Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-052 - Section IV Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
SECTION IV - GLOSSARY
AAFP
American Academy of Family Physicians
AAP
American Academy of Pediatrics
ABESPA
Arkansas Board of Examiners in Speech-Language
						  Pathology and Audiology
ACD
Augmentative Communication Device
ACIP
Advisory Committee on Immunization
						  Practices
ACES
Arkansas Client Eligibility System
ACS
Alternative Community Services
ADE
Arkansas Department of Education
ADH
Arkansas Department of Health
ADL
Activities of Daily Living
AFDC
Aid to Families with Dependent Children (cash
						  assistance program replaced by the Transitional Employment Assistance (TEA)
						  assistance program)
AFMC
Arkansas Foundation for Medical Care, Inc.
AH EC
Area Health Education Centers
ALF
Assisted Living Facilities
ALS
Advance Life Support
ALTE
Apparent Life Threatening Events
AMA
American Medical Association
APD
Adults with Physical Disabilities
ARS
Arkansas Rehabilitation Services
ASC
Ambulatory Surgical Centers
AS HA
American Speech-Language-Hearing
						  Association
BIPA
Benefits Improvement and Protection Act
BLS
Basic Life Support
CARF
Commission on Accreditation of Rehabilitation
						  Facilities
CCRC
Children's Case Review Committee
CFA
One Counseling and Fiscal Agent
CFR
Code of Federal Regulations
CHMS
Child Health Management Services
CLIA
Clinical Laboratory Improvement Amendments
CME
Continuing Medical Education
CMHC
Community Mental Health Center
CMS
Centers for Medicare and Medicaid Services
COA
Council on Accreditation
CON
Certification of Need
CPT
Physicians' Current Procedural Terminology
CRNA
Certified Registered Nurse Anesthetist
CSHCN
Children with Special Health Care Needs
CSWE
Council on Social Work Education
D&E
Diagnosis and Evaluation
DAAS
Division of Aging and Adult Services
DBS
Division of Blind Services (currently named Division of
						  Services for the Blind)
DCFS
Division of Children and Family Services
DCO
Division of County Operations
DD
Developmentally Disabled
DDS
Developmental Disabilities Services
DDTCS
Developmental Day Treatment Clinic Services
DHS
Department of Human Services
DLS
Daily Living Skills
DME
Durable Medical Equipment
DMHS
Division of Mental Health Services
DMS
Division of Medical Services (Medicaid)
DOS
Date of Service
DRG
Diagnosis Related Group
DRS
Developmental Rehabilitative Services
DSB
Division of Services for the Blind (formerly Division
						  of Blind Services)
DSH
Disproportionate Share Hospital
DURC
Drug Utilization Review Committees
DYS
Division of Youth Services
EAC
Estimated Acquisition Cost
EDS
Electronic Data Systems
EFT
Electronic Funds Transfer
EIN
Employer Identification Number
EOB
Explanation of Benefits
EOMB
Explanation of Medicaid Benefits. EOMB may also refer
						  to Explanation of Medicare Benefits.
