016.06.02 Ark. Code R. § 048 - Arkansas Medicaid Provider Manual - Assisted Living Provider Manual
The purpose of Section I is to explain the role the provider plays in the Arkansas Medicaid Program. The information conveyed will provide the users with an understanding of Medicaid program policy. It also contains information the provider may need to answer questions that individuals often ask about the Medicaid Program.
When fully utilized, this manual will be an effective tool for the provider office personnel. For instance, it may serve as a tool for training billing clerks by providing them with a basic knowledge of the Medicaid Program, covered and non-covered services, special billing procedures and detailed instructions for accurate completion of claims. Proper use of this manual will result in a reduction of errors in claim filing, thus expediting payment.
The manual will be an effective tool if it is properly maintained. The fiscal agent, EDS, will mail each provider all manual updates when produced. These updates should be promptly filed in the manual according to the procedures discussed in Section 101.100. Information that has not yet been incorporated into this manual is issued via Official Notices and Remittance Advice (RA) messages. Official Notices and RAs are filed in the back of this manual.
All manuals, Official Notices and RAs are also available for downloading, without charge, from the Medicaid Home Page Web Site at www.medicaid.state.ar.us. These documents are maintained in separate folders on the Web Site. Downloading all three sets of documents for the program in question will ensure the provider of having the most current policy information available.
Three major areas are covered in Section I.
The manual is designed to accommodate new pages as further interpretations of the law and changes in policy and procedures are made. These changes are released to the provider in the form of a manual update, an Official Notice or an RA (remittance advice) message. The fiscal agent, EDS, will issue these changes as directed by the Division of Medical Services (DMS). Periodically, all changes made to Medicaid policy will be promulgated and incorporated into each Medicaid provider manual as policy.
An update transmittal letter will accompany each update to this manual. Updates will have sequential identification numbers assigned, e.g., Update Transmittal #1. The transmittal letter identifies the new page numbers to be added and/or the pages to be replaced and provides any other information about the update being made. An Update Control Log has been provided in the back of the manual to record updates received. When an update package is received, the updated manual pages should be filed in the provider manual, removing the pages being revised. The effective date should be entered on the Update Control Log opposite the appropriate update number. When the update is complete, the transmittal letter should be filed immediately after the update control log in ascending sequence by update number.
Effective for dates of service on or after July 1, 1999, extra copies of paper manuals, manual updates and official notices may be purchased through EDS. EDS will charge $32.50 per manual. There will be an annual charge of $35.00 for manual updates and official notices. The cost for a provider manual with updates/official notices will be $67.50. Requests for manuals, updates and official notices may be sent to EDS, Manual Order, PO Box 8036, Little Rock, AR 72203-8036.
All manuals, manual updates, Official Notices and RAs are available for downloading, without charge, from the Arkansas Medicaid Home Page Web Site at www.medicaid.state.ar.us.
Section 7 of Act 280 of 1939 and Act 416 of 1977 gave authority to the State of Arkansas, the Division of Social Services, now referred to as the Department of Human Services, to establish and maintain a medical care program for the indigent. It also gave authority to the Commissioner of Social Services, now called the Director of the Department of Human Services, to set forth and administer the rules and regulations necessary to carry out such a program. Out of this legislation, the Arkansas Medical Assistance Program was formed.
Title XIX of the Social Security Act provides for federal grants to the states for their medical assistance programs. Originally enacted by the Social Security Amendments of 1965 and Public Law 89-97, Title XIX was approved on July 30, 1965. Although officially entitled "Grants to States for Medical Assistance Programs," this title is popularly called "Medicaid." The stated purpose of Title XIX is to enable the states to furnish the following:
Thus, the Medicaid Program is a joint federal-state program that provides necessary medical services to eligible persons who would not be able to pay for such services.
In Arkansas, the Division of Medical Services administers the program and is responsible for all parts of the program. Within the Division, the Office of Long Term Care is responsible for nursing homes.
The Arkansas Medicaid Program provides, with limitations, the following services: Federally Mandated Services
* Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for Persons Under Age 21 (Child Health Services)
* Family Planning Services
* Federally Qualified Health Center (FQHC) Services
* Home Health Services
* Inpatient Hospital Services
* Laboratory and X-Ray Services
* Nurse-Midwife Services
* Nurse Practitioner Services
* Nursing Facility Services for Individuals Age 21 or Older who are categorically eligible (e.g., Aid to the Aged, Blind or Disabled)
* Outpatient Hospital Services
* Physician Services
* Rural Health Clinic Services
Optional Services
* Ambulatory Surgical Center Services
* Audiological Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Targeted Case Management for Pregnant Women
* Targeted Case Management Services for Adults with a Developmental Disability
* Targeted Case Management Services for Recipients Age 60 and Older
* Certified Registered Nurse Anesthetist (CRNA)
* Child Health Management Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Chiropractic Services
* Dental Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Developmental Day Treatment Clinic Services (DDTCS)
* Domiciliary Care Services
* Durable Medical Equipment
* End-Stage Renal Disease (ESRD) Facility Services
* Hyperalimentation Services
* Hospice Services
* Inpatient Psychiatric Services for Individuals Under Age 21
* Inpatient Rehabilitative Hospital Services
* Intermediate Care Facility Services for Mentally Retarded
* Medical Supplies
* Nursing Facility Services for patients under 21 years of age
* Occupational, Physical, Speech Therapy Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Personal Care Services
* Podiatrist Services
* Portable X-Ray Services
* Private Duty Nursing Services (for Ventilator-Dependent of all ages and High-Technology Non-Ventilator Dependent for persons under 21 in the Child Health Services (EPSDT) Program)
* Prescription Drugs
* Psychologist Services (Arkansas Medicaid limits this service to persons under 21 in the Child Health Services (EPSDT) Program)
* Rehabilitative Services for Persons with Mental Illness (RSPMI)
* Rehabilitative Services for Persons with Physical Disabilities (RSPD)
* Transportation Services (Ambulance, Non-Public)
* Ventilator Equipment
* Visual Services
The following Medicaid covered services are available for recipients under age 21 through the Child Health Services (EPSDT) Program:
* Eye Prostheses
* Repairs and Replacements of Eyeglasses
* Hearing Aid Services
Medical Clearance Audiological Exam Purchase of Hearing Aid
* Immunizations
* Allergy/ Desensitization Injections and Antigens
* Child Health Management Services
* Inpatient Psychiatric Care
* Cochlear Implantation
* Durable Medical Equipment (DME), e.g. specialized wheelchairs
* Psychology Services
* Chiropractic Services
* Occupational, Physical, Speech Therapy Services
Additional services may be covered if determined to be medically necessary as a result of a Child Health Services (EPSDT) screening/referral. These services include, but are not limited to:
* Targeted Case Management Services for Recipients Under the Age of 21
* Orthotic Appliances
* Prosthetic Devices
* Respiratory Care Services
The Division of Medical Services (DMS) encourages all Medicaid providers to participate in providing Child Health Services (EPSDT) screening services to eligible Medicaid recipients. DMS provides patient outreach, including assistance in scheduling screening appointments and providing transportation for the recipients to all providers' offices. Except in certain counties that require a primary care physician (PCP) referral, recipients have freedom of choice in selecting a provider for screening services. To make certain this occurs, all local county offices will be given lists of providers who have agreed to accept referrals and provide Child Health Services (EPSDT) screenings. This list will be updated as additions, deletions and address and/or telephone number changes occur. Information regarding PCP referrals is located in Sections 180 through 187. The list of counties requiring a PCP referral is located in Section 184.
A complete screening package includes the following components as appropriate for the age and sex of the child:
All of the components listed above are required for a complete Child Health Services (EPSDT) medical screen. The tests and procedures used in screening are intended to be quick, inexpensive and easy to administer. They are not necessarily intended to provide conclusive proof of a problem or abnormality, only the indication that one may exist.
Cases, in which problems or abnormalities are indicated, should be referred for diagnosis. If the child is receiving care from a participating Child Health Services (EPSDT) Medicaid provider, then screening, diagnosis and treatment may be provided by that same practitioner.
Providers billing Medicaid for diagnosis or treatment must certify that their services result from a Child Health Services (EPSDT) screening or referral. The certification is a matter of entering "Y" in the "EPSDT Indicator" field in the AEVCS format. Field numbers (#s) and valid values for each claim type/provider type are:
Individuals interested in providing Child Health Services (EPSDT) screening services or receiving more information, may call (501) 682-8297 or 1-800-482 -1141.
The following services are available for eligible recipients through Medicaid Home and Community Based 2176 Waivers:
ElderChoices has been designed for individuals age 65 and over, who, without the services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain Medicaid eligible individuals at home in order to preclude or postpone institutionalization.
ElderChoices eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
More detailed information may be found in the ElderChoices manual.
The Developmental Disability Services Alternative Community Services (DDS-ACS) waiver has been designed for individuals who, without the services, would require institutionalization and could not otherwise reside in the community. Individuals eligible for the services must not be residents of a hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).
DDS-ACS eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
Services supplied through this program are:
More detailed information may be found in the DDS-ACS manual.
The Alternatives for Adults with Physical Disabilities (APD) Waiver has been designed for disabled individuals age 21 through 64, who receive Supplemental Security Income, or are Medicaid eligible by virtue of their disability and who, without the provision of the services, would require a nursing facility level of care.
APD eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
The services offered through the waiver are:
More detailed information may be found in the APD manual.
The following services are available for eligible recipients through Medicaid 1915(b) waivers:
In the Primary Care Physician Managed Care Program, a Medicaid recipient chooses a physician or single-entity provider who is responsible for the management of the recipient's total health care. The primary care physician provides primary care services, health education and referrals to other needed medical services when necessary. The PCP also coordinates and monitors prescribed medical and rehabilitation services on behalf of the recipient.
More detailed information, including exemptions in the PCP Program, may be found in Sections 180 through 187 of this manual.
The Medicaid Non-Emergency Transportation (NET) Waiver Services for Medicaid recipients have been established statewide. The program requires Medicaid recipients to contact a local transportation broker to obtain non-emergency transportation for appointments to Medicaid covered services. Transportation brokers are individuals who have contracted with the Division of Medical Services (DMS) to supply the non-emergency transportation (NET) services. The NET broker must provide transportation to and from medical providers for Medicaid covered services.
Transportation providers for the Developmentally Disabled (DD) population may choose to provide services for the Developmentally Disabled population as a fee-for-service provider for transportation to and from a Developmental Day Treatment Clinic Service (DDTCS) facility or contract with the transportation broker in their region to provide non-emergency transportation services. The broker must provide transportation to and from medical providers for Medicaid covered services. Active Children's Medical Services (CMS) recipients may still use CMS vans for transportation.
The Arkansas Medicaid Non-Emergency Transportation Waiver Program does not include services for Nursing Facility residents, Intermediate Care Facilities for Mentally Retarded (ICF-MR) residents, Qualified Medicare Beneficiaries (QMBs), Special Low Income Qualified Medicare Beneficiaries (SMBs), Qualifying Individuals-Is and 2s (QI-ls and 2s), ARKids First participants or Family Planning Waiver recipients.
More detailed information may be found in the Transportation manual and on the Arkansas Medicaid Home Page at www.medicaid.state.ar.us.
Programs
The following services are available for eligible individuals through 1115 Research and Demonstration Waiver Programs:
ARKids First was designed to integrate uninsured children, age 18 and under, into the health care system. ARKids First benefits are comparable to those of State employees/Teachers insurance program.
ARKids First providers must be enrolled in the Arkansas Medicaid Program.
Eligibility criteria for ARKids First are:
ARKids First participants are required to select a Primary Care Physician at the time of application.
For more information, refer to the ARKids First provider manual and to the Arkansas Medicaid Home Page at www.medicaid.state.ar.us.
The Arkansas Department of Human Services, in collaboration with the Arkansas Department of Health, established the Family Planning demonstration Waiver Program (Category 69). Eligibility for the program is limited to women of childbearing age who are not currently certified in any other Medicaid category. The target population is women age 14 to age 44, but all women at risk of unintended pregnancy will be allowed to apply for the program. The family income must be at or below 133% of the Federal Poverty Level.
Recipients are not required to have a photo Medicaid identification card. Their Medicaid coverage entitles them to only family planning services with the provider of their choice. They are not required to select a Primary Care Physician (PCP).
Eligible Family Planning Waiver Services recipients remain Medicaid-eligible for the duration of the five year waiver, implemented September 1, 1997, with no reevaluation or change-in-status reporting requirements. Loss of eligibility will occur only when a woman moves from the state, becomes Medicaid eligible in another aid category, becomes pregnant, or requests that her case be closed.
The Utilization Review Section of the Arkansas Medicaid Program has the responsibility for assuring quality medical care for its recipients along with protecting the integrity of both state and federal funds supporting the Medical Assistance Program. The tasks of the Utilization Review Section are mandated by federal regulations. To realize completion of the tasks assigned, a system has been developed which retrospectively evaluates medical practice patterns by comparing each provider's pattern to norms and limits set by all providers of the same specialty. This system utilizes the information that appears on the Medicaid claim. Utilization Review reports are then printed for all providers who exceed the norms or limits established by their peers. The staff evaluating these computerized reports are experienced medical review analysts who work under the direction of the Medicaid Program's Medical Director, and who have access to the expertise of a Peer Review Committee plus a full complement of specialty consultants on an as-needed basis.
Review analysts may, from time to time, contact a provider to supply the provider with information from these reports as well as to request additional information regarding their medical practice. The provider's cooperation in responding to these contacts will allow for greater accuracy in evaluation.
The Utilization Review Section is also responsible for conducting on-site medical audits for the purpose of verifying the nature and extent of services paid for by the Medicaid Program. This section is responsible for researching all inquiries from recipients in response to the Explanation of Medicaid Benefits (EOMB) and for approving requests for procedures requiring prior authorization.
Providers to be reviewed on-site are selected based on Surveillance and Utilization Review Subsystem (SURS) exceptions (the peer weighted computerized program), random sample selection and community referrals. Providers selected for an on-site audit will not be notified in advance.
Providers are reminded that pertinent records concerning the provision of Medicaid covered health care services are to be made available during regular business hours to all Division of Medical Services staff acting within the scope and course of their employment. Pertinent records are also to be made available to the Division's contractual review organization, i.e. Arkansas Foundation for Medical Care, Inc. /Professional Review Organization (AFMC/PRO). All Medicaid providers are required to keep and maintain records that fully disclose the type and extent of services provided to an Arkansas Medicaid recipient. The nature of the reviews will be to primarily review documentation for services provided, but will, at certain times, be used to evaluate the medical necessity of the delivered services in the view of the professional staff and consultants of the Medicaid Program.
When records are stored off-premise or in active use, the audited provider may certify, in writing, that the records in question are in active use or off-premise storage and set a date and hour within three (3) working days, at which time the records will be available. However, the audited provider will not be allowed to delay production for matters of convenience, including availability of personnel.
The Utilization Review Section is responsible for recovering Medicaid funds from providers when necessary. Situations resulting in recoupment include, but are not limited to, the following:
When recoupment is deemed appropriate, Utilization Review forwards an Explanation of Recoupment to the provider. This explanation includes the name(s) of the patient(s), date(s) of service, date(s) of payment and the reason for the repayment request. Upon receipt of this notice, the provider has thirty days to forward a check for the refund amount or advise the Utilization Review Section of their wish to appeal the recoupment action. Failure to respond to the recoupment notice will result in the recoupment amount being deducted from future Medicaid reimbursement.
Upon receipt of an Explanation of Recoupment, the provider has thirty (30) days in which to supply written notice of appeal. The appeal process is fully explained in the letter that accompanies the Explanation of Recoupment. In brief, the process is as follows:
The purposes of the recipient lock-in rule are to better enable physicians and pharmacists to provide quality care and to assure that the Medicaid Program does not unintentionally facilitate recipient drug abuse or injury from overmedication or drug interaction. An eligible recipient, when correctly identified by application of a utilization algorithm and clinical review to have utilized Medicaid pharmacy services at a frequency or amount not medically necessary, will be required to select one provider of pharmacy services and will be informed that Medicaid will deny claims for pharmacy services submitted by any provider other than the provider selected by the recipient.
At least 30 days before implementing a recipient lock-in, the Division of Medical Services (DMS) or its agents will mail a notice to the recipient at the address listed on the recipient's eligibility records stating the reasons for the intended action. This notice will state the process for reconsideration by the recipient. If, upon reconsideration by DMS or its agent, the recipient is not satisfied with the decision to be locked in to one pharmacy provider, the recipient will be notified by the State of the process to appeal in accordance with the Department of Human Services Appeal Procedures.
Within 10 days of receiving the notice of the decision to be locked in, the recipient must select one pharmacy provider.
In cases of provider restriction, the provider selected will be notified prior to the actual "lock-in," so adequate time is allowed for selection of another provider should the first provider find he cannot provide the needed services. If a recipient fails or refuses to choose one provider, a list of providers used by the recipient will be reviewed and a provider will be chosen.
When a recipient is involved in restriction, the eligibility verification transaction will reflect "lock-in to other provider." The restriction will be removed after demonstration by the recipient that the abusive situation has been corrected.
Application of this rule will not result in the denial, suspension, termination, reduction or delay of medical assistance to any recipient.
The cooperation of all providers is necessary to assure that recipients receive notice upon the implementation of any provider restriction. Any provider who believes a particular recipient should be considered for recipient lock-in should notify the Pharmacy Unit/Utilization Review Section, Division of Medical Services, by calling (501) 683-4120/(501) 682-8334.
