016.29.23 Ark. Code R. § 001 - Clinical Trials Attestation SPA and Provider Manual Updates

Section II

Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

210.100 Introduction

The Medical Assistance (Medicaid) Program helps eligible individuals obtain necessary medical care.

A. Medicaid coverage is based on medical necessity.
1. See Section IV of this manual for the Medicaid Program's definition of medical necessity.
2. Some examples of services that are not medically necessary are treatments or procedures that are cosmetic or that the medical profession does not generally accept as a standard of care (e.g., an inpatient admission to treat a condition that requires only outpatient treatment).
B. Medicaid denies coverage of services that are not medically necessary. Denial for lack of medical necessity is done in several ways.
1. When Arkansas Medicaid's Division of Medical Services' Medical Director for Clinical Affairs determines that a service is never medically necessary, the Division of Medical Services (DMS) enters the service's procedure code, revenue code and/or diagnosis code into the Medicaid Management Information System (MMIS) as non-payable, which automatically prevents payment.
2. A number of services are covered only with the Program's prior approval or prior authorization. One of the reasons for requiring prior approval of payment or prior authorization for a service is that some services are not always medically necessary and Medicaid wants its own medical professionals to review the case record before making payment or before the service is provided.
3. Lastly, Medicaid retrospectively reviews medical records of services for which claims have been paid in order to verify that the medical record supports the service(s) for which Medicaid paid and to confirm or refute the medical necessity of the services documented in the record.
C. Unless a service's medical necessity or lack of medical necessity has been established by statute or regulation, medical necessity determinations are made by the Arkansas Medicaid Program's Medical Director, by the Program's Quality Improvement Organizations (QIO) and/or by other qualified professionals or entities authorized and designated by the Division of Medical Services.
D. When Arkansas Medicaid's Division of Medical Services' Medical Director for Clinical Affairs, QIO or other designee determines - whether prospectively, concurrently or retrospectively - that a hospital service is not medically necessary, Medicaid covers neither the hospital service nor any related physician services.
212.200 Exclusions - Inpatient

The following items are not covered as inpatient hospital services:

A. Beauty shop
B. Cot for visitors
C. Meals for visitors
D. Television
E. Telephone
F. Guest tray
G. Private duty nurse
H. Take-home drugs and supplies
I. Services not reasonable or necessary for the treatment of an illness or injury
J. Private room (unless physician certifies that it is medically necessary or unless no semi-private rooms are available)
K. Autopsies

Medicaid does not cover services that are cosmetic, not medically necessary, or that are not generally accepted by the medical profession. Medicaid does not cover services that are not documented by diagnoses that certify medical necessity. Arkansas Medicaid has identified some ICD diagnosis codes that do not certify medical necessity. See Sections 272.460 and 272.470 for diagnosis codes that are not covered by Arkansas Medicaid.

215.300 Non-Covered Services

Medicaid does not cover services that are cosmetic, not medically necessary or that are not generally accepted by the medical profession. Medicaid does not cover services that are not documented by diagnoses that certify medical necessity. Arkansas Medicaid has identified some ICD diagnosis codes that do not certify medical necessity. See Sections 272.460 and 272.470 for diagnosis codes that are not covered by Arkansas Medicaid.

215.301 Routine Standard of Care Associated with Qualifying Clinical Trials

Effective for items and services furnished on or after 01/01/2022, Medicaid covers the routine costs of qualifying clinical trials, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participation in all clinical trials.

In and out of state providers must submit the Medicaid attestation form for all members participating in a clinical trial to the Utilization Review Section of the Division of Medical Services. (Contact Information is listed on the Medicaid attestation form.

All other Medicaid rules apply.

Routine costs of a clinical trial are defined as:

Items and services that are otherwise generally available to Medicaid clients (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-coverage decision) that are provided in either the experimental or the control arms of a clinical trial except:

A. The investigational item or service, itself unless otherwise covered outside of the clinical trial;
B. Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and
C. Items and services customarily provided by the research sponsors free-of-charge for any enrollee in the trial.

Routine costs in clinical trials include:

A. Items or services that are typically provided absent a clinical trial (e.g., conventional care);
B. Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and
C. Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service, for the diagnosis or treatment of complications.
SECTION IV - GLOSSARY
400.000

AAFP

American Academy of Family Physicians

AAFP

American Academy of Family Physicians

AAP

American Academy of Pediatrics

ABESPA

Arkansas Board of Examiners in Speech-Language Pathology and Audiology

ABHSCI

Adult Behavioral Health Services for Community Independence

ACD

Augmentative Communication Device

ACIP

Advisory Committee on Immunization Practices

ACES

Arkansas Client Eligibility System

ACS

Alternative Community Services

ADDT

Adult Developmental Day Treatment

ADE

Arkansas Department of Education

ADH

Arkansas Department of Health

ADL

Activities of Daily Living

AFDC

Aid to Families with Dependent Children (cash assistance program replaced by the Transitional Employment Assistance (TEA) program)