EPSDT
Early and Periodic Screening, Diagnosis and
						  Treatment
ESC
Education Services Cooperative
FEIN
Federal Employee Identification Number
FPL
Federal Poverty Level
FQHC
Federally Qualified Health Center
GME
Graduate Medical Education
GUL
Generic Upper Limit
HCBS
Home and Community Based Services
HCPCS
Healthcare Common Procedure Coding System
HDC
Human Development Center
HHS
The Federal Department of Health and Human
						  Services
HIC Number
Health Insurance Claim Number
HIPAA
Health Insurance Portability and Accountability Act of
						  1996
HMO
Health Maintenance Organization
IADL
Instrumental Activities of Daily Living
ICD-9-CM
International Classification of Diseases, Ninth
						  Edition, Clinical Modification
ICF/MR
Intermediate Care Facility/ Mental
						  Retardation
ICN
Internal Control Number
IDEA
Individuals with Disabilities Education Act
IDG
Interdisciplinary Group
IEP
Individualized Educational Program
IFSP
Individualized Family Service Plan
IMD
Institution for Mental Diseases
IPP
Individual Program Plan
IUD
Intrauterine Devices
JCAHO
Joint Commission on Accreditation of Healthcare
						  Organization
LAC
Licensed Associate Counselor
LCSW
Licensed Certified Social Worker
LEA
Local Education Agencies
LMFT
Licensed Marriage and Family Therapist
LMHP
Licensed Mental Health Practitioner
LPC
Licensed Professional Counselor
LPE
Licensed Psychological Examiner
LSPS
Licensed School Psychology Specialist
LTC
Long Term Care
MAC
Maximum Allowable Cost
MAPS
Multi-agency Pan of Services
MART
Medicaid Agency Review Team
MEI
Medicare Economic Index
MMIS
Medicaid Management Information System
MNIL
Medically Needy Income Limit
MPPPP
Medicaid Prudent Pharmaceutical Purchasing
						  Program
MSA
Metropolitan Statistical Area
MUMP
Medicaid Utilization Management Program
NBCOT
National Board for Certification of Occupational
						  Therapy
NCATE
North Central Accreditation for Teacher
						  Education
NDC
National Drug Code
NET
Non-Emergency Transportation Services
NF
Nursing Facility
NPI
National Provider Identifier
OBRA
Omnibus Budget Reconciliation Act
OHCDS
Organized Health Care Delivery System
OTC
Over the Counter
PA
Prior Authorization
PAC
Provider Assistance Center
PCP
Primary Care Physician
PERS
Personal Emergency Response Systems
PES
Provider Electronic Solutions
PHS
Public Health Services
PIM
Provider Information Memorandum
PL
Public Law
POC
Plan of Care
POS
Place of Service
PPS
Prospective Payment System
PRN
Pro Re Nata or "As Needed"
PRO
Professional Review Organization
ProDUR
Prospective Drug Utilization Review
QMB
Qualified Medicare Beneficiary
QMRP
Qualified Mental Retardation Professional
RA
Remittance Advice. Also called Remittance and Status
						  Report.
RFP
Request for Proposal
RHC
Rural Health Clinic
RID
Recipient Identification Number
RSPD
Rehabilitative Services for Persons with Physical
						  Disabilities
RSPMI
Rehabilitation Services for Persons with Mental
						  Illness
RSYC
Rehabilitative Services for Youth and
						  Children
RTC
Residential Treatment Centers
RTP
Return to Provider
RTU
Residential Treatment Units
SBMH
School Based Mental Health Services
SD
Spend Down
SFY
State Fiscal Year
SMB
Special Low Income Qualified Medicare
						  Beneficiaries
SNF
Skilled Nursing Facility
SSA
Social Security Administration
SSI
Supplemental Security Income
SURS
Surveillance and Utilization Review
						  Subsystem
TCM
Targeted Case Management
TEA
Transitional Employment Assistance
TEFRA
Tax Equity and Fiscal Responsibility Act
TOS
Type of Service
TPL
Third Party Liability
UPL
Upper Payment Limit
UR
Utilization Review
VFC
Vaccines for Children
VRS
Voice Response System
Accommodation
A type of hospital room, e.g., private, semiprivate,
						  ward, etc.
Activities of Daily Living (ADL)
Personal tasks which are ordinarily performed on a
						  daily basis and include eating, mobility/transfer, dressing, bathing, toileting
						  and grooming.
Adjudicate
To determine whether a claim is to be paid or
						  denied.
Adjustments
Transactions to correct claims paid in error or to
						  adjust payments from a retroactive change.
Admission
Actual entry and continuous stay of the recipient as an
						  inpatient to an institutional facility.
Affiliates
Persons having an overt or covert relationship such
						  that any one of them directly or indirectly controls or has the power to
						  control another.
Agency
The Division of Medical Services.
Aid Category
A designation within SSI or state regulations under
						  which a person may be eligible for public assistance.
Aid to Families with Dependent Children
						  (AFDC)
A Medicaid eligibility category.
Allowed Amount
The maximum amount Medicaid will pay for a service as
						  billed before applying recipient coinsurance orcopay, previous TPL payment,
						  spend down liability or other deducted charges.
American Medical Association (AMA)
National association of physicians.
Ancillary Services
Services available to a patient other than room and
						  board. For example: pharmacy, X-ray, lab and central supplies.
