial cycle) will receive an RA.
Electronic Funds Transfer (EFT) allows providers to have their Medicaid payments automatically deposited instead of receiving a check. See Section I of the provider manual for an enrollment form and additional information.
The RA is the first source of reference if there are questions regarding a particular claim. If the RA does not resolve the question and it becomes necessary to contact the EDS Provider Assistance Center, reference the applicable claim number. This number will assist EDS staff in providing the answers to questions.
It is necessary for the provider to retain all copies of the RAs to assist in keeping claims and payment records current. Also, this is the provider?s only record of paid and denied claims.
The RA is also a status report that inventories the current status of active claims. Should a submitted claim not appear on the RA within four to six weeks after submission, the EDS Provider Assistance Center may be contacted. If the result of this call is the claim, in fact, has not been processed or is not being processed, EDS will ask the provider to resubmit a legible copy of the claim form or to refile the claim electronically.
There are seven main segments of an RA:
Report Heading
Paid Claims
Denied Claims
Adjusted Claims
Claims In Process
Financial Items
Claims Payment Summary
Refer to the explanation and example of the RA on the following pages. The printed column headings at the top of each page and the numbered field headings are described to help in reading the RA.
|
Report Heading |
Description |
|
1. Provider Name and Address |
The name and address of the Medicaid provider to whom the Medicaid payment will be made. |
|
2. RA Number |
A unique identification number assigned to each RA. |
|
3. Provider Number |
The unique 9-digit number to which this RA pertains. The payment associated with each RA is reported to the IRS on the federal tax ID linked to each provider number. |
|
4. Control Number |
Internal page number for all RAs produced on each cycle date. |
|
5. Report Sequence |
Assigned sequentially for the provider?s convenience in identifying the RA. The first RA received from EDS for the calendar year is numbered ?1,? the second ?2,? etc. Filing your RAs in chronological order by this number ensures that none are missing. |
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6. Date |
The date the RA was produced. This is also the ?checkwrite? date, or the date on the check associated with this RA. |
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7. Page |
The number assigned to each page comprising the RA. Numbering begins with ?1? and increases sequentially. |
|
8. Name and Recipient ID |
The recipient?s last name, first name, middle initial and 10-digit Medicaid identification number. Claims are sorted alphabetically, by patient last name. |
|
9. Service Dates |
Format MM/DD/YY (Month, Day, Year) in ?From? and ?To? dates of service. For each detail, ?From? indicates the beginning date of service and ?To? indicates the ending date of service. |
|
10. Days or Units |
The number of times a particular service is billed within the given service dates. |
|
11. Procedure/Revenue/Drug Code and Description |
Procedure code - CPT or HCPCS code corresponding to the service on the claim. The type of service code directly precedes the 5-digit procedure code. |
|
12. Total Billed |
The amount the provider bills per detail. |
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13. Non-Allowed |
The amount of the billed charge that is non-allowed per detail. |
|
14. Total Allowed |
The total amount Medicaid allows for that detail. (Total Allowed = Total Billed - Non-Allowed) |
|
15. Spend Down |
The amount of money a patient must pay toward his medical expenses when his income exceeds the Medicaid financial guidelines. |
|
16. Patient Liability |
Not applicable. |
|
17. Other Deducted Charges |
The total amount paid by other resources (other insurance or co-pay if either exist). |
|
18. Paid Amount |
The amount Medicaid pays (Paid Amount = Total Allowed - Other Deducted Charges). |
|
19. Explanation of Benefit Code(s) |
A number corresponding to a message which explains the action taken on claims. The messages for each explanation code are listed on the final page of the RA. |
|
20. Cover Page Messages |
Messages written for provider information. |
This section shows all claims that have been paid, or partially paid, since the previous checkwrite.
