reglab/statecodes huggingface dataset:
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-027 - Provider Manual Update Transmittal PHARMACY 3-12

Current through Register Vol. 49, No. 6, June, 2024
Section II
Pharmacy
251.301
Generic Upper Limit
			 Override
The prescriber must determine whether the Medicaid recipient
				meets the required conditions to override a generic upper limit (GUL) cost of a
				drug. The prescriber must also complete the required MedWatch (see below)
				documentation to allow a prior authorization (PA) for a "Brand Medically
				Necessary" override of the GUL to reimburse at the brand name reimbursement
				rate.
MedWatch is the Food and Drug Administration (FDA)
				Safety Information and Adverse Event Reporting Program that allows healthcare
				professionals to report serious problems that they suspect are associated with
				certain drugs they prescribe.
The following criteria must be met to override the GUL when
				calculating the allowable amount of reimbursement:
A. For MedWatch drugs, the following
			 conditions are required for approval of a Brand Medically Necessary override:
1. The prescriber shall establish that the
			 recipient's condition meets the definition provided for the medical necessity
			 of dispensing any brand name drug when a generic equivalent is available.
In the context of this policy, "Brand Medically Necessary" is
				defined as the necessity to prescribe and dispense a brand name medication when
				use of a generic product has resulted in adverse reaction(s)
to the
				generic
, allergic reaction(s)
to the generic
or therapeutic failure
of the
				generic
.
a. Adverse
			 reaction caused by a generic must meet one of the following criteria:
1. Life threatening
2. Hospitalization
3. Disability
4. Required intervention to prevent
			 impairment or damage
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-028 - Targeted Case Management Update Transmittal 2-12 and State Plan Amendment #2012-011

Current through Register Vol. 49, No. 6, June, 2024
Section II
Targeted Case Management
204.000
Participation Requirements for Providers of Targeted Case Management for
			 Beneficiaries Age Sixty (60) and Older
Providers of targeted case management who are restricted to
				serving persons sixty (60) years of age and older must be certified by the
				Division of Aging and Adult Services as an organization qualified to provide
				targeted case management services.
In order to be certified by the Division of Aging and Adult
				Services, the provider must meet the following qualifications:
A. Be located in the state of
			 Arkansas
B. Be licensed as a Class
			 A or Class B Home Health Agency by the Arkansas Division of Health or a unit of
			 state government or an agency
C. Be
			 able to demonstrate one year of experience in performing case management
			 services (experience must be within the past 3 years)
D. Be able to demonstrate one year of
			 experience in working specifically with individuals in the targeted group
			 (experience must be within the past 3 years)
E. Have an administrative capacity to insure
			 quality of services in accordance with state and federal requirements
F. Have the financial management capacity and
			 system that provides documentation of services and costs
G. Have the capacity to document and maintain
			 individual case records in accordance with state and federal
			 requirements
H. Be able to
			 demonstrate that the provider has current liability coverage
I. Employ qualified case managers who:
1. Reside in or near the area of
			 responsibility; and
2. Are licensed
			 in the state of Arkansas as a social worker (Licensed Master Social Worker or
			 Licensed Social Worker), a registered nurse or a licensed practical nurse;
			 or
3. Have a bachelor's degree from
			 an accredited institution in a health and human services field, plus two years'
			 experience in the delivery of human services to the elderly; or
4. Have performed satisfactorily as a case
			 manager serving the targeted population for a period of two (2) years
			 (experience must be within the past 3 years).
A copy of the current certification must accompany the provider
				application and Medicaid contract.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-029 - Episode Performance Payments for Ambulatory URL, ADHD and Perinatal Care

Current through Register Vol. 49, No. 6, June, 2024
Section ll Episodes
			 of Care
200.000 EPISODES OF CARE GENERAL
			 INFORMATION
200.100 Episode Definition/Scope
			 of Services This section describes, for each episode type, the rules for
			 determining the specific services included in a particular episode.
A.
Episode
			 subtypes:
Episode types may be divided into two or more
			 subtypes distinguished by more specific diagnostic criteria or other clinical
			 information.
B.
Episode triggers:
Services or events
			 that may initiate an episode.
C.
Episode duration:
The time before and
			 after an episode trigger during which medical assistance may be included in an
			 episode.
D.
Episode services:
.
Criteria used to
			 determine which medical assistance is included or excluded in an episode when
			 delivered within the episode duration. Services excluded across all episode
			 types are: nursing home claims, EPSDT claims and managed care claims and fees.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-032 - Program of All-Inclusive Care for the Elderly (PACE) Update Transmittal PACE 2-12