Arkansas Client Eligibility System (ACES)
A state computer system in which data is entered to
						  update assistance eligibility information and recipient files.
Arkansas Foundation for Medical Care, Inc.
						  (AFMC)
State professional review organization.
Attending Physician
See Performing Physician.
Automated Eligibility Verification Claims Submission
						  (AEVCS)
On-line system for providers to verify eligibility of
						  recipients and submit claims to fiscal agent.
Base Charge
A set amount allowed for a participating provider
						  according to specialty.
Beneficiary
Person who meets the Medicaid eligibility requirements,
						  receives an ID card and is eligible for Medicaid services, (formerly
						  recipient)
Benefits
Services available under the Arkansas Medicaid
						  Program.
Billed Amount
The amount billed to Medicaid for a rendered
						  service.
Buy-In
A process whereby the state enters into an agreement
						  with the Bureau of Health Insurance, Social Security Administration, to obtain
						  Medicare Part B (and part A when needed) for Medicaid beneficiaries who are
						  also eligible for Medicare. The state pays the monthly Medicare premium(s) on
						  behalf of the beneficiary.
Care Plan
See Plan of Care (POC)
Casehead
An adult responsible for an AFDC or Medicaid
						  child.
Categorically Needy
All individuals receiving financial assistance under
						  the state's approved plan under Title 1, IV-A, X, XIV and XVI of the Social
						  Security Act or in need under the state's standards for financial eligibility
						  in such a plan.
Centers for Medicare and Medicaid Services
Federal agency that administers federal Medicaid
						  funding.
Child Health Services
Arkansas Medicaid's Early and Periodic Screening,
						  Diagnosis and Treatment (EPSDT) Program.
Children's Services
A Title V Children with Special Health Care Needs
						  Program administered by the Arkansas Division of Developmental Disabilities
						  Services to provide medical care and service coordination to chronically and
						  disabled children.
Claim
A request for payment for services
						  rendered.
Claim Detail
See Line Item.
Clinic
(1) A facility for diagnosis and treatment of
						  outpatients. (2) A group practice in which several physicians work
						  together.
Closed-end Provider Agreement
An agreement for a specific period of time not to
						  exceed 12 months which must be renewed in order for the provider to continue to
						  participate in the Title XIX Program.
Coinsurance
The portion of allowed charges the patient is
						  responsible for under Medicare. This may be covered by other insurance such as
						  Medi-Pak or Medicaid (if entitled). This also refers to the portion of a
						  Medicaid covered inpatient hospital stay for which the beneficiary is
						  responsible.
Contract
Written agreement between a provider of medical
						  services and the Arkansas Division of Medical Services. A contract must be
						  signed by each provider of services participating in the Medicaid
						  Program.
Co-pay
The portion of the maximum allowable (either that of
						  Medicaid or a third-party payer) that the insured or beneficiary must
						  pay.
Cosmetic Surgery
Any surgical procedure directed at improving appearance
						  but not medically necessary.
Covered Service
Service which is within the scope of the Arkansas
						  Medicaid Program.
Current Procedural Terminology
A listing published annually by AMA consisting of
						  current medical terms and the corresponding procedure codes used for reporting
						  medical services and procedures performed by physicians.
Credit Claim
A claim transaction which has a negative effect on a
						  previously processed claim.
Crossover Claim
A claim for which both Titles XVIII (Medicare) and XIX
						  (Medicaid) are liable for reimbursement of services provided to a beneficiary
						  entitled to benefits under both programs.
Date of Service
Date or dates on which a beneficiary receives a covered
						  service. Documentation of services and units received must be in the
						  beneficiary's record for each date of service.
Deductible
The amount the Medicare beneficiary must pay toward
						  covered benefits before Medicare or insurance payment can be made for
						  additional benefits. Medicare Part A and Part B deductibles are paid by
						  Medicaid within the program limits.
Debit Claim
A claim transaction which has a positive effect on a
						  previously processed claim.
Denial
A claim for which payment is disallowed.
Department of Health and Human Services
						  (HHS)
Federal health and human services agency.
Department of Human Services (DHS)
State human services agency.
Dependent
A spouse or child of the individual who is entitled to
						  benefits under the Medicaid Program.
