Therapy 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 ..................................................................................................................... 3
Eligibility .......................................................................................................................... 4
Restricted Aid Categories ............................................................................................ 4
All Arkansas Medicaid Aid Categories .......................................................................... 6
Therapy Benefits ........................................................................................................... 10
Program Coverage ........................................................................................................ 11
Prior Authorization Request Procedures for Augmentative Communication Device (ACD)
...................................................................................................................................... 14
Evaluation .................................................................................................................. 14
Contact List for Reviews, Managed Care and Authorizations ........................................ 15
National Place of Service Codes ................................................................................... 16
Quick Tips for Submitting Claims................................................................................... 17
Introduction to Billing .................................................................................................. 17
CMS-1500 Billing Procedures - Occupational, Physical, Speech Therapy Procedure
Codes ..................................................................................................................... 17
Augmentative Communication Device (ACD) Évaluation ........................................ 20
Billing Instructions - Paper Only ................................................................................. 20
Completion of the CMS-1500 Claim Form............................................................... 20
Special Billing Procedures.......................................................................................... 27
Common Billing Errors ............................................................................................... 28
Brief Overview of Benefits ............................................................................................. 29
Contact Information ....................................................................................................... 30
i
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 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

National Place of Service (POS) reference sheet for paper and electronic claims

Billing Paper Claims

Correcting Common Billing Errors

Contact Information
3
Arkansas Medicaid Therapy 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
are required to 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
your 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 primary care case management program, ConnectCare, requires Medicaid
beneficiaries and waiver participants to enroll with a primary care physician (PCP)
unless specifically exempt from that requirement.
See these sections of your Arkansas Medicaid provider manual for more information
related to eligibility:

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
On the following pages are a consolidated list of aid categories with restrictions and a
complete list of aid categories taken from Section 124.000 of your Arkansas Medicaid
provider manual.
4
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 nonMedicaid 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
TB-related services only.
5
Arkansas Medicaid Therapy 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: Plan description “PW unborn ch-noster/FP cov”
indicates there is no sterilization or family planning benefits
for the expectant mother.
62 PW-PE (Pregnant
Woman Presumptive
Eligibility)
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)
All Arkansas Medicaid Aid Categories
The following is the full list of beneficiary aid categories. Some categories may provide a
full range of benefits, may offer limited benefits or may be a category that requires cost
sharing by a beneficiary. The following codes describe each level of coverage.
FR
full range
LB
limited benefits
6
AC
additional cost sharing
MNLB medically needy limited benefits
Category
Description
Code
01 ARKIDS B
ARKids First Demonstration
LB, AC
07 BCC
Breast and Cervical Cancer Prevention and Treatment
FR
08 TB-Limited
Tuberculosis – Limited Benefits
LB
10 N WD
NewCo*
Working Disabled – New Cost Sharing (N)
FR, AC
10 R WD
RegCo*
Working Disabled – Regular Medicaid Cost Sharing
(R)
FR, AC
11 AABD
AABD
FR
13 SSI
SSI
FR
14 SSI
SSI
FR
16 AA-EC
AA-EC
MNLB
17 AA-SD
Aid to the Aged Medically Needy Spend Down
MNLB
18 QMB-AA
Aid to the Aged-Qualified Medicare Beneficiary (QMB)
LB
18 S AR
Seniors*
ARSeniors
FR
20 AFDCGRANT
Transitional Employment Assistance (TEA, formerly
AFDC) Medicaid
FR
25 TM
Transitional Medicaid
FR
26 AFDC-EC
AFDC Medically Needy Exceptional Category
MNLB
27 AFDC-SD
AFDC Medically Needy Spend Down
MNLB
31 AAAB
Aid to the Blind
FR
33 SSI
SSI Blind Individual
FR
34 SSI
SSI Blind Spouse
FR
35 SSI
SSI Blind Child
FR
36 AB-EC
Aid to the Blind-Medically Needy Exceptional Category
MNLB
37 AB-SD
Aid to the Blind-Medically Needy Spend Down
MNLB
38 QMB-AB
Aid to the Blind-Qualified Medicare Beneficiary (QMB)
LB
41 AABD
Aid to the Disabled
FR
43 SSI
SSI Disabled Individual
FR
44 SSI
SSI Disabled Spouse
FR
45 SSI
SSI Disabled Child
FR
7
Arkansas Medicaid Therapy Billing Tips
Category
Description
Code
46 AD-EC
Aid to the Disabled-Medically Needy Exceptional
Category
MNLB
47 AD-SD
Aid to the Disabled-Medically Needy Spend Down
MNLB
48 QMB- AD
Aid to the Disabled-Qualified Medicare Beneficiary
(QMB)
LB
49 TEFRA
TEFRA Waiver for Disabled Child
AC
51 U-18
Under Age 18 No Grant
FR
52 ARKIDS A
Newborn
FR
56 U-18 EC
Under Age 18 Medically Needy Exceptional Category
MNLB
57 U-18 SD
Under Age 18 Medically Needy Spend Down
MNLB
58 QI-1
Qualifying Individual-1 (Medicaid pays only the
Medicare premium.)
LB
61 PW-PL
Women Health Waiver- Pregnant Women, Infants &
Children Poverty Level (SOBRA). A 100 series suffix
(the last 3 digits of the ID number) is a pregnant
woman; a 200 series suffix is an ARKids First-A child.
LB (for the
pregnant
woman only)
61 PW “Unborn
Child”
Pregnant Women PW Unborn CH-no Ster cov – Does
not cover sterilization or any other family planning
services.
LB (for the
pregnant
women only)
62 PW-PE
Pregnant Women Presumptive Eligibility
LB
63 ARKIDS A
SOBRA Newborn
FR
65 PW-NG
Pregnant Women No Grant
FR
66 PW-EC
Pregnant Women Medically Needy Exceptional
Category
MNLB
67 PW-SD
Pregnant Women Medically Needy Spend Down
MNLB
69 FAM PLAN
Women’s Health Waiver (Family Planning)
LB
76 UP-EC
Unemployed Parent Medically Needy Exceptional
Category
MNLB
77 UP-SD
Unemployed Parent Medically Needy Spend Down
MNLB
80 RRP-GR
Refugee Resettlement Grant
FR
81 RRP-NG
Refugee Resettlement No Grant
FR
86 RRP-EC
Refugee Resettlement Medically Needy Exceptional
Category
MNLB
FR (for
SOBRA
children)
8
Category
Description
Code
87 RRP-SD
Refugee Resettlement Medically Needy Spend Down
MNLB
88 SLI-QMB
Specified Low Income Qualified Medicare Beneficiary
(SMB) (Medicaid pays only the Medicare premium.)
LB
91 FC
Foster Care
FR
92 IVE-FC
IV-E Foster Care
FR
96 FC-EC
Foster Care Medically Needy Exceptional Category
MNLB
97 FC-SD
Foster Care Medically Needy Spend Down
MNLB
9
Arkansas Medicaid Therapy Billing Tips
Therapy Benefits
Arkansas Medicaid applies the following therapy benefits to all therapy services in this
program:

Medicaid will reimburse up to four (4) occupational, physical and speech therapy
evaluation units (1 unit = 30 minutes) per discipline, per state fiscal year (July 1
through June 30) without authorization. Additional evaluation units will require an
extended therapy request.

Medicaid will reimburse up to four (4) occupational, physical and speech therapy
units (1 unit = 15 minutes) daily, per discipline, without authorization. Additional
therapy units will require an extended therapy request.

