Therapy Billing Tips Provider Reference Supplement

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1 Therapy Billing Tips Provider Reference Supplement HP Enterprise Services, Arkansas Title XIX Document Date: 5/12/2010

2 HP Enterprise Services Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, Arkansas (501) HP Enterprise Services and the HP Enterprise Services logo are registered trademarks of HP Enterprise Services. All other logos, trademarks or service marks used herein are the property of their respective owners. HP Enterprise Services is an equal opportunity employer and values the diversity of its people HP Enterprise Services. All rights reserved.

3 Contents Introduction... 3 Eligibility... 4 Restricted Aid Categories... 4 All Arkansas Medicaid Aid Categories... 6 Therapy Benefits Program Coverage Prior Authorization Request Procedures for Augmentative Communication Device (ACD) Evaluation Contact List for Reviews, Managed Care and Authorizations National Place of Service Codes Quick Tips for Submitting Claims Introduction to Billing CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes Augmentative Communication Device (ACD) Évaluation Billing Instructions - Paper Only Completion of the CMS-1500 Claim Form Special Billing Procedures Common Billing Errors Brief Overview of Benefits Contact Information i

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5 Introduction This Billing Tips document serves as a training supplement for Arkansas Medicaid providers but does not supersede official program documentation including: Arkansas Medicaid provider manuals, Official Notices and transmittal letters published by the Division of Medical Services and distributed by HP Enterprise Services. This document focuses on Arkansas Medicaid eligibility and billing issues and incorporates the following quick reference items for your convenience: Consolidated list of restricted aid categories National Place of Service (POS) reference sheet for paper and electronic claims Billing Paper Claims Correcting Common Billing Errors Contact Information 3

6 Arkansas Medicaid Therapy Billing Tips Eligibility Beneficiary eligibility for the Arkansas Medicaid program is determined at the Department of Human Services (DHS) county office. A beneficiary s eligibility may begin and end on any day of any month. Because program eligibility is date specific, providers are required to check each beneficiary s eligibility on the date of service and are encouraged to do so using one of the following tools: PES Arkansas Medicaid Direct Data Entry (DDE) website Both tools verify eligibility electronically for a specific date or range of dates, including retroactive eligibility for a year. For more information on eligibility, refer to Section I of your Arkansas Medicaid provider manual. Restricted Aid Categories Many providers ask a question that is closely related to eligibility: Is there a list of aid categories that require a primary care physician? The answer is no. Arkansas Medicaid s primary care case management program, ConnectCare, requires Medicaid beneficiaries and waiver participants to enroll with a primary care physician (PCP) unless specifically exempt from that requirement. See these sections of your Arkansas Medicaid provider manual for more information related to eligibility: Section , which lists the groups of individuals who may not enroll with a PCP Section , which lists Medicaid covered services that do not require PCP referral On the following pages are a consolidated list of aid categories with restrictions and a complete list of aid categories taken from Section of your Arkansas Medicaid provider manual. 4

7 The table below lists and briefly describes restricted aid categories. Post it at your workstation to use as a convenient quick reference: Aid Category 01 ARKids First-B (PCP Required) 03 CMS (Children s Medical Services) Non-Medicaid (No PCP Required) 04 DDS (Developmental Disability Services) Non-Medicaid (NO PCP Required) *6 Medically Needy Exceptional (PCP Required) *7 Spend Down (No PCP Required) (PCP required for Breast Care, 07) 08 Tuberculosis (NO PCP Required) Restriction Beneficiaries may have co-payment requirements. Beneficiaries may be ineligible for certain services (see the ARKids First-B provider manual for exclusions.) All services must be prior authorized by the CMS office. DDS non-medicaid provider ID numbers end with 86. DDS non-medicaid beneficiary ID numbers begin with Only DDS non-medicaid providers may bill for DDS non- Medicaid beneficiaries. DDS beneficiaries may be dually eligible and receive additional services in another category. Beneficiaries are eligible for a full range of benefits except nursing facility and personal care. Beneficiaries must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. Note: Aid category 07 BCC has full benefits. Beneficiary coverage includes drugs, physician services, outpatient services, rural health clinic encounters. Federally Qualified Health Center (FQHC) and clinic visits for TB-related services only. 5