Diagnosis
The identity of a condition, cause or
						  disease.
Diagnostic Admission
Admission to a hospital primarily for the purpose of
						  diagnosis.
Disallow
To subtract a portion of a billed charge that exceeds
						  the Medicaid maximum or to deny an entire charge because Medicaid pays Medicare
						  Part A and B deductibles subject to program limitations for eligible
						  beneficiaries.
Discounts
A discount is defined as the lowest available price
						  charged by a provider to a client or third party payer, including any discount,
						  for a specific service during a specific period by an individual provider. If a
						  Medicaid provider offers a professional or volume discount to any customer,
						  claims submitted to Medicaid must reflect the same discount.
Example: If a laboratory provider charges a private
						  physician or clinic a discounted rate for services, the charge submitted to
						  Medicaid for the same service must not exceed the discounted price charged to
						  the physician or clinic. Medicaid must be given the benefit of discounts and
						  price concessions the lab gives any one of its customers.
Duplicate Claim
A claim that has been submitted or paid previously or a
						  claim that is identical to a claim in process.
Durable Medical Equipment
Equipment that (1) can withstand repeated use and (2)
						  is used to serve a medical purpose. Examples include a wheelchair or hospital
						  bed.
Early and Periodic Screening, Diagnosis and Treatment
						  (EPSDT)
A federally mandated Medicaid program for eligible
						  individuals under the age of 21. See Child Health Services.
Electronic Data Systems Corporation (EDS)
Current fiscal agent for the state Medicaid
						  program.
Eligible
(1) To be qualified for Medicaid benefits. (2) One who
						  is qualified for benefits.
Eligibility File
A file containing individual records for all persons
						  who are eligible or have been eligible for Medicaid.
Emergency Services
Inpatient or outpatient hospital services that a
						  prudent layperson with an average knowledge of health and medicine would
						  reasonably believe are necessary to prevent death or serious impairment of
						  health and which, because of the danger to life or health, require use of the
						  most accessible hospital available and equipped to furnish those
						  services.
Source: 42 U.S. Code of Federal Regulations (42 CFR)
						  and §424.101.
Error Code
A numeric code indicating the type of error found in
						  processing a claim. Also known as an "Explanation of Benefits (EOB) code" or a
						  "HIPAA Explanation of Benefits (HEOB) code."
Estimated Acquisition Cost
The estimated amount a pharmacy actually pays to obtain
						  a drug.
Experimental Surgery
Any surgical procedure considered experimental in
						  nature.
Explanation of Medicaid Benefits (EOMB)
A statement mailed once per month to selected
						  beneficiaries to allow them to confirm the Medicaid service which they
						  received.
Family Planning Services
Any medically approved diagnosis, treatment,
						  counseling, drugs, supplies or devices prescribed or furnished by a physician,
						  nurse practitioner, certified nurse-midwife, pharmacy, hospital, family
						  planning clinic, rural health clinic (RHC), Federally Qualified Health Center
						  (FQHC) or the Department of Health to individuals of child-bearing age for
						  purposes of enabling such individuals freedom to determine the number and
						  spacing of their children.
Field Audit
An activity performed whereby a provider's facilities,
						  procedures, records and books are audited for compliance with Medicaid
						  regulations and standards. A field audit may be conducted on a routine basis,
						  or on a special basis announced or unannounced.
Fiscal Agent
An organization authorized by the State of Arkansas to
						  process Medicaid claims.
Fiscal Agent Intermediary
A private business firm which has entered into a
						  contract with the Arkansas Department of Human Services to process Medicaid
						  claims.
Fiscal Year
The twelve-month period between settlements of
						  financial accounts.
Generic Upper Limit (GUL)
The maximum drug cost that may be used to compute
						  reimbursement for specified multiple-source drugs unless the provisions for a
						  Generic Upper Limit override have been met. The Generic Upper Limit may be
						  established or revised by the Centers for Medicare and Medicaid Services (CMS)
						  or by the State Medicaid Agency.
Group
Two or more persons. If a service is a "group" therapy
						  or other group service, there must be two or more persons present and receiving
						  the service.
Group Practice
A medical practice in which several practitioners
						  render and bill for services under a single pay-to provider identification
						  number.
