016-06-05 Ark. Code R. § 100
Section I imparts general program information about the Arkansas Medicaid Program. It includes information about beneficiary eligibility and explains the provider's role and responsibilities in utilizing the program. The Primary Care Case Management (PCCM) Program is explained in detail. The information conveyed will provide users with an understanding of Medicaid Program policy. It also contains information the provider may need to answer questions often asked about the Medicaid Program.
Four major areas are covered in Section I.
Provider manuals contain the policies and procedures of the Arkansas Medicaid Program. These policies and procedures are generally based on federal and state laws and federal regulations. Medicaid provider manual policy and procedures, and changes thereto, will be promulgated as required by the state's Administrative Procedure Act.
When fully utilized, each program manual is an effective tool for the provider. It provides information about the Medicaid Program, covered and non-covered services, billing procedures and detailed instructions for accurate completion of claims.
Provider manuals are available at the Arkansas Medicaid Web site
(http://www.medicaid.state.ar.us), on the Arkansas Medicaid Provider Reference compact disc (CD) and on paper. As new providers are enrolled, they will be asked if they have Internet access to the provider manuals. Those who do not have Internet access will be asked to specify the medium they will use. Providers are encouraged, however, to use an electronic medium.
The manuals are organized as follows:
Sections I, III, IV and V are the same in each manual; only Section II is program and provider specific.
The manuals are divided into numbered sections with a heading and a revision date such as "101.000 Provider Manuals 4-1-06 ". Text that appears underlined and blue to Web site and CD users is "linked" to the information being referenced so that it may be viewed or printed. The paper version contains the same underlined text, though not in blue, so paper users must locate the "linked" information in Section V.
Provider manuals are updated when necessitated by changes in federal or state laws, changes in interpretations of the law, changes in federal regulations, changes in DMS policy and procedures and when clarifications are warranted. These changes are released to the provider in the form of a manual update, an official notice or a remittance advice (RA) message.
As changes are made, the changed sections are dated with the revision date of the change. The provider manuals on the Arkansas Medicaid Provider Reference CD, updated and issued twice a year, display the issue date in the footer on the left. Official notices and RAs issued during the previous quarter are also incorporated into this CD. This will enable the user to ensure that the latest version is being used. Since paper copies may be printed from the CD, the date will appear in the footer of printed copies.
Provider manual changes are made automatically on the Arkansas Medicaid Web site; providers are notified via e-mail or paper when an applicable manual update, official notice or RA is issued. Providers must supply an e-mail address to receive e-mail notification of any supplementary material.
Providers who receive paper copies of manual updates, official notices and RAs must maintain the paper supplements as they are received. Only the revised section(s) are issued in manual updates.
Policy and procedure changes are highlighted in the electronic media (Web site and CD) and are shaded in the paper manuals to aid the provider in quickly reviewing changes; minor wording changes are not highlighted. The highlighting feature is provided as a convenience to providers.
An update transmittal letter accompanies each manual update. Manual updates are assigned sequential identification numbers, e.g., Update Transmittal #1. The transmittal letter identifies the new sections being added and/or the sections being replaced or deleted, explains what is being changed and provides any other information about the update. Manual updates are recorded on the update log located in Appendix A of the manual.
For persons maintaining a printed copy of a manual, the updated manual sections should be manually filed in the provider manual, and the outdated sections should be crossed out or removed, as appropriate. The effective date should be entered on the update log opposite the appropriate update number. Transmittal letters should be filed immediately following the update log in descending numerical order by update number. Immediately following the transmittal letters should be the official notices, which are numbered sequentially and should be filed with the most recent first. The RAs will follow the official notices, with the most recent filed first.
The fiscal agent, EDS, will issue changes as directed by the Division of Medical Services (DMS).
All provider manuals, manual updates, official notices and RAs are available for downloading, without charge, from the Arkansas Medicaid Web site (http://www.medicaid.state.ar.us/).
Prior to enrollment, providers will be asked if they have Internet access. Those who do not have Internet access will choose if they want to receive their manual by CD or on paper.
At that time, providers choosing to use the CD will receive a copy of the Arkansas Medicaid Provider Reference CD and will receive the CD without charge. The providers using the CD will be asked if they want to receive manual updates, official notices and RAs pertaining to their program through e-mail notification or mailed paper copies. E-mail notifications contain a link to the Arkansas Medicaid Web site; therefore, Internet access is required for e-mail notifications.
Providers choosing a paper copy of their provider manual will be issued a paper copy without charge. These providers will receive paper copies of all manual updates, official notices and RAs that pertain to their program through the mail.
Persons, entities and organizations that are not enrolled providers may purchase a copy of the Arkansas Medicaid Provider Reference CD or a paper copy of a provider manual through EDS.
Enrolled providers may purchase extra copies of the Arkansas Medicaid Provider Reference CD or extra paper copies of a manual through EDS. See information below regarding purchasing copies.
The cost for a copy of the most recent Arkansas Medicaid Provider Reference CD is $10.00.
The cost for a printed copy of an Arkansas Medicaid provider manual is $125.00.
Orders for CDs and printed manuals should be sent to EDS, Technical Publications. A check for the appropriate amount should be included with the order and be written to "EDS". View or print the EDS manual order contact information.
Titles XIX and XXI of the Social Security Act created a joint federal-state medical assistance program commonly referred to as Medicaid. Ark. Code Ann. § 20-77-107 authorizes the Department of Health and Human Services to establish a Medicaid Program in Arkansas.
Title XIX of the Social Security Act provides for federal grants to states for medical assistance programs. The stated purpose of Title XIX is to enable the states to furnish the following:
The Medicaid Program is a joint federal-state program that provides necessary medical services to eligible persons who would not be able to pay for such services.
In Arkansas, the Division of Medical Services (DMS) administers the program. Within the Division, the Office of Long Term Care (OLTC) is responsible for nursing home policy and procedures.
The Arkansas Medicaid Program provides, with limitations, the services listed in sections 103.100 and 103.200.
