016.05.18 Ark. Code R. 004
Arkansas Code Annotated §§ 20-48-1101 -1108, authorizes the use of a successor program for early intervention day treatment for children. The Department of Human Services, Division of Developmental Disabilities Services ("DDS") is responsible for the implementation, general administration, and oversight of the successor program for early intervention day treatment for children. Division of Provider Services and Quality Assurance (DPSQA) is responsible for certification and licensure criteria as the regulatory entity governing this successor program.
Child Health Management Services (CHMS) means an array of clinic services for children intended to provide full medical multidiscipline diagnosis, evaluation, and treatment of developmental delays in Medicaid recipients who meet eligibility criteria and for whom the treatment has been deemed medically necessary.
Developmental Day Treatment Clinic Services (DDTCS) for children means early intervention day treatment provided to children by a nonprofit community program that is licensed to provide center-based community services by the Division of Developmental Disabilities.
For both CHMS and DDTCS for children, early intervention day treatment means services provided by a pediatric day treatment program run by early childhood specialists, overseen by a physician and serving children with developmental disabilities, developmental delays, and a medical condition.
For both CHMS and DDTCS for children, early intervention day treatment includes without limitation diagnostic, screening, evaluation, preventive, therapeutic, palliative, rehabilitative and habilitative services, including speech, occupational, and physical therapies and any medical or remedial services recommended by a physician for the maximum reduction of physical or mental disability and restoration of the child to the best possible functional level. Early Intervention day treatment is available year-round to children aged 0-6; and in the summer months for children aged 6-21.
CHMS, DDTCS for children or the successor programs constitute the State's early intervention day treatment program.
Successor program means a program that provides early intervention day treatment to children that is created to replace in whole the CHMS and DDTCS for children programs. For profit and nonprofit providers from CHMS and DDTCS programs may participate, conditioned on program compliance.
Early Intervention Day Treatment (EIDT) is the successor program under Ark. Code Ann. §§ 20-48-1101 -1108.
Determination of underserved status for expansion of services
An expansion of early intervention day treatment services in a county is necessary when the Division of Developmental Disabilities Services determines that a county is underserved with regard to:
EIDT providers must meet the provider participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
EIDT providers may furnish and claim reimbursement for covered services in the Arkansas Medicaid Program subject to all requirements and restrictions set forth and referenced in this manual. Claims must be filed according to the specifications in this manual. Covered services must be medically necessary and prescribed by the child's primary care physician (PCP). When referring to or prescribing EIDT services, the PCP shall not make any self-referrals in violation of state or federal law.
Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) within fifty (50) miles of the state line may be enrolled as EIDT providers if they meet all Arkansas Medicaid participation requirements.
Pediatrics
An academic medical center program specializing in developmental pediatrics is eligible for reimbursement as an EIDT provider if it is certified as an Academic Medical Center by DPSQA. An Academic Medical Center must meet the following requirements:
Only an EIDT that is certified as an Academic Medical Center Program may bill the following codes, in addition to those listed in Section 232.100:
90791, U9 | 99202 | 99215, U1 | 99173 | |
90791, U1.U9 | 96105 | 99203 | 92551 | T1016 |
90887 | 96111 | 99204 | 92567 | T1025 |
96101 UA | 96118 | 99205 | 92587 |
96101.UA, UB | 99201 | 99205, U1 | 95961 |
Documentation and provider participation requirements are detailed within Section 140.000, Provider Participation, of this Manual.
Medicaid will accept electronic signatures if the electronic signatures comply with Arkansas Code Ann. §§ 25-31-103 etseq.
Individuals with Disabilities Education Act (IDEA)
DDS is the lead agency responsible for the general administration and supervision of the programs and activities utilized to carry out the provisions of Part C of the IDEA. First Connections is the DDS program in Arkansas that administers, monitors, and carries out all Part C of IDEA activities and responsibilities for the state. The First Connections program ensures that appropriate early intervention services are available to all infants and toddlers from birth to thirty-six (36) months of age (and their families) that are suspected of having a developmental delay.
Federal regulations under Part C of the IDEA require "primary referral sources" to refer any child suspected of having a developmental delay or disability for early intervention services. An EIDT is considered a primary referral source under Part C of IDEA regulations.
Each EIDT must, within two (2) working days of first contact, refer all infants and toddlers from birth to thirty-six (36) months of age for whom there is a diagnosis or suspicion of a developmental delay or disability. The referral must be made to the DDS First Connections Central Intake Unit, which serves as the State of Arkansas' single point of entry to minimize duplication and expedite service delivery. Each EIDT is responsible for maintaining documentation evidencing that a proper and timely referral to First Connections has been made.