|
Field Name |
Description |
|
1. County Code |
A unique 2-digit number assigned to each recipient?s county of residence. |
|
2. RCC |
Reimbursement Cost Containment - The reimbursement rate on file for a hospital. This item doesn?t apply to claims filed on HCFA-1500. |
|
3. Coins, Deductible, PA/LEA, MCR Paid Amt., TPL |
Coinsurance, deductible and the Medicare paid amount will be listed for crossover claims. Third Party Liability will show the amount paid by other insurance coverage. If applicable, the prior authorization number will be listed after ?PA/LEA.? |
|
4. Claim Control Number |
A unique 13-digit control number assigned to each claim by EDS for internal control purposes. Please use this internal control number (ICN) when corresponding with EDS about a claim. |
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Example: 0599033067530 (ICN) Format: RRYYDDDBBBSSS |
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a. RR-05 - The first and second digits indicate the media the claim was submitted on to EDS (e.g., ?05? - AEVCS, ?10? - magnetic tape, ?98? - paper, ?50? - adjusted claims). |
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b. YY-99 - The third and fourth digits indicate the year the claim was received. |
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c. DDD-033 - The fifth, sixth and seventh digits indicate the day of the year, or Julian date, the claim was received (e.g., 033 = February 2). |
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d. The remaining digits are used for internal record-keeping purposes. |
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5. Medical Record Number |
The ?patient control number? entered in electronic claim format, or ?patient account number? (field 26) entered on the HCFA-1500 paper claim. |
|
6. Diagnosis |
The primary diagnosis code used on the claim. |
|
7. Servicing Physician |
The servicing physician?s (performing provider) provider number appears only on RAs for groups or clinics. |
|
8. Admit = |
Date of admission to a facility. |
This section identifies denied claims and denied adjustments. Denial reasons may include: ineligible status, non-covered services and claims billed beyond the filing time limits. Claims in this section will be referenced alphabetically by the recipient?s last name, thereby facilitating reconciliation with provider records. Up to three code numbers will appear in the column entitled EOB (Explanation of Benefit) codes. Definitions of EOB codes are on the last page of the RA. The EOB messages regarding denied claims specify the reason EDS is unable to process the claims further.
Denied claims are finalized, and no additional action will be taken on the claims unless the provider has additional information that would allow some payment and refiles the claim accordingly.
Denied claims are listed on the RA in the same format as paid claims.
Payment errors - underpayments and overpayments as well as payments for the wrong procedure code, wrong dates of service, wrong place of service, etc - can be adjusted by canceling (?voiding?) the incorrectly adjudicated claim and processing the claim as if it were a new claim. Most adjustment transactions appear in the Adjusted Claims section of the RA. Denied adjustments appear at the end of the Denied Claims section of the RA.
The simplest explanation of an adjustment transaction is:
Adjustments sometimes appear complicated because the necessary accounting and documentation procedures add a number of elements to an otherwise routine transaction. Also, there are variations in the accounting and documentation procedures, because there is more than one way to submit an adjustment and there is more than one way to adjudicate and record adjustments. There are positive (additional payment is paid to the provider) and negative (the provider owes EDS additional funds) adjustments, adjustments involving withholding of previously paid amounts, adjustments submitted with check payments and denied adjustments. The following subsections thoroughly explain adjustments, how they appear on the RA, and the meaning, from a bookkeeping perspective, of each significant element.
The Adjusted Claims section has two parts. Each part is divided into two segments. The first part is the adjustment transaction. The adjustment transaction is divided into a ?Credit To? segment and a ?Debit To? segment.
The first segment of the adjustment transaction is the ?Credit To? segment. In this section, EDS identifies the adjustment transaction, the adjusted claim, and the previously paid amount EDS will withhold from today?s check as a result of this adjustment. The adjustment transaction is identified by an internal control number (ICN) that follows the field heading, ?Claim Number.? Adjustment ICNs are formatted in the same way as claim numbers; the first two digits of an adjustment ICN are ?50.? Immediately to the right of the adjustment ICN are the words ?Credit To,? followed by the claim number and paid date of the original claim that paid in error.
Underneath the ?Credit To? line are displayed the recipient?s Medicaid ID number, the claim beginning and ending dates of service and the provider?s medical record number (or the patient account number) from the original claim, followed by the original billed amount. Keep in mind that EDS adjusts the entire claim, even if only one detail paid in error, so the total billed amount shown here is the total billed amount of the entire claim being adjusted. At the right end of this line, in the ?Paid Amount? column, is the amount originally paid on the claim, which is the amount EDS will withhold from today?s remittance.
The actual withholding of the original paid amount does not occur in the Adjusted Claims section; it occurs in the Financial Items section of the RA. Adjustments are listed in Financial Items, with the appropriate amounts displayed under the field headings ?Original Amount,? ?Beginning Balance,? ?Applied Amount? and ?New Balance.? (Please see the discussion of Financial Items in section 324.600.) Finally, the total of all amounts withheld from the remittance is displayed under ?Withheld Amount,? in the Claims Payment Summary section of the RA.