All requests for extended therapy services must comply with Sections 216.300
through 216.315 of the Occupational, Physical, Speech Therapy Services provider
manual.
10
Program Coverage
The Arkansas Medicaid Occupational, Physical and Speech Therapy Program
reimburses therapy services for Medicaid-eligible individuals under the age of 21 in the
Child Health Services (EPSDT) Program.
Therapy services for individuals aged 21 and older are only covered when provided
through the following Medicaid Programs: Developmental Day Treatment Clinic
Services (DDTCS), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease
(ESRD), Home Health, Hospice and Physician/Independent Lab/CRNA/Radiation
Therapy Center. Refer to the Medicaid provider manuals for conditions of coverage and
benefit limits.
Medicaid reimbursement is conditional upon providers’ compliance with Medicaid policy
as stated in your provider manual, manual update transmittals and official program
correspondence.
All Medicaid benefits are based on medical necessity. Refer to the Glossary section of
your Medicaid provider manual for a definition of medical necessity.
Occupational therapy, physical therapy and speech-language pathology services are
those services defined by applicable state and federal rules and regulations. These
services are covered only when the following conditions exist.
A. Services are provided only by appropriately licensed individuals who are enrolled as
Medicaid providers in keeping with the participation requirements in Section 201.000
of the Occupational, Physical, Speech Therapy Services provider manual.
B. Services are provided as a result of a referral from the beneficiary’s primary care
physician (PCP). If the beneficiary is exempt from the PCP process, then the
attending physician must make the referrals.
C. Treatment services must be provided according to a written prescription signed by
the PCP or the attending physician, as appropriate.
D. Treatment services must be provided according to a treatment plan or a plan of care
(POC) for the prescribed therapy, developed and signed by providers credentialed or
licensed in the prescribed therapy or by a physician.
E. Medicaid covers occupational therapy, physical therapy and speech therapy services
when provided to eligible Medicaid beneficiaries under age 21 in the Child Health
Services (EPSDT) Program by qualified occupational, physical or speech therapy
providers.
F. Speech therapy services ONLY are covered for beneficiaries in the ARKids First-B
program benefits.
G. Therapy services for individuals over age 21 are only covered when provided
through the following Medicaid Programs: Developmental Day Treatment Clinic
Services (DDTCS), Hospital/Critical Access Hospital (CAH), Rehabilitative Hospital,
Home Health, Hospice and Physician. Refer to these Medicaid provider manuals for
conditions of coverage and benefit limits.
11
Arkansas Medicaid Therapy Billing Tips
An individual who has been admitted as an inpatient to a hospital or is residing in a
nursing care facility is not eligible for occupational therapy, physical therapy and speechlanguage pathology services under this program. Individuals residing in residential care
facilities and supervised living facilities may be eligible for these therapy services when
provided on or off site from the facility.
A. Occupational, physical and speech therapy services require a referral from the
beneficiary’s primary care physician (PCP) unless the beneficiary is exempt from
PCP Program requirements. If the beneficiary is exempt from the PCP process,
referrals for therapy services are required from the beneficiary’s attending physician.
All therapy services for beneficiaries under the age of 21 years require referrals and
prescriptions be made utilizing the “Occupational, Physical and Speech Therapy for
Medicaid Eligible Recipients Under Age 21” form DMS-640.
B. Occupational, physical and speech therapy services also require a written
prescription signed by the PCP or attending physician, as appropriate.
1. Providers of therapy services are responsible for obtaining renewed PCP
referrals every six months even if the prescription for therapy is for one year.
2. A prescription for therapy services is valid for the length of time specified by
the prescribing physician, up to one year.
3. When a school district is providing therapy services in accordance with a
child’s Individualized Education Program (IEP), a PCP referral is required at
the beginning of each school year. The PCP referral for the therapy services
related to the IEP can be for the 9-month school year and a 6-month referral
renewal is not necessary unless the PCP specifies otherwise.
4. The PCP or attending physician is responsible for determining medical
necessity for therapy treatment.
a. The individual’s diagnosis must clearly establish and support that the
prescribed therapy is medically necessary.
b. Diagnosis codes and nomenclature must comply with the coding
conventions and requirements established in Internal Classification of
Disease, 9th revision, Clinical Modification (ICD-9-CM); Volumes I
and II, in the edition Medicaid has certified as current for the patient’s
dates of service.
c. Please note that diagnosis codes V57.1, V57.2 and V57.3 are not specific
enough to identify the medical necessity for therapy treatment and may
not be used.
5. Providers of therapy services must use form DMS-640 – “Occupational,
Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21
Prescription/Referral” – to obtain the PCP referral and the written prescription
for therapy services for any beneficiary under the age of 21 years. .
Exclusive use of this form will facilitate the process of obtaining referrals and
prescriptions from the PCP or attending physician. A copy of the prescription
must be maintained in the beneficiary’s records. The original prescription is
to be maintained by the physician. Form DMS-640 must be used for the
12
initial referral for evaluation and a separate DMS-640 is required for the
prescription. After the initial referral using the form DMS-640 and initial
prescription utilizing a separate form DMS-640, subsequent referrals and
prescriptions for continued therapy may be made at the same time using the
same DMS-640. Instructions for completion of form DMS-640 are located on
the back of the form. Medicaid will accept an electronic signature provided
that it is in compliance with Arkansas Code 25-31-103.
6. To order copies from HP Enterprise Services, use Form HP-MFR-001 –
Medicaid Forms Request in Section V of your provider manual.
7. A treatment plan developed and signed by a provider who is credentialed and
licensed in the prescribed therapy or by a physician is required for the
prescribed therapy.
a. The plan must include goals that are functional, measurable and specific
for each individual child.
b. Services must be provided in accordance with the treatment plan, with
clear documentation of service rendered. Refer to Section 204.000,
subpart D, of the Occupational, Physical, Speech Therapy Services
provider manual for more information on required documentation.
C. Make-up therapy sessions are covered in the event a therapy session is canceled or
missed if determined medically necessary and prescribed by the beneficiary’s PCP.
Any make-up therapy session requires a separate prescription from the original
prescription previously received. Form DMS-640 must be used by the PCP or
attending physician for any make-up therapy session prescriptions.
D. Therapy services carried out by an unlicensed therapy student may be covered only
when the following criteria are met:

Therapies performed by an unlicensed student must be under the direction of
a licensed therapist and the direction is such that the licensed therapist is
considered to be providing the medical assistance.

To qualify as providing the service, the licensed therapist must be present
and engaged in student oversight during the entirety of any encounter that
the provider expects Medicaid to cover.
Refer to Section 260.000 of the Occupational, Physical, Speech Therapy Services
provider manual for procedure codes and billing instructions and Section 216.100
information regarding extended therapy benefits.
13
Arkansas Medicaid Therapy Billing Tips
Prior Authorization Request Procedures for
Augmentative Communication Device (ACD)
Evaluation
To perform an evaluation for the augmentative communication device (ACD), the
provider must request prior authorization from the Division of Medical Services,
Utilization Review Section, using the following procedures.
A. A primary care physician (PCP) written referral is required for prior authorization of
the ACD evaluation. If the beneficiary is exempt from the PCP process, then the
attending physician must make the referral.
B. The physical and intellectual capabilities (functional level) of the beneficiary must be
documented in the referral. The referring physician must justify the medical reason
the individual requires the ACD.
C. If the beneficiary is currently receiving speech therapy, the speech-language
pathologist must document the prerequisite communication skills for the
augmentative communication system and the cognitive level of the beneficiary.
D. A completed Request for Prior Authorization and Prescription Form (DMS-679) must
be used to request prior authorization. Copies of form DMS-679 can be requested
using the Medicaid Form Request, HP-MFR-001.
E. Submit the request to the Division of Medical Services, Utilization Review Section.
When the PA request is received in Utilization Review, it is given to the Medical
Director to review and make a decision.
F. For approved requests, a PA control number will be assigned and entered in item 10
on the DMS-679 and returned to the provider. For denied requests, a denial letter
with the reason for denial will be mailed to the requesting provider and the Medicaid
beneficiary.
NOTE: Prior authorization for therapy services only applies to the augmentative
communication evaluation. Refer to Section 215.000 of the Occupational,
Physical, Speech Therapy Services provider manual for additional
information.
14
Contact List for Reviews and Authorizations
Arkansas Foundation for
Medical Care (AFMC)
Q Source of AR