Part B of the Individuals with Disabilities Education Act (IDEA)
Local Education Agencies ("LEA") have the responsibility to ensure that children ages three (3) until entry into Kindergarten who have or are suspected of having a disability under Part B of IDEA ("Part B") receive a Free Appropriate Public Education. The Arkansas Department of Education provides each EIDT with the option of participating in Part B as an LEA. Participation as an LEA requires an EIDT to provide special education and related services in accordance with Part B ("Special Education Services") to all children with disabilities it is serving aged three (3) until entry into Kindergarten. A participating EIDT is also eligible to receive a portion of the federal grant funds made available to LEAs under Part B in any given fiscal year.
Each EIDT must therefore make an affirmative election to either provide or not provide Special Education Services to all children with disabilities it is serving aged three (3) until entry into Kindergarten.
For further clarification related to Special Education Services refer to the DPSQA EIDT Licensure Manual.
View or print the Arkansas Department of Education Special Education contact information,
Services available through EIDT include occupational, physical and speech therapy and evaluation as an essential component of the individual treatment plan (ITP) for an individual accepted for developmental disabilities services.
An EIDT facility may contract with or employ qualified therapy practitioners. The individual therapy practitioner who actually performs a service on behalf of the EIDT facility must be identified on the claim as the performing provider when the EIDT facility bills for that service. This action is taken in compliance with the federal Improper Payments Information Act of 2002 (IPIA), Public Law 107-300 and the resulting Payment Error Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).
If the facility contracts with a qualified therapy practitioner, the criteria for group providers of therapy services apply (See Section 201.100 of the Occupational, Physical, Speech Therapy Services manual) The qualified therapy practitioner who contracts with the facility must be enrolled with Arkansas Medicaid. The contract practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that service.
If the facility employs a qualified therapy practitioner, that practitioner has the option of either enrolling with Arkansas Medicaid or requesting a Practitioner Identification Number (View or print form DMS-7708). The employed practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that service.
Medicaid assists eligible individuals to obtain medical care in accordance with the guidelines specified in Section I of this Manual. Reimbursement may be made for medically necessary, covered Early Intervention Day Treatment Services provided to Medicaid beneficiaries, aged 0-21, at qualified provider facilities. Services may be provided year-round to beneficiaries aged 0-6, and during the summer months for beneficiaries aged 6-21.
Reimbursement for covered services will be approved only when the beneficiary's physician has determined that EIDT services are medically necessary:
If the child has been diagnosed with one of the following diagnoses or has been deemed to meet the institutional level of care (as shown on a DMS-703),, the physician or EIDT provider may send all relevant documentation to DHS' Third Party Vendor for review in lieu of referring the patient for a developmental screen:
A clinician will review the submitted documentation to determine if a developmental screen is needed.
To receive EIDT day habilitation services, the beneficiary must have a documented developmental disability or delay, as shown on the results of an annual comprehensive developmental evaluation. The comprehensive annual developmental evaluation must include a norm referenced (standardized) evaluation and a criterion referenced evaluation. The norm referenced evaluation must be the most current addition of the Battelle Developmental Inventory (BDI). The Criterion referenced evaluation must be the most current edition of one of the following and appropriate for the child's age:
The evaluator must document that the test protocols for each instrument used were followed, and that the evaluator met the qualification to administer the instrument. The length of the service may not exceed one unit per date of service. The billable unit includes time spent administering the test, time spent scoring the test and/or time spent writing a test report. Services are covered once each calendar year if the service is deemed necessary.
Physical, Occupational and Speech Therapy evaluations must meet qualifying scores as written in the Medicaid Occupational, Physical and Speech Therapy Provider manual.
For children who have a documented delay in the areas of social emotional and adaptive only, a referral must be made to an appropriate head start, home visiting, or Early Interventions or Part B program. This referral must be documented and placed in the child's evaluation record.
EIDT core services are provided in certified clinics and include the following core services when (a) prescribed by the beneficiary's physician; (b) medically necessary; (c) provided on an outpatient basis; and (d) provided in accordance with a written Individual Treatment Plan (ITP) and this Manual:
EIDT nursing services are available for beneficiaries who are medically fragile, have complex health needs, or both, if prescribed by the beneficiary's PCP in accordance with this manual.
Nothing other than the services listed in Sections 213.100 and 213.200 are covered as an EIDT services, including educational services, supervised living services, and inpatient services
The evaluation service is a component of the process of determining a person's eligibility for habilitative services and habilitative services in the summer. Evaluation services are covered separately from habilitative services.
