Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-013 - Sections I & III of all Medicaid Provider Manuals

100.100 Introduction

Section I imparts general program information about the Arkansas Medicaid Program. It includes information about beneficiary eligibility and explains the provider's role and responsibilities. The intent of Section I is to provide users with an understanding of Medicaid Program objectives and regulations. Additionally it contains details providers may need to answer questions often asked about the Medicaid Program. Six major areas are covered in Section I.

101.000 Provider Manuals

Provider manuals contain the policies and procedures of the Arkansas Medicaid Program. These policies and procedures are generally based on federal and state laws and federal regulations. Medicaid provider manual policy and procedures, and changes thereto, are promulgated as required by the state's Administrative Procedure Act.

When fully utilized, each program manual is an effective tool for the provider. It provides information about the Medicaid Program, covered and non-covered services, billing procedures and detailed instructions for completing paper claims.

Obtain provider manuals from the Arkansas Medicaid Web site (http://www.medicaid.state.ar.us), on the Arkansas Medicaid Provider Reference compact disc (CD) and on paper. As new providers are enrolled, they are asked whether they have Internet access to the provider manuals. Those who do not have Internet access will be asked to specify the medium they will use. Providers are encouraged, however, to use an electronic medium.

101.200 Updates

Provider manuals are amended ("updated") in accordance with new, repealed or revised federal and state legislative and legal clarifications, Changes in DMS medical policy, new administrative or billing procedures and numerous other requirements, are implemented 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.

Provider manual pages are updated automatically on the Arkansas Medicaid Web site; providers are notified via e-mail or mail when an applicable manual update transmittal, official notice or RA message is issued. Providers must give Provider Enrollment an e-mail address to receive e-mail notification of the supplementary material.

Providers receiving paper copies of manual update transmittals, official notices and RAs must maintain the paper supplements as they are received. Only the revised sections 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 help providers quickly review changes. Minor wording changes (usually corrected spelling, punctuation or grammar) are not highlighted. An update transmittal memorandum accompanies updated provider manual sections. Provider manual update transmittals are assigned sequential identification numbers, e.g., Update Transmittal #1. The transmittal memo identifies any new sections being added and the sections being replaced, deleted or amended. It provides brief explanations of the revisions... Provider manual update transmittals are recorded on the update log located in Appendix A of the manual.

For persons maintaining a printed provider 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 transmittal memo effective date should be entered on the update log opposite the appropriate update transmittal number. Transmittal memos should be filed immediately following the update log in descending numerical order by transmittal number. Immediately following the transmittal memos 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.

101.300 Obtaining Provider Manuals

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 without charge 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 transmittals, 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 the fiscal agent.

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.

102.000 Legal Basis of the Medicaid Program

Titles XIX and XXI of the Social Security Act created a joint federal-state medical assistance program commonly referred to as Medicaid. Ark. Code Ann. § 20-77-107 authorizes the Department of Human Services to establish a Medicaid Program in Arkansas. The Medicaid Program provides necessary medical services to eligible persons who would not be able to pay for such services.

Title XIX of the Social Security Act provides for federal grants to states for medical assistance programs. The stated purpose of Title XIX is to enable the states to furnish the following assistance:

103.100 Federally Mandated Services

103.200 Optional Services

105.100 Alternatives for Adults with Physical Disbilities

The Alternatives for Adults with Physical Disabilities (APD) waiver program is for disabled individuals age 21 through 64 who receive Supplemental Security Income (SSI) or that are Medicaid eligible by virtue of their disability and without the services provided by the waiver program 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 that the beneficiary may choose either home and community-based services or institutional services.

The services offered through the waiver are:

105.110 ARKids First-B

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

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

105.120 ConnectCare: Primary Care Case Management (PCCM)

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 (specified by the PCP of Medicaid and ARKids First-B.

A PCP contracts with DMS to provide primary care, health education and case management for his or her 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, therefore; he or she is responsible 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-beneficiaries, and children participating in ARKids First-B, must enroll with a PCP to receive Medicaid-covered or ARKids First-B services. Some individuals are not required to enroll with a PCP. A few services are covered without PCP referral. See Sections 170.000 through 173 000 for details regarding ConnectCare.

105.130 DDS Alternative Community Services (ACS)

The Developmental Disability Services Alternative Community Services (DDS ACS) waiver program is for beneficiaries who, without the waiver's services, would require institutionalization. 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 advising the beneficiary that he or she may freely choose between waiver's and institutional services.

