Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.12-014 - AAPD-1-11; ASC-2-11; DDSACS-1-11; DDTCS-1-11; FQHC-1-11; Hospital-4-11; INCHOICE-2-11; INPPSYCH-1-11; LCAL-1-11; MEDX-1-11; PERSCARE-3-11; PHYSICN-3-11; PORTX-1-11; RURLHLTH-1-11; TRANSP-3-11; SECI-4-11 and SECV-12-1 - Special Language
Current through Register Vol. 49, No. 9, September, 2024
211.000 Scope
The Arkansas Medicaid Program offers certain home and community-based outpatient services as an alternative to nursing home placement. These services are available to individuals with physical disabilities age 21 through 64 who have received a determination of physical disability by SSI/SSA or DHS Medical Review Team (MRT) and who, without the provision of home and community-based services, would require a nursing facility (NF) level of care. The participant's income must be equal to or less than 300% of the SSI eligibility limit.
The community-based services offered through the Alternatives for Adults with Physical Disabilities Home and Community-Based Waiver, described herein as Alternatives, are as follows:
These services are designed to maintain Medicaid eligible beneficiaries at home in order to preclude or postpone institutionalization of the individual.
Please note that in accordance with 42 CFR 441.301(b)(l)(ii), alternatives services are not covered for inpatients of nursing facilities, hospitals or other inpatient institutions.
213.200 Attendant Care Service
Attendant Care Service is assistance to a medically stable individual with a physical disability in accomplishing tasks of daily living that the participant is unable to complete independently. Assistance may vary from actually doing a task for the participant, to assisting the participant to perform the task or to providing safety support while the participant performs the task. Housekeeping activities that are incidental to the performance of care may also be furnished. Housekeeping activities as described above may not exceed 20% of the Attendant's overall time worked as authorized on the waiver plan of care. Attendant Care Services may also include supervision, companion services, socialization, and transportation assistance when it is incidental to providing Attendant Care services, accompanying a participant to assist with shopping, errands, etc.
Parti cipants who can comprehend the rights and accept the responsibilities of consumer-directed care may wish to have Alternatives Attendant Care Services included on their plan of care. The participant's plan of care will be submitted to the attending physician for his or her review and approval.
C To aid in the Attendant Care recruitment process, participants will be apprised of the minimum qualifications set forth for provider certification (See Section 213.220) and the Medicaid enrollment and reimbursement process. The participant will be instructed to notify the DAAS Rehab Counselor or RN when an attendant has been recruited. The DAAS Waiver Counselor or RN will facilitate the development of a formal service agreement between the participant and the Attendant, using the form AAS-9512, Attendant Care Service Agreement. Instructions are provided with the Attendant Care packet.
D When the AAS-9512, Attendant Care Service Agreement, is finalized, the Attendant will apply for DAAS certification and Medicaid provider enrollment. The DAAS Rehab Counselor or RN or designee will assist as needed to expedite this process. As an enrolled Medicaid provider, the attendant will be responsible for all applicable Medicaid participation requirements, including claims submission.
Service agreements and required tax documents do not transfer from one waiver client to another or from one waiver provider to another. All service agreements and tax forms are specific to each employer and employee working arrangement.
213.300 Agency Attendant Care
Agency Attendant Care services are the provision of assistance to a medically stable individual with a physical disability to accomplish those tasks of daily living that the individual is unable to complete independently and that are performed by an Attendant Care employee hired by an agency selected by the waiver participant. Assistance may vary from actually doing a task for the individual to assisting the individual with the task or to providing safety support while the individual performs the task. Housekeeping activities that are incidental to the performance of care may also be furnished. Housekeeping activities as described above may not exceed 20% of the attendant's overall time worked as authorized on the waiver plan of care. Agency Attendant Care Services may also include supervision, companion services, socialization, and transportation assistance when it is incidental to providing Attendant Care Services while accompanying a participant to assist with shopping, errands, etc.
If Agency Attendant Care Services are selected, participants may choose to have their services provided through an agency that is certified by the Division of Aging and Adult Services to provide Agency Attendant Care. When the participant chooses to have Attendant Care Services provided through an agency, the participant may choose one of two agency Attendant Care Services options:
) participant/co-employer where the participant functions as the co-employer (managing employer) of employees hired by an Attendant Care agency, and the agency manages the hiring and fiscal responsibilities or 2) a traditional agency model for Attendant Care Services where the agency performs both the managing of the Attendant Care employee and hiring and fiscal responsibilities.
If the participant chooses the traditional agency model option, the agency performs both the responsibilities of managing the Attendant Care employee and the hiring and fiscal responsibilities. Participants who decide to have their Attendant Care services provided through an agency may wish to have Alternatives Agency Attendant Care Services included on their plan of care. The participant's plan of care is submitted to the participant's attending physician for his or her review and approval.
216.500 Acknowledgement Statement for Hysterectomies and Sterilization
Consent Form
The acknowledgement statement for hysterectomies must be signed by the patient or a representative and the sterilization consent form must be signed by the patient. For beneficiaries with physical disabilities, these required statements must be signed by the patient. If the patient signs with an "X," two witnesses must also sign and include a statement regarding the reason the patient signed with an "X," such as, stroke, paralysis, legally blind, etc. This procedure is to be used for patients who are not mentally impaired.
For hysterectomies for individuals with intellectual disabilities, the acknowledgement of sterility statement is required. A guardian must petition the court for permission to sign for the patient giving consent for the procedure to be performed. A copy of the court petition and the acknowledgement statement must be attached to the claim. Sterilization procedures for birth control purposes are not covered for the mentally incompetent.
214.000 Respite Services
Respite services are provided on a short-term basis to beneficiaries unable to care for themselves due to the absence of or need for relief of non-paid primary caregivers. Room and board may not be claimed when respite is provided in the beneficiary's home or a private place of residence. Room and board is not a covered service except when provided as part of respite furnished in a facility that is approved by the State as a respite care facility.
Receipt of respite services does not necessarily preclude a beneficiary from receiving other services on the same day. For example, a beneficiary may receive day services, such as supported employment, on the same day as respite services.
When respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Respite may not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Respite services are not to supplant the responsibility of the parent or guardian.
Respite services may be provided through a combination of basic child care and support services required to meet the needs of a child. When respite is provided in a licensed day care facility, licensed day care home or other lawful child care setting, waiver will only pay for the support staff required by the beneficiary's developmental disability. Parents and guardians will remain responsible for the cost of basic child care fees.
Respite services are separate and distinct from educational services provided at a school where attendance is mandated and the primary focus of the institution is the accomplishment of specified educational goals.
Respite may be provided in the following locations:
214.131 Early Intervention
Early intervention is a facility-based program designed to provide one-on-one direct training to the child and the parent or caregiver. The intent of early intervention is to work with parents and caregivers to assist them with training the child. The parent or caregiver of the child must participate in the programming to learn how to work with the child in the home.
214.132 Pre-School
Pre-school service is a facility-based program designed to provide specialized services to children who have been diagnosed with a developmental disability or developmental delay and who are not school age. School age is defined as having reached the age of five years on or before the date set by the Arkansas Department of Education. A child reaching age five after that date is not considered school age until the next school year.
Services must be provided for the purpose of teaching habilitation goals as set forth in the plan of care. Services are established on a unit-of-service basis. Each unit of service equals one hour. A maximum of five units per day is allowed.
Time spent in transit from the person's place of residence to the provider facility and from the facility back to the person's place of residence is not included in the unit of service calculation.