Program | Coverage |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (Child Health Services) | Under Age 21 |
Family Planning | All Ages |
Federally Qualified Health Center (FQHC) | All Ages |
Home Health | All Ages |
Inpatient Hospital | All Ages |
Laboratory and X-Ray | All Ages |
Certified Nurse-Midwife | All Ages |
Nurse Practitioner | All Ages |
Nursing Facility | Age 21 or Older |
Outpatient Hospital | All Ages |
Physician | All Ages |
Rural Health Clinic | All Ages |
Program | Coverage |
Ambulatory Surgical Center | All Ages |
Audiological | Under Age 21 |
Certified Registered Nurse Anesthetist (CRNA) | All Ages |
Child Health Management Services (CHMS) | Under Age 21 |
Chiropractic Services | All Ages |
Dental Services | Under Age 21 |
Developmental Day Treatment Clinic Services (DDTCS) | Pre-School and Ages 18 and Over |
Developmental Rehabilitation Services | Under Age 3 |
Domiciliary Care | All Ages |
Durable Medical Equipment | All Ages |
End-Stage Renal Disease (ESRD) Facility Services | All Ages |
Hearing Aid Services | Under Age 21 |
Hospice | All Ages |
Hyperalimentation | All Ages |
Inpatient Psychiatric Services | Under Age 21 |
Intermediate Care Facility Services for Mentally Retarded | All Ages |
Medical Supplies | All Ages |
Nursing Facility | Under Age 21 |
Occupational, Physical and Speech Therapy | Under Age 21 |
Outpatient Mental Health Services | All Ages |
Orthotic Appliances | All Ages |
Personal Care | All Ages |
Podiatrist | All Ages |
Portable X-Ray | All Ages |
Prescription Drugs | All Ages |
Private Duty Nursing Services (High Technology, Non-Ventilator Dependant, EPSDT Program) | Under Age 21 |
Private Duty Nursing Services (Ventilator-Dependent) | All Ages |
Prosthetic Devices | All Ages |
Rehabilitative Hospital and Extended Rehabilitative Hospital Services | All Ages |
Rehabilitative Services for Persons with Mental Illness (RSPMI) | All Ages |
Rehabilitative Services for Persons with Physical Disabilities (RSPD) | Under Age 21 |
Respiratory Care | Under Age 21 |
Targeted Case Management for Beneficiaries of Children's Medical Services (CMS) | Under Age 21 |
Targeted Case Management for Pregnant Women | Women Ages 14 to 44 |
Targeted Case Management for Beneficiaries Age 22 and Older with a Developmental Disability | Age 22 or Older |
Targeted Case Management for Beneficiaries Age 60 and Older | Age 60 or Older |
Targeted Case Management for Beneficiaries in the Division of Children and Family Services | Under Age 21 |
Targeted Case Management for Beneficiaries in the Division of Youth Services | Under Age 21 |
Targeted Case Management for Beneficiaries in the Child Health Services (EPSDT) Program | Under Age 21 |
Targeted Case Management for Beneficiaries under Age 21 with a Developmental Disability | Under Age 21 |
Targeted Case Management for SSI Beneficiaries and TEFRA Waiver Beneficiaries | Under Age 17 |
Transportation Services (Ambulance, Non-Emergency) | All Ages |
Ventilator Equipment | All Ages |
Visual Care | All Ages |
Program
Medicaid covers certain services only through the Child Health Services (EPSDT) Program for individuals underage 21. See the Child Health Services (EPSDT) manual and the appropriate provider program manual for more information.
The services detailed in Sections 105.100 through 105.190 are available for eligible beneficiaries through waivers of federal regulations.
The Alternatives for Adults with Physical Disabilities (APD) waiver has been designed for disabled individuals age 21 through 64 who receive Supplemental Security Income (SSI) or are Medicaid eligible by virtue of their disability and who, without the provision of the services, would require a nursing facility level of care.
APD eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
The services offered through the waiver are:
These services are available only to individuals who are eligible under the waiver's conditions. More detailed information is found in the APD provider manual.
ARKids First-B was designed to integrate uninsured children age 18 and under into the health care system. ARKids First-B benefits are comparable to those of the state employees/teachers insurance program. Most services require cost sharing.
The following is a summary of the eligibility criteria for ARKids First-B:
For more information, refer to the ARKids First-B provider manual and to the Arkansas Medicaid Web site at www.medicaid.state.ar.us.
In ConnectCare, a Medicaid beneficiary selects and enrolls with a primary care physician (PCP) that has contracted with DMS to be responsible for managing the health care of a limited number (a number chosen by the PCP, between 10 and 1000) of Medicaid beneficiaries.
A PCP contracts with DMS to provide primary care, health education and case management for a self-limited number of Medicaid enrollees. DMS pays the PCP a monthly per-enrollee case management fee in addition to the regular Medicaid fee-for-service reimbursement.
The PCP is responsible for referring enrollees to specialists and other providers, which includes the responsibility for deciding whether a particular referral is medically necessary. A PCP may make such decisions in consultation with physicians or other professionals as needed and in accordance with his or her medical training and experience; however, a PCP is not required to make any referral simply because it is requested.
A PCP coordinates his or her enrollees' medical and rehabilitative services with the providers of those services. Medical and rehabilitative professionals to whom a PCP refers a patient are required to report to or consult with the PCP so that the PCP can coordinate care and monitor an enrollee's status, progress and outcomes.
Most Medicaid-eligible individuals, as well as children participating in ARKids First-B, must enroll with a PCP in order to receive Medicaid-covered or ARKids First-B services. Some individuals are not required to enroll with a PCP. A few services are covered for all Medicaid and ARKids First-B eligibles without PCP referral. See Sections 170.000 through 183.000 for details regarding ConnectCare.
The Developmental Disability Services Alternative Community Services (DDS ACS) Waiver is designed for individuals who, without the services, would require institutionalization and could not otherwise reside in the community. Participants must not be residents of a hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).
DDS ACS eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-
effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.
Services supplied through this program are:
More detailed information may be found in the DDS ACS Waiver provider manual.
ElderChoices is designed for individuals age 65 and over, who, without the services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain Medicaid-eligible individuals at home in order to preclude or postpone institutionalization.
ElderChoices eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based waiver services and institutional services.
More detailed information may be found in the ElderChoices provider manual.
The Division of Aging and Adult Services (DAAS) and the Division of Medical Services (DMS) jointly administer Independent Choices, a Section 1115 demonstration project. Participants in this project choose to forego traditional personal care services furnished by a Medicaid-enrolled agency in exchange for the right to direct their own care (consumer direction). Individuals that choose Independent Choices accept the risks, rights and responsibilities that consumer direction involves.
A participant may hire one or more assistants, employing whomever he or she wishes except his or her spouse or a person to whom a court of law has granted legal responsibility for the participant ("a guardian of the person"). Medicaid provides each participant with a cash allowance that the participant uses to meet his or her personal care needs. Participants pay their assistants from their cash allowance. Additionally, the participants may use cash allowance funds for certain other purchases when those purchases are included in their individualized cash expenditure plan.
Independent Choices includes individualized counseling and fiscal agent services provided by counseling fiscal agencies (CFA) that contract with Medicaid for those purposes. Each participant has a designated CFA. A CFA is responsible for educating each of its assigned Independent Choices participants in consumer direction. CFAs are also required to help participants develop and maintain an individualized cash expenditure plan and to provide participants with bookkeeping services related to cash allowance receipts and disbursements.
More detailed information may be found in the Independent Choices Manual.