Subject: SOURCES OF INFORMATION
Effective Date: 7-1-80
Any questions regarding provider enrollment, participation requirements and/or contracts should be directed to this unit. Their office may be contacted at (501) 682-8502 or 1-800-482 -1141 (In-State WATS).
EDS, a contractor, performs provider relations and the processing of Medicaid claims. EDS Provider Representatives are available to assist providers with detailed billing or policy | questions and to schedule on-site technical assistance with AEVCS and NECS software. To contact a representative, providers may call the Provider Assistance Center at 1-800-457 -4454 (In-State WATS) or (501) 376-2211 (local or out-of-state). Representatives can be reached directly by calling (501) 374-6609.
Children's Medical Services (CMS) assists providers with questions regarding prior authorization of services for individuals under age 21 in several programs. The programs involved are Targeted Case Management, Personal Care, Private Duty Nursing and Occupational, Physical and Speech Therapy and for certain prosthetic items in the Prosthetics program. They assist providers with questions regarding extension of benefits for the Prosthetics program, the Personal Care and Private Duty Nursing programs and with supplies in the Home Health program. The community based CMS nurse is responsible for prior authorizations. Providers may call (501) 682-2277, (501) 682-2270 or 1-800-482 -5850, extension 22277. Extension 22270 may be utilized to obtain the telephone number for the community based organization for a specific child. CMS Central Office may be contacted by FAX at (501) 682-8247 or (501) 682-1779.
The Utilization Review Section of the Division of Medical Services is available to assist providers with questions regarding extension of benefits and prior authorization of services for individuals age 21 and over, and for specified services for individuals under age 21, with the exception of prescription drug prior authorizations. Utilization Review may be contacted directly by calling (501) 682-8340. Providers may call 1-800-482 -1141 (toll free within Arkansas) and leave a message. The call will be returned as soon as possible. The Personal Care, Inpatient Psychiatric and Home Health Units are sections within Utilization Review. The Arkansas Foundation for Medical Care, Inc. performs medical/surgical prior authorizations. AFMC's telephone numbers are: (501) 649-8501 for general questions, for procedure precertification and length of stay review (MUMP), 1-800-426 -2234 for In-State and Out-of-State, and (501) 649-0715 in the Fort Smith area.
Customer Assistance, a Section of the Division of County Operations, investigates recipient inquiries regarding Medicaid eligibility and I.D. card inquiries. Recipients may call 1-800-482 -8988 toll free, or TDD 1-501-682 -8275.
Any materials needed in an alternate format, such as large print, can be obtained by contacting the Americans with Disabilities Act Coordinator at (501) 682-8365 (voice) or (501) 682-6789 (TDD).
This unit responds to Medicaid recipient inquiries regarding Medicaid coverage and benefits, assists out-of-state providers with claim filing procedures, verifies recipient eligibility, and maintains recipient correspondence files. Recipients may contact this unit at 1-800-482 -5431 (In-State WATS) or (501) 682-8502. Providers may contact this unit at (501) 682-8502, 1-800-482 -1141 (In-State WATS) or 1-800-482 -5850, extension 28502 (Out-of-State WATS).
The Dental Coordinator assists providers with questions regarding dental services. The Dental Coordinator may be contacted directly by calling (501) 682-8336, (501) 682-8332 or (501)682-8502.
The Visual Care Coordinator assists providers with questions regarding visual care services. The Visual Care Coordinator may be contacted directly by calling (501) 682-8342 or (501)682-8502.
Providers may also reach the Dental and Visual Care Units by calling In-State WATS 1-800-482 -1141 or Out-of-State WATS 1-800-482 -5850, Ext. 28502.
EDS, the fiscal agent, has a Provider Assistance Center that is available for billing questions and can be reached at (501) 376-2211 or In-State WATS 1-800-457 -4454 between the hours of 8:00 AM and 4:30 PM, Monday through Friday except for the following holidays:
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New Year's Day |
Labor Day |
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Good Friday |
Thanksgiving Day and Friday after |
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Memorial Day |
Christmas Eve and Christmas Day |
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Independence Day |
The State's Program Communications Unit is available to answer providers' questions and direct their telephone calls at (501) 682-8502, In-State WATS 1-800-482 -1141 or Out-of-State WATS 1-800-482 -5850, ext. 28502, Monday through Friday from 8:00 AM through 4:30 PM, except for the following holidays:
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New Year's Day |
Labor Day |
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Martin Luther King, Jr. Day |
Veterans Day |
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President's Day |
Thanksgiving Day (and Friday after*) |
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Memorial Day |
Christmas Eve and Christmas Day |
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Independence Day |
* given at the Governor's discretion |
Subject: RECIPIENT ELIGIBILITY
Effective Date: 7-1-80
The Department of Human Services (DHS) County Office or the District Social Security Office determines recipient eligibility certification. The category of aid each office is responsible for is described below.
Family Support Specialists in the DHS County Offices have the responsibility of evaluating the circumstances of an individual or family to determine the proper category through which aid should be received. The Medicaid recipient aid categories are listed in Section 136 of this manual.
After evaluation, the DHS County Office establishes Medicaid eligibility dates in accordance with State and Federal policy and regulations.
Social Security Representatives have the responsibility of evaluating an individual's circumstances to determine eligibility for the Supplementary Security Income (SSI) program administered by the Social Security Administration. The following are SSI aid categories:
SSI entitlement also establishes Medicaid eligibility.
Recipient eligibility in the Arkansas Medicaid Program is date specific. Medicaid eligibility may begin or end on any day of a month. An AEVCS eligibility verification transaction response displays the current eligibility period through the date of the inquiry.
Medicaid recipients may be eligible for Medicaid benefits for the three-month period prior to the date of application when eligibility requirements for that three-month period are met. The DHS County Office establishes retroactive eligibility.
Subject: MEDICAID ID CARD
Effective Date: 7-1-80
Medicaid recipients are issued a magnetic identification card similar to a credit card. Each identification card displays a hologram, and for most Medicaid categories, a picture of the recipient. Children under the age of five and nursing home/waiver recipients are not pictured. New recipients of the Family Planning Wavier (Category 69) are not pictured unless they were certified using an existing case number and have a previously issued photo ID card. The Division of County Operations issues the Medicaid identification card to Medicaid recipients. THE MEDICAID IDENTIFICATION CARD DOES NOT GUARANTEE ELIGIBILITY FOR A RECIPIENT. Payment is subject to verification of recipient eligibility at the time services are provided. The eligibility transaction is accomplished at the point-of-sale (POS) device by swiping the card and performing a few simple keystrokes. If the recipient does not have a Medicaid ID card, the Medicaid identification number can be typed in. This will require a point-of-sale (POS) device, EDS supplied software for a personal computer (PC) or an office management system modified to process an eligibility verification transaction. Refer to Section 133 for verification of recipient eligibility procedures, and to Section 301 for additional POS device information.
The following is an explanation of information contained on a Medicaid ID card:
Click here to view image
NOTE: ARKids First identification cards have a different appearance than the Medicaid identification card. See pages 1-3 and 1-4 of the ARKids First Manual for more information.
When recipients report non-receipt or loss of a Medicaid card, refer the recipients to the local DHS County Office or the Division of County Operations, Customer Assistance, at its toll free number 1-800-482 -8988 or TDD 1-501-682 -8275. To receive a photo ID, the recipient must go to the Revenue Office or DHS County Office two days after approval notification by the DHS County Office.
The Division of Medical Services has implemented the Automated Eligibility Verification and Claims Submission (AEVCS) technology. With AEVCS, Medicaid providers are able to verify a patient's Medicaid eligibility for a specific date or range of dates, including retroactive eligibility for the past year. Providers may obtain other useful information, such as the status of benefits used during the current fiscal year, other insurance or Medicare coverage, etc. See Section III of this manual for further information on AEVCS.
EDS and the Division of Medical Services (DMS) will verify Medicaid eligibility by telephone only for "Limited Services Providers" (see Section II) in non-bordering states and in the case of retroactive eligibility with dates of service one year prior to card issuance.
When a provider suspects misuse of a Medicaid Identification Card, the provider should contact the Utilization Review Section of Arkansas Division of Medical Services by calling 1-800-482 -1141 toll free or (501) 682-8218. An investigation will then be made.
Subject: MEDICAID RECIPIENT AID CATEGORIES
Effective Date: 7-1-80
The following is a list of recipient aid categories. As categories of eligibility are added or deleted, providers will be notified.
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Category |
Description |
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01 AK |
ARKids First |
AK-No Grant |
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11 AA |
Aid to the Aged |
AA-No Grant |
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13 AI |
Aged SSI Individual |
AA-Grant |
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14 AS |
Aged SSI Spouse |
AA-Grant |
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16 AA-EC |
Aged Exceptional Category |
AA-MN |
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17 AA-SD |
Aged Spend Down |
AA-MN |
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18 AA-QMB |
Aged Qualified Medicare Beneficiary (QMB) |
AA-No Grant |
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20 TEA |
Transitional Employment Assistance Grant |
TEA-Grant |
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and/or Medicaid |
TEA-No Grant |
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25 TM |
Transitional Medicaid |
AFDC-No Grant |
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26 AFDC-EC |
AFDC Exceptional Category |
AFDC-MN |
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27 AFDC-SD |
AFDC Spend Down |
AFDC-MN |
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31 AB |
Aid to the Blind |
AB-No Grant |
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33 BI |
Blind SSI Individual |
AB-Grant |
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34 BS |
Blind SSI Spouse |
AB-Grant |
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35 BC |
Blind SSI Child |
AB-Grant |
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36 AB-EC |
Blind Exceptional Category |
AB-MN |
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37 AB-SD |
Blind Spend Down |
AB-MN |
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38 AB-QMB |
Blind Qualified Medicare Beneficiary (QMB) |
AA-No Grant |
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41 AD |
Aid to the Disabled |
AD-No Grant |
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43 DI |
Disabled SSI Individual |
AD-Grant |
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44 DS |
Disabled SSI Spouse |
AD-Grant |
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45 DC |
Disabled SSI Child |
AD-Grant |
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46 AD-EC |
Disabled Exceptional Category |
AD-MN |
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47 AD-SD |
Disabled Spend Down |
AD-MN |
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48 AD-QMB |
Disabled Qualified Medicare Beneficiary (QMB) |
AD-No Grant |
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49 TEFRA |
Disabled TEFRA Child |
AD-No Grant |
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51 U-18 |
Under Age 18 No Grant |
U-18-No Grant |
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52 NB |
Newborn |
NB-No Grant |
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56 U-18 EC |
Under Age 18 Exceptional Category |
U-18-MN |
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57 U-18 SD |
Under Age 18 Spend Down |
U-18-MN |
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58QI-1 |
Qualifying Individual - 1 |
QI-1 |
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61 PW-PL |
Pregnant Women Infants & Children Poverty Level (SOBRA) |
PW-No Grant |
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62 PW-PE |
Pregnant Women Presumptive Eligibility |
PW-No Grant |
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63 PW-NB |
SOBRA Newborn |
PW-No Grant |
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65 PW-NG |
Pregnant Women No Grant |
PW-No Grant |
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66 PW-EC |
Pregnant Women Exceptional Category |
PW-MN |
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67 PW-SD |
Pregnant Women Spend Down |
PW-MN |
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69 FP |
Family Planning Waiver |
FP-W |
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76 UP-EC |
Unemployed Parent Exceptional Category |
UP-MN |
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77 UP-SD |
Unemployed Parent Spend Down |
UP-MN |
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78 QI-2 |
Qualifying Individual - 2 |
QI-2 |
|
80 RRP-GR |
Refugee Resettlement Grant |
RRP-Grant |
|
81 RRP-NG |
Refugee Resettlement No Grant |
RRP-No Grant |
|
86 RRP-EC |
Refugee Resettlement Exceptional Category |
RRP-MN |
|
87 RRP-SD |
Refugee Resettlement Spend Down |
RRP-MN |
|
88 SMB |
Specified Low Income Qualified Medicare Beneficiary (SMB) |
SMB |
|
91 FC |
Foster Care |
FC-No Grant |
|
92 IV-E-FC |
IV-E Foster Care |
FC-No Grant |
|
96 FC-EC |
Foster Care Exceptional Category |
FC-MN |
|
97 FC-SD |
Foster Care Spend Down |
FC-MN |
The Health Care Financing Administration (HCFA) permits states to cover a number of home and community-based services to individuals who would otherwise reside in nursing homes. To allow this coverage, HCFA waives the regulation requiring actual residence in a nursing facility as a prerequisite for Medicaid eligibility. The Medicaid Program refers to these home and community-based programs as "waiver" programs. There are a number of waivers available to states, each with its own guidelines and restrictions and each having special recipient eligibility restrictions for services.
Individuals eligible for Medicaid under a waiver program have in their Medicaid eligibility file a waiver indicator. The indicator appears on the AEVCS eligibility verification transaction response after the words "WAIVER ELIGIBLE." When a recipient's eligibility file contains a waiver indicator, denoting participation in a home and community-based waiver, that recipient is eligible for only the Medicaid-covered services listed in their plan of care. A nurse or other professional manages the recipient's case and maintains their plan of care. The case manager lists in the plan of care all medical services the client is to receive, whether or not Medicaid covers the services.
A written individual plan of care for each participating recipient is an absolute requirement of a home and community-based waiver. The plan of care must include an assessment of the patient to determine the services necessary to prevent institutionalization. It must also list the medical and other services the patient will require, as well as the frequency of each service and the type of provider to furnish the service. The patient may choose the provider of each service from among those available.
When a Medicaid recipient participates in a home and community-based waiver program, Medicaid reimburses providers for only those Medicaid-covered services listed in the participant's plan of care. Medicaid providers must document in the waiver program participant's record that all services rendered are part of the participant's plan of care. Medicaid will recoup payments for services not listed in the plan of care.
Medicaid requires waiver program clients to choose a primary care physician (PCP). See Section 180 for complete information regarding the Primary Care Physician Managed Care Program.
Subject: ELIGIBILITY VERIFICATION TRANSACTION FORMAT
Effective Date: 1-1-94_______
The following shows the descriptions and values for each of the fields associated with an eligibility verification request transaction.
|
Field # |
Field Name |
Values/ Comments |
Required Field |
|
EVS0010 |
Transaction Code |
Code associated with type of transaction. "AREV" |
Yes |
|
EVS0020 |
Software Version |
"00" |
Yes |
|
EVS0030 |
Terminal ID |
Number that identifies the user's terminal. EDS will assign this number at the time of testing and certification. |
Yes |
|
EVS0040 |
Filler |
Not Used |
|
|
EVS0050 |
Filler |
Not Used |
|
|
EVS0060 |
Transaction Type |
Number to identify the type of transaction sent. "00" = Eligibility Verification |
|
|
EVS0070 |
Filler |
Not Used |
|
|
EVS0080 |
Pay To Provider Number |
Provider's Medicaid ID Number 9 digit numeric i.e., 100000001. |
Yes |
|
EVS0090 |
Filler |
Not Used |
|
|
EVS0100 |
Recipient ID |
Recipient's Medicaid ID Number. 10 digit numeric, ID i.e., 0100000101 |
Yes |
|
EVS0110 |
Filler |
Not Used |
|
|
EVS0120 |
Filler |
Not Used |
|
|
EVS0130 |
Filler |
Not Used |
|
EVS0140 |
Filler |
Not Used |
|
|
EVS0150 |
Filler |
Not Used |
|
|
EVS0160 |
Filler |
Not Used |
|
|
EVS0170 |
Filler |
Not Used |
|
|
EVS0180 |
"From" Date of Service |
"From" date of service. Format = CCYYMMDD |
Yes |
|
EVS0190 |
"To" Date of Service |
"To" date of service. Format = CCYYMMDD |
Yes |
|
EVS0200 |
Screen Type |
Type of EPSDT screening information being requested. "M" = Medical "V" = Vision "D" = Dental "H" = Hearing Blank = None |
Yes |
Subject: RECIPIENT ELIGIBLE RESPONSE FORMAT NON-NURSING HOME
Effective Date: 1-1-94________
The following shows the descriptions and values for each of the fields associated with an eligibility verification response transaction when the recipient is eligible.
