016.06.02 Ark. Code R. § 037 - Children's Medical Services (CMS) Respite Care Provider Manual
Individual CMS respite caregivers, Division of Developmental Disabilities Services (DDS) licensed community-based providers and child care facilities that meet the participation requirements may be enrolled as CMS respite care providers.
The provider enrollment requirements listed below must be met to participate in the Arkansas Medicaid Program as a CMS respite care provider:
Children's Medical Services (CMS), Division of Developmental Disabilities Services (DDS) is responsible for certifying all providers of CMS respite care services.
The Service Agreement and Certification/Delegation of CMS Respite Caregiver (DMS-852) certifies that the provider has met the requirements and qualifications to be a CMS respite care provider. Form DMS-852 must be signed by the CMS respite care provider, parent or legal guardian, and a registered nurse (unless the CMS respite care provider is a registered nurse). CMS will review the DMS-852 and, if the certification criteria are met, will certify the provider by signing the DMS-852. CMS will retain a copy of the signed certification statement on all certified CMS respite care providers. The original, signed certification will be sent to the provider. (See section 214.700.)
CMS is responsible for furnishing the Division of Medical Services (DMS) Provider Enrollment Unit with written notification of the certification status of CMS respite care providers. CMS certifications must be renewed by the providers annually.
In addition to the certification requirement in section 201.100, the individual CMS respite caregiver must also meet the following criteria:
To meet the criterion for a healthcare paraprofessional, the DMS-852 must be signed and dated by an RN. The RN's signature certifies that the CMS respite caregiver meets the healthcare paraprofessional requirement specified in the School Nurse Roles and Responsibilities Practice Guidelines, is properly trained to perform the duties that are necessary to take care of the client and these duties (listed on the DMS-852) are appropriate to be delegated to the individual CMS respite caregiver.
CMS respite care providers in Arkansas and the six (6) bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements as outlined in section 201.000.
Providers in non-bordering states are not eligible to participate in the CMS Respite Care Program.
CMS respite care providers must develop and maintain sufficient written records to corroborate that the services provided are of the type, frequency, duration and scope outlined in the CMS respite plan of care and confirm that the services were actually furnished.
CMS respite care providers must maintain a record of the following:
CMS respite care providers must maintain all records for a period of five (5) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever period is longer. The records must be made available to authorized representatives of the Arkansas Department of Human Services, Division of Medical Services, Children's Medical Services, the State Medicaid Fraud Unit, and representatives of the Department of Health and Human Services and its authorized agents or officials. Failure to furnish records upon request will result in sanctions being imposed.
All documentation must be made available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business during normal business hours. If an audit determines that recoupment is necessary, there will be only thirty (30) days after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted at a later date.
The CMS Respite Care Program is administered by Children's Medical Services of the Arkansas Department of Human Services, Division of Developmental Disabilities Services (hereafter referred to as CMS). The CMS Respite Care Program operates under the authority of a home and community-based waiver authorized under Section 1915(c) of the Social Security Act.
The Arkansas Medicaid Program offers certain home and community-based services to recipients to decrease the likelihood of institutionalization. The purpose of the CMS Respite Care Program is to provide temporary physical and emotional relief to families who are caring for clients with disabilities. This relief promotes continued care in the home, thereby reducing the likelihood of institutionalization of the client.
CMS respite care services are available only to Medicaid-eligible CMS clients who meet the CMS respite care eligibility criteria (see sections 214.000 through 214.700).
CMS is responsible for determining the client's eligibility for CMS respite care services. No primary care physician (PCP) referral is necessary to receive CMS respite care services.
The following individuals or services are not covered under the CMS Respite Care Program:
The following benefit limits apply to CMS respite care services:
In an emergency situation and subject to the availability of funds, additional CMS respite care services may be provided to families who have met the $1000 per client per twelve (12) months limit. A parent or legal guardian may request an extension of CMS respite care benefits by contacting the CMS respite care coordinator.
If the client is determined to be eligible for the extended CMS respite care benefits, the amount granted will be determined on a case-by-case basis.
CMS respite care services are limited to CMS clients who meet the CMS respite care eligibility criteria. The CMS respite care eligibility criteria consist of the following process:
The eligibility evaluation criteria for CMS respite care services is discussed in detail in sections 214.100 through 214.700.
The parent or legal guardian must complete the application packet for CMS respite care services. The application packet will include:
(A copy of the above forms can be found in this manual.)
The family may request the CMS respite care application by telephone or writing to the address below:
Arkansas Department of Human Services Children's Medical Services Family Friends CMS Respite Care P.O. Box 1437, Slot S380 Little Rock, AR 72203-1437
Toll Free Telephone: 1-800-482 -5850, ext. 22277.
A CMS respite care coordinator is available by telephone, at the number listed above, as a resource for families and CMS respite care providers to resolve any questions or problems they may encounter during the application process and after approval of CMS respite care services.
FAMILY FRIENDS RESPITE CARE
APPLICATION FORM FOR FAMILIES
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CMS clients must be Medicaid eligible in one of the following aid categories:
Current Medicaid and categorical eligibility must be verified as part of the eligibility evaluation process. SSI eligibility is determined by the Social Security Administration. TEFRA eligibility is determined by the Department of Human Services, Division of County Operations.
CMS respite care services are available to Medicaid-eligible CMS clients from birth up to age 19.
NOTE: After age 16, SSI and TEFRA clients who have a diagnosis of mental retardation and/or developmental delay will require an additional CMS-eligible diagnosis to remain eligible for CMS and CMS respite care services.