Living Choices Assisted Living is a home and community-based services waiver that is administered jointly by the Division of Aging and Adult Services (DAAS) and the Division of Medical Services (DMS). Qualifying individuals are persons aged 21 and older who are blind, elderly or disabled and who have been determined by Medicaid to be eligible for an intermediate level of care in a nursing facility.
Parti cipants in Living Choices must reside in Level II assisted living facilities (ALFs), in apartment-style living units. The assisted living environment encourages and protects individuality, privacy, dignity and independence. Each Living Choices participant receives personal, health and social services in accordance with an individualized plan of care developed and maintained in cooperation with a DAAS-employed registered nurse. A participant's individualized plan of care is designed to promote and nurture his or her optimal health and well being.
Living Choices providers furnish "bundled services" in the amount, frequency and duration required by the Living Choices plans of care. They facilitate participants' access to medically necessary services that are not components of Living Choices bundled services, but which are ordered by participants' plans of care. Living Choices providers receive per diem Medicaid reimbursement for each day a participant is in residence and receives services. The per diem amount is based on a participant's "tier of need", which DAAS-employed RNs determine and periodically re-determine by means of comprehensive assessments performed in accordance with established medical criteria. There are four tiers of need.
Living Choices participants are eligible to receive up to nine Medicaid-covered prescriptions per month. More detailed information may be found in the Living Choices Assisted Living provider manual.
Medicaid non-emergency transportation (NET) services for Medicaid beneficiaries are furnished, under the authority of a capitated selective contract waiver, by twelve regional brokers. Medicaid beneficiaries contact their local transportation broker for non-emergency transportation to appointments with Medicaid providers.
Providers transporting Medicaid beneficiaries to Developmental Day Treatment Clinic Service (DDTCS) providers for DDTCS services have been allowed to remain enrolled as fee for service providers for that purpose only, if they so choose. All other Medicaid non-emergency transportation for DDTCS clients must be obtained through the regional broker.
The Arkansas Medicaid non-emergency transportation waiver program does not include transportation services for:
More detailed information may be found in the Transportation provider manual and on the Arkansas Medicaid Web site at www.medicaid.state.ar.us.
The Arkansas Department of Health and Human Services implemented the Family Planning Demonstration Waiver Program in September of 1997. The demonstration was renamed the Women's Health Demonstration Program in 2002. Eligibility for the program is limited to women of childbearing age who are not currently certified in any other Medicaid category. The target population contains women age 14 to age 44, but all women at risk of unintended pregnancy are allowed to apply for the program. The family income must be at or below 200% of the Federal Poverty Level.
Participants are not required to have a photo Medicaid identification card. Their Medicaid coverage entitles them to receive only Medicaid covered family planning services. Beneficiaries may use the participating and willing provider of their choice.
The Utilization Review (UR) Section of the Arkansas Medicaid Program has the responsibility for assuring quality medical care for Medicaid beneficiaries along with protecting the integrity of both state and federal funds supporting the Medicaid Program.
The tasks of the Utilization Review Section are mandated by federal regulations. The nature of these reviews is to review documentation for services provided and evaluate the medical necessity of the delivered services. Review analysts may request additional information regarding the provider's medical practice.
The Utilization Review Section is also responsible for conducting on-site medical audits for the purpose of verifying the nature and extent of services paid for by the Medicaid Program. Providers selected for an on-site audit will not be notified in advance.
Each Medicaid provider is required to contemporaneously create and maintain records that completely and accurately explain all evaluations, care, diagnoses and any other activities of the provider in connection with its delivery of medical assistance to any Medicaid beneficiary. Pertinent records concerning the provision of Medicaid covered health care services are to be made available upon request during regular business hours to DMS, its contractors and designees and the Medicaid Fraud Control Unit.
When records are stored off-premise or are in active use, the audited provider may certify, in writing, that the records in question are in active use or off-premise storage and set a date and hour within three (3) working days, at which time the records will be made available. However, the provider will not be allowed to delay for matters of convenience, including availability of personnel.
The UR section is also responsible for researching all inquiries from beneficiaries in response to the Explanation of Medicaid Benefits (EOMB) and for reviewing requests for procedures and services requiring prior authorization.
The Utilization Review Section is responsible for the recoupment of Medicaid funds from providers. Situations resulting in recoupment include, but are not limited to, the following:
When a recoupment decision is made, UR will forward a Notice of Decision/Action to the provider. This notice must comply with section 190.006 of this manual and must include the name(s) of the patient(s), date(s) of service, date(s) of payment and the reason(s) for the recoupment decision.
Upon receipt of this notice, the provider has thirty (30) calendar days in which to pursue one of the following actions:
See sections 160.000 through 169.000 for rules and procedures related to administrative reconsideration and appeals.
Any questions regarding provider enrollment, participation requirements and/or contracts should be directed to the Provider Enrollment unit. View or print the Provider Enrollment contact information.
EDS, a contractor, performs provider relations and the processing of Medicaid claims. EDS Provider Representatives are available to assist providers with detailed billing or policy questions and to schedule on-site technical assistance. To contact a representative, providers may call the Provider Assistance Center. View or print the EDS Provider Assistance Center contact information.
The Utilization Review Section of the Division of Medical Services is available to assist providers with questions regarding extension of benefits and prior authorization of services for individuals age 21 and over, and for specified services for individuals under age 21, with the exception of prescription drug prior authorizations. View or print the Utilization Review contact information.The Personal Care, Inpatient Psychiatric and Home Health Units are located within the Utilization Review Section.
Arkansas Foundation for Medical Care, Inc., (AFMC) performs medical and/or surgical prior authorizations. View or print the AFMC contact information.
Customer Assistance, a section of the Division of County Operations, handles beneficiary inquiries regarding Medicaid eligibility and the Medicaid identification card. View or print the Division of County Operations Customer Assistance Section contact information.
Any materials needed in an alternate format, such as large print, can be obtained by contacting the Americans with Disabilities Act Coordinator. View or print the Americans with Disabilities Act Coordinator contact information.
This unit responds to Medicaid beneficiary inquiries regarding Medicaid coverage and benefits, assists out-of-state providers with claim filing procedures, verifies beneficiary eligibility and maintains beneficiary correspondence files. View or print the Program Communications Unit contact information.
The dental coordinator assists providers with questions regarding dental services. View or print the Dental Coordinator contact information.
The visual care coordinator assists providers with questions regarding visual care services. View or print the Visual Care Coordinator contact information.
EDS, the fiscal agent, has a Provider Assistance Center that is available for billing questions. View or print the EDS Provider Assistance Center contact information.
The state's Program Communications Unit is available to answer providers' questions and direct their telephone calls. View or print the Program Communications Unit contact information.
