Section VClaim FormsRed-ink Claim Forms
The following is a listing of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information on where to get the forms and links to samples of the forms are available below. To view a sample of the form click the form name.
Claim Type | Where To Get Them |
Professional - CMS-1500 | Business Form Supplier |
Institutional - CMS-1450 | Business Form Supplier |
EPSDT - DMS-694** | EDS - 1-800-457 -4454 |
Visual Care - DMS-26-V | EDS - 1-800-457 -4454 |
Inpatient Crossover - EDS-MC-001 | EDS - 1-800-457 -4454 |
Long Term Care Crossover - EDS-MC-002 | EDS - 1-800-457 -4454 |
Outpatient Crossover - EDS-MC-003 | EDS - 1-800-457 -4454 |
Professional Crossover - EDS-MC-004 | EDS - 1-800-457 -4454 |
** A printable PROVIDER INTEROFFICE DOCUMENTATION ONLY version of this form is available below under Arkansas Medicaid Forms.
Claim Forms
The following is a listing of the non-red-ink claim forms required by Arkansas Medicaid. Information on where to get a supply of the forms and links to samples of the forms are available below. To view a sample of the form click the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form - | Client Employer |
AAS-9559 | |
Dental - ADA-J510 | Business Form Supplier |
Hospice/INH Claim Form - DHS-754 | EDS - 1-800-457 -4454 |
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name | Form Number |
Acknowledgement of Hysterectomy Information | DMS-2606 |
Address Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | EDS-AR-004 |
AFMC Personal Care Assessment and Service Plan for Medicaid Beneficiaries Under Age 21 | AFMC-201 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components | AFMC-103 |
AFMC Request For Bilaminate Skin Substitutes | AFMC-RBSS |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
Arkansas Medicaid Provider Application and Contract | DMS-652 |
ARKids First Mental Health Services Provider Qualification Form | DMS-612 |
Assisted Living Waiver Plan of Care | AAS-9565 |
Authorization for Payment for Services Provided | MAP-8 |
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2633 |
Certification of Schools to Provide Comprehensive EPSDT Services | CSPC-EPSDT |
Certification Statement for Abortion | DMS-2698 |
CHMS Benefit Extension for Diagnosis/Evaluation Procedures | AFMC-102 |
CHMS Request for Prior Authorization | AFMC-101 |
Claim Correction Request | DMS-2647 |
Consent for Release of Information | DMS-619 |
DDTCS Transportation Log | DMS-638 |
DDTCS Transportation Survey | DMS-632 |
Dental Treatment Additional Information | DMS-32-A |
Disproportionate Share Questionnaire | DMS-628 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Claim Form - You may print this version for use in charts and electronic billing documentation; however, if you submit a paper claim for billing, you must use the red-ink version (see Red-ink Claim Forms above.) | EPSDT-DMS-694 |
EPSDT Provider Agreement | DHHS-831 |
Evaluation Form Lower-Limb | DMS-646 |
Explanation of Check Refund | EDS-CR-002 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Hospital/Physician/Certified Nurse Midwife Referral for Newborn Infant Medicaid Coverage | DCO-645 |
Individual Renewal Form for DDTCS Therapists & School Based Therapists | DMS-0663 |
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet | DMS-2685 |
Lower-Limb Prosthetic Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | None |
Medicaid Claim Inquiry Form | EDS-CI-003 |
Medicaid Form Request | EDS-MFR-001 |
Medical Assistance Dental Disposition | DMS-2635 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC | DMS-633 |
Notice Of Noncompliance | DMS-635 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral | DMS-640 |
Personal Care Assessment and Service Plan | DMS-618 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies | DMS-2615 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Selection and Change Form | DMS-2609 |
Prosthetic-Orthotic Lower-Limb Amputee Evaluation | DMS-650 |
Prosthetic-Orthotic Upper-Limb Amputee Evaluation | DMS-648 |
Provider Communication Form | AAS-9502 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Extension of Benefits | DMS-699 |
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services | DMS-671 |
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21 | DMS-602 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification | DMS-2692 |