The client must meet one (1) of the levels of care listed below:
NOTE: After age 16, a diagnosis of mental retardation and/or developmental delay requires an additional CMS-eligible diagnosis in order to remain eligible for CMS and CMS respite care services.
The level of care determination is performed by the CMS Eligibility Committee. This committee consists of three (3) members:
Social Worker, licensed by the State of Arkansas with at least two years of experience as a social worker.
The CMS Eligibility Committee is responsible for the following:
CMS RESPITE CARE WAIVER
LEVEL OF FUNCTIONING SURVEY FOR THE MENTALLY RETARDED/DEVELOPMENTALLY DISABLED
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CMS Respite Care Waiver
Level of Functioning Survey For the Mentally Retarded/Developmentally Disabled
Instructions for Completing
For determining level of care eligibility for MR/DD Respite Waiver services, consider the individual's functioning in community environments. Complete the attached survey presuming the needed services and supports are not in place for the individual. Please note that, for items in the Health Status section, needed care or supervision may be provided by caregivers other than a licensed nurse.
DEFINITIONS:
"No Assistance" means no help is needed.
"Prompting/Structuring" means prior to the functioning, some verbal direction and/or some rearrangement of the environment is needed.
"Supervision" means that a helper must be present during the functioning and provide only verbal direction, gestural prompts, and/or guidance.
"Some Direct Assistance" means that a helper must be present and provide some physical guidance/support (with or without verbal direction).
"Total Care" means that a helper must perform all or nearly all of the functions.
"Rarely" means that the behavior occurs quarterly or less.
"Sometimes" means that a behavior occurs once a month or less.
"Often " means that a behavior occurs 2-3 times a month.
"Regularly" means that a behavior occurs weekly or more.
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CMS RESPITE CARE WAIVER
LEVEL OF FUNCTIONING SURVEY FOR THE PHYSICALLY DISABLED
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CMS Respite Care Waiver
Level of Functioning Survey For the Physically Disabled
Instructions for Completing
For determining level of care eligibility for Physically Disabled Respite Waiver services, consider the individual's functioning in community environments. Complete the attached survey presuming the needed services and supports are not in place for the individual. Please note that, for items in the Health Status section, needed care or supervision may be provided by caregivers other than a licensed nurse.
DEFINITIONS:
"No Assistance" means no help is needed.
"Prompting/Structuring" means prior to the functioning, some verbal direction and/or some rearrangement of the environment is needed.
"Supervision" means that a helper must be present during the functioning and provide only verbal direction, gestural prompts, and/or guidance.
"Some Direct Assistance" means that a helper must be present and provide some physical guidance/support (with or without verbal direction).
"Total Care" means that a helper must perform all or nearly all of the functions.
"Rarely" means that the behavior occurs quarterly or less.
"Sometimes" means that a behavior occurs once a month or less.
"Often " means that a behavior occurs 2-3 times a month.
"Regularly" means that a behavior occurs weekly or more.
LEVEL OF FUNCTIONING SURVEY
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Addendum to LOF Survey
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Each eligible client must have an approved individualized CMS respite plan of care before CMS respite care services are approved. CMS will send the family a CMS Respite Care Waiver Plan of Care (DMS-661) for completion.
The CMS respite plan of care is the fundamental tool used to ensure that the services to be furnished are appropriate to and adequate for the nature and severity of the individual's disability. The parent(s) or legal guardian(s) of the client will complete, sign and submit the CMS respite plan of care form to CMS for approval.
The parent or legal guardian may contact the CMS respite care coordinator for assistance in completing the CMS respite plan of care.
The CMS respite plan of care must include the following information:
CMS must approve, recommend changes or deny the plan of care. If the plan is denied, the CMS respite care coordinator will work with the family to design an acceptable plan of care and to make revisions during the year, if necessary. Families may appeal any denied plan of care. See section 218.000 for the appeal process for Medicaid recipients.
CMS will furnish a copy of the approved CMS respite plan of care to the parent or legal guardian and to each CMS respite care provider. CMS will retain the original plan of care. CMS will review the CMS respite plan of care annually.
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The parent(s) or legal guardian will be given freedom of choice to receive services in an institution or in a home and community-based setting.
CMS will mail the Freedom of Choice and Fair Hearing (DMS-669) to the parent or legal guardian. The parent, legal guardian or CMS client (if 18 years old) must indicate, in writing, the choice selected by completing and signing the form. CMS respite care services cannot be authorized until CMS receives the completed form.
In addition, the Freedom of Choice and Fair Hearing form advises the parent or legal guardian of their right to a fair hearing if they are denied their choice of services or providers. Also, the instructions for filing a request for a fair hearing are provided.
CMS will retain the completed form for documentation of freedom of choice and fair hearing opportunity.
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The Service Agreement and Certification/Delegation of CMS Respite Caregiver form (DMS-852) initially must be completed by the parent or legal guardian and approved by an RN. The parent or legal guardian will list on the DMS-852 the duties and/or tasks to be performed by the CMS respite caregiver while caring for the client. Only those duties listed on the DMS-852 will be performed by the CMS respite caregiver.
In accordance with the Arkansas State Board of Nursing School Nurse Roles and Responsibilities Practice Guidelines, a registered nurse (RN) may delegate certain tasks to the CMS respite caregiver by approving and signing the DMS-852. The RN must assess and train, if necessary, the CMS respite caregiver in performing the duties that may be delegated. If the RN determines that the CMS respite caregiver is capable of performing the duties, he or she must complete and sign DMS-852 certifying that the duties are appropriate to delegate to the CMS respite caregiver and the CMS respite caregiver is qualified to perform the duties.