Evaluation services are covered once per calendar year, if the service is deemed medically necessary by a physician. For children age 18 or less who are enrolling (including those who have been discharged and are re-enrolling) in the habilitative services program (ages 0-6), medical necessity of evaluation services is determined by an age appropriate developmental screen conducted in accordance with the Manual Governing Independent Assessments and Developmental Screens Children who are only enrolled in the summer habilitation services do not have to undergo a developmental screen.
If the physician or EIDT provider believes that the beneficiary has a significant, documented developmental diagnosis, disability or delay such that he or she does not need a developmental screen, the physician or EIDT provider may send relevant documentation for review by a clinician. The clinician will determine the necessity of a developmental screen.
Evaluation services are reimbursed on a per unit basis, with one unit equal to 15 minutes. There is a maximum of four (4) units per year. The billable unit includes time spent administering the test, scoring the test, and/or writing a test report.
Habilitative Services may be provided to a child before they reach school age, including children who are aged 5-6, if the kindergarten year has been waived.
(d Documented experience working with children with special needs and twelve (12) hours of completed college courses in any of the following areas:
There must be one (1) ECDS for every forty (40) beneficiaries enrolled at an EIDT site.
Age Group | Ratio |
0-18 months | 1:4 |
18-36 months | 1:5 |
3-4 years | 1:7 |
4-6 years | 1:8 |
Occupational, physical, and speech therapy services must be medically necessary to the treatment of the beneficiary's developmental disability or delay, in accordance with the Medicaid Provider Manual for Occupational, Physical, and Speech Therapy Services, Section II. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy.
Beneficiaries aged 6-21 may receive day habilitative services during the months of May, June, July, and August, when school is not in session if they
AND
The purpose of these services is to continue habilitation instruction to prevent regression during the summer months while school is not in session. Habilitation activities in the summer must be based on the goals and objectives of the beneficiary's Individual Treatment Plan (ITP).
Nursing services that are needed by a beneficiary and that can only be performed by a licensed nurse may be performed and billed by an EIDT. For the purposes of this Manual, nursing services are defined as the following, or similar, activities:
Reimbursable nursing services do not include the taking of temperature or provision of standard first aid.
Administration of medication alone is not enough to qualify a child to receive nursing services-
Nursing services must be performed by a licensed Registered Nurse or Licensed Practical Nurse, and must be within the nurse's scope of practice as set forth by the Arkansas State Board of Nursing.
To establish medical necessity for nursing services the beneficiary must have a medical diagnosis and a comprehensive nursing evaluation approved by a PCP that designates the need for nursing services. The evaluation must specify what the needed nursing services are. Based on the nursing evaluation, the PCP must authorize the number of nursing units per day.
Medicaid will reimburse up to 4 units of nursing per day without authorization. Additional nursing units will require an extension of benefits.
For each beneficiary receiving services at an EIDT, an annual Individual Treatment Plan (ITP) must be developed. The ITP consists of a written, individualized plan to improve the beneficiary's condition. The ITP must contain:
The annual ITP must be developed by the Early Childhood Development Specialist assigned to the child.
The reimbursement methodology for Early Intervention Clinic-based Day Treatment (EIDT) is a "fee schedule" methodology. Under the fee schedule methodology, reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowed for each procedure. The maximum allowable fee for a procedure is the same for all EIDT providers.
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://medlcald.mmls.arkansas.gov/ under the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
Arkansas Medicaid conducts retrospective review of the core EIDT services:
The purpose of retrospective review is to promote effective, efficient and economical delivery of health care services.
The Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program, performs retrospective reviews of medical records to determine if services delivered and reimbursed by Medicaid meet medical necessity requirements as outlined in the Medicaid Provider Manual and any applicable Certification Standards. View or print QIO contact information.
The Division of Medical Services (DMS), Utilization Review Section (UR) is required to initiate the recoupment process for all services denied by the contracted QIO, for not meeting the medical necessity requirements. Based on QIO findings during retrospective reviews, recoupment will be initiated, as appropriate.
DMS, or its QIO, will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid beneficiary name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the claim has been denied.
When a provider or beneficiary wishes to ask for administrative reconsideration of a DHS decision, he or she must follow the procedure laid out in the Medicaid Provider Manual, Section 161.200.
When the Division of Medical Services (DMS) denies coverage of services, the beneficiary or the provider may request a fair hearing to appeal the denial of services from the Department of Health and Human Services. To do so, the beneficiary or provider must follow the procedures laid out in the Medicaid Provider Manual, Sections 160.000 and 190.000.