|
Field # |
Field Name |
Values/ Comments |
|
EVA0010 |
POS Return |
If non-zero, a system error has occurred. |
|
EVA0020 |
Filler |
Not Used |
|
EVA0030 |
Transaction ID |
Number to identify the type of transaction reviewed. "00" = Eligibility Verification |
|
EVA0040 |
Return Code |
Code assigned by the OLTP to identify the status. "E" = Eligible "R" = Rejected |
|
EVA0050 |
Authorization Code |
Code given by the OLTP for an accepted eligibility transaction. Used internally by EDS. |
|
EVA0060 |
Filler |
Not Used |
|
EVA0070 |
Full First Name |
Recipient's full first name. |
|
EVA0080 |
Full Last Name |
Recipient's full last name. |
|
EVA0090 |
Sex |
Indicates whether the recipient is male or female. "M" = Male "F" = Female |
|
EVA0100 |
Screen Type |
Indicates the type of screening information the provider has requested. "V" = Vision "D" = Dental "H" = Hearing "M" = Medical Blank = None |
|
EVAOllO |
Screen Date |
Indicates the date of the last screening for the screen type requested by the provider. Format = CCYYMMDD |
|
EVA0120 |
Buy-In Code |
Indicates whether the recipient has Medicare buy-in segments. "A" = Part-A "B" = Part-B "X" = Both "N" = None "C" = Call for additional information |
|
EVA0130 |
Third Party/Absent Parent |
Indicates whether the recipient has other insurance through an absent parent. "Y" = Yes "N" = No |
|
Eligibility Segment |
Occurs 4 times. |
|
|
EVA0140 |
Aid Category |
Indicates the aid category for the recipient's eligibility segment. "62" = PW/PE "18", "38" or "48" = QMB |
|
EVA0150 |
Eligibility Begin Date |
Indicates the begin date of the eligibility segment. Format = CCYYMMDD |
|
EVA0160 |
Eligibility End Date |
Indicates the end date of the eligibility segment. Format = CCYYMMDD |
|
EVA0170 |
County and District |
Indicates county (first two digits) and district (last digit) of residence for the recipient. County codes are found on page 1-24 of this manual. |
|
EVA0180 |
Additional Eligibility |
Indicates if the recipient has additional eligibility segments. "Y" = Yes "N" = No |
|
EVA0190 |
Lock-In |
Indicates if a recipient is locked into a specific provider. "O" = Another provider "Y" = You "N" = Not a Lock-in "C" = Call for additional information (Multiple Lock-in segments or locked-in for part of dates) |
|
EVA0200 |
Waiver Indicator |
Indicates if recipient is Waiver Eligible. "N" = Not eligible "Y" = Yes "C" = Call for additional information "B" = Both Wl and W2 (Eligible for specific waiver type) |
|
EVA0210 |
Waiver Type |
Indicates the type of waiver service the recipient has. "Wl" =W1 Waiver "W2" =W2 Waiver |
|
EVA0220 |
Waiver Amount |
Not Used |
|
EVA0230 |
Spenddown |
Indicates if recipient has spenddown. "N" = None "Y" = Yes "C" = Call for additional information (More spenddown information exists) |
|
EVA0240 |
Spenddown Amount |
Indicates the amount of spenddown the recipient has. |
|
EVA0250 |
Spenddown End Date |
Indicates the end date for the spenddown segment. Format = CCYYMMDD |
|
The following fields are unique for each provider type. |
||
|
Pharmacy (07) |
||
|
EVA0260 |
Prescriptions Used |
Number of prescriptions the recipient has used in a month. |
|
EVA0270 |
LTC Indicator |
Indicates if the recipient has Long Term Care benefits. "N" = None "Y" = Yes "C" = Call for additional information (Eligible for part of dates) |
|
EVA0280 |
Filler |
Not Used Physician (01, 02, 03, 04) |
|
EVA0290 |
Outpatient Visits Used |
Number of outpatient visits the recipient has used towards the benefit limit as of the last cycle. |
|
EVA0300 |
Physician Visits Used |
Number of physician visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0310 |
Hospital Days Used |
Number of hospital days the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0320 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0330 |
C onsultations Used |
Number of consultations used by the recipient towards the benefit limit as of the last claims processing cycle. Hospital (05) |
|
EVA0340 |
Outpatient Visits Used |
Number of outpatient visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0350 |
Physician Visits Used |
Number of physician visits the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0360 |
Hospital Days Used |
Number of hospital days the recipient has used towards the benefit limit as of the last claims processing cycle. |
|
EVA0370 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0380 |
C onsultations Used |
Number of consultations used by the recipient towards the benefit limit as of the last claims processing cycle. Independent Lab and Radiology (09, 10) |
|
EVA0390 |
Lab and X-Ray Amount Used |
Total dollar amount for Lab and X-Ray used by the recipient towards the benefit limit as of the last claims processing cycle. |
|
EVA0400 |
Filler |
Not Used |
|
Optometrist/Optician (22) |
||
|
EVA0410 |
Vision Exam |
Indicates the date of the recipient's last vision examination. Format = CCYYMMDD |
|
EVA0420 |
Filler |
Not Used Other |
|
EVA0430 |
Filler |
Not Used |
|
EVA0440 |
TPL Count |
Number of TPL segments that this recipient has. |
|
TPL Segments |
Occurs 0-3 times |
|
|
EVA0450 |
TPL Company Code |
Code assigned to identify the specific third party carrier. |
|
EVA0460 |
TPL Company Name |
Name of the third party carrier. |
|
EVA0470 |
TPL Address |
Street address of the third party carrier. |
|
EVA0480 |
TPL City |
City of the third party carrier. |
|
EVA0490 |
TPL State |
State of the third party carrier. |
|
EVA0500 |
TPL Zip |
Zip code of the third party carrier. |
|
EVA0510 |
TPL Policy |
Policy number with the third party carrier. |
|
EVA0520 |
TPL Group Policy |
Group policy number with third party carrier. |
|
EVA0530 |
TPL Group Name |
Name of the third party group. |
|
EVA0540 |
TPL Subscriber Number |
Subscriber's ID number. |
|
EVA0550 |
TPL Subscriber Name |
Subscriber's name. |
|
EVA0560 |
TPL Relation Code |
Recipient's relationship to the subscriber. |
|
EVA0570 |
TPL Begin Date |
Date the third party coverage began. Format = CCYYMMDD |
|
EVA0580 |
TPL End Date |
Date the third party coverage ended. Format = CCYYMMDD |
|
EVA0590 |
TPL Coverage Codel |
Identifies the type of services covered by the third party carrier. |
|
EVA0600 |
TPL Coverage Code2 |
Identifies the type of services covered by the third party carrier. |
|
EVA0610 |
TPL Coverage Code3 |
Identifies the type of services covered by the third party carrier. |
Subject: RECIPIENT INELIGIBLE/ERROR RESPONSE FORMAT
Effective Date: 1-1-94________
The following shows the descriptions and values for each of the fields associated with an eligibility verification response transaction when the recipient is ineligible.
|
Field # |
Field Name |
Values/ Comments |
|
EVR0010 |
POS Return |
If non-zero, a system error has occurred. |
|
EVR0020 |
Filler |
Not Used |
|
EVR0030 |
Transaction Type |
Number to identify the type of transaction received. "00" = Eligibility Verification |
|
EVR0040 |
Return Code |
Code assigned by the OLTP to identify the status. "R" = Rejected |
|
EVR0050 |
Error Count |
Number of errors to follow. |
|
Error Segments |
Occurs 1-9 times |
|
|
EVR0060 |
Error Code |
Code associated with the errors found on this transaction. |
|
EVR0070 |
Detail Number |
Location on the transaction where the error has occurred. "00" = Header |
Subject: PROVIDER PARTICIPATION
Effective Date: 7-1-80
Any provider of services must be enrolled in the Arkansas Medicaid Program prior to reimbursement being made for any services provided to Arkansas Medicaid recipients.
All providers must complete an application and a provider contract and return them to the | Division of Medical Services within 30 days from the date they were sent from the Enrollment Unit. Please review Section II of this manual relative to provider participation requirements.
Upon receipt and approval of the above information by the Enrollment Unit, a provider number will be assigned to each approved provider. This number must be used on all claims and correspondence submitted to Arkansas Medicaid.
Provider eligibility will be retroactive 6 months from the date the provider agreement was received by the Division of Medical Services, the effective date of the provider's license or certification, or the date the service became a part of the Arkansas Medicaid Program, whichever date is the most current.
Instructions for billing and specific details concerning the Arkansas Medicaid Program are contained within this manual. Please read all sections of the manual before signing the contract. The manual is an extension of your Medicaid contract and must be complied with in order to participate in the Arkansas Medicaid Program.
On the following pages, you will find a copy of the provider application and contract and instructions for completing these forms.
All providers must sign an Arkansas Medicaid Provider Contract. The signature must be an original signature of the individual provider. The contract for a group practice, hospital, other institution or agency must be signed by the authorized representative of the provider.
DIVISION OF MEDICAL SERVICES
MEDICAL ASSISTANCE PROGRAM
PROVIDER APPLICATION
As a condition for entering into or renewing a provider agreement all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.
Whenever changes in this information occur, please submit the change in writing to:
Division of Medical Services Provider Enrollment Unit P.O. Box 1437, Slot 1101 Little Rock, AR 72203-1437
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the applicant:
|
Section I |
All providers |
|
Section II |
Facilities Only |
|
Section III |
Pharmacists/Registered Respiratory Therapist Only |
|
Section IV |
Provider Group Affiliations |
|
Electronic Fund Transfer |
|
|
| Managed Care Agreement |
Primary Care Physician |
|
W-9 Tax Form |
All Providers |
|
Contract |
All Providers |
Providers enrolled in the Arkansas Medicaid Program must agree to the following conditions of participation:
The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare claims for "physician" services furnished to individuals who are eligible for Medicare and Medicaid, including those eligible as Qualified Medicare Beneficiaries (QMB's).
According to Medicare regulations, "physician" services, for the purpose of this policy, are services furnished by physicians, dentists, optometrists, chiropractors and podiatrists.
As described above, "physician" services furnished to an individual enrolled under Medicare who is also eligible for Medicaid, including Qualified Medicare Beneficiaries, may only be made on an assignment related basis.
Subject: RESPONSIBILITIES OF THE MEDICAID RECIPIENT
Effective Date: 4-1-92
Section 1902 (a) (14) of the Social Security Act permits States to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments or similar cost sharing charges.
If an individual who makes payment at the time of service is later found to be Medicaid eligible and Medicaid is filed, the individual must be refunded the full amount of his/her payment for covered services. If it is agreeable with the individual, these funds may be credited against unpaid non-covered services that are the responsibility of the recipient.
Information relating to cost sharing follows in Sections 143.210 through 143.240.
For inpatient admissions on and before October 31, 2001, the coinsurance charge per admission for Medicaid recipients is 22% of the hospital's per diem amount, applied on the first Medicaid covered day.
Example:
A Medicaid recipient is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1890.00, the recipient will pay $110.00 (22% Medicaid coinsurance rate).
For inpatient admissions on or after November 1, 2001, the coinsurance charge per admission for Medicaid recipients is 10% of the hospital's per diem amount, applied on the first Medicaid covered day.
Example:
A Medicaid recipient is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00; the recipient will pay $50.00 (10% Medicaid coinsurance rate).
For inpatient admissions on or before October 31, 2001, the coinsurance charge per admission for Medicaid recipients who are also Medicare Part A beneficiaries, is 22% of the hospital's Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.
Example:
A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.
If, on a subsequent admission, Medicare Part A assesses coinsurance; Medicaid will deduct from the Medicaid payment, an amount equal to 22% of one day's Medicaid per diem, for inpatient admissions through October 31, 2001. The patient will be responsible for that amount.
Effective for dates of service on or after November 1, 2001, the coinsurance charge per admission for Medicaid recipients who are also Medicare Part A beneficiaries, is 10% of the hospital's Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.
Example:
A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.
If, on a subsequent admission, Medicare Part A assesses coinsurance; Medicaid will deduct from the Medicaid payment, an amount equal to 10% of one day's Medicaid per diem. The patient will be responsible for that amount.
Arkansas Medicaid has a recipient copayment policy in the Pharmacy Program. The copayment amount for the Pharmacy Program is applied per prescription. The recipient is responsible for paying the provider a copayment amount based on the following table:
|
Medicaid Maximum Amount |
Recipient Copay |
|
$10.00 or less |
$0.50 |
|
$10.01 to $25.00 |
$1.00 |
|
$25.01 to $50.00 |
$2.00 |
|
$50.01 or more |
$3.00 |
As required by 42 CFR 447.53(b), the following services are excluded from the recipient cost sharing coinsurance/copayment policy:
The fact that a recipient is a resident of a nursing facility does not on its own exclude the Medicaid services provided to the recipient from the cost sharing policy. Unless a Medicaid recipient has applied for long term care assistance through the Arkansas Medicaid Program, been found eligible and Medicaid is making a vendor payment to the nursing facility (NF or ICF/MR) for the recipient, the Medicaid services are not excluded from the cost sharing policy.
The provider must maintain sufficient documentation in the recipient's medical record which substantiates the exclusion from the recipient cost sharing policy.
In the absence of knowledge or indication to the contrary, the provider may accept the recipient's assertion that he/she can not afford to pay the cost sharing coinsurance/copayment amount. The provider may not deny services to any eligible individual due to the individual's inability to pay the cost of the coinsurance/copayment amount. However, the individual's inability to pay does not eliminate his/her liability for the coinsurance/copayment charge. The recipient's inability to pay the coinsurance/copayment amount will not alter the Medicaid reimbursement amount for the claim. Unless the recipient or service is excluded from the coinsurance/copayment policy as listed in Section 143.230, the Medicaid reimbursement amount will be calculated according to current reimbursement methodology minus the appropriate coinsurance amount or appropriate copayment amount.
The method of collecting the coinsurance/copayment amount from the recipient is the responsibility of the provider. In cases of claim adjustments, the responsibility of refunding or collecting additional cost sharing coinsurance/copayment from the recipient will remain the responsibility of the provider.
Subject: QUALIFIED MEDICARE BENEFICIARY PROGRAM
Effective Date: 4-1-92
The Qualified Medicare Beneficiary (QMB) program was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low income Medicare beneficiaries. If a person is eligible for the QMB program, Medicaid will pay the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance on other medical services. Medicaid will also pay the Medicare Part A premium, the Medicare Part A hospital deductible and the Medicare Part A coinsurance.
To be eligible, the individuals must be age 65 or older, blind or disabled and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal, but cannot exceed the Federal Poverty Level (FPL).
Countable resources may equal but cannot exceed twice the current Supplemental Security Income (SSI) resource limitations.
With the exception of medically needy spend-down categories, individuals may not be certified in a QMB category and in another Medicaid category for simultaneous periods. QMBs do not receive the full range of Medicaid benefits.
For a QMB eligible, Medicaid pays only Medicare covered services.
Subject: QUALIFIED MEDICARE BENEFICIARY AND
SPECIFIED LOW INCOME MEDICARE _____________BENEFICIARIES PROGRAMS__________________
Effective Date: 4-1-92
Qualified Medicare Beneficiaries do not receive prescription drug benefits through the Medicaid program, however, individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the AEVCS eligibility display to verify the QMB category of service. The category of service for a QMB will reflect AA-QMB, AB-QMB or AD-QMB. QMB eligibles are limited to cost sharing of Medicare services. The AEVCS system will display the current eligibility.
Not all providers are mandated to accept Medicare assignment on QMB eligibles (See Section 142.1). However, if a non-physician desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he/she must accept assignment on that claim and enter the information required by Medicare on assigned claims.
When treated by a provider who must accept Medicare assignment according to Section 142, Conditions of Participation, the recipient is not responsible for the difference between the billed charges and the Medicare allowable amount.
Interested individuals may apply for the QMB program at their local Department of Human Services (DHS) county office.
The Specified Low Income Medicare Beneficiaries Program (SMB) was mandated by Section 4501 of the Omnibus Budget Reconciliation Act of 1990, effective January 1, 1993.
Individuals eligible as SMBs are not eligible for the full range of Medicaid benefits. They are eligible for only the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do not receive a Medicaid card.
Eligibility criteria for the SMB program are similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and receiving Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Their countable income must be greater than, but not equal to 100% of the current Federal Poverty Level, and less than, but not equal to 120% of the current Federal Poverty Level.
Subject: SPECIFIED LOW INCOME MEDICARE
BENEFICIARIES AND QUALIFYING _____________INDIVIDUALS! PROGRAM____________________ R
Effective Date: 4-1-92
The resource limit may be equal to but cannot exceed twice the current SSI resource limitations.
Interested individuals may apply for services at their local Department of Human Services (DHS) county office.
The Balanced Budget Act of 1997, Section 4732, (
Public
Law
Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Countable income must be at least 120%, but less than 135% of the current Federal Poverty Level.
Countable resources may equal but cannot exceed twice the current SSI resource limitations.
Individuals interested in the program may apply for services at their local DHS county office.
Subject: QUALIFYING INDIVIDUALS-2 PROGRAM
Effective Date: 12-1-98
Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) created the Qualifying Individuals-2 (QI-2) program. Individuals eligible as QI-2 are not eligible for Medicaid benefits. They are eligible for payment for only a portion of the Medicare Part B premium. No other Medicare cost sharing charges will be covered. Individuals eligible for QI-2 will not receive a Medicaid card, and, unlike QMBs and SMBs, may not be certified in another Medicaid category for simultaneous periods. Individuals who are eligible for both QI-2 and spend down will have to choose which coverage is wanted for a particular period of time.
Eligibility for the QI-2 program includes the following criteria: The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A Hospital Insurance and Medicare Part B Medical Insurance. Countable income must be at least 135% but less than 175% of the Federal Poverty Level.
Countable resources may equal but cannot exceed twice the current SSI resource limitations.
Individuals interested in the program may apply for services at their local DHS county office.
Subject: RECIPIENT NOTIFICATION OF DENIED MEDICAID CLAIM
Effective Date: 12-1-98
Due to a Federal court ruling, the Division of Medical Services is required to notify Medicaid recipients when a claim for Medicaid payment is denied. A letter is forwarded to recipients each time a medical claim for payment is denied by the Medicaid Program. The notice includes the recipient's name, provider's name, date of service, explanation of service and reason for denial. The notice includes recipient responsibility regarding payment of the denied Medicaid claim.
If the letter indicates the recipient is not responsible for the unpaid amount, the provider may not request payment from the recipient. If the letter indicates the recipient is responsible for the unpaid amount, the provider is responsible for contacting the recipient for payment. For program information regarding responsibilities of the recipient, please refer to Section 143 of this manual. Please refer to Page 1-57 of this manual for an example of the recipient notification of denied Medicaid claim.