Services supplied through this program are:

105.140 ElderChoices

ElderChoices is designed for beneficiaries aged 65 and older, who, without the waiver's services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain beneficiaries at home and preclude or postpone institutionalization.

105.170 Non-Emergency Transportation Services (NET)

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

105.180 TEFRA

The Arkansas Department of Human Services implemented the TEFRA waiver effective January 1,2003. The TEFRA waiver covers beneficiaries 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. of 2005 TEFRA children, aid category 49, receive the full range of Medicaid services. However, a premium may be required, based on parental income. See Section 124.220 for the premium chart.

105.190 Women's Health (Family Planning)

The Arkansas Department of Health and the Arkansas Department of 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 is women aged 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. (FPL, which changes every October 1).

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

110.100 Provider Enrollment Contractor

EDS, a contractor, performs provider enrollment functions for Medicaid. Any questions regarding provider enrollment participation requirements or contracts should be directed to the EDS Provider Enrollment unit. View or print the Provider Enrollment contact information.

110.400 Arkansas Foundation for Medical Care, Inc. (AFMC)

110.500 Customer Assistance

Customer Assistance, of the Division of County Operations, handles beneficiary inquiries regarding Medicaid eligibility, the Medicaid identification card and Medicaid coverage and benefits.. View or print the Division of County Operations Customer Assistance Section contact information.

121.000 Introduction

Medicaid eligibility determinants are such things as income (individual or household), resources, and medical needs with charges exceeding one's ability to pay, age or disability, current residency in Arkansas and other factors. The full range of criteria is beyond the scope of this provider manual. Eligibility inquires should be made to the local DHS office in the needy individual's county of residence.

122.000 Agencies Responsible for Determining Eligibility

The Department of Human Services (DHS) local county offices or district Social Security offices determine beneficiary eligibility certification. The category of aid each office is responsible for is described below. The Department of Health determines presumptive eligibility for pregnant women in the SOBRA Pregnant Women, Infants and Children aid category.

District Social Security offices determine Supplemental Security Income (SSI) eligibility, which automatically confers Medicaid eligibility.

122.100 Department of Human Services County Offices

Family Support Specialists in the DHS 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 and determination, the DHS 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.

122.300 Department of Health

The Department determines presumptive eligibility for category 62, Pregnant Women-Presumptive Eligibility. The Department 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.

123.000 Medicaid Eligibility

Under its contract with the Division of Medical Services, EDS has deployed Provider Electronic Solutions Application (PES) technology. With PES, Medicaid providers are able to verify a patient's Medicaid eligibility for a specific date or range of dates, including retroactive eligibility for the past year. Providers may obtain other useful information, such as the status of benefits used during the current fiscal year, other insurance or Medicare coverage, etc. See Section III of this manual for further information on PES and other electronic solutions. Providers should print and retain eligibility documentation in the beneficiary's record each time services are provided or to document retroactive eligibility.

EDS and DMS will verify Medicaid eligibility by telephone only for "Limited Services Providers" (see Section II) in non-bordering states and in the case of retroactive eligibility for dates of service that are more than a year prior to the eligibility authorization date.

123.100 Date Specific Medicaid Eligibility

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. A PES electronic eligibility verification inquiry and positive response (i.e. the beneficiary is eligible on the date of service) guarantees that a claim for service on that date will not deny for ineligibility.

123.200 Retroactive Medicaid Eligibility

Medicaid beneficiaries may be found eligible for Medicaid benefits for the three-month period before the application date, if eligibility requirements for the three-month period are met. The DHS county offices establish retroactive eligibility. Initial SSI eligibility is usually retroactive.

124.110 ARKids First-B

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

Covered services provided to ARKids First-B participants are within the same scope of services provided to Arkansas Medicaid (ARKids First-A and other full-benefit) 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.

124.120 Medically Needy

The medically needy category helps provide medical care for those individuals who are medically eligible for benefits, but while their income and/or resources exceed the Medicaid's limits for other types of assistance they are but are insufficient to pay for all or part of necessary medical care.

Individuals in such circumstances are frequently eligible for the full range of Medicaid benefits except long term care (which includes ICF/MR) and personal care services.

For more information regarding the medically needy program, providers may access the Medicaid Web site at www.medicaid.state.ar.us.