8 Arkansas Medicaid Therapy Billing Tips Aid Category *8 QMB (Qualified Medicare Beneficiary) (No PCP Required) 61 PW-PL (Pregnant Woman Infants and Children Poverty level) (No PCP Required For Pregnant Woman) (PCP Required for the Infants and children) 62 PW-PE (Pregnant Woman Presumptive Eligibility) (No PCP Required) 69 Women s Health Wavier (No PCP Required) 58, 78, 88 SLIMB (Specified Low Income Medicare Beneficiary)(SMB) (No PCP Required) Restriction Medicaid pays Medicare premiums, coinsurance and deductible. If the service provided is not a Medicare covered service, Medicaid will not pay for the service under the QMB policy. Note: Aid category 18 S has full benefits. This category contains both pregnant women and children. Providers must use the last three-(3) digits of the Medicaid ID number to determine benefits. When the last three (3) digits are in the 100 series (i.e., 101, 102, etc.), the beneficiary is eligible as an adult and is eligible for pregnancy-related services only. When the last three (3) digits are in the 200 series (i.e., 201, 202, etc.), the beneficiary is eligible as a child and receives a full range of Medicaid services. Note: Plan description PW unborn ch-noster/fp cov indicates there is no sterilization or family planning benefits for the expectant mother. A temporary aid category that pays for ambulatory, prenatal services only. Medicaid pays for family planning preventative services only, such as birth control or counseling. A claim for a beneficiary in this category must contain both a family planning diagnosis code and a family planning procedure code. Medicaid pays only their Medicare premium. All Arkansas Medicaid Aid Categories The following is the full list of beneficiary aid categories. Some categories may provide a full range of benefits, may offer limited benefits or may be a category that requires cost sharing by a beneficiary. The following codes describe each level of coverage. FR LB full range limited benefits 6

9 AC additional cost sharing MNLB medically needy limited benefits Category Description Code 01 ARKIDS B ARKids First Demonstration LB, AC 07 BCC Breast and Cervical Cancer Prevention and Treatment FR 08 TB-Limited Tuberculosis Limited Benefits LB 10 N WD NewCo* 10 R WD RegCo* Working Disabled New Cost Sharing (N) Working Disabled Regular Medicaid Cost Sharing (R) 11 AABD AABD FR 13 SSI SSI FR 14 SSI SSI FR FR, AC FR, AC 16 AA-EC AA-EC MNLB 17 AA-SD Aid to the Aged Medically Needy Spend Down MNLB 18 QMB-AA Aid to the Aged-Qualified Medicare Beneficiary (QMB) LB 18 S AR Seniors* 20 AFDC- GRANT ARSeniors Transitional Employment Assistance (TEA, formerly AFDC) Medicaid 25 TM Transitional Medicaid FR 26 AFDC-EC AFDC Medically Needy Exceptional Category MNLB 27 AFDC-SD AFDC Medically Needy Spend Down MNLB 31 AAAB Aid to the Blind FR 33 SSI SSI Blind Individual FR 34 SSI SSI Blind Spouse FR 35 SSI SSI Blind Child FR 36 AB-EC Aid to the Blind-Medically Needy Exceptional Category MNLB 37 AB-SD Aid to the Blind-Medically Needy Spend Down MNLB 38 QMB-AB Aid to the Blind-Qualified Medicare Beneficiary (QMB) LB 41 AABD Aid to the Disabled FR 43 SSI SSI Disabled Individual FR 44 SSI SSI Disabled Spouse FR 45 SSI SSI Disabled Child FR FR FR 7

10 Arkansas Medicaid Therapy Billing Tips Category Description Code 46 AD-EC Aid to the Disabled-Medically Needy Exceptional Category MNLB 47 AD-SD Aid to the Disabled-Medically Needy Spend Down MNLB 48 QMB- AD Aid to the Disabled-Qualified Medicare Beneficiary (QMB) 49 TEFRA TEFRA Waiver for Disabled Child AC 51 U-18 Under Age 18 No Grant FR 52 ARKIDS A Newborn FR 56 U-18 EC Under Age 18 Medically Needy Exceptional Category MNLB 57 U-18 SD Under Age 18 Medically Needy Spend Down MNLB 58 QI-1 Qualifying Individual-1 (Medicaid pays only the Medicare premium.) 61 PW-PL Women Health Waiver- Pregnant Women, Infants & Children Poverty Level (SOBRA). A 100 series suffix (the last 3 digits of the ID number) is a pregnant woman; a 200 series suffix is an ARKids First-A child. LB LB LB (for the pregnant woman only) FR (for SOBRA children) 61 PW Unborn Child Pregnant Women PW Unborn CH-no Ster cov Does not cover sterilization or any other family planning services. 62 PW-PE Pregnant Women Presumptive Eligibility LB 63 ARKIDS A SOBRA Newborn FR 65 PW-NG Pregnant Women No Grant FR 66 PW-EC Pregnant Women Medically Needy Exceptional Category LB (for the pregnant women only) MNLB 67 PW-SD Pregnant Women Medically Needy Spend Down MNLB 69 FAM PLAN Women s Health Waiver (Family Planning) LB 76 UP-EC Unemployed Parent Medically Needy Exceptional Category MNLB 77 UP-SD Unemployed Parent Medically Needy Spend Down MNLB 80 RRP-GR Refugee Resettlement Grant FR 81 RRP-NG Refugee Resettlement No Grant FR 86 RRP-EC Refugee Resettlement Medically Needy Exceptional Category MNLB 8

