016-06-14 Ark. Code R. § 3
Field Name and Number | Instructions for Completion |
1. (type of coverage) | Not required. |
1a. INSURED?S I.D. NUMBER (For Program in Item 1) | Beneficiarys 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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets.. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiarys condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 Alternatives for Adults with Physical Disabilities waiver services. |
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 | Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9- Revision (ICD-10-CM)diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
23. PRIOR AUTHORIZATION NUMBER | Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
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 241.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. See Section 241.100. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 | Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
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 providers Medicaid file. If it changes, please contact Provider Enrollment. |
26. PATIENT?S ACCOUNT N O. | 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. RESERVED | Reserved for NUCC use. |
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. |
Field # | Field name | Description |
1. | (blank) | Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. 3b. | PAT CNTL # MED REC # | The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the same date in both sections of the field. Format: MMDDYY. |
7. | Not used | Reserved for assignment by the NUBC. |
8a. 8b. | PATIENT NAME (blank) | Enter the patient?s last name and first name. Middle initial is optional. Not required. |
9. | PATIENT ADDRESS | Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Not required. |
13. | ADMISSION HR | Not required. |
14. | ADMISSION TYPE | Not required. |
15. | ADMISSION SRC | Not required. |
16. | DHR | Not applicable. |
17. | STAT | Not applicable. |
18.-28. | CONDITION CODES | Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Not applicable. |
a. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
b. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
40. | VALUE CODES | Not applicable. |
41. | VALUE CODES | Not applicable. |
42. | REV CD | Enter a revenue code when applicable. See the UB-04 Manual and this provider manual. |
43. | DESCRIPTION | See the UB-04 Manual. Required for paper claims only. |
44. | HCPCS/RATE/HIPPS CODE | Enter a surgery or diagnostic procedure code. |
45. | SERV DATE | Each procedure code or revenue code requires a date of service in this field. Date format: MMDDYY. |
46. | SERV UNITS | Enter the applicable number of units. |
47. | TOTAL CHARGES | Enter the product of the charge per unit times the number of units. |
48. | NON-COVERED CHARGES | Not applicable. |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPPA National Plan Identifier; otherwise report the legacy/proprietary number.. |
52. | REL INFO | Required. See the UB-04 Manual. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | 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 or ARKids First-B co-payments. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
58. A, B, C | INSURED?S NAME | Comply with the UB-04 Manual?s instructions. |
59. A, B, C | P REL | Not applicable. Comply with the UB-04 Manual?s instructions when there are other payers. |
60. A, B, C | INSURED?S UNIQUE ID | Enter the patient?s Medicaid identification number on the first line of the field. |
61. A, B, C | GROUP NAME | Not applicable. See UB-04 Manual when there are other payers. |
62. A, B, C | INSURANCE GROUP NO | When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Enter any applicable prior authorization or benefit extension number in field 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0? designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. processing requirements. |
67. A-H | (blank) | Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Not applicable. |
70. | PATIENT REASON DX | Not applicable. |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not applicable. |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI is not required. |
QUAL | Enter 0B, indicating state license number. Enter the surgeon?s state license number in the second part of the field. | |
LAST | Enter the surgeon?s last name. | |
FIRST | Enter the surgeon?s first name. | |
77. | OPERATING NPI | NPI is not required. |
QUAL | Not applicable. | |
LAST | Not applicable. | |
FIRST | Not applicable. | |
78. | OTHER NPI | NPI is not required. |
QUAL | Enter 0B, indicating state license number. Enter the referring physician?s state license number in the second part of the field. | |
LAST | Enter the referring physician?s last name. | |
FIRST | Enter the referring physician?s first name. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
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 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 last name and first name. |
3. PATIENT?S BIRTH DATE | Beneficiary?s date of birth as given on the 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 complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary resides. |
STATE | Two-letter postal code for the state in which the beneficiary resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary?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. RESERVED | Reserved for NUCC use. |
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 beneficiary. |
b. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information'' about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. |
c. INSURANCE PLAN NAME OR PROGRAM NAME | Not required. 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. |
Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiarys condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 DDS Alternative Community Services (ACS) Waiver services. If services are the result of a Child Health Services (EPSDT) screening/referral, enter the referral source, including name and title. |
a. (blank) | The 9-digit Arkansas Medicaid provider ID number of the referring physician. |
b. 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 inpatient hospitalization, enter the beneficiary?s admission and discharge dates. Format: MM/DD/YY. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9- Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 262.100 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
For anesthesia, when billed with modifier(s) P1, P2, P3, P4, or P5, hours and minutes must be entered in the shaded portion of that detail in field 24D. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any beneficiary of the providers 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 providers Medicaid file. If it changes, please contact Provider Enrollment. |
26. PATIENT?S ACCOUNT N O. | 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 of 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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
11. INSURED?S POLICY GROUP | Not required when Medicaid is the only payer. |
a. INSURED?S DATE OF BIRTH | Not required. |
SEX | Not required. |
b. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiarys condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation' 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for Chiropractic services. Enter the referring physician?s 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9- Revision (ICD-10-CM) diagnosis coding. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 242.200 for codes. |
C. EMG . | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 providers 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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 |
CITY | |
STATE | |
ZIP CODE | |
TELEPHONE (Include Area Code) | |
8. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiarys condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiarys condition or treatment Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation' 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for CHMS 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. ADDITIONAL CLAIM INFORMATION | For tracking purposes, occupational, physical and speech therapy providers are required to enter one of the following therapy codes: |
Code | Category |
A | Individuals from birth through 2 years who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. |
B | Individuals ages 0 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Plan (IP) through the Division of Developmental Disabilities Services. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services has not attained age 5 by September 15 of the current school year, 2) the individual receiving services is receiving the services under an Individualized Plan, 3) the Individualized Plan is through the Division of Developmental Disabilities Services. |
When using code C or D, providers must also include the 4-digit LEA (local education agency) code assigned to each school district. For example: C1234 | |
C (and 4-digit LEA code) | Individuals ages 3 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Education Plan (IEP) through an education service cooperative. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services is between the ages of 3 through 5 years and has not attained age 5 by September 15 of the current school year, 2) the individual receiving services is receiving the services under an Individualized Education Plan, 3) the Individualized Education Plan is through an education service cooperative. |
D (and 4-digit LEA code) 4 | Individuals ages 5 (by September 15) to 21 years who are receiving therapy services under an Individualized Education Plan (IEP) through a school district. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services is between the ages of 5 (by September 15 of the current school year) to 21 years. 2) the individual receiving services is receiving the services under an Individualized Education Plan, 3) the Individualized Education Plan is through a school district. |
E | Individuals ages 18 years and up who are receiving therapy services through the Division of Developmental Disabilities Services. |
F | Individuals ages 18 years and up who are receiving therapy services through individual or group providers not included in any of the previous categories (A-E). |
G | Individuals ages birth through 17 years who are receiving therapy/pathology services through individual or group providers not included in any of the previous categories (A-F). |
Not used. | |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of the ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9- Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. See Sections 262.100 through 262.140. |
MODIFIER | Modifier(s) if applicable. See Section 262.120. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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. PATIENTS ACCOUNT N O. | 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 or co-payments. |
30. RESERVED | Reserved for NUCC use. |
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 providers 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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 certified nurse-midwife services except for EPSDT services other than newborn care. 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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. Some 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 272.200 for codes. |
C. EMG | Check ?Yes? of leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Section 272.100. For unlisted procedure codes, enter the description of the service and attach a procedure report. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 N O. | 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 received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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 |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 Children?s Services TCM. 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
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 the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 |
