The Arkansas Medicaid Occupational, Physical and Speech Therapy Program reimburses ... Diagnosis codes and nomenclature must comply with the coding ...
Therapy Billing Tips Provider Reference Supplement
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 3 Eligibility 4 Restricted Aid Categories 4 All Arkansas Medicaid Aid Categories 6 Therapy Benefits 10 Program Coverage 12 Prior Authorization Request Procedures for Augmentative Communication Device (ACD) 15 Evaluation 15 Contact List for Reviews, Managed Care and Authorizations 16 National Place of Service Codes 18 Quick Tips for Submitting Claims 19 Introduction to Billing 19 CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes 19 Augmentative Communication Device (ACD) Évaluation 22 Billing Instructions - Paper Only 22 Completion of the CMS-1500 Claim Form 22 Special Billing Procedures 29 Common Billing Errors 30 Brief Overview of Benefits 31 Contact Information 32
This Billing Tips document serves as a training supplement for Arkansas Medicaid providers but does not supersede official program documentation including: Arkansas Medicaid provider 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
• National Place of Service (POS) reference sheet for paper and electronic claims
• Billing Paper Claims
• Correcting Common Billing Errors
• Contact Information
Beneficiary eligibility for the Arkansas Medicaid program is determined at the Department of Human Services (DHS) county office. A beneficiary’s eligibility may begin and end on any day of any month. Because program eligibility is date specific, providers are required to check each beneficiary’s eligibility on the date of service and are encouraged to do so using one of the following tools:
• Arkansas Medicaid Direct Data Entry (DDE) website
Both tools verify eligibility electronically for a specific date or range of dates, including retroactive eligibility for a year. For more information on eligibility, refer to Section I of your Arkansas Medicaid provider manual.
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 these sections of your Arkansas Medicaid provider manual for more information related to eligibility:
• 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
On the following pages are a consolidated list of aid categories with restrictions and a complete list of aid categories taken from Section 124.000 of your Arkansas Medicaid provider manual.
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) | |
All Arkansas Medicaid Aid Categories
The following is the full list of beneficiary aid categories. Some categories may provide a full range of benefits, may offer limited benefits or may be a category that requires cost sharing by a beneficiary. The following codes describe each level of coverage.
FR full range
LB limited benefits
AC additional cost sharing
MNLB medically needy limited benefits
|Category |Description |Code | |01 ARKIDS B |ARKids First Demonstration |LB, AC | |07 BCC |Breast and Cervical Cancer Prevention and |FR | | |Treatment | | |08 TB-Limited|Tuberculosis – Limited Benefits |LB | |10 N WD |Working Disabled – New Cost Sharing (N) |FR, AC | |NewCo* | | | |10 R WD |Working Disabled – Regular Medicaid Cost |FR, AC | |RegCo* |Sharing (R) | | |11 AABD |AABD |FR | |13 SSI |SSI |FR | |14 SSI |SSI |FR | |16 AA-EC |AA-EC |MNLB | |17 AA-SD |Aid to the Aged Medically Needy Spend Down |MNLB | |18 QMB-AA |Aid to the Aged-Qualified Medicare |LB | | |Beneficiary (QMB) | | |18 S AR |ARSeniors |FR | |Seniors* | | | |20 AFDC-GRANT|Transitional Employment Assistance (TEA, |FR | | |formerly AFDC) Medicaid | | |25 TM |Transitional Medicaid |FR | |26 AFDC-EC |AFDC Medically Needy Exceptional Category |MNLB | |27 AFDC-SD |AFDC Medically Needy Spend Down |MNLB | |31 AAAB |Aid to the Blind |FR | |33 SSI |SSI Blind Individual |FR | |34 SSI |SSI Blind Spouse |FR | |35 SSI |SSI Blind Child |FR | |36 AB-EC |Aid to the Blind-Medically Needy |MNLB | | |Exceptional Category | | |37 AB-SD |Aid to the Blind-Medically Needy Spend Down|MNLB | |38 QMB-AB |Aid to the Blind-Qualified Medicare |LB | | |Beneficiary (QMB) | | |41 AABD |Aid to the Disabled |FR | |43 SSI |SSI Disabled Individual |FR | |44 SSI |SSI Disabled Spouse |FR | |45 SSI |SSI Disabled Child |FR | |46 AD-EC |Aid to the Disabled-Medically Needy |MNLB | | |Exceptional Category | | |47 AD-SD |Aid to the Disabled-Medically Needy Spend |MNLB | | |Down | | |48 QMB- AD |Aid to the Disabled-Qualified Medicare |LB | | |Beneficiary (QMB) | | |49 TEFRA |TEFRA Waiver for Disabled Child |AC | |51 U-18 |Under Age 18 No Grant |FR | |52 ARKIDS A |Newborn |FR | |56 U-18 EC |Under Age 18 Medically Needy Exceptional |MNLB | | |Category | | |57 U-18 SD |Under Age 18 Medically Needy Spend Down |MNLB | |58 QI-1 |Qualifying Individual-1 (Medicaid pays only|LB | | |the Medicare premium.) | | |61 PW-PL |Women Health Waiver- Pregnant Women, |LB (for the| | |Infants & Children Poverty Level (SOBRA). |pregnant | | |A 100 series suffix (the last 3 digits of |woman only)| | |the ID number) is a pregnant woman; a 200 |FR (for | | |series suffix is an ARKids First-A child. |SOBRA | | | |children) | |61 PW “Unborn|Pregnant Women PW Unborn CH-no Ster cov – |LB (for the| |Child” |Does not cover sterilization or any other |pregnant | | |family planning services. |women only)| |62 PW-PE |Pregnant Women Presumptive Eligibility |LB | |63 ARKIDS A |SOBRA Newborn |FR | |65 PW-NG |Pregnant Women No Grant |FR | |66 PW-EC |Pregnant Women Medically Needy Exceptional |MNLB | | |Category | | |67 PW-SD |Pregnant Women Medically Needy Spend Down |MNLB | |69 FAM PLAN |Women’s Health Waiver (Family Planning) |LB | |76 UP-EC |Unemployed Parent Medically Needy |MNLB | | |Exceptional Category | | |77 UP-SD |Unemployed Parent Medically Needy Spend |MNLB | | |Down | | |80 RRP-GR |Refugee Resettlement Grant |FR | |81 RRP-NG |Refugee Resettlement No Grant |FR | |86 RRP-EC |Refugee Resettlement Medically Needy |MNLB | | |Exceptional Category | | |87 RRP-SD |Refugee Resettlement Medically Needy Spend |MNLB | | |Down | | |88 SLI-QMB |Specified Low Income Qualified Medicare |LB | | |Beneficiary (SMB) (Medicaid pays only the | | | |Medicare premium.) | | |91 FC |Foster Care |FR | |92 IVE-FC |IV-E Foster Care |FR | |96 FC-EC |Foster Care Medically Needy Exceptional |MNLB | | |Category | | |97 FC-SD |Foster Care Medically Needy Spend Down |MNLB |
Arkansas Medicaid applies the following therapy benefits to all therapy services in this program:
• Medicaid will reimburse up to four (4) occupational, physical and speech therapy evaluation units (1 unit = 30 minutes) per discipline, per state fiscal year (July 1 through June 30) without authorization. Additional evaluation units will require an extended therapy request.
• Medicaid will reimburse up to four (4) occupational, physical and speech therapy units (1 unit = 15 minutes) daily, per discipline, without authorization. Additional therapy units will require an extended therapy request.
• All requests for extended therapy services must comply with Sections 216.300 through 216.315 of the Occupational, Physical, Speech Therapy Services provider manual.
The Arkansas Medicaid Occupational, Physical and Speech Therapy Program reimburses therapy services for Medicaid-eligible individuals under the age of 21 in the Child Health Services (EPSDT) Program.
Therapy services for individuals aged 21 and older are only covered when provided through the following Medicaid Programs: Developmental Day Treatment Clinic Services (DDTCS), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD), Home Health, Hospice and Physician/Independent Lab/CRNA/Radiation Therapy Center. Refer to the Medicaid provider manuals for conditions of coverage and benefit limits.
Medicaid reimbursement is conditional upon providers’ compliance with Medicaid policy as stated in your provider manual, manual update transmittals and official program correspondence.
