Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-034 - Occupational, Physical, Speech Therapy Services Update Transmittal #60
Current through Register Vol. 49, No. 9, September, 2024
SECTION II - CERTIFIED NURSE-MIDWIFE
To participate in the Arkansas Medicaid Program, providers must adhere to all applicable professional standards of care and conduct.
Midwife Providers
All providers of certified nurse-midwife services must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:
Ambulance service for Medicaid beneficiaries is covered by Medicaid when the ambulance transportation is medically necessary, as determined by the certified nurse-midwife.
It is the responsibility of the transportation provider to maintain documentation that will verify the medical necessity of transportation provided.
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
The certified nurse-midwife's prescriptive authority (when applicable) only extends to legend drugs in Schedule III through Schedule V. Medicaid reimbursement will be limited to prescriptions for drugs in these schedules.
Multisource Drugs Listing/Generic Upper Limits.
As additions or deletions by labelers are submitted to the state by the Centers for Medicare and Medicaid Services (CMS), the Web site is updated.
LTC patients must receive prescribed drugs within a specific period of time after the prescribed order. For prescribed drugs that require prior authorization (PA) and are administered in oral dosage forms for which a 5-day supply may be calculated and dispensed, one 5-day supply of the drug may be provided to the LTC recipient upon receipt of the prescription and reimbursed by Arkansas Medicaid without receipt of PA.
Within 5 days of the prescription of a drug requiring PA and for which no PA has been obtained, the pharmacist and the physician must consult to determine if there is a therapeutically equivalent drug that does not require PA. The results of the consultation must be documented in writing.
If a non-PA, therapeutically equivalent drug exists, the physician must write a substitute prescription for the non-PA drug.
Program and ARKids First-B Program
The Arkansas Medical Assistance Program includes a Child Health Services (EPSDT) Program for eligible individuals under age 21. The purpose of this program is to detect and treat health problems in their early stages and to provide well child health care such as immunizations.
Similar services are also covered through the ARKids First-B Program. This program covers children age 18 years and younger.
Certified nurse-midwives may provide routine newborn care that includes the physical examination of the baby and conference(s) with the newborn's parents. These services are considered to be the initial Child Health Services (EPSDT) screen and may be covered as the initial preventive health screen for those eligible for the ARKids First-B Program.
Certified nurse-midwives interested in enrolling in the Child Health Services (EPSDT) Program or the ARKids First-B Program should contact the Central Child Health Services Office. View or print the Central Child Health Services Office contact information.
The Arkansas Medicaid Program has the responsibility for assuring quality medical care for its beneficiaries along with protecting the integrity of the funds supporting the program. The Division of Medical Services is committed to these goals, provides staff and resources to the prevention, detection and correction of known abuse. These tasks can only be accomplished through the cooperation and support of the provider community.
A certified nurse-midwife who has reason to suspect either beneficiary or provider abuse or unacceptable quality of care should contact the Utilization Review Section of Arkansas Division of Medical Services. An investigation will then be made. View or print the Arkansas Division of Medical Services, Utilization Review Section contact information.
Examples of the types of abuse you may detect include:
The Medical Assistance Program is designed to assist Medicaid beneficiaries obtain medical care within the guidelines specified in Section I of this manual. Certified nurse-midwives who are licensed by the Arkansas State Board of Nursing and certified by the American College of Nurse-Midwives (ACNM) and who are enrolled in the Arkansas Medicaid Program may be reimbursed for their services within the Arkansas Medicaid Program's limitations.
Licensed certified nurse-midwives may be reimbursed for their services to Medicaid beneficiaries. (See Section I of this manual for an explanation of the Medicaid ID card.)
Services may be provided in a variety of settings, including an office, a birthing center or clinic, a beneficiary's home or a hospital.
Services performed by a certified nurse-midwife require a primary care physician (PCP) referral, except those services with family planning, obstetrical or gynecological diagnosis codes.