If the recipient disagrees with the decision made on the Medicaid claim, he/she may file for a fair hearing with the Department of Human Services.
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Subject: ADMINISTRATIVE REMEDIES & SANCTIONS
Effective Date: 4-1-92
The following sanctions may be invoked against providers based on the grounds specified in the following sections:
Sanctions may be imposed by the Director against a provider for any one or more of the following reasons:
licensure).
Subject: FORMAL HEARINGS
Effective Date: 4-1-92________
| Should the Division of Medical Services have information that indicates that a provider may have submitted bills and/or has been practicing in a manner inconsistent with program requirements and/or may have received payment for which he may not be properly entitled, appropriate action will be taken to notify the provider of the discrepancies noted. The notification will be in writing and will set forth:
Where the Agency has notified a provider of a violation pursuant to paragraph 161 of an overpayment, payments may be withheld on pending and subsequent entitlements in an amount reasonably calculated to approximate the amounts in question, or payments may be suspended pending a final determination.
Where the Agency intends to withhold or suspend payments, it shall notify the provider in writing and shall include a statement of the provider's right to request formal review of such decision, if appropriate.
Within 10 calendar days after notice of the Agency's intention to sanction, the provider may request a formal hearing. Such request must be in writing. Within 20 calendar days following date of request for hearing, the provider must submit, in writing, a statement and supporting documents setting forth, with particularity, those asserted violations, discrepancies and dollar amounts which the provider contends are in compliance with all rules and regulations and the reasons for such contentions. Suspension or withholding of payments may continue until such time as a final determination is made regarding the appropriateness of the disagreement or amount in question.
Unless a timely and proper request for a formal hearing is received by the Agency, the findings of the Agency shall be considered a final and binding administrative determination.
No formal review will be granted if the basis for termination is a failure to meet standards (including licensure or registration) required by Federal or State law for participation in the Medicaid program.
When a formal hearing is scheduled, the Division of Medical Services shall notify the provider and/or his attorney in writing of the date, time and place of the hearing. Notice shall be mailed not less than 10 calendar days before the scheduled date of the hearing.
Any party may appear and be heard at any proceeding described herein through an attorney-at-law or through a designated representative. All persons appearing in proceedings before the Agency shall conform to the standards of conduct practiced by attorneys before the courts of the States. If a person does not conform to those standards, the hearing officer may decline to permit the person to appear in the proceeding or may exclude the person from the proceeding.
A person appearing in a representative capacity shall file a written notice of appearance on behalf of a provider identifying himself by name, address and telephone number; identifying the party represented and shall have a written authorization to appear on behalf of the provider. The Agency shall notify the provider in writing of the name and telephone number of its representative.
All papers filed in any proceeding shall be typewritten on legal sized white paper using one side of the paper only. They shall bear a caption clearly showing the title of the proceeding in connection with which they are filed together with the docket number, if any.
The party, his authorized representative or attorney shall sign all papers, and all papers shall contain his address and telephone number. At least an original and two copies of all papers shall be filed with the Division of Medical Services.
A party shall arrange for the presence of his witnesses at the hearing.
At any time prior to the completion of the hearing, amendments may be allowed on just and reasonable terms to add any party who ought to have been joined, discontinued as to any party, change the allegations or defenses or add new causes of action of defenses. Where the Agency seeks to add a party or a cause of action or change an allegation, notice shall be given pursuant to Section 161, Notice of Violation, and Section 163.1, Notice, Service and Proof of Service, to the appropriate parties except that the provisions of Section 161.2, Right to Review, and Section 161.3, Notice of Formal Hearings, shall not apply. Where a party other than the Division of Medical Services seeks to add a party or change a defense, notice shall be given pursuant to Section 163.1, Notice, Service and Proof of Service. The hearing officer shall continue the hearing for such time as he deems appropriate, and notice of the new date shall be given pursuant to Section 166, Continuances or Further Hearings.
A complete record of the proceedings shall be made. The testimony shall be transcribed, and copies of other documentary evidence shall be reproduced when directed by the hearing officer. The record will also be transcribed and reproduced at the request of a party to the hearing provided he bears the cost thereof.
Subject: ADVANCE DIRECTIVES
Effective Date:10-1-93
On December 1, 1991, the requirements for advance directives in
the Patient Self Determination Act of 1990, Sections 4206 and 4751 of the
Omnibus Budget Reconciliation Act 1990,
P.L.
Medicaid certified hospitals, nursing facilities, hospices, home health agencies and personal care agencies must conform to the requirements imposed by the Health Care Financing Administration. The federal requirements mandate conformity to current State law. Accordingly, providers must:
* Provide all adult patients (not just Medicaid patients) with written information about their rights under State law to make health care decisions, including the right to accept or refuse medical or surgical treatment and the right to execute advance directives. This information must be provided:
* Maintain written policies, procedures and materials concerning advance directives to ensure compliance with the law.
* Inform all patients and residents about the provider's policy on implementing advance directives.
* Document in each patient's medical record whether the patient has received information regarding advance directives. Providers must also document whether patients have signed an advance directive and must record the terms of the advance directive.
* Not discriminate against an individual based on whether they have executed an advance directive. All parties responsible for the patient's care are obligated to honor the patient's wishes as stated in the patient's advance directive. A provider who objects to a patient's advance directive on moral grounds must, as promptly as practicable, take all reasonable steps to transfer care to another provider.
* Educate staff and the community on advance directives.
* Tell patients if they wish to complete a health care declaration, the health care provider will provide them with information and a health care declaration form. Providers should acquire a supply of the declaration forms and become familiar with the form.
* Tell patients they have a right to reaffirm advance directives, to change the advance directive or to revoke the advance directive at any time and in any manner, including an oral statement to the attending physician or other health care provider.
On the following pages are a sample form describing advance directives and a sample declaration form which meets the requirements of law. A description of advance directive must be distributed to each patient.
HEALTH CARE DECLARATIONS IN ARKANSAS
OVERVIEW
Under Arkansas Law*, if you are a competent adult age 18 or older, you have the right to participate in making your own medical treatment decisions, including the right to accept or refuse specific forms of health care. As one means of exercising this right, the law allows you to complete written declarations containing instructions as to the kinds of health care decisions you wish to have made on your behalf if you become terminally ill or permanently unconscious and unable to make such decisions on your own. These declarations serve much the same purpose under Arkansas law as "living wills" serve in other states.
SUGGESTED FORMS OF DECLARATION
Arkansas law specifies two standard forms of declaration, one dealing with the possibility of terminal illness, the other dealing with the possibility of permanent unconsciousness. If you wish to make a declaration, you are free to use either or both of these suggested forms, and you are also free to use different wording. You may obtain the standard forms or information on where to obtain them from your physician or other health care provider or from your attorney.
You should be aware that the standard forms do not necessarily address all of the choices you may have the legal right to make. For example, you may wish to insert more detailed instructions concerning your care, such as whether you do or do not wish to have water and food given to you through artificial means if you become terminally ill or permanently unconscious. If you have questions that your physician or health care provider is unable to answer, or if you wish to modify the standard forms by adding special instructions, you may wish to consult with a lawyer or other qualified professional.
CHOICES CONTAINED IN THE STANDARD FORMS OF DECLARATION
Each of the standard forms of declaration allows you to choose one of the following approaches:
STEPS FOR COMPLETING A DECLARATION
To be effective, your declaration(s) must be signed by you or by someone else acting at your direction and must be witnessed by two individuals. A declaration becomes effective when both of the following have occurred:
IF YOU WISH TO REVOKE YOUR DECLARATION(s)
If you have completed a health care declaration and later wish to revoke it, you may do so at any time and in any manner, without regard to your mental or physical condition at the time you wish to revoke. A revocation becomes effective when it is communicated to the attending physician or other health care provider by the person who is revoking, or by someone who is a witness to the revocation. Methods of revocation include, for example, a clear written or oral expression of your wish to revoke or physical destruction of the original and any copies of the declaration.
COMPLETING A HEALTH CARE DECLARATION FOR ANOTHER PERSON
In the case of minors and adults who are no longer able to make health care decisions, a declaration may be executed by another person acting on their behalf. Arkansas law establishes the following order of priority and provides that a declaration may be executed by the first of the following individuals, or category of individuals, who exists and is reasonably available for consultation:
SAFEGUARDS
In addition, Arkansas law affords the following protections:
A.C.A. 20-17-201, etseq. Other rights of minors are covered in A.C.A. 20-17-214.
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Subject: THE ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM
Effective Date:10-1-93
The Arkansas Medicaid Primary Care Physician Managed Care Program is a statewide program. Medicaid recipients must select a primary care physician (PCP). The PCP will provide primary care services and health education, and referral to specialty physicians, hospital care, or other services when necessary. The PCP is to assess the recipient's medical condition and to initiate or recommend treatment or therapy as needed. The PCP must assist the recipient in locating needed medical services. The PCP will also coordinate and monitor, on behalf of the recipient, prescribed medical and rehabilitation services. Recipients participating in the PCP Managed Care Program may receive services only from their PCP unless the PCP refers them to another provider, or unless they access a service not requiring a PCP referral. See Section 184 for services not requiring a PCP referral.
Medicaid recipient participation in the program is mandatory except for:
* Recipients who have Medicare as their primary insurance.
* Recipients who are Children's Medical Services (CMS) clients.
* Recipients who reside in a nursing facility (nursing home).
* Recipients who reside in an intermediate care facility for the mentally retarded (ICF/MR).
* Recipients with Medically Needy-Spend Down categories of eligibility. MN means "Medically Needy." The second digit of the numeric Recipient Aid Category is always 7 for Spend-Down categories. See Section 136 of any Arkansas Medicaid provider manual for aid category information.
* Recipients with a retroactive eligibility period. Medicaid will not require PCP enrollment for the period between the beginning of the retroactive eligibility segment and the date of the eligibility authorization. If eligibility extends beyond the authorization date, Medicaid will require enrollment with a PCP unless the recipient is otherwise exempt from PCP program requirements.
* Recipients who are temporarily outside the State of Arkansas. Medicaid will not require PCP enrollment during the recipient's absence from the state.
To ensure the availability of their choice, recipients must select three primary care physicians (PCPs). They must list their choices in the order of their preference. They may choose from among the following types of providers.
* Family practitioner
* General practitioner
* Internal medicine
* Obstetrician/gynecologist
* Pediatrician
* Single-Entity Primary Care Physician Providers
Medicaid recipients wishing to receive primary health care through a single-entity PCP need not enroll with a specific physician. They may choose an FQHC or one of the designated clinics as their PCP.
If a recipient's first choice is a PCP who already has a maximum Medicaid recipient caseload, the recipient's next selection will be effective. Every individual family member eligible for Medicaid must choose a PCP. The PCP may be the same or different for each family member.
Recipients must choose a PCP who provides primary care services in the same geographical area as the recipient's residence. Medicaid defines the recipient's geographical area inside the State of Arkansas as the recipient's county of residence, counties adjacent to the county of residence and counties which adjoin the counties adjacent to the county of residence. Recipients whose county of residence is an Arkansas county bordering another state may select a PCP in specific cities (see Section 185.12) in the state bordering their county of residence.
DHS county office staff will give each Medicaid applicant a written and oral explanation of the PCP program. Applicants must complete form DMS-2609, Primary Care Physician Selection and Change Form, while in the DHS office, indicating the first, second and third choices of each Medicaid-eligible family member. Applicants may request and receive a copy of the completed form. The county office must retain a copy of the form in the applicant's file. The DHS office will access the Voice Response System (VRS) and enter the PCP's Medicaid provider number into the Automated Eligibility Verification and Claims Submission (AEVCS) system.
AEVCS will display, on an eligibility verification transaction, the name of the recipient's PCP and the beginning date of the recipient's current enrollment with the PCP. Medicaid will not reimburse providers for PCP-restricted services unless AEVCS displays the PCP name. Medicaid providers who are not PCPs should advise recipients with no PCP that Medicaid will not pay the provider's charges until the recipient selects a PCP and obtains a referral for the service.
A recipient without a PCP may make their selection at the PCP's office. The PCP's office staff will enter the selection via the VRS. The enrollment will be effective immediately upon entry, and its effective date will be the date of entry.
Individuals covered by Medicaid because they are recipients of Supplemental Security Income (SSI) do not choose a PCP when they apply for SSI. When they become eligible for Medicaid, they must choose a PCP at the DHS office in their county of residence or at the office of their chosen PCP. Recipients will document their PCP choice on the Selection and Change Form. Medicaid provider office staff will copy, for their patient's use, form DMS-2609 from page 1-79 of any Medicaid provider manual. The PCP office will access the VRS and enter the PCP's Medicaid provider number. The telephone number of the VRS is 1-800-805 -1512. The recipient may request and receive a copy of the completed selection form. The PCP office must retain a copy of the form in the recipient's file.
Effective July 1, 1996, staff at participating acute care hospitals may facilitate PCP selection. Medicaid will cover only approved emergency services for recipients with no PCP. A Medicaid recipient with no PCP, seeking non-emergency services, must complete a selection form. Hospital personnel will enter the PCP selection via the VRS. The enrollment will be effective immediately upon entry, and its effective date will be the date of entry. The recipient may request and receive a copy of the completed selection form. The hospital staff must forward a copy of the selection form to the PCP entered on the VRS.
Only DHS county offices may change PCP selection per recipient or PCP request. Recipients and PCPs requesting a change of PCP selection must submit written requests to the DHS office in the recipient's county of residence.
The recipient will complete a Selection and Change Form. County office staff will access the VRS to change the PCP. The recipient may request and receive a copy of the completed selection form. The county office must retain a copy of the form in the recipient's file.
PCPs must submit their change requests by letter to the county DHS office. The county office will forward to the recipient, a Selection and Change form by which to indicate their new selection. The PCP must also give the recipient written notice, 30 days in advance of the effective date of the termination, that the PCP has requested removal of the recipient from the PCP's caseload and that the recipient must select another PCP (see Conditions of Participation, Section 185.12).
* It is important to note that county office staff cannot remove a PCP from the computer file; they can only replace a PCP's provider number with that of another PCP. When DHS or a Medicaid provider enrolls a recipient with a PCP, the recipient remains enrolled with that PCP until the recipient's current eligibility ends, until the provider no longer participates, or until a DHS county office enters a different PCP provider number into the VRS.
The recipient or the PCP may change the PCP selection for access purposes.
The recipient, the PCP or the State may change the PCP selection for cause.
Medicaid defines the expression "for cause," in this context, to mean: "substantive and verifiable reasons other than those regarding recipient access to physician primary care services."
The recipient may request a change of PCP for cause no more often than every 6 months. The recipient may change their selection of a PCP because their arrangement with the PCP is not acceptable to the recipient. Examples of an unacceptable arrangement include, but are not limited to:
The PCP may request that the recipient change their selection of a PCP because the arrangement with the recipient is not acceptable to the PCP. Examples of an unacceptable arrangement include, but are not limited to:
The PCP must request the change in writing, forwarding a copy to the recipient and to the DHS office in the recipient's county of residence.
The PCP may request a PCP change for cause no sooner than 6 months after the last requested PCP change for the same recipient. For example, if the physician requests that a patient change PCPs, and subsequently agrees to reenroll them as a PCP Managed Care Program patient, the physician may not request another PCP change for cause until 6 months have elapsed since the date of the previous change request for cause.
It is possible for a Medicaid recipient to enroll or reenroll as a managed care patient with a PCP who has previously dismissed them for cause. If this occurs and the PCP wishes not to renew the relationship, the PCP must again submit a written request to the DHS county office and give the recipient 30 days notice to select another PCP. The 6-month waiting period will not apply to properly documented cases of this nature.
The State may initiate a PCP change request as often as necessary. Examples of reasons the State would ask recipients to change PCPs include, but are not limited to:
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Medicaid services not generally performed by the PCP require a PCP referral. The services listed below are exempt from this requirement.
EPSDT Screens Require PCP Referral for Residents of these Counties:
|
Benton |
Craighead |
Grant |
Marion |
Pulaski |
|
Boone |
Crawford |
Johnson |
Ouachita |
Randolph |
|
Carroll |
Faulkner |
Lawrence |
Perry |
Saline |
|
Clark |
Franklin |
Lonoke |
Poinsett |
Sebastian |
|
Clay |
Garland |
Madison |
Pope |
Washington |
(ICF/MR) services.
Recipients eligible for Medicaid under the guidelines of the waiver programs specified in Section 184 need no PCP referral for waiver services only. When accessing any other Medicaid services, participants in those waiver programs are subject to all requirements of the PCP Managed Care Program. In addition, case managers of waiver program recipients must list in the recipient's plan of care, all services the recipient receives. Waiver program recipients are not eligible for State Plan services unless those services are part of their plan of care and unless the recipient obtains the necessary referrals and otherwise meets all Medicaid Program requirements.
Only those physicians and clinics listed in Section 182.10 may qualify as PCPs. Physicians whose specialty is emergency care or who practice exclusively in hospital emergency departments may not enroll as PCPs. Practitioners in the physician specialties listed in Section 182.10 must enroll as PCPs or DMS will terminate their enrollment in the Arkansas Medicaid Physician Program. Of the specialties eligible to enroll as PCPs, only obstetricians and gynecologists are exempt from mandatory PCP enrollment.
A PCP may have up to 1000 Medicaid recipients on their caseload at one time. The State may, at its discretion, raise the recipient limit per PCP in areas the federal government has designated as medically underserved. The State may, at its discretion, raise the recipient limit for an individual PCP, at that PCP's request, if the limit creates hardship on the PCP's practice.