All Medicaid benefits are based on medical necessity. Refer to the Glossary section of your Medicaid provider manual for a definition of medical necessity.
Occupational therapy, physical therapy and speech-language pathology services are those services defined by applicable state and federal rules and regulations. These services are covered only when the following conditions exist.
A. Services are provided only by appropriately licensed individuals who are enrolled as Medicaid providers in keeping with the participation requirements in Section 201.000 of the Occupational, Physical, Speech Therapy Services provider manual.
B. Services are provided as a result of a referral from the beneficiary’s primary care physician (PCP). If the beneficiary is exempt from the PCP process, then the attending physician must make the referrals.
C. Treatment services must be provided according to a written prescription signed by the PCP or the attending physician, as appropriate.
D. Treatment services must be provided according to a treatment plan or a plan of care (POC) for the prescribed therapy, developed and signed by providers credentialed or licensed in the prescribed therapy or by a physician.
E. Medicaid covers occupational therapy, physical therapy and speech therapy services when provided to eligible Medicaid beneficiaries under age 21 in the Child Health Services (EPSDT) Program by qualified occupational, physical or speech therapy providers.
F. Speech therapy services ONLY are covered for beneficiaries in the ARKids First-B program benefits.
G. Therapy services for individuals over age 21 are only covered when provided through the following Medicaid Programs: Developmental Day Treatment Clinic Services (DDTCS), Hospital/Critical Access Hospital (CAH), Rehabilitative Hospital, Home Health, Hospice and Physician. Refer to these Medicaid provider manuals for conditions of coverage and benefit limits.
An individual who has been admitted as an inpatient to a hospital or is residing in a nursing care facility is not eligible for occupational therapy, physical therapy and speech-language pathology services under this program. Individuals residing in residential care facilities and supervised living facilities may be eligible for these therapy services when provided on or off site from the facility.
A. Occupational, physical and speech therapy services require a referral from the beneficiary’s primary care physician (PCP) unless the beneficiary is exempt from PCP Program requirements. If the beneficiary is exempt from the PCP process, referrals for therapy services are required from the beneficiary’s attending physician. All therapy services for beneficiaries under the age of 21 years require referrals and prescriptions be made utilizing the “Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21” form DMS-640.
H. Occupational, physical and speech therapy services also require a written prescription signed by the PCP or attending physician, as appropriate.
1. Providers of therapy services are responsible for obtaining renewed PCP referrals every six months even if the prescription for therapy is for one year.
2. A prescription for therapy services is valid for the length of time specified by the prescribing physician, up to one year.
3. When a school district is providing therapy services in accordance with a child’s Individualized Education Program (IEP), a PCP referral is required at the beginning of each school year. The PCP referral for the therapy services related to the IEP can be for the 9-month school year and a 6-month referral renewal is not necessary unless the PCP specifies otherwise.
4. The PCP or attending physician is responsible for determining medical necessity for therapy treatment.
a. The individual’s diagnosis must clearly establish and support that the prescribed therapy is medically necessary. b. Diagnosis codes and nomenclature must comply with the coding conventions and requirements established in Internal Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM); Volumes I and II, in the edition Medicaid has certified as current for the patient’s dates of service. c. Please note that diagnosis codes V57.1, V57.2 and V57.3 are not specific enough to identify the medical necessity for therapy treatment and may not be used.
5. Providers of therapy services must use form DMS-640 – “Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 Prescription/Referral” – to obtain the PCP referral and the written prescription for therapy services for any beneficiary under the age of 21 years. . Exclusive use of this form will facilitate the process of obtaining referrals and prescriptions from the PCP or attending physician. A copy of the prescription must be maintained in the beneficiary’s records. The original prescription is to be maintained by the physician. Form DMS-640 must be used for the initial referral for evaluation and a separate DMS-640 is required for the prescription. After the initial referral using the form DMS-640 and initial prescription utilizing a separate form DMS-640, subsequent referrals and prescriptions for continued therapy may be made at the same time using the same DMS-640. Instructions for completion of form DMS-640 are located on the back of the form. Medicaid will accept an electronic signature provided that it is in compliance with Arkansas Code 25-31-103.
6. To order copies from HP Enterprise Services, use Form HP-MFR-001 – Medicaid Forms Request in Section V of your provider manual.