In order for the CMS respite care provider to meet the certification requirement (see sections 201.100 and 201.110), the DMS-852 must be signed and dated by the individuals listed below:
NOTE: If the CMS respite caregiver is an RN, the signature of a registered nurse is not required on DMS-852.
CMS will mail the DMS-852 to each family. The parent or legal guardian is responsible for returning the completed form to CMS with all required signatures. The signed DMS-852 must be on file with CMS before services may begin. CMS will retain a copy of the signed DMS-852 and mail the original form to the CMS respite caregiver.
A DMS-852 must be completed and signed annually. If the family changes providers or obtains additional providers, an additional DMS-852 must be completed for each new CMS respite care provider, signed by the required individuals and forwarded to CMS before payment can begin to the new providers.
Also, if changes in the client's condition result in additional or different duties and/or tasks, the family must obtain a new DMS-852, signed by all required individuals, to ensure that delegation of the new duties is appropriate and the CMS respite caregiver is trained and qualified to perform the duties.
The CMS respite caregiver must retain a copy of the DMS-852 for his or her records. (See section 204.000 for records requirement.)
After the client's CMS respite care services application is approved, CMS will furnish billing forms (HCFA-1500) to the family for completion by the CMS respite caregiver as services are provided. (See Section III of this manual for special billing procedures.)
Arkansas Department of Human Services Family Friends Respite Waiver Program
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It is the parent or legal guardian's responsibility to notify the CMS respite care provider at least twenty-four hours prior to an appointment for CMS respite care services if the appointment must be cancelled.
If the client is expected to be out of the home for 30 days or longer, the parent or legal guardian must notify CMS.
CMS respite care services allow temporary physical and emotional relief to a family that is caring for a client with disabilities.
DMS-852 will list specific duties the CMS respite caregiver must provide while the client is in his or her care. The duty areas are communication, feeding, mobility assistance, toileting, dressing, administering certain medications and other duties that will be defined by the parent or legal guardian and RN, depending on the client's needs.
It is the parent or legal guardian's responsibility to provide clear and precise written instructions to the CMS respite caregiver regarding the client's needs. It is the CMS respite caregiver's responsibility to ensure that all instructions are performed as stated.
One (1) unit of CMS respite care service equals 15 minutes, e.g., if the duration of the service is one hour and 30 minutes, Medicaid will cover 6 units.
Services of less than one hour duration per date of service are not covered, e.g., 50 minutes of service on a given date are not covered.
Services of less than fifteen minutes in duration are not covered, e.g., if the service lasts one hour and 20 minutes, Medicaid will cover only one hour and 15 minutes (5 units).
Odd minutes may not be saved to add to minutes from a previous date of service.
(See section 213.000 for benefit limits and Section III of this manual for the procedure code.)
To ensure that the CMS Respite Care Program requirements are being met, the Medicaid agency will perform annual reviews of a random sampling of client records. Also, an annual client satisfaction and program evaluation survey of the total CMS respite care client population will be conducted to determine whether quality standards are met. Appropriate action(s) (e.g. recommendation for training, disqualification of provider, etc.) will be taken if an investigation of negative allegations reveals that quality standards are not met.
When an adverse decision (e.g., application denied, case closed, choice of providers denied, plan of care denied, etc.) is received from CMS, the Medicaid recipient may request a fair hearing from the Department of Human Services for reconsideration of the denied services.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Arkansas Department of Human Services within thirty (30) days of the date of the denial or adverse action notice. Submit the appeal request to:
Arkansas Department of Human Services Appeals and Hearings Section P.O. Box 1437, SlotN401 Little Rock, AR 72203-1437
CMS respite care services do not require prior authorization, but must be provided in accordance with the approved CMS respite plan of care.
Reimbursement in the CMS Respite Care Program is by fee schedule. Payment is the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable amount for each service.
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 a standing Rate Review Panel established by the Director of the Division of Medical Services which 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 (DHS) 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.
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:
CMS respite care providers must complete and forward HCFA-1500 billing claims to Children's Medical Services (CMS). CMS will electronically bill Arkansas Medicaid on behalf of the CMS respite care providers. (See Billing Instructions - Paper Claims Only, section 311.200.)
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."
Claims for dates of service over 12 months in the past may not be electronically transmitted to EDS. 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, CMS will send a completed Adjustment Request Form (Form EDS-AR-004, following section 331.000 of this manual) 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.
CMS will submit a paper claim to the address below, attaching:
CMS will send these materials to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
CMS will submit a paper claim to the address below, attaching:
CMS will 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 Medicaid Management Information System (MMIS). This software analyzes procedure codes and compares them to nationally accepted published standards to recommend more accurate billing. If you think your claim was paid incorrectly, see section 330.000 for information about how to use the Adjustment Request Form. If you think your claim was denied incorrectly, contact the Provider Assistance Center (PAC) at the numbers listed below.
ClaimCheck® developers based the software's edits on the guidelines contained in the Physicians' Current Procedural Terminology (CPT) book, and Arkansas Medicaid customized the software for local policy and procedure codes. Please note that ClaimCheck® implementation does not affect Medicaid policy.
If there are other questions regarding the function of ClaimCheck® edits, call the Provider Assistance Center (PAC) 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 or Remittance Advice (RA) to each provider with claims paid, denied or pending, as of the previous weekend processing cycle. (Sections 320.000 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, CMS will 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, use the Medicaid Claim Inquiry Form, EDS-CI-003, provided by EDS. 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 330.000 of this manual for the Adjustment Request Form and information regarding adjustments.
