Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-010 - SPA #2015-008, MedX 1-15, Hospital 7-15, SecV 3-15

Current through Register Vol. 49, No. 6, June, 2024
Revision: HCFA-PM-91-4 (BPD)
Supplement 1 to
				Attachment 4.19-B
AUGUST 1991
Page 2
Revised: January 1, 2016
OMB No.:
				0938
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY
				ACT
State/Territory:
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-
OTHER TYPES OF CARE
Payment of Medicare Part A and Part B
				Deductible/Coinsurance
________________________________________________________________________________
QMBs: Part A
MR
Deductibles
MR
Coinsurance
Part B
MR
Deductibles
MR
Coinsurance
				________________________________________________________________________________
Other Part A
MR
Deductibles
MR
Coinsurance
Medicaid
Recipients Part B
MR
Deductibles
MR
Coinsurance
________________________________________________________________________________
Dual Part A
MR
Deductibles
MR
Coinsurance
Eligible
(QMB Plus) Part B
MR
Deductibles
MR
Coinsurance
________________________________________________________________________________
QMBs:
*Part A
SP
Deductibles
SP
Coinsurance
Inpatient
				Hospital
services only
				________________________________________________________________________________
Other
*Part A
SP
Deductibles
SP
Coinsurance
Inpatient
				Hospital
Medicaid
Recipients
services only
________________________________________________________________________________
Dual
*Part A
SP
Deductibles
SP
Coinsurance
Inpatient
				Hospital
Eligible
(QMB Plus)
services only
Revision: HCFA-PM-91-4 (BPD)
Supplement 1 to
				Attachment 4.19-B
AUGUST 1991
Page 3
Revised: January 1, 2016
OMB No.:
				0938
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY
				ACT
State/Territory:
ARKANSAS
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-
OTHER TYPES OF CARE
Payment of Medicare Part A and Part B
				Deductible/Coinsurance
________________________________________________________________________________
*The payment of the Medicare Part A deductible and
				coinsurance for inpatient hospital services is based on the
				following.
(1)
If the
			 Medicare payment amount equals or exceeds the Medicaid payment rate, the state
			 is not required to pay the Medicare Part A deductible/coinsurance on a
			 crossover claim.
(2)
If the Medicare payment amount is less than the Medicaid payment rate, the
			 state is required to pay the Medicare Part A deductible/coinsurance on a
			 crossover claim, but the amount of payment is limited to the lesser of the
			 deductible/coinsurance or the amount remaining after the Medicare payment
			 amount is subtracted from the Medicaid payment rate.
Coverage of a recipient's deductible and/or coinsurance
				liabilities as specified in this section satisfies the state's obligation to
				provide Medicaid coverage for services that would have been paid in the absence
				of Medicare coverage.
The payment of all other Part A deductible and
				coinsurance is based on the Medicare rate.
(3) The Medicaid agency will use the Medicare
			 all-inclusive payment rate for cost reimbursement of FQHC encounter
			 coinsurance. The Medicaid agency will cost settle for the coinsurance
			 percentage. The Medicaid agency will cost settle for the coinsurance percentage
			 of the FQHC Medicare encounter cost after the final encounter cost has been
			 determined by the Medicare intermediary.
(4) Effective for dates of service on or
			 after September 1, 1999, the State will make copayments for Medicare/Medicaid
			 recipients who are enrolled in a Medicare HMO. The service categories and
			 maximum copayment amount are:
Service
Maximum Copayment
Emergency Room
$25.00 (payable to facility)
Physician/Chiropractor/Podiatrist (excluding
						  Psychiatry/Psychology -see below)
$ 5.00 (payable to physician/
						  chiropractor/podiatrist
Occupational, Physical and Speech Therapy
$ 5.00 (payable to facility)
Psychiatrist/Psychologist
50% (payable to provider) - Medi-Pak HMO
$20.00 (payable to provider) -
Medicare Complete HMO
Provider Manual Update Transmittal
				MEDX-1-15
Section II
Medicare/Medicaid Crossover Only
230.000
REIMBURSEMENT
230.010
Medicare Reimbursement
Medicaid's payment toward the Medicare Part B coinsurance
				and/or deductible is full payment of the amount submitted to Medicaid.
230.100
Inpatient Hospital
			 Services Reimbursement
Effective for all claims and claim adjustments with dates of
				service on and after January 1, 2016, the Division of Medical Services will
				implement Medicaid reimbursement for Medicare Part A coinsurance and
				deductibles related to inpatient hospital services to the lesser of the
				Medicaid allowed amount minus the Medicare payment or the sum of the Medicare
				coinsurance and deductible. If the Medicaid allowed amount minus the Medicare
				paid amount is zero or a negative number, Medicaid's reimbursement will be
				zero.
