016.06.17 Ark. Code R. § 019 - Personal Care Manual
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
The following requirements must be met prior to certification by the Division of Aging and Adult Services (DAAS) by providers of attendant care services. The provider must:
£;. Employ and supervise direct care staff who:
Each provider must maintain adequate documentation to support that direct care staff meets the training and, as applicable, testing requirements according to licensure, agency policy and DAAS certification.
Attendant Care service providers who hold a current Arkansas State Board of Health Class A and/or Class B license or Private Care Agency license must recertify with DAAS every three years; however, the provider must submit a copy the agency's current license to DAAS each year when the license is renewed.
Providers are required to submit copy of renewed license to DAAS.
NOTE: The Class A, Class B or Private Care Agency license provider's
ElderChoices and AAPD certification will be valid as an Attendant Care services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices and AAPD.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of Hot Home-Delivered Meat services, a provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable
Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
IL Sll owners, principals, employees, and contract staff of a hot, home-delivered mea] services provider must comply with criminal background:checks according to Arkansas jStste Law at 20-33-213 and 20-38-101 _etsecj\
£. Notify the DAAS RN immediately if:
NOTE: Changes in service delivery must receive prior approval by the DAAS RN who is responsible for the individual's Person-Centered Service Plan (PCSP). Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Hot Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals provider's ElderChoices certification will be valid as an ARCholces Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
In order to become approved providers of frozen meals, providers must meet all applicable requirements of the Division of Aging and Adult Services (DAAS) Nutrition Services Program Policy Number 206.
To be certified by DAAS as a provider of Home-Delivered Meal services, a meal provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable
Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
£. Provide frozen meals that:
NOTE: The milk must be delivered to the beneficiary at least seven (7) days prior to its expiration date.
NOTE: Changes In service delivery must receive prior approval by the DAAS RN who is responsible for the individual's Person-Centered Services Plan (PCSP). Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Frozen Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals ElderChoices provider's certification will be valid as an ARChoices Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Home Health
Providers
Home Health providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Enrolled providers must submit copies of license and certification renewals to the Provider Enrollment Unit, Division of Medical Services (DMS), within 30 days of the issuance of those documents. View or print Provider Enrollment Unit contact information.
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment
A comprehensive medical screening program for all eligible Medicaid children requires the medical provider to assume overall responsibility for detection and treatment of conditions found among these young patients. This means the provider should have knowledge of specialized referral services available within the community and should maintain continuing relationships with physician specialists. It also requires the provider to work closely with the Arkansas Department of Human Services office staff to ensure that eligible children in need of medical attention take full advantage of the medical services available to them. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information.
The screening procedures outlined in Sections 213.000 and 215.000 of this manual are considered the minimal elements of a comprehensive screening. Other procedures may be included depending upon the child's age and health history. Each of the screening procedures is based on recommendations from the federal Department of Health and Human Services and the American Academy of Pediatrics. Each screening should be billed separately, providing the appropriate information for each of the applicable screening components. Other specific procedures may be used at the screener's discretion as long as the following federally mandated components are included in the complete medical screening procedure: observe and measure growth and development, give nutritional advice, immunize, counsel and give health education and perform laboratory procedures applicable for the age of the child.
Requirements for Periodic Medical. Visual. Hearing and Dental Screenings
Distinct periodicity schedules have been established for medical screening services, vision services, hearing services and dental services (i.e., each of these services has its own periodicity schedule). Periodic visual, hearing and dental screens should not duplicate prior services.
Private Duty Nursing Services______
Private Duty Nursing Services {PDN) providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Providers who have agreements with Medicaid to provide other services to Medicaid beneficiaries must have a separate provider application and Medicaid contract to provide private duty nursing services. A separate provider number is assigned.
______Section H
Rural Health Clinic
_______Section II
Physician/Independent Lab/CRNA/Radiatlon Therapy Center
The Arkansas Medicaid Program depends upon the participation and cooperation of Arkansas physicians for access to most categories of health care.
Most Medicaid covered services require a physician's prescription and/or certification that a service is medically necessary. Arkansas' physicians are active partners with Medicaid in the prudent use of the State's Medicaid dollars for excellent and consistent medical care. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information and referral processes.
__________Section I
Section H
IndependentChoices
The Division of Aging and Adult Services (DAAS) is the point of entry for all enrollment activity for IndependentChoices. The program is limited based on an approved number through the Medicaid State Plan.
The individual or their designee will first call the IndependentChoices toll-free number at 888-682-0044 or 866-710-0456. Information about the program is provided to the individual and verification made that the individual is currently enrolled in a Medicaid category that covers personal assistance services. If the individual is currently enrolled in an appropriate Medicaid category and has an assessed physical dependency need for "hands on" assistance with personal care needs, DAAS will enter the participant's information into a DAAS database. If the individual is not currently enrolled in an appropriate Medicaid category, the individual will be referred to the DHS County Office for eligibility determination.
The IndependentChoices counselor, nurse and fiscal agent will then work with the individual to complete the enrollment forms either by mail and telephone contact or by a face-to-face meeting. The individual will be provided with a program manual, which explains the individual's responsibilities regarding enrollment and continuing participation. The individual must complete the forms in the Enrollment Packet, which consists of the Participant Responsibilities and Agreement, the Backup Personal Assistant and the Authorization to Disclose Health Information. The individual must also complete the forms in the Employer Packet, which includes the Limited Power of Attorney, IRS and direct deposit forms related to being a household employer. Each personal assistant must complete the forms in the Employee Packet which include the standard tax withholding forms normally completed by an employee, the Employment Eligibility Verification Form (I-9), a Participant/Personal Assistant Agreement, Employment Application and a Provider Agreement. Each packet includes step-by-step instructions on how to complete the above forms. Assistance is available to the individual, Decision-Making Partner/Communications Manager and the personal assistant to help complete the forms and answer any questions.
As part of the enrollment process, the DAAS RN will complete an assessment using the Home and Community Based Services (HCBS) Level of Care Assessment Tool. The DAAS RN will determine, through the completed assessment and professional judgment, the level of medical necessity. This determination creates the budget for self-directed services. Eligibility for personal care services is based on the same criteria as state plan personal care services. NOTE: For ARChoices beneficiaries, the DAAS RN will determine the need for personal care and attendant care hours needed. The ARChoices plan of care will reflect that the beneficiary chooses IndependentChoices as the provider. DAAS-HCBS staff will obtain authorization from DHS professional staff or contractors) designated by DHS for persons not receiving ARChoices waiver services.