In accordance with Act 409 of 1995: "Nurse-Midwifery means the performance, for compensation, of nursing skills relevant to the management of women's health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, family planning and gynecological needs of women, within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the client."
Medicaid beneficiaries are responsible for payment for services beyond the established benefit limits unless the Division of Medical Services (DMS) authorizes an extension of a particular benefit. If a beneficiary elects to receive a service for which DMS has denied a benefit extension, or for which DMS subsequently denies a benefit extension, the patient is responsible for payment.
NOTE: When serving ARKids First-B beneficiaries, Aid Category 01, use the ARKids First-B provider manual for benefit limits that are specific to that category.
The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient acute care/general hospitals, in-state and out-of-state.
Length-of-stay determinations are made by the Quality Improvement Organization (QIO), Arkansas Foundation for Medical Care, Inc. (AFMC), under contract to the Arkansas Medicaid Program.
Individuals in all Medicaid eligibility categories and all age groups, except individuals underage one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at the time of admission are exempt from the MUMP policy for dates of service before their first birthday. Refer to item "D" below for the procedure to follow when a child's first birthday occurs during an inpatient stay.
The procedures for the MUMP are as follows:
If the retroactive eligibility is not identified until after discharge and the hospital bills and receives a denial for any days past the original four allowed, then the hospital may call for post-extension evaluation approval of the denied days, which, if granted, may be rebilled. If the length of stay is more than 30 days, the provider may submit the entire medical record to AFMC to review.
Send a copy of the denial notice received from the third party payer to AFMC. View or print AFMC contact information. Include a note requesting post certification and the full name of the requester and a phone number where the requester may be reached. Upon receipt of the denial copy and the provider request, an AFMC coordinator will call the provider and obtain certification information.
Medicaid has established a maximum paid amount (benefit limitation) of $500 per state fiscal year (July 1 through June 30) for beneficiaries aged 21 and older, for outpatient laboratory and machine tests and outpatient radiology.
For the purpose of coverage and reimbursement determination, outpatient hospital certified nurse-midwife services are divided into the following two types of service:
Special Coverage Requirements - Certified nurse-midwives may bill a hospital outpatient visit as an emergency when the patient's medical condition constitutes an emergency medical condition, in compliance with Section 1867 of the Social Security Act.
Special Coverage Requirements - Non-emergency certified nurse-midwife services in an outpatient hospital setting are covered as a visit and the professional component for machine tests, radiology and anatomical laboratory procedures.
Beneficiaries aged 21 and older are limited to a total of 12 outpatient hospital visits a year. This benefit limit includes outpatient hospital services provided in an acute care/general hospital or a rehabilitative hospital. This yearly limit is based on the state fiscal year (July 1 through June 30). Outpatient hospital services include the following:
Refer to section 272.120 for the procedure code subject to the non-emergency outpatient hospital benefit limit.
Generally outpatient hospital services for beneficiaries underage 21 are not benefit limited.
The Arkansas Medicaid Program exempts the following ICD-9-CM diagnoses from the extension of benefit requirements.
|
1. Malignant Neoplasm |
Diagnosis code range 140.0 through 208.91 |
|
2. HIV or AIDS |
Diagnosis code 042 |
|
3. Renal failure |
Diagnosis code range 584 through 586 |
|
4. Pregnancy |
Diagnosis code range 630 through 677, with applicable 4th and 5th digits, diagnosis codes V22.0, V22.1 and V28 through V29, with applicable 4th digits. |
When a Medicaid beneficiary has exhausted the Medicaid established benefit limit for certified nurse-midwife outpatient hospital services, benefits are automatically extended for these diagnoses.
Beneficiaries age 21 and older are limited to twelve (12) visits per state fiscal year (July 1 through June 30) for services. For services provided by a certified nurse-midwife, physician's services, rural health clinic services, medical services furnished by a dentist or office medical services by an optometrist or a combination of the five.
For example: a beneficiary who has had two office medical visits to the dentist, one office medical visit to an optometrist and two visits to a physician has used five of the limit of twelve visits per state fiscal year.