AHEC

Area Health Education Centers

ALF

Assisted Living Facilities

ALS

Advance Life Support

ALTE

Apparent Life-Threatening Events

AMA

American Medical Association

APD

Adults with Physical Disabilities

ARS

Arkansas Rehabilitation Services

ASC

Ambulatory Surgical Centers

ASHA

American Speech-Language-Hearing Association

BIPA

Benefits Improvement and Protection Act

BLS

Basic Life Support

CARF

Commission on Accreditation of Rehabilitation Facilities

CCRC

Children's Case Review Committee

CFA

One Counseling and Fiscal Agent

CFR

Code of Federal Regulations

CLIA

Clinical Laboratory Improvement Amendments

CME

Continuing Medical Education

CMHC

Community Mental Health Center

CMS

Centers for Medicare and Medicaid Services

COA

Council on Accreditation

CON

Certification of Need

CPT

Physicians' Current Procedural Terminology

CRNA

Certified Registered Nurse Anesthetist

CSHCN

Children with Special Health Care Needs

CSWE

Council on Social Work Education

D&E

Diagnosis and Evaluation

DAAS

Division of Aging and Adult Services

DBS

Division of Blind Services (currently named Division of Services for the Blind)

DCFS

Division of Children and Family Services

DCO

Division of County Operations

DD

Developmentally Disabled

DDS

Developmental Disabilities Services

DHS

Department of Human Services

DLS

Daily Living Skills

DME

Durable Medical Equipment

DMHS

Division of Mental Health Services

DMS

Division of Medical Services (Medicaid)

DOS

Date of Service

DRG

Diagnosis Related Group

DRS

Developmental Rehabilitative Services

DDSCES

Developmental Disabilities Services Community and Employment Support

DSB

Division of Services for the Blind (formerly Division of Blind Services)

DSH

Disproportionate Share Hospital

DURC

Drug Utilization Review Committees

DYS

Division of Youth Services

EIDT

Early Intervention Day Treatment

EAC

Estimated Acquisition Cost

EFT

Electronic Funds Transfer

EIN

Employer Identification Number

EOB

Explanation of Benefits

EOMB

Explanation of Medicaid Benefits. EOMB may also refer to Explanation of Medicare Benefits.

EPSDT

Early and Periodic Screening, Diagnosis, and Treatment

ESC

Education Services Cooperative

FEIN

Federal Employee Identification Number

FPL

Federal Poverty Level

FQHC

Federally Qualified Health Center

GME

Graduate Medical Education

GUL

Generic Upper Limit

HCBS

Home and Community Based Services

HCPCS

Healthcare Common Procedure Coding System

HDC

Human Development Center

HHS

The Federal Department of Health and Human Services

HIC Number

Health Insurance Claim Number

HIPAA

Health Insurance Portability and Accountability Act of 1996

HMO

Health Maintenance Organization

IADL

Instrumental Activities of Daily Living

ICD

International Classification of Diseases

ICF/IID

Intermediate Care Facility for Individuals with Intellectual Disabilities

ICN

Internal Control Number

IDEA

Individuals with Disabilities Education Act

IDG

Interdisciplinary Group

IEP

Individualized Educational Program

IFSP

Individualized Family Service Plan

IMD

Institution for Mental Diseases

IPP

Individual Program Plan

IUD

Intrauterine Devices

JCAHO

Joint Commission on Accreditation of Healthcare Organization

LAC

Licensed Associate Counselor

LCSW

Licensed Certified Social Worker

LEA

Local Education Agencies

LMFT

Licensed Marriage and Family Therapist

LPC

Licensed Professional Counselor

LPE

Licensed Psychological Examiner

LSPS

Licensed School Psychology Specialist

LTC

Long Term Care

MAC

Maximum Allowable Cost

MAPS

Multi-agency Plan of Services

MART

Medicaid Agency Review Team

MEI

Medicare Economic Index

MMIS

Medicaid Management Information System

MNIL

Medically Needy Income Limit

MPPPP

Medicaid Prudent Pharmaceutical Purchasing Program

MSA

Metropolitan Statistical Area

MUMP

Medicaid Utilization Management Program

NBCOT

National Board for Certification of Occupational Therapy

NCATE

North Central Accreditation for Teacher Education

NDC

National Drug Code

NET

Non-Emergency Transportation Services

NF

Nursing Facility

NPI

National Provider Identifier

OBRA

Omnibus Budget Reconciliation Act

OHCDS

Organized Health Care Delivery System

OBHS

Outpatient Behavioral Health Services

OTC

Over the Counter

PA

Prior Authorization

PAC

Provider Assistance Center

PASSE

Provider-led Arkansas Shared Savings Entity Program

PCP

Primary Care Physician

PERS

Personal Emergency Response Systems

PHS

Public Health Services

PIM

Provider Information Memorandum

PL

Public Law

POC

Plan of Care

POS

Place of Service

PPS

Prospective Payment System

PRN

Pro Re Nata or "As Needed"

