Licensed Mental Health Practitioners
Section II
SECTION II - LICENSED MENTAL HEALTH PRACTITIONERS
CONTENTS
200.000
201.000
201.100
201.110
201.120
201.130
202.000
203.000
203.100
203.200
203.300
204.000
205.000
210.000
211.000
211.100
211.200
211.210
211.220
212.000
212.100
212.200
212.300
212.400
213.000
214.000
215.000
216.000
217.000
218.000
218.100
LICENSED MENTAL HEALTH PRACTITIONERS GENERAL INFORMATION
Arkansas Medicaid Participation Requirements for Licensed Mental Health
Practitioners - Licensed Certified Social Worker (LCSW), Licensed Marriage and
Family Therapist (LMFT), Licensed Professional Counselor (LPC) and Psychologist
Certification Requirements for LCSW, LMFT and LPC Providers
Licensed Certified Social Workers (LCSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Professional Counselors (LPC)
Group Providers of Licensed Mental Health Practitioner Services
Psychologists Practicing in Arkansas and Bordering States
Routine Services Provider - Psychologists
Non-Bordering States - Psychologists
Limited Service Providers - Psychologists
LCSW, LMFT and LPC Participating in Arkansas and Bordering States
The Psychologist’s Role in the Child Health Services (EPSDT) Program
PROGRAM COVERAGE
Introduction
Non-Refusal Requirement
Primary Care Physician (PCP) Referral
When the Child is Ineligible for Medicaid at Time of Service
Renewal of PCP Referral
Scope
Treatment Plan Requirements
Place of Service
Hospital Visits
RSPMI and Inpatient Psychiatric for Under Age 21
Exclusions
Covered Services
Diagnosis and Clinical Impression
Reserved
Documentation
Electronic Signatures
Reserved
240.000
PRIOR AUTHORIZATION
250.000
REIMBURSEMENT
251.000
251.010
251.100
252.000
260.000
261.000
262.000
262.100
262.200
262.300
262.310
262.400
Method of Reimbursement
Fee Schedules
Billing for Fifteen Minute Units
Rate Appeal Process
BILLING PROCEDURES
Introduction to Billing
CMS-1500 Billing Procedures
Licensed Mental Health Practitioner Procedure Codes
National Place of Service Codes
Billing Instructions - Paper Only
Completion of CMS-1500 Claim Form
Special Billing Procedures
Section II-1
Licensed Mental Health Practitioners
200.000
LICENSED MENTAL HEALTH PRACTITIONERS
GENERAL INFORMATION
201.000
Arkansas Medicaid Participation Requirements for Licensed Mental
Health Practitioners - Licensed Certified Social Worker (LCSW),
Licensed Marriage and Family Therapist (LMFT), Licensed
Professional Counselor (LPC) and Psychologist
Section II
7-1-05
In order to ensure quality and continuity of care, all mental health providers approved to receive
Medicaid reimbursement for services provided to the under age 21 Medicaid population must
meet specific qualifications for their services and staff.
Licensed Mental Health Practitioner providers must meet the Provider Participation and
enrollment requirements contained within Section 140.000 of this manual as well as the
following criteria to be eligible to participate in the Arkansas Medicaid Program:
A.
For the LCSW, LMFT and LPC, a copy of the certification letter from the Division of
Behavioral Health Services (DBHS) must accompany the provider application. Any
changes or subsequent certifications must be furnished to Arkansas Medicaid when
received. See Sections 201.100 through 201.130 for the DBHS certification requirements.
B.
Providers of Licensed Mental Health Practitioner services have the option of enrolling in
the Title XVIII (Medicare) Program.
Providers who have agreements with Medicaid to provide other services to Medicaid
beneficiaries must submit a separate provider application and Medicaid contract to provide
Licensed Mental Health Practitioner services. A separate provider number is assigned.
An LCSW may not be enrolled in both the Targeted Case Management (TCM) and the
Licensed Mental Health Practitioner Medicaid Programs. He or she must choose the
program in which he or she wishes to enroll.
201.100
Certification Requirements for LCSW, LMFT and LPC Providers
10-13-03
Providers of LCSW, LMFT and LPC services must be certified by the Division of Behavioral
Health Services (DBHS) in order to be eligible to participate in the Arkansas Medicaid Program.
All Licensed Certified Social Workers, Licensed Marriage and Family Therapists and Licensed
Professional Counselors must meet the following requirements for certification:
A.
The provider must complete all necessary forms required by the Arkansas Medicaid
Program for application for provider status.
B.
In order to be approved as a provider of outpatient mental and behavioral health services,
a provider must meet the following criteria.
1.
The provider must submit his or her plan to provide:
a.
MEDICATION MANAGEMENT - The LCSW, LMFT and LPC must provide
proof of an affiliation agreement with a physician and/or psychiatrist who will
provide prescription and management of any necessary psychotropic
medications to adequately treat the diagnosis and symptoms of the Medicaid
beneficiary.
b.
PHYSICIAN BACK-UP - LCSW, LMFT and LPC providers must have
physician back up for referral and consultation, as necessary. The provider's
plan must include provisions for the Medicaid beneficiary to see a physician
face-to-face within a specified time when mental health symptoms indicate
potential benefit of medication to treat and/or stabilize symptoms.
c.