Review and authorization (PAs)

Provides utilization and quality reviews for various
Medicaid programs

UR for PCPs

Reviews ER, OP clinics, Assistant Surgeon

Authorizes hospital stays and certain procedures

Authorizes inpatient stays over 4 days (Mump
Review)

1-888-987-1200 option 2

www.afmc.org

Review and authorization (PAs)

Therapy review (under 21), PA for personal care
(under 21) and ePrescribing Initiative

(501) 801-6910

Nancy Archer, Executive Director

narcher@qsource.org

www.qsource.org
15
Arkansas Medicaid Therapy Billing Tips
National Place of Service Codes
Electronic and paper claims now require the same National Place of Service Code.
Place of Service
POS Codes
Doctor’s Office
11
Patient’s Home
12
Day Care Facility
52
Night Care Facility
52
Other Locations
99
Residential Treatment Center
56
16
Quick Tips for Submitting Claims
This section outlines quick tips for therapy providers in Medicaid. These billing tips
address some of the most common billing errors identified by the HP Provider
Assistance Center (PAC). Topics include the following:

Introduction to Billing

Procedure code quick reference

Therapy service code quick reference

Special billing procedures

Common billing errors
Introduction to Billing
Occupational, physical and speech therapy 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 the your provider manual contains information about Provider Electronic
Solutions (PES) and other available options for electronic claim submission.
CMS-1500 Billing Procedures - Occupational, Physical, Speech
Therapy Procedure Codes
The following occupational, physical and speech-language pathology procedure codes
are payable for therapy services indicated. Refer to Section IV - Glossary - of your
Medicaid provider manual for definitions of “group” and “individual” as they relate to
therapy sessions.
A. Occupational Therapy
Procedure
Code
Required
Modifiers
Description
97003
—
Evaluation for Occupational Therapy
(30-minute unit; maximum of 4 units per state fiscal year, July
1 through June 30)
97530
—
Individual Occupational Therapy
(15-minute unit; maximum of 4 units per day)
97150
U2
Group Occupational Therapy
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
17
Arkansas Medicaid Therapy Billing Tips
Procedure
Code
Required
Modifiers
97530
UB
Description
Individual Occupational Therapy by Occupational Therapy
Assistant
(15-minute unit; maximum of 4 units per day)
97150
UB, U1
Group Occupational Therapy by Occupational Therapy
Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
18
B. Physical Therapy
Procedure
Code
Required
Modifier
Description
97001
—
Evaluation for Physical Therapy
(30-minute unit; maximum of 4 units per state fiscal year, July
1 through June 30)
97110
—
Individual Physical Therapy
(15-minute unit; maximum of 4 units per day)
97150
—
Group Physical Therapy
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
97110
UB
Individual Physical Therapy by Physical Therapy Assistant
(15-minute unit; maximum of 4 units per day)
97150
UB
Group Physical Therapy by Physical Therapy Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
C. Speech-Language Pathology
Procedure
Code
Required
Modifier
Description
92506
—
Evaluation for Speech Therapy
(30-minute unit; maximum of 4 units per state fiscal year, July
1 through June 30)
92507
—
Individual Speech Session
(15-minute unit; maximum of 4 units per day)
92508
—
Group Speech Session
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
92507
UB
Individual Speech Therapy by Speech-Language Pathology
Assistant
(15-minute unit; maximum of 4 units per day)
92508
UB
Group Speech Therapy by Speech-Language Pathology
Assistant
(15-minute unit; maximum of 4 units per day, maximum of 4
clients per group)
19
Arkansas Medicaid Therapy Billing Tips
Augmentative Communication Device (ACD) Evaluation
The following procedure codes require prior authorization before services may be
provided.
Procedure
Code
92607
92608
Description
Augmentative Communication Device Evaluation
Billing Instructions - Paper Only
HP Enterprise Services 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.
Carefully follow these instructions to help HP Enterprise Services efficiently process
claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if
necessary information is omitted.
Forward completed claim forms to the HP Enterprise Services Claims Department.
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.