124.130 Pregnant Women, Infants & Children

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 SQBRA pregnant women (PW-PL) receive only services related to the pregnancy and services that if not provided to PW-PLs could complicate the pregnancy. Generally, PW-PL eligible's are covered for postpartum follow-up services and family planning services; however it is important to note that their PW-PL eligibility ends on the last day of the month in which the 60th postpartum day occurs, PW-Unbom Child group (covered through the State Child Health Insurance program, which is authorized by Section 4901 of the Balanced Budget Act of 1997) does not cover sterilization or any other family planning services. Therefore providers need to verify eligibility to determine if the pregnant women is PW-PL or PW "Unborn Child (when providers check eligibility the system will reflect: PW Unborn CH-no Ster cov" for the Unborn Child group).

A pregnant woman whose unborn child will be a US citizen (PW-Unborn Child) receives the same pregnancy services as those in the PW-PL category;however after delivery, no family planning services (including sterilization) are covered.

124.140 Pregnant Women Presumptive Eligibility

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

124.150 Qualified Medicare Beneficiaries (QMB)

The Qualified Medicare Beneficiary (QMB) group was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low-income Medicare beneficiaries. QMBs do not receive the full range of Medicaid benefits. For example, QMBs do not receive prescription drug benefits from Medicaid or drugs not covered under Medicare Part D. If a person is eligible for QMB, Medicaid pays the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance, less any Medicaid cost sharing, for Medicare covered medical services. Medicaid also pays the Medicare Part A hospital deductible and the Medicare Part A co insurance, less any Medicaid cost sharing. Medicaid pays the the Medicare Part A premium for QMBs whose employment history is insufficient for Title XVIII to pay it. Certain QMBs may be eligible for other limited Medicaid services. Only Medicare/Medicaid dual eligilbes qualify for coverage of Medicaid services that Medicare does not cover.

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 may not exceed 100% of the Federal Poverty Level (FPL). Countable resources may be equal to but not 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 simultaneously. However, some QMBs may simultaneously receive assistance in the medically needy categories, SOBRA pregnant women (61 and 62), Family Planning (69) and TB (08). QMBsgenerally do not have Medicaid coverage for any service that is not covered under Medicare; with the exception of the above listed categories.

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.

Most providers are not federally mandated to accept Medicare assignment (See Section 142.700). However, if a physician or non-physician (by Medicare's definition) provider desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he or she must accept Medicare assignment on that claim (see Section 142.200 D) and enter the information required by Medicare on assigned claims. When a provider accepts Medicare according to section 142.200 D the beneficiary is not responsible for the difference between the billed charges and the Medicare allowed amount. Medicaid will pay a QMB's or Medicare/Medicaid dual eligible's Medicare cost sharing (less any applicable Medicaid cost sharing) for Medicare covered services.

Interested individuals may be directed to apply for the QMB program at their local Department of Human Services (DHS) county office.

124.160 Qualifying lndividuals-1 (QI-1)

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 do not receive a Medicaid card. Additionally, unlike QMBs and SMBs, they 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 must choose which coverage they want 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 payment 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 fiscal year) Federal Poverty Level.

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

124.170 Specified Low-Income Medicare Beneficiaries (SMB)

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 only for Medicaid 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 those for QMB program. The individuals must be aged 65 or older, blind or disabled and entitled to receive Medicare Part A hospital insurance and Medicare Part B 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 not exceed twice the current SSI resource limitations.

Interested individuals may apply for SMB eligibility at their local Department of Human Services (DHS) county office.

124.180 Tuberculosis (TB)

The TB aid category is for low-income individuals of all ages who are infected or who are suspected to be infected with Tuberculosis (TB). Application may be made through the Arkansas Department 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:

124.190 Women's Health (Family Planning)

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

124.200 Beneficiary Aid Categories with Additional Cost Sharing

Certain programs require additional cost sharing for Medicaid services. These programs are discussed in sections 124.210 through 124.230.

124.210 ARKids First-B

Covered services provided to ARKids First-B participants are (with only a few exceptions) 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.

124.230 Working Disabled

The Working Disabled category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are aged 16 through 64; disabled £S defined by Supplemental Security Income (SSI) criteria; and who meet the income and resource criteria may be eligible in this category.

