Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-024 - Medicare/Medicaid Crossover Only Provider Manual Update Transmittal #56

Current through Register Vol. 49, No. 6, June, 2024
Section II
			 Medicare/Medicaid Crossover Only
200.000
			 MEDICARE/MEDICAID CROSSOVER ONLY GENERAL
INFORMATION
To participate in the Arkansas Medicaid Program, providers must
				adhere to all applicable professional standards of care and conduct. The
				following sections provide participation requirements for each provider type
				whose services are included in this manual.
201.000
Arkansas Medicaid
			 Participation Requirements for Medicare/Medicaid Crossover Only Providers
			 Located in the State of Arkansas
Providers of Medicare (Title XVIII) covered services who are
				interested in participating in the Medicaid (Title XIX) Program solely for the
				Arkansas Medicaid payment of Medicare coinsurance and deductible amounts for
				services not covered by Medicaid and/or do not meet the enrollment criteria for
				other Medicaid programs must meet the following criteria:
A. The provider must complete and submit to
			 the Medicaid Provider Enrollment Unit a provider application (form DMS-652), a
			 Medicaid contract (form DMS-653) and a request for Taxpayer Identification
			 Number and Certification (Form W-9).
View or print a provider
			 application (form DMS-652), a Medicaid contract (form DMS-653) and a Request
			 for Taxpayer Identification Number and Certification (Form
			 W-9).
B.
			 Enrollment as a Medicaid provider is conditioned upon approval of a completed
			 provider application and the execution of a Medicaid Provider contract. Persons
			 and entities that are excluded or debarred under any state or federal law,
			 regulation or rule are not eligible to enroll or to remain enrolled, as
			 Medicaid providers.
C. Provider
			 must be enrolled in the appropriate Title XVIII (Medicare) Program and accept
			 Medicare assignment on all claims filed on behalf of dually Medicare / Arkansas
			 Medicaid beneficiaries, including Qualified Medicare Beneficiaries (QMB).
202.000
Providers
			 in Arkansas and Bordering States
Providers of Title XVIII (Medicare) covered services in
				Arkansas and the six bordering states (Louisiana, Mississippi, Missouri,
				Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if
				they meet the participation and enrollment criteria as specified in section
				201.000.
Routine Services Provider
A. Provider is enrolled in the program as a
			 regular Medicare/Medicaid Crossover Only provider of routine
			 services.
B. Reimbursement will
			 only be for beneficiary cost share for paid Medicare-covered
			 services.
C. Claims must be filed
			 according to the specifications in this manual.
202.100
Providers in States Not
			 Bordering Arkansas
A. Providers in
			 states not bordering Arkansas may enroll as Medicare/Medicaid Crossover Only
			 closed-end providers after they have furnished services to an Arkansas Medicaid
			 QMB and have a claim for Medicare cost share to file with Arkansas Medicaid.
View or print Provider Enrollment Unit contact
			 information.
A non-bordering state provider may download
			 the provider manual and provider application materials from the Arkansas
			 Medicaid website,
www.medicaid.state.ar.us/lnternetSolution/Provider/Provider.aspx
,
and submit a completed application and claim to the Medicaid Provider
			 Enrollment Unit.
B. The provider
			 must complete and submit to the Medicaid Provider Enrollment Unit a provider
			 application (form DMS-652), a Medicaid contract (form DMS-653) and a request
			 for Taxpayer Identification Number and Certification (Form W-9).
View or print a provider application (form DMS-652), a
			 Medicaid contract (form DMS-653) and a Request for Taxpayer Identification
			 Number and Certification (Form W-9).
C. Enrollment as a Medicaid provider is
			 conditioned upon approval of a completed provider application and the execution
			 of a Medicaid Provider contract. Persons and entities that are excluded or
			 debarred under any state or federal law, regulation or rule are not eligible to
			 enroll or to remain enrolled, as Medicaid providers.
D. Providers must be enrolled in the
			 appropriate Title XVIII (Medicare) Program and accept Medicare assignment on
			 all claims filed on behalf of dually eligible Medicare / Arkansas Medicaid
			 beneficiaries, including Qualified Medicare Beneficiaries (QMB).
E. Closed-end providers remain enrolled for
			 one year.
1. If a closed-end Medicare/Medicaid
			 Crossover Only provider treats another Arkansas Medicaid/Medicare dually
			 eligible beneficiary during the year of enrollment and bills Medicaid either
			 manually, electronically or by automated crossover, the enrollment may continue
			 for one year past the newer claim's last date of service, provided the
			 enrollment file is kept current.
2.
			 During the enrollment period, the provider may file any subsequent claims
			 electronically, manually, or by means of automatic crossover through the
			 original Medicare plan.
3.
			 Closed-end providers with the necessary capability (see section
			 241.000 ) are strongly encouraged
			 to submit claims electronically or through the Arkansas Medicaid website.
			 Front-end processing of electronic and web-based claims ensures prompt
			 adjudication and facilitates reimbursement.
211.000
Scope
The Arkansas Medicaid Program covers certain services provided
				to persons eligible for Medicaid through the Qualified Medicare Beneficiary
				(QMB) Program.
