Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-016 - Section V (7-1-09) and Epsdt Update # 120

Current through Register Vol. 49, No. 6, June, 2024
Section V
Provider Manual Update
			 Transmittal
Provider Inter-office Use
Patient Charting and Electronic Billing Documention Version
				Only
This Copy Not To Be Used For Paper Claim Billing
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Instructions for Completion of the EPSDT Claim Form -
				DMS-694
EDS offers providers several options for electronic billing.
				Therefore, claims submitted on paper are paid once a month. The only claims
				exempt from this process are those which require attachments or manual
				pricing.
To bill for a Child Health Services (EPSDT) screening service,
				use the claim form DMS-694. The numbered items correspond to numbered fields on
				the claim form. The DMS-694 is used as a combined referral, screening results
				document and a billing form. Each screening should be billed separately,
				providing the appropriate information for each of the screening components. The
				following numbered items correspond to numbered fields on the claim
				form.
Medical services such as immunizations and laboratory
				procedures may also be billed on the DMS-694 when provided in conjunction with
				a Child Health Services (EPSDT) screening, as well as other treatment services
				provided.
The following instructions must be read and carefully adhered
				to, so that EDS can efficiently process claims. Accuracy, completeness and
				clarity are important. Claims cannot be processed if applicable information is
				not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be forwarded to the EDS Claims
				Department.
View or print the EDS Claims Department contact
				information.
NOTE: A provider rendering services without verifying
				eligibility for each date of service does so at the risk of not being
				reimbursed for the services.
Field Name and Number
Instructions for Completion
1. Patient's Last Name
Enter the patient's last name.
2. Patient's First Name
Enter patient's first name.
3. Patient's Middle Initial
Enter patient's middle initial.
4. Patient's Sex
Check "M" for male or "F" for female.
5. Patient's Medicaid ID No.
Enter the entire 10-digit patient Medicaid
						  identification number.
6. Casehead's Name
Enter the casehead name for TEA children only.
						  Patient's name has been requested in Blocks 1, 2 and 3.
7. County of Residence
Enter the patient's county of residence.
8. Date of Birth
Enter the patient's date of birth in month and year
						  format as it appears on the Medicaid identification card.
9. Street Address
Enter the patient's street address.
10. City
Enter the patient's city of residence.
11. If a Patient is a Referral Enter Name of Referring
						  Physician
Provider Number
If the patient is a referral, enter the name of the
						  referring physician and his or her provider number.
12. Medical Record Number
This is an optional entry that the provider may use for
						  accounting purposes. Enter the patient's account number, if applicable. Up to
						  16 numeric or alpha characters will be accepted. This number will appear on the
						  Remittance Advice (RA) and is a method of identifying payment of the
						  claim.
13. Provider Phone Number
Pay To: Provider Name and Address
Pay To: Provider Number
Enter the provider's complete name, address, and
						  provider number. If a clinic billing is involved, use the clinic provider
						  number. Telephone number is requested but not required.
14. Other Health Insurance
Coverage (Enter Name of Plan and Policy
						  Number)
If applicable, enter the name of the insurance plan and
						  the policy number of any health insurance coverage carried by the patient other
						  than Medicaid. The patient's Medicaid identification card should indicate "Yes"
						  if other coverage is carried by the beneficiary.
15. Was Condition Related to:
A. Patient's Employment
B. An Accident
Check "Yes" if the patient's condition was employment
						  related. If the condition was not employment related, check "No."
Check "Yes" if the patient's condition was related to
						  an accident. Check "No" if the condition was not accident related.
16. Primary Diagnosis or Nature of Injury
Diagnosis Code
Enter the description of the primary reason for
						  treatment of the patient.
Enter the ICD-9-CM Code that identifies the primary
						  diagnosis.
18. Type of Screen Periodic Interperiodic
Not required for Medicaid. Completed by Human Services,
						  if applicable.