Current through Register Vol. 49, No. 6, June, 2024
Section II Program
			 of All-Inclusive Care for the Elderly (PACE)
202.200
Staff Oversight Responsibility
			 (
			 42 CFR §
											460.71 )
A. The PACE Organization must ensure that all
			 employees and contracted staff providing care directly to participants
			 demonstrate the skills, licensure, and/or certifications necessary for
			 performance of their position.
1. The PACE
			 Organization must provide all staff with an orientation that includes, at a
			 minimum, the organization's mission, philosophy, policies on participant
			 rights, emergency plan, ethics, and the PACE Program and any policies related
			 to the job duties.
2. The provider
			 must develop a competency evaluation program that identifies those skills,
			 knowledge and abilities that must be demonstrated by direct participant care
			 staff.
3. The competency program
			 must be evidenced as completed before performing participant care and on an
			 on-going basis by qualified professionals. Certification of the satisfactory
			 completion of the competency program must be in the personnel files of all
			 staff.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.12-035 - State Plan Amendment #2012-007 and Section 1 4-12 - Recover Audit Contractors (RAC) Audit Requirement

Current through Register Vol. 49, No. 6, June, 2024
SECTION I -
			 GENERAL POLICY
143.000
Recovery Audit
			 Contractors (RACs)
Pursuant to
				42 C.F.R. §§
											455.502 - .516, each state Medicaid program
				must contract with recovery audit contractors (RACs). Pursuant to these federal
				regulations, the Arkansas Medicaid program will coordinate the following
				activities:
A. RAC review of claims
			 submitted by providers to identify overpayments or underpayments;
B. Coordination between Arkansas Medicaid and
			 the RAC for recoupment of overpayments;
C. Coordination of recovery audit efforts of
			 RAC and other auditing entities;
D.
			 Referral of suspected fraud and/or abuse to the Medicaid Fraud Control Unit
			 (MFCU) or other appropriate law enforcement agency; and
E. Limitation of the number and frequency of
			 medical records to be reviewed by the RAC
F. Coordination of the administrative
			 reconsideration and appeal process as set forth in Section
			 160.000 of this manual.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-003 - Provider Manual Update Transmittal Episode 1-13 and Provider Manual Update Transmittal Sec I-2-13

Current through Register Vol. 49, No. 6, June, 2024
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE
ATTACHMENT 4.19-B
4.
b. Early
			 and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age and
			 Treatment of Conditions Found
(17) Psychology
			 Services
A.
INCENTIVES TO IMPROVE CARE
			 QUALITY, EFFICIENCY, AND ECONOMY
V.
APPLICATION
: Complete details including technical information
			 regarding specific quality and reporting metrics, performance thresholds and
			 incentive adjustments are available in the Episodes of Care Medicaid Manual
			 available at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx
and also at the Arkansas Health Care Payment Improvement Initiative
			 website at
http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Attention Deficit Hyperactivity Disorder (ADHD) Episodes
Effective for dates of service on or after October 1, 2013, the
				defined scope of services within the following episode(s) of care are subject
				to incentive adjustments:
(1)
Oppositional Defiant Disorder (ODD) Episodes
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-006 - Developmental Disabilities Services Alternative Community Services (DDS-ACS) 1915(c) Home and Community Based Services waiver

Current through Register Vol. 49, No. 6, June, 2024
Application for a §1915(c) Home and Community-Based
				Services Waiver
PURPOSE OF THE HCBS WAIVER
				PROGRAM
___________________________________
The Medicaid Home and Community-Based Services (HCBS) waiver
				program is authorized in §1915(c) of the Social Security Act. The program
				permits a State to furnish an array of home and community-based services that
				assist Medicaid beneficiaries to live in the community and avoid
				institutionalization. The State has broad discretion to design its waiver
				program to address the needs of the waiver's target population. Waiver services
				complement and/or supplement the services that are available to participants
				through the Medicaid State plan and other federal, state and local public
				programs as well as the supports that families and communities provide.
The Centers for Medicare & Medicaid Services (CMS)
				recognizes that the design and operational features of a waiver program will
				vary depending on the specific needs of the target population, the resources
				available to the State, service delivery system structure, State goals and
				objectives, and other factors. A State has the latitude to design a waiver
				program that is cost-effective and employs a variety of service delivery
				approaches, including participant direction of services.
Request for an Amendment to a § 1915(c) Home and
				Community-Based
Services Waiver
1.
Request Information
A. The
State
of
Arkansas
requests approval for an amendment to the following Medicaid home and
			 community-based services waiver approved under authority of §1915(c) of
			 the Social Security Act.
B.
Program Title:
Alternative Community Services Waiver
				Amendment
C.
Waiver NumbenAR.0188 Original Base Waiver Number: AR.0188.
D.
Amendment
Number: AR.0188.R04.04
E.
Proposed Effective Date:
(mm/dd/yy)
07/01/13
Approved Effective Date of Waiver being Amended:
				07/01/09
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-010 - Provider Manual Update Transmittal: THERAPY-1-13