24-HOUR AVAILABILITY - LCSW, LMFT and LPC providers must have an
Section II-2
Licensed Mental Health Practitioners
Section II
easily accessible system of mental health care seven days a week, 24-hours a
day in order to assure Medicaid beneficiaries will receive adequate crisis
services, if needed. The provider must be able to provide proof of a
relationship with an entity capable of providing such crisis services and
services that require a more intensive level of care and/or intervention (such as
a hospital, community mental health center, etc.)
d.
201.110
COLLABORATION - LCSW, LMFT and LPC providers will collaborate with
other agencies and/or institutions involved in the beneficiary’s care to ensure
continuity and quality of service delivery.
2.
Services must be provided by a licensed, certified mental health professional, which
by virtue of his or her licensure may practice independently and without supervision.
3.
Documentation of services rendered must meet the requirements defined by
Arkansas Medicaid guidelines.
4.
The LCSW, LMFT and LPC provider must meet all certification requirements as
established by the Division of Behavioral Health Services for each level of care
and/or type of service they are applying to provide to the child/adolescent population.
To request certification, Form DMS-633 - Mental Health Services Provider
Qualification Form for LCSW, LMFT and LPC must be submitted to DBHS. View or
print form DMS-633.
Licensed Certified Social Workers (LCSW)
10-13-03
In order to receive certification from DBHS, an LCSW must meet the requirements outlined in
Section 201.100 as well as the following:
A.
The LCSW must have a master's degree in social work from a graduate school of social
work accredited by the Council on Social Work Education (CSWE).
B.
The LCSW must be state licensed and certified to practice as a licensed certified social
worker (LCSW) in the State of Arkansas and in good standing with the Arkansas Social
Work Licensing Board.
C.
The LCSW must provide proof of two years’ post-licensure experience treating children
and adolescents with mental illness.
D.
The LCSW must possess professional liability coverage at a minimum level of
$1,000,000.00 per episode and $1,000,000.00 aggregate. He or she must be able to
provide proof of such coverage, with the applicant named on the policy as the insured.
E.
The LCSW must be accessible 24 hours a day, seven days a week either directly or
through a back-up plan approved by the Division of Behavioral Health Services at the time
the provider enrollment application is submitted.
201.120
Licensed Marriage and Family Therapist (LMFT)
10-13-03
In order to receive certification from DBHS, an LMFT must meet the requirements outlined in
Section 201.100 as well as the following:
A.
The LMFT must possess a master's degree in mental health counseling from an
accredited college or university.
B.
The LMFT must be licensed as a licensed marriage and family therapist and in good
standing with the Arkansas Board of Examiners in Counseling.
C.
The LMFT must meet all licensure requirements as held forth in Arkansas Law, Act 244 of
1997 for Licensed Professional Counselors (LPC) and Licensed Marriage and Family
Therapists (LMFT).
Section II-3
Licensed Mental Health Practitioners
Section II
D.
The LMFT must provide proof of two years’ post-licensure experience treating children and
adolescents with mental illness.
E.
The LMFT must possess professional liability coverage at a minimum level of
$1,000,000.00 per episode and $1,000,000.00 aggregate. He or she must be able to
provide proof of such coverage, with the applicant named on the policy as the insured.
F.
The LMFT must be accessible 24 hours a day, seven days a week either directly or
through a back-up plan approved by the Division of Behavioral Health Services at the time
the provider enrollment application is submitted.
201.130
Licensed Professional Counselors (LPC)
10-13-03
In order to receive certification from DBHS, an LPC must meet the requirements outlined in
Section 201.100 as well as the following:
A.
The LPC must possess a master's degree in mental health counseling from an accredited
college or university.
B.
The LPC must be licensed as a licensed professional counselor and be in good standing
with the Arkansas Board of Examiners in Counseling.
C.
The LPC must meet all licensure requirements as held forth in Arkansas Law, Act 244 of
1997 for Licensed Professional Counselors (LPC) and Licensed Marriage and Family
Therapists (LMFT).
D.
The LPC must provide proof of two years’ post-licensure experience treating children and
adolescents with mental illness.
E.
The LPC must possess professional liability coverage at a minimum level of
$1,000,000.00 per episode and $1,000,000.00 aggregate. He or she must be able to
provide proof of such coverage, with the applicant named on the policy as the insured.
F.
The LPC must be accessible 24 hours a day, seven days a week either directly or through
a back-up plan approved by the Division of Behavioral Health Services at the time the
provider enrollment application is submitted.
202.000
Group Providers of Licensed Mental Health Practitioner Services
10-13-03
Group providers of Licensed Mental Health Practitioner services must meet the following criteria
in order to be eligible for participation in the Arkansas Medicaid Program.
If a licensed mental health practitioner is a member of a group, each individual licensed mental
health practitioner and the group must both enroll according to the following criteria:
A.
Each individual licensed mental health practitioner within the group must enroll following
the criteria established in Sections 201.000 through 204.000.
B.
All group providers are “pay to” providers only. The service must be performed and billed
by a Medicaid-enrolled licensed mental health practitioner within the group.