To inquire about a claim, the CMS respite care coordinator will complete and submit the Medicaid Claim Inquiry Form to EDS. A copy of this form follows these instructions. In order to answer the inquiry as quickly and accurately as possible, please follow these instructions:
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Field Name and Number |
Instructions for Completion |
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1. |
Provider Number |
Enter the 9-digit Arkansas Medicaid provider number assigned. If requesting information regarding a clinic billing, indicate the clinic provider number. |
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2. |
Provider Name and Address |
Enter the name and address of the provider as shown on the claim in question. |
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3. |
Recipient Name (First, Last) |
Enter the patient's name as shown on the claim in question. |
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4. |
Recipient ID |
Enter the 10-digit Medicaid identification number assigned to the patient. |
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5. |
Billed Amount |
Enter the amount the Medicaid Program was billed for the service. |
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6. |
Remittance Advice Date |
Enter the date of the Medicaid RA on which the claim most recently appeared. |
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7. |
Date(s) of Service |
Enter the month, day and year of the date of service, or the date range. |
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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." |
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9. |
Provider Message/Reason for Inquiry |
State the specific description of the problem and any remarks that may be helpful to the person answering the inquiry. |
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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 the 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:
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Acknowledgement of Hysterectomy Information |
(DMS-2606) |
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Adjustment Request Form - Medicaid XIX |
(EDS-AR-004) |
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Certification Statement for Abortion |
(DMS-2698) |
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Consent for Release of Information |
(DMS-619) |
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DDTCS Transportation Survey |
(DMS-632) |
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DDTCS Transportation Log |
(DMS-638) |
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EPSDT |
(DMS-694) |
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Explanation of Check Refund |
(EDS-CR-002) |
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Hospice/INH Claim Form |
(DHS-754) |
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Hospital/Physician/Certified Nurse Midwife Referral for |
(DCO-645) |
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Newborn Infant Medicaid Coverage |
|
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Inpatient Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-001) |
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Long Term Care Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-002) |
|
Medicaid Claim Inquiry Form |
(EDS-CI-003) |
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Medicaid Form Request |
(EDS-MFR-001) |
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Medicaid Prior Authorization and Extension of Benefits Request |
(DMS-2694) |
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Medical Equipment Request for Prior Authorization & |
(DMS-679) |
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Prescription |
|
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Mental Health Services Provider Qualification Form for LCSW, |
(DMS-633) |
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LMFT and LPC |
|
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Occupational, Physical and Speech Therapy for Medicaid Eligible |
(DMS-640) |
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Recipients Under Age 21 Prescription/Referral |
|
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Outpatient Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-003) |
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Personal Care Assessment and Service Plan |
(DMS-618) |
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Primary Care Physician Selection and Change Form |
(DMS-2609) |
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Professional Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-004) |
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Referral for Medical Assistance |
(DMS-630) |
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Request for Extension of Benefits |
(DMS-699) |
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Request for Extension of Benefits for Medical Supplies for |
(DMS-602) |
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Medicaid Recipients Under Age 21 |
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Request for Prior Authorization and Prescription for |
(DMS-2615) |
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Hyperalimentation |
|
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Request for Private Duty Nursing Services Prior Authorization |
(DMS-2692) |
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and Prescription - Initial Request or Recertification |
|
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Request for Targeted Case Management Prior Authorization for |
(DMS-601) |
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Recipients Under Age 21 |
|
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Sterilization Consent Form |
(DMS-615) |
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Sterilization Consent Form - Information for Men |
(PUB-020) |
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Sterilization Consent Form - Information for Women |
(PUB-019) |
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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 provider may request the HCFA-1500 claim form by contacting the CMS respite care coordinator at (501) 682-8207.
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CMS respite care providers use the HCFA-1500 format to bill the Arkansas Medicaid Program for services provided to eligible Medicaid recipients. CMS respite care providers must submit a paper HCFA-1500 claim form. See section 311.200 for detailed billing instructions.
The CMS respite care coordinator's staff will electronically bill the Arkansas Medicaid Program on behalf of the CMS respite care provider using the AEVCS system. Payment will be sent directly to the provider who performed the services.
The Automated Eligibility Verification and Claims Submission (AEVCS) system is the electronic method for verifying a recipient's eligibility and filing claims for payment. 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 by CMS.
EDS processes each week's accumulation of claims during the weekend cycle. The deadline for each weekend cycle is 12:00 midnight Friday.
The following table lists the values/comments for each of the fields associated with an electronically filed HCFA-1500 claim transaction. The last column provides a cross-reference to section 311.300 of this manual for specific field requirements and instructions.