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 N O. | 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. RESERVED | Reserved for NUCC use. |
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 |
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. |
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 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 last name and first name. |
3. PATIENT?S BIRTH DATE | Beneficiary?s date of birth as given on the 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 complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary resides. |
STATE | Two-letter postal code for the state in which the beneficiary resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary?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. RESERVED | Reserved for NUCC use. |
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 | Policy and/or group number of the insured beneficiary. |
b. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 DDS Alternative Community Services (ACS) Waiver 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 inpatient hospitalization, enter the beneficiary?s admission and discharge dates. Format: MM/DD/YY. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 272.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Section 272.100. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any beneficiary 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 |
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 N O. | 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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIMS CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. (blank) 17b. NPI | Referring physician?s name and title. DDTCS optional therapy services require primary care physician (PCP) referral. The 9-digit Arkansas Medicaid provider ID number of the referring physician. 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. ADDITIONAL CLAIM INFORMATION | For tracking purposes, DDTCS providers are required to enter one of the following therapy codes: |
Code | Category |
A | Individuals from birth through 2 years who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. |
B | Individuals ages 0 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Plan (IP) through the Division of Developmental Disabilities Services. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services has not attained age 5 by September 15 of the current school year, 2) the individual receiving services is receiving the services under an Individualized Plan and 3) the Individualized Plan is through the Division of Developmental Disabilities Services. |
When using code C or D, providers must also include the 4-digit LEA (local education agency) code assigned to each school district. For example: C1234 | |
C (and 4-digit LEA code) | Individuals ages 3 through 5 years (if individual has not reached age 5 by September 15) who are receiving therapy services under an Individualized Education Plan (IEP) through an education service cooperative. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services is between the ages of 3 through 5 years and has not attained age 5 by September 15 of the current school year, 2) the individual receiving services is receiving the services under an Individualized Education Plan and 3) the Individualized Education Plan is through an education service cooperative. |
D (and 4-digit LEA code) | Individuals aged 5 (by September 15) to 21 years who are receiving therapy services under an Individualized Education Plan (IEP) through a school district. NOTE: This code is to be used only when all three of the following conditions are in place: 1) the individual receiving services is between the ages of 5 (by September 15 of the current school year) to 21 years, 2) the individual receiving services is receiving the services under an Individualized Education Plan and 3) the Individualized Education Plan is through a school district. |
E | Individuals aged 18 years and up who are receiving therapy services through the Division of Developmental Disabilities Services. |
F | Individuals aged 18 years and up who are receiving therapy services through individual or group providers not included in any of the previous categories (A-E). |
G | Individuals aged birth through 17 years who are receiving therapy/pathology services through individual or group providers not included in any of the previous categories (A-F). |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 262.100 through 262.110. |
MODIFIER | Enter the applicable modifier from Section 262.110. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 N O. | 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 or co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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 |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 Children?s Services TCM. 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
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 the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 N O. | 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 ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
Field # | Field name | Description |
1. | (blank) | Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. 3b. | PAT CNTL # MED REC # | The provider may use this optional field for accounting purposes. The entry appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. Inpatient and Outpatient: Required .Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. The FROM and THROUGH dates cannot span the State?s fiscal year end (June 30) or the provider?s fiscal year end. To file correctly for covered days that span a fiscal year end, submit 2 claims. E.g., the THROUGH date is the last day of the fiscal year that ended during the stay. |
7. | Not used | Reserved for assignment by the NUBC. |
8a. 8b. | PATIENT NAME (blank) | Required: Enter the beneficiary?s last name and first name. Middle initial is optional. Not required. |
9. | PATIENT ADDRESS | Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Enter the admission date. Format: MMDDYY. |
13. | ADMISSION HR | Not applicable to Domiciliary Care. |
14. | ADMISSION TYPE | Not applicable to Domiciliary Care. |
15. | ADMISSION SRC | Not applicable to Domiciliary Care. |
16. | DHR | Not applicable to Domiciliary Care. |
17. | STAT | Inpatient: Enter the national code indicating the patient?s status on the Statement Covers Period THROUGH date (field 6). Outpatient: Not applicable. |
18.-28. | CONDITION CODES | Not applicable to Domiciliary Care. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Not applicable to Domiciliary Care. Outpatient: See the UB-04 manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Not applicable to Domiciliary Care. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | Not applicable to Domiciliary Care. |
39.-41. | VALUE CODES AND AMOUNTS | Not applicable to Domiciliary Care. |
42. | REV CD | Enter the Revenue Code 0110. |
43. | DESCRIPTION | Enter room and board. |
44. | HCPCS/RATE/HIPPS CODE | Enter the facility?s daily rate for room and board. |
45. | SERV DATE | Not applicable to Domiciliary Care. |
46. | SERV UNITS | Enter the number of days being billed. |
47. | TOTAL CHARGES | Enter the total charges for the period indicated in the ?Statement Covers Period? |
48. | NON-COVERED CHARGES | Not applicable to Domiciliary Care. |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier, otherwise report the legacy/proprietary number. |
52. | REL INFO | Not required. |
53. | ASG BEN | Not required. |
54. | PRIOR PAYMENTS | Required when applicable. See the UB-04 Manual. |
55. | EST AMOUNT DUE | Not required. |
56. | NPI | Not applicable to Domiciliary Care. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Required. Enter the patient?s Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Not applicable to Domiciliary Care. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Not applicable to Domiciliary Care unless the claim is a replacement or a void. See the UB-04 manual if applicable. |
65. A, B, C | EMPLOYER NAME | When applicable, based upon fields 51 and 62 enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0? designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Not applicable to Domiciliary Care. |
70. | PATIENT REASON DX | Not applicable to Domiciliary Care. |
71. | PPS CODE | Not required. |
72 | ECI | Not applicable to Domiciliary Care. |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not applicable to Domiciliary Care. |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI is not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI is not required. |
QUAL | Not required. | |
LAST | Not required. | |
FIRST | Not required. | |
78. | OTHER NPI | NPI is not required. |
QUAL | Not required. | |
LAST | Not required. | |
FIRST | Not required. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not required. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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. Some 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. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 |
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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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. Some 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. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 |
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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 ElderChoices 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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. Some 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 | Enter the appropriate place of service code. See Section 262.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 | Not required for ElderChoices. |
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 N O. | 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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. EPSDT PAPER CLAIMS | For all EPSDT paper claim submissions, please enter the letters ?EPSDT? in BOX 10d on the CMS-1500 claim form. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. |
Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. | |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for most Physician/Independent Lab/CRNA/Radiation Therapy Center services provided by non-PCPs. Enter the referring physician?s 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 292.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
For anesthesia, when billed with modifier(s) P1, P2, P3, P4, or P5, hours and minutes must be entered in the shaded portion of that detail in field 24D. | |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 | EPSDT Reason Codes are required for EPSDT services. Please enter the appropriate 2 byte reason code in the upper shaded part of the detail line. AV ? Available ? Not Used (patient refused referral) NU ? Not Used (used when no EPSDT patient referral was given) S2 ? Under Treatment (patient is currently under treatment for referred diagnostic or corrective health problem) ST ? New Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.) Family Planning Indicator is not applicable for this claim type. |
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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
11. INSURED?S POLICY GROUP | Not required when Medicaid is the only payer. |
a. INSURED?S DATE OF | Not required. |
SEX | Not required. |
b. OTHER CLAIM ID | Not required. |
c. INSURANCE PLAN NAME OR PROGRAM | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 # | Not applicable. |
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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. EMPLOYER?S NAME OR SCHOOL NAME | Required when items 9a and 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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a, 9c and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for Hearing 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. LOCAL EDUCATION AGENCY (LEA) NUMBER | Insert LEA number. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.110. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
Field # | Field name | Description |