203.000
Psychologists Practicing in Arkansas and Bordering States
10-13-03
Psychologists in Arkansas and the bordering states of Louisiana, Mississippi, Missouri,
Oklahoma, Tennessee and Texas will be enrolled as routine services providers.
203.100
A.
Routine Services Provider - Psychologists
10-13-03
The provider will be enrolled in the program as a regular provider of routine services.
Section II-4
Licensed Mental Health Practitioners
Section II
B.
Reimbursement will be available for all LCSW, LMFT, LPC and Psychologist services
covered in the Arkansas Medicaid Program.
C.
Claims will be filed according to Section 260.000 of this manual.
203.200
Non-Bordering States - Psychologists
10-13-03
Psychologists in non-bordering states may be enrolled only as limited-service providers.
203.300
Limited Service Providers - Psychologists
3-1-11
Out-of-state psychologists may be enrolled in the Arkansas Medicaid program to provide
emergency services or non-emergency services not available in Arkansas that are medically
necessary and prior-authorized.
A.
Non-emergency services not available in Arkansas that are medically necessary must be
prior authorized. Each request for these services must be made in writing, forwarded to
the Utilization Review Section and approved before the service is provided. View or print
the Utilization Review Section contact information. An Arkansas Medicaid application
and contract must be downloaded from the Arkansas Medicaid website and submitted to
Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon
approval of the provider application and the Medicaid contract. View or print the
provider enrollment and contract package (Application Packet). View or print
Provider Enrollment Unit contact information.
B.
“Emergency services” are defined as 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 §422.2 and §424.101.
Limited services provider claims will be manually reviewed prior to processing to ensure that
only emergency or prior-authorized services are approved for payment. These claims should be
mailed to the Division of Behavioral Health Services. View or print the Division of Behavioral
Health Services contact information.
204.000
LCSW, LMFT and LPC Participating in Arkansas and Bordering
States
9-1-14
LCSW, LMFT and LPC providers must be located within the State of Arkansas. They will be
enrolled as routine services providers.
A.
The LCSW, LMFT and LPC must be enrolled in the program as a regular provider of
routine services.
B.
Reimbursement will be available for all LCSW, LMFT and LPC services covered in the
Arkansas Medicaid Program.
C.
Claims will be filed according to Section 260.000 of this manual. This includes ICD and
HCPCS codes for all services rendered.
205.000
The Psychologist’s Role in the Child Health Services (EPSDT)
Program
1-15-11
The Arkansas Medical Assistance Program includes a Child Health Services (EPSDT) Program
for eligible individuals under 21 years of age. The purpose of this program is to detect and treat
Section II-5
Licensed Mental Health Practitioners
Section II
health problems in their early stages and to provide well-child health care such as
immunizations.
Child Health Services (EPSDT) providers must refer to the Child Health Services (EPSDT)
manual for additional information.
Psychologists interested in the Child Health Services (EPSDT) Program should contact the
Child Health Services Office. View or print the Child Health Services Office contact
information.
Psychologists may bill Child Health Services (EPSDT) on the CMS-1500 claim using the proper
Child Health Services (EPSDT) provider manual. See the EPSDT provider manual for
information regarding EPSDT screenings. Ancillary charges, such as lab and X-ray, associated
with Child Health Services (EPSDT) should be listed in the patient record. Providers may bill
electronically for Child Health Services (EPSDT). View or print form CMS-1500.
210.000
PROGRAM COVERAGE
211.000
Introduction
10-13-03
Medicaid (Arkansas Medical Assistance Program) is designed to assist eligible Medicaid
beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual.
Reimbursement will be made for allowed services rendered by a Medicaid enrolled provider
within the Medicaid Program limitations as outlined in Section II of this manual.
211.100
Non-Refusal Requirement
10-13-03
The licensed mental health practitioner may not refuse services to a Medicaid-eligible
beneficiary under age 21 unless, based upon the primary mental health diagnosis, the provider
does not possess the services or program to adequately treat the beneficiary’s mental health
needs.
211.200
Primary Care Physician (PCP) Referral
7-1-05
A primary care physician (PCP) referral is required for each Medicaid beneficiary under age 21
for outpatient mental health services. See Section 180.000 of this manual for the PCP
procedures. A PCP referral is generally obtained prior to providing service to Medicaid eligible
children. However, a PCP is given the option of providing a referral after a service is provided.
If a PCP chooses to make a referral after a service has been provided, the referral must be
received by the LMHP provider no later 45 calendar days after the date of service. The PCP
has no obligation to give a retroactive referral.
The LMHP provider may not file a claim and will not be reimbursed for any services provided
that require a PCP referral unless the referral is received.
211.210
When the Child is Ineligible for Medicaid at Time of Service
10-13-03
A.
When a child who is not eligible for Medicaid receives an outpatient mental health service,
an application for Medicaid eligibility may be filed by the child or his or her representative.
B.
If the application for Medicaid coverage is approved, a PCP referral is not required for the
period prior to the Medicaid authorization date. This period is considered retroactive
eligibility and does not require a referral.
C.
A PCP referral is required no later than five (5) calendar days after the authorization date.