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 | DMS-601 |
Service Log - Personal Care Delivery and Aides Notes | DMS-873 |
Sterilization Consent Form | DMS-615 English DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | None |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502
AAS-9565
Address Change
AFMC-101
AFMC-102
AFMC-103
AFMC-201
AFMC-RBSS
CMS-485
CSPC-EPSDT
DCO-645
DDS/FS#0001.a
DHHS-831
DMS-0663
DMS-2606
DMS-2609
DMS-2610
DMS-2615
DMS-2618
DMS-2633
DMS-2634
DMS-2635
DMS-2647
DMS-2685
DMS-2687
DMS-2692
DMS-2698
DMS-32-A
DMS-32-O
DMS-601
DMS-602
DMS-612
DMS-615
DMS-616
DMS-618
DMS-619
DMS-628 DMS-630 DMS-632 DMS-633 DMS-635 DMS-638 DMS-640 DMS-646 DMS-647 DMS-648 DMS-649 DMS-650 DMS-651 DMS-652 DMS-671 DMS-673 DMS-679 DMS-686
DMS-693
DMS-694
DMS-694 chart version
DMS-699
DMS-873
ECSE-R
EDS-AR-004
EDS-CI-003
EDS-CR-002
EDS-MFR-001
MAP-8
Performance Report
PUB-019
PUB-020
Explanation of Updates
Residential Care Facility (RCF) Personal Care providers: Please note that Medicaid will pay as billed, any charge that is less thanthe Daily Service Rate for the Level of Care that the provider's claim indicates.
Please Note:
Effective for dates of service on and after March 1, 2008, DMS will reimburse RCF Personal Care providers a Daily Service Rate that corresponds to the Level of Care the provider bills to Medicaid. To receive correct payment, RCF Personal Care providers must ensure that each daily charge to Medicaid for each client is not less than the Daily Service Rate corresponding to the client's service-plan related Level of Care that is in effect on the date(s) of service for which the provider bills.
As a service to RCF Personal Care providers, to reduce the possibility of providers' billing differing amounts, the following table shows the Levels of Care Daily Service Rate Schedule in effect for dates of service on and after March 1, 2008. The Daily Service Rate Schedule is for the use of RCF Personal Care providers only. It is not in the Personal Care Provider Manual and it will not be incorporated into the manual.
RCF Personal Care Daily Service Rate Schedule
Level of Care | Prescribed Units per Service Plan | Daily Service Rate |
Level 1 | 100 | $11.38 |
Level 2 | 101-119 | $12.53 |
Level 3 | 120-139 | $14.72 |
Level 4 | 140-158 | $16.91 |
Level 5 | 159-177 | $19.10 |
Level 6 | 178-196 | $21.29 |
Level 7 | 197-216 | $23.48 |
Level 8 | 217-235 | $25.67 |
Level 9 | 236-255 | $27.91 |
Level 10 | 256 | $29.12 |
Section 213.530 : This is a new section that sets forth rules regarding where and for whom Residential Care Facility (RCF) Personal Care providers may furnish Medicaid-covered services. Section 215.100 : This section has been included: 1) to reflect and incorporate amended rules regarding form DMS-618 and other assessment and service plan formats; and2) to set forth a rule that RCF Personal Care providers may use only form DMS-618 for the purposes for which DMS designed the form.Section IIPersonal Care213.530 Personal Care in Residential Care Facilities (RCFs) 7-1-07A. Residential Care Facilities (RCFs) enrolled as Personal Care providers may furnish Medicaid-covered personal care services, on their own RCF-licensed premises, to their own clients (i.e. personal-care qualified Medicaid beneficiaries whose residence is the RCF).B. RCF Personal Care providers may not provide Medicaid-covered Personal Care services at any other locations or for any other Medicaid beneficiaries.C. RCF Personal Care providers are subject to the same requirements as all other Personal Care providers unless this manual, other official documents or jurisdictional court or consent decrees explicitly state otherwise as, for instance, in parts A and B above.215.000 Personal Care Assessment and Service Plan 7-1-07215.100 Assessment and Service Plan Formats 7-1-07A. The Division of Medical Services (DMS), in some circumstances and for certain specified providers, requires exclusive use of form DMS-618 (View or print form DMS-618.) to satisfy particular Program documentation requirements.1. Whether Medicaid does or does not require exclusive use of form DMS-618, all documentation required by the Personal Care Program must meet or exceed DMS regulations as stated in this manual and other official communications.2. When using form DMS-618, attachments may be necessary to complete assessments and service plans and/or to comply with other