Eligibility is based on many factors that vary depending on the beneficiary's aid category. Eligibility factors often include income, resources, age or disability, current residency in Arkansas and other factors.
The Department of Health and Human Services (DHHS) local county offices or district Social Security offices determine beneficiary eligibility certification. The category of aid each office is responsible for is described below. The Department of Health determines presumptive eligibility for certain Medicaid categories.
Family Support Specialists in the DHHS county offices are responsible for evaluating the circumstances of an individual or family to determine eligibility, and if eligible, the proper aid category through which Medicaid should be received.
After evaluation, the DHHS county office establishes Medicaid eligibility dates in accordance with state and federal policy and regulations. See sections 123.000 and 124.000 of this manual for further explanation.
Social Security representatives are responsible for evaluating an individual's circumstances to determine eligibility for the Supplementary Security Income (SSI) program administered by the Social Security Administration. SSI includes aged, blind and disabled categories. The SSI aid categories are listed in Section 124.000.
To be eligible for SSI, an aged, blind or disabled person must also meet income, resource and other eligibility criteria.
Individuals entitled to SSI automatically receive Medicaid.
Within the DHHS office, the Division of Health determines presumptive eligibility for category 62, titled Pregnant Women-Presumptive Eligibility. The Division of Health is the designated application point for Breast and Cervical Cancer Prevention and Treatment and for Tuberculosis aid categories; however, the Division of County Operations makes the final eligibility determination.
Under its contract with the Division of Medical Services, EDS has deployed Provider Electronic Solutions Application (PES) technology. With PES, Medicaid providers are able to verify a patient's Medicaid eligibility for a specific date or range of dates, including retroactive eligibility for the past year. Providers may obtain other useful information, such as the status of benefits used during the current fiscal year, other insurance or Medicare coverage, etc. See Section III of this manual for further information on PES and other electronic solutions.
EDS and DMS will verify Medicaid eligibility by telephone only for "Limited Services Providers" (see Section II) in non-bordering states and in the case of retroactive eligibility for dates of service that are more than a year prior to the eligibility authorization date.
Beneficiary eligibility in the Arkansas Medicaid Program is date specific. Medicaid eligibility may begin or end on any day of a month. A PES electronic response displays the current eligibility period through the date of the inquiry.
Medicaid beneficiaries may be eligible for Medicaid benefits for the three-month period prior to the date of application provided eligibility requirements for that three-month period are met. The DHHS county offices establish retroactive eligibility.
DMS must notify a Medicaid beneficiary when a claim for Medicaid payment is denied, in whole or in part, or is not acted upon with reasonable promptness. The notice must comply with section 191.002 of this manual and it must include the following:
If the notice indicates the beneficiary is not responsible for the unpaid amount, the provider may not request payment from the beneficiary. If the letter indicates the beneficiary is responsible for the unpaid amount, the provider may contact the beneficiary for payment. For program information regarding the beneficiary's responsibilities, refer to section 132.000 of this manual. View or print an example of the beneficiary notification of denied Medicaid claim.
When a beneficiary disagrees with the Medicaid claim denial, he or she may appeal. See sections 191.000 - 191.006 for a complete explanation of beneficiary due process.
The beneficiary lock-in rule enables physicians and pharmacists to provide quality care and assures that the Medicaid Program does not unintentionally facilitate drug abuse or injury from overmedication or drug interaction.
If a beneficiary has utilized pharmacy services at a frequency or amount that is not medically necessary, as determined by a computerized algorithm and clinical review process, DMS can "lock-in" the beneficiary by requiring him or her to choose a single provider of pharmacy services. After lock-in, DMS will deny claims for pharmacy services submitted by any provider other than the selected provider. The selected provider will be notified prior to lock-in, so that adequate time is allowed for selection of another pharmacy if the selected provider cannot provide the needed services.
If a beneficiary fails or refuses to choose one provider, a list of providers used by the beneficiary will be reviewed and a provider will be chosen at random. DMS will ensure that the beneficiary has reasonable access, taking into account geographic location and reasonable travel time, to pharmacy services of adequate quality.
Before imposing lock-in, DMS or its agent will mail a notice to the beneficiary in accordance with the beneficiary due process rules found in section 191.000 of this manual. The notice will also inform the beneficiary of his or her right to request administrative reconsideration and outline that process. If the beneficiary does not appeal or request reconsideration, he must choose a pharmacy using the selection form enclosed with the notice.
When a beneficiary has been locked-in, eligibility verification transactions will reflect "lock-in to other provider." The restriction will be removed after demonstration by the beneficiary that the abusive situation has been corrected. Application of this rule will not result in the denial, suspension, termination, reduction or delay of medical assistance to any beneficiary.
Any provider who believes that a particular beneficiary should be considered for beneficiary lock-in should notify the Division of Medical Services, Pharmacy Unit/Utilization Review Section. View or print the Division of Medical Services, Pharmacy Unit/Utilization Review Section contact information.
The following is the full list of beneficiary aid categories. Some categories provide a full range of benefits while others may offer limited benefits or may require cost sharing by a beneficiary. The following codes describe each level of coverage.
FR full range
LB limited benefits
AC additional cost sharing
MNLB medically needy limited benefits
Category | Description | Code |
01 ARKIDS B | ARKids First Demonstration | LB, AC |
07BCC | Breast and Cervical Cancer Prevention and Treatment | FR |
08 TB-Limited | Tuberculosis - Limited Benefits | LB |
1N WD NewCo* | Working Disabled - New Cost Sharing (N) | FR, AC |
1R WD RegCo* | Working Disabled - Regular Medicaid Cost Sharing I | FR, AC |
11 AABD | AABD | FR |
13 SSI | SSI | FR |
14 SSI | SSI | FR |
16AA-EC | AA-EC | MNLB |
17AA-SD | Aid to the Aged Medically Needy Spend Down | MNLB |
18QMB-AA | Aid to the Aged-Qualified Medicare Beneficiary (QMB) | LB |
18 AR Seniors* | ARSeniors | FR |
20 AFDC-GRANT | Transitional Employment Assistance (TEA, formerly AFDC) Medicaid | FR |
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 |
46 AD-EC | Aid to the Disabled-Medically Needy Exceptional Category | MNLB |
47 AD-SD | Aid to the Disabled-Medically Needy Spend Down | MNLB |
48QMB-AD | Aid to the Disabled-Qualified Medicare Beneficiary (QMB) | LB |
49 TEFRA | TEFRA Waiver for Disabled Child | AC |
51 U-18 | Under Age 18 No Grant | FR |
52ARKIDSA | 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 |
58QI-1 | Qualifying lndividual-1 (Medicaid pays only the Medicare premium. | LB |
61 PW-PL | 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 (for the pregnant woman only) FR (for SOBRA children) |
62 PW-PE | Pregnant Women Presumptive Eligibility | LB |
63ARKIDSA | SOBRA Newborn | FR |
65 PW-NG | Pregnant Women No Grant | FR |
66 PW-EC | Pregnant Women Medically Needy Exceptional Category | MNLB |
67 PW-SD | Pregnant Women Medically Needy Spend Down | MNLB |
69 FAM PLAN | Family Planning Waiver | 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 |
87 RRP-SD | Refugee Resettlement Medically Needy Spend Down | MNLB |
88SLI-QMB | Specified Low Income Qualified Medicare Beneficiary (SMB) (Medicaid pays only the Medicare premium.) | LB |
8S AR Seniors* | ARSeniors | FR |
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 |
* In the system design, only 2 spaces have been allotted to the numerical designation for categories. Therefore, the Working Disabled category, which is category 10, is shown on the system as 1, plus the alpha character that designates the individual's level of cost sharing, i.e., 1Nor1R. See list for explanation.