After the in-home assessment, the DAAS RN will complete the paperwork and coordinate with the IndependentChoices counselor. The counselor will process all of the completed enrollment forms. The assessment is sent to DHS professional staff or contractors) designated by DHS for authorization if the beneficiary is not authorized for services through a waiver plan of care for ARChoices. State and IRS tax forms will be retained by the fiscal agent. Disbursement of funds to a beneficiary or their employee will not occur until all required forms are accurately completed and in the possession of the fiscal agent.
Personal care assessments for beneficiaries aged 21 years or older and authorized DHS professional staff or contractors) designated by DHS in excess of 14.75 hours per week are forwarded to DAAS for coordination with Utilization Review in the Division of Medical Services for approval. View or print Utilization Review contact Information. For beneficiaries under age 21, all personal care hours must be authorized through Medicaid's contracted Quality Improvement Organization (QIO). View or print AFMC contact information.
IndependentChoices follows the rules and regulations found in the Arkansas Medicaid Personal Care Provider Manual in determining and authorizing personal care hours. For beneficiaries receiving services through the ARChoices waiver program, the signature of the DAAS RN is sufficient to authorize personal care services. After the service plan is authorized, the actual day services begin is dependent upon all of the following conditions:
If the beneficiary is not also a beneficiary of ARChoices services, then continuation of personal assistance services requires reauthorization prior to the end of the current service plan end date.
When the approval by Utilization Review is received, or the beneficiary needs 14.75 hours or less per week, the IndependentChoices Counselor will contact the beneficiary or Decision-Making Partner/Communications Manager to develop the cash expenditure plan. The Medicaid beneficiary as the employer and the counselor will determine when IndependentChoices services can begin, but may not commence prior to the date authorized by DHS professional staff or contractors) designated by DHS.
All personal assistant services must be prior authorized in accordance with the procedures in the Personal Care Provider Manual.
IndependentChoices services are designed to be provided in the home or workplace of the participant. Services may be provided outside the participant's home or workplace if DHS professional staff or contractors) designated by DHS authorizes the services during a trip or vacation.
Parti cipants may be disenrolled for the following reasons:
Whenever a participant is involuntarily disenrolled, the IndependentChoices program will mail a notice to close the case. The notice will provide at least 10 days but no more than 30 days before IndependentChoices will be discontinued, depending on the situation. During the transition period, the counselor will work with the participant or Decision-Making Partner to provide services to help the individual transition to the most appropriate services available
The IndependentChoices participant is the employer of record, and as such, hires a Personal Assistant who meets these requirements:
Section U
Hospice
Hospice Services providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Medicaid beneficiaries are allowed to receive Medicaid personal care services, in addition to hospice aide services, if the personal care services are unrelated to the terminal condition or the hospice provider is using the personal care services to supplement the hospice aide and homemaker services.
Prior Authorization for personal care for beneficiaries receiving both hospice services and personal care services will be considered based on the individual beneficiary's physical dependency needs. Requests for personal care services require an Independent Assessment to determine medical necessity and to assure duplication of services will be adjusted accordingly. Please refer to the Independent Assessment Guide for related information.
NOTE: Based on audit findings, it is imperative that required documentation be recorded by the hospice provider and available in the hospice record. Documentation must substantiate all services provided. It is the hospice provider's responsibility to coordinate care and assure there is no duplication of services. While hospice care and personal care services are not mutually exclusive, documentation must support the inclusion of both services and the corresponding amounts on the care plan. To avoid duplication and to support hospice care in the home that provides the amount of services required to meet the needs of the beneficiary, the amount of personal care services needed beyond the care provided by the hospice agency must meet the criteria detailed in this section. Most often, if personal care services are in place prior to hospice services starting, the amount of personal care services will be reduced to avoid any duplication, if those services are not reduced or discontinued, documentation in the hospice and personal care records must explain the need for both and be supported by the policy in this section.
Personal Care
Providers
Numerous agencies, organizations and other entities may qualify for enrollment in the Arkansas Medicaid Personal Care Program. Participation requirements vary among these different types of providers. Sections 200.110 through 200.160 outline the participation requirements specific to each type of personal care provider. Section 201.000 describes the procedures required to enroll in the Medicaid Program. Sections 201.010 through 201.050 set forth the licensing, certification and other requirements specific to each type of personal care provider.
All owners, principals, employees, and contract staff of a personal care provider must comply with criminal background checks according to Arkansas State Law at 20-33-213 and 20-38-101 ef seq.
I ndependentChoices;
* Assistance with medications is a personal care service only to the extent that the Arkansas Nurse Practice Act and implementing regulations permit a personal care aide to perform the service.
No condition of this section alters or adversely affects the status of individuals who are furnished personal care in sheltered workshops or similarly authorized habilitative environments. There may be a few beneficiaries working in sheltered workshops solely or primarily because they have access to personal care in that setting. This expansion of personal care outside the home may enable some of those individuals to move or attempt to move into an integrated work setting.
Care Providers
On rare occasions, a personal care beneficiary might have urgent cause to travel to a locality outside his or her personal care provider's service area. If DHS professional staff or contractors) designated by DHS authorizes personal care during the beneficiary's stay in that locality, the beneficiary may choose a personal care provider agency in the service area to which he or she is traveling.
If the selected provider is an in-state provider, the selected provider's services may be covered if all the following requirements are met:
If the provider is an out-of-state provider, the provider must also download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application and contract to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and Medicaid contract. View or print the provider enrollment and contract package (Application Packet).
The selected provider must also submit to the Division of Medical Services, Utilization Review Section, a written request for prior authorization accompanied with copies of the provider's license, Medicare certification, beneficiary's identifying information and the beneficiary's service plan. View or print Division of Medical Services. Utilization Review Section contact information.
Plan
The DAAS RN is responsible for developing an ARChoices Plan of Care that includes both waiver and non-waiver services. Once developed, the Plan of Care is signed by the DAAS RN authorizing the services listed.
