Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-030 - Personal Care Provider Manual Update Transmittal #107

Current through Register Vol. 49, No. 6, June, 2024
Section II
Personal Care
262.410
Completing a CMS-1500 Claim
			 Form for Personal Care
When a provider must bill on a paper claim, the fiscal agent
				accepts only red-lined, sensor-coded CMS-1500 claim forms. Claim photocopies
				and claim forms that are not sensor-coded cannot be processed.
Field Name and Number
Instructions for Completion
1. (type of coverage)
Not required.
1a. INSURED'S I.D. NUMBER (For Program in Item
						  1)
Beneficiary's 10-digit Medicaid or ARKids First-A
						  identification number.
2. PATIENT'S NAME (Last Name, First Name, Middle
						  Initial)
Beneficiary's last name and first name.
3. PATIENT'S BIRTH DATE
Beneficiary's date of birth as given on the
						  individual's Medicaid or ARKids First-A 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 complete mailing address
						  (street address or post office box).
CITY
Name of the city in which the beneficiary
						  resides.
STATE
Two-letter postal code for the state in which the
						  beneficiary resides.
ZIP CODE
Five-digit ZIP code; nine digits for post office
						  box.
TELEPHONE (Include Area Code)
The beneficiary'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)
CITY
STATE
ZIP CODE
TELEPHONE (Include Area Code)
Required if the insured's address is different from the
						  patient's address.
8. PATIENT STATUS
Not required.
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. OTHER INSURED'S DATE OF BIRTH
Not required.
SEX
Not required.
c. EMPLOYER'S NAME OR SCHOOL NAME
Required when items 9 a-d are required. Name of the
						  insured individual's employer and/or school.
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. RESERVED FOR LOCAL USE
Not used.
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. EMPLOYER'S NAME OR SCHOOL NAME
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 9a through 9d.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
Not required.
13. INSURED'S OR
AUTHORIZED PERSON'S SIGNATURE
Not required.
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.
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE
						  FIRST DATE
Not required.
16. DATES PATIENT UNABLE TO WORK IN CURRENT
						  OCCUPATION
Not required.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a. (blank) 17b. NPI
Name and title of the referral source.
The 9-digit Arkansas Medicaid provider ID number of the
						  referring physician when applicable.
Not required.
18. HOSPITALIZATION DATES RELATED TO CURRENT
						  SERVICES
Not applicable.
19. RESERVED FOR LOCAL USE
Schools, school districts and education service
						  cooperatives must enter the LEA number of the facility or district providing
						  the service.
20. OUTSIDE LAB? $ CHARGES
Not required. Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY
Diagnosis code for the primary medical condition for
						  which services are being billed. Up to three additional diagnosis codes can be
						  listed in this field for information or documentation purposes. Use the
						  International Classification of Diseases, Ninth Revision (ICD-9-CM) diagnosis
						  coding current as of the date of service.
22. MEDICAID RESUBMISSION CODE
ORIGINAL REF. NO.
Reserved for future use. Reserved for future
						  use.
23. PRIOR AUTHORIZATION NUMBER
The prior authorization or benefit extension control
						  number when applicable.
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. A provider 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 service on each day of the date
						  sequence.
3. RCFs may bill for a date span of any length within
						  the same calendar month, provided the client was present every day of the date
						  span and all services provided within the date span were at the same Level of
						  Care.
B.
PLACE OF SERVICE
Two-digit national standard place of service
						  code.
C.
EMG
Not required.
D.
PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS
One CPT or HCPCS procedure code for each detail.
MODIFIER
Modifier(s) when applicable.
E.
DIAGNOSIS POINTER
Enter in each detail the single number-1, 2, 3 or 4-
						  that corresponds to a diagnosis code in Item 21 (numbered 1, 2, 3 or 4) and
						  that supports most definitively the medical necessity of the service(s)
						  identified and charged in that detail. Enter only one number in E of each
						  detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3 or 4, and it must
						  be the only character in that field.
F.
$ CHARGES
The full charge for the services totaled in the detail.
						  This charge must be the usual charge to any client patient, or other recipient
						  of the provider's services.
RCFs' charges should equal no less than the product of
						  the number of units (days) times the client's Daily Service Rate. If the charge
						  is less, Medicaid will pay the billed charge.
G.
DAYS OR UNITS
The units (in whole numbers) of service provided during
						  the period indicated in Field 24A of the detail.
H.
EPSDT/Family Plan
Enter E if the services resulted from a Child Health
						  Services (EPSDT) screening and referral.
I.
ID QUAL
Not required.
J.
RENDERING PROVIDER ID #
Not applicable.
NPI
Not required.
25. FEDERAL TAX I.D. NUMBER
Not required. This information is carried in the
						  provider's Medicaid file. If it changes, advise Provider Enrollment so that the
						  year-end 1099 will be correct and reported correctly.
26. PATIENT'S ACCOUNT NO.
Optional entry for providers' accounting and
						  account-retrieval purposes. Enter up to 16 numeric, alphabetic or alpha-numeric
						  characters. This character set 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 of all charges on the
						  claim.
29. AMOUNT PAID
Enter the total of payments received from other sources
						  on this claim. Do not include amounts previously paid by Medicaid.
30. BALANCE DUE
From the total charge, subtract amounts received from
						  other sources and enter the result.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING
						  DEGREES OR CREDENTIALS
The performing provider or an individual authorized by
						  the performing provider or by an institutional, corporate, business or other
						  provider organization, must sign and date the claim, certifying that the
						  services were furnished by the provider, under (when applicable) the direction
						  of the individual provider or other qualified individual, and in strict and
						  verifiable accordance with all applicable rules of the Medicaid program in
						  which the provider participates. A "provider's signature" is the provider's or
						  authorized individual's personally written signature, a rubber stamp of the
						  signature, an automated signature or a typed signature. The name of a group
						  practice, a facility or institution, a corporation, a business or any other
						  organization will prevent the claim from being processed.
32. SERVICE FACILITY
LOCATION INFORMATION
If services were not performed at the beneficiary's
						  home or at the provider's facility (
e.g.
, school, DDS facility
						  etc.) enter the name, street address, city, state and zip code of the facility,
						  workplace etc. where services were performed. If services were furnished at
						  multiple sites (for instance, when job-seeking), indicate "multiple locations"
						  or leave blank.
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.