214.133 Adult Development
Adult development is a facility-based program providing specialized habilitation services to adults who have been diagnosed with a developmental disability. Qualifying individuals must be between ages 18 and 21 with a diploma or certificate of completion, or age 21 and older.
Commensurate wage must be paid under a current Wage and Hour Sheltered Workshop Certificate.
Adult development services are established on a unit-of-service basis. Each unit of service equals one hour in the facility with a maximum of five units reimbursable per day.
Time spent in transit from the person's place of residence to the provider facility and from the facility back to the person's place of residence is not included in the unit of service calculation.
216.410 Informed Consent to Sterilization
Either of these exceptions to the 30-day waiting period must be properly documented on the form DMS-615. View or print Sterilization Consent Form DMS-615 and checklist.
212.100 Scope - Inpatient
"Inpatient hospital services" are defined in the Arkansas Medical Assistance Program as those items and services ordinarily furnished by the hospital for care and treatment of inpatients and are provided under the direction of a licensed practitioner (physician or dentist with staff affiliation) of a facility maintained primarily for treatment and care of injured persons, individuals with disabilities, or sick persons. Such inpatient services must be medically justified, documented, certified and re-certified by the Quality Improvement Organization (QIO) and are payable by Medicaid if provided on a Medicaid covered day.
A "Medicaid covered day" is defined as a day for which the recipient is Medicaid eligible, the patient's inpatient benefit has not been exhausted, the patient's inpatient stay is medically necessary, the day is not part of a hospital stay for a non-payable procedure or non-authorized procedure (see Sections 220.000 and 244.000), and the claim is filed on time. (See Section III of this manual for reference to "Timely Filing.")
The following services are covered inpatient hospital services if medically necessary for treatment of the patient and if the date of service is a Medicaid covered day:
"Accommodation" means the type of room provided for the patient while receiving inpatient hospital services. The Medicaid Program will cover the semi-private room or ward accommodations and intensive care. A private room will only be covered when such accommodations are medically necessary, as certified by the patient's attending physician. Private rooms are considered medically necessary only when the patient's condition requires him or her to be isolated to protect his or her health or welfare, or to protect the health of others.
Operating room charges for services and supplies associated with surgical procedures are covered inpatient hospital services.
Anesthesia charges for services and/or supplies furnished by the hospital are covered inpatient hospital services.
Blood, blood components and blood administration charges are covered when not available to the recipient from other sources. Hospitals are encouraged to replace blood that is used by a Medicaid recipient through his or her friends and relatives, or through the Red Cross whenever possible.
Drugs and biologicals furnished by the hospital for the care and treatment of patients are covered inpatient hospital services. Take-home drugs are non-covered inpatient hospital services under the Arkansas Medicaid Program.
The coverage of inpatient hospital services includes the non-physician services related to machine tests, laboratory and radiology procedures provided to inpatients. The hospital where the patient is hospitalized will be responsible for providing or securing these services. The party who furnishes these non-physician services is permitted to bill only the hospital.
If a patient is transferred to another hospital to receive services on an outpatient basis, the cost of the transfer is included in the hospital reimbursement amount. The ambulance company may not bill Medicaid or the recipient for the service.
Necessary medical and surgical supplies and equipment that are furnished by the hospital for the care and treatment of patients are covered inpatient hospital services. Supplies and equipment for use outside the hospital are not covered by Medicaid.
Physical and inhalation therapy and other necessary services, as well as supply charges for these services that are furnished by the hospital, are covered inpatient hospital services.
Delivery room charges for services and supplies associated with obstetrical procedures are covered inpatient hospital services.
Services other than the non-covered services identified in Section 212.200, which are not specified above.
216.410 Informed Consent to Sterilization
200.100 IndependentChoices
The Arkansas Department of Human Services (DHS) was granted an 1115 Research and Demonstration waiver to implement IndependentChoices, a Cash and Counseling Demonstration and Evaluation Project in 1998. On April 1, 2008, the IndependentChoices program became a state plan service under 1915(j) of the Social Security Act. IndependentChoices is operated by the Division of Aging and Adult Services (DAAS). The program offers Medicaid-eligible aged and individuals with disabilities an opportunity to self-direct their personal assistant services.
The IndependentChoices program has been operational since 1998. Some of the results of evaluations performed by Mathematica Policy Research, Inc. specifically identified these results that may positively impact community services in Arkansas:
Operation of the IndependentChoices program as a state plan service will use the positive foundation established through lessons learned as an 1115 Research and Demonstration Waiver to continue to offer opportunities for improved life in the community.
IndependentChoices seeks to increase the opportunity for consumer direction and control for Medicaid beneficiaries receiving or needing personal assistant services. Personal Assistant services in IndependentChoices include state plan personal care for Medicaid beneficiaries and Adult Companion and Homemaker services for ElderChoices beneficiaries. IndependentChoices offers an allowance and counseling services in place of traditional agency-provided personal assistance services and items related to personal assistance needs.
The participant or designee is the employer and accepts the responsibility in directing the work of their employee to the degree necessary to meet their individual needs for assistance with activities of daily living and instrumental activities of daily living.
If the IC participant can make decisions regarding his or her care but does not feel comfortable reading and filling out forms or talking on the phone, he or she can appoint a Communications Manager. The Communications Manger can act as the participant's voice and complete and sign forms, etc., but will not make decisions for the participant. The Communications Manager will not hire, train, supervise or fire the personal assistant for the IC participant.
If the participant needs someone to hire and supervise the personal assistant, make decisions about care and administer the cash expenditure plan as well as complete all forms, a Decision-Making Partner will be appointed.
IndependentChoices participants or their Decision-Making Partners must be able to assume the responsibilities of becoming an employer by hiring, training, supervising and firing if necessary their directly hired workers. In doing so the program participant accepts the risks, rights and responsibilities of directing their care and having their health care needs met.
The IndependentChoices program respects the employer authority of the Medicaid beneficiary who chooses to direct his or her care by hiring an employee who will be trained by the employer or Decision-Making Partner to provide assistance how, when, and where the employer or Decision-Making Partner determines will best meet the participant's individual needs. The Medicaid beneficiary assumes the risks, rights and responsibilities of having their health care needs met in doing so.
215.220 Composition of the Facility-Based Team (42 CFR 441.156)
210.000 PROGRAM COVERAGE
Living Choices Assisted Living is a home and community-based services waiver program that is administered jointly by the Division of Medical Services (DMS, the state Medicaid agency) and the Division of Aging and Adult Services (DAAS), under the waiver authority of Section 1915(c) of the Social Security Act. Home and community-based services waiver programs cover services designed to allow specific populations of individuals to live in their own homes or in certain types of congregate settings.
The rules and regulations for licensure of Level II Assisted Living Facilities (ALF) are administered by the Office of Long Term Care within DMS. As agencies of the Arkansas Department of Human Services (DHS), DAAS, DMS and the Division of County Operations (DCO) administer the policies and procedures and the rules and regulations governing provider and beneficiary participation in the Living Choices Program.
Individuals found eligible for the Living Choices Program may participate in the program only as residents of licensed Level II ALF.
211.100 Eligibility for the Living Choices Assisted Living Program
214.000 Eligibility Criteria for QMB Program
This program has been designed to assist low income elderly and individuals with disabilities who are covered by Medicare Part A. The person must be 65 or older, blind or an individual with a disability and eligible for or enrolled in Medicare Part A. Arkansas Medicaid also covers Part B medical services coinsurance and deductible amounts for beneficiaries enrolled under the above criteria.
Beneficiaries interested in applying for the QMB Program should contact their local county Department of Human Services office. The applicant should call the county office to inquire about the eligibility criteria, what documents are needed to determine eligibility and whether an appointment is necessary.