Current through Register Vol. 49, No. 6, June, 2024
Section II
Occupational, Physical,
			 Speech Therapy Services
214.300
Occupational and Physical Therapy Guidelines for Retrospective
Review
A.
			 Medical Necessity
Occupational and physical therapy services must be medically
				necessary to the treatment of the individual's illness or injury. A diagnosis
				alone is not sufficient documentation to support the medical necessity of
				therapy. To be considered medically necessary, the following conditions must be
				met:
1. The services must be
			 considered under accepted standards of practice to be a specific and effective
			 treatment for the patient's condition.
2. The services must be of such a level of
			 complexity or the patient's condition must be such that the services required
			 can be safely and effectively performed only by or under the supervision of a
			 qualified physical or occupational therapist.
3. There must be reasonable expectation that
			 therapy will result in a meaningful improvement or a reasonable expectation
			 that therapy will prevent a worsening of the condition. (See the medical
			 necessity definition in the Glossary of this manual.)
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-012 - Rehabilitative Services for Persons with Mental Illness Provider Manual Update Transmittal RSPMI 3-12

Current through Register Vol. 49, No. 6, June, 2024
Section II
Rehabilitative Services for Persons with Mental Illness
224.201
Psychiatric Diagnostic
			 Assessment - Initial
The purpose of this service is to determine the existence,
				type, nature and most appropriate treatment of a mental illness or emotional
				disorder as defined by DSM-IV or ICD-9. This face-to-face psycho diagnostic
				assessment must be conducted by one of the following:
*
an Arkansas-licensed physician, preferably one
				with specialized training and experience in psychiatry (child and adolescent
				psychiatry for beneficiaries under age 18)
*
an Adult Psychiatric Mental Health Advanced
				Nurse Practitioner/Family Psychiatric Mental Health Advanced Nurse Practitioner
				(PMHNP-BC)
The PMHNP-BC must meet all of the following
				requirements:
*
Licensed by the Arkansas State Board of
				Nursing
*
Practicing with licensure through the American
				Nurses Credentialing Center
*
Practicing under the supervision of an
				Arkansas-licensed psychiatrist who has an affiliation with the RSPMI program
				and with whom the PMHNP-BC has a collaborative agreement. The findings of the
				Psychiatric Diagnostic Assessment - Initial conducted by the PMHNP-BC must be
				discussed with the supervising psychiatrist within 45 days of the beneficiary
				entering care. The collaborative agreement must comply with all Board of
				Nursing requirements and must spell out, in detail, what the nurse is
				authorized to do and what age group they may treat.
*
Practicing within the scope of practice as
				defined by the Arkansas Nurse Practice Act
*
Practicing within a PMHNP-BC's experience and
				competency level The initial Psychiatric Diagnostic Assessment must
				include:
A. An interview with the
			 beneficiary, which covers the areas outlined below. The initial Psychiatric
			 Diagnostic Assessment may build on information obtained through other
			 assessments reviewed by the physician or the PMHNP-BC and verified through the
			 physician's or the PMHNP-BC's interview. The interview should obtain or verify
			 all of the following:
1. The beneficiary's
			 understanding of the factors leading to the referral
2. The presenting problem (including symptoms
			 and functional impairments)
3.
			 Relevant life circumstances and psychological factors
4. History of problems
5. Treatment history
6. Response to prior treatment
			 interventions
7. Medical history
			 (and examination as indicated)
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-015 - State Plan Amendment #2013-013 and Section I 5-13

Current through Register Vol. 49, No. 6, June, 2024
Section I
181.000 Incentives to Improve Care Quality,
			 Efficiency and Economy
A. Definitions
1. An "episode" refers to a defined
			 collection of related Medicaid-covered health care services provided to a
			 specific Medicaid beneficiary.
2.
			 An "episode type" is defined by a diagnosis, health care intervention, or
			 condition during a specific timeframe (or performance period).
3. "Thresholds" are the upper and lower
			 reimbursement benchmarks for an episode of care.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-002 - #2013-014: Rate Increase for ParaGuard Intrauterine Copper Contraceptive Device (IUD)

Current through Register Vol. 49, No. 6, June, 2024
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE ATTACHMENT 4.19-B
4.
c.
			 Family Planning Services
Reimbursement is based on the lesser of the amount billed or
				the maximum Title XIX (Medicaid) charge allowed. State developed fee schedule
				rates are the same for both public and private providers.
1. The Title XIX (Medicaid) maximum for
			 Family Planning services is 100% of the current physician Medicaid maximum.
At the beginning of each calendar year, the State Agency will
				negotiate with the affected provider group representatives to arrive at a
				mutually acceptable increase or decrease from the maximum rate. Market forces,
				such as private insurance rate, medical and general inflation figures, changes
				in practice costs and changes in program requirements, will be considered
				during the negotiation process. Any agreed upon increase or decrease will be
				implemented at the beginning of the following State Fiscal Year, July 1, with
				any appropriate State Plan changes.
2. Intrauterine Devices (IUDs)
Effective for claims with dates of service January 1,
				2014 and after, the intrauterine device (IUD) is reimbursed based on 100% of
				the manufacturer's list price as of April 15, 2011.
Effective for claims with dates of service July 1, 2010 and
				after, the levongestrel releasing IUD is reimbursed based on 100% of the
				manufacturer's list price as of May 5, 2010.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-017 - Methods and Standards for Establishing Payment Rates - Family Planning Services

