Current through Register Vol. 49, No. 9, September, 2024
Section I
131.000
Charges that Are Not the
Responsibility of the Beneficiary
Except for cost sharing responsibilities outlined in Sections
133.000 - 135.000, a beneficiary is not liable for the following
charges:
A. A claim or portion of a
claim denied for lack of medical necessity.
B. Charges in excess of the Medicaid maximum
allowable rate.
C. A claim or
portion of a claim denied due to provider error.
D. A claim or portion of a claim denied
because of errors made by DMS or the Arkansas Medicaid fiscal agent.
E. A claim or portion of a claim denied due
to changes made in state or federal mandates after services were
performed.
F. A claim or portion of
a claim denied because a provider failed to obtain prior, concurrent, or
retroactive authorization for a service.
G. A claim or portion of a claim denied
because the claim did not meet Electronic Visit Verification (EVV) requirements
(see 145.000).
H. The difference
between the beneficiary Medicaid cost sharing responsibility, if any, and the
Medicare or Medicare Advantage co-payments.
I. Medicaid pays the difference, if any,
between the Medicaid maximum allowable fee and the total of all payments
previously received by the provider for the same service. Medicaid
beneficiaries are not responsible for deductibles, co-payments, or coinsurance
amounts to the extent that such payments, when added to the amounts paid by
third parties, equal or exceed the Medicaid maximum for that service, even if
the Medicaid payment is zero. The beneficiary is responsible for paying
applicable Medicaid cost share amounts.
J. The beneficiary is not responsible for
insurance cost share amounts if the claim is for a Medicaid-covered service by
a Medicaid-enrolled provider who accepted the beneficiary as a Medicaid
patient. Arkansas Medicaid pays the difference between the amount paid by
private insurance and the Medicaid maximum allowed amount. Medicaid will not
make any payment if the amount received from the third party insurance is equal
to or greater than the Medicaid allowable rate.
If an individual who makes payment at the time of service is
later found to be Medicaid eligible and Medicaid is billed, the individual must
be refunded the full amount of his or her payment for the covered service(s).
If it is agreeable with the individual, these funds may be credited against
unpaid non-covered services and Medicaid cost-sharing amounts that are the
responsibility of the beneficiary.
The beneficiary may not be billed for the completion and
submission of a Medicaid claim form.
Exception: Medicaid does not cover the deductible,
co-payments, or other cost share amounts levied to Medicare Part D
drugs.
145.000
Electronic Visit Verification
(EVV) for In-Home Personal Care, Attendant Care, and
Respite-Services
145.100
Legal Basis and Scope of EVV Requirement
In accordance with section 12006 of the 21st Century Cures Act
(42 U.S.C. §
1396b(l)), the Arkansas
Department of Human Services (DHS) is implementing an electronic visit
verification (EVV) system for in-home personal care services (PCS), attendant
care, and respite services paid by Medicaid.
An EVV system is a telephone-, computer-, or other
technology-based system under which visits conducted as part of personal care
services or home health care services are electronically verified with respect
to:
1. The type of service(s)
performed;
2. The individual
receiving the service(s);
3. The
date of the service(s);
4. The
location of service delivery;
5.
The individual providing the service(s); and
6. The time the service(s) begins and ends.
The EVV requirement establishes utilization standards for
provider agencies to electronically verify home visits and verify that clients
receive the services authorized for their support and for which Medicaid is
being billed.
The EVV requirement applies to Medicaid PCS, attendant care,
and respite care provided during an in-home visit under the Medicaid State
Plan, the Provider-Led Arkansas Shared Savings Entity (PASSE), the ARChoices
Medicaid §1915(c) Home and Community-Based Services Waiver, or under any
self-direction plan.
PCS, attendant care, and respite services provided to more than
one person throughout a shift in 24-hour residential settings are not subject
to the EVV requirement because they do not involve an "in home" visit. This
includes without limitation PCS, attendant care, and respite services provided
in a group home, assisted living facility, hospital, nursing facility, or other
congregate setting.
PCS, attendant care or respite services provided to a student
in a public school is not subject to the EVV requirement because it does not
involve an "in-home" visit.
Additional information regarding EVV is available from the DHS
EVV Vendor. View or print the DHS EVV Vendor contact
information.
145.200
EVV Participation
Requirements
To submit a claim for any service that is subject to the EVV
requirement or pay based upon a self-directed plan of care subject to the EVV
requirement, a provider must:
1.
Submit and maintain on file with both DHS Provider Enrollment and the DHS EVV
Vendor a contact e-mail address for the provider. The e-mail address must be
one that is active and is controlled and regularly checked by the provider. The
e-mail address must be a business address that is unique to the provider and
must not be an employee's personal e-mail address or other shared address. The
e-mail address submitted by a provider to DHS Provider Enrollment will be the
e-mail address used by the DHS EVV Vendor to create the provider's account to
access the EVV system;
2. Obtain
from DHS a Medicaid Practitioner Identification Number (PIN) for each and every
caregiver employed or contracted by the provider to furnish care for which
Medicaid PCS, attendant care, or respite care claims may be
submitted;
3. Submit, with every
claim for a service subject to the EVV requirement, the PIN for the caregiver
providing the service to the beneficiary. The PIN shall be listed in the field
for the Rendering Provider ID#;
4.
