Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.14-003 - 2014 Manual Updates: APDWVR 2-13, AUTISM 1-13, ASCI 1-13, CHIRO 1-13, CHMS 2-13, etc

Current through Register Vol. 49, No. 6, June, 2024
Section II
Alternatives for Adults with Physical Disabilities Waiver
242.110
Completion of CMS-1500 Claim
			 Form
Field Name and Number
Instructions for Completion
1. (type of coverage)
Not required.
1a. INSURED?S I.D. NUMBER (For Program in Item
						  1)
Beneficiarys or participant?s 10-digit Medicaid or
						  ARKids First-A or ARKids First-B identification number.
2. PATIENT?S NAME (Last Name, First Name, Middle
						  Initial)
Beneficiary?s or participant?s last name and first
						  name.
3. PATIENT?S BIRTH DATE
Beneficiary?s or participant?s date of birth as given
						  on the individual?s Medicaid or ARKids First-A or ARKids First-B identification
						  card. Format: MM/DD/YY.
SEX
Check M for male or F for female.
4. INSURED?S NAME (Last Name, First Name, Middle
						  Initial)
Required if insurance affects this claim. Insured?s
						  last name, first name, and middle initial.
5. PATIENT?S ADDRESS (No., Street)
Optional. Beneficiary?s or participant?s complete
						  mailing address (street address or post office box).
CITY
Name of the city in which the beneficiary or
						  participant resides.
STATE
Two-letter postal code for the state in which the
						  beneficiary or participant resides.
ZIP
CODE
Five-digit zip code; nine digits for post office
						  box.
TELEPHONE (Include Area Code)
The beneficiary?s or participant?s telephone number or
						  the number of a reliable message/contact/ emergency telephone.
6. PATIENT RELATIONSHIP TO INSURED
If insurance affects this claim, check the box
						  indicating the patient?s relationship to the insured.
7. INSURED?S ADDRESS (No., Street)
Required if insured?s address is different from the
						  patient?s address.
CITY
STATE
ZIP CODE
TELEPHONE (Include Area Code)
8. RESERVED
Reserved for NUCC use.
9. OTHER INSURED?S NAME (Last name, First Name, Middle
						  Initial)
If patient has other insurance coverage as indicated in
						  Field 11d, the other insured?s last name, first name, and middle
						  initial.
a. OTHER INSURED?S POLICY OR GROUP NUMBER
Policy and/or group number of the insured
						  individual.
b. RESERVED
Reserved for NUCC use.
SEX
Not required.
c. RESERVED
Reserved for NUCC use.
d. INSURANCE PLAN NAME OR PROGRAM NAME
Name of the insurance company.
10. IS PATIENT?S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
Check YES or NO.
b. AUTO ACCIDENT?
Required when an auto accident is related to the
						  services. Check YES or NO.
PLACE (State)
If 10b is YES, the two-letter postal abbreviation for
						  the state in which the automobile accident took place.
c. OTHER ACCIDENT?
Required when an accident other than automobile is
						  related to the services. Check YES or NO.
10d. CLAIM CODES
The ?Claim Codes? identify additional information about
						  the beneficiary?s condition or the claim. When applicable, use the Claim Code
						  to report appropriate claim codes as designated by the NUCC. When required to
						  provide the subset of Condition Codes, enter the condition code in this field.
						  The subset of approved Condition Codes is found at
www.nucc.org
under Code Sets..
11. INSURED?S POLICY GROUP OR FECA NUMBER
Not required when Medicaid is the only payer.
a. INSURED?S DATE OF BIRTH
Not required.
SEX
Not required.
b. OTHER CLAIM ID NUMBER
Not required.
c. INSURANCE PLAN NAME OR PROGRAM NAME
Not required.
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
When private or other insurance may or will cover any
						  of the services, check YES and complete items 9, 9a and 9d. Only one box can be
						  marked.
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE
Enter ?Signature on File,? ?SOF? or legal
						  signature.
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE
Enter ?Signature on File,? ?SOF? or legal
						  signature.
14. DATE OF CURRENT:
ILLNESS (First symptom) OR INJURY (Accident) OR
						  PREGNANCY (LMP)
Required when services furnished are related to an
						  accident, whether the accident is recent or in the past. Date of the
						  accident.