|
Field Name |
Values/ Comments |
Refer to section 311.300 |
|
Header 1 Information |
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|
Provider ID |
Required field for all claim types. The 9-digit identification number of the provider who is to receive payment for the service. If the number you enter on the claim is not on file or not eligible on the dates of service you enter, the claim will not be accepted. |
Field 33 |
|
Recipient - ID |
The 10-digit, assigned identification number of the individual receiving services. |
Field 1A |
|
Recipient First Name |
At least the first character of the recipient's first name. |
Field 2 |
|
Recipient Last Name |
At least the first two letters of the recipient's last name. |
Field 2 |
|
Patient Account # |
Unique number assigned by the provider's facility for the recipient. Optional field. |
Field 26 |
|
Prior Authorization # |
Not applicable to CMS respite care services. |
Field 23 |
|
Referring Phys ID |
Not applicable to CMS respite care services. |
Field 17A |
|
Header 2 Information |
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|
Diagnosis Code |
The identity of a condition or disease for which the service is being billed. Diagnosis codes are listed in the ICD-9-CM code book and are 3 to 5 characters. |
Field 21 |
|
Header 2 Information |
||
|
Employment Related? |
If the service being billed was necessary because of a job-related incident, type Y. If not, type N. |
Field 10A |
|
Incident Date |
Date of incident that required the patient to be hospitalized. |
Field 14 |
|
Accident Related? |
If the condition is the result of an accident, type Y. If not, type N. |
Field 10B or IOC |
|
Hospital Admit Date |
Not applicable to CMS respite care services. |
Field 18 |
|
Facility Name |
If the services were rendered somewhere other than an office or home, type the name of the facility. |
Field 32 |
|
Facility Address |
If the services were rendered somewhere other than an office or home, type the address of the facility. |
Field 32 |
|
Outside Lab Work? |
Not applicable to CMS respite care services. |
Field 20 |
|
Therapy Services Code |
Not applicable to CMS respite care services. |
Field 19 |
|
School District Code |
Not applicable to CMS respite care services. |
Field 19 |
|
Other Insurance? |
If recipient has other insurance coverage, type Y. If not, type N. |
N/A |
|
TPL Paid Amount |
The amount paid by the other insurance company. If Other Insurance? is Y and TPL Denial Date is blank, this field is required. |
Field 29 |
|
TPL Denial Date |
The date on which the other insurance company denied payment for services billed. |
N/A |
|
TPL Information |
||
|
Carrier Code |
Code assigned by the state to identify Third Party Liability (TPL) or other insurance carrier name and address. When you verify eligibility, the response includes the TPL Carrier Code along with other TPL information for the recipient. If you enter this code on a claim, you do not have to type the TPL company's name and address. |
N/A |
|
Policy Number |
The recipient's third party insurance company policy number. |
Field 11 |
|
Company Name |
The name of the third party insurance company. |
Field 11C |
|
Address |
Type the address of the third party insurance company. |
N/A |
|
Second TPL |
Indicates whether the recipient has a second insurance. Response required if primary insurance is entered. "Y" = Yes "N" = No. |
Field 11D |
|
Carrier Code |
Code assigned by the state to identify the second Third Party Liability (TPL) or other insurance carrier name and address. |
N/A |
|
Policy Number |
The recipient's additional third party insurance company policy number. |
Field 9A |
|
Company Name |
The name of the second third party insurance company. |
Field 9D |
|
Address |
The address of the second third party insurance company. |
N/A |
|
Insured/ Other Than Recipient - First Name |
If the recipient is not the insured person, type the first name of the insured person. |
Field 4 |
|
Insured/ Other Than Recipient - Last Name |
If the recipient is not the insured person, type the last name of the insured person. |
Field 4 |
|
Insured/ Other Than Recipient - Address |
If the recipient is not the insured person, type the address of the insured person. |
Field 7 |
|
Employer or School Name |
Name of recipient's employer or school. |
Field 9C |
|
Detail Information |
||
|
From DOS |
Beginning date of service. For spanning dates of service, do not include any date on which no service was rendered. Units of service must be the same for each of the dates included in the span. |
Field 24A |
|
To DOS |
Ending date of service. 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 311.400 for a list of codes.) |
Field 24B |
|
TOS |
Type of service code. (See section 311.400 for a list of codes.) |
Field 24C |
|
Procedure |
The procedure code for the service provided. |
Field 24D |
|
Modifier |
Not applicable to CMS respite care services. |
Field 24D |
|
Hours |
Not applicable to CMS respite care services. |
Field 24D |
|
Minutes |
Not applicable to CMS respite care services. |
Field 24D |
|
Extreme Age |
Not applicable to CMS respite care services. |
N/A |
|
Surgical Avoid |
Not applicable to CMS respite care services. |
N/A |
|
Hypothermia |
Not applicable to CMS respite care services. |
N/A |
|
Hypertension |
Not applicable to CMS respite care services. |
N/A |
|
Pressure |
Not applicable to CMS respite care services. |
N/A |
|
Circulation |
Not applicable to CMS respite care services. |
N/A |
|
Units |
Required field for all claim types. Number of units of a service that were supplied for the claim detail. |
Field 24G |
|
Diagnosis |
Not applicable to CMS respite care services. |
Field 24E |
|
Charges |
