016-06-05 Ark. Code R. § 62
Field Number and Name | Description |
1. Provider Name, Address and Telephone Number | Inpatient and Outpatient: Enter the provider's name, city, state, ZIP code and telephone number. |
2. Unassigned Data Field | |
3. Patient Control Number | Inpatient and Outpatient: The provider may use this optional field for accounting purposes. Up to 16 numeric or alphabetic characters are accepted. |
4. Type of Bill | Inpatient and Outpatient: Enter the applicable three-digit code found in the National Uniform Billing Data Element Specifications Manual (the "Uniform Billing Manual") for the type of bill. |
5. Federal Tax Number | This locator is not required for Medicaid. |
6. Statement Covers Period | Enter the beginning and ending service dates (MMDDYY) of the period covered by this claim. Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields of this locator. The FROM and THROUGH dates in FL 6 may not span the State's fiscal year end or the provider's fiscal year end. To file correctly for covered inpatient days that span a fiscal year end: 1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that has ended. On a first claim or a continuing claim, the patient status code in FL 22 must indicate that the beneficiary is still a patient on the THROUGH date in order for the THROUGH date to be payable. 2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. When the discharge date is the first day of the provider's fiscal year or the State's fiscal year, only one (admission through discharge) claim is necessary, because Medicaid does not reimburse a hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. When an inpatient is discharged on the same date he or she is admitted, the day is covered when the type of bill code indicates that the claim is for admission through discharge, the patient status code indicates discharge or transfer and the FROM and THROUGH dates are the same. |
fields of this locator. The dates in this locator must fall within the same fiscal year - the State's fiscal year and the hospital's fiscal year. When billing for multiple dates of service on a single claim, a date of service is required in FL 45 for each HCPCS and/or revenue code in FL 42 and FL 44. | |
7. Covered Days | Inpatient: Enter the number of days being billed on this claim. A "Medicaid covered day" is a medically necessary inpatient day that is not part of a hospital stay for a non-payable procedure or a non-authorized procedure, a day for which the beneficiary is Medicaid eligible and has available inpatient benefits and a day for which a Medicaid claim is timely filed. Outpatient: Not applicable to outpatient claims. |
8. Non-Covered Days | This locator is not required for Medicaid. |
9. Coinsurance Days | This locator is not required for Medicaid. |
10. Lifetime Reserve Days | This locator is not required for Medicaid. |
11. Unassigned Data Field | |
12. Patient's Name | Inpatient and Outpatient: Enter the patient's last name, first name and middle initial. |
13. Patient's Address | Inpatient and Outpatient: Optional entry. Enter the patient's full mailing address. |
14. Patient's Birth Date | Inpatient and Outpatient: Enter the patient's date of birth in MM/DD/YY format. |
15. Patient's Sex | Inpatient and Outpatient: Enter "M" for male or "F" for female. |
16. Patient's Marital Status | This locator is not required for Medicaid. |
17. Admission Date | Inpatient: Enter the date of admission for inpatient services. Outpatient: Not required for outpatient claims. |
18. Admission Hour | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient or outpatient care. Outpatient Only: When a beneficiary is admitted for outpatient services more than once in a day, file a separate claim for each admission. |
19. Type of Admission | Inpatient: Enter the code from the Uniform Billing Manual that indicates the priority of this inpatient admission. Outpatient: Not required for outpatient claims. |
20. Source of Admission | Inpatient and Outpatient: Required for inpatient and outpatient. |
21. Discharge Hour | Inpatient and Outpatient: Enter the hour the patient was discharged from inpatient or outpatient care. |
22. Patient's Status | Inpatient: Enter the national code indicating the patient's status as of the statement covers THROUGH date (FL 6). Outpatient: Not applicable |
23. Medical Record Number | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
24- Condition Codes 30. | Inpatient and Outpatient: Required when applicable. Refer to the Uniform Billing Manual for the codes used to identify conditions relating to this bill. |
31. Unassigned Data Field | |
32- Occurrence Codes and 35. Dates | Inpatient and Outpatient: Required when applicable. Refer to the Uniform Billing Manual for codes defining significant events related to this bill. |
36. Occurrence Span Codes and Dates | Inpatient: Enter the first and last days approved, per the facility's PSRO/UR plan, in the FROM and THROUGH fields. Outpatient: Not applicable |
37- Unassigned Data Fields 38. | |
39- Value Codes and 41. Amounts | This locator is not required for Medicaid. |
42. Revenue Code | Inpatient and Outpatient: Enter applicable revenue codes as directed by the Uniform Billing Manual, this provider manual and official Medicaid correspondence. |
43. Revenue Description | Inpatient and Outpatient: Enter the description of the revenue code in FL 42 or the HCPCS procedure code in FL 44. |
44. HCPCS/Rates | Inpatient and Outpatient: Enter a HCPCS procedure code when directed by this manual or official Medicaid correspondence. |
