ATTACHMENT 4.19-B METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
-OTHER TYPES OF CARE
18. Hospice Care
Arkansas Medicaid reimburses hospice providers in accordance with the
Medicaid fee schedule and hospice wage index requirements pubhshed annually by
CMS. For the Routine Home Care and Continuous Home Care rates, the hospice wage
index to be applied to the wage component subject to index is based on the
location of the individual's home. For the Inpatient Respite Care and General
Inpatient Care rates, the hospice wage index to be applied to the wage
component subject to index is based on the location of the hospice. Pubhc and
private providers are reimbursed the same rates.
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
18. Hospice Care
! The hospice patient must be terminally ill which is defined as
having a medical prognosis with a life expectancy of six months or less. The
terminal illness must be certified by the patient's attending physician and
hospice services prescribed.
! Patients must voluntarily elect to receive hospice services and
choose the hospice provider. Hospice election is by Aelection periods-.
Election periods in the Arkansas Medicaid Hospice Program correspond to the
election periods established for Medicare. The initial hospice election period
is of 90 days duration and is followed by a second 90-day election period. The
patient is then eligible for an unlimited number of 60-day election
periods.
! Election of the hospice benefit results in a waiver of the
beneficiary's rights to payment for only those services which are
related to the treatment of the terminal illness or related conditions and
common to both Title XVIII and Title XIX. The beneficiary does not
waive rights to payment for services related to the terminal illness that are
unique to Title XIX.
! Hospice services must be provided primarily in a patient's
residence.
A patient may elect to receive hospice services in a nursing facility
or an intermediate care facility for the mentally retarded
(ICF/MR) if the hospice and the facility have a written agreement under
which the hospice takes full responsibility for the professional management of
the patient's hospice care, and the facility agrees to provide room and board
to the patient.
! Hospice services must be provided consistent with a written plan of
care.
! Dually eligible (Medicare and Medicaid) beneficiaries
must elect hospice care in the Medicare and
Medicaid hospice programs simultaneously to be eligible for Medicaid
hospice services.
ATTACHMENT 3.1-B
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
18. Hospice Care
! The hospice patient must be terminally ill which is defined as
having a medical prognosis with a life expectancy of six months or less. The
terminal illness must be certified by the patient's attending physician and
hospice services prescribed.
! Patients must voluntarily elect to receive hospice services and
choose the hospice provider.
Hospice election is by Aelection periods-. Election periods in the
Arkansas Medicaid Hospice Program correspond to the election periods
established for Medicare. The initial hospice election period is of 90 days
duration and is followed by a second 90-day election period. The patient is
then eligible for an unlimited number of 60-day election periods.
! Election of the hospice benefit results in a waiver of the
beneficiary's rights to payment for only those services which are
related to the treatment of the terminal illness or related conditions and
common to both Title XVIII and Title XIX. The beneficiary does not
waive rights to payment for services related to the terminal illness that are
unique to Title XIX.
! Hospice services must be provided primarily in a patient's
residence.
A patient may elect to receive hospice services in a nursing facility
or an intermediate care facility for the mentally retarded
(ICF/MR) if the hospice and the facility have a written agreement under
which the hospice takes full responsibility for the professional management of
the patient's hospice care, and the facility agrees to provide room and board
to the patient.
! Hospice services must be provided consistent with a written plan of
care.
! Dually eligible (Medicare and Medicaid) beneficiaries
must elect hospice care in the Medicare and Medicaid hospice program
simultaneously to be eligible for Medicaid hospice services.
Provider Manual Update Transmittal #55
200.000 HOSPICE GENERAL INFORMATION
201.000
Arkansas Medicaid Participation
Requirements for IHospice
Providers
201.100
Enrollment Criteria
Providers of hospice services must meet the following
criteria to be eligible for participation in the Arkansas Medicaid
Program:
A. The hospice provider must
be certified as a Title XVIII (Medicare) hospice provider.
1. The provider must submit a copy of the
Medicare certification to Provider Enrollment when submitting the Hospice
Program application and contract.
2. Subsequent Medicare certifications must be
forwarded to Provider Enrollment within 30 days of issuance.
3. Failure to ensure that current Medicare
certification is on file with Provider Enrollment will result in termination
from the Arkansas Medicaid Program.