241.300
Instructions for Completion of the Inpatient and Outpatient Services
			 Medicare - Medicaid Crossover Invoice - CMS-1450 (UB-04)
HP Enterprise Services offers providers several options for
				electronic billing. Therefore, claims submitted on paper are paid once a month.
				The only claims exempt from this process are those which require attachments or
				manual pricing.
To bill for Medicare - Medicaid crossover inpatient or
				outpatient services, use the claim form CMS-1450 (UB-04).
View a sample CMS-1450 (UB-04) claim form.
Arkansas Medicaid does not supply providers with Uniform Billing claim
				forms. Numerous vendors sell CMS-1450 (UB-04) forms.
Read and carefully adhere to the following instructions. The
				numbered items correspond to fields on the claim form. Accuracy, completeness
				and clarity are important. Claims cannot be processed if applicable information
				is not supplied or is illegible. Paper claims should be typed whenever
				possible.
Completed claim forms should be forwarded to the HP Enterprise
				Services Claims Department.
View or print the HP Enterprise Services
				Claims Department contact information.
NOTE: A provider rendering services without verifying
				eligibility for each date of service does so at the risk of not being
				reimbursed for the services.
Field #
Field name
Description
1.
(blank)
Inpatient and Outpatient Crossover:
Enter the provider's name (physical address - service location) and
						  billing address, including city, state, zip code, and telephone number.
2.
(blank)
Inpatient and Outpatient Crossover:
The address that the provider submitting the bill intends payment to
						  be sent if different from FL 01. (Use this address for provider's return
						  address for returned mail.)
3a.
PAT CNTL #
Inpatient and Outpatient Crossover:
The provider may use this optional field for accounting purposes. It
						  appears on the RA beside the letters "MRN." Up to 16 alphanumeric characters
						  are accepted.
3b.
MED REC #
Inpatient and Outpatient Crossover:
Required. Enter up to 15 alphanumeric characters.
4.
TYPE OF BILL
Inpatient and Outpatient Crossover:
See the UB-04 manual. Four-digit code with a leading zero that indicates the
						  type of bill.
5.
FED TAX NO
The number assigned to the provider by the Federal
						  government for tax reporting purposes. Also known as tax identification number
						  (TIN) or employer identification number (EIN).
6.
STATEMENT COVERS PERIOD
Enter the covered beginning and ending service dates.
						  Format: MMDDYY.
Inpatient Crossover:
Enter the dates
						  of the first and last covered days in the FROM and THROUGH fields.
The FROM and THROUGH dates cannot span the State's
						  fiscal year end (June 30) or the provider's fiscal year end.
To file correctly for covered inpatient days that span
						  a fiscal year end:
1. Submit one interim claim (a first claim or a
						  continuing claim, as applicable) on which the THROUGH date is the last day of
						  the fiscal year that ended during the stay.
On a first claim or a continuing claim, the patient
						  status code in field 17 must indicate that the beneficiary is still a patient
						  on the indicated THROUGH date.
2. Submit a second interim claim (a continuing claim or
						  a last claim, as applicable) on which the FROM date is the first day of the new
						  fiscal year.
When the discharge date is the first day of the
						  provider's fiscal year or the state's fiscal year, only one (bill type:
						  admission through discharge) claim is necessary, because Medicaid does not
						  reimburse a hospital for a discharge day unless the discharge day is also the
						  first covered day of the inpatient stay.
When an inpatient is discharged on the same date he or
						  she is admitted, the day is covered when the TYPE OF BILL code indicates that
						  the claim is for admission through discharge, the STAT (patient status) code
						  indicates discharge or transfer, and the FROM and THROUGH dates are
						  identical.
Outpatient Crossover:
To bill on a
						  single claim for outpatient services occurring on multiple dates, enter the
						  beginning and ending service dates in the FROM and THROUGH fields of this
						  field.
The dates in this locator must fall within the same
						  fiscal year - the state's fiscal year and the hospital's fiscal year.
When billing for multiple dates of service on a single
						  claim, a date of service is required in field 45 for each HCPCS code in field
						  44 and/or each revenue code in field 42.
7.
Crossover Indicator
Inpatient and Outpatient Crossover:
Required. Enter XOI for an Inpatient Crossover or XOO for an Outpatient
						  Crossover.
8a. 8b.
