Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-034 - Occupational, Physical, Speech Therapy Services Update Transmittal #60

Current through Register Vol. 49, No. 6, June, 2024
SECTION II -
			 CERTIFIED NURSE-MIDWIFE
200.000
CERTIFIED NURSE-MIDWIFE GENERAL INFORMATION
201.000
Introduction
To participate in the Arkansas Medicaid Program, providers must
				adhere to all applicable professional standards of care and conduct.
202.000
Arkansas Medicaid
			 Participation Requirements for Certified Nurse-
Midwife Providers
All providers of certified nurse-midwife services must meet the
				following criteria in order to be eligible for participation in the Arkansas
				Medicaid Program:
A. The provider must
			 complete 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. A
			 current copy of the certified nurse-midwife license from the Arkansas State
			 Board of Nursing must accompany the provider application and Medicaid contract.
1. Su
bsequen
t
			 renewals of license must be forwarded to Provider Enrollment within 30 days of
			 issuance.
2. If the renewal
			 document(s) have not been received within this time period, the provider will
			 have an additional, and final, 30 days to comply.
C. The certified nurse-midwife who provides
			 intrapartum care must have a consulting agreement with a Medicaid-enrolled
			 physician and must furnish the name of the consulting physician with the
			 provider application and the Medicaid contract.
1. The consulting physician must be available
			 within thirty (30) minutes of the hospital admitting the certified
			 nurse-midwife's laboring patients or within thirty (30) minutes of the
			 alternative birth site if the patient is not transported to the
			 hospital.
2. A licensed certified
			 nurse-midwife will not be deemed an agent or employee of the physician solely
			 on the basis of a collaborative or consulting physician agreement and will be
			 enrolled as an independent provider with the Arkansas Medicaid Program in the
			 category of Certified Nurse-Midwife.
D. Subsequent changes in the name of the
			 consulting physician must be immediately provided to Arkansas
			 Medicaid.
E. The certified
			 nurse-midwife who has prescriptive authority must furnish the Certificate of
			 Prescriptive Authority Number issued by the Arkansas State Board of Nursing
			 with the provider application and Medicaid contract. Any changes in
			 prescriptive authority must be immediately reported to Arkansas
			 Medicaid.
F. Enrollment as a
			 Medicaid provider is conditioned upon approval of a completed provider
			 application and the execution of a Medicaid Provider Agreement.
G. 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.
202.200
Providers in Arkansas and
			 Bordering States
A. Providers in
			 Arkansas and the six bordering states may be enrolled in the Medicaid Program
			 as routine services providers if they meet all Arkansas Medicaid participation
			 requirements outlined in section 202.000.
B. Reimbursement may be available for all
			 covered certified nurse-midwife services in the Arkansas Medicaid Program.
			 Claims must be filed according to billing procedures provided in this
			 manual.
202.300
Certified Nurse-Midwives in States Not Bordering Arkansas
A. Providers in states not bordering Arkansas
			 are called limited services providers because they may enroll in Arkansas
			 Medicaid only after they have treated an Arkansas Medicaid beneficiary and have
			 a claim to file, and because their enrollment automatically expires.
1. A non-bordering state provider may send a
			 claim to Provider Enrollment and Provider Enrollment will forward by return
			 mail a provider manual and a provider application and contract.
View or print Medicaid Provider Enrollment Unit contact
			 information
.
2.
			 Alternatively, a non-bordering state provider may download the provider manual
			 and provider application materials from the Arkansas Medicaid website,
			 www.medicaid.state.ar.us
,
and then submit the application and
			 claim to the Medicaid Provider Enrollment Unit.
B. Limited services providers remain enrolled
			 for one year.
1. If a limited services
			 provider treats another Arkansas Medicaid beneficiary during the year of
			 enrollment and bills Medicaid, the enrollment may continue for one year past
			 the newer claim's last date of service, if the provider keeps the enrollment
			 file current.
2. During the
			 enrollment period the provider may file any subsequent claims directly to
			 EDS.
3. Limited services providers
			 are strongly encouraged to submit claims through the Arkansas Medicaid website
			 because the front-end processing of web-based claims ensures prompt
			 adjudication and facilitates reimbursement.
203.000
Required
			 Medical Records
A. Providers must
			 contemporaneously create 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.
B. Providers
			 furnishing any Medicaid-covered good or service for which a prescription,
			 admission order, physician's order, care plan or other order for service
			 initiation, authorization or continuation is required by law, by Medicaid rule,
			 or both, must obtain a copy of the prescription, care plan or order within five
			 (5) business days of the date it is written. Providers also must maintain a
			 copy of each prescription, care plan or order in the beneficiary's medical
			 record and follow all prescriptions, care plans, and orders as required by law,
			 by Medicaid rule, or both.
C. 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.
D. All records must be kept for a period of
			 five (5) years from the ending date of service or until all audit questions,
			 appeal hearings, investigations or court cases are resolved, whichever is
			 longer. Failure to furnish medical records upon request may result in sanctions
			 being imposed. (See Section I of this manual.)
