Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-030 - Personal Care Provider Manual Update Transmittal #107

Field Name and Number

Instructions for Completion

1. (type of coverage)

Not required.

1a. INSURED'S I.D. NUMBER (For Program in Item 1)

Beneficiary's 10-digit Medicaid or ARKids First-A identification number.

2. PATIENT'S NAME (Last Name, First Name, Middle Initial)

Beneficiary's last name and first name.

3. PATIENT'S BIRTH DATE

Beneficiary's date of birth as given on the individual's Medicaid or ARKids First-A identification card. Format: MM/DD/YY.

SEX

Check M for male or F for female.

4. INSURED'S NAME (Last Name, First Name, Middle Initial)

Required if insurance affects this claim. Insured's last name, first name and middle initial.

5. PATIENT'S ADDRESS (No., Street)

Optional. Beneficiary's complete mailing address (street address or post office box).

CITY

Name of the city in which the beneficiary resides.

STATE

Two-letter postal code for the state in which the beneficiary resides.

ZIP CODE

Five-digit ZIP code; nine digits for post office box.

TELEPHONE (Include Area Code)

The beneficiary's telephone number or the number of a reliable message/contact/ emergency telephone

6. PATIENT RELATIONSHIP TO INSURED

If insurance affects this claim, check the box indicating the patient's relationship to the insured.

7. INSURED'S ADDRESS (No., Street)

CITY

STATE

ZIP CODE

TELEPHONE (Include Area Code)

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

8. PATIENT STATUS

Not required.

9. OTHER INSURED'S NAME (Last name, First Name, Middle Initial)

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

a. OTHER INSURED'S POLICY OR GROUP NUMBER

Policy and/or group number of the insured individual.

b. OTHER INSURED'S DATE OF BIRTH

Not required.

SEX

Not required.

c. EMPLOYER'S NAME OR SCHOOL NAME

Required when items 9 a-d are required. Name of the insured individual's employer and/or school.

d. INSURANCE PLAN

NAME OR PROGRAM NAME

Name of the insurance company.

10. IS PATIENT'S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

Check YES or NO.

b. AUTO ACCIDENT?

Required when an auto accident is related to the services. Check YES or NO.

PLACE (State)

If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.

c. OTHER ACCIDENT?

Required when an accident other than automobile is related to the services. Check YES or NO.

10d. RESERVED FOR LOCAL USE

Not used.

11. INSURED'S POLICY GROUP OR FECA NUMBER

Not required when Medicaid is the only payer.

a. INSURED'S DATE OF BIRTH

Not required.

SEX

Not required.

b. EMPLOYER'S NAME OR SCHOOL NAME

Not required.

c. INSURANCE PLAN

NAME OR PROGRAM NAME

Not required.

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d.

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE

Not required.

13. INSURED'S OR

AUTHORIZED PERSON'S SIGNATURE

Not required.

14. DATE OF CURRENT:

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)

Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE

Not required.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

Not required.

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

17a. (blank) 17b. NPI

Name and title of the referral source.

The 9-digit Arkansas Medicaid provider ID number of the referring physician when applicable.

Not required.

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

Not applicable.

19. RESERVED FOR LOCAL USE

Schools, school districts and education service cooperatives must enter the LEA number of the facility or district providing the service.

20. OUTSIDE LAB? $ CHARGES

Not required. Not required.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) diagnosis coding current as of the date of service.

22. MEDICAID RESUBMISSION CODE

ORIGINAL REF. NO.

Reserved for future use. Reserved for future use.

23. PRIOR AUTHORIZATION NUMBER

The prior authorization or benefit extension control number when applicable.

24A.

DATE(S) OF SERVICE

The "from" and "to" dates of service for each billed service. Format: MM/DD/YY.

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

2. A provider may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the date sequence.

3. RCFs may bill for a date span of any length within the same calendar month, provided the client was present every day of the date span and all services provided within the date span were at the same Level of Care.

B.

PLACE OF SERVICE

Two-digit national standard place of service code.

C.

EMG

Not required.

D.

PROCEDURES, SERVICES, OR SUPPLIES

CPT/HCPCS

One CPT or HCPCS procedure code for each detail.

MODIFIER

Modifier(s) when applicable.

E.

DIAGNOSIS POINTER

Enter in each detail the single number-1, 2, 3 or 4- that corresponds to a diagnosis code in Item 21 (numbered 1, 2, 3 or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3 or 4, and it must be the only character in that field.

F.

$ CHARGES

The full charge for the services totaled in the detail. This charge must be the usual charge to any client patient, or other recipient of the provider's services.

RCFs' charges should equal no less than the product of the number of units (days) times the client's Daily Service Rate. If the charge is less, Medicaid will pay the billed charge.

G.

DAYS OR UNITS

The units (in whole numbers) of service provided during the period indicated in Field 24A of the detail.

H.

EPSDT/Family Plan

Enter E if the services resulted from a Child Health Services (EPSDT) screening and referral.

I.

ID QUAL

Not required.

J.

RENDERING PROVIDER ID #

Not applicable.

NPI

Not required.

25. FEDERAL TAX I.D. NUMBER

Not required. This information is carried in the provider's Medicaid file. If it changes, advise Provider Enrollment so that the year-end 1099 will be correct and reported correctly.

26. PATIENT'S ACCOUNT NO.

Optional entry for providers' accounting and account-retrieval purposes. Enter up to 16 numeric, alphabetic or alpha-numeric characters. This character set appears on the Remittance Advice as "MRN."

27. ACCEPT ASSIGNMENT?

Not required. Assignment is automatically accepted by the provider when billing Medicaid.

28. TOTAL CHARGE

Total of Column 24F-the sum of all charges on the claim.

29. AMOUNT PAID

Enter the total of payments received from other sources on this claim. Do not include amounts previously paid by Medicaid.

30. BALANCE DUE

From the total charge, subtract amounts received from other sources and enter the result.

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

The performing provider or an individual authorized by the performing provider or by an institutional, corporate, business or other provider organization, must sign and date the claim, certifying that the services were furnished by the provider, under (when applicable) the direction of the individual provider or other qualified individual, and in strict and verifiable accordance with all applicable rules of the Medicaid program in which the provider participates. A "provider's signature" is the provider's or authorized individual's personally written signature, a rubber stamp of the signature, an automated signature or a typed signature. The name of a group practice, a facility or institution, a corporation, a business or any other organization will prevent the claim from being processed.

32. SERVICE FACILITY

LOCATION INFORMATION

If services were not performed at the beneficiary's home or at the provider's facility (e.g., school, DDS facility etc.) enter the name, street address, city, state and zip code of the facility, workplace etc. where services were performed. If services were furnished at multiple sites (for instance, when job-seeking), indicate "multiple locations" or leave blank.

a. (blank)

Not required.

b. (blank)

Not required.

33. BILLING PROVIDER INFO & PH #

Billing provider's name and complete address. Telephone number is requested but not required.

a. (blank)

Not required.

b. (blank)

Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.