Most Medicaid categories provide the full range of Medicaid services as specified in the Arkansas Medicaid State Plan. However, certain categories offer a limited benefit package. These categories are discussed below.
Act 407 of 1997 established the ARKids First Program. The ARKids First-B Program integrates uninsured children into the health care system. ARKids First-B benefits are comparable to the Arkansas state employees/teachers insurance program.
Covered services provided to ARKids First-B participants are within the same scope of services provided to Arkansas Medicaid beneficiaries, but may be subject to different benefit limits.
Refer to the ARKids First-B provider manual for the scope of each service covered under the ARKids First-B Program.
The medically needy category was established to provide medical care for those individuals who are medically eligible for benefits, but whose income and/or resources exceed the limits for other types of assistance but are insufficient to provide for all or part of their medical care. A full range of benefits is available for those individuals with the exception of long term care (which includes ICF/MR) and personal care services.
For more information regarding the medically needy program, providers may access the Medicaid Web site at www.medicaid.state.ar.us.
The infants and children in the SOBRA (Sixth Omnibus Budget Reconciliation Act of 1986) aid category receive the full range of Medicaid benefits; however, the pregnant women receive only services related to the pregnancy and services that if not provided could complicate the pregnancy.
Covered services are those that are related to the pregnancy and services that, if not provided, could complicate the pregnancy. Services are further limited to ambulatory prenatal care (hospitalization is not covered).
The Qualified Medicare Beneficiary (QMB) aid category was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low-income Medicare beneficiaries. If a person is eligible for QMB, Medicaid will pay the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance, less any Medicaid cost sharing, for other medical services. Medicaid will also pay the Medicare Part A premium, the Medicare Part A hospital deductible and the Medicare Part A coinsurance, less any Medicaid cost sharing. Certain QMBs are also eligible for Medicaid services.
To be eligible for QMB, individuals must be age 65 or older, blind or disabled and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal but cannot exceed 100% of the Federal Poverty Level (FPL).
Countable resources may equal but cannot exceed twice the current Supplemental Security Income (SSI) resource limitations.
Generally, individuals may not be certified in a QMB category and in another Medicaid category for simultaneous periods. However, QMBs may simultaneously receive assistance in the medically needy spend down categories of SOBRA pregnant women (61 and 62), Family Planning (69) and TB (08).
QMBs do not receive the full range of Medicaid benefits. For example, QMBs do not receive prescription drug benefits.
For a QMB eligible, Medicaid pays only his or her Medicare cost sharing (less the individual's Medicaid cost-sharing) for Medicare covered services.
Individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the electronic eligibility display to verify the QMB category of service. The category of service for a QMB will reflect QMB-AA, QMB-AB or QMB-AD. The system will display the current eligibility.
Not all providers are mandated to accept Medicare assignment on QMB eligibles (See Section 142.100). However, if a non-physician desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he or she must accept assignment on that claim and enter the information required by Medicare on assigned claims.
When treated by a provider who must accept Medicare assignment according to section 142.000 (Conditions of Participation) the beneficiary is not responsible for the difference between the billed charges and the Medicare allowed amount.
Interested individuals may apply for the QMB program at their local Department of Health and Human Services (DHHS) county office.
The Balanced Budget Act of 1997, Section 4732, (Public law 105-33) created the Qualifying lndividuals-1 (QI-1) aid category. Individuals eligible as QI-1 are not eligible for Medicaid benefits. They are eligible only for the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. Individuals eligible for QI-1 will not receive a Medicaid card, and, unlike QMBs and SMBs, may not be certified in another Medicaid category for simultaneous periods. Individuals who meet the eligibly requirements for both QI-1 and medically needy spend down will have to choose which coverage is wanted for a particular period of time.
Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A hospital insurance and Medicare Part B medical insurance. Countable income must be at least 120% but less than 135% of the current Federal Poverty Level.
Countable resources may equal but cannot exceed twice the current SSI resource limitations.
The Specified Low Income Medicare Beneficiaries Program (SMB) was mandated by Section 4501 of the Omnibus Budget Reconciliation Act of 1990.
Individuals eligible as specified low income Medicare beneficiaries (SMB) are not eligible for the full range of Medicaid benefits. They are eligible for only the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do not receive a Medicaid card.
Eligibility criteria for the SMB program are similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A hospital insurance and Medicare Part B medical insurance. Their countable income must be greater than, but not equal to 100% of the current Federal Poverty Level, and less than, but not equal to 120% of the current Federal Poverty Level.
The resource limit may be equal to but cannot exceed twice the current SSI resource limitations.
Interested individuals may apply for services at their local Department of Health and Human Services (DHHS) county office.
The TB aid category is for low-income individuals of all ages who are infected or who are suspected to be infected with TB. Application may be made through the Division of Health by contacting the local county health unit.
Individuals eligible in the TB aid category are not required to select a Primary Care Physician (PCP) since this is a limited services category.
Eligible individuals will receive only TB related services and only from the following service categories:
Only the following drugs are covered through the TB aid category:
Capreomycin/1 gm vial | Mycobutin/150 mg capsules |
Ethambutol/400 mg tablets | Pyrazinamide/500 mg tablets |
lsoniazid/100 mg tablets | Rifampin/150 mg capsules |
lsoniazid/300 mg tablets | Rifampin/300 mg capsules |
Levofloxacin/250 mg tablets | Isoniazid/Rifampin 150/300 mg capsules |
Levofloxacin/500 mg tablets | Streptomycin Sulfate, USP Sterile 1 gm/vial |
Women in aid category 69 (FP-W) are eligible for all family planning services, subject to the benefit limits listed in the appropriate provider manual.
Women in the FP-W category who elect sterilization are covered for one post-sterilization visit per state fiscal year (July 1 through June 30).