If the PCP referral is not obtained within five (5) calendar days of the Medicaid
authorization date, reimbursement will begin, if all other requirements are met, the date the
Section II-6
Licensed Mental Health Practitioners
Section II
PCP referral is received. To verify the authorization date, a provider may call the Hewlett
Packard Enterprise telephone number in this notice or call the local DHS Office.
211.220
Renewal of PCP Referral
10-13-03
If a beneficiary continues to require outpatient mental health services for 6 months or more, the
PCP referral must be renewed every 6 months.
212.000
Scope
10-13-03
The program for Licensed Mental Health Practitioner – licensed certified social worker (LCSW),
licensed marriage and family therapist (LMFT), licensed professional counselor (LPC) and
Psychologist consists of a range of mental health diagnostic, therapeutic, rehabilitative or
palliative services provided by a duly licensed LCSW, LMFT, LPC or Psychologist to Medicaideligible beneficiaries under age 21 suffering from psychiatric conditions as described in the
American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV) and subsequent
revisions.
Medicaid covered Licensed Mental Health Practitioner services may be provided only when:
A.
Referred, by a Medicaid-enrolled physician, in writing or orally. The referral must be
renewed every six (6) months. The written referral or documentation of the oral referral
must include:
1.
The name of the referring Medicaid-enrolled physician,
2.
The referring Medicaid-enrolled physician’s Medicaid identification number and
3.
The date of the referral.
B.
Provided to Medicaid beneficiaries under age 21;
C.
Provided to outpatients;
D.
Provided by a licensed mental health practitioner – LCSW, LMFT, LPC or psychologist;
E.
When applicable, provided by a psychologist according to an Individualized Education
Plan (IEP) and
F.
Included in a treatment plan.
212.100
Treatment Plan Requirements
10-13-03
An individualized, written treatment plan must be developed for each beneficiary receiving
mental health services and included in the patient record. The treatment plan must be updated
no less than every 90 days.
The treatment plan must include at a minimum:
A.
Beneficiary name, date of birth and Medicaid number,
B.
Diagnosis according to the DSM-IV, including all five axes,
C.
Strengths and problems, based on the documented assessment,
D.
Clearly defined goals and objectives,
E.
Specific services planned with expected frequency and duration,
F.
Discharge plan and
Section II-7
Licensed Mental Health Practitioners
G.
Section II
Input of beneficiary and/or family, as appropriate.
212.200
Place of Service
10-13-03
A.
Licensed certified social worker, licensed marriage and family therapist and licensed
professional counselor services are covered only when provided in the provider’s office.
B.
Psychologist’s services are reimbursed by Medicaid when provided in:
212.300
1.
The provider’s office;
2.
An outpatient acute care hospital setting or
3.
A public school system setting under the authority of the Arkansas Department of
Education.
Hospital Visits
10-13-03
Licensed mental health practitioner – licensed certified social worker (LCSW), licensed marriage
and family therapist (LMFT), licensed professional counselor (LPC) and psychologist services
are available only to outpatients. Licensed mental health practitioner services are not available
to inpatients.
“Inpatient” means a patient admitted to a medical institution on recommendation of a physician
or dentist and is receiving room, board and professional services in the institution on a
continuous 24-hour-a-day basis; or who is expected by the institution to receive room, board and
professional services for a 24-hour period or longer, even though the situation may later develop
such that the patient dies, is discharged or is transferred to another facility and does not actually
stay in the institution for 24 hours.
212.400
RSPMI and Inpatient Psychiatric for Under Age 21
10-13-03
Services provided by a licensed mental health practitioner in the Rehabilitation Services for
Persons with Mental Illness (RSPMI) Program must be billed by the RSPMI provider. Services
provided by a Licensed Mental Health Practitioner in an inpatient psychiatric facility for under
age 21 must be billed by the inpatient psychiatric facility. The licensed mental health practitioner
may not bill for RSPMI and inpatient psychiatric services. A beneficiary is not eligible to receive
the services of an independent licensed mental health practitioner on the same date the
beneficiary receives RSPMI services.
213.000
Exclusions
10-13-03
The following are non-covered Licensed Mental Health Practitioner Services:
A.
Rehabilitative Services for Persons With Mental Illness (RSPMI) when billed by the LCSW,
LMFT, LPC or Psychologist.
B.
Licensed Mental Health Practitioner services provided in a supervised living or residential
treatment facility.
C.
Educational services.
D.
Telephone contacts with patient or collateral.
E.
Inpatient Hospital Services.
F.
Inpatient Psychiatric Services.
.
Medicaid-covered outpatient mental health services provided by an LCSW, LMFT or LPC
cannot be provided for ARKids First-B participants.
Section II-8
Licensed Mental Health Practitioners
214.000
Covered Services
Section II
10-13-03
Services provided by Licensed Mental Health Practitioners are billed on a per unit basis, where
one unit equals 15 minutes. Services less than 15 minutes in duration are not reimbursable.
Refer to Section 260.000 of this manual for a description of covered services and procedure
codes that are reimbursable by Arkansas Medicaid to Licensed Mental Health Practitioners.
215.000
Diagnosis and Clinical Impression
9-1-14
Diagnosis and clinical impression shall be required in the terminology of ICD for billing
purposes.