1. | (blank) | Enter the provider?s name, (physical address ? service location) city, state, zip code and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for providers return address for returned mail.) |
3a. 3b. | PAT CNTL # MED REC # | The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. , Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. To bill on a single claim for home health services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. The dates in this locator must fall within the same fiscal year - the state?s fiscal year and the home health agency?s fiscal year. When a service-date span overlaps either fiscal-year end, submit 2 claims, with the first claim?s THROUGH date on or before the fiscal-year end date and the second claim?s FROM date on or after the first day of the new fiscal year. |
7. | Not used | Reserved for assignment by the NUBC. |
8a. 8b. | PATIENT NAME (blank) | Enter the patient?s last name and first name. Middle initial is optional. Not required. |
9. | PATIENT ADDRESS | Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Not required. |
13. | ADMISSION HR | Not required. |
14. | ADMISSION TYPE | Not required. |
15. | ADMISSION SRC | Not required. |
16. | DHR | Not required. |
17. | STAT | Not applicable. |
18.-28. | CONDITION CODES | Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Not applicable. |
a. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
b. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
40 | VALUE CODES | Not applicable. |
41. | VALUE CODES | Not applicable. |
42. | REV CD | Not applicable. |
43. | DESCRIPTION | Not required. |
44. | HCPCS/RATE/HIPPS CODE | See this provider manual for procedure codes. |
45. | SERV DATE | Enter a service date for each procedure code. Date format: MMDDYY. |
46. | SERV UNITS | Comply with the UB-04 Manual?s instructions. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | Not applicable. |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required. See the UB-04 Manual. |
53. | ASG BEN | Not required. |
54. | PRIOR PAYMENTS | 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 or ARKids First-B co-payments. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Enter the patient?s Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Enter any applicable prior authorization or benefit extension control number on line 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission or subsequently develop, and that have an effect on the treatment received, the medical supplies needed or the number and types of visits required. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Not required. |
70. | PATIENT REASON DX | Not required. See the UB-04 Manual |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not applicable |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Not applicable. | |
LAST | Not applicable. | |
FIRST | Not applicable. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the referring physician?s state license number in the second | |
LAST | Enter the referring physician?s last name. | |
FIRST | Enter the referring physician?s first name. | |
79. | OTHER NPI/QUAL/LAST/FIRST | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
Field # | Field name | Description |
01. | (blank) | Required: Enter the Hospice provider?s name, (physical address ? service location) city, state, ZIP code and telephone number. |
02. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
03a. 03b. | PAT CNTL # MED REC # | Required: This field is for accounting purposes. Enter the patient?s financial account number; the number the Hospice uses to retrieve individual patients? financial account information. The account (?PAT CNTL?) number appears on the RA, labeled ?MRN.? This number ensures correct identification when reconciling the Medicaid remittance with patients? accounts. HP Enterprise Services accepts up to 16 alphanumeric characters in this field. Required: Enter the patient?s medical record number; the number the Hospice uses to file and retrieve individual patients? medical records. HP Enterprise Services accepts up to 15 alphanumeric characters in this field. |
04. | TYPE OF BILL | Required: The first two digits must be 08 (Special Facility). The third digit must be 1 (Hospice, non-hospital based) or 2 (Hospice, hospital based). Use the applicable code from the UB-04 Manual for the fourth (i.e., frequency) digit. |
05. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
06. | STATEMENT COVERS PERIOD?FROM and THROUGH | Required: Enter the first and last service dates on this claim. In the Hospice Program, these dates must be within the same calendar month. The format is MMDDYY. |
07. | Not used | Reserved for assignment by the NUBC. |
08a. 08b. | PATIENT NAME (blank) | Required: Enter the patient?s last name, first name and middle initial. Not required. |
09. | PATIENT ADDRESS | Optional. |
10. | BIRTH DATE | Required: Enter the patient?s date of birth. The format is MMDDCCYY. |
11. | SEX | Required: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Enter the date that hospice services began or the date that the hospice plan of care was approved, whichever date is more recent. If the beneficiary has elected, then revoked hospice in the past, and then later re-elected hospice, enter the date services began under the most recent re-election or the date that the most recent new plan of care was authorized, whichever is more recent. The format is MMDDYY. |
13. | ADMISSION HR | Not applicable to Hospice |
14. | ADMISSION TYPE | Not applicable to Hospice |
15. | ADMISSION SRC | Not applicable to Hospice |
16. | DHR | Not applicable to Hospice |
17. | STAT | Required: From the UB-04 manual, enter the code indicating the patient?s disposition or discharge status on the Statement Covers Period THROUGH date (field 6). |
18.-28. | CONDITION CODES | Enter when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Enter when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Not applicable to Hospice |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | Not applicable to Hospice |
39. a. b. | VALUE CODES CODE AMOUNT | Required when the claim is for only one consecutive period (within the same calendar month) of one Hospice care category (except Continuous Home Care) and that consecutive period is identical to the period identified by the Statement Covers Period (field 6) FROM and THROUGH dates. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. Not applicable to Continuous Home Care. When applicable, as determined by the VALUE CODES requirement rule, enter 80. When applicable, as determined by the VALUE CODES requirement rule, enter the number of days between the Statement Covers Period FROM date and THROUGH date (field 6), inclusive. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Required: Enter the applicable Hospice Program revenue code. When the claim is for Continuous Home Care, enter revenue code 0652 once for each date of service |
43. | DESCRIPTION | Required: From the UB-04 Manual, enter the Hospice revenue code?s Standard Abbreviation. Required only on paper claims |
44. | HCPCS/RATE/HIPPS CODE | Not applicable to Hospice |
45. | SERV DATE | Required on claims for Continuous Home Care. Enter the applicable date of service for each entry of revenue code 0652. Every service date must be within the Statement Covers Period FROM and THROUGH dates (field 6), inclusive. Required when the claim is for non-sequential service dates for one Hospice care category (excluding Continuous Home Care, which has its own billing rules) or for more than one Hospice care category. When required, enter a service date for each entry of each Hospice revenue code. Service dates must be within the Statement Covers Period FROM and THROUGH dates (field 6), inclusive. |
46. | SERV UNITS | When service dates are required in field 45, service units are required in field 46. For Continuous Home Care, enter total hours of service for each service date. For the other three categories of Hospice care, enter ?1? for each service date when service dates are required. |
47. | TOTAL CHARGES | Required: Enter the total charge for the revenue code on each line (Units times the charge for one unit of service). |
48. | NON-COVERED CHARGES | Not applicable to Hospice |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Required: Enter ?Medicaid? |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required: One of two alternative entries 1) ?I? (?Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes?) when the Hospice provider has not collected a Release of Information Certification Signature from the patient or the patient?s representative, or 2) ?Y? (?Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim?). This is a HIPAA Privacy Rule requirement. |
53. | ASG BEN | Not applicable to Hospice |
54. | PRIOR PAYMENTS | Required when applicable. Enter all payments made by any other parties toward this bill. See the UB-04 Manual |
55. | EST AMOUNT DUE | Not applicable to Medicaid |
56. | NPI | Not required on paper claims. |
57. | OTHER PRV ID | Required: Enter the 9-digit Arkansas Medicaid provider ID number of the billing Hospice provider. |
58. A, B, C | INSURED?S NAME | Not applicable to Medicaid. |
59. A, B, C | P REL | Not applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Required; Enter the patient?s Medicaid identification number. |
61. A, B, C | GROUP NAME | Required when the patient is insured by another payer or other payers. Refer to the UB-04 manual. |
62. A, B, C | INSURANCE GROUP NO | Required when applicable. See the UB-04 Manual. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Required only when a benefit extension was required for an Inpatient Respite Care stay. When required, enter the benefit extension control number. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | Required when a beneficiary is covered by other insurance through an employer. Enter the employer?s name. |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. | (blank) | Required when applicable. Enter any ICD-9-CM or ICD-10-CM diagnosis codes for other conditions that coexist with the terminal condition. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required. Enter the most specific ICD-9-CM or ICD-10-CM diagnosis code that corresponds to the beneficiary?s terminal condition. |
70. | PATIENT REASON DX | Not applicable to Hospice |
71. | PPS CODE | Not required. |
72 | ECI | Not applicable to Hospice. |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not applicable to Hospice. |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Required: Enter 0B, indicating state license number. Enter the attending physician?s state license number in the second part of the field. | |
LAST | Required: Enter the last name of the primary attending physician during this episode of care. | |
FIRST | Required: Enter the primary attending physician?s first name. | |
77. | OPERATING NPI | Not applicable to Hospice |
QUAL | Not applicable to Hospice | |
LAST | Not applicable to Hospice | |
FIRST | Not applicable to Hospice | |
78. | OTHER NPI | NPI not required. |
QUAL | Required: Enter 0B, indicating state license number. Enter the referring physician?s state license number in the second part of the field. | |
LAST | Required: Enter the referring physician?s last name. | |
FIRST | Required: Enter the referring physician?s first name. | |
NOTE: When there is no referring physician, enter the same information entered in field 76. | ||
79. | OTHER NPI | NPI not required. |
QUAL | Required for Inpatient Respite Care and General Inpatient Care claims. Enter 0B, indicating state license number. Enter the inpatient facility?s state license number in the second part of the field. | |
LAST | Not applicable | |
FIRST | Not applicable. | |
80. | REMARKS | For provider?s use. Providers may enter the inpatient facility?s name and/or other notes here. |
81. | Not used | Reserved for assignment by the NUBC. |
Field # | Field name | Description |
01. | (blank) | Required: Enter the billing (i.e., Hospice) provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
02. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