PATIENT NAME (blank)
Inpatient and Outpatient Crossover:
Enter the patient's last name and first name. Middle initial is
						  optional.
Not required.
9.
PATIENT ADDRESS
Inpatient and Outpatient Crossover:
Enter the patient's full mailing address. Optional.
10.
BIRTH DATE
Inpatient and Outpatient Crossover:
Enter the patient's date of birth. Format: MMDDYYYY.
11.
SEX
Inpatient and Outpatient Crossover:
Enter M for male, F for female, or U for unknown.
12.
ADMISSION DATE
Inpatient Crossover:
Enter the
						  inpatient admission date. Format: MMDDYY.
Outpatient Crossover:
Not
						  required.
13.
ADMISSION HR
Inpatient and Outpatient Crossover:
Enter the national code that corresponds to the hour during which the patient
						  was admitted for inpatient care.
14.
ADMISSION TYPE
Inpatient Crossover:
Enter the code
						  from the Uniform Billing Manual that indicates the priority of this inpatient
						  admission.
Outpatient Crossover:
Not
						  required.
15.
ADMISSION SRC
Inpatient and Outpatient Crossover:
Admission source. Required. Code 1, 2, 3, or 4 is required when the code in
						  field 14 is 4.
16.
DHR
Inpatient Crossover:
See the UB-04
						  Manual. Required except for type of bill 021x. Enter the hour the patient was
						  discharged from inpatient care.
17.
STAT
Inpatient Crossover:
Enter the
						  national code indicating the patient's status on the Statement Covers Period
						  THROUGH date (field 6).
Outpatient Crossover:
Not
						  applicable.
18.-28.
CONDITION CODES
Inpatient and Outpatient Crossover:
Required when applicable. See the UB-04 Manual for requirements and for the
						  codes used to identify conditions or events relating to this bill.
29.
ACDT STATE
Not required.
30.
(blank)
Unassigned data field.
31.-34.
OCCURRENCE CODES AND DATES
Inpatient and Outpatient Crossover:
Required when applicable. See the UB-04 Manual.
31a
(blank)
Inpatient and Outpatient Crossover:
Required. Must have a value of 50 with the Medicare Paid Date. Format:
						  MMDDYYYY.
35.-36.
OCCURRENCE SPAN CODES AND DATES
Inpatient Crossover:
Enter the dates
						  of the first and last days approved, per the facility's PSRO/UR plan, in the
						  FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY.
Outpatient Crossover:
See the UB-04
						  Manual.
37.
Not used
Responsible Party Name and Address
VALUE CODES
Reserved for assignment by the NUBC.
38.
See the UB-04 Manual.
39.
Outpatient Crossover:
Not
						  required.
Inpatient Crossover:
39a.
CODE
Enter 80.
AMOUNT
Enter number of covered days. Enter number of days
						  (units billed) to the left of the vertical dotted line and enter two zeros (00)
						  to the right of the vertical dotted line.
39b.
CODE
Enter 81.
AMOUNT
Enter number of non-covered days. Enter number of days
						  (units billed) to the left of the vertical dotted line and enter two zeros (00)
						  to the right of the vertical dotted line
40.
VALUE CODES
Inpatient and Outpatient Crossover:
Required.
40a.
CODE
Enter A1.
AMOUNT
Regular deductible amount.
40b.
CODE
Enter A2.
AMOUNT
Co-insurance amount.
40c.
CODE
Enter 06.
AMOUNT
Blood deductible amount.
41.
VALUE CODES REV CD
DESCRIPTION
HCPCS/RATE/HIPPS CODE
SERV DATE
Not required.
42.
Inpatient and Outpatient Crossover:
See the UB-04 Manual.
43.
See the UB-04 Manual.
44.
See the UB-04 Manual.
45.
Inpatient Crossover:
Not
						  applicable.
Outpatient Crossover:
Date format:
						  MMDDYY.
46.
SERV UNITS
Comply with the UB-04 Manual's instructions when
						  applicable to Medicaid.
47.
TOTAL CHARGES
Comply with the UB-04 Manual's instructions when
						  applicable to Medicaid.
48.
NON-COVERED CHARGES
Not used
PAYER NAME
See the UB-04 Manual, line item "Total" under
						  "Reporting."
49.
Reserved for assignment by the NUBC.
50.
Line A is required and is for the Medicare payment. For
						  lines B and C, see the UB-04 for additional regulations.
51.
HEALTH PLAN ID
Report the HIPAA National Plan Identifier; otherwise
						  report the legacy/proprietary number.
52.
REL INFO ASG BEN PRIOR PAYMENTS
Required when applicable. See the UB-04 Manual.
