Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-010 - Medicaid Alternatives for Adults with Physical Disabilities Waiver Provider Manual Update Transmittal #32
Current through Register Vol. 49, No. 9, September, 2024
SECTION II - ALTERNATIVES FOR ADULTS WITH PHYSICAL DISABILITIES WAIVER
Providers of Alternatives for Adults with Physical Disabilities Waiver services in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined in Section 201.000.
A routine services provider may be enrolled in the program as a provider of routine Alternatives services to eligible Arkansas Medicaid beneficiaries. Reimbursement may be available for all attendant care and environmental accessibility adaptation/adaptive equipment services covered in the Arkansas Medicaid Program. Claims must be filed according to Section 240.000 of this manual.
The client intake and assessment process includes application for waiver services at the Department of Health and Human Services (DHHS) county office in the client's resident county, a determination of categorical eligibility, a nursing facility 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.
Once an application has been approved, waiver services must be provided in order for eligibility to continue. Unless stated otherwise below, the county Department of Health and Human Services (DHHS) office must be notified immediately by the waiver counselor when waiver services are discontinued and action will be initiated by the DHHS county office to close the waiver case.
An individual cannot receive waiver services while in an institution. The following policy applies to active waiver cases when the individual is hospitalized or enters a nursing facility for an expected stay of short duration.
When a waiver client is absent from the home for reasons other than institutionalization, the DHHS county office will not be notified unless the client does not return home within 20 days. If, after 20 days, the client has not returned home and the providers can no longer deliver services as prescribed by the plan of care (e.g., the client has left the state and the return date is unknown), the waiver counselor will notify the DHHS county office. Action will be taken by the DHHS county office to close the waiver case. No alternatives services are covered during a client's absence.
Because the provider has more frequent contact with the client, the provider may become aware of changes in the client's status sooner than the Waiver Counselor or DHHS County Office. It is the provider's responsibility to report these changes immediately so proper action can be taken. Providers must complete the Provider Communication Form (AAS-9502) and send it to the waiver counselor. A copy must be retained in the provider's client case record. Whether the change may or may not result in action by the DHHS county office, providers must report all changes in the client's status to the waiver counselor.
Attendant care service is assistance to a medically stable, physically disabled individual in accomplishing tasks of daily living that the individual is unable to complete independently. Assistance may vary from actually doing a task for the individual, to assisting the individual to perform the task or to providing safety support while the individual performs the task. Housekeeping activities that are incidental to the performance of care may also be furnished.
Clients who can comprehend the rights and accept the responsibilities of consumer-directed care may wish to have alternatives attendant care services included on their plan of care. The client's plan of care will be submitted to the client's attending physician for his or her review and approval.
When Alternatives for Adults with Physical Disabilities Waiver services are denied, the beneficiary may request a fair hearing from the Department of Health and Human Services according to sections 191.000 - 191.006 of the Arkansas Medicaid Provider Manuals.
Appeal requests must be submitted to the Department of Health and Human Services Appeals and Hearings Section. View or print DHHS Appeals and Hearings Section contact information.
Prior authorization is not required in this program.
A provider may request reconsideration of a Medicaid Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification to the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and, if necessary, will contact the provider to arrange a conference. Regardless of the Program decision, the provider will be afforded the opportunity for a full explanation of the factors involved and the Program decision. Within 20 calendar days of receipt of the request for review, the Assistant Director will notify the provider of the action to be taken by the Division or the date for the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
Alternatives for Adults with Physical Disabilities Waiver providers use the CMS-1500 form and the Alternatives Attendant Care Provider Claim Form (AAS-9559) to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claims submission.
The following procedure codes must be billed with a type of service "9":
|
Procedure Code |
Description |
|
S5165 |
Environmental Accessibility Adaptations/Adaptive Equipment |
|
S5125 |
Attendant Care |
|
Place of Service |
Paper Claims |
Electronic Claims |
Type of Service (paper only) |
|
Patient's Home |
4 |
12 |
9 - Alternatives Waiver |
Claims submitted on paper are paid once a month. The only claims exempt from this process are those that require attachments or manual pricing.
To bill for environmental accessibility adaptations/adaptive equipment services, use the CMS-1500. The numbered items correspond to numbered fields on the claim form. View a sample CMS-1500 form. The following instructions must be read and carefully followed so that EDS can efficiently process claims. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be forwarded to the EDS Claims Department. View or print EDS Claims Department contact information.
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
|
Field Name and Number |
Instructions for Completion |
|
1. Type of Coverage a. 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 |
If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial. |
|
a. Other Insured's Policy or Group Number |
Enter the policy or group number of the other insured. |
|
b. Other Insured's Date of Birth |
This field is not required for Medicaid. |
|
Sex |
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 related to employment (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. |
|
d. 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: |
Not required. |
|
Illness 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 Alternatives for Adults with Physical Disabilities waiver services. |
|
a. I.D. Number of Referring Physician |
Enter the 9-digit Medicaid provider number of the referring physician. |
|
18. Hospitalization Dates Related to Current Services |
Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
|
19. Reserved for Local Use |
Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
|
20. Outside Lab? |
Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
|
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 receipt dates. |
|
22. Medicaid Resubmission Code |
Reserved for future use. |
|
Original Ref No. |
Reserved for future use. |
|
23. Prior Authorization Number |
Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
|
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 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 242.200 for codes. |
|
C. Type of Service |
Enter the appropriate type of service code. See Section 242.200 for codes. |
|
D. Procedures, Services or Supplies |
|
|
CPT/HCPCS |
Enter the correct CPT or HCPCS procedure code from Section 242.100. |
|
Modifier |
Not applicable to Alternatives for Adults with Physical Disabilities Waiver claims. |
|
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 Alternatives for Adults with Physical Disabilities Waiver claims. |
|
1. 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 required. |
|
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. Do not enter any payment by the beneficiary. |
|
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#." |
Instructions
EDS offers providers several options for electronic billing. Claims submitted on paper are paid once a month. The only claims exempt from this process are those that require attachments or manual pricing.
To bill for attendant care services, use the Alternatives Attendant Care Provider Claim Form (AAS-9559). View a sample Alternatives Attendant Care Provider Claim Form (Form AAS-9559.) The following instructions must be read and carefully followed so that EDS can efficiently process claims. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible.
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
Form AAS-9559 is obtained from the client's employer after the top portion of the form is completed by the Division of Aging and Adult Services (DAAS) Waiver Counselor. The form must be signed by the client or an authorized person.
The middle portion of the form is used by the provider to record the amount of time worked by entering the information requested on the form.
The bottom section of the form is for provider identification information. The prior authorization number for authorized services must be entered on the line where indicated. The provider must sign the form. Refer to the DAAS Attendant Care Provider Manual for complete billing information.
Claims for attendant care services must be filed in 15 minute units with a daily maximum of 32 units.
Attendant care services may be billed either electronically or on paper. Refer to Section III of this manual for information on electronic billing.
When filing paper claims for attendant care, Form AAS-9559 must be used.
