Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-015 - Personal Care Provider Manual Update Transmittal #94

Current through Register Vol. 49, No. 6, June, 2024
Section II
Personal Care
202.000
Routine Services Providers and
			 Closed-End Providers
202.200
Personal Care Providers not Licensed in Arkansas
A. Personal care providers not licensed in
			 Arkansas may not provide personal care services in Arkansas.
B. Personal care providers not licensed in
			 Arkansas may participate in Arkansas Medicaid only as closed-end
			 providers.
C. Personal care
			 providers not licensed in Arkansas may become closed-end providers under two
			 sets of circumstances.
1. Personal care
			 providers not licensed in Arkansas may become Arkansas Medicaid closed-end
			 providers in accordance with the rules that follow in section
			 202.210 and any applicable rules
			 set forth between sections
			 200.000 and
			 202.000, exclusive.
2. Personal care providers not licensed in
			 Arkansas may become Arkansas Medicaid "secondary" closed-end providers in
			 accordance with the rules at sections
			 213.600 through
			 213.610 and any applicable rules
			 set forth between sections
			 200.000 and
			 202.000, exclusive.
202.210
Closed-End Personal Care Providers
A. See the participation requirements at
			 sections 213.600 through
			 213.610 for the means by which
			 personal care providers not licensed in Arkansas may become eligible to enroll
			 as Arkansas Medicaid Personal Care "secondary" closed-end providers.
B. With the exception of the participation
			 requirements for "secondary" closed-end providers, personal care providers in
			 states not bordering Arkansas may enroll in Arkansas Medicaid as closed-end
			 providers only after they have served an Arkansas Medicaid beneficiary and they
			 have a claim or claims to file for reimbursement.
1. Enrollment as a closed-end provider
			 automatically expires after a year unless they perform and bill for subsequent
			 services for Arkansas Medicaid beneficiaries during the year. See part C
			 below.
2. To enroll, providers must
			 download the Personal Care provider manual (which includes provider application
			 materials in Section
			 V ) from the Arkansas Medicaid
			 website, www.medicaid.state.ar.us, and then submit all required documentation,
			 including a completed provider application, a Medicaid contract and their
			 claim(s) to the Medicaid Provider Enrollment Unit.
View
			 Medicaid Provider Enrollment Unit contact
			 information.
C. Closed-end providers remain enrolled for
			 one year.
1. If a closed-end provider serves
			 another Arkansas Medicaid beneficiary during the provider's year of enrollment
			 and bills Arkansas Medicaid for the service, the provider's enrollment may
			 continue for one year past the most recent date of service, conditioned upon
			 the provider's keeping the enrollment file current.
2. During a closed-end enrollment period, a
			 closed-end provider may file any subsequent claims directly to EDS.
3. Closed-end providers are strongly
			 encouraged to submit any such subsequent claims by available electronic means
			 or through the Arkansas Medicaid website because Arkansas Medicaid's front-end
			 processing of electronic and web-based claims ensures prompt adjudication and
			 facilitates reimbursement.
204.000
Record Maintenance and
			 Availability
A. Personal Care
			 providers are required to keep documentation and records as described in this
			 section, in section
			 221.000 and elsewhere in this
			 manual and in officially promulgated, approved and published rules not yet
			 incorporated into this manual.
B.
			 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 delivery of medical assistance to
			 any Medicaid beneficiary.
C.
			 Providers furnishing any Medicaid-covered good or service for which a
			 prescription, admission order or physician's order is required by law, by
			 Medicaid rule or both, must obtain a copy of the aforementioned prescription or
			 order within five business days of the date it is written (or of the date given
			 orally, when an oral order is permitted).
D. Providers also must maintain a copy of
			 each prescription, care plan, service plan or order in the beneficiary's
			 medical record and follow all prescriptions, care plans, service plans and
			 orders as required by law, by Medicaid rule, or both.
E. All required records must be kept for a
			 period of five years from the ending date of service or until all audit
			 questions, appeal hearings, investigations or court cases are resolved,
			 whichever period is longer.
F.
			 Providers must make available, on request, to any of the individuals and
			 entities identified in subparts F1 through F3 below, all records related to any
			 Medicaid beneficiary to whom the provider has furnished Medicaid-covered
			 services for which the provider has sought and/or obtained reimbursement from
			 Arkansas Medicaid, or for which the provider intends to bill Medicaid.