The signed ARChoices Plan of Care will suffice as the "Personal Care Authorization" for services required in the Personal Care Program. The signature of the DAAS RN on the ARChoices Plan of Care simply replaces the need for the prior authorization of personal care services. The personal care service plan, developed by the Personal Care provider, is still required.
As the ARChoices Plan of Care is effective for one year, once signed by the DAAS RN; the authorization for personal care services, when included on the ARChoices Plan of Care, will be for one year from the date of the DAAS RN's signature, unless revised by the DAAS RN or the personal care sen/ice plan needs to be revised, whichever occurs first. If personal care services continue unchanged as authorized on the ARChoices Plan of Care, a new service plan is not required at the 6-month interval.
NOTE: For ARChoices participants who receive personal care through traditional agency services or have chosen to receive their personal care services through the IndependentChoices Program, the ARChoices plan of care, signed by a DAAS RN, will serve as the authorization for personal care services for one year from the date of the DAAS RN's signature, as described above.
The responsibility of developing a personal care service plan is not placed with the DAAS RN. The personal care provider is still required to complete a service plan, as described in the Arkansas Medicaid Personal Care Provider Manual.
The Arkansas Medicaid Program waives no other Personal Care Program requirements with regard to personal care service plan authorizations obtained by DAAS RNs.
Requested changes to the personal care services included on the ARChoices Plan of Care may originate with the personal care RN or the DAAS RN, based on the beneficiary's circumstances. Unless requested by an IndependentChoices beneficiary, the individual or agency requesting revisions to the Personal Care services on the ARChoices Plan of Care is responsible for securing any required signatures authorizing the change prior to the ARChoices Plan of Care being revised. The DAAS RN will obtain electronic signatures for dates of service on or after January 1,2013.
If revised by the DAAS RN, a copy of the revised ARChoices Plan of Care and a Start of Care Form (AAS-9510) will be mailed to the personal care provider within 10 working days after being revised. If authorization is secured by the Personal Care agency, a copy of the revised personal care order, signed by the provider, must be sent to the DAAS RN prior to implementing any revisions. Once received, the ARChoices Plan of Care will be revised accordingly within 10 days of its receipt. If any problems are encountered with implementing the requested revisions, the DAAS RN will contact the personal care provider to discuss possible alternatives. These discussions and the final decision regarding the requested revisions must be documented in the nurse narrative. The final decision, as stated above, rests with the DAAS RN.
For IndependentChoices participants, the DMS-618 is not required. Only the AR Path assessment will be used by the DAAS RN.
For IndependentChoices participants who are also active waiver participants in the ARChoices Program, the assessment tool used for waiver level of care determination and the waiver plan of care will suffice to support authorization for personal care services, if signed by the DAAS RN. Eligibility for personal care services is based on the same criteria as state plan personal care services. Services are effective the date of the DAAS RN's signature on the waiver assessment tool or the waiver plan of care, whichever is the latter of the two. Personal care services provided prior to that date are not eligible for Medicaid reimbursement. The waiver assessment tool and the waiver plan of care must include, at least, the information included on the DMS-618 that is utilized to support the medical necessity, eligibility and amount of personal care services provided through IndependentChoices or agency personal care services. This information is required in documentation whether or not an extension of benefits is requested. As with all required documentation, this information must be available in the participant's chart or electronic record and available for audit and Quality Management Strategy reviews.
A beneficiary must receive services in accordance with an individualized service plan.
regarding the delivery of services. The plan must reflect whether the individual is receiving services in more than one setting. If a beneficiary is receiving services in more than one setting, it must be dear in which setting a beneficiary receives a particular service or assistance. See part G of Section 215.200, Section 216.201 and Sections 220.110 through 220.112.
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Sample Assessment Entry |
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Eating: |
The beneficiary needs someone to place eating utensils in his grasp and to retrieve them when he drops them. |
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Oral hygiene: |
The beneficiary needs someone to place his toothbrush in his grasp and to retrieve it when he drops it. |
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Sample Service Plan Entry |
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Eating: |
Place the {object) in {beneficiary's name)'s grasp. |
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Oral hygiene: |
Retrieve the {object) when (beneficiary's name) drops it and replace the (object) in his grasp. |
NOTE: Subsections (A) (3) and (B) are not applicable to IndependentChoices program.
When a beneficiary receives services from more than one personal care provider, each provider must comply with the following requirements.
NOTE: This section is not applicable to the IndependentChoices program.
Rule D in this section is effective for dates of service on and after March 1,2008.
The personal care provider must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the Department of Health and Human Services and its authorized agents or officials; records including:
Reviews will be completed by DHS professional staff or contractors) designated by DHS within fifteen (15) working days of receipt of a complete PA request.
When a provider must bill on a paper claim, the fiscal agent accepts only red-lined, sensor-coded CMS-1500 claim forms. Claim photocopies and claim forms that are not sensor-coded cannot be processed.
