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Durable Medical Equipment Billing Tips Provider Reference Supplement





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HP Enterprise Services, Arkansas Title XIX Document Date: 5/12/2010



















HP Enterprise Services Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, Arkansas 72201 (501) 374-6608





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Contents Introduction 4 Restricted Aid Categories 5 DME Exclusions 8 Prescription and Referral Renewal 8 Getting a Prior Authorization 8 DME Services Provided 10 Place of Service Codes 11 Modifiers 12 Paper Billing Instructions 13 Contact Information 18



Introduction

This Billing Tips document serves as a training supplement for Arkansas Medicaid providers, but does not supersede official program documentation including: Arkansas Medicaid Provider Reference manuals, Official Notices and transmittal letters published by the Division of Medical Services and distributed by HP Enterprise Services.

This document focuses on Arkansas Medicaid eligibility and billing issues and incorporates the following quick reference items for your convenience:

Consolidated list of restricted aid categories

DME Exclusions

DME Covered Services

Place of Service Codes

Modifiers

Paper Billing Instructions

Restricted Aid Categories

Many providers ask a question that is closely related to eligibility: “Is there a list of aid categories that require a primary care physician?” The answer is no. Arkansas Medicaid’s primary care case management program, ConnectCare, requires Medicaid beneficiaries and waiver participants to enroll with a primary care physician (PCP) unless specifically exempt from that requirement. See the following sections of your Arkansas Medicaid provider reference manual for more information:

Section 171.000, which lists the groups of individuals who may not enroll with a PCP

Section 176.000, which lists Medicaid covered services that do not require PCP referral



The table below lists and briefly describes restricted aid categories. Post it at your workstation to use as a convenient quick reference:

|Aid Category |Restriction | |01 ARKids First-B |Beneficiaries may have co-payment requirements. | |(PCP Required) |Beneficiaries may be ineligible for certain | | |services (see the ARKids First-B provider manual| | |for exclusions.) | |03 CMS (Children’s |All services must be prior authorized by the CMS| |Medical Services) |office. | |Non-Medicaid | | |(No PCP Required) | | |04 DDS (Developmental |DDS non-Medicaid provider ID numbers end with | |Disability Services) |‘86’. | |Non-Medicaid |DDS non-Medicaid beneficiary ID numbers begin | |(NO PCP Required) |with ‘8888’. | | |Only DDS non-Medicaid providers may bill for DDS| | |non-Medicaid beneficiaries. | | |DDS beneficiaries may be dually eligible and | | |receive additional services in another category.| |*6 Medically Needy |Beneficiaries are eligible for a full range of | |Exceptional |benefits except nursing facility and personal | |(PCP Required) |care. | |*7 Spend Down |Beneficiaries must pay toward medical expenses | |(No PCP Required) |when income and resources exceed the Medicaid | |(PCP required for |financial guidelines. | |Breast Care, 07) |Note: Aid category 07 BCC has full benefits. | |08 Tuberculosis |Beneficiary coverage includes drugs, physician | |(NO PCP Required) |services, outpatient services, rural health | | |clinic encounters. | | |Federally Qualified Health Center (FQHC) and | | |clinic visits for TB-related services only. |