rules.a. An assessing Registered Nurse (RN) must sign or initial and date each attachment he or she adds to a required personal care document.b. The authorizing physician must sign (or initial) and date each attachment he or she adds to a service plan or other required document.B. The Division of Medical Services requires Residential Care Facility (RCF) Personal Care providers to use exclusively form DMS-618 and to comply with all rules applicable to RCFs regarding the use of form DMS-618.216.200 Tasks Associated with Covered Routines 7-1-07Effective for dates of service on and after March 1, 2008, all regulations regarding personal care aides' logging beginning and ending times (i.e., time of day) of individual services, and all references to any such regulations, do not apply to RCF Personal Care providers.
217.000 Benefit Limits 7-1-07Effective for dates of service on and after March 1, 2008, Arkansas Medicaid does not grant to beneficiaries whose residence is an RCF, extension of the personal care benefit for personal care provided at the RCF by the RCF Personal Care provider.
A. Medicaid imposes a 64-hour benefit limit, per month, per client, on personal care aide services for clients aged 21 and older.B. The 64-hour limitation applies to the monthly aggregated hours of personal care aide services at all authorized locations except RCFs.C. Providers may request extensions of this benefit for reasons of medical necessity. Submit written requests for benefit extensions to the Division of Medical Services, Utilization Review Section. View or print Division of Medical Services, Utilization Review Section contact information.220.000 Service Administration 7-1-07Effective for dates of service on and after March 1, 2008, RCF Personal Care providers are exempt from all requirements of sections 220.000 through 221.000-whether by explicit statement or reference-to record or log the time of day (clock time) when a service begins or ends.
220.100 Service Supervision 7-1-07Effective for dates of service on and after March 1, 2008, RNs supervising RCF Personal Care providers' personal care aides shall write, in a designated area on form DMS-873, instructions to aides and comments regarding the client and/or the aide.
A. The provider must assure that the delivery of personal care services by personal care aides is supervised. 1. Supervision must be performed by a registered nurse (RN).2. Alternatively, a Qualified Mental Retardation Professional (QMRP) may fulfill the RN supervision requirement for personal care services to clients residing in alternative living situations or alternative family homes, authorized or licensed by the Division of Developmental Disabilities Services.B. The supervisor has the following responsibilities.1. The supervisor must instruct the personal care aide in a. Which routines, activities and tasks to perform in executing a client's service plan,b. The minimum frequency of each routine or activity and c. The maximum number of hours per month of personal care service delivery, as authorized in the service plan.2. At least once a month, the supervisor must a. Review the aide's records,b. Document the record review andc. If necessary, further instruct the aide and document the nature of and the reasons for further instructions.3. At least three times every 183 days (six months) at intervals no greater than 62 days, the supervisor must visit the client at the service delivery location to conduct on-site evaluation. a. Medicaid requires that at least one of these supervisory visits must be when the aide is not present.b. At least one visit must be while the aide is present and furnishing services.4. When the aide is present during the visit the supervising RN or QMRP musta. Observe and document(1) The condition of the client,(2) The type and quality of the personal care aide's service provision and(3) The interaction and relationship between the client and the aide;b. Modify the service plan, if necessary, based on the observations and findings from the visit andc. If necessary, further instruct the aide and document the nature of and the reasons for further instructions.5. When the aide is not present during the visit, the supervising RN or QMRP must a. Observe and document the condition of the client,b. Observe and document, from available evidence, the type and quality of the personal care aide's service