PRO

Professional Review Organization

ProDUR

Prospective Drug Utilization Review

QIDP

Qualified Intellectual Disabilities Professional

QMB

Qualified Medicare Beneficiary

RA

Remittance Advice. Also called Remittance and Status Report

RFP

Request for Proposal

RHC

Rural Health Clinic

BID

Beneficiary Identification Number

RSPD

Rehabilitative Services for Persons with Physical Disabilities

RSYC

Rehabilitative Services for Youth and Children

RTC

Residential Treatment Centers

RTP

Return to Provider

RTU

Residential Treatment Units

SBMH

School-Based Mental Health Services

SD

Spend Down

SFY

State Fiscal Year

SMB

Special Low-Income Qualified Medicare Beneficiaries

SNF

Skilled Nursing Facility

SSA

Social Security Administration

SSI

Supplemental Security Income

SURS

Surveillance and Utilization Review Subsystem

TCM

Targeted Case Management

TEA

Transitional Employment Assistance

TEFRA

Tax Equity and Fiscal Responsibility Act

TOS

Type of Service

TPL

Third Party Liability

UPL

Upper Payment Limit

UR

Utilization Review

VFC

Vaccines for Children

VRS

Voice Response System

Accommodation

A type of hospital room, e.g., private, semiprivate, ward, etc.

Activities of Daily Living (ADL)

Personal tasks that are ordinarily performed daily and include eating, mobility/transfer, dressing, bathing, toileting, and grooming

Adjudicate

To determine whether a claim is to be paid or denied

Adjustments

Transactions to correct claims paid in error or to adjust payments from a retroactive change

Admission

Actual entry and continuous stay of the beneficiary as an inpatient to an institutional facility

Affiliates

Persons having an overt or covert relationship such that any individual directly or indirectly controls or has the power to control another individual

Agency

The Division of Medical Services

Aid Category

A designation within SSI or state regulations under which a person may be eligible for public assistance

Aid to Families with Dependent Children (AFDC)

A Medicaid eligibility category

Allowed Amount

The maximum amount Medicaid will pay for a service as billed before applying beneficiary coinsurance or co-pay, previous TPL payment, spend down liability, or other deducted charges

American Medical Association (AMA)

National association of physicians

Ancillary Services

Services available to a patient other than room and board. For example: pharmacy, X-ray, lab, and central supplies

Arkansas Client Eligibility System (ACES)

A state computer system in which data is entered to update assistance eligibility information and beneficiary files

Attending Physician

See Performing Physician.

Automated Eligibility Verification Claims Submission (AEVCS)

Online system for providers to verify eligibility of beneficiaries and submit claims to fiscal agent

Base Charge

A set amount allowed for a participating provider according to specialty

Beneficiary

Person who meets the Medicaid eligibility requirements, receives an ID card, and is eligible for Medicaid services (formerly recipient)

Benefits

Services available under the Arkansas Medicaid Program

Billed Amount

The amount billed to Medicaid for a rendered service

Buy-In

A process whereby the state enters into an agreement with the Medicaid/Medicare and the Social Security Administration to obtain Medicare Part B (and part A when needed) for Medicaid beneficiaries who are also eligible for Medicare. The state pays the monthly Medicare premium(s) on behalf of the beneficiary.

Care Plan

See Plan of Care (POC).

Case Head

An adult responsible for an AFDC or Medicaid child

Categorically Needy

All individuals receiving financial assistance under the state's approved plan under Title I, IV-A, X, XIV, and XVI of the Social Security Act or in need under the state's standards for financial eligibility in such a

Centers for Medicare and Medicaid Services

Federal agency that administers federal Medicaid funding

Child Health Services

Arkansas Medicaid's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

Children with Chronic Health Conditions (CHC)

A Title V Children with Special Health Care Needs Program administered by the Arkansas Division of Developmental Disabilities Services to provide medical care and service coordination to children with chronic physical illnesses or disabilities.

Claim

A request for payment for services rendered

Claim Detail

See Line Item.

Clinic

(1) A facility for diagnosis and treatment of outpatients. (2) A group practice in which several physicians work together

Coinsurance

The portion of allowed charges the patient is responsible for under Medicare. This may be covered by other insurance, such as Medi-Pak or Medicaid (if entitled). This also refers to the portion of a Medicaid covered inpatient hospital stay for which the beneficiary is responsible.