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

125.100 Explanation of Medicaid Identification Card

Medicaid beneficiaries are issued a magnetic identification card similar to a credit card. Each identification card displays a hologram, and for many Medicaid categories, a picture of the beneficiary. Children under the age of five, ARKids First-B participants, nursing home patients and home and community-based waiver beneficiaries are not pictured. New participants in the Women's Health Program (Family Planning Wavier Category 69) and ARKids First -A are not pictured unless their current certification is under an existing case number and they 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:

125.200 Non-Receipt or Loss of Card by Beneficiary

When beneficiaries report non-receipt or loss of a Medicaid card, refer them to the local DHS County Office or the Division of County Operations, Customer Assistance. View or print the Division of County Operations. Customer Assistance contact information.

131.000 Charges that Are Not the Responsibility of the Beneficiary

Except for cost-sharing responsibilities outlined in sections 133.000 -135.000, a beneficiary is not liable for the following charges:

132.000 Charges that are the Responsibility of the Beneficiary

A beneficiary is responsible for:

133.000 Cost Sharing

There are four forms of cost sharing in the Medicaid Program: co-insurance, co-payment, deductibles and premiums. Each is in the following sections 133.100 through 133.500

133.100 Inpatient Hospital Coinsurance Charge for Medicaid Beneficiaries

Without Medicare.

For inpatient admissions, the Medicaid coinsurance charge per admission for non-exempt Medicaid beneficiaries aged 18 and older is 10% of the hospital's interim Medicaid per diem, applied on the first Medicaid covered day. (See section 124.230 for Working Disabled cost-sharing requirements.)

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).

133.200 Inpatient Hospital Coinsurance Charge to ARKids First-B

Beneficiaries

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

Example:

An ARKids First-B beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid per diem 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).

133.300 Inpatient Hospital Coinsurance Charge to Medicare-Medicaid Dually

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 Medicare 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.

133.400 Co-payment on Prescription Drugs

Arkansas Medicaid has a beneficiary co-payment requirement in the Pharmacy Program. The payment is applied per prescription. Non-exempt beneficiaries aged 18 and older are responsible for paying the provider a co-payment amount based on the following table: (See section 124.230 for Working Disabled cost-sharing requirements. See ARKids First B manual for ARKids-First B cost-sharing requirements.)

133.500 Co-Payment of Eyeglasses for Beneficiaries Aged 21 and Older

Arkansas Medicaid has a beneficiary co-payment requirement in the Visual Care Program. Medicaid Beneficiaries 21 years of age and older must pay a $2.00 co-payment for Visual Care prescription services. Nursing home residents are exempt from the co-pay requirement.

134.000 Exclusions from Cost Sharing Policy

As required by 42 C.F.R. § 447.53(b), the following services are excluded from the beneficiary cost sharing requirement:

135.000 Collection of Coinsurance/Co-payment

The method of collecting the coinsurance/co-payment amount from the beneficiary is the provider's responsibility. I n cases of claim adjustments, the responsibility of refunding or collecting additional cost sharing (coinsurance or co-payment) from the beneficiary remains the provider's responsibility.

The provider may not deny services to a Medicaid beneficiary because of the individual's inability to pay the coinsurance or co-payment. However, the individual's inability to pay does not eliminate his or her liability for the coinsurance or co-payment charge.

The beneficiary's inability to pay the coinsurance or co-payment does not alter the Medicaid reimbursement for the claim. Unless the beneficiary or the service is exempt from cost-sharing requirements as listed in section 134.000.Medicaid reimbursement is made in accordance with the current reimbursement methodology and when applicable cost sharing amounts are deducted from the maximum allowable fee before payment.

136.000 Patient Self Determination Act

The Patient Self Determination Act of 1990, Sections 4206 and 4751 of the Omnibus Budget Reconciliation Act of 1990, P.L. 101-508 requires that Medicaid certified hospitals and other health care providers and organizations, give patients information about their right to make their own health decisions, including the right to accept or refuse medical treatment. This legislation does not require individuals to execute advance directives.

Medicaid certified hospitals, nursing facilities, hospices, home health agencies and personal care agencies must conform to the requirements imposed by Centers for Medicare & Medicaid Services (CMS). The federal requirements mandate conformity to current state law. Accordingly, providers must employ the following procedures:

141.000 Provider Enrollment

Any provider of health care services must be enrolled in the Arkansas Medicaid Program before Medicaid will cover any services provided to Arkansas Medicaid beneficiaries. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.

The Division of Medical Services has contracted with EDS to provide enrollment services for new providers and changes to current provider enrollment files. However, the unit will still be known as the Medicaid Provider Enrollment Unit.