Current through Register Vol. 49, No. 6, June, 2024
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE
ATTACHMENT 4.19-B
4.
C.
			 Family Planning Services
Reimbursement is based on the lesser of the amount billed or
				the maximum Title XIX (Medicaid) charge allowed. State developed fee schedule
				rates are the same for both public and private providers.
1. The Title XIX (Medicaid) maximum for
			 Family Planning services is 100% of the current physician Medicaid maximum.
At the beginning of each calendar year, the State Agency will
				negotiate with the affected provider group representatives to arrive at a
				mutually acceptable increase or decrease from the maximum rate. Market forces,
				such as private insurance rate, medical and general inflation figures, changes
				in practice costs and changes in program requirements, will be considered
				during the negotiation process. Any agreed upon increase or decrease will be
				implemented at the beginning of the following State Fiscal Year, July 1, with
				any appropriate State Plan changes.
2. Intrauterine Devices (lUDs)
Effective for claims with dates of service January 1, 2014 and
				after, the intrauterine device (lUD) is reimbursed based on 100% of the
				manufacturer's list price as of April 15,2011. Effective for claims with dates
				of service
October 1, 2014
and after, the
52 mg
Levongestrel-Releasing
Intrauterine Contraceptive System
is
				reimbursed based on 100% of the manufacturer's list price as of
November
				18, 2013. Effective for claims with dates of service October 1, 2014 and after,
				the 13.5 mg Levongestrel-Releasing Intrauterine Contraceptive System is
				reimbursed based on 100% of the manufacturer's list price as of January 1,
				2013.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-019 - Perinatal Care Episode 3-14

Current through Register Vol. 49, No. 6, June, 2024
211.000
PERINATAL CARE EPISODES
211.600
Thresholds for
			 Incentive Payments
A. The acceptable
			 threshold is $3,852.00.
B. The
			 commendable threshold is $3,245.00.
C. The gain sharing limit is
			 $2,000.00.
D. The gain sharing
			 percentage is 50%.
E. The risk
			 sharing percentage is 50%.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-020 - Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) Episodes

Current through Register Vol. 49, No. 6, June, 2024
221.000
ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
			 EPISODES
221.600
Thresholds for Incentive Payments
A. The acceptable threshold is
			 $1,876.00.
B. The commendable
			 threshold is $1,339.00.
C. The gain
			 sharing limit is $859.00.
D. The
			 gain sharing percentage is 50%.
TO: Arkansas Medicaid Health Care Providers - Episodes of
				Care
DATE: October 1, 2014
SUBJECT: Provider Manual Update Transmittal
				EPISODE-4-14
REMOVE
INSERT
Section
Date
Section
Date
221.600
_____
221.600
10-1-14
Explanation of Updates
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-003 - SPA #2015-005: Methods and Standards for Establishing Payment Rates - Other Types of Care

Current through Register Vol. 49, No. 6, June, 2024
ATTACHMENT 4.19-B
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-OTHER TYPES OF CARE
8. Private
			 Duty Nursing to enhance the effectiveness of treatment for ventilator-dependent
			 beneficiaries, high technology non-ventilator beneficiaries or tracheotomy
			 beneficiaries
Reimbursement is based on the lesser of the amount billed or
				the maximum Title XIX (Medicaid) charge allowed. The State is under a U. S.
				District Court order that sets out the process for rates to be determined. That
				process includes evaluation of rates based upon market forces as they impact on
				access. Payment of the resultant rates is ordered by the court.
The agency's private duty nursing fee schedule rates were set
				as of
July 1, 2015
and are effective for fee schedule services on
				or after that date. All fee schedule rates are published on the agency's
				website
(www.medicaid.state.ar.us)
.
				Except as noted in the plan, state developed fee schedule rates are calculated
				using the same method for both governmental and private providers of private
				duty nursing services.
Effective for dates of service on or after October 1, 1994,
				reimbursement for private duty nursing medical supplies is based on 100% of the
				Medicare maximum for medical supplies reflected in the 1993 Arkansas Medicare
				Pricing File not to exceed the Title XIX coverage limitations as specified in
				Attachment 3.1 -A, page 3d, and Attachment 3.1-B, page 4a.
Effective for dates of service on or after
July 1,
				2015
, RN and LPN hourly reimbursement rate maximums are set based on
				market analysis of salaries, fringe benefits and administrative/overhead costs.
				Market analysis included the following steps:
Acquir
ed 2013
wage rates from the Federal Bureau
				of Labor Statistics
for Arkansas
,
*
Determining employee benefit costs by using
Skilled Nursing Facility cost reports submitted as of July 1,
				2014,
*
Assessing overhead costs by calculating the
				percent of direct to indirect costs reported in the most recent audited
				Medicare Home Health cost reports by the top 70% of Medicaid reimbursed
				non-hospital home health providers during SFY 2007,
and
* It was estimated that a private duty nurse will travel
				approximately 8 miles each hour
.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-009 - SPA #2015-003: Ambulatory Surgical Center