provision, andc. Query the client or the client's representative and document pertinent information regarding the client's opinion of (1) The type and quality of the aide's service,(2) The aide's conduct and(3) The adequacy of the working relationship of the client and the aide;d. Modify the service plan, if necessary, based on observations and findings from the visit, ande. Further instruct the aide, if necessary, and document the nature of and the reasons for further instructions.C. The provider must review the service plan and the aide's records as necessary, but no less often than every 62 days. The review will ensure that the daily aggregate time estimate in the service plan accurately reflects the actual average time the aide spends delivering personal care aide services to a client.220.110 Service Log 7-01-07Instructions in this section apply to all clients' service logs, with one exception. Effective for dates of service on and after March 1, 2008, RCF Personal Care providers maintain their service logs by means of the format and instructions of form DMS-873, "Arkansas Department of Human Services Division of Medical Services Instructions for completing the Service Log & Aide Notes For Personal Care Services in a Residential Care Facility". Effective for dates of service on and after March 1, 2008, form DMS-873 is found in Section V of this manual and DMS requires that RCF Personal Care providers use it exclusively for its designated purposes. See section 220.111 for special documentation requirements regarding multiple clients who are attended by one aide. Those instructions at section 220.111 do not apply to RCF Personal Care providers, effective for dates of service on and after March 1, 2008. See section 220.112 for special documentation requirements regarding multiple aides attending one client. Those instructions at section 220.112 do not apply to RCF Personal Care providers, effective for dates of service on and after March 1, 2008. The examples in these sections and in section 220.110 are related to food preparation, but personal care clients may receive other services in congregate settings if their individual assessments support their receiving assistance in that fashion.
A. Medicaid covers only service time that is supported by an aide's service log.B. Service time in excess of the maximum service time estimates in the authorized service plan is covered only when the provider complies with the rules in sections 215.330 and 220.110 through 220.112.C. The time estimate in the service plan is not service documentation. It is an estimate of the anticipated minimum and maximum daily duration of medically necessary personal care aide service for an individual client.D. For each service date, for each client, the personal care aide must record the following: 1. The time of day the aide begins the client's services.2. The time of day the aide ends a client's services. This is the time of day the aide concludes the service delivery, not necessarily the time the aide leaves the client's service delivery location.3. Notes regarding the client's condition as instructed by the service supervisor.4. Task performance difficulties.5. The justification for any emergency unscheduled tasks and documentation of the prior-approval or post-approval of the unscheduled tasks.6. The justification for not performing any scheduled service plan required tasks.7. Any other observations the aide believes are of note or that should be reported to the supervisor.E. If the aide discontinues performing service-plan-required tasks at any time before completing all of the required tasks for the day, the aide will record: 1. The beginning time of the non-service-plan-required activities,2. The ending time of the non-service-plan-required activities,3. The beginning time of the aide's resumption of service-plan-required activities and4. The beginning and ending times of any subsequent breaks in service-plan-required aide activities.5. If the aide discontinues or interrupts the client's service-plan-required activities at one location to begin service-plan-required activities at another location, the aide must record the beginning and ending times of service at each location.220.111 Service Log for Multiple Clients 7-1-07Effective for dates of service on and after March 1, 2008, the rules in this section do not apply to RCF Personal Care providers.