|Aid Category |Restriction | |*8 QMB (Qualified |Medicaid pays Medicare premiums, coinsurance and| |Medicare Beneficiary) |deductible. | |(No PCP Required) |If the service provided is not a Medicare | | |covered service, Medicaid will not pay for the | | |service under the QMB policy. | | |Note: Aid category 18 S has full benefits. | |61 PW-PL (Pregnant |This category contains both pregnant women and | |Woman Infants and |children. Providers must use the last three-(3) | |Children Poverty |digits of the Medicaid ID number to determine | |level) |benefits. | |(No PCP Required For |When the last three (3) digits are in the 100 | |Pregnant Woman) |series (i.e., 101, 102, etc.), the beneficiary | |(PCP Required for the |is eligible as an adult and is eligible for | |Infants and children) |pregnancy-related services only. | | |When the last three (3) digits are in the 200 | | |series (i.e., 201, 202, etc.), the beneficiary | | |is eligible as a child and receives a full range| | |of Medicaid services. | | |Note: Plan description “PW unborn ch-noster/FP | | |cov” indicates there is no sterilization or | | |family planning benefits for the expectant | | |mother. | |62 PW-PE (Pregnant |A temporary aid category that pays for | |Woman Presumptive |ambulatory, prenatal services only. | |Eligibility) | | |(No PCP Required) | | |69 Women’s Health |Medicaid pays for family planning preventative | |Wavier |services only, such as birth control or | |(No PCP Required) |counseling. | | |A claim for a beneficiary in this category must | | |contain both a family planning diagnosis code | | |and a family planning procedure code. | |58, 78, 88 SLIMB |Medicaid pays only their Medicare premium. | |(Specified Low Income | | |Medicare | | |Beneficiary)(SMB) | | |(No PCP Required) | |

DME Exclusions

Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to:

Over-the-counter items provided through the Arkansas Medicaid Pharmacy Program (except as specified).

Over-the-counter drugs (except as specified).

Products that bear the Federal legend “Caution: Federal Law Prohibits Dispensing without a Prescription” (except as specified).

Specialized wheelchair equipment that has been previously purchased by any payer. Specialized wheelchair equipment may not be reordered unless the patient’s condition changes and necessitates a change in prescription. This change in condition must be thoroughly documented.

Wheelchairs for individuals under 21 years of age within two years of the purchase of a specialized wheelchair.

Wheelchairs for individuals age 21 and over within five years of the purchase or rental of a wheelchair.

Foodstuffs.

Hyperalimentation.

Services that duplicate any other service provided to the patient or that replace existing patient supports.

Prescription and Referral Renewal

At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from the beneficiary’s primary care physician and, if applicable, send a new prior authorization form to the applicable entity.

Getting a Prior Authorization

Requests for prior authorization will be handled by either Utilization Review, a section within the Division of Medical Services or by the Arkansas Foundation for Medical Care (AFMC), depending on the service that is being requested.

A. To request prior authorization for wheelchair and wheelchair seating systems, providers must use form DMS-679 and send the information to the Utilization Review Section. The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to the Division of Medical Services, Utilization Review Section. The third copy of the form must be retained in the provider’s records. B. Requests for prior authorization of some medical supplies (i.e., compression burn garments), orthotic appliances, prosthetic devices and all durable medical equipment, excluding wheelchairs and wheelchair seating systems, must be submitted to AFMC on the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components Form (DMS-679A). See section V of your provider manual for the form.

DME Services Provided

|Service |Age |Benefit | | | |Limit/Restrictions | |Diapers and Underpads |3 and older |$130 per month | |Apnea Monitors |Under age 1 |PA required | |Augmentative |All Ages |$7500 lifetime/PA | |Communication Device | |required for age 21+ | |Electronic Blood |All Ages |PA required | |Pressure Monitor and | | | |Cuff | | | |Enteral Nutrition |Under 21 |1 per day/PA required | |Infusion Pump and | | | |Enteral Feeding Pump | | | |Supple Kit | | | |Home Blood Glucose |All Ages |Pregnant Women Only | |Monitor | | | |Insulin Pump and |All Ages |PA required | |Supplies | | | |MIC-KEY Skin Level |Under 21 |2 per SFY/PA required | |Gastrostomy Tube | | | |(Mic-Key Button) and | | | |Supplies | | | |Specialized |All Ages |Some may require PA | |Rehabilitative | | | |Equipment | | | |Specialized |Two through Adult |Some require PA | |Wheelchairs and | | | |Wheelchair Seating | | | |Systems | | | |Medical Supplies |All Ages |$250 per month | |Nutritional Formula |Under Age 21 |30 units per day | |Food Thickeners |All Ages |N/A | |Orthotic Appliances |All Ages |$3000 per SFY for age | | | |21+ | | | |PA required for age | | | |21+ | |Prosthetic Devices |All Ages |$20000 per SFY for age| | | |21+ | | | |PA required for age | | | |21+ | |Oxygen and Oxygen |All Ages |PA required | |Supplies | | |