E. Certified nurse-midwives are required to
			 keep the following patient records:
1. History
			 and physical examinations.
2.
			 Appropriate diagnosis or chief complaint, when applicable, on each
			 visit.
3. Tests and
			 results.
4. Diagnoses.
5. Treatment, including
			 prescriptions.
6. Signature or
			 initials of the certified nurse-midwife after each visit.
7. Copies of records pertinent to services
			 delivered by the certified nurse-midwife and billed to Medicaid.
8. Records must contain service dates of any
			 services billed to Medicaid, including service dates for all components of
			 global services billed.
9. Record
			 of physician referral or consultation, if applicable.
204.000
Certified
			 Nurse-Midwife's Role in the Medicaid Program
204.100
Ambulance Services
Ambulance service for Medicaid beneficiaries is covered by
				Medicaid when the ambulance transportation is medically necessary, as
				determined by the certified nurse-midwife.
It is the responsibility of the
transportation
provider to maintain documentation that
				will verify the medical necessity of transportation provided.
204.200
Certified Nurse-Midwife's Role
			 in the Prescription Drug Program
Medicaid covers prescription drugs in accordance with policies
				and regulations set forth in this section and pursuant to orders
				(prescriptions) from authorized prescribers. The Arkansas Medicaid Program
				complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP)
				that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of
				1990.
This law requires Medicaid to limit coverage to drugs manufactured
				by pharmaceutical companies that have signed rebate agreements.
Except
				for drugs in the categories excluded from coverage, Arkansas Medicaid covers
				all drug products manufactured by companies with listed labeler codes.
The certified nurse-midwife's prescriptive authority
				(when applicable) only extends to legend drugs in Schedule III through Schedule
				V. Medicaid reimbursement will be limited to prescriptions for drugs in these
				schedules.
A. Prescribers must
			 refer to the Arkansas Medicaid Web site at
http://www.medicaid.state.ar.us/
to
			 obtain the following information:
Multisource Drugs Listing/Generic Upper Limits.
1. Covered cough and cold preparations (see
			 part C, 7 of this section).
2.
			 Covered over-the-counter (OTC) products (see part C, 8 of this
			 section).
3. Drugs requiring prior
			 authorization (PA), the forms to be completed for PA requests and the
			 procedures required of the prescriberto request prior authorization.
4. List of alternative drugs that do not
			 require PA.
5. Information on
			 MedWatch, the Food and Drug Administration (FDA) Safety Information and Adverse
			 Event Reporting Program.
As additions or deletions by labelers are submitted to the
				state by the Centers for Medicare and Medicaid Services (CMS), the Web site is
				updated.
B.
			 Providers must follow the procedures below when prescribing drugs for Medicaid
			 beneficiaries.
1. In addition to following the
			 preserver's normal procedure for prescribing drugs, the prescriber must include
			 his or her Medicaid provider number on all prescriptions for Medicaid
			 beneficiaries, whether or not the drug prescribed is a controlled substance.
			 The prescriber's Medicaid provider number is essential for tracking and
			 utilization review purposes.
2. The
			 requirement to include the prescriber's Medicaid provider number is a condition
			 of participation in the Arkansas Medicaid Program. Administrative sanctions
			 will be imposed for noncompliance. If prescription pads are not preprinted with
			 the prescriber's name, it is essential that the physician's signature be
			 legible.
3. When the prescriber
			 determines that a particular brand is medically necessary, the prescriber must
			 write "This Brand Medically Necessary" in his or her own handwriting on the
			 face of the prescription. A rubber stamp is not acceptable. The statements "Do
			 not substitute" or "Dispense as written" are not sufficient. For prescriptions
			 ordered by telephone, a written prescription that includes the required
			 statement must also be provided to the pharmacist.
C. Coverage Limitations
1. Medicaid-eligible beneficiaries aged 21
			 and older are limited to three (3) prescriptions per month, each filled for a
			 maximum of one month's supply. Extensions of an individual's drug benefit up to
			 six (6) prescriptions per month may be considered for reasons of medical
			 necessity. The prescribing provider must request an extension.
2. A prescription may be filled for a maximum
			 of one month's supply. A thirty-one (31) day supply is allowed.
3. Up to five refills within six months of
			 the date the prescription is issued are covered if specified by the prescriber.
			 Renewals or continuations of drug therapy beyond six months require another
			 prescription.
4. Prescriptions for
			 any family planning item will not be counted toward the beneficiary's monthly
			 three-prescription limit.
5.
			 Medicaid beneficiaries under age 21 are not subject to the prescription benefit
			 limit.
6. Long-term care
			 (LTC)-certified Medicaid beneficiaries are not subject to the prescription
			 benefit limit.