The QMB program was created by the Medicare Catastrophic
				Coverage Act and uses Medicaid funds to assist low income Medicare
				beneficiaries. If a person is eligible for the QMB program, Medicaid will pay
				the Medicare Part B premium, the Medicare Part B deductible and the Medicare
				Part B coinsurance on other medical services not to exceed the Medicaid maximum
				allowable amount. Medicaid will also pay the Medicare Part A premium, the
				Medicare Part A hospital deductible and the Medicare Part A coinsurance, less
				the Medicaid coinsurance charge for inpatient admission. For non-exempt
				Medicaid beneficiaries age 18 and older, this coinsurance amount is 10% of the
				hospital's interim Medicaid per diem, applied on the first Medicaid covered day
				only.
Persons eligible through the QMB program do not receive the
				full range of Medicaid benefits. For a QMB eligible, Medicaid covers only those
				benefits listed above on Medicare-covered services.
If the service
				provided to a QMB-eligible is not a Medicare-covered service, such as personal
				care or ambulance transportation to a doctor's office, Medicaid does not cover
				the service for that individual
.
212.000
Medicaid Payment of Medicare
			 Coinsurance/Deductible
The Omnibus Budget Reconciliation Act of 1989 requires the
				mandatory assignment of Medicare claims for "physician" services furnished to
				individuals who are eligible for Medicare
and Medicaid,
including those eligible as Qualified Medicare Beneficiaries
				(QMBs).
According to Medicare regulations, "physician" services, for the
				purpose of this policy, are services furnished by physicians, dentists,
				optometrists, chiropractors and podiatrists.
Item 1-C. of the "Contract To Participate In The Arkansas
				Medical Assistance Program Administered By The Division Of Medical Services
				Title XIX (Medicaid)" further requires acceptance of assignment under Title
				XVIII (Medicare) in order to
				receive payment under Title XIX (Medicaid) for any applicable deductible or
				coinsurance that may be due and payable under Title XIX (Medicaid). Services
				furnished to an individual enrolled under Medicare who is also
210.000
PROGRAM
			 COVERAGE
eligible for Medicaid, including Qualified Medicare
				Beneficiaries (QMB)
may only be reimbursed on an assignment related
				basis.
213.000
QMB Medicaid ID Card
QMB beneficiaries receive a Medicaid ID after a determination
				that they are eligible for the program. Providers must verify eligibility and
				category by one of the various electronic means available (See Section
				III; 301.100-301.210 and 301.300
				of this manual) or by contacting The Division of Medical Services Program
				Communications Unit
(V
				iew or print Program Communications Unit Contact Information)
.
The category of service for a QMB is QMB-AA, QMB-AB or QMB-AD.
				Additionally, the electronic verification includes the statement "Limited to
				cost sharing of Medicare services."
214.000
Eligibility Criteria for QMB
			 Program
This program has been designed to assist low income elderly and
				disabled persons who are covered by Medicare Part A. The person must be 65 or
				older, blind or disabled and eligible for or enrolled in Medicare Part A.
				Arkansas Medicaid also covers Part B medical services coinsurance and
				deductible amounts for beneficiaries enrolled under the above criteria.
Beneficiaries interested in applying for the QMB Program should
				contact their local county Department of Health and Human Services office. The
				applicant should call the county office to inquire about the eligibility
				criteria, what documents are needed to determine eligibility and whether an
				appointment is necessary.
215.200
Documentation in Beneficiary
			 Files
The provider must contemporaneously establish and maintain
				records that completely and accurately explain all evaluations, care, diagnoses
				and any other activities of the provider in connection with its delivery of
				medical assistance to any Medicaid beneficiary. All entries in a beneficiary's
				file must be signed and dated by the individual who provided the service, along
				with the individual's title. The documentation must be kept in the
				beneficiary's case file, along with the beneficiary's name, Medicaid
				identification number, and the date the service was provided.
215.300
Record Keeping Requirements
A. All records must be completed
			 promptly, filed and retained for a period of five (5) years from the date of
			 service or until all audit questions, appeal hearings, investigations or court
			 cases are resolved, whichever is longer.
B. The provider must make available to the
			 Division of Medical Services, its contractors and designees and the Medicaid
			 Fraud Control Unit all records related to any Medicaid beneficiary. When
			 records are stored off-premise or are in active use, the provider may certify,
			 in writing, that the records in question are in active use or in off-premise
			 storage and set a date and hour within three (3) working days at which time the
			 records will be made available. However, the provider will not be allowed to
			 delay for matters of convenience, including availability of
			 personnel.
C. All documentation
			 must be made available to representatives of the Division of Medical Services
			 at the time of an audit conducted by the Medicaid Program Integrity Unit. All
			 documentation must be available at the provider's place of business. If an
			 audit determines that recoupment is necessary, there will be only thirty (30)
			 days after the date of the recoupment notice in which additional documentation
			 will be accepted. Additional documentation will not be accepted after the
			 thirty-day period.
Failure to furnish records upon request may
				result in sanctions being imposed.