Healthcare Common Procedure Coding System
						  (HCPCS)
Federally defined procedure codes.
Health Insurance Claim Number
Number assigned to Medicare beneficiaries and
						  individuals eligible for SSI.
Hospital
An institution that meets the following
						  qualifications:
* Provides diagnostic and rehabilitation services to
						  inpatients.
* Maintains clinical records on all
						  patients.
* Has by-laws with respect to its staff of
						  physicians.
* Requires each patient to be under the care of a
						  physician, dentist or certified nurse-midwife.
* Provides 24-hour nursing service.
* Has a hospital utilization review plan in
						  effect.
* Is licensed by the State.
* Meets other health and safety requirements set by the
						  Secretary of Health and Human Services.
Hospital-Based Physician
A physician who is a hospital employee and is paid for
						  services by the hospital.
ID Card
An identification card issued to Medicaid beneficiaries
						  and ARKids First-B participants containing encoded data that permits a provider
						  to access the card-holder's eligibility information.
Individual
A single person as distinguished from a group. If a
						  service is an "individual" therapy or service, there may be only one person
						  present who is receiving the service.
Inpatient
A patient admitted to a hospital or skilled nursing
						  facility who occupies a bed and receives inpatient services.
In-Process Claim (Pending Claim)
A claim that suspends during system processing for
						  suspected error conditions such as: all processing requirements appear not to
						  be met. These conditions must be reviewed by EDS or DMS and resolved before
						  processing of the claim can be completed. (See suspended claim.)
Inquiry
A request for information.
Institutional Care
Care in an authorized private, non-profit, public or
						  state institution or facility. Such facilities include schools for the deaf,
						  and/or blind and institutions for the handicapped.
Instrumental Activities of Daily Living
						  (IADL)
Tasks which are ordinarily performed on a daily or
						  weekly basis and include meal preparation, housework, laundry, shopping, taking
						  medications and travel/transportation.
Intensive Care
Isolated and constant observation care to patients
						  critically ill or injured.
Interim Billing
A claim for less than the full length of an inpatient
						  hospital stay. Also, a claim that is billed for services provided to a
						  particular date even though services continue beyond that date. It may or may
						  not be the final bill for a particular beneficiary's services.
Internal Control Number (ICN)
The unique 13 digit claim number that appears on a
						  Remittance Advice.
International Classification of Diseases, Ninth
						  Edition, Clinical Modification (ICD-9CM)
A diagnosis coding system used by medical providers to
						  identify a patient's diagnosis and/or diagnoses on medical records and
						  claims.
Investigational Product
Any product that is considered investigational or
						  experimental and that is not approved by the Food and Drug Administration. The
						  Arkansas Medicaid Program does not cover investigational products.
Julian Date
Chronological date of the year, 001 through 365 or 366,
						  preceded on a claims number (ICN) by a two (2) digit year designation. Claim
						  number example: 03231 (August 19, 2003).
Length Of Stay
Period of time a patient is in the hospital. Also, the
						  number of days covered by Medicaid within a single inpatient stay.
Line Item
A service provided to a beneficiary. A claim may be
						  made up of one or more line items for the same beneficiary. Also called a claim
						  detail.
Long Term Care (LTC)
An office within the Arkansas Division of Medical
						  Services responsible for nursing facilities.
Long Term Care Facility
A nursing facility.
Maximum Allowable Cost (MAC)
The maximum drug cost which may be reimbursed for
						  specified multi-source drugs. This term is interchangeable with generic upper
						  limit.
Medicaid Provider Number
A unique identifying number assigned to each provider
						  of services in the Arkansas Medicaid Program, required for identification
						  purposes.
Medicaid Management Information System
						  (MMIS)
The automated system utilized to process Medicaid
						  claims.
Medical Assistance Section
A section within the Arkansas Division of Medical
						  Services responsible for administering the Arkansas Medical Assistance
						  Program.
Medically Needy
Individuals whose income and resources exceed the
						  levels for assistance established under a state or federal plan for
						  categorically needy, but are insufficient to meet costs of health and medical
						  services.
Medical Necessity
All Medicaid benefits are based upon medical necessity.