LTC patients must receive prescribed drugs within a specific
				period of time after the prescribed order. For prescribed drugs that require
				prior authorization (PA) and are administered in oral dosage forms for which a
				5-day supply may be calculated and dispensed, one 5-day supply of the drug may
				be provided to the LTC recipient upon receipt of the prescription and
				reimbursed by Arkansas Medicaid without receipt of PA.
Within 5 days of the prescription of a drug requiring PA and
				for which no PA has been obtained, the pharmacist and the physician must
				consult to determine if there is a therapeutically equivalent drug that does
				not require PA. The results of the consultation must be documented in
				writing.
If a non-PA, therapeutically equivalent drug exists, the
				physician must write a substitute prescription for the non-PA drug.
7. Cough and cold preparations are
			 not covered except for those listed on the Web site at
http://www.medicaid.state.ar.us/
in
			 the covered cough and cold products list. Coverage is restricted to
			 Medicaid-eligible beneficiaries under age 21 and for certified long-term care
			 beneficiaries. Any over-the-counter cough and cold products listed at the Web
			 site are not covered for certified long-term care beneficiaries.
8. Over-the-counter (OTC) products are not
			 covered except for those listed on the Web site at
http://www.medicaid.state.ar.us/
in
			 the covered over-the-counter products list. OTC products are not covered for
			 certified long-term care beneficiaries.
9. When prescribing pharmaceuticals to
			 Medicaid beneficiaries who are excluded from the cost sharing
			 (coinsurance/copayment) policy, the prescribing provider must write "Excluded
			 from copay" on the face of the prescription. (Refer to Section I of this manual
			 for more information.)
204.300
Certified Nurse-Midwife's Role
			 in the Child Health Services (EPSDT)
Program and ARKids First-B Program
The Arkansas Medical Assistance Program includes a Child Health
				Services (EPSDT) Program for eligible individuals under age 21. The purpose of
				this program is to detect and treat health problems in their early stages and
				to provide well child health care such as immunizations.
Similar services are also covered through the ARKids First-B
				Program. This program covers children age 18 years and younger.
Certified nurse-midwives may provide routine newborn care that
				includes the physical examination of the baby and conference(s) with the
				newborn's parents. These services are considered to be the initial Child Health
				Services (EPSDT) screen and may be covered as the initial preventive health
				screen for those eligible for the ARKids First-B Program.
Certified nurse-midwives interested in enrolling in the Child
				Health Services (EPSDT) Program or the ARKids First-B Program should contact
				the Central Child Health Services Office.
View or print the
				Central Child Health Services Office contact
				information.
204.400
Certified Nurse-Midwife's Role
			 in Hospital Services
A. Medicaid covers
			 medically necessary hospital services, within the constraints of the Medicaid
			 Utilization Management Program (MUMP) and applicable benefit limitations.
			 (Refer to sections 213.200 through 213.220.)
B. The care and treatment of a patient must
			 be under the direction of a licensed physician, a certified nurse-midwife or
			 dentist with hospital staff affiliation.
C. Arkansas Foundation for Medical Care,
			 Inc., (AFMC) is the Medicaid agency's quality improvement organization (QIO).
1. AFMC reviews for the Medicaid Utilization
			 Management Program (MUMP), all inpatient hospital transfers and all inpatient
			 stays longer than four days.
2. The
			 QIO also performs post-payment reviews of hospital claims for medical necessity
			 determinations.
D.
			 Hospital claims are also subject to review by the Medical Director for the
			 Medicaid Program.
1. If Medicaid denies a
			 hospital's claim for lack of medical necessity, payments to certified
			 nurse-midwives for evaluation and management services incidental to the
			 hospitalization are subject to recoupment by the Medicaid agency.
2. Certified nurse-midwives and hospitals may
			 not bill a Medicaid beneficiary for a service Medicaid has declared not
			 medically necessary.
3. Certified
			 nurse-midwives and hospitals may not bill as outpatient services any inpatient
			 services previously denied for lack of medical necessity as inpatient
			 services.
204.500
Certified Nurse-Midwife's Role
			 in Preventing Program Abuse
The Arka
nsas Medicaid Program has the
				responsibility for assuring quality medical care for its beneficiaries along
				with protecting the integrity of the funds supporting the program. The Division
				of Medical Services is committed to these goals, provides staff and resources
				to the prevention, detection and correction of known abuse. These tasks can
				only be accomplished through the cooperation and support of the provider
				community.
A certified nurse-midwife who has reason to suspect either
				beneficiary or provider abuse or unacceptable quality of care should contact
				the Utilization Review Section of Arkansas Division of Medical Services. An
				investigation will then be made.
View or print the Arkansas
				Division of Medical Services, Utilization Review Section contact
				information.
Examples of the types of abuse you may detect include:
A. Beneficiary over-utilization of
			 services
B. Beneficiary misuse or
			 inappropriate utilization of services
C. Beneficiary misuse of I.D. card
D. Poor quality of service
E. Provider over-utilization or abuse