11 Category Description Code 87 RRP-SD Refugee Resettlement Medically Needy Spend Down MNLB 88 SLI-QMB Specified Low Income Qualified Medicare Beneficiary (SMB) (Medicaid pays only the Medicare premium.) 91 FC Foster Care FR 92 IVE-FC IV-E Foster Care FR 96 FC-EC Foster Care Medically Needy Exceptional Category MNLB 97 FC-SD Foster Care Medically Needy Spend Down MNLB LB 9

12 Arkansas Medicaid Therapy Billing Tips Therapy Benefits Arkansas Medicaid applies the following therapy benefits to all therapy services in this program: Medicaid will reimburse up to four (4) occupational, physical and speech therapy evaluation units (1 unit = 30 minutes) per discipline, per state fiscal year (July 1 through June 30) without authorization. Additional evaluation units will require an extended therapy request. Medicaid will reimburse up to four (4) occupational, physical and speech therapy units (1 unit = 15 minutes) daily, per discipline, without authorization. Additional therapy units will require an extended therapy request. All requests for extended therapy services must comply with Sections through of the Occupational, Physical, Speech Therapy Services provider manual. 10

13 Program Coverage The Arkansas Medicaid Occupational, Physical and Speech Therapy Program reimburses therapy services for Medicaid-eligible individuals under the age of 21 in the Child Health Services (EPSDT) Program. Therapy services for individuals aged 21 and older are only covered when provided through the following Medicaid Programs: Developmental Day Treatment Clinic Services (DDTCS), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD), Home Health, Hospice and Physician/Independent Lab/CRNA/Radiation Therapy Center. Refer to the Medicaid provider manuals for conditions of coverage and benefit limits. Medicaid reimbursement is conditional upon providers compliance with Medicaid policy as stated in your provider manual, manual update transmittals and official program correspondence. All Medicaid benefits are based on medical necessity. Refer to the Glossary section of your Medicaid provider manual for a definition of medical necessity. Occupational therapy, physical therapy and speech-language pathology services are those services defined by applicable state and federal rules and regulations. These services are covered only when the following conditions exist. A. Services are provided only by appropriately licensed individuals who are enrolled as Medicaid providers in keeping with the participation requirements in Section of the Occupational, Physical, Speech Therapy Services provider manual. B. Services are provided as a result of a referral from the beneficiary s primary care physician (PCP). If the beneficiary is exempt from the PCP process, then the attending physician must make the referrals. C. Treatment services must be provided according to a written prescription signed by the PCP or the attending physician, as appropriate. D. Treatment services must be provided according to a treatment plan or a plan of care (POC) for the prescribed therapy, developed and signed by providers credentialed or licensed in the prescribed therapy or by a physician. E. Medicaid covers occupational therapy, physical therapy and speech therapy services when provided to eligible Medicaid beneficiaries under age 21 in the Child Health Services (EPSDT) Program by qualified occupational, physical or speech therapy providers. F. Speech therapy services ONLY are covered for beneficiaries in the ARKids First-B program benefits. G. Therapy services for individuals over age 21 are only covered when provided through the following Medicaid Programs: Developmental Day Treatment Clinic Services (DDTCS), Hospital/Critical Access Hospital (CAH), Rehabilitative Hospital, Home Health, Hospice and Physician. Refer to these Medicaid provider manuals for conditions of coverage and benefit limits. 11