Required for all claim types. Provide the amount billed for a service performed for this detail. If you bill more than one unit of service on a detail, provide the total charge for all units billed for that detail. |
Field 24F |
|
Fund Code |
Not applicable to Medicaid claims. |
N/A |
|
EPSDT/Family Planning |
If the service was rendered as the result of an EPSDT screening, type E. If the service was rendered under the Family Planning Program, type F. If neither condition applies, leave this field blank. |
Field 24H |
|
Performing Provider ID |
Required field for all claim types. The 9-digit identification number of the provider who performed the service. If the number you enter on the claim is not on file or not eligible on the dates of service you enter, the claim will not be accepted. |
Field 24K |
|
Field Name |
Values/ Comments |
|
Recipient ID |
Displays the 10 digit assigned identification number of the individual receiving services. |
|
Recipient Name |
Displays the recipient's first and last name. |
|
Patient Acct |
Patient Account - Displays the unique number assigned by the provider's facility for the recipient. |
|
Transaction Type |
Displays the transaction type. This response will read "HCFA-1500". |
|
Date |
Displays the date the claim was submitted. |
|
Time |
Displays the time the claim was submitted. |
|
Pay to Provider Number |
Displays the provider number of the provider that is to receive payment. |
|
Primary TPL - TPL Indicator |
Displays "Y" for yes or "N" for no, depending on the information that was submitted. |
|
Secondary TPL -TPL Indicator |
Displays "Y" for yes or "N" for no, depending on the information that was submitted. |
|
Employment Related |
Displays "Y" for yes or "N" for no, depending on the information that was submitted. |
|
Accident Related |
Displays "Y" for yes or "N" for no, depending on the information that was submitted. |
|
Outside Lab Work |
Displays "Y" for yes or "N" for no, depending on the information that was submitted. |
|
Diagnosis |
Not applicable to CMS respite care services. |
|
Detail Number |
Displays the number of the detail that was submitted, up to six. Each detail and detail criteria will be listed separately. |
|
From Date of Service |
Displays the beginning date of service for the detail submitted. |
|
To Date of Service |
Displays the ending date of service for the detail submitted. |
|
Place of Service |
Displays the place of service for the detail submitted. |
|
Type of Service |
Displays the type of service for the detail submitted. |
|
Procedure Code |
Displays the procedure code for the detail submitted. |
|
Diagnosis |
Not applicable to CMS respite care services. |
|
Charge |
Displays the dollar amount billed for the detail submitted. |
|
Number of Units |
Displays the number of units for the detail submitted. |
|
Modifier |
Not applicable to CMS respite care services. |
|
Performing Provider |
Medicaid ID number of the provider who performed the procedure. |
|
Total Amount Billed |
Displays the total amount billed for the submitted claim. |
|
TPL Amount |
Displays the total amount from other insurances on the claim submitted. |
|
Net Amount Billed |
Displays the amount billed minus the TPL amount on the submitted claim. |
|
Claim Submission Accepted - Net Amount Billed |
Displays the net billed amount for the claim submitted. |
|
ICN |
Displays the unique 13-digit internal control number assigned by EDS to the submitted claim. |
|
Field Name |
Values/ Comments |
|
Provider ID |
Enter the 9-digit identification number of the provider who filed the claim being reversed. |
|
Patient ID |
Enter the 10 digit assigned identification number of the individual receiving services. |
|
ICN |
Enter the unique 13-digit internal control number assigned by EDS to an accepted or adjudicated claim. |
|
Field Name |
Values/ Comments |
|
Transaction Type |
Displays the transaction type. This response will read "Claim Reversal". |
|
Date |
The date of the claim reversal. |
|
Time |
The time of the claim reversal. |
|
Provider ID |
Displays the 9-digit identification number of the provider who filed the reversed claim. |
|
Patient ID |
Displays the 10 digit assigned identification number of the individual that received the services. |
|
ICN |
Displays the unique 13-digit internal control number assigned by EDS to an accepted or adjudicated claim. |
If a claim or claim reversal is rejected, PES will display error codes and the meaning of the codes.
The CMS respite care provider must complete the HCFA-1500 claim form for each recipient of CMS respite care services. The numbered items correspond to numbered fields on the claim form. (A sample HCFA-1500 claim form follows these billing instructions.) The provider's signature is required in field 31 of the HCFA-1500 claim form.
It is the provider's responsibility to obtain the parent's or legal guardian's signature on the HCFA-1500 claim form. The parent or legal guardian must sign in field 13 to certify that the information reported on the form (i.e., dates of service, units of service) is correct.
The provider must retain a copy of the completed form (with both signatures) for his or her records. (See section 204.000 of this manual for documentation requirements.)
To complete the billing process, the parent or provider must send the completed HCFA-1500 claim form to the CMS respite care coordinator at:
Arkansas Department of Human Services Children's Medical Services P.O. Box 1437, Slot S380 Little Rock, AR 72203
The CMS respite care coordinator will review the HCFA-1500 claim form to check for:
All discrepancies must be resolved prior to authorizing Medicaid payment.
The CMS respite care coordinator's staff will bill Medicaid on behalf of the provider using the AEVCS system. Payment will be sent directly to the provider who rendered the services.
