Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-035 - Targeted Case Management Update #105

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
Targeted Case Management
262.310
Completion of CMS-1500 Claim
			 Form
Field Name and Number
Instructions for Completion
1. (type of coverage)
Not required.
1a. INSURED'S I.D. NUMBER (For Program in Item
						  1)
Beneficiary's or participant's 10-digit Medicaid or
						  ARKids First-A or ARKids First-B identification number.
2. PATIENT'S NAME (Last
Name, First Name, Middle Initial)
Beneficiary's or participant's last 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, First Name, Middle Initial)
Required if insurance affects this claim. Insured's
						  last name, first name, and middle initial.
5. PATIENT'S ADDRESS (No., Street)
Optional. Beneficiary's or 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 Code)
The beneficiary's or participant's telephone number or
						  the number of a reliable message/contact/ emergency telephone.
6. PATIENT RELATIONSHIP TO INSURED
If insurance affects this claim, check the box
						  indicating the patient's relationship to the insured.
7. INSURED'S ADDRESS (No., Street)
Required if insured's address is 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 name, First Name, Middle
						  Initial)
If patient has other insurance coverage as indicated in
						  Field 11d, the other insured's last name, first name, and middle
						  initial.
a. OTHER INSURED'S POLICY OR GROUP NUMBER
Policy and/or group number of the insured
						  individual.
b. OTHER INSURED'S DATE OF BIRTH
Not required.
SEX
Not required.
c. EMPLOYER'S NAME OR SCHOOL NAME
Required when items 9 a-d are required. Name of the
						  insured individual's employer and/or school.
d. INSURANCE PLAN
NAME OR PROGRAM NAME
Name of the insurance company.
10. IS PATIENT'S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
Check YES or NO.
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 FECA NUMBER
Not required when Medicaid is the only payer.
a. INSURED'S DATE OF BIRTH
Not required.
SEX
Not required.
b. EMPLOYER'S NAME OR SCHOOL NAME
Not required.
c. INSURANCE PLAN
NAME OR PROGRAM NAME
Not required.
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
When private or other insurance may or will cover any
						  of the services, check YES and complete items 9a through 9d.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
Not required.
13. INSURED'S OR
AUTHORIZED PERSON'S SIGNATURE
Not required.
14. DATE OF CURRENT:
ILLNESS (First symptom) OR INJURY (Accident) OR
						  PREGNANCY (LMP)
Required when services furnished are related to an
						  accident, whether the accident is recent or in the past. Date of the
						  accident.
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE
						  FIRST DATE
Not required.
16. DATES PATIENT UNABLE TO WORK IN CURRENT
						  OCCUPATION
Not required.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
Primary Care Physician (PCP) referral is not required
						  for targeted case management services. 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 RELATED TO CURRENT
						  SERVICES
When the serving/billing provider's 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
Local Education Agency (LEA) code that identifies the
						  school district in which services are provided.
20. OUTSIDE LAB?
Not required.
$ CHARGES
Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Diagnosis code for the primary 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 CODE
Reserved for future use.
ORIGINAL REF. NO.
Reserved for future use.
23. PRIOR AUTHORIZATION NUMBER
The prior authorization or benefit extension control
						  number if applicable.
24A. 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 for codes.
C. EMG
Not required.
D. PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS
Enter the correct CPT or HCPCS procedure code from
						  Section 262.100.
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. 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 co-payments.
30. BALANCE DUE
From the total charge, subtract amounts received from
						  other sources and enter the result.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING
						  DEGREES OR CREDENTIALS
The provider or designated authorized individual must
						  sign and date the 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 INFORMATION
If other than home or office, enter 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 & PH #
Billing provider's name and complete 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.