016-06-15 Ark. Code R. § 21
Providers of targeted case management who are restricted to serving persons sixty (60) years of age and older or serving persons ages twenty-one (21) and older with a physical disability and those sixty-five (65) and older who participate in the ARChoices in Homecare (ARChoices) 1915(c) waiver must be certified by the Division of Aging and Adult Services as an organization qualified to provide targeted case management services.
In order to be certified by the Division of Aging and Adult Services, the provider must meet the following qualifications:
A copy of the current certification must accompany the provider application and Medicaid contract.
This target population consists of beneficiaries who are ages twenty-one (21) and younger who:
Developmental Disabilities Services
This target population consists of beneficiaries who are ages twenty-one (21) and younger and who:
DDS certified case managers enrolled as Medicaid targeted case managers must obtain written verification that any beneficiary they wish to bill for has been certified as eligible to receive services from the Division of Developmental Disabilities Services. This documentation must be obtained from the DDS service coordinator responsible for the beneficiary's county of residence and must be maintained in the beneficiary's record. Providers may request a list of DDS service coordinators and their locations from the local DHS county office.
Developmental Disability Who Are Not Receiving DDS ACS Waiver Services
This target population consists of beneficiaries who are ages twenty-two (22) and older and who: are:
This target population consists of beneficiaries ages sixty (60) and older as well as beneficiaries ages twenty-one (21) and older with a physical disability or ages sixty-five (65) and older who participate in the ARChoices waiver who have limited functional capabilities in two or more ADLs or lADLs resulting in a need for coordination of multiple services and/or other resources or are in a situation or condition that poses imminent risk of death or serious bodily harm and who demonstrates the lack of mental capacity to comprehend the nature and consequences of remaining in that situation or condition.
A physician must prescribe all services provided by an enrolled targeted case management provider unless the participant is in the ARChoices waiver and the service is authorized by the DAAS RN. However, the physician is not medically responsible for the services and does not supervise the TCM provider or the service provider.
Targeted case management services for beneficiaries under age twenty-one (21) who are not eligible for DDS must be prescribed as a result of a Child Health Services/EPSDT screen. The prescription must be renewed within the applicable periodicity schedule, not to exceed a maximum of twelve (12) months. The original and all subsequent renewed prescriptions must be signed and dated by the physician (no stamped signatures will be accepted) and must be filed and retained by the targeted case manager in the beneficiary's record. Obtaining the physician's orders and prescriptions is not a covered TCM service.
Targeted case management services for all other target groups must be prescribed after the physician examines the beneficiary. The prescription must be renewed every 12 months. The initial and all subsequent renewed or revised prescriptions must be signed and dated by the physician (no stamped signature will be accepted) and must be filed and retained by the targeted case manager in the beneficiary's record. It is the responsibility of the TCM provider to ensure the MD order for TCM services is complete, signed and dated.
If a beneficiary is required to participate in the ConnectCare Primary Care Case Management (PCCM) Program, the beneficiary's PCP must write the prescription for targeted case management services after the physician has examined the beneficiary. Additional information regarding the PCP Program may be found in Section I.
NOTE: As stated in this manual, an ARChoices in Homecare (ARChoices) waiver plan of care developed by the DAAS RN for the ARChoices Program replaces any other plan of care. The ARChoices plan of care must include all appropriate ARChoices services and certain non-waiver services appropriate for the beneficiary. This most often includes Targeted Case Management. The service providers and the ARChoices beneficiary must review and follow the signed authorized plan of care. Each service included on the ARChoices plan of care must be justified by the DAAS RN. This justification is based on medical necessity, the beneficiary's physical, mental and functional status, other support services available to the beneficiary and other factors deemed appropriate by the DAAS RN.
For ARChoices participants whose waiver plan of care includes TCM at the time the DAAS RN signs the plan of care, the ARChoices plan of care, signed by a DAAS RN, will serve as the authorization for TCM services for one year from the date of the DAAS RN's signature. No additional TCM order signed by a physician is required.
This component is an annual face-to-face contact with the beneficiary and contact with other professionals, caregivers or other parties on behalf of the beneficiary. Assessment is performed for the purpose of collecting information about the beneficiary's situation and functioning and to determine and identify the beneficiary's problems and needs.
The TCM assessment is a comprehensive assessment that includes medical, social, educational, and other services. It goes beyond the assessment process used in determining eligibility for the 1915(c) waiver program(s). It addresses all facets of the individual's everyday life in determining how any problem or need might be met and what services are available in the individual's community.
For TCM beneficiaries ages 60 and older or the ARChoices participants, the maximum units allowed for this service may not exceed twelve (12) units per assessment/service plan visit. All references to units are in 15 minute increments.
This component includes activities that focus on needs identification. Activities, at a minimum, include:
NOTE: The TCM service plan is a comprehensive care plan that includes medical, social, educational, and other services that have been identified and included on the service plan for purposes in meeting the identified goals. The TCM service plan goes beyond the ARChoices waiver plan of care developed by the DAAS RN. The TCM service plan addresses all facets of the individual's everyday life in determining how a problem or need will be met and what services are available in the individual's community.
NOTE: Annual reassessments and service plan development are allowed, in fact, encouraged. This policy does not prohibit annual reassessments and service plan development. Reassessments may be conducted any time the case manager deems it appropriate, however, when reassessments are performed more frequently than annually, justification for conducting a full reassessment, rather than a monitoring visit, must be included in the documentation contained in the case record.
TCM service plans must be renewed, at least, annually.
This component includes activities that help link Medicaid eligible beneficiaries with medical, social, educational providers and/or other programs and services that are capable of addressing identified needs and achieving goals specified in the service plan. For example, making referrals to providers for needed services and scheduling appointments may be considered case management. This component details:
See Section 262.100 for the appropriate procedure code.
This component includes activities and contacts that are necessary to ensure the TCM care plan is effectively implemented and adequately addressing the needs of the Medicaid-eligible beneficiary.
The maximum units allowed for this service may not exceed six (6) units per monitoring visit when providers are dealing with beneficiaries ages 21 and older.
Monitoring and follow-up activities include making necessary adjustments in the TCM care plan and service arrangements with providers, according to established program guidelines.
Face-to-face monitoring contacts must be completed as often as deemed necessary, based on the professional judgment of the TCM, but no less frequent than established in Medicaid TCM program policy.
Provider "A" has been chosen by the beneficiary to provide home delivered meals. The beneficiary has also chosen provider "A" for case management services. Case management by provider "A" may not be billed for any activity associated with the provision of home delivered meals. It is the responsibility of the direct service provider to ensure quality services are provided. In this example, the home delivered meal provider is responsible for ensuring meals are delivered timely and to the beneficiary's satisfaction. Case management activity does not include monitoring the provision of home delivered meals by the same agency.
This same policy applies to any service where the case management agency is the same agency providing the in-home service.
Provider "B" has been chosen by the beneficiary to provide personal care. The beneficiary has also chosen provider "B" for targeted case management services. Case management by provider "B" may not be billed for any activity associated with the quality of the personal care services being provided by the same agency. It is the responsibility of the direct service provider to ensure quality services are provided.
In this example, the personal care provider is responsible for ensuring personal care services are provided to the satisfaction of the beneficiary and according to the plan of care (POC) that includes the personal care service. This includes whether or not the aide performs the duties assigned, arrives timely, stays the assigned period of time, is courteous and meets the requirements established for the Personal Care Program by the Arkansas Medicaid Program.
See Section 262.100 for the appropriate procedure code and modifier.
Based on the state fiscal year (SFY) July through June, beneficiaries ages twenty-one (21) and older are limited to fifty (50) hours (200 units) of targeted case management services per year.
Regardless of the overall SFY benefit limit, each waiver plan of care must specify the number of units being authorized and documentation must reflect how those units are utilized. Utilization must be reasonable, documented, and justified in the case record, based on the beneficiary's overall medical condition, support services available to the beneficiary, and in-home services currently in place.
If a TCM beneficiary is also a home and community based waiver beneficiary, such as ARChoices, the waiver plan of care supersedes any other plan of care. Therefore, the number of units authorized on the waiver plan of care may not be exceeded unless prior approved by the DHS RN. Approval will not be granted after the services are already provided.
For audit purposes, the authorization must be in writing, placed in the beneficiary's file, and available for auditors.
Prior authorization (PA) is required and must be obtained before providing targeted case management services for Medicaid eligible beneficiaries under the age of 21.
Prior authorization (PA) is not applicable for targeted case management (TCM) services for those beneficiaries who are twenty-one (21) years of age and older, who have been diagnosed with a developmental disability, nor for beneficiaries sixty (60) years of age and older, nor beneficiaries ages 21 and older or 65 and older who are participating in the ARChoices Program.
The procedure code in this section must be billed either electronically or on paper with the proper modifier indicated. Prior authorization is required when billing for beneficiaries under age 21. There are benefit limits for TCM services for beneficiaries ages 21 and older. See Section 242.000 for prior authorization requirements and Section 220.000 for information about benefit limits.
The column labeled U21, 21+, and 60+ indicates that the procedure code or the procedure code along with a particular modifier must be used when billing for beneficiaries under age 21, for those ages 21 and older who have been diagnosed with a developmental disability, or for those ages 60 and older.
The following procedure codes and modifiers must be used to bill for targeted case management services:
*** (...) This symbol, along with text in parenthesis, indicates the Arkansas Medicaid description of the service.
National Code | Modifier | U21 21 + 60+ | Local Code Description |
T1017 | U21 | A (Assessment/Service Plan Development) | |
T1017 | U2 | 21 + | A (Assessment/Service Plan Development) |
T1017 | U5 | 60+ | A (Assessment/Service Plan Development) |
T1017 | UA | 21+ in ARChoices | A (Assessment/Service Plan Development) |
T1017 | U4 | U21.21 + | A (Service Management/Referral and Linkage) |
T1017 | U6 | 60+ | A (Service Management/Referral and Linkage) |
T1017 | UB | 21+ in ARChoices | A (Service Management/Referral and Linkage) |
T1017 | U1 | U21 | A (Service Monitoring/Service Plan Updating) |
T1017 | U3 | 21 + | *** (Service Monitoring/Service Plan Updating) |
T1017 | U7 | 60+ | *** (Service Monitoring/Service Plan Updating) |
T1017 | UC | 21+ in ARChoices | *** (Service Monitoring/Service Plan Updating) |
The DAAS RN is responsible for developing an ARChoices Plan of Care that includes both waiver and non-waiver services. Once developed, the Plan of Care is signed by the DAAS RN authorizing the services listed.
The signed ARChoices Plan of Care will suffice as the "Personal Care Authorization" for services required in the Personal Care Program. The signature of the DAAS RN on the ARChoices Plan of Care simply replaces the need for the physician's signature authorizing personal care services. The personal care service plan, developed by the Personal Care provider, is still required.
As the ARChoices Plan of Care is effective for one year, once signed by the DAAS RN; the authorization for personal care services, when included on the ARChoices Plan of Care, will be for one year from the date of the DAAS RN's signature, unless revised by the DAAS RN or the personal care service plan needs to be revised, whichever occurs first. If personal care services continue unchanged as authorized on the ARChoices Plan of Care, a new service plan is not required at the 6-month interval.
NOTE: For ARChoices participants who receive personal care through traditional agency services or have chosen to receive their personal care services through the IndependentChoices Program, the ARChoices plan of care, signed by a DAAS RN, will serve as the authorization for personal care services for one year from the date of the DAAS RN's signature, as described above.
The responsibility of developing a personal care service plan is not placed with the DAAS RN. The personal care provider is still required to complete a service plan, as described in the Arkansas Medicaid Personal Care Provider Manual.
The Arkansas Medicaid Program waives no other Personal Care Program requirements with regard to personal care service plan authorizations obtained by DAAS RNs.