Contract

Written agreement between a provider of medical services and the Arkansas Division of Medical Services. A contract must be signed by each provider of services participating in the Medicaid Program.

Co-pay

The portion of the maximum allowable (either that of Medicaid or a third-party payer) that the insured or beneficiary must pay

Cosmetic Surgery

Any surgical procedure directed at improving appearance but not medically necessary

Covered Service

Service which is within the scope of the Arkansas Medicaid Program

Current Procedural Terminology

A listing published annually by AMA consisting of current medical terms and the corresponding procedure codes used for reporting medical services and procedures performed by physicians

Credit Claim

A claim transaction which has a negative effect on a previously processed claim.

Crossover Claim

A claim for which both Titles XVIII (Medicare) and XIX (Medicaid) are liable for reimbursement of services provided to a beneficiary entitled to benefits under both programs

Date of Service

Date or dates on which a beneficiary receives a covered service. Documentation of services and units received must be in the beneficiary's record for each date of service.

Deductible

The amount the Medicare beneficiary must pay toward covered benefits before Medicare or insurance payment can be made for additional benefits. Medicare Part A and Part B deductibles are paid by Medicaid within the program limits.

Debit Claim

A claim transaction which has a positive effect on a previously processed claim

Denial

A claim for which payment is disallowed

Department of Health and Human Services (HHS)

Federal health and human services agency

Department of Human Services (DHS)

State human services agency

Dependent

A spouse or child of the individual who is entitled to benefits under the Medicaid Program

Diagnosis

The identity of a condition, cause, or disease

Diagnostic Admission

Admission to a hospital primarily for the purpose of diagnosis

Disallow

To subtract a portion of a billed charge that exceeds the Medicaid maximum or to deny an entire charge because Medicaid pays Medicare Part A and B deductibles subject to program limitations for eligible beneficiaries

Discounts

A discount is defined as the lowest available price charged by a provider to a client or third-party payer, including any discount, for a specific service during a specific period by an individual provider. If a Medicaid provider offers a professional or volume discount to any customer, claims submitted to Medicaid must reflect the same discount.

Example: If a laboratory provider charges a private physician or clinic a discounted rate for services, the charge submitted to Medicaid for the same service must not exceed the discounted price charged to the physician or clinic. Medicaid must be given the benefit of discounts and price concessions the lab gives any of its customers.

Duplicate Claim

A claim that has been submitted or paid previously or a claim that is identical to a claim in process

Durable Medical Equipment

Equipment that (1) can withstand repeated use and (2) is used to serve a medical purpose. Examples include a wheelchair or hospital bed.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

A federally mandated Medicaid program for eligible individuals under the age of twenty-one (21). See Child Health Services.

Education Accreditation

When an individual is required to possess a bachelor's degree, master's degree, or a Ph.D. degree in a specific profession. The degree must be from a program accredited by an organization that is approved by the Council for Higher Education Accreditation (CHEA).

Electronic Signature

An electronic or digital method executed or adopted by a party with the intent to be bound by or to authenticate a record, which is: (a) Unique to the person using it; (b) Capable of verification; (c) Under the sole control of the person using it; and (d) Linked to data in such a manner that if the data are changed the electronic signature is invalidated. An Electronic Signature method must be approved by the DHS Chief Information Officer or his or her designee before it will be accepted. A list of approved electronic signature methods will be posted on the state Medicaid website.

Eligible

(1) To be qualified for Medicaid benefits. (2) An individual who is qualified for benefits

Eligibility File

A file containing individual records for all persons who are eligible or have been eligible for Medicaid

Emergency Services

Inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

Source: 42 U.S. Code of Federal Regulations (42 CFR) and §424.101.

Error Code

A numeric code indicating the type of error found in processing a claim also known as an "Explanation of Benefits (EOB) code" or a "HIPAA Explanation of Benefits (HEOB) code"

Estimated Acquisition

The estimated amount a pharmacy actually pays to obtain a drug

Experimental Surgery

Any surgical procedure considered experimental in nature

Explanation of Medicaid Benefits (EOMB)

A statement mailed once per month to selected beneficiaries to allow them to confirm the Medicaid service which they received

Family Planning Services

Any medically approved diagnosis, treatment, counseling, drugs, supplies, or devices prescribed or furnished by a physician, nurse practitioner, certified nurse-midwife, pharmacy, hospital, family planning clinic, rural health clinic (RHC), Federally Qualified Health Center (FQHC), or the Department of Health to individuals of child-bearing age for purposes of enabling such individuals freedom to determine the number and spacing of their children.

Field Audit

An activity performed whereby a provider's facilities, procedures, records, and books are audited for compliance with Medicaid regulations and standards. A field audit may be conducted on a routine basis, or on a special basis announced or unannounced.