Enter the qualifier to the right of the vertical dotted
						  line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last
						  Menstrual Period.
15. OTHER DATE
Enter another date related to the beneficiarys
						  condition or treatment. Enter the qualifier between the left-hand set of
						  vertical, dotted lines.
The ?Other Date? identifies additional date information
						  about the beneficiary?s condition or treatment. Use qualifiers:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-Ray 471 Prescription
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date) 444 First Visit
						  or Consultation
16. DATES PATIENT UNABLE TO WORK IN CURRENT
						  OCCUPATION
Not required.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
Primary Care Physician (PCP) referral is not required
						  for Alternatives for Adults with Physical Disabilities waiver services.
17a. (blank)
The 9-digit Arkansas Medicaid provider ID number of the
						  referring physician.
17b. NPI
Not required.
18. HOSPITALIZATION DATES RELATED TO CURRENT
						  SERVICES
Not applicable to Alternatives for Adults with Physical
						  Disabilities Waiver claims.
19. ADDITIONAL CLAIM INFORMATION
Identifies additional information about the
						  beneficiary?s condition or the claim. Enter the appropriate qualifiers
						  describing the identifier. See
www.nucc.org
for qualifiers.
20. OUTSIDE LAB?
Not required.
$ CHARGES
Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Enter the applicable ICD indicator to identify which
						  version of ICD codes is being reported.
Use ?9? for ICD-9-CM.
Use ?0? for ICD-10-CM.
Enter the indicator between the vertical, dotted lines
						  in the upper right-hand portion of the field.
Diagnosis code for the primary medical condition for
						  which services are being billed. Use the International Classification of
						  Diseases, Ninth Revision (ICD-9-
Revision (ICD-10-CM)diagnosis coding for dates of
						  service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM
						  diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter
						  of the line. Use the highest level of specificity.
22. RESUBMISSION CODE ORIGINAL REF. NO.
Reserved for future use.
Any data or other information listed in this field does
						  not/will not adjust, void or otherwise modify any previous payment or denial of
						  a claim. Claim payment adjustments, voids and refunds must follow previously
						  established processes in policy.
23. PRIOR AUTHORIZATION NUMBER
Not applicable to Alternatives for Adults with Physical
						  Disabilities Waiver claims.
24A. DATE(S) OF SERVICE
The ?from? and ?to? dates of service for each billed
						  service. Format: MM/DD/YY.
1. On a single claim detail (one charge on one line),
,
bill only for services provided within a single calendar
						  month.
2. Providers may bill on the same claim detail for two
						  or more sequential dates of service within the same calendar month when the
						  provider furnished equal amounts of the service on each day of the date
						  sequence.
B. PLACE OF SERVICE
Two-digit national standard place of service code. See
						  Section 241.200 for codes.
C. EMG
Check ?Yes? or leave blank if ?No.? EMG identifies if
						  the service was an emergency.
D. PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS
One CPT or HCPCS procedure code for each detail. See
						  Section 241.100.
MODIFIER
Modifier(s) if applicable.
E. DIAGNOSIS POINTER
Enter the diagnosis code reference letter (pointer) as
						  shown in Item Number 21 to relate to the date of service and the procedures
						  performed to the primary diagnosis. When multiple services are performed, the
						  primary reference letter for each service should be listed first; other
						  applicable services should follow. The reference letter(s) should be A-L or
						  multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from
						  Item Number 21 that relates to the reason the service(s) was performed.
F. $ CHARGES
The full charge for the service(s) totaled in the
						  detail. This charge must be the usual charge to any client, patient, or other
						  recipient of the provider?s services.
G. DAYS OR UNITS
The units (in whole numbers) of service(s) provided
						  during the period indicated in Field 24A of the detail.
H. EPSDT/Family Plan
Not applicable to Alternatives for Adults with Physical
						  Disabilities Waiver claims.
I. ID QUAL
Not required.
J. RENDERING PROVIDER ID #
The 9-digit Arkansas Medicaid provider ID number of the
						  individual who furnished the services billed for in the detail.
NPI
Not required.