14 Arkansas Medicaid Therapy Billing Tips An individual who has been admitted as an inpatient to a hospital or is residing in a nursing care facility is not eligible for occupational therapy, physical therapy and speechlanguage pathology services under this program. Individuals residing in residential care facilities and supervised living facilities may be eligible for these therapy services when provided on or off site from the facility. A. Occupational, physical and speech therapy services require a referral from the beneficiary s primary care physician (PCP) unless the beneficiary is exempt from PCP Program requirements. If the beneficiary is exempt from the PCP process, referrals for therapy services are required from the beneficiary s attending physician. All therapy services for beneficiaries under the age of 21 years require referrals and prescriptions be made utilizing the Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 form DMS-640. B. Occupational, physical and speech therapy services also require a written prescription signed by the PCP or attending physician, as appropriate. 1. Providers of therapy services are responsible for obtaining renewed PCP referrals every six months even if the prescription for therapy is for one year. 2. A prescription for therapy services is valid for the length of time specified by the prescribing physician, up to one year. 3. When a school district is providing therapy services in accordance with a child s Individualized Education Program (IEP), a PCP referral is required at the beginning of each school year. The PCP referral for the therapy services related to the IEP can be for the 9-month school year and a 6-month referral renewal is not necessary unless the PCP specifies otherwise. 4. The PCP or attending physician is responsible for determining medical necessity for therapy treatment. a. The individual s diagnosis must clearly establish and support that the prescribed therapy is medically necessary. b. Diagnosis codes and nomenclature must comply with the coding conventions and requirements established in Internal Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM); Volumes I and II, in the edition Medicaid has certified as current for the patient s dates of service. c. Please note that diagnosis codes V57.1, V57.2 and V57.3 are not specific enough to identify the medical necessity for therapy treatment and may not be used. 5. Providers of therapy services must use form DMS-640 Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 Prescription/Referral to obtain the PCP referral and the written prescription for therapy services for any beneficiary under the age of 21 years.. Exclusive use of this form will facilitate the process of obtaining referrals and prescriptions from the PCP or attending physician. A copy of the prescription must be maintained in the beneficiary s records. The original prescription is to be maintained by the physician. Form DMS-640 must be used for the 12

15 initial referral for evaluation and a separate DMS-640 is required for the prescription. After the initial referral using the form DMS-640 and initial prescription utilizing a separate form DMS-640, subsequent referrals and prescriptions for continued therapy may be made at the same time using the same DMS-640. Instructions for completion of form DMS-640 are located on the back of the form. Medicaid will accept an electronic signature provided that it is in compliance with Arkansas Code To order copies from HP Enterprise Services, use Form HP-MFR-001 Medicaid Forms Request in Section V of your provider manual. 7. A treatment plan developed and signed by a provider who is credentialed and licensed in the prescribed therapy or by a physician is required for the prescribed therapy. a. The plan must include goals that are functional, measurable and specific for each individual child. b. Services must be provided in accordance with the treatment plan, with clear documentation of service rendered. Refer to Section , subpart D, of the Occupational, Physical, Speech Therapy Services provider manual for more information on required documentation. C. Make-up therapy sessions are covered in the event a therapy session is canceled or missed if determined medically necessary and prescribed by the beneficiary s PCP. Any make-up therapy session requires a separate prescription from the original prescription previously received. Form DMS-640 must be used by the PCP or attending physician for any make-up therapy session prescriptions. D. Therapy services carried out by an unlicensed therapy student may be covered only when the following criteria are met: Therapies performed by an unlicensed student must be under the direction of a licensed therapist and the direction is such that the licensed therapist is considered to be providing the medical assistance. To qualify as providing the service, the licensed therapist must be present and engaged in student oversight during the entirety of any encounter that the provider expects Medicaid to cover. Refer to Section of the Occupational, Physical, Speech Therapy Services provider manual for procedure codes and billing instructions and Section information regarding extended therapy benefits. 13

