016.06.05 Ark. Code R. 052
A primary care physician (PCP) referral is required for each Medicaid recipient under age twenty-one for outpatient mental health services. See Section I of this manual for the PCP procodures. A PCP referral is generally obtained prior to providing service to Mcdicaid-eligiblo children. However, a PCP is given the option of providing a referral after a service is provided. If a PCP chooses to make a referral after a service has been provided, the referral must be received by the SBMH provider no later 45 calendar days after the date of service. The PCP has no obligation to give a retroactive referral.
The SBMH provider may not file a claim and will not be reimbursed for any services provided that require a PCP referral unless the referral is received.
However. a PCP is giwn 1hf: option ol providing a referral after a service is provided. If a PCP chooses to makt; a referral after a service has been provided, the referral must bo received by the SBMH provider no later 45 calendar days after the date of authorisation. The PCP has no obligation to give a ri-'troactivfi relerral.
The- SBMH piovidor may not file a claim and will not hn reimbursed for any services provided that require a PCP n.-forrui unless the rofnrral is received.
View or print EDS PAC contact information. View or print DHS contact information.
The following is a list of covered services available in the School-Based Mental Health Services Program. Practitioners enrolled as school-based mental health services provider personnel may provide the services on this list according to their scope of practice as identified by the licensure requirements.
The services are billed on a per unit basis. One unit equals 15 minutes. Services less than 15 minutes in duration are not reimbursable. The unit maximum shown below each procedure code description is a daily maximum.
Procedure Code | Required Modifier | Description and Definition | Length of Service |
90801 | Diaqnosis Direct clinical service provided by school-based mental health services provider personnel for the purpose of determining the existence, type, nature and most appropriate treatment of a mental illness or related disorder as described in the DSM-IV. This psycho-diagnostic process may include, but not be limited to, a psychosocial and medical history, diagnostic findings and recommendations. | 8-unit maximum | |
96100 | Diaqnosis - Psvcholoqical Test/Evaluation A single diagnostic test administered to a client by school-based mental health services provider personnel. This procedure should reflect the mental abilities, aptitudes, interests, attitudes, motivation, emotional and personality characteristics of the client. | 8-unit maximum | |
96100 | UB | Diaqnosis - Psvcholoqical Testinq-Batterv Two (2) or more diagnostic tests administered to a client by school-based mental health services provider personnel. This battery should assess the mental abilities, aptitudes, interests, attitudes, emotions, motivation and personality characteristics of the client. | 8-unit maximum |
90887 | Interpretation of Diaqnosis A direct service provided by school-based mental health services provider personnel for the purpose of interpreting the results of diagnostic activities to the patient and/or significant others. If significant others are involved, appropriate consent forms may need to be obtained. | 4-unit maximum | |
H0046 | Crisis Manaqement Visit An unscheduled direct service contact between an identified patient and school-based mental health services provider personnel for the purpose of preventing an inappropriate or more restrictive placement. | 4-unit maximum | |
H0004 | Individual Outpatient - Theraov Session Scheduled individual outpatient care provided by school-based mental health services provider personnel to a patient for the purposes of treatment and remediation of a condition described in DSM-IV and subsequent revisions. | 4-unit maximum |
90847 | U6 | Marital/Familv TheraDV Family therapy shall be treatment provided to two or more family members and conducted by school-based mental health services provider personnel for the purpose of alleviating conflict and promoting harmony. | 6-unit maximum |
H0046 | Individual Outpatient - Collateral Services A face-to-face contact by school-based mental health services provider personnel with other professionals, caregivers or other parties on behalf of an identified patient to obtain relevant information necessary to the patient's assessment, evaluation and treatment. | 4-unit maximum | |
90853 | Group Outpatient - Group Therapy A direct service contact between a group of patients and school-based mental health services provider personnel for the purposes of treatment and remediation of a psychiatric condition | 6-unit maximum |
Field Name and Number | Instructions for Completion |
1. Type of Coverage 1a. Insured's I.D. Number | This field is not required for Medicaid. Enter the patient's 10-digit Medicaid identification number. |
2. Patient's Name | Enter the patient's last name and first name. |
3. Patient's Birth Date Sex | Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card. Check "M" for male or "F" for female. |
4. Insured's Name | Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial. |
5. Patient's Address | Optional entry. Enter the patient's full mailing address, including street number and name, (post office box or RFD), city name, state name and zip code. |