204.200 Medical Criteria
PACE participants must meet one of the following criteria: The individual is unable to perform either of the following:
NOTE: If an individual has a diagnosis of serious mental illness or mental retardation, the individual will not be eligible for PACE unless the individual has medical needs unrelated to the diagnosis of serious mental illness or mental retardation and meets the criteria set out in Sections 204.100 and 204.200 above.
213.540 Employment-related Personal Care Outside the Home
No condition of this section alters or adversely affects the status of individuals who are furnished personal care in sheltered workshops or similarly authorized habilitative environments. There may be a few beneficiaries working in sheltered workshops solely or primarily because they have access to personal care in that setting. This expansion of personal care outside the home may enable some of those individuals to move or attempt to move into an integrated work setting.
contact the Department of Human Services local office in the county in which the beneficiary resides.
217.120 Duration of Benefit Extension
244.000 Duration of PA
251.280 Hysterectomies
Hysterectomies, except those performed for malignant neoplasm, carcinoma in-situ and severe dysplasia will require prior authorization regardless of the age of the beneficiary. (See Section 261.100 of this manual for instructions for obtaining prior authorization.) Those hysterectomies performed for carcinoma in-situ or severe dysplasia must be confirmed by a tissue report. The tissue report must be obtained prior to surgery. Cytology reports alone will not confirm the above two diagnoses, nor will cytology reports be considered sufficient documentation for performing a hysterectomy. Mild or moderate dysplasia is not included in the above and any hysterectomy performed for mild or moderate dysplasia will require prior authorization.
The patient or her representative, if any, must sign and date the Acknowledgement of Hysterectomy Information (Form DMS-2606) not more than 180 days prior to the hysterectomy procedure being performed. View or print form DMS-2606 and instructions for completion. Copies of this form can be ordered from HP Enterprise Services according to the procedures in Section III.
If an individual has a physical disability and signs the consent form with an "X," two witnesses must also sign and include a statement regarding the reason the patient signed with an "X," such as stroke, paralysis, legally blind, etc
Please note that the acknowledgement statement must be submitted with the claim for payment. The Medicaid agency will not approve any hysterectomy for payment until the acknowledgement statement has been received.
If the patient needs the Acknowledgement of Hysterectomy Information Form (DMS-2606) in an alternative format, such as large print, contact our Americans with Disabilities Coordinator. View or print the Americans with Disabilities Coordinator contact information.
For hysterectomies for the mentally incompetent, the acknowledgement of sterility statement is required. A guardian must petition the court for permission to sign for the patient giving consent for the procedure to be performed. A copy of the court petition and the acknowledgement statement must be attached to the claim.
All hysterectomies paid by Federal and State funds will be subject to random selection for post-payment review. At the time of such review, the medical records must document the medical necessity of hysterectomies performed for carcinoma in-situ and severe dysplasia and must contain tissue reports confirming the diagnosis. The tissue must have been obtained prior to surgery.
The medical record of those hysterectomies performed for malignant neoplasms must contain a tissue report confirming such a diagnosis. However, the tissue may be obtained during surgery, e.g., frozen sections. Any medical record found on post-payment review which does not contain a tissue report confirming the diagnosis or any medical record found which does not document the medical necessity of performing such surgery will result in recovery of payments made for that surgery.
Medicaid does not coverany hysterectomy performed for the sole purpose of sterilization.
217.231 Informed Consent to Sterilization
261.000 Arkansas Medicaid Participation Requirements for DDTCS
Transportation Providers
All non-emergency medical transportation will be provided by the transportation broker for the region in which the beneficiary lives with the exception of transportation to and from a Developmental Day Treatment Clinic Services (DDTCS) center when the transportation is provided by the center.
The DDTCS provider may choose to provide transportation services for individuals with developmental disabilities as a fee-for-service provider to and from a DDTCS facility. A transportation broker must provide transportation to and from medical providers.
The DDTCS transportation providers must meet the following criteria to be eligible for participation in the Arkansas Medicaid Program:
105.100 Alternatives for Adults with Physical Disabilities
The Alternatives for Adults with Physical Disabilities (APD) waiver program is for individuals with a physical disability age 21 through 64 who receive Supplemental Security Income (SSI) or who are Medicaid eligible by virtue of their disability and who, but for 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 and a cost comparison to determine the cost-effectiveness of the plan of care. The beneficiary must be notified that he/she may choose either home and community-based services or institutional services.
The services offered through the waiver are:
These services are available only to individuals who are eligible under the waiver's conditions. Detailed information is found in the APD provider manual.
105.160 Living Choices Assisted Living
Living Choices Assisted Living is a home- and community-based services waiver that is administered jointly by the Division of Aging and Adult Services (DAAS) and the Division of Medical Services (DMS). Qualifying individuals are Medicaid-eligible persons aged 21 and older who have been determined by Medicaid to be eligible for an intermediate level of care in a nursing facility. The individual must be a person with a physical disability, blind or elderly.
Parti cipants in Living Choices must reside in Level II assisted living facilities (ALFs), in apartment-style living units. The assisted living environment encourages and protects individuality, privacy, dignity and independence. Each Living Choices participant receives personal, health and social services in accordance with an individualized plan of care developed and maintained in cooperation with a DAAS-employed registered nurse. A participant's individualized plan of care is designed to promote and nurture his or her optimal health and well being.
Living Choices providers furnish "bundled services" in the amount, frequency and duration required by the Living Choices plans of care. They facilitate participants' access to medically necessary services that are not components of Living Choices bundled services, but which are ordered by participants' plans of care. Living Choices providers receive per diem Medicaid reimbursement for each day a participant is in residence and receives services. The per diem amount is based on a participant's "tier of need," which DAAS-employed RNs determine and periodically re-determine by means of comprehensive assessments performed in accordance with established medical criteria. There are four tiers of need.
Living Choices participants are eligible to receive up to nine Medicaid-covered prescriptions per month. More detailed information may be found in the Living Choices Assisted Living provider manual.
122.200 District Social Security Offices
Social Security representatives are responsible for evaluating an individual's circumstances to determine eligibility for the Supplemental Security Income (SSI) program administered by the Social Security Administration. SSI includes aged, blind and permanently and totally disabled categories. The SSI aid categories are listed in Section 124.000.
To be eligible for SSI, an individual must be aged, blind or be an individual with a permanent and total disability. All income, resource and other eligibility criteria must be met.
Individuals entitled to SSI automatically receive Medicaid.
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 coinsurance, less any Medicaid cost sharing. Medicaid pays 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 individuals considered to be Medicare/Medicaid dually eligible 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 an individual with a disability and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal but 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). QMB generally do not have Medicaid coverage for any service that is not covered under Medicare; with the exception of the above listed categories and individuals dually eligible.
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 (by Medicare's definition) or non-physician 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 an individual with a disability 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 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 forQMB program. The individuals must be aged 65 or older, blind or an individual with disabilities 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.
124.230 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, with a disability as 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:
Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as "WD RegCO."
Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as "WD NewCo".