An aide delivering services to two or more clients at the same service location, during the same period (discontinuing or interrupting a client's service plan required tasks to begin or resume service plan required tasks for another client, or performing an authorized service simultaneously for two or more clients), must comply with the applicable instructions in parts A or B below:
A. If providing services for only two clients, the aide must record in each client's service log 1. The name of each individual for whom they are simultaneously performing personal care service and2. The beginning and ending times of service for each client and the beginning and ending times of each interruption and of each resumption of service.B. If services are performed in a congregate setting (more than two clients) the service log must state 1. The actual time of day (clock-time) that the congregate services begin and end and2. The number of individuals, and the name of each individual, both Medicaid-eligible and non-Medicaid eligible, who received the documented congregate services during that period.220.112 Service Log for Multiple Aides with One Client 7-1-07Effective for dates of service on and after March 1, 2008, the rules in this section do not apply to RCF Personal Care providers.
When two or more aides attend a single client, each aide must record the beginning and ending times of each service plan required routine or activity of daily living that she or he performs for the client, regardless of whether another aide is performing a service plan required routine or activity of daily living at the same time.
221.000 Documentation 7-1-07Rule D in this section is effective for dates of service on and after March 1, 2008.
The personal care provider must keep and make available to authorized representatives of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the Department of Health and Human Services and its authorized agents or officials; records including:
A. If applicable, certification by the Home Health State Survey Agency as a participant in the Title XVIII Program. Agencies that provided Medicaid personal care services before July 1, 1986 are exempt from this requirement.B. When applicable, copies of pertinent residential care facility license(s) issued by the Office of Long Term Care.D. Effective for dates of service on and after March 1, 2008, RCF Personal Care providers will be required, when requested by DHS, to provide payroll records to validate service plans and service logs.E. Documents signed by the supervising RN or QMRP, including: 1. The initial and all subsequent assessments.2. Instructions to the personal care aide regarding:a. The tasks the aide is to perform,b. The frequency of each task and c. The maximum number of hours and minutes per month of aide service authorized by the client's attending physician.3. Notes arising from the supervisor's visits to the service delivery location, regarding: a. The condition of the client,b. Evaluation of the aide's service performance,c. The client's evaluation of the aide's service performance andd. Difficulties the aide encounters performing any tasks.4. The service plan and service plan revisions: a. The justifications for service plan revisions,b. Justification for emergency, unscheduled tasks andc. Documentation of prior or post approval of unscheduled tasks.F. Any additional or special documentation required to satisfy or to resolve questions arising during, from or out of an investigation or audit. "Additional or special documentation," refers to notes, correspondence, written or transcribed consultations with or by other healthcare professionals (i.e., material in the client's or provider's records relevant to the client's personal care services, but not necessarily specifically mentioned in the foregoing requirements). "Additional or special documentation," is not a generic designation for inadvertent omissions from program policy. It does not imply and one should not infer from it that, the State may arbitrarily demand media, material, records or documentation irrelevant or unrelated to Medicaid Program policy as stated in this manual and in official program correspondence.G. The personal care aide's training records, including:2. Skills test results and3. Personal care aide certification.H. The personal care aide's daily service notes for each client, reflecting: 2. The routines performed on that date of service, noted to affirm completion of each task.3. The time of day the aide began performing the first service-plan-required task for the client;4. The time of day the aide stopped performing any service-plan-required task to perform any non-service-plan-required function;5. The time of day the aide stopped performing any non-service-plan-required function to resume service-plan-required tasks and6. The time of day the aide completed the last service-plan-required task for the day for that client.I. Notes, orders and records reflecting the activities of the physician, the supervising RN or QMRP, the aide and the client or the client's representative; as those activities affect delivering personal care services.250.100 Reimbursement Methods 7-1-07A. Reimbursement for personal care services is the lesser of the billed amount per unit of service or Medicaid's maximum allowable fee (herein also referred to as "rate" or "the rate") per unit.B. Reimbursement for Arkansas Medicaid Personal Care services is based on a 15-minute unit of service.C. Effective for dates of service on and after March 1, 2008, RCF Personal Care provider reimbursement is in accordance with a multi-hour daily service rate system, employing Medicaid maximum allowable fees (Daily Service Rates) determined by individual clients' Levels of Care.250.200 RCF Personal Care Reimbursement Methodology 7-1-07A. The RCF Personal Care reimbursement methodology is designed with the intent that reimbursement under the multi-hour Daily Service Rate system closely approximates what reimbursement would have been if the providers were to have billed by units of service furnished.B. Whenever the unit rate (i.e., the maximum allowable amount per fifteen minutes service) for personal care services changes, Daily Service Rates under the RCF methodology are correspondingly adjusted in accordance with the initial methodology by which they were established and which is described in detail in the following sections.C. The Daily Service Rate paid for personal care services is based on a Level of Care determined from the resident's service plan.250.210 Level of Care 7-1-07There are 10 Levels of Care, each based on the average number of 15-minute units of service per month required to fulfill a client's service plan.