216.000
Reserved
217.000
Documentation
11-1-09
10-13-03
The Licensed Mental Health Practitioner must develop and maintain sufficient written
documentation to support each medical or remedial therapy, service, activity or session for
which billing is made. This documentation, at a minimum, must consist of material that includes:
A.
Physician referral - Referral for medically necessary services, either verbally or in writing,
by a Medicaid-enrolled physician with the physician’s Medicaid ID Number and the date of
the referral. The referral must be renewed every six (6) months.
B.
Specific services rendered.
C.
Date and actual time the services were rendered.
D.
Place the services were rendered.
E.
Length of service.
F.
Progress notes for each service provided, which includes information on patient response
to treatment rendered. Each progress note should directly address treatment plan goals
and objectives.
G.
Comprehensive assessment includes but is not limited to:
1.
Complete demographic information;
2.
Presenting problem;
3.
History of present problem;
4.
Psychiatric history;
5.
Substance abuse history;
6.
Medical and developmental history;
7.
Family and or social history;
8.
Mental status examination and
9.
Clinical impression and diagnosis.
H.
Treatment plan, to include clearly defined goals and objectives with documented input of
the beneficiary, the beneficiary’s family or guardian, or both, as appropriate. The
treatment plan is to be updated no less than every 90 days.
I.
Discharge plan, to include input of the beneficiary, the beneficiary’s family or guardian, or
both, as appropriate.
Section II-9
Licensed Mental Health Practitioners
Section II
This documentation must be maintained in the beneficiary’s medical record.
218.000
Electronic Signatures
10-8-10
Medicaid will accept electronic signatures provided the electronic signatures comply with
Arkansas Code § 25-31-103 et seq.
218.100
Reserved
11-1-09
240.000
PRIOR AUTHORIZATION
7-1-10
Prior Authorization is required for certain services provided to Medicaid-eligible individuals under
age 21. Prior authorization requests must be sent to ValueOptions. View or print
ValueOptions contact information.
Prior authorization is required for the following procedure codes:
Procedure
Code
Required
Modifier
Description
H0004
—
Individual Outpatient—Therapy Session
90847
90847
U1
U2
Marital/Family Therapy Psychologist
90847
U1
Marital/Family Therapy LCSW, LMFT, LPC
90853
90857
U1
—
Group Outpatient—Group Therapy
250.000
REIMBURSEMENT
251.000
Method of Reimbursement
10-13-03
Reimbursement is based on the lesser of the billed amount or the Title XIX maximum allowable
for each procedure.
251.010
Fee Schedules
12-1-12
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee
schedule link is located at https://www.medicaid.state.ar.us under the provider manual
section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas
Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed.
Information may be changed or updated at any time to correct a discrepancy and/or error.
Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid
maximum.
251.100
Billing for Fifteen Minute Units
10-13-03
Arkansas Medicaid does not reimburse services that are billed in 15-minute increments that are
provided for less than 15 minutes. The number of minutes services were provided to a Medicaid
beneficiary in one day must be added for a total number of minutes. Divide the total by 15 for
the number of units to be billed for the day. (This number must not exceed the daily maximum.)
Minutes in the remainder may be carried over and added to the minutes for another day.
Section II-10
Licensed Mental Health Practitioners
Section II
Example: The total number of minutes of services provided to a Medicaid beneficiary on
Monday equals 20. The provider may bill 1 unit and carry over 5 minutes. The total number of
minutes of services provided to the same beneficiary on Tuesday equals 25. When the 5
minutes that were carried over from Monday are added to Tuesday’s total, the new total for
Tuesday equals 30. The provider may bill 2 units for Tuesday if this does not exceed the daily
maximum for the service.
Documentation in the beneficiarys record must reflect clearly exactly how the number of units
are determined.
252.000
Rate Appeal Process
10-13-03
A provider may request reconsideration of a Program decision by writing to the Assistant
Director, Division of Medical Services. This request must be received within 20 calendar days
following the application of policy and/or procedure or the notification of the provider of its rate.
Upon receipt of the request for review, the Assistant Director will determine the need for a
Program/Provider conference and will contact the provider to arrange a conference if needed.
Regardless of the Program decision, the provider will be afforded the opportunity for a
conference, if he or she so wishes, for a full explanation of the factors involved in the Program
decision. Following review of the matter, the Assistant Director will notify the provider of the
action to be taken by the Division within 20 calendar days of receipt of the request for review or
the date of the Program/Provider conference.
If the decision of the Assistant Director, Division of Medical Services, is unsatisfactory, the
provider may then appeal the question to a standing Rate Review Panel established by the
Director of the Division of Medical Services, which will include one member of the Division of
Medical Services, a representative of the provider association and a member of the Department
of Human Services (DHS) management staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days
following the notification of the initial decision by the Assistant Director, Division of Medical
Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days
after receipt of a request for such appeal. The question(s) will be heard by the panel, and a
recommendation will be submitted to the Director of the Division of Medical Services.
260.000
BILLING PROCEDURES
261.000
Introduction to Billing
7-1-07
Licensed Mental Health Practitioner providers use the CMS-1500 form to bill the Arkansas
Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim
may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and
other available options for electronic claim submission.