The cost sharing amounts for the "WD NewCo" eligibles are listed in the chart below:
|
Program Services |
New Co-Payment* |
|
Ambulance |
$10 per trip |
|
Ambulatory Surgical Center |
$10 per visit |
|
Audiological Services |
$10 per visit |
|
Augmentative Communication Devices |
10% of the Medicaid maximum allowable amount |
|
Child Health Management Services |
$10 per day |
|
Chiropractor |
$10 per visit |
|
Dental |
$10 per visit (no co-pay on EPSDT dental screens) |
|
Developmental Disability Treatment Center |
$10 per day |
|
Services |
|
|
Diapers, Underpads and Incontinence Supplies |
None |
|
Domiciliary Care |
None |
|
Durable Medical Equipment (DME) |
20% of Medicaid maximum allowable amount per DME item |
|
Emergency Department: Emergency Services |
$10 per visit |
|
Emergency Department: Non-emergency Services |
$10 per visit |
|
End Stage Renal Disease Services |
None |
|
Early and Periodic Screening, Diagnosis and Treatment |
None |
|
Eyeglasses |
None |
|
Family Planning Services |
None |
|
Federally Qualified Health Center (FQHC) |
$10 per visit |
|
Hearing Aids (not covered for individuals aged 21 and over) |
10% of Medicaid maximum allowable amount |
|
Home Health Services |
$10 per visit |
|
Hospice |
None |
|
Hospital: Inpatient |
25% of the hospital's Medicaid per diem for the first Medicaid-covered inpatient day |
|
Hospital: Outpatient |
$10 per visit |
|
Hyperalimentation |
10% of Medicaid maximum allowable amount |
|
Immunizations |
None |
|
Laboratory and X-Ray |
$10 per encounter, regardless of the number of services per encounter |
|
Medical Supplies |
None |
|
Inpatient Psychiatric Services for Under Age 21 |
25% of the facility's Medicaid per diem for the first Medicaid-covered day |
|
Outpatient Behavioral Health |
$10 per visit |
|
Nurse Practitioner |
$10 per visit |
|
Private Duty Nursing |
$10 per visit |
|
Certified Nurse Midwife |
$10 per visit |
|
Orthodontia (not covered for individuals aged 21 and older) |
None |
|
Orthotic Appliances |
10% of Medicaid maximum allowable amount |
|
Personal Care |
None |
|
Physician |
$10 per visit |
|
Podiatry |
$10 per visit |
|
Prescription Drugs |
$10 for generic drugs; $15 for brand name |
|
Prosthetic Devices |
10% of Medicaid maximum allowable amount |
|
Rehabilitation Services for Persons with Physical Disabilities (RSPD) |
25% of the first covered day's Medicaid inpatient per diem |
|
Rural Health Clinic |
$10 per core service encounter |
|
Targeted Case Management |
10% of Medicaid maximum allowable rate per unit |
|
Occupational Therapy (Age 21 and older have limited coverage**) |
$10 per visit |
|
Physical Therapy (Age 21 and older have limited coverage**) |
$10 per visit |
|
Speech Therapy (Age 21 and older have limited coverage**) |
$10 per visit |
|
Transportation (non-emergency) |
None |
|
Ventilator Services |
None |
|
Visual Care |
$10 per visit |
* Exception:Cost sharing for nursing facility services is in the form of "patient liability" which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above.
** Exception:This service is NOT covered for individuals within the Occupational, Physical and Speech Therapy Program for individuals aged 21 and older.
NOTE: Providers must consult the appropriate provider manual to determine coverage and benefits.
SECTION IV - GLOSSARY
|
AAFP |
American Academy of Family Physicians |
|
AAP |
American Academy of Pediatrics |
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ABESPA |
Arkansas Board of Examiners in Speech-Language Pathology and Audiology |
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ACD |
Augmentative Communication Device |
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ACIP |
Advisory Committee on Immunization Practices |
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ACES |
Arkansas Client Eligibility System |
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ACS |
Alternative Community Services |
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ADE |
Arkansas Department of Education |
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ADH |
Arkansas Department of Health |
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ADL |
Activities of Daily Living |
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AFDC |
Aid to Families with Dependent Children (cash assistance program replaced by the Transitional Employment Assistance (TEA) program) |
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AFMC |
Arkansas Foundation for Medical Care, Inc. |
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AHEC |
Area Health Education Centers |
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ALF |
Assisted Living Facilities |
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ALS |
Advance Life Support |
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ALTE |
Apparent Life Threatening Events |
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AMA |
American Medical Association |
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APD |
Adults with Physical Disabilities |
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ARS |
Arkansas Rehabilitation Services |
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ASC |
Ambulatory Surgical Centers |
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AS HA |
American Speech-Language-Hearing Association |
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BIPA |
Benefits Improvement and Protection Act |
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BLS |
Basic Life Support |
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CARF |
Commission on Accreditation of Rehabilitation Facilities |
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CCRC |
Children's Case Review Committee |
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CFA |
One Counseling and Fiscal Agent |
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CFR |
Code of Federal Regulations |
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CHMS |
Child Health Management Services |
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CLIA |
Clinical Laboratory Improvement Amendments |
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CME |
Continuing Medical Education |
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CMHC |
Community Mental Health Center |
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CMS |
Centers for Medicare and Medicaid Services |
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COA |
Council on Accreditation |
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CON |
Certification of Need |
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CPT |
Physicians' Current Procedural Terminology |
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CRNA |
Certified Registered Nurse Anesthetist |
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CSHCN |
Children with Special Health Care Needs |
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CSWE |
Council on Social Work Education |
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D&E |
Diagnosis and Evaluation |
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DAAS |
Division of Aging and Adult Services |
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DBS |
Division of Blind Services (currently named Division of Services for the Blind) |
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DCFS |
Division of Children and Family Services |
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DCO |
Division of County Operations |
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DD |
Developmentally Disabled |
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DDS |
Developmental Disabilities Services |
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DDTCS |
Developmental Day Treatment Clinic Services |
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DHS |
Department of Human Services |
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DLS |
Daily Living Skills |
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DME |
Durable Medical Equipment |
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DMHS |
Division of Mental Health Services |
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DMS |
Division of Medical Services (Medicaid) |
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DOS |
Date of Service |
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DRG |
Diagnosis Related Group |
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DRS |
Developmental Rehabilitative Services |
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DSB |
Division of Services for the Blind (formerly Division of Blind Services) |
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DSH |
Disproportionate Share Hospital |
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DURC |
Drug Utilization Review Committees |
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DYS |
Division of Youth Services |
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EAC |
Estimated Acquisition Cost |
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EFT |
Electronic Funds Transfer |
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EIN |
Employer Identification Number |
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EOB |
Explanation of Benefits |
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EOMB |
Explanation of Medicaid Benefits. EOMB may also refer to Explanation of Medicare Benefits. |
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EPSDT |
Early and Periodic Screening, Diagnosis and Treatment |
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ESC |
Education Services Cooperative |
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FEIN |
Federal Employee Identification Number |
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FPL |
Federal Poverty Level |
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FQHC |
Federally Qualified Health Center |
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GME |
Graduate Medical Education |
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GUL |
Generic Upper Limit |
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HCBS |
Home and Community Based Services |
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HCPCS |
Healthcare Common Procedure Coding System |
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HDC |
Human Development Center |
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HHS |
The Federal Department of Health and Human Services |
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HIC Number |
Health Insurance Claim Number |
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HIPAA |
Health Insurance Portability and Accountability Act of 1996 |
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HMO |
Health Maintenance Organization |