Current through Register Vol. 49, No. 6, June, 2024
9. Clinic Services
(2) Family Planning Clinic Services Payment
			 based on reasonable negotiated rate.
(3) Maternity Clinic Services
Payment based on reasonable negotiated rate.
Effective for claims with dates of service on or after July 1,
				1992, the Title XIX maximum rates were decreased by 20%
(4) Ambulatory Surgical Center Services
Act 1352 of the 2013 Arkansas General Assembly established
				reimbursement for Ambulatory Surgery Centers based on 80% of the Medicare
				Ambulatory Surgery Center procedure code reimbursement rates. Reimbursement is
				based on the lesser of the provider's actual charges for the service or the
				Title XIX (Medicaid) maximum. These rates are effective for dates of service
				beginning July 1, 2013
through June 30, 2015
. All rates are
				published on the agency's website
(www.medicaid.state.ar.us)
.
				Except as otherwise noted in the plan, state developed fee schedule rates are
				the same for both governmental and private providers of Ambulatory Surgical
				Center services. Medicaid will follow Medicare procedure code updates.
Effective July 1, 2015 Act 1236 as amended by the 2015
				Arkansas General Assembly adjusted reimbursement for Ambulatory Surgery Centers
				to 95% of the Medicare Ambulatory Surgery Center procedure codes reimbursement
				rates. Also in accordance with this amendment Medicaid may adopt and assign a
				CPT code for a comparable procedure (if the procedure code is not listed on the
				Medicare ASC procedure code listing) only if the code was approved by Medicaid
				before the procedure was performed.
In accordance with the Act, Implantable Devices which are not
				bundled as part of the appropriate procedure code will be reimbursed at a
				pass-through cost; if the combined documented cost of the appropriate
				implantable devices is greater than 50% of the appropriate Medicaid maximum
				procedure code reimbursement rate. If multiple devices are included for one
				patient, then the total provided devices' cost is calculated and then compared
				to the appropriate procedure code. The implantable devices' reimbursement
				provision is also effective for dates of service beginning July 1, 2013
through June 30, 2015
. These implantable devices are listed in
				the provider manual which can be found on the agency's website at
https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/asc.aspx.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-013 - RURLHLTH 4-15: Rural Health Clinic Update

Current through Register Vol. 49, No. 6, June, 2024
Section II
Rural Health Clinic
213.000
Staff Requirements and
			 Responsibilities
A. The RHC must have
			 a health care staff that includes one or more physicians and one or more
			 physician assistants or nurse practitioners. The physicians, physician
			 assistants or nurse practitioners may be the owners of the RHC and/or under
			 agreement with the RHC to carry out the responsibilities required.
B. The staff may include ancillary personnel
			 who are supervised by the professional staff.
C. A physician, physician assistant or nurse
			 practitioner must be available to furnish patient care services at times the
			 RHC operates. These staff must be available to furnish patient care services at
			 least 50% of the time the RHC operates.
D. The physician must provide medical
			 direction for the RHC activities and consultation for the medical supervision
			 of the health care staff. The physician also must participate in developing,
			 executing and periodically reviewing policies, services, patient records and
			 must provide medical orders and medical care services to patients of the
			 RHC.
E. The physician assistant and
			 nurse practitioner, as members of the RHC staff, must participate in the
			 development, execution and periodic review of the written policies governing
			 the services the RHC furnishes and participate with the physician in a periodic
			 review of patients' health records.
F. The physician assistant or nurse
			 practitioner must perform the following functions, to the extent they are not
			 being performed by a physician:
1. Provide
			 services in accordance with RHC policies;
2. Arrange for or refer patient for services
			 that cannot be provided by the RHC; and
3. Assure adequate patient health records are
			 maintained and transferred as required when patients are referred.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-014 - Coverage of Vaccine Current Procedure Terminology

Current through Register Vol. 49, No. 6, June, 2024
Coverage of Vaccine Current Procedure Terminology
				(CPT®) Procedure Code 90651
I.
Background Information
			 on Vaccines
A. The
			 Vaccines for Children (VFC) program was established to enable free access to
			 childhood immunizations for Medicaid-eligible children under age nineteen.
The Arkansas Department of Health oversees the VFC program in
				Arkansas. To enroll in the VFC program and obtain the vaccines, providers may
				contact the Arkansas Department of Health at (800) 462-0599 or (501)
				661-2000.
Arkansas Medicaid reimburses an administration fee for
				immunizations included in the VFC program. Providers billing for administration
				of immunizations should use the appropriate CPT® code and required
				modifier(s).
All procedure codes under the VFC program must be billed
				electronically or on paper, using either the CMS-1500 claim form or the
				CMS-1450 claim form.
Medicaid policy regarding immunizations for adults remains
				unchanged by the VFC program.
B. The purpose of this notice of rule making
			 is to inform Arkansas Medicaid providers of coverage of the CPT® procedure
			 code 90651 under the VFC program and the State Children's Health Insurance
			 Program (SCHIP).
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-015 - HOSP 9-15 & SPA 2015-006