The following services are counted toward the 12 visits per state fiscal year limit established for the Certified Nurse-Midwife Program:
Global obstetric fees are not counted against the 12-visit limit. Itemized obstetric office visits are counted in the limit.
Extensions of the benefit limit will be considered for services beyond the established benefit limit when documentation verifies medical necessity. Refer to section 214.000 of this manual for procedures for obtaining extension of benefits.
Beneficiaries underage 21 in the Child Health Services (EPSDT) Program are not benefit limited.
A request for administrative reconsideration of an extension of benefits denial must be in writing and sent to AFMC within 30 calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation as detailed in section 214.120. The deadline request will be enforced as indicated in sections 190.012 and 190.013 of this manual. A request received by AFMC within 35 calendar days of a denial will be deemed timely. A request received later than 35 calendar days gives rise to a rebuttable presumption that it is not timely.
Please see section 190.000 for information regarding administrative appeals
One new patient visit is covered every three (3) years per beneficiary per attending provider.
Medicaid pays for one basic family planning visit per beneficiary per Arkansas state fiscal year (July 1 through June 30). This basic visit comprises the following:
Medicaid covers three periodic family planning visits per beneficiary per state fiscal year (July 1 through June 30). The periodic visit includes follow-up medical history, weight and blood pressure and counseling regarding contraceptives and possible complications of contraceptives. The purpose of the periodic visits is to evaluate the patient's contraceptive program, renew or change the contraceptive prescription and provide the patient with additional opportunities for counseling regarding reproductive health and family planning.
Aid Category 61 also includes benefits to unborn children of alien pregnant women who meet the eligibility requirements. The benefits for this eligibility category are the same as those for Aid Category 61 with the exception of sterilization procedures and family planning services. System eligibility verification will specify "PW unborn ch-no ster cov/FP."
The beneficiary is responsible for payment of services not covered under the PW categories.
There is also a temporary Aid Category 62, Pregnant Women-Presumptive Eligibility (PW-PE). Coverage is restricted to prenatal services and services for conditions that may complicate the pregnancy. These services are further limited to the outpatient setting only.
Aid Categories 62 (PW-PE), 65 (PW-NG), 66 (PW-EC) and 67 (PW-SD) only cover the pregnant woman. Aid Categories 65, 66 and 67 have lower income limits than those listed above for Aid Category 61. Only Aid Category 61 may include eligible pregnant women and/or children.
When billing for services to a patient in "observation status," certified nurse-midwives must adhere to Arkansas Medicaid definitions of inpatient and outpatient. Observation status is an outpatient designation. Certified nurse-midwives must also follow the guidelines and definitions in Physician's Current Procedural Terminology (CPT), under "Hospital Observation Services" and "Evaluation and Management Services Guidelines."
The following Arkansas Medicaid criteria determine inpatient and outpatient status:
Outpatient surgical procedures are covered as all inclusive services only. One evaluation and management service, including certified nurse-midwife non-emergency outpatient visits, is covered per beneficiary per day.
The certified nurse-midwife or his or her office nurse must furnish the following specific information to AFMC: (All calls will be tape recorded.)
The caller must provide all patient identification information and medical information related to the necessity of the procedure.
AFMC will give approval or denial of the Prior Authorization request by telephone with follow-up in writing. If authorization is approved, AFMC will assign a prior authorization control number that must be entered in the appropriate field in the CMS-1500 (formerly HCFA-1500) claim format on the system when billing for the procedure. If surgery is involved, a copy of the authorization will be mailed to the hospital where the service will be performed. If the hospital has not received a copy of the authorization before the time of admission, the hospital will contact the admitting certified nurse-midwife or AFMC to verify that prior authorization has been granted.
It is the responsibility of the primary surgeon to distribute a copy of the authorization to the assistant surgeon if the assistant has been requested and approved. The prior authorization control number must be entered in the appropriate field in the PES claim format when the procedure is billed. The Medicaid Program will not pay for inpatient hospital services that require prior authorization if the prior authorization has not been requested and approved.