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HP |
Hewlett Packard |
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IADL |
Instrumental Activities of Daily Living |
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ICD-9-CM |
International Classification of Diseases, Ninth Edition, Clinical Modification |
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ICF/MR |
Intermediate Care Facility/Mental Retardation |
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ICN |
Internal Control Number |
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IDEA |
Individuals with Disabilities Education Act |
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IDG |
Interdisciplinary Group |
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IEP |
Individualized Educational Program |
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IFSP |
Individualized Family Service Plan |
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IMD |
Institution for Mental Diseases |
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IPP |
Individual Program Plan |
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IUD |
Intrauterine Devices |
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JCAHO |
Joint Commission on Accreditation of Healthcare Organization |
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LAC |
Licensed Associate Counselor |
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LCSW |
Licensed Certified Social Worker |
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LEA |
Local Education Agencies |
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LMFT |
Licensed Marriage and Family Therapist |
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LMHP |
Licensed Mental Health Practitioner |
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LPC |
Licensed Professional Counselor |
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LPE |
Licensed Psychological Examiner |
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LSPS |
Licensed School Psychology Specialist |
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LTC |
Long Term Care |
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MAC |
Maximum Allowable Cost |
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MAPS |
Multi-agency Plan of Services |
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MART |
Medicaid Agency Review Team |
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MEI |
Medicare Economic Index |
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MMIS |
Medicaid Management Information System |
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MNIL |
Medically Needy Income Limit |
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MPPPP |
Medicaid Prudent Pharmaceutical Purchasing Program |
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MSA |
Metropolitan Statistical Area |
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MUMP |
Medicaid Utilization Management Program |
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NBCOT |
National Board for Certification of Occupational Therapy |
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NCATE |
North Central Accreditation for Teacher Education |
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NDC |
National Drug Code |
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NET |
Non-Emergency Transportation Services |
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NF |
Nursing Facility |
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NPI |
National Provider Identifier |
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OBRA |
Omnibus Budget Reconciliation Act |
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OHCDS |
Organized Health Care Delivery System |
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OTC |
Over the Counter |
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PA |
Prior Authorization |
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PAC |
Provider Assistance Center |
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PCP |
Primary Care Physician |
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PERS |
Personal Emergency Response Systems |
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PES |
Provider Electronic Solutions |
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PHS |
Public Health Services |
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PIM |
Provider Information Memorandum |
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PL |
Public Law |
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POC |
Plan of Care |
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POS |
Place of Service |
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PPS |
Prospective Payment System |
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PRN |
Pro Re Nata or "As Needed" |
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PRO |
Professional Review Organization |
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ProDUR |
Prospective Drug Utilization Review |
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QMB |
Qualified Medicare Beneficiary |
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QMRP |
Qualified Mental Retardation Professional |
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RA |
Remittance Advice. Also called Remittance and Status Report |
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RFP |
Request for Proposal |
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RHC |
Rural Health Clinic |
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RID |
Recipient Identification Number |
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RSPD |
Rehabilitative Services for Persons with Physical Disabilities |
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RSPMI |
Rehabilitation Services for Persons with Mental Illness |
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RSYC |
Rehabilitative Services for Youth and Children |
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RTC |
Residential Treatment Centers |
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RTP |
Return to Provider |
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RTU |
Residential Treatment Units |
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SBMH |
School-Based Mental Health Services |
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SD |
Spend Down |
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SFY |
State Fiscal Year |
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SMB |
Special Low Income Qualified Medicare Beneficiaries |
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SNF |
Skilled Nursing Facility |
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SSA |
Social Security Administration |
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SSI |
Supplemental Security Income |
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SURS |
Surveillance and Utilization Review Subsystem |
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TCM |
Targeted Case Management |
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TEA |
Transitional Employment Assistance |
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TEFRA |
Tax Equity and Fiscal Responsibility Act |
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TOS |
Type of Service |
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TPL |
Third Party Liability |
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UPL |
Upper Payment Limit |
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UR |
Utilization Review |
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VFC |
Vaccines for Children |
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VRS |
Voice Response System |
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Accommodation |
A type of hospital room, e.g., private, semiprivate, ward, etc. |
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Activities of Daily Living (ADL) |
Personal tasks that are ordinarily performed on a daily basis and include eating, mobility/transfer, dressing, bathing, toileting and grooming |
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Adjudicate |
To determine whether a claim is to be paid or denied |
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Adjustments |
Transactions to correct claims paid in error or to adjust payments from a retroactive change |
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Admission |
Actual entry and continuous stay of the beneficiary as an inpatient to an institutional facility |
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Affiliates |
Persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another |
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Agency |
The Division of Medical Services |
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Aid Category |
A designation within SSI or state regulations under which a person may be eligible for public assistance |
|
Aid to Families with Dependent Children (AFDC) |
A Medicaid eligibility category |
|
Allowed Amount |
The maximum amount Medicaid will pay for a service as billed before applying beneficiary coinsurance or co-pay, previous TPL payment, spend down liability or other deducted charges |
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American Medical Association (AMA) |
National association of physicians |
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Ancillary Services |
Services available to a patient other than room and board. For example: pharmacy, X-ray, lab and central supplies |
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Arkansas Client Eligibility System (ACES) |
A state computer system in which data is entered to update assistance eligibility information and beneficiary files |
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Arkansas Foundation for Medical Care, Inc. (AFMC) |
State professional review organization |
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Attending Physician |
See Performing Physician. |
|
Automated Eligibility Verification Claims Submission (AEVCS) |
On-line system for providers to verify eligibility of beneficiaries and submit claims to fiscal agent |
|
Base Charge |
A set amount allowed for a participating provider according to specialty |
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Beneficiary |
Person who meets the Medicaid eligibility requirements, receives an ID card and is eligible for Medicaid services (formerly recipient) |
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Benefits |
Services available under the Arkansas Medicaid Program |
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Billed Amount |
The amount billed to Medicaid for a rendered service |
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Buy-In |
A process whereby the state enters into an agreement with the Medicaid/Medicare and the Social Security Administration to obtain Medicare Part B (and part A when needed) for Medicaid beneficiaries who are also eligible for Medicare. The state pays the monthly Medicare premium(s) on behalf of the beneficiary. |
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Care Plan |
See Plan of Care (POC). |
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Casehead |
An adult responsible for an AFDC or Medicaid child |
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Categorically Needy |
All individuals receiving financial assistance under the state's approved plan under Title 1, IV-A, X, XIV and XVI of the Social Security Act or in need under the state's standards for financial eligibility in such a plan |
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Centers for Medicare and Medicaid Services |
Federal agency that administers federal Medicaid funding |
|
Child Health Services |
Arkansas Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program |
|
Children's Services |
A Title V Children with Special Health Care Needs Program administered by the Arkansas Division of Developmental Disabilities Services to provide medical care and service coordination to children with chronic physical illnesses or disabilities. |
|
Claim |
A request for payment for services rendered |
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Claim Detail |
See Line Item. |
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Clinic |
(1) A facility for diagnosis and treatment of outpatients. (2) A group practice in which several physicians work together |
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Coinsurance |
The portion of allowed charges the patient is responsible for under Medicare. This may be covered by other insurance, such as Medi-Pak or Medicaid (if entitled). This also refers to the portion of a Medicaid covered inpatient hospital stay for which the beneficiary is responsible. |
|
Contract |
Written agreement between a provider of medical services and the Arkansas Division of Medical Services. A contract must be signed by each provider of services participating in the Medicaid Program. |
|
Co-pay |
The portion of the maximum allowable (either that of Medicaid or a third-party payer) that the insured or beneficiary must pay |
|
Cosmetic Surgery |
Any surgical procedure directed at improving appearance but not medically necessary |
|
Covered Service |
Service which is within the scope of the Arkansas Medicaid Program |
|
Current Procedural Terminology |
A listing published annually by AMA consisting of current medical terms and the corresponding procedure codes used for reporting medical services and procedures performed by physicians |
|
Credit Claim |
A claim transaction which has a negative effect on a previously processed claim. |
|
Crossover Claim |
A claim for which both Titles XVIII (Medicare) and XIX (Medicaid) are liable for reimbursement of services provided to a beneficiary entitled to benefits under both programs |
|
Date of Service |
Date or dates on which a beneficiary receives a covered service. Documentation of services and units received must be in the beneficiary's record for each date of service. |
|
Deductible |
The amount the Medicare beneficiary must pay toward covered benefits before Medicare or insurance payment can be made for additional benefits. Medicare Part A and Part B deductibles are paid by Medicaid within the program limits. |
|
Debit Claim |
A claim transaction which has a positive effect on a previously processed claim |
|
Denial |
A claim for which payment is disallowed |
|
Department of Health and Human Services (HHS) |
Federal health and human services agency |
|
Department of Human Services (DHS) |
State human services agency |
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Dependent |
A spouse or child of the individual who is entitled to benefits under the Medicaid Program |
|
Diagnosis |
The identity of a condition, cause or disease |
|
Diagnostic Admission |
Admission to a hospital primarily for the purpose of diagnosis |
|
Disallow |
To subtract a portion of a billed charge that exceeds the Medicaid maximum or to deny an entire charge because Medicaid pays Medicare Part A and B deductibles subject to program limitations for eligible beneficiaries |
|
Discounts |
A discount is defined as the lowest available price charged by a provider to a client or third-party payer, including any discount, for a specific service during a specific period by an individual provider. If a Medicaid provider offers a professional or volume discount to any customer, claims submitted to Medicaid must reflect the same discount. |
|
Example: If a laboratory provider charges a private physician or clinic a discounted rate for services, the charge submitted to Medicaid for the same service must not exceed the discounted price charged to the physician or clinic. Medicaid must be given the benefit of discounts and price concessions the lab gives any one of its customers. |
|
|
Duplicate Claim |
A claim that has been submitted or paid previously or a claim that is identical to a claim in process |
|
Durable Medical Equipment |
Equipment that (1) can withstand repeated use and (2) is used to serve a medical purpose. Examples include a wheelchair or hospital bed. |
|
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) |
A federally mandated Medicaid program for eligible individuals under the age of 21. See Child Health Services. |
|
Education Accreditation |
When an individual is required to possess a bachelor's degree, master's degree, or a Ph.D. degree in a specific profession. The degree must be from a program accredited by an organization that is approved by the Council for Higher Education Accreditation (CHEA). |
|
Electronic Signature |
An electronic or digital method executed or adopted by a party with the intent to be bound by or to authenticate a record, which is: (a) Unique to the person using it; (b) Capable of verification; (c) Under the sole control of the person using it; and (d) Linked to data in such a manner that if the data are changed the electronic signature is invalidated. An Electronic Signature method must be approved by the DHS Chief Information Officer or his designee before it will be accepted. A list of approved electronic signature methods will be posted on the state Medicaid website. |
|
Eligible |
(1) To be qualified for Medicaid benefits. (2) One who is qualified for benefits |
|
Eligibility File |
A file containing individual records for all persons who are eligible or have been eligible for Medicaid |
|
Emergency Services |
Inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. |
|
Source: 42 U.S. Code of Federal Regulations (42 CFR) and §424.101. |
|
|
Error Code |
A numeric code indicating the type of error found in processing a claim; also known as an "Explanation of Benefits (EOB) code" or a "HIPAA Explanation of Benefits (HEOB) code" |
|
Estimated Acquisition Cost |
The estimated amount a pharmacy actually pays to obtain a drug |
|
Experimental Surgery |
Any surgical procedure considered experimental in nature |
|
Explanation of Medicaid Benefits (EOMB) |
A statement mailed once per month to selected beneficiaries to allow them to confirm the Medicaid service which they received |
|
Family Planning Services |
Any medically approved diagnosis, treatment, counseling, drugs, supplies or devices prescribed or furnished by a physician, nurse practitioner, certified nurse-midwife, pharmacy, hospital, family planning clinic, rural health clinic (RHC), Federally Qualified Health Center (FQHC) or the Department of Health to individuals of child-bearing age for purposes of enabling such individuals freedom to determine the number and spacing of their children. |
|
Field Audit |
An activity performed whereby a provider's facilities, procedures, records and books are audited for compliance with Medicaid regulations and standards. A field audit may be conducted on a routine basis, or on a special basis announced or unannounced. |
|
Fiscal Agent |
An organization authorized by the State of Arkansas to process Medicaid claims |
|
Fiscal Agent Intermediary |
A private business firm which has entered into a contract with the Arkansas Department of Human Services to process Medicaid claims |
|
Fiscal Year |
The twelve-month period between settlements of financial accounts |
|
Generic Upper Limit (GUL) |
The maximum drug cost that may be used to compute reimbursement for specified multiple-source drugs unless the provisions for a Generic Upper Limit override have been met. The Generic Upper Limit may be established or revised by the Centers for Medicare and Medicaid Services (CMS) or by the State Medicaid Agency. |
|
Group |
Two or more persons. If a service is a "group" therapy or other group service, there must be two or more persons present and receiving the service. |
|
Group Practice |
A medical practice in which several practitioners render and bill for services under a single pay-to provider identification number |
|
Healthcare Common Procedure Coding System (HCPCS) |
Federally defined procedure codes |
|
Health Insurance Claim Number |
Number assigned to Medicare beneficiaries and individuals eligible for SSI |
|
Hospital |
An institution that meets the following qualifications: |
|
* Provides diagnostic and rehabilitation services to inpatients |
|
|
* Maintains clinical records on all patients |
|
|
* Has by-laws with respect to its staff of physicians |
|
|
* Requires each patient to be under the care of a physician, dentist or certified nurse-midwife |
|
|
* Provides 24-hour nursing service |
|
|
* Has a hospital utilization review plan in effect |
|
|
* Is licensed by the State |
|
|
* Meets other health and safety requirements set by the Secretary of Health and Human Services |
|
|
Hospital-Based Physician |
A physician who is a hospital employee and is paid for services by the hospital |
|
HP Enterprise Services |
Current fiscal agent for the state Medicaid program |
|
ID Card |
An identification card issued to Medicaid beneficiaries and ARKids First-B participants containing encoded data that permits a provider to access the card-holder's eligibility information |
|
Individual |
A single person as distinguished from a group. If a service is an "individual" therapy or service, there may be only one person present who is receiving the service. |
|
Inpatient |
A patient, admitted to a hospital or skilled nursing facility, who occupies a bed and receives inpatient services. |
|
In-Process Claim (Pending Claim) |
A claim that suspends during system processing for suspected error conditions such as: all processing requirements appear not to be met. These conditions must be reviewed by HP ENTERPRISE SERVICES or DMS and resolved before processing of the claim can be completed. See Suspended Claim. |
|
Inquiry |
A request for information |
|
Institutional Care |
Care in an authorized private, non-profit, public or state institution or facility. Such facilities include schools for the deaf, and/or blind and institutions for individuals with disabilities. |
|
Instrumental Activities of Daily Living (IADL) |
Tasks which are ordinarily performed on a daily or weekly basis and include meal preparation, housework, laundry, shopping, taking medications and travel/transportation |
|
Intensive Care |
Isolated and constant observation care to patients critically ill or injured |
|
Interim Billing |
A claim for less than the full length of an inpatient hospital stay. Also, a claim that is billed for services provided to a particular date even though services continue beyond that date. It may or may not be the final bill for a particular beneficiary's services. |
|
Internal Control Number (ICN) |
The unique 13-digit claim number that appears on a Remittance Advice |
|
International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9CM) |
A diagnosis coding system used by medical providers to identify a patient's diagnosis and/or diagnoses on medical records and claims |
|
Investigational Product |
Any product that is considered investigational or experimental and that is not approved by the Food and Drug Administration. The Arkansas Medicaid Program does not cover investigational products. |
|
Julian Date |
Chronological date of the year, 001 through 365 or 366, preceded on a claims number (ICN) by a two-digit-year designation. Claim number example: 03231 (August 19, 2003). |
|
Length Of Stay |
Period of time a patient is in the hospital. Also, the number of days covered by Medicaid within a single inpatient stay. |
|
Limited Services Provider Agreement |
An agreement for a specific period of time not to exceed 12 months, which must be renewed in order for the provider to continue to participate in the Title XIX Program. |
|
Line Item |
A service provided to a beneficiary. A claim may be made up of one or more line items for the same beneficiary. Also called a claim detail. |
|
Long Term Care (LTC) |
An office within the Arkansas Division of Medical Services responsible for nursing facilities |
|
Long Term Care Facility |
A nursing facility |
|
Maximum Allowable Cost (MAC) |
The maximum drug cost which may be reimbursed for specified multi-source drugs. This term is interchangeable with generic upper limit. |
|
Medicaid Provider Number |
A unique identifying number assigned to each provider of services in the Arkansas Medicaid Program, required for identification purposes |
|
Medicaid Management Information System (MMIS) |
The automated system utilized to process Medicaid claims |
|
Medical Assistance Section |
A section within the Arkansas Division of Medical Services responsible for administering the Arkansas Medical Assistance Program |
|
Medically Needy |
Individuals whose income and resources exceed the levels for assistance established under a state or federal plan for categorically needy, but are insufficient to meet costs of health and medical services |
|
Medical Necessity |
All Medicaid benefits are based upon medical necessity. A service is "medically necessary" if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service. For this purpose, a "course of treatment" may include mere observation or (where appropriate) no treatment at all. The determination of medical necessity may be made by the Medical Director for the Medicaid Program or by the Medicaid Program Quality Improvement Organization (QIO). Coverage may be denied if a service is not medically necessary in accordance with the preceding criteria or is generally regarded by the medical profession as experimental inappropriate or ineffective using unless objective clinical evidence demonstrates circumstances making the service necessary. |
|
Mis-Utilization |
Any usage of the Medicaid Program by any of its providers and/or beneficiaries which is not in conformance with both State and Federal regulations and laws (includes fraud, abuse and defects in level and quality of care) |
|
National Drug Code |
The unique 11 -digit number assigned to drugs which identifies the manufacturer, drug, strength and package size of each drug |
|
National Provider Identifier (NPI) |
A standardized unique health identifier for health care providers for use in the health care system in connection with standard transactions for all covered entities. Established by the Centers for Medicare & Medicaid Services, HHS, in compliance with HIPAA Administrative Simplification - 45 CFR Part 162. |
|
Non-Covered Services |
Services not medically necessary, services provided for the personal convenience of the patient or services not covered under the Medicaid Program |
|
Nonpatient |
An individual who receives services, such as laboratory tests, performed by a hospital, but who is not a patient of the hospital |
|
Nurse Practitioner |
A professional nurse with credentials that meet the requirements for licensure as a nurse practitioner in the State of Arkansas |
|
Outpatient |
A patient receiving medical services, but not admitted as an inpatient to a hospital |
|
Over-Utilization |
Any over usage of the Medicaid Program by any of its providers and/or beneficiaries not in conformance with professional judgment and both State and Federal regulations and laws (includes fraud and abuse) |
|
Participant |
A provider of services who: (1) provides the service, (2) submits the claim and (3) accepts Medicaid's reimbursement for the services provided as payment in full |
|
Patient |
A person under the treatment or care of a physician or surgeon, or in a hospital |
|
Payment |
Reimbursement to the provider of services for rendering a Medicaid-covered benefit |
|
Pay-to Provider |
A person, organization or institution authorized to receive payment for services provided to Medicaid beneficiaries by a person or persons who are a part of the entity |
|
Pay-to Provider Number |
A unique identifying number assigned to each pay-to provider of services (Clinic/Group/Facility) in the Arkansas Medicaid Program or the pay-to provider group's assigned National Provider Identifier (NPI). Medicaid reports provider payments to the Internal Revenue Service under the Employer Identification Number "Tax ID" linked in the Medicaid Provider File to the pay-to provider identification number. |
|
Per Diem |
A daily rate paid to institutional providers |
|
Performing Physician |
The physician providing, supervising, or both, a medical service and claiming primary responsibility for ensuring that services are delivered as billed |
|
Person |
Any natural person, company, firm, association, corporation or other legal entity |
|
Place of Service (POS) |
A nationally approved two-digit numeric code denoting the location of the patient receiving services |
|
Plan of Care |
A document utilized by a provider to plan, direct or deliver care to a patient to meet specific measurable goals; also called care plan, service plan or treatment plan |
|
Postpayment Utilization Review |
The review of services, documentation and practice after payment |
|
Practitioner |
An individual who practices in a health or medical service profession |
|
Prepayment Utilization Review |
The review of services, documentation and practice patterns before payment |
|
Prescription |
A health care professional's legal order for a drug which, in accordance with federal and/or state statutes, may not be obtained otherwise; also an order for a particular Medicaid covered service |
|
Prescription Drug (RX) |
A drug which, in accordance with federal and/or state statutes, may not be obtained without a valid prescription |
|
Primary Care Physician (PCP) |
A physician responsible for the management of a beneficiary's total medical care. Selected by the beneficiary to provide primary care services and health education. The PCP will monitor on an ongoing basis the beneficiary's condition, health care needs and service delivery be responsible for locating, coordinating and monitoring medical and rehabilitation services on behalf of the beneficiary and refer the beneficiary for most specialty services, hospital care and other services. |
|
Prior Approval |
The approval for coverage and reimbursement of specific services prior to furnishing services for a specified beneficiary of Medicaid. The request for prior approval must be made to the Medical Director of the Division of Medical Services for review of required documentation and justification for provision of service. |
|
Prior Authorization (PA) |
The approval by the Arkansas Division of Medical Services, or a designee of the Division of Medical Services, for specified services for a specified beneficiary to a specified provider before the requested services may be performed and before payment will be made. Prior authorization does not guarantee reimbursement. |
|
Procedure Code |
A five-digit numeric or alpha numeric code to identify medical services and procedures on medical claims |
|
Professional Component |
A physician's interpretation or supervision and interpretation of laboratory, X-ray or machine test procedures |
|
Profile |
A detailed view of an individual provider's charges to Medicaid for health care services or a detailed view of a beneficiary's usage of health care services |
|
Provider |
A person, organization or institution enrolled to provide and be reimbursed for health or medical care services authorized under the State Title XIX Medicaid Program |
|
Provider Identification Number |
A unique identifying number assigned to each provider of services in the Arkansas Medicaid Program or the provider's assigned National Provider Identifier (NPI), when applicable, that is required for identification purposes |
|
Provider Relations |
The activity within the Medicaid Program which handles all relationships with Medicaid providers |
|
Quality Assurance |
Determination of quality and appropriateness of services rendered |
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Quality Improvement Organization |
A Quality Improvement Organization (QIO) is a federally mandated review organization required of each state's Title XIX (Medicaid) program. Arkansas Medicaid has contracted with the Arkansas Foundation for Medical Care, Inc. (AFMC) to be its QIO. The QIO monitors hospital and physician services billed to the state's Medicare intermediary and the Medicaid program to assure high quality, medical necessity and appropriate care for each patient's needs. |
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Railroad Claim Number |
The number issued by the Railroad Retirement Board to control payments of annuities and pensions under the Railroad Retirement Act. The claim number begins with a one- to three-letter alphabetic prefix denoting the type of payment, followed by six or nine numeric digits. |
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Referral |
An authorization from a Medicaid enrolled provider to a second Medicaid enrolled provider. The receiving provider is expected to exercise independent professional judgment and discretion, to the extent permitted by laws and rules governing the practice of the receiving practitioner, and to develop and deliver medically necessary services covered by the Medicaid program. The provider making the referral may be a physician or another qualified practitioner acting within the scope of practice permitted by laws or rules. Medicaid requires documentation of the referral in the beneficiary's medical record, regardless of the means the referring provider makes the referral. Medicaid requires the receiving provider to document the referral also, and to correspond with the referring provider regarding the case when appropriate and when the referring provider so requests. |
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Reimbursement |
The amount of money remitted to a provider |
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Rejected Claim |
A claim for which payment is refused |
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Relative Value |
A weighting scale used to relate the worth of one surgical procedure to any other. This evaluation, expressed in units, is based upon the skill, time and the experience of the physician in its performance. |
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Remittance |
A remittance advice |
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Remittance Advice (RA) |
A notice sent to providers advising the status of claims received, including paid, denied, in-process and adjusted claims. It includes year-to-date payment summaries and other financial information. |
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Reported Charge |
The total amount submitted in a claim detail by a provider of services for reimbursement |
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Retroactive Medicaid Eligibility |
Medicaid eligibility which may begin up to three (3) months prior to the date of application provided all eligibility factors are met in those months |
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Returned Claim |
A claim which is returned by the Medicaid Program to the provider for correction or change to allow it to be processed properly |
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Sanction |
Any corrective action taken against a provider |
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Screening |
The use of quick, simple medical procedures carried out among large groups of people to sort out apparently well persons from those who may have a disease or abnormality and to identify those in need of more definitive examination or treatment |
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Signature |
The person's original signature or initials. The person's signature or initials may also be recorded by an electronic or digital method, executed or adopted by the person with the intent to be bound by or to authenticate a record. An electronic signature must comply with Arkansas Code Annotated § 25-31-101 -105, including verification through an electronic signature verification company and data links invalidating the electronic signature if the data is changed. |
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Single State Agency |
The state agency authorized to administer or supervise the administration of the Medicaid Program on a statewide basis |
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Skilled Nursing Facility (SNF) |
A nursing home, or a distinct part of a facility, licensed by the Office of Long Term Care as meeting the Skilled Nursing Facility Federal/State licensure and certification regulations. A health facility which provides skilled nursing care and supportive care on a 24-hour basis to residents whose primary need is for availability of skilled nursing care on an extended basis. |
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Social Security Administration (SSA) |
A federal agency which makes disability and blindness determinations for the Secretary of the HHS |
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Social Security Claim Number |
The account number used by SSA to identify the individual on whose earnings SSA benefits are being paid. It is the Social Security Account Number followed by a suffix, sometimes as many as three characters, designating the type of beneficiary (e.g., wife, widow, child, etc.). |
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Source of Care |
A hospital, clinic, physician or other facility which provides services to a beneficiary under the Medicaid Program |
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Specialty |
The specialized area of practice of a physician or dentist |
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Spend Down (SD) |
The amount of money a beneficiary must pay toward medical expenses when income exceeds the Medicaid financial guidelines. A component of the medically needy program allows an individual or family whose income is over the medically needy income limit (MNIL) to use medical bills to spend excess income down to the MNIL. The individual(s) will have a spend down liability. The spend down column of the remittance advice indicates the amount which the provider may bill the beneficiary. The spend down liability occurs only on the first day of Medicaid eligibility. |
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Status Report |
A remittance advice |
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Supplemental Security Income (SSI) |
A program administered by the Social Security Administration. This program replaced previous state administered programs for aged, blind or individuals with disabilities (except in Guam, Puerto Rico and the Virgin Islands). This term may also refer to the Bureau of Supplemental Security Income within SSA which administers the program. |
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Suspended Claim |
An "In-Process Claim" which must be reviewed and resolved |
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Suspension from Participation |
An exclusion from participation for a specified period of time |
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Suspension of Payments |
The withholding of all payments due to a provider until the resolution of a matter in dispute between the provider and the state agency |
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Termination from Participation |
A permanent exclusion from participation in the Title XIX Program |
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Third Party Liability (TPL) |
A condition whereby a person or an organization, other than the beneficiary or the state agency, is responsible for all or some portion of the costs for health or medical services incurred by the Medicaid beneficiary (e.g., a health insurance company, a casualty insurance company or another person in the case of an accident, etc.). |
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Utilization Review (UR) |
The section of the Arkansas Division of Medical Services which performs the monitoring and controlling of the quantity and quality of health care services delivered under the Medicaid Program |
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Void |
A transaction which deletes |
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Voice Response System (VRS) |
Voice-activated system to request prior authorization for prescription drugs and for PCP assignment and change |
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Ward |
An accommodation of five or more beds |
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Withholding of Payments |
A reduction or adjustment of the amounts paid to a provider on pending and subsequently due payments |
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Worker's Compensation |
A type of Third Party Liability for medical services rendered as the result of an on-the-job accident or injury to a beneficiary for which the employer's insurance company may be obligated under the Worker's Compensation Act |
DIVISION OF MEDICAL SERVICES STERILIZATION CONSENT FORM
NOTICE:YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR
WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
ARKANSAS DEPARTMENT OF HUMAN SERVICES
Division of Medical Services Checklist for DMS-615 - Sterilization Consent Form
DIVISION OF MEDICAL SERVICES
ARKANSAS MEDICAID - TITLE XIX
ACKNOWLEDGEMENT OF HYSTERECTOMY INFORMATION
ALWAYS COMPLETE THIS SECTION
Beneficiary's Name ______________________________________ Medicaid ID # ____________________
Physician's Name ______________________________________ Date of Hysterectomy ____________________
COMPLETE ONLY ONE OF THE REMAINING SECTIONS: COMPLETE ALL BLANKS IN THAT SECTION
I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy being performed, that if a hysterectomy is performed on me it will render me permanently incapable of reproducing.
Witness Signature Date Patient's Signature Date
I certify that before I performed the hysterectomy procedure on the beneficiary listed above: (Check one)
Cause of Sterility
Physician's Signature Date
The guardian must petition the court for permission to sign for the patient giving consent for the procedure to be performed. A copy of the court petition must be attached to the claim.
I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy being performed, that if a hysterectomy is performed on the above beneficiary, it will render her permanently incapable of reproducing.
Witness Signature Date Patient's Representative Signature Date
PHYSICIAN'S STATEMENT FOR MENTALLY INCOMPETENT
I affirm that the hysterectomy I performed on the above beneficiary was medically necessary due to
Reason for Hysterectomy and was not done for sterilization purposes, and that to the best of my knowledge, the individual on whom the hysterectomy was performed is mentally incompetent. Before I performed the hysterectomy on her, I counseled her representative, orally and in writing, that the hysterectomy would render that individual permanently incapable of reproducing; and, the individual's representative has signed a written acknowledgement of receipt of the foregoing information.
Physician's Signature Date
Attach a copy to claim form when submitting for payment. Provide copies for patient and for your files. ADDITIONAL DOCUMENTATION MAY BE REQUESTED BEFORE PAYMENT IS MADE.
DMS-2606 (Rev. 7/12)