EIDT providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claims submission.
EIDT core services are reimbursable on a per unit basis. Partial units are not reimbursable. Service time less than a full unit of service may not be rounded up to a full unit of service and may not be carried over to the next service date. Must use the Type of Service (TOS) code M.
Procedure Code | Required Modifier | Description |
T1015 | U6, UB | Habilitative Services Aged 0-6 (1unit equals 1 hour, maximum of 5 units per day) |
T1015 | U6.UC | Habilitative Services in the Summer Aged 6-21 (1 unit equals 1 hour, maximum of five units per day) |
T1002 | U6 | Nursing Services (1 unit equals 15 minutes of service; maximum of 4 units per day) |
T1023 | U6, UC | Comprehensive Annual Developmental Evaluation (not to be billed for therapy evaluations) (1 unit equals 1 hour; maximum of 1 unit) |
99367 | UA | Treatment Plan developed by EIDT professionals and the client's caregiver(s) Plan must include short and long term goals and objectives and include appropriate activities to meet those goals and objectives (1 unit equals 15 minutes, limit of 4 units annually) |
Occupational Therapy Procedure Codes
Procedure Code | Required Modifier(s) | Description |
97003 | - | Evaluation for occupational therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) |
97150 | U1.UB | Group occupational therapy by occupational therapy assistant (15-minute unit, maximum of 6 units per week, maximum of 4 clients per group) |
97150 | U2 | Group occupational therapy by Occupational Therapist (15-minute unit; maximum of 6 units per week, maximum of 4 clients per group) |
97530 | - | Individual occupational therapy by Occupational Therapist (15-minute unit; maximum of 6 units per week) |
97530 | UB | Individual occupational therapy by occupational therapy assistant (15-minute unit; maximum of 6 units per week) |
The following procedure codes must be used for therapy services in the EIDT Program for Medicaid beneficiaries of all ages.
Physical Therapy Procedure Codes
Procedure Code | Required Modifler(s) | Description |
97001 | - | Evaluation for physical therapy (30-minute unit; maximum of 4 units per state fiscal year, July 1 through June 30) |
97110 | - | Individual physical therapy by Physical Therapist (15-minute unit; maximum of 6 units per week) |
97110 | UB | Individual physical therapy by physical therapy assistant (15-minute unit; maximum of 6 units per week) |
97150 | - | Group physical therapy by Physical Therapist (15-minute unit; maximum of 6 units per week, maximum of 4 clients per group) |
97150 | UB | Group physical therapy by physical therapy assistant (15-minute unit; maximum of 6 units per week, maximum of 4 clients per group) |
Speech Therapy Procedure Codes
Procedure Code | Required Modifier(s) | Description |
92521 | UA | .'*Evaluation of speech fluency (e.g. stuttering, cluttering) (maximum of four 30-minute units per state fiscal year, July 1 through June 30) |
92522 | UA | *"*Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria) (maximum of four 30-minute units per state fiscal year, July 1 through June 30) |
92523 | UA | ."*Evaluation of speech sound production (e.g. articulation, phonological process, apraxia, dysarthria) with evaluation of language comprehension and expression (e.g. receptive and expressive language) (maximum of four 30-minute units per state fiscal year, July 1 through June 30) |
92524 | UA | .".Behavioral and qualitative analysis of voice and resonance (maximum of four 30-minute units per state fiscal year, July 1 through June 30) |
92507 | - | Individual speech session by Speech Therapist (15-minute unit; maximum of 6 units per week) |
92507 | UB | Individual speech therapy by speech language pathology assistant (15-minute unit; maximum of 6 units per week) |
92506 | - | Group speech session by Speech Therapist (15-minute unit; maximum of 6 units per week, maximum of 4 clients per group) |
92508 | UB | Group speech therapy by speech language pathology assistant (15-minute unit; maximum of 6 units per week, maximum of 4 clients per group) |
NOTE: &(...) This symbol, along with text in parentheses, Indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.
There is a weekly maximum of 6 units for each discipline: occupational, physical, and speech therapy.
Electronic and paper claims now require the same National Place of Service code.
Place of Service | POS Codes |
Day Care Facility/EIDT Clinic | 99 |
DHS* billing vendor 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-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form CMS-1500.
Carefully follow these instructions to help DHS' billing vendor efficiently process claims. Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the Hewlett Packard Enterprise Claims Department. View or print the DHS billing vendor Claims Department contact information.