Consulting physicians are responsible for calling AFMC to have their required and/or restricted procedures added to the PA file. They will be given the prior authorization number at the time of the call on those cases that are approved. A letter verifying the PA number will be sent to the consultant upon request.
Post-authorization will be granted only for emergency procedures and/or for services provided to a Medicaid beneficiary during a period of retroactive eligibility. Requests for emergency procedures must be applied for no later than the first working day after the procedure has been performed. In cases of retroactive eligibility, AFMC must be contacted for post-authorization within 60 days of the eligibility authorization date.
Providers performing surgical procedures that require prior authorization are allowed 60 days from the date of service to obtain a prior authorization number. Providers must follow the post-procedural authorization process when obtaining an authorization number for the procedures listed in section 213.500.
All requests for post-procedural authorizations for eligible beneficiaries are to be made to the Arkansas Foundation for Medical Care (AFMC) by telephone within 60 days of the date of service. These calls will be tape-recorded. View or print AFMC contact information.
The beneficiary and provider identifying criteria and all of the medical data necessary to justify the procedures must be provided to AMFC.
As medical information will be exchanged for the previously performed procedures, these calls must be made by the certified nurse-midwife or a nursing member of his or her staff.
The provider will be issued a PA number at the time of the call if the procedure requested is approved. A follow-up letter will be mailed to the certified nurse-midwife on the same day.
The Arkansas Medicaid Program continues to recommend that providers obtain prior authorization for procedures requiring prior authorization in order to prevent risk of denial due to lack of medical necessity.
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 of the provider of a procedure rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Assistant Director of the 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.
The intent of the Hospital/Physician/Certified Nurse-Midwife Referral Program is fourfold.
The hospital, physician or certified nurse-midwife should inform needy individuals of possible medical assistance available under the Medicaid Program and refer all interested individuals to Arkansas Department of Health and Human Services by means of form DMS-630, Referral for Medical Assistance. View or print form DMS-630 and instructions for completion.
The hospital, physician or certified nurse-midwife should be prepared to provide itemized statements on all individuals referred to the Arkansas Department of Health and Human Services for potential use in the eligibility determination. The representative of the hospital, physician or certified nurse-midwife is responsible for the accurate completion of the Referral for Medical Assistance Form (DMS-630). After the required information has been entered on the form, the representative will read and explain the authorization section to the beneficiary before securing her signature. Once the signature is obtained, the representative will sign and date the form and forward it to the local county Health and Human Services office in the client's county of residence.
The county Health and Human Services Office addresses are available from the Arkansas Division of Medical Services.
Upon receipt of the Referral for Medical Assistance form DMS-630, the local Department of Health and Human Services county office will contact the beneficiary. Action must be completed within a specified period of time on all applications taken during follow-up. Once a determination has been made, the local County Health and Human Services office will notify the hospital, physician or certified nurse-midwife by completing Section 2 of form DMS-630. The three (3) types of disposition are:
The beneficiary is responsible for presenting his or her Medicaid identification card to the hospital, physician or certified nurse-midwife for billing purposes each time he or she receives a service.
Section 1 of Form DMS-630 is used by hospitals/physicians/certified nurse-midwives to refer to the Arkansas Department of Health and Human Services any needy individuals who might not otherwise be aware of or apply for Medical Assistance under the Medicaid Program. Section 2 of Form DMS-630 is used by the Arkansas Department of Health and Human Services to notify the hospital/physician/certified nurse-midwife of the disposition of the referral on that patient.
Enter, in sequence, hospital/physician/certified nurse-midwife name and address; patient account number; local county Department of Health and Human Services office name and address; client's first name, middle initial and last name; signature of hospital/physician/certified nurse-midwife representative; date signed; name of hospital/physician/certified nurse-midwife; signature of client, address and date signed.