16 Arkansas Medicaid Therapy Billing Tips Prior Authorization Request Procedures for Augmentative Communication Device (ACD) Evaluation To perform an evaluation for the augmentative communication device (ACD), the provider must request prior authorization from the Division of Medical Services, Utilization Review Section, using the following procedures. A. A primary care physician (PCP) written referral is required for prior authorization of the ACD evaluation. If the beneficiary is exempt from the PCP process, then the attending physician must make the referral. B. The physical and intellectual capabilities (functional level) of the beneficiary must be documented in the referral. The referring physician must justify the medical reason the individual requires the ACD. C. If the beneficiary is currently receiving speech therapy, the speech-language pathologist must document the prerequisite communication skills for the augmentative communication system and the cognitive level of the beneficiary. D. A completed Request for Prior Authorization and Prescription Form (DMS-679) must be used to request prior authorization. Copies of form DMS-679 can be requested using the Medicaid Form Request, HP-MFR-001. E. Submit the request to the Division of Medical Services, Utilization Review Section. When the PA request is received in Utilization Review, it is given to the Medical Director to review and make a decision. F. For approved requests, a PA control number will be assigned and entered in item 10 on the DMS-679 and returned to the provider. For denied requests, a denial letter with the reason for denial will be mailed to the requesting provider and the Medicaid beneficiary. NOTE: Prior authorization for therapy services only applies to the augmentative communication evaluation. Refer to Section of the Occupational, Physical, Speech Therapy Services provider manual for additional information. 14

17 Contact List for Reviews and Authorizations Arkansas Foundation for Medical Care (AFMC) Review and authorization (PAs) Provides utilization and quality reviews for various Medicaid programs UR for PCPs Reviews ER, OP clinics, Assistant Surgeon Authorizes hospital stays and certain procedures Authorizes inpatient stays over 4 days (Mump Review) option 2 Q Source of AR Review and authorization (PAs) Therapy review (under 21), PA for personal care (under 21) and eprescribing Initiative (501) Nancy Archer, Executive Director 15

18 Arkansas Medicaid Therapy Billing Tips National Place of Service Codes Electronic and paper claims now require the same National Place of Service Code. Place of Service POS Codes Doctor s Office 11 Patient s Home 12 Day Care Facility 52 Night Care Facility 52 Other Locations 99 Residential Treatment Center 56 16

19 Quick Tips for Submitting Claims This section outlines quick tips for therapy providers in Medicaid. These billing tips address some of the most common billing errors identified by the HP Provider Assistance Center (PAC). Topics include the following: Introduction to Billing Procedure code quick reference Therapy service code quick reference Special billing procedures Common billing errors Introduction to Billing Occupational, physical and speech therapy providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary. Section III of the your provider manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission. CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure Codes The following occupational, physical and speech-language pathology procedure codes are payable for therapy services indicated. Refer to Section IV - Glossary - of your Medicaid provider manual for definitions of group and individual as they relate to therapy sessions. A. Occupational Therapy Procedure Code Required Modifiers Description Evaluation for Occupational Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) Individual Occupational Therapy (15-minute unit; maximum of 4 units per day) U2 Group Occupational Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 17

20 Arkansas Medicaid Therapy Billing Tips Procedure Code Required Modifiers Description UB Individual Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day) UB, U1 Group Occupational Therapy by Occupational Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 18

21 B. Physical Therapy Procedure Code Required Modifier Description Evaluation for Physical Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) Individual Physical Therapy (15-minute unit; maximum of 4 units per day) Group Physical Therapy (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) UB Individual Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day) UB Group Physical Therapy by Physical Therapy Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) C. Speech-Language Pathology Procedure Code Required Modifier Description Evaluation for Speech Therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) Individual Speech Session (15-minute unit; maximum of 4 units per day) Group Speech Session (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) UB Individual Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day) UB Group Speech Therapy by Speech-Language Pathology Assistant (15-minute unit; maximum of 4 units per day, maximum of 4 clients per group) 19

22 Arkansas Medicaid Therapy Billing Tips Augmentative Communication Device (ACD) Evaluation The following procedure codes require prior authorization before services may be provided. Procedure Code Description Augmentative Communication Device Evaluation Billing Instructions - Paper Only HP Enterprise Services offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing. Bill Medicaid for professional services with form CMS The numbered items in the following instructions correspond to the numbered fields on the claim form. Carefully follow these instructions to help HP Enterprise Services efficiently process claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if necessary information is omitted. Forward completed claim forms to the HP Enterprise Services Claims Department. NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. Completion of the CMS-1500 Claim Form Field Name and Number 1. (type of coverage) Not required. 1a. INSURED S I.D. NUMBER (For Program in Item 1) 2. PATIENT S NAME (Last Name, First Name, Middle Initial) Instructions for Completion Beneficiary s or participant s 10-digit Medicaid or ARKids First-A or ARKids First-B identification number. 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. 20