Each PCP may determine their Medicaid caseload limit up to 1000 recipients. In no instance will DMS require a PCP to accept more recipients on their caseload than the PCP has designated as their limit.
PCPs may increase or decrease their caseload limit by no fewer than 10 slots at a time. A PCP must submit a written request to the Division of Medical Services, Provider Enrollment Unit, to change the size of their caseload.
Internal medicine practitioners, obstetricians and gynecologists are exempt from mandatory Child Health Services (EPSDT) enrollment. Area Health Education Centers (AHECs), and the family practice and internal medicine clinics at the University of Arkansas Medical Sciences campus, are the only physician group providers that may enroll as single-entity primary care physician providers.
* A pediatrician may refuse to accept a recipient on their caseload if the recipient is 14 years of age or older.
* An obstetrician/gynecologist may refuse to accept on their caseload a male recipient.
* An obstetrician/gynecologist may refuse to accept on their caseload a female under the age of 12 years.
* An internal medicine practitioner may refuse to accept on their caseload a recipient 16 years of age or younger.
A PCP will make available 24 hour, 7 days per week access to service for the recipients in their caseload. Each physician will follow the standards of community practice for the county in which they practice.
In counties with adequate physician coverage, PCPs will provide for the after-hours care of their patients. Presently, the following counties have adequate physician coverage: Benton, Craighead, Faulkner, Garland, Jefferson, Miller, Pulaski, Saline, Sebastian, Union, Washington and White. In those counties, when Medicaid recipients present to the emergency department for non-emergency care, hospital staff must remind them to contact their PCP, the PCP's designated substitute or the physician on call for their PCP, regardless of the day or the time of day. Please refer to Sections 185.51, 185.52 and 185.53 for policy information regarding physician substitutes in the PCP Managed Care Program.
* The PCP's documentation must state the nature of the patient's complaint and the hospital medical staffs diagnosis and treatment, including pertinent comments and recommendations, such as suggestions that the patient follow up with a visit to their PCP.
* Documentation by the PCP's office and the hospital must include the date and the time hospital staff contacts the PCP.
If a recipient has no PCP, hospital staff will offer to enroll them with a PCP. Medicaid will provide participating hospitals with current listings of local area PCPs. Hospital personnel will enter the recipient's selection via the Voice Response System (VRS), and the enrollment will be effective immediately.
"Inadequate physician coverage" means there are not enough physicians in an area to provide one another with after hours support, and local physicians must refer their patients to the hospital emergency department after their regular office hours. In some such counties, local physicians staff the emergency department part-time or they are on call for one another part-time. The fact remains, however, that in those areas, local physicians are not able to provide full-time coverage among themselves.
* The PCP's documentation must state the nature of the patient's complaint and the hospital medical staffs diagnosis and treatment, including pertinent comments and recommendations, such as suggestions that the patient follow up with a visit to their PCP.
* Documentation by the PCP's office and the hospital must include the date and the time hospital staff contacts the PCP.
If a recipient has no PCP, hospital staff will offer to enroll them with a PCP. Medicaid will provide participating hospitals with current listings of local area PCPs. Hospital personnel will enter the recipient's selection via the Voice Response System, and the enrollment will be effective immediately.
A PCP agrees to provide primary care services and health education; and to refer patients to specialty physicians, hospital care, or other services when necessary. The PCP will assess the recipient's medical condition and initiate or recommend treatment or therapy as needed. The PCP must assist the recipient in locating needed medical services. The PCP will also coordinate and monitor, on behalf of the recipient, prescribed medical and rehabilitation services.
Recipients participating in the PCP Managed Care Program may receive services only from their PCP unless the PCP refers them to another provider, or unless they access a service not requiring a PCP referral. A PCP may refer a recipient to a specific, named provider only if they name more than one provider and allow the recipient to choose. If the recipient elects to see a provider without a referral, the recipient will be responsible for the charges incurred. With respect to the quality and appropriateness of services, PCPs must accept co-responsibility for the ongoing care of referred patients. Services requiring a PCP referral may not begin until the PCP makes the referral. The PCP must renew, at least every 6 months, any referral for ongoing care. Medicaid defers to the physician's professional judgment in this regard and does not require that the PCP see the patient before making or renewing a referral.
Medicaid provides an optional referral form, the DMS-2610, located on page 1-88 that the PCP may use to facilitate referrals. A PCP may also make a referral orally or by note or letter. Medicaid requires documentation of the referral in the recipient's medical record, regardless of the means by which the PCP makes the referral. Medicaid requires the provider receiving the referral to document it also, and to correspond with the PCP regarding the case when appropriate and when the PCP so requests.
Medicaid permits physicians to substitute for PCPs in some situations. In addition to the requirements found in section 313.490 of the Physicians/Independent Lab/CRN A/Radiation Therapy Center Provider Manual, the following 3 requirements apply to all PCP substitutions by physicians.
Physicians affiliated with a Rural Health Clinic or enrolled in a Medicaid-enrolled physician group may substitute for a recipient's PCP if the PCP is unavailable. Acceptable reasons for a PCP not to be available are: the PCP's schedule is full because of an unusual number of urgent or time-consuming cases; recipients require services outside the PCP's normal working hours; or the PCP is ill, on vacation or other leave of absence, or in surgery. Habitual over scheduling of patients is not an acceptable reason for a PCP's use of a substitute. PCPs and substitutes must fully document each substitution as a PCP referral.
Individual practitioners must designate a substitute physician to take telephone calls, see recipients and make appropriate referrals when the PCP is unavailable. Acceptable reasons for a PCP not to be available are: recipients require services outside the PCP's normal working hours; or the PCP is ill, on vacation or other leave of absence, or in surgery. Habitual over scheduling or having too great a caseload are not acceptable reasons for a PCP's use of a substitute. PCPs and substitutes must fully document each substitution as a PCP referral.
Licensed nurse practitioners or licensed physician assistants, employed by a Medicaid-enrolled Rural Health Clinic (RHC) provider, may not function as PCP substitutes. However, they may provide primary care for the PCP's recipients, with certain restrictions.
PCPs will continue to bill Medicaid on a fee for service basis. Additionally, Medicaid will pay the PCP a monthly management fee. Medicaid will pay a set amount per month, for each recipient enrolled with the PCP on the last day of the month, regardless of the duration of the recipient's enrollment with the PCP. The PCP will receive the payments quarterly; in October, January, April and July. An accompanying Remittance Advice and Status Report (RA) will itemize the payments, by recipient and enrollment month. The RA will list each PCP's managed care patients alphabetically, and will include each recipient's Medicaid identification number and address.
The PCP only refers recipients for access to a specific type of medical service. The PCP may refer recipients to a specific, named provider as long as more than one choice is given to the recipient. However, if the recipient elects to go to a non-referred-to provider, the recipient will then be responsible for the charges incurred. The PCP does not authorize any Medicaid service provision. The PCP program does not modify any Medicaid provider policy. All providers still must follow all Medicaid policy regulating the specific Medicaid services they are providing, such as medical necessity requirements, prior authorization, care plan development, etc. It remains the responsibility of the referred-to/billing provider, who renders service, to document that all Medicaid program requirements are met.
Except for the excluded services listed in Section 184, provider claims for services not authorized by the PCP will be denied. Providers, who have received a referral from a PCP, must indicate authorization by the PCP on the Medicaid claim to assure the appropriateness of the referral. This authorization is the PCP's Medicaid physician provider number which will be indicated on the Referral Form or verbally given to the provider referred to by the PCP. The provider must have documentation of the referral in the recipient's medical record via the referral form or notation of verbal referral.
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Subject: GENERAL INFORMATION
Effective Date: 1-1-03
The Arkansas Medicaid Living Choices Assisted Living Program is a home and community based services waiver program, operating under the authority of section 1915(c) of the Social Security Act.
In the text of this manual, the Living Choices Assisted Living Program is generally referred to informally as "Living Choices" or "the Living Choices Program", with a few recurring exceptions. Section headings throughout the manual contain the full name of the program. Certifications, forms or other documents with established legal or regulatory standing are identified by their official name or title, which may include the full name of the Living Choices Program. The complete name of the program is also used wherever needed to help ensure accuracy or clarity.
The following paragraphs identify providers that may qualify as Living Choices providers. Additionally, they provide an overview of Living Choices waiver provider certification and Medicaid provider enrollment for each Living Choices provider category, including some procedural and legal details. See sections 200.110, 200.Ill, 200.120 and 200.130 for detailed outlines of the requirements for provider participation in the Arkansas Medicaid Living Choices Assisted Living Program
Level II Assisted Living Facilities are eligible to qualify (through DAAS certification) for Medicaid enrollment as Living Choices providers. Qualified Level II Assisted Living Facility providers contract with Medicaid as Living Choices Assisted Living Facility providers to provide and claim reimbursement for Living Choices bundled services instead of contracting with another entity (i.e. a licensed home health agency) that is enrolled with Medicaid to provide and receive payment for those services. Living Choices includes provisions for alternative methods of delivering services because assisted living facilities have different business and staffing arrangements and the Medicaid authority-the Social Security Act-stipulates that Medicaid must make payment only to the provider of a service. Additional details in this regard are provided in sections 200.200 through 200.230.
Effective for dates of service on and after January 1, 2003, DAAS-certified Level II Assisted Living Facilities may enroll in Medicaid as Living Choices Assisted Living Facilities-Direct Services Providers. The "Direct Services Provider" label is a designation that presently serves only to further distinguish Living Choices facility providers from Living Choices agency providers, but which may serve a larger purpose as the Living Choices Program undergoes further development.
A Level II Assisted Living Facility must comply with certain criteria and procedures to enroll in Arkansas Medicaid as a Living Choices Assisted Living Facility-Direct Services Provider. This section describes those criteria and procedures, as well as the actions that DAAS and DMS undertake to facilitate the enrollment process.
Division of Aging and Adult Services
P.O. Box 1437, Slot S530
Little Rock, Arkansas 72203-1437
Within their licensing regulations, Level II Assisted Living Facilities (ALF) may contract with home health agencies and other entities and individuals to provide required and optional services for residents of the ALF. In the Living Choices Program, an ALF that chooses not to be the Medicaid-enrolled provider of Living Choices services may contract only with a licensed, DAAS-certified home health agency to furnish Living Choices bundled services. The Medicaid authority-the Social Security Act-stipulates that Medicaid must make payment only to the provider of a service. Additional details in this regard are provided in section 200.200.
A Licensed Class A Home Health Agency is eligible for DAAS certification only if it has a contract with a Level II Assisted Living Facility to deliver all Living Choices bundled services furnished in that facility. DAAS certification qualifies the agency to enroll in the Living Choices Program. A home health agency must have a separate certification and a separate Medicaid provider number for each ALF in which it is the Living Choices provider.
To enroll as a Living Choices Assisted Living Agency, the agency must comply with certain procedures and criteria. This section describes those criteria and procedures, as well as the actions DAAS and DMS take to facilitate enrollment.
Division of Aging and Adult Services
P.O. Box 1437, Slot S530
Little Rock, Arkansas 72203-1437
A pharmacist enrolling as a Living Choices Assisted Living Pharmacist Consultant provider must comply with certain criteria and procedures. This section describes those criteria and procedures, as well as actions DMS and DAAS will take to facilitate Medicaid enrollment. A Consultant Pharmacist in Charge must have separate DAAS certification and a separate Medicaid provider number for each ALF in which he or she provides Living Choices Pharmacist Consultant services.
Division of Aging and Adult Services
P.O. Box 1437, Slot S530
Little Rock, Arkansas 72203-1437
The purpose of this section is to describe the types of employment and contractual arrangements that Medicaid regulations allow Living Choices facilities and agencies to make for the delivery of Living Choices bundled services. The legal basis for these requirements is the Social Security Act (the Act) at Section 1902(a)(27), Section 1902(a)(32) and Section 1902 (a)(23).
Living Choices Assisted Living Agencies have available two methods by which they may engage staff to furnish Living Choices bundled services.
Living Choices Facilities and Agencies must keep the following records documenting attendant care services.
Living Choices Pharmacist consultants must maintain records as required by their Consultant Pharmacist in Charge certification.
Subject: PROGRAM COVERAGE
Effective Date: 1-1-03
Living Choices Assisted Living is a home and community-based services waiver program that is administered jointly by the Division of Medical Services (DMS, the state Medicaid agency) and the Division of Aging and Adult Services (DAAS), under the waiver authority of Section 1915(c) of the Social Security Act. Home and community based services waiver programs cover services designed to allow specific populations of individuals (in this case, persons aged 21 and older who are blind, elderly or disabled and eligible for a nursing home intermediate level of care) to live in their own homes or in certain types of congregate settings.
The rules and regulations for licensure of Level II Assisted Living Facilities are administered by the Office of Long Term Care within DMS. The policies and procedures and the rules and regulations governing provider and beneficiary participation in the Living Choices Program are administered by DAAS, DMS and the Division of County Operations (DCO); all are agencies of the Arkansas Department of Human Services (DHS).
Individuals found eligible for the Living Choices Program may participate in the program only as residents of licensed Level II ALFs.
Section 300 of the Level II Assisted Living Facilities Rules and Regulations manual defines assisted living as: "Housing, meals, laundry, social activities, transportation, one or more personal services, direct care services, health care services, 24-hour supervision and care, and limited nursing services." Medicaid, by federal law, may not cover beneficiaries' room and board except in nursing and intermediate care facilities. Medicaid covers some services only under certain conditions. Of the services listed above, Arkansas Medicaid covers many health care services, personal care services and medical transportation under its Title XIX (Medicaid) State Plan. However, the federal rules and regulations governing Medicaid State Plan services create barriers to providing the type of individualized packages of services that make assisted living an effective and attractive alternative to living alone or in a nursing home. This home and community based services waiver program permits Medicaid coverage of assisted living services that otherwise could not be covered.
Individuals participating in the Living Choices Program reside in apartment-style living units in licensed Level II Assisted Living Facilities (ALF) and receive individualized personal, health and social services that enable optimal maintenance of their individuality, privacy, dignity and independence. The assisted living environment actively encourages and supports these values through effective methods of service delivery and facility or program operation. The environment promotes residents' self-direction and personal decision-making while protecting their health and safety.
Assisted living includes 24-hour on-site response staff to assist with residents' known physical dependency needs or other conditions, as well as to manage unanticipated situations and emergencies. Assisted living provider staff will perform their duties and conduct themselves in a manner that fosters and promotes residents' dignity and independence. Supervision, safety and security are required components of the assisted living environment. Living Choices includes therapeutic social and recreational activities suitable to residents' abilities, interests and needs.
Services are provided on a regular basis in accordance with individualized plans of care that are authorized by a physician. Assisted living participants reside in their own living units, which are separate and distinct from all others. Laundry and meal preparation and service are in a congregate setting for participants who choose not to perform those activities themselves.
Assisted living residents negotiate, execute and sign an occupancy admission agreement with the assisted living provider. Each occupancy admission agreement contains a health care services section (if a health assessment establishes that there are health care needs) and a direct care services section. Not all residents have a health care services section. Some residents may have a health care services section only periodically.
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Medicaid covers Living Choices services on a daily, all-inclusive basis, rather than on an itemized per-service basis. A day is a covered date of service when a participant receives any of the services described in sections 212.100 through 212.500 between 12:00 AM on a given day and 12:00 AM of the following day. A day is not a covered date of service when a participant does not receive any Living Choices services between 12:00 AM of that day and 12:00 AM of the following day.
The assisted living RN must evaluate each Living Choices Program participant at least every three months, more often if necessary. The assisted living RN must alert the DAAS RN to any indication that a participant's direct care services needs are changing or have changed, so that the DAAS RN can reassess the individual.
Each Living Choices participant will be evaluated at least annually by a DAAS RN. The DAAS RN evaluates the resident to determine whether a nursing home intermediate level of care is still appropriate and whether the plan of care should continue unchanged or be revised. Re-evaluations and subsequent plan of care revisions must be made within fourteen days of any significant change in the participant's status.
Limited nursing services are acts that may be performed by licensed personnel while carrying out their professional duties, but do not include twenty-four (24) hour nursing supervision of residents. Limited nursing services provided through the Living Choices Program are not services requiring substantial and specialized nursing skills that are provided by home health agencies or other licensed health care agencies.
Living Choices limited nursing services will be provided by registered nurses (RN), licensed practical nurses (LPN) and Certified Nursing Assistants (CNA).
RN limited nursing services include:
LPN limited nursing services are provided under the supervision of an RN and include:
Certified Nursing Assistants (CNAs) under the supervision of an RN or LPN may perform basic medical duties as set forth in Part II, Unit VII of the Rules and Regulations governing Long Term Care Facility Nursing Assistant Curriculum. These basic medical duties include:
Living Choices providers must provide therapeutic social and recreational activities as ordered on the plan of care.
Living Choices providers must assist participants with obtaining and accessing non-medical transportation as required on the plan of care.
Living Choices Pharmacist Consultant services are the duties required by the Level II Assisted Living Facility Regulations for Consultant Pharmacists in Charge.
Other individuals or agencies may also furnish care directly or under arrangement with the Living Choices provider, but the care provided by other entities may only supplement that provided by the Living Choices provider and may not supplant it.
Parti cipants in the Living Choices Assisted Living Program may receive Title XIX (Medicaid) State Plan services that are provided by enrolled Medicaid providers, (e.g., medical equipment rental, prescription drugs), if those services are included in the participant's plan of care. Participants may not receive services under the Arkansas Medicaid Personal Care Program.