Place of Service Codes

Electronic and paper claims require the same national place of service (POS) code.

|Place of Service |POS Codes | |Inpatient Hospital |21 | |Outpatient Hospital |22 | |Doctor’s Office |11 | |Patient’s Home |12 | |Day Care Facility |52 | |Night Care Facility |52 | |Nursing Facility |32 | |Skilled Nursing Facility |31 | |Ambulance |41 | |Other Locations |99 | |Independent Laboratory |81 | |Ambulatory Surgical Center |24 | |Residential Treatment Center |56 | |Specialized Treatment Facility |56 | |Comprehensive Outpatient |62 | |Rehabilitative Facility | | |Independent Kidney Disease |65 | |Treatment Center | | |Inpatient Psychiatric Facility |51 |



Modifiers

|Modifiers | |EP-Service provided as part of EPSDT Program | |KH-Durable Medical Equipment (DME) item, initial claim, first month's| |rental | |NU-New Equipment | |RR-Durable Medical Equipment (DME) Rental | |U1-Medicaid Level of Care 1 (defined by state) | |U2-Medicaid level of Care 2 (defined by state) | |U3-Medicaid level of care 3 (defined by state) | |U4-Medicaid level of care 4 (defined by state) | |U5-Medicaid level of care 5 (defined by state) | |UE-Used durable medical equipment (DME) | |52-Reduced Services |