53.
Required. See "Notes" at field 53 in the UB-04
						  Manual.
54.
Inpatient and Outpatient Crossover:
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.
55.
EST AMOUNT DUE
NPI
OTHER PRV ID
Situational. See the UB-04 Manual.
56.
Not required.
57.
Enter the 9-digit Arkansas Medicaid provider ID number
						  of the billing provider in first line of field.
58. A, B, C
INSURED'S NAME
P REL
INSURED'S UNIQUE ID
Inpatient and Outpatient Crossover:
Comply with the UB-04 Manual's instructions when applicable to Medicaid.
59. A, B, C
Inpatient and Outpatient Crossover:
Comply with the UB-04 Manual's instructions when applicable to Medicaid.
60. A, B, C
Inpatient and Outpatient Crossover:
Enter the patient's Medicaid identification number in first line of
						  field.
61. A, B, C
GROUP NAME
Inpatient and Outpatient Crossover:
Using the plan name if the patient is insured by another payer or other payers,
						  follow instructions for field 60.
62. A, B, C
INSURANCE GROUP NO
TREATMENT
AUTHORIZATION
CODES
Inpatient and Outpatient Crossover:
When applicable, follow instructions for fields 60 and 61.
63. A, B, C
Inpatient Crossover:
Enter any
						  applicable prior authorization, benefit extension, or MUMP certification
						  control number on line 63A.
Outpatient Crossover:
Enter any
						  applicable prior authorization or benefit extension numbers on line 63A.
64. A, B, C
DOCUMENT CONTROL NUMBER
Inpatient and Outpatient Crossover:
Required. Enter the Medicare ICN. Must be 14 characters or less.
65. A, B, C
EMPLOYER NAME
Inpatient and Outpatient
						  Crossover:
When applicable, based upon fields 51 through 62, enter the
						  name(s) of the individuals and entities that provide health care coverage for
						  the patient (or may be liable).
66.
DX
Diagnosis Version Qualifier. See the UB-04
						  Manual.
Use "9" for ICD-9-CM.
Use "0" for ICD-10-CM.
Comply with the UB-04 Manual's instructions on claims
						  processing requirements.
67. A-H
(blank)
Inpatient and Outpatient Crossover:
Enter the ICD CM diagnosis codes corresponding to additional conditions that
						  coexist at the time of admission, or develop subsequently, and that have an
						  effect on the treatment received or the length of stay. Fields are available
						  for up to 8 codes.
68.
Not used
Reserved for assignment by the NUBC.
69.
ADMIT DX
Required for inpatient. See the UB-04 Manual.
70.
PATIENT REASON DX
See the UB-04 Manual.
71.
PPS CODE
Not required.
72
ECI
See the UB-04 Manual. Required when applicable (for
						  example, TPL and torts).
73.
Not used
Reserved for assignment by the NUBC.
74.
PRINCIPAL PROCEDURE
CODE DATE
Inpatient Crossover:
Required on
						  inpatient claims when a procedure was performed. On all interim claims, enter
						  the codes for all procedures during the hospital stay.
Outpatient Crossover:
Not
						  applicable.
Principal procedure code.
Format: MMDDYY.
74a-74e
OTHER PROCEDURE
CODE DATE
Inpatient Crossover:
Required on
						  inpatient claims when a procedure was performed. On all interim claims, enter
						  the codes for all procedures during the hospital stay.
Outpatient Crossover:
Not
						  applicable.
Inpatient claims only. Other procedure code(s).
Inpatient claims only. Format: MMDDYY.
75.
Not used
Reserved for assignment by the NUBC.
76.
ATTENDING NPI QUAL
LAST FIRST
NPI not required.
Enter 0B, indicating state license number. Enter the
						  state license number in the second part of the field.
Enter the last name of the primary attending
						  physician.
Enter the first name of the primary attending
						  physician.
77.
OPERATING NPI
NPI not required.
QUAL
Enter 0B, indicating state license number. Enter the
						  operating physician's state license number in the second part of the
						  field.
LAST
Enter the last name of the operating physician.
FIRST
Enter the first name of the operating physician.
78.
OTHER NPI
NPI not required.
QUAL
Enter 0B, indicating state license number. Enter the
						  state license number in the second part of the field.
LAST
Enter the last name of the primary care
						  physician.
FIRST
Enter the first name of the primary care
						  physician.
79.
OTHER NPI/QUAL/LAST/FIRS
Not used.
80.
REMARKS
For provider's use.
81.
Not used
Reserved for assignment by the NUBC.