1. The Arkansas Division of Medical Services,
			 which includes the Division's Medicaid Program
			 I ntegrity Unit and authorized
			 employees, contractors and designees of the Division
2. The Medicaid Fraud Control Unit of the
			 Arkansas Office of the Attorney General
3. Representatives of the Secretary of Health
			 and Human Services
G.
			 When requested records are stored off-premise or are in active use, the
			 provider must certify in writing that the records in question are in active use
			 or in off-premise storage; and the provider must set a date and hour when the
			 records shall be made available to the requesting authority.
1. The date and hour when the records shall
			 be made available to the requesting authority must be within 3 working days of
			 the time that access to the records was requested.
2. Providers are not allowed to delay access
			 to requested records for reasons related to the provider's
			 convenience.
3. Providers are not
			 allowed to delay access to requested records by claiming the unavailability of
			 sufficient personnel to fulfill the request.
H. Furnishing records on request to
			 authorized individuals and agencies is a contractual obligation of providers
			 enrolled in the Medicaid Program.
I. Sanctions will be imposed for failure to
			 furnish records in accordance with official Medicaid guidelines. Section I of
			 this manual contains detailed information regarding provider and beneficiary
			 sanctions.
J. If any authorized
			 audit determines that recoupment of Medicaid payments is necessary, the
			 Division of Medical Services will accept additional documentation for only
			 thirty days after the date of the notification of recoupment. Additional
			 documentation will not be accepted later.
213.540
Employment-related Personal
			 Care Outside the Home
No condition of this section alters or adversely affects the
				status of individuals who are furnished personal care in sheltered workshops or
				similarly authorized habilitative environments. There may be a few
				beneficiaries working in sheltered workshops solely or primarily because they
				have access to personal care in that setting. This expansion of personal care
				outside the home may enable some of those individuals to move or attempt to
				move into an integrated work setting.
A. Personal care may be provided outside the
			 home when the requirements in subparts A1 through A5 are met and the services
			 are necessary to assist a disabled individual to obtain or retain employment.
1. The beneficiary must have an authorized,
			 individualized personal care service plan that includes the covered personal
			 care services necessary to and appropriate for an employed individual or for an
			 individual seeking employment.
2.
			 The beneficiary must be aged 16 or older.
3. The beneficiary's disability must meet the
			 Social Security/SSI disability definition.
a
			 A beneficiary's disability may be confirmed by verifying his or her eligibility
			 for SSI, Social Security disability benefits or a Medicaid disability aid
			 category, such as Working Disabled or DDS Alternative Community Services
			 waiver.
b. If uncertain whether a
			 beneficiary qualifies under this disability provision, contact the Department
			 of Human Services local office in the county in which the beneficiary resides.
4. One of the following
			 two conditions must be met.
a. The beneficiary
			 must work at least 40 hours per month in an integrated setting (i.e., a
			 workplace that is not a sheltered workshop and where non-disabled individuals
			 are employed or are eligible for employment on parity with disabled
			 applicants).
b. Alternatively, the
			 beneficiary must be actively seeking employment that requires a minimum of 40
			 hours of work per month in an integrated setting.
5. The beneficiary must earn at least minimum
			 wage or be actively seeking employment that pays at least minimum
			 wage.
B. Personal care
			 aides may assist beneficiaries with personal care needs in a client's workplace
			 and at employment-related locations, such as human resource offices, employment
			 agencies or job interview sites.
C.
			 Employment-related personal care associated with transportation is covered as
			 follows.
1. Aides may assist beneficiaries
			 with transportation to and from work or job-seeking and
during
transportation to and from work or for job-seeking.
2. All employment-related services, including
			 those associated with transportation, must be included in detail (i.e., at the
			 individual task performance level; see section
			 215.300, part F) in the service
			 plan and all pertinent service documentation.
3. Medicaid does not cover mileage associated
			 with any personal care service.
4..
			 Authorized, necessary and documented assistance with transportation to and from
			 work for job-seeking and during transportation to and from work or for
			 job-seeking is neither subject to nor included in the eight-hour per month
			 benefit limit that applies to shopping for personal care items and
			 transportation to stores to shop for personal care items, but it is included in
			 the 64-hour per month personal care benefit limit for beneficiaries aged 21 and
			 older.
