1915(j) Self-Directed Personal Assistance Services
vi. Involuntary Disenrollment A. The circumstances under which a participant may be involuntarily disenrolled from self-directing personal assistance services, and returned to traditional service delivery model are noted below. Parti cipants may be disenrolled for the following reasons:
1. Health and Welfare: Any time DAAS feels the health and welfare of the participant is compromised by continued participation in the IndependentChoices Program, the participant may be returned to the traditional personal care program. Prior to this point the counselor has worked with the participant offering suggestions, identifying or changing representatives or employees to better meet the needs of the consumer, making in-home visits as needed by APS or HCBS RNs, and working to resolve these concerns. If no resolution is available, meeting the participant's health and well-being needs is of most importance; including referral back to the traditional model.2. Change in Condition: Should the participant's cognitive ability to direct his/her own care diminish to a point where the participant can no longer self-direct and there is no responsible representative available to direct the care the counselor will seek out sources of support. If no resources are available, the IndependentChoices case will be closed. The participant will be informed of the pending closure by letter. The letter will include a list of traditional personal care agencies serving the participant's area. If the participant is also a 1915(c) waiver recipient, an e-mail will be auto generated to the HCBS RN or targeted case manager. The e-mail to the HCBS RN or targeted case manager is auto generated and populated with the appropriate names once a closure date is entered in the database. The e-mail will inform the HCBS RN or targeted case manager of the pending closure of the IndependentChoices case necessitating a change in the HCBS service plan. Within five days of sending the letter the counselor will follow up with the participant to determine which agency the participant may wish to choose. The counselor will coordinate the referral with the agency provider. However, if the participant declines agency services, the counselor will respect the choice made by the participant. The participant may choose to have their needs met by informal caregivers.3. Misuse of Allowance: A notice will be issued should the participant or the representative who manages their cash allowance: 1) fail to pay related state and federal payroll taxes; 2) use the allowance to purchase items unrelated to personal care needs; 3) fail to pay the salary of a personal assistant; or 4) misrepresent payment of a personal assistant's salary. The counselor will discuss the violations with the participant and allow the participant to take corrective action including restitution if applicable. The participant will be permitted to remain in the program, but will be assigned to the fiscal intermediary, who will provide maximum bookkeeping support and services. The participant or representative will be notified that further failure to follow the expenditure plan will result in disenrollment and a report filed with Office of Medicaid Inspector General when applicable. vii. Involuntary Disenrollment Should an unapproved expenditure or oversight occur a second time, the participant/ representative will be notified that their IndependentChoices case is being closed and the participant is being returned to traditional personal care. Office of Medicaid Inspector Generalis informed of situations as required. The State will assure interruption of services will not occur while the participant is transitioning from IndependentChoices to traditional services.
4. Underutilization of Allowance: The fiscal intermediary is responsible for monitoring the use of Medicaid funds received on behalf of the participant. If the participant is underutilizing the allowance and not using the allowance according to their cash expenditure plan, the fiscal intermediary will inform the counseling entities through quarterly reports and monthly reports upon request. The counselor will discuss problems that are occurring with the participant and their support network. Together the parties will resolve the underutilization. The counselor will continue to monitor the participant's use of their allowance through both reviewing of reports and personal contact with the participant. If a pattern of underutilization continues to occur, future discussions will focus on what is in the best interest of the participant in meeting their ADLs even if the best solution is a return to agency services. Unused funds are returned to the Arkansas Medicaid program within 45 days upon disenrollment. Funds accrued in the absence of a savings plan will be returned to the Arkansas Medicaid program within a twelve month filing deadline. Exceptions to involuntary disenrollment may be considered if the participant has been hospitalized for an extended period of time or has had a brief visit out of state with approval by the participant's physician. Person-centered planning allows the flexibility of decision making based on individual needs that best meet the needs of the participant.5. Failure to Assume Employer Authority: Failure to Assume Employer Authority occurs when a participant fails to fulfill the role of employer and does not respond to counseling support. Participants who fail in their employer responsibilities but do not have a representative will be given the opportunity to select a representative who can assume employer responsibilities on behalf of the participant. Disenrollment will not occur without guidance and counseling by the counselor or by the fiscal intermediary. When this occurs, the counselor will coordinate agency personal care services to the degree requested by the participant. The participant may wish to self-advocate from a list provided by the counselor, ask the counselor to coordinate, or may simply wish to receive personal assistance services informally. The participant's wishes will be respected.A. The State will provide the following safeguards to ensure continuity of services and assure participant health, safety and welfare during the period of transition between self-directed and traditional service delivery models. ATTACHMENT 4.42-A Page 1
Revised:January 1,2016
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State/Territory: ARKANSAS
Methodology of Compliance Oversight Regarding False Claims Act
The State will ensure an entity's compliance with section 1902(a)(68) of the Act using the following methodology of compliance oversight:
(a) An entity as defined by section 1902(a)(68) of the Act must submit a Certification of Compliance with Employee Education About False Claims Recovery to the Office of the Medicaid Inspector General (OMIG).OMIGwill identify the entity or entities covered under 1902(a)(68) of the Act, which covers any entity receiving five million dollars or more for the federal fiscal year (FFY). The state plans to mail out the initial Certification request for calendar years 2007 and 2008 no later than May 31, 2008. The request will explain that compliance is mandatory. Identified entities will have one month (from the date the entity receives the Certification request) to comply with the request for calendar years 2007 and 2008.
The certification will not be specific to a single fiscal year. The certification is an attestation stating that the entity is in compliance with section 1902(a)(68). Following the initial determination for certification, the OMIGwill review and compile any new information concerning any new entities meeting the threshold requirement for inclusion under this provision by December thirty-first (31) of each year. OMIGwill then notify each entity of their responsibilities regarding false claims education. Entities will have one month thereafter to comply with the request. OMIGwill validate the attestation on a sample basis each year. The false claims education requirement will be incorporated into OMIG'sreview program.
(b) This Certification will state that the entity:(1) Has written policies that include detailed information about the False Claims Act and other provisions named in section 1902(a)(68)(A); and(2) The policies include: i. The entity's policies and procedures for detecting and preventing waste, fraud, and abuse; and ii. A specific discussion of the laws described in the written policies; and iii. A specific discussion of the rights of employees to be protected as whistleblowers; and(3) The policies are readily available, in paper or electronic form, to all employees, contractors, or agents.(4) The false Claims policy must be added to the provider's employee handbook if the provider has such a handbook. Employee handbooks will be reviewed for compliance as part of an audit by OMIG.(5) Review for compliance will begin by OMIGstaff July 1, 2008.(c) As part of a OMIG Review, the OMIGwill include additional procedures to ensure compliance with section 1902(a)(68). The procedures will include a review of the entity's written policies according to the terms of the Certification described in paragraph (b).
215.000 Record Keeping Requirements (Consumer Directed ServicesExcluded)
DHS requires retention of all records for six (6) years. All medical records shall be completed promptly, filed and retained for a minimum of six (6) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish records upon request may result in sanctions being imposed.
A. The provider must contemporaneously create and maintain records that completely and accurately explain all evaluations, care, diagnoses and any other activities of the provider in connection with any Medicaid beneficiary.B. Providers furnishing any Medicaid-covered good or service for which a prescription is required by law, by Medicaid rule, or both, must have a copy of the prescription for such good or service. The provider must obtain a copy of the prescription within five (5) business days of the date the prescription is written.C. The provider must maintain a copy of each relevant prescription in the Medicaid beneficiary's records and follow all prescriptions and care plans.D. Providers must adhere to all applicable professional standards of care and conduct.E. The provider must make available to the Division of Medical Services, its contractors and designees, the state Medicaid Fraud Control Unit, Office of Medicaid Inspector General, representatives of the Center for Medicare & Medicaid Services (CMS) and its authorized agents or officials, all records related to any Medicaid beneficiary. 1. All documentation must be available at the provider's place of business.2. When records are stored off-premise or are in active use, the provider may certify in writing that the records in question are in active use or in off-premise storage and set a date and hour within three (3) working days, at which time the records will be made available. However, the provider will not be allowed to delay for matters of convenience, including availability of personnel.3. If an audit determines that recoupment is necessary, there will be no more than thirty (30) days after the date of the recoupment notice in which additional documentation will be accepted.215.100Record Keeping Requirements for Consumer-Directed ServicesDHS requires retention of all records for six (6) years from the date the attendant care service was provided, or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer.
A. The Consumer-Directed Attendant Care provider must maintain sufficient written documentation to support the Alternatives attendant care service for which billing is submitted to Medicaid for reimbursement. As the definition of Attendant Care Services is a bundled service that may include several different tasks as directed by the beneficiary on any given day, the signature of the beneficiary on the DHS-9559 supports that the service was provided based on the waiver Plan of care and was sufficient and satisfactory. No daily log or additional documentation is required to support the provision of Attendant Care Services under the consumer-directed model. NOTE: For Consumer-Directed Attendant Care providers submitting paper claims to HP for processing, the claim form will be maintained by HP for audit purposes. Maintaining a copy of the claim form in the beneficiary's home or the Attendant Care provider's home is not required. For Attendant Care providers submitting claims to HP through other means (electronically), it is
the provider and beneficiary's responsibility to maintain at least one copy of the DHS-9559 for audit purposes. The copy may be at the beneficiary's residence or the provider's residence-Regardless of the billing method chosen, every billing claim form MUST be signed by both the Attendant Care provider AND the beneficiary-Maintaining a copy of the waiver plan of care in the beneficiary's home is reguired, regardless of the claims submission process chosen.
B. Failure to maintain sufficient documentation to support billing practices may result in recoupment of Medicaid payment made to the provider.C. All written documentation must be made available to authorized representatives of DAAS, the Division of Medical Services (DMS), the state Medicaid Fraud Control Unit, Office of Medicaid Inspector General, representatives of the Center for Medicare & Medicaid Services (CMS) and its authorized agents or officials, if requested.
216.100Vehicle ModificationsVehicle modifications are adaptations to an automobile or van to accommodate the special needs of the beneficiary. Vehicle adaptations are specified by the service plan as necessary to enable the beneficiary to integrate more fully into the community and to ensure the health, welfare, and safety of the beneficiary.
Payment for permanent modification of a vehicle is based on the cost of parts and labor, which must be quoted and paid separately from the purchase price of the vehicle to which the modifications are or will be made.
Transfer of any part of the purchase price of a vehicle, including preparation and delivery, to the price of a modification is a fraudulent activity. All suspected fraudulent activity will be reported to the Office of Medicaid Inspector General for investigation.
Reimbursement for a permanent modification cannot be used or considered as down payment for a vehicle.
Lifts that require vehicle modification and the modifications are, for purposes of approval and reimbursement, one project and cannot be separated by plan of care years in order to obtain up to the maximum for each component.
Permanent vehicle modifications may be replaced if the vehicle is stolen, damaged beyond repair as long as the damage is not through negligence of the vehicle owner, or used for more than its reasonable useful lifetime.
A. A vehicle has reached its reasonable useful lifetime when repairs are required to make the vehicle useable, and the cost of the repairs exceeds the fair market value of the vehicle in repaired condition.B. Cost of repair shall be determined by repair estimates from three qualified repairers.C. Vehicle value shall be determined by reference to sales listing for similar vehicles within a 200 mile radius of the beneficiary's home, and to listings in Dallas, Texas; Kansas City, Missouri; Saint Louis, Missouri and Memphis, Tennessee.D. If the beneficiary or legally responsible party sells or trades a permanently modified vehicle before the vehicle reaches its reasonable useful lifetime, the modification will not be replaced on any replacement vehicle. Instead, the beneficiary may be eligible for partial payment based on the estimated remaining residual value of the vehicle at the time of sale.1. Estimated residual value shall be determined by comparing the purchase price of the modified vehicle when acquired by the beneficiary or legally responsible party when the vehicle value at the time of sale determined as stated above.2. Example: A permanently modified vehicle purchased for $30,000 is sold with a value of $20,000 (66% residual value). If parts and labor for the modification of the replacement vehicle are $10,000, the amount paid is $3,333 (33%).E. Vehicle modifications apply only to modifications and not to routine auto maintenance or repairs for the vehicle.F. The following are specifically excluded:1. Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the beneficiary;2. Purchase, down payment or lease of a vehicle as documented by the vehicle sales contract and requested invoices;3. Regularly scheduled upkeep and maintenance of a vehicle, except upkeep and maintenance of the modification.
200.500Quality MeasuresThis section describes, for each episode type, the data and measures which Medicaid will track and evaluate to ensure provision of high-quality care for each episode type.
A.Quality measures "to pass":Measures for which a PAP must meet or exceed a minimum threshold in order to qualify for a full positive supplemental payment for that episode type.B.Quality measures "to track":Measures for which a PAP's performance is not linked to supplemental payments. Performance on these measures may result in an Office of Medicaid Inspector General review. For quality measures "to pass" and quality measures "to track" that require data not available from claims, PAPs must submit data through the provider portal in order to qualify for a full positive supplemental payment.
231.600Involuntary DisenrollmentParti cipants may be disenrolled for the following reasons:
A.Health, Safety and Well-being:At any time that DAAS determines that the health, safety and well-being of the participant is compromised by continued participation in the IndependentChoices Program, the participant may be returned to the traditional personal care program.B.Change in Condition:Should the participant's cognitive ability to direct his or her own care diminish to a point where he or she can no longer direct his or her own care and there is no Decision-Making Partner available to direct the care, the IndependentChoices case will be closed. The counselor will assist the participant with a referral to traditional services.C.Misuse of Allowance:Should a participant or the Decision-Making Partner who is performing all of their payroll functions (and not using the fiscal agent) use the allowance to purchase items unrelated to personal care needs, fail to pay the salary of an assistant, misrepresent payment of an assistant's salary, or fail to pay related state and federal payroll taxes, the participant or Decision-Making Partner will receive a warning notice that such exceptions to the conditions of participation are not allowed. The participant will be permitted to remain on the program, but will be assigned to the fiscal intermediary, who will provide maximum bookkeeping services. The participant or Decision-Making Partner will be notified that further failure to follow the expenditure plan could result in disenrollment. Should an unapproved expenditure or oversight occur a second time, the participant or Decision-Making Partner will be notified that the IndependentChoices case is being closed and they are being returned to traditional personal assistance services. The Office of Medicaid Inspector General is informed of situations as required. The counselor will assist the participant with transition to traditional services. The preceding rules are also applicable to participants using the fiscal agent.D.Underutilization of Allowance: The fiscal agent is responsible for monitoring the use of the Medicaid funds received on behalf of the participant. If the participant is underutilizing the allowance and not using it according to the cash expenditure plan, the fiscal agent will inform the counseling entities through quarterly reports and monthly reports on request. The counselor will discuss problems that are occurring with the participant and their support network. The counselor will continue to monitor the participant's use of their allowance through both review of reports and personal contact with the participant. If underutilization continues to occur, future discussions will focus on what is in the best interest of the participant in meeting their ADL's even if the best solution is a return to agency services. Unused funds are returned to the Arkansas Medicaid program within 45 days after disenrollment. Funds accrued in the absence of a savings plan will be returned to Medicaid within a twelve-month filing deadline. Involuntary disenrollment may be considered if the participant has been hospitalized for more than 30 days and a discharge date is unknown to the participant or Decision-Making Partner. Participants with approval by their physician for an out-of-state visit may be involuntarily disenrolled if their stay extends past the approval period authorized by their physician. The participant is required to provide a copy of the physician's authorizations to their counselor for monitoring purposes.E.Failure to Assume Employer Authority:Failure to Assume Employer Authority occurs when a participant fails to fulfill the role of employer and does not respond to counseling support. Disenrollment will not occur without guidance and counseling by the counselor or by the fiscal intermediary. When this occurs, the counselor will coordinate agency personal care services to the degree requested by the participant. The participant may wish to self-advocate from a list provided by the counselor, ask the counselor to coordinate or may simply wish to receive personal assistance services informally. The participant's wishes will be respected. Whenever a participant is involuntarily disenrolled, the IndependentChoices program will mail a notice to close the case. The notice will provide at least 10 days but no more than 30 days before IndependentChoices will be discontinued, depending on the situation. During the transition period, the counselor will work with the participant or Decision-Making Partner to provide services to help the individual transition to the most appropriate services available.
TOC required
203.000Office of Medicaid Inspector GeneralA PACE Organization must have a formal process in place to gather information and must be able to respond in writing to a request from CMS and/or the State Administering Agency (SAA) for information regarding:
A. Persons with criminal convictions.B. A PACE Organization must not employ individuals or contract with organizations or individuals: 1. Who have been excluded from participation in the Medicare or Medicaid programs;2. Who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social service programs under title XX of the Social Security Act; or3. In any capacity where an individual's contact with participants would pose a potential risk because the individual has been convicted of physical, sexual, drug or alcohol abuse.C. Direct or indirect interest in contracts. No member of the PACE Organization's governing body or any immediate family member may have a direct or indirect interest in any contract that supplies any administrative or care-related service or materials to the PACE Organization.
204.000Administrative Requirements for PharmaciesA. Pharmacy providers are prohibited from offering incentives (e.g., discounts, rebates, refunds or any other similar gratuity) for the purpose of soliciting the patronage of Medicaid beneficiaries. (See Section I of this manual.)B. Pharmacies may be required to participate in studies as the Department of Health and Human Services deems necessary in order to maintain an equitable program.C. In order to maintain the integrity of the program, the Arkansas Division of Medical Services has the right to collect medication samples from the recipients (or long-term care facility, if a beneficiary is a patient there).D. Information regarding ownership or financial interest and the identity of any agent or managing employee convicted of a Medicaid-related offense must be provided to the Arkansas Division of Medical Services within thirty (30) days of a written request.
203.310Physician's Role In Preventing Program AbuseThe Arkansas Medicaid Program must assure quality medical care for its beneficiaries and protect the integrity of the funds supporting the Program. The Division of Medical Services is committed to this goal by providing staff and resources to the prevention, detection and correction of abuse. However, these goals can be met only with the cooperation and support of the provider community. The physician is often in a position to detect certain program abuses. The Medicaid Program requests your assistance as a primary care provider to help assure quality care and the integrity of the program. (See Section I subsection 110.700 for additional information regarding the Office of Medicaid Inspector General.)
223.170Written ReportsA written report of the inspection team's conclusions will be forwarded to the facility and to the Office of Medicaid Inspector General within 14 calendar days of the last day of inspection. The written report will clearly identify any area of deficiency that requires submission of a Corrective Action Plan.
223.180 Corrective Action PlansThe provider is required to submit a Corrective Action Plan designed to rectify any area of deficiency noted in the written report of the Inspection of Care review. The Corrective Action Plan must be submitted to the contracted utilization review agency within 30 calendar days of the date of the written report. The contractor will review the Corrective Action Plan and forward it, with recommendations, to the Office of Medicaid Inspector General.
223.190Other ActionsOther actions that may be taken as part of the Inspection of Care include, but are not limited to:
A. Beneficiaries determined to no longer meet medical necessity criteria for substance abuse services will no longer be eligible for SATS.B. Follow-up Inspections of Care may be recommended by the contracted utilization review agency and required by Division of Medical Services to verify the implementation and effectiveness of corrective actions. Follow-up inspections may be focused on the issues addressed by the Corrective Action Plan or may be a complete re-Inspection of Care, at the sole discretion of the Division of Medical Services.C. Review by the Office of Medicaid Inspector General. TOC required
214.100Utilization Review and Office of Medicaid Inspector GeneralA. The Utilization Review and Office of Medicaid Inspector General of the Arkansas Medicaid Program have the responsibility for assuring quality medical care for Medicaid beneficiaries and for protecting the integrity of state and federal funds supporting the Medical Assistance Program. Those responsibilities are mandated by federal regulations.B. The Utilization Review and Office of Medicaid Inspector General shall: 1. Conduct on-site medical audits for the purpose of verifying the nature and extent of services paid for by the Medicaid Program,2. Research all inquiries from beneficiaries in response to the Explanation of Medicaid Benefits and3. Retrospectively evaluate medical practice patterns and providers' patterns by comparing each provider's pattern to norms and limits set by all the providers of the same specialty.
205.000Records Ambulance Providers Are Required to KeepA. Ambulance providers are required to keep the following records and, upon request, to immediately furnish the records to authorized representatives of the Arkansas Division of Medical Services and the State Medicaid Fraud Control Unit and to representatives of the Department of Human Services: 1. The beneficiary's diagnosis, ICD code, if known, and/or the conditions or symptoms requiring non-emergency ambulance service. (Diagnosis is not required for emergency ground ambulance service.)2. Copy of the Physician Certification Statement (PCS) for non-emergency ambulance service to include the ICD diagnosis code, if known, and/or the conditions or symptoms establishing medical necessity.3. Documentation required by Medicare for ambulance services provided to dual-eligible beneficiaries.4. Number of miles traveled - Mileage at transport origin and mileage at transport destination, while loaded, must be documented. (Medicaid only reimburses patient loaded miles.) Definition of rounding with decimals:When rounding numbers involving decimals, there are two (2) rules to remember: Rule One: Determine what your rounding digit is and look to the right side of it. If that digit is 4, 3, 2, or 1, simply drop all digits to the right of it. Rule Two:Determine what your rounding digit is and look to the right side of it. If that digit is 5, 6, 7, 8, or 9, add one to the rounding digit and drop all digits to the right of it.5. The Patient Care Report (PCR) is documentation used in both non-emergency and emergency transports and should contain at a minimum: a. Origin of the call (i.e., 911, hospital, nursing home, private residence),b. Origin of transport or pick-up (on occasion the origin of the call and the pick-up location are different),c. Date and times inclusive of time call received, unit in route to scene, arrival on scene, en route to destination, arrival at destination,d. The Arkansas Department of Health (ADH) vehicle permit number or the unit call sign of the responding unit/ambulance (if licensed in Arkansas),f. Certification/licensure of all crew members responding, unit and the level of ambulance service provided, andg. A complete subjective and objective assessment of patient being transported, monitoring of patient's condition and supplies used in transport.B. All required records must be kept for a period of five (5) years from the ending date of service; or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever period is longer.C. Furnishing medical records on request to authorized individuals and agencies listed above in subpart A is a contractual obligation of providers enrolled in the Medicaid Program. Failure to furnish medical records upon request may result in the imposition of sanctions.D. The provider must contemporaneously establish and maintain records that completely and accurately explain all assessments and aspects of care, including the response, interview, physical exam, any diagnostic procedures performed, any non-invasive or invasive procedures performed, diagnoses, supplies used and any other activities performed in connection with any Medicaid beneficiary.E. At the time of an audit by the Office of Medicaid Inspector General, all documentation must be available at the provider's place of business during normal business hours. There will be no more than thirty days allowed after the date of any recoupment notice in which additional documentation will be accepted.
202.000Visual Care Records Providers are Required to KeepVisual care providers are required to keep the following records and, upon request, must immediately furnish the records to authorized representatives of the Division of Medical Services, the state Medicaid Fraud Control Unit, representatives of the Department of Human Services and the Centers for Medicare and Medicaid Services:
A. History and visual care examination on initial visit.B. Chief complaint on each visit.E. Treatment, including prescriptions.F. Signature or initials of visual care provider after each visit.G. Copies of hospital and/or emergency room records that are available to disclose services. 1. All records must be kept for five (5) years from the ending date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish these records upon request may result in sanctions being imposed.2. All documentation must be immediately made available to representatives of the Division of Medical Services at the time of an audit by the Office of Medicaid Inspector General. All documentation must be available at the provider's place of business. When a recoupment is necessary, no more than thirty (30) days will be allowed after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the 30 days allowed after recoupment.3. Visual Care providers furnishing any Medicaid-covered good or service for which a prescription is required by law, by Medicaid rule, or both, must have a copy of the prescription for such good or service. The Visual Care provider must obtain a copy of the prescription within five (5) business days of the date the prescription is written.4. The Visual Care provider must maintain a copy of each relevant prescription in the Medicaid beneficiary's records and follow all prescriptions and care plans. TOC required
110.700Medicaid Fraud Detection and Investigation ProgramFederal Regulations require the implementation of a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate utilization of care and services and excess reimbursements by the Medicaid program. The purpose of the Office of the Medicaid Inspector General (OMIG) is to investigate fraud allegations and ensure Arkansas' Medicaid compliance. [Title XIX of the Social Security Act, Arkansas Code Annotated, 42 C.F.R. § 455 and the Arkansas State Plan].
The goal of the unit is to verify the nature and extent of services reimbursed by the Medicaid program, while ensuring reimbursements made are consistent with the quality of care being provided and protecting the integrity of both state and federal funds.
Responsibilities of the unit include the following:
A. Verifying medical services meet an accepted standard of care and are rendered as billedB. Verifying services are provided by qualified providers to eligible beneficiariesC. Verifying reimbursement for services is correct and that all funds identified for collection prior to Medicaid reimbursement are pursued The OMI G Section is responsible for conducting on-site medical reviews for the purpose of verifying the above tasks as well as record keeping and other specified information. Providers selected for an on-site review will not be notified in advance. Review analysts may request additional information regarding the provider's medical practice. View or print Office of Medicaid I nspector General contact information.
Additionally, the OMIG Section is responsible for the identification and recoupment of questioned costs claimed for reimbursement from Medicaid funds when warranted. Situations resulting in recoupment include, but are not limited to, the following:
A. When duplicate payments are madeB. When the Quality Improvement Organization (QIO) denies all or part of a hospital admissionC. When medical consultants to the Medicaid Program determine lack of medical necessityD. When Medicaid, Medicare or the Attorney General's Medicaid Fraud Unit discovers evidence of overpaymentE. When a provider has been assessed a monetary penalty for failure to follow a corrective action plan which was developed to correct a pattern of non-compliance as provided in Sections 151.000 and 190.005 When a review is completed, Office of Medicaid Inspector General will forward a findings report to the provider. If questioned costs are identified through the review, a "Notice of Decision/Action" will be forwarded to the provider. This notice must comply with Section 190.006 of this manual and must include the name(s) of the patient(s), date(s) of service, date(s) of payment and the reason(s) for the recoupment decision.
Upon receipt of this notice, the provider has thirty-five (35) calendar days in which to pursue one of the following actions:
A. Forward a check for the indicated recoupment amountB. Request administrative reconsiderationC. Appeal See Sections 160.000 through 169.000 for rules and procedures related to administrative reconsideration and appeals.
125.300Reporting Suspected Misuse of I.D. CardWhen a provider suspects misuse of a Medicaid identification card, the provider should contact the Office of Medicaid Inspector General. An investigation will then be made. V iew or print the Office of Medicaid I nspector General contact information.
161.200Administrative ReconsiderationA. Within 30 calendar days after notice of an adverse decision/action, the provider may request administrative reconsideration. Requests must be in writing and include: 1. A copy of the letter or notice of adverse decision/action2. Additional documentation that supports medical necessity Administrative reconsideration does not postpone any adverse action that may be imposed pending appeal.
B. Requests for reconsideration must be submitted as follows:1. In situations where the adverse decision/action has been taken by a reviewing agent, the request must be directed to that reviewing agent. Contact information for the department's reviewing agents can be found in Section V of this manual. General rules regarding due process are contained in Section I of each provider manual; but some administrative reconsideration and appeal processes are program-specific and are set forth in Section II of the applicable program manual.2. When an adverse decision/action has been taken by the Division of Medical Services, the request for reconsideration must be directed to Office of Medicaid Inspector General (OMIG). View or print the Office of Medicaid Inspector General contact information.Within 20 calendar days of receiving a timely and complete request for administrative reconsideration, the Director of the Division of Medical Services will designate a reviewer, who did not participate in the initial determination leading to the adverse decision/action, who is knowledgeable in the subject matter of the administrative reconsideration, to review the reconsideration request and associated documents. The reviewer shall recommend to the Director that the adverse decision/action be sustained, reversed or modified. The Director may adopt or reject the recommendation in whole or in part. A reconsideration request received within 35 calendar days of the written notice will be deemed timely. The request must be mailed or delivered by hand. Faxed or E-mailed requests will not be accepted.
No administrative reconsideration is allowed if the adverse decision/action is due to loss of licensure, accreditation or certification.
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 |
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-873 |
AAS-9506 | DMS-2634 | Spanish | DMS-673 | ECSE-R |
AAS-9559 | DMS-2647 | DMS-619 | DMS-679 | HP-0288 |
Address Chanqe | DMS-2685 | DMS-628 | DMS-679A | HP-AR-004 |
DMS-2687 | DMS-630 | DMS-683 | HP-CI-003 |
Autodeposit | DMS-2692 | DMS-632 | DMS-686 | HP-CR-002 |
CMS-485 | DMS-2698 | DMS-633 | DMS-689 | HP-MFR-001 |
CSPC-EPSDT | DMS-2704 | DMS-635 | DMS-693 | HP-MS-005 |
DDS/FS#0001.a | DMS-32-A | DMS-638 | DMS-699 | MAP-8 |
DMS-0101 | DMS-32-0 | DMS-640 | DMS-699A | Performance Report |
DMS-0688 | DMS-601 | DMS-647 | DMS-7708 |
DMS-102 | DMS-602 | DMS-648 | DMS-7736 | Provider Enrollment Application and Contract Package |
DMS-201 | DMS-612 | DMS-649 | DMS-7782 |
DMS-202 | DMS-615 English | DMS-650 | DMS-7783 |
DMS-2606 | DMS-651 | DMS-831 |
DMS-2608 | DMS-615 Spanish | DMS-652 | DMS-840 | PUB-019 |
DMS-2609 | DMS-652-A | DMS-841 | PUB-020 |
DMS-2610 | DMS-616 | DMS-653 | DMS-844 | |
DMS-2615 | DMS-618 English | DMS-664 | DMS-845 | |
DMS-2618 | | DMS-671 | DMS-846 | |
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, 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 Assocciation
Arkansas Office of Medicaid Inspector General (OMIG)
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
016.06.16 Ark. Code R. § 005