						  A service is "medically necessary" if it is reasonably calculated to prevent,
						  diagnose, correct, cure, alleviate or prevent the worsening of conditions that
						  endanger life, cause suffering or pain, result in illness or injury, threaten
						  to cause or aggravate a handicap or cause physical deformity or malfunction and
						  if there is no other equally effective (although more conservative or less
						  costly) course of treatment available or suitable for the beneficiary
						  requesting the service. For this purpose, a "course of treatment" may include
						  mere observation or (where appropriate) no treatment at all. The determination
						  of medical necessity may be made by the Medical Director for the Medicaid
						  Program or by the Medicaid Program Quality Improvement Organization (QIO).
						  Coverage may be denied if a service is not medically necessary accordance with
						  the preceding criteria or is generally regarded by the medical profession as
						  experimental inappropriate or ineffective using unless objective clinical
						  evidence demonstrates circumstances making the service necessary.
Mis-Utilization
Any usage of the Medicaid Program by any of its
						  providers and/or beneficiaries which is not in conformance with both State and
						  Federal regulations and laws (includes fraud, abuse and defects in level and
						  quality of care).
National Drug Code
The unique eleven digit number assigned to drugs which
						  identifies the manufacturer, drug, strength and package size of each
						  drug.
National Provider Identifier (NPI)
A standardized unique health identifier for health care
						  providers for use in the health care system in connection with standard
						  transactions for all covered entities. Established by the Centers for Medicare
						  & Medicaid Services, HHS, in compliance with HIPAA Administrative
						  Simplification -45 CFR Part 162.
Non-Covered Services
Services not medically necessary, services provided for
						  the personal convenience of the patient or services not covered under the
						  Medicaid Program.
Nonpatient
An individual who receives services, such as laboratory
						  tests, performed by a hospital, but who is not a patient of the
						  hospital.
Nurse Practitioner
A professional nurse with credentials that meet the
						  requirements for licensure as a nurse practitioner in the State of
						  Arkansas.
Outpatient
A patient receiving medical services, but not admitted
						  as an inpatient to a hospital.
Over-Utilization
Any over usage of the Medicaid Program by any of its
						  providers and/or beneficiaries not in conformance with professional judgment
						  and both State and Federal regulations and laws (includes fraud and
						  abuse).
Participant
A provider of services who: (1) provides the service,
						  (2) submits the claim and (3) accepts Medicaid's reimbursement for the services
						  provided as payment in full.
Patient
A person under the treatment or care of a physician or
						  surgeon, or in a hospital.
Payment
Reimbursement to the provider of services for rendering
						  a Medicaid covered benefit.
Pay-to Provider
A person, organization or institution authorized to
						  receive payment for services provided to Medicaid beneficiaries by a person or
						  persons who are a part of the entity.
Pay-to Provider Number
A unique identifying number assigned to each pay-to
						  provider of services (Clinic/Group/Facility) in the Arkansas Medicaid Program
						  or the pay-to provider group's assigned National Provider Identifier (NPI).
						  Medicaid reports provider payments to the Internal Revenue Service under the
						  Employer Identification Number "Tax ID" linked in the Medicaid Provider File to
						  the pay-to provider identification number.
Per Diem
A daily rate paid to institutional
						  providers.
Performing Physician
The physician providing, supervising, or both, a
						  medical service and claiming primary responsibility for ensuring that services
						  are delivered as billed.
Person
Any natural person, company, firm, association,
						  corporation or other legal entity.
Place of Service (POS)
An alpha or numeric code denoting the location of the
						  patient receiving services.
Plan of Care
A document utilized by a provider to plan, direct or
						  deliver care to a patient to meet specific measurable goals. Also called care
						  plan, service plan or treatment plan.
Postpayment Utilization Review
The review of services, documentation and practice
						  after payment.
Practitioner
An individual who practices in a health or medical
						  service profession.
Prepayment Utilization Review
The review of services, documentation and practice
						  patterns before payment.
Prescription
A health care professional's legal order for a drug
						  which, in accordance with federal and/or state statutes, may not be obtained
						  otherwise. Also an order for a particular Medicaid covered service.
Prescription Drug (RX)
A drug which, in accordance with federal and/or state
						  statutes, may not be obtained without a valid prescription.