Living Choices attendant care services must be provided by an individual who, at minimum, is a certified personal care aide. There is no licensing authority or a single certifying authority for personal care aides in Arkansas. Providers and private training programs that follow the training guidelines in this manual may train and certify personal care aides.
A personal care aide training program may be offered by any organization meeting the standards in this manual for:
A qualified personal care aide training and certification program must include instruction in each of the following subject areas.
Classroom and supervised practical training must total at least 40 hours.
Medicaid requires personal care aides to participate in least twelve (12) hours of in-service training every twelve (12) months after achieving Personal Care Aide certification.
Subject: PRIOR AUTHORIZATION
Effective Date: 1-1-03 |
Prior authorization is not applicable to the Living Choices Assisted Living Program.
Subject: REIMBURSEMENT
Effective Date: 1-1-03
Medicaid reimbursement to Living Choices facility and agency providers is a daily rate that corresponds to the tier of need in which a participant is placed by the DAAS RN. The determination of the tier of need is based on the comprehensive assessment. There are four tiers of need. The daily rate pays for all direct care services in the participant's plan of care. Reimbursement is for services only; room and board are to be paid by the participant or his or her legal representative.
A day is a covered date of service when a Living Choices participant receives any of the services described in sections 212.100 through 212.500 between 12:00 AM of that day and 12:00 AM of the following day.
Reimbursement of pharmacist consultants is a daily fee, paid at the lesser of the billed charge or the Medicaid maximum allowable fee. The pharmacist consultant's services for individual residents may occur over several days, and the provider may bill Medicaid for a span of consecutive days, but the pharmacist consultant may bill Medicaid only one time per month, per participant.
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.
Subject: GENERAL INFORMATION
Effective Date: 1-1-03
The purpose of Section III of the Arkansas Medicaid Manual is to explain the procedures for billing in the Arkansas Medicaid Program.
Three major areas are covered in this section:
The Automated Eligibility Verification and Claims Submission (AEVCS) System is the method of submitting Medicaid claims electronically. Medicaid requires AEVCS submission of the following claim types: UB-92, HCFA-1500, Visual Care, Dental, EPSDT, Pharmacy and Hospice/INH.
Providers have several choices of AEVCS submission methods: personal computer (PC)-based software, point of sale (POS) devices, or adapting their current office management system to submit claims in the proper format to AEVCS.
Provider Electronic Solution (PES) Application software is available for any provider who submits Medicaid claims. The software requires, at a minimum, 486/66 processor with 8 MB RAM, 25 MB free space, CD-ROM drive, and Windows 95. We strongly recommend running the software on a Pentium 100 (or greater) processor with 16 MB RAM, 25 MB free space, CD-ROM drive and Windows 95, Windows 98, or Windows NT 4.0 or higher. Claims can be transmitted for processing by almost any Hayes-compatible modem, with the exception of the US Robotics Voice Modem and Hewlett-Packard's HP "Pavillion". Eligibility verifications are part of the base software system. The software supports all claim types: HCFA-1500, UB-92, Dental, EPSDT, Hospice/INH, Pharmacy and Visual Care. The software also supports all Medicare/Medicaid crossover claim types: Inpatient Crossover, Outpatient Crossover, Professional Crossover and Long Term Care Crossover.
EDS maintains a Provider Assistance Center to assist Medicaid providers during regular business hours from 8:00 a.m. to 4:30 p.m. Central Time. See section 119 of this manual for EDS holiday closings. Should you have any questions concerning claims payment, please contact the Provider Assistance Center at 1-800-457 -4454 (Toll Free) within Arkansas or locally and out-of-state at (501) 376-2211.
EDS has a staff of representatives available during regular business hours from 8:00 a.m. to 4:30 p.m. (see section 119 of this manual for EDS holiday closings) to assist with any needs concerning POS devices. Please call the AEVCS Help Desk at 1-800-457 -4275 (Toll Free) within Arkansas or locally and out-of-state at (501) 375-1025 for help with questions regarding software or POS devices.
EDS has a full time staff of Provider Representatives available for consultation regarding billing problems that cannot be resolved through the Provider Assistance Center. Provider Representatives are available to visit your office to provide training on billing.
The Code of Federal Regulations (42 CFR), at 447.45 (d) (1), states 'The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service." The 12 month filing deadline applies to all claims, including:
There are no exceptions to the 12 month filing deadline policy. However, the definitions and additional federal regulations below will permit some flexibility for those who adhere closely to them.
Federal regulations dictate that providers must file the Medicaid portion of claims for dually eligible beneficiaries within 12 months of the beginning date of service. The Medicare claim will establish timely filing for Medicaid, if the provider files with Medicare during the 12 month Medicaid filing deadline. Medicaid may then consider payment of Medicare deductible and/or coinsurance, even if the Medicare intermediary or carrier crosses the claim to Medicaid after more than a year has passed since the date of service. Medicaid may also consider such a claim for payment if Medicare notifies only the provider and does not electronically forward the claim to Medicaid. Federal regulations permit Medicaid to pay its portion of the claim within 6 months after the Medicaid "agency or the provider receives notice of the disposition of the Medicare claim."
The definitions of the terms, clean claim and new claim, help to determine which claims and adjustments Medicaid may consider for payment, when more than 12 months have passed since the beginning date of service.
42 CFR, at 447.45 (b), defines a clean claim as a claim that Medicaid can process "...without obtaining additional information from the provider of the service or from a third party." The definition "...includes a claim with errors originating in a State's claims system."
A claim that denies for omitted or incorrect data, or for missing attachments, is not a clean claim. A claim filed more than 12 months after the beginning date of service is not a clean claim, except under the special circumstances described below.
A new claim is a claim that is unique, differing from all other claims in at least one material fact. It is very important to note that identical claims, received by Medicaid on different days, differ in the material fact of their receipt date, and are both new claims, unless defined otherwise in the next paragraph.
Sometimes a clean claim pays incorrectly or denies incorrectly. When a provider files an adjustment request for such a claim, or refiles the claim after 12 months have passed from the beginning date of service, the submission is not necessarily a new claim. The adjustment or claim may be within the filing deadline. For Medicaid to consider that the submission is not a new claim and, therefore, is within the filing deadline, the adjustment or claim must meet two requirements:
Retroactive eligibility does not constitute an exception to the filing deadline policy. If an appeal or other administrative action delays an eligibility determination, the provider must submit the claim within the 12-month filing deadline. If the claim denies for recipient ineligibility, the provider may resubmit the claim when the patient becomes eligible for the retroactive date(s) of service. Medicaid may then consider the claim for payment because the provider submitted the initial claim within the 12-month filing deadline, and the denial was not the result of an error by the provider.
To submit a claim for services rendered to a patient who is not yet eligible for Medicaid, enter, on the claim form or on the electronic format, a pseudo Medicaid recipient identification number, 9999999999. Medicaid will deny the claim. Retain the denial or rejection for proof of timely filing, if eligibility determination occurs more than 12 months after the date of service.
Occasionally, the state Medicaid agency or a federal agency, such as the Social Security Administration, is unable to complete a Medicaid eligibility determination in time for service providers to file timely claims. Arkansas Medicaid's claims processing system is unable to accept a claim for services rendered to an ineligible individual, and to suspend that claim until the individual is retroactively eligible for the claim dates of service. To resolve this dilemma, Arkansas Medicaid considers the pseudo recipient identification number 9999999999 to represent, an "...error originating within (the) State's claims system." Therefore, a claim containing that number is a clean claim if it contains all other information necessary for correct processing. By defining the initial claim as a clean claim, denied by processing error, we may allow the provider to refile the claim when the government agency completes the eligibility determination. The provider must submit with the claim, proof of the initial filing and a letter or other documentation sufficient to explain that administrative processes (such as determination of SSI eligibility) prevented the resubmittal before the filing deadline.
When it is necessary to submit an adjustment or resubmit a claim to Medicaid after 12 months have passed since the beginning date of service, the procedures below must be followed.
If the fiscal agent has incorrectly paid a clean claim, and the error has made it impossible to adjust the payment before 12 months have passed since the beginning date of service, a completed Adjustment Request Form (form EDS-AR-004, section 330.000 of this manual) must be submitted to the address specified on the form. Attach the documentation necessary to explain why the error has prevented re-filing the claim until more than 12 months have passed after the beginning date of service.
Submit a paper claim to the address below, attaching:
Send these materials to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
Submit a paper claim to the address below, attaching:
Send these materials to:
EDS
Provider Assistance Center
P.O. Box 8036
Little Rock, AR 72203-8036
To solve some of the billing problems associated with differing interpretations of procedure code descriptions, EDS implemented the ClaimCheck® enhancement to the Arkansas Medicaid Management Information System (MMIS) system. 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 a complete explanation of the RA). Use the RA to verify claim receipt and to track claims through the system. Claims transmitted through the Automated Eligibility Verification and Claims Submission (AEVCS) system will appear on the RA within 2 weeks of transmission. Paper claims and adjustments may take as long as six weeks to appear on the RA.
If a claim does not appear on the RA within the amount of time appropriate for its method of submission, contact the EDS Provider Assistance Center. A Provider Assistance Center Representative can explain what system activity, if any, regarding the submission, has occurred since EDS printed and mailed the last RA. If the transaction on the RA cannot be understood, or is in error, the representative can explain its 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 following items on the Medicaid Claim Inquiry Form must be completed. A copy of this form follows these instructions. In order to answer your inquiry as quickly and accurately as possible, please follow these instructions:
|
Field Name and Number |
Instructions for Completion |
|
|
1. |
Provider Number |
Enter the 9-digit Arkansas Medicaid provider number assigned. If requesting information regarding a clinic billing, indicate the clinic provider number. |
|
2. |
Provider Name and Address |
Enter the name and address of the provider as shown on the claim in question. |
|
3. |
Recipient Name (First, Last) |
Enter the patient's name as shown on the claim in question. |
|
4. |
Recipient ID |
Enter the 10-digit Medicaid identification number assigned to the patient. |
|
5. |
Billed Amount |
Enter the amount the Medicaid Program was billed for the service. |
|
6. |
Remittance Advice Date |
Enter the date of the Medicaid RA on which the claim most recently appeared. |
|
7. |
Date(s) of Service |
Enter the month, day and year of the earliest date of service or the date range. |
|
8. |
ICN (Claim Number) |
Enter the 13-digit claim control number assigned to the claim by Medicaid. If the claim in question is shown on a Medicaid RA, this number will appear under the heading "Claim Number." |
|
9. |
Provider Message/Reason for Inquiry |
State the specific description of the problem and any remarks that may be helpful to the person answering the inquiry. |
|
10. |
Signature, Phone and Date |
The provider of service or designated authorized individual inquiring must sign and date the form. |
NOTE: The lower section of the form is reserved for the response to your inquiry.
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To order EDS-supplied forms, please use the Medicaid Form Request, Form EDS-MFR-001. An example of the form appears in this section. EDS supplies the following forms:
|
Acknowledgement of Hysterectomy Information |
(DMS-2606) |
|
Adjustment Request Form - Medicaid XIX |
(EDS-AR-004) |
|
Certification Statement for Abortion |
(DMS-2698) |
|
Consent for Release of Information |
(DMS-619) |
|
DDTCS Transportation Survey |
(DMS-632) |
|
DDTCS Transportation Log |
(DMS-638) |
|
EPSDT |
(DMS-694) |
|
Explanation of Check Refund |
(EDS-CR-002) |
|
Hospice/INH Claim Form |
(DHS-754) |
|
Hospital/Physician/Certified Nurse Midwife Referral for |
(DCO-645) |
|
Newborn Infant Medicaid Coverage |
|
|
Inpatient Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-001) |
|
Long Term Care Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-002) |
|
Medicaid Claim Inquiry Form |
(EDS-CI-003) |
|
Medicaid Form Request |
(EDS-MFR-001) |
|
Medicaid Prior Authorization and Extension of Benefits Request |
(DMS-2694) |
|
Medical Equipment Request for Prior Authorization & |
(DMS-679) |
|
Prescription |
|
|
Mental Health Services Provider Qualification Form for LCSW, |
(DMS-633) |
|
LMFT and LPC |
|
|
Occupational, Physical and Speech Therapy for Medicaid Eligible |
(DMS-640) |
|
Recipients Under Age 21 Prescription/ Referral |
|
|
Outpatient Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-003) |
|
Personal Care Assessment and Service Plan |
(DMS-618) |
|
Primary Care Physician Selection and Change Form |
(DMS-2609) |
|
Professional Services Medicare-Medicaid Crossover Invoice |
(EDS-MC-004) |
|
Referral for Medical Assistance |
(DMS-630) |
|
Request for Extension of Benefits |
(DMS-699) |
|
Request for Extension of Benefits for Medical Supplies for |
(DMS-602) |
|
Medicaid Recipients Under Age 21 |
|
|
Request for Prior Authorization and Prescription for |
(DMS-2615) |
|
Hyperalimentation |
|
|
Request for Private Duty Nursing Services Prior Authorization |
(DMS-2692) |
|
and Prescription - Initial Request or Recertification |
|
|
Request for Targeted Case Management Prior Authorization for |
(DMS-601) |
|
Recipients Under Age 21 |
|
|
Sterilization Consent Form |
(DMS-615) |
|
Sterilization Consent Form - Information for Men |
(PUB-020) |
|
Sterilization Consent Form - Information for Women |
(PUB-019) |
|
Visual Care |
(DMS-26-V) |
Complete the Medicaid Form Request, and indicate the quantity needed for each form.
Mail your request to: EDS
Provider Assistance Center
P. O. Box 8036
Little Rock, AR 72203-8036
The Medicaid Program does not provide copies of the HCFA-1500 claim form. The provider may request a supply of this claim form from any available vendor. An available vendor is the U.S. Government Printing Office.
Orders may be submitted to the U.S. Government Printing Office via phone, fax, letter, e-mail or the Internet. The contact information is given below:
Superintendent of Documents P.O. Box 371954 Pittsburgh, PA 15250-7954
Phone: (Toll Free) (866) 512-1800, between
7:30 a.m. and 4:30 p.m. Fax: (202) 512-2250
Website: http://bookstore.gpo.govE-Mail: or ders@gpo. gov
EDS requires the use of red-ink (sensor coded) HCFA-1500 claim originals instead of copies. A new processing system uses scanners to distinguish between red ink of the form fields and blue or black ink claim data (provider number, Recipient Identification Number (RID), procedure codes, etc.).
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Subject: BILLING PROCEDURES
Effective Date: 1-1-03
Assisted living providers use the HCFA-1500 claim format to bill the Arkansas Medicaid Program for services provided to eligible Medicaid recipients. Each claim should contain charges for only one recipient.
Providers submitting claims electronically must maintain a daily electronic claim transaction summary, signed by an authorized individual. Refer to the Medicaid provider contract (form DMS-653).
The Automated Eligibility Verification and Claims Submission (AEVCS) system is the electronic method for verifying a recipient's eligibility and filing claims for payment. A provider may file a claim immediately after providing a service. AEVCS will edit the claim for billing errors and advise of the claim's acceptance into the processing system for adjudication. If AEVCS rejects the claim, it will list up to 9 reasons for the rejection and permit the claim to be corrected and resubmitted.
EDS processes each week's accumulation of claims during the weekend cycle. The deadline for each weekend cycle is 12:00 midnight Friday.
Section 301.100 of this manual contains information on available AEVCS options.
The following table lists the values/comments for each of the fields associated with a Provider Electronic Solution (PES) Professional claim transaction. The last column provides a cross-reference to section 311.500 of this manual for specific field requirements and instructions.
Subject: BILLING PROCEDURES - PES
Effective Date: 1-1-03
|
Field Name |
Values/ Comments |
Refer to Section 311.500 |
|
Header 1 Inform |
ation |
|
|
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 the Assisted Living program. |
Field 23 |
|
Referring Phys ID |
Not applicable to the Assisted Living program. |
Field 17A |
|
Header 2 Information |
||
|
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. Each code identifies the condition or disease that makes the service medically necessary. |
Field 21 |
|
Employment Related? |
Not applicable to the Assisted Living program. |
Field 10A |
|
Incident Date |
Not applicable to the Assisted Living program. |
Field 14 |
|
Accident Related? |
Not applicable to the Assisted Living program. |
Field 10B or IOC |
|
Hospital Admit Date |
Not applicable to the Assisted Living program. |
Field 18 |
|
Facility Name |
Not applicable to the Assisted Living program. |
Field 32 |
|
Facility Address |
Not applicable to the Assisted Living program. |
Field 32 |
|
Outside Lab Work? |
Not applicable to the Assisted Living program. |
Field 20 |
|
Therapy Services Code |
Not applicable to the Assisted Living program. |
Field 19 |
|
School District Code |
Not applicable to the Assisted Living program. |
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 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 |
The address of the third party insurance company. |
N/A |
|
Second TPL |
Indicates whether the recipient has a second third party insurance. Response required if primary insurance is entered; "Y" = Yes "N" = No. |
Field 11D |
|
Carrier Code |
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. |
N/A |
|
Employer or School Name |
Name of insured's employer or school. |
Field 9C |
|
Detail Informatic |
[GREATER THAN]n |
|
|
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. (For a list of codes, see section 311.300.) |
Field 24B |
|
TOS |
Type of service code. (For a list of codes, see section 311.300.) |
Field 24C |
|
Procedure |
The procedure code for the service provided. |
Field 24D |
|
Modifier |
Not applicable to the Assisted Living program. |
Field 24D |
|
Hours |
Not applicable to the Assisted Living program. |
Field 24D |
|
Minutes |
Not applicable to the Assisted Living program. |
Field 24D |
|
Extreme Age |
Not applicable to the Assisted Living program. |
N/A |
|
Surgical Avoid |
Not applicable to the Assisted Living program. |
N/A |
|
Hypothermia |
Not applicable to the Assisted Living program. |
N/A |
|
Hypotension |
Not applicable to the Assisted Living program. |
N/A |
|
Pressure |
Not applicable to the Assisted Living program. |
N/A |
|
Circulation |
Not applicable to the Assisted Living program. |
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 |
The identity of a condition or disease for which the service is being billed for this detail. Diagnosis codes are listed in the ICD-9-CM code book and are 3 to 5 characters. |
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, type the total charge for all units billed for that detail. |
Field 24F |
|
Fund Code |
Not applicable to Medicaid claims. |
N/A |
|
EPSDT/Family Planning |
Not applicable to the Assisted Living program. |
Field 24H |
|
Performing Provider ID |
Not applicable to the Assisted Living program. |
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 |
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 |
Not applicable to the Assisted Living program. |
|
Diagnosis |
Displays up to four diagnosis codes and related descriptions. |
|
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 |
Displays the diagnosis code the detail is referring to. |
|
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 the Assisted Living program. |
|
Performing Provider |
Displays the Performing Provider ID for the detail submitted. |
|
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. When a claim is reversed the ICN is no longer valid. |
If a claim or claim reversal is rejected, PES will display error codes and the meaning of the codes.