03a. | PAT CNTL # | Required: Enter the patient?s financial account number; the number the Hospice uses to retrieve individual patients? financial account information. This account number appears on the RA, labeled ?MRN.? Use this number to ensure correct identification when reconciling the Medicaid remittance with patients? accounts. HP Enterprise Services accepts up to 16 alphanumeric characters in this field. |
03b. | MED REC # | Required: Enter the patient?s medical record number; the number the Hospice uses to file and retrieve individual patients? medical records. HP Enterprise Services accepts up to 15 alphanumeric characters in this field. |
04. | TYPE OF BILL | Required: The first two digits must be 08 (Special Facility). The third digit must be 1 (Hospice, non-hospital based) or 2 (Hospice, hospital based). Use the applicable frequency code from the UB-04 Manual for the fourth digit. |
05. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
06. | STATEMENT COVERS PERIOD?FROM and THROUGH | Required The FROM date in field 06 is the date of the first day on this claim for which the Hospice provider claims reimbursement for nursing facility or ICF/MR room and board. The format is MMDDYY. The THROUGH date in field 06 is either the patient?s discharge date or the last day on this claim for which the Hospice provider claims reimbursement for Nursing Facility or ICF/MR Room and Board. When a patient is temporarily transferred to a hospital, an Inpatient Hospice Facility or home, the transfer date is a discharge date with respect to Nursing Facility or ICF/MR Room and Board reimbursement. The date that Hospice home care in the facility resumes or the date that the patient?s Hospice plan of care is approved, whichever is more recent, is the FROM date in field 06 of the next claim for that patient?s Nursing Facility or ICF/MR Room and Board. In the Hospice Program, the ?STATEMENT COVERS PERIOD? FROM and THROUGH dates must always be within the same calendar month. The format is MMDDYY. |
07. | Not used | Reserved for assignment by the NUBC. |
08a. | PATIENT NAME | Required: Enter the patient?s last name, first name and middle initial. |
08b. | (blank) | Not required. |
09. | PATIENT ADDRESS | Optional. |
10. | BIRTH DATE | Required: Enter the patient?s date of birth. The format is MMDDYYYY. |
11. | SEX | Required: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Required: Enter the date that nursing facility or ICF/MR Hospice services began at this facility or the date that the plan of care was approved for nursing facility or ICF/MR Hospice home care, whichever date is more recent. When a Hospice client has been discharged and temporarily transferred to a hospital, an Inpatient Hospice Facility, a different nursing facility or ICF/MR or home, and then readmitted to this facility, enter the readmission date, the date that nursing facility or ICF/MR Hospice services resumed at this facility or the date that a new or revised plan of care for Hospice home care in this facility was approved, whichever date is more recent. If the beneficiary has elected, and then revoked nursing facility or ICF/MR Hospice home care in the past; and then later re-elected nursing facility or ICF/MR Hospice home care, enter the date that Hospice care resumed under the re-election or the date that the new plan of care was authorized, whichever is more recent. The format is MMDDYY. |
13. | ADMISSION HR | Not applicable to Hospice |
14. | ADMISSION TYPE | Not applicable to Hospice |
15. | ADMISSION SRC | Not applicable to Hospice |
16. | DHR | Not applicable to Hospice |
17. | STAT | Required: From the UB-04 manual, enter the patient status code indicating the patient?s disposition or discharge status on the ?STATEMENT COVERS PERIOD? THROUGH date (field 06). |
18.-28. | CONDITION CODES | Required when applicable. See the UB-04 Manual for any applicable requirements and for the NUBC-authorized codes that identify conditions or events relating to this bill. Use only condition codes that are NUBC-approved for the service date(s). |
29. | ACDT STATE | Not applicable to Hospice |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Not applicable to Hospice nursing facility or ICF/MR Room and Board. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Not applicable to Hospice nursing facility or ICF/MR Room and Board. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | Not applicable to Hospice nursing facility or ICF/MR Room and Board. |
39. a. | VALUE CODES CODE AMOUNT | Required Enter 80. Required: Enter the number of days for which nursing facility or ICF/MR room and board is due, as indicated by the ?STATEMENT COVERS PERIOD? FROM and THROUGH dates. The THROUGH date is covered unless it is a transfer date or a discharge date. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Required: Enter 0658 or 0659 |
43. | DESCRIPTION | Required: Enter the revenue code?s standard abbreviation, ?HOSPICE/R&B NURSE FAC.? |
44. | HCPCS/RATE/HIPPS CODE | Not applicable to Hospice |
45. | SERV DATE | Not applicable to Hospice Nursing Facility or ICF/MR Room and Board |
46. | SERV UNITS | Not applicable to Hospice Nursing Facility or ICF/MR Room and Board |
47. | TOTAL CHARGES | Required: Enter the total charge. The daily room and board rate times the covered days equals the total charge. |
48. | NON-COVERED CHARGES | Not applicable to Hospice |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Required: Enter ?Medicaid.? |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required: One of two alternative entries; 1) ?I? (?Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes?) when the Hospice provider has not collected a Release of Information Certification Signature from the patient or the patient?s representative, and state or federal laws do not supersede the HIPAA Privacy Rule by requiring that a signature be collected; or 2) ?Y? (?Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim?). Completing this field as instructed is a HIPAA Privacy Rule requirement. |
53. | ASG BEN | Not applicable to Medicaid |
54. | PRIOR PAYMENTS | Required when applicable. Enter the total amount paid by any parties (other than Medicaid) toward this bill. See the UB-04 Manual for details. |
55. | EST AMOUNT DUE | Not applicable to Medicaid |
56. | NPI | Not required on paper claims. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing (i.e., Hospice) provider. |
58. A, B, C | INSURED?S NAME | Not applicable to Medicaid. |
59. A, B, C | P REL | Not applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Enter the patient?s Medicaid identification number. |
61. A, B, C | GROUP NAME | If the patient is insured by another payer or other payers, see the UB-04 manual. |
62. A, B, C | INSURANCE GROUP NO | When applicable, see the UB-04 Manual. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Not applicable to Hospice nursing facility or ICF/MR room and board. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input is permitted. |
65. A, B, C | EMPLOYER NAME | When a beneficiary is covered by other insurance through an employer, enter the employer?s name. |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. | (watermarked) | Enter the ICD-9-CM or ICD-10-CM diagnosis code corresponding to the beneficiary?s terminal condition. |
67 A-Q | (watermarked) | Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to other conditions that coexist with the terminal condition. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Not applicable to Hospice nursing facility or ICF/MR room and board. |
70. | PATIENT REASON DX | Not applicable to Hospice |
71. | PPS CODE | Not applicable to Hospice |
72 | ECI | Not applicable to Hospice. |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not applicable to Hospice. |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the primary attending physician?s state license number in the second part of the field. | |
LAST | Enter the primary attending physician?s last name. | |
FIRST | Enter the primary attending physician?s first name. | |
77. | OPERATING NPI | Not applicable to Hospice |
QUAL | Not applicable to Hospice | |
LAST | Not applicable to Hospice | |
FIRST | Not applicable to Hospice | |
78. | OTHER NPI | NPI is not required |
QUAL | Enter 0B, indicating state license number. Enter, in the second part of the field, the state license number of the nursing facility or ICF/MR in which the patient resides. | |
LAST | Enter the name of the nursing facility or the ICF/MR in which the patient resides | |
FIRST | Not applicable. | |
79. | OTHER NPI | Not applicable to Hospice |
QUAL | Not applicable to Hospice | |
LAST | Not applicable to Hospice | |
FIRST | Not applicable to Hospice | |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
Field # | Field name | Description |
1. | (blank) | Inpatient and Outpatient: Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. | PAT CNTL # | Inpatient and Outpatient: The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. |
3b. | MED REC # | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields. The FROM and THROUGH dates cannot span the State?s fiscal year end (June 30) or the provider?s fiscal year end. To file correctly for covered inpatient days that span a fiscal year end: 1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that ended during the stay. On a first claim or a continuing claim, the patient status code in field 17 must indicate that the beneficiary is still a patient on the indicated THROUGH date. 2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. When the discharge date is the first day of the provider?s fiscal year or the state?s fiscal year, only one (bill type: admission through discharge) claim is necessary, because Medicaid does not reimburse a hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. When an inpatient is discharged on the same date he or she is admitted, the day is covered when the TYPE OF BILL code indicates that the claim is for admission through discharge, the STAT (patient status) code indicates discharge or transfer, and the FROM and THROUGH dates are identical. Outpatient: To bill on a single claim for outpatient services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. The dates in this locator must fall within the same fiscal year ? the state?s fiscal year and the hospital?s fiscal year. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42 . |
7. | Not used | Reserved for assignment by the NUBC. |
8a. | PATIENT NAME | Inpatient and Outpatient: Enter the patient?s last name and first name. Middle initial is optional. |
8b. | (blank) | Not required. |
9. | PATIENT ADDRESS | Inpatient and Outpatient: Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Inpatient and Outpatient: Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Inpatient: Enter the inpatient admission date. Format: MMDDYY. Outpatient: Not required. |
13. | ADMISSION HR | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient care. |
14. | ADMISSION TYPE | Inpatient: Enter the code from the Uniform Billing Manual that indicates the priority of this inpatient admission. Outpatient: Not required. |
15. | ADMISSION SRC | Inpatient and Outpatient: Admission source. Required. Code 1, 2, 3, or 4 is required when the code in field 14 is 4. |
16. | DHR | Inpatient: See the UB-04 Manual. Required except for type of bill 021x. Enter the hour the patient was discharged from inpatient care. |
17. | STAT | Inpatient: Enter the national code indicating the patient?s status on the Statement Covers Period THROUGH date (field 6). Outpatient: Not applicable. |
18.-28. | CONDITION CODES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Inpatient: Enter the dates of the first and last days approved, per the facility?s PSRO/UR plan, in the FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY. |
Outpatient: See the UB-04 Manual. | ||
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Outpatient: Not required. Inpatient: |
a. | CODE | Enter 80. |
AMOUNT | Enter number of covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
b. | CODE | Enter 81. |
AMOUNT | Enter number of non-covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Inpatient and Outpatient: See the UB-04 Manual. |
43. | DESCRIPTION | See the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | Inpatient: Not applicable. |
