Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.12-029 - Episode Performance Payments for Ambulatory URL, ADHD and Perinatal Care
Current through Register Vol. 49, No. 9, September, 2024
Section ll Episodes of Care
This section specifies, for each episode type, the types of providers eligible to be Principal Accountable Providers (PAPs) for an episode type and the algorithm used to determine the PAP(s) for an individual episode. For each episode of care, providers designated as PAPs hold the main responsibility for ensuring that the episode is delivered with appropriate quality and efficiency.
This section describes, for each episode type, criteria to exclude an episode from calculation of a PAP's average performance.
Across all episode types, episodes are excluded for dual-eligible Medicaid and Medicare beneficiaries and for Third Party Liability (TPL) beneficiaries.
This section describes,for each episodeitype, adjustments to the reimbursement amount attributable to a PAP forthe purpose of calculating performance and determining supplemental payment incentives.
Across all episode types, the reimbursement amount attributable to a PAP for facility claims for acute inpatient hospitalizations is adjusted to a per diem rate of $850.
This section describes, for each episode type, the data and measures which Medicaid will track and evaluate to ensure provision of high-quality care for each episode type,
For quality measures "to pass" and quality measures "to track" that require data not available ? from claims, PAPs must submit data through the provider portal in order to qualify for a full positive supplemental payment.
This section describes, for each episode type, the specific values used to calculate positive or negativesupplemental payments. This Includes an acceptable threshold, a commendable threshold, a gain sharing limit and a risk sharing percentage.
This section describes, for each episode type, the minimum case volume required for a PAP to qualify for positive or negativesupplemental payments. PAPs who do not meetthe minimum casevolumefor an episodetype will not be eligible for positive or negative suppjemental payments for that episode type.
Office visits, clinic visits or emergency department visits with a primary diagnosis of an Acute Ambulatory URI ("URI") that do not fall within the time window of a previous URI episode.
Episodes begin on the day of the triggering visit and conclude after 21 days.
All services relating to the treatment of a URI within the duration of the episode are included. The following services are excluded:
The Principal Accountable Provider (PAP) for an episode is the first Arkansas Medicaid enrolled and qualified provider to diagnose a beneficiary with an Acute Ambulatory URI during an in-person visit within the time window for the episode.
Episodes meeting one or more of the following criteria will be excluded:
The reimbursement for the initial visit that is attributable to the PAP is normalized across different places of service (eg., "Level 2" visits will count equally toward average reimbursement regardless of place of service). Reimbursements for the facility claim associated with the initial visit are not counted in the total reimbursements attributed to a PAP for calculation of performance,.
Reimbursement attributed tothe calculation of a PAP's performance for beneficiaries 10 and under is adjusted to reflect age-related variations in treatment usjng a multiplier determined by regression.
The minimum case volume is 5 total cases for each episode subtype per 12 month period.
A live birth on a facility claim
Episode begins 40 weeks prior to delivery and ends 60 days after delivery
All medical assistance with a pregnancy-related ICD-9 diagnosis code is included. Medical assistance related to neonatal care is not included..
For each episode, the Principal Accountable Provider (PAP) is the provider or provider group that performs the delivery.
Episodes meeting one or more of the following criteria will be excluded:
For the purposes of determining a PAP's performance, the total reimbursement attributable to the PAP is adjusted to reflect risk and/or severity factors captured in the claims data for each episode in order to be fair to providers with high-risk patients, to avoid any incentive for adverse selection of patients and to encourage high-quality, efficient care. Medicaid, with clinical input from Arkansas providers, will identify risk factors via literature, Arkansas experience and clinical expertise. Using standard statistical techniques and clinical review, risk factors will be tested for statistical and clinical significance to identify a reasonable number of factors that have meaningful explanatory power (p [LESS THAN] 0.01) for predicting total reimbursement per episode. Some factors which have meaningful explanatory power may be excluded from the set of selected risk factors where necessary to avoid potential for manipulation through coding practices. Episode reimbursement attributable to a PAP for calculating average adjusted episode reimbursement are adjusted based on selected risk factors. Over time, Medicaid may add or subtract risk factors in line with new research and/or empirical evidence.
The minimum casevplume is 5 total cases per 12 month period.
Level I subtype episodes are triggered by either two medical claims with a primary diagnosis of ADHD or a medical claim with a primary diagnosis of ADHD as well as a pharmacy claim for medication used to treat ADHD. Level II subtype episodes are triggered by a completed Severity Certification followed by either two medical claims with a primary diagnosis of ADHD or a medical claim with a primary diagnosis of ADHD as well as a pharmacy claim for medication used to treat ADHD.
The standard episode duration is a 12-month period beginning at the time of the first trigger claim. A Level I episode will conclude at the initiation of a new Level II episode if a Severity Certification is completed during the 12-month period.
All claims with a primary diagnosis of ADHD as well as all medications indicated for ADHD or used in the treatment of ADHD.