Paper Billing Instructions

|Field Name and Number |Instructions for Completion | |1. (type of coverage) |Not required. | |1a. INSURED’S I.D. NUMBER |Beneficiary’s or participant’s 10-digit | |(For Program in Item 1) |Medicaid or ARKids First-A or ARKids | | |First-B identification number. | |2. PATIENT’S NAME (Last |Beneficiary’s or participant’s last name | |Name, First Name, Middle |and first name. | |Initial) | | |3. PATIENT’S BIRTH DATE |Beneficiary’s or participant’s date of | | |birth as given on the individual’s | | |Medicaid or ARKids First-A or ARKids | | |First-B identification card. Format: | | |MM/DD/YY. | | SEX |Check M for male or F for female. | |4. INSURED’S NAME (Last |Required if insurance affects this claim. | |Name, First Name, Middle |Insured’s last name, first name and middle| |Initial) |initial. | |5. PATIENT’S ADDRESS (No. |Optional. Beneficiary’s or participant’s | |Street) |complete mailing address (street address | | |or post office box). | | CITY |Name of the city in which the beneficiary | | |or participant resides. | | STATE |Two-letter postal code for the state in | | |which the beneficiary or participant | | |resides. | | ZIP CODE |Five-digit ZIP code; nine digits for post | | |office box. | | TELEPHONE (Include Area |The beneficiary’s or participant’s | |Code) |telephone number or the number of a | | |reliable message/contact/ emergency | | |telephone. | |6. PATIENT RELATIONSHIP TO|If insurance affects this claim, check the| |INSURED |box indicating the patient’s relationship | | |to the insured. | |7. INSURED’S ADDRESS (No.,|Required if insured’s address is different| |Street) |from the patient’s address. | | CITY | | | STATE | | | ZIP CODE | | | TELEPHONE (Include Area | | |Code) | | |8. PATIENT STATUS |Not required. | |9. OTHER INSURED’S NAME |If patient has other insurance coverage as| |(Last name, First Name, |indicated in Field 11d, the other | |Middle Initial) |insured’s last name, first name and middle| | |initial. | |a. OTHER INSURED’S POLICY |Policy and/or group number of the insured | |OR GROUP NUMBER |individual. | |b. OTHER INSURED’S DATE OF|Not required. | |BIRTH | | |SEX |Not required. | |c. EMPLOYER’S NAME OR |Required when items 9 a-d are required. | |SCHOOL NAME |Name of the insured individual’s employer | | |and/or school. | |d. INSURANCE PLAN NAME OR |Name of the insurance company. | |PROGRAM NAME | | |10. IS PATIENT’S CONDITION| | |RELATED TO: | | |a. EMPLOYMENT? (Current or|Check YES or NO. | |Previous) | | |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. | |10d. RESERVED FOR LOCAL |Not used. | |USE | | |11. INSURED’S POLICY GROUP|Not required when Medicaid is the only | |OR FECA NUMBER |payer. | |a. INSURED’S DATE OF BIRTH|Not required. | | SEX |Not required. | |b. EMPLOYER’S NAME OR |Not required. | |SCHOOL NAME | | |c. INSURANCE PLAN NAME OR |Not required. | |PROGRAM NAME | | |d. IS THERE ANOTHER HEALTH|When private or other insurance may or | |BENEFIT PLAN? |will cover any of the services, check YES | | |and complete items 9a through 9d. | |12. PATIENT’S OR |Not required. | |AUTHORIZED PERSON’S | | |SIGNATURE | | |13. INSURED’S OR |Not required. | |AUTHORIZED PERSON’S | | |SIGNATURE | | |14. DATE OF CURRENT: |Required when services furnished are | |ILLNESS (First symptom) OR|related to an accident, whether the | |INJURY (Accident) OR |accident is recent or in the past. Date | |PREGNANCY (LMP) |of the accident. | |15. IF PATIENT HAS HAD |Not required. | |SAME OR SIMILAR ILLNESS, | | |GIVE FIRST DATE | | |16. DATES PATIENT UNABLE |Not required. | |TO WORK IN CURRENT | | |OCCUPATION | | |17. NAME OF REFERRING |Primary Care Physician (PCP) referral is | |PROVIDER OR OTHER SOURCE |not required for prosthetics. If services| | |are the result of a Child Health Services | | |(EPSDT) screening/ referral, enter the | | |referral source, including name and title.| |17a. (blank) |The 9-digit Arkansas Medicaid provider ID | | |number of the referring physician. | |17b. NPI |Not required. | |18. HOSPITALIZATION DATES |When the serving/billing provider’s | |RELATED TO CURRENT |services charged on this claim are related| |SERVICES |to a beneficiary’s or participant’s | | |inpatient hospitalization, enter the | | |individual’s admission and discharge | | |dates. Format: MM/DD/YY. | |19. RESERVED FOR LOCAL USE|Not used. | |20. OUTSIDE LAB? |Not required. | | $ CHARGES |Not required. | |21. DIAGNOSIS OR NATURE OF|Diagnosis code for the primary medical | |ILLNESS OR INJURY |condition for which services are being | | |billed. Up to three additional diagnosis | | |codes can be listed in this field for | | |information or documentation purposes. | | |Use the International Classification of | | |Diseases, Ninth Revision (ICD-9-CM) | | |diagnosis coding current as of the date of| | |service. | |22. MEDICAID RESUBMISSION |Reserved for future use. | |CODE | | | ORIGINAL REF. NO. |Reserved for future use. | |23. PRIOR AUTHORIZATION |The prior authorization or benefit | |NUMBER |extension control number if applicable. | |24 A. 