Immediately following the ?Net Adjustment? line is the complete adjudication of the reprocessed claim, cross-referenced to the original claim number. The last line displays the new paid amount. The difference between the paid amount in the ?Credit To? segment and the paid amount in the ?Debit To? segment is the amount shown in ?Net Adjustment.? (See subpart B, above.)
At the end of the adjustment transactions is the total number of adjusted claims in today?s RA, the total of all billed amounts, the total non-allowed amounts and the total of all paid amounts, the last being the total ?Debit To? amount, as well.
For information purposes, the last segment is the total of all ?Net Adjustment? amounts in today?s RA. Net adjustment amounts displayed with ?CR? are treated as negative numbers in the calculation of the net adjustment total.
Some providers prefer to send a check for the overpayment amount with their adjustment request. In such a case, the original paid amount displayed in the ?Credit To? segment is listed in the Financial Items section of the RA with an EOB code indicating that EDS has received a check for that amount. Also, since EDS does not withhold that amount from the remittance, it appears in the Claims Payment Summary section under ?Credit Amount? (instead of appearing under ?Withheld Amount?). If EDS acknowledges more than one payment by check in Financial Items, the total of those check payments appears under ?Credit Amount? in the Claims Payment Summary section. Amounts shown under ?Credit Amount? are never deducted from the remittance because they are already paid.
Occasionally an adjusted claim is denied. Adjustments can be denied for any of the reasons for which any other claim can be denied. Denied adjustments do not appear in the Adjusted Claims section. Denied adjustments do not have ?Credit To? segments. Denied adjustments do not reflect a cross-reference to the original claim. Denied adjustments appear at the end of the Denied Claims section. Their adjudication is displayed by detail, in the same manner as an adjustment ?Debit To? segment. The original paid amount of the claim intended to be adjusted is withheld from the remittance and it is so indicated in the Financial Items section, listed under the adjustment ICN.
This section lists those claims that have been entered into the system but have not reached final disposition. Please do not rebill a claim shown in this section, as it is already in our system and will result in a rejection as a duplicate claim. These claims will appear on subsequent RAs in this section until they are paid, denied or returned.
Summary totals follow this section.
|
Field Name |
Description |
|
1. Recipient ID |
The recipient?s 10-digit Medicaid identification number. |
|
2. Patient Name |
The recipient?s last name, first name and middle initial. |
|
3. Service Dates: From |
The beginning date of service for this claim. |
|
4. Service Dates: To |
The ending date of service for this claim. |
|
5. Claim Number |
The unique 13-digit number assigned to each claim for control purposes. |
|
6. Total Billed |
The total amount billed by the provider. (The sum of the detail lines.) |
|
7. Medical Record |
The ?patient control number? entered in electronic claim format, or ?patient account number? (field 26) entered on the HCFA-1500 paper claim. |
|
8. Explanation of Benefit Code(s) |
Numeric representation of messages which explain what research is being done to the claim before payment can occur. Detailed descriptions of these messages will be listed on the last page of the RA. |
This section contains a listing of the payments refunded by the provider, amounts recouped since the previous checkwrite, payouts and other transactions. It also includes any other recoupment activities being applied that will reflect negatively to the provider?s total earnings for the year. The Explanation of Benefit codes beside each item indicate the action taken.
The ?Credit To? entries from the Adjusted Claims section that are being recouped are listed in the Financial Items section. The ?Credit To? portion of all adjusted claims appears in the Adjusted Claims section as information only and is actually applied in the Financial Items section.
|
Field Name |
Description |
|
1. Recipient ID |
The recipient?s 10-digit Medicaid identification number. |
|
2. From DOS |
The from date of service. |
|
3. Transaction Dates |
The date on which this transaction was entered into the system. |
|
4. Claim Control Number |
The unique number assigned to this transaction by EDS. |
|
5. Reference |
Information that may be of help in identifying the transaction (example, recipient?s name). |
|
6. Original Amount |
The original amount of the transaction. This amount will be the same on each RA for a particular transaction until it has been completed. |
|
7. Beginning Balance |
The amount remaining for this transaction prior to this RA. (For example, if a recoupment had been initiated for $1,000.00, but only $200.90 was deducted, then the next RA would show a beginning balance of $799.10 to be recouped.) |
|
8. Applied Amount |
The amount applied on this RA to the beginning balance. (If the provider sent a refund check for two different recipients or if the monies were recouped from two different recipients, then the amounts applicable to each recipient would be displayed in the applied amount column individually.) |
|
9. New Balance |
The amount left for this transaction after this RA. |
|
10. Explanation of Benefit Code(s) |
The last page of the RA will give detailed descriptions. |
This section contains a listing of all AEVCS transactions by the transaction category and transaction type submitted by the provider. It also contains separate totals for claim transactions, reversal transactions and total transactions for this provider.