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Field Name and Number |
Instructions for Completion |
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1. (type of coverage) |
Not required. |
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1a. INSURED'S I.D. NUMBER (For Program in Item 1) |
Beneficiary's 10-digit Medicaid or ARKids First-A identification number. |
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2. PATIENT'S NAME (Last Name, First Name, Middle Initial) |
Beneficiary's last name and first name. |
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3. PATIENT'S BIRTH DATE |
Beneficiary's date of birth as given on the individual's Medicaid or ARKids First-A identification card. Format: MM/DD/YY. |
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SEX |
Check M for male or F for female. |
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4. INSURED'S NAME (Last Name, First Name, Middle Initial) |
Required if insurance affects this claim. Insured's last name, first name and middle initial. |
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5. PATIENTS ADDRESS (No., Street) |
Optional. Beneficiary's complete mailing address (street address or post office box). |
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CITY |
Name of the city in which the beneficiary resides. |
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STATE |
Two-letter postal code for the state in which the beneficiary resides. |
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ZIP CODE |
Five-digit ZIP code; nine digits for post office box. |
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TELEPHONE (Include Area Code) |
The beneficiary's telephone number or the number of a reliable message/contact/ emergency telephone |
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6. PATIENT RELATIONSHIP TO INSURED |
If insurance affects this claim, check the box indicating the patient's relationship to the insured. |
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7. INSURED'S ADDRESS (No., Street) |
Required if the insured's address is different from the patient's address. |
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CITY |
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STATE |
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ZIP CODE |
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TELEPHONE (Include Area Code) |
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8. RESERVED |
Reserved for NUCC use. |
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9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) |
If patient has other insurance coverage as indicated in Field 11d, the other Insured's last name, first name and middle initial. |
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a. OTHER INSURED'S POLICY OR GROUP NUMBER |
Policy and/or group number of the insured individual. |
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b. RESERVED |
Reserved for NUCC use. |
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SEX |
Not required. |
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c. EMPLOYER'S NAME OR SCHOOL NAME |
Required when items 9a and d are required. Name of the insured individual's employer and/or school. |
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d. INSURANCE PLAN NAME OR PROGRAM NAME |
Name of the insurance company. |
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10. IS PATIENT'S CONDITION RELATED TO: |
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a. EMPLOYMENT? (Current or Previous) |
Check YES or NO. |
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b. AUTO ACCIDENT? |
Required when an auto accident is related to the services. Check YES or NO. |
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PLACE (State) |
If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. |
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c. OTHER ACCIDENT? |
Required when an accident other than automobile is related to the services. Check YES or NO. |
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d. CLAIM CODES |
The "Claim Codes" identify additional information about the beneficiary's condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition codes is found at www.nucc.oraunder Code Sets. |
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11 . INSURED'S POLICY GROUP OR FECA NUMBER |
Not required when Medicaid is the only payer. |
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a. INSURED'S DATE OF BIRTH |
Not required. |
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SEX |
Not required. |
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b. OTHER CLAIM ID NUMBER |
Not required. |
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c. INSURANCE PLAN NAME OR PROGRAM NAME |
Not required. |
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d. IS THERE ANOTHER HEALTH BENEFIT PLAN? |
When private or other insurance may or will cover any of the services, check YES and complete items 9, 9a, 9c and 9d.Only one box can be marked. |
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12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE |
Enter "Signature on File," "SOF" or legal signature. |
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13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE |
Enter "Signature on File," "SOF" or legal signature. |
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14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) |
Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness ; 484 Last Menstrual Period. |
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15. OTHER DATE |
Enter another date related to the beneficiary's condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The "Other Date" identifies additional date information about the beneficiary's condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION |
Not required. |
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17. NAME OF REFERRING PROVIDER OR OTHER SOURCE |
Name and title of the referral source. |
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17a. (blank) |
The 9-digit Arkansas Medicaid provider ID number of the referring physician when applicable. |
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17b. N PI |
Not required. |
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18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES |
Not applicable. |
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19. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER |
Insert LEA number. |
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20. OUTSIDE LAB? |
Not required. |
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$ CHARGES |
Not required. |
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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY |
Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use"9nforlCD-9-CM. Use"0"forlCD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
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22. RESUBMISSION CODE |
Reserved for future use. |
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ORIGINAL REF. NO. |
Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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23. PRIOR AUTHORIZATION NUMBER |
The prior authorization or benefit extension control number when applicable. |
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24A. DATE(S) OF SERVICE |
The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. A provider may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the date sequence. 3. RCFs may bill for a date span of any length within the same calendar month, provided the beneficiary was present every day of the date span and all services provided within the date span were at the same Level of Care. |
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B. PLACE OF SERVICE |
Two-digit national standard place of service code. |
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C. EMG |
Enter UT for "Yes" or leave blank if "No." EMG identifies if the service was an emergency. |
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D. PROCEDURES, SERVICES, OR SUPPLIES |
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CPT/HCPCS |
One CPT or HCPCS procedure code for each detail. |
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MODIFIER |
Modifier(s) when applicable. |
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E. DIAGNOSIS POINTER |
Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The "Diagnosis Pointer" is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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F. $ CHARGES |
The full charge for the services totaled in the detail. This charge must be the usual charge to any client, patient or other beneficiary of the provider's services. RCFs' charges should equal no less than the product of the number of units (days) times the beneficiary's Daily Service Rate. If the charge is less, Medicaid will pay the billed charge. |
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G. DAYS OR UNITS |
The units (in whole numbers) of service provided during the period indicated in Field 24A of the detail. |
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H. EPSDT/Family Plan |
Enter E if the services resulted from a Child Health Services (EPSDT) screening and referral. |
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1. ID QUAL |
Not required. |
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J. RENDERING PROVIDER ID# |
Not applicable. |
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NPI |
Not required. |
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25. FEDERAL TAX I.D. NUMBER |
Not required. This information is carried in the provider's Medicaid file. If it changes, advise Provider Enrollment so that the year-end 1099 will be correct and reported correctly. |
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26. PATIENT'S ACCOUNT NO. |
Optional entry for providers' accounting and account-retrieval purposes. Enter up to 16 numeric, alphabetic or alpha-numeric characters. This character set appears on the Remittance Advice as UMRN." |
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27. ACCEPT ASSIGNMENT? |
Not required. Assignment is automatically accepted by the provider when billing Medicaid. |
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28. TOTAL CHARGE |
Total of Column 24F-the sum of all charges on the claim. |
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29. AMOUNT PAID |
Enter the total of payments received from other sources on this claim. Do not include amounts previously paid by Medicaid. |
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30. RESERVED |
Reserved for NUCC use. |
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31. SIGNATURE OF PROVIDER |
The performing provider or an individual authorized by the performing provider or by an institutional, corporate, business or other provider organization, must sign and date the claim, certifying that the services were furnished by the provider, under (when applicable) the direction of the individual provider or other qualified individual, and in strict and verifiable accordance with all applicable rules of the Medicaid program in which the provider participates. A "provider's signature" is the provider's or authorized individual's personally written signature, a rubber stamp of the signature, an automated signature or a typed signature. The name of a group practice, a facility or institution, a corporation, a business or any other organization will prevent the claim from being processed. |
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32. SERVICE FACILITY LOCATION INFORMATION |
If services were not performed at the beneficiary's home or at the provider's facility (e.g., school, DDS facility etc.) enter the name, street address, city, state and zip code of the facility, workplace etc. where services were performed. If services were furnished at multiple sites (for instance, when job-seeking), indicate "multiple locations" or leave blank. |
|
a. (blank) |
Not required. |
|
b. (blank) |
Not required. |
|
33. BILLING PROVIDER INFO & |
Billing provider's name and complete address. |
|
PH# |
Telephone number is requested but not required. |
|
a. (blank) |
Not required. |
|
b. (blank) |
Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
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.
