Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 05 - Developmental Disabilities Services
Rule 016.05.17-005 - DDS Community and Employment Supports (CES) Waiver and Medicaid Provider Manual #2-17

Universal Citation: AR Admin Rules 016.05.17-005

Current through Register Vol. 49, No. 9, September, 2024

Application for a §1915(c) Home and Community-Based Services Waiver

200.000 DDS COMMUNITY EMPLOYMENT SUPPORTS (CES) WAIVER GENERAL INFORMATION

201.000 Arkansas Medicaid Program Participation Requirements for DDS CES Waiver Program

All Division of Developmental Disabilities Services (DDS) Community and Employment Supports (CES) 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:

Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq.

All willing and qualified providers have the opportunity to enroll as a waiver provider. DDS provides continuous open enrollment for waiver service providers. Potential providers should contact DDS Quality Assurance staff for information on the CES certification standards. Once a provider is certified by DDS. the provider must contact the DMS Provider Enrollment Unit to enroll as a Medicaid provider.

Certified and enrolled providers are allowed to specify the maximum number of persons they can serve, the county they can sen/e, the services they can provide and the service levels they can offer based on staff availability. Waiver beneficiaries have the freedom of choice of service providers. Once a provider is chosen by a beneficiary and meets the designations made by the provider, the provider cannot refuse to provide services unless the provider cannot assure the health and safety of the beneficiary. It is incumbent upon the provider to prove the individual cannot be served by the provider. The burden of proof also requires written identification of the cause for the failure to provide health and safety supported by documentation that attests to that condition.

Before a provider can decrease the maximum number of beneficiaries they will serve, drop an existing county they serve, a service, or service level, the provider must identify any beneficiary cun-ently being served who would be affected. The provider will be required to continue providing services to any beneficiary who would be affected by the changes until such time as DDS can secure a new provider and services are in place under the new provider. If a provider elects to change the existing county served or the maximum number of participants served, the change cannot be made if it will adversely impact any beneficiary currently receiving services from the provider. The provider's maximum number of beneficiaries served may only be reduced through ceasing provision of services in a designated county or counties, freezing the number of persons they serve at the current number and reducing the number through attrition, or ceasing provision of services to those beneficiaries they have most recently begun sen/ing. DDS will freeze new referrals when a provider requests to make changes in the above items but will not approve the changes for existing beneficiaries until such time as the transition to a new provider has occurred. Further, when less than an entire county is deleted from coverage, the provider must articulate in writing a business reason for making the change and demonstrate that the selection process is not capricious or arbitrary, does not result in discrimination and does not unfairly distinguish between levels of care. The process cannot be used to eliminate difficult families or beneficiaries. Other than business reasons for closing entire counties or programs, beneficiaries can only be discontinued if the provider cannot assure health and safefy.

Option: Based on individual choice, a provider may continue to serve a beneficiary without serving others in the county when the individual served relocates their place of residence.

201.100 Providers of DDS CES Waiver Services in Arkansas and Bordering

States Trade Area Cities

DDS CES waiver services are limited to Arkansas and bordering state trade area cities. The DOS must certify providers located in a bordering state trade area city as CES v/aiver providers before services may be provided for Arkansas Medicaid beneficiaries.

Bordering state trade area cities are Monroe and Shreveport, Louisiana; Clari[LESS THAN]sdale and Greenville, Mississippi; Poplar Bluff and Springfield, Missouri; Poteau and Sallisaw, Oklahoma; Memphis, Tennessee and Texarikana, Texas.

201.200 Organized Health Care Delivery System Provider

The DDS CES waiver allows a provider who is licensed and certified as a DDS CES case management entity or a DDS CES supportive living services provider to enroll in the Ari[LESS THAN]ansas Medicaid Program as a DDS CES organized health care delivery system (OHCDS) provider.

The option of OHCDS is available to any cunrent or future provider through a written agreement between DDS and the provider entity. The agreement requires each OHCDS provider to guarantee that any sub-contractor will abide by all Medicaid regulations and provides that the OHCDS provider assumes all liability for contract noncompliance. The OHCDS provider must also have a written contract that sets forth specifications and assurances that work will be completed timely, satisfactorily to the beneficiary being sen/ed and with quality maintained. The OHCDS provider is responsible for ensuring that services were delivered and proper documentation, including a signed customer satisfaction statement, has been submitted prior to billing.

As long as the OHCDS provider delivers at least one waiver service directly utilizing its own employees, an OHCDS provider may provide any other DDS CES waiver service via a subcontract with an entity qualified to fumish the service. The subcontract must ensure financial accountability and that services were delivered, property documented and billed. The primary use of OHCDS is consultation, adaptive equipment, environmental modifications, supplemental support and specialized medical supplies.

The OHCDS provider furnishes the sen/ices as the beneficiary's provider of choice as described in that beneficiary's person-centered service plan

202.000 Documentation Requirements

DDS CES waiver providers must keep and property maintain written records. Along with the required enrollment documentation, which is detailed in Section 141.000, the follovwng records must be included in the beneficiary's case files maintained by the provider.

202.100 Documentation in Beneficiary's Case Files

DDS CES waiver providers must develop and maintain sufficient written documentation to support each sen/ice for which billing is made. This documentation, at a minimum, must consist of:

A. A copy of the beneficiary's person-centered service plan, including any amendments thereto.

B. The specific services rendered.

C. The date and actual time the services were rendered.

D. The name of the individual who provided the service.

E. The relationship of the sen/ice to the treatment regimen of the beneficiary's person-centered service plan.

F. Updates describing the beneficiary's progress or lack thereof. Updates should be maintained on a daily basis or at each contact with or on behalf of the beneficiary. Progress notes must be signed and dated by the provider of the service.

G. Certification statements, narratives and proofs that support the cost-effectiveness and medical necessity of the service to be provided.

Additional documentation and information may be required dependent upon the service to be provided.

202.200 HCBS Settings Requirements

Home and Community-Based Services (HCBS) Settings

All providers must meet the following Home and Community-Based Services (HCBS) Settings regulations as established by CMS. The federal regulation for the new mle 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:

A. Chosen by the individual from among setting options including non-disability-specific settings (as well as an independent setting) and an option for a private unit in a residential setting.

1. Choice must be included in the person-centered service plan.

2. Choice must be based on the individual's needs, preferences and, for residential settings, resources available for room and board.

B. Ensures an individual's rights of privacy, dignity and respect and freedom from coercion and restraint.

C. Opimizes, but does not regiment, individual initiative, autonomy and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.

D. Facilitates individual choice regarding services and supports and who provides them.

F. In a provider-owned or -controlled residential setting (e.g.. Group Homes), in addition to the qualities specified above, the following conditions must be met:

1. The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services, and the Individual has, at a minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant law of the State, county, city, or other designated entity. For settings in which landlord/tenant laws do not apply, the State must ensure that a lease, residency agreement or other form of written agreement will be in place for each HCBS participant and that the document provides protections that address eviction processes and appeals comparable to those provided under the jurisdiction's landlord/tenant law.

2. Each individual has privacy in their sleeping or living unit:

a. Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors.

b. Beneficiaries sharing units have a choice of roommates in that setting.

c. Beneficiaries have tlie freedom to fumisfi and decorate their sleeping or living units within the lease or other agreement.

3. Beneficiaries have the freedom and support to control their own schedules and activities and have access to food at any time.

4. Beneficiaries are able to have visitors of their choosing at any time.

5. The setting is physically accessible to the individual.

6. Any modification of the additional conditions specified in items 1 through 4 above must be supported by a specific assessed need and justified in the person-centered service plan. The following requirements must be documented in the person-centered service plan:

a. Identify a specific and individualized assessed need.

b. Document the positive interventions and supports used prior to any modifications to the person-centered service plan.

c. Document less intrusive methods of meeting the need that have been tried but did not work.

d. Include a clear description of the condition that is directly proportionate to the specific assessed need.

e. Include regular collection and review of data to measure the ongoing effectiveness of the modification.

f. Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.

g. Include the informed consent of the individual.

h. Include an assurance that Interventions and supports will cause no harm to the individual.

210.000 PROGRAM COVERAGE

211.000 Scope

The Medicaid program offers certain home and community-based services (HCBS) as an alternative to institutionalization. These services are available for eligible beneficiaries with a developmental disability who would othenwise require an Intenmediate care facility for the intellectually disabled/developmentally disabled (ICF/ID/DD)level of care. This waiver does not provide education or therapy services.

The purpose of the CES waiver is to support beneficiaries of all ages who have a developmental disatjility, meet the institutional level of care, and require waiver support services to live in the community and thus prevent institutionalization.

The goal is to create a flexible array of services that will allow people to reach their maximum potential in decision-making, employment and community integration; thus giving their lives the meaning and value they choose.

The objectives are as follows:

A. To transition eligible persons who choose the waiver option from residential facilities into the community

B. To provide priority services to persons who meet criteria for the third tier of service {requiring supports 24 hours a day, seven (7) days a week)

C. To enhance and maintain community living for all persons participating in the waiver program

DDS is responsible for day-to-day operation of the waiver. All waiver services are accessed through DDS Adult Services, DDS Children's Services or the ICF/ID/DD services intake and referral staff.

All CES waiver services must be prior authorized by DDS and based on an independent assessment and functional evaluations. All services must be delivered based on the approved person-centered service plan.

Waiver services will not be furnished to persons while they are inpatients of a hospital, nursing facility (NF), or ICF/ID/DD unless payment to the hospital. NF, or ICF/ID/DD is being made through private pay or private insurance.

A person may be placed in abeyance in three-month increments (with status report every month) for up to 12 months when the following conditions are met:

A. The need for absence must be for the purposes of treatment in a licensed or certified program or facility for the purposes of behavior stabilization, physical or mental health treatment.

B. The loss of home or loss of the primary non-paid caregiver.

C. The request must be in writing with supporting evidence included.

D. The request must be prior approved by DDS.

E. A minimum of one visit or one contact each month is required.

NOTE: The DDS Specialist is responsible for conducting or assuring the conducting of the contacts or monitoring visits with applicable documentation filed in the case record.

F. All requests for abeyance are to be faxed to the DDS Waiver Program Director for Adult and Waiver Services. Monthly status reports are required to be submitted to the DDS Waiver Program Director as long as the person Is in abeyance. Each request for continuance must be submitted in writing and supported by evidence of treatment status or progress. Requests for continuance must be made prior to the expiration of the abeyance period.

In order for beneficiaries to continue to be eligible for waiver services while they are in abeyance the following two requirements must be met:

A. It must be demonstrated that a beneficiary needs case management and at least one other service as documented in their person-centered service plan.

B. Beneficiaries must receive monthly monitoring of waiver services.

As stated in the Medical Sen/ices Manual, Section 1348, an individual living in a public institution is not eligible for Medicaid.

A. Public institutions include county jails, state and federal penitentiaries, juvenile detention centers, and other correctional or holding facilities.

B. Wilderness camps and boot camps are considered a public institution if a governmental unit has any degree of administrative control.

C. Inmate status will continue until the indictment against the individual is dismissed or until he or she is released from custody either as "not guilty" or for some other reason (bail, parole, pardon, suspended sentence, home release program, probation, etc.)

Thus, a person who is living in a public Institution as defined above would be deemed ineligible for Medicaid and thus the waiver program.

211.200 Risk Assessment

A. DDS will not authorize or continue waiver services under line following conditions:

1. The health and safety of the beneficiary, the beneficiary's caregivers, workers or others are not assured.

2. The beneficiary or legally responsible person has refused or refuses to participate in the plan of care development or to permit implementation of the plan of care or any part thereof that is deemed necessary to assure health and safety.

3. The beneficiary or legally responsible person refuses to pemnit the on-site entry of: case manager to conduct required visits, caregivers to provide scheduled care, DDS, DIVIS, DHS or CMS officials acting in their role as oversight authority for compliance or audit purposes.

4. The beneficiary applying for, or receiving, waiver sen/ices requires 24-hour nursing care on a continuous basis as prescribed by a physician.

5. The beneficiary participating in the waiver program is incarcerated or is an inmate in a state or local correctional facility.

6. The person is deemed ineligible based on a DDS Psychological Team assessment or reassessment for meeting ICF/IID level of care.

7. The beneficiary is deemed ineligible based on not meeting or not complying with requirements for determining continued Medicaid income eligibility.

8. The beneficiary does not undergo an independent assessment by a third-party vendor.

B. Safeguards concerning the use of restraints or seclusion:

1. Physical restraints (use of a staff member's body to prevent injury to the beneficiary or another person) are allowed in cases of emergency. An emergency exists for any of the following conditions:

a. The beneficiary has not responded to de-escalation techniques and continues to escalate behavior

b. The beneficiary is a danger to self or others

c. The safety of the beneficiary and those nearby cannot be assured through positive reinforcers

An individual must be continuously under direct observation of staff members during any use of restraints.

If the use of personal restraints occurs more than three (3) times per month, use should be discussed by the interdisciplinary team and addressed in the plan of care. When emergency procedures are implemented, plan of care revisions including, but not limited to, psychological counseling, review of medications with possible medication change or a change in environmental stressors that are noted to precede escalation of behavior may be implemented.

1. Use of mechanical or chemical restraint is not allowed. Seclusion is not allowed.

2. DDS standards require that providers will not allow maltreatment or corporal punishment (the application of painful stimuli to the body In an attempt to terminate behavior or as a penalty for behavior) of individuals. Providers' policies and procedures must state that corporal punishment is prohibited.

C. Safeguards concerning the use of restrictive intervention:

1. Restrictive inten/entions may be used.

2. DDS standards require the use of a behavior management plan for all beneficiaries whose behavior may warrant intervention. The behavior management plan must specify what will constitute the use of restrictive inten/entions, the length of time to be used, who will authorize the use of restrictive intervention and the methods for monitoring the beneficiary.

When the behavior plan is implemented, all use of restrictive interventions must be documented in the beneficiary's case record and should include the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.

3. Restrictive interventions include

a. Absence from a specific social activity

b. Temporary loss of a personal possession

c. Time out or separation

4. Restrictive interventions cannot Include

a. Aversion techniques

b. Restrictions to an individual's rights, including the right to physically leave

c. Mechanical or chemical restraints

d. Seclusion

These interventions might be implemented to deal with aggressive or disruptive behaviors related to the activity or possession. Staff, families and the beneficiary are trained by the provider to recognize and report unauthorized use of restrictive interventions.

Before absence from a specific social activity or temporary loss of personal possession is implemented, the beneficiary is first counseled about the consequences of the behavior and the choices they can make.

1. All personnel who are involved in the use of restrictive interventions must receive training in behavior management techniques as well as training in abuse and neglect laws, mies and regulations and policies. The personnel must be qualified to perform, develop, implement and monitor or provide direction intervention as applicable.

2. Use of restrictive interventions requires submission of an incident report that must be submitted no later than the end of the second business day following the incident. The DDS Quality Assurance staff investigates each incident and monitors use of restrictive interventions for possible overuse or inappropriate use. DDS Quality Assurance staff will notify entities involved with the complaint or service concern the results of their review. If there is credible evidence to support the complaint or concern, the provider will be required to submit a plan of correction. Failure to complete corrective action measures may result In the provider being placed on provisional status or revocation of certification.

D. Behavior Management Plans

Before use of restraints or restrictive interventions, providers must develop a written behavior management plan to ensure the rights of beneficiaries. The plan must include a provision for alternative methods to avoid the use of restraints and seclusions.

The behavior management plan must

1. Be written or supervised by a qualified professional who is at minimum a Qualified Developmental Disabilities Professional (QDDP)

2. Be designed so that the rights of the individual are protected

3. Preclude procedures that are punishing, physically painful, emotionally frightening involve deprivation, or put the individual at medical risk

4. Identify the behavior to be decreased

5. Identify the behavior to be increased

6. Identify what things should be provided or avoided in the individual's environment on a daily basis to decrease the likelihood of the identified behavior

7. Identify the methods that staff should use to manage behavior, in order to ensure consistency from setting to setting and from person to person

8. Identify the event that likely occurs right before a behavior of concern

9. Identify what staff should do if the event occurs

10. Identify what staff should do if the behavior to be increased or decreased occurs, and

11. Involve the fewest interventions or strategies as possible

The behavior management plan must also specify the length of time the restraint or restrictive intervention is to be used, who will authorize the use of restraint or seclusion and the methods for monitoring the beneficiary.

Behavior management plans cannot include procedures that are punishing, physically painful, emotionally frightening, depriving, or that put the beneficiary at medical risk.

E. Reports of Use of Restraints or Restrictive Interventions

All use of restraint must be documented in the beneficiary's case record, including the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.

1 The use of restraint or unauthorized seclusion must be reported to the DDS Quality Assurance section via an incident report form that must be submitted no later than the end of the second business day following the incident. The DDS Quality Assurance staff investigates each incident and monitors use of restraints for possible overuse or inappropriate use of restraints or seclusion. DDS Quality Assurance staff will notify entities involved with the complaint or service concern the results of their review.)f there is credible evidence to support the complaint or concern, the provider will be required to submit a plan of correction. Failure to complete corrective action measures may result in the provider being placed on provisional status or revocation of certification.

2. Each person working within the provider agency must complete Introduction to Behavior Management, Abuse and Neglect and any other training as deemed necessary as a result of deficiencies or corrective actions.

212.000 Description of Services

DDS CES services provide the support necessary for a beneficiary to live in the community. Without these services, the beneficiary would require institutionalization.

Services provided under this program are as follows:

A. Supportive Living

B. Respite Sen/ices

C. Supported Employment

D. Adaptive Equipment

E. Environmental Modifications

F. Specialized Medical Supplies

G. Supplemental Support Service

H. Case Management Services

I. Consultation Services

J. Crisis Intervention Services

K. Community Transition Services

213.000 Supportive Living

Supportive living is an array of individually tailored services and activities provided to enable eligible beneficiaries to reside successfully in their own homes, with their family, or in an alternative living residence or setting. Alternative living residences include apartments, leased or ovmed homes, or provider group homes. Supportive living services must be provided in an integrated community setting. The services are designed to assist beneficiaries in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in the home- and community-based setting. Sen/ices are flexible to allow for unforeseen changes needed in schedules and times of service delivery. Services are approved as maximum days that can be adjusted within the annual plan year to meet changing needs. The total number of days cannot be increased or decreased without a revision. Care and supervision for which payment will be made are those activities that directly relate to active treatment goals and objectives.

A. Residential Habilitation Supports

Supports to assist the beneficiary to acquire, retain or improve skills in a wide variety of areas that directly affect their ability to reside as independently as possible in the communijy. The supports that may be provided to a beneficiary include:

1. Decision making, including the identification of and response to dangerously threatening situations, making decisions and choices affecting the person's life and initiating changes in living arrangement or life activities.

2. Money management, including training, assistance or both in handling personal finances, making purchases and meeting personal financial obligations.

3. Daily living skills, including habilitative training in accomplishing routine housekeeping tasks, meal preparation, dressing, personal hygiene, administration of medications (to the extent permitted under state law) and other areas of daily living including proper use of adaptive and assistive devices, appliances, home safety, first aid and emergency procedures.

4. Socialization, including training, assistance or both, in participation in general community activities, and establishing relationships with peers. Activity training includes assisting the person to continue to participate on an ongoing basis.

5. Community integration experiences, including activities intended to instruct the beneficiary In daily living and community living skills in an integrated setting. Included are such activities as shopping, church attendance, sports, participation in clubs, etc. Community experiences include activities and supports to accomplish individual goals or learning areas including recreation and specific training or leisure activities. Each activity is then adapted according to the beneficiary's individual needs.

6. Non-medical transportation to or from community integration experiences is an integral part of this service and is included in the daily rate computation. DDS will assure duplicate billing between waiver sen/ices and other Medicaid state plan services will not occur. The habilitation objectives to be served by such training must be documented in the beneficiary's service plan. Whenever possible, family. neighbors, friends or community agencies tliat can provide this service without charge must be utilized.

Exclusions: Transportation to and from medical, dental and professional appointments inclusive of therapists. Non-medical transportation does not include transportation for other household members.

7. Mobility, including training, assistance or both aimed at enhancing movement within the person's living arrangement, mastering the use of adaptive aids and equipment, accessing and using public transportation, independent travel or movement within the community.

8. Communication, including training in vocabulary building, use of augmentative communication devices and receptive and expressive language.

9. Behavior shaping and management, including training, assistance or both in appropriate expressions of emotions or desires, compliance, assertiveness, acquisition of socially appropriate behaviors or reduction of inappropriate behaviors.

10. Reinforcement of therapeutic services, including conducting exercises or reinforcing physical, occupational, speech and other therapeutic programs.

11. Health maintenance activities may be provided by a supportive living worker. All health maintenance activities, except injections and IVs, can be done in the home by a designated care aide, such as a supportive living worker. With the exception of injectable medication administration, tasks that beneficiaries would otherwise do for themselves, or have a family member do, can be performed by a paid designated care aide at their direction, as long as the criteria specified in the Arkansas Nurse Practices Consumer Directed Care Act has been met. Health maintenance activities are available in the Arkansas Medicaid State Plan as self-directed services. State plan services must be exhausted before accessing waiver funding for health maintenance activities.

B. Companion and Activities Therapy

Companion and activities therapy services provide reinforcement of habilitative training. This reinforcement is accomplished by using animals as modalities to motivate beneficiaries to meet functional goals. Through the utilization of an animal's presence, enhancement and incentives are provided to beneficiaries to practice and accomplish such functional goals as

1. Language skills

2. Increased range of motion

3. Socialization by developing the interpersonal relationships skills of interaction, cooperation and trust and the development of self-respect, self-esteem, responsibility, confidence and assertiveness

Exclusions: This service does not include the cost of veterinary or other care, food, shelter or ancillary equipment that may be needed by the animal that is providing reinforcement.

C. Direct Care Supervision

The direct care supervisor employed by the supportive living provider is responsible for assuring the delivery of all supportive living direct-care services including the following activities:

1. Coordinating all direct service workers who provide care through the direct service provider

2. Serving as liaison between the beneficiary, parents, legal representatives, case management entity and DDS officials

3. Coordinating schedules for both waiver and generic service categories

4. Providing direct planning input and preparing all direct service provider segments of any initial plan of care and annual continued stay review

5. Assuring the integrity of all direct care service Medicaid waiver billing

6. Arranging for staffing of all alternative living settings

7. Assuring transportation as identified in beneficiary's person-centered service plan specific to supportive living services

8. Assuring timely collaboration with the case management entity to obtain comprehensive behavior and assessment reports, continued person-centered case plans with revisions as needs change and information and documents required for ICF/IID level of care and waiver Medicaid eligibility determination

9. Reviewing the person's records and environments in which services are provided by accessing appropriate professional sources to determine whether the person is receiving appropriate support in the management of medication. Minimum components are as follows:

a. The direct care supervisor has an on-going responsibility for monitoring beneficiary medication regimens. While the provider may not staff a person on a 24/7 schedule, the provider is responsible around the clock to ensure that the person-centered service plan identifies and addresses all the needs with other supports as necessary to assure the health and welfare of the beneficiary.

b. Staff, at all times, are aware of the medications being used by the beneficiary.

c. Staff are knowledgeable of potential side effects of the medications being used by the beneficiary through the prescribing physician, nurse and pharmacist at the time medications are ordered.

d. All medications consumed are prescribed or approved by the beneficiary's physician or other health care practitioner.

e. The beneficiary or legally responsible person is informed by the prescribing physician about the nature and effect of medication being consumed and consents to the consumption of those medications prior to consumption.

f. Staff are implementing the service provider's policies and procedures as to medication management, appropriate to the beneficiary's needs as monitored by the direct care supervisor in accordance with acceptable personnel policies and practices and by the case manager at least monthly.

g. If psychotropic medications are being used for behavior, the direct care supervisor and case manager are responsible to assure appropriate positive behavior programming is present and in use with programming reviews at least monthly.

h. The consumption of medications is monitored at least monthly by the direct care supervisor to ensure that they are accurately consumed as prescribed.

i. Toxicology screenings are conducted on a frequency determined by the prescribing physician with case manager oversight.

j. Any administration of medication or other nursing tasks or activities are

performed in accordance with the Nurse Practice and Consumer Directed Care Acts and are monitored by the direct care supervisor in accordance with acceptable personnel practices and by the case manager at least monthly.

k. Medications are regulariy reviewed to monitor their effectiveness, to address the reason for which they were prescribed and for possible side effects.

I. Medication errors are effectively detected by the direct care supervisor by review of the medication log and with appropriate response up to and inclusive of incident reporting and reporting to the Nursing Board.

m. Frequency of monitoring is based on the physician's prescription for administration of medication.

n. The physician approving the service level of support and the person-centered service plan is responsible for monitoring and detemriining contraindications when multiple medications are prescribed. A minimum review is at the annual continued stay review of the person-centered service plan for approval and recertification.

Direct care staff are required to complete daily activity logs for activities that occur during the work timeframe with such activities linked to the person-centered service plan objectives. The direct care supervisor is required to monitor the wofk of the direct care staff and to sign off on timesheets maintained to document wori[LESS THAN] performed. All monitoring activities, reviews and reports must be documented and available upon request from authorized DDS or DMS staff.

NOTE; Failure to satisfactorUy document activities according to DMS requirements may result in non-payment or recoupment of payment of services.

Beneficiaries may access both supportive living and respite on the same date as long as the two services are distinct, do not overiap and the daily rate maximum is con-ectly prorated as to the portion of the day that each respective service was actually provided. DDS monitors this provision through retrospective annual review with providers responsible for maintaining adequate time records and activity case notes or activity logs that support the service deliveries. A maximum daily rate is established in accordance with budget neutrality wherein both supportive living and respite cannot exceed the daily maximum.

Controls in place to assure payments are made only for services rendered include requirement by assigned staff to complete daily activity logs for activities that occurred during the work timeframe with such activities linked to the person-centered case plan objectives; supervision of staff by the direct care supervisor with sign-off on timesheets maintained weekly; audits and reviews conducted by DDS Quality Assurance annually and at random; DDS Waiver Services annual retrospective reviews, random attendance at planning meetings and visits to the home; DMS random audits; and oversight by the chosen and assigned case manager. Retainer payments may be made to providers of habilitation while the waiver participant is hospitalized or absent from his/her home.

213.300 Benefit Limits for Supportive Living

The maximum daily rate for the supportive living array, which includes both supportive living and respite services is based upon the tier of support identified in the beneficiary's person-centered service plan after completion of the independent assessment This daily rate includes provider-indirect costs for each component of service. DDS must prior authorize daily rates for all tiers of support.

Tier 3: Maximum Daily Rate is $391.95 with a maximum of $143, 061.75 annually.

Tier 2: Maximum Daily Rate is $184.80 vyith a maximum of $67,452.00 annually.

All units must be billed in accordance with the beneficiary's person-centered service plan. Extensions of benefits will be provided when extended benefits are detenmined to be medically necessary and do not exceed the maximum daily rate.

See Section 260.000 for billing information.

See Section 224.000 for payment guidelines of relatives or legal guardians.

214.000 Respite Services

Respite services are provided on a sliort-term basis to beneficiaries unable to care for themselves due to the absence of or need for relief of non-paid primary caregivers. Room and board may not be claimed when respite is provided in the beneficiary's home or a private place of residence. Room and board is not a covered sen/ice except when provided as part of respite furnished in a facility that is approved by the State.

Receipt of respite sen/ices does not necessarily preclude a beneficiary from receiving other services on the same day. For example, a beneficiary may receive day services, such as supported employment, on the same day as respite services.

When respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Respite may not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Respite services are not to supplant the responsibility of the parent or guardian.

Respite services may be provided through a combination of basic child care and support services required to meet the needs of a child.

Respite may be provided in the following locations:

A. Beneficiary's home or private place of residence

B. The private residence of a respite care provider

C. Foster home

D. Group home

. Licensed respite facility

F. Other community residential facility approved by the state, not a private residence G? Licensed or accredited residential mental health facility

214.100 Benefit Limits for Respite Services

The maximum daily rate for the supportive living array, which includes both supportive living and respite services, collectively or individually is based upon the tier of support identified in the beneficiary's person-centered service plan, after completion of the independent assessment. This daily rate includes provider indirect costs for each component of service. DDS must prior authorize daily rates for all tiers of support.

Tier 3 - maximum daily rate is $391.95 with a maximum annual rate of $143,061.75.

Tier 2 - maximum daily rate Is $184.80 with a maximum annual rate of $67,452.00.

All units must be billed In accordance with the beneficiary's person-centered sen/Ice plan. Extensions of benefits will be provided when extended benefits are determined to be medically necessary.

See Section 260.000 for billing information.

215.000 Supported Employment

Supported employment is a tailored array of services that offers ongoing support to beneficiaries with the most significant disabilities to assist in their goal of woridng in competitive integrated work settings for at least minimum wage. It is intended for individuals for whom competitive employment has not traditionally occurred, or has been interrupted or intemiittent as a result of a significant disability, and who need ongoing supports to maintain their employment.

The supported employment sen/ice array includes:

A. Discovery Career Planning: Information is gathered about a beneficiary's interests, strengths, skills, the types of supports that are the most effective and the types of environments and activities where the participant is at his or her best. These services should result in the development of the Individual Career Profile which includes specific recommendations regarding the beneficiary's employment support needs, preferences, abilities and characteristics of optimal work environment. The following activities may be a component of Discovery/Career Planning: review of the beneficiary's work history, interest and skills; job exploration; job shadov\/ing; infomnational interviewing, including mock interview; job and task analysis activities; situational assessments to assess the beneficiary's interest and aptitude in a particular type of job; employment preparation (i.e. resume development); benefits counseling; business plan development for self-employment; and volunteerism.

B. Employment Path: Beneficiary receiving these services must have goals related to employment in integrated community settings in their person-center service plan. Activities must be designed and developed to support the employment goals outlined in the person-centered service plan. Such activities should develop and teach soft skills utilized in integrated employment including, but not limited to, following directions, attending to tasks, problem-solving skills and strategies, mobility training, effective and appropriate communication (verbal and nonverbal) and time management.

Employment Path is a time-limited service and requires prior authorization for the first 12 months. One reauthorization of up to twelve months is possible, but only if the beneficiary is also receiving job development services that indicate the beneficiary is actively seeking employment.

C. Employment Supports.

1. Job Development: Individualized services that are specific in nature to obtaining a certain employment opportunity. The Initial outcome of Job Development is the Job Development Plan. The Job Development Plan must be created and incorporated with the individual Career Profile no later than 30 days after Job Development services begin. The Job Development Plan must, at a minimum, specify:

a. Short- and long-term employment goa|s

b. Target wages

c. Task hours

d. Special conditions that apply to the wori[LESS THAN]slte for the beneficiary

e. Jobs that will be developed or tasks that will be customized through negotiations with potential employers

f. Initial list of employer contacts

g. Plan for how many employers will be contacted each week

h. Conditions for use of on-site job coaching

2. Job Coaching: On-site activities that may be provided to a beneficiary once employment is obtained. Activities provided under this service may Include, but are not limited to, completing job duty and task analysis; assisting the beneficiary to learn to do the job by the least intmslve method available; developing compensatory strategies if needed to cue beneficiary to complete the job; analyzing the work environment during Initial training/teaming of the job and making determinations regarding modificafions or assistive technology. Services are authorized for twelve months. A fading plan must be developed for Job Coaching services that show how the goals of this service will be achieved in 12 months. Additional authorizations of Job Coaching with no additional fading gains will require additional documentation of level of need for service.

Job Coaching may also be utilized when the beneficiary chooses self-employment. Activities such as assisting the beneficiary to identify potential business

opportunities, develop a business plan, as well as develop and launch a business are included. Waiver funds may not be used to defray expenses associated with starting or operating a business, such as capital expenses, advertising, hiring or training of empjoyees.

3. Extended Services: The expected outcome of extended services is sustained paid employment at or above minimum wage with associated benefits and the opportunity for advancement in a Job that meets the beneficiary's personal and career planning goals. Employment supports: Extended Services allows for the continued monitoring of employment outcomes through regular contact with the beneficiary and the employer. A minimum of one contact per quarter with the employer is required.

215.100 Supported Employment Exclusions

Supported employment requires related activities to be identified and included in outcomes with an accompanying work plan submitted as documentation of need for service.

Payment for employment services excludes:

A. Incentive payments made to an employer of waiver beneficiaries to encourage or subsidize an employer's participation in the program.

B. Payments that are passed through to waiver beneficiaries.

C. Payments for training that are not directly related to the waiver beneficiary's employment.

D. Reimbursement if the beneficiary is not able to perform the essential functions of the job. The functions of a job coach are to "coach," not to do the wori[LESS THAN] for the person.

E. CES waiver supported employment services when the same services are othenwise funded under the Rehabilitation Act of 1973 or Public Law 94-142. This means that such services must be exhausted before waiver-supported employment services can be approved or reimbursement can be claimed.

F. Services provided in a sheltered wori[LESS THAN]shop or other similar type of vocational service furnished in a specialized facility.

215.200 Documentation Requirements for Supported Employment

Supported employment providers must maintain documentation in each waiver beneficiary's file to demonstrate the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or Individual with Disabilities Education Act (20 U.S.C. 1401 et. seq).

Documentation must include proof from the funded provider where services were exhausted.

For Discovery Career Planning, the provider must create and maintain an individual Career Profile-Discovery Staging Record to demonstrate compliance and delivery of sen/ice.

For Employment Path Services, the provider must maintain the person-centered service plan, the beneficiary's progress notes, and the Arkansas Rehabilitation Services Referral to demonstrate compliance and delivery of service.

For Job Development Plan Services, the provider must maintain the Job Development Plan and beneficiary's remuneration statement.

For Extended Services, the provider must maintain the Arkansas Rehabilitation Services letter of closure, beneficiary's remuneration statement (paycheck stub) and beneficiary's worit schedule, if available, to demonstrate compliance with and delivery of this service.

See Section 202.200 for other InfonnaHon to be retained for beneficiary's file.

215.300 Benefit Limits for Supported Employment

Discovery/Career Planning: Allowed maximum is 50 hours per weel[LESS THAN] over a six-week period to complete the activities and create the Individual Career Profile. There is an outcome payment upon submission of the Profile and required documentation.

Employment Path: Allowed maximum is 25 hours per week alone or combined with Employment Supports in small group. Only twelve months of service may be authorized with one reauthorization allowed if the beneficiary is receiving Job Development Sen/ices that indicate he or she is actively seeking employment. A milestone payment is available if the beneficiary obtains individualized, competitive integrated employment or self-employment during the first 12-month authorization.

Employment Supports Job Development: This is outcome-based reimbursement, payable in stages to incentivize retention of the job. The total outcome payment is $3000.00. The payment schedule is as follows:

A. 60% at the end of the beneficiary's first pay period.

B. 25% when the beneficiary has completed four (4) weeks on the job.

C. 15% when the beneficiary has completed eight (8) weeks on the job.

Employment Supports-Job Coaching: Allowed maximum of 40 hours per week. Twelve months of services are authorized, and the provider must have a fading plan. The provider must document necessity of additional services to have additional services authorized without a fading pjaji:

Employment Supports-Extended Sen/ices: Allowed maximum of 20% of the beneficiary's weekly scheduled work hours.

See Section 260.000 for billing information.

216.000 Adaptive Equipment

The adaptive equipment sen/ice includes an item or a piece of equipment that is used to increase, maintain or improve functional capabilities of individuals to perform daily life tasks that would not be possible othenwise. The adaptive equipment service provides for the purchase, leasing, and as necessary, repair of adaptive, therapeutic and augmentative equipment that enables individuals to increase, maintain or improve their functional capacity to perfomn daily life tasks that would not be possible othenvise.

Adaptive equipment needs for supportive employment are included. This sen/ice may include specialized equipment such as devices, controls or appliances that will enable the person to perceive, to control or to communicate with the environment In which they live.

Adaptive equipment includes "enabling technology," that empowers the beneficiary to gain independence through customizable technologies to allow them to safely perform activities of daily living without assistance, while still providing for monitoring and response for those beneficiaries, as needed. Enabling technology must be shown to meet a goal of the beneficiary's person-centered sen/ice plan, ensure beneficiary's health and safety, and provide for adequate monitoring and response for beneficiary's needs. Before enabling technology will be provided, it must be documented that an assessment was conducted and a plan was created to show how the enabling technology will meet those requirements.

Equipment may only be covered if not available to the beneficiary from any other source. Professional consultation must be accessed to ensure that the equipment will meet the needs of the beneficiary when the purchase will at a minimum exceed $500.00. Consultation must be conducted by a medical professional as detemiined by the beneficiary's condition for which the

equipment is needed. All items must meet applicable standards of manufacture, design and installation.

All adaptive equipment must be solely for the waiver beneficiary. All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over $1,000.00 will require three bids with the lowest bid with comparable quality being awarded; however, DDS may require three bids for any requested purchase.

Computer equipment may be approved when it allows the beneficiary control of his or her environment, assists in gaining independence or when it can be demonstrated that it is necessary to protect the health and safety of the beneficiary. The waiver does not cover supplies. Printers may be approved for non-verbal beneficiaries.

Communication boards are allowable devices. Computers may be approved for communication when there is substantial documentation that a computer will meet the needs of the beneficiary more appropriately than a communication board.

Software will be approved only when required to operate the accessories included for environmental control or to provide text-to-speech capability.

Conditions: The care and maintenance of adaptive equipment, vehicle modifications, and personal emergency response systems are entrusted to the beneficiary or legally responsible person for whom the aids are purchased. Negligence (defined as failure to properiy care for or perfomn routine maintenance of) shall mean that the sen/ice will be denied for a minimum of two (2) plan years. Any abuse or unauthorized selling of aids by the beneficiary or legally responsible person shall mean the aids will not be replaced using waiver funding.

Exclusions:

A. Swimming pools (in-ground or above-ground) and hot tubs are not allowable as either an environmental modification or adaptive equipment.

B. Computer supplies.

C. Computer desk or other furniture items are not covered.

D. Medicaid-purchased equipment cannot be donated if the equipment being donated is needed by another waiver beneficiary residing In the residence.

216.100 Adaptive Equipment; Vehicle Modifications

Vehicle 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 pemianent modification cannot be used or considered as down payment for a vehicle.

Lifts that require vehicle modification and the modifications themselves 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 amount allowed.

Exclusions:

A. Adaptations or improvements to the vehicle that are of general utility and are not of direct medical or remedial benefit to the beneficiary

B. Purchase, down payment, monthly car payment, or lease cost of a vehicle;

C. Regularly scheduled upl[LESS THAN]eep and maintenance of a vehicle and the modification to the vehicle.

216.200 Adaptive Equipment; Personal Emergency Response System (PERS)

A PERS may be approved when it can be demonstrated as necessary to protect the health and safety of the beneficiary. A PERS is a stationary or portable electronic device that is used in the beneficiary's place of residence that allovre the beneficiary to secure help in an emergency. The system must be connected to a response center staffed by trained professionals who respond upon activation of the PERS. The beneficiary may also wear a portable "help" button to allow for mobility. PERS services are limited to beneficiaries who live alone or who are alone for significant parts of the day and have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. Included in this service are assessment, purchase, installation, testing, and monthly rental fees. A PERS shall include cost of installation and testing as well as monthly monitoring performed by the response center.

216.300 Benefit Limits for Adaptive Equipment

The maximum annual expenditure for adaptive equipment including vehicle modifications and PERS, and environmental modifications is $7,687.50 per person.

The maximum allowed can be increased upon showing a medical necessity, with the difference in the total required amount and the allowed maximum ($7,687.50) being deducted from the supportive living maximum allowance.

216.400 Required Documentation for Adaptive Equipment

When the adaptive equipment modification will be over $1,000.00. the provider must document that it obtained at least three bids, and that the lowest bid with comparable quality was awarded, DDS may require three bids for any requested purchase.

217.000 Environmental Modifications

Environmental modifications are made to or at the waiver beneficiary's home, required by the person-centered service plan and are necessary to ensure the health, welfare and safety of the beneficiary or that enable the beneficiary to function with greater independence and without which the beneficiary would require institutionalization.

Environmental modification may include the installation of ramps and grab-bars, widening of doonways, modification of bathroom facilities, installation of specialized electric and plumbing systems to accommodate medical equipment, installation of sidewalks or pads to accommodate ambulatory impairments, and home property fencing when medically necessary to assure non-elopement, wandering or straying of persons who have dementia, Alzheimer's disease or other causes of memory loss or confusion as to location, or decreased mental capacity or aberrant behaviors.

Expenses for the installation of the environmental modification and any repairs made necessary by the instaflfadon process are afcwabfe. Porfabfe or defachabfe moo'fWcafons thai can be relocated with the beneficiary and that have a written consent from the property owner or legal representative will be considered. Requests for modification must include an original photo of

the site where modifications will be done; to-scale sketch plans of the proposed modification project; identification of other specifications relative to materials, time for project completion and expected outcomes; labor and materials breakdown and assurance of compliance with any local building codes. Final inspection for the quality of the modification and compliance with specifications and local codes is the responsibility of the waiver case manager. Payment to the contractor is to be withheld until the work meets specifications including a signed customer satisfaction statement.

All services must be provided as directed by the beneficiary's person-centered service plan and in accordance with all applicable state or local building codes.

Environmental modifications must be made within the existing square footage of the residence and cannot add to the square footage of the building.

Modifications are considered and approved as single, all-encompassing projects and, as such, cannot be split whereby a part of the project Is submitted in one service plan year and another part submitted in the next service plan year. Any such activity is prohibited. All modifications must be completed within the plan-of-care year in which the modifications are approved.

All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over $1,000.00 will require three bids, with the lowest bid with comparable quality being awarded. However, DDS may require three bids for any requested modification.

Environmental modifications may only be funded through the waiver if not available to the beneficiary from any other source. If the beneficiary may receive environmental modifications through the Medicaid State Plan, a denial by Utilization Review will be required prior to approval for funding through the waiver.

217.100 Environmental Modifications Exclusions

Modifications or improvements made to or at the beneficiary's home which are of general utility and are not of direct medical or remedial benefit to the beneficiary (e.g., carpeting, roof repair, central air conditioning, etc.) are excluded as covered services. Also excluded are modifications or improvements that are of aesthetic value such as designer wallpaper, marble counter tops, ceramic tile, etc.

Outside fencing is limited to one fence per lifetime. Total perimeter fencing is excluded.

Expenses for remodeling or landscaping which are cosmetic, designed to hide the existence of the modification, or result from erosion are not allowable.

Environmental modifications that are permanent fixtures will not be approved for rental property without prior written authorization and a release of current or future liability by the residential property owner.

Environmental modifications may not be used to adapt living arrangements that are owned or leased by providers of waiver services.

Swimming pools (both in- and out-of-ground) and hot tubs (spas) are not allowable.

The moving of modifications, such as fencing or ceiling tracks and adaptive equipment that may be permanently affixed to the structure or outside premises, is not allowable.

217.200 Benefit Limits for Environmental Modifications

A beneficiary's annual expenditure for environmental modifications and adaptive equipment cannot exceed $7,687.50 per person.

218.000 Specialized Medical Supplies

A physician must order or document the need for all specialized medical equipment. All items must be included in the person-centered service plan. Specialized medical equipment and supplies include:

A. Items necessary for life support or to address physical conditions along with the ancillary supplies and equipment necessary for the proper functioning of such items.

B. Durable and non-durable medical equipment not available under the Arkansas Medicaid State Plan that is necessary to address beneficiary functional limitations.

C. Necessary medical supplies not available under the Arkansas Medicaid State Plan. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the state plan and exclude those items that are not of direct medical or remedial benefit to the beneficiary. All items shall meet applicable standards of manufacture, design and installation The most cost-effective item will be considered first

Additional supply items are covered as a waiver sen/ice when they are considered essential and medically necessary for home and community care. Covered items include:

A. Nutritional supplements

B. Non-prescription medications. Alternative medicines not Federal Drug Administration-approved are excluded from coverage.

C. Prescription drugs, minus the cost of drugs covered by Medicare Part D, when extended benefits are available under the Arkansas Medicaid State Plan.

When the items are included in Arkansas Medicaid State Plan services, a dental of extension of benefits by QMS Utilization Review will be required prior to approval for waiver funding by DDS.

218.100 Benefit Limits for Specialized Medical Supplies

The maximum annual allowance for specialized medical supplies, supplemental supports and community transition sen/ices is $3690.00.

When a non-prescription or prescription medication is necessary to maintain or avoid health deterioration, the $3,690.00 limit may be increased with the difference in the specialized medical supplies maximum allowance and the required amount deducted from the supportive living maximum daily allowance. All such requests must be prior approved by the DDS Assistant Director of Waiver Services.

See Section 260.000 for billing infomriation.

219.000 Supplemental Support Service

The supplemental support service helps improve or enable the continuance of community living-Supplemental support service will be based on demonstrated needs as identified in a beneficiary's person-centered service plan as unforeseen problems arise that, unless remedied, could cause disruptions in the beneficiary's services, placement, or place him or her at risk of Institutionalization. Waiver funds will be used as the payer of last resort,

219.100 Reserved

219.200 Supplemental Support Service Benefit Limits

This service can be accessed only as a last resort. Lacic of other available resources must be proven.

The maximum annual allowance for supplemental support, community transition services, and specialized medical supplies is $3,690.00.

220.000 Case Management Services

Case management services assist beneficiaries In gaining access to needed waiver services and other Arkansas Medicaid State Plan services, as well as medical, social, educational and other generic services, regardless of the funding source to which access is available.

Case management sen/ices include responsibility for guidance and support in all life activities. The intent of case management services is to enable waiver beneficiaries to receive a full range of appropriate services in a planned, coordinated, efficient and effective manner.

These activities include locating, coorclinating and assuring the Implementation of and monitoring:

A. All proposed waiver services

B. Other IVIedicaid state plan services

C. Needed medical, social, educational and other publically funded services, regardless of the funding source

D. Infomial community supports needed by beneficiaries and their families

Case management services consist of the following activities:

A. Arranging for the provision of services and additional supports

B. Monitoring and reviewing beneficiary services included in the person-centered sen/lce plan

C. Facilitating crisis intervention

D. Guidance and support to obtain generic services and supports

E. Case planning

F. Needs assessment and refferal for resources

G. Monitoring to assure quality of care and case reviews that focus on the beneficiary's progress in meeting goals and objectives established through the case plan

H. Providing assistance relative to obtaining waiver Medicaid eligibility and ICF/ID/DD level-of-care eligibility determinations

I. Assuring the integrity of all case management Medicaid waiver billing in that the sen/ice delivered must have prior authorization and meet required waiver sen/ice definitions and must be delivered before billing can occur

J. Assuring submission of timely (advance) and comprehensive behavior and/or assessment reports, continued person-centered service plans, revisions as needs change, and infomiation and documentation required for ICF/UD level of care and waiver Medicaid eligibility detemninations

K. Arranging for access to advocacy services as requested by tlie beneficiary

L. Monitoring and reviewing services to assure healtli and safety of the beneficiary

M. Upon receipt of DDS approvals or denials of requested services, ensuring that a copy is provided to the beneficiary or legal representative

N. Providing assistance with the appeals process when the appeal option is chosen by the beneficiary or legal representative

O. Planning meetings are scheduled by the case manager on behalf of the beneficiary, at a time and in a location that is convenient for the beneficiary or legal representative. The planning meeting will only include the case manager, the beneficiary or legal representative and other persons invited by the beneficiary.

Case Management will be provided up to a maximum of a 90-day transition period for all beneficiaries who seek to voluntarily withdraw from waiver services unless the beneficiary does not want to continue to receive the service. The transition period will allow for follow-up to ensure that the beneficiary is referred to other available services and to assure that the beneficiary's needs can be met through optional services It also sen/es to ensure that the person understands the effects and outcomes of withdrawal and to ascertain if the person was coerced or othen/vise was unduly influenced to withdraw. During this 90-day timeframe, the person remains enrolled in the waiver, the case remains open, and waiver services will continue to be available until the beneficiary finalizes their intent to withdraw.

The State of Arkansas adheres to CMS regulation as it relates to conflict-free case management. Case Management services may not include the provision of direct services to the beneficiary that are typically or othenwise covered as service under CES Waiver of Stale Plan. The organization may not provide case management services to any person to whom they provide any direct services without adhering to the following firewalls and protections:

A. The individual who performs the annual needs-based assessment may not be a provider of services on the person-centered service plan and may not provide direct care.

B. The beneficiary should be encouraged to advocate or have an advocate present during all planning meetings

C. Providers will administratively separate case management functions and staff and direct-care functions and staff

Case management services are available at two tiers of support. They are:

A. Tier 3: Requiring care 24 hours per day, seven (7) days per week; and

B. Tier 2: Requiring care of less than 24 hours per day, seven (7) days per week.

The minimum requirement for service contacts is one face-to-face contact per month:

Abeyance: It is sometimes necessary to place a case in abeyance to allow the case to remain open while the beneficiary is temporarily placed in a licensed or certified treatment program for the purpose of behavior, physical, or health treatment or stabilization. On a monthly basis, the case manager must conduct a monitoring contact and report the status to DDS.

See Section 260.000 for billing information.

220.100 Transitional Case Management

Case Management services may be available during the last 180 consecutive days of a Medicaid eligible person's institutional stay to allow case management activities to be perfonned related to transitioning the person to the community. The person must be approved and in the waiver program for case management to be billed.

220.200 Benefit Limits for Case Management

Tlie maximum reimbursement limit per beneficiary is $117,70 per month and $1,412.40 annually.

Abeyance will be approved in three-month increments when the beneficiary will be out of service for at least one morith. Abeyance cannot exceed one year.

Case management is provided only through the waiver to beneficiaries who are age 21 and over. All medically necessary case management services are provided to children under the age of 21 through the Medicaid State Plan EPSDT benefit

221.000 Consultation Services

Consultation sen/ices are clinical and therapeutic sen/ices that assist waiver beneficiaries, parents, guandians, legally responsible individuals, and service providers in carrying out the beneficiary's person-centered service plan.

A. Consultation activities may be provided by professionals who are licensed as:

1. Psychologists

2. Psychological examiners

3. Mastered social workers

4. Professional counselors

5. Speech pathologists

6. Occupational therapists

7. Physical therapists

8. Registered nurses

9. Certified parent educators or provider trainers

10. Certified communication and environmental control specialists

11. Dietitians

12. Rehabilitation counselors

13. Recreational therapists

14. Qualified Developmental Disabilities Professionals (QDDP)

15. Positive Behavioral Supports (PBS) Specialists

16. Behavior Analysts

These services are indirect In nature. The parent educator or provider trainer is authorized to provide the activities identified below in items 2,3,4, 5,7, and 13. The provider agency will be responsible for maintaining the necessary information to document staff qualifications. Staff who meet the certification criteria necessary for other consultation functions may also provide these activities. Selected staff or contract individuals may not provide training in other categories unless they possess the specific qualifications required to perfomn the other consultation activities. Use of this service for provider training cannot be used to supplant provider trainer responsibilities included in provider indirect costs.

B. Activities involved In consultation services include:

1. Providing updated psychological and adaptive behavior assessments

2. Screening, assessing and developing therapeutic treatment plans

3. Assisting in tlie design and integration of individual objectives as part of the overall individualized service planning process as applicable to the consultation specialty

4. Training of direct services staff or family members in canning out special community living services strategies identified in the person-centered sen/ice plan as applicable to the consultation specialty

5. Providing information and assistance to the individuals responsible for developing the beneficiary's person-centered service plan as applicable to the consultation specialty

6. Participating on the interdisciplinary team, when appropriate to the consultant's specialty

7. Consulting with and providing information and technical assistance with other sen/ice providers or with direct service staff and/or family members in canrying out a beneficiary's person-centered service plan specific to the consultant's specialty

8. Assisting direct services staff or family members in making necessary program adjustments in accordance with the beneficiary's person-centered sen/ice plan as applicable to the consultation specialty

9. Detemiinlng the appropriateness and selection of adaptive equipment to include communication devices, computers and software consistent with the consultant's specialty

10. Training and/or assisting beneficiaries, direct services staff or family members in the set-up and use of communication devices, computers and software consistent with the consultant's specialty

11. Screening, assessing and developing positive behavior support plans; assisting staff in implementation, monitoring, reassessment and modification of the positive behavior support plan consistent with the consultant's specialty

12. Training of direct services staff and/or family members by a professional consultant in:

a. Activities to maintain specific behavioral management programs applicable to the beneficiary

b. Activities to maintain speech pathology, occupational therapy or physical therapy program treatment modalities specific to the beneficiary

c. The provision of medical procedures not previously prescribed but now necessary to sustain the beneficiary in the community

13. Training or assisting by advocacy to beneficiaries and family members on how to self-advocate

14. Rehabilitation counseling for the purposes of supported employment supports that do not supplant the Federal Rehabilitation Act of 1973 and PL 94-142 and the supports provided through Arkansas Rehabilitation Services

15. Training and assisting beneficiaries, direct services staff or family members in proper nutrition and special dietary needs

221.100 Benefit Limits for Consultation Services

The maximum amount payable for consultation sen/ices, per person is $1,320.00 annually. It is reimbursable at no more than $136.40 per hour.

See Section 260.000 for billing information.

222.000 Crisis Intervention Services

Crisis intervention services are defined as sen/ices delivered in the beneficiary's place of residence or other local community site by a mobile inten/ention team or professional.

Intervention services must be available 24 hours a day, 365 days a year and must be targeted to provide technical assistance and training in the areas of behavior already identified. Services are limited to a geographic area conducive to rapid Inten/ention as defined by the provider responsible to deploy the team or professional. Services may be provided in a setting as determined by the nature of the crisis, i.e., residence where behavior is happening, neutral ground, local clinic or school setting, etc. The following criteria must be met:

A. The beneficiary is receiving waiver services.

B. The beneficiary needs non-physical inten/ention to maintain or re-establish behavior management or positive programming plan.

C. Intervention is on-site in the community.

The maximum rate of reimbursement for this service is $127.10 per hour, The annual maximum is $2,640.00.

Crisis intervention services are only provided as a waiver service to individuals who are age 21 and over. All medically necessary crisis inten/ention sen/ices for children under age 13 are covered as part of the Medicaid State Plan EPSDT benefit.

See Section 260.000 for billing infonnation.

223.000 Community Transition Services

Community transition services are non-recurring set-up expenses for beneficiaries who are transitioning from an institutional or another provider-operated living arrangement to a living arrangement in a private residence where the beneficiary or his or her guardian is directly responsible for his or her own living expenses. Waiver funds can be accessed once it has been detemnined that the waiver is the payer of last resort.

Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:

A. Security deposits that are required to obtain a lease on an apartment or home

B. Essential household furnishings and moving expense required to occupy and use a community domicile, including fumiture, window coverings, food preparation items, and bed/bath linens

C. Set-up fees or deposits for utility or service access, including telephone, electricity, heating and water

D. Services necessary for the beneficiary's health and safety such as pest eradication and one-time cleaning prior to occupancy

E. Moving expenses

Community transition sen/ices are furnished only to the extent that they are reasonable and necessary as determined through the person-centered service plan development process, cleariy identified in the person-centered sen/ice plan and the person Is unable to meet such expense or when the services cannot be obtained from other sources.

Duplication of environmental modifications will be prevented through DDS control of prior authorizations for approvals.

Costs for community transition sen/ices furnished to beneficiaries returning to the community from a Medicaid institutional setting through entrance to the waiver are considered to be incurred and billable when the person is determined to be eligible for the waiver services. The beneficiary must be reasonably expected to be eligible for and to enroll in the waiver. If for any unseen

reason the beneficiary does not enroll in the waiver (e.g., due to death or a significant change in condition), transitional services may be billed to Medicaid.

Exclusions: Community transition services may not include payment for room and board, monthly rental or mortgage expense, food, regular utility charges, and/or household appliances or items that are intended for purely diversional or recreational purposes. Community transition services may not be used to pay for furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and sen/ices are inherent to the service they are already providing.

Diversionary or recreational items such as televisions, cable TV access, VCRs or DVD players are not allowable.

223.100 Benefit Limits for Community Transition Services

The maximum annual allowance for supplemental support, community transition services, and specialized medical supplies is $3,690.00.

See Section 260.000 for billing Infomnation.

230.000 ELIGIBILITY ASSESSMENT

The intake and assessment process for the DDS CES Waiver Program includes:

A. Determination of categorical eligibility

B. Institutional level-of-care detemiination

C. Comprehensive diagnosis and evaluation, including an independent assessment for functional need

D. Development of a person-centered service plan

E. Cost comparison to determine cost-effectiveness

F. Notification of a choice between home and community-based services and institutional services.

230.100 Categorical Eligibility Determination

Current eligibility for the Aritansas Medicaid Program must be verified as part of the intake and assessment process for admission into the CES Waiver Program. Medicaid eligibility is detennined by the Division of Developmental Disabilities Services or by the Social Security Administration for SSI Medicaid eligibles.

Failure to obtain any required eligibility determination, whether initial or subsequent (time-bound) reassessments, will result in the beneficiary's case being closed. Once closure has occurred, and the appeals processes are exhausted, the affected person will have to make a new request for services through the waiver program intake process.

For supportive living arrangements, the Medicaid eligibility date is retroactive to the date the Medicaid application is received at the DDS Medicaid Unit or no more than three (3) months prior to the receipt of the Medicaid application, whichever is less.

230.200 Level of Care Determination

Based on intellectual and behavioral assessment submitted by the provider, the ICF/ID/DD level of care detemiination is performed by the Division of Developmental Disabilities. The ICF/ID/DD level of care criteria provides an objective and consistent method for evaluating the need for

institutional placement in the absence of community alternatives. The level of care determination must be completed and the beneficiary determined to

A. Require the level of care provided in an ICF/ID/DD.

B. Need institutionalization in an ICF/ID/DD in the near future (in a month or less) but for the provision of waiver services.

Recertification, based on intellectual and behavioral assessments submitted by the provider at appropriate age milestones, will be performed by DDS to determine the beneficiary's continuing need for an ICF/ID/DD level of care.

The annual level of care determination is made by a QDDP.

230.210 Tiers of Support

Coverage is provided within two tiers of support, The two tiers are as follows:

Tier 3: Institutional level of care

Tier 2: Institutional level of care less than 24/7

Tiers will be determined through an independent assessment conducted by a third-party vendor that will assess the participant in the following areas:

1. Individual areas. Including

a. [GREATER THAN] Medical history, current medical conditions, or conditions observed by the assessor or self-reported by the beneficiary

b. Behavioral

c. Home living activities

d. Community activities

e. Employment

f. Health and safety assessment

g. Social functioning

2. Caregiver (natural supports) areas, including

a. Physical/behavioral (health)

b. Involvement

c. Social resources

d. Family stress

e. Safety

3. Cunrent Risk Assessment Review, including

a. Safety Plan, if available

b. Behavior Plan

c. Physical Plan

d. Medical Plan

The independent assessment must be used in conjunction with the appiication pacltets and other applicable functional assessments to create the persoji-centered service plan.

230.300 Comprehensive Diagnosis and Evaluation

A comprehensive diagnosis and evaluation (D&E) must be administered in order to determine that applicants are persons with a developmental disability and meet institutional level of care prior to receiving CES waiver services from DDS.

The comprehensive diagnosis and evaluation includes a series of examinations and obsen/ations performed or validated and approved by professionals leading to conclusions and findings.

The examinations and/or assessments include, but are not limited to:

A. A thorough medical examination and other evaluations deemed necessary by the physician

B. A psychological assessment

C. A social history/sociological examination

D. An educational assessment, if applicable

E. An appraisal of adaptive behavior

F. All other examinations, assessments and evaluations necessary to describe the beneficiary's needs

G. Areas of Need form

Failure to submit the reassessments in advance of eligibility expiration date will result in the denial of case management reimbursement for the period the determination is overdue. Failure to obtain any required eligibility determination, whether Initial or subsequent time-bound reassessments, may result in the beneficiary's case being closed.

When a beneficiary's case has been closed, the affected person must make a new request for services through the waiver program intake process in order for services to continue. This will be considered a new application to the waiver program.

230.400 Person-Centered Service Plan

During the initial sixty (60) days of DDS CES waiver services, a beneficiary receives services based on a DDS pre-approved initial person-centered sen/ice plan that provides for case management at the prevailing rate, up to sixty (60) days; and supportive living services for direct-care supervision up to sixty (60) days. It may include transitional funding when the person is transitioning from an institution to the community. Persons residing In a Medicaid-reimbursed facility may receive case management the last 180 consecutive days of the institutional stay.

NOTE: The fully-developed person-centered service plan may be submitted, approved and implemented prior to the expiration of the initial person-centered service plan. The initial plan period is simply the maximum time frame for developing, submitting, obtaining approval from DDS and implementing the person-centered service plan. An extension may be granted when there is supporting documentation justifying the delay.

Prior to expiration of ttie interim sen/ice plan, eacti beneficiary eligible for CES waiver services must have an individualized, specific, written person-centered service plan developed by a multi-agency team and approved by the DDS authority. The members of the team will determine services to be provided, frequency of service provision, number of units of service and cost for those services while ensuring that the beneficiary's desired outcomes, needs and preferences are addressed. Team members and a physician, via the DDS 703 form, certify the beneficiary's condition (level of care) and appropriateness of services initially and at the annual continued-stay review. The person-centered service plan development is conducted once every 12 months in accordance with the continued-stay review date or as changes in the beneficiary's condition require a revision to the person-centered service plan.

The person-centered service plan must be designed with consideration given to the independent assessment results and to assure that services provided will be:

A. specific to the beneficiary's unique circumstances and potential for personal growth.

B. Provided in the least restrictive environment possible.

C. Developed within a process assuring participation of those concerned with the beneficiary's welfare. Participants of the multi-agency team included the beneficiary's chosen case manager, the beneficiary or legal representative and additional persons whom the beneficiary chooses to invite to the planning meeting, as long as all rules pertaining to confidenUality and conflict of interest are met. If invited, the DDS Waiver Specialist attends the planning meetings randomly, in an effort to assure an annual 10% attendance ratio. Mandatory attendance by the case manager is required to ensure the written person-centered service plan meets the requirements of regulations, the desires of the beneficiary or legal representative, is submitted timely, and is approved by DDS prior to service delivery.

D. Monitored and adjusted to reflect changes in the beneficiary's needs. A person-centered sen/ice plan revision may be requested at any time the beneficiary's needs change.

E. Provided within a system that safeguards the beneficiary's rights.

F. Documented carefully, with assurance that appropriate records will be maintained.

G. Will assure the beneficiary's and others' health and safety. The person-centered service plan development process identifies risks and makes sure that they are addressed through backup plans and risk management agreements, including how and who will be responsible for ongoing monitoring of risk level and risk management strategies, and how staff will be trained regarding those risks. A complete description of backup arrangements must be included in the person-centered service plan. All strategies must be designed to respect the needs and preferences of the beneficiary. All risk management strategies must be analyzed by the team at least quarteriy as part of the PCSP review.

H. Consider cost-efficient options that foster independence, such as shared staffing and other adaptions. When such options are not utilized in the PCSP for a Tier 3 participant, it must be documented that the participant's health and safety require one-on-one staffing, 24 hours a day.

230.410 Person-Centered Service Plan Required Documentation

A. General Infonnation

Identification infonnation must include:

1. Beneficiary's full name and address

2. Beneficiary's Medicaid number

3. Guardian or Power of Attorney with an address (when applicable)

4. Number of individuals with MR/DD residing in home of waiver beneficiary and type of residence

5. Physician Level of Care Certification

6. Names, titles and signatures of the multi-agency team members responsible for the development of the beneficiary's person-centered service plan

7. Results of the independent assessment and any other functional assessments used to develop the person-centered service plan

B. Budget Sheet, Worksheets and Provider Information Information must include:

1. Identification of the type of waiver services to be provided

2. Name of the provider delivering the service

3. Total amount by service

4. Total plan amount authorized

5. Beginning and ending date for each service

6. Supported Living Array worksheet listing units and total cost by sen/ice and level of support

7. Adaptive Equipment, Environmental Modifications, Specialized Medical Supplies, Supplemental Support, and Community Transition worksheets listing units and total cost by service

8. Provider Infonmation sheet showing case management provider, case manager, supportive living provider, and direct care supen/isor

C. Narrative justification for the revision to the initial plan of care must, at a minimum, justify the need for requested sen/ices. Nanative justification for annual continued-stay reviews must address utilization of sen/ices used or unused within the past year, justify new services requested and address risk assessment.

D. The person-centered service plan must include:

1. I dentification of i ndivid ua I objectives

2. Frequency of review of the objectives

3. List of medical and other services, including waiver and non-waiver sen/ices necessary to obtain expected objectives

4. Expected outcomes including any sen/ice barriers

E. Product and service cost-effectiveness certification statement, with supporting documentation certifying that products, goods and services to be purchased meet applicable codes and standards and are cost-competitive for comparable quality.

240.000 PRIOR AUTHORIZATION

CES waiver services require prior authorization by the Division of Developmental Disabilities Services. In the absence of prior authorization, reimbursement will be denied and will not be approved retroactively.

241.000 Approval Authority

For the purpose of person-centered service plan approvals, DDS is the Medicaid authority.

A. The DDS prior authorization process requires that all pervasive level-of-support service plans, problematic service plans, or plans not clearly based on documented need must have approval by DDS Plan of Care Review Team.

1. Problematic is based on individual circumstances, a change in condition, or a new service request as determined by the DDS Waiver Specialist or by request of the case manager.

2. The DDS Plan of Care Review Team consists of the DDS Waiver Program director or designee, DDS Waiver Area Managers, DDS Psychology Team member and other expert professionals such as nurses, physicians or therapists. The DDS Waiver Specialist is responsible for presenting the case to the team. The waiver participant or legal representative is permitted to attend the meeting and present supporting evidence why the services requested should be approved, as long as all rules pertaining to confidentiality and conflict of interest are met.

3. The DDS Waiver Specialist must conduct an In-home visit for all Tier 3 service plans and may conduct an in-home visit for problematic service plans or plans that are not based on documented need. Failure of the beneficiary or legal representative to permit DDS from conducting the in-home visit may result In the denial of service request and may result in case closure.

B. Tier 2 service plans will be subject to a local-level approval process.

C. All waiver services must be needed to prevent institutionalization.

D. All beneficiaries receiving medications must also receive appropriate support in the management of medlcallon(s). The use of psychotropic medications for behavior will require the development, implementation and monitoring of a written positive behavior plan.

E. Service requests that will supplant Department of Education responsibilities WILL NOT be approved. This includes voluntary decisions to withdraw from, or never enter, the Department of Education public school system. The waiver does not provide educational services, including educational materials, equipment, supplies or aids.

F. All person-centered service plans are subject to review by a qualified physician and random audit scrutiny by DDS Specialists, DDS Area Managers, DDS Licensure staffer DMS Quality Assurance staff. In addition, the following activities will occur:

1. Review of provider standards and actions that provide for the assurance of a beneficiary's health and welfare

2. Monitoring of compliance with standards for any state licensure or certification requirement for persons furnishing services provided under this waiver

3. Assurance that the requirements are met on the date that the service is furnished

4. Quality assurance reviews by DDS staff include announced and unannounced quarteriy on-site home visits.

5. Random review equal to a percent as prescribed by DDS Licensure Unit's certification policy.

G. All service requests are subject to review by DDS and may necessitate the gathering and submission of additional justification, infonnation and clarification before prior approval is made. In this event, It is the primary responsibility of the case management provider, with cooperation from the procurement source, to satisfy the request(s) within the prescribed time frames.

H. It is the responsibility of the case management services provider with cooperation from the direct services providers to ensure that all requests for sen/ices are submitted in a timely

manner to allow for DDS prior authorization activities prior to the expiration of existing plans or expected implementation of revisions.

I. Initially, a beneficiary receives up to sixty (60) days of DDS CES waiver services based on a DDS pre-approved interim service plan. The pre-approved interim plan will include case management and supportive living service for direct care supervision and may include community transition services when the person is transitioning from an institution to the community. For transitional case management, the sixty (60)-day interim plan begins with the date of discharge.

1. At any time during the initial sixty (60) days or transitional case management period, the case manager will complete the planning process and submit a detailed person-centered sen/ice plan that identifies all needed, medically necessary services for the remainder of the plan of care year. Once approval is obtained, these services may be implemented.

2. Wafver services wfrt not be refmbursed for any date of servtce that occurs prior to the date the beneficiary's person-centered service plan is approved, the date the beneficiary Is determined to be ICF/IID-eligible, or the date the beneficiary is deemed Medicaid waiver-eligible, whichever date is last.

3. All changes of service or tier revisions must have prior authorization. Services that are not prior authorized will not be reimbursed.

J. Emergency approvals may be obtained via telephone, facsimile or e-mail, with retroactive reimbursement pennitted as long as the notice of emerxjency, with request for service change, is received by DDS within 24 hours from the time the emergency situation was known. All electronically transmitted requests for emergency services must be followed with written notification and requests must be supported with documented proof of emergency. Failure to properly document proof of emergency shall result in approval being rescinded.

251.000 Method of Reimbursement

The reimbursement rates for DDS CES waiver sen/ices will be according to the lesser of the billed amount or the Title XIX (Medicaid) maximum for each procedure.

The maximum supportive living daily rate is inclusive of administration costs that cannot in any event exceed 20% of the total supportive living array for a beneficiary.

If fringe benefits exceed 25%, documentation must be submitted with a person-centered service plan and budget request. Fringe benefits cannot exceed 32%.

The administration and fringe costs are subject to audit and must be documented to support the rate charged.

261.000 Introduction to Billing

DDS CES waiver providers use the CMS-1500 claim fonn to bill the Ari[LESS THAN]ansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim should contain charges for only one tieneficiary.

Section III of this manual contains infonmation about Provider Electronic Solutions (PES) and other available options for electronic claim submission.

262.000 DDS CES Waiver Procedure Codes

The following procedure codes and any associated modifier(s) must be billed for DDS CES Waiver Services. Prior authorization is required for all services.

Procedure Code	Ml	M2	PA	Description	Unit of Service	National POS Codes
H2016	Y	Supportive Living	1 Day	12,99, 14
H2023	Y	Supported Employment	15 Minutes	99
S5151	Y	Respite Services	1 Day	12, 99, 14,54
T2020	UA	Y	Supplemental Support Services	1 Package	12, 99, 14
T2022	Y	Case Management Services	1 Month	12, 99, 14
T2025	Y	Consultation Services	1 Hour	12,99, 14
T2028	Y	Specialized Medical Equipment	1 Package	12, 99,14
T2020	UA	U1	Y	Community Transition Services	1 Package	99,14, 54
T2022	U2	Y	Transitional Case Management	1 Month	99,14, 54
T2034	U1	UA	Y	Crisis Intervention Services	1 Hour	99,12
K0108	Y	CES environmental modifications	1 Package	12
S5160	Y	Adaptive equipment, personal emergency response system (PERS), installation and testing,	1 Package	12,14
S5161	Y	Adaptive equipment, personal emergency response system (PERS), service fee, per month, excludes installation and testing	1 Package	12,14
S5162	Y	Adaptive equipment, personal emergency response system (PERS), purchase only	1 Package	12, 14
S5165	U1	Y	CES adaptive equipment, per service	1 Package	12.14

262.210 Completion of CMS-1500 Claim Form

Field Name and Number	Instructions for Completion
1. (type of coverage)	Not required.
la. INSURED'S I.D. NUMBER (For Program in Item 1)	Beneficiary's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number
2. PATIENTS NAME (Last Name, First Name, Middle Initial)	Beneficiary's last name and first name.
3. PATIENT'S BIRTH DATE SEX	Beneficiary's date of birth as given on the Medicaid or ARKids FIrst-A or ARKids First-B identification card. Fonnat: 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 complete mailing address (street address or post office box). Name of the city in which the beneficiary resides. Two-letter postal code for the state in which the beneficiary resides. Five-digit zip code; nine digits for post office box. The beneficiary's telephone number or the number of a reliable message/contacl/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 d. INSURANCE PLAN NAME OR PROGRAM NAME	If patient has other Insurance coverage as indicated in Field lid, the other insured's last name, first name, and middle initial. Policy and/or group number of the insured beneficiary. Reserved for NUCC use. Not required. Reserved for NUCC use. 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 sen/ices. Check YES or NO. If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. Required virtien an accident other than automobile is related to the services. Check YES or NO. The "Claim Codes" identify additional infomiation 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.ora under Code Sets.
11. INSURED'S POLICY GROUP OR FECA NUMBER a. INSURED'S DATE OF BIRTH SEX b. OTHER CLAIM ID NUMBER c. INSURANCE PUN 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. PATIENTS 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 ftjmished 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 Menstmal 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 infomriation 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 DDS Community and Employment Supports (CES) Waiver services. If sen/ices 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 refenring 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 inpatient hospitalization, enter the beneficiary's admission and discharge dates. Fomiat: MM/DD/YY.
19. ADDITIONAL CLAIM INFORMATION	Identifies additional information about the beneficiary's condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.ora for 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" for ICD-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 Intemational 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 othenvise 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. Fornnat: MM/DDAT. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider fumished equal amounts of the service on each day of the date sequence. Two-digit national standard place of service code. See Section 262.100 for codes. Enter "Y" for "Yes" or leave blank if "No." EMG identifies if the service was an emergency. Enter the correct CPT or HCPCS procedure code from Section 262.000. Modifier(s) if applicable.
E. DIAGNOSIS POINTER F. $ CHARGES G. DAYS OR UNITS H. EPSDT/Famlly Plan I. 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 perfonmed 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 servlce(s) was performed. The full charge for the service(s) totaled In the detail. This charge must be the usual charge to any beneficiary of the provider's services. The units (In whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. Not required. The 9-digit Arkansas Medicaid provider ID number of the Individual who fumished 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 O.	Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN."
27. ACCEPT ASSIGNMENT?	Not required. Assignment is automatically accepted by the provider when billing Medicaid.
28. TOTAL CHARGE	Total of Column 24F-the sum all charges on the claim.
29. AMOUNT PAID	Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. Do not include in this total the automatically deducted Medicaid co-payments.
30. RESERVED	Reserved for NUCC use.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS	The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.
32. SERVICE FACILITY LOCATION INFORMATION 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.

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Arkansas Administrative CodeAgency 016 - DEPARTMENT OF HUMAN SERVICESDivision 05 - Developmental Disabilities ServicesRule 016.05.17-005 - DDS Community and Employment Supports (CES) Waiver and Medicaid Provider Manual #2-17

Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 05 - Developmental Disabilities Services
Rule 016.05.17-005 - DDS Community and Employment Supports (CES) Waiver and Medicaid Provider Manual #2-17