Outpatient: Date format: MMDDYY. | ||
46. | SERV UNITS | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | See the UB-04 Manual, line item ?Total? under ?Reporting.? |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required when applicable. See the UB-04 Manual. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | Inpatient and Outpatient: 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 or ARKids First-B co-payments. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider in first line of field. |
58. A, B, C | INSURED?S NAME | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Inpatient and Outpatient: Enter the patient?s Medicaid identification number in first line of field. |
61. A, B, C | GROUP NAME | Inpatient and Outpatient: Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | Inpatient and Outpatient: When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Inpatient: Enter any applicable prior authorization, benefit extension, or MUMP certification control number on line 63A. Outpatient: Enter any applicable prior authorization or benefit extension numbers on line 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | Inpatient and Outpatient: When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Inpatient and Outpatient: Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required for inpatient. See the UB-04 Manual. |
70. | PATIENT REASON DX | See the UB-04 Manual. |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Principal procedure code. | |
DATE | Format: MMDDYY. | |
74a-74e | OTHER PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Inpatient claims only. Other procedure code(s). | |
DATE | Inpatient claims only. Format: MMDDYY. | |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI QUAL | NPI not required. Enter 0B, indicating state license number. Enter the state license number in the second part of the field. |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the operating physician?s state license number in the second part of the field. | |
LAST | Enter the last name of the operating physician. | |
FIRST | Enter the first name of the operating physician. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 ? Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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. Some 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. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the services was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 N O. | 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. RESERVED | Reserved for NUCC use. |
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. |
Field # | Field name | Description |
1. | (blank) | Inpatient and Outpatient: Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. | PAT CNTL # | Inpatient and Outpatient: The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. |
3b. | MED REC # | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields. The FROM and THROUGH dates cannot span the State?s fiscal year end (June 30) or the provider?s fiscal year end. To file correctly for covered inpatient days that span a fiscal year end: 1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that ended during the stay. On a first claim or a continuing claim, the patient status code in field 17 must indicate that the beneficiary is still a patient on the indicated THROUGH date. 2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. When the discharge date is the first day of the provider?s fiscal year or the state?s fiscal year, only one (bill type: admission through discharge) claim is necessary, because Medicaid does not reimburse a hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. When an inpatient is discharged on the same date he or she is admitted, the day is covered when the TYPE OF BILL code indicates that the claim is for admission through discharge, the STAT (patient status) code indicates discharge or transfer, and the FROM and THROUGH dates are identical. Outpatient: To bill on a single claim for outpatient services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. The dates in this locator must fall within the same fiscal year ? the state?s fiscal year and the hospital?s fiscal year. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42. |
7. | Not used | Reserved for assignment by the NUBC. |
8a. | PATIENT NAME | Inpatient and Outpatient: Enter the patient?s last name and first name. Middle initial is optional. |
8b. | (blank) | Not required. |
9. | PATIENT ADDRESS | Inpatient and Outpatient: Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Inpatient and Outpatient: Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Inpatient: Enter the inpatient admission date. Format: MMDDYY. Outpatient: Not required. |
13. | ADMISSION HR | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient care. |
14. | ADMISSION TYPE | Inpatient: Enter the code from the Uniform Billing Manual that indicates the priority of this inpatient admission. Outpatient: Not required. |
15. | ADMISSION SRC | Inpatient and Outpatient: Admission source. Required. Code 1, 2, 3, or 4 is required when the code in field 14 is 4. |
16. | DHR | Inpatient: See the UB-04 Manual. Required except for type of bill 021x. Enter the hour the patient was discharged from inpatient care. |
17. | STAT | Inpatient: Enter the national code indicating the patient?s status on the Statement Covers Period THROUGH date (field 6). Outpatient: Not applicable. |
18.-28. | CONDITION CODES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Inpatient: Enter the dates of the first and last days approved, per the facility?s PSRO/UR plan, in the FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY. Outpatient: See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Outpatient: Not required. Inpatient: |
a. | CODE | Enter 80. |
AMOUNT | Enter number of covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted | |
b. | CODE | Enter 81. |
AMOUNT | Enter number of non-covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Inpatient and Outpatient: See the UB-04 Manual. |
43. | DESCRIPTION | See the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | Inpatient: Not applicable. Outpatient: See the UB-04 Manual. Format: MMDDYY. |
46. | SERV UNITS | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | See the UB-04 Manual, line item ?Total? under ?Reporting.? |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required when applicable. See the UB-04 Manual. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Inpatient and Outpatient: Enter the patient?s Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Inpatient and Outpatient: Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | Inpatient and Outpatient: When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Inpatient: Enter any applicable prior authorization, benefit extension, or MUMP certification control number on line 63A. Outpatient: Enter any applicable prior authorization or benefit extension number on line 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | Inpatient and Outpatient: When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Inpatient and Outpatient: Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required for inpatient. See the UB-04 Manual. |
70. | PATIENT REASON DX | See the UB-04 Manual. |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Principal procedure code. | |
DATE | Format: MMDDYY. | |
74a-74e | OTHER PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Other procedure code(s). | |
DATE | Format: MMDDYY. | |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the operating physician. | |
FIRST | Enter the first name of the operating physician. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
Field Number and Name | Instructions for Completion |
1. (type of coverage) | Not required. |
1a. INSURED?S I.D. NUMBER (For Program in Item 1) | Beneficiary?s 10-digit Medicaid identification number. |
2. PATIENT?S NAME (Last Name, First Name, Middle Initial) | Beneficiary?s last name and first name. |
3. PATIENT?S BIRTH DATE | Beneficiary?s date of birth as given on the individual?s Medicaid 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 complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary resides. |
STATE | Two-letter postal code for the state in which the beneficiary resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary?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 beneficiary?s relationship to the insured. |
7. INSURED?S ADDRESS (No., Street) | Required if insured?s address is different from the beneficiary?s address. |
CITY | |
STATE | |
ZIP CODE | |
TELEPHONE (Include Area Code) | |
8. RESERVED | Reserved for NUCC use. |
9. OTHER INSURED?S NAME (Last name, First Name, Middle Initial) | If beneficiary 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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
d. INSURANCE PLAN NAME OR PROGRAM NAME | Name of the insurance company. |
10. IS PATIENT?S CONDITION RELATED TO: | |
a. EMPLOYMENT? (Current or Previous) | Not required. |
b. AUTO ACCIDENT? | Not required. |
PLACE (State) | Not required. |
c. OTHER ACCIDENT? | Not required. |
10d. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source. |
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 | Not required. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 |
B. PLACE OF SERVICE | Two-digit national standard place of service code. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the provider?s usual charge to any beneficiary. |
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 | Not required. |
I. ID QUAL | Not required. |
J. RENDERING PROVIDER ID # | Not required. |
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 N O. | 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 of 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. RESERVED | Reserved for NUCC use. |
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 | 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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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. Some 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. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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. Some 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 | Enter the appropriate place of service code. See Section 252.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 252.100 through 252.130. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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 | Not required. |
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 TELEPHONE (Include Area Code) | Five-digit zip code; nine digits for post office box. 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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. EMPLOYER?S NAME OR SCHOOL NAME | Required when items 9 a and 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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
11. INSURED?S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
a. INSURED?S DATE OF BIRTH | Not required. This field is not required for Medicaid. |
SEX | Not required. |
b. OTHER CLAIM ID NUMBER | 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 9, 9a, 9c and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for Private Duty Nursing services. Enter the referring physician?s name. |
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. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER | Insert LEA number. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE ORIGINAL REF. NO. | Reserved for future use. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. |
B. PLACE OF SERVICE | Two-digit national standard place of service code. See Section 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | A modifier is required when billing for a second patient?s PDN services. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not include this total or the automatically deducted Medicaid co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
When a provider must bill on a paper claim, the fiscal agent accepts only red-lined, sensor-coded CMS-1500 claim forms. Claim photocopies and claim forms that are not sensor-coded cannot be processed.
