016-06-09 Ark. Code R. § 35
Field Name and Number | Instructions for Completion |
1. (type of coverage) | Not required. |
1a. INSURED'S I.D. NUMBER (For Program in Item 1) | Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number. |
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) | Beneficiary's or participant's last name and first name. |
3. PATIENT'S BIRTH DATE | Beneficiary's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY. |
SEX | Check M for male or F for female. |
4. INSURED'S NAME (Last Name, First Name, Middle Initial) | Required if insurance affects this claim. Insured's last name, first name, and middle initial. |
5. PATIENT'S ADDRESS (No., Street) | Optional. Beneficiary's or participant's complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary or participant resides. |
STATE | Two-letter postal code for the state in which the beneficiary or participant resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone. |
6. PATIENT RELATIONSHIP TO INSURED | If insurance affects this claim, check the box indicating the patient's relationship to the insured. |
7. INSURED'S ADDRESS (No., Street) | Required if insured's address is different from the patient's address. |
CITY | |
STATE | |
ZIP CODE | |
TELEPHONE (Include Area Code) | |
8. PATIENT STATUS | Not required. |
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) | If patient has other insurance coverage as indicated in Field 11d, the other insured's last name, first name, and middle initial. |
a. OTHER INSURED'S POLICY OR GROUP NUMBER | Policy and/or group number of the insured individual. |
b. OTHER INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
c. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9 a-d are required. Name of the insured individual's employer and/or school. |
d. INSURANCE PLAN NAME OR PROGRAM NAME | Name of the insurance company. |
10. IS PATIENT'S CONDITION RELATED TO: | |
a. EMPLOYMENT? (Current or Previous) | Check YES or NO. |
b. AUTO ACCIDENT? | Required when an auto accident is related to the services. Check YES or NO. |
PLACE (State) | If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. |
c. OTHER ACCIDENT? | Required when an accident other than automobile is related to the services. Check YES or NO. |
10d. RESERVED FOR LOCAL USE | Not used. |
11. INSURED'S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
a. INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
b. EMPLOYER'S NAME OR SCHOOL NAME | Not required. |
c. INSURANCE PLAN NAME OR PROGRAM NAME | Not required. |
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d. |
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) | Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. |
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE | Not required. |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Primary Care Physician (PCP) referral is not required for targeted case management services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
17a. (blank) | The 9-digit Arkansas Medicaid provider ID number of the referring physician. |
17b. NPI | Not required. |
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY. |
19. RESERVED FOR LOCAL USE | Local Education Agency (LEA) code that identifies the school district in which services are provided. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) diagnosis coding current as of the date of service. |
22. MEDICAID RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Reserved for future use. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24A. DATE(S) OF SERVICE | The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. |
1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. | |
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. | |
B. PLACE OF SERVICE | Two-digit national standard place of service code. See Section 262.200 for codes. |
C. EMG | Not required. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Section 262.100. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter in each detail the single number-1, 2, 3, or 4-that corresponds to a diagnosis code in Item 21 (numbered 1, 2, 3, or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3, or 4, and it must be the only character in that field. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other recipient of the provider's services. |
G. DAYS OR UNITS | The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. |
H. EPSDT/Family Plan | Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. |
I. ID QUAL | Not required. |
J. RENDERING PROVIDER ID # | The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail. |
NPI | Not required. |
25. FEDERAL TAX I.D. NUMBER | Not required. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. PATIENT'S ACCOUNT NO. | Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN." |
27. ACCEPT ASSIGNMENT? | Not required. Assignment is automatically accepted by the provider when billing Medicaid. |
28. TOTAL CHARGE | Total of Column 24F-the sum all charges on the claim. |
29. AMOUNT PAID | Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. * Do not include in this total the automatically deducted Medicaid co-payments. |
30. BALANCE DUE | From the total charge, subtract amounts received from other sources and enter the result. |
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS | The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
32. SERVICE FACILITY LOCATION INFORMATION | If other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed. |
a. (blank) | Not required. |
b. (blank) | Not required. |
33. BILLING PROVIDER INFO & PH # | Billing provider's name and complete address. Telephone number is requested but not required. |
a. (blank) | Not required. |
b. (blank) | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
016.06.09 Ark. Code R. § 035