B. The hospice provider must be licensed by
the Division of Health Facility Services, Arkansas Division of Health. The
provider must submit a copy of their current license. The provider must submit
copies of license renewals when they are issued.
C. The hospice provider must complete a
provider application (form DMS-652), a Medicaid contract (form DMS-653) and a
Request for Taxpayer Identification Number and Certification (Form W-9) with
the Arkansas Medicaid Program.
View or print a provider
application (form DMS-652), Medicaid contract (form DMS-653) and Request for
Taxpayer Identification Number and Certification (Form
W-9).
D.
Enrollment as a Medicaid provider is conditioned upon approval of a completed
provider application and the execution of a Medicaid Provider Contract. Persons
and entities that are excluded or debarred under any state or federal law,
regulation or rule are not eligible to enroll, or to remain enrolled, as
Medicaid providers.
E. The Hospice
provider must adhere to all applicable professional standards of care and
conduct.
201.110
Hospice Inpatient Facilities
A.
Providers of short-term inpatient care for hospice patients must be certified
by the Division of Health Facility Services, Arkansas Division of Health, as
hospice inpatient facilities.
1. The
patient's designated hospice provider pays the provider of short-term inpatient
services and bills Medicaid for reimbursement.
2. Hospices that have arrangements with
certified hospice inpatient facilities must maintain documentation of each such
facility's current certification status.
B. Acute care hospitals enrolled in the
Arkansas Medicaid Program may provide short-term inpatient care under
arrangements with hospice providers. Medicaid requires no additional licensing
or certification.
C. Hospices may
make arrangements for inpatient respite care with skilled nursing facilities
that meet the standards at
42
CFR,
418.100, (a) and (e). Hospices making
such arrangements must maintain documented assurances that the facilities meet
the referenced standards.
202.000
Record Retention
Requirements
A. The hospice provider
must l[LESS THAN]eep all required documentation and records for a period of
five (5) years from the date of service or until all audit questions, appeal
hearings, investigations or court cases are resolved, whichever period is
longer.
B. The hospice provider
must contemporaneously establish and maintain records that completely and
accurately explain all evaluations, care, diagnoses and any other activities in
connection with any Medicaid beneficiary. Failure to furnish records upon
request may result in sanctions being imposed.
C. The hospice provider must immediately make
available to the Division of Medical Services, its contractors and designees
and the Medicaid Fraud Control Unit all records related to any Medicaid
beneficiary.
D. All documentation
must be available at the provider's place of business.
E. Hospice providers furnishing any
Medicaid-covered good or service for which a prescription is required by law,
by Medicaid rule, or both, must have a copy of the prescription for such good
or service. The provider must obtain a copy of the prescription within five (5)
business days of the date the prescription is written.
F. The hospice provider must maintain a copy
of each relevant prescription in the Medicaid beneficiary's records and follow
all prescriptions and care plans.
G. In the event of post-payment denials with
subsequent recoupment of payment for services, DMS will only accept additional
documentation received within thirty calendar days following the date of the
recoupment letter. No documentation will be accepted after thirty
days.
H. See Section 220.000 for a
complete listing of required documentation.
210.200
Conditions for Provision of
IHospice Service
A. Hospice services
require primary care physician (PCP) referral unless the patient is exempt from
PCP referral requirements.
B. The
hospice patient must be terminally ill. "Terminally ill" is defined as having a
medical prognosis with a life expectancy of six months or less. The hospice
must obtain the certification that an individual is terminally ill in
accordance with the following requirements:
1. For the first 90-day election period of
hospice coverage, the hospice must obtain, no later than two days after the
initiation of hospice care, written certification statements signed by the
hospice medical director or the physician member of the hospice
interdisciplinary group and the individual's attending physician or PCP.
a. If the hospice does not obtain a written
certification within two days after the initiation of hospice care, an oral
certification may be obtained within these two days, and a written
certification obtained no later than eight days after care is
initiated.
b. If these requirements
are not met, the provider is not eligible for reimbursement of hospice services
furnished before the date that written certification is obtained.
2. For any subsequent election
period, the hospice must obtain, no later than two calendar days after the
beginning of that period, a written certification statement prepared by the
hospice medical director or the physician member of the hospice's
interdisciplinary group.