7. A treatment plan developed and signed by a provider who is credentialed and licensed in the prescribed therapy or by a physician is required for the prescribed therapy.
a. The plan must include goals that are functional, measurable and specific for each individual child. b. Services must be provided in accordance with the treatment plan, with clear documentation of service rendered. Refer to Section 204.000, subpart D, of the Occupational, Physical, Speech Therapy Services provider manual for more information on required documentation.
I. Make-up therapy sessions are covered in the event a therapy session is canceled or missed if determined medically necessary and prescribed by the beneficiary’s PCP. Any make-up therapy session requires a separate prescription from the original prescription previously received. Form DMS-640 must be used by the PCP or attending physician for any make-up therapy session prescriptions.
J. Therapy services carried out by an unlicensed therapy student may be covered only when the following criteria are met:
• Therapies performed by an unlicensed student must be under the direction of a licensed therapist and the direction is such that the licensed therapist is considered to be providing the medical assistance.
• To qualify as providing the service, the licensed therapist must be present and engaged in student oversight during the entirety of any encounter that the provider expects Medicaid to cover.
Refer to Section 260.000 of the Occupational, Physical, Speech Therapy Services provider manual for procedure codes and billing instructions and Section 216.100 information regarding extended therapy benefits.
Prior Authorization Request Procedures for Augmentative Communication Device (ACD)
To perform an evaluation for the augmentative communication device (ACD), the provider must request prior authorization from the Division of Medical Services, Utilization Review Section, using the following procedures.
A. A primary care physician (PCP) written referral is required for prior authorization of the ACD evaluation. If the beneficiary is exempt from the PCP process, then the attending physician must make the referral.
B. The physical and intellectual capabilities (functional level) of the beneficiary must be documented in the referral. The referring physician must justify the medical reason the individual requires the ACD.
C. If the beneficiary is currently receiving speech therapy, the speech- language pathologist must document the prerequisite communication skills for the augmentative communication system and the cognitive level of the beneficiary.
D. A completed Request for Prior Authorization and Prescription Form (DMS- 679) must be used to request prior authorization. Copies of form DMS- 679 can be requested using the Medicaid Form Request, HP-MFR-001.
E. Submit the request to the Division of Medical Services, Utilization Review Section. When the PA request is received in Utilization Review, it is given to the Medical Director to review and make a decision.
F. For approved requests, a PA control number will be assigned and entered in item 10 on the DMS-679 and returned to the provider. For denied requests, a denial letter with the reason for denial will be mailed to the requesting provider and the Medicaid beneficiary.
NOTE: Prior authorization for therapy services only applies to the augmentative communication evaluation. Refer to Section 215.000 of the Occupational, Physical, Speech Therapy Services provider manual for additional information.
Contact List for Reviews and Authorizations
|Arkansas Foundation for|Review and authorization (PAs) | |Medical Care (AFMC) |Provides utilization and quality reviews | | |for various Medicaid programs | | |UR for PCPs | | |Reviews ER, OP clinics, Assistant Surgeon| | |Authorizes hospital stays and certain | | |procedures | | |Authorizes inpatient stays over 4 days | | |(Mump Review) | | |1-888-987-1200 option 2 | | |www.afmc.org | |Q Source of AR |Review and authorization (PAs) | | |Therapy review (under 21), PA for | | |personal care (under 21) and ePrescribing| | |Initiative | | |(501) 801-6910 | | |Nancy Archer, Executive Director | | |[email protected]
| | |www.qsource.org |
National Place of Service Codes
Electronic and paper claims now require the same National Place of Service Code.
|Place of Service |POS Codes | |Doctor’s Office |11 | |Patient’s Home |12 | |Day Care Facility |52 | |Night Care Facility |52 | |Other Locations |99 | |Residential Treatment |56 | |Center | |
Quick Tips for Submitting Claims
This section outlines quick tips for therapy providers in Medicaid. These billing tips address some of the most common billing errors identified by the HP Provider Assistance Center (PAC). Topics include the following:
• Introduction to Billing
• Procedure code quick reference
• Therapy service code quick reference
• Special billing procedures
• Common billing errors
Introduction to Billing
Occupational, physical and speech therapy providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of the your provider manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes
The following occupational, physical and speech-language pathology procedure codes are payable for therapy services indicated. Refer to Section IV - Glossary - of your Medicaid provider manual for definitions of “group” and “individual” as they relate to therapy sessions.