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
The following requirements must be met prior to certification by the Division of Aging and Adult Services (DAAS) by providers of attendant care services. The provider must:
£;. Employ and supervise direct care staff who:
Each provider must maintain adequate documentation to support that direct care staff meets the training and, as applicable, testing requirements according to licensure, agency policy and DAAS certification.
Attendant Care service providers who hold a current Arkansas State Board of Health Class A and/or Class B license or Private Care Agency license must recertify with DAAS every three years; however, the provider must submit a copy the agency's current license to DAAS each year when the license is renewed.
Providers are required to submit copy of renewed license to DAAS.
NOTE: The Class A, Class B or Private Care Agency license provider's
ElderChoices and AAPD certification will be valid as an Attendant Care services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices and AAPD.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of Hot Home-Delivered Meat services, a provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable
Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
IL Sll owners, principals, employees, and contract staff of a hot, home-delivered mea] services provider must comply with criminal background:checks according to Arkansas jStste Law at 20-33-213 and 20-38-101 _etsecj\
£. Notify the DAAS RN immediately if:
NOTE: Changes in service delivery must receive prior approval by the DAAS RN who is responsible for the individual's Person-Centered Service Plan (PCSP). Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Hot Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals provider's ElderChoices certification will be valid as an ARCholces Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
In order to become approved providers of frozen meals, providers must meet all applicable requirements of the Division of Aging and Adult Services (DAAS) Nutrition Services Program Policy Number 206.
To be certified by DAAS as a provider of Home-Delivered Meal services, a meal provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable
Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
£. Provide frozen meals that:
NOTE: The milk must be delivered to the beneficiary at least seven (7) days prior to its expiration date.
NOTE: Changes In service delivery must receive prior approval by the DAAS RN who is responsible for the individual's Person-Centered Services Plan (PCSP). Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Frozen Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals ElderChoices provider's certification will be valid as an ARChoices Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Home Health
Providers
Home Health providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Enrolled providers must submit copies of license and certification renewals to the Provider Enrollment Unit, Division of Medical Services (DMS), within 30 days of the issuance of those documents. View or print Provider Enrollment Unit contact information.
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment
A comprehensive medical screening program for all eligible Medicaid children requires the medical provider to assume overall responsibility for detection and treatment of conditions found among these young patients. This means the provider should have knowledge of specialized referral services available within the community and should maintain continuing relationships with physician specialists. It also requires the provider to work closely with the Arkansas Department of Human Services office staff to ensure that eligible children in need of medical attention take full advantage of the medical services available to them. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information.
The screening procedures outlined in Sections 213.000 and 215.000 of this manual are considered the minimal elements of a comprehensive screening. Other procedures may be included depending upon the child's age and health history. Each of the screening procedures is based on recommendations from the federal Department of Health and Human Services and the American Academy of Pediatrics. Each screening should be billed separately, providing the appropriate information for each of the applicable screening components. Other specific procedures may be used at the screener's discretion as long as the following federally mandated components are included in the complete medical screening procedure: observe and measure growth and development, give nutritional advice, immunize, counsel and give health education and perform laboratory procedures applicable for the age of the child.
Requirements for Periodic Medical. Visual. Hearing and Dental Screenings
Distinct periodicity schedules have been established for medical screening services, vision services, hearing services and dental services (i.e., each of these services has its own periodicity schedule). Periodic visual, hearing and dental screens should not duplicate prior services.
Private Duty Nursing Services______
Private Duty Nursing Services {PDN) providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Providers who have agreements with Medicaid to provide other services to Medicaid beneficiaries must have a separate provider application and Medicaid contract to provide private duty nursing services. A separate provider number is assigned.
______Section H
Rural Health Clinic
_______Section II
Physician/Independent Lab/CRNA/Radiatlon Therapy Center
The Arkansas Medicaid Program depends upon the participation and cooperation of Arkansas physicians for access to most categories of health care.
Most Medicaid covered services require a physician's prescription and/or certification that a service is medically necessary. Arkansas' physicians are active partners with Medicaid in the prudent use of the State's Medicaid dollars for excellent and consistent medical care. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information and referral processes.
__________Section I
Section H
IndependentChoices
The Division of Aging and Adult Services (DAAS) is the point of entry for all enrollment activity for IndependentChoices. The program is limited based on an approved number through the Medicaid State Plan.
The individual or their designee will first call the IndependentChoices toll-free number at 888-682-0044 or 866-710-0456. Information about the program is provided to the individual and verification made that the individual is currently enrolled in a Medicaid category that covers personal assistance services. If the individual is currently enrolled in an appropriate Medicaid category and has an assessed physical dependency need for "hands on" assistance with personal care needs, DAAS will enter the participant's information into a DAAS database. If the individual is not currently enrolled in an appropriate Medicaid category, the individual will be referred to the DHS County Office for eligibility determination.
The IndependentChoices counselor, nurse and fiscal agent will then work with the individual to complete the enrollment forms either by mail and telephone contact or by a face-to-face meeting. The individual will be provided with a program manual, which explains the individual's responsibilities regarding enrollment and continuing participation. The individual must complete the forms in the Enrollment Packet, which consists of the Participant Responsibilities and Agreement, the Backup Personal Assistant and the Authorization to Disclose Health Information. The individual must also complete the forms in the Employer Packet, which includes the Limited Power of Attorney, IRS and direct deposit forms related to being a household employer. Each personal assistant must complete the forms in the Employee Packet which include the standard tax withholding forms normally completed by an employee, the Employment Eligibility Verification Form (I-9), a Participant/Personal Assistant Agreement, Employment Application and a Provider Agreement. Each packet includes step-by-step instructions on how to complete the above forms. Assistance is available to the individual, Decision-Making Partner/Communications Manager and the personal assistant to help complete the forms and answer any questions.