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. Providers 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 the service on each day of the date | | |sequence. | |B. PLACE OF SERVICE |Two-digit national standard place of | | |service code. See Section 242.200 for | | |codes. | |C. EMG |Not required. | |D. PROCEDURES, SERVICES OR| | |SUPPLIES | | | CPT/HCPCS |Enter the correct CPT or HCPCS procedure | | |code from Sections 242.100 through | | |242.195. | | MODIFIER |Modifier(s) if applicable. | |E. DIAGNOSIS POINTER |Enter in each detail the single number—1, | | |2, 3 or 4—that corresponds to a diagnosis | | |code in Item 21 (numbered 1, 2, 3 or 4) | | |and that supports most definitively the | | |medical necessity of the service(s) | | |identified and charged in that detail. | | |Enter only one number in E of each detail.| | |Each DIAGNOSIS POINTER number must be only| | |a 1, 2, 3 or 4, and it must be the only | | |character in that field. | |F. $ CHARGES |The full charge for the service(s) totaled| | |in the detail. This charge must be the | | |usual charge to any client, patient or | | |other recipient of the provider’s | | |services. | |G. DAYS OR UNITS |The units (in whole numbers) of service(s)| | |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/referral. | |I. ID QUAL |Not required. | |J. RENDERING PROVIDER ID #|The 9-digit Arkansas Medicaid provider ID | | |number of the individual who furnished the| | |services billed for in the detail. | | NPI |Not required. | |25. FEDERAL TAX I.D. |Not required. This information is carried| |NUMBER |in the provider’s Medicaid file. If it | | |changes, please contact Provider | | |Enrollment. | |26. PATIENT’S ACCOUNT N O.|Optional entry that may be used for | | |accounting purposes; use up to 16 numeric | | |or alphabetic characters. This number | | |appears on the Remittance Advice as “MRN.”| |27. ACCEPT ASSIGNMENT? |Not required. Assignment is automatically| | |accepted by the provider when billing | | |Medicaid. | |28. TOTAL CHARGE |Total of Column 24F—the sum all charges on| | |the claim. | |29. AMOUNT PAID |Enter the total of payments previously | | |received on this claim. Do not include | | |amounts previously paid by Medicaid. *Do | | |not include in this total the | | |automatically deducted Medicaid or ARKids | | |First-B co-payments. | |30. BALANCE DUE |From the total charge, subtract amounts | | |received from other sources and enter the | | |result. | |31. SIGNATURE OF PHYSICIAN|The provider or designated authorized | |OR SUPPLIER INCLUDING |individual must sign and date the claim | |DEGREES OR CREDENTIALS |certifying that the services were | | |personally rendered by the provider or | | |under the provider’s direction. | | |“Provider’s signature” is defined as the | | |provider’s actual signature, a rubber | | |stamp of the provider’s signature, an | | |automated signature, a typewritten | | |signature or the signature of an | | |individual authorized by the provider | | |rendering the service. The name of a | | |clinic or group is not acceptable. | |32. SERVICE FACILITY |If other than home or office, enter the | |LOCATION INFORMATION |name and street, city, state and ZIP code | | |of the facility where services were | | |performed. | | a. (blank) |Not required. | | b. (blank) |Not required. | |33. BILLING PROVIDER INFO |Billing provider’s name and complete | |& PH # |address. 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. |

Contact Information

Providers needing assistance on billing, enrollment or technical support should call HP Enterprise Services at one of the following assistance numbers:

1.800.457.4454 (outside of Little Rock but in-state)

(501) 376-2211 (local or out-of-state)

Depending on the type of assistance needed, follow the instructions in the phone system to reach the appropriate department. The provider assistance departments are:

Provider Assistance Center - The provider assistance center is open weekdays 8 a.m. to 5 p.m. to assist providers with claim issues, billing questions and denials.

EDI support center - The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software downloads and setup support, software training and data transmission failures.

Medicaid Provider Enrollment - The Medicaid Provider Enrollment Unit is open weekdays 8 a.m. to 5 p.m. to assist providers with enrollment in the Arkansas Medicaid program, changing PCP caseloads and updating demographic information.

HP Enterprise Services Provider Representatives - HP Enterprise Services Provider Representatives are available to visit your facility by appointment. They assist providers with billing issues, software delivery and setup, escalated issues and policy questions. See the Arkansas Medicaid website for a list of representatives by counties.

Research Analyst - The PAC Research Analyst assist providers with escalated billing issues, claim appeals and special processing requests. See the Arkansas Medicaid website for contact information by county. [pic]

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