Subject: BILLING PROCEDURES
Effective Date: 1-1-03
The following are place of service and type of service codes applicable to the Living Choices Assisted Living Program.
|
Place of Service Code |
Type of Service Code |
|
4 - Patient's Home (Level II Assisted Living Facility) |
9 - Other Medical Services (Living Choices Assisted Living Services) |
Subject: BILLING PROCEDURES - PAPER CLAIMS
Effective Date: 1-1-03
To bill for office medical services, the HCFA-1500 claim form must be completed. The following numbered items correspond to the numbered fields on the claim form. A sample HCFA-1500 claim form follows these billing instructions.
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
|
Field Name and Number |
Instructions for Completion |
|
|
1. |
Type of Coverage |
This field is not required for Medicaid. |
|
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 patient's last name and first name as they 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. |
|
|
4. |
Insured's Name |
Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial. |
|
5. |
Patient's Address |
Optional entry. Enter the patient's full mailing address, including street number and name, (post office box or RFD), city name, state name and zip code. |
|
6. |
Patient Relationship to Insured |
Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim. |
|
7. |
Insured's Address |
Required if insured's address is different from the patient's address. |
|
8. |
Patient Status |
This field is not required for Medicaid. |
|
9. |
Other Insured's Name |
If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial. |
|
a. Other Insured's Policy or Group Number |
Enter the policy or group number of the other insured. |
|
|
b. Other Insured's Date of Birth |
This field is not required for Medicaid. |
|
|
Sex |
This field is not required for Medicaid. |
|
|
c. Employer's Name or School Name |
Enter the employer's name or school name. |
|
|
d. Insurance Plan Name or Program Name |
Enter the name of the insurance company. |
|
|
10. |
Is Patient's Condition Related to: |
|
|
a. Employment |
Not applicable to the Assisted Living program. |
|
|
b. Auto Accident |
Not applicable to the Assisted Living program. |
|
|
c. Other Accident |
Not applicable to the Assisted Living program. |
|
|
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 is not required for Medicaid. |
|
14. |
Date of Current: Illness Injury Pregnancy |
Not applicable to the Assisted Living program. |
|
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 |
Primary Care Physician (PCP) referral is not required for Assisted Living services. |
|
17a. |
I.D. Number of Referring Physician |
Not applicable to the Assisted Living program. |
|
18. |
Hospitalization Dates Related to Current Services |
Not applicable to the Assisted Living program. |
|
19. |
Reserved for Local Use |
Not applicable to the Assisted Living program. |
|
20. |
Outside Lab? |
This field is not required for Medicaid |
|
21. |
Diagnosis or Nature of Illness or Injury |
Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with HCFA diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service. |
|
22. |
Medicaid Resubmission Code |
Reserved for future use. |
|
Original Ref No. |
Reserved for future use. |
|
|
23. |
Prior Authorization Number |
Not applicable to the Assisted Living program. |
|
24. |
A. Dates of Service |
Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service. 1. On a single claim detail (one charge on one line), bill only for services within a single calendar month. 2. Providers may bill, on the same claim detail, for two (2) or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the span. |
|
B. Place of Service |
Enter the appropriate place of service code. See section 311.300 for codes. |
|
|
C. Type of Service |
Enter the appropriate type of service code. See section 311.300 for codes. |
|
D. Procedures, Services or Supplies |
|
|
CPT/HCPCS |
Enter the correct CPT or HCPCS procedure code from sections 314.000 of this manual. |
|
Modifier |
Not applicable to the Assisted Living program. |
|
E. Diagnosis Code |
Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM. |
|
F. $ Charges |
Enter the charge for the service. This charge should be the provider's usual charge to private 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 |
Not applicable to the Assisted Living program. |
|
I. EMG |
Emergency - This field is not required for Medicaid. |
|
J. COB |
Coordination of Benefit - This field is not required for Medicaid. |
|
K. Reserved for Local Use |
Not applicable to the Assisted Living program. |
|
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 below 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, Including Degrees or Credentials |
The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
|
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# |
Enter the 9-digit pay-to provider number in Field 33 after "GRP#." |
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Subject: SPECIAL BILLING PROCEDURES
Effective Date: 1-1-03
The HCPCS procedure codes listed below represent the services Medicaid covers in the Living Choices Assisted Living Program. One unit equals one day of service. Units of service may not exceed the number of days in the service month. Each unit of service billed must be supported by a date of service.
Dates of service may be itemized or expressed in a date of service range; i.e., "From Date" and "Through Date". A date of service range may include only covered days. A day is a covered date of service when a participant receives any of the services described in sections 212.100 through 212.500 of this manual, between 12:00 AM on a given day and 12:00 AM of the following day. A day is not a covered date of service when a participant does not receive any Living Choices services between 12:00 AM of that day and 12:00 AM of the following day.
A Pharmacist Consultant may bill for one day (one unit) of service for one Living Choices participant if he or she performs any Pharmacist Consultant services for that participant on a given day, no matter how minimal the service. All of the services performed for a participant during a calendar month must be billed on one claim. Pharmacist consultants may bill Medicaid for the total number of days in a month on which a service was performed, but they may submit to Medicaid only one claim per client per month. It is permissible to bill for several sequential days in a single claim detail if a service was provided on each day in the sequence.
|
HCPCS Codes |
Description |
|
Z2784 |
Living Choices Assisted Living Tier 1 |
|
Z2785 |
Living Choices Assisted Living Tier 2 |
|
Z2786 |
Living Choices Assisted Living Tier 3 |
|
Z2787 |
Living Choices Assisted Living Tier 4 |
|
Z2789 |
Living Choices Assisted Living Pharmacist Consultant |
RESERVED
Subject: FINANCIAL INFORMATION - REMITTANCE AND STATUS REPORT
Effective Date: 1-1-03
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 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 in the following sections. The printed column headings at the top of each example 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 numerical 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 |
The CPT or HCPCS procedure code billed 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 copay if either exists). |
|
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 that explains the action taken on claims. The messages for the explanation codes are listed on the final page of the RA. |
|
20. |
COVER PAGE MESSAGES |
Messages written for provider information. |
This section shows the 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 |
Does not apply to professional claims, including Assisted Living claims. |
|
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 was 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 claims that have been entered into the processing system but have not reached final disposition. Do not rebill a claim shown in this section, because it is already being processed and will result in a rejection as a duplicate claim. These claims will appear in this section until they are paid or denied.
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 Benefits 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 other recoupment activities that will negatively affect 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 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 TRANSACTIONS |
The total number of claims transmitted and the total charges for the transaction category. |
|
6. |
TOTAL REVERSAL TRANSACTIONS |
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 Medicaid payments and credits made to the provider, for the specific RA pay period under "Current Processed," and for the year under "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. |
|
| 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 1ST/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. |
Subject: FINANCIAL INFORMATION - ADJUSTMENT REQUEST FORM
Effective Date: 1-1-03
Use the Adjustment Request Form to correct a claim payment (even if the paid amount is $0.00) or to correct erroneous information on a paid claim. Include sufficient information on the request form to process the adjustment correctly. 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 proper redlined crossover form must be attached. If a provider submits an Adjustment Request Form that is not valid, the EDS Adjustment Unit will notify the provider.
Adjustment Request Forms should be filed as soon as the incorrect payment has been identified. Requests for correction or review must be submitted to EDS within the 12-month timely filing deadline. Adjustment requests cannot be processed if more than 12 months have passed since the "from date of service".
The following instructions explain how to complete the form. A copy of the form is included following these instructions. Read the instructions carefully and be sure to complete all Adjustment Request Forms thoroughly and accurately so that they may be handled efficiently.
|
Field Name and Number |
Instructions for Completion |
|
|
1. |
Provider Number |
Enter the 9-digit Arkansas Medicaid provider number under which payment is to be made. |
|
2. |
Provider Name and Address |
Complete this field with the same information with which you bill Medicaid. |
|
3. |
Overpayment (Credit) |
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 the wrong dates of service. This box should be checked onlv 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 recipient identification number exactlv 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 the services. |
|
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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Subject: FINANCIAL INFORMATION - EXPLANATION OF CHECK REFUND FORM
Effective Date: 1-1-03
The Arkansas Medicaid Program generates RAs each week for providers who have claims paid, denied or in process. If an overpayment occurs, the provider is responsible for refunding the Medicaid Program.
Providers may refund to the Medicaid Program 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. Submit a completed Explanation of Check Refund Form 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 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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Subject: FINANCIAL INFORMATION - ADDITIONAL PAYMENT SOURCES
Effective Date: 1-1-03
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 dual Medicare/Medicaid eligibility and 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.
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.
Subject: REFERENCE BOOKS
Effective Date: 1-1-03
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 who 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.
Subject: GLOSSARY
Effective Date: 7-1-80 |
|
ACS |
Alternative Community Services |
|
ACES |
Arkansas Client Eligibility System |
|
ADL |
Activities of Daily Living |
|
AEVCS |
Automated Eligibility Verification and Claims Submission |
|
AFDC |
Aid to Families with Dependent Children |
|
AFMC |
Arkansas Foundation for Medical Care, Inc. |
|
AMA |
American Medical Association |
|
CMHC |
Community Mental Health Center |
|
CMS |
Children's Medical Services |
|
CPT |
Physicians' Current Procedural Terminology |
|
DAAS |
Division of Aging and Adult Services |
|
DBS |
Division of Blind Services |
|
DCFS |
Division of Children and Family Services |
|
DCO |
Division of County Operations |
|
DDS |
Developmental Disabilities Services |
|
DHS |
Department of Human Services |
|
DME |
Durable Medical Equipment |
|
DMHS |
Division of Mental Health Services |
|
DMS |
Division of Medical Services (Medicaid) |
|
DOS |
Date of Service |
|
DYS |
Division of Youth Services |
|
EAC |
Estimated Acquisition Cost |
|
EDS |
Electronic Data Systems |
|
EFT |
Electronic Funds Transfer |
|
EOMB |
Explanation of Medicaid Benefits. EOMB may also refer to Explanation of Medicare Benefits. |
|
EPSDT |
Early and Periodic Screening, Diagnosis and Treatment |
|
GUL |
Generic Upper Limit |
|
HCBS |
Home and Community Based Services |
|
HCFA |
Health Care Financing Administration |
|
HCPCS |
HCFA Common Procedure Coding System |
|
HHS |
The Federal Department of Health and Human Services |
|
HIC Number |
Health Insurance Claim Number |
|
IADL |
Instrumental Activities of Daily Living |
|
ICD-9-CM |
International Classification of Diseases, Ninth Edition, Clinical Modification |
|
ICF/MR |
Intermediate Care Facility/ Mental Retardation |
|
ICN |
Internal Control Number |
|
LTC |
Long Term Care |
|
MAC |
Maximum Allowable Cost |
|
MMIS |
Medicaid Management Information System |
|
MNIL |
Medically Needy Income Limit |
|
NDC |
National Drug Code |
|
NF |
Nursing Facility |
|
PA |
Prior Authorization |
|
PCP |
Primary Care Physician |
|
POC |
Plan of Care |
|
POS |
Place of Service or Point of Sale, depending on usage |
|
PRO |
Professional Review Organization |
|
QMB |
Qualified Medicare Beneficiary |
|
RA |
Remittance Advice. Also called Remittance and Status Report. |
|
RFP |
Request for Proposal |
|
RTP |
Return to provider or to return a claim to the provider |
|
SD |
Spend Down |
|
SNF |
Skilled Nursing Facility |
|
SSA |
Social Security Administration |
|
SSI |
Supplemental Security Income |
|
TPL |
Third Party Liability |
|
UR |
Utilization Review |
|
VRS |
Voice Response System |
|
Accommodation |
A type of hospital room, e.g., private, semiprivate, ward, etc. |
|
Activities of Daily Living (ADL) |
Personal tasks which are ordinarily performed on a daily basis and include eating, mobility/ transfer, dressing, bathing, toileting and grooming. |
|
Adjudicate |
To determine whether a claim is to be paid or denied. |
|
Adjustments |
Transactions to correct claims paid in error or to adjust payments from a retroactive change. |
|
Admission |
Actual entry and continuous stay of the recipient as an inpatient to an institutional facility. |
|
Affiliates |
Persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another. |
|
Agency |
The Division of Medical Services. |
|
Aid Category |
A designation within SSI or state regulations under which a person may be eligible for public assistance. |
|
Aid to Families with Dependent Children (AFDC) |
A Medicaid eligibility category. |
|
Allowed Amount |
The maximum amount Medicaid will pay for a service as billed before applying recipient coinsurance or copay, previous TPL payment, spend down liability or other deducted charges. |
|
American Medical Association (AMA) |
National association of physicians. |
|
Ancillary Services |
Services available to a patient other than room and board. For example: pharmacy, X-ray, lab and central supplies. |
|
Arkansas Client Eligibility System (ACES) |
A state computer system in which data is entered to update assistance eligibility information and recipient files. |
|
Arkansas Foundation for Medical Care, Inc. (AFMC) |
State professional review organization. |
|
Attending Physician |
See Performing Physician. |
|
Automated Eligibility Verification Claims Submission (AEVCS) |
On-line system for providers to verify eligibility of recipients and submit claims to fiscal agent. |
|
Base Charge |
A set amount allowed for a participating provider according to specialty. |
|
Benefits |
Services available under the Arkansas Medicaid Program. |
|
Billed Amount |
The amount billed to Medicaid for a rendered service. |
|
Buy-In |
A process whereby the state enters into an agreement with the Bureau of Health Insurance, Social Security Administration, to obtain supplementary medical insurance benefits (Medicare, Part A or B) for eligible recipients. The state pays the monthly premium on behalf of the recipient. |
|
Care Plan |
See Plan of Care (POC) |
|
Casehead |
An adult responsible for an AFDC or Medicaid child. |
|
Categorically Needy |
All individuals receiving financial assistance under the state's approved plan under Title I, IV-A, X, XIV and XVI of the Social Security Act or in need under the state's standards for financial eligibility in such a plan. |
|
Child Health Services |
Arkansas Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. |
|
Children's Medical Services (CMS) |
A Title V Children with Special Health Care Needs Program administered by the Arkansas Division of Medical Services to provide medical care and service coordination to chronically and disabled children. |
|
Claim |
A request for payment for services rendered. |
|
Claim Detail |
See Line Item. |
|
Clinic |
(1) A facility for diagnosis and treatment of outpatients. (2) A group practice in which several physicians work together. |
|
Closed-end Provider Agreement |
An agreement for a specific period of time not to exceed 12 months which must be renewed in order for the provider to continue to participate in the Title XIX Program. |
|
Coinsurance |
The portion of allowed charges the patient is responsible for under Medicare. This may be covered by other insurance such as Medi-Pak or Medicaid (if entitled). This also refers to the portion of a Medicaid covered inpatient hospital stay for which the recipient is responsible. |
|
Contract |
Written agreement between a provider of medical services and the Arkansas Division of Medical Services. A contract must be signed by each provider of services participating in the Medicaid Program. |
|
Co-pay |
The portion of the total charge for medical services that the insured or recipient must pay. |
|
Cosmetic Surgery |
Any surgical procedure directed at improving appearance but not medically necessary. |
|
Covered Service |
Service which is within the scope of the Arkansas Medicaid Program. |
|
Credit Claim |
A claim transaction which has a negative effect on a previously processed claim. |
|
Crossover Claim |
A claim for which both Titles XVIII (Medicare) and XIX (Medicaid) are liable for services rendered to a recipient entitled to benefits under both programs. |
|
Date of Service |
Date or dates on which a recipient receives a covered service. Documentation of services and units received must be in the recipient's record for each date of service. |
|
Deductible |
The amount the Medicare recipient must pay toward covered benefits before Medicare or insurance payment can be made for additional benefits. Medicare Part A and Part B deductibles are paid by Medicaid within the program limits. |
|
Debit Claim |
A claim transaction which has a positive effect on a previously processed claim. |
|
Denial |
A claim for which payment is disallowed. |
|
Department of Health and Human Services |
Federal health and human services agency. |
|
(HHS) |
|
|
Department of Human Services |
State human services agency. |
|
Dependent |
A spouse or child of the individual who is entitled to benefits under the Medicaid Program. |
|
Diagnosis |
The identity of a condition, cause or disease. |
|
Diagnostic Admission |
Admission to a hospital primarily for the purpose of diagnosis. |
|
Disallow |
To subtract a portion of a billed charge which exceeds the Medicaid maximum allowable fee or to deny an entire charge because Medicaid pays Medicare Part A and B deductibles subject to program limitations for eligible recipients. |
|
Discounts |
A discount is defined as the lowest available price charged by a provider to a client or third party payor, including any discount, for a specific service during a specific period of time by an individual provider. If a Medicaid provider offers a professional or volume discount to any customer, the same discount must exist for claims submitted to Medicaid. |
|
Example: If a laboratory provider charges a private physician or clinic a discounted rate for services, the charge submitted to Medicaid for the same service must not exceed the discounted price charged to the physician or clinic. Medicaid must be given the benefit of discounts and price concessions the lab gives any one of its customers. |
|
Duplicate Claim |
A claim which has been submitted or paid previously or a claim which is identical to a claim in process. |
|
Durable Medical Equipment |
Equipment which (1) can withstand repeated use and (2) is used to serve a medical purpose. Examples include a wheelchair or hospital bed. |
|
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) |
A federally mandated Medicaid program for eligible individuals under the age of 21. See Child Health Services. |
|
Electronic Data Systems Corporation (EDS) |
Current fiscal agent for the state Medicaid program. |
|
Eligible |
(1) To be qualified for Medicaid benefits. (2) One who is qualified for benefits. |
|
Eligibility File |
A file containing individual records for all persons who are eligible or have been eligible for Medicaid. |
|
Emergency Services |
Inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. Source: 42 U.S. Code of Federal Regulations §422.2 and §424.101. |
|
Error Code |
A numeric code indicating the type of error found in processing a claim. |
|
Estimated Acquisition |
The estimated amount a pharmacy actually pays to obtain a drug. |
|
Cost |
|
|
Experimental Surgery |
Any surgical procedure considered experimental in nature. |
|
Explanation of Medicaid Benefits (EOMB) |
A statement mailed once per month to selected recipients to allow them to confirm the Medicaid service which they received. |
|
Family Planning Services 1 |
Any medically approved diagnosis, treatment, counseling, drugs, supplies or devices which are prescribed or furnished by a physician, nurse practitioner, certified nurse-midwife or the Health Department to individuals of child-bearing age for purposes of enabling such individuals freedom to determine the number and spacing of their children. |
|
Field Audit |
An activity performed whereby a provider's facilities, procedures, records and books are audited for conformance to Medicaid standards. A field audit may be conducted on a routine basis, or on a special basis. |
|
Fiscal Agent |
An organization authorized by the State of Arkansas to process Medicaid claims. |