D. All personal
			 care for beneficiaries under age 21 requires prior authorization.
E. Providers furnishing both
			 employment-related personal care outside the home and non-employment related
			 personal care at home or elsewhere for the same beneficiary must comply with
			 the applicable rules at sections
			 215.350,
			 215.351 and
			 262.100.
214.100
Physician Authorization of
			 Personal Care Services
A. An
			 individualized personal care service plan signed (original signature) and dated
			 by the client's PCP or attending physician, constitutes the physician's
			 personal care authorization.
1. The attending
			 physician and the client must have a face-to-face visit before the physician
			 may authorize personal care services, unless the physician has seen the client
			 within the 60 days preceding the beginning date of service established in the
			 proposed service plan.
2. The
			 attending physician must review the assessment and service plan to ensure that
			 the personal care aide's assigned tasks appropriately address the client's
			 individual physical dependency needs.
3. Based on the assessment and the
			 physician's medical evaluation, the attending physician must authorize only
			 individualized personal care services that constitute medically necessary
			 assistance with the client's physical dependency needs in the client's home or
			 other authorized locations rather than in an institution.
B. The personal care service plan authorized
			 by the physician must specify the following items.
1. The date services are to begin
2. The duration of need for
			 services
3. The expected results of
			 the services
C. Personal
			 care services may not begin before the client's attending physician authorizes
			 the individualized personal care service plan.
D. Services may not commence before the
			 beginning date of service established by the authorized service plan.
E. The physician may change the frequency,
			 scope or duration of service in the service plan.
F. The physician may add to, delete from or
			 otherwise modify the service plan.
G. The physician's authorization of the
			 service plan must be by dated original signature only. A stamp or signature
			 initialed by a
locum tenens
is the only acceptable substitute
			 for an original signature by the attending physician.
H. The physician must date and sign or
			 initial any revisions to the service plan, as well as any attachments he or she
			 adds to the service plan.
I. The
			 physician must maintain a copy of the signed service plan and signed copies of
			 any subsequent authorized service plan revisions with the client's permanent
			 medical record.
215.350
Service Plan Requirements for a Single Provider and a Single Beneficiary
			 at Multiple Service Locations
A. Only
			 one service plan for personal care services is necessary when a single provider
			 is delivering services to a client in more than one authorized
			 location.
B. The service plan must
			 identify which tasks the aide performs at each location.
1. When the aide performs the same or similar
			 tasks at each location, the service plan must separately identify the tasks at
			 each location in accordance with the criteria in sections
			 215.300 and
			 215.310.
2. The aide's service documentation must
			 reflect the service location distinctions.
215.351
Service Plan Requirements for
			 Multiple Providers
When a client receives services from more than one personal
				care provider, each provider must comply with the following
				requirements.
A. Each provider must
			 create an individualized service plan and collaborate with the beneficiary's
			 other personal care provider(s) to create a comprehensive service plan.
1. Each comprehensive service plan must
			 clearly state which provider provides which services, where and on which day(s)
			 they do so, which time(s) of day they furnish services and the maximum and
			 minimum amount of time per day and per week that the provider will take to
			 perform those services.
3. Each
			 comprehensive service plan must be authorized, signed and dated by the client's
			 primary care physician (PCP) unless the beneficiary is not required to enroll
			 with a PCP, in which case the comprehensive service plan must be authorized,
			 signed and dated by the beneficiary's primary attending physician.
B. Each time a personal care
			 provider intends to revise or renew a comprehensive service plan, that provider
			 must notify the beneficiary's other personal care provider(s) to agree on the
			 revision or renewal and to submit the revised or renewed comprehensive plan to
			 the authorizing physician for approval.
C. If the providers cannot agree on a
			 comprehensive service plan, plan revision or plan renewal, the providers shall
			 submit the various alternatives to the authorizing physician, who shall
			 determine the terms of the final comprehensive service plan.
D. Any Medicaid provider having knowledge
			 that another Medicaid provider has failed to comply with a service plan,
			 including a comprehensive service plan, shall notify the DMS Director of such
			 failure within 10 business days of the occurrence, or sooner if the
			 beneficiary's life or health is threatened.