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.
Field Name and Number | Instructions for Completion |
1. (type of coverage) 1a. INSURED'S l.D. NUMBER (For Program in Item 1) | Not required. Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number. |
2. PATIENTS NAME (Last Name, First Name, Middle Initial) | Beneficiary's or participant's last name and first name. |
3. PATIENTS BIRTH DATE SEX | 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. 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. PATIENTS 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 insureds last name, first name, and middle initial. |
a. OTHER INSUREDS 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 PATIENTS 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. |
d. 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.orgunder Code Sets. |
11. INSURED'S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
a. INSURED'S DATE OF | Not required. |
BIRTH | |
SEX | Not required. |
b. OTHER CLAIM ID | Not required. |
NUMBER | |
c. INSURANCE PLAN | Not required. |
NAME OR PROGRAM | |
NAME | |
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 PERSONS 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 beneficiary's 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 required for EIDT services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
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. | ADDITIONAL CLAIM INFORMATION | 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 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, 3) the Individualized Plan is through the Division of Developmental Disabilities Services. | |
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) | 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 Plan (IEP) through an education service cooperative. |
NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services Is between the ages of 3 through 5 years and 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 Education Plan, 3) the Individualized Education Plan Is through an education service cooperative. | |
D (and 4-digit LEA code) | Individuals ages 5 (by September 15) to 21 years who are receiving therapy services under an Individualized Education Plan (IEP) through a school district. |
NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services Is between the ages of 5 (by September 15 of the current school year) to 21 years. 2) the individual receiving services is receiving the services under an Individualized Education Plan, 3) the Individualized Education Plan Is through a school district. | |
E | Individuals ages 18 years and up who are receiving therapy services through the Division of Developmental Disabilities Services- |
F | Individuals ages 18 years and up who are receiving therapy services through individual or group providers not included in any of the previous categories (A-E). |
G | Individuals ages birth through 17 years who are receiving therapy/pathology services through individual or group providers not included in any of the previous categories (A-F). |
Not used. | |
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 the ICD codes is being reported. |
Use "9" for ICD-9-CM. | |
Use"0"forlCD-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 appropriate International Classification of Diseases (ICD). List no more than 12 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 | Reserved for future use. |
ORIGINAL REF. NO. | 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 | The prior authorization or benefit extension control number if 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. 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 262.200 for codes. |
C. EMG | Enter "Y" for "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 Sections 262.100 through 262.140. |
MODIFIER | Modifier(s) if applicable. See Section 262.120. |
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 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. |
1. 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 provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. PATIENTS 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 or 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. |
Not applicable to this program.
ATTACHMENT 3.I-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
Apnea (cardiorespiratory) monitors are provided for eligible recipients in the EPSDT Program. Use of the apnea monitors must be medically necessary and prescribed by a physician. Prior authorization is not required for the initial one month period. If the apnea monitor is needed longer than the initial month, prior authorization is required,
EIDT services provide diagnosis and evaluation for the purpose of early intervention and prevention for eligible recipients in the EPSDT Program. Services are provided, if identified by an Independent Assessment in accordance with the Independent Assessment Manual, in multi-disciplinary clinic based setting as defined in 42 CFR § 440.90.
ATTACHMENT 3.1-B
Apnea (cardiorespiratory) monitors are provided for eligible recipients in the EPSDT Program. Use of the apnea monitors must be medically necessary and prescribed by a physician. Prior authorization is not required for the initial one month period. If the apnea monitor is needed longer than the initial month, prior authorization is required.
EIDT services provide diagnosis and evaluation for the purpose of early intervention and prevention for eligible recipients in the EPSDT Program. Services arc provided, if identified by an Independent Assessment in accordance with the Independent Assessment Manual, in multi-disciplinary clinic based setting as defined in 42 CFR § 440.90.
ATTACHMENT 4.19-B
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES-OTHER TYPES OF CARE
Reimbursement for comprehensive evaluation is based on the lesser of the amount billed or the Title XIX (Medicaid) charge allowed. The Title XIX maximum was established based on a 1980 survey conducted by Developmental Disabilities Services (DDS) of 85 Arkansas Developmental Day Treatment providers of their operational costs excluding their therapy services. An average operational cost was derived for each service. Then an average number of units was derived for each service. The average operational cost for each service was divided by the average units for that particular service to arrive at a maximum rate.
The Title XIX (Medicaid) maximum rates were established based on the following:
Extensions of benefits will be provided for all EIDT services, if medically necessary.
016.05.18 Ark. Code R. 004