Completion - Section 2
Leave blank; Section 2 will be completed by the local Department of Health and Human Services county office.
When ordering Form DMS-630 please complete a Medicaid Form Request (Form EDS-MFR-001) and mail it to the EDS Provider Assistance Center. View or print the EDS Provider Assistance Center contact information. Please give the provider's complete mailing address and the number of forms being requested. View or print form DMS-630 and instructions for completion.
Federal law mandates Medicaid coverage of infants born to Medicaid beneficiaries for a period of up to 12 months, as long as the mother remains Medicaid eligible (or would continue to be eligible if still pregnant) and as long as the infant resides with the mother.
A Hospital/Physician/Certified Nurse-Midwife Referral for Newborn Infant Medicaid Coverage Form (DCO-645) must be completed to report the birth of a Medicaid eligible infant. View or print form DCO-645 and instructions for completion. The referring provider must complete and mail the form to the DHHS County Office of the mother's resident county within 5 days of the infant's birth, when possible. The form will serve the Division of County Operations as verification of the birth date of the infant as well as documentation of relationship.
If all vital information and signatures are on the form when received and it is verified that the mother was an Arkansas Medicaid beneficiary at the time of delivery and the DHHS County Office has verified by collateral that the child lives with its mother, a newborn certification will be made within 20 working days from receipt of the completed Form DCO-645. The DHHS County Office service representative must then complete Part III of the form and return it to the provider within the 20-day period. A Form DCO-700 will be mailed to the infant's mother to notify her of the application's approval or denial.
When ordering Form DCO-645, please complete a Medicaid Form Request (Form EDS-MFR-001) and mail it to the EDS Provider Assistance Center. View or print the EDS Provider Assistance Center contact information. Please give the provider's complete mailing address and the number of forms being requested.
Certified Nurse-Midwife providers use the CMS-1500 (formerly HCFA-1500) form 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 are payable to a certified nurse-midwife. Procedure codes marked with an asterisk (*) require modifiers when applicable. Refer to section 272.400 for modifiers and other services requiring special billing procedures.
|
J0290 |
J0360 |
J0460 |
J0500 |
J0520 |
J0530 |
J0540 |
|
J0550 |
J0560 |
J0570 |
J0580 |
J0610 |
J0670 |
J0690 |
|
J0694 |
J0696 |
J0697 |
J0698 |
J0702 |
J0710 |
J0970 |
|
J1000 |
J1055* |
J1100* |
J1200 |
J1240 |
J1320 |
J1330 |
|
J1380 |
J1390 |
J1410 |
J1435 |
J1580 |
J1626 |
J1670 |
|
J1751 |
J1752 |
J1815 |
J1840 |
J1850 |
J1890 |
J1940 |
|
J1980 |
J2001 |
J2400 |
J2510 |
J2540 |
J2590 |
J2650 |
|
J2675 |
J2700 |
J2788 |
J2790 |
J2912 |
J2916 |
J3070 |
|
J3250 |
J3260 |
J3301 |
J3302 |
J3303 |
J3370 |
J3410 |
|
J7030 |
J7300* |
J7302* |
J7303* |
J7306* |
P9612 |
P9615 |
|
S0612* |
T1015* |
T1502* |
10060 |
10120 |
10140 |
10160 |
|
11100 |
11200 |
11300 |
11305 |
11400 |
11420 |
11975* |
|
11976* |
11977* |
12001 |
12002 |
12041 |
12042 |
17110 |
|
17111 |
17250 |
19000 |
19001 |
36000 |
36415* |
54150 |
|
56405 |
56420 |
56501 |
56605 |
56606 |
56740 |
56820 |
|
56821 |
57061 |
57150 |
57160 |
57180 |
57420 |
57421 |
|
57452 |
57454 |
57455 |
57456 |
57500 |
57505 |
57511 |
|
57800 |
58300* |
58301* |
58999 |
59020 |
59025 |
59030 |
|
59050 |
59051 |
59160 |
59300 |
59400 |
59409 |
59410 |
|
59414 |
59425* |
59426* |
59610 |
59612 |
59614 |
59899 |
|
64430 |
76815 |
76816 |
76818 |
76819 |
76857 |
80055 |
|
81000 |
81001 |
81002 |
81003 |
81005 |
81007 |
81015 |
|
81025 |
82042 |
82043 |
82044 |
82247 |
82248 |
82270 |
|
82274 |
82947 |
82948 |
82950 |
82951 |
82962 |
83020 |
|
83021 |
83520 |
83896 |
84703 |
84830 |
84999 |
85013 |
|
85014 |
85018 |
85660 |
86060 |
86318 |
86403 |
86580 |
|
86585 |
86592 |
86593 |
86687 |
86701 |
87075 |
87081 |
|
87088 |
87177 |
87205 |
87210 |
87390 |
87470 |
87490 |
|
87536 |
87590 |
87880 |
89330 |
90371 |
90385 |
90656 |
|
90658 |
90703 |
90707 |
90732 |
90743 |
90744 |
90746 |
|
90748 |
90749 |
90765 |
90766 |
90767 |
90768 |
90774 |
|
90775 |
90779 |
99054 |
99058 |
99199 |
99201 |
99202 |
|
99203 |
99204 |
99205 |
99211 |
99212 |
99213 |
99214 |
|
99215 |
99217 |
99218 |
99219 |
99220 |
99221 |
99222 |
|
99223 |
99231 |
99232 |
99233 |
99234 |
99235 |
99236 |
|
99238 |
99281 |
99282 |
99283 |
99284 |
99285 |
99301 |
|
99302 |
99303 |
99311 |
99312 |
99313 |
99341 |
99342 |
|
99343 |
99347 |
99348 |
99349 |
99401* |
99402* |
99431 |
|
99432 |
99435 |
99440 |
EDS offers providers several options for electronic billing. Therefore, 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 certified nurse-midwife services, use form CMS-1500. The numbered items correspond to numbered fields on the claim form. View a CMS-1500 sample form.