Certain programs require beneficiaries to share the cost for Medicaid services received. These programs are discussed below.
Covered services provided to ARKids First-B participants are within the same scope of services provided to Arkansas Medicaid beneficiaries, but may be subject to cost sharing requirements. See Section II of the ARKids First-B provider manual for a list of services that require cost sharing and the amount of participant liability for each service.
Eligibility category 49 contains children under age 19 who are eligible for Medicaid services as authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and amended by the Omnibus Budget Reduction Act. Children in category 49 receive the full range of Medicaid services. However, there are cost sharing requirements. Some parents are required to pay monthly premiums according to the chart below.
TEFRA Cost Share Schedule
Family Income | Monthly Prem | urns | ||
From | To | % | From | To |
$0 | $25,000 | 0.00% | $0 | $0 |
$25,001 | $50,000 | 1.00% | $21 | $42 |
$50,001 | $75,000 | 1.25% | $52 | $78 |
$75,001 | $100,000 | 1.50% | $94 | $125 |
From | To | % | From | To |
$100,001 | $125,000 | 1.75% | $146 | $182 |
$125,001 | $150,000 | 2.00% | $208 | $250 |
$150,001 | $175,000 | 2.25% | $281 | $328 |
$175,001 | $200,000 | 2.50% | $365 | $417 |
$200,001 | And above | 2.75% | $458 | $458 |
The maximum premium is $5,500 per year ($458 per month) for income levels of $200,001 and above.
The premiums listed above represent family responsibility. They will not increase if a family has more than one TEFRA eligible child.
The Working Disabled category is an employment initiative designed to serve as a "bridge" to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64 and who are disabled according to Supplemental Security Income (SSI) criteria are eligible in this category.
There are two levels of cost sharing in this aid category, depending on the individual's income:
Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy and inpatient hospital). They are designated in the system as "WD RegCO".
Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".
The cost sharing amounts for the "WD NewCo" eligibles is listed in the chart below:
Program Services | New Co-Payment* |
Ambulance | $10 per trip |
Ambulatory Surgical Center | $10 per visit |
Audiological Services | $10 per visit |
Augmentative Communication Devices | 10% of the Medicaid maximum allowable amount |
Child Health Management Services | $10 per day |
Chiropractor | $10 per visit |
Dental (limited to individuals underage 21)** | $10 per visit (no co-pay on EPSDT dental screens) |
Developmental Disability Treatment Center | $10 per day |
Services | |
Diapers, Underpads and Incontinence Supplies | None |
Domiciliary Care | None |
Durable Medical Equipment (DME) | 20% of Medicaid maximum allowable amount per DME item |
Emergency Department: Emergency Services | $10 per visit |
Emergency Department: Non-emergency Services | $10 per visit |
End Stage Renal Disease Services | None |
Early and Periodic Screening, Diagnosis and Treatment | None |
Eyeglasses | None |
Family Planning Services | None |
Federally Qualified Health Center (FQHC) | $10 per visit |
Hearing Aids (not covered for individuals age 21 and over) | 10% of Medicaid maximum allowable amount. |
Home Health Services | $10 per visit |
Hospice | None |
Hospital: Inpatient | 25% of the hospital's Medicaid per diem for the first Medicaid-covered inpatient day |
Hospital: Outpatient | $10 per visit |
Hyperalimentation | 10% of Medicaid maximum allowable amount |
Immunizations | None |
Laboratory and X-Ray | $10 per encounter, regardless of the number of services per encounter |
Medical Supplies | None |
Inpatient Psychiatric Services for Under Age 21 | 25% of the hospital's Medicaid per diem for the first Medicaid-covered day |
Outpatient Mental and Behavioral Health | $10 per visit |
Nurse Practitioner | $10 per visit |
Private Duty Nursing | $10 per visit |
Certified Nurse Midwife | $10 per visit |
Orthodontia (not covered for individuals age 21 and older) | None |
Orthotic Appliances | 10% of Medicaid maximum allowable amount |
Personal Care | None |
Physician | $10 per visit |
Podiatry | $10 per visit |
Prescription Drugs | $10 for generic drugs; $15 for brand name |
Prosthetic Devices | $10% of Medicaid maximum allowable amount |
Rehabilitation Services for Persons with Physical Disabilities (RSPD) | 25% of first day's Medicaid in-patient per diem (first covered day) |
Rural Health Clinic | $10 per core service encounter |
Targeted Case Management | 10% of Medicaid maximum allowable rate per unit |
Occupational Therapy (Age 21 and older have limited coverage***) | $10 per visit |
Physical Therapy (Age 21 and older have limited coverage***) | $10 per visit |
Speech Therapy (Age 21 and older have limited coverage***) | $10 per visit |
Transportation (non-emergency) | None |
Ventilator Services | None |
Vision Care | $10 per visit |
* Exception: Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.
** Exception: Dental services for individuals age 21 and older must be medically necessary, because the individual is experiencing a life-threatening condition.
*** Exception: This service is NOT covered for individuals age 21 and older in the Occupational, Physical and Speech Therapy Program.
NOTE: Providers should consult the appropriate provider manual to determine coverage and benefits.
Medicaid beneficiaries are issued a magnetic identification card similar to a credit card. Each identification card displays a hologram, and for most Medicaid categories, a picture of the beneficiary. Children under the age of five, ARKids-B, nursing home and home and community-based waiver beneficiaries are not pictured. New beneficiaries of the Family Planning Wavier (Category 69) and ARKids-A are not pictured unless they were certified using an existing case number and have a previously issued photo ID card. The Division of County Operations issues the Medicaid identification card to Medicaid beneficiaries.
THE MEDICAID IDENTIFICATION CARD DOES NOT GUARANTEE ELIGIBILITY FOR A BENEFICIARY. Payment is subject to verification of beneficiary eligibility at the time services are provided. See section 123.000 for verification of beneficiary eligibility procedures, and Section III for electronic eligibility verification information.
The following is an explanation of information contained on a Medicaid ID card:
NOTE: ARKids First-B identification cards have a different appearance than the Medicaid identification card. See the ARKids First-B Manual for more information.
When beneficiaries report non-receipt or loss of a Medicaid card, refer them to the local DHHS County Office or the Division of County Operations, Customer Assistance. View or print the Division of County Operations, Customer Assistance contact information.
When a provider suspects misuse of a Medicaid identification card, the provider should contact the Utilization Review Section of Arkansas Division of Medical Services. An investigation will then be made. View or print the Utilization Review Section contact information.
Subject to cost-sharing responsibilities outlined in sections 133.000- 135.000, a beneficiary is not liable for the following:
The beneficiary is not responsible for insurance cost share amounts if the claim is for a Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as a Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by private insurance and the Medicaid maximum allowed amount. Medicaid will not make any payment if the amount received from the third party insurance is equal to or greater than the Medicaid allowable rate.