A. Level 1 includes RCF Personal Care clients whose service plans comprise 100 units or less per month of medically necessary personal care.B. Level 10 includes RCF Personal Care clients whose service plans comprise 256 or more units per month of medically necessary personal care.C. Level 2 through Level 9 were established in equal increments between 101 and 255 units per month.250.211 Level of Care Determination 7-1-07A. The average of a service plan's monthly units of service is used to determine each client's Level of Care.B. Calculate a client's average number of monthly units of personal care as follows.1. Add the minimum and maximum hourly Weekly Totals from a completed form DMS-618, "Personal Care Assessment and Service Plan," and divide the sum by 2 to obtain average weekly hours of service.2. Convert the average obtained in step 1 to minutes by multiplying it by 60.3. Divide the minutes by 15 (15 minutes equals one unit of service) to calculate weekly average units of service.4. Multiply the weekly average units from step 3 by 52 (Weeks in a year) and divide the product by 12 (Months in a year) to calculate monthly average units of service.5. Consult the "RCF Personal Care Service Rate Schedule" on page 2 of the Personal Care Provider Manual Update Transmittal #75 Memorandum and "Explanation of Updates" to find the applicable Daily Multi-Hour Service Rate for each Level of Care.250.212 Rate Development 7-1-07A. The Level 1 Daily Service Rate was calculated as follows.1. Multiplied 100 (15-minute units) by 12 (Months in a year)2. Divided units per year calculated in step 1 by 365 (The average number of days in a year) to calculate average units per day3. Multiplied average units (Unrounded) per day obtained in step 2 by the current Personal Care maximum allowable fee per unit and rounded the product to the nearest 100th to calculate the Level I Daily Service RateB. The Level 10 Daily Service Rate was calculated as follows. 1. Multiplied 256 (Maximum monthly units) by 12 (Months per year)2. Divided the product calculated in step 1 by 365 (The average number of days in a year) to calculate average maximum units per day3. Multiplied average maximum units per day from step 2 by the current Personal Care maximum allowable fee per unit and rounded the product to the nearest 100th to calculate the Level 10 Daily Service RateC. The Daily Service Rates for Level 2 through Level 9 were calculated as follows.1. The difference between 255 and 101 (154) was divided into eight equal increments that then were designated Levels of Care ("Levels") 2 through 9.2. The sum of the beginning and ending values within each Level of Care was divided by 2 to calculate the Level's average units per month.3. The average units per month was multiplied by 12 (Months per year) to calculate average annual units.4. The average annual units calculated in step 3 was divided by 365 (The average number of days in a year) to arrive at average units per day.5. The average units per day calculated in step 5 was multiplied by the current Personal Care maximum allowable fee per unit and the product was rounded to the nearest 100th.261.000 Introduction to Billing 7-1-07A. Personal Care providers use the CMS-1500 claim form to bill the Arkansas Medicaid Program on paper for services provided to Medicaid beneficiaries.B. Providers using the Provider Electronic Solutions (PES) software use the Professional claim format.C. A claim may contain charges for only one beneficiary.D. Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.262.100 Personal Care Billing 7-1-07A. Providers must use applicable HCPCS procedure codes and modifiers listed in the following section.B. All billing by any media requires the correct national standard place of service code.262.101 Personal Care for a Client Aged 21 or Older (Non-RCF) 7-1-07Procedure Code Modifier | Service Description |
T1019 U3 | Personal Care for a non-RCF Client Aged 21 or Older, per 15 minutes |
262.102 Personal Care for a Client Under 21 (Non-RCF)Procedure Code Modifier | Service Description |