216.000
Coverage
A. Personal care services are covered by the
			 Arkansas Medicaid Program when they are
1.
			 Authorized by a physician in accordance with an individualized service
			 plan,
2. Prior authorized by DMS or
			 its designee when the beneficiary is under the age of 21,
3. Provided by an individual who is
a. Qualified to provide the
			 services,
b. Supervised by a
			 registered nurse (RN) or (when applicable) a Qualified Mental Retardation
			 Professional (QMRP) and c. Not a member of the beneficiary's family
			 and
4. Furnished in the
			 beneficiary's home or, at the State's option, in another
			 location.
B. Medicaid
			 restricts coverage of personal care to services directly helping a beneficiary
			 with certain specified routines and activities, regardless of the beneficiary's
			 ability or inability to execute other non-covered routines and
			 activities.
216.200
Tasks Associated with Covered Routines
Effective for dates of service on and after July 1, 2007, from
				this section (section 216.200) through section
				221.000, all regulations
				regarding personal care aides' logging beginning and ending times (i.e., time
				of day) of individual services, and all references to any such regulations, do
				not apply to Residential Care Facility (RCF) Personal Care providers.
221.000
Documentation
Personal care providers must maintain all applicable
				documentation identified in this section (section 221.000) and comply with all
				applicable provisions and requirements of Section
				I and section
				204.000 of this manual.
A. When applicable, and exempting all
			 agencies that provided Arkansas Medicaid Personal Care services before July 1,
			 1986, proof of certification by the Home Health State Survey Agency as a
			 participant in the Title XVIII (Medicare) Program
B. When applicable, proof of current
			 licensure by the Office of Long Term Care as a Residential Care Facility (RCF),
			 a Level I Assisted Living Facility (ALF-1) or a Level II Assisted Living
			 Facility (ALF-2)
C. A valid
			 provider agreement and a valid Medicaid contract
D. Effective for dates of service on and
			 after July 1, 2007, RCF Personal Care providers' payroll records constitute
			 documentation required to enable validation of their service plans and service
			 logs.
E. Documents signed by the
			 supervising RN or QMRP, including the following items.
1. The initial and all subsequent
			 assessments
2. Instructions to the
			 personal care aide regarding a. The tasks the aide is to perform b. The
			 frequency of each task c. The maximum number of hours and minutes per month of
			 aide service authorized by the client's attending physician
3. Notes arising from the supervisor's visits
			 to the service delivery location, regarding a. The condition of the client b.
			 Evaluation of the aide's service performance c. The client's evaluation of the
			 aide's service performance d. Difficulties the aide encounters performing any
			 tasks
4. The service plan and
			 service plan revisions
5. The
			 justifications for service plan revisions
6. Justification for emergency, unscheduled
			 tasks
7. Documentation of prior or
			 post approval of unscheduled tasks
F. Any additional or special documentation
			 required to satisfy or to resolve questions arising during, from or out of an
			 investigation or audit. "Additional or special documentation," refers to notes,
			 correspondence, written or transcribed consultations with or by other
			 healthcare professionals (i.e., material in the client's or provider's records
			 relevant to the client's personal care services, but not necessarily
			 specifically mentioned in the foregoing requirements). "Additional or special
			 documentation," is not a generic designation for inadvertent omissions from
			 program policy. It does not imply and one should not infer from it that, the
			 State may arbitrarily demand media, material, records or documentation
			 irrelevant or unrelated to Medicaid Program policy as stated in this manual and
			 in officially promulgated, approved and distributed rules not yet incorporated
			 into this manual.
G. The personal
			 care aides' training records, including
1.
			 Examination results
2. Skills test
			 results
3. Personal care aide
			 certification
H.
			 Excluding Residential Care Facility Personal Care providers, whose personal
			 care aides log services and make required notations on form DMS-873 in
			 accordance with that form's instructions, the personal care aide's daily
			 service notes for each client, which shall include all applicable items in
			 subparts H1-H6.