23 Field Name and Number 4. INSURED S NAME (Last Name, First Name, Middle Initial) 5. PATIENT S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code) 8. PATIENT STATUS Not required. 9. OTHER INSURED S NAME (Last name, First Name, Middle Initial) a. OTHER INSURED S POLICY OR GROUP NUMBER b. OTHER INSURED S DATE OF BIRTH SEX c. EMPLOYER S NAME OR SCHOOL NAME Instructions for Completion Required if insurance affects this claim. Insured s last name, first name and middle initial. Optional. Beneficiary s or participant s complete mailing address (street address or post office box). Name of the city in which the beneficiary or participant resides. Two-letter postal code for the state in which the beneficiary or participant resides. Five-digit ZIP code; nine digits for post office box. The beneficiary s or participant s telephone number or the number of a reliable message/contact/ emergency telephone. If insurance affects this claim, check the box indicating the patient s relationship to the insured. Required if insured s address is different from the patient s address. If patient has other insurance coverage as indicated in Field 11d, the other insured s last name, first name and middle initial. Policy and/or group number of the insured individual. Not required. Not required. Required when items 9 a-d are required. Name of the insured individual s employer and/or school. 21

24 Arkansas Medicaid Therapy Billing Tips Field Name and Number d. INSURANCE PLAN NAME OR PROGRAM NAME 10. IS PATIENT S CONDITION RELATED TO: a. EMPLOYMENT? (Current or Previous) Instructions for Completion Name of the insurance company. 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 11. INSURED S POLICY GROUP OR FECA NUMBER a. INSURED S DATE OF BIRTH SEX b. EMPLOYER S NAME OR SCHOOL NAME c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE 13. INSURED S OR AUTHORIZED PERSON S SIGNATURE 14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) Not used. Not required when Medicaid is the only payer. Not required. Not required. Not required. Not required. When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d. Not required. Not required. Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. 22

25 Field Name and Number 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE Instructions for Completion Not required. Not required. Primary Care Physician (PCP) referral is required for Occupational, Physical and Speech Therapy Services. Enter the referring physician s name. 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 When the serving/billing provider s services charged on this claim are related to a beneficiary s or participant s inpatient hospitalization, enter the individual s admission and discharge dates. Format: MM/DD/YY. 19. Reserved for Local Use For tracking purposes, occupational, physical and speech therapy providers are required to enter one of the following therapy codes: Code Category A Individuals from birth through 2 years (but not 3 years old before September 15 of the current school year) who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. B Individuals ages 0 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Plan (IP) through the Division of Developmental Disabilities Services. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services has not attained age 5 by September 15 of the current school year, 2) the individual receiving services is receiving the services under an Individualized Plan and 3) the Individualized Plan is through the Division of Developmental Disabilities Services. 23

26 Arkansas Medicaid Therapy Billing Tips Field Name and Number When using code C or D, providers must also include the 4-digit LEA (local education agency) code assigned to each school district. For example: C1234 C (and 4-digit LEA code) Instructions for Completion Individuals ages 3 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Education Program (IEP) through an education service cooperative. NOTE: This code set is to be used only when all three of the following conditions are in place: 1) the individual receiving services was 3 years old before September 15 of the current school year and was not 5 years old before September 15 of the current school year, 2) the individual is receiving the services under an IEP maintained by an education service cooperative and 3) therapy services are being furnished by a) the ESC, which is an enrolled Medicaid therapy provider, or by b) a Medicaid-enrolled therapist or therapy group provider. D (and 4-digit LEA code) Individuals ages 5 (by September 15) to 21 years who are receiving therapy services under an IEP through a school district. E F NOTE: This code set is to be used only when all three of the following conditions are in place: 1) the individual receiving services was 5 years old before September 15 of the current school year and was not 21 years old before September 15 of the current school year, 2) the individual is receiving the services under an IEP and 3) the IEP is through a school district. Individuals ages 18 through 20 years who are receiving therapy services through the Division of Developmental Disabilities Services. Individuals ages 18 through 20 years who are receiving therapy services from individual or group providers not included in any of the previous categories (A-E). 24

27 Field Name and Number G 20. OUTSIDE LAB? Not required. $ CHARGES Not required. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER Instructions for Completion Individuals ages birth through 17 years who are receiving therapy/pathology services from individual or group providers not included in any of the previous categories (A-F). 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. Reserved for future use. Reserved for future use. The prior authorization or benefit extension control number if applicable. 24 A. 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 of the Occupational, Physical, Speech Therapy Services provider manual for codes. C. EMG Not required. D. PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS MODIFIER Enter the correct CPT or HCPCS procedure code from Sections through of the Occupational, Physical, Speech Therapy Services provider manual. Modifier(s), if applicable. 25