|
Fiscal Agent Intermediary |
A private business firm which has entered into a contract with the Arkansas Department of Human Services to process Medicaid claims. |
|
Fiscal Year |
The twelve-month period between settlements of financial accounts. |
|
Generic Upper Limit (GUL) |
The maximum drug cost which may be used to compute reimbursement for specified multiple-source drugs unless the provisions for a Generic Upper Limit override have been met. The Generic Upper Limit may be established or revised by the Health Care Financing Administration (HCFA) or by the State Agency. |
|
Group Practice |
A medical practice in which several practitioners render and bill for services under a single provider number. |
|
HCFA Common Procedure Coding System (HCPCS) |
Federally defined procedure codes. |
|
Health Care Financing Administration (HCFA) |
Federal agency which administers federal Medicaid funding. |
|
Health Insurance Claim Number |
Number assigned to Medicare recipients and individuals eligible for SSI. |
|
Hospital |
An institution which meets the following qualifications: |
|
1. Provides diagnostic and rehabilitation services to inpatients. 2. Maintains clinical records on all patients. 3. Has by-laws with respect to its staff of physicians. 4. Requires each patient to be under the care of a physician, dentist or certified nurse-midwife. 5. Provides 24-hour nursing service. 6. Has a hospital utilization review plan in effect. 7. Is licensed by the State. 8. Meets other health and safety requirements set by the Secretary of Health and Human Services. |
|
|
Hospital-Based Physician |
A physician who is a hospital employee and is paid for services by the hospital. |
|
ID Card |
An identification card issued to Medicaid recipients containing the encoded data to permit a provider to access the recipient's Medicaid eligibility information. |
|
Inpatient |
A patient admitted to a hospital or skilled nursing facility who occupies a bed and receives inpatient services. |
|
In-Process Claim (Pending Claim) |
A claim which suspends during system processing for suspected error conditions because all processing requirements are not met. These conditions must be reviewed by EDS or DMS and resolved before processing of the claim can be completed. (See suspended claim.) |
|
Inquiry |
A request for information. |
|
Institutional Care |
Care in an authorized private, non-profit, public or state institution or facility. Such facilities include schools for the deaf, and/or blind and institutions for the handicapped. |
|
Instrumental Activities of Daily Living (IADL) |
Tasks which are ordinarily performed on a daily or weekly basis and include meal preparation, housework, laundry, shopping, taking medications and travel/ transportation. |
|
Intensive Care |
Isolated and constant observation care to patients critically ill or injured. |
|
Interim Billing |
A claim for less than the full length of an inpatient hospital stay. Also, a claim which is billed for services provided to a particular date even though more services will be provided. It may or may not be the final bill for a particular recipient's services. |
|
Internal Control Number (ICN) |
The unique 13 digit claim number which appears on a Remittance Advice. |
|
International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9CM) |
A diagnosis coding system for identifying a patient's diagnosis on a claim used by medical providers. |
|
Investigational Product |
Any product which is considered investigational, experimental and not approved by the Food and Drug Administration. The Arkansas Medicaid Program does not cover investigational products. |
|
Julian Date |
Chronological date of the year, 001 through 365 or 366, preceded by a two (2) digit year designation. Claim number example: 97231. |
|
Length Of Stay |
Period of time a patient is in the hospital. Also, the number of days covered by Medicaid within a single inpatient stay. |
|
Line Item |
A service provided to a recipient. A claim may be made up of one or more line items for the same recipient. Also called a claim detail. |
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Long Term Care (LTC) |
An office within the Arkansas Division of Medical Services responsible for nursing facilities. |
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Long Term Care Facility |
A nursing facility. |
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Maximum Allowable Cost (MAC) |
The maximum drug cost which may be reimbursed for specified multi-source drugs. This term was replaced by generic upper limit. |
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Medicaid Management Information System (MMIS) |
The automated system utilized to process Medicaid claims. |
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Medical Assistance Section |
A section within the Arkansas Division of Medical Services responsible for administering the Arkansas Medical Assistance Program. |
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Medically Needy |
Individuals whose income and resources exceed those levels for assistance established under a state or federal plan, but are insufficient to meet costs of health and medical services. |
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Medical Necessity |
All Medicaid benefits are based upon medical necessity. A service is "medically necessary" if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions which endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the recipient requesting the service. For this purpose, a "course of treatment" may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program, Professional Review Organization or Peer Review Committee for the Medicaid Program. Coverage may be denied if the requested service is not medically necessary according to the preceding criteria or is generally regarded by the medical profession as experimental or unacceptable, unless objective clinical evidence demonstrates circumstances making the requested services necessary. |
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Mis-Utilization |
Any usage of the Medicaid Program by any of its providers and/or recipients which is not in conformance with both State and Federal regulations and laws (includes fraud, abuse and defects in level and quality of care). |
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National Drug Code |
The unique eleven digit number assigned to drugs which identifies the manufacturer, drug, strength and package size of each drug. |
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Non-Covered Services |
Services not medically necessary, services provided for the personal convenience of the patient or services not covered under the Medicaid Program. |
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Nonpatient |
An individual who receives services, such as laboratory tests, performed by a hospital, but who is not a patient of the hospital. |
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Nurse Practitioner |
A professional nurse with credentials which meet the requirements for licensure as a nurse practitioner in the State of Arkansas. |
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Outpatient |
A patient receiving medical services, but not admitted as an inpatient to a hospital. |
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Over-Utilization |
Any over usage of the Medicaid Program by any of its providers and/or recipients not in conformance with professional judgement and both State and Federal regulations and laws (includes fraud and abuse). |
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Participant |
A provider of services who: (1) provides the service, (2) submits the claim and (3) accepts the amount determined to be the reasonable charge for the services provided as payment in full. |
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Patient |
A person under the treatment or care, of a physician or surgeon, or in a hospital. |
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Payment |
Reimbursement to the provider of services for rendering a Medicaid covered benefit. |
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Pay to Provider |
A person, organization or institution authorized to receive payment for services provided to eligible Medicaid recipients by a person or persons who are a part of the entity. |
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Pay to Provider Number |
A 9-digit number assigned to each Pay to Provider. Medicaid reports provider payments to the Internal Revenue Service under the Employee Identification Number "Tax ID" linked in the Medicaid Provider File to the pay to provider number. |
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Peer |
A person or committee in the same profession as the provider. |
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Peer Review |
An activity performed by a group or groups of practitioners or other providers, by which the practices of their peers are reviewed for conformance to generally accepted standards. |
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Per Diem |
A daily rate paid to institutional providers. |
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Performing Physician |
The physician providing, supervising, or both, a medical service and claiming primary responsibility for ensuring that services are delivered as billed. |
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Person |
Any natural person, company, firm, association, corporation or other legal entity. |
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Physician's Current Procedural Terminology |
An AMA approved listing of medical terms and identifying codes for reporting medical services and procedures performed by physicians. |
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Place of Service (POS) |
An alpha or numeric code denoting the actual place services are provided. |
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Plan of Care |
A document utilized by a provider to plan, direct or deliver care to a patient to meet specific measurable goals. Also called care plan, service plan or treatment plan. |
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Point of Sale Device (POS) |
A device used to submit and verify claims electronically through AEVCS. |
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Postpayment Utilization Review |
The review of services and practice after payment. |
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Practitioner |
An individual provider; one who practices in a health or medical service profession. |
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Prepayment Utilization Review |
The review of services and practice patterns before payment. |
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Prescription |
A health care professional's legal order for a drug which, in accordance with federal and/or state statutes, may not be obtained otherwise. Also means an order for a particular Medicaid covered service. |
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Prescription Drug (RX) |
A drug which, in accordance with federal and/or state statutes, may not be obtained without a valid prescription. |
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Primary Care Physician (PCP) |
A physician responsible for the management of a recipient's total medical care. Selected by the recipient to provide primary care services and health education. The PCP will monitor on an ongoing basis the recipient's condition, health care needs and service delivery and also be responsible for locating, coordinating and monitoring medical and rehabilitation services on behalf of the recipient and refer the recipient for most specialty services, hospital care and other services. |
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Prior Authorization (PA) |
The approval by the Arkansas Division of Medical Services or a designee of the Division of Medical Services, for specified services for a specified recipient to a specified provider before the requested services may be performed and before payment will be made. |
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Procedure Code |
A five digit numeric or alpha numeric code to identify medical services and procedures on medical claims. |
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Professional Component |
A physician's interpretation or supervision and interpretation of laboratory, X-ray or machine test procedures. |
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Professional Review Organization (PRO) |
The Professional Review Organization is the federally mandated review organization for the state under the authority of the Arkansas Foundation for Medical Care, Inc. This organization monitors hospital and physician services billed to the state's Medicare intermediary and the Medicaid program to assure high quality, medical necessity and appropriate care for each patient's needs. |
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Profile |
A detailed view of an individual provider's charges to Medicaid for health care services or a detailed view of a recipient's usage of health care services. |
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Provider |
A person, organization or institution enrolled to provide health or medical care services authorized under the State Title XIX Medicaid Program. |
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Provider Number |
A nine-character code assigned to each provider of services in the Arkansas Medicaid Program for identification purposes. |
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Provider Relations |
The activity within the Medicaid Program which handles all relationships with Medicaid providers. |
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Quality Assurance |
Determination of quality and appropriateness of services rendered. |
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Railroad Claim Number |
The number issued by the Railroad Retirement Board to control payments of annuities and pensions under the Railroad Retirement Act. The claim number begins with a one to three letter alphabetic prefix denoting the type of payment, followed by six or nine numeric digits. |
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Recipient |
Person who meets the Medicaid eligibility requirements, receives an ID card and is eligible for Medicaid services. |
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Referral |
An authorization from a Medicaid enrolled provider to a second Medicaid enrolled provider. The receiving provider is expected to exercise independent professional judgment and discretion, to the extent permitted by laws and rules governing the practice of the receiving practitioner, and develop and deliver medically necessary services covered by the Medicaid program. The provider making the referral may be a physician or another qualified practitioner acting within the scope of practice permitted by laws or rules. Medicaid requires documentation of the referral in the recipient's medical record, regardless of the means the referring provider makes the referral. Medicaid requires the receiving provider to document the referral also, and to correspond with the referring provider regarding the case when appropriate and when the referring provider so requests. |
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Reimbursement |
The amount of money remitted to a provider. |
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Rejected Claim |
A claim for which payment is refused. |
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Relative Value |
A weighting scale used to relate the worth of one surgical procedure to any other. This evaluation, expressed in units, is based upon the skill, |
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time and the experience of the physician in its performance. |
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Remittance |
A remittance advice. |
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Remittance Advice (RA) |
A notice sent to providers advising the status of claims received, including paid, denied, in-process and adjusted claims. It includes year-to-date payment summaries and other financial information. |
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Reported Charge |
The total amount submitted in a claim detail by a provider of services for reimbursement. |
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Retroactive Medicaid Eligibility |
Medicaid eligibility which may begin up to three (3) months prior to the date of application provided all eligibility factors are met in those months. |
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Returned Claim |
A claim which is returned by the Medicaid Program to the provider for correction or change to allow it to be processed properly. |
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Sanction |
Any corrective action taken against a provider. |
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Screening |
The use of quick, simple medical procedures carried out among large groups of people to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of more definitive examination or treatment. |
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Signature |
Signature or initials means the person's original signature, or the person's signature or initials may be recorded by an electronic or digital method executed or adopted by the person with the intent to be bound by or to authenticate a record. An electronic signature must comply with Arkansas Code Annotated § 25-31-101 -105, including verification through an electronic signature verification company and data links invalidating the electronic signature if the data is changed. |
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Single State Agency |
The state agency authorized to administer or supervise the administration of the medical assistance program on a statewide basis. |
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Skilled Nursing Facility (SNF) |
A nursing home, or a distinct part of a facility, licensed by the Office of Long Term Care as meeting the Skilled Nursing Facility Federal/State licensure and certification regulations. A health facility which provides skilled nursing care and supportive care on a 24-hour basis to residents whose primary need is for availability of skilled nursing care on an extended basis. |
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Social Security Administration (SSA) |
A federal agency which makes disability and blindness determinations for the Secretary of the HHS. |
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Social Security Claim Number |
The account number used by SSA to identify the individual on whose earnings SSA benefits are being paid. I t is the Social Security Account Number followed by a suffix, sometimes as many as three characters, designating the type of beneficiary (e.g., wife, widow, child, etc.). |
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Source of Care |
A hospital, clinic, physician or other facility which provides services to a beneficiary under the Medicaid Program. |
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Specialty |
The specialized area of practice of a physician or dentist. |
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Spend Down (SD) |
The amount of money a recipient must pay toward medical expenses when income exceeds the Medicaid financial guidelines. A component of the medically needy program allows an individual or family whose income is over the medically needy income limit (MNI L) to use medical bills to spend excess income down to the MNI L. The individual(s) will have a spend down liability. The spend down column of the remittance advice indicates the amount which the provider may bill the recipient. The spend down liability occurs only on the first day of Medicaid eligibility. |
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Status Report |
A remittance advice. |
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Supplemental Security Income (SSI) |
A program administered by the Social Security Administration. This program replaced previous state administered programs for aged, blind or disabled recipients (except in Guam, Puerto Rico and the Virgin Islands). This term may also refer to the Bureau of Supplemental Security Income within SSA which administers the program. |
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Suspended Claim |
An "In-Process Claim" which must be reviewed and resolved. |
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Suspension from |
An exclusion from participation for a specified period of time. |
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Participation |
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Suspension of Payments |
The withholding of all payments due to a provider until the resolution of a matter in dispute between the provider and the state agency. |
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Termination from |
A permanent exclusion from participation in the Title XIX Program. |
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Participation |
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Third Party Liability (TPL) |
A condition whereby a person or an organization, other than the recipient or the state agency, is responsible for all or some portion of the costs for health or medical services incurred by the Medicaid recipient (e.g., a health insurance company, a casualty insurance company or another person in the case of an accident, etc.). |
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Utilization Review (UR) |
The section of the Arkansas Division of Medical Services which performs the monitoring and controlling of the quantity and quality of health care services delivered under the Medicaid Program. |
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Void |
A transaction which deletes. |
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Voice Response System (VRS) |
Voice activated system to request prior authorization for prescription drugs and for PCP assignment and change. |
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Ward |
An accommodation of five or more beds. |
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Withholding of Payments |
A reduction or adjustment of the amounts paid to a provider on pending and subsequently due payments. |
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Worker's Compensation |
A type of Third-Party Liability for medical services rendered as the result of an on-the-job accident or injury to a recipient for which the employer's insurance company may be obligated under the Worker's Compensation Act. |
Subject: UPDATE CONTROL LOG
Effective Date: 1-1-03
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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.