|
Field Name |
Description |
|
1. Transaction Category |
This field indicates the type of transaction submitted by the provider. |
|
2. Transaction Types |
The type of claim transmitted by the provider. |
|
3. Transaction Count |
The total number of transactions for the transaction type. |
|
4. Transaction Amount |
The total charges for transactions transmitted for the transaction type. |
|
5. Total Claim Transaction |
The total number of claims transmitted and the total charges for the transaction category. |
|
6. Total Reversal Transaction |
The total number of reversals submitted by the provider. This is informational only as there are no transaction fees for reversals. |
|
7. Total Transactions For This Provider |
The total number of AEVCS transactions, including claims transmitted, reversals, eligibility verifications and total charges. |
This section summarizes all Medicaid payments and credits made to each provider for the specific RA pay period entitled ?Current Processed? as well as for the year entitled ?Year to Date Total.?
|
Field Name |
Description |
|
1. Days or Units |
The total days or units paid, denied and adjusted. |
|
2. Claims Paid |
Total number of claims paid, denied and adjusted by the Medicaid Program. |
|
3. Claims Amount |
Total paid amount from Paid Claims section plus any supplemental payouts (e.g., resulting from a ?Debit To? adjustment listed in the Adjusted Claims section). |
|
4. Withheld Amount |
Total amount withheld from RA (e.g., resulting from ?Credit To? Adjustments). This amount is the sum of the ?Applied Amount? fields of the Financial Items section. |
|
5. Net Pay Amount |
Claims amount less withheld amount(s). This is the amount of the provider?s check. |
|
6. Credit Amount |
Total amount refunded to the Medicaid Program by the provider. EDS posts check refunds here. See Section 330 |
|
7. Net 1099 Amount |
The provider?s income reported to Federal and State governments for tax purposes. This amount is derived from the Net Pay Amount less the Credit Amount. |
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8. Tax Amount |
The amount of tax withheld on this RA. Not currently used. |
|
9. Quarterly Tax Amount |
The cumulative amount of tax withheld for this financial quarter. Not currently used. |
|
10. AEVCS Transaction Fees |
Total amount of AEVCS transaction fees charged to the provider. |
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11. AEVCS Transaction Recoupment Amount |
Total amount of AEVCS transaction fees withheld from the RA. This amount is obtained from the ?Total Transactions For This Provider? field of the AEVCS transaction section. |
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12. Deferred Compensation Recoup Amount |
Amount withheld from the RA and deposited in the provider?s designated account for deferred compensation. |
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13. ARKids 1st/CHIP/Medicaid Summary |
A summary count and total amount paid for ARKids First, CHIP and Medicaid claims. |
|
14. Explanation of Benefit Code(s) |
The descriptions of all explanation of benefit codes used in the RA. |
|
15. Federal Tax ID |
The provider?s social security number or federal Employer Identification Number (EIN). All monies paid to the provider will be reported to the IRS under this number. If the number listed is incorrect, contact the provider enrollment unit to update the file. |
Developmental Rehabilitation Services sample RA
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FINANCIAL INFORMATION - ADJUSTMENT REQUEST FORM
The Adjustment Request Form is to be submitted for the reconsideration of a previously paid claim (even if the paid amount is $0.00) due to incomplete or inaccurate claim information, processing errors or pricing file errors. All of the necessary information for processing the adjustment must be included on the request form. A copy of the corrected claim or transaction and a copy of the page of the RA it was paid on may be attached to offer further clarification. However, on joint Medicare/Medicaid claims, the Explanation of Medicare Benefits (EOMB) must be attached. If a provider submits an Adjustment Request Form that is not valid, the EDS Adjustment Unit will notify the provider.
Adjustment Request Forms should be filed as soon as the incorrect payment has been identified. Requests for correction or review must be submitted to EDS within the 12-month timely filing deadline. Adjustment requests cannot be processed if more than 12 months have passed since the ?from date of service?.
