Rural Health Clinic
Billing Tips
Provider Reference Supplement
HP Enterprise Services, Arkansas Title XIX
Document Date: 5/12/2010
HP Enterprise Services
Arkansas Title XIX Account
500 President Clinton Avenue, Suite 400
Little Rock, Arkansas 72201
(501) 374-6608
HP Enterprise Services and the HP Enterprise Services logo are registered trademarks of HP Enterprise
Services.
All other logos, trademarks or service marks used herein
are the property of their respective owners.
HP Enterprise Services is an equal opportunity employer and values the diversity of its people.
© 2010 HP Enterprise Services.
All rights reserved.
Contents
Introduction ..................................................................................................................... 5
Eligibility .......................................................................................................................... 6
Restricted aid categories .............................................................................................. 6
Quick Tips for Submitting Claims..................................................................................... 9
Correcting Common Billing Errors ................................................................................ 9
Rural Health Clinic Core Services .............................................................................. 10
Billing Instructions ...................................................................................................... 12
Revenue Codes ......................................................................................................... 12
Non-Payable Diagnosis Codes .................................................................................. 12
Family Planning ......................................................................................................... 13
EPSDT and ARKids First-B Medical Screenings ........................................................ 13
Diagnosis Codes not Covered for Beneficiaries under 21 .......................................... 15
National Place of Service Codes ................................................................................ 15
Benefit Limits ............................................................................................................. 16
Contact Information ....................................................................................................... 17
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Arkansas Medicaid Rural Health Billing Tips
Introduction
This Billing Tips document serves as a training supplement for Arkansas Medicaid
providers, but does not supersede official program documentation including: Arkansas
Medicaid Provider Reference manuals, Official Notices and transmittal letters published
by the Division of Medical Services and distributed by HP Enterprise Services.
This document focuses on Arkansas Medicaid eligibility and billing issues and
incorporates the following quick reference items for your convenience:

Consolidated list of restricted aid categories

Provider Electronic Solutions (PES) claims submission instructions

Eligibility request details

Claim status report details

Rural Health Revenue Codes

Rural Health Non Payable/Non Covered Diagnosis Codes

Place of Service Codes

Benefit Limits
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Arkansas Medicaid Rural Health Billing Tips
Eligibility
Beneficiary eligibility for the Arkansas Medicaid program is determined at the
Department of Human Services (DHS) county office. A beneficiary’s eligibility may begin
and end on any day of any month. Because program eligibility is date specific, providers
should check each beneficiary’s eligibility on the date of service and are encouraged to
do so using one of the following tools:

PES

Arkansas Medicaid Direct Data Entry (DDE) website
Both tools verify eligibility electronically for a specific date or range of dates, including
retroactive eligibility for a year. For more information on eligibility, refer to Section I of the
Arkansas Medicaid provider manual.
Restricted aid categories
Many providers ask a question that is closely related to eligibility: “Is there a list of aid
categories that require a primary care physician?” The answer is no. Arkansas
Medicaid’s managed-care program, ConnectCare, stipulates that every Medicaid
beneficiary and Medicaid waiver participant must enroll with a primary care physician
(PCP) unless he or she is specifically exempt from that requirement.
See the following sections of your Arkansas Medicaid provider manual for more
information:
Section 171.000, which lists the groups of individuals who may not enroll with a PCP
Section 176.000, which lists Medicaid covered services that do not require PCP
referral
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The table below lists and briefly describes restricted aid categories. Post it at your
workstation to use as a convenient quick reference:
Aid Category
Restriction
01 ARKids First-B
Beneficiaries may have co-payment requirements.
(PCP Required)
Beneficiaries may be ineligible for certain services (see the ARKids
First-B provider manual for exclusions.)
03 CMS (Children’s Medical
Services)
All services must be prior authorized by the CMS office.
Non-Medicaid
(No PCP Required)
04 DDS (Developmental
Disability Services)
Non-Medicaid
(NO PCP Required)
DDS non-Medicaid provider ID numbers end with ‘86’.
DDS non-Medicaid beneficiary ID numbers begin with ‘8888’.
Only DDS non-Medicaid providers may bill for DDS non-Medicaid
beneficiaries.
DDS beneficiaries may be dually eligible and receive additional
services in another category.
*6 Medically Needy
Exceptional
Beneficiaries are eligible for a full range of benefits except nursing
facility and personal care.
(PCP Required)
*7 Spend Down
(No PCP Required)
(PCP required for Breast
Care, 07)
08 Tuberculosis
(NO PCP Required)
Beneficiaries must pay toward medical expenses when income and
resources exceed the Medicaid financial guidelines.
Note:
Aid category 07 BCC has full benefits.
Beneficiary coverage includes drugs, physician services, outpatient
services, rural health clinic encounters.
Federally Qualified Health Center (FQHC) and clinic visits for TBrelated services only.
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Arkansas Medicaid Rural Health Billing Tips
Aid Category
Restriction
*8 QMB (Qualified Medicare
Beneficiary)
Medicaid pays Medicare premiums, coinsurance and deductible.
(No PCP Required)
If the service provided is not a Medicare covered service, Medicaid
will not pay for the service under the QMB policy.
Note:
Aid category 18 S has full benefits.
61 PW-PL (Pregnant Woman
Infants and Children Poverty
level)
This category contains both pregnant women and children.
Providers must use the last three-(3) digits of the Medicaid ID
number to determine benefits.
(No PCP Required For
Pregnant Woman)
When the last three (3) digits are in the 100 series (i.e., 101, 102,
etc.), the beneficiary is eligible as an adult and is eligible for
pregnancy-related services only.
(PCP Required for the Infants
and children)
When the last three (3) digits are in the 200 series (i.e., 201, 202,
etc.), the beneficiary is eligible as a child and receives a full range
of Medicaid services.
Note:
62 PW-PE (Pregnant Woman
Presumptive Eligibility)
Plan description “PW unborn ch-noster/FP cov” indicates
there is no sterilization or family planning benefits for the
expectant mother.
A temporary aid category that pays for ambulatory, prenatal
services only.
(No PCP Required)
69 Women’s Health Wavier
(No PCP Required)
Medicaid pays for family planning preventative services only, such
as birth control or counseling.
A claim for a beneficiary in this category must contain both a family
planning diagnosis code and a family planning procedure code.
58, 78, 88 SLIMB (Specified
Low Income Medicare
Beneficiary)(SMB)
Medicaid pays only their Medicare premium.
(No PCP Required)
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Quick Tips for Submitting Claims
This section outlines quick tips for Rural Health Clinic providers in Medicaid. These
billing tips address some of the most common billing errors identified by the HP
Enterprise Services Provider Assistance Center (PAC). Topics include the following:
Correcting common billing errors
Procedure code quick reference
Rural Health Revenue Codes
Non Payable Diagnosis Codes
Non Covered Diagnosis Codes for Beneficiaries under 21
Place of Service Codes
Benefit Limits
Correcting Common Billing Errors
Refer to the chart below to learn how to correct common billing errors that are
associated with certain Explanation of Benefits (EOB) codes:
EOB Code
Error
Method of Correction
263 and 267 Beneficiary is partially or
totally ineligible for the DOS.
Verify the beneficiary is eligible for all
claim dates of service. Resubmit the
claim/portion of the claim for the time of
eligibility.
208
Beneficiary aid category 69 is
limited to family planning
services only.
Verify that the original claim has a
family planning diagnosis and
procedure code. Correct and resubmit
the claim.
252
Medicaid ID number
submitted does not match
patient’s name on Medicaid
ID card.
Verify eligibility through Medicaid’s
electronic eligibility system and
resubmit the claim with correct
information.
469 or 470