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 10-digit Medicaid or ARKids First-A identification number. |
2. PATIENT?S NAME (Last Name, First Name, Middle Initial) | Beneficiary?s last name and first name. |
3. PATIENT?S BIRTH DATE | Beneficiary?s date of birth as given on the individual?s Medicaid or ARKids First-A 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 complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary resides. |
STATE | Two-letter postal code for the state in which the beneficiary resides. |
ZIP CODE | Five-digit ZIP code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary?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 the insured?s address is different from the patient?s address. |
CITY | |
STATE | |
ZIP CODE | |
TELEPHONE (Include Area Code) | |
8. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. EMPLOYER?S NAME OR SCHOOL NAME | Required when items 9a and 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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a, 9c and 9d.Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness ; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of the referral source. |
17a. (blank) | The 9-digit Arkansas Medicaid provider ID number of the referring physician when applicable. |
17b. NPI | Not required. |
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | Not applicable. |
19. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER | Insert LEA number. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2004. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number when 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. A provider 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 service on each day of the date sequence. 3. RCFs may bill for a date span of any length within the same calendar month, provided the beneficiary was present every day of the date span and all services provided within the date span were at the same Level of Care. |
B. PLACE OF SERVICE | Two-digit national standard place of service code. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) when applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the services totaled in the detail. This charge must be the usual charge to any beneficiary patient, or other recipient of the provider?s services. RCFs? charges should equal no less than the product of the number of units (days) times the beneficiary?s Daily Service Rate. If the charge is less, Medicaid will pay the billed charge. |
G. DAYS OR UNITS | The units (in whole numbers) of service 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 and referral. |
I. ID QUAL | Not required. |
J. RENDERING PROVIDER ID # | Not applicable. |
NPI | Not required. |
25. FEDERAL TAX I.D. NUMBER | Not required. This information is carried in the provider?s Medicaid file. If it changes, advise Provider Enrollment so that the year-end 1099 will be correct and reported correctly. |
26. PATIENT?S ACCOUNT NO. | Optional entry for providers? accounting and account-retrieval purposes. Enter up to 16 numeric, alphabetic or alpha-numeric characters. This character set 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 of all charges on the claim. |
29. AMOUNT PAID | Enter the total of payments received from other sources on this claim. Do not include amounts previously paid by Medicaid. |
30. RESERVED | Reserved for NUCC use. |
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS | The performing provider or an individual authorized by the performing provider or by an institutional, corporate, business or other provider organization, must sign and date the claim, certifying that the services were furnished by the provider, under (when applicable) the direction of the individual provider or other qualified individual, and in strict and verifiable accordance with all applicable rules of the Medicaid program in which the provider participates. A ?provider?s signature? is the provider?s or authorized individual?s personally written signature, a rubber stamp of the signature, an automated signature or a typed signature. The name of a group practice, a facility or institution, a corporation, a business or any other organization will prevent the claim from being processed. |
32. SERVICE FACILITY LOCATION INFORMATION | If services were not performed at the beneficiary?s home or at the provider?s facility (e.g., school, DDS facility etc.) enter the name, street address, city, state and zip code of the facility, workplace etc. where services were performed. If services were furnished at multiple sites (for instance, when job-seeking), indicate ?multiple locations? or leave blank. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d.Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 Pharmacy 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Not applicable to Pharmacy claims. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in the Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not include in this total the automatically deducted Medicaid or Arkids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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 | Policy and/or group number of the insured individual. |
NUMBER b. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for most Physician/Independent Lab/CRNA/Radiation Therapy Center services provided by non-PCPs. Enter the referring physician?s 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 292.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. For anesthesia, when billed with modifier(s) P1, P2, P3, P4, or P5, hours and minutes must be entered in the shaded portion of that detail in field 24D. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for Podiatrist 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.130. |
MODIFIER | Not applicable to Podiatrist Services claims. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | . Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation. 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. |
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 | Not applicable to portable X-ray. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.110. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition codes, enter the condition codes in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 prosthetics. 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding For dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. |
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 |
B. PLACE OF SERVICE | Two-digit national standard place of service code. See Section 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.195. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 |
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 N O. | 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
Field # | Field name | Description |
1. | (blank) | Inpatient and Outpatient: Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail). |
3a. | PAT CNTL # | Inpatient and Outpatient: The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. |
3b. | MED REC # | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields. The FROM and THROUGH dates cannot span the State?s fiscal year end (June 30) or the provider?s fiscal year end. To file correctly for covered inpatient days that span a fiscal year end: 1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that ended during the stay. On a first claim or a continuing claim, the patient status code in field 17 must indicate that the beneficiary is still a patient on the indicated THROUGH date. 2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. When the discharge date is the first day of the provider?s fiscal year or the state?s fiscal year, only one (bill type: admission through discharge) claim is necessary, because Medicaid does not reimburse a |
hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. When an inpatient is discharged on the same date he or she is admitted, the day is covered when the TYPE OF BILL code indicates that the claim is for admission through discharge, the STAT (patient status) code indicates discharge or transfer, and the FROM and THROUGH dates are identical. Outpatient: To bill on a single claim for outpatient services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. The dates in this field must fall within the same fiscal year ? the state?s fiscal year and the hospital?s fiscal year. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42. | ||
7. | (blank) | Reserved for assignment by the NUBC. |
8a. | PATIENT NAME | Inpatient and Outpatient: Enter the patient?s last name and first name. Middle initial Is optional. |
8b. | (blank) | Not required. |
9. | PATIENT ADDRESS | Inpatient and Outpatient: Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Inpatient and Outpatient: Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Inpatient: Enter the inpatient admission date. Format: MMDDYY. Outpatient: Not required. |
13. | ADMISSION HR | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient care. |
14. | ADMISSION TYPE | Inpatient: Enter the code from the UB-04 Manual that indicates the priority of this inpatient admission. Outpatient: Not required. |
15. | ADMISSION SRC | Inpatient and Outpatient: Admission source. |
16. | DHR | Inpatient: See the UB-04 Manual. Required. Enter the hour the patient was discharged from inpatient care. |
17. | STAT | Inpatient: Enter the national code indicating the patient?s status on the Statement Covers Period THROUGH date (field 6). Outpatient: Not applicable. |
18.-28. | CONDITION CODES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Inpatient: Enter the dates of the first and last days approved, per the facility?s PSRO/UR plan, in the FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY. Outpatient: See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Outpatient: Not required. Inpatient: |
a. | CODE | Enter 80. |
AMOUNT | Enter number of covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
b. | CODE | Enter 81. |
AMOUNT | Enter number of non-covered days. Enter number of days (units billed) to the left of the vertical dotted line and enter two zeros (00) to the right of the vertical dotted line. | |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Inpatient and Outpatient: See the UB-04 Manual. |
43. | DESCRIPTION | See the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | Inpatient: Not applicable. Outpatient: See the UB-04 Manual. Format: MMDDYY. |
46. | SERV UNITS | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | See the UB-04 Manual, line item ?Total? under ?Reporting.? |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required when applicable. See the UB-04 Manual. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | Inpatient and Outpatient: Required when applicable. 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 or ARKids First-B co-payments. See the UB-04 Manual. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual.. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Inpatient and Outpatient: Enter the patient?s Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Inpatient and Outpatient: Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | Inpatient and Outpatient: When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Inpatient: Enter any applicable prior authorization, benefit extension, or MUMP certification control number in field 63A. Outpatient: Enter any applicable prior authorization or benefit extension number in field 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | Inpatient and Outpatient: When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0? designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Inpatient and Outpatient: Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required for inpatient. See the UB-04 Manual. |
70. | PATIENT REASON DX | See the UB-04 Manual. |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Principal procedure code. | |
DATE | Format: MMDDYY. | |
74a-74e | OTHER PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Other procedure code(s). | |