45. Service Date | Inpatient: Not applicable Outpatient: When billing for more than one date of service on a single claim, enter a date of service for each charge. |
46. Units of Service | Inpatient: Enter the number of covered days for each accommodation revenue code entered in FL 46. The aggregate units for all accommodation revenue codes must equal the total covered days billed in FL 7. For all other revenue codes, enter the aggregate units of service furnished on Medicaid-covered days only. Outpatient: Enter the quantitative measure of each service provided for the patient on each date of service indicated. |
47. Total Charges | Inpatient: Enter only the charges for ancillary and accommodation services provided on Medicaid-covered days. Do not report non-covered charges on Medicaid billings. Outpatient: Enter the charge for each service for each date of service. |
48. Non-Covered Charges | This locator is not applicable to Medicaid. |
49. Unassigned Data Field | |
50. Payer Identification | Inpatient and Outpatient: Enter the name of each payer from which the provider might expect some payment for the bill, including Medicaid. List payers in order of responsibility, i.e., primary, secondary, etc. |
51. Medicaid Provider Number | Inpatient and Outpatient: Enter the hospital's 9-digit Arkansas Medicaid provider number. |
52. Release of Information Certificate Indicator | This locator is not required by Medicaid. |
53. Assignment of Benefits Certification Indicator | This locator is not required by Medicaid. |
54. Prior Payments | Inpatient and Outpatient: Required when applicable. Enter each amount the hospital has received toward payment of this bill before billing Medicaid. Each amount must correspond to a payer listed in FL 50, in order of responsibility. |
55. Estimated Amount Due | This locator is not applicable to Medicaid. |
56- Unassigned Data Fields 57. | |
58. A, Insured's Name B, C | Inpatient and Outpatient: Complete this locator according to the instructions in the Uniform Billing Manual. |
59. A, Patient's Relationship to B, C Insured | Inpatient and Outpatient: Enter the appropriate code as referenced in the Uniform Billing Manual indicating the relationship of the patient to the identified insured. |
60. A, Identification Number B, C | Inpatient and Outpatient: Enter the insured's unique identification number assigned by the payer organization on the line corresponding to the payer listed in FL 50. Enter the patient's Medicaid identification number. |
61. A, Insured Group Name B, C | Inpatient and Outpatient: Enter the insured's group plan name if the patient is insured by another payer. |
62. A, Insurance Group B, C Number | Inpatient and Outpatient: Enter the insured's group plan number if the patient is insured by another payer. |
63. A, Treatment Authorization B, C Code | Inpatient: Enter any applicable prior authorization or MUMP certification number. Outpatient: Enter any applicable prior authorization number. |
64. A, Employment Status B, C Code | This locator is not applicable to Medicaid. |
65. A, Employer Name B, C | Inpatient and Outpatient: When applicable, based upon FL 61 through 64, enter the name of the employer that provides health care coverage for the patient. |
66. A, Employer Location B, C | Inpatient and Outpatient: When applicable, enter the location of the insured's employer. |
67. Principal Diagnosis Code | Inpatient: Enter the ICD-9-CM code for the principal discharge diagnosis. Outpatient: Enter the ICD-9-CM code describing the primary condition for which the patient is receiving outpatient services. |
68- Other Diagnosis Codes 75. | Inpatient and Outpatient: Enter the ICD-9-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and which have an effect on the treatment received or the length of stay. |
76. Admitting Diagnosis Code | Inpatient: Enter the ICD-9-CM diagnosis code corresponding to the diagnosis that prompted the patient's admission to the hospital. Outpatient: Not required |
77. E Code | This locator is not required by Medicaid. |
78. Unassigned Data Field | |
79. Procedure Coding Method Used | This locator is not required for Medicaid. |
80- Principal and Other 81. Procedure Codes and Dates | Inpatient: Enter the HCPCS procedure codes identifying the surgical/obstetrical procedures performed and the dates (MMDD) on which those procedures were performed. On all interim claims, enter the procedure codes that apply to the complete hospital stay. Outpatient: Not applicable |
82. Attending Physician ID | Inpatient and Outpatient: Required. Enter the name and state license number of the primary attending physician. On claims from hospitals outside Arkansas, if the attending physician is not enrolled in Arkansas Medicaid, enter the physician's name, followed by the letters "NP," followed by the physician's license number. |
83. Other Physician ID First Field Second Field | Inpatient: Required when there is surgery. Enter the name and state license number of the operating surgeon. Inpatient and Outpatient: Required when applicable. When the patient has been referred by his or her PCP to the attending (admitting) physician, enter the PCP's name and Medicaid provider number. |
84. Remarks | For provider's use. |
85. Provider Representative Signature | Inpatient and Outpatient: 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 hospital is not acceptable. |
86. Date Bill Submitted | Inpatient and Outpatient: Enter the date the bill was signed or sent to the Arkansas Medicaid Program for payment. |
016.06.05 Ark. Code R. § 062