262.000
CMS-1500 Billing Procedures
262.100
Licensed Mental Health Practitioner Procedure Codes
9-1-13
The following services are billed on a per unit basis. Unless otherwise specified in the
appropriate CPT or HCPCS book, one unit equals 15 minutes. Services less than 15 minutes in
duration are not reimbursable. Services billed on a per hour basis according to CPT or HCPCS
must be billed for a full hour of service. Services less than 1 hour are not reimbursable. See
Section 251.000 for instructions for billing more than full units.
Section II-11
Licensed Mental Health Practitioners
Section II
NOTE: Effective for claims received on or after December 5, 2005, modifiers UA
and/or UB must be used with the appropriate procedure codes as described
below.
Procedure
Code
Required
Modifier
90791
U1
Diagnosis
Direct clinical service provided by a licensed
mental health practitioner for the purpose of
determining the existence, type, nature and most
appropriate treatment of a mental illness or
related disorder as described in the DSM-IV.
This psychodiagnostic process may include but is
not limited to a psychosocial and medical history,
diagnostic findings and recommendations.
8 unit
maximum
per day.
96101
UA
Diagnosis—Psychological Test/Evaluation
Payable only to psychologists.
A single diagnostic test administered to a client
by a licensed psychologist. This procedure
should reflect the mental abilities, aptitudes,
interests, attitudes, motivation, emotional and
personality characteristics of the client.
8 unit
maximum
per day.
96101
UA, UB
Diagnosis—Psychological Testing-Battery
Payable only to psychologists.
Two (2) or more diagnostic tests administered to
a client by a psychologist. This battery should
assess the mental abilities, aptitudes, interests,
attitudes, emotions, motivation and personality
characteristics of the client.
8 unit
maximum
per day.
90887
—
Interpretation of Diagnosis
A direct service provided by a licensed mental
health practitioner for the purpose of interpreting
the results of diagnostic activities to the patient
and/or significant others. If significant others are
involved, appropriate consent forms may need to
be obtained.
4 unit
maximum
per day.
Crisis Management Visit
An unscheduled direct service contact between
an identified patient and a licensed mental health
practitioner for the purpose of preventing an
inappropriate or more restrictive placement.
4 unit
maximum
per day.
Individual Outpatient—Therapy Session
Scheduled individual outpatient care provided by
a licensed mental health practitioner to a patient
for the purposes of treatment and remediation of
a condition described in DSM-IV and subsequent
revisions.
4 unit
maximum
per day.
H2011
(Psychologist)
H0046
(LCSW,
LMFT, LPC)
H0004
—
Description
Length of
Service
Section II-12
Licensed Mental Health Practitioners
Section II
Procedure
Code
Required
Modifier
90847
90847
U1
U2
Marital/Family Therapy
Family therapy shall be treatment provided to two
or more family members and conducted by a
licensed mental health practitioner for the
purpose of alleviating conflict and promoting
harmony.
6 unit
maximum
per day.
90846
90846
U1
U2
Marital/Family Therapy without patient present
Family therapy shall be treatment provided to two
or more family members and conducted by a
licensed mental health practitioner for the
purpose of alleviating conflict and promoting
harmony.
6 unit
maximum
per day.
H0046
(Psychologist)
H0046
(LCSW,
LMFT, LPC)
U2
Individual Outpatient—Collateral Services
A face-to-face contact by a licensed mental
health practitioner with other professionals,
caregivers or other parties on behalf of an
identified patient to obtain relevant information
necessary to the patient’s assessment,
evaluation and treatment.
4 unit
maximum
per day.
90853
90857
—
Group Outpatient—Group Therapy
A direct-service contact between a group of
patients and a LCSW, LMFT or LPC for the
purposes of treatment and remediation of a
psychiatric condition.
6 unit
maximum
per day.
90853
90857
U1
U1
Group Outpatient—Group Therapy
A direct-service contact between a group of
patients and a psychologist for the purposes of
treatment and remediation of a psychiatric
condition.
6 unit
maximum
per day
262.200
U1
Length of
Service
Description
7-1-07
National Place of Service Codes
Electronic and paper claims now require the same National Place of Service code.
Psychologist:
Place of Service
POS Code
Outpatient Hospital
22
Provider’s Office
11
Other—Public School System Setting
99
LCSW, LMFT, LPC:
Place of Service
POS Code
Provider’s Office
11
Section II-13
Licensed Mental Health Practitioners
262.300
Section II
Billing Instructions - Paper Only
7-1-07
Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore,
claims submitted on paper are lower priority and are paid once a month. The only claims exempt
from this rule are those that require attachments or manual pricing.
Bill Medicaid for professional services with form CMS-1500. The numbered items in the
following instructions correspond to the numbered fields on the claim form. View a sample form
CMS-1500.
Carefully follow these instructions to help Hewlett Packard Enterprise efficiently process claims.
Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary
information is omitted.
Forward completed claim forms to the Hewlett Packard Enterprise Claims Department. View or
print the Hewlett Packard Enterprise Claims Department contact information.
NOTE: A provider delivering services without verifying beneficiary eligibility for each
date of service does so at the risk of not being reimbursed for the services.
262.310
Completion of CMS-1500 Claim Form
Field Name and Number
Instructions for Completion
1.
Not required.
