Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-016 - Section V (7-1-09) and Epsdt Update # 120
Current through Register Vol. 49, No. 9, September, 2024
Section V Provider Manual Update Transmittal
Provider Inter-office Use
Patient Charting and Electronic Billing Documention Version Only
This Copy Not To Be Used For Paper Claim Billing
Instructions for Completion of the EPSDT Claim Form - DMS-694
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 which require attachments or manual pricing.
To bill for a Child Health Services (EPSDT) screening service, use the claim form DMS-694. The numbered items correspond to numbered fields on the claim form. The DMS-694 is used as a combined referral, screening results document and a billing form. Each screening should be billed separately, providing the appropriate information for each of the screening components. The following numbered items correspond to numbered fields on the claim form.
Medical services such as immunizations and laboratory procedures may also be billed on the DMS-694 when provided in conjunction with a Child Health Services (EPSDT) screening, as well as other treatment services provided.
The following instructions must be read and carefully adhered to, 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. Patient's Last Name |
Enter the patient's last name. |
|
2. Patient's First Name |
Enter patient's first name. |
|
3. Patient's Middle Initial |
Enter patient's middle initial. |
|
4. Patient's Sex |
Check "M" for male or "F" for female. |
|
5. Patient's Medicaid ID No. |
Enter the entire 10-digit patient Medicaid identification number. |
|
6. Casehead's Name |
Enter the casehead name for TEA children only. Patient's name has been requested in Blocks 1, 2 and 3. |
|
7. County of Residence |
Enter the patient's county of residence. |
|
8. Date of Birth |
Enter the patient's date of birth in month and year format as it appears on the Medicaid identification card. |
|
9. Street Address |
Enter the patient's street address. |
|
10. City |
Enter the patient's city of residence. |
|
11. If a Patient is a Referral Enter Name of Referring Physician Provider Number |
If the patient is a referral, enter the name of the referring physician and his or her provider number. |
|
12. Medical Record Number |
This is an optional entry that the provider may use for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alpha characters will be accepted. This number will appear on the Remittance Advice (RA) and is a method of identifying payment of the claim. |
|
13. Provider Phone Number Pay To: Provider Name and Address Pay To: Provider Number |
Enter the provider's complete name, address, and provider number. If a clinic billing is involved, use the clinic provider number. Telephone number is requested but not required. |
|
14. Other Health Insurance Coverage (Enter Name of Plan and Policy Number) |
If applicable, enter the name of the insurance plan and the policy number of any health insurance coverage carried by the patient other than Medicaid. The patient's Medicaid identification card should indicate "Yes" if other coverage is carried by the beneficiary. |
|
15. Was Condition Related to: A. Patient's Employment B. An Accident |
Check "Yes" if the patient's condition was employment related. If the condition was not employment related, check "No." Check "Yes" if the patient's condition was related to an accident. Check "No" if the condition was not accident related. |
|
16. Primary Diagnosis or Nature of Injury Diagnosis Code |
Enter the description of the primary reason for treatment of the patient. Enter the ICD-9-CM Code that identifies the primary diagnosis. |
|
18. Type of Screen Periodic Interperiodic |
Not required for Medicaid. Completed by Human Services, if applicable. |
|
SECTION II |
|
|
19. Social Worker Identification |
Not required for Medicaid. Completed by Human Services, if applicable. This section is used by school districts and education service cooperatives enrolled in the EPSDT program to include an LEA code. |
|
SECTION III |
|
|
20. Examination Report |
To be completed by screening provider at time of screen. |
|
A. Basic Screening Item A, Numbers 1 through 6 Item A, Number 7 |
Check "Normal" or "Abnormal" for each component. Check "Counseled," "Treated" or "Referred" as applicable. Give results of the lab tests performed at the time of screen. |
|
Item B |
Immunization status appropriate forage and health history. If immunization cannot be performed, note the reason along with the return appointment in "Comments" section. |
|
ItemC |
Enter any other services rendered. |
|
21. Comments |
Briefly explain any problems identified and describe |
|
treatment or referral. If referred, indicate the name of the provider to whom the referral was made. |
|
|
22. A. Date of Service |
Enter the "from" and "to" dates of service for each service provided in MM/DD/YY format. A single date of service need not be entered twice on the same line. |
|
B. Place of Service |
Enter the appropriate place of service code. See Section 242.200 for codes. |
|
C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances) Procedure Code (Identify) |
Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.). |
|
D. Diagnosis Code |
Enter the ICD-9-CM code, which corresponds with the procedures performed. |
|
E. Charges |
Enter the charges for the rendered services. These charges should be the provider's current usual and customary fee to private clients. |
|
F. Days or Units |
Enter days or units of service rendered. |
|
G. TOS |
Enter the appropriate type of service code. See Section 242.200 for codes. |
|
H. Performing Provider Number |
If the billing provider noted in Block 13 is a clinic or group, enter the attending provider's provider number. |
|
23. Total Charges |
Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form. |
|
24. Covered by Insurance |
Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24. |
|
25. Balance Due |
Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. |
|
26. Provider's Signature |
The provider or designated authorized individual must sign 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, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
|
27. Billing Date |
Enter date signed. |
Provider Manual Update Transmittal #120
Section II
Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment
Screening, Diagnosis and Treatment (EPSDT) Program
The following steps are necessary in order to complete a Child Health Services (EPSDT) screen:
A full medical screen must, at a minimum, include: a comprehensive health and developmental history (including assessment of both physical and mental health development); a comprehensive unclothed physical exam; appropriate immunizations according to age and health history; laboratory tests (including appropriate blood lead level assessment); and health education (including anticipatory guidance).