Completion of the 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)
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.
20
Field Name and Number
Instructions for Completion
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.
6.
PATIENT RELATIONSHIP TO
INSURED
If insurance affects this claim, check the box
indicating the patient’s relationship to the
insured.
7.
INSURED’S ADDRESS (No.,
Street)
Required if insured’s address is different from
the patient’s address.
CITY
STATE
ZIP CODE
TELEPHONE (Include Area
Code)
8.
PATIENT STATUS
Not required.
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.
OTHER INSURED’S
DATE OF BIRTH
Not required.
SEX
Not required.
EMPLOYER’S NAME OR
SCHOOL NAME
Required when items 9 a-d are required. Name
of the insured individual’s employer and/or
school.
c.
21
Arkansas Medicaid Therapy Billing Tips
Field Name and Number
d.
INSURANCE PLAN
NAME OR PROGRAM
NAME
Instructions for Completion
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.
OTHER ACCIDENT?
Required when an accident other than
automobile is related to the services. Check
YES or NO.
c.
10d. RESERVED FOR LOCAL
USE
11. INSURED’S POLICY GROUP
OR FECA NUMBER
Not used.
Not required when Medicaid is the only payer.
INSURED’S DATE OF
BIRTH
Not required.
SEX
Not required.
b.
EMPLOYER’S NAME OR
SCHOOL NAME
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 9a through 9d.
a.
12. PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE
Not required.
13. INSURED’S OR AUTHORIZED
PERSON’S SIGNATURE
Not required.
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)
22
Field Name and Number
Instructions for Completion
15. IF PATIENT HAS HAD SAME
OR SIMILAR ILLNESS, GIVE
FIRST DATE
Not required.
16. DATES PATIENT UNABLE TO
WORK IN CURRENT
OCCUPATION
Not required.
17. NAME OF REFERRING
PROVIDER OR OTHER
SOURCE
Primary Care Physician (PCP) referral is
required for Occupational, Physical and
Speech Therapy Services. Enter the referring
physician’s name.
17a. (blank)
The 9-digit Arkansas Medicaid provider ID
number of the referring physician.
17b. NPI
Not required.
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.
For tracking purposes, occupational, physical
and speech therapy providers are required to
enter one of the following therapy codes:
Reserved for Local Use
Code
Category
A
Individuals from birth through 2 years (but not 3
years old before September 15 of the current
school year) who are receiving therapy
services under an Individualized Family
Services Plan (IFSP) through the Division of
Developmental Disabilities Services.
B
Individuals ages 0 through 5 years (if individual
has not reached age 5 by September 15) who
are receiving therapy services under an
Individualized Plan (IP) through the Division of
Developmental Disabilities Services.
NOTE: This code is to be used only when
all three of the following conditions are in
place: 1) the individual receiving services
has not attained age 5 by September 15 of
the current school year, 2) the individual
receiving services is receiving the services
under an Individualized Plan and 3) the
Individualized Plan is through the Division
of Developmental Disabilities Services.
23
Arkansas Medicaid Therapy Billing Tips
Field Name and Number
Instructions for Completion
When using code C or D, providers
must also include the 4-digit LEA
(local education agency) code
assigned to each school district.
For example: C1234
C (and 4-digit LEA code)
Individuals ages 3 through 5 years (if individual
has not reached age 5 by September 15) who
are receiving therapy services under an
Individualized Education Program (IEP)
through an education service cooperative.
NOTE: This code set is to be used only
when all three of the following conditions
are in place: 1) the individual receiving
services was 3 years old before September
15 of the current school year and was not 5
years old before September 15 of the
current school year, 2) the individual is
receiving the services under an IEP
maintained by an education service
cooperative and 3) therapy services are
being furnished by a) the ESC, which is an
enrolled Medicaid therapy provider, or by b)
a Medicaid-enrolled therapist or therapy
group provider.
D (and 4-digit LEA code)
Individuals ages 5 (by September 15) to 21
years who are receiving therapy services under
an IEP through a school district.
NOTE: This code set is to be used only