25. FEDERAL TAX I.D. NUMBER
Not required. This information is carried in the
						  providers Medicaid file. If it changes, please contact Provider
						  Enrollment.
26. PATIENT?S ACCOUNT N O.
Optional entry that may be used for accounting
						  purposes; use up to 16 numeric or alphabetic characters. This number appears on
						  the Remittance Advice as ?MRN.?
27. ACCEPT ASSIGNMENT?
Not required. Assignment is automatically accepted by
						  the provider when billing Medicaid.
28. TOTAL CHARGE
Total of Column 24F?the sum all charges on the
						  claim.
29. AMOUNT PAID
Enter the total of payments previously received on this
						  claim. Do not include amounts previously paid by Medicaid. Do not include in
						  this total the automatically deducted Medicaid co-payments.
30. RESERVED
Reserved for NUCC use.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING
						  DEGREES OR CREDENTIALS
The provider or designated authorized individual must
						  sign and date 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, an automated 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.
32. SERVICE FACILITY LOCATION INFORMATION
If other than home or office, enter the name and
						  street, city, state, and zip code of the facility where services were
						  performed.
a. (blank)
Not required.
b. (blank)
Not required.
33. BILLING PROVIDER INFO & PH #
Billing provider?s name and complete address. Telephone
						  number is requested but not required.
a. (blank)
Not required.
b. (blank)
Enter the 9-digit Arkansas Medicaid provider ID number
						  of the billing provider.
242.310
Billing Instructions ? Paper
			 Only
Field #
Field name
Description
1.
(blank)
Enter the provider?s name, (physical address ? service
						  location) city, state, zip code, and telephone number.
2.
(blank)
The address that the provider submitting the bill
						  intends payment to be sent if different from FL 01. (Use this address for
						  provider?s return address for returned mail.)
3a. 3b.
PAT CNTL # MED REC #
The provider may use this optional field for accounting
						  purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric
						  characters are accepted.
Required. Enter up to 15 alphanumeric
						  characters.
4.
TYPE OF BILL
See the UB-04 manual. Four-digit code with a leading
						  zero that indicates the type of bill.
5.
FED TAX NO
The number assigned to the provider by the Federal
						  government for tax reporting purposes. Also known as tax identification number
						  (TIN) or employer identification number (EIN).
6.
STATEMENT COVERS PERIOD
Enter the same date in both sections of the field.
						  Format: MMDDYY.
7.
Not used
Reserved for assignment by the NUBC.
8a. 8b.
PATIENT NAME (blank)
Enter the patient?s last name and first name. Middle
						  initial is optional.
Not required.
9.
PATIENT ADDRESS
Enter the patient?s full mailing address.
						  Optional.
10.
BIRTH DATE
Enter the patient?s date of birth. Format:
						  MMDDYYYY.
11.
SEX
Enter M for male, F for female, or U for
						  unknown.
12.
ADMISSION DATE
Not required.
13.
ADMISSION HR
Not required.
14.
ADMISSION TYPE
Not required.
15.
ADMISSION SRC
Not required.
16.
DHR
Not applicable.
17.
STAT
Not applicable.
18.-28.
CONDITION CODES
Required when applicable. See the UB-04 Manual for
						  requirements and for the codes used to identify conditions or events relating
						  to this bill.
29.
ACDT STATE
Not required.
30.
(blank)
Unassigned data field.
31.-34.
OCCURRENCE CODES AND DATES
Required when applicable. See the UB-04 Manual.
35.-36.
OCCURRENCE SPAN CODES AND DATES
See the UB-04 Manual.
37.
Not used
Reserved for assignment by the NUBC.
38.
Responsible Party Name and Address
See the UB-04 Manual.
39.
VALUE CODES
Not applicable.
a.
CODE
Not applicable.
AMOUNT
Not applicable.
b.
CODE
Not applicable.
AMOUNT
Not applicable.
40.
VALUE CODES
Not applicable.
41.
VALUE CODES
Not applicable.
42.
REV CD
Enter a revenue code when applicable. See the UB-04
						  Manual and this provider manual.
43.
DESCRIPTION
See the UB-04 Manual. Required for paper claims
						  only.
44.
HCPCS/RATE/HIPPS CODE
Enter a surgery or diagnostic procedure code.