SECTION II
19. Social Worker Identification
Not required for Medicaid. Completed by Human Services,
						  if applicable. This section is used by school districts and education service
						  cooperatives enrolled in the EPSDT program to include an LEA code.
SECTION III
20. Examination Report
To be completed by screening provider at time of
						  screen.
A. Basic Screening
Item A, Numbers 1 through 6
Item A, Number 7
Check "Normal" or "Abnormal" for each component. Check
						  "Counseled," "Treated" or "Referred" as applicable.
Give results of the lab tests performed at the time of
						  screen.
Item B
Immunization status appropriate forage and health
						  history. If immunization cannot be performed, note the reason along with the
						  return appointment in "Comments" section.
ItemC
Enter any other services rendered.
21. Comments
Briefly explain any problems identified and
						  describe
treatment or referral. If referred, indicate the name
						  of the provider to whom the referral was made.
22. A. Date of Service
Enter the "from" and "to" dates of service for each
						  service provided in MM/DD/YY format. A single date of service need not be
						  entered twice on the same line.
B. Place of Service
Enter the appropriate place of service code. See
						  Section 242.200 for codes.
C. Fully Describe Procedures, Medical Services or
						  Supplies Furnished For Each Date Given
(Explain Unusual Services or
						  Circumstances)
Procedure Code (Identify)
Enter the appropriate HCPCS, CPT and state assigned
						  procedure code and describe any services or circumstances, e.g., what age
						  periodicity screen has been provided and describe procedures performed
						  (including screen, lab test, immunizations, etc.).
D. Diagnosis Code
Enter the ICD-9-CM code, which corresponds with the
						  procedures performed.
E. Charges
Enter the charges for the rendered services. These
						  charges should be the provider's current usual and customary fee to private
						  clients.
F. Days or Units
Enter days or units of service rendered.
G. TOS
Enter the appropriate type of service code. See Section
						  242.200 for codes.
H. Performing Provider Number
If the billing provider noted in Block 13 is a clinic
						  or group, enter the attending provider's provider number.
23. Total Charges
Enter the total of Column 22E. This block should
						  contain a sum of charges for all services indicated on the claim
						  form.
24. Covered by Insurance
Enter the total amount of funds received from other
						  sources. The source of payment should be indicated in Block 14. If payment was
						  received from the patient, indicate in Block 14, but DO NOT include the amount
						  in Block 24.
25. Balance Due
Enter the net charge. This amount is obtained by
						  subtracting the amount received from other sources from the total
						  charge.
26. Provider's Signature
The provider or designated authorized individual must
						  sign the claim certifying that the services were personally rendered by the
						  provider or under the provider's direction. "Provider's signature" is defined
						  as the provider's actual signature, a rubber stamp of the provider's signature,
						  a typewritten signature or the signature of an individual authorized by the
						  provider rendering the service. The name of a clinic or group is not
						  acceptable.
27. Billing Date
Enter date signed.
Provider Manual Update Transmittal #120
Section II
Child Health Services/Early and Periodic Screening, Diagnosis,
				and Treatment
213.000
Provider's Role in the Child Health Services Early and Periodic
Screening, Diagnosis and Treatment (EPSDT)
				Program
The following steps are necessary in order to complete a Child
				Health Services (EPSDT) screen:
A. When
			 a child arrives for a Child Health Services (EPSDT) screening appointment, ask
			 to see the current Medical Assistance Identification Card (Medicaid Card).
			 Verify Medicaid eligibility electronically before services are
			 rendered.
B. Screen the child
			 according to the procedures outlined in Sections
			 215.000,
			 216.000,
			 217.000,
			 218.000 or
			 219.000 of this manual. All
			 elements of the screen must be completed and documented before the screen is
			 considered complete. This includes the evaluation of lab results and the
			 provision of or referral for immunizations.