The following instructions explain how to complete the form. A copy of the form is included following these instructions. Read the instructions carefully and be sure to complete all Adjustment Request Forms thoroughly and accurately so that they may be handled efficiently.
|
Field Name and Number |
Instructions for Completion |
|
1. Provider Number |
Enter the 9-digit Arkansas Medicaid provider number under which payment is to be made. |
|
2. Provider Name and Address |
Complete this field with the same information with which you bill Medicaid. |
|
3. Overpayment (Credit) |
Should apparent duplicate payments, incorrect payments or overpayments be received, please submit an adjustment request and check the box labeled overpayment. EDS will withhold (recoup) the overpayment amount from future claims payments. |
|
4. Underpayment (Debit) |
Should a claim be underpaid, check the box labeled underpayment to have the correct amount added to future claims payments. |
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5. Informational Corrections |
Check this box if the claim paid the correct amount using incorrect information such as wrong dates of service. This box should be checked only if it will not affect the amount paid. |
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6. Claim Number (ICN - Internal Control Number) |
Enter the 13-digit claim number exactly as it is printed on your RA. |
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7. Patient Name |
Enter the patient?s last name, first name and middle initial. |
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8. Recipient ID Number |
Enter the entire 10-digit Medicaid identification number assigned to the recipient as it appears on the RA. |
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9. Remittance Advice Date |
Enter the date of the RA, which is found at the top right corner of the RA. |
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10. Date(s) of Service |
Enter the beginning and ending month, day and year of services rendered. |
|
11. Billed Amount |
Enter the amount the Medicaid Program was actually billed for the service(s). |
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12. Paid Amount |
Enter the amount actually paid by Medicaid for the service(s) in question. |
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13. Description of the Problem |
Indicate a specific reason for the adjustment request and the nature of the incorrect payment. |
|
14. Signature and Date |
Enter the signature of the requester and the date the adjustment request was prepared. |
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FINANCIAL INFORMATION - EXPLANATION OF CHECK REFUND FORM
The Arkansas Medicaid Program provides RAs each week to providers who have claims paid, denied or in process. If an overpayment or a payment error has occurred, providers are responsible for refunding the Medicaid Program.
Refunds to the Medicaid Program may be accomplished by sending a check in the amount of the overpayment made payable to the Arkansas Medicaid Program or by returning the original check issued by EDS. The Arkansas Medicaid Explanation of Check Refund Form must be completed and submitted with the refund.
In instances of underpayment, some providers prefer returning a check in the amount of the underpayment or the original check instead of requesting an adjustment. When EDS posts the refund, the amount of the refund will appear in the Claims Payment Summary section of the RA. The provider may then resubmit the original or corrected claim for correct adjudication and payment.
Provide the following information in the appropriate fields on an Arkansas Medicaid Explanation of Check Refund Form for each refund you send to EDS:
This information will allow the refund to be processed accurately and efficiently.
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FINANCIAL INFORMATION - ADDITIONAL PAYMENT SOURCES
The Medicaid Program is required by federal regulations to utilize all third party sources and to seek reimbursement for services that have also been paid by Medicaid. Third party? means an individual, institution, corporation or public or private agency that is liable to pay all or part of the medical cost of injury, disease or disability of a Medicaid recipient. Examples of third party resources are:
The Medicaid policies concerning the handling of cases involving Medicare/Medicaid coverage differ from the policies concerning other third party coverage.
Arkansas Rehabilitation Services (ARS) is not a third party source. If ARS and Medicaid pay for the same service, refund ARS.
If medical services are provided in Arkansas to a patient who is entitled to Medicare under the Social Security Act and also to Medicaid benefits, it is necessary to file a claim only with Medicare. If the Medicare fiscal intermediary is Arkansas Blue Cross/Blue Shield or Mississippi Blue Cross/Blue Shield (Medicare intermediary for Louisiana, Missouri and Mississippi), the claim should be filed according to Medicare?s instructions and sent to the Medicare intermediary. The claim will automatically cross to Medicaid. Mississippi Blue Cross/Blue Shield will cross over only Medicare Part A claims.
According to the terms of the Medicaid provider contract, a provider must ?accept Medicare assignment under Title XVIII in order to receive payment under Title XIX for any appropriate deductible or coinsurance which may be due and payable under Title XIX.?
When the Medicare intermediary or carrier completes the processing of the claim, they will forward it to EDS on computer tape. EDS will process it in the next weekend cycle for payment of coinsurance and deductible. The transaction will usually appear on the Medicaid RA within 3 weeks of payment by Medicare. If it does not appear within that time, you should request payment according to the instructions below.
When a provider learns of a patient?s Medicaid eligibility only after filing a claim to Medicare, the instructions below should be followed after Medicare pays the claim.
Some Medicare carriers and intermediaries do not cross claims to Arkansas Medicaid. Claims for Medicare beneficiaries entitled under the Railroad Retirement Act never cross to Medicaid.
EDS provides software with which to electronically bill Medicaid for Professional Crossover claims that do not cross to Medicaid. Institutional providers and those without electronic billing capability must mail a copy of the claim payment information from the Medicare Payment Report to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
On the Medicare Payment Report:
Write or type, within the circle, the Medicaid pay-to provider number to which Medicaid will write the check.
EDS staff must be able to locate and read the Medicare payment date and the Medicare claim?s internal control number. Please ensure those items are present and readable.
Any charges denied by Medicare will not be automatically forwarded to Medicaid for reimbursement. In cases where the patient does not have Medicare coverage, but is eligible for Medicaid, it will be necessary for the provider to file a claim with Medicaid.
Any adjustment made by Medicare will not be automatically forwarded to Medicaid. If Medicare makes an adjustment that results in an overpayment or underpayment by Medicaid, submit an Adjustment Request Form with a copy of the Medicare EOMB reflecting Medicare?s adjustment. Enter the Medicaid provider number and the patient?s Medicaid identification number on the face of the Medicare EOMB.
Many persons eligible for Arkansas Medicaid are covered by private insurance or may sustain injuries for which a third party could be liable. The following is an explanation of the patient?s and the provider?s role in the detection of third party sources and in the reimbursement of the third party payment to the Medicaid Program for services that have been paid by Medicaid.
EDS has a full time staff of trained professionals to assist with any questions or problems regarding third party liability, including, but not limited to, payment of claims with third party liability and requests for insurance information. Should a provider have any questions concerning third party liability, the EDS Provider Assistance Center may be contacted at 1-800-457 -4454 (Toll Free) within Arkansas or locally and out-of-state at (501) 376-2211.
It is the responsibility of the recipient to report the name and policy number of any other payment source to the provider of medical services at the time services are provided. The recipient must also authorize the insurance payment to be made directly to the provider.
It is the provider?s responsibility to be alert to the possibility of third party sources and to make every effort to obtain third party insurance information. The provider should also inquire about liability coverage in accident cases and pursue this or notify Medicaid. It is the responsibility of the provider to file a claim with the third party source and to report the third party payment to the Medicaid Program. If a provider is aware that a Medicaid recipient has other insurance that is not reflected when billing through AEVCS, the insurance information should be faxed to the DMS Third-Party Liability unit at (501) 682-1644.
All Medicaid claims, including claims which involve third party liability, are filed on an assignment basis. In no case may the recipient be billed for charges above the Medicaid allowable on paid claims. A claim is considered paid, even though the actual Medicaid payment has been reduced to zero by the amount of third party liability. This applies whether the third party payment was reported on the original claim or whether it was refunded by way of an adjustment or by personal check. All services billed which are limited by the Medicaid Program count toward the patient?s benefit limits even in cases where the amount of Medicaid payment is reduced to zero by the amount of third party liability, except for Medicare crossover claims with no secondary payer other than Medicaid.
The AEVCS system provides fields to capture any Third Party Liability (TPL) information the provider may obtain. The provider is required to record TPL for each claim submitted.
When an AEVCS user enters a claim for services to a recipient who has other insurance coverage for the service and enters a TPL paid amount of $0.00, the point of sale (POS) device prompts the user to enter the date of the denial EOB or the date of the EOB showing that the allowed amount was applied to the insurance deductible.
REFERENCE BOOKS
The Arkansas Medicaid Program uses the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as a reference for coding primary and secondary diagnoses for all providers that are required to file claims with diagnosis codes completed.
To order the ICD-9-CM, please call 1-800-678 -TEXT.
MEDICODE
5225 Wiley Post Way
Suite 500
Salt Lake City, UT 84116
FAX: 1-801-323 -3183
The State of Arkansas uses the HCFA Common Procedure Coding System (HCPCS). HCPCS is composed of unique state assigned codes and CPT codes. If applicable, the state-assigned codes are listed in the Billing Procedures Section of this manual. The Physician?s Current Procedural Terminology (CPT) is the basic component of the HCFA Common Procedure Coding System (HCPCS).
To order the CPT, please call 1-800-678 -TEXT.
MEDICODE
5225 Wiley Post Way
Suite 500
Salt Lake City, UT 84116
FAX: 1-801-323 -3183
CPT is a systematic listing of medical terms and identifying codes for reporting medical services provided by physicians. Each procedure or service is identified with a 5-digit code. The use of CPT codes simplifies the reporting of services.
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Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.