Primary Care Physician (PCP)
A physician responsible for the management of a
						  beneficiary's total medical care. Selected by the beneficiary to provide
						  primary care services and health education. The PCP will monitor on an ongoing
						  basis the beneficiary's condition, health care needs and service delivery be
						  responsible for locating, coordinating and monitoring medical and
						  rehabilitation services on behalf of the beneficiary and refer the beneficiary
						  for most specialty services, hospital care and other services.
Prior Approval
The approval for coverage and reimbursement of specific
						  services prior to furnishing services for a specified beneficiary of Medicaid.
						  The request for prior approval must be made to the Medical Director of the
						  Division of Medical Services for review of required documentation and
						  justification for provision of service.
Prior Authorization (PA)
The approval by the Arkansas Division of Medical
						  Services or a designee of the Division of Medical Services, for specified
						  services for a specified beneficiary to a specified provider before the
						  requested services may be performed and before payment will be made.
Prior authorization does not guarantee reimbursement.
Procedure Code
A five-digit numeric or alpha numeric code to identify
						  medical services and procedures on medical claims.
Professional Component
A physician's interpretation or supervision and
						  interpretation of laboratory, X-ray or machine test procedures.
Profile
A detailed view of an individual provider's charges to
						  Medicaid for health care services or a detailed view of a beneficiary's usage
						  of health care services.
Provider
A person, organization or institution enrolled to
						  provide and be reimbursed for health or medical care services authorized under
						  the State Title XIX Medicaid Program.
Provider
Identification
Number
A unique identifying number assigned to each provider
						  of services in the Arkansas Medicaid Program or the provider's assigned
						  National Provider Identifier (NPI), when applicable, that are required for
						  identification purposes.
Provider Relations
The activity within the Medicaid Program which handles
						  all relationships with Medicaid providers.
Quality Assurance
Determination of quality and appropriateness of
						  services rendered.
Quality Improvement Organization
A Quality Improvement Organization (QIO) is a federally
						  mandated review organization required of each state's Title XIX (Medicaid)
						  program. Arkansas Medicaid has contracted with the Arkansas Foundation for
						  Medical Care, Inc. (AFMC) to be its QIO. The QIO monitors hospital and
						  physician services billed to the state's Medicare intermediary and the Medicaid
						  program to assure high quality, medical necessity and appropriate care for each
						  patient's needs.
Railroad Claim Number
The number issued by the Railroad Retirement Board to
						  control payments of annuities and pensions under the Railroad Retirement Act.
						  The claim number begins with a one to three letter alphabetic prefix denoting
						  the type of payment, followed by six or nine numeric digits.
Recipient
Person who meets the Medicaid eligibility requirements,
						  receives an ID card and is eligible for Medicaid services, (renamed
						  beneficiary)
Referral
An authorization from a Medicaid enrolled provider to a
						  second Medicaid enrolled provider. The receiving provider is expected to
						  exercise independent professional judgment and discretion, to the extent
						  permitted by laws and rules governing the practice of the receiving
						  practitioner, and develops and delivers medically necessary services covered by
						  the Medicaid program. The provider making the referral may be a physician or
						  another qualified practitioner acting within the scope of practice permitted by
						  laws or rules. Medicaid requires documentation of the referral in the
						  beneficiary's medical record, regardless of the means the referring provider
						  makes the referral. Medicaid requires the receiving provider to document the
						  referral also, and to correspond with the referring provider regarding the case
						  when appropriate and when the referring provider so requests.
Reimbursement
The amount of money remitted to a provider.
Rejected Claim
A claim for which payment is refused.
Relative Value
A weighting scale used to relate the worth of one
						  surgical procedure to any other. This evaluation, expressed in units, is based
						  upon the skill, time and the experience of the physician in its
						  performance.
Remittance
A remittance advice.
Remittance Advice (RA)
A notice sent to providers advising the status of
						  claims received, including paid, denied, in-process and adjusted claims. It
						  includes year-to-date payment summaries and other financial
						  information.
Reported Charge
The total amount submitted in a claim detail by a
						  provider of services for reimbursement.