As part of the enrollment process, the DAAS RN will complete an assessment using the Home and Community Based Services (HCBS) Level of Care Assessment Tool. The DAAS RN will determine, through the completed assessment and professional judgment, the level of medical necessity. This determination creates the budget for self-directed services. Eligibility for personal care services is based on the same criteria as state plan personal care services. NOTE: For ARChoices beneficiaries, the DAAS RN will determine the need for personal care and attendant care hours needed. The ARChoices plan of care will reflect that the beneficiary chooses IndependentChoices as the provider. DAAS-HCBS staff will obtain authorization from DHS professional staff or contractors) designated by DHS for persons not receiving ARChoices waiver services.
After the in-home assessment, the DAAS RN will complete the paperwork and coordinate with the IndependentChoices counselor. The counselor will process all of the completed enrollment forms. The assessment is sent to DHS professional staff or contractors) designated by DHS for authorization if the beneficiary is not authorized for services through a waiver plan of care for ARChoices. State and IRS tax forms will be retained by the fiscal agent. Disbursement of funds to a beneficiary or their employee will not occur until all required forms are accurately completed and in the possession of the fiscal agent.
Personal care assessments for beneficiaries aged 21 years or older and authorized DHS professional staff or contractors) designated by DHS in excess of 14.75 hours per week are forwarded to DAAS for coordination with Utilization Review in the Division of Medical Services for approval. View or print Utilization Review contact Information. For beneficiaries under age 21, all personal care hours must be authorized through Medicaid's contracted Quality Improvement Organization (QIO). View or print AFMC contact information.
IndependentChoices follows the rules and regulations found in the Arkansas Medicaid Personal Care Provider Manual in determining and authorizing personal care hours. For beneficiaries receiving services through the ARChoices waiver program, the signature of the DAAS RN is sufficient to authorize personal care services. After the service plan is authorized, the actual day services begin is dependent upon all of the following conditions:
If the beneficiary is not also a beneficiary of ARChoices services, then continuation of personal assistance services requires reauthorization prior to the end of the current service plan end date.
When the approval by Utilization Review is received, or the beneficiary needs 14.75 hours or less per week, the IndependentChoices Counselor will contact the beneficiary or Decision-Making Partner/Communications Manager to develop the cash expenditure plan. The Medicaid beneficiary as the employer and the counselor will determine when IndependentChoices services can begin, but may not commence prior to the date authorized by DHS professional staff or contractors) designated by DHS.
All personal assistant services must be prior authorized in accordance with the procedures in the Personal Care Provider Manual.
IndependentChoices services are designed to be provided in the home or workplace of the participant. Services may be provided outside the participant's home or workplace if DHS professional staff or contractors) designated by DHS authorizes the services during a trip or vacation.
Parti cipants may be disenrolled for the following reasons:
Whenever a participant is involuntarily disenrolled, the IndependentChoices program will mail a notice to close the case. The notice will provide at least 10 days but no more than 30 days before IndependentChoices will be discontinued, depending on the situation. During the transition period, the counselor will work with the participant or Decision-Making Partner to provide services to help the individual transition to the most appropriate services available
The IndependentChoices participant is the employer of record, and as such, hires a Personal Assistant who meets these requirements:
Section U
Hospice
Hospice Services providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
Medicaid beneficiaries are allowed to receive Medicaid personal care services, in addition to hospice aide services, if the personal care services are unrelated to the terminal condition or the hospice provider is using the personal care services to supplement the hospice aide and homemaker services.
Prior Authorization for personal care for beneficiaries receiving both hospice services and personal care services will be considered based on the individual beneficiary's physical dependency needs. Requests for personal care services require an Independent Assessment to determine medical necessity and to assure duplication of services will be adjusted accordingly. Please refer to the Independent Assessment Guide for related information.
NOTE: Based on audit findings, it is imperative that required documentation be recorded by the hospice provider and available in the hospice record. Documentation must substantiate all services provided. It is the hospice provider's responsibility to coordinate care and assure there is no duplication of services. While hospice care and personal care services are not mutually exclusive, documentation must support the inclusion of both services and the corresponding amounts on the care plan. To avoid duplication and to support hospice care in the home that provides the amount of services required to meet the needs of the beneficiary, the amount of personal care services needed beyond the care provided by the hospice agency must meet the criteria detailed in this section. Most often, if personal care services are in place prior to hospice services starting, the amount of personal care services will be reduced to avoid any duplication, if those services are not reduced or discontinued, documentation in the hospice and personal care records must explain the need for both and be supported by the policy in this section.
Personal Care
Providers
Numerous agencies, organizations and other entities may qualify for enrollment in the Arkansas Medicaid Personal Care Program. Participation requirements vary among these different types of providers. Sections 200.110 through 200.160 outline the participation requirements specific to each type of personal care provider. Section 201.000 describes the procedures required to enroll in the Medicaid Program. Sections 201.010 through 201.050 set forth the licensing, certification and other requirements specific to each type of personal care provider.
All owners, principals, employees, and contract staff of a personal care provider must comply with criminal background checks according to Arkansas State Law at 20-33-213 and 20-38-101 ef seq.
I ndependentChoices;
* Assistance with medications is a personal care service only to the extent that the Arkansas Nurse Practice Act and implementing regulations permit a personal care aide to perform the service.
No condition of this section alters or adversely affects the status of individuals who are furnished personal care in sheltered workshops or similarly authorized habilitative environments. There may be a few beneficiaries working in sheltered workshops solely or primarily because they have access to personal care in that setting. This expansion of personal care outside the home may enable some of those individuals to move or attempt to move into an integrated work setting.
Care Providers
On rare occasions, a personal care beneficiary might have urgent cause to travel to a locality outside his or her personal care provider's service area. If DHS professional staff or contractors) designated by DHS authorizes personal care during the beneficiary's stay in that locality, the beneficiary may choose a personal care provider agency in the service area to which he or she is traveling.
If the selected provider is an in-state provider, the selected provider's services may be covered if all the following requirements are met:
If the provider is an out-of-state provider, the provider must also download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application and contract to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and Medicaid contract. View or print the provider enrollment and contract package (Application Packet).