C. Patients must voluntarily elect to receive
hospice services and choose their hospice provider.
D. Patients who elect to receive hospice
services must receive hospice services instead of certain other Medicaid
benefits. See Section 214.000, subpart D, for more details in this
regard.
E. Hospice services must be
provided primarily in a patient's place of residence.
1. A patient may elect to receive hospice
services in a nursing facility or intermediate care facility for the mentally
retarded (ICF/MR) if:
a. The Department of
Health and Human Services has determined that the patient is eligible for
nursing facility or ICF/MR care and
b. The hospice and the facility have a
written agreement under which:
i. The hospice
takes full responsibility for the professional management of the patient's
hospice care and
ii. The facility
agrees to provide room and board to the patient.
2. When a patient elects to receive hospice
care in a nursing facility or ICF/MR, the hospice pays the nursing facility or
ICF/MR for the patient's room and board and bills Medicaid for
reimbursement.
F.
Hospice services must be provided in accordance with a written plan of
care.
211.210
Routine Home Care
Each day the patient is at his or her place of residence or at a
nursing facility or ICF/MR, and the patient receives less than eight hours of
hospice care in one calendar day (midnight to midnight), it is a routine home
care day.
211.220
Continuous Home Care
A. Continuous
home care is to be provided only during a period of crisis in which more than
routine care is required to achieve palliation or management of the patient's
acute medical symptoms.
B. For a
day of hospice care to qualify as a continuous home care day, a minimum of
eight hours of care must be provided during a twenty-four-hour day which begins
and ends at midnight.
1. This care need not be
continuous, e.g., four hours of care could be provided in the morning and
another four hours in the evening of that day.
2. A nurse must be providing care for more
than half of the period of care each day.
3. Homemaker and aide services may also be
provided to supplement the nursing care.
C. Continuous home care is a covered service
for hospice patients who reside in nursing facilities or ICF/MR's.
211.230
Inpatient Respite
Care
A. Inpatient respite care is
short-term inpatient care provided to the patient only when necessary to
relieve the family members or other persons caring for the individual at home.
1. Inpatient respite care may be provided
only twice and is not covered for more than five consecutive days per
stay.
2. The sixth and subsequent
days of an inpatient respite stay are covered only as routine home care
days.
B. A hospice
patient may receive inpatient respite care at an acute care inospital, in a
inospice inpatient facility or in a sl[LESS THAN]illed nursing facility tinat
meets the standards at
42
CFR,
418.100, (a) and (e).
C. Hospice patients residing in nursing
facilities or ICF/MR's are not eligible for inpatient respite care.
214.000
Election
A. A patient electing hospice care must file
an election statement with the designated hospice.
1. The provider must furnish a printed
statement that meets all the conditions of this section.
2. The patient must sign and date the
election statement.
B.
An election to receive hospice care continues through the initial election
period and through any subsequent election periods without a break in care as
long as the patient remains in the care of the hospice.
C. A patient must designate an effective date
for the election period.
1. The effective date
may be the first day of hospice care or any subsequent day of hospice
care.
2. A patient may not
designate an effective date that is earlier than the date on which the election
is made.
D. A patient
must waive all rights to Medicaid coverage of the following services for the
duration of the election of hospice care:
1.
Hospice care provided by a hospice other than the hospice designated by the
patient, unless provided under arrangements made by the designated
hospice.
2. Any Medicaid services
that are related to treatment of the terminal condition for which hospice care
was elected or of a related condition; or that are equivalent to hospice care
except for services:
a. Provided (either
directly or under arrangement) by the designated hospice.
b. Provided as room and board by a nursing
facility or ICF/MR if the individual is a resident.
c. Provided by the patient's attending
physician if that physician is not an employee of the designated hospice or
receiving compensation from the hospice for those services.
3. Home Health Program services
and drugs and biologicals obtained through the Arkansas Medicaid Pharmacy
Program for the palliation and management of symptoms related to the patient's
terminal illness,
E.
When an election period ends, the patient's waiver of other Medicaid benefits
expires and regular Medicaid coverage is possible if the patient revokes
hospice care for the subsequent election period.
F. An individual eligible for both Medicare
and Medicaid must elect the hospice benefit simultaneously under both
programs.