Read and carefully adhere to the following instructions 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 the 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 |
This field is not required for Medicaid. |
|
1a. Insured's I.D. Number |
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 |
Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card. |
|
Sex |
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 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 Injury Pregnancy |
Required only if medical care being billed is related to an accident. Enter the date of the accident. |
|
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 certified nurse-midwife services except for EPSDT services other than newborn care. 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 certified nurse-midwife. |
|
20. Outside Lab? |
This field is not required for Medicaid. |
|
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 CMS 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, if applicable. |
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24. A. Dates of Service |
Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service. |
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1. On a single claim detail (one charge on one line), bill only for services within a single calendar month. |
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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. |
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B. Place of Service |
Enter the appropriate place of service code. See Section 272.200 for codes. |
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C. Type of Service |
Enter the appropriate type of service code. See Section 272.200 for codes. |
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D. Procedures, Services or Supplies |
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CPT/HCPCS |
Enter the correct CPT or HCPCS procedure code from section 272.100. For unlisted procedure codes, enter the description of the service and attach a procedure report. |
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Modifier |
Use applicable modifier. |
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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. |
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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. |
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G. Days or Units |
Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A. |
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H. EPSDT/Family Plan |
Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral. |
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1. EMG |
Emergency - This field is not required for Medicaid. |
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J. COB |
Coordination of Benefit - This field is not required for Medicaid. |
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K. Reserved for Local Use |
When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#." |
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When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#." |
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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. |
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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. |
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27. Accept Assignment |
This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid. |
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28. Total Charge |
Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.) |
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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 recipient, unless the recipient has an insurer that requires co-pay. In such a case, enter the sum of the insurer's payment and the recipient's co-pay. (See NOTE below Field 30.) |
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30. Balance Due |
Enter the total amount due. 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. |
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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. |
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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 valid. |
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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. |
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33. Physician's/Supplier's Billing Name, Address, ZIP Code & Phone# |
Enter the billing provider's name and complete address. Telephone number is requested but not required. |
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PIN # |
This field is not required for Medicaid. |
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GRP# |
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. |
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Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#." |
Services for anesthesia must be billed in the CMS-1500 claim format.