The selected provider must also submit to the Division of Medical Services, Utilization Review Section, a written request for prior authorization accompanied with copies of the provider's license, Medicare certification, beneficiary's identifying information and the beneficiary's service plan. View or print Division of Medical Services. Utilization Review Section contact information.
Plan
The DAAS RN is responsible for developing an ARChoices Plan of Care that includes both waiver and non-waiver services. Once developed, the Plan of Care is signed by the DAAS RN authorizing the services listed.
The signed ARChoices Plan of Care will suffice as the "Personal Care Authorization" for services required in the Personal Care Program. The signature of the DAAS RN on the ARChoices Plan of Care simply replaces the need for the prior authorization of personal care services. The personal care service plan, developed by the Personal Care provider, is still required.
As the ARChoices Plan of Care is effective for one year, once signed by the DAAS RN; the authorization for personal care services, when included on the ARChoices Plan of Care, will be for one year from the date of the DAAS RN's signature, unless revised by the DAAS RN or the personal care sen/ice plan needs to be revised, whichever occurs first. If personal care services continue unchanged as authorized on the ARChoices Plan of Care, a new service plan is not required at the 6-month interval.
NOTE: For ARChoices participants who receive personal care through traditional agency services or have chosen to receive their personal care services through the IndependentChoices Program, the ARChoices plan of care, signed by a DAAS RN, will serve as the authorization for personal care services for one year from the date of the DAAS RN's signature, as described above.
The responsibility of developing a personal care service plan is not placed with the DAAS RN. The personal care provider is still required to complete a service plan, as described in the Arkansas Medicaid Personal Care Provider Manual.
The Arkansas Medicaid Program waives no other Personal Care Program requirements with regard to personal care service plan authorizations obtained by DAAS RNs.
Requested changes to the personal care services included on the ARChoices Plan of Care may originate with the personal care RN or the DAAS RN, based on the beneficiary's circumstances. Unless requested by an IndependentChoices beneficiary, the individual or agency requesting revisions to the Personal Care services on the ARChoices Plan of Care is responsible for securing any required signatures authorizing the change prior to the ARChoices Plan of Care being revised. The DAAS RN will obtain electronic signatures for dates of service on or after January 1,2013.
If revised by the DAAS RN, a copy of the revised ARChoices Plan of Care and a Start of Care Form (AAS-9510) will be mailed to the personal care provider within 10 working days after being revised. If authorization is secured by the Personal Care agency, a copy of the revised personal care order, signed by the provider, must be sent to the DAAS RN prior to implementing any revisions. Once received, the ARChoices Plan of Care will be revised accordingly within 10 days of its receipt. If any problems are encountered with implementing the requested revisions, the DAAS RN will contact the personal care provider to discuss possible alternatives. These discussions and the final decision regarding the requested revisions must be documented in the nurse narrative. The final decision, as stated above, rests with the DAAS RN.
For IndependentChoices participants, the DMS-618 is not required. Only the AR Path assessment will be used by the DAAS RN.
For IndependentChoices participants who are also active waiver participants in the ARChoices Program, the assessment tool used for waiver level of care determination and the waiver plan of care will suffice to support authorization for personal care services, if signed by the DAAS RN. Eligibility for personal care services is based on the same criteria as state plan personal care services. Services are effective the date of the DAAS RN's signature on the waiver assessment tool or the waiver plan of care, whichever is the latter of the two. Personal care services provided prior to that date are not eligible for Medicaid reimbursement. The waiver assessment tool and the waiver plan of care must include, at least, the information included on the DMS-618 that is utilized to support the medical necessity, eligibility and amount of personal care services provided through IndependentChoices or agency personal care services. This information is required in documentation whether or not an extension of benefits is requested. As with all required documentation, this information must be available in the participant's chart or electronic record and available for audit and Quality Management Strategy reviews.
A beneficiary must receive services in accordance with an individualized service plan.
regarding the delivery of services. The plan must reflect whether the individual is receiving services in more than one setting. If a beneficiary is receiving services in more than one setting, it must be dear in which setting a beneficiary receives a particular service or assistance. See part G of Section 215.200, Section 216.201 and Sections 220.110 through 220.112.
| Sample Assessment Entry | |
| Eating: | The beneficiary needs someone to place eating utensils in his grasp and to retrieve them when he drops them. |
| Oral hygiene: | The beneficiary needs someone to place his toothbrush in his grasp and to retrieve it when he drops it. |
| Sample Service Plan Entry | |
| Eating: | Place the {object) in {beneficiary's name)'s grasp. |
| Oral hygiene: | Retrieve the {object) when (beneficiary's name) drops it and replace the (object) in his grasp. |
NOTE: Subsections (A) (3) and (B) are not applicable to IndependentChoices program.
When a beneficiary receives services from more than one personal care provider, each provider must comply with the following requirements.
NOTE: This section is not applicable to the IndependentChoices program.
Rule D in this section is effective for dates of service on and after March 1,2008.
The personal care provider must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the Department of Health and Human Services and its authorized agents or officials; records including:
Reviews will be completed by DHS professional staff or contractors) designated by DHS within fifteen (15) working days of receipt of a complete PA request.
When a provider must bill on a paper claim, the fiscal agent accepts only red-lined, sensor-coded CMS-1500 claim forms. Claim photocopies and claim forms that are not sensor-coded cannot be processed.
