Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-051 - Section III - Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
Section III
301.100
Electronic Claims Submission
EDS furnishes software and X.12/NCPDP companion documents at no
				charge to the provider for all transactions utilized by Arkansas
				Medicaid.
When submitting claims electronically, Medicaid providers use
				the following claim types: ASC X.12N 4010A 837P (professional), 837I
				(institutional and long-term care), 837D (dental), NCPDP 5.1/1.1 (pharmacy).
				Your provider type is determined by the last two digits of your Arkansas
				Medicaid provider ID. For example, the provider type of a hospital with the
				Arkansas Medicaid provider ID 123456705 is 05.
The following provider types can bill on an
				837P:
01
02
03
04
05
08
09
10
15
16
17
18
19
20
21
22
23
24
26
27
28
29
30
31
32
33
34
35
37
38
39
40
41
42
43
44
45
46
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
The following provider types can bill on an
				837I:
05
11
12
13
14
15
21
25
26
27
28
29
36
41
42
47
64
99
The following provider types can bill on an
				837D:
08
30
31
79
80
The following provider types can bill on an
				NCPDP:
07
16
EDS processes each week's accumulations of claims during a
				weekend cycle. The deadline for each weekend cycle is midnight Friday.
Providers submitting claims electronically must maintain a
				daily electronic claim transaction summary, signed by an authorized individual.
				Please refer to the Provider Contract (Form DMS-653), Item "K."
View or print form DMS-653.
NOTE: The provider is charged a transaction fee for each
				electronic claim submitted and each instance of electronic eligibility
				verification.
314.411
The "Credit To" Segment
The first segment of the adjustment transaction is the "Credit
				To" segment. In this section, EDS identifies the adjustment transaction, the
				adjusted claim and the previously paid amount EDS will withhold from today's
				check as a result of this adjustment. The adjustment transaction is identified
				by an internal control number (ICN) that follows the field heading "Claim
				Number." Adjustment ICNs are formatted in the same way as claim numbers; the
				first two digits of an adjustment ICN are "50." Immediately to the right of the
				adjustment ICN are the words "Credit To," followed by the claim number and paid
				date of the original claim that was paid in error.
Underneath the "Credit To" line are displayed the recipient's
				Medicaid ID number, the claim beginning and ending dates of service and the
				provider's medical record number (or the patient account number) from the
				original claim, followed by the original billed amount. Keep in mind that EDS
				adjusts the entire claim, even if only one detail paid in error, so the total
				billed amount shown here is the total billed amount of the entire claim being
				adjusted. At the right end of this line, in the "Paid Amount" column, is the
				amount originally paid on the claim, which is the amount EDS will withhold from
				today's remittance.
The actual withholding of the original paid amount does not
				occur in the
Adjusted Claims
section; it occurs in the
Financial Items
section of the RA. Adjustments are listed in
Financial Items
, with the appropriate amounts displayed under
				the field headings "Original Amount," "Beginning Balance," "Applied Amount" and
				"New Balance." (See the discussion of
Financial Items
in
				Section 314.600.) Finally, the total of all amounts withheld from the
				remittance (except transaction fees charged for each electronic claim and
				eligibility verification) is displayed under "Withheld Amount," in the
Claims Payment Summary
section of the RA.
314.412
The "Debit To" Segment
A. The second segment of the adjustment
			 transaction is the "Debit To" segment. In this segment, EDS displays the
			 adjudication of the reprocessed claim and, for informational purposes, the net
			 adjustment amount. The net adjustment amount is the additional amount to be
			 paid in this remittance because of the adjustment, or it is the amount by which
			 the remittance will be less than the total of all paid claims minus transaction
			 fees (charged for each electronic claim and eligibility verification) and other
			 withheld amounts.
B. The "Net
			 Adjustment" amount-the amount due to EDS when adjusting an overpayment, or the
			 amount due to the provider when adjusting an underpayment-is on the second line
			 of the "Debit To" segment.
1. In the case of
			 an adjustment of an underpayment, the "Net Adjustment" amount will be added to
			 the total paid claims amount on today's remittance.
2. If EDS is due the amount shown as the net
			 adjustment, the letters "CR" will immediately follow the amount. "CR" means
			 that the claim's original paid amount is greater than the new paid amount (as
			 when the original payment is an overpayment), and the amount denoted by "CR" is
			 the (negative) difference.
C. Adjudication:
Immediately following the "Net Adjustment" line is the complete
				adjudication of the reprocessed claim, cross-referenced to the original claim
				number. The last line displays the new paid amount. The difference between the
				paid amount in the "Credit To" segment and the paid amount in the "Debit To"
				segment is the amount shown in "Net Adjustment." (See part B, above.)
331.100
Medicare
			 Part D drug benefits
Effective January 1, 2006, the Medicaid agency will not cover
				any Part D drug for full-benefit dual eligible individuals who are entitled to
				receive Medicare benefits under Part A or Part B.
The Medicaid agency provides coverage, to the same extent that
				it provides coverage for all Medicaid recipients, for the following excluded or
				otherwise restricted drugs or classes of drugs, or their medical uses-with the
				exception of those covered by Part D plans as supplemental benefits through
				enhanced alternative coverage as provided in
				42
				CFR §
											423.104(f) (1) (ii)
				(A) - to full benefit dual-eligible
				beneficiaries under the Medicare Prescription Drug Benefit-Part D.
The following 1927-D excluded drugs, set forth on the Arkansas
				Medicaid Website (www.medicaid.state.ar.us), are covered.
* select agents when used for weight gain
* select agents when used for the symptomatic relief of cough
				and colds
* select prescription vitamins and mineral products, except
				prenatal vitamins and fluoride select nonprescription drugs
* select agents when used to promote smoking cessation
* barbiturates
* benzodiazepines