Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-012 - Transportation Provider Manual Update Transmittal #67

93041*

A0380

A0382

A0390

A0398

A0422

A0426

A0427

A0429

J0150*

J1940

J2270*

J3490*

J0152*

J0170*

J0280*

J0460*

J1094*

J1100*

J1160*

J1200*

J2060*

J2175*

J2310*

J2550*

J2560*

J3360*

J3410*

J3475*

J3480*

Q4076*

Procedure Code

Required Modifier

Description

A0436

Emergency, per mile, loaded, helicopter air ambulance

A0422

U1

Emergency, oxygen, helicopter air ambulance

A0431

Ambulance service, emergency, basic pick-up, helicopter, one unit per day

A0428

Ambulance service, ILS intermediate transport, mileage and disposable supplies billed separately

A0380

TF

ILS mileage (per mile)

T2002**

Non-emergency ground ambulance transportation, hospital to nursing facility

A0435

U1 UB U2 UB U3 UB U4 UB U5 UB U6 UB

Piston propelled fixed air ambulance per mile Turboprop fixed wing air ambulance per mile Jet (fixed wing) one unit equals one mile Piston propelled fixed wing air ambulance per hour Turboprop fixed wing air ambulance per hour Jet (fixed wing) one unit equals one hour

A0434

Air Ventilator/Respiratory Therapist, one unit equals one hour

Field Name and Number

Instructions for Completion

1. Type of Coverage 1a. Insured's I.D. Number

This field is not required for Medicaid.

Enter the patient's 10-digit Medicaid identification number.

2. Patient's Name

Enter the patient's last name and first name.

3. Patient's Birth Date Sex

Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card.

Check "M" for male or "F" for female.

4. Insured's Name

Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial.

5. Patient's Address

Optional entry. Enter the patient's full mailing address, including street number and name, (post office box or RFD), city name, state name and ZIP code.

6. Patient Relationship to Insured

Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim.

7. Insured's Address

Required if insured's address is different from the patient's address.

8. Patient Status

This field is not required for Medicaid.

9. Other Insured's Name a. Other Insured's Policy or Group Number b. Other Insured's Date of Birth

Sex

If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial.

Enter the policy or group number of the other insured. This field is not required for Medicaid. This field is not required for Medicaid.

c. Employer's Name or School Name

Enter the employer's name or school name.

d. Insurance Plan Name or Program Name

Enter the name of the insurance company.

10. Is Patient's Condition Related to:

a. Employment

Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO."

b. Auto Accident

Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter State postal abbreviation) where the accident took place. Check "NO" if not auto accident related.

c. Other Accident

Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related.

10d. Reserved for Local Use

This field is not required for Medicaid.

11. Insured's Policy Group or FECA Number

Enter the insured's policy group or FECA number.

a. Insured's Date of Birth

This field is not required for Medicaid.

Sex

This field is not required for Medicaid.

b. Employer's Name or School Name

Enter the insured's employer's name or school name.

c. Insurance Plan Name or Program Name

Enter the name of the insurance company.

d. Is There Another Health Benefit Plan?

Check the appropriate box indicating whether there is another health benefit plan.

12. Patient's or Authorized Person's Signature

This field is not required for Medicaid.

13. Insured's or Authorized Person's Signature

This field is not required for Medicaid.

14. Date of Current: Illness

Required only if medical care being billed is related to an accident. Enter the date of the accident.

Injury Pregnancy

15. If Patient Has Had Same or Similar Illness, Give First Date

This field is not required for Medicaid.

16. Dates Patient Unable to Work in Current Occupation

This field is not required for Medicaid.

17. Name of Referring Physician or Other Source

Primary Care Physician (PCP) referral is not required for Ambulance Transportation services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.

17a. I.D. Number of Referring Physician

Enter the 9-digit Medicaid provider number of the referring physician.

18. Hospitalization Dates Related to Current Services

For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format.

19. Reserved for Local Use

Not applicable to Ambulance Transportation Services.

20. Outside Lab?

Not applicable to Ambulance Transportation Services.

21. Diagnosis or Nature of Illness or Injury

Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with HCFA diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service.

22. Medicaid Resubmission Code

Reserved for future use.

Original Ref No.

Reserved for future use.

23. Prior Authorization Number

Enter the prior authorization number, for ground ambulance service to facilities outside the 50-mile radius in states bordering Arkansas.

24. A. Dates of Service

Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service.

1. On a single claim detail (one charge on one line), bill only for services within a single calendar month.

2. Providers may bill, on the same claim detail, for two (2) or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the span.

B. Place of Service

Enter the appropriate place of service code. See Section 252.200 for codes.

C. Type of Service

Enter the appropriate type of service code. See Section 252.200 for codes.

D. Procedures, Services or Supplies

CPT/HCPCS

Enter the correct CPT or HCPCS procedure code.

Modifier

Enter the applicable modifier

E. Diagnosis Code

Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM.

F. $ Charges

Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed.

G. Days or Units

Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A.

H. EPSDT/Family Plan

Not applicable to Ambulance Transportation Services.

I. EMG

Emergency - This field is not required for Medicaid.

J. COB

Coordination of Benefit - This field is not required for Medicaid.

K. Reserved for Local Use

Not applicable to Ambulance Transportation Services.

25. Federal Tax I.D. Number

This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.

26. Patient's Account No.

This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted.

27. Accept Assignment

This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid.

28. Total Charge

Enter the total of Column 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.)

29. Amount Paid

Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. (See NOTE below Field 30.)

30. Balance Due

Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge.

NOTE: For Fields 28, 29 and 30, up to 26 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due.

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. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)

If other than home or office, enter the name and address, specifying the street, city, state and ZIP code of the facility where services were performed.

33. Physician's/Supplier's Billing Name, Address, ZIP Code & Phone #

PIN #

GRP #

Enter the billing provider's name and complete address. Telephone number is requested but not required.

This field is not required for Medicaid.

Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K.

Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#."