If an individual who makes payment at the time of service is later found to be Medicaid eligible and Medicaid is billed, the individual must be refunded the full amount of his or her payment for the covered service(s). If it is agreeable with the individual, these funds may be credited against unpaid non-covered services that are the responsibility of the beneficiary.
The beneficiary may not be billed for the completion and submission of a Medicaid claim form.
A beneficiary is responsible for:
The beneficiary is also responsible for any applicable cost-sharing amounts such as enrollment fees, premiums, deductibles, coinsurance, or co-payments imposed by the Medicaid Program pursuant to 42 C.F.R. §§ 447.50- 447.60 (2004). These cost-sharing responsibilities are outlined in sections 133.000 - 135.000 of this manual.
There are three forms of cost sharing in the Medicaid Program: co-insurance, co-payment and premiums. Each is discussed below.
Beneficiaries
For inpatient admissions, the coinsurance charge per admission for non-exempt Medicaid beneficiaries age 18 and older is 10% of the hospital's interim Medicaid per diem, applied on the first Medicaid covered day.
Example:
A Medicaid beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid interim per diem is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00; the beneficiary will pay $50.00 (10% Medicaid coinsurance rate).
Beneficiaries
For inpatient admissions, the coinsurance charge per admission for ARKids First-B beneficiaries is 20% of the hospital's Medicaid per diem, applied on the first Medicaid covered day.
Example:
An ARKids First-B beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1900.00 and the beneficiary will pay $100.00 (20% Medicaid coinsurance rate).
Eligible Beneficiaries
The coinsurance charge per admission for Medicaid beneficiaries, who are also Medicare Part A beneficiaries, is 10% of the hospital's Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.
Example:
A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.
If, on a subsequent admission, Medicare Part A assesses coinsurance; Medicaid will deduct from the Medicaid payment, an amount equal to 10% of one day's Medicaid per diem. The patient will be responsible for that amount.
Arkansas Medicaid has a beneficiary co-payment policy in the Pharmacy Program. The co-payment for the Pharmacy Program is applied per prescription. Non-exempt beneficiaries age 18 and older are responsible for paying the provider a co-payment amount based on the following table:
Medicaid Maximum Amount | Beneficiary Co-pay |
$10.00 or less | $0.50 |
$10.01 to $25.00 | $1.00 |
$25.01 to $50.00 | $2.00 |
$50.01 or more | $3.00 |
Arkansas Medicaid has a recipient co-payment policy in the visual care program. Medicaid -eligible recipients who are 21 years or age and older must pay a $2.00 co-payment to the visual care provider for prescription services. Nursing home residents are excluded from this co-pay.
As required by 42 C.F.R. § 447.53(b), the following services are excluded from the beneficiary cost sharing (coinsurance/co-payment) policy:
The fact that a beneficiary is a resident of a nursing facility does not on its own exclude the Medicaid services provided to the beneficiary from the cost sharing policy. Unless a Medicaid beneficiary has applied for long term care assistance through the Arkansas Medicaid Program, been found eligible and Medicaid is making a vendor payment to the nursing facility (NF or ICF/MR) for the beneficiary, the Medicaid services are not excluded from the cost sharing policy.
The provider must maintain sufficient documentation in the beneficiary's medical record that substantiates the exclusion from the beneficiary cost sharing policy.
The method of collecting the coinsurance/co-payment amount from the beneficiary is the responsibility of the provider. In cases of claim adjustments, the responsibility of refunding or collecting additional cost sharing (coinsurance/co-payment) from the beneficiary will remain the responsibility of the provider.
The provider may not deny services to any eligible individual due to the individual's inability to pay the cost of the coinsurance/co-payment amount. However, the individual's inability to pay does not eliminate his or her liability for the coinsurance/co-payment charge.
The beneficiary's inability to pay the coinsurance/co-payment amount will not alter the Medicaid reimbursement amount for trie claim. Unless the beneficiary or service is excluded from the coinsurance/co-payment policy as listed in section 134.000, the Medicaid reimbursement amount will be calculated according to current reimbursement methodology minus the appropriate coinsurance amount or appropriate co-payment amount.
The Patient Self Determination Act of 1990, Sections 4206 and 4751 of the Omnibus Budget Reconciliation Act of 1990, P.L. 101-508 requires that Medicaid certified hospitals and other health care providers and organizations, give patients information about their right to make their own health decisions, including the right to accept or refuse medical treatment. This legislation does not require individuals to execute advance directives.
Medicaid certified hospitals, nursing facilities, hospices, home health agencies and personal care agencies must conform to the requirements imposed by Centers for Medicare & Medicaid Services (CMS). The federal requirements mandate conformity to current state law. Accordingly, providers must:
A description of advance directive must be distributed to each patient. View or print a sample form describing advance directives and a sample declaration form that meets the requirements of law.
Any provider of services must be enrolled in the Arkansas Medicaid Program before reimbursement may be made for any services provided to Arkansas Medicaid beneficiaries. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.
The Division of Medical Services has contracted with EDS to provide enrollment services for new providers and changes to current provider enrollment files. However, the unit will still be known as the Medicaid Provider Enrollment Unit.
Providers must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print the provider application (Form DMS-652), the Medicaid contract (Form DMS-653) and the Request for Taxpayer Identification Number and Certification (Form W-9).
A potential provider may complete the necessary forms for enrollment and submit them via the Internet by connecting to the Arkansas Medicaid web site at www.medicaid.state.ar.usor they may return the printed forms to the Medicaid Provider Enrollment Unit. View or print the Medicaid Provider Enrollment Unit contact information.
Section II of all provider manuals contains information relative to provider participation requirements.
Upon receipt and approval of the above information by the Medicaid Provider Enrollment Unit, a provider number will be assigned to each approved provider. This number must be used on all claims and correspondence submitted to Arkansas Medicaid.
Provider eligibility will be retroactive one year from the date the provider agreement is approved, the effective date of the provider's license or certification or the date a service became available through the Arkansas Medicaid Program, whichever date is the latest.
Instructions for billing and specific details concerning the Arkansas Medicaid Program are contained within this manual. Providers must read all sections of the manual beforesigning the contract. The manual is incorporated by reference into the Medicaid contract and providers must comply with its terms and conditions in order to participate in the Arkansas Medicaid Program.
All providers must sign an Arkansas Medicaid Provider Contract. The signature must be an original signature of the individual provider. The authorized representative of the provider must sign the contract for a group practice, hospital, agency or other institution.
Providers enrolled in the Arkansas Medicaid Program must agree to and meet the conditions of participation contained in sections 142.000 through 142.700.