DATE | Format: MMDDYY. | |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Not applicable. | |
LAST | Not applicable. | |
FIRST | Not applicable. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
Field # | Field name | Description |
1. | (blank) | Inpatient and Outpatient: Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. | PAT CNTL # | Inpatient and Outpatient: The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. |
3b. | MED REC # | Inpatient and Outpatient: Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Inpatient and Outpatient: See the UB-04 manual. Four-digit code with a leading zero that indicates the type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the covered beginning and ending service dates. Format: MMDDYY. Inpatient: Enter the dates of the first and last covered days in the FROM and THROUGH fields. The FROM and THROUGH dates cannot span the State?s fiscal year end (June 30) or the provider?s fiscal year end. To file correctly for covered inpatient days that span a fiscal year end: 1. Submit one interim claim (a first claim or a continuing claim, as applicable) on which the THROUGH date is the last day of the fiscal year that ended during the stay. On a first claim or a continuing claim, the patient status code in field 17 must indicate that the beneficiary is still a patient on the indicated THROUGH date. 2. Submit a second interim claim (a continuing claim or a last claim, as applicable) on which the FROM date is the first day of the new fiscal year. When the discharge date is the first day of the provider?s fiscal year or the state?s fiscal year, only one (bill type: admission through discharge) claim is necessary, because Medicaid does not reimburse a hospital for a discharge day unless the discharge day is also the first covered day of the inpatient stay. |
When an inpatient is discharged on the same date he or she is admitted, the day is covered when the TYPE OF BILL code indicates that the claim is for admission through discharge, the STAT (patient status) code indicates discharge or transfer, and the FROM and THROUGH dates are identical. Outpatient: To bill on a single claim for outpatient services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields of this field. The dates in this locator must fall within the same fiscal year ? the state?s fiscal year and the hospital?s fiscal year. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42. | ||
7. | (blank) | Reserved for assignment by the NUBC. |
8a. | PATIENT NAME | Inpatient and Outpatient: Enter the patient?s last name and first name. Middle initial is optional. |
8b. | (blank) | Not required. |
9. | PATIENT ADDRESS | Inpatient and Outpatient: Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Inpatient and Outpatient: Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Inpatient and Outpatient: Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Inpatient: Enter the inpatient admission date. Format: MMDDYY. Outpatient: Not required. |
13. | ADMISSION HR | Inpatient and Outpatient: Enter the national code that corresponds to the hour during which the patient was admitted for inpatient care. |
14. | ADMISSION TYPE | Inpatient: Enter the code from the Uniform Billing Manual that indicates the priority of this inpatient admission. Outpatient: Not required. |
15. | ADMISSION SRC | Inpatient and Outpatient: Admission source. Required. Code 1, 2, 3, or 4 is required when the code in field 14 is 4. |
16. | DHR | Inpatient: See the UB-04 Manual. Required except for type of bill 021x. Enter the hour the patient was discharged from inpatient care. |
17. | STAT | Inpatient: Enter the national code indicating the patient?s status on the Statement Covers Period THROUGH date (field 6). Outpatient: Not applicable. |
18.-28. | CONDITION CODES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | Inpatient: Enter the dates of the first and last days approved, per the facility?s PSRO/UR plan, in the FROM and THROUGH fields. See the UB-04 Manual. Format: MMDDYY. Outpatient: See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Outpatient: Not required. Inpatient: |
a. | CODE | Enter 80. |
AMOUNT | Enter number of covered days. | |
b. | CODE | Enter 81. |
AMOUNT | Enter number of noncovered days. | |
40. | VALUE CODES | Not required. |
41. | VALUE CODES | Not required. |
42. | REV CD | Inpatient and Outpatient: See the UB-04 Manual. |
43. | DESCRIPTION | See the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | Inpatient: Not applicable. Outpatient: See the UB-04 Manual. Format: MMDDYY. |
46. | SERV UNITS | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
47. | TOTAL CHARGES | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
48. | NON-COVERED CHARGES | See the UB-04 Manual, line item ?Total? under ?Reporting.? |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required when applicable. See the UB-04 Manual. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | Inpatient and Outpatient: Required when applicable. See the UB-04 Manual. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Inpatient and Outpatient: Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | Inpatient and Outpatient: Enter the patient?s Medicaid identification number on first line of field. |
61. A, B, C | GROUP NAME | Inpatient and Outpatient: Using the plan name if the patient is insured by another payer or other payers follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | Inpatient and Outpatient: When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Inpatient: Enter any applicable prior authorization, benefit extension, or MUMP certification control number in field 63A. Outpatient: Enter any applicable prior authorization or benefit extension number in field 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | Inpatient and Outpatient: When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0? designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Inpatient and Outpatient: Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Required for inpatient. See the UB-04 Manual. |
70. | PATIENT REASON DX | See the UB-04 Manual. |
71. | PPS CODE | Not required. |
72. | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Principal procedure code. | |
DATE | Format: MMDDYY. | |
74a-74e | OTHER PROCEDURE | Inpatient: Required on inpatient claims when a procedure was performed. On all interim claims, enter the codes for all procedures during the hospital stay. Outpatient: Not applicable. |
CODE | Other procedure code(s). | |
DATE | Format: MMDDYY. | |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the operating physician. | |
FIRST | Enter the first name of the operating physician. | |
78. | OTHER NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRS | Not required. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | Not required. |
c. INSURANCE PLAN NAME OR PROGRAM | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for RSPMI services for individuals under age 21. 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 252.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure codes from Sections 252.100 through 252.150. |
MODIFIER | Use applicable modifier. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 |
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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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 | Enter the name and street, city, state, and zip code of the facility where services were performed. |
a. (blank) | Not required. |
b. Service Site Medicaid ID number | Enter the 9-digit Arkansas Medicaid provider ID number of the service site. |
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. |
Field # | Field name | Description |
1. | (blank) | Enter the provider?s name, (physical address ? service location) city, state, zip code, and telephone number. |
2. | (blank) | The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for provider?s return address for returned mail.) |
3a. | PAT CNTL # | The provider may use this optional field for accounting purposes. It appears on the RA beside the letters ?MRN.? Up to 16 alphanumeric characters are accepted. |
3b. | MED REC # | Required. Enter up to 15 alphanumeric characters. |
4. | TYPE OF BILL | Type of Bill Enter the three digit numeric code found in the Data Specifications Manual to indicate the specific type of bill. |
5. | FED TAX NO | The number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN). |
6. | STATEMENT COVERS PERIOD | Enter the beginning and ending service dates of the period covered by this bill. To bill on a single claim for services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields. The ?FROM? and ?THROUGH? dates may not span calendar months. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42. |
7. | Not used | Reserved for assignment by the NUBC. |
8a. 8b. | PATIENT NAME (blank) | Enter the patient?s last name and first name. Middle initial is optional. Not required. |
9. | PATIENT ADDRESS | Enter the patient?s full mailing address. Optional. |
10. | BIRTH DATE | Enter the patient?s date of birth. Format: MMDDYYYY. |
11. | SEX | Enter M for male, F for female, or U for unknown. |
12. | ADMISSION DATE | Not applicable. |
13. | ADMISSION HR | Not applicable. |
14. | ADMISSION TYPE | Not applicable. |
15. | ADMISSION SRC | Not applicable. |
16. | DHR | Not applicable. |
17. | STAT | Not applicable. |
18.-28. | CONDITION CODES | Required when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill. |
29. | ACDT STATE | Not required. |
30. | (blank) | Unassigned data field. |
31.-34. | OCCURRENCE CODES AND DATES | Required when applicable. See the UB-04 Manual. |
35.-36. | OCCURRENCE SPAN CODES AND DATES | See the UB-04 Manual. |
37. | Not used | Reserved for assignment by the NUBC. |
38. | Responsible Party Name and Address | See the UB-04 Manual. |
39. | VALUE CODES | Not required. |
a. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
b. | CODE | Not applicable. |
AMOUNT | Not applicable. | |
40. | VALUE CODES | Not applicable. |
41. | VALUE CODES | Not applicable. |
42. | REV CD | Enter 0521 for an RHC Visit (encounter). |
43. | DESCRIPTION | Enter the Revenue Code?s corresponding Standard Abbreviation found in the UB-04 Manual. |
44. | HCPCS/RATE/HIPPS CODE | See the UB-04 Manual. |
45. | SERV DATE | When the ?FROM? and ?THROUGH? dates indicate the claim is for multiple dates of service, enter the service (encounter) date for each revenue code. Always enter the service date of each HCPCS or CPT procedure code. Format: MMDDYY. |
46. | SERV UNITS | Enter the number of units furnished of each itemized service per date of service. |
47. | TOTAL CHARGES | The total charge for the line-item number of units reported in field 46. See the UB-04 Manual for additional information. |
48. | NON-COVERED CHARGES | Not required. |
49. | Not used | Reserved for assignment by the NUBC. |
50. | PAYER NAME | Line A is required. See the UB-04 for additional regulations. |
51. | HEALTH PLAN ID | Report the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number. |
52. | REL INFO | Required. |
53. | ASG BEN | Required. See ?Notes? at field 53 in the UB-04 Manual. |
54. | PRIOR PAYMENTS | 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 or ARKids First-B co-payments. |
55. | EST AMOUNT DUE | Situational. See the UB-04 Manual. |
56. | NPI | Not required. |
57. | OTHER PRV ID | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider on first line of field. |
58. A, B, C | INSURED?S NAME | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
59. A, B, C | P REL | Comply with the UB-04 Manual?s instructions when applicable to Medicaid. |
60. A, B, C | INSURED?S UNIQUE ID | On line A, enter the RHC patient?s Arkansas Medicaid or ARKids First (A or B) identification number on first line of field. |
61. A, B, C | GROUP NAME | Using the plan name if the patient is insured by another payer or other payers, follow instructions for field 60. |
62. A, B, C | INSURANCE GROUP NO | When applicable, follow instructions for fields 60 and 61. |
