016-06-18 Ark. Code R. § 2

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Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.18-002 - Chiropracitc Services, 172.000, 211.000, 242.300

Section I

172.100 Services not Requiring a PCP Referral

The services listed in this section do not require a PCP referral.

A. ARChoices waiver services

B. Anesthesia services, excluding outpatient pain management

C. Assessment (including the physician's assessment) in the emergency department of an acute care hospital to determine whether an emergency condition exists. The physician and facility assessment services do not require a PCP referral {rf the Medicaid beneficiary Is enrolled with a PCP)

D. Chiropractic Services

E. Dental services

F. DDS Alternative Community Services (ACS) Waiver services

G. Developmental Day Treatment Clinic Services (DDTCS) core services

H. Disease control services for communicable diseases, including testing for and treating sexually transmitted diseases such as HIV/AIDS

I. Domiciliary care

J. Emergency services in an acute care hospital emergency department, including emergency physician services

K. Family Planning services

L. Gynecological care

M. Inpatient hospital admissions on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment

N. Mental health services, as follows:

1. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and practicing as an individual practitioner.

2. Rehabilitative services for persons with mental illness (RSPMI Program) ages 21 or older, or for specified procedures for persons under age 21 as listed in the RSPMI provider manual, Section 216.000.

3. Rehabilitative Services for Youth and Children (RSYC) Program.

O. Obstetric (antepartum, delivery and postpartum) services.

1. Only obstetric-gynecologic services are exempt from the PCP referral requirement.

2. The obstetrician or the PCP may order home health care for antepartum or postpartum complications.

3. The PCP must perform non-obstetric, non-gynecologic medical services for a pregnant woman or refer her to an appropriate provider.

P. Nursing facility services and intermediate care facility for individuals with I ntellectual disabilities (ICF/IID) services

Q. Ophthalmology services, including eye examinations, eyeglasses, and the treatment of diseases and conditions of the eye

R. Optometry services

S. Pharmacy services

T. Physician services for inpatients in an acute care hospital. This includes:

1. Direct patient care (initial and subsequent evaluation and management services, surgery, etc.), and

2. Indirect care (pathology, Interpretation of X-rays, etc.)

U. Hospital non-emergency or outpatient clinic services on the effective date of PCP enrollment or on the day after the effective date of PCP enrollment

V. Physician visits (except consultations) In the outpatient departments of acute care hospitals:

1. Medicaid will cover these services without a PCP referral only If the Medicaid beneficiary is enrolled with a PCP and the services are within applicable benefit limitations.

2. Consultations require PCP referral.

W. Professional components of diagnostic laboratory, radiology and machine tests In the outpatient departments of acute care hospitals. Medicaid cavers these services without a PCP referral only:

1. If the Medicaid beneficiary is enrolled with a PCP and

2. The services are within applicable benefit limitations.

X. Targeted Case Management services provided by the Division of Youth Services or the Division of Children and Family Services under an inter-agency agreement with the Division of Medical Services

Y. Transportation (emergency and non-emergency) to Medfcaid-covered services

Z. Other services, such as sexual ebuse examinations, when the Medicaid Program determines that restricting access to care would be detrimental to the patient's welfare or to program Integrity, or would create unnecessary hardship.

Section tl

Chiropractic

211.000 Introduction

Arkansas Medicaid assists Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual.

Chiropractic services are covered by Medicaid only to correct a subluxation of the spine (by manual manipulation). Chiropractic services do not require a referral from the Medicaid beneficiary's primary care physician (PCP). Chiropractic services are covered by Medicaid for beneficiaries of all ages.

242.310 Completion of the CMS-1500 Claim Form

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-diglt Medicaid or ARKids First-A or ARKids First-B identification number.
2. PATIENTS NAME (Last Name, First Name, Middle initial)	Beneficiary's or participant's last name and first name.
3. PATIENTS BIRTH DATE	Beneficiary's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY.
SEX	Check M for male or F for female.
4. INSURED'S NAME (Last Name, First Name, Middle Initial)	Required If insurance affects this claim, insured's last name, first name, and middle initial.
5. PATIENTS ADDRESS (No., Street)	Optional. Beneficiary's or participant's complete mailing address (street address or post office box).
CiTY	Name of the city in which the beneficiary or participant resides.
STATE	Two-letter postal code for the state In which the beneficiary or participant resides.
ZIP CODE	Five-digit zip code; nine digits for post office box.
TELEPHONE (Include Area Code)	The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone.
6. PATIENT RELATIONSHIP TO INSURED	If insurance affects this claim, check the box indicating the patient's relationship to the insured.
7. INSURED'S ADDRESS (No., Street)	Required if insured's address is different from the patient's address.
CITY
STATE
ZIP CODE

TELEPHONE (Include Area Code)
8. RESERVED	Reserved for NUCC use.
9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial)	If patient has other Insurance coverage as Indicated In Field 11d, the other Insured's last name, first name, and middle Initial.
a. OTHER INSURED'S POLICY OR GROUP NUMBER	Policy and/or group number of the insured individual.
b. RESERVED	Reserved for NUCC use.
SEX	Not required.
c. RESERVED	Reserved for NUCC use.
d. INSURANCE PLAN NAME OR PROGRAM NAME	Name of the Insurance company.
10. IS PATIENTS CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)	Check YES or NO.
b. AUTO ACCIDENT?	Required when an auto accident is related to the services. Check YES or NO.
PLACE (State)	If 10b is YES, the two-!etier postal abbreviation for the state in which the automobile accident took place.
c. OTHER ACCIDENT?	Required when an accident other than automobile Is related to the services. Check YES or NO.
d. CLAIM CODES	The "Claim Codes" identify additional information about the beneficiary's condition or the claim. When applicable, use the Claim Code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code In this field. The subset of approved Condition Codes is found atwww.nucc.oraunder Code Sets.
11. INSURED'S POLICY GROUP OR FECA NUMBER	Not required when Medicaid is the only payer.
a. INSURED'S DATE OF BIRTH	Not required.
SEX	Not required.
b. OTHER CLAIM ID NUMBER	Not required.
c. INSURANCE PLAN NAME OR PROGRAM NAME	Not required.
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?	When private or other insurance may or will cover any of the services, check YES and complete items 9,9a and 9d. Only one box can be marked.

12. PATIENTS OR AUTHORIZED PERSON'S SIGNATURE	Enter "Signature on Flte," "SOP or legal signature.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE	Enter "Signature on File," "SOP 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	Not required.
17a. (blank)	Not required.
17b. NPI
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES	When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY.
19. ADDITIONAL CLAIM INFORMATION	Identifies additional information about the beneficiary's condition or the claim. Enter the appropriate qualifiers describing the identifier. See wyvw.nq9c.0rqfor qualifiers.

20. OUTSIDE LAB?	Not required
$ CHARGES	Not required.
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY	Enter the eppliceble ICD indicator to Identify which version of ICD codes is being reported.
	Use"9"forlCD-9-CM.
	Use"0"fbrlCD-10-CM.
	Enter the Indicator between the vertical, dotted lines in the upper right-hand portion of the field.
i	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	Reserved for future use.
ORIGINALREF.NO.	Any data or other Information listed In this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes In policy.
23. PRIOR AUTHORIZATION NUMBER	The prior authorization or benefit extension control number ff applicable.
24A. DATE(S) OF SERVICE	The from" and "to" dates of service for each Wiled service. Formal- MM/DD/YY.
	1. On a singte claim detail (one charge on one line), bill only for services provided within a single calendar month.
	2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.
B. PLACE OF SERVICE	Two-digit national standard place of service code. See Section 242.200 for codes.
C. EMG	Enter "Y" for "Yes" or leave blank if "No." EMG identifies if the service was an emergency.
D. PROCEDURES. SERVICES, OR SUPPLIES
CPT/HCPCS	One CPT or HCPCS procedure code for each detail.
MODIFIER	Modifiers) if applicable.
E. DIAGNOSIS POINTER	Enter the diagnosis code reference letter (pointer) as shown In Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letters) should be A*L or multiple letters as applicable. The "Diagnosis Pointer" Is the line letter from Item Number 21 that relates to the reason the service(s) was performed.
F. $ CHARGES	The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other recipient of the provider's services.
G. DAYS OR UNITS	The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.
H. EPSDT/FamHyPlan	Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral.
1. IDQUAL	Not required.
J. RENDERING PROVIDER ID#	Enter the 9-dlgit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail or
NPI	Enter NPI of the Individual who furnished the services billed for in the detail.
25. FEDERAL TAX I.D. NUMBER	Not required. This information Is carried in the provider's Medicaid file. If It changes, please contact Provider Enrollment
26. PATIENTS ACCOUNT NO.	Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN."
27. ACCEPT ASSIGNMENT?	Not required. Assignment is automatically accepted by the provider when billing Medicaid.
28. TOTAL CHARGE	Total of Column 24F-the sum all charges on the claim.
29. AMOUNT PAID	Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not Include in this total the automatically deducted Medicaid or ARKids First-B co-payments.
30. RESERVED	Reserved for NUCC use.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS	The provider or designated authorized Individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group Is not acceptable.

32. SERVICE FACILITY LOCATION INFORMATION	ff other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed.
a. (blank)	Not required.
b.(Wank)	Not required.
33. BILLING PROVIDER INFO &	Billing provider's name end complete address.
PH#	Telephone number Is requested but not required.
a. (blank)	Enter NPI of the billing provider or
b. (blank)	Enter the 9-dfgJt Arkansas Medicaid provider ID number of the billing provider.

ATTACHMENT 3.1-A

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

CATEGORICALLY NEEDY

6.Medical care and any other type of remedial care recognized under State law, furnished by licensed practitioners

within the scope of their practice as defined by State law.

b.Optometrists' Services

(2)One eye exam every twelve (12) months for eligible recipient under 21 years of age in the Child Health Services (EPSDT) Program. Extensions of the benefit limit will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

(3)Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July I through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, sped fled in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

c.Chiropractors' Services

(1)Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVIII.

(2)Services are limited to treatment by means of manual manipulation of the spine which the chiropractor is legally authorized by the State to perform.

(3)Effective for dates of service on or after July I, 1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July I through June 30) for eligible Medicaid recipients age 21 and older. Services provided to recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

(4)Effective for dates of service on or after January 1,2018, chiropractic services do not require a referral by the beneficiary's primary care physician (PCP).

d.Advanced Nurse Practitioners and Registered Nurse Practitioners

Office medical services provided by an advanced nurse practitioner and registered nurse practitioner are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, speci fied in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

(2)One eye exam every twelve (12) months for eligible recipients under 21 years of age in the Child Heallh Services (EPSDT) Program. Extensions of the benefit limit will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

(3)Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife and services provided by an advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

c.Chiropractors* Services

(1)Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVIII.

(2)Services are limited to treatment by means of manual manipulation of the spine which (he chiropractor is legally authorized by the State to perform.

(3)Effective for dales of service on or after July 1,1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for eligible Medicaid recipients age 21 and older. Services provided to recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

(4)Effective for dates ofservice on or after January 1,2018, chiropractic services do not require a referral by the beneficiary's primary care physician (PCP).

d.Advanced Nurse Practitioners and Registered Nurse Practitioners

Office medical services provided by an advanced nurse practitioner and registered nurse practitioner are limited to twelve (12) visits per State Fiscal Year (July I through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a demist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

(2) One eye exam every twelve (12) months for eligible recipient under 21 years of age in the Child Health Services (EPSDT) Program. Extensions of the benefit limit will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

(3) Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

c. Chiropractors' Services

(1) Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVHI.

(2) Services are limited to treatment by means of manual manipulation of the spine which the chiropractor is legally authorized by the State to perform.

(3) Effective for dates of service on or after July I, 1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for eligible Medicaid recipients age 21 and older. Services provided to recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

(4) Effective for dates of service on or after January 1,2018, chiropractic services do not require a referral by the beneficiary's primary care physician (PCP).

d. Advanced Nurse Practitioners and Registered Nurse Practitioners

Office medical services provided by an advanced nurse practitioner and registered nurse practitioner are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

(2) One eye exam every twelve (12) months for eligible recipients under 21 years of age in the Child Health Services (EPSDT) Program. Extensions of the benefit limit will be provided if medically necessary for recipients in the Child Health Services (EPSDT) Program.

(3) Office medical services provided by an optometrist are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife and services provided by an advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

c. Chiropractors' Services

(1) Services are limited to licensed chiropractors meeting minimum standards promulgated by the Secretary of HHS under Title XVIII.

(2) Services are limited to treatment by means of manual manipulation of the spine which the chiropractor is legally authorized by the State to perform.

(3) Effective for dates of service on or after July 1, 1996, chiropractic services will be limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for eligible Medicaid recipients age 21 and older. Services provided to recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

(4)Effective for dates of service on or after January 1,2018, chiropractic services do not require a referral by the beneficiary's primary care physician (PCP).

d. Advanced Nurse Practitioners and Registered Nurse Practitioners

Office medical services provided by an advanced nurse practitioner and registered nurse practitioner are limited to twelve (12) visits per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and over. The benefit limit will be in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, rural health clinic services, certified nurse midwife services and advanced practice nurse or registered nurse practitioner or a combination of the six. For services beyond the twelve (12) visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries in the Child Health Services (EPSDT) Program are not benefit limited.

016.06.18 Ark. Code R. § 002

4/20/2018