Fiscal Agent

An organization authorized by the State of Arkansas to process Medicaid claims

Fiscal Agent Intermediary

A private business firm which has entered into a contract with the Arkansas Department of Human Services to process Medicaid claims

Fiscal Year

The twelve-month period between settlements of financial accounts

Generic Upper Limit (GUL)

The maximum drug cost that may be used to compute reimbursement for specified multiple-source drugs unless the provisions for a Generic Upper Limit override have been met. The Generic Upper Limit may be established or revised by the Centers for Medicare and Medicaid Services (CMS) or by the State Medicaid Agency.

Group

Two (2) or more persons. If a service is a "group" therapy or other group service, there must be two (2) or more persons present and receiving the service.

Group Practice

A medical practice in which several practitioners render and bill for services under a single pay-to provider identification number

Healthcare Common Procedure Coding System (HCPCS)

Federally defined procedure codes

Health Insurance Claim Number

Number assigned to Medicare beneficiaries and individuals eligible for SSI

Hospital

An institution that meets the following qualifications:

* Provides diagnostic and rehabilitation services to inpatients

* Maintains clinical records on all patients

* Has by-laws with respect to its staff of physicians

* Requires each patient to be under the care of a physician, dentist, or certified nurse-midwife

* Provides 24-hour nursing service

* Has a hospital utilization review plan in effect

* Is licensed by the State

* Meets other health and safety requirements set by the Secretary of Health and Human Services

Hospital-Based Physician

A physician who is a hospital employee and is paid for services by the hospital

ID Card

An identification card issued to Medicaid beneficiaries and ARKids First-B participants containing encoded data that permits a provider to access the card-holder's eligibility information

Individual

A single person as distinguished from a group. If a service is an "individual" therapy or service, there may be only one (1) person present who is receiving the service.

Inpatient

A patient, admitted to a hospital or skilled nursing facility, who occupies a bed and receives inpatient services.

In-Process Claim (Pending Claim)

A claim that suspends during system processing for suspected error conditions such as: all processing requirements appear not to be met. These conditions must be reviewed by the Arkansas Medicaid fiscal agent or DMS and resolved before processing of the claim can be completed. See Suspended Claim.

Inquiry

A request for information

Institutional Care

Care in an authorized private, non-profit, public, or state institution or facility. Such facilities include schools for the deaf, or blind and institutions for individuals with disabilities.

Instrumental Activities of Daily Living (IADL)

Tasks which are ordinarily performed on a daily or weekly basis and include meal preparation, housework, laundry, shopping, taking medications, and travel/transportation

Intensive Care

Isolated and constant observation care to patients critically ill or injured

Interim Billing

A claim for less than the full length of an inpatient hospital stay. Also, a claim that is billed for services provided to a particular date even though services continue beyond that date. It may or may not be the final bill for a particular beneficiary's services.

Internal Control Number (ICN)

The unique 13-digit claim number that appears on a Remittance Advice

International Classification of Diseases

A diagnosis coding system used by medical providers to identify a patient's diagnosis or diagnoses on medical records and claims

Investigational Product

Any product that is considered investigational or experimental and that is not approved by the Food and Drug Administration. The Arkansas Medicaid Program does not cover investigational products but does cover routine standard of care associated with qualifying clinical trials.

Julian Date

Chronological date of the year, 001 through 365 or 366, preceded on a claims number (ICN) by a two-digit-year designation. Claim number example: 03231 (August 19, 2003).

Length of Stay

Period of time a patient is in the hospital. Also, the number of days covered by Medicaid within a single inpatient stay.

Limited Services Provider Agreement

An agreement for a specific period of time not to exceed twelve (12) months, which must be renewed in order for the provider to continue to participate in the Title XIX Program.

Line Item

A service provided to a beneficiary. A claim may be made up of one (1) or more line items for the same beneficiary. Also called a claim detail.

Long Term Care (LTC)

An office within the Arkansas Division of Medical Services responsible for nursing facilities

Long Term Care Facility

A nursing facility

Maximum Allowable Cost (MAC)

The maximum drug cost which may be reimbursed for specified multi-source drugs. This term is interchangeable with generic upper limit.

Medicaid Provider Number

A unique identifying number assigned to each provider of services in the Arkansas Medicaid Program, required for identification purposes

Medicaid Management Information System (MMIS)

The automated system utilized to process Medicaid claims

Medical Assistance Section

A section within the Arkansas Division of Medical Services responsible for administering the Arkansas Medical Assistance Program

Medically Needy

Individuals whose income and resources exceed the levels for assistance established under a state or federal plan for categorically needy, but are insufficient to meet costs of health and medical services

Medical Necessity

All Medicaid benefits are based upon medical necessity. A service is "medically necessary" if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service. For this purpose, a "course of treatment" may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program or by the Medicaid Program Quality Improvement Organization (QIO). Coverage may be denied if a service is not medically necessary in accordance with the preceding criteria or is generally regarded by the medical profession as inappropriate or ineffective unless objective clinical evidence demonstrates circumstances making the service necessary.