Providers must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (FormW-9). View or print the provider application (Form DMS-652), the Medicaid contract (Form DMS-653) and the Request for Taxpayer Identification Number and Certification (Form W-9).

A potential provider may complete the necessary forms for enrollment and submit them via the Internet by connecting to the Arkansas Medicaid web site at www.medicaid.state.ar.usor they may return the printed forms to the Medicaid Provider Enrollment Unit. View or print the Medicaid Provider Enrollment Unit contact information.

Section II of each program's provider manual contains provider type-specific participation requirements.

Upon receipt and approval of required documentation and a Medicaid contract the Medicaid Provider Enrollment Unit, will assign a unique Medicaid number to the provider. The assigned provider number is linked to the provider's tax identification number (either a Social Security number of a federal Employer Identification Number) and to the provider's National Provider Identifier (NPI) unless the provider is an atypical provider not required to have an NPI. Provider eligibility is retroactive one year from the date the provider agreement is approved, the effective date of the provider's license or certification or the date Medicaid implemented the provider's program or, whichever date is the most recent.

Instructions for billing and specific details concerning the Arkansas Medicaid Program are contained within this manual. Providers must read aN sections of the manual before signing the contract. The manual is incorporated by reference into the Medicaid contract and providers must comply with its terms and conditions in order to participate in the Arkansas Medicaid Program.

All providers must sign an Arkansas Medicaid Provider Contract. The signature must be an original signature of the individual provider. The provider's authorized representative may sign the contract for a group practice, hospital, agency or other institution.

142.700 Mandatory Assignment of Claims for "Physician" Service 1216s and Medicaid's Mandatory Assignment of Claims for Provider Services

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 andjvledicaid, 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, reimbursement for "physician" services furnished to an individual enrolled under Medicare who is also eligible for Medicaid, including qualified Medicare beneficiaries may only be made on an assignment related basis. Not all providers are federally mandated to accept Medicare assignment (See Section 142.200). However, if a physician or Medicaid enrolled non-physician desires Medicaid reimbursement for the insured's cost share on a Medicare claim* he or she must accept assignment on that claim (See Section 142.200D) and enter the information required by Medicare on assigned claims. The beneficiary is not responsible for the difference between the billed charges and the Medicare allowed amount.

Item 1 -C of the Contract to participate in the Arkansas Medical Assistance Program (View or print Form DMS-653 Section V of the Provider Manual)requires enrollment and acceptance of assignment under Title XIX (Medicaid) for any applicable deductible or coinsurance that may be due and payable under Medicaid.

When a beneficiary is dually eligible for Medicare and Medicaid, including those eligible as qualified Medicare beneficiaries (QMBs) and is provided services that are covered by Medicare, Medicaid willnot reimburse for applicable deductible or coinsurance that may be due and payable under Medicare if Medicare has not been billed and made payment prior to billing Medicaid. The beneficiary cannot be billed the difference in Medicare and Medicaid payment or billed chares on assigned claims.

Claims properly filed directly to the original Medicare plan intermediary by Arkansas Medicaid enrolled providers should automatically cross to Medicare's Coordination of Benefits Assignment (COBA) process then to Arkansas Medicaid, once Medicare processing and payment has been completed. The cross over claim should process in the next weekend cycle for Medicaid payment of applicable coinsurance and deductibles (usually within four to six weeks of Medicare payment).However, claims for Medicare beneficiaries entitled under the Railroad Retirement Act or Medicare Advantage will not automatically cross to Arkansas Medicaid for payment and must be filed directly with Arkansas Medicaid after Medicare payment has been received by the provider. See Section -330.000 of this Provider Manual for further information.

171.100 PCP-Qualified Physicians and Single-Entity Providers

171.110 Exclusions

171.170 PCP for Out of State Services

Services that require PCP referral or PCP enrollment within Arkansas require PCP referral or PCP enrollment as applicable, when furnished outside of Arkansas.

172.100 Services not Requiring a PCP Referral

The services listed in this section do not require a PCP referral.

172.200 Medicaid-Eiigibie Individuals that may not Enroll with a PCP

All Medicaid-eligible individuals and ARKids First-B participants must enroll with a PCP unless they:

173.610 PCP Transfers by Enrollee Request

ConnectCare enrollees may transfer their PCP enrollment at any time, for any stated reason.

