016.06.08 Ark. Code R. 037 - Ambulatory Surgical Centers Provider Manual Update Transmittal #108

Section II

Ambulatory Surgical Center

230.100 Reimbursement

Covered outpatient surgical procedures are assigned to one of four groups for reimbursement purposes. Billing instructions are in Section 242.110.

A. Medicaid has established a maximum allowable fee for each surgical group.

1. Reimbursement is the lesser of the billed charge or the maximum allowable fee for the applicable surgical group.

2. The maximum allowable fees are global fees that include all of the covered ASC facility services listed in section 210.200.

3. Lab, X-ray and machine tests that are not directly related to the surgery are covered separately.

B. Billings for surgical procedures that have not been assigned to a surgical group are manually reviewed and manually priced by medical professionals on staff at the Division of Medical Services) requiring that the claim be submitted on a paper UB-04 claim form and accompanied by an operative report.

C. Some covered services payable to ASCs are not surgical or are not included in surgical groups for reimbursement purposes. Refer to sections 216.600 through 216.900 for coverage information regarding such services.

D. When multiple surgical procedures are performed on the same date of service, all charges except lab, x-ray and machine tests must be billed using the most complex applicable procedure code.

241.000 Introduction to Billing

Ambulatory Surgical Center providers use the Uniform Billing form CMS-1450 (UB-04) to bill the Arkansas Medicaid Program on paper. Each claim may contain charges for only one beneficiary.

A Medicaid claim may contain only one billing provider's charges for services furnished to only one Medicaid beneficiary.

Section III of this manual contains information regarding Provider Electronic Solutions (PES) and other available options for electronic claims submission.

When multiple surgical procedures are performed on the same date of service, all charges except lab, x-ray and machine tests must be billed using the most complex procedure code.

Notes

016.06.08 Ark. Code R. 037

10/2/2008