Mis-Utilization

Any usage of the Medicaid Program by any of its providers or beneficiaries which is not in conformance with both State and Federal regulations and laws (including, but not limited to, fraud, abuse, and defects in level and quality of care)

National Drug Code

The unique 11-digit number assigned to drugs which identifies the manufacturer, drug, strength, and package size of each drug

National Provider Identifier (NPI)

A standardized unique health identifier for health care providers for use in the health care system in connection with standard transactions for all covered entities. Established by the Centers for Medicare & Medicaid Services, HHS, in compliance with HIPAA Administrative Simplification - 45 CFR Part 162.

Non-Covered Services

Services not medically necessary, services provided for the personal convenience of the patient or services not covered under the Medicaid Program

Nonpatient

An individual who receives services, such as laboratory tests, performed by a hospital, but who is not a patient of the hospital

Nurse Practitioner

A professional nurse with credentials that meet the requirements for licensure as a nurse practitioner in the State of Arkansas

Outpatient

A patient receiving medical services, but not admitted as an inpatient to a hospital

Over-Utilization

Any over usage of the Medicaid Program by any of its providers or beneficiaries not in conformance with professional judgment and both State and Federal regulations and laws (including, but not limited to, fraud and abuse)

Participant

A provider of services who: (1) provides the service, (2) submits the claim and (3) accepts Medicaid's reimbursement for the services provided as payment in full

Patient

A person under the treatment or care of a physician or surgeon, or in a hospital

Payment

Reimbursement to the provider of services for rendering a Medicaid-covered benefit

Pay-to Provider

A person, organization, or institution authorized to receive payment for services provided to Medicaid beneficiaries by a person or persons who are a part of the entity

Pay-to Provider Number

A unique identifying number assigned to each pay-to provider of services (Clinic/Group/Facility) in the Arkansas Medicaid Program or the pay-to provider group's assigned National Provider Identifier (NPI). Medicaid reports provider payments to the Internal Revenue Service under the Employer Identification Number "Tax ID" linked in the Medicaid Provider File to the pay-to provider identification number.

Per Diem

A daily rate paid to institutional providers

Performing Physician

The physician providing, supervising, or both, a medical service and claiming primary responsibility for ensuring that services are delivered as

Person

Any natural person, company, firm, association, corporation, or other legal entity

Place of Service (POS)

A nationally approved two-digit numeric code denoting the location of the patient receiving services

Plan of Care

A document utilized by a provider to plan, direct, or deliver care to a patient to meet specific measurable goals; also called care plan, service plan, or treatment plan

Postpayment Utilization Review

The review of services, documentation, and practice after payment

Practitioner

An individual who practices in a health or medical service profession

Prepayment Utilization Review

The review of services, documentation, and practice patterns before payment

Prescription

A health care professional's legal order for a drug which, in accordance with federal or state statutes, may not be obtained otherwise; also, an order for a particular Medicaid covered service

Prescription Drug (RX)

A drug which, in accordance with federal or state statutes, may not be obtained without a valid prescription

Primary Care Physician (PCP)

A physician responsible for the management of a beneficiary's total medical care. Selected by the beneficiary to provide primary care services and health education. The PCP will monitor on an ongoing basis the beneficiary's condition, health care needs and service delivery, be responsible for locating, coordinating, and monitoring medical and rehabilitation services on behalf of the beneficiary, and refer the beneficiary for most specialty services, hospital care, and other services.

Prior Approval

The approval for coverage and reimbursement of specific services prior to furnishing services for a specified beneficiary of Medicaid. The request for prior approval must be made to the Medical Director of the Division of Medical Services for review of required documentation and justification for provision of service.

Prior Authorization (PA)

The approval by the Arkansas Division of Medical Services, or a designee of the Division of Medical Services, for specified services for a specified beneficiary to a specified provider before the requested services may be performed and before payment will be made. Prior authorization does not guarantee reimbursement.

Procedure Code

A five-digit numeric or alpha numeric code to identify medical services and procedures on medical claims

Professional Component

A physician's interpretation or supervision and interpretation of laboratory, X-ray, or machine test procedures

Profile

A detailed view of an individual provider's charges to Medicaid for health care services or a detailed view of a beneficiary's usage of health care

services

Provider

A person, organization, or institution enrolled to provide and be reimbursed for health or medical care services authorized under the State Title XIX Medicaid Program

Provider Identification Number

A unique identifying number assigned to each provider of services in the Arkansas Medicaid Program or the provider's assigned National Provider Identifier (NPI), when applicable, that is required for identification

purposes

Provider Relations

The activity within the Medicaid Program which handles all relationships with Medicaid providers

Quality Assurance

Determination of quality and appropriateness of services rendered

Quality Improvement Organization

A Quality Improvement Organization (QIO) is a federally mandated review organization required of each state's Title XIX (Medicaid) program. The QIO monitors hospital and physician services billed to the state's Medicare intermediary and the Medicaid program to assure high quality, medical necessity, and appropriate care for each patient's needs.