A full medical screen must, at a minimum, include: a
				comprehensive health and developmental history (including assessment of both
				physical and mental health development); a comprehensive unclothed physical
				exam; appropriate immunizations according to age and health history; laboratory
				tests (including appropriate blood lead level assessment); and health education
				(including anticipatory guidance).
All parts of the screening package must be furnished to the
				Child Health Services (EPSDT) participant in order for the screening to qualify
				as a full medical Child Health Services (EPSDT) screening service.
I mmunizations that are
				appropriate based on age and health history, but which are contraindicated at
				the time of the screening, may be rescheduled at an appropriate time or
				referred to another provider.
C. Record the screening findings on the
			 DMS-694 or on the American Dental Association (ADA) form for dental screens.
View or print a DMS-694 sample form
.
The
			 DMS-694 screening form or the ADA (dental) form must be completed on each
			 individual screened for Child Health Services (EPSDT) in order to comply with
			 federal reporting and Child Health Services (EPSDT) requirements. The DMS-694
			 will record whether each of the recommended screening procedures required by
			 the periodicity schedule is performed, whether referral is necessary for health
			 problems discovered during the screen and the date of the required referral
			 appointment if one is made. Providers must be careful to complete Section
			 I of Form DMS-694 or the ADA
			 (dental) form using the beneficiary's name and Medicaid ID number exactly as
			 shown on the Medicaid card.
D. Talk
			 to the parent about the screening results, explaining in detail the findings
			 and any recommendations for diagnosis and treatment.
E. If the child needs further diagnosis
			 and/or treatment, complete the referral section of the DMS-694 by checking the
			 appropriate referral box.
F. Upon
			 completion of the EPSDT screening, mail the original DMS-694 form to the EDS
			 Claims Department, or file electronically using the 694 format. Retain copy 3
			 for the provider files.
View or print the EDS Claims
			 Department contact information.
G. If the screener provides treatment as a
			 result of the screening, the charges for the treatment procedures may be
			 submitted on the DMS-694 form. Do not submit charges for office visit services
			 on the DMS-694.
H. Treatment
			 services offered as a result of a Child Health Services (EPSDT) screen are not
			 limited to the Medicaid services specified under "Scope of Program" in Section
			 I of this manual. If a condition is diagnosed through a Child Health Services
			 (EPSDT) screen that requires treatment services not normally covered under the
			 Arkansas Medicaid Program, those treatment services will also be considered for
			 reimbursement.
I. When a provider
			 performs a Child Health Services (EPSDT) screen and/or refers the patient to
			 another provider for services not covered by Arkansas Medicaid, the referring
			 provider must give the beneficiary a prescription for the services. The
			 prescription must indicate the services being prescribed and state the services
			 are being prescribed due to a Child Health Services (EPSDT) screen.
The prescription for services must be dated by the provider
				referring the patient. The prescription for the non-covered service is
				acceptable if services were prescribed and the prescription is dated within the
				applicable periodicity schedule, not to exceed a maximum of 12 months.
J. The provider may verify whether
			 a periodic screen is due under the appropriate periodicity schedule by means of
			 an electronic eligibility verification transaction. The system's response
			 display will reveal each type of screen, e.g., medical, visual, dental and
			 hearing and the date of the last screen of each type indicated by the provider
			 initiating the eligibility verification transaction.
K. School districts and education service
			 cooperatives enrolled in the EPSDT program and providing EPSDT screenings must
			 include a Local Education Agency (LEA) code in section 19 of the DMS-694. The
			 LEA code is used to determine federal matching funds to the Child Health
			 Services (EPSDT) program.
The Department of Human Services (DHS) county offices will
				continue to refer Medicaid beneficiaries to providers for Child Health Services
				(EPSDT) screens. However, a provider may initiate the health screen for an
				eligible beneficiary at the appropriate time without a referral from the DHS
				county office.
An eligible child must be referred by the PCP, if the child is
				to be screened by a provider who is not the PCP.