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
Hospital/Critical Access Hospital (CAH)/End Stage Renal
			 Disease (ESRD)
250.622
Arkansas
			 State Operated Teaching Hospital Adjustment
Effective May 9, 2000, Arkansas State Operated Teaching
				Hospitals qualify for an inpatient rate adjustment.
A. The adjustment shall result in total
			 payments to the hospitals that are equal to but not in excess of the individual
			 facility's Medicare-related upper payment limit.
B. The adjustment is calculated as follows:
1. Using the most current audited data,
			 Arkansas Medicaid determines each State Operated Teaching Hospital's base
			 Medicare per discharge rate and base Medicaid per-discharge rate.
a. Arkansas Medicaid will use the date of the
			 Medicaid Notice of Provider Reimbursement (NPR) received by the Division of
			 Medical Services from the Medicare Intermediary to determine the most recent
			 audited cost report period for rate adjustment purposes.
b. The most current audited cost report
			 period is used when an earlier period's NPR is finalized after a later
			 period's.
c. In order to be used to
			 calculate the rate adjustment amount, the Medicaid NPR received from the
			 Medicare Intermediary must be dated before July 1 of the state fiscal year
			 (SFY) for which the adjustment payments will be made.
2. The base per-discharge rates are trended
			 forward to the current fiscal year using an annual Consumer Price Index
			 inflation factor.
3. Once the
			 per-discharge rates have been trended forward, the Medicare per-discharge rate
			 is divided by the Medicare case mix index and the Medicaid per-discharge rate
			 is divided by the Medicaid case mix index.
a.
			 The Medicare case mix index reflects the hospital's average diagnosis related
			 group (DRG) weight for Medicare patients.
b. The Medicaid case mix index reflects the
			 hospital's average DRG weight for Medicaid patients using the Medicare
			 DRGs.
4. The base
			 Medicaid per-discharge rate is subtracted from the base Medicare per discharge
			 rate.
5. The difference is
			 multiplied by the hospital's Medicaid case mix index.
6. The adjusted difference is multiplied by
			 the number of Medicaid discharges at the hospital for the most recent fiscal
			 year.
7. The result is the amount
			 of the annual State Operated Teaching Hospital Adjustment.
8. Payment is made on an annual basis before
			 the end of the state fiscal year (June 30).
9. Effective for state fiscal year 2016 and
			 forward, the state may elect to use the most recent cost report available as of
			 June 30 if the audited cost report is more than 2 years old as of June 30 for
			 the above calculation.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-019 - Pharmacy 3-15: Prescription Refill Limit

Current through Register Vol. 49, No. 6, June, 2024
Section II.Pharmacy
213.200
Prescription Refill
			 Limit
Refills are reimbursable under the Arkansas Medicaid Pharmacy
				Program only if they are specifically authorized on the original prescription
				or if authorized by the prescribing provider at a later date and recorded by
				the pharmacist on the original prescription when refilled. In no event is any
				prescription to be refilled more than five (5) times or beyond six (6) months
				after the date of the original issue, whichever comes first. Renewals or
				continuation of drug therapy beyond five refills or six months requires a new,
				original prescription.
Pharmacies will have a maximum of fourteen (14) days to reverse
				original prescriptions and refills that were not provided to the
				recipient.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-020 - Ambulatory Surgical Center 2-15, ARKids 3-15, Certifified Nurse Midwife 1-15. Early Periodic Screening Diagnosis and Treatment 2-15, Hospital 3-15, Federally Qualified Health Center 2-15, Home Health 3-15, Hyperalimentation 2-15, Physician 4-15, Prosethetics 5-15, Rural Health Clinic 2-15, Nurse Practioner 2-15, Transportation 1-15

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
ARKids FIrst-B
262.431 Billing of Multi-Use and Single-Use
			 Vials 11-1-15
Arkansas Medicaid follows the billing protocol per the Federal
				Deficit Reduction Act of 2005 for drugs.
A. Multiple units may be billed when
			 applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump
			 are not classified as "take-home drugs." Refer to payable CRT code ranges 96365
			 through 96379.
B. When submitting
			 Arkansas Medicaid drug claims, drug units should be reported in multiples of
			 the dosage included in the HCPCS procedure code description. If the dosage
			 given is not a multiple of the number provided in the HCPCS code description,
			 the provider shall round up to the nearest whole number in order to express the
			 HCPCS description number as a multiple.
1.
Single-Use Vials:
If the provider must discard the remainder of a
single-use vial
or other package after administering the
			 prescribed dosage of any given drug, Arkansas Medicaid will cover the amount of
			 the drug discarded along with the amount administered.
2.
Multi-Use Vials:
Multi-use
			 vials are not subject to payment for any discarded amounts of the drug. The
			 units billed must correspond with the units administered to the
			 beneficiary.
3.
Documentation:
The provider must clearly document in the patient's
			 medical record the actual dose administered in addition to the exact amount
			 wasted and the total amount the vial is labeled to contain.
4.
Paper Billing:
For drug
			 HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete
			 every field of the
DMS-664
"Procedure Code/NDC Detail Attachment
			 Form." Attach this form and any other required documents to your claim when
			 submitting it for processing.
Remember to verify the milligrams given to the patient and then
				convert to the proper units for billing.
Follow the Centers for Disease Control (CDC) requirements for
				safe practices regarding expiration and sterility of multi-use vials.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-021 - State Plan Amendments #2015-004 & 2015-007; Targeted Case Management 2-15; IndependentChoices 2-15; Personal Care 3-15; ARChoices-New-15 and ARChoices Waiver