Notwithstanding any other provisions in the provider manual, medical assistance included in an ADHD episode shall not be subject to prior authorization requirements.
Determination of the Principal Accountable Provider (PAP).is based upon which provider is responsible for the largest number of claims within the episode.
If the provider responsible for the largest number of claims is a physician or an RSPMI provider organization, that provider is designated the PAP. In instances in which two providers are responsible for an equal number of claims within the episode, the provider whose claims accounted for a greater proportion of total reimbursement will be designated PAP.
If the provider responsible for the largest number of claims is a licensed clinical psychologist operating outside of an RSPMI provider organization, that provider is a co-PAP with the physician or RSPMI provider providing the next largest number of claims within the episode. In instances in which two providers are responsible for an equal number of claims within the episode, the provider whose claims accounted for a greater proportion of total reimbursement will be designated co-PAP.
Where there are co-PAPs for an episode, the positive or negative supplemental payments are divided equally between the co-PAPs.
Episodes meeting one or more of the following criteria will be excluded:
Total reimbursement attributable to the PAP for episodes with a duration of less than 12 months will be scaled linearly to determine a reimbursement per 12-months for the purpose of calculating the PAP's performance.
The minimum case volume is 5 total cases per 12 month period.
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
Rural health clinic services are limited to twelve (12) visits a year for beneficiaries age 21 and older. This yearly limit is based on the State Fiscal Year (July I through June 30). The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist and certified nurse midwife services. Beneficiaries will be allowed twelve (12) visits per State Fiscal Year for rural health clinic services, physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services or a combination of the five. For physicians' services, medical services provided by a dentist, office medical services furnished by an optometrist certified nurse midwife services or rural health clinic core services beyond the 12 visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
Rural Health Clinic core services are defined as follows:
Services and supplies "incident to" the professional services of physicians, physician assistants and/or nurse practitioners are those which are commonly furnished in connection with these professional services, are generally furnished in the physician's office and are ordinarily rendered without charge or included in the clinic's bills; e.g., laboratory services, ordinary medications and other services and supplies used in patient primary care services.
Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the Rural Health Clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the Rural Health Clinic will count against the limit established in the plan for that service.
Effective for claims with dates of service on or after July 1,1995, federally qualified health center (FQHC) services are limited to twelve (12) encounters per beneficiary, per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and older. For federally qualified health center core services beyond the 12 visit limit, extensions will be provided if medically necessary. Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
FQHC hospital visits are limited to one day of care for inpatient hospital covered days regardless of the number of hospital visits rendered. The hospital visits do not count against the FQHC encounter benefit limit.
Extended Rehabilitative Hospital Services are services for the rehabilitation of patients with various neurological, musculo-skeletal, orthopedic and other medical conditions following stabilization of their acute medical conditions. Extended Rehabilitative Hospital Services are a global service, covering all rehabilitative, psychological and/or social services required of the admitting facility for licensure, certification and/or accreditation.
The following services are included in the global coverage of an Extended Rehabilitative Hospital:
Persons eligible for admission must have at least one of the following neurological conditions: Post acute traumatic or acquired brain injury. This includes and is limited to viral encephalitis, meningitis, aneurysms, cerebral vascular accident/stroke, post-operative tumors, anoxia, hypoxias, toxic encephalopathies, refractory seizure disorders and congenital neurological brain disorders. These conditions can be with or without moderate to severe behavioral disorders secondary to a brain injury.
An Extended Rehabilitative Hospital must be licensed by the Division of Health as a Rehabilitative Hospital. An Extended Rehabilitative Hospital must also be certified as a Title XVIII (Medicare) Rehabilitative Hospital provider. Extended Rehabilitative Hospital services are provided by a licensed practitioner who is directly related to the beneficiary's rehabilitative adjustment.
Extended Rehabilitative Hospital services provided are limited to thirty (30) days per state fiscal year, July 1 through June 30, for ages 21 and older. No extensions will be considered. However, beneficiaries who are under the age of 21 years and in the Child Health Services (EPSDT) Program are not limited to the thirty (30) day annual benefit limit. The thirty (30) day annual benefit limit only applies to services provided in an RSPD facility and does not include days counted toward any other Medicaid Program benefit limit, e.g., hospital, nursing home, etc.
Service delivery is delivery is the same as inpatient hospital services described in Attachment 3.1-A, Page la, Item 1, minus the room and board component.