A. Occupational Therapy
|Procedure|Required |Description | |Code |Modifiers| | |97003 |— |Evaluation for Occupational Therapy | | | |(30-minute unit; maximum of 4 units per state | | | |fiscal year, July 1 through June 30) | |97530 |— |Individual Occupational Therapy | | | |(15-minute unit; maximum of 4 units per day) | |97150 |U2 |Group Occupational Therapy | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) | |97530 |UB |Individual Occupational Therapy by Occupational | | | |Therapy Assistant | | | |(15-minute unit; maximum of 4 units per day) | |97150 |UB, U1 |Group Occupational Therapy by Occupational | | | |Therapy Assistant | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) |
B. Physical Therapy
|Procedure|Required |Description | |Code |Modifier | | |97001 |— |Evaluation for Physical Therapy | | | |(30-minute unit; maximum of 4 units per state | | | |fiscal year, July 1 through June 30) | |97110 |— |Individual Physical Therapy | | | |(15-minute unit; maximum of 4 units per day) | |97150 |— |Group Physical Therapy | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) | |97110 |UB |Individual Physical Therapy by Physical Therapy | | | |Assistant | | | |(15-minute unit; maximum of 4 units per day) | |97150 |UB |Group Physical Therapy by Physical Therapy | | | |Assistant | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) |
C. Speech-Language Pathology
|Procedure|Required |Description | |Code |Modifier | | |92506 |— |Evaluation for Speech Therapy | | | |(30-minute unit; maximum of 4 units per state | | | |fiscal year, July 1 through June 30) | |92507 |— |Individual Speech Session | | | |(15-minute unit; maximum of 4 units per day) | |92508 |— |Group Speech Session | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) | |92507 |UB |Individual Speech Therapy by Speech-Language | | | |Pathology Assistant | | | |(15-minute unit; maximum of 4 units per day) | |92508 |UB |Group Speech Therapy by Speech-Language Pathology| | | |Assistant | | | |(15-minute unit; maximum of 4 units per day, | | | |maximum of 4 clients per group) |
Augmentative Communication Device (ACD) Evaluation
The following procedure codes require prior authorization before services may be provided.
|Procedure | | |Code |Description | |92607 |Augmentative Communication Device Evaluation | |92608 | |
Billing Instructions - Paper Only
HP Enterprise Services offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing.
Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form.
Carefully follow these instructions to help HP Enterprise Services efficiently process claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the HP Enterprise Services Claims Department.
NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services.
Completion of the CMS-1500 Claim Form
|Field Name and Number |Instructions for Completion | |1. (type of coverage) |Not required. | |1a. INSURED’S I.D. NUMBER |Beneficiary’s or participant’s | |(For Program in Item 1) |10-digit Medicaid or ARKids First-A | | |or ARKids First-B identification | | |number. | |2. PATIENT’S NAME (Last Name,|Beneficiary’s or participant’s last | |First Name, Middle Initial) |name and first name. | |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 Name,|Required if insurance affects this | |First Name, Middle Initial) |claim. Insured’s last name, first | | |name and middle initial. | |5. PATIENT’S ADDRESS (No., |Optional. Beneficiary’s or | |Street) |participant’s 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, | |INSURED |check the box indicating the | | |patient’s relationship to the | | |insured. | |7. INSURED’S ADDRESS (No., |Required if insured’s address is | |Street) |different from the patient’s address.| | CITY | | | STATE | | | ZIP CODE | | | TELEPHONE (Include Area | | |Code) | | |8. PATIENT STATUS |Not required. | |9. OTHER INSURED’S NAME (Last|If patient has other insurance | |name, First Name, Middle |coverage as indicated in Field 11d, | |Initial) |the other insured’s last name, first | | |name and middle initial. | |a. OTHER INSURED’S POLICY OR |Policy and/or group number of the | |GROUP NUMBER |insured individual. | |b. OTHER INSURED’S DATE OF |Not required. | |BIRTH | | |SEX |Not required. | |c. EMPLOYER’S NAME OR SCHOOL |Required when items 9 a-d are | |NAME |required. 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 USE |Not used. | |11. INSURED’S POLICY GROUP OR|Not required when Medicaid is the | |FECA NUMBER |only payer. | |a. INSURED’S DATE OF BIRTH |Not required. | | SEX |Not required. | |b. EMPLOYER’S NAME OR SCHOOL |Not required. | |NAME | | |c. INSURANCE PLAN NAME OR |Not required. | |PROGRAM NAME | | |d. IS THERE ANOTHER HEALTH |When private or other insurance may | |BENEFIT PLAN? |or will cover any of the services, | | |check YES and complete items 9a | | |through 9d. | |12. PATIENT’S OR AUTHORIZED |Not required. | |PERSON’S SIGNATURE | | |13. INSURED’S OR AUTHORIZED |Not required. | |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. | |PREGNANCY (LMP) |Date of the accident. | |15. IF PATIENT HAS HAD SAME |Not required. | |OR SIMILAR ILLNESS, GIVE | | |FIRST DATE | | |16. DATES PATIENT UNABLE TO |Not required. | |WORK IN CURRENT OCCUPATION | | |17. NAME OF REFERRING |Primary Care Physician (PCP) referral| |PROVIDER OR OTHER SOURCE |is required for Occupational, | | |Physical and Speech Therapy Services.| | |Enter the referring physician’s name.| |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 |services charged on this claim are | | |related 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 |For tracking purposes, occupational, | | |physical and speech therapy providers| | |are required to enter one of the | | |following therapy codes: | |Code |Category | |A |Individuals from birth through 2 | | |years (but not 3 years old before | | |September 15 of the current school | | |year) who are receiving therapy | | |services under an Individualized | | |Family Services Plan (IFSP) through | | |the Division of Developmental | | |Disabilities Services. | |B |Individuals ages 0 through 5 years | | |(if individual has not reached age 5 | | |by September 15) who are receiving | | |therapy services under an | | |Individualized Plan (IP) through the | | |Division of Developmental | | |Disabilities Services. | | |NOTE: This code is to be used only | | |when all three of the following | | |conditions are in place: 1) the | | |individual receiving services has not| | |attained age 5 by September 15 of the| | |current school year, 2) the | | |individual receiving services is | | |receiving the services under an | | |Individualized Plan and 3) the | | |Individualized Plan is through the | | |Division of Developmental | | |Disabilities Services. | |When using code C or D, | | |providers must also include | | |the 4-digit LEA (local | | |education agency) code | | |assigned to each school | | |district. For example: | | |C1234 | | |C (and 4-digit LEA code) |Individuals ages 3 through 5 years | | |(if individual has not reached age 5 | | |by September 15) who are receiving | | |therapy services under an | | |Individualized Education Program | | |(IEP) through an education service | | |cooperative. | | |NOTE: This code set is to be used | | |only when all three of the following | | |conditions are in place: 1) the | | |individual receiving services was 3 | | |years old before September 15 of the | | |current school year and was not 5 | | |years old before September 15 of the | | |current school year, 2) the | | |individual is receiving the services | | |under an IEP maintained by an | | |education service cooperative and 3) | | |therapy services are being furnished | | |by a) the ESC, which is an enrolled | | |Medicaid therapy provider, or by b) a| | |Medicaid-enrolled therapist or | | |therapy group provider. | |D (and 4-digit LEA code) |Individuals ages 5 (by September 15) | | |to 21 years who are receiving therapy| | |services under an IEP through a | | |school district. | | |NOTE: This code set is to be used | | |only when all three of the following | | |conditions are in place: 1) the | | |individual receiving services was 5 | | |years old before September 15 of the | | |current school year and was not 21 | | |years old before September 15 of the | | |current school year, 2) the | | |individual is receiving the services | | |under an IEP and 3) the IEP is | | |through a school district. | |E |Individuals ages 18 through 20 years | | |who are receiving therapy services | | |through the Division of Developmental| | |Disabilities Services. | |F |Individuals ages 18 through 20 years | | |who are receiving therapy services | | |from individual or group providers | | |not included in any of the previous | | |categories (A-E). | |G |Individuals ages birth through 17 | | |years who are receiving | | |therapy/pathology services from | | |individual or group providers not | | |included in any of the previous | | |categories (A-F). | |20. OUTSIDE LAB? |Not required. | | $ CHARGES |Not required. | |21. DIAGNOSIS