45.
SERV DATE
Each procedure code or revenue code requires a date of
						  service in this field.
Date format: MMDDYY.
46.
SERV UNITS
Enter the applicable number of units.
47.
TOTAL CHARGES
Enter the product of the charge per unit times the
						  number of units.
48.
NON-COVERED CHARGES
Not applicable.
49.
Not used
Reserved for assignment by the NUBC.
50.
PAYER NAME
Line A is required. See the UB-04 for additional
						  regulations.
51.
HEALTH PLAN ID
Report the HIPPA National Plan Identifier; otherwise
						  report the legacy/proprietary number..
52.
REL INFO
Required. See the UB-04 Manual.
53.
ASG BEN
Required. See ?Notes? at field 53 in the UB-04
						  Manual.
54.
PRIOR PAYMENTS
Enter the total of payments previously received on this
						  claim. Do not include amounts previously paid by Medicaid. * Do
not
include in this total the automatically deducted Medicaid or ARKids
						  First-B co-payments.
55.
EST AMOUNT DUE
Situational. See the UB-04 Manual.
56.
NPI
Not required.
57.
OTHER PRV ID
Enter the 9-digit Arkansas Medicaid provider ID number
						  of the billing provider.
58. A, B, C
INSURED?S NAME
Comply with the UB-04 Manual?s instructions.
59. A, B, C
P REL
Not applicable. Comply with the UB-04 Manual?s
						  instructions when there are other payers.
60. A, B, C
INSURED?S UNIQUE ID
Enter the patient?s Medicaid identification number on
						  the first line of the field.
61. A, B, C
GROUP NAME
Not applicable. See UB-04 Manual when there are other
						  payers.
62. A, B, C
INSURANCE GROUP NO
When applicable, follow instructions for fields 60 and
						  61.
63. A, B, C
TREATMENT
AUTHORIZATION
CODES
Enter any applicable prior authorization or benefit
						  extension number in field 63A.
64. A, B, C
DOCUMENT CONTROL NUMBER
Field used internally by Arkansas Medicaid. No provider
						  input.
65. A, B, C
EMPLOYER NAME
When applicable, based upon fields 51 through 62, enter
						  the name(s) of the individuals and entities that provide health care coverage
						  for the patient (or may be liable).
66.
DX
Diagnosis Version Qualifier. See the UB-04
						  Manual.
Qualifier Code ?9? designating ICD-9-CM diagnosis
						  required on claims representing services through September 30, 2014.
Qualifier Code ?0? designating ICD-10-CM diagnosis
						  required on claims representing services on or after October 1, 2014.
processing requirements.
67. A-H
(blank)
Enter the ICD-9-CM or ICD-10-CM diagnosis codes
						  corresponding to additional conditions that coexist at the time of admission,
						  or develop subsequently, and that have an effect on the treatment received.
						  Fields are available for up to 8 codes.
68.
Not used
Reserved for assignment by the NUBC.
69.
ADMIT DX
Not applicable.
70.
PATIENT REASON DX
Not applicable.
71.
PPS CODE
Not required.
72
ECI
See the UB-04 Manual. Required when applicable (for
						  example, TPL and torts).
73.
Not used
Reserved for assignment by the NUBC.
74.
PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE
						  CODES AND DATES
Not applicable.
75.
Not used
Reserved for assignment by the NUBC.
76.
ATTENDING NPI
NPI is not required.
QUAL
Enter 0B, indicating state license number. Enter the
						  surgeon?s state license number in the second part of the field.
LAST
Enter the surgeon?s last name.
FIRST
Enter the surgeon?s first name.
77.
OPERATING NPI
NPI is not required.
QUAL
Not applicable.
LAST
Not applicable.
FIRST
Not applicable.
78.
OTHER NPI
NPI is not required.
QUAL
Enter 0B, indicating state license number. Enter the
						  referring physician?s state license number in the second part of the
						  field.
LAST
Enter the referring physician?s last name.
FIRST
Enter the referring physician?s first name.
79.
OTHER NPI/QUAL/LAST/FIRS
Not used.
80.
REMARKS
For provider?s use.
81.
Not used
Reserved for assignment by the NUBC.