| Field Name and Number | Instructions for Completion |
| 1. (type of coverage) | Not required. |
| 1a. INSURED'S I.D. NUMBER (For Program in Item 1) | Beneficiary's 10-digit Medicaid or ARKids First-A identification number. |
| 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) | Beneficiary's last name and first name. |
| 3. PATIENT'S BIRTH DATE | Beneficiary's date of birth as given on the individual's Medicaid or ARKids First-A identification card. Format: MM/DD/YY. |
| SEX | Check M for male or F for female. |
| 4. INSURED'S NAME (Last Name, First Name, Middle Initial) | Required if insurance affects this claim. Insured's last name, first name and middle initial. |
| 5. PATIENTS ADDRESS (No., Street) | Optional. Beneficiary's complete mailing address (street address or post office box). |
| CITY | Name of the city in which the beneficiary resides. |
| STATE | Two-letter postal code for the state in which the beneficiary resides. |
| ZIP CODE | Five-digit ZIP code; nine digits for post office box. |
| TELEPHONE (Include Area Code) | The beneficiary's telephone number or the number of a reliable message/contact/ emergency telephone |
| 6. PATIENT RELATIONSHIP TO INSURED | If insurance affects this claim, check the box indicating the patient's relationship to the insured. |
| 7. INSURED'S ADDRESS (No., Street) | Required if the insured's address is different from the patient's address. |
| CITY |
| STATE | |
| ZIP CODE | |
| TELEPHONE (Include Area Code) | |
| 8. RESERVED | Reserved for NUCC use. |
| 9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) | If patient has other insurance coverage as indicated in Field 11d, the other Insured's last name, first name and middle initial. |
| a. OTHER INSURED'S POLICY OR GROUP NUMBER | Policy and/or group number of the insured individual. |
| b. RESERVED | Reserved for NUCC use. |
| SEX | Not required. |
| c. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9a and d are required. Name of the insured individual's employer and/or school. |
| d. INSURANCE PLAN NAME OR PROGRAM NAME | Name of the insurance company. |
| 10. IS PATIENT'S CONDITION RELATED TO: | |
| a. EMPLOYMENT? (Current or Previous) | Check YES or NO. |
| b. AUTO ACCIDENT? | Required when an auto accident is related to the services. Check YES or NO. |
| PLACE (State) | If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. |
| c. OTHER ACCIDENT? | Required when an accident other than automobile is related to the services. Check YES or NO. |
| d. CLAIM CODES | The "Claim Codes" identify additional information about the beneficiary's condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition codes is found at www.nucc.oraunder Code Sets. |
| 11 . INSURED'S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
| a. INSURED'S DATE OF BIRTH | Not required. |
| SEX | Not required. |
| b. OTHER CLAIM ID NUMBER | Not required. |
| c. INSURANCE PLAN NAME OR PROGRAM NAME | Not required. |
| d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | When private or other insurance may or will cover any of the services, check YES and complete items 9, 9a, 9c and 9d.Only one box can be marked. |
| 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | Enter "Signature on File," "SOF" or legal signature. |
| 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | Enter "Signature on File," "SOF" or legal signature. |
| 14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) | Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness ; 484 Last Menstrual Period. |
| 15. OTHER DATE | Enter another date related to the beneficiary's condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The "Other Date" identifies additional date information about the beneficiary's condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
| 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
| 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of the referral source. |
| 17a. (blank) | The 9-digit Arkansas Medicaid provider ID number of the referring physician when applicable. |
| 17b. N PI | Not required. |
| 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | Not applicable. |
| 19. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER | Insert LEA number. |
| 20. OUTSIDE LAB? | Not required. |
| $ CHARGES | Not required. |
| 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use"9nforlCD-9-CM. Use"0"forlCD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
| 22. RESUBMISSION CODE | Reserved for future use. |
| ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
| 23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number when applicable. |
| 24A. DATE(S) OF SERVICE | The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. A provider may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the date sequence. 3. RCFs may bill for a date span of any length within the same calendar month, provided the beneficiary was present every day of the date span and all services provided within the date span were at the same Level of Care. |
| B. PLACE OF SERVICE | Two-digit national standard place of service code. |
| C. EMG | Enter UT for "Yes" or leave blank if "No." EMG identifies if the service was an emergency. |
| D. PROCEDURES, SERVICES, OR SUPPLIES | |
| CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
| MODIFIER | Modifier(s) when applicable. |
| E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The "Diagnosis Pointer" is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
| F. $ CHARGES | The full charge for the services totaled in the detail. This charge must be the usual charge to any client, patient or other beneficiary of the provider's services. RCFs' charges should equal no less than the product of the number of units (days) times the beneficiary's Daily Service Rate. If the charge is less, Medicaid will pay the billed charge. |
| G. DAYS OR UNITS | The units (in whole numbers) of service provided during the period indicated in Field 24A of the detail. |
| H. EPSDT/Family Plan | Enter E if the services resulted from a Child Health Services (EPSDT) screening and referral. |
| 1. ID QUAL | Not required. |
| J. RENDERING PROVIDER ID# | Not applicable. |
| NPI | Not required. |
| 25. FEDERAL TAX I.D. NUMBER | Not required. This information is carried in the provider's Medicaid file. If it changes, advise Provider Enrollment so that the year-end 1099 will be correct and reported correctly. |
| 26. PATIENT'S ACCOUNT NO. | Optional entry for providers' accounting and account-retrieval purposes. Enter up to 16 numeric, alphabetic or alpha-numeric characters. This character set appears on the Remittance Advice as UMRN." |
| 27. ACCEPT ASSIGNMENT? | Not required. Assignment is automatically accepted by the provider when billing Medicaid. |
| 28. TOTAL CHARGE | Total of Column 24F-the sum of all charges on the claim. |
| 29. AMOUNT PAID | Enter the total of payments received from other sources on this claim. Do not include amounts previously paid by Medicaid. |
| 30. RESERVED | Reserved for NUCC use. |
| 31. SIGNATURE OF PROVIDER | The performing provider or an individual authorized by the performing provider or by an institutional, corporate, business or other provider organization, must sign and date the claim, certifying that the services were furnished by the provider, under (when applicable) the direction of the individual provider or other qualified individual, and in strict and verifiable accordance with all applicable rules of the Medicaid program in which the provider participates. A "provider's signature" is the provider's or authorized individual's personally written signature, a rubber stamp of the signature, an automated signature or a typed signature. The name of a group practice, a facility or institution, a corporation, a business or any other organization will prevent the claim from being processed. |
| 32. SERVICE FACILITY LOCATION INFORMATION | If services were not performed at the beneficiary's home or at the provider's facility (e.g., school, DDS facility etc.) enter the name, street address, city, state and zip code of the facility, workplace etc. where services were performed. If services were furnished at multiple sites (for instance, when job-seeking), indicate "multiple locations" or leave blank. |
| a. (blank) | Not required. |
| b. (blank) | Not required. |
| 33. BILLING PROVIDER INFO & | Billing provider's name and complete address. |
| PH# | Telephone number is requested but not required. |
| a. (blank) | Not required. |
| b. (blank) | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |