Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-100 - Section I Provider Manual Update Transmittal

The manuals are organized as follows:

Provider manuals are updated when necessitated by changes in federal or state laws, changes in interpretations of the law, changes in federal regulations, changes in DMS policy and procedures and when clarifications are warranted. These changes are released to the provider in the form of a manual update, an official notice or a remittance advice (RA) message.

As changes are made, the changed sections are dated with the revision date of the change. The provider manuals on the Arkansas Medicaid Provider Reference CD, updated and issued twice a year, display the issue date in the footer on the left. Official notices and RAs issued during the previous quarter are also incorporated into this CD. This will enable the user to ensure that the latest version is being used. Since paper copies may be printed from the CD, the date will appear in the footer of printed copies.

Provider manual changes are made automatically on the Arkansas Medicaid Web site; providers are notified via e-mail or paper when an applicable manual update, official notice or RA is issued. Providers must supply an e-mail address to receive e-mail notification of any supplementary material.

Providers who receive paper copies of manual updates, official notices and RAs must maintain the paper supplements as they are received. Only the revised section(s) are issued in manual updates.

Policy and procedure changes are highlighted in the electronic media (Web site and CD) and are shaded in the paper manuals to aid the provider in quickly reviewing changes; minor wording changes are not highlighted. The highlighting feature is provided as a convenience to providers.

An update transmittal letter accompanies each manual update. Manual updates are assigned sequential identification numbers, e.g., Update Transmittal #1. The transmittal letter identifies the new sections being added and/or the sections being replaced or deleted, explains what is being changed and provides any other information about the update. Manual updates are recorded on the update log located in Appendix A of the manual.

For persons maintaining a printed copy of a manual, the updated manual sections should be manually filed in the provider manual, and the outdated sections should be crossed out or removed, as appropriate. The effective date should be entered on the update log opposite the appropriate update number. Transmittal letters should be filed immediately following the update log in descending numerical order by update number. Immediately following the transmittal letters should be the official notices, which are numbered sequentially and should be filed with the most recent first. The RAs will follow the official notices, with the most recent filed first.

The fiscal agent, EDS, will issue changes as directed by the Division of Medical Services (DMS).

All provider manuals, manual updates, official notices and RAs are available for downloading, without charge, from the Arkansas Medicaid Web site (http://www.medicaid.state.ar.us/).

Prior to enrollment, providers will be asked if they have Internet access. Those who do not have Internet access will choose if they want to receive their manual by CD or on paper.

At that time, providers choosing to use the CD will receive a copy of the Arkansas Medicaid Provider Reference CD and will receive the CD without charge. The providers using the CD will be asked if they want to receive manual updates, official notices and RAs pertaining to their program through e-mail notification or mailed paper copies. E-mail notifications contain a link to the Arkansas Medicaid Web site; therefore, Internet access is required for e-mail notifications.

Providers choosing a paper copy of their provider manual will be issued a paper copy without charge. These providers will receive paper copies of all manual updates, official notices and RAs that pertain to their program through the mail.

Persons, entities and organizations that are not enrolled providers may purchase a copy of the Arkansas Medicaid Provider Reference CD or a paper copy of a provider manual through EDS.

Enrolled providers may purchase extra copies of the Arkansas Medicaid Provider Reference CD or extra paper copies of a manual through EDS. See information below regarding purchasing copies.

The Medicaid Program is a joint federal-state program that provides necessary medical services to eligible persons who would not be able to pay for such services.

In Arkansas, the Division of Medical Services (DMS) administers the program. Within the Division, the Office of Long Term Care (OLTC) is responsible for nursing home policy and procedures.

The Alternatives for Adults with Physical Disabilities (APD) waiver has been designed for disabled individuals age 21 through 64 who receive Supplemental Security Income (SSI) or are Medicaid eligible by virtue of their disability and who, without the provision of the services, would require a nursing facility level of care.

APD eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.

The services offered through the waiver are:

ARKids First-B was designed to integrate uninsured children age 18 and under into the health care system. ARKids First-B benefits are comparable to those of the state employees/teachers insurance program. Most services require cost sharing.

The following is a summary of the eligibility criteria for ARKids First-B:

In ConnectCare, a Medicaid beneficiary selects and enrolls with a primary care physician (PCP) that has contracted with DMS to be responsible for managing the health care of a limited number (a number chosen by the PCP, between 10 and 1000) of Medicaid beneficiaries.

A PCP contracts with DMS to provide primary care, health education and case management for a self-limited number of Medicaid enrollees. DMS pays the PCP a monthly per-enrollee case management fee in addition to the regular Medicaid fee-for-service reimbursement.

The PCP is responsible for referring enrollees to specialists and other providers, which includes the responsibility for deciding whether a particular referral is medically necessary. A PCP may make such decisions in consultation with physicians or other professionals as needed and in accordance with his or her medical training and experience; however, a PCP is not required to make any referral simply because it is requested.

A PCP coordinates his or her enrollees' medical and rehabilitative services with the providers of those services. Medical and rehabilitative professionals to whom a PCP refers a patient are required to report to or consult with the PCP so that the PCP can coordinate care and monitor an enrollee's status, progress and outcomes.

Most Medicaid-eligible individuals, as well as children participating in ARKids First-B, must enroll with a PCP in order to receive Medicaid-covered or ARKids First-B services. Some individuals are not required to enroll with a PCP. A few services are covered for all Medicaid and ARKids First-B eligibles without PCP referral. See Sections 170.000 through 183.000 for details regarding ConnectCare.

The Developmental Disability Services Alternative Community Services (DDS ACS) Waiver is designed for individuals who, without the services, would require institutionalization and could not otherwise reside in the community. Participants must not be residents of a hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).

DDS ACS eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, a cost comparison to determine the cost-

effectiveness of the plan of care and notification of a choice between home and community-based services and institutional services.

Services supplied through this program are:

ElderChoices is designed for individuals age 65 and over, who, without the services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain Medicaid-eligible individuals at home in order to preclude or postpone institutionalization.

The Division of Aging and Adult Services (DAAS) and the Division of Medical Services (DMS) jointly administer Independent Choices, a Section 1115 demonstration project. Participants in this project choose to forego traditional personal care services furnished by a Medicaid-enrolled agency in exchange for the right to direct their own care (consumer direction). Individuals that choose Independent Choices accept the risks, rights and responsibilities that consumer direction involves.

A participant may hire one or more assistants, employing whomever he or she wishes except his or her spouse or a person to whom a court of law has granted legal responsibility for the participant ("a guardian of the person"). Medicaid provides each participant with a cash allowance that the participant uses to meet his or her personal care needs. Participants pay their assistants from their cash allowance. Additionally, the participants may use cash allowance funds for certain other purchases when those purchases are included in their individualized cash expenditure plan.

Independent Choices includes individualized counseling and fiscal agent services provided by counseling fiscal agencies (CFA) that contract with Medicaid for those purposes. Each participant has a designated CFA. A CFA is responsible for educating each of its assigned Independent Choices participants in consumer direction. CFAs are also required to help participants develop and maintain an individualized cash expenditure plan and to provide participants with bookkeeping services related to cash allowance receipts and disbursements.

More detailed information may be found in the Independent Choices Manual.

Living Choices Assisted Living is a home and community-based services waiver that is administered jointly by the Division of Aging and Adult Services (DAAS) and the Division of Medical Services (DMS). Qualifying individuals are persons aged 21 and older who are blind, elderly or disabled and who have been determined by Medicaid to be eligible for an intermediate level of care in a nursing facility.

Parti cipants in Living Choices must reside in Level II assisted living facilities (ALFs), in apartment-style living units. The assisted living environment encourages and protects individuality, privacy, dignity and independence. Each Living Choices participant receives personal, health and social services in accordance with an individualized plan of care developed and maintained in cooperation with a DAAS-employed registered nurse. A participant's individualized plan of care is designed to promote and nurture his or her optimal health and well being.

Living Choices providers furnish "bundled services" in the amount, frequency and duration required by the Living Choices plans of care. They facilitate participants' access to medically necessary services that are not components of Living Choices bundled services, but which are ordered by participants' plans of care. Living Choices providers receive per diem Medicaid reimbursement for each day a participant is in residence and receives services. The per diem amount is based on a participant's "tier of need", which DAAS-employed RNs determine and periodically re-determine by means of comprehensive assessments performed in accordance with established medical criteria. There are four tiers of need.

Living Choices participants are eligible to receive up to nine Medicaid-covered prescriptions per month. More detailed information may be found in the Living Choices Assisted Living provider manual.

Medicaid non-emergency transportation (NET) services for Medicaid beneficiaries are furnished, under the authority of a capitated selective contract waiver, by twelve regional brokers. Medicaid beneficiaries contact their local transportation broker for non-emergency transportation to appointments with Medicaid providers.

Providers transporting Medicaid beneficiaries to Developmental Day Treatment Clinic Service (DDTCS) providers for DDTCS services have been allowed to remain enrolled as fee for service providers for that purpose only, if they so choose. All other Medicaid non-emergency transportation for DDTCS clients must be obtained through the regional broker.

The Arkansas Medicaid non-emergency transportation waiver program does not include transportation services for:

The Arkansas Department of Health and Human Services implemented the Family Planning Demonstration Waiver Program in September of 1997. The demonstration was renamed the Women's Health Demonstration Program in 2002. Eligibility for the program is limited to women of childbearing age who are not currently certified in any other Medicaid category. The target population contains women age 14 to age 44, but all women at risk of unintended pregnancy are allowed to apply for the program. The family income must be at or below 200% of the Federal Poverty Level.

Participants are not required to have a photo Medicaid identification card. Their Medicaid coverage entitles them to receive only Medicaid covered family planning services. Beneficiaries may use the participating and willing provider of their choice.

The Utilization Review Section is responsible for the recoupment of Medicaid funds from providers. Situations resulting in recoupment include, but are not limited to, the following:

Family Support Specialists in the DHHS county offices are responsible for evaluating the circumstances of an individual or family to determine eligibility, and if eligible, the proper aid category through which Medicaid should be received.

After evaluation, the DHHS county office establishes Medicaid eligibility dates in accordance with state and federal policy and regulations. See sections 123.000 and 124.000 of this manual for further explanation.

Social Security representatives are responsible for evaluating an individual's circumstances to determine eligibility for the Supplementary Security Income (SSI) program administered by the Social Security Administration. SSI includes aged, blind and disabled categories. The SSI aid categories are listed in Section 124.000.

To be eligible for SSI, an aged, blind or disabled person must also meet income, resource and other eligibility criteria.

Individuals entitled to SSI automatically receive Medicaid.

Within the DHHS office, the Division of Health determines presumptive eligibility for category 62, titled Pregnant Women-Presumptive Eligibility. The Division of Health is the designated application point for Breast and Cervical Cancer Prevention and Treatment and for Tuberculosis aid categories; however, the Division of County Operations makes the final eligibility determination.

Beneficiary eligibility in the Arkansas Medicaid Program is date specific. Medicaid eligibility may begin or end on any day of a month. A PES electronic response displays the current eligibility period through the date of the inquiry.

Medicaid beneficiaries may be eligible for Medicaid benefits for the three-month period prior to the date of application provided eligibility requirements for that three-month period are met. The DHHS county offices establish retroactive eligibility.

DMS must notify a Medicaid beneficiary when a claim for Medicaid payment is denied, in whole or in part, or is not acted upon with reasonable promptness. The notice must comply with section 191.002 of this manual and it must include the following:

The beneficiary lock-in rule enables physicians and pharmacists to provide quality care and assures that the Medicaid Program does not unintentionally facilitate drug abuse or injury from overmedication or drug interaction.

If a beneficiary has utilized pharmacy services at a frequency or amount that is not medically necessary, as determined by a computerized algorithm and clinical review process, DMS can "lock-in" the beneficiary by requiring him or her to choose a single provider of pharmacy services. After lock-in, DMS will deny claims for pharmacy services submitted by any provider other than the selected provider. The selected provider will be notified prior to lock-in, so that adequate time is allowed for selection of another pharmacy if the selected provider cannot provide the needed services.

If a beneficiary fails or refuses to choose one provider, a list of providers used by the beneficiary will be reviewed and a provider will be chosen at random. DMS will ensure that the beneficiary has reasonable access, taking into account geographic location and reasonable travel time, to pharmacy services of adequate quality.

Before imposing lock-in, DMS or its agent will mail a notice to the beneficiary in accordance with the beneficiary due process rules found in section 191.000 of this manual. The notice will also inform the beneficiary of his or her right to request administrative reconsideration and outline that process. If the beneficiary does not appeal or request reconsideration, he must choose a pharmacy using the selection form enclosed with the notice.

When a beneficiary has been locked-in, eligibility verification transactions will reflect "lock-in to other provider." The restriction will be removed after demonstration by the beneficiary that the abusive situation has been corrected. Application of this rule will not result in the denial, suspension, termination, reduction or delay of medical assistance to any beneficiary.

Most Medicaid categories provide the full range of Medicaid services as specified in the Arkansas Medicaid State Plan. However, certain categories offer a limited benefit package. These categories are discussed below.

Act 407 of 1997 established the ARKids First Program. The ARKids First-B Program integrates uninsured children into the health care system. ARKids First-B benefits are comparable to the Arkansas state employees/teachers insurance program.

Covered services provided to ARKids First-B participants are within the same scope of services provided to Arkansas Medicaid beneficiaries, but may be subject to different benefit limits.

Refer to the ARKids First-B provider manual for the scope of each service covered under the ARKids First-B Program.

The medically needy category was established to provide medical care for those individuals who are medically eligible for benefits, but whose income and/or resources exceed the limits for other types of assistance but are insufficient to provide for all or part of their medical care. A full range of benefits is available for those individuals with the exception of long term care (which includes ICF/MR) and personal care services.

The infants and children in the SOBRA (Sixth Omnibus Budget Reconciliation Act of 1986) aid category receive the full range of Medicaid benefits; however, the pregnant women receive only services related to the pregnancy and services that if not provided could complicate the pregnancy.

Covered services are those that are related to the pregnancy and services that, if not provided, could complicate the pregnancy. Services are further limited to ambulatory prenatal care (hospitalization is not covered).

The Qualified Medicare Beneficiary (QMB) aid category was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low-income Medicare beneficiaries. If a person is eligible for QMB, Medicaid will pay the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance, less any Medicaid cost sharing, for other medical services. Medicaid will also pay the Medicare Part A premium, the Medicare Part A hospital deductible and the Medicare Part A coinsurance, less any Medicaid cost sharing. Certain QMBs are also eligible for Medicaid services.

To be eligible for QMB, individuals must be age 65 or older, blind or disabled and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal but cannot exceed 100% of the Federal Poverty Level (FPL).

Countable resources may equal but cannot exceed twice the current Supplemental Security Income (SSI) resource limitations.

Generally, individuals may not be certified in a QMB category and in another Medicaid category for simultaneous periods. However, QMBs may simultaneously receive assistance in the medically needy spend down categories of SOBRA pregnant women (61 and 62), Family Planning (69) and TB (08).

QMBs do not receive the full range of Medicaid benefits. For example, QMBs do not receive prescription drug benefits.

For a QMB eligible, Medicaid pays only his or her Medicare cost sharing (less the individual's Medicaid cost-sharing) for Medicare covered services.

Individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the electronic eligibility display to verify the QMB category of service. The category of service for a QMB will reflect QMB-AA, QMB-AB or QMB-AD. The system will display the current eligibility.

Not all providers are mandated to accept Medicare assignment on QMB eligibles (See Section 142.100). However, if a non-physician desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he or she must accept assignment on that claim and enter the information required by Medicare on assigned claims.

When treated by a provider who must accept Medicare assignment according to section 142.000 (Conditions of Participation) the beneficiary is not responsible for the difference between the billed charges and the Medicare allowed amount.

Interested individuals may apply for the QMB program at their local Department of Health and Human Services (DHHS) county office.

The Balanced Budget Act of 1997, Section 4732, (Public law 105-33) created the Qualifying lndividuals-1 (QI-1) aid category. Individuals eligible as QI-1 are not eligible for Medicaid benefits. They are eligible only for the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. Individuals eligible for QI-1 will not receive a Medicaid card, and, unlike QMBs and SMBs, may not be certified in another Medicaid category for simultaneous periods. Individuals who meet the eligibly requirements for both QI-1 and medically needy spend down will have to choose which coverage is wanted for a particular period of time.

Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A hospital insurance and Medicare Part B medical insurance. Countable income must be at least 120% but less than 135% of the current Federal Poverty Level.

Countable resources may equal but cannot exceed twice the current SSI resource limitations.

The Specified Low Income Medicare Beneficiaries Program (SMB) was mandated by Section 4501 of the Omnibus Budget Reconciliation Act of 1990.

Individuals eligible as specified low income Medicare beneficiaries (SMB) are not eligible for the full range of Medicaid benefits. They are eligible for only the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do not receive a Medicaid card.

Eligibility criteria for the SMB program are similar to that of the QMB program. The individuals must be age 65 or older, blind or disabled and entitled to receive Medicare Part A hospital insurance and Medicare Part B medical insurance. Their countable income must be greater than, but not equal to 100% of the current Federal Poverty Level, and less than, but not equal to 120% of the current Federal Poverty Level.

The resource limit may be equal to but cannot exceed twice the current SSI resource limitations.

Interested individuals may apply for services at their local Department of Health and Human Services (DHHS) county office.

The TB aid category is for low-income individuals of all ages who are infected or who are suspected to be infected with TB. Application may be made through the Division of Health by contacting the local county health unit.

Individuals eligible in the TB aid category are not required to select a Primary Care Physician (PCP) since this is a limited services category.

Eligible individuals will receive only TB related services and only from the following service categories:

Women in aid category 69 (FP-W) are eligible for all family planning services, subject to the benefit limits listed in the appropriate provider manual.

Women in the FP-W category who elect sterilization are covered for one post-sterilization visit per state fiscal year (July 1 through June 30).

Certain programs require beneficiaries to share the cost for Medicaid services received. These programs are discussed below.

Covered services provided to ARKids First-B participants are within the same scope of services provided to Arkansas Medicaid beneficiaries, but may be subject to cost sharing requirements. See Section II of the ARKids First-B provider manual for a list of services that require cost sharing and the amount of participant liability for each service.

Eligibility category 49 contains children under age 19 who are eligible for Medicaid services as authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and amended by the Omnibus Budget Reduction Act. Children in category 49 receive the full range of Medicaid services. However, there are cost sharing requirements. Some parents are required to pay monthly premiums according to the chart below.

The Working Disabled category is an employment initiative designed to serve as a "bridge" to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64 and who are disabled according to Supplemental Security Income (SSI) criteria are eligible in this category.

There are two levels of cost sharing in this aid category, depending on the individual's income:

Medicaid beneficiaries are issued a magnetic identification card similar to a credit card. Each identification card displays a hologram, and for most Medicaid categories, a picture of the beneficiary. Children under the age of five, ARKids-B, nursing home and home and community-based waiver beneficiaries are not pictured. New beneficiaries of the Family Planning Wavier (Category 69) and ARKids-A are not pictured unless they were certified using an existing case number and have a previously issued photo ID card. The Division of County Operations issues the Medicaid identification card to Medicaid beneficiaries.

THE MEDICAID IDENTIFICATION CARD DOES NOT GUARANTEE ELIGIBILITY FOR A BENEFICIARY. Payment is subject to verification of beneficiary eligibility at the time services are provided. See section 123.000 for verification of beneficiary eligibility procedures, and Section III for electronic eligibility verification information.

The following is an explanation of information contained on a Medicaid ID card:

When a provider suspects misuse of a Medicaid identification card, the provider should contact the Utilization Review Section of Arkansas Division of Medical Services. An investigation will then be made. View or print the Utilization Review Section contact information.

The beneficiary is not responsible for insurance cost share amounts if the claim is for a Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as a Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by private insurance and the Medicaid maximum allowed amount. Medicaid will not make any payment if the amount received from the third party insurance is equal to or greater than the Medicaid allowable rate.

If an individual who makes payment at the time of service is later found to be Medicaid eligible and Medicaid is billed, the individual must be refunded the full amount of his or her payment for the covered service(s). If it is agreeable with the individual, these funds may be credited against unpaid non-covered services that are the responsibility of the beneficiary.

The beneficiary may not be billed for the completion and submission of a Medicaid claim form.

The beneficiary is also responsible for any applicable cost-sharing amounts such as enrollment fees, premiums, deductibles, coinsurance, or co-payments imposed by the Medicaid Program pursuant to 42 C.F.R. §§ 447.50- 447.60 (2004). These cost-sharing responsibilities are outlined in sections 133.000 - 135.000 of this manual.

Beneficiaries

For inpatient admissions, the coinsurance charge per admission for non-exempt Medicaid beneficiaries age 18 and older is 10% of the hospital's interim Medicaid per diem, applied on the first Medicaid covered day.

Example:

A Medicaid beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid interim per diem is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00; the beneficiary will pay $50.00 (10% Medicaid coinsurance rate).

Beneficiaries

For inpatient admissions, the coinsurance charge per admission for ARKids First-B beneficiaries is 20% of the hospital's Medicaid per diem, applied on the first Medicaid covered day.

Example:

An ARKids First-B beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1900.00 and the beneficiary will pay $100.00 (20% Medicaid coinsurance rate).

Eligible Beneficiaries

The coinsurance charge per admission for Medicaid beneficiaries, who are also Medicare Part A beneficiaries, is 10% of the hospital's Arkansas Medicaid per diem amount, applied on the first Medicaid covered day only.

Example:

A Medicare beneficiary, also eligible for Medicaid, is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem amount is $500.00.

Arkansas Medicaid has a beneficiary co-payment policy in the Pharmacy Program. The co-payment for the Pharmacy Program is applied per prescription. Non-exempt beneficiaries age 18 and older are responsible for paying the provider a co-payment amount based on the following table:

Arkansas Medicaid has a recipient co-payment policy in the visual care program. Medicaid -eligible recipients who are 21 years or age and older must pay a $2.00 co-payment to the visual care provider for prescription services. Nursing home residents are excluded from this co-pay.

The fact that a beneficiary is a resident of a nursing facility does not on its own exclude the Medicaid services provided to the beneficiary from the cost sharing policy. Unless a Medicaid beneficiary has applied for long term care assistance through the Arkansas Medicaid Program, been found eligible and Medicaid is making a vendor payment to the nursing facility (NF or ICF/MR) for the beneficiary, the Medicaid services are not excluded from the cost sharing policy.

The provider must maintain sufficient documentation in the beneficiary's medical record that substantiates the exclusion from the beneficiary cost sharing policy.

A description of advance directive must be distributed to each patient. View or print a sample form describing advance directives and a sample declaration form that meets the requirements of law.

A provider must submit, within 35 days of the date of a request by representatives of the Secretary of Health and Human Services or the Division of Medical Services, full and complete information about:

Crime

Before the Division of Medical Services enters into or renews a provider agreement, or at any time upon written request by DMS, the provider must disclose to DMS the identity of any person who:

Within thirty days a provider must refund any money the state is obligated to repay the federal government as a result of disallowance, recoupment or other adverse action in connection with Medicaid payments to the provider.

The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare claims for "physician" services furnished to individuals who are eligible for Medicare and Medicaid, including those eligible as qualified Medicare beneficiaries (QMBs). According to Medicare regulations, "physician" services, for the purpose of this policy, are services furnished by physicians, dentists, optometrists, chiropractors and podiatrists.

As described above, "physician" services furnished to an individual enrolled under Medicare who is also eligible for Medicaid ("QMB-plus"), including qualified Medicare beneficiaries (QMBs not eligible for benefits covered by Medicaid and not covered by Medicare), may only be made on an assignment-related basis.

A request received within 35 calendar days of the written notice will be deemed timely. A request received later than 35 calendar days will be considered on an individual basis. The request must be mailed or delivered by hand. Faxed or emailed requests will not be accepted.

No administrative reconsideration is allowed if the adverse decision/action is due to loss of licensure, accreditation or certification.