The following list includes Family Planning Services Program procedure codes payable to certified nurse-midwives. When filing paper claims for family planning services, certified nurse-midwives must use type of service code "A." Applicable modifiers must be used for both electronic and paper claims. All procedure codes in this table require a family planning diagnosis code in each claim detail.
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Procedure Code |
Required Modifier(s) |
Description |
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J1055 |
FP |
Medroxyprogesterone Acetate for contraceptive use |
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J7300 |
FP |
Intrauterine Copper Contraceptive |
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J7302 |
FP |
Levonorgestrel-Releasing Intrauterine Contraceptive System |
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J7303 |
FP |
Contraceptive supply, hormone containing vaginal ring, each |
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J7306 |
FP |
Levonorgestrel (contraceptive) implant system, including implants and supplies |
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S0612* |
FP, SB, UB |
Annual Post-Sterilization Visit |
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11975 |
FP, SB |
Implantation of Contraceptive Capsules |
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11976 |
FP, SB |
Removal of Contraceptive Capsules |
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11977 |
FP, SB |
Removal and Reinsertion of Contraceptive Capsules |
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36415 |
FP |
Collection of Venous Blood by Venipuncture |
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58300 |
FP, SB |
Insertion of Intrauterine Device |
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58301 |
FP, SB |
Removal of Intrauterine Device |
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99402 |
FP, SB |
Basic Family Planning Visit |
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99401 |
FP, SB, UA |
Periodic Family Planning Visit |
* Women in the FP-W category (eligibility category 69) who have undergone sterilization are eligible only for this annual follow-up visit.
The following services are covered for beneficiaries of all ages. However, when these services are provided to individuals age 21 and older, a diagnosis of ICD-9-CM 140.0 - 208.91, or 042 must exist.
These injections are payable when provided in the certified nurse-midwife's office. Multiple units may be billed.
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J0290 |
J0360 |
J0460 |
J0500 |
J0520 |
J0530 |
J0540 |
J0550 |
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J0560 |
J0570 |
J0580 |
J0610 |
J0670 |
J0690 |
J0694 |
J0696 |
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J0697 |
J0698 |
J0702* |
J0710 |
J0970 |
J1000 |
J1100* |
J1200 |
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J1240 |
J1320 |
J1330 |
J1380 |
J1390 |
J1410 |
J1435 |
J1580 |
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J1626 |
J1670 |
J1815 |
J1840 |
J1850 |
J1890 |
J1940 |
J1980 |
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J2000 |
J2001 |
J2400 |
J2510 |
J2540 |
J2590 |
J2650 |
J2675 |
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J2700 |
J2912 |
J3070 |
J3250 |
J3260 |
J3301 |
J3302 |
J3303 |
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J3370 |
J3410 |
J7030 |
*When procedures J0702 and J1100 are furnished to patients aged 21 and older, a diagnosis of ICD-9-CM 140.0 - 208.91, 042 or 640 - 648.93 must exist.
Certified nurse-midwives billing in the Arkansas Medicaid Program for injections should bill the appropriate procedure code for the specific injection being performed.
Certified nurse-midwives may bill the injection procedure codes on form CMS-1500 or electronically.
If the patient is scheduled for injection only, the provider may not bill for an office visit but may bill for the injection.