332.100 Medicare-Medicaid Crossover Claim Filing Procedures

If medical services are provided to a patient who is entitled to and is enrolled with coverage within the original Medicare plan under the Social Security Act and also to Medicaid benefits, it is necessary to file a claim only with the original Medicare plan. The claim must be filed according to Medicare's instructions and sent to the Medicare intermediary. The claim should automatically cross to Medicaid if the provider is properly enrolled with Arkansas Medicaid and indicates the beneficiary's dual eligibility on the Medicare claim form. According to the terms of the Medicaid provider contract, a provider must "accept Medicare assignment under Title XVII I (Medicare) in order to receive payment under Title XIX (Medicaid) for any appropriate deductible or coinsurance which may be due and payable under Title XIX (Medicaid)." See Section I -142.700 for further information regarding Medicare/Medicaid mandatory acceptance of assignment for providers.

When the original Medicare plan intermediary completes the processing of the claim, the payment information is automatically crossed to Medicare's Coordination of Benefits Agreement (COBA) process and from there crossed to Arkansas Medicaid and the claim is processed in the next weekend cycle for Medicaid payment of applicable coinsurance and deductible. The transaction will usually appear on the provider's Medicaid RA within four (4) to six (6) weeks of payment by Medicare. If it does not appear within that time, payment should be requested according to the instructions below.

Claims for Medicare beneficiaries entitled under the Railroad Retirement Act do not cross to Medicaid. The provider of services must request payment of co-insurance and deductible amounts through Medicaid according to the instructions below, after Railroad Retirement Act Medicare pays the claim.

Medicare Advantage/Medigap Plans (like HMOs and PPOs) are health plan options that are available to beneficiaries, approved by Medicare, but run by private companies. These companies' bill Medicare and pay directly through the private company for benefits that are a part of the Medicare Program, as well as offering enhanced coverage provisions to enrollees. Since these claims are paid through private companies and not through the original Medicare plan directly, these claims do not automatically cross to Medicaid and the provider must request payment of Medicare covered services co-insurance and deductible amounts through Medicaid according to the instructions below, after the Medicare Advantage/Medigap plan pays the claim.

When a provider learns of a patient's Medicaid eligibility only after filing a claim to Medicare, the instructions below should be followed after Medicare pays the claim.

Instructions: EDS provides software and Web-based technology with which to electronically bill Medicaid for crossover claims that do not cross to Medicaid. Additional information regarding electronic billing can be located in this Section - Subsections 301.000 through 301.200. Providers are strongly encouraged to submit claims electronically or through the Arkansas Medicaid website. Front-end processing of electronically and web-based submitted claims ensures prompt adjudication and facilitates reimbursement.

Providers without electronic billing capability must mail a red-ink original claim of the appropriate crossover invoice to the address on the top of the form (see examples of red-ink original forms in Section V of this manual). To order copies of the appropriate Medicare-Medicaid crossover invoice, please use the Medicaid Form Request (EDS-MFR-001). View or print form EDS-MFR-001.I ndicate the quantity of each form required and send the request to the Provider Assistance Center (PAC). V iew or print PAC contact information. Instructions for filling out the invoice are included with the ordered forms.

When you complete the appropriate red-lined Medicare-Medicaid crossover form, sign and date the form and mail it to the address printed at the top of the form.

332.200 Denial of Claim by Medicare

Any charges denied by either the original Medicare plan, a Medicare Advantage/Medigap plan, or Railroad Retirement, will not be automatically forwarded to Medicaid for reimbursement. An appropriate Medicaid claim form must be completed and a copy of the Medicare denial statement attached. Claims under these circumstances must be forwarded to the Provider Assistance Center (PAC) for processing. V iew or print PAC contact information.

332.300 Adjustments by Medicare

Any adjustment made by the original Medicare plan, a Medicare Advantage/Medigap plan, or Medicare Railroad Retirement, will not be automatically forwarded to Medicaid. If either Medicare payment source makes an adjustment that results in an overpayment or underpayment by Medicaid, the provider must submit an Adjustment Request Form - Medicaid XIX (View or print Adjustment Request Form-Medicaid XIX EDS-AR-004), available in Section V of this manual, an appropriate red-lined Medicare-Medicaid crossover form, completed with the corrected crossover billing information, and a copy of the Medicare EOMB reflecting Medicare's adjustment. Enter the provider identification number and the patient's Medicaid identification number on the face of the Medicare EOMB and mail all documents to the address located on the Adjustment Request Form (EDS-AR-004).