Railroad Claim Number

The number issued by the Railroad Retirement Board to control payments of annuities and pensions under the Railroad Retirement Act. The claim number begins with a one- to three-letter alphabetic prefix denoting the type of payment, followed by six (6) or nine (9) numeric digits.

Referral

An authorization from a Medicaid enrolled provider to a second Medicaid enrolled provider. The receiving provider is expected to exercise independent professional judgment and discretion, to the extent permitted by laws and rules governing the practice of the receiving practitioner, and to develop and deliver medically necessary services covered by the Medicaid program. The provider making the referral may be a physician or another qualified practitioner acting within the scope of practice permitted by laws or rules. Medicaid requires documentation of the referral in the beneficiary's medical record, regardless of the means the referring provider makes the referral. Medicaid requires the receiving provider to document the referral also, and to correspond with the referring provider regarding the case when appropriate and when the referring provider so requests.

Reimbursement

The amount of money remitted to a provider

Rejected Claim

A claim for which payment is refused

Relative Value

A weighting scale used to relate the worth of one (1) surgical procedure to any other. This evaluation, expressed in units, is based upon the skill, time, and the experience of the physician in its performance.

Remittance

A remittance advice

Remittance Advice (RA)

A notice sent to providers advising the status of claims received, including paid, denied, in-process, and adjusted claims. It includes year-to-date payment summaries and other financial information.

Reported Charge

The total amount submitted in a claim detail by a provider of services for reimbursement

Retroactive Medicaid Eligibility

Medicaid eligibility which may begin up to three (3) months prior to the date of application provided all eligibility factors are met in those months

Returned Claim

A claim which is returned by the Medicaid Program to the provider for correction or change to allow it to be processed properly

Routine Standard of Care Associated with Qualifying Clinical Trials

Effective for items and services furnished on or after 01/01/2022, Medicaid covers the routine costs of qualifying clinical trials, as such costs are defined below, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participation in all clinical trials. All other Medicaid rules apply.

Routine costs of a clinical trial include all items and services that are otherwise generally available to Medicaid beneficiaries (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-coverage decision) that are provided in either the experimental or the control arms of a clinical trial except:

The investigational item or service, itself unless otherwise covered outside of the clinical trial;

* Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and

* Items and services customarily provided by the research sponsors free-of-charge for any enrollee in the trial.

Routine costs in clinical trials include:

* Items or services that are typically provided absent a clinical trial (e.g., conventional care);

* Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and

* Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service, for the diagnosis or treatment of complications.

Sanction

Any corrective action taken against a provider

Screening

The use of quick, simple, medical procedures carried out among large groups of people to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of more definitive examination or treatment

Signature

The person's original signature or initials. The person's signature or initials may also be recorded by an electronic or digital method, executed, or adopted by the person with the intent to be bound by or to authenticate a record. An electronic signature must comply with Arkansas Code Annotated § 25-31-101 -105, including verification through an electronic signature verification company and data links invalidating the electronic signature if the data is changed.

Single State Agency

The state agency authorized to administer or supervise the administration of the Medicaid Program on a statewide basis

Skilled Nursing Facility (SNF)

A nursing home, or a distinct part of a facility, licensed by the Office of Long-Term Care as meeting the Skilled Nursing Facility Federal/State licensure and certification regulations. A health facility which provides skilled nursing care and supportive care on a 24-hour basis to residents whose primary need is for availability of skilled nursing care on an extended basis.

Social Security Administration (SSA)

A federal agency which makes disability and blindness determinations for the Secretary of the HHS

Social Security Claim Number

The account number used by SSA to identify the individual on whose earnings SSA benefits are being paid. It is the Social Security Account Number followed by a suffix, sometimes as many as three (3) characters, designating the type of beneficiary (e.g., wife, widow, child, etc.).

Source of Care

A hospital, clinic, physician, or other facility which provides services to a beneficiary under the Medicaid Program

Specialty

The specialized area of practice of a physician or dentist

Spend Down (SD)

The amount of money a beneficiary must pay toward medical expenses when income exceeds the Medicaid financial guidelines. A component of the medically needy program allows an individual or family whose income is over the medically needy income limit (MNIL) to use medical bills to spend excess income down to the MNIL. The individual(s) will have a spend down liability. The spend down column of the remittance advice indicates the amount which the provider may bill the beneficiary. The spend down liability occurs only on the first day of Medicaid eligibility.