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Procedure Code |
Description of Special Coverage |
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J1751 |
Injection, iron dextran, 165, 50 mg (Effective for dates of service on and after 3-1-06, use procedure code J1751 in place of procedure code J1750. Payable when diagnosis is 280.9.) |
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J1752 |
Injection, iron dextran, 267, 50 mg (Effective for dates of service on and after 3-1-06, use procedure code J1752 in place of procedure code J1750. Payable when diagnosis is 280.9) |
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J2788 |
Injection, Rho D immune globulin, human, mini dose 50 meg (limited to one injection per pregnancy). |
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J2790 |
Injection, Rho D immune globulin, human, full dose, 300 meg (limited to one injection per pregnancy). |
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90371 |
Hepatitis B Immune Serum Globulin (ISG). One unit equals Vi cc with a maximum of 10 units billable per day. This code is covered for all ages. |
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90385 |
Rho(D) immune globulin (Rhlg), human, mini-dose, for intramuscular use |
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90703 |
Tetanus absorbed, for intramuscular or jet injections. |
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90707 |
Maternal measles/mumps/rubella (MMR). Arkansas Medicaid extends coverage of Measles, Mumps and Rubella (MMR) vaccine to women of childbearing age (ages 21 through 44) who may be at risk of exposure to these illnesses. Coverage is limited to two (2) per lifetime. |
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90732 |
Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use. This code is payable for eligible individuals of all ages. Patients age 21 and older who receive the injections should be considered by the provider as high risk. |
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90746 |
Hepatitis B vaccine, adult dosage, for intramuscular use (covered for ages 19 and older). |
Effective for dates of service on and after March 1, 2006, procedure code 90799 is non-payable. Procedure code T1502 is to be used for "administration only" of IM and/or subcutaneous injections and requires a modifier U1 when billed electronically or on paper. When filing paper claims use type of service "9". Procedure code T1502 must be used when the drug is not supplied by the provider who administers the drug.
Beneficiaries Under Age 21
Providers should refer to the Child Health Services (EPSDT) Provider manual and the ARKids First-B Provider manual for covered services and billing procedures.
Providers should use the appropriate CPT procedure codes when billing for certified nurse-midwife visits in a nursing facility.
If either condition is not met, the claim will be denied. The denial will state either "monthly billing required" or "beneficiary ineligible for service dates."
Itemi zed billing must be used when the following conditions exist:
NOTE: Payment will not be made for emergency room certified nurse-midwife charges
for an OB patient admitted directly from the emergency room into the hospital for delivery.
Certified nurse-midwives must use procedure code 59425 with modifier UA to bill for one to three visits for antepartum care without delivery.
Procedure code 59425 with no modifier must be used by providers to bill four to six visits for antepartum care without delivery. Procedure code 59426 with no modifier is to be used for 7 or more visits without delivery.
This enables certified nurse-midwives rendering care to the patient during the pregnancy, but not delivering the baby, to receive reimbursement for their services provided. Coverage for this service will include routine sugar and protein analysis. One unit equals one visit. Units of service billed with this procedure code will not be counted against the patient's office visit benefit limit.
Providers must enter the "from" and "through" dates of service on the claim and the number of units being billed. One visit equals one unit of service. Providers must submit the claim within 12 months of the first date of service.
For example: An OB patient is seen by the certified nurse-midwife on 1-10-05, 2-10-05, 3-10-05, 4-10-05, 5-10-05 and 6-10-05. The patient then moves and begins seeing another provider prior to the delivery. The certified nurse-midwife may submit a claim with dates of service shown as 1-10-05 through 6-10-05 and 6 units of service entered in the appropriate field. This claim must be received by EDS prior to 12 months from 1-10-05 to fall within the 12-month filing deadline. The certified nurse-midwife must have on file the patient's medical record that reflects each date of service being billed.
Procedure code T1015 (modifier U3) should be billed for a non-emergency certified nurse-midwife visit.
The following are the requirements regarding substitute certified nurse-midwife billing identification:
Under the above billing arrangements, the billing (regular) certified nurse-midwife (or group) must keep on file a record that shows the substitute certified nurse-midwife's name and each service provided by the substitute certified nurse-midwife. This record must be made available upon request. A record of the service must include the date and place of the service, the procedure code, the charge and the beneficiary involved.
These billing requirements apply to all substitute certified nurse-midwife services regardless of whether a managed care primary care physician is involved.