Retroactive Medicaid Eligibility
Medicaid eligibility which may begin up to three (3)
						  months prior to the date of application provided all eligibility factors are
						  met in those months.
Returned Claim
A claim which is returned by the Medicaid Program to
						  the provider for correction or change to allow it to be processed
						  properly.
Sanction
Any corrective action taken against a
						  provider.
Screening
The use of quick, simple medical procedures carried out
						  among large groups of people to sort out apparently well persons from those who
						  may have a disease or abnormality and to identify those in need of more
						  definitive examination or treatment.
Signature
Signature or initials means the person's original
						  signature, or the person's signature or initials may be recorded by an
						  electronic or digital method executed or adopted by the person with the intent
						  to be bound by or to authenticate a record. An electronic signature must comply
						  with Arkansas Code Annotated §
													25-31-101
						  -105, including verification through an electronic signature verification
						  company and data links invalidating the electronic signature if the data is
						  changed.
Single State Agency
The state agency authorized to administer or supervise
						  the administration of the Medicaid Program on a statewide basis.
Skilled Nursing Facility (SNF)
A nursing home, or a distinct part of a facility,
						  licensed by the Office of Long Term Care as meeting the Skilled Nursing
						  Facility Federal/State licensure and certification regulations. A health
						  facility which provides skilled nursing care and supportive care on a 24-hour
						  basis to residents whose primary need is for availability of skilled nursing
						  care on an extended basis.
Social Security Administration (SSA)
A federal agency which makes disability and blindness
						  determinations for the Secretary of the HHS.
Social Security Claim Number
The account number used by SSA to identify the
						  individual on whose earnings SSA benefits are being paid. It is the Social
						  Security Account Number followed by a suffix, sometimes as many as three
						  characters, designating the type of beneficiary (e.g., wife, widow, child,
						  etc.).
Source of Care
A hospital, clinic, physician or other facility which
						  provides services to a beneficiary under the Medicaid Program.
Specialty
The specialized area of practice of a physician or
						  dentist.
Spend Down (SD)
The amount of money a recipient must pay toward medical
						  expenses when income exceeds the Medicaid financial guidelines. A component of
						  the medically needy program allows an individual or family whose income is over
						  the medically needy income limit (MNIL) to use medical bills to spend excess
						  income down to the MNIL. The individual(s) will have a spend down liability.
						  The spend down column of the remittance advice indicates the amount which the
						  provider may bill the recipient. The spend down liability occurs only on the
						  first day of Medicaid eligibility.
Status Report
A remittance advice.
Supplemental Security Income (SSI)
A program administered by the Social Security
						  Administration. This program replaced previous state administered programs for
						  aged, blind or disabled beneficiaries (except in Guam, Puerto Rico and the
						  Virgin Islands). This term may also refer to the Bureau of Supplemental
						  Security Income within SSA which administers the program.
Suspended Claim
An "In-Process Claim" which must be reviewed and
						  resolved.
Suspension from Participation
An exclusion from participation for a specified period
						  of time.
Suspension of Payments
The withholding of all payments due to a provider until
						  the resolution of a matter in dispute between the provider and the state
						  agency.
Termination from Participation
A permanent exclusion from participation in the Title
						  XIX Program.
Third Party Liability (TPL)
A condition whereby a person or an organization, other
						  than the beneficiary or the state agency, is responsible for all or some
						  portion of the costs for health or medical services incurred by the Medicaid
						  beneficiary (e.g., a health insurance company, a casualty insurance company or
						  another person in the case of an accident, etc.).
Utilization Review (UR)
The section of the Arkansas Division of Medical
						  Services which performs the monitoring and controlling of the quantity and
						  quality of health care services delivered under the Medicaid
						  Program.
Void
A transaction which deletes.
Voice Response System (VRS)
Voice activated system to request prior authorization
						  for prescription drugs and for PCP assignment and change.
Ward
An accommodation of five or more beds.
Withholding of Payments
A reduction or adjustment of the amounts paid to a
						  provider on pending and subsequently due payments.
Worker's Compensation
A type of Third-Party Liability for medical services
						  rendered as the result of an on-the-job accident or injury to a beneficiary for
						  which the employer's insurance company may be obligated under the Worker's
						  Compensation Act.