230.000
REIMBURSEMENT
Medicaid's payment toward the Medicare Part A and Part B
				coinsurance and/or deductible is full payment of the amount submitted to
				Medicaid from Medicare less the Medicaid coinsurance amount (Part A), for
				non-exempt Medicaid beneficiaries age 18 and older, applied on the first
				Medicaid covered day of an inpatient stay.
240.000
BILLING
			 PROCEDURES
241.000
Claim Filing Procedures
If medical services are provided to a patient who is entitled
				to and receives coverage within the original Medicare plan under the Social
				Security Act and also to Arkansas Medicaid benefits, it is necessary to file a
				claim only with the original Medicare plan. The claim should be filed according
				to Medicare's instructions and sent to the Medicare intermediary. The claim
				will automatically cross to Medicaid if the provider is properly enrolled with
				Arkansas Medicaid and indicates the beneficiary's dual eligibility on the
				Medicare claim form. According to the terms of the Medicaid contract, a
				provider must "accept Medicare assignment under Title XVIII in order to receive payment
				under Title XIX for any appropriate deductible or coinsurance which may be due
				and payable under Title XIX."
When the original Medicare plan intermediary completes the
				processing of the claim, the payment information is automatically crossed to
				Arkansas Medicaid and the claim is processed in the next weekend cycle for
				Medicaid payment of applicable coinsurance and deductible. The transaction will
				usually appear on the provider's Medicaid RA within 3 weeks of payment by
				Medicare. If it does not appear within that time, the provider must request
				payment according to the instructions below.
Claims for Medicare beneficiaries entitled under the Railroad
				Retirement Act do not cross to Medicaid. The provider of services must request
				payment of coinsurance and deductible amounts through Medicaid according to the
				instructions below after Medicare pays the claim.
Medicare Advantage Plans (like HMOs and PPOs) are health plan
				options that are available to beneficiaries, approved by Medicare, but run by
				private companies. These companies bill and pay directly for benefits that are
				a part of the Medicare Program, as well as offering enhanced coverage
				provisions to enrollees. Since these claims are paid through private companies
				and not through the original Medicare plan directly, these claims will not
				automatically cross to Medicaid and the provider must request payment of
				Medicare covered services coinsurance and deductible amounts through Medicaid
				according to the instructions below after the Medicare plan pays the
				claim.
When a provider learns of a patient's Medicaid eligibility only
				after filing a claim to Medicare, the instructions below should be followed
				after Medicare pays the claim.
Instructions:
EDS
				provides software and Web-based technology with which to electronically bill
				Medicaid for professional crossover claims that do not automatically cross to
				Medicaid. Additional information regarding electronic billing can be located in
				Section III - 301.000 through 301.200 of this manual. Providers are strongly
				encouraged to submit claims electronically or through the Arkansas Medicaid
				website. Front-end processing of electronically and web-based submitted claims
				ensures prompt adjudication and facilitates reimbursement.
Institutional providers and those without electronic billing or
				web-based capabilities must mail a red-ink original claim of the appropriate
				crossover invoice to the address on the top of the form (see examples of
				red-ink original forms in Section
				V of this manual). To order
				copies of the appropriate Medicare-Medicaid crossover invoice, please use the
				Medicaid Form Request (EDS-MFR-001).
View or print form
				EDS-MFR-001
.
Indicate the quantity
				of each form required and send the request to the Provider Assistance Center
				(PAC).
View or print PAC contact information.
Instructions for filling out the invoice are included with the ordered
				forms.
241.100
Billing
			 Instructions
The Medicaid Program is required by federal regulations to
				utilize all third party sources and to seek reimbursement for services that
				have also been paid by Medicaid. "Third party" means an individual,
				institution, corporation or public or private agency that is liable to pay all
				or part of the medical cost of injury, disease or disability of a Medicaid
				beneficiary. Examples of third party resources are:
A. Insurance Policies
1. Private health
2. Group health
3. Liability
4. Automobile and/or medical
			 insurance
5. Family health
			 insurance carried by an absent parent
6. Medicare supplements
			 ("Medi-Gap")
B. Worker's
			 Compensation
C. Veteran's
			 Administration
D. CHAMPUS
The Medicaid policies concerning the handling of cases
				involving Medicare/Medicaid coverage differ from the policies concerning other
				third party coverage.
Arkansas Rehabilitation Services (ARS) is not a third party
				source. If ARS and Medicaid pay for the same service, ARS must be refunded. See
				Section III of this manual for additional billing information.
241.200
Adjustments by Medicare
Any adjustment made by Medicare will not be automatically
				forwarded to Medicaid. If Medicare makes an adjustment that results in an
				overpayment or underpayment by Medicaid, submit an Adjustment Request Form,-
				Medicaid XIX available in Section V of this manual, with a copy of the Medicare
				EOMB reflecting Medicare's adjustment.
(View or print
				Adjustment Request Form -Medicaid XIX EDS-AR-004.)
Enter
				the provider's identification number and the patient's Medicaid identification
				number on the face of the Medicare EOMB.