6. Patient Relationship to Insured | Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim. |
7. Insured's Address | Required if insured's address is different from the patient's address. |
8. Patient Status | This field is not required for Medicaid. |
9. Other Insured's Name a. Other Insured's Policy or Group Number b. Other Insured's Date of Birth Sex c. Employer's Name or School Name d. Insurance Plan Name or Program Name | If patient has other insurance coverage as indicated in Field 11D, enter the other insured's Jast name, first name and middle initial. Enter the policy or group number of the other insured. This field is not required for Medicaid. This field is not required for Medicaid. Enter the employer's name or school name. Enter the name of the insurance company. |
10. Is Patient's Condition Related to: a. Employment b. Auto Accident | Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO." Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter state postal abbreviation) where the accident took place. Check "NO" if not auto accident related. |
c. Other Accident 10d. Reserved for Local Use | Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related. This field is not required for Medicaid. |
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? | Enter the insured's policy group or FECA number. This field is not required for Medicaid. This field is not required for Medicaid. Enter the insured's employer's name or school name. Enter the name of the insurance company. Check the appropriate box indicating whether there is another health benefit plan. |
12. Patient's or Authorized Person's Signature | This field is not required for Medicaid. |
13. Insured's or Authorized Person's Signature | This field is not required for Medicaid. |
14. Date of Current: Illness Injury Pregnancy | Required only if medical care being billed is related to an accident. Enter the date of the accident. |
15. If Patient Has Had Same or Similar Illness, Give First Date | This field is not required for Medicaid. |
16. Dates Patient Unable to Work in Current Occupation | This field is not required for Medicaid. |
17. Name of Referring Physician or Other Source 17a. I.D. Number of Referring Physician | Enter the name of the referring physician. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. Enter the 9-digit Medicaid provider number of the referring physician. |
18. Hospitalization Dates Related to Current Services | For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format. |
19. Reserved for Local Use | Not applicable to SBMH. |
20. Outside Lab? | This field is not required for Medicaid. |
21. Diagnosis or Nature of Illness or Injury | Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with CMS diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service. |
22. Medicaid Resubmission Code Original Ref No. | Reserved for future use. Reserved for future use. |
23. Prior Authorization Number | Enter the prior authorization number, if applicable. |
24. A. Dates of Service B. Place of Service C. Type of Service D. Procedures, Services or Supplies CPT/HCPCS Modifier E. Diagnosis Code F. $ Charges G. Days or Units H. EPSDT/Family Plan i. EMG J. COB K. Reserved for Local Use | Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service. 1. On a single claim detail (one charge on one line), bill only for services within a single calendar month. 2. Providers may bill, on the same claim detail, for two (2) or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the span. Enter the appropriate place of service code. See Section 272.200 for codes. Enter the appropriate type of service code. See Section 272.200 for codes. Enter the correct CPT or HCPCS procedure code. Use applicable modifier. Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM. Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed. Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A. Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral. Emergency - This field is not required for Medicaid. Coordination of Benefit - This field is not required for Medicaid. When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#." When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#." |
25. Federal Tax I.D. Number | This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. Patient's Account No. | This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted. |
27. Accept Assignment | This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid. |
28. Total Charge | Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.) |
29. Amount Paid | Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. (See NOTE below Field 30.) |
30. Balance Due | Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. NOTE: For Fields 28, 29 and 30, up to 26 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due. |
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. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office) | If other than home or office, enter the name and address, specifying the street, city, state and zip code of the facility where services were performed. |
33. Physician's/Supplier's Billing Name, Address, ZIP Code & Phone # PIN# GRP# | Enter the billing provider's name and complete address. Telephone number is requested but not required. This field is not required for Medicaid. Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K. Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#." |
016.06.05 Ark. Code R. 052