(type of coverage)
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
9-1-14
Beneficiary’s or participant’s 10-digit Medicaid or
ARKids First-A or ARKids First-B identification
number.
2.
PATIENT’S NAME (Last
Name, First Name, Middle
Initial)
Beneficiary’s or participant’s last name and first
name.
3.
PATIENT’S BIRTH DATE
Beneficiary’s or participant’s date of birth as given on
the individual’s Medicaid or ARKids First-A or ARKids
First-B identification card. Format: MM/DD/YY.
SEX
Check M for male or F for female.
4.
INSURED’S NAME (Last
Name, First Name, Middle
Initial)
Required if insurance affects this claim. Insured’s last
name, first name, and middle initial.
5.
PATIENT’S ADDRESS (No.,
Street)
Optional. Beneficiary’s or participant’s complete
mailing address (street address or post office box).
CITY
Name of the city in which the beneficiary or
participant resides.
STATE
Two-letter postal code for the state in which the
beneficiary or participant resides.
ZIP CODE
Five-digit zip code; nine digits for post office box.
TELEPHONE (Include Area
Code)
The beneficiary’s or participant’s telephone number
or the number of a reliable message/contact/
emergency telephone.
PATIENT RELATIONSHIP TO
INSURED
If insurance affects this claim, check the box
indicating the patient’s relationship to the insured.
6.
Section II-14
Licensed Mental Health Practitioners
Field Name and Number
7.
INSURED’S ADDRESS (No.,
Street)
Section II
Instructions for Completion
Required if insured’s address is different from the
patient’s address.
CITY
STATE
ZIP CODE
TELEPHONE (Include Area
Code)
8.
RESERVED
Reserved for NUCC use.
9.
OTHER INSURED’S NAME
(Last name, First Name,
Middle Initial)
If patient has other insurance coverage as indicated
in Field 11d, the other insured’s last name, first
name, and middle initial.
a.
OTHER INSURED’S
POLICY OR GROUP
NUMBER
Policy and/or group number of the insured individual.
b.
RESERVED
Reserved for NUCC use.
SEX
Not required.
c.
RESERVED
Reserved for NUCC use.
d.
INSURANCE PLAN
NAME OR PROGRAM
NAME
Name of the insurance company.
10. IS PATIENT’S CONDITION
RELATED TO:
a.
EMPLOYMENT? (Current
or Previous)
Check YES or NO.
b.
AUTO ACCIDENT?
Required when an auto accident is related to the
services. Check YES or NO.
PLACE (State)
If 10b is YES, the two-letter postal abbreviation for
the state in which the automobile accident took place.
c.
OTHER ACCIDENT?
Required when an accident other than automobile is
related to the services. Check YES or NO.
d.
CLAIM CODES
The “Claim Codes” identify additional information
about the beneficiary’s condition or the claim. When
applicable, use the Claim Code to report appropriate
claim codes as designated by the NUCC. When
required to provide the subset of Condition Codes,
enter the condition code in this field. The subset of
approved Condition Codes is found at
www.nucc.org under Code Sets.
11. INSURED’S POLICY GROUP
OR FECA NUMBER
a.
Not required when Medicaid is the only payer.
INSURED’S DATE OF
BIRTH
Not required.
SEX
Not required.
Section II-15
Licensed Mental Health Practitioners
Field Name and Number
Section II
Instructions for Completion
b.
OTHER CLAIM ID
NUMBER
Not required.
c.
INSURANCE PLAN
NAME OR PROGRAM
NAME
Not required.
d.
IS THERE ANOTHER
HEALTH BENEFIT
PLAN?
When private or other insurance may or will cover
any of the services, check YES and complete items
9, 9a and 9d. Only one box can be marked.
12. PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE
Enter “Signature on File,” “SOF” or legal signature.
13. INSURED’S OR
AUTHORIZED PERSON’S
SIGNATURE
Enter “Signature on File,” “SOF” or legal signature.
14. DATE OF CURRENT:
Required when services furnished are related to an
accident, whether the accident is recent or in the
past. Date of the accident.
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
Enter the qualifier to the right of the vertical dotted
line. Use Qualifier 431 Onset of Current Symptoms or
Illness; 484 Last Menstrual Period.
15. OTHER DATE
Enter another date related to the beneficiary’s
condition or treatment. Enter the qualifier between
the left-hand set of vertical, dotted lines.
The “Other Date” identifies additional date
information about the beneficiary’s condition or
treatment. Use qualifiers:
454 Initial Treatment
304 Latest Visit or Consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-Ray
471 Prescription
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date)
444 First Visit or Consultation
16. DATES PATIENT UNABLE
TO WORK IN CURRENT
OCCUPATION
Not required.
17. NAME OF REFERRING
PROVIDER OR OTHER
SOURCE
Name and title of referral source, whether an
individual (such as a PCP) or a clinic or other facility.
17a. (blank)
The 9-digit Arkansas Medicaid provider ID number of
the referring physician.
17b. NPI
Not required.
Section II-16
Licensed Mental Health Practitioners
Section II
Field Name and Number
Instructions for Completion
18. HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
When the serving/billing provider’s services charged
on this claim are related to a beneficiary’s or
participant’s inpatient hospitalization, enter the
individual’s admission and discharge dates. Format:
MM/DD/YY.