G. When a hospice
discharges a patient because the patient's condition is no longer considered
terminal, the patient's waiver of other Medicaid benefits expires immediately
and regular Medicaid coverage is possible.
218.000
Plan of Care
A written plan of care must be established and maintained for each
individual admitted to a hospice program and the care provided to an individual
must be in accordance with the plan.
A. The attending physician, the medical
director or physician designee and the interdisciplinary group must establish
the plan of care before hospice care begins.
B. The attending physician, the medical
director or physician designee and the interdisciplinary group must review and
update the plan at intervals specified in the plan. Reviews must be
documented.
C. The plan of care
must:
1. Include an assessment of the
individual's needs and identification of the services, including a. Management
of discomfort b. Symptom relief
2.
State in detail the scope and frequency of services needed to meet the
patient's and family's needs.
D. In establishing the initial plan of care,
the member of the interdisciplinary group who assesses the patient's needs must
meet or confer by telephone with at least one other IDG member before writing
the initial plan of care.
1. At least one of
the persons developing the initial plan of care must be a nurse or
physician.
2. The plan must be
established on the same day as the assessment if the day of the assessment is
to be a covered day of hospice care.
3. The other two members of the IDG must
review the initial plan of care and provide their contributions to it within
two calendar days following the day of assessment.
E. Waiver Services
1. Waiver Eligibility
Some Medicaid beneficiaries are eligible under special programs known
as waivers. The claims system will indicate waiver eligibility status with "NO"
(not a waiver client) or the letter "W" followed by a number currently (1 or
2).
Waiver clients may receive only services listed in the plan of care
designed for them under the guidelines of the waiver program in which they
participate.
2.
ElderChoices Waiver Clients
a. If the hospice
provider intends to initiate care to a W2 waiver client, contact must be made
with the DHHS County Office in the client's county of residence for the name
and location of the DHHS R.N. responsible for the client's ElderChoices plan of
care. Through contact with the DHHS R.N., the hospice services may be included
in the plan of care before rendering the service.
b. The ElderChoices plan of care supersedes
any other plan of care previously developed by another Medicaid provider for
the beneficiary. The ElderChoices plan of care must be obtained from the
client's family.
c. The
ElderChoices plan of care must include all appropriate ElderChoices services
and certain non-waiver services appropriate to the applicant, such as
Hospice.
d. The hospice provider
must report services to an ElderChoices client to the DHHS RN. The services
must be included on the ElderChoices plan of care prior to beginning services.
All changes in services or changes in the ElderChoices client's circumstances
must be reported promptly to the DHHS RN. Services provided that are not
included on the ElderChoices plan of care may be subject to recoupments by the
Arkansas Medicaid Program.
240.300
Method of Service Reimbursement
for IHospice Patients Residing in Nursing Facilities or ICF/IVIR's
A. Reimbursement for IVIedicaid-eligible
patients residing in nursing facilities or ICF/IVIR's is limited to room and
board.
1. Medicaid pays the hospice provider
an amount equal to 95% of the Medicaid nursing facility/ICF/MR room and board
payment.
2. The hospice pays that
amount to the nursing facility or ICF/MR.
B. Nursing facility or ICF/MR residents may
elect hospice if their nursing facility or ICF/MR has an agreement with a
Medicaid hospice provider.
1. Medicaid pays
the hospice for their care along with a separate rate to cover room and
board.
2. Medicaid will not pay the
nursing facility or ICF/MR directly for room and board.
C. The Arkansas Medicaid Program remits
reimbursement for room and board to the hospice.
D. The hospice then remits that amount to the
nursing facility or ICF/MR.
1. Room and board
services include the performance of personal care services including assistance
in activities of daily living, socializing activities, administration of
medication, maintaining the cleanliness of a resident's room and supervising
and assisting in the use of durable medical equipment and prescribed
therapies.
2. Room and board is
reimbursable only in conjunction with routine home care or continuous home
care.
E. Billing for
routine home care and continuous home care for patients residing in nursing
facilities or ICF/MR's requires a special procedure. See Section
252.410 for special billing
instructions.
F. See Section
253.300 for billing instructions
related to nursing facility or ICF/MR room and board reimbursement.
240.400
Rate
Appeal Process
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 or 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
Health and Human Services (DHHS) 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 suchi appeal. Thie question(s) will be hieard by thie panel and a
recommendation will be submitted to the Director of the Division of Medical
Services.