28 Arkansas Medicaid Therapy Billing Tips Field Name and Number Instructions for Completion 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 service(s) totaled in the detail. This charge must be the usual charge to any client, patient or other beneficiary 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 Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. I. ID QUAL Not required. J. RENDERING PROVIDER ID # NPI The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail. Not required. 25. FEDERAL TAX I.D. NUMBER Not required. This information is carried in the provider s Medicaid file. If it changes, please contact Provider Enrollment. 26. PATIENT S ACCOUNT NO. 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 or ARKids First-B co-payments. 30. BALANCE DUE From the total charge, subtract amounts received from other sources and enter the result. 26

29 Field Name and Number 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32. SERVICE FACILITY LOCATION INFORMATION a. (blank) Not required. b. (blank) Not required. 33. BILLING PROVIDER INFO & PH # a. (blank) Not required. Instructions for Completion 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. If other than home or office, enter the name and street, city, state and ZIP code of the facility where services were performed. Billing provider s name and complete address. Telephone number is requested but not required. b. (blank) Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. Special Billing Procedures Services must be billed according to the care provided and to the extent each procedure is provided. Occupational, physical and speech therapy services do not require prior authorization with the exception of ACD evaluations. ACD evaluations do require prior authorization. Refer to Section of the Occupational, Physical, Speech Therapy Services provider manual for information about the augmentative communication device evaluation. Extended therapy services may be requested for all medically necessary therapy services for beneficiaries under age 21. Refer to Sections through of the Occupational, Physical, Speech Therapy Services provider manual for more information. 27

30 Arkansas Medicaid Therapy Billing Tips Common Billing Errors Refer to the chart below to learn how to correct common billing errors that are associated with certain Explanation of Benefits (EOB) codes: EOB Code Error Method of Correction 263 and 267 Beneficiary is partially or totally ineligible for the DOS. 208 Beneficiary aid category 69 is limited to family planning services only. 252 Medicaid ID number submitted does not match patient s name on Medicaid ID card. 469 or 470 Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS and price. 103 Claim does not meet the timely filing requirements for Medicaid. 952 Service requires Primary Care Physician referral. 199 ARKids First-B beneficiary is older than 18 years old. Verify the beneficiary is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility. Verify that the original claim has a family planning diagnosis and procedure code. Correct and resubmit the claim. Verify eligibility through Medicaid s electronic eligibility system and resubmit the claim with correct information. Verify that the service is not a duplicate bill. Resubmit the corrected claim Claims must be received by HP Enterprise Services within 365 days from the To DOS. Claims received beyond this deadline will not be paid. Resubmit the claim with the corrected PCP information required for adjudication. ARKids First-B beneficiary s eligibility ends on their 19th birthday. The from DOS cannot exceed the 19th birthday. 28

31 Brief Overview of Benefits Under 21 4 Evaluations per SFY Up to four 15-Minute Units per Day ARKids First-B only Eligible for Speech Therapy See Section of the Occupational, Physical, Speech Therapy Services provider manual for additional information. 29

32 Arkansas Medicaid Therapy Billing Tips Contact Information Providers needing assistance on billing, enrollment or technical support should call HP Enterprise Services at one of the following assistance numbers: (outside of Little Rock but in-state) (501) (local or out-of-state) Depending on the type of assistance needed, follow the instructions in the phone system to reach the appropriate department. The provider assistance departments are: Provider Assistance Center - The provider assistance center is open weekdays 8 a.m. to 5 p.m. to assist providers with claim issues, billing questions and denials. EDI support center - The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software downloads and setup support, software training and data transmission failures. HP Provider Enrollment - The HP-Medicaid Provider Enrollment Unit is open weekdays 8 a.m. to 5 p.m. to assist providers with enrollment in the Arkansas Medicaid program, changing PCP caseloads and updating demographic information. HP Provider Representatives - HP Provider Representatives are available to visit your facility by appointment. They assist providers with billing issues, software delivery and setup, escalated issues and policy questions. See the Arkansas Medicaid website for a list of representatives by counties. Research Analyst - The PAC Research Analyst assist providers with escalated billing issues, claim appeals and special processing requests. See the Arkansas Medicaid website for contact information by county. 30

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