Current through Register Vol. 49, No. 6, June, 2024
SECTION II -
			 TARGETED CASE MANAGEMENT
204.000
Participation Requirements for Providers of Targeted Case Management for
			 Beneficiaries Ages Sixty (60) and Older Including ARChoices in Homecare Waiver
			 Participants
Providers of targeted case management who are restricted to
				serving persons sixty (60) years of age and older or serving persons ages
				twenty-one (21) and older with a physical disability and those sixty-five (65)
				and older who participate in the ARChoices in Homecare (ARChoices) 1915(c)
				waiver must be certified by the Division of Aging and Adult Services as an
				organization qualified to provide targeted case management services.
In order to be certified by the Division of Aging and Adult
				Services, the provider must meet the following qualifications:
A. Be located in the state of
			 Arkansas|
B. Be licensed as a Class
			 A or Class B Home Health Agency or Private Care Agency by the Arkansas
			 Department of Health or a unit of state government or be a private or public
			 incorporated agency whose stated purpose is to provide case management to the
			 elderly or adults with physical disabilities;
C. Be able to demonstrate one year of
			 experience in performing case management services| (Experience must be within
			 the past 3 years);
D. Be able to
			 demonstrate one year of experience in working specifically with individuals in
			 the targeted group. (Experience must be within the past 3 years);
E. Have an administrative capacity to insure
			 quality of services in accordance with state and federal
			 requirements;
F. Have the financial
			 management capacity and system that provides documentation of services and
			 costs;
G. Have the capacity to
			 document and maintain individual case records in accordance with state and
			 federal requirements!
H. Be able to
			 demonstrate that the provider has current liability coverage; and
I. Employ qualified case managers who must:
1. Reside in or near the area of
			 responsibility; and
2. Be licensed
			 in the state of Arkansas as a social worker (Licensed Master Social Worker or
			 Licensed Certified Social Worker), a registered nurse or a licensed practical
			 nurse; or
3. Have a bachelor's
			 degree from an accredited institution in a health and human services field,
			 plus two years' experience in the delivery of human services to the elderly;
			 or
4. Have performed satisfactorily
			 as a case manager serving the targeted population for a period of two (2) years
			 (experience must be within the past 3 years).
A copy of the current certification must accompany the provider
				application and Medicaid contract.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-008 - Rules and Regulations for the Arkansas Long Term Care Facility Nursing Assistant Training Program

Current through Register Vol. 49, No. 6, June, 2024
Section VI
QUALIFICATIONS OF INSTRUCTORS
A.
Primary Instructor
			 (PI)
1. The Primary Instructor
			 shall be a Registered Nurse currently licensed in Arkansas, or holding a
			 multi-state privilege to practice. If the Registered Nurse moves from a Compact
			 state to Arkansas, the Registered Nurse shall meet the requirements for
			 licensure in Arkansas as established by the Arkansas State Board of Nursing.
			 The Registered Nurse shall not be employed or act as an Instructor if the
			 Registered Nurse's license to practice has any current disciplinary action on
			 the license by the licensing entity or authority.
2. The Primary Instructor must possess a
			 minimum of two (2) years nursing experience including at least one (1) year of
			 long term care nursing services within the last five (5) years. Experience may
			 include, but is not limited to, employment in a nursing assistant education
			 program or employment in or supervision of nursing students in a nursing
			 facility or unit, geriatrics department (excluding geriatric psychiatry),
			 long-term acute care hospital, home care, hospice care or other long term care
			 setting.
3. In a facility-based
			 program, the training of nursing assistants may be performed under the general
			 supervision of the Director of Nursing (DON), who is prohibited from performing
			 the actual training (unless replacement DON coverage is provided).
4. An individual who will be the Primary
			 Instructor and meets the above criteria may submit the Application for Program
			 Approval (Form DMS-724) identifying their qualifications to teach. This must
			 include nursing experience, supervisory experience, teaching experience and/or
			 certificate of attendance in an instructor workshop.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-009 - Notice of Rule Making - Notice 005-15