1. The date of
			 service
2. The routines performed
			 on that date of service, noted to affirm completion of each task
3. The time of day the aide began performing
			 the first service-plan-required task for the client
4. The time of day the aide stopped
			 performing any service-plan-required task to perform any
			 non-service-plan-required function
5. The time of day the aide stopped
			 performing any non-service-plan-required function to resume
			 service-plan-required tasks
6. The
			 time of day the aide completed the last service-plan-required task for the day
			 for that client
I.
			 Notes, orders and records reflecting the activities of the physician, the
			 supervising RN or QMRP, the aide and the client or the client's representative
			 as those activities affect delivering personal care services
262.100
Personal Care
			 Billing
A. Providers must use
			 applicable HCPCS procedure codes and modifiers listed in sections
			 262.101 through
			 262.105.
B. All billing by any media requires the
			 correct 2-digit national standard place of service code.
C. When a beneficiary's individualized
			 service plan provides for services at more than one location (note the
			 exception at part C5), the provider must bill separately for services furnished
			 at each location, except when billing for services that occurred on the same
			 day and there are no unique place of service codes or unique procedure code
			 modifiers for each service.
1. When billing
			 for services that occurred on the same day and there are no unique procedure
			 code modifiers for each place of service, bill for each service that has a
			 unique procedure modifier on a separate detail (line).
2. When billing for services that occurred on
			 the same day in different locations and each location does not have a unique
			 place of service code, bill for each service that is associated with a unique
			 place of service code on a separate detail.
3. When billing for services that occurred on
			 the same day in different locations and each location does not have a unique
			 place of service code, add the units of service that must be billed with place
			 of service code
99
(Other Locations) and bill for the sum of those
			 units on a separate detail.
4. When
			 personal care services are furnished at different locations on different days
			 and the locations have the same place of service code, bill for each day's
			 services on a separate claim detail. (Note the exception at part C5)
5. Employment-related personal care services
			 occur at a variety of locations, but providers are to bill for them as if they
			 occurred at only one location (
99
) because of the lack of specific
			 place of service codes applicable to those services.
a.
Always bill for employment related
			 services separately from all other personal care.
b. Employment related services may be billed
			 on the same claim and (when applicable) for the same day as other personal care
			 services, but they must be billed as separate claim details, because
			 employment-related services have been assigned a unique procedure code modifier
			 for identification and tracking purposes.
C. Only services occurring within the same
			 calendar month may be billed for on the same claim detail.
262.105
Employment-Related Personal
			 Care Outside the Home
Procedure Code
Modifier
Service Description
T1019
U5
Employment-related personal care outside the home,
						  beneficiary aged 16 or older, per 15 minutes. This service requires prior
						  authorization for beneficiaries under age 21.
262.110
Coding Personal Care Places of
			 Service
A. The client's home is the
			 client's residence, subject to the exclusions in section
			 213.500, part B. For example, if
			 a client lives in a residential care facility (RCF) or an assisted living
			 facility (ALF-1 or ALF-2)), then the RCF or the ALF is the client's home and is
			 so indicated on a claim by place of service code
12
.
B. Section 213.520, part A, explains and
			 describes special circumstances under which a place of service is deemed
			 "public school."
1. The Arkansas Department of
			 Education (ADE) sometimes deems a student's home a "public school," a place of
			 service to be coded
03.
2. Under certain circumstances, the ADE deems
			 a Division of Developmental Disabilities Services community provider facility
			 ("DDS facility") a "public school," also a place of service that is coded
03.
C. When
			 beneficiaries receiving personal care in a DDS facility are not in the charge
			 of a school district (for example, they are older than school age or have
			 graduated), the place of service code is
99
, "Other Places of
			 Service," because there is no national code for a community provider facility
			 for the developmentally disabled.
D. The place of service code is
99
, "Other Places of Service," when personal care is
			 employment-related outside the home as described in section
			 213.540 of this manual and in the
			 following subparts D1 and D2, because there are no national standard place of
			 service codes for employment-related locations outside the home.
1. When a personal care aide is assisting a
			 client with personal care needs in a client's workplace, or at an
			 employment-related location outside the home, such as a human resource office,
			 an employment agency or a job interview site, use place of service code
99.
2. Use place of
			 service code
99
when a personal care aide is assisting a client
			 with transportation to and from work or job-seeking or during transportation to
			 and from work or job-seeking.