Extended Rehabilitative Hospital Services are available to eligible Medicaid recipients of all ages when medically necessary as determined by the PRO. Services are limited to 30 days per State Fiscal Year for beneficiaries age 21 and older. Recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
Rural health clinic services are limited to twelve (12) visits a year for beneficiaries age 21 and older. This yearly limit is based on the State Fiscal Year (July I through June 30). The benefit limit will be considered in conjunction with the benefit limit established for physicians' services, medical services furnished by a dentist, office medical services furnished by an optometrist and certified nurse midwife services. Beneficiaries will be allowed twelve (12) visits per State Fiscal Year for rural health clinic services, physicians* services, medical services furnished by a dentist, office medical services furnished by an optometrist, certified nurse midwife services or a combination of the five. For physicians' services, medical services provided by a dentist, office medical services furnished by an optometrist certified nurse midwife services or rural health clinic core services beyond the 12 visit limit, extensions will be provided if medically necessary. Certain services, specified in the appropriate provider manual, are not counted toward the 12 visit limit. Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
Rural Health Clinic core services are defined as follows:
Services and supplies "incident to" the professional services of physicians, physician assistants and/or nurse practitioners are those which are commonly furnished in connection with these professional services, are generally furnished in the physician's office and are ordinarily rendered without charge or included in the clinic's bills; e.g., laboratory services, ordinary medications and other services and supplies used in patient primary care services.
Rural health clinic ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the Rural Health Clinic offers such a service (e.g. dental, visual, etc.). The "other ambulatory services" that are provided by the Rural Health Clinic will count against the limit established in the plan for that service.
Effective for claims with dates of service on or after July 1, 1995, federally qualified health center (FQHC) services are limited to twelve (12) encounters per beneficiary, per State Fiscal Year (July 1 through June 30) for beneficiaries age 21 and older. For federally qualified health center core services beyond the 12 visit limit, extensions will be provided if medically necessary. Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.
FQHC hospital visits are limited to one day of care for inpatient hospital covered days regardless of the number of hospital visits rendered. The hospital visits do not count against the FQHC encounter benefit limit.
ATTACHMENT 4.19-A
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -INPATIENT HOSPITAL SERVICES
Complete details including technical information regarding specific quality and reporting metrics, performance thresholds and incentive adjustments are available inthe Episodes of Care Medicaid Manual available at https://www.medicaid.state.ar.us/InternetSolution/PrOvider/docs/docs.aspxand also at the Arkansas Health Care Payment Improvement Initiative website at http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding specific quality and reporting metrics, performance thresholds and incentive adjustments are available in the Episodes of Care Medicaid Manual available at https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/docs.aspx and also at the Arkansas Health Care Payment Improvement Initiative website at http://www.paymentinitiative.org/Pages/default.aspx.
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
hrtps://
Effective for dates of service on or after October 1,2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Negotiated statewide contract bid.
Reimbursement is based on the lower of the amount billed or the Title XIX (Medicaid) maximum allowable. Except as otherwise noted in the state plan, state developed fee schedule rates are the same for both governmental and private providers of RSPMI services. The agency's fee schedule rates were set as of April 1, 1988 and are effective for services provided on or after that date. All rates are published on the agency's website at www.medicaid.state.ar.us.
Effective for dates of service on or after April 1, 2004, reimbursement rates (payments) for inpatient visits in acute care hospitals by board certified psychiatrists shall be as ordered by the United States District Court for the Eastern District of Arkansas in the case of Arkansas Medical Society v. Reynolds. Refer to Attachment 4.19-B, Item 5, for physician reimbursement.
The State shall not claim FFP for any non institutional service provided to individuals who are residents of facilities that meet the Federal definition of an institution for mental diseases or a psychiatric residential treatment facility as described in Federal regulations at 42 CFR 1440 and 14460 and 42 CFR 441 Subparts C and D. Reimbursement of RSPMI services that are provided in HMD's will be discontinued for services provided on or after September 1, 2011.
For RSPMI services provided in clinics operated by State operated teaching hospitals.
Effective for claims with dates of service on or after March 1, 2002, Arkansas State Operated Teaching Hospital psychiatric clinics that are not part of a hospital outpatient department shall be reimbursed based on reasonable costs with interim payments at the RSPMI fee schedule rates and a year-end cost settlement. The provider will be paid the lesser of actual costs identified using a CMS approved cost report or customary charges. Each Arkansas State Operated Teaching Hospital with qualifying psychiatric clinics shall submit an annual cost report. Said cost report shall be submitted within five (5) months after the close of the hospital's fiscal year. Failure to file the cost report within the prescribed period, except as expressly extended by the State Medicaid Agency, may result in suspension of reimbursement until the cost report is filed. The State Medicaid Agency will review the submitted cost report and make a tentative settlement within 60 days of the receipt of the cost report and will make final settlement in the following year after all Medicaid charges and payments have been processed. The final settlement will be calculated and made at the same time as the next year's tentative settlement is calculated and made.
Medical professionals affiliated with Arkansas State Operated Teaching Hospitals are not eligible for additional reimbursement for services provided in these clinics.
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
DX MEDICATD PAYMENTS: Subject to the incentive adjustments described below, providers, including PAPs, furnish medically necessary care to eligible beneficiaries and are paid in accordance with the published Medicaid reimbursement methodology in effect on the date of service.
Complete details including technical information regarding
specific quality and reporting metrics, performance thresholds and incentive
adjustments are available in the Episodes of Care Medicaid Manual available at
Effective for dates of service on or after October 1, 2012, the defined scope of services within the following episode(s) of care are subject to incentive adjustments:
