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Welcome to Arkansas Medicaid. Education and support for therapy providers. Agenda. Introductions Facilities Medicaid organization and requirements Program overview Claims submission and billing tips Medicaid tools and support Discussion. Arkansas Medicaid. Who does what?.

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Welcome to Arkansas Medicaid


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    Presentation Transcript
    1. Welcome to Arkansas Medicaid Education and support for therapy providers

    2. Agenda • Introductions • Facilities • Medicaid organization and requirements • Program overview • Claims submission and billing tips • Medicaid tools and support • Discussion

    3. Arkansas Medicaid Who does what? • Division of Medical Services (DMS) • County offices • EDS • AFMC • ConnectCare

    4. DMS Administrators of Medicaid • Medical Services – establishes policy for all programs. • Provider Reimbursement – establishes reimbursement rates. • TPL – validates Third-Party Liability information. • Program Planning and Development – distributes policy.

    5. DHS County Office County Case Workers • Work directly with recipients. • Determine eligibility aid category and eligibility period. • Assist with Primary Care Physician (PCP) assignments.

    6. EDS Fiscal Agent • Provider Enrollment • Claims processing • Remittance • Provider Assistance • Medicaid Management Information System (MMIS)

    7. EDS Provider Enrollment • On January 3rd, 2005, EDS assumed responsibility for enrolling providers in the Arkansas Medicaid program. The EDS Provider Enrollment team processes new provider applications and assigns provider numbers upon successful completion of the application process. • The EDS Provider Enrollment team also assists existing providers needing to renew, update, or change their demographic or group affiliation information.

    8. EDS Provider Enrollment Monday through Friday (8 a.m. - 5p.m.) Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211 Fax: 501.374.0746 Medicaid Provider Enrollment Unit EDS PO Box 8105 Little Rock, 72203-8105

    9. EDS Claims processing • EDS received more that 26 million Arkansas Medicaid claims last year and processed more than 23 million of them electronically with the Electronic Data Interchange (EDI) processing system. • EDS supports electronic transactions every day, all day (and night) through the Internet, Provider Electronic Solutions (PES) software, vendor systems, clearinghouses, and paper submissions.

    10. EDS Claim volume Number of claims (millions) State Fiscal Year EDI claims Total claims

    11. EDS Claim adjudication • Adjudication is the process of approving or denying a submitted claim. • Providers benefit greatly when their Medicaid claims are processed quickly. • Last year, EDS again beat its goal of taking claims from receipt to adjudication in a mere four days.

    12. EDS Claim adjudication Days Month of State Fiscal Year 2004

    13. EDS 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 delivery and setup support, software training, and data transmission failures. Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211

    14. EDS Remittance • 42% of 2003 payments to Arkansas Medicaid providers were made using electronic funds transfer (EFT). • 49% percent of all providers are paid using EFT.

    15. EDS Provider Relations • Provider manuals and tools • Provider Assistance Center • Help desk for software and vendors • Workshops and presentations • Individual provider training

    16. AFMC Liaison, utilization, reviews • Acts as Medicaid policy liaison for providers and the state. • Provides managed care, ARKids, and waiver quality assurance reviews. • Provides utilization monitoring and quality reviews for PCPs. • Reviews therapy claims.

    17. AFMC Recipient complaints AFMC hosts the Medicaid Recipient Hotline. If a recipient has a complaint about services, a provider, or other problems relating to the program, they can call Medicaid Recipient Hotline from 8am to 4:30pm M-F. 1.888.987.1200

    18. ConnectCare Managed Care helpline • Enrolls recipients with PCP. • Educates recipients, county case workers, and providers about PCP requirements. • 1.800.275.1131

    19. Contractual requirements for providers

    20. Provider manual Section I essentials • Available program services • Contacts • Recipient eligibility • Recipient responsibility • Provider participation guidelines • Administrative remedies and sanctions • Managed care program requirements • PCP requirements and participation

    21. Provider manual Section II essentials • Scope of program • Prior authorization requirements • Reimbursement • Billing procedures

    22. Provider manual Section III essentials • General – ECS, timely filing, forms • Remittance and status reports • Adjustments • Other sources of payment (third-party payers)

    23. PCPs Primary responsibilities • Providing health education. • Assessing medical conditions and initiating and recommending treatment or therapy. • Referring to specialty physicians, hospital care, and therapists. • Locating needed medical services. • Coordinating prescribed medical and rehabilitation services with other professionals. • Monitoring the enrollees’ prescribed medical and rehabilitation services.

    24. Recipient Primary responsibilities • Select a PCP (most recipients). • Report changes in income or circumstances. • Report TPL.

    25. Medicaid program overview

    26. Benefits Overview Arkansas Medicaid administers 42 programs. Here are just a few of the many benefits available to eligible recipients. • Physician services • Inpatient hospital • Outpatient hospital • Lab/x-ray • Prescription • Therapy (OT/PT/Speech) • Mental health • Emergency room • Long term care • Hospice • Dentistry (under 21) • Medical equipment

    27. Benefits Recipients Arkansas Medicaid operates as a managed care program. Most recipients are required to have a PCP and most services require PCP referral. Recipients that are not required to enroll with a PCP include: • Recipients with Medicare coverage • Residents of an ICFMR • Residents of LTC facilities • Recipients on spend down aid categories • Retroactively eligible recipients

    28. Benefit limits Therapy services Recipients under age 21: • Four evaluations per SFY • Up to four 15-minute units per day See OT, PT, Speech manual – 213.200

    29. Aid Categories

    30. Aid Categories Overview All Medicaid recipients are assigned to an aid category with corresponding levels of coverage. These are listed in section one of the Arkansas Medicaid provider manuals. See Section I manual – 124.000

    31. Aid Categories General classifications • FR - Full benefits • MNLB – Medically needy, limited benefits • AC - Additional cost sharing • LB - Limited benefits

    32. Aid Categories Limited benefits These Medicaid recipients are limited to specific services according to their aid category.

    33. Aid Category 01 ARKids First B • Recipients may have limited services. • Recipients may have co-payment requirements.

    34. Aid Category 03 Children’s Medical Services (CMS) • Services must be prior-authorized. • This is a non-Medicaid category.

    35. Aid Category 04 Developmental Disability Services • This is a non-Medicaid category. • DDS non-Medicaid provider ID number end with 86. • DDS non-Medicaid recipient ID numbers begin with 8888. • Only DDS non-Medicaid providers may bill for DDS non-Medicaid recipients.

    36. Aid Category *6 Medically Needy Exceptional These recipients are eligible for the full range of Medicaid services except: • Nursing Facility • Personal Care

    37. Aid Category *7 Spend down • Recipients must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. • Aid Category 07 BCC (Breast and Cervical Cancer) has full benefits.

    38. Aid Category 08 Tuberculosis (TB) Recipient coverage includes drugs, physician services, outpatient services, rural health clinic encounters, Federally Qualified Health Center (FQHC), and clinic visits for TB related services only.

    39. Aid Category *8 Qualified Medicare Beneficiary • For QMB recipients, Medicaid pays Medicare premiums, coinsurance, and deductible. • If the service provided is not a Medicare-covered service, then Medicaid will not pay for the service under the QMB policy. • 8S – ARSeniors has full benefits.

    40. Aid Category 61 Pregnant Woman Infants and Children Poverty Level (PW-PL) • Contains both pregnant women and children. Providers must use the last three (3) digits of the Medicaid ID number to determine benefits. When the last three digits are: • 100 series (101, 102, etc.) the recipient is eligible as an adult for pregnancy-related services only; • 200 series (201, 202, etc.) the recipient is eligible as a child and receives a full range of Medicaid services. • A pregnant teen may be eligible either as a child or as an adult. The last three digits of her ID number determine the services for which she is eligible. • If the plan description is “PW unborn ch-noster/FP cov” then there is no sterilization or family planning benefit.

    41. Aid Category 62 Pregnant Woman Presumptive Eligibility (PW-PE) This is a temporary aid category that pays ambulatory, prenatal care services only. Delivery and hospitalization is not covered in this category.

    42. Aid Category 69 Family Planning Waiver (FPW) • Medicaid pays for family planning preventative services only, such as birth control, counseling, etc. • A claim for a recipient in this category must contain both a family planning diagnosis code and a family planning procedure code.

    43. Aid Categories 58, 78, 88 Specified Low Income Medicare Beneficiary (SLIMB, SMB) • Recipients are not eligible for any Medicaid services. • Medicaid pays only their Medicare premium.

    44. Verify eligibility

    45. Verify eligibility 270 Eligibility Request Recipient eligibility is date specific; it may begin or end on any day. It is the provider’s responsibility to check each recipient’s eligibility on the date of service to ensure payment for claims.

    46. Verify eligibility 271 Request Response File RECEIVED DATE: 10/31/2003 ---------------------------------------------- I N F O R M A T I O N S O U R C E INFORMATION SOURCE: ARKANSAS MEDICAID SOURCE PRIMARY ID: 123456789 ---------------------------------------------- P R O V I D E R I N F O R M A T I O N PROVIDER LAST NAME: DRLAST PROVIDER FIRST NAME: DRFIRST PROVIDER NUMBER: 199999901 ---------------------------------------------- R E C I P I E N T I N F O R M A T I O N (continued next) Who information is coming from Pay-To provider name Pay-To provider number

    47. Verify eligibility 271 Request Response File cont. ---------------------------------------------- R E C I P I E N T I N F O R M A T I O N ELIGIBILITY AUTHORIZATION #: 12345678901234 TRACE #: 999999999999999 RECIPIENT LAST NAME: DUGGER RECIPIENT FIRST NAME: JEFFERY RECIPIENT ID: 1999999991 RECIPIENT DOB: 01/01/2000 ----------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N (continued next) EDS authorization number Trace number Recipient name as it appears with AR Medicaid Keyed ID number DOB listed with Medicaid

    48. Verify eligibility 271 Request Response File cont. Shows coverage ---------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N ELIGIBILITY/BENEFIT: 1 ACTIVE COVERAGE PLAN DESCRIPTION: 01ARKIDS 1ST ELIGIBILITY PERIOD: 01/01/2004-07/01/2004 COUNTY: 731 WHITE ELIGIBILITY/BENEFIT: R TPL INSURANCE TYPE: C1 COMMERCIAL TPL MEMBER #: 999999999 TPL POLICY #: 7777777 TPL GROUP #: 666666 PLAN NAME: ACME INSURANCE ELIGIBILITY PERIOD: 01/01/2000 – 07/01/2004 COVERAGE 1: FULL COVERAGE LAST/ORG NAME: ACME INSURANCE COMPANY CODE: ABC ADDRESS LINE 1: P.O. BOX 1000 CITY: LITTLE ROCK STATE: AR ZIP: 72201 (continued next) Aid category Dates of eligibility County of residence TPL information Type of TPL Member number Policy number Group number Plan name Dates of coverage Type of coverage Name of insurer Company code Address

    49. Verify eligibility 271 Request Response File cont. (continued previous) ---------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N ELIGIBILITY/BENEFIT: L PRIMARY CARE PROVIDER DATE TIME PERIOD: 01/01/2004 – 07/01/2004 LAST/ORG NAME: PCPLAST FIRST NAME: PCPFIRST NAME SUFFIX: MD TELEPHONE: 5013746608 ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTION SERVICE TYPE: AL VISION (OPTOMETRY) DATE TIME PERIOD: 03/20/1998 ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTION SERVICE TYPE: AM FRAMES DATE TIME PERIOD: 03/20/1998 PCP information PCP effective dates PCP’s name and phone number returned if applicable NOTE: Only benefits used will appear on eligibility in PES

    50. Verify eligibility New in PES 2.04 and online • Up to four recipient eligibility segments with matching recipient IDs • EPSDT screening information • Medicare A and B effective dates