Current through Register Vol. 49, No. 6, June, 2024
Coverage of Vaccine Current Procedure Terminology
				(CPT®) Procedure Codes 90620 and
				90621
I.
General Background Information on Vaccines
A. The Vaccines for Children (VFC) program
			 was established to enable free access to childhood immunizations for
			 Medicaid-eligible children under age nineteen.
The Arkansas Department of Health oversees the VFC program in
				Arkansas. To enroll in the VFC program and obtain the vaccines, providers may
				contact the Arkansas Department of Health at 1-800-462 -0599 or (501)
				661-2000.
Arkansas Medicaid reimburses an administration fee for
				immunizations included in the VFC program. Providers billing for administration
				of immunizations should use the appropriate CPT®
				code and required modifier(s).
All procedure codes under the VFC program may be billed
				electronically or on paper, using either the CMS-1500 claim form or the
				CMS-1450 claim form.
Medicaid policy regarding immunizations for adults remains
				unchanged by the VFC program.
B. The purpose of this notice of rulemaking
			 is to inform Arkansas Medicaid providers of coverage of the
			 CPT® procedure codes
90620
and
90621
under the VFC program and the State Children's Health
			 Insurance Program (SCHIP) per Centers for Disease Control and Prevention (CDC)
			 designation as of June 24, 2015.
C.
			 In addition, this notice is to inform providers that eligible, adult
			 beneficiaries are covered by CPT® procedure
			 codes
90620
and
90621
vaccines per Centers for Disease
			 Control and Prevention (CDC) recommendation as of June 24, 2015.
Any administration fee for adult vaccines is included in the
				reimbursement fee for the CPT® procedure
				code.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-020 - 2016 CPT and HCPCS Procedure Code Conversion

Current through Register Vol. 49, No. 6, June, 2024
Requirements for Requests for Molecular Pathology
				Laboratory Services
Procedural Policy
To reduce delays in processing requests and to avoid
				returning requests due to incomplete and/or
lack of documentation, the following procedures must be
				followed.
I. Requests for
			 molecular pathology laboratory services must be requested and a prior
			 authorization received prior to billing the claims.
II. The Request for Molecular Pathology
			 Laboratory Services (Form DMS-841) must accompany the supporting clinical
			 record when submitting a paper request.
III. Molecular Pathology Laboratory Services
			 requests will be denied if received after the timely filing time frame (12
			 months beyond the date of service).
IV. AFMC Molecular Pathology Laboratory
			 requests will be considered if all of the following documentation is received
			 with the request.
A.
All fields of form
			 DMS-841 must be correctly completed by entering the following
			 information:
(1) Enter performing
			 provider's name.
(2) Enter the
			 provider ID # and taxonomy code of performing provider.
(3) Enter the address the provider will use
			 to receive correspondence regarding this request.
(4) If the provider is a member of a group,
			 enter the group provider ID #.
(5)
			 Performing provider's signature and credentials must be entered in this
			 field.
(6) Enter the beneficiary's
			 full name.
(7) Enter the
			 beneficiary's complete address.
(8)
			 Enter the beneficiary's Medicaid ID #.
(9) Enter the beneficiary's date of birth and
			 sex.
(10) Enter the service from
			 date.
(11) Enter the service to
			 date.
(12) Enter the diagnosis
			 code.
(13) Enter the diagnosis code
			 description.
(14) Enter the
			 procedure code and applicable modifier(s). (If there are more than 8
			 procedures, additional procedures must be added to a separate, completed
			 form.)
(15) Enter the procedure
			 code description.
(16) Enter the
			 number of units.
Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-021 - Living Choices Assisted Living Waiver Renewal and Living Choices Assisted Living Update #2-15

Current through Register Vol. 49, No. 6, June, 2024
Section II
Living Choices Assisted Living
200.105
Provider Assurances
A. Staffing
The Provider agrees that he or she will maintain adequate
				staffing levels to ensure timely and consistent delivery of services to all
				beneficiaries for whom they have accepted a Living Choices Assisted Living
				Waiver Plan of Care.
The Provider agrees:
1. Personnel responsible for direct service
			 delivery will be properly trained and in compliance with all applicable
			 licensure requirements. The Provider agrees to require personnel to participate
			 in any appropriate training provided by, or requested by, the Department of
			 Human Services. The Provider acknowledges the cost of training courses for
			 certification and/or licensure is not reimbursable through DHS.
2. Each service worker possesses the
			 necessary skills to perform the specific services required to meet the needs of
			 the beneficiary he/she is to serve.
3. Staff is required to attend orientation
			 training prior to allowing the employee to deliver any Living Choices Assisted
			 Living Waiver service(s). This orientation shall include, but not be limited
			 to, a:
a. Description of the purpose and
			 philosophy of the Living Choices Assisted Living Waiver Program;
b. Discussion and distribution of the
			 provider agency's written code of ethics;
c. Discussion of activities which shall and
			 shall not be performed by the employee;
d. Discussion, including instructions,
			 regarding Living Choices Assisted Living Waiver record keeping
			 requirements;
e. Discussion of the
			 importance of the Plan of Care;
f.
			 Discussion of the agency's procedure for reporting changes in the beneficiary's
			 condition;
g. Discussion, including
			 potential legal ramifications, of the beneficiary's right to
			 confidentiality.