Duplicate billing. Claim is
identical to another claim for
DOS, performing provider,
procedure, TOS and price.
Verify that the service is not a duplicate
bill. Resubmit the corrected claim
103
Claim does not meet the
timely filing requirements for
Medicaid.
Claims must be received by HP
Enterprise Services within 365 days
from the “To” DOS. Claims received
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Arkansas Medicaid Rural Health Billing Tips
EOB Code
Error
Method of Correction
beyond this deadline will not be paid.
952
Service requires Primary
Care Physician referral.
Resubmit the claim with the corrected
PCP information required for
adjudication.
199
ARKids 1st B beneficiary is
older than 18 years old.
ARKids 1st B beneficiary’s eligibility
ends on their 19th birthday. The “from”
DOS cannot exceed the 19th birthday.
Rural Health Clinic Core Services
Rural Health Clinic core services are as follows:
A. Professional services that are performed by a physician at the clinic or are performed
away from the clinic by a physician whose agreement with the clinic provides that he
or she will be paid by the clinic for such services;
B. Services and supplies furnished “incident to” a physician’s professional services;
C. Services of physician assistants, nurse practitioners, nurse midwives and specialized
nurse practitioners. These non-physician professional services are covered when:
1. Furnished by a nurse practitioner, physician assistant, nurse midwife or
specialized nurse practitioner who is employed by, or receives compensation
from, the rural health clinic;
2. Furnished under the medical supervision of a physician;
3. Furnished in accordance with any medical orders for the care and treatment of a
patient prepared by a physician;
4. They are a type that the nurse practitioner, physician assistant, nurse midwife or
specialized nurse practitioner who furnished the service is legally permitted to
perform by the state in which the service is provided and
5. They would be covered if furnished by a physician.
D. Services and supplies that are furnished as an incident to professional services
furnished by a nurse practitioner, physician assistant, nurse midwife or other
specialized nurse practitioner and
E. Visiting nurse services on a part-time or intermittent basis to home-bound patients
(limited to areas in which there is a shortage of home health agencies).
1. For purposes of visiting nurse care, a home-bound patient is one who is
permanently or temporarily confined to his or her place of residence because of a
medical or health condition. Institutions, such as a hospital or nursing care
facility, are not considered a patient’s residence.
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2. A patient’s place of residence is where he or she lives, unless he or she is in an
institution such as a nursing facility, hospital or intermediate care facility for the
mentally retarded (ICF/MR).
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Arkansas Medicaid Rural Health Billing Tips
Billing Instructions
Rural Health Clinics can bill on the following claim forms:
1. UB-04 claim form (used for most RHC billing)
2. CMS-1500 (used for billing well child visits)
3. DMS-694 Billing Procedures, EPSDT claim form (used for billing EPSDT
screening)
Revenue Codes
RHCs may use only these revenue codes when billing.
Code
Description
520
Encounter—Independent Rural Health Clinic
521
Encounter—Provider-based Rural Health Clinic
524
Basic or Periodic Family Planning Visit—Independent Rural Health Clinic
525
Basic of Periodic Family Planning Visit—Provider-based Rural Health Clinic
Non-Payable Diagnosis Codes
The following ICD-9-CM diagnosis codes are non-payable.
Code
Description
V57.1
Other physical therapy
V57.2
Occupational therapy and vocational rehabilitation
V57.3
Speech therapy
V72.5
Radiological examination, not elsewhere classified
V72.6
Laboratory examination
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Family Planning
Revenue
Code
Description
Procedure
Code
Description
Modifier
0524
Basic or Periodic Family
Planning Visit Independent RHC
99401
Periodic Family
Planning Visit
U9
0524
Basic or Periodic Family
Planning Visit Independent RHC
99402
Basic Family
Planning Visit
U9
0525
Basic or Periodic Family
Planning Visit Provider-Based
RHC
99401
Periodic Family
Planning Visit
U9
0525
Basic or Periodic Family
Planning Visit Provider-Based
RHC
99402
Basic Family
Planning Visit
U9
EPSDT and ARKids First-B Medical Screenings
Revenue
Code
NA
Description
EPSDT Periodic Complete Medical Screen
(New Patient)
NA
EPSDT Periodic Complete Medical Screen
(New Patient)
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
EPSDT Periodic Complete Medical Screen
(New Patient)
EPSDT Periodic Complete Medical Screen
(New Patient)
EPSDT Periodic Complete Medical Screen
(New Patient)
EPSDT Periodic Complete Medical Screen
(New Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(New Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(New Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(New Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(New Foster Care Patient)
ARKids Complete Medical Screen (New
Patient)
ARKids Complete Medical Screen (New
Patient)
ARKids Complete Medical Screen (New
Patient)
Procedure
Code
Mod
#1
Mod
#2
99381
EP
U1
99382
EP
U1
99383
EP
U1
99384
EP
U1
99385
EP
U1
99381
EP
H9
99382
EP
H9
99383
EP
H9
99384
EP
H9
99385
EP
H9
99381
99382
99383
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Arkansas Medicaid Rural Health Billing Tips
Revenue
Code