All parts of the screening package must be furnished to the Child Health Services (EPSDT) participant in order for the screening to qualify as a full medical Child Health Services (EPSDT) screening service.
I mmunizations that are appropriate based on age and health history, but which are contraindicated at the time of the screening, may be rescheduled at an appropriate time or referred to another provider.
The prescription for services must be dated by the provider referring the patient. The prescription for the non-covered service is acceptable if services were prescribed and the prescription is dated within the applicable periodicity schedule, not to exceed a maximum of 12 months.
The Department of Human Services (DHS) county offices will continue to refer Medicaid beneficiaries to providers for Child Health Services (EPSDT) screens. However, a provider may initiate the health screen for an eligible beneficiary at the appropriate time without a referral from the DHS county office.
An eligible child must be referred by the PCP, if the child is to be screened by a provider who is not the PCP.
|
Field Name and Number |
Instructions for Completion |
|
|
1. |
Patient's Last Name |
Enter the patient's last name. |
|
2. |
Patient's First Name |
Enter patient's first name. |
|
3. |
Patient's Middle Initial |
Enter patient's middle initial. |
|
4. |
Patient's Sex |
Check "M" for male or "F" for female. |
|
5. |
Patient's Medicaid ID No. |
Enter the entire 10-digit patient Medicaid identification number. |
|
6. |
Casehead's Name |
Enter the casehead name for TEA children only. Patient's name has been requested in Blocks 1, 2 and 3. |
|
7. |
County of Residence |
Enter the patient's county of residence. |
|
8. |
Date of Birth |
Enter the patient's date of birth in month and year format as it appears on the Medicaid identification card. |
|
9. |
Street Address |
Enter the patient's street address. |
|
10 |
. City |
Enter the patient's city of residence. |
|
11 |
. If a Patient is a Referral Enter Name of Referring Physician Provider Number |
If the patient is a referral, enter the name of the referring physician and 9-digit Medicaid provider number, if available. |
|
12 |
. Medical Record Number |
This is an optional entry that the provider may use for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alpha characters will be accepted. This number will appear on the Remittance Advice (RA) and is a method of identifying payment of the claim. |
|
13 |
. Provider Phone Number Pay To: Provider Name and Address Pay To: Provider Number |
Enter the provider's complete name, address and 9-digit Arkansas Medicaid provider number. If a clinic billing is involved, use the 9-digit clinic provider number. Telephone number is requested but not required. |
|
14 |
. Other Health Insurance Coverage (Enter Name of Plan and Policy Number) |
If applicable, enter the name of the insurance plan and the policy number of any health insurance coverage carried by the patient other than Medicaid. The patient's Medicaid identification card should indicate "Yes" if other coverage is carried by the beneficiary. |
|
15 |
. Was Condition Related to: A. Patient's Employment B. An Accident |
Check "Yes" if the patient's condition was employment related. If the condition was not employment related, check "No." Check "Yes" if the patient's condition was related to an accident. Check "No" if the condition was not accident related. |
|
16 |
. Primary Diagnosis or Nature of Injury Diagnosis Code |
Enter the description of the primary reason for treatment of the patient. Enter the ICD-9-CM Code that identifies the primary diagnosis. |
|
18 |
. Type of Screen Periodic Interperiodic |
Not required for Medicaid. Completed by Human Services, if applicable. |
|
SECTION II |
||
|
19. Ide |
Social Worker ntification |
This section is used by school districts and education cooperatives enrolled in the EPSDT program to include a Local Education Agency (LEA) code. |
|
SECTION III |
||
|
20. |
Examination Report |
To be completed by screening provider at time of screen. |
|
A. |
Basic Screening |
|
|
Item A, Numbers 1 through 6 |
Check "Normal" or "Abnormal" for each component. Check "Counseled," "Treated" or "Referred" as applicable. |
|
|
Item A, Number 7 |
Give results of the lab tests performed at the time of screen. |
|
|
Item B |
Immunization status appropriate for age and health history. If immunization cannot be performed, note the reason along with the return appointment in "Comments" section. |
|
|
ItemC |
Enter any other services rendered. |
|
|
21. |
Comments |
Briefly explain any problems identified and describe treatment or referral. If referred, indicate the name of the provider to whom the referral was made. |
|
22. |
A. Date of Service |
Enter the "from" and "to" dates of service for each service provided in MM/DD/YY format. A single date of service need not be entered twice on the same line. |
|
B. Place of Service |
Enter the appropriate place of service code. See Section 242.200 for codes. |
|
|
C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances) Procedure Code (Identify) |
Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.). |
|
|
D. Diagnosis Code |
Enter the ICD-9-CM code, which corresponds with the procedures performed. |
|
|
E. Charges |
Enter the charges for the rendered services. These charges should be the provider's current usual and customary fee to private clients. |
|
|
F. Days or Units |
Enter days or units of service rendered. |
|
|
G. Performing Provider Number |
If the billing provider noted in Block 13 is a clinic or group, enter the attending provider's 9-digit Arkansas Medicaid provider number. |
|
|
23. |
Total Charges |
Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form. |
|
24. |
Covered by Insurance |
Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24. |
|
25. |
Balance Due |
Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. |
|
26. |
Provider's Signature |
The provider or designated authorized individual must sign 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, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
|
27. |
Billing Date |
Enter date signed. |