T1019 | Personal Care for a (non-RCF) Client Under 21, per 15 |
| | minutes (requires prior authorization) |
262.104 Personal Care In an RCF 7-1-07A. To bill for RCF Personal Care, use HCPCS procedure code T1020 and the modifier corresponding to the client's Level of Care in effect for the date(s) of service being billed.B. The Level of Care that a provider bills must be consistent with the client's service plan in effect on the day that the provider furnished the personal care services billed. Level of Care Specifications and Modifiers for Procedure Code 11020
Levels of Care | Minimum Service Units | Maximum Service Units | Modifier |
Level 1 | Less than 100 | 100 | U1 |
Level 2 | 101 | 119 | U2 |
Level 3 | 120 | 139 | U3 |
Level 4 | 140 | 158 | U4 |
Level 5 | 159 | 177 | U5 |
Level 6 | 178 | 196 | U6 |
Level 7 | 197 | 216 | U7 |
Level 8 | 217 | 235 | U8 |
Level 9 | 236 | 255 | U9 |
Level 10 | 256 | 256 | UA |
262.105 Billing RCF Personal Care ServicesA. RCF Personal Care providers may not bill for days during which a client received no personal care services (for instance, he or she was away for a day or more); therefore, do not include in the billed dates of service any days the client was absent.B. For each unbroken span of days of service, multiply the days of service by the applicable Daily Service Rate and bill that amount on the corresponding claim detail.262.110 Coding Home and DDS Facility Places of ServiceA. The client's home is the client's residence, subject to the exclusions in section 213.500, part B. For example, if a client lives in a residential care facility (RCF) or an assisted living facility (ALF), then the RCF or ALF is the client's home and is so indicated on a claim by place of service code 12.B. Section 213.520, part A, explains and describes special circumstances under which the place of service is deemed "public school."1. The Arkansas Department of Education (ADE) sometimes deems a student's home a "public school," coded 03.2. Under certain circumstances, the ADE deems a Division of Developmental Disabilities Services community provider facility ("DDS facility") a "public school," also coded 03. C. When beneficiaries receiving personal care in a DDS facility are not in the charge of their school district, the place of service code is 99, "Other Place of Service," because there is no national code for a DDS clinic or facility.262.300Calculating Individual Service Times for Services Delivered in a 7-1-07Congregate Setting
Rules in this section and its subsections regard calculation and determination of service-time to convert into billing units (Fifteen-minute units). Effective for dates of service on and after March 1, 2008, those rules do not apply to RCF Personal Care providers' billing. Rules in this section and its subsections that are applicable to assessments and service plan development continue to apply to RCFs.
If services, such as meal preparation in a congregate setting, are delivered simultaneously, only the actual proportionate service time attributable to each individual client is covered.
A. The provider shall compute the covered time by dividing the actual aide clock-hours, attributing a proportionate share to each individual and multiplying each individual's proportionate share by a percentage arrived at from the individual's assessment. For example: 1. If an individual is totally dependent and cannot prepare a meal, the provider would be eligible for 100 percent of the client's proportionate share.2. If a resident is totally capable of preparing a meal, the provider is not eligible for any reimbursement for any of the client's proportionate share.3. If the client has an impairment that limits but does not totally prevent meal preparation the provider will be eligible for reimbursement of 50 percent of the individual's proportionate share of the aide's time.B. The client's assessment must describe, in narrative form, his or her level of impairment with respect to each physical dependency with which the client receives assistance in a congregate setting.