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Description
ARKids Complete Medical Screen (New
Patient)
ARKids Complete Medical Screen (New
Patient)
EPSDT Periodic Complete Medical Screen
(Established Patient)
EPSDT Periodic Complete Medical Screen
(Established Patient)
EPSDT Periodic Complete Medical Screen
(Established Patient)
EPSDT Periodic Complete Medical Screen
(Established Patient)
EPSDT Periodic Complete Medical Screen
(Established Patient)
EPSDT Periodic Complete Medical Screen
(Established Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(Established Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(Established Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(Established Foster Care Patient)
EPSDT Periodic Complete Medical Screen
(Established Foster Care Patient)
ARKids Complete Medical Screen
(Established Patient)
ARKids Complete Medical Screen
(Established Patient)
ARKids Complete Medical Screen
(Established Patient)
ARKids Complete Medical Screen
(Established Patient)
ARKids Complete Medical Screen
(Established Patient)
EPSDT Newborn Care/Screen in Hospital
EPSDT Newborn Care/Screen in Hospital
EPSDT Newborn Care/Screen in Hospital
Newborn Care/Screen in Hospital
Newborn Care/Screen in Hospital
Newborn Care/Screen in Hospital
Procedure
Code
Mod
#1
Mod
#2
99391
EP
U2
99392
EP
U2
99393
EP
U2
99394
EP
U2
99395
EP
U2
99391
EP
H9
99392
EP
H9
99393
EP
H9
99394
EP
H9
99395
EP
H9
EP
EP
EP
UA
UA
UA
UA
UA
UA
99384
99385
99391
99392
99393
99394
99395
99460
99461
99463
99460
99461
99463
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Diagnosis Codes not Covered for Beneficiaries under 21
The following ICD-9-CM diagnosis codes are non-payable for beneficiaries under the
age of 21. Refer to the Child Health Services (EPSDT) provider manual and the ARKids
First-B provider manual for instructions regarding procedure and diagnosis coding on
well childcare claims.
Code
Description
V70.0
Routine general medical examination at a health care facility
V70.3
Other medical examination for administrative purposes
V70.5
Health examination of defined subpopulations
V70.7
Examination for normal comparison or control in clinical research
V70.9
Unspecified general medical examination
V72.85
Other specified examination
National Place of Service Codes
Electronic and paper claims now require the same National Place of Service code.
Place of Service
POS Codes
Inpatient Hospital
21
Outpatient Hospital
22
Doctor’s Office
11
Patient’s Home
12
Ambulatory Surgical Center
24
Day Care Facility or DDTCS Facility
99
Nursing Facility
32
Skilled Nursing Facility
31
Other Locations
99
Independent Laboratory
81
End Stage Renal Disease Treatment Facility
65
Emergency Room
23
Inpatient Psychiatric Facility
51
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Arkansas Medicaid Rural Health Billing Tips
Benefit Limits
A. There is no RHC encounter benefit limit for Medicaid beneficiaries under the age of
21 in the Child Health Services (EPSDT) Program.
B. A benefit limit of 12 visits per state fiscal year (SFY), July 1 through June 30, has
been established for beneficiaries aged 21 and older. The following services are
counted toward the 12 visits per SFY benefit limit.
1. Physician visits in the office, patient’s home or nursing facility
2. Certified nurse-midwife visits
3. RHC encounters
4. Medical services provided by a dentist
5. Medical services provided by an optometrist
6. Advanced nurse practitioner services
Global obstetric fees are not counted against the 12-visit limit. Itemized obstetric office
visits are counted in the limit.
Extensions of the benefit limit will be considered for services beyond the established
benefit limit when documentation verifies medical necessity. Refer to section 218.310 of
the Rural Health Clinic provider for procedures for obtaining extension of benefits.
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Contact Information
Providers needing assistance on billing, enrollment or technical support should call HP
Enterprise Services at one of the following assistance numbers:
1-800-457-4454 (outside of Little Rock but in-state)
(501) 376-2211 (local or out-of-state)
Depending on the type of assistance needed, follow the instructions in the phone system
to reach the appropriate department. The provider assistance departments are:
Provider Assistance Center - The provider assistance center is open weekdays 8
a.m. to 5 p.m. to assist providers with claim issues, billing questions and denials.
EDI support center - The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to
assist providers with electronic claim submission issues, 997 batch responses,
PES software downloads and setup support, software training and data
transmission failures.
Medicaid Provider Enrollment - The Medicaid Provider Enrollment Unit is open
weekdays 8 a.m. to 5 p.m. to assist providers with enrollment in the Arkansas
Medicaid program, changing PCP caseloads and updating demographic
information.
HP Enterprise Services Provider Representatives - HP Enterprise Services Provider
Representatives are available to visit your facility by appointment. They assist
providers with billing issues, software delivery and setup, escalated issues and
policy questions. See the Arkansas Medicaid website for a list of representatives
by counties.
Research Analyst - The PAC Research Analyst assist providers with escalated billing
issues, claim appeals and special processing requests. See the Arkansas
Medicaid website for contact information by county.
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