Use an EVV system that documents and verifies every in-home visit resulting in
a claim for reimbursement. A provider must use the EVV system furnished by the
DHS EVV Vendor or a third-party EVV system that has been certified by the DHS
EVV Vendor;
5. Require caregivers
employed or contracted by the provider to use EVV for all in-home Medicaid-paid
PCS, attendant care, or respite care, and train the caregivers on the use of
the provider's chosen EVV system;
6. If the provider uses the DHS EVV system,
register the provider's caregivers with the EVV system. By registering a
caregiver with the DHS EVV system, the provider is attesting that all
applicable requirements, including without limitation training requirements,
have been satisfied for that caregiver. A caregiver who is excluded or debarred
from participation in Medicaid under any state or federal law is not eligible
to register with the DHS EVV system;
7. Create and maintain documentation to
justify any manual modifications, adjustments, or exceptions made by the
provider in the EVV system after a caregiver has entered or failed to enter any
required information;
8. Comply
with EVV requirements established by the Centers for Medicare & Medicaid
Services (CMS);
9. Comply with
applicable federal and state laws regarding confidentiality of information
about clients receiving services; and
10. Ensure that DHS may review documentation
generated by an EVV system or obtain a copy of that documentation at no
charge.
145.300
EVV Claims Requirements
EVV is required for the following procedure codes and modifiers
when the Place of Service is coded as the beneficiary's home (POS code
12):
|
Procedure Code
|
Modifier
|
Service Description
|
|
T1019
|
|
Personal Care for a (non-RCF) Beneficiary Under
21
|
|
T1019
|
U3
|
Personal Care for a non-RCF Beneficiary Aged 21 or
Older
|
|
S5125
|
U2
|
Agency Attendant Care Traditional
|
|
S5150
|
|
Respite Care - In-Home
|
A claim for any of these procedure codes and modifiers may be
rejected or denied, or subject to recoupment, if delivery of the service was
not verified by EVV or if there is any inconsistency among or between:
1. The data submitted in the claim;
2. The data recorded by EVV for the claimed
service;
3. The data in the
approved prior authorization or plan of care applicable to the claimed service;
or
4. Address or other eligibility
data maintained in the Medicaid Management Information System (MMIS) or other
eligibility system maintained by DHS.
A claim for any of these procedure codes and modifiers is
subject to the EVV requirement regardless of how the claim is submitted,
including third-party EVV vendors, through a PASSE claims system, or through a
self-direction plan.
For PCS delivered in a beneficiary's home, it is a fraudulent
billing practice to list any Place of Service (POS) code other than POS code
12, unless the Provider Manual or other Rule explicitly permits the use of a
different POS code.
The EVV Requirement also applies to any equivalent services
provided to a beneficiary through the Independent Choices program, or any other
self-direction program made available under the state plan or AR Choices. Such
equivalent services may be rejected or denied if delivery of the service was
not verified by EVV or if there is any inconsistency among or
between:
1. The data
submitted in the claim;
2. The data
recorded by EVV for the claimed service;
3. The data in the approved prior
authorization or plan of care applicable to the claimed service; or
4. Address or other eligibility data
maintained in the Medicaid Management Information System (MMIS) or other
eligibility system maintained by DHS.
145.400
Third Party EVV System
Requirements
A third-party EVV system procured and chosen by a provider or
Managed Care Organization (MCO) or self-directed services vendor must be
certified by the DHS EVV Vendor as meeting the following requirements:
1. The provider must submit a written
attestation that the third-party EVV system meets or exceeds all applicable CMS
and DHS requirements. Certification of a third-party EVV system is valid only
so long as the system continues to meet or exceed all applicable CMS and DHS
requirements;
2. The DHS EVV Vendor
must certify that the third-party EVV system has the technical capabilities to
receive and transmit all EVV data in a way that is compatible with the DHS EVV
system; and
3. The third-party EVV
system must timely collect and submit to the DHS EVV Vendor all data required
for EVV verification of a claim, including without limitation:
a. The procedure code and modifier for the
service(s) delivered, and the specific ADL/IADL task(s) performed by the
caregiver during the visit;
b.
Identifying information for the beneficiary, including without limitation the
beneficiary's Medicaid identification number;
c. The date of the service(s);
d. The location where the service(s) were
delivered;
e. Identifying
information for the agency and the individual caregiver providing the
service(s), including without limitation a Practitioner Identification Number
(PIN) as assigned by DHS for the individual caregiver who is listed as the
rendering provider;
f. Universal
Time Code (UTC) for the time the service(s) begins and ends; and g. EVV capture
method (including without limitation telephony, GPS, or fixed visit) and
corresponding validation data (including without limitation phone number,
coordinates, or encryption key); and
4. By including a caregiver in any EVV data
submitted to the DHS EVV Vendor, the provider is attesting that all applicable
requirements, including without limitation training requirements and background
checks, have been satisfied for that caregiver. Claims made for services
performed by a caregiver who is excluded or debarred from participation in
Medicaid may be denied or rejected and are subject to recoupment.