19.
Identifies additional information about the
beneficiary’s condition or the claim. Enter the
appropriate qualifiers describing the identifier. See
www.nucc.org for qualifiers.
ADDITIONAL CLAIM
INFORMATION
20. OUTSIDE LAB?
$ CHARGES
21. DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Not required.
Not required.
Enter the applicable ICD indicator to identify which
version of ICD codes is being reported.
Use “9” for ICD-9-CM.
Use “0” for ICD-10-CM.
Enter the indicator between the vertical, dotted lines
in the upper right-hand portion of the field.
Diagnosis code for the primary medical condition for
which services are being billed. Use the appropriate
International Classification of Diseases (ICD). List no
more than 12 diagnosis codes. Relate lines A-L to
the lines of service in 24E by the letter of the line.
Use the highest level of specificity.
22. RESUBMISSION CODE
ORIGINAL REF. NO.
Reserved for future use.
Any data or other information listed in this field does
not/will not adjust, void or otherwise modify any
previous payment or denial of a claim. Claim
payment adjustments, voids, and refunds must follow
previously established processes in policy.
23. PRIOR AUTHORIZATION
NUMBER
The prior authorization or benefit extension control
number if applicable.
24A.
The “from” and “to” dates of service for each billed
service. Format: MM/DD/YY.
DATE(S) OF SERVICE
1. On a single claim detail (one charge on one line),
bill only for services provided within a single
calendar month.
2. Some providers may bill on the same claim detail
for two or more sequential dates of service within
the same calendar month when the provider
furnished equal amounts of the service on each
day of the date sequence.
B.
PLACE OF SERVICE
Two-digit national standard place of service code.
C.
EMG
Enter “Y” for “Yes” or leave blank if “No.” EMG
identifies if the service was an emergency.
Section II-17
Licensed Mental Health Practitioners
Field Name and Number
D.
Section II
Instructions for Completion
PROCEDURES,
SERVICES, OR
SUPPLIES
CPT/HCPCS
One CPT or HCPCS procedure code for each detail.
MODIFIER
Modifier(s) if applicable.
E.
DIAGNOSIS POINTER
Enter the diagnosis code reference letter (pointer) as
shown in Item Number 21 to relate to the date of
service and the procedures performed to the primary
diagnosis. When multiple services are performed, the
primary reference letter for each service should be
listed first; other applicable services should follow.
The reference letter(s) should be A-L or multiple
letters as applicable. The “Diagnosis Pointer” is the
line letter from Item Number 21 that relates to the
reason the service(s) was performed.
F.
$ CHARGES
The full charge for the service(s) totaled in the detail.
This charge must be the usual charge to any client,
patient, or other beneficiary of the provider’s services.
G.
DAYS OR UNITS
The units (in whole numbers) of service(s) provided
during the period indicated in Field 24A of the detail.
H.
EPSDT/Family Plan
Enter E if the services resulted from a Child Health
Services (EPSDT) screening/referral.
I.
ID QUAL
Not required.
J.
RENDERING
PROVIDER ID #
The 9-digit Arkansas Medicaid provider ID number of
the individual who furnished the services billed for in
the detail.
NPI
Not required.
25. FEDERAL TAX I.D. NUMBER
Not required. This information is carried in the
provider’s Medicaid file. If it changes, please contact
Provider Enrollment.
26. PATIENT’S ACCOUNT N O.
Optional entry that may be used for accounting
purposes; use up to 16 numeric or alphabetic
characters. This number appears on the Remittance
Advice as “MRN.”
27. ACCEPT ASSIGNMENT?
Not required. Assignment is automatically accepted
by the provider when billing Medicaid.
28. TOTAL CHARGE
Total of Column 24F—the sum all charges on the
claim.
29. AMOUNT PAID
Enter the total of payments previously received on
this claim. Do not include amounts previously paid by
Medicaid. Do not include in this total the
automatically deducted Medicaid or ARKids First-B
co-payments.
30. RESERVED
Reserved for NUCC use.
Section II-18
Licensed Mental Health Practitioners
Section II
Field Name and Number
Instructions for Completion
31. SIGNATURE OF PHYSICIAN
OR SUPPLIER INCLUDING
DEGREES OR
CREDENTIALS
The provider or designated authorized individual
must sign and date the claim certifying that the
services were personally rendered by the provider or
under the provider’s direction. “Provider’s signature”
is defined as the provider’s actual signature, a rubber
stamp of the provider’s signature, an automated
signature, a typewritten signature, or the signature of
an individual authorized by the provider rendering the
service. The name of a clinic or group is not
acceptable.
32. SERVICE FACILITY
LOCATION INFORMATION
If other than home or office, enter the name and
street, city, state, and zip code of the facility where
services were performed.
a. (blank)
Not required.
b. (blank)
Not required.
33. BILLING PROVIDER INFO &
PH #
262.400
Billing provider’s name and complete address.
Telephone number is requested but not required.
a. (blank)
Not required.
b. (blank)
Enter the 9-digit Arkansas Medicaid provider ID
number of the billing provider.
Special Billing Procedures
10-13-03
Not applicable to this program.
Section II-19