252.000
CMS-1450 (formerly UB-92) Billing Procedures
252.100
Hospice Revenue Codes
The following revenue codes must be used to bill for hospice services
for Medicaid-eligible beneficiaries:
|
Revenue Code
|
Description
|
|
651
|
Routine Home Care
|
|
652
|
Continuous Home Care
|
|
655
|
Inpatient Respite Care
|
|
656
|
General Inpatient Care
|
See section
253.300 for billing instructions
to claim reimbursement for nursing facility room and board for hospice patients
who reside in nursing facilities or ICF/MR's.
252.300
Billing Instructions - CMS-1450
Paper Only
EDS offers providers several options for electronic billing. Therefore,
claims submitted on paper are paid once a month. The only claims exempt from
this process are those which require attachments or manual pricing.
Since the CMS-1450 is a uniform claim form to be used nationwide for
submitting claims to all third party payers, providers are responsible for
purchasing their own forms from approved vendors. Medicaid will not furnish the
claim form.
View a CMS-1450 sample form.
To ensure that claims are processed with a minimal amount of delay,
providers should complete all required fields of the CMS-1450 claim form. The
CMS-1450 data specifications manual should be used as a guide. The manual was
developed by the National Uniform Billing Committee, whose work is coordinated
through the offices of the American Hospital Association.
View or print the contact information to purchase the
CMS-1450 Data Element Specifications handbook.
Out-of-state providers should be aware of instructions for completing
the CMS-1450 claim form. These instructions may be found in the Arkansas
Medicaid Manual and the CMS-1450 data specifications manual.
To bill for hospice services, use the claim form CMS-1450. Listed below
are instructions for filing the CMS-1450 with the Arkansas Medicaid Program.
More comprehensive instructions are contained in the CMS-1450 data
specifications manual. The numbered items correspond to the numbered locators
on the CMS-1450.
The following instructions must be read and carefully adhered to, so
that EDS can efficiently process claims. Accuracy, completeness and clarity are
important. Claims cannot be processed if applicable information is not supplied
or is illegible. Claims should be typed whenever possible.
Please forward the original of the completed form to EDS Claims
Department.
View or print the EDS Claims contact
information. One copy of the claim form should be retained
for your records.
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.
252.400
Special Billing Procedures
252.410
Billing for Hospice Services
for Residents of Nursing Facilities or
ICF/MR's
A.
Pursuant to
Public
Law 105-33, Medicaid must mal[LESS THAN]e payment to inospices witin
respect to tine geograpinical location of the patient.
1. Please comply with the following
instructions when billing for hospice services for patients residing in nursing
facilities or ICF/MR's.
2. These
instructions apply only to the hospice provider billing on a CMS-1450 claim
form or billing electronically in the CMS-1450 claim format.
B. When billing for routine home
care or continuous home care for hospice patients residing in nursing
facilities and ICF/MR's:
1. Enter Z9 as a
Condition Code and
2. Enter the
Arkansas Medicaid Long Term Care provider number of the nursing facility or
ICF/MR in one of the following fields:
a. The
data field labeled "Other Physician ID" in PES.
b. The first field of Form Locator 83,
labeled "Other Phys ID" (First line of Form Locator 83).
C. Compliance with the above
special billing instructions is required.
252.420
Billing for Short-Term
Inpatient Care for Hospice Patients
A.
Pursuant to
PL
105-33, Medicaid must make payment to hospices with respect to the
geographical location of the patient.
1.
Please comply with the following instructions when billing for short-term
inpatient services for hospice patients.
2. These instructions apply only to the
hospice provider, billing on a CMS-1450 claim form or billing electronically in
the CMS-1450 claim format.
B. When billing for inpatient respite care or
general inpatient care:
1. Enter Z9 as a
Condition Code and
2. Enter the
Arkansas Medicaid Hospital provider number of the hospital to which the patient
has been admitted in one of the following fields:
a. The data field labeled "Other Physician
ID" in PES.
b. The first field of
Form Locator 83, labeled "Other Phys ID" (First line of Form Locator
83).
253.300
Billing Instructions -
Hospice/INH Claim Form
The Hospice/INH claim form (DHS-754) must be used when billing for room
and board for all patients receiving hospice care in a nursing
facility or an ICF/MR. A separate claim must be submitted for each month of
service billed. Listed below are instructions for filing the
Hospice/INH claim form with the Arkansas Medicaid Program. The numbered items
correspond to the numbered fields on the Hospice/INH claim form. The following
instructions must be adhered to, so that claims for payment can be processed
efficiently. Accuracy, completeness and clarity are important since a claim
cannot be processed if all information is not supplied or is unreadable.
View a Hospice/INH Claim DHS-754 sample
form.
Forward Hospice claims (DHS-754) to EDS Claims Department.
View or print the EDS Claims contact
information.
253.310
Completion of the Hospice/INH
Claim Form
|
Field Name and Number
|
Description
|
|
1.
|
Provider Medicaid ID
|
Enter the 9-digit Medicaid Hospice provider number.
|
|
2.
|
Medicaid Number and Name of the Facility the Patient Resides
in
|
Enter the full name and 9-digit Medicaid provider number of the
nursing facility/ICF/MR in which the patient resides.
|
|
3.
|
Provider Name and Address
|
Enter the Hospice provider's name and address.
|
|
4.
|
Patient Medicaid ID Number, Last Name and First
Name
|
Enter the patient's Medicaid ID number, last name and first
name exactly as it appears on the Medicaid ID card.
|
|
5.
|
Medical Record Number (MRN)
|
Optional entry. Up to 10 alphanumeric characters may be
entered. The MRN appears on the Remittance Advice exactly as it is entered on
the claim form.
|
|
6.
|
Patient Status on Last End Date of Service
|
Enter the two-digit patient status code effective for the
beneficiary on the ending date of service.
01 - Discharged to home
02 - Discharged to hospital
03 - Discharged to a Residential Care Facility (RCF)
04 - Discharged to other
05 - Transferred to Nursing Facility
06 - Transferred to ICF/MR 20 - Expired
30 - Still a patient
|
|
7.
|
Patient Admit Date
|
Enter the date of admission into the nursing facility or ICF/MR
in CCYYMMDD (e.g., 19950101) format.
|
|
8.
|
Primary Diagnosis
|
Required. Enter the ICD-9-CM code for the primary
diagnosis.
|
|
9.
|
Secondary Diagnosis
|
Required, if applicable. Enter additional appropriate ICD-9-CM
diagnosis codes.
|
|
10.
|
Total Beds Occupied in Facility
|
This field is not required by Medicaid.
|
|
11.
|
TPL Information
|
Required, if applicable. The name, address and policy number of
the primary insurance carrier must be entered in this field. Enter the amount
received toward payment of this bill prior to billing Medicaid. If no payment
was received, enter the date of denial (CCYYMMDD format) from the primary
insurance carrier and attach a copy of the EOMB.
|
|
12. Beginning Date of Service
|
Enter the beginning date of service of the period covered by
this bill in CCYYMMDD format. Service dates may not span calendar months. A
separate claim form must be submitted for each month of service
billed.
|
|
13. Ending Date of Service
|
Enter the ending date of service of the period covered by this
bill in CCYYMMDD format. Service dates may not span calendar months. A separate
claim form must be submitted for each month of service billed.
|
|
14. Total Days
|
Enter the total number of days being billed from the beginning
to the ending dates of service for each claim detail.
|
|
15. Leave of Absence (LOA) Code
|
Enter the Medicaid LOA code for the type of leave being
reported for the patient on the claim detail. LOA and non-LOA days cannot be
billed on the same claim detail.
1 - LOA to Home
2 - LOA to Hospital [GREATER THAN]85% occupancy
3 - LOA to Hospital [LESS THAN]85% occupancy
4 - LOA no pay to HDC
5 - LOA no pay, Medicare covered
|
|
16. Remarks
|
This field is not required by Medicaid.
|
|
17. Provider Representative Signature
|
The provider or designated authorized individual must sign and
date the claim certifying that the services were personally rendered by the
provider or under the provider's direction. "Provider's signature" is defined
as the provider's actual signature, a rubber stamp of the provider's signature,
an automated signature, a typewritten signature or the signature of an
individual authorized by the provider rendering the service.
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18. Date
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Enter the date the bill was signed or sent to the Arkansas
Medicaid Program for payment.
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