Status Report

A remittance advice

Supplemental Security Income (SSI)

A program administered by the Social Security Administration. This program replaced previous state administered programs for aged, blind, or individuals with disabilities (except in Guam, Puerto Rico, and the Virgin Islands). This term may also refer to the Bureau of Supplemental Security Income within SSA which administers the program.

Suspended Claim

An "In-Process Claim" which must be reviewed and resolved

Suspension from Participation

An exclusion from participation for a specified period

Suspension of Payments

The withholding of all payments due to a provider until the resolution of a matter in dispute between the provider and the state agency

Termination from Participation

A permanent exclusion from participation in the Title XIX Program

Third Party Liability (TPL)

A condition whereby a person or an organization, other than the beneficiary or the state agency, is responsible for all or some portion of the costs for health or medical services incurred by the Medicaid beneficiary (e.g., a health insurance company, a casualty insurance company, or another person in the case of an accident, etc.).

Utilization Review (UR)

The section of the Arkansas Division of Medical Services which performs the monitoring and controlling of the quantity and quality of health care services delivered under the Medicaid Program

Void

A transaction which deletes

Voice Response System (VRS)

Voice-activated system to request prior authorization for prescription drugs and for PCP assignment and change

Ward

An accommodation of five (5) or more beds

Withholding of Payments

A reduction or adjustment of the amounts paid to a provider on pending and subsequently due payments

Worker's Compensation

A type of Third-Party Liability for medical services rendered as the result of an on-the-job accident or injury to a beneficiary for which the employer's insurance company may be obligated under the Worker's Compensation Act

ATTACHMENT 3.1-A

State/Territory: Arkansas

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY GROUP(S)

30. Coverage of Routine Patient Cost in Qualifying Clinical Trials

*The state needs to check each assurance below.

Provided: _01/01/2022

I. General Assurances:

Routine Patient Cost - Section 1905(gg)(1)

_X __ Coverage of routine patient cost for items and services as defined in section 1905(gg)(1) that are furnished in connection with participation in a qualified clinical trial.

Qualifying Clinical Trial - Section 1905(gg)(2)

_ X__A qualified clinical trial is a clinical trial that meets the definition at section 1905(gg)(2).

Coverage Determination - Section 1905(gg)(3)

_X _A determination with respect to coverage for an individual participating in a qualified clinical trial will be made in accordance with section 1905(gg)(3).

PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 210 of the Consolidated Appropriations Act of 2021 amending section 1905(a) of the Social Security Act (the Act), by adding a new mandatory benefit at section 1905(a)(30). Section 210 mandates coverage of routine patient services and costs furnished in connection with participation by Medicaid beneficiaries in qualifying clinical trials effective January 1, 2022. Section 210 also amended sections 1902(a)(10)(A) and 1937(b)(5) of the Act to make coverage of this new benefit mandatory under the state plan and any benchmark or benchmark equivalent coverage (also referred to as alternative benefit plans, or ABPs). Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #74). Public burden for all of the collection of information requirements under this control number is estimated to take about 56 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C 4-26-05, Baltimore, Maryland 21244-1850.

ATTACHMENT 3.1-B

State/Territory: Arkansas

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

MEDICALLY NEEDY GROUP(S)

30. Coverage of Routine Patient Cost in Qualifying Clinical Trials

*The state needs to check each assurance below.

Provided: ___X____

I. General Assurances:

Routine Patient Cost - Section 1905(gg)(1)

_X__Coverage of routine patient cost for items and services as defined in section 1905(gg)(1) that are furnished in connection with participation in a qualified clinical trial.

Qualifying Clinical Trial - Section 1905(gg)(2)

_X__A qualified clinical trial is a clinical trial that meets the definition at section 1905(gg)(2).

Coverage Determination - Section 1905(gg)(3)

_X__A determination with respect to coverage for an individual participating in a qualified clinical trial will be made in accordance with section 1905(gg)(3).

PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing Section 210 of the Consolidated Appropriations Act of 2021 amending section 1905(a) of the Social Security Act (the Act), by adding a new mandatory benefit at section 1905(a)(30). Section 210 mandates coverage of routine patient services and costs furnished in connection with participation by Medicaid beneficiaries in qualifying clinical trials effective January 1, 2022. Section 210 also amended sections 1902(a)(10)(A) and 1937(b)(5) of the Act to make coverage of this new benefit mandatory under the state plan and any benchmark or benchmark equivalent coverage (also referred to as alternative benefit plans, or ABPs). Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 #74). Public burden for all of the collection of information requirements under this control number is estimated to take about 56 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C 4-26-05, Baltimore, Maryland 21244-1850.

Notes

016.29.23 Ark. Code R. § 001
Adopted by Arkansas Register Volume 48, Number 11, Effective 10/30/2023

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.


No prior version found.