This rule does not apply to:
A provider must submit, within 35 days of the date of a request by representatives of the Secretary of Health and Human Services or the Division of Medical Services, full and complete information about:
Crime
Before the Division of Medical Services enters into or renews a provider agreement, or at any time upon written request by DMS, the provider must disclose to DMS the identity of any person who:
Within thirty days a provider must refund any money the state is obligated to repay the federal government as a result of disallowance, recoupment or other adverse action in connection with Medicaid payments to the provider.
The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare claims for "physician" services furnished to individuals who are eligible for Medicare and Medicaid, including those eligible as qualified Medicare beneficiaries (QMBs). According to Medicare regulations, "physician" services, for the purpose of this policy, are services furnished by physicians, dentists, optometrists, chiropractors and podiatrists.
As described above, "physician" services furnished to an individual enrolled under Medicare who is also eligible for Medicaid ("QMB-plus"), including qualified Medicare beneficiaries (QMBs not eligible for benefits covered by Medicaid and not covered by Medicare), may only be made on an assignment-related basis.
Sanctions may be imposed against a provider for any one or more of the following reasons:
The following sanctions may be invoked against providers based on the grounds specified in Section 151.000:
If the Division of Medical Services identifies an act or omission for which a sanction may be issued, the Division will notify the provider of the act or omission in writing.
Unless a timely and complete request for administrative reconsideration or appeal is received by the Department of Health and Human Services, the findings of DHHS as set forth in the notice shall be considered a final and binding administrative determination.
When a provider has been sanctioned, the Department of Health and Human Services shall notify the applicable professional society, and any licensing, certifying or accrediting agency of the findings made and the sanctions imposed.
When a provider's participation in the Medicaid Program has been suspended or terminated, the Department of Health and Human Services shall notify the beneficiaries for whom the provider claims payment for services that such provider has been suspended or terminated. Such notice may include the reason for suspension or termination.
Upon receipt of reliable evidence that the circumstances involve fraud, willful misrepresentation or both, DMS may withhold Medicaid payments, in whole or in part, without first notifying the provider of its intention to withhold.
Wthin five days of taking the action, the Division of Medical Services will send a Notice of Non-Compliance (form DMS-635) that explains the reasons for withholding payment and the provider's right to administrative reconsideration or appeal.
All withholdings or payment actions will be temporary and will not continue after:
Administrative reconsideration does not postpone any adverse action that may be imposed pending appeal. Requests for reconsideration must be submitted as follows:
A request received within 35 calendar days of the written notice will be deemed timely. A request received later than 35 calendar days will be considered on an individual basis. The request must be mailed or delivered by hand. Faxed or emailed requests will not be accepted.
No administrative reconsideration is allowed if the adverse decision/action is due to loss of licensure, accreditation or certification.
Wthin 30 calendar days of receiving notice of adverse decision/action, or 10 calendar days of receiving an administrative reconsideration decision that upholds all or part of any adverse decision/action, whichever is later, the provider may appeal.
A notice of appeal must be in writing and state with particularity all findings, determinations, and adverse decisions/actions that the provider alleges are not supported by applicable laws (including state and federal laws and rules and applicable professional standards) or both. The appeal should be mailed or delivered to the Office of Appeals and Hearings, P.O. Box 1437, Slot N401, Little Rock, AR 72203-1437. No appeal is allowed if the adverse decision/action is due to loss of licensure, accreditation or certification.
When an appeal hearing is scheduled, the Office of Hearings and Appeals shall notify the provider or; if the provider is represented by an attorney, the provider's attorney, in writing, of the date, time and place of the hearing. Notice shall be mailed not less than 10 calendar days before the scheduled date of the hearing.
Individual providers may represent themselves. A partner may represent the partnership. A limited liability company or corporation may be represented by an officer or the chief operating official. A professional association may be represented by a principal of the association. Representatives must be courteous in all activities undertaken in connection with the appeal, and must obey the orders of the hearing officer regarding the presentation of the appeal. Failure to do so may result in exclusion from the appeal hearing, or the entry of an order denying discovery.
Any party may appear and be heard at any proceeding described herein through an attorney-at-law. All attorneys shall conform to the standards of conduct practiced by attorneys before the courts of Arkansas. If an attorney does not conform to those standards, the hearing officer may exclude the attorney from the proceeding.
A person appearing in a representative capacity shall file a written notice of appearance on behalf of a provider identifying himself by name, address and telephone number; identifying the party represented and shall have a written authorization to appear on behalf of the provider. The Department of Health and Human Services shall notify the provider in writing of the name and telephone number of its representative.
All papers filed in any proceeding shall be typewritten on legal-sized white paper using one side of the paper only. They shall bear a caption clearly showing the title of the proceeding and the docket number, if any.
The party and/or his authorized representative or attorney shall sign all papers, and all papers shall contain his/her address and telephone number. At a minimum, an original and two copies of all papers shall be filed with the Office of Hearings and Appeals.
A party shall arrange for the presence of his or her witnesses at the hearing.
At any time prior to the completion of the hearing, amendments to the adverse decision/action, the provider's notice of appeal, or both, may be allowed on just and reasonable terms to add or discontinue any party, change the allegations or defenses, or add new causes of action or defenses.
Where the Division of Medical Services seeks to add a party or a cause of action or change an allegation, notice shall be given pursuant to section 154.000, "Notice of Violation," and section 163.100, "Notice, Service and Proof of Service," to the appropriate parties except that the provisions of section 161.200, "Administrative Reconsideration," and section 162.000, "Notice of the Administrative Appeal Hearing," shall not apply.
Where a party other than the Division of Medical Services seeks to add a party or change a defense, notice shall be given pursuant to Section 163.100, "Notice, Service and Proof of Service."
The hearing officer shall continue the hearing for such time as he deems appropriate, and notice of the new date shall be given pursuant to Section 166.000, "Continuances or Additional Hearings."
Written notice of the time and place of a continued or additional hearing shall be given, except that when a continuance or additional hearing is ordered during a hearing, oral notice may be given to each party present.
If a party fails to appear at a hearing, the hearing officer may dismiss the appeal or enter a determination adverse to the non-appearing party. A copy of the decision shall be mailed to each party. The hearing officer may, upon motion, set aside the decision and reopen the hearing for mistake, inadvertence, surprise, excusable neglect, fraud, or misrepresentation.
The Division of Medical Services (DMS) shall tape-record the hearings, or cause the hearings to be tape-recorded. If the final DMS determination is appealed, the tape recording shall be transcribed, and copies of other documentary evidence shall be reproduced for filing under the Administrative Procedure Act.
ConnectCare enrollees may transfer their PCP enrollment at any time, for any stated reason.
A PCP may request that an individual transfer his or her PCP enrollment to another PCP because the arrangement with that individual is not acceptable to the PCP.
016.06.05 Ark. Code R. § 100