when all three of the following conditions
are in place: 1) the individual receiving
services was 5 years old before September
15 of the current school year and was not
21 years old before September 15 of the
current school year, 2) the individual is
receiving the services under an IEP and 3)
the IEP is through a school district.
E
Individuals ages 18 through 20 years who are
receiving therapy services through the Division
of Developmental Disabilities Services.
F
Individuals ages 18 through 20 years who are
receiving therapy services from individual or
group providers not included in any of the
previous categories (A-E).
24
Field Name and Number
G
20. OUTSIDE LAB?
$ CHARGES
Instructions for Completion
Individuals ages birth through 17 years who are
receiving therapy/pathology services from
individual or group providers not included in
any of the previous categories (A-F).
Not required.
Not required.
21. DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Diagnosis code for the primary medical
condition for which services are being billed.
Up to three additional diagnosis codes can be
listed in this field for information or
documentation purposes. Use the International
Classification of Diseases, Ninth Revision
(ICD-9-CM) diagnosis coding current as of the
date of service.
22. MEDICAID RESUBMISSION
CODE
Reserved for future use.
ORIGINAL REF. NO.
Reserved for future use.
23. PRIOR AUTHORIZATION
NUMBER
The prior authorization or benefit extension
control number if applicable.
24
The “from” and “to” dates of service for each
billed service. Format: MM/DD/YY.
A.
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. 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. See Section 262.200 of the
Occupational, Physical, Speech Therapy
Services provider manual for codes.
C.
EMG
Not required.
D.
PROCEDURES,
SERVICES OR
SUPPLIES
CPT/HCPCS
Enter the correct CPT or HCPCS procedure
code from Sections 262.100 through 262.120
of the Occupational, Physical, Speech Therapy
Services provider manual.
MODIFIER
Modifier(s), if applicable.
25
Arkansas Medicaid Therapy Billing Tips
Field Name and Number
Instructions for Completion
E.
DIAGNOSIS POINTER
Enter in each detail the single number—1, 2, 3
or 4—that corresponds to a diagnosis code in
Item 21 (numbered 1, 2, 3 or 4) and that
supports most definitively the medical
necessity of the service(s) identified and
charged in that detail. Enter only one number in
E of each detail. Each DIAGNOSIS POINTER
number must be only a 1, 2, 3 or 4, and it must
be the only character in that field.
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 NO.
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. BALANCE DUE
From the total charge, subtract amounts
received from other sources and enter the
result.
26
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 #
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
Services must be billed according to the care provided and to the extent each procedure
is provided. Occupational, physical and speech therapy services do not require prior
authorization with the exception of ACD evaluations. ACD evaluations do require prior
authorization. Refer to Section 215.000 of the Occupational, Physical, Speech Therapy
Services provider manual for information about the augmentative communication device
evaluation.
Extended therapy services may be requested for all medically necessary therapy
services for beneficiaries under age 21. Refer to Sections 216.000 through 216.310 of
the Occupational, Physical, Speech Therapy Services provider manual for more
information.
27
Arkansas Medicaid Therapy Billing Tips
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
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 First-B beneficiary
is older than 18 years old.
ARKids First-B beneficiary’s eligibility
ends on their 19th birthday. The
“from” DOS cannot exceed the 19th
birthday.
28
Brief Overview of Benefits

Under 21 – 4 Evaluations per SFY

Up to four 15-Minute Units per Day

ARKids First-B only Eligible for Speech Therapy

See Section 216.100 of the Occupational, Physical, Speech Therapy Services
provider manual for additional information.
29
Arkansas Medicaid Therapy Billing Tips
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.

HP Provider Enrollment - The HP-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 Provider Representatives - HP 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.
30