|
Field Name and Number |
Instructions for Completion |
|
|
1. |
Type of Coverage |
This field is not required for Medicaid. |
|
la. |
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 client's last name and first name as thev appear 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. |
|
Sex |
Check "M" for male or "F" for female. |
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|
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 the 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. |
|
|
Sex |
This field is not required for Medicaid. |
|
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c. Employer's Name or School Name |
Enter the employer's name or school name. |
|
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d. Insurance Plan Name or Program Name |
Enter the name of the insurance company. |
|
|
10. |
Is Patient's Condition Related to |
|
|
a. Employment |
Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO." |
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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. |
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|
c. Other Accident |
Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related. |
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|
lOd |
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. |
|
|
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 must be signed by the parent or legal guardian of the patient. |
|
14. |
Date of Current: Illness Injury Pregnancy |
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 |
Not applicable to CMS respite care services. |
|
17.a |
I.D. Number of Referring Physician |
Not applicable to CMS respite care services. |
|
18. |
Hospitalization Dates Related to Current Services |
Not applicable to CMS respite care services. |
|
19. |
Reserved for Local Use |
Not applicable to CMS respite care services. |
|
20. |
Outside Lab Work? |
Not applicable to CMS respite care services. |
|
21. |
Diagnosis or Nature of Illness or Injury |
Not applicable to CMS respite care services. |
|
22. |
Medicaid Resubmission Code |
Reserved for future use. |
|
Original Ref No. |
Reserved for future use. |
|
|
23. |
Prior Authorization Number |
Not applicable to CMS respite care services. |
|
24. |
A. Dates 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 06-15-01 through 07-14-01 must be billed on two lines: 06-15-01 to 06-30-01 and 07-01-01 to 07-14-01. 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 311.400 for a list of codes. |
|
|
C. Type of Service |
Enter the appropriate type of service code. See section 311.400 for a list of codes. |
|
D. Procedures, Services or Supplies |
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CPT/HCPCS |
Enter the correct HCPCS procedure code from section 311.410. |
|
|
Modifier |
Not applicable to CMS respite care claims. |
|
|
E. Diagnosis Code |
Not applicable to CMS respite care claims. |
|
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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. |
|
|
H. EPSDT/Family Plan |
Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral and "F" if services rendered are Family Planning related. |
|
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I. EMG |
Emergency - This field is not required for Medicaid. |
|
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J. COB |
Coordination of Benefit - This field is not required for Medicaid. |
|
|
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#." 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#." |
|
25. |
Federal Tax I.D. Number |
This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
|
26. |
Patient's Account No. |
This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted. |
|
27. |
Accept Assignment |
This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid. |
|
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 in Field 30.) |
|
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 amount previously paid by Medicaid. Do not enter any payment by the recipient, unless the recipient has an insurer that requires copay. In such a case, enter the sum of the insurer's payment and the recipient's copay. (See NOTE below Field 30.) |
|
30. |
Balance Due |
Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. 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. |
|
31. |
Signature of Physician or Supplier, |
The provider or designated authorized individual |
|
Including Degrees or Credentials |
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. |
|
33. |
Physician's/Supplier's Billing Name, Address, ZIP Code & Phone # |
Enter the billing provider's name and complete address. Telephone number is requested but not required. |
|
PIN # |
This field is not required for Medicaid. |
|
|
GRP# |
Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K. Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#." |
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Place of Service |
TyPe °f Service |
|
4 - Patient's Home |
9 - Other Medical Service |
|
5 - Day Care Facility |
|
|
I - Day Treatment Centers |
|
|
J - Respite Care Facility |
Use the following procedure code for CMS respite care services:
Procedure CodeDescription
Z2631 CMS Respite Care Services
1 unit =15 minutes minimum of 4 units per day maximum of 96 units per day
RESERVED
The Remittance and Status Report, or Remittance Advice (RA), is a computer generated document that reports the status and payment breakdown of all claims submitted to Medicaid for processing. It is designed to simplify provider accounting by facilitating reconciliation of claim and payment records.
An RA is generated and 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. The RA explains the 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.
Since the RA is a provider's only record of paid and denied claims, it is necessary for the provider to retain all copies of the RAs.
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 The RA is a status report of active claims. It is the first source of reference to resolve questions regarding a claim. If the RA does not resolve the question, it may be necessary to contact the EDS Provider Assistance Center (PAC). PAC will need the claim number from the RA to research the question. The Provider Assistance Center (PAC) may be contacted at (501) 376-2211 (local and out-of-state) or 1-800-457 -4454 (in-state WATS).
If a claim does not appear on the RA within six weeks after submission, contact PAC. If PAC can find no record of the claim, they will suggest resubmitting it.
There are eight main segments of an RA:
Report Heading Paid Claims Denied Claims Adjusted Claims Claims In Process Financial Items AEVCS Transactions 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. |
|
6. |
DATE |
The date the RA was produced. This is also the "checkwrite" date, or the date on the check associated with this RA. |
|
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. |
|
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. |
CO |
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. |
COST SHARE, PA/LEA, TPL |
"COST SHARE=" displays Medicaid and ARKids First-B copay amounts. "PA/LEA=" displays applicable prior authorization or LEA numbers. Third Party Liability (TPL) will show the amount paid from insurance or other sources. |
|
4. |
CLAIM 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. Example: 0599033067530 (ICN) Format: RRYYDDDBBBSSS 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). b. YY-99 - The third and fourth digits indicate the year the claim was received. 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). d. The remaining digits are used for internal record-keeping purposes. |
|
5. |
MRN |
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. |
DIAG |
Diagnosis - The primary diagnosis code used on the claim. |
|
7. |
SERV PHYS |
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. |
|
9. |
COINS, DED, MCR PD, TPL |
Coinsurance, deductible, the Medicare paid amount and will be listed for crossover claims. Third Party Liability (TPL) will show the amount paid from insurance or other sources. |
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 final. No additional action will be taken on denied claims.
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 sections 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 part 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. |
ICN |
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. |
EOB CODE(S) |
Explanation of Benefit Codes - 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 adjusted claims appears in the Adjusted Claims section as information only and is actually applied in the Financial Items section.
|
Field Name |
Description |
|
|
1. |
RECIP ID |
Recipient ID - The recipient's 10-digit Medicaid identification number. |
|
2. |
FROM DOS |
The from date of service. |
|
3. |
TXN DATES |
Transaction Dates - The date on which this transaction was entered into the system. |
|
4. |
CONTROL NUMBER |
The unique number assigned to this transaction by EDS. |
|
5. |
REFERENCE |
Information that may be of help in identifying the transaction (For example, claim number or AEVCS transaction fees). |
|
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 before 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. |
EOB |
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 CMS respite care coordinator on behalf of 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 units paid, denied and adjusted. Includes details added to indicate ARKids First-B copays. Does not include crossovers. |
|
2. |
CLAIMS PAID |
Total number of claims paid, denied and adjusted by the Medicaid Program, including crossovers. |
|
3. |
CLAIMS AMOUNT |
Total paid amount from Paid Claims section plus any supplemental payouts (e.g., resulting from a positive adjustment listed in the Adjusted Claims section). |
|
4. |
WITHHELD AMOUNT |
Total amount withheld from RA (e.g., resulting from negative adjustments). This amount is the sum of the "Applied Amount" fields of the Financial Items section. This does not include the withheld AEVCS transaction amount. |
|
5. |
NET PAY AMOUNT |
Claims amount less withheld amount(s), including AEVCS transaction fees. This is the amount of the provider's payment. |
|
6. |
CREDIT AMOUNT |
Total amount refunded to the Medicaid Program by the provider. EDS posts refunds here. See section 330.000. |
|
7. |
NET 1099 AMOUNT |
The provider's income reported to federal and state governments for tax purposes. This amount is the "Net Pay Amount" plus the "AEVCS Transaction Recoupment Amount". AEVCS transaction fees are paid with taxable revenue, so they are added back to the "Net Pay Amount" for tax reporting purposes. |
|
8. |
TAX AMOUNT |
The amount of tax withheld on this RA. Not currently used. |
|
9. |
QTR TAX AMOUNT |
Quarterly Tax Amount - The cumulative amount of tax withheld for this financial quarter. Not currently used. |
|
Field Name |
Description |
|
|
10. |
AEVCS TXN FEES |
AEVCS Transaction Fees - Total amount of AEVCS transaction fees charged to the provider. |
|
11. |
AEVCS TXN RECOUP AMT |
AEVCS Transaction Recoupment Amount - Total amount of AEVCS transaction fees withheld from the payment. This amount is obtained from the "Total Transactions For This Provider" field under the 'Transaction Amount" column of the AEVCS transactions section. |
|
12. |
DEF COMP RECOUP AMT |
Deferred Compensation Recoup Amount -Amount withheld from the payment and deposited in the provider's designated account for deferred compensation. |
|
13. |
ARKIDS 1 ST/CHIP/MEDICAID SUMMARY |
A summary count and total amount paid for ARKids First, CHIP and Medicaid claims. |
|
14. |
DESCRIPTION OF EOB CODES |
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. |
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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. CMS will submit an Adjustment Request Form on behalf of the CMS respite care providers. 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 CMS 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 by CMS 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.
|
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) |
If duplicate payments, incorrect payments or overpayments are made, submit an adjustment request and check the box labeled overpayment. EDS will withhold (recoup) the overpayment amount from future claims payments. |
|
4. |
Underpayment (Debit) |
If a claim is underpaid, check the box labeled underpayment to have the correct amount added to future claims payments. |
|
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. |
|
6. |
Claim Number (ICN - Internal Control Number) |
Enter the 13-digit claim number exactly as it is printed on your RA. |
|
7. |
Patient Name |
Enter the patient's last name, first name and middle initial. |
|
8. |
Recipient ID Number |
Enter the entire 10-digit Medicaid identification number assigned to the recipient as it appears on the RA. |
|
9. |
Remittance Advice Date |
Enter the date of the RA, which is found at the top right corner of the RA. |
|
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). |
|
12. |
Paid Amount |
Enter the amount actually paid by Medicaid for the service(s) in question. |
|
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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The Arkansas Medicaid Program provides RAs each week to providers who have claims paid, denied or in process. If an overpayment occurs, the provider is 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 the original check or forwarding a check in the amount of the underpayment instead of requesting an adjustment. When EDS posts the refund, the amount of the refund appears 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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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 red-lined copy of the appropriate crossover invoice to the address on the top of the form.
To order copies of the appropriate Medicare-Medicaid crossover invoice, please use the Medicaid Form Request, Form EDS-MFR-001. Instructions for filling out the invoice are included with the ordered forms. Indicate the quantity of each form needed and mail your request to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
A sample copy of the Professional Services Medicare-Medicaid Crossover Invoice is provided below. When you complete the appropriate red lined Medicare-Medicaid crossover form, sign and date the form, and mail it to the address printed at the top of the Crossover Invoice.
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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, providers may submit an adjustment using the PES software provided by EDS. Providers may also submit an Adjustment Request Form with a copy of the proper red lined crossover form reflecting Medicare's adjustment. Enter the Medicaid provider number and the patient's Medicaid identification number from 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, payment of claims involving third party liability and requests for insurance information. Providers should contact the EDS Provider Assistance Center (PAC) for any questions regarding third party liability. PAC may be contacted at (501) 376-2211 (local and out-of-state) or 1-800-457 -4454 (in-state WATS).
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 by AEVCS, the insurance information should be faxed to the DMS Third-Party Liability Unit at (501) 682-1644.
All Medicaid claims, including claims that 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 paid services that are limited by the Medicaid Program count toward the patient's benefit limits even when 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 software prompts the user to enter the date of the denial Explanation of Benefits (EOB) or the date of the EOB showing that the allowed amount was applied to the insurance deductible.
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.
You can order the ICD-9-CM, online at http://www.ingenixonline.com/, or contact Ingenix using the information provided below.
Ingenix
P.O. Box 27116
Salt Lake City, UT 84127-0116
Fax: 1-800-982 -4033 Telephone: 1-877-464 -3649
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).
You can order the CPT, online at http: / / www, ingenixonline .com/, or contact Ingenix using the information provided below.
Ingenix
P.O. Box 27116
Salt Lake City, UT 84127-0116
Fax: 1-800-982 -4033 Telephone: 1-877-464 -3649
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.