If personal care services are not currently being provided when the DAAS RN develops the ARChoices Plan of Care, the DAAS RN will determine if personal care services are needed. If so, the service, amount, frequency, duration and the recipient's provider of choice will be included on the ARChoices Plan of Care. A copy of the ARChoices Plan of Care and a Start of Care form (AAS-9510) will be forwarded to the personal care provider, as is current practice for waiver services. The Start of Care form must be returned to the DAAS RN within 10 working days from mailing or action may be taken by the DAAS RN to secure another personal care provider or modify the ARChoices Plan of Care. (The ARChoices Plan of Care is dated the date it is mailed.) Before taking action to secure another provider or modifying the Plan of Care, the applicant and/or family members will be contacted to discuss possible alternatives. Communications related to participation in the IndependentChoices program will be conveyed electronically through "tasks" communicated through Med Compass software, a new data system used to help manage waiver and IndependentChoices services.
This Plan of Care supersedes any other Plan of Care that may have been previously developed by another Medicaid provider for the applicant. The ARChoices Plan of Care must include all appropriate ARChoices services and certain non-waiver services appropriate for the applicant, such as Personal Care.
An agency providing services to an ARChoices beneficiary must report these services to the DAAS RN. The services being provided to the ARChoices beneficiary must be included on the ARChoices Plan of Care. Prior to beginning services or revising services provided to an ARChoices beneficiary, contact the DAAS RN so the Plan of Care is properly revised and approved. Please report all changes in services and changes in the ARChoices beneficiary's circumstances to the DAAS RN immediately upon learning of the change. Certain services provided to an ARChoices beneficiary that are not included on the ARChoices Plan of Care may be subject to recoupment by the Medicaid Program.
If the DAAS RN is aware that personal care services are currently being provided when the ARChoices Plan of Care is developed, the DAAS RN will contact the personal care provider to verify the current order and amount of personal care services in place. If requested verbally, the request must be documented in the ARChoices nurse narrative. It is the personal care provider's responsibility to provide the requested information to the DAAS RN immediately upon receipt of the request. If a copy is not received within 10 working days of the request, the DAAS RN will process the ARChoices Plan of Care, as developed by the DAAS RN.
NOTE: It is the IndependentChoices employer or personal care provider's responsibility to place information regarding their presence in the home in a prominent location so that the DAAS RN will be aware that they are serving the beneficiary. Preferably, the provider will place the information on the refrigerator or under the phone the applicant uses, unless the applicant objects. If so, the provider will place the information in a location satisfactory to the applicant, as long as it is readily available and easily accessible by the DAAS RN.
The personal care service plan developed by the personal care provider must meet all requirements as detailed in the personal care provider manual. This includes, but is not limited to, the amount of personal care services, personal care tasks, frequency and duration. The DAAS RN will not alter the current number of personal care units, unless a waiver Plan of Care cannot be developed without duplicating services. If personal care units must be altered, the DAAS RN will contact the personal care provider to discuss available alternatives prior to making any revisions. The ARChoices Plan of Care and the required justification for each service remains the responsibility of the DAAS RN. Therefore, final decisions regarding services included on the ARChoices Plan of Care rest with the DAAS RN.
NOTE: For the IndependentChoices program, services are effective the date of the DAAS RN's signature on the assessment tool or the waiver plan of care, whichever is the latter of the two.
Requested changes to the personal care services included on the ARChoices Plan of Care may originate with the personal care RN or the DAAS RN, based on the recipient's circumstances. Unless requested by an IndependentChoices beneficiary, the individual or agency requesting revisions to the Personal Care services on the ARChoices Plan of Care is responsible for securing any required signatures authorizing the change prior to the ARChoices Plan of Care being revised. The DAAS RN will obtain electronic signatures for dates of service on or after January 1, 2013.
If revised by the DAAS RN, a copy of the revised ARChoices Plan of Care and a Start of Care Form (AAS-9510) will be mailed to the personal care provider within 10 working days after being revised. If authorization is secured by the Personal Care agency, a copy of the revised personal care order, signed by the physician, must be sent to the DAAS RN prior to implementing any revisions. Once received, the ARChoices Plan of Care will be revised accordingly within 10 days of its receipt. If any problems are encountered with implementing the requested revisions, the DAAS RN will contact the personal care provider to discuss possible alternatives. These discussions and the final decision regarding the requested revisions must be documented in the nurse narrative. The final decision, as stated above, rests with the DAAS RN.
When the Medicaid Program, as authorized by the ARChoices Plan of Care, reimburses for Personal Care services, all Medicaid audits will be performed based on that authorization. Therefore, all documentation by the Personal Care provider must tie services rendered to services authorized as reflected on the ARChoices Plan of Care.
For IndependentChoices participants, the DMS-618 is not required. Only the AR Path assessment will be used by the DAAS RN.
For IndependentChoices participants who are also active waiver participants in the ARChoices Program, the assessment tool used for waiver level of care determination and the waiver plan of care will suffice to support authorization for personal care services, if signed by the DAAS RN. Eligibility for personal care services is based on the same criteria as state plan personal care services. Services are effective the date of the DAAS RN's signature on the waiver assessment tool or the waiver plan of care, whichever is the latter of the two. Personal care services provided prior to that date are not eligible for Medicaid reimbursement. The waiver assessment tool and the waiver plan of care must include, at least, the information included on the DMS-618 that is utilized to support the medical necessity, eligibility and amount of personal care services provided through IndependentChoices or agency personal care services. This information is required in documentation whether or not an extension of benefits is requested. As with all required documentation, this information must be available in the participant's chart or electronic record and available for audit and Quality Management Strategy reviews.
ARChoices is designed for beneficiaries ages 21 and older who, without the waiver's services, would require an intermediate level of care in a nursing home. Individuals ages 21 through 64 must have a physical disability as determined through Social Security Railroad Retirement or DHS's Medical Review Team. The services listed below are designed to maintain beneficiaries at home and preclude or postpone institutionalization.
ARChoices eligibility requires a determination of categorical eligibility, a determination of level of care, the development of a plan of care and a cost comparison to determine the cost-effectiveness of the plan of care. ARChoices requires notifying the beneficiary that he or she may freely choose between waiver services and institutional services.
Refer to the ARChoices provider manual for more detailed information.
The Working Disabled category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64, with a disability as defined by Supplemental Security Income (SSI) criteria and who meet the income and resource criteria may be eligible in this category.
There are two levels of cost sharing in this aid category, depending on the individual's income:
Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as "WD RegCO."
Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".
The cost sharing amounts for the "WD NewCo" eligibles are listed in the chart below:
Program Services | New Co-Payment* |
ARChoices Waiver Services | None |
Ambulance | $10 per trip |
Ambulatory Surgical Center | $10 per visit |
Audiological Services | $10 per visit |
Augmentative Communication Devices | 10% of the Medicaid maximum allowable amount |
Child Health Management Services | $10 per day |
Chiropractor | $10 per visit |
Dental | $10 per visit (no co-pay on EPSDT dental screens) |
Developmental Disability Treatment Center Services | $10 per day |
Diapers, Underpads and Incontinence Supplies | None |
Domiciliary Care | None |
Durable Medical Equipment (DME) | 20% of Medicaid maximum allowable amount per DME item |
Emergency Department: Emergency Services | $10 per visit |
Emergency Department: Non-emergency Services | $10 per visit |
End Stage Renal Disease Services | None |
Early and Periodic Screening, Diagnosis and Treatment | None |
Eyeglasses | None |
Family Planning Services | None |
Federally Qualified Health Center (FQHC) | $10 per visit |
Hearing Aids (not covered for individuals ages 21 and over) | 10% of Medicaid maximum allowable amount |
Home Health Services | $10 per visit |
Hospice | None |
Hospital: Inpatient | 25% of the hospital's Medicaid per diem for the first Medicaid-covered inpatient day |
Hospital: Outpatient | $10 per visit |
Hyperalimentation | 10% of Medicaid maximum allowable amount |
Immunizations | None |
Laboratory and X-Ray | $10 per encounter, regardless of the number of services per encounter |
Medical Supplies | None |
Inpatient Psychiatric Services for Under Age 21 | 25% of the facility's Medicaid per diem for the first Medicaid-covered day |
Outpatient Behavioral Health | $10 per visit |
Nurse Practitioner | $10 per visit |
Private Duty Nursing | $10 per visit |
Certified Nurse Midwife | $10 per visit |
Orthodontia (not covered for individuals ages 21 and older) | None |
Orthotic Appliances | 10% of Medicaid maximum allowable amount |
Personal Care | None |
Physician | $10 per visit |
Podiatry | $10 per visit |
Prescription Drugs | $10 for generic drugs; $15 for brand name |
Prosthetic Devices | 10% of Medicaid maximum allowable amount |
Rehabilitation Services for Persons with Physical Disabilities (RSPD) | 25% of the first covered day's Medicaid inpatient per diem |
Rural Health Clinic | $10 per core service encounter |
Targeted Case Management | 10% of Medicaid maximum allowable rate per unit |
Occupational Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Physical Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Speech Therapy (Age 21 and older have limited coverage**) | $10 per visit |
Transportation (non-emergency) | None |
Ventilator Services | None |
Visual Care | $10 per visit |
* Exception: Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.
** Exception: This service is NOT covered for individuals within the Occupational, Physical and Speech Therapy Program for individuals ages 21 and older.
NOTE: Providers must consult the appropriate provider manual to determine coverage and benefits.
The services listed in this section do not require a PCP referral.
Claim Forms
Red-ink Claim Forms
The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Professional - CMS-1500 | Business Form Supplier |
Institutional-CMS-1450* | Business Form Supplier |
Visual Care - DMS-26-V | 1-800-457-4454 |
Inpatient Crossover- HP-MC-001 | 1-800-457-4454 |
Long Term Care Crossover- HP-MC-002 | 1-800-457-4454 |
Outpatient Crossover- HP-MC-003 | 1-800-457-4454 |
Professional Crossover- HP-MC-004 | 1-800-457-4454 |
* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly UB-04) for billing.
Claim Forms
The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form -AAS-9559 | Client Employer |
Dental - ADA-J430 | Business Form Supplier |
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name | Form Link |
Acknowledgement of Hysterectomy Information | DMS-2606 |
Address Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | HP-AR-004 |
Adverse Effects Form | DMS-2704 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components | DMS-679A |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Application for WebRA Hardship Waiver | DMS-7736 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Participation Agreement | DMS-844 |
Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form | DMS-845 |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Withdrawal Form | DMS-846 |
ARKids First Behavioral Health Services Provider Qualification Form | DMS-612 |
Authorization for Automatic Deposit | autodeposit |
Authorization for Payment for Services Provided | MAP-8 |
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2633 |
Certification of Schools to Provide Comprehensive EPSDT Services | CSPC-EPSDT |
Certification Statement for Abortion | DMS-2698 |
Change of Ownership Information | DMS-0688 |
Child Health Management Services Enrollment Orders | DMS-201 |
Child Health Management Services Discharge Notification Form | DMS-202 |
CHMS Benefit Extension for Diagnosis/Evaluation Procedures | DMS-699A |
CHMS Request for Prior Authorization | DMS-102 |
Claim Correction Request | DMS-2647 |
Consent for Release of Information | DMS-619 |
Contact Lens Prior Authorization Request Form | DMS-0101 |
Contract to Participate in the Arkansas Medical Assistance Program | DMS-653 |
DDTCS Transportation Log | DMS-638 |
DDTCS Transportation Survey | DMS-632 |
Dental Treatment Additional Information | DMS-32-A |
Disclosure of Significant Business Transactions | DMS-689 |
Disproportionate Share Questionnaire | DMS-628 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Provider Agreement | DMS-831 |
Explanation of Check Refund | HP-CR-002 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet | DMS-2685 |
Individual Renewal Form for School-Based Audiologists | DMS-7782 |
Lower-Limb Prosthetic Evaluation | DMS-650 |
Lower-Limb Prosthetic Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | HP-MS-005 |
Medicaid Claim Inquiry Form | HP-CI-003 |
Medicaid Form Request | HP-MFR-001 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC | DMS-633 |
Notice Of Noncompliance | DMS-635 |
NPI Reporting Form | DMS-683 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral | DMS-640 |
Ownership and Conviction Disclosure | DMS-675 |
Personal Care Assessment and Service Plan | DMS-618 English DMS-618 Spanish |
Practitioner Identification Number Request Form | DMS-7708 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies | DMS-2615 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Participation Agreement | DMS-2608 |
Primary Care Physician Selection and Change Form | DMS-2609 |
Procedure Code/NDC Detail Attachment Form | DMS-664 |
Provider Application | DMS-652 |
Provider Communication Form | AAS-9502 |
Provider Data Sharing Agreement - Medicare Parts C & D | DMS-652-A |
Provider Enrollment Application and Contract Package | Application Packet |
Quarterly Monitoring Form | AAS-9506 |
Referral for Audiology Services - School-Based Setting | DMS-7783 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Appeal | DMS-840 |
Request for Extension of Benefits | DMS-699 |
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services | DMS-671 |
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21 | DMS-602 |
Request for Molecular Pathology Laboratory Services | DMS-841 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification | DMS-2692 |
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 | DMS-601 |
Research Request Form | HP-0288 |
Service Log - Personal Care Delivery and Aides Notes | DMS-873 |
Sterilization Consent Form | DMS-615 English DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Targeted Case Management Contact Monitoring Form | DMS-690 |
Upper-Limb Prosthetic Evaluation | DMS-648 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | Vendorperformreport |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502 | DMS-2633 | DMS-618 | DMS-675 | DMS-846 |
AAS-9506 | DMS-2634 | Spanish | DMS-673 | DMS-873 |
AAS-9559 | DMS-2647 | DMS-619 | DMS-679 | ECSE-R |
Address Chanqe | DMS-2685 | DMS-628 | DMS-679A | HP-0288 |
DMS-2687 | DMS-630 | DMS-683 | HP-AR-004 | |
Autodeposit | DMS-2692 | DMS-632 | DMS-686 | HP-CI-003 |
CMS-485 | DMS-2698 | DMS-633 | DMS-689 | HP-CR-002 |
CSPC-EPSDT | DMS-2704 | DMS-635 | DMS-690 | HP-MFR-001 |
DDS/FS#0001.a | DMS-32-A | DMS-638 | DMS-693 | HP-MS-005 |
DMS-0101 | DMS-32-0 | DMS-640 | DMS-699 | MAP-8 |
DMS-0688 | DMS-601 | DMS-647 | DMS-699A | Performance Report |
DMS-102 | DMS-602 | DMS-648 | DMS-7708 | |
DMS-201 | DMS-612 | DMS-649 | DMS-7736 | Provider Enrollment Application and Contract Package |
DMS-202 | DMS-615 English | DMS-650 | DMS-7782 | |
DMS-2606 | DMS-651 | DMS-7783 | ||
DMS-2608 | DMS-615 Spanish | DMS-652 | DMS-831 | |
DMS-2609 | DMS-652-A | DMS-840 | PUB-019 | |
DMS-2610 | DMS-616 | DMS-653 | DMS-841 | PUB-020 |
DMS-2615 | DMS-618 English | DMS-664 | DMS-844 | |
DMS-2618 | DMS-671 | DMS-845 |
Arkansas Medicaid Contacts and Links
Click the link to view the information.
American Hospital Association
Americans with Disabilities Act Coordinator
Arkansas Department of Education, Health and Nursing Services Specialist
Arkansas Department of Education, Special Education
Arkansas Department of Finance Administration, Sales and Tax Use Unit
Arkansas Department of Human Services, Division of Aging and Adult Services
Arkansas Department of Human Services, Appeals and Hearings Section
Arkansas Department of Human Services, Division of Behavioral Health Services
Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services, Division of Children and Family Services, Contracts Management Unit
Arkansas Department of Human Services, Children's Services
Arkansas Department of Human Services, Division of County Operations, Customer Assistance Section
Arkansas Department of Human Services, Division of Medical Services
Arkansas DHS, Division of Medical Services Director
Arkansas DHS, Division of Medical Services, Benefit Extension Requests, UR Section
Arkansas DHS, Division of Medical Services, Dental Care Unit
Arkansas DHS, Division of Medical Services, HP Enterprise Services Provider Enrollment Unit
Arkansas DHS, Division of Medical Services, Financial Activities Unit
Arkansas DHS, Division of Medical Services, Hearing Aid Consultant
Arkansas DHS, Division of Medical Services, Medical Assistance Unit
Arkansas DHS, Division of Medical Services, Medical Director for Clinical Affairs
Arkansas DHS, Division of Medical Services, Pharmacy Unit
Arkansas DHS, Division of Medical Services, Program Communications Unit
Arkansas DHS, Division of Medical Services, Program Integrity Unit (PI)
Arkansas DHS, Division of Medical Services, Provider Reimbursement Unit
Arkansas DHS, Division of Medical Services, Third-Party Liability Unit
Arkansas DHS, Division of Medical Services, UR/Home Health Extensions
Arkansas DHS, Division of Medical Services, Utilization Review Section
Arkansas DHS, Division of Medical Services, Visual Care Coordinator
Arkansas Department of Health
Arkansas Department of Health, Health Facility Services
Arkansas Department of Human Services, Accounts Receivable
Arkansas Foundation for Medical Care
Arkansas Foundation for Medical Care, Retrospective Review for Therapy and Prior Authorization for Personal Care for Under Age 21
Arkansas Hospital Association
ARKids First-B
ARKids First-B ID Card Example
Central Child Health Services Office (EPSDT)
ConnectCare Helpline
County Codes
Dental Contractor
HP Enterprise Services Claims Department
HP Enterprise Services EDI Support Center (formerly AEVCS Help Desk)
HP Enterprise Services Inquiry Unit
HP Enterprise Services Manual Order
HP Enterprise Services Provider Assistance Center (PAC)
HP Enterprise Services Supplied Forms
Example of Beneficiary Notification of Denied ARKids First-B Claim
Example of Beneficiary Notification of Denied Medicaid Claim
First Connections Infant & Toddler Program, Developmental Disabilities Services
First Connections Infant & Toddler Program, Developmental Disabilities Services, Appeals
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health Care Declarations
Immunizations Registry Help Desk
Magellan Pharmacy Call Center
Medicaid ID Card Example
Medicaid Managed Care Services (MMCS)
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Partners Provider Certification
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications, Division of Behavioral Health Services
Select Optical
Standard Register
Table of Desirable Weights
UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk
U.S. Government Printing Office
ValueOptions
Vendor Performance Report
The IndependentChoices program is a state plan service under 1915(j) of the Social Security Act. IndependentChoices is operated by the Division of Aging and Adult Services (DAAS). The program offers Medicaid-eligible individuals who are elderly and individuals with disabilities an opportunity to self-direct their personal assistant services.
IndependentChoices seeks to increase the opportunity for consumer direction and control for Medicaid beneficiaries receiving or needing personal assistant services. Personal Assistant services in IndependentChoices include state plan personal care for Medicaid beneficiaries and attendant care services for ARChoices beneficiaries in Homecare (ARChoices). IndependentChoices offers an allowance and counseling services in place of traditional agency-provided personal assistance services and items related to personal assistance needs.
The participant or designee is the employer and accepts the responsibility in directing the work of their employee to the degree necessary to meet their individual needs for assistance with activities of daily living and instrumental activities of daily living.
If the IC participant can make decisions regarding his or her care but does not feel comfortable reading and filling out forms or talking on the phone, he or she can appoint a Communications Manager. The Communications Manager can act as the participant's voice and complete and sign forms, but will not make decisions for the participant. The Communications Manager will not hire, train, supervise or fire the personal assistant for the IC participant.
If the participant needs someone to hire and supervise the personal assistant, make decisions about care and administer the cash expenditure plan as well as complete all forms, a Decision-Making Partner will be appointed.
IndependentChoices participants or their Decision-Making Partners must be able to assume the responsibilities of becoming an employer by hiring, training, supervising and firing if necessary their directly hired workers. In doing so the program participant accepts the risks, rights and responsibilities of directing their care and having their health care needs met.
The IndependentChoices program respects the employer authority of the participant who chooses to direct his or her care by hiring an employee who will be trained by the employer or Decision-Making Partner to provide assistance how, when, and where the employer or Decision-Making Partner determines will best meet the participant's individual needs. The Medicaid beneficiary assumes the risks, rights and responsibilities of having their health care needs met in doing so.
NOTE: The IndependentChoices Program follows the rules and regulations of the State Plan approved Personal Care Program, unless stated otherwise in this manual.
To be eligible for IndependentChoices, a participant must:
The Division of Aging and Adult Services (DAAS) is the point of entry for all enrollment activity for IndependentChoices. The program is limited based on an approved number through the Medicaid State Plan.
The individual or their designee will first call the IndependentChoices toll-free number at 888-682-0044 or 866-710-0456. Information about the program is provided to the individual and verification made that the individual is currently enrolled in a Medicaid category that covers personal assistance services. If the individual is currently enrolled in an appropriate Medicaid category and has an assessed physical dependency need for "hands on" assistance with personal care needs, DAAS will enter the participant's information into a DAAS database. If the individual is not currently enrolled in an appropriate Medicaid category, the individual will be referred to the DHS County Office for eligibility determination.
The IndependentChoices counselor, nurse and fiscal agent will then work with the individual to complete the enrollment forms either by mail and telephone contact or by a face-to-face meeting. The individual will be provided with a program manual, which explains the individual's responsibilities regarding enrollment and continuing participation. The individual must complete the forms in the Enrollment Packet, which consists of the Participant Responsibilities and Agreement, the Backup Personal Assistant and the Authorization to Disclose Health Information. The individual must also complete the forms in the Employer Packet, which includes the Limited Power of Attorney, IRS and direct deposit forms related to being a household employer. Each personal assistant must complete the forms in the Employee Packet which include the standard tax withholding forms normally completed by an employee, the Employment Eligibility Verification Form (I-9), a Participant/Personal Assistant Agreement, Employment Application and a Provider Agreement. Each packet includes step-by-step instructions on how to complete the above forms. Assistance is available to the individual, Decision-Making Partner/Communications Manager and the personal assistant to help complete the forms and answer any questions.
As part of the enrollment process, the DAAS RN will complete an assessment using the Home and Community Based Services (HCBS) Level of Care Assessment Tool. The DAAS RN will determine, through the completed assessment and professional judgment, the level of medical necessity. This determination creates the budget for self-directed services. Eligibility for personal care services is based on the same criteria as state plan personal care services. NOTE: For ARChoices beneficiaries, the DAAS RN will determine the need for personal care and attendant care hours needed. The ARChoices plan of care will reflect that the beneficiary chooses IndependentChoices as the provider. DAAS-HCBS staff will obtain physician authorization for persons not receiving ARChoices waiver services.
After the in-home assessment, the DAAS RN will complete the paperwork and coordinate with the IndependentChoices counselor. The counselor will process all of the completed enrollment forms. The assessment is sent to the beneficiary's physician for authorization if the beneficiary is not authorized for services through a waiver plan of care for ARChoices. State and IRS tax forms will be retained by the fiscal agent. Disbursement of funds to a beneficiary or their employee will not occur until all required forms are accurately completed and in the possession of the fiscal agent.
Personal care assessments for beneficiaries aged 21 years or older and authorized by the beneficiary's physician in excess of 14.75 hours per week are forwarded to DAAS for coordination with Utilization Review in the Division of Medical Services for approval. View or print Utilization Review contact information.For beneficiaries under age 21, all personal care hours must be authorized through Medicaid's contracted Quality Improvement Organization (QIO). View or print AFMC contact information.
IndependentChoices follows the rules and regulations found in the Arkansas Medicaid Personal Care Provider Manual in determining and authorizing personal care hours. The initial authorization for personal assistance services may not begin until the beneficiary's primary care physician or an advanced practice nurse enrolled in the Arkansas Medicaid APN program seeing patients in an Arkansas Medicaid enrolled Rural Health Clinic or Federally Qualified Health Center signs and dates the Home and Community Based Services (HCBS) Level of Care Assessment Tool. For beneficiaries receiving services through the ARChoices waiver program, the APN or physician's signature is not required. The signature of the DAAS RN is sufficient to authorize personal care services. After the service plan is authorized, the actual day services begin is dependent upon all of the following conditions:
If the beneficiary is not a recipient of ARChoices services, then continuation of personal assistance services requires reauthorization prior to the end of the current service plan end date.
When required for non-waiver beneficiaries, the earlier of the two following conditions will suffice for the face-to-face visit required sixty days prior to the begin date of the new service plan:
When the approval by Utilization Review is received, or the beneficiary needs 14.75 hours or less per week, the IndependentChoices Counselor will contact the beneficiary or Decision-Making Partner/Communications Manager to develop the cash expenditure plan. The Medicaid beneficiary as the employer and the counselor will determine when IndependentChoices services can begin, but may not commence prior to the date authorized by the physician. The beneficiary is required to have a face-to-face visit with their physician within 60 days of the date that the physician signs the Assessment Tool or 60 days prior to the service plan begin date and each subsequent reassessment. At no time will services begin prior to the first day of the previous month unless authorized by the Division of Aging and Adult Services.
The cash allowance allows the program participant to purchase those services that help the program participant receive assistance at times of the day that best meet his or her individual preferences. The allowance also supports the purchase of goods and services that lessen the need for human assistance while increasing the participant's ability to maintain independence in the community.
Primarily the allowance is used to pay the participant's employee's salary. The list of services listed below was developed by the IndependentChoices Advisory Committee comprised of representatives from Area Agencies on Aging, Department of Health, Spinal Cord Commission and advocates. Not all of these services are widely used, but the availability of these services on an individual basis has impacted the quality of life of individual program participants.
Following is a list of possible uses of the cash allowance:
Medicaid beneficiaries are allowed to receive Medicaid personal care services, in addition to hospice aide services, if the personal care services are unrelated to the terminal condition or the hospice provider is using the personal care services to supplement the hospice aide and attendant care services.
Extension of benefits for personal care for beneficiaries receiving both hospice services and personal care services will be considered based on the individual beneficiary's physical dependency needs. Requests for increased personal care hours will be reviewed for medical necessity; duplication of services will be adjusted accordingly.
NOTE: Based on audit findings, it is imperative that required documentation be recorded by the hospice provider and available in the hospice record. Documentation must substantiate all services provided. It is the hospice provider's responsibility to coordinate care and assure there is no duplication of services. While hospice care and personal care services are not mutually exclusive, documentation must support the inclusion of both services and the corresponding amounts on the care plan. To avoid duplication and to support hospice care in the home that provides the amount of services required to meet the needs of the beneficiary, the amount of personal care services needed beyond the care provided by the hospice agency must meet the criteria detailed in this section. Most often, if personal care services are in place prior to hospice services starting, the amount of personal care services will be reduced to avoid any duplication. If those services are not reduced or discontinued, documentation in the hospice and personal care records must explain the need for both and be supported by the policy in this section.
In-home services are designed to reduce or prevent inappropriate institutionalization by maintaining, strengthening or restoring an eligible participant's function in his or her own home. IndependentChoices allows ARChoices participants the choice of self-directed attendant care services rather than receiving attendant care services through a certified agency.
The DAAS RN will determine the number of hours of attendant care services needed by the participant as indicated on the ARChoices Plan of Care. If the participant chooses to self-direct attendant care services, the DAAS RN will refer the participant to the IndependentChoices program by sending the plan of care to IndependentChoices, notating that IndependentChoices was selected.
HCBS Waiver Program
All ARChoices Home and Community-Based Services (HCBS) Waiver providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program:
ARChoices HCBS Waiver providers must be certified by the Division of Aging and Adult Services (DAAS) as having met all Centers for Medicare and Medicaid Services (CMS) approved provider criteria for the service(s) they wish to enroll to provide.
Certification by the Division of Aging and Adult Services does not guarantee enrollment in the Medicaid program.
All providers must maintain their provider files at the Hewlett Packard Enterprise Provider Enrollment Unit by submitting current certification, licensure, all DAAS-issued certification renewals and any other renewals affecting their status as a Medicaid-eligible provider, etc.
Copies of certifications and renewals required by DAAS must be maintained by DAAS to avoid loss of provider certification. These copies must be submitted to DAAS Provider Certification. View or print the Division of Aging and Adult Services Provider Certification contact information. Payment cannot be authorized for services provided beyond the certification period.
An ARChoices provider must be physically located in the State of Arkansas or physically located in a bordering state and serving a trade-area city. The trade-area cities are limited to Monroe and Shreveport, Louisiana; Clarksdale and Greenville, Mississippi; Poplar Bluff and Springfield, Missouri; Poteau and Sallisaw, Oklahoma; Memphis, Tennessee; and Texarkana, Texas.
All providers must be licensed and/or certified by their states' appropriate licensing/certifying authorities. Copies of all appropriate licenses and certifications must be submitted to DAAS for certification as a potential ARChoices provider.
Arkansas Medicaid does not provide ARChoices Waiver services in non-bordering states.
The Provider agrees that he or she will maintain adequate staffing levels to ensure timely and consistent delivery of services to all beneficiaries for whom they have accepted an ARChoices Waiver Person-Centered Service Plan (PCSP).
The Provider agrees:
The Provider agrees to follow and/or enforce for each employee providing services to an ARChoices Waiver beneficiary a written code of ethics that shall include, but not be limited to, the following:
All providers must meet the following Home and Community-Based Services (HCBS) Settings regulations as established by CMS. The federal regulation for the new rule is 42 CFR 441.301(c) (4)-(5).
Settings that are HCBS must be integrated in and support full access of beneficiaries receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources and receive services in the community, to the same degree of access as beneficiaries not receiving Medicaid HCBS.
HCBS settings must have the following characteristics:
The Arkansas Medical Assistance (Medicaid) Program offers certain home and community-based outpatient services as an alternative to nursing home placement. These services are available to persons age 21 through 64 who are determined to have a physical disability through the Social Security Administration or the DHS Medical Review Team (MRT) and require an intermediate level of care in a nursing facility, or are 65 years of age or older and require an intermediate level of care in a nursing facility. The community-based services offered through the ARChoices Home and Community-Based Waiver, described herein as ARChoices, are as follows:
These services are designed to maintain Medicaid eligible beneficiaries at home in order to preclude or postpone institutionalization of the individual.
In accordance with 42 CFR 441.301(b) (1) (ii) ARChoices services may not be provided to inpatients of nursing facilities, hospitals or other inpatient institutions except for inpatient respite services.
The beneficiary intake and assessment process for the ARChoices Program includes a determination of categorical eligibility, financial eligibility, a nursing facility level of care determination, the development of a PCSP and the beneficiary's notification of his or her choice between home and community-based services and institutional services.
Symptoms Scale was designed to identify individuals at risk of serious decline. It can serve as an outcome where the objective is to minimize problems related to declines in function, or as a pointer to identify persons whose conditions are unstable.
CHESS, originally developed for use with nursing home residents, has been adapted for use with other instruments in the interRAI suite. It creates a 6- point scale from 0 = not at all unstable to 5 = highly unstable, with higher levels predictive of adverse outcomes such as mortality, hospitalization, pain, caregiver stress and poor self-rated health. (RE: http://www.interrai.org/scales.html)
To be determined eligible for the ARChoices Waiver, an applicant must require a nursing facility intermediate level of care. Registered Nurses employed by the Division of Aging and Adult Services (DAAS RNs) perform a comprehensive assessment of each applicant to determine his or her personal assistance and health care needs. The assessment tool is ArPath, the electronic interRAI home care instrument, which evaluates the individual's level of care need.
The intermediate level of care determination is based on the comprehensive assessment performed by the DAAS RN, using standard criteria for functional need in evaluating an individual's need for nursing home placement in the absence of community alternatives. The level of care determination, in accordance with nursing home admission criteria, must be completed and the individual deemed eligible for an intermediate level of care by a licensed medical professional prior to receiving ARChoices services.
The DAAS RN performs a comprehensive assessment at least annually. The results of the level of care determination and the reevaluation are documented on form DHS-704, Decision for Nursing Home Placement.
Providers may submit relevant medical, social and personal information concerning beneficiaries to the DAAS RN prior to reassessments. Providers may upload information to http://www.daas.ar.gov/provrequest.htmlso that it can be received immediately by the appropriate DAAS RN. It is up to providers to submit the information in a timely manner. DAAS RNs schedule reassessments 6 to 10 weeks ahead of the expiration date. To ensure that the DAAS RN receives the information prior to the reassessments, providers need to submit the information no later than 12 weeks prior to the expiration date of the PCSP. DAAS will not provide providers with any special alerts or reminders of the expiration date. It is up to the provider to keep track of this date and submit the information in a timely manner.
NOTE: While federal guidelines require level of care reassessment at least annually, DAAS may reassess a beneficiary's level of care and/or need any time it is deemed appropriate by the DAAS RN to ensure that a beneficiary is appropriately placed in the ARChoices program and is receiving services suitable to his or her needs.
The implementation of the PCSP by a provider must ensure that services are:
NOTE: Each service included on the ARChoices PCSP must be justified by the
DAAS RN. This justification is based on medical necessity, the beneficiary's physical, mental and functional status, other support services available to the beneficiary and other factors deemed appropriate by the DAAS RN.
Each ARChoices service must be provided according to the beneficiary PCSP. For services included in the waiver PCSP, Medicaid reimbursement is limited to the amount and frequency that is authorized in the PCSP. As detailed in the Medicaid Program provider contract, providers may bill only after services are provided.
NOTE: PCSPs are updated annually by the DAAS RN and sent to the ARChoices provider prior to the expiration of the current PCSP. However, the provider has the responsibility for monitoring the PCSP expiration date and ensuring that services are delivered according to a valid PCSP. At least 30 and no more than 45 days before the expiration of each PCSP, the provider shall notify the DAAS RN via email and copy the RN supervisor of the PCSP expiration date.
Services are not compensable unless there is a valid and current person-centered service plan in effect on the date of service.
REVISIONS TO A BENEFICIARY PERSON-CENTERED SERVICE PLAN MAY ONLY BE MADE BY THE DHS RN.
NOTE: All revisions to the PCSP must be authorized by the DAAS RN. A revised PCSP will be sent to each appropriate provider. Regardless of when services are provided, unless the provider and the service are authorized on an ARChoices PCSP, services are considered non-covered and do not qualify for Medicaid reimbursement. Medicaid expenditures paid for services not authorized on the ARChoices PCSP are subject to recoupment.
Each ARChoices PCSP will include Targeted Case Management, unless refused by the waiver beneficiary. The Targeted Case Manager is responsible for monitoring the beneficiary's status on a regular basis for changes in their service need, referring the beneficiary for reassessment, if necessary, and reporting any beneficiary complaints and changes in status to the DAAS RN or Nurse Manager immediately upon learning of the change.
NOTE: As stated in this manual, the service provider and the ARChoices beneficiary must review and follow the signed authorized PCSP. Each service included on the ARChoices PCSP must be justified by the DAAS RN. This justification is based on medical necessity, the beneficiary's physical, mental and functional status, other support services available to the beneficiary and other factors deemed appropriate by the DAAS RN.
For ARChoices beneficiaries whose waiver PCSP includes TCM at the time the DAAS RN signs the PCSP, the ARChoices PCSP, signed by a DAAS RN, will serve as the authorization for TCM services for one year from the date of the DAAS RN's signature, as described above.
The ARChoices registered nurse (DAAS RN) may develop a provisional PCSP prior to establishment of Medicaid eligibility, based on information obtained during the in-home functional assessment, when recommending functional approval based on the nursing home criteria. The DAAS RN must discuss the provisional PCSP policy and have the approval of the applicant prior to completing and processing the provisional PCSP. The PCSP will be developed by the applicant and the DAAS RN and signed by the applicant or the applicant's representative and the DAAS RN.
The provisional PCSP will include all current PCSP information, except for the waiver eligibility date and the Medicaid beneficiary ID number.
The provisional PCSP will be mailed to the waiver applicant and each provider included on the PCSP. If the beneficiary and the provider accept the risk of ineligibility, the provider must begin services within an established time frame as determined by the Division of Aging and Adult Services (DAAS) and notify the DAAS RN, via Start Services form AAS-9510, that services have started. The DAAS RN will track the start of care dates and give the applicant options when services are not started.
The provisional PCSP will expire 60 days from the date signed by the applicant and the DAAS RN. A PCSP that has been approved with a Medicaid number and waiver eligibility date must be in place no later than the expiration date of the provisional PCSP.
The waiver eligibility date will be established retroactively, effective on the day the provisional PCSP was signed by the applicant or applicant's representative and the DAAS RN, if:
AND
NOTE: If waiver services were provided and the applicant dies prior to approval of the application, waiver eligibility will begin (if all other eligibility requirements are met) on the date waiver service(s) began and end on the date of death.
NOTE: Under no circumstances will waiver eligibility begin prior to the date of application or the date the provisional PCSP is signed by the DAAS RN and the applicant or the applicant's representative, whichever is later.
Prior to the expiration date of the provisional PCSP, the DAAS RN will send the comprehensive PCSP to the waiver beneficiary and all providers included on the PCSP. The comprehensive PCSP will replace the provisional PCSP. The comprehensive PCSP will include the Medicaid beneficiary ID number, the waiver eligibility date established according to policy and the comprehensive PCSP expiration date.
The comprehensive PCSP expiration date will be 365 days from the date of the DAAS RN's signature on form AAS-9503, the ARChoices PCSP. Once the application is either approved or denied by the DHS county office, the providers will be notified by the DAAS RN. The notification for the approval will be in writing via a PCSP that includes the waiver eligibility date and Medicaid ID number. The notification for a denial will be via a form AAS-9511 reflecting the date of denial.
The policy regarding retroactive eligibility applies to applicants entering the waiver program from the community and to applicants entering the program from an institution. The same process and the same policy determining the waiver eligibility date will apply to applications of each type.
EXCEPTION: No waiver eligibility date may be established prior to an applicant's discharge date from an institution. Therefore, if a provisional PCSP is developed while an applicant is a resident of a nursing home or an inpatient in an institution, the earliest waiver eligibility date will be the day the applicant is discharged from the facility.
NOTE: For inpatients, if a waiver application is filed at the local DHS county office prior to discharge AND if a provisional PCSP is developed by the DAAS RN prior to discharge, it may be possible to establish retroactive eligibility back to the date the applicant returned to his or her home if the applicant is ultimately found eligible for the program. (Note: Medicaid beneficiaries in nursing facilities do not have to complete a new application when applying for ARChoices. Their signature on the PCSP electing waiver services serves as the application.)
If no waiver application is filed and no functional assessment or provisional PCSP is completed by the DAAS RN prior to an applicant's discharge from an
institution, retroactive eligibility will not be possible back to the date the applicant returned to his home.
Functional assessments and PCSPs may be completed during a period of institutionalization; however, a discharge date must be scheduled. Since the purpose of the assessment and the PCSP is to depict the applicant's condition and needs in the home, premature assessments and PCSP development do not meet the intent of the program.
This policy applies to applicants leaving hospitals or nursing facilities.
Neither waiver providers nor waiver applicants are required to begin or receive services prior to an eligibility determination by the Division of County Operations. When services are started based on the receipt of a provisional PCSP, it is the responsibility of each provider to explain the process and financial liability to the applicant and/or representative prior to beginning services. The decision to begin services prior to an eligibility determination must be a joint decision between the provider and the applicant, both of whom must understand the financial liability of the applicant if eligibility is not established.
NOTE: Regardless of the reason for the denial and regardless of when a new waiver application may be filed, a provisional PCSP will only be utilized on a current waiver application. Once an application is denied, a new provisional PCSP must be developed if a subsequent waiver application is filed.
(PCSP) with Personal Care Services
The following applies to individuals receiving both personal care services and ARChoices services.
The responsibility of developing a personal care service plan is not placed with the DAAS RN. The personal care provider is still required to complete a service plan, as described in the Arkansas Medicaid Personal Care Provider Manual.
NOTE: For ARChoices participants who have chosen to receive their personal care services through the IndependentChoices Program, the ARChoices PCSP, signed by a DAAS RN, will serve as the authorization for personal care services for one year from the date of the DAAS RN's signature, as described above.
NOTE: It is the personal care provider's responsibility to place information regarding the agency's presence in the home in a prominent location so that the DAAS RN will be aware that the provider is serving the beneficiary.
Preferably, the provider will place the information atop the refrigerator or under the phone the beneficiary uses, unless the beneficiary objects. If so, the provider will place the information in a location satisfactory to the beneficiary, as long as it is readily available to and easily accessible by the DAAS RN.
Requested changes to the personal care services included on the ARChoices PCSP may originate with the personal care RN or the DAAS RN, based on the recipient's circumstances. Unless requested by an IndependentChoices beneficiary, the individual or agency requesting revisions to the Personal Care services on the ARChoices PCSP is responsible for securing any required signatures authorizing the change prior to the ARChoices PCSP being revised. The DAAS RN will obtain electronic signatures for dates of service on or after January 1, 2013.
If revised by the DAAS RN, a copy of the revised ARChoices PCSP and a Start of Care Form (AAS-9510) will be mailed to the personal care provider within 10 working days after being revised. If authorization is secured by the Personal Care agency, a copy of the revised personal care order, signed by the physician, must be sent to the DAAS RN prior to implementing any revisions. Once received, the ARChoices PCSP will be revised accordingly within 10 days of its receipt. If any problems are encountered with implementing the requested revisions, the DAAS RN will contact the personal care provider to discuss possible alternatives. These discussions and the final decision regarding the requested revisions must be documented in the nurse narrative. The final decision rests with the DAAS RN.
When the Medicaid Program, as authorized by the ARChoices PCSP, reimburses for personal care services, all Medicaid audits will be performed based on that authorization. Therefore, all documentation by the personal care provider must tie services rendered to authorized services as reflected on the ARChoices PCSP.
Medicaid beneficiaries are allowed to receive Medicaid personal care services, in addition to hospice aide services, if the personal care services are unrelated to the terminal condition or the hospice provider is using the personal care services to supplement the hospice aide and homemaker services.
Extension of benefits for personal care for beneficiaries receiving both hospice services and personal care services will be considered based on the individual beneficiary's physical dependency needs. Requests for increased personal care hours will be reviewed for medical necessity; duplication of services will be adjusted accordingly.
NOTE: Based on audit findings, it is imperative that required documentation be recorded by the hospice provider and available in the hospice record. Documentation must substantiate all services provided. It is the hospice provider's responsibility to coordinate care and assure there is no duplication of services. While hospice care and personal care services are not mutually exclusive, documentation must support the inclusion of both services and the corresponding amounts on the care plan. To avoid duplication and to support hospice care in the home that provides the amount of services required to meet the needs of the beneficiary, the amount of personal care services needed beyond the care provided by the hospice agency must meet the criteria detailed in this section. Most often, if personal care services are in place prior to hospice services starting, the amount of personal care services will be reduced to avoid any duplication. If those services are not reduced or discontinued, documentation in the hospice and personal care records must explain the need for both and be supported by the policy in this section.
Once an ARChoices eligibility application has been approved, waiver services must be provided in a home and community-based services setting for eligibility to continue. Unless stated otherwise below, the county Department of Human Services (DHS) office must be notified immediately by the DAAS RN when waiver services are discontinued and action will be initiated by the DHS county office to close the waiver case. Providers will be notified by the DAAS RN.
An individual cannot receive ARChoices Waiver services while in an institution. The following policy applies to any inpatient stay where Medicaid pays the facility for the date of admission, i.e., hospitals, nursing homes, rehab facilities, etc., for active waiver cases when the beneficiary is hospitalized or enters a nursing facility for an expected stay of short duration.
NOTE: Nursing facility admissions, when referenced in this section, do not include ARChoices beneficiaries admitted to a nursing facility to receive facility-based respite services.
NOTE: The Arkansas Medicaid Program considers an individual an inpatient of a facility beginning with the date of admission. Therefore, payment to the inpatient facility begins on the date of admission. Payment to the inpatient facility does not include the date of discharge.
Payment for ARChoices services may be allowed for the date of a beneficiary's admission to an inpatient facility if the provider can provide verification that services were provided before the beneficiary was admitted. In order for payment to be allowed, providers are responsible for obtaining the following:
* Copies of claim forms or timesheets listing the times that services were provided
* A statement from the inpatient facility showing the time that the beneficiary was admitted
* This information must be submitted to DAAS within 10 working days of receiving a request for verification.
If providers are unable to provide proof that ARChoices services were provided before the beneficiary was admitted to the inpatient facility, then payments will be subject to recoupment. ARChoices services provided on the same day the beneficiary is discharged from the inpatient facility are billable when provided according to policy and after the beneficiary was discharged.
When a waiver beneficiary is absent from the home for reasons other than institutionalization, the DHS county office will not be notified unless the beneficiary does not return home within 30 days. If, after 30 days, the beneficiary has not returned home and the providers can no longer deliver services as prescribed by the OCSO (e.g., the beneficiary has left the state and the return date is unknown), the DAAS RN will notify the county office. Action will be taken by the county office to close the waiver case.
NOTE: It is the responsibility of the provider to notify the DAAS RN immediately via form AAS-9511 upon learning of a change in the beneficiary's status.
Because the provider has more frequent contact with the beneficiary, many times the provider becomes aware of changes in the beneficiary's status sooner than the DAAS RN, Case Manager, or DHS county office. It is the provider's responsibility to report these changes immediately so proper action may be taken. Providers must complete the Waiver Provider Communication - Change of Participant Status Form (AAS-9511) and send it to the DAAS RN. A copy must be retained in the provider's beneficiary case record. Regardless of whether the change may result in action by the DHS county office, providers must immediately report all changes in the beneficiary's status to the DAAS RN.
The Case Manager is responsible for monitoring the beneficiary's status on a regular basis for changes in service need, referring the beneficiary for reassessment if necessary and reporting any beneficiary complaints and changes in status to the DAAS RN, or DAAS RN Supervisor immediately upon learning of the change.
All ARChoices services, except for Adult Family Homes, may be provided by a beneficiary's relative, unless stated otherwise in this manual. No Adult Family Home provider, employee or family member of the provider may be related to the Adult Family Home waiver beneficiary.
For the purposes of this section, a relative or family member shall be defined as all persons related to the beneficiary by virtue of blood, marriage, or adoption. The following is applicable for all waiver services:
Under no circumstances may Medicaid payment be made for any waiver service rendered by the waiver beneficiary's:
All providers, including relatives, are required to meet all ARChoices provider certification requirements, Arkansas Medicaid enrollment requirements and provide services according to the beneficiary's PCSP and any established benefit limits for that specific service.
Procedure Code | Modifier | Description |
S5140 | U1 | Adult Family Homes Level A |
S5140 | U2 | Adult Family Homes Level B |
S5140 | U3 | Adult Family Homes Level C |
Adult Family Homes services are personal care and supportive services (e.g., attendant care, transportation and medication oversight (to the extent permitted under State Law)), provided in a certified private home by a principal care provider who lives in the home.
Payment for Adult Family Home services is not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Payment for Adult Family Home services does not include payments made, directly or indirectly, to members of the beneficiary's immediate family.
Adult Family Home services provide a family living environment for adults who are functionally impaired and who, due to the severity of their functional impairments, are considered to be at imminent risk of death or serious bodily harm and, as a consequence, are not capable of fully independent living.
The number of beneficiaries served by an Adult Family Home may not exceed three (3) and beneficiaries must be unrelated to the adult family home provider. "Unrelated" is defined as any person who is not related to the provider by virtue of blood, marriage, or adoption. Other than the Adult Family Home provider, immediate family members or caregivers residing in the adult family home with the waiver beneficiary are prohibited from receiving Medicaid reimbursement for direct provision of any ARChoices services.
Adult Family Home services shall be included in the PCSP only when it is necessary to prevent the permanent institutionalization of a beneficiary as determined by the DAAS RN. The Adult Family Home provider is responsible for meeting the needs of the waiver beneficiary, as defined by this waiver service description, 24 hours/day, 7 days/week.
Adult Family Homes add a dimension of family living to the provision of supportive services and personal care services such as:
Services are provided in a home-like setting. The provider must include the beneficiary in the life of the family as much as possible. The provider must assist the beneficiary in becoming or remaining active in the community.
Services must be provided according to the participant's written ARChoices PCSP.
There are three (3) different reimbursement rates for Adult Family Homes based on the Level of Care required for the individual beneficiary. Level of Care is indicated by using a modifier with CPTCodeS5140.
One (1) unit of service equals one (1) day. Adult Family Homes are limited to a maximum of thirty-one (31) units per month. Room and board costs are not included as a part of this service. Service payments are for the provision of daily living care to the beneficiary.
For any given year of the ARChoices Waiver, Adult Family Homes shall charge waiver residents no more than 90.8% of the current Individual SSI Benefit amount rounded to the nearest dollar for room and board. For any given year of the ARChoices Waiver, ARChoices Waiver beneficiaries shall receive 9% of the current Individual SSI Benefit amount rounded to the nearest dollar for personal needs allowance.
The waiver eligible person will cover the cost of room and board in the Adult Family Home. In addition, the DHS County Office will determine individual liability for care services based on the waiver eligible person's available resources. Medicaid will cover the remaining cost of waiver services provided to the waiver eligible person. The personal needs allowance is adequate to meet the other expenses of the waiver eligible person in the Adult Family Home and exceeds the personal needs allowance for beneficiaries in long term care facilities.
The Adult Family Home waiver beneficiary may receive up to 600 hours (2,400 units) of long-term facility-based respite per state fiscal year. The service of Adult Family Home is not allowed on the same date of service as respite service.
BENEFICIARIES RECEIVING ADULT FAMILY HOMES SERVICES ARE NOT ELIGIBLE TO RECEIVE ANY OTHER ARCHOICES SERVICE, EXCEPT FOR LONG-TERM FACILITY-BASED RESPITE.
Enrollment as an ARChoices Adult Family Homes provider requires certification by the Department of Human Services, Division of Aging and Adult Services (DAAS), as an Adult
Family Home. Adult Family Homes providers must complete an application packet, including Medicaid Provider forms; be tested over designated training materials and achieve a passing score and submit the home for inspection by designated DAAS staff. If substitute caregivers are identified, these beneficiaries must meet the same training and testing requirements as the Adult Family Homes provider. In addition, drug screens and background checks are required for the provider, substitute care givers and provider family members residing in the home and who are over the age of sixteen. Providers must recertify with DAAS annually. This requires submission of a renewal application packet and home inspection, as well as documentation of at least twelve hours of related training activities.
An Adult Family Home, for the purpose of the ARChoices Program, does not include any house, institution, hotel or other similar living situation that supplies room and board only, room only, or board only.
As a condition of certification, each Adult Family Homes provider shall execute with and provide to each beneficiary an admission agreement specifying services to be provided, the beneficiary's cost for room and board, conditions and rules governing the beneficiary and grounds for termination of residency. Each Adult Family Homes provider will also be required to develop and maintain written program policies. Program policies must include and comply with the HCBS Settings rules found in section 201.000.
NOTE: The Adult Family Home provider's ElderChoices certification will be valid as an ARChoices Adult Family Home provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
NOTE: At the next annual certification, the Adult Family Home provider must have policies in place that include and comply with the HCBS Settings rules found in section 201.000.
Procedure Code | Modifier | Description |
S5125 | U2 | Attendant Care Services |
S5125 | Attendant Care Self-Directed Model |
Attendant Care services are designed to reduce or prevent inappropriate institutionalization by maintaining, strengthening or restoring an eligible beneficiary's functioning in his or her own home or elsewhere in the community where the beneficiary engages in activities, including work-related activities.
Attendant care services consists of assistance with activities of daily living (ADLs), instrumental activities of daily living (lADLs) and health-related tasks through hands-on assistance, supervision and/ or cueing.
Hands-on assistance, supervision and/or cueing are defined as:
Activities of daily living include:
Instrumental activities of daily living include:
The provision of ADLs and lADLs does not entail nursing care.
Beneficiaries may choose to self-direct this service through Arkansas's IndependentChoices program under 1915(j) authority; or may receive services through an agency. The IndependentChoices Medicaid Provider Manual describes the self-directed service delivery model.
Attendant Care services must be provided according to the beneficiary ARChoices written PCSP.
A brief description of the service(s) provided, including the signature and title of the individual rendering the service, must be documented in the beneficiary's case record. See Section 214.000 for additional documentation requirements.
Benefit limits will be determined on a client basis based on the assessed level of need by the DAAS RN. The highest RUG level allows a maximum allocation of 81 hours per week (324 units), 359 hours per month (1,436 units), or 4,212 hours per year (16,848 units).
Fifteen (15) minutes of service equals one (1) unit.
An ARChoices beneficiary who spends more than five (5) hours (20 units) at an adult day services or adult day health services facility or who is receiving short-term, facility-based respite care will not be eligible for attendant care services on the same date of service unless authorized by the DAAS RN.
An ARChoices beneficiary receiving long-term, facility-based respite care is not eligible for attendant care services on the same date of service.
The following requirements must be met prior to certification by the Division of Aging and Adult Services (DAAS) by providers of attendant care services. The provider must:
Each provider must maintain adequate documentation to support that direct care staff meets the training and, as applicable, testing requirements according to licensure, agency policy and DAAS certification.
Attendant Care service providers who hold a current Arkansas State Board of Health Class A and/or Class B license or Private Care Agency license must recertify with DAAS every three years; however, the provider must submit a copy the agency's current license to DAAS each year when the license is renewed.
Providers are required to submit copy of renewed license to DAAS.
NOTE: The Class A, Class B or Private Care Agency license provider's ElderChoices and AAPD certification will be valid as an Attendant Care services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices and AAPD.
Environmental Accessibility Adaptations/Adaptive Equipment services enable the individual to increase, maintain and/or improve his or her functional capacity to perform daily life tasks that would not be possible otherwise. Environmental Accessibility Adaptations/Adaptive Equipment is physical adaptations to the home that are necessary to ensure the health, welfare and safety of the beneficiary, to function with greater independence in the home and preclude or postpone institutionalization. Adaptive equipment also enables the Alternatives beneficiary to increase, maintain and/or improve his/her functional capacity to perform daily life tasks that would not be possible otherwise and perceive, control or communicate with the environment in which he or she lives.
Excluded are adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, air conditioning and others. Adaptations which add to the total square footage of the home are excluded from this benefit. All services must be in accordance with applicable state or local building codes. All dwellings that receive adaptations must be in good repair and have the appearance of sound structure.
Permanent fixtures are not allowed on rented or leased properties.
Equipment
The overall cap for Environmental Accessibility Adaptations/Adaptive Equipment is $7,500 per the lifetime of the eligible waiver beneficiary, including this service if received under the Alternatives for Adults with Physical Disabilities (AAPD) waiver. If a waiver beneficiary is receiving Environmental Accessibility Adaptations and Adaptive Equipment, the combined cost cannot exceed the $7,500 overall cap. A waiver beneficiary may access through the waiver several occurrences of Environmental Accessibility Adaptations or for several items of Adaptive Equipment over a span of years, or he/she may access the whole $7,500 at one time. Once the $7,500 per eligible beneficiary is reached, no further Environmental Accessibility Adaptations/Adaptive Equipment can be accessed through the waiver by the eligible waiver beneficiary during his/her remaining lifetime.
Adaptations/Adaptive Equipment
Acceptable environmental accessibility adaptations/adaptive equipment must be necessary for the welfare of the beneficiary and may include, but are not limited to:
Adaptations/Adaptive Equipment
Unacceptable environmental accessibility adaptations/adaptive equipment to the home include, but are not limited to:
Examples:
Individuals or businesses seeking certification by the Division of Aging and Adult Services and enrollment as Medicaid providers of environmental accessibility adaptations/adaptive equipment services must meet the following criteria:
NOTE: All environmental modifications requiring electrical or plumbing work must be completed by a licensed professional. If a contractor subcontracts with an electrician or plumber, the contractor must submit a copy of the subcontractor's license with the claim form.
Prior to payment for this service, the waiver beneficiary is required to secure 3 separate itemized bids for the same service. The bids are reviewed by the DAAS RN or designee prior to submission for Medicaid payment. If only two bids can be secured due to a shortage of qualified providers in the service area, documentation attesting to the attempt to secure bids and the shortage of providers must be provided.
Each claim must be signed by the provider, the waiver beneficiary and DAAS RN, or designee. A statement of satisfaction form must be signed by the waiver beneficiary prior to any claim being submitted.
Note: The Environmental Modification provider's AAPD certification will be valid as an ARChoices Environmental Modification provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under AAPD.
Hot Home-Delivered Meals provide one meal per day with a nutritional content equal to 33 1/3 percent of the Dietary Reference Intakes established by the Food and Nutrition Board of the National Academy of Sciences. The meals must comply with the Dietary Guidelines for Americans and with the DAAS Nutrition Services Program Policy Number 206.
Hot Home-Delivered Meal services provide one daily nutritious meal to eligible beneficiaries who are homebound. Homebound is defined as a person with normal inability to leave home without assistance (physical or mental) from another person; a person who is frail, homebound by reason of illness or incapacitating disability or otherwise isolated; or for whom leaving home requires considerable and taxing effort by the individual and absences from the home are infrequent, relatively short in duration or are attributable to the need to receive medical treatment.
Additionally, the beneficiary must:
The provision of a Home-Delivered Meal is the most cost-effective method of ensuring a nutritiously adequate meal.
The Home-Delivered Meals provider must maintain a log sheet signed by the beneficiary that includes date and time of delivery each time a meal is delivered to document receipt of the meal.
Hot Home-Delivered Meals must be provided according to the beneficiary's written ARChoices PCSP.
Procedure Code | Required Modifier | Description |
S5170 | U2 | Hot Home-Delivered Meal |
S5170 | - | Frozen Home-Delivered Meal |
S5170 | U1 | Emergency Home-Delivered Meal |
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of Hot Home-Delivered Meal services, a provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
NOTE: Changes in service delivery must receive prior approval by the DAAS RN who is responsible for the individual's PCSP. Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
NOTE: This requirement DOES NOT apply to those ARChoices beneficiaries whose ARChoices PCSP includes attendant care services or personal care services at least three (3) times per week.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Hot Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals provider's ElderChoices certification will be valid as an ARChoices Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Frozen Home-Delivered Meals service provides one meal per day with a nutritional content equal to 33 1/3 percent of the Dietary Reference Intakes established by the Food and Nutrition Board of the National Academy of Sciences. The meals must comply with the Dietary Guidelines for Americans and with DAAS Nutrition Services Program Policy Number 206.
The goal of the Frozen Home-Delivered Meals service is to supplement, not replace, the Hot Home-Delivered Meal service by providing one daily nutritious meal to homebound persons at risk of being institutionalized who:
NOTE: While the individual has freedom of choice regarding this service, it is the responsibility of the DAAS RN developing the PCSP to ensure the appropriateness of the service. A hot meal delivered daily remains the food service of choice, when available. Therefore, a frozen meal must be approved by the DAAS RN. The service must be included on the PCSP. If the individual responsible for developing the PCSP does not think the frozen meals are appropriate for the individual, other options will be considered. Those options include removing the Home-Delivered Meal service rather than authorizing a frozen meal.
It is the certified provider's responsibility to deliver the meals regardless if they are hot or frozen. Meals may not be left on the doorstep. The meals cannot be mailed to the individual via United States Postal Service or delivered by paid carrier such as Fed Ex or UPS.
The beneficiary must:
Frozen Home-Delivered Meals must be documented on the ARChoices PCSP by the DAAS RN and must be provided in accordance with the beneficiary's written ARChoices PCSP.
In order to become approved providers of frozen meals, providers must meet all applicable requirements of DAAS Nutrition Services Program Policy Number 206.
To be certified by DAAS as a provider of Home-Delivered Meal services, a meal provider must:
*NOTE: For providers located in Arkansas, all requirements must meet applicable Arkansas laws and regulations. For Home-Delivered Meal providers located in bordering states, all requirements must meet their states' applicable laws and regulations.
NOTE: The milk must be delivered to the beneficiary at least seven (7) days prior to its expiration date.
NOTE: Changes in service delivery must receive prior approval by the DAAS RN who is responsible for the individual's PCSP. Requests must be submitted in writing to the DAAS RN. Any changes in the individual's circumstances must be reported to the DAAS RN via form AAS-9511.
NOTE: This requirement DOES NOT apply to those ARChoices beneficiaries whose ARChoices PCSP includes Attendant Care services and/or Personal Care services at least three (3) times per week.
Home-Delivered Meals, hot or frozen, shall be included in the beneficiary's PCSP only when they are necessary to prevent the institutionalization of an individual.
Frozen Home-Delivered Meals providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Food Establishment Permit at all times.
NOTE: The Home-Delivered Meals ElderChoices provider's certification will be valid as an ARChoices Home-Delivered Meals provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
One unit of service equals one meal. The maximum number of Home-Delivered Meals eligible for Medicaid reimbursement per month equals 31 meals. This includes hot, frozen or a combination of the two. There is no separate benefit limit for frozen meals.
The maximum number of emergency meals per SFY is four (4).
Frozen Home-Delivered Meals may be provided daily to eligible beneficiaries. A maximum of seven (7) meals may be delivered at one time.
Home-Delivered Meal providers may deliver more than seven meals at one time, if:
Home-Delivered Meal providers delivering frozen meals may deliver 14 at one time if the DAAS RN enters 14 meals delivery approved in the comments section of the HDM entry on the PCSP. If this statement is not on the PCSP, or if any of the other factors above are not in place, the meal providers cannot deliver more than seven (7) meals at one time.
An ARChoices individual may not be provided with a Hot or Frozen Home-Delivered Meal on any day during which the individual receives more than five (5) hours of in-home or facility-based Respite care or more than five (5) hours of Adult Day Services or Adult Day Health Services. (Licensure mandates that providers of these services provide a meal or meals; therefore, a Home-Delivered Meal on these dates is a duplicative service and prohibited under waiver guidelines.)
NOTE: Medicaid reimbursement for Home-Delivered Meals is not allowed on the same day to beneficiaries who are also attending Adult Day Services, Adult Day Health Services, or facility-based Respite care for more than five (5) hours. When applying this policy, the time of day the beneficiary receives day services or respite services is also a factor. Whether there is duplication of services will be determined by comparing the time of day during which services occur.
When considering whether a Home-Delivered Meal is billable for an individual receiving Adult Day Services, Adult Day Health Services or facility-based Respite services, on a specific date of service, the following must be applied:
If an ARChoices beneficiary is receiving Adult Day Services, Adult Day Health Services or facility-based Respite at any time between the hours of 11:00 a.m. and 1:30 p.m. and the noon meal is routinely served to others at the facility during this timeframe, the noon meal must also be served to this individual. A Home-Delivered meal is not allowable on the same date of service. This is true regardless of the total number of Adult Day Services, Adult Day Health Services, or Respite hours provided.
In instances where the ARChoices beneficiary wishes to receive a combination of hot and frozen meals, the DAAS RN shall evaluate the beneficiary's situation based on the criteria set forth in Section 213.320, Frozen Home-Delivered Meals. If the criteria are met, the DAAS RN may prescribe on the PCSP a combination of hot and frozen meals to be delivered.
Beneficiaries may receive up to four (4) emergency meals per state fiscal year. The meals must:
Procedure Code | Required Modifier | Description |
S5161 | UA | PERS Unit |
S5160 | - | PERS Installation |
The Personal Emergency Response System (PERS) is an in-home, 24-hour electric support system with two-way verbal and electronic communication with an emergency control center. PERS enables an elderly, infirm or homebound individual to secure immediate help in the event of a physical, emotional or environmental emergency.
PERS is specifically designed for high-risk beneficiaries whose needs have been carefully determined based on their level of medical vulnerability, functional impairment and social isolation. PERS is not intended to be a universal benefit. The DAAS RN must verify that the individual is capable, both physically and mentally, of operating the PERS unit.
PERS must be included in the beneficiary's written ARChoices PCSP.
PERS providers must contact each beneficiary at least once per month to test the system's operation. The provider shall maintain a log of test calls that includes the date and time of the test, specific test results, corrective actions and outcomes.
A log of all beneficiary calls received must be maintained by the emergency response center. The log must reflect the date, time and nature of the call and the response initiated by the center. All calls must be documented in the beneficiary's record. See Section 214.000 for other documentation requirements.
One (1) unit of service equals one (1) day. PERS is limited to a maximum of thirty-one (31) units per month.
The installation of PERS will be allowed once per lifetime or period of eligibility. Claims submitted for the installation of PERS should use procedure code S5160. Procedure code S5160 may be billed for ARChoices beneficiaries who are accessing PERS services for their first time or for the current period of re-eligibility for ARChoices Waiver Services. In the event of extenuating circumstances that result in the need for reinstallation, the provider may contact the Division of Aging and Adult Services for extension of the benefit.
View or print Division of Aging and Adult Services contact information.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of personal emergency response services, a provider must:
PERS providers must recertify annually with DAAS.
NOTE: The PERS ElderChoices provider's certification will be valid as an ARChoices PERS provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Procedure Code | Required Modifier | Description |
S5100 | U1 | Adult Day Services, 8-16 Units Per Date of Service |
S5100 | - | Adult Day Services, 20 - 40 Units Per Date of Service |
Adult day services facilities are licensed by the Office of Long-Term Care (OLTC) to provide care and supervision to meet the needs of four (4) or more functionally impaired adults for periods of less than 24 hours but more than two (2) hours per day, in a place other than the beneficiaries' own homes.
When provided according to the beneficiary's written ARChoices PCSP, ARChoices beneficiaries may receive adult day services for two (2) or more hours per day (8 units), not to exceed ten (10) hours per day (40 units), when the services are prescribed by the beneficiary's attending physician and provided according to the beneficiary's written PCSP. Adult day services of less than two (2) hours per day (8 units) are not reimbursable by Medicaid. Adult day services may be utilized up to fifty (50) hours per week (200 units), not to exceed two hundred thirty (230) hours per month (920 units). One (1) unit of service equals 15 minutes.
As required, beneficiaries who are present in the facility for more than five (5) hours a day (20 units, procedure code S5100) must be served a nutritious meal that equals one-third of the Recommended Daily Allowance. Therefore, ARChoices beneficiaries are not eligible to receive a home-delivered meal on the same day they receive more than five (5) hours (20 units) of adult day services. Additionally, beneficiaries who attend an adult day service for more than five (5) hours (20 units) are not eligible to receive attendant care services on the same date of service unless authorized by the DAAS RN.
NOTE: As stated in this manual, home-delivered meals may not be provided on the same day for an individual who attends adult day services, adult day health services, or facility-based respite care for more than 5 hours (20 units). The time of day the beneficiary is receiving day services, day health services or respite services is also a factor in the application of this policy. The time of day services are received will be reviewed by the DAAS RN and/or DHS audit staff and considered when determining any duplication in services for beneficiaries participating in the ARChoices Program.
Providers must consider the following to determine whether a home-delivered meal is billable for an individual receiving day services, day health services or facility-based respite services on a specific date of service.
If an ARChoices beneficiary is receiving day services, day health services or facility-based respite between the hours of 11:00 a.m. and 1:30 p.m. and the noon meal is routinely served to others at the facility during this time frame, the noon meal must also be served to this individual. A home-delivered meal is not allowable on the same date of service. This is true regardless of the total number of day services or respite units provided.
Adult day services and day health services providers are required to maintain a daily attendance log of beneficiaries. Section 214.000 contains information regarding additional documentation requirements.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of adult day services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by the Arkansas Department of Human Services, Office of Long-Term Care as a long-term adult day care facility. Providers in the designated trade area cities in states that border Arkansas must be licensed and/or certified by the appropriate state agency as an Adult Day Care Facility.
In order to be certified by DAAS, Adult Day Services providers must meet the HCBS Settings rules found in section 201.000.
Adult Day Services providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Adult Day Care license at all times.
In order to be recertified by DAAS, Adult Day Services providers must meet the HCBS Settings rules found in section 201.000.
Providers are required to submit copy of renewed license to DAAS.
NOTE: The Adult Day Services ElderChoices provider's certification will be valid as an ARChoices Adult Day Services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Procedure Code | Required Modifier | Description |
S5100 | TD, U1 | Adult Day Health Services, 8-16 units Per Date of Service |
S5100 | TD | Adult Day Health Services, 20 - 40 units Per Date of Service |
Adult day health services facilities are licensed to provide a continuing, organized program of rehabilitative, therapeutic and supportive health services, social services and activities to beneficiaries who are functionally impaired and who, due to the severity of their functional impairment, are not capable of fully independent living.
Adult day health services programs provide rehabilitative and health services directed toward meeting the health restoration and maintenance needs of the beneficiary that cannot be provided by adult day care programs. Adult day health services are appropriate only for beneficiaries whose facility-developed care plans specify one or more of the following health services:
ARChoices beneficiaries may receive adult day health services for two (2) or more hours per day (8 units), not to exceed ten (10) hours per day (40 units) when the service is provided according to the beneficiary's written ARChoices PCSP. Adult day health services of less than two (2) hours per day (8 units) are not reimbursable by Medicaid. Adult day health services may be utilized up to fifty (50) hours per week (200 units), not to exceed two hundred thirty (230) hours per month (920 units).
Beneficiaries who are present in the facility for more than five (5) hours a day (20 units, procedure code S5100, modifier TD) must be served a nutritious meal that equals one-third of the Recommended Daily Dietary Allowances. Therefore, ARChoices beneficiaries are not eligible to receive a home-delivered meal on the same day they receive more than five (5) hours of adult day health services. Additionally, beneficiaries who attend an adult day health services for more than five (5) hours (20 units) are not eligible to receive attendant care services on the same date of service unless authorized by the DAAS RN.
Adult day health services providers are required by licensure to maintain a daily attendance log of beneficiaries. See Section 214.000 for additional documentation requirements.
NOTE: As stated in this manual, home-delivered meals may not be provided on the same day for an individual who attends adult day services, adult day health services, or facility-based respite care for more than 5 hours (20 units). The time of day the beneficiary is receiving day services or respite services is also a factor in the application of this policy. The time of day services are received will be reviewed by the DAAS RN and/or DHS audit staff and considered when determining any duplication in services for beneficiaries participating in the ARChoices Program.
Providers must consider the following to determine whether a home-delivered meal is billable for an individual receiving day services or facility-based respite services on a specific date of service.
If an ARChoices beneficiary is receiving day services or facility-based respite between the hours of 11:00 a.m. and 1:30 p.m. and the noon meal is routinely served to others at the facility during this time frame, the noon meal must also be served to the individual. A home-delivered meal is not allowable on the same date of service. This is true regardless of the total number of day services or respite hours provided.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of adult day health services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by Arkansas Department of Human Services, Office of Long-term Care as a long-term adult day health care facility. Providers in the designated trade area cities in states that border Arkansas must be licensed and/or certified by the appropriate state agency as an Adult Day Health Care Facility.
In order to be certified by DAAS, Adult Day Health Services providers must meet the HCBS Settings rules found in section 201.000.
Adult Day Health Services providers must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current Adult Day Health Care license at all times. In order to be recertified, Adult Day Health Services providers must meet the HCBS Settings rules found in section 201.000.
Providers are required to submit copy of renewed license to DAAS.
NOTE: Adult day services and adult day health services are not allowed on the same date of service.
NOTE: The Adult Day Health Services ElderChoices provider's certification will be valid as an ARChoices Adult Day Health Services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
Procedure Code | Description |
T1005 | Long-Term Facility-Based Respite Care |
S5135 | Short-Term Facility-Based Respite Care |
S5150 | In-Home Respite Care |
Respite care services provide temporary relief to persons providing long-term care for beneficiaries in their homes. Respite care may be provided outside of the beneficiary's home to meet an emergency need or to schedule relief periods in accordance with the regular caregiver's need for temporary relief from continuous care giving. If there is no primary caregiver, respite care services will not be deemed appropriate and subsequently will not be prescribed by the beneficiary's physician.
In the event the in-home medical assessment performed by the DAAS RN substantiates a need for respite care services, the service will be prescribed as needed, via the beneficiary's PCSP, not to exceed an hourly maximum. The DAAS RN will establish the service limitation based on the beneficiary's medical need, other services included on the PCSP and support services available to the beneficiary. Respite care services must be provided according to the beneficiary's written PCSP.
An individual living in the home with the beneficiary is prohibited from serving as a Respite Services provider for the beneficiary.
In-home respite care may be provided by licensed personal care or home health agencies. Reimbursement will be made for direct care rendered according to the beneficiary's PCSP by trained respite workers employed and supervised by certified in-home respite providers.
Providers rendering respite care services in the beneficiary's home must bill procedure code S5150. One (1) unit of service for procedure code S5150 equals 15 minutes.
Eligible beneficiaries may receive up to 24 hours (96 units) of in-home respite care per date of service. For the state fiscal year (SFY), July 1 through June 30 each year, eligible beneficiaries may receive up to 1200 hours (4800 units) of In-Home Respite Care, or Facility-Based Respite Care or a combination of the two services.
When respite care is provided, the provision of or payment for other duplicate services under the waiver is prohibited. When a respite care provider is in the home to provide respite care services, the provider is responsible for all other in-home ARChoices services included on the beneficiary's PCSP. For example, if attendant care services and/or home-delivered meals are included on the PCSP, the respite provider must provide these services while in the home. No other ARChoices service, other than PERS, may be reimbursed for the same time period.
Facility-based respite care may be provided outside the beneficiary's home on a short- or long-term basis by certified adult family homes, residential care facilities, nursing facilities, adult day care facilities, adult day health care facilities, Level I and Level II Assisted Living Facilities and hospitals.
Facility-based providers rendering services for eight (8) hours or less per date of service must bill S5135 for short-term, facility-based respite care. One (1) unit of service for procedure code S5135 equals 15 minutes. Eligible beneficiaries may receive up to 8 hours (32 units) of short-term, facility-based respite care per date of service.
Facility-based providers rendering services for more than 8 hours/day must bill T1005 for long-term, facility-based respite care. One (1) unit of service for procedure code T1005 equals 15 minutes. A beneficiary may receive up to 24 hours (96 units) of service per date of service if the provider bills procedure code T1005.
Facility-based respite care services include short-term and long-term respite care services and can include any combination of billing codes S5135 or T1005. A single provider may provide both long-term and short-term facility-based respite care services for a particular beneficiary.
Eligible beneficiaries may receive up to 1200 hours (4800 units) per SFY of Facility-Based Respite Care- or In-Home Respite Care, or a combination of the two. Adult Family Home beneficiaries are limited to 600 hours (2400 units) of long-term facility-based respite per state fiscal year.
Beneficiaries receiving long-term, facility-based respite care services may receive only ARChoices PERS services concurrently.
Please refer to the NOTE found in Section 213.500 regarding Home-Delivered Meals and facility-based respite services.
To be certified by the Division of Aging and Adult Services (DAAS) as a provider of in-home respite care services, a provider must:
In-Home Respite Care providers as described in A. above must recertify with DAAS every three years; however, DAAS must maintain a copy of the agency's current license at all times.
Providers are required to submit copy of renewed license to DAAS.
NOTE: The Class A, Class B or Private Care Agency license ElderChoices provider's certification will be valid as a Respite services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
To be certified by the Division of Aging and Adult Services as a provider of facility-based respite care services, a provider must be licensed in their state as one or more of the following:
Facility-Based Respite Care providers as listed above, with the exception of a certified adult family home, must recertify with DAAS every three years; however, DAAS must maintain a current copy of the facility's current license at all times.
A certified and Medicaid enrolled adult family home which is also certified by DAAS to provide facility-based respite services must recertify with DAAS annually.
NOTE: The Class A, Class B or Private Care Agency facility-based respite ElderChoices provider's license certification will be valid as a facility-based respite services provider under the ARChoices Waiver program. The provider will not be required to recertify until the expiration of the previous certification under ElderChoices.
In addition to the service-specific documentation requirements previously listed, ARChoices providers must develop and maintain sufficient written documentation to support each service for which billing is made. This documentation, at a minimum, must consist of:
A provider's failure to maintain sufficient documentation to support his or her billing practices may result in recoupment of Medicaid payment.
No documentation for ARChoices services, as with all Medicaid services, may be made in pencil.
ARChoices providers are required to utilize all program forms as appropriate and as instructed by the Division of Medical Services and the Division of Aging and Adult Services. These forms include but are not limited to:
Providers may request form AAS-9511 by writing to the Division of Aging and Adult Services. View or print the Division of Aging and Adult Services contact information.
Forms AAS-9503 and AAS-9510 will be mailed to the provider by the DAAS RN.
Instructions for completion and retention are included with each form. If there are questions regarding any ARChoices form, providers may contact the DAAS RN in your area.
See Section 142.300 for additional record keeping requirements.
Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code 25-31-103.
Services provided under the ARChoices Program do not require prior authorization.
The reimbursement rates for ARChoices services will be according to the lesser of the billed amount or the Title XIX (Medicaid) maximum for each procedure.
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://www.medicaid.state.ar.usunder the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
ARChoices providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
The following procedure codes must be billed for ARChoices Services. Electronic and paper claims now require the same National Place of Service code.
Procedure Code | Modifiers | Description | Unit of Service | National POS for Claims |
S5140 | Level A- U1 Level B - U2 Level C - U3 | Adult Family Homes | 1 day | 99 |
S5125 | Attendant Care Services | 15 minutes | 12 | |
S5125 | U2 | Agency Attendant Care Traditional | 15 minutes | 99 |
S5170 | U2 | Home-Delivered Meals | 1 meal | 12 |
S5170 | Frozen Home-Delivered Meal | 1 meal | 12 | |
S5170 | U1 | Emergency Home Delivered Meals | 1 meal | 12 |
S5161 | UA | Personal Emergency Response System | 1 day | 12 |
S5160 | Personal Emergency Response System -Installation | One install | 12 | |
S5100 | U1 | Adult Day Services, 2 to 4 hours per date of service | 15 minutes | 99 |
S5100 | Adult Day Services, 5 to 10 hours per date of service | 15 minutes | 99 | |
S5100 | TD, U1 | Adult Day Health Services, 2 to 4 hours per date of service | 15 minutes | 99 |
S5100 | TD | Adult Day Health Services, 5 to 10 hours per date of service | 15 minutes | 99 |
S5150 | Respite Care - In-Home | 15 minutes | 12 | |
S5135 | Respite Care - Short-Term Facility-Based | 15 minutes | 99,21,32 | |
T1005 | Respite Care - Long-Term Facility-Based | 15 minutes | 21,32,99 |
Place of Service | Paper Claims | Electronic Claims |
Inpatient Hospital | 1 | 21 |
Patient's Home | 4 | 12 |
Day Care Facility | 5 | 99 |
Nursing Facility | 7 | 32 |
Other Locations | 0 | 99 |
Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing.
Bill Medicaid for ARChoices services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form CMS-1500.
Carefully follow these instructions to help Hewlett Packard Enterprise efficiently process claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the Hewlett Packard Enterprise Claims Department. View or print the Hewlett Packard Enterprise Claims Department contact information.
NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services.
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 SEX | 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. 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) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Optional. Beneficiary's or participant's complete mailing address (street address or post office box). Name of the city in which the beneficiary or participant resides. Two-letter postal code for the state in which the beneficiary or participant resides. 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) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Required if insured's address is different from the patient's address. |
8. RESERVED | Reserved for NUCC use. |
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial) a. OTHER INSURED'S POLICY OR GROUP NUMBER b. RESERVED SEX c. RESERVED | If patient has other insurance coverage as indicated in Field 11 d, the other insured's last name, first name and middle initial. Policy and/or group number of the insured individual. Reserved for NUCC use. Not required. 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) b. AUTO ACCIDENT? PLACE (State) c. OTHER ACCIDENT? d. CLAIM CODES | Check YES or NO. Required when an auto accident is related to the services. Check YES or NO. If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. Required when an accident other than automobile is related to the services. Check YES or NO. 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.orqunder Code Sets. |
11. INSURED'S POLICY GROUP OR FECA NUMBER a. INSURED'S DATE OF BIRTH SEX b. OTHER CLAIM ID NUMBER c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | Not required when Medicaid is the only payer. Not required. Not required. Not required. Not required. 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 | Primary Care Physician (PCP) referral is not required for ARChoices services. If services are the result of a Child Health Services (EPSDT) screening/referral, enter the referral source, including name and title. 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 | Identifies additional information about the beneficiary's or the claim. Enter the appropriate qualifiers describinq the identifier. See www.nucc.orqfor qualifiers. |
20. OUTSIDE LAB? $ CHARGES | Not required. 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"forlCD-9-CM. Use"0"forlCD-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 appropriate International Classification of Diseases (ICD). List no more than 12 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 B. PLACE OF SERVICE C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES CPT/HCPCS MODIFIER | 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. Enter the appropriate place of service code. See Section 262.200 for codes. Enter "Y" for "Yes" or leave blank if "No." EMG identifies if the service was an emergency. One CPT or HCPCS procedure code for each detail. Modifier(s) if applicable. |
E. DIAGNOSIS POINTER F. $ CHARGES G. DAYS OR UNITS H. EPSDT/Family Plan 1. IDQUAL J. RENDERING PROVIDER ID# NPI | 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. 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. The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. Not required for ARChoices. Not required. The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail. 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 0. | 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 a. (blank) b. (blank) | If other than home or office, enter the name and street, city, state and zip code of the facility where services were performed. Not required. Not required. |
33. BILLING PROVIDER INFO &PH# a. (blank) b. (blank) | Billing provider's name and complete address. Telephone number is requested but not required. Not required. Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
Not applicable to this program.
Application for a §1915(c) Home and Community-Based
Services Waiver
016.06.15 Ark. Code R. § 021