OR NATURE OF |Diagnosis code for the primary | |ILLNESS OR INJURY |medical 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 262.200 of | | |the Occupational, Physical, Speech | | |Therapy Services provider manual for | | |codes. | |C. EMG |Not required. | |D. PROCEDURES, SERVICES OR | | |SUPPLIES | | | CPT/HCPCS |Enter the correct CPT or HCPCS | | |procedure code from Sections 262.100 | | |through 262.120 of the Occupational, | | |Physical, Speech Therapy Services | | |provider manual. | | 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 beneficiary | | |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. NUMBER |Not required. This information is | | |carried in the provider’s Medicaid | | |file. If it changes, please contact | | |Provider Enrollment. | |26. PATIENT’S ACCOUNT NO. |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 OR|The provider or designated authorized| |SUPPLIER INCLUDING DEGREES OR|individual must sign and date the | |CREDENTIALS |claim certifying that the services | | |were personally rendered by the | | |provider or under the provider’s | | |direction. “Provider’s signature” is | | |defined as the provider’s actual | | |signature, a rubber stamp of the | | |provider’s signature, an automated | | |signature, a typewritten signature or| | |the signature of an individual | | |authorized by the provider rendering | | |the service. The name of a clinic or | | |group is not acceptable. | |32. SERVICE FACILITY LOCATION|If other than home or office, enter | |INFORMATION |the 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. |
Special Billing Procedures
Services must be billed according to the care provided and to the extent each procedure is provided. Occupational, physical and speech therapy services do not require prior authorization with the exception of ACD evaluations. ACD evaluations do require prior authorization. Refer to Section 215.000 of the Occupational, Physical, Speech Therapy Services provider manual for information about the augmentative communication device evaluation.
Extended therapy services may be requested for all medically necessary therapy services for beneficiaries under age 21. Refer to Sections 216.000 through 216.310 of the Occupational, Physical, Speech Therapy Services provider manual for more information.
Common Billing Errors
Refer to the chart below to learn how to correct common billing errors that are associated with certain Explanation of Benefits (EOB) codes:
|EOB Code |Error |Method of Correction | |263 and 267 |Beneficiary is |Verify the beneficiary is | | |partially or totally |eligible for all claim dates | | |ineligible for the |of service. Resubmit the | | |DOS. |claim/portion of the claim for| | | |the time of eligibility. | |208 |Beneficiary aid |Verify that the original claim| | |category 69 is |has a family planning | | |limited to family |diagnosis and procedure code. | | |planning services |Correct and resubmit the | | |only. |claim. | |252 |Medicaid ID number |Verify eligibility through | | |submitted does not |Medicaid’s electronic | | |match patient’s name |eligibility system and | | |on Medicaid ID card. |resubmit the claim with | | | |correct information. | |469 or 470 |Duplicate billing. |Verify that the service is not| | |Claim is identical to|a duplicate bill. Resubmit the| | |another claim for |corrected claim | | |DOS, performing | | | |provider, procedure, | | | |TOS and price. | | |103 |Claim does not meet |Claims must be received by HP | | |the timely filing |Enterprise Services within 365| | |requirements for |days from the “To” DOS. Claims| | |Medicaid. |received beyond this deadline | | | |will not be paid. | |952 |Service requires |Resubmit the claim with the | | |Primary Care |corrected PCP information | | |Physician referral. |required for adjudication. | |199 |ARKids First-B |ARKids First-B beneficiary’s | | |beneficiary is older |eligibility ends on their 19th| | |than 18 years old. |birthday. The “from” DOS | | | |cannot exceed the 19th | | | |birthday. |
Brief Overview of Benefits
• Under 21 – 4 Evaluations per SFY
• Up to four 15-Minute Units per Day
• ARKids First-B only Eligible for Speech Therapy
• See Section 216.100 of the Occupational, Physical, Speech Therapy Services provider manual for additional 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.
• HP Provider Enrollment - The HP-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 Provider Representatives - HP 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]