63. A, B, C | TREATMENT AUTHORIZATION CODES | Enter any applicable prior authorization or benefit extension number on line 63A. |
64. A, B, C | DOCUMENT CONTROL NUMBER | Field used internally by Arkansas Medicaid. No provider input. |
65. A, B, C | EMPLOYER NAME | When applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable). |
66. | DX | Diagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code ?9? designating ICD-9-CM diagnosis required on claims representing services through September 30, 2014. Qualifier Code ?0?designating ICD-10-CM diagnosis required on claims representing services on or after October 1, 2014. Comply with the UB-04 Manual?s instructions on claims processing requirements. |
67. A-H | (blank) | Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes. |
68. | Not used | Reserved for assignment by the NUBC. |
69. | ADMIT DX | Not required. |
70. | PATIENT REASON DX | Not applicable. |
71. | PPS CODE | Not required. |
72 | ECI | See the UB-04 Manual. Required when applicable (for example, TPL and torts). |
73. | Not used | Reserved for assignment by the NUBC. |
74. | PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATES | Not required. |
75. | Not used | Reserved for assignment by the NUBC. |
76. | ATTENDING NPI | NPI not required. |
QUAL | Enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary attending physician. | |
FIRST | Enter the first name of the primary attending physician. | |
77. | OPERATING NPI | NPI not required. |
QUAL | Not applicable. | |
LAST | Not applicable. | |
FIRST | Not applicable. | |
78. | OTHER NPI | NPI not required. |
QUAL | When applicable, enter 0B, indicating state license number. Enter the state license number in the second part of the field. | |
LAST | Enter the last name of the primary care physician. | |
FIRST | Enter the first name of the primary care physician. | |
79. | OTHER NPI/QUAL/LAST/FIRST | Not used. |
80. | REMARKS | For provider?s use. |
81. | Not used | Reserved for assignment by the NUBC. |
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 beneficiary?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. RESERVED | Reserved for NUCC use. |
9. OTHER INSURED?S NAME (Last name, First Name, Middle Initial) | If beneficiary 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 | Policy and/or group number of the insured beneficiary. |
b. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 SAT 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 beneficiary?s admission and discharge dates. Format: MM/DD/YY. |
19. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24. A. 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 252.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure codes from Sections 252.100 through 252.120. |
MODIFIER | Use applicable modifier. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any beneficiary, 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. Must be a certified, enrolled SATS provider. |
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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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 | Enter the name and street, city, state, and zip code of the facility where services were performed. |
a. (blank) | Not required. |
b. Service Site Medicaid ID number | Enter the 9-digit Arkansas Medicaid provider ID number of the service site. |
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. |
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. RESERVED | Reserved for NUCC use. |
9. OTHER INSURED?S NAME (Last name, First Name, Middle Initial) | If beneficiary 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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. EMPLOYER?S NAME OR SCHOOL NAME | Required when items 9a and 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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a, 9c and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE | Enter the name of the referring physician. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
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. Local Educational Agency (LEA) Number | Insert LEA number. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding current for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 272.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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-payment. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. EMPLOYER?S NAME OR SCHOOL NAME | Required when items 9 a and 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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a, 9c and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER | Insert LEA number. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
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 the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 |
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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
11. INSURED?S POLICY GROUP | Not required when Medicaid is the only payer. |
a. INSURED?S DATE OF | Not required. |
SEX | Not required. |
b. OTHER CLAIM ID | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation , 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 required for Occupational, Physical, and Speech Therapy Services. Enter the referring physician?s name. |
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. ADDITIONAL CLAIM INFORMATION | For tracking purposes, occupational, physical and speech therapy providers are required to enter one of the following therapy codes: |
Code | Category |
A | Individuals from birth through 2 years who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. |
B | Individuals ages 0 to 6 years who are receiving therapy services under an Individualized Plan (IP) through the Division of Developmental Disabilities Services. NOTE: This code is to be used only when all three of the following conditions are in place: 1) The individual receiving services has not attained the age of 6. 2) The individual receiving services is receiving the services under an Individualized Plan. 3) The Individualized Plan is through the Division of Developmental Disabilities Services. |
When using code C or D, providers must also include the 4-digit LEA (local education agency) code assigned to each school district. For example: C1234 | |
C (and 4-digit LEA code) | Individuals ages 3 to 5 years who are receiving therapy services under an Individualized Education Program (IEP) through a school district or education service cooperative. NOTE: This code set is to be used only when all three of the following conditions are in place: 1) The individual receiving services is 3 years old and is not yet 5 years old. 2) The individual is receiving the services under an IEP maintained by a school district or education service cooperative. 3) Therapy services are being furnished by a) the school district or an ESC, which is an enrolled Medicaid therapy provider, or by b) a Medicaid-enrolled therapist or therapy group provider. |
D (and 4-digit LEA code) | Individuals ages 5 to 21 years who are receiving therapy services under an IEP through a school district or an education service cooperative. NOTE: This code set is to be used only when all three of the following conditions are in place: 1) The individual receiving services is 5 years old and is not yet 21 years old. 2) The individual is receiving the services under an IEP. 3) The IEP is through a school district or an education service cooperative. |
E | Individuals ages 18 through 20 years who are receiving therapy services through the Division of Developmental Disabilities Services. |
F | Individuals ages 18 through 20 years who are receiving therapy services from individual or group providers not included in any of the previous categories (A-E). |
G | Individuals ages birth through 17 years who are receiving therapy/pathology services from individual or group providers not included in any of the previous categories (A-F). |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding current for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 262.100 through 262.120. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 Ambulance Transportation 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers. |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
23. PRIOR AUTHORIZATION NUMBER | Enter the prior authorization number, for ground ambulance service to facilities outside the 50-mile radius in states bordering Arkansas. |
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 252.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | One CPT or HCPCS procedure code for each detail. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 | Not applicable to Ambulance Transportation Services. |
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 N O. | 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 payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not include in this total the automatically deducted Medicaid or Arkids-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 ventilator equipment 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 242.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Section 242.100. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 N O. | 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. RESERVED | Reserved for NUCC use. |
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. |
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. RESERVED | Reserved for NUCC use. |
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. RESERVED | Reserved for NUCC use. |
SEX | Not required. |
c. RESERVED | Reserved for NUCC use. |
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. CLAIM CODES | The ?Claim Codes? identify additional information about the beneficiary?s condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.orgunder Code Sets. |
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. OTHER CLAIM ID NUMBER | 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 9, 9a and 9d. Only one box can be marked. |
12. PATIENT?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
13. INSURED?S OR AUTHORIZED PERSON?S SIGNATURE | Enter ?Signature on File,? ?SOF? or legal signature. |
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. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. |
15. OTHER DATE | Enter another date related to the beneficiary?s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The ?Other Date? identifies additional date information about the beneficiary?s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation |
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 visual care 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. ADDITIONAL CLAIM INFORMATION | Identifies additional information about the beneficiary?s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.orgfor qualifiers |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use ?9? for ICD-9-CM. Use ?0? for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) for dates of service before 10-1-2014 or Tenth Revision (ICD-10-CM) diagnosis coding for dates of service on or after 10-1-2014. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. |
22. RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids, and refunds must follow previously established processes in policy. |
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 243.200 for codes. |
C. EMG | Check ?Yes? or leave blank if ?No.? EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 243.100 through 243.150. |
MODIFIER | Modifier(s) if applicable. |
E. DIAGNOSIS POINTER | Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The ?Diagnosis Pointer? is the line letter from Item Number 21 that relates to the reason the service(s) was performed. |
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 beneficiary 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 or ARKids First-B co-payments. |
30. RESERVED | Reserved for NUCC use. |
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. |
016.06.14 Ark. Code R. § 003