016.05.20 Ark. Code R. 005
ATTACHMENT 3.1-A
Revised: January 1, 2021
A qualified physical therapist assistant may provide services under the supervision of a licensed physical therapist.
All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.
Medical Screens are provided based on the recommendations of the American Academy of Pediatrics. Childhood immunizations are provided based on the Advisory Committee on Immunization Practices (ACIP).
The State will provide other health care described in Section 1905(a) of the Social Security Act that is found to be medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, even when such health care is not otherwise covered under the State Plan.
A qualified occupational therapist assistant may provide services under the supervision of a licensed occupational therapist.
All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.
A qualified speech-language therapist assistant may provide services under the supervision of a licensed speech-language therapist.
All therapies' service definitions and providers must meet the requirements of 42 C.F.R. § 440.110.
Diapers/underpads are limited to $130.00 per month, per beneficiary. The $130.00 benefit limit is a combined limit for diapers/underpads provided through the Prosthetics Program and Home Health Program. The benefit limit may be extended with proper documentation. Only patients with a medical diagnosis other than infancy which results in incontinence of the bladder and/or bowel may receive diapers. This coverage does not apply to infants who would otherwise be in diapers regardless of their medical condition. Providers cannot bill for underpads/diapers if a beneficiary is under the age of three years.
Physical therapists must meet the requirements outlined in 42 CFR 440.110(a).
Services under this item are limited to physical therapy when provided by a home health agency and prescribed by a physician. Effective for dates of service on or after July 1, 2017, individual and group physical therapy are limited to six (6) units per week. Effective for dates on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limits will be provided if medically necessary for eligible Medicaid recipients.
Enrolled providers are Private Duty Nursing Agencies licensed by Arkansas Department of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.
Services are covered for Medicaid-eligible beneficiaries age 21 and over when determined medically necessary and prescribed by a physician.
Beneficiaries 21 and over to receive PDN Nursing Services must require constant supervision, visual assessment and monitoring of both equipment and patient. In addition the beneficiary must be:
Services under this item are limited to physical therapy when provided by a home health agency and prescribed by a physician. Effective for dates of service on or after July 1, 2017, individual and group physical therapy are limited to six (6) units per week. Effective for dates of service on or after January 1, 2021, physical therapy evaluations are limited to two (2) units per State Fiscal Year (July 1 through June 30). Extensions of the benefit limit will be provided if medically necessary for eligible Medicaid recipients.
Speech-Language Pathology services and qualified Speech-Language Pathologists meet the requirements set forth in 42 CFR 440.110. Speech-Language Pathology Assistants work under the supervision of the Speech-Language Pathologist in accordance with the State's licensing and supervisory requirements.
Physical Therapy services and qualified Physical Therapists meet the requirements set forth in 42 CFR 440.110. Physical Therapy assistants work under the supervision of the Physical Therapist in accordance with the State's licensing and supervisory requirements.
Occupational Therapy services and qualified Occupational Therapists meet the requirements set forth in 42 CFR 440.110. Occupational Therapy assistants work under the supervision of the Occupational Therapist in accordance with the State's licensing and supervisory requirements.
Audiology services and qualified Audiologists meet the requirements set forth in 42 CFR 440.110.
Speech Generating Device (SGD) Evaluation - Effective for dates of service on or after September 1, 1999, Speech Generating Device (SGD) evaluation is covered for eligible Medicaid recipients of all ages. One SGD evaluation may be performed every three (3) years based on medical necessity. The benefit limit may be extended for individuals under age 21.
Listed below are covered occupational therapy services:
Description
Evaluation for occupational therapy Individual occupational therapy
Group occupational therapy
Individual occupational therapy by occupational therapy assistant
Occupational therapy by occupational therapy assistant
At the beginning of each calendar year, Medicaid officials and the Arkansas Occupational Therapy Association or it-s successor will arrive at mutually agreeable increase or decrease in reimbursement rates based on the market forces as they impact on access. Any agreed upon increase or decrease will be implemented at the beginning of the following state fiscal year, July I with any appropriate State Plan changes.
Listed below are covered speech-language therapy services:
Description
Evaluation of speech language voice, communication, auditory processing and/or aural rehabilitation status Individual speech-language therapy session
Group speech-language therapy session
Individual speech-language therapy by speech-language pathology assistant
Group speech-language therapy by speech language pathology assistant
Effective for cost reporting periods ending June 30, 2000 or after, outpatient hospital services provided at an Arkansas State Operated Teaching Hospital will be reimbursed based on reasonable costs with interim payments in accordance with 2.a.(1) and a year-end cost settlement.
Arkansas Medicaid will use the lesser of the reasonable costs or customary charges to establish cost settlements. Except for graduate medical education costs, the cost settlements will be calculated using the methods and standards used by the Medicare Program. Graduate medical education costs are reimbursed as described in Attachment 4.19-A, Page 8a for inpatient hospital services.
Effective for dates of service on or after September 1, 1999, reimbursement for a Speech Generating Device (SGD) Evaluation is based on the lesser of the provider's actual charge for the service or the Title XIX (Medicaid) maximum. The XIX (Medicaid) maximum is based on the current hourly rate for both disciplines of therapy involved in the evaluation process. The Medicaid maximum for speech-language therapy is $25.36 per (20 mins.) unit x's 3 units per date of service (DOS) and occupational therapy is $18.22 per (15 mins.) unit x's 4 units per DOS equals a total of $148.96 per hour. Two (2) hours per DOS is allowed. This would provide a maximum reimbursement rate per DOS of $297.92.
Effective for dates of service on or after November 1, 2002, covered outpatient/clinic services provided by Indian Health Services (IHS) and Tribal 638 Health Facilities will be reimbursed the IHS outpatient/clinic rate published by the Office of Management and Budget (OMB). Covered IHS outpatient/clinic services include only those services that are covered under other Arkansas Medicaid programs. This rate is an all-inclusive rate with no year-end cost settlement. The initial rate is the published IHS outpatient rate for calendar year 2002. The rate will be adjusted to the OMB published rate annually or for any other period identified by OMB.
Effective for dates of service on or after October I, 1999, the Arkansas Medicaid maximum rates for physical therapy services, occupational therapy services and speech-language therapy services are based on court-ordered rates issued by the United States District Court, Eastern District of Arkansas, Western Division and agreed upon by the Division of Medical Services and representatives of the Arkansas Physical Therapy Association, the Arkansas Occupational Therapy Association and the Arkansas Speech-Language-Hearing Association.
The agency's therapy fee schedule rates were set as of January 1, 2008 and are effective for services on or after that date. All therapy fee schedule rates are published on the agency's website (www.medicaid.state.ar.us). A uniform rate for these services is paid to all governmental and non- governmental providers unless otherwise indicated in the state plan. The State assures that physical therapists, occupational therapists and speech-language therapists will meet the requirements contained in 42 CFR 440.110.
Therapy Assistants - Effective for dates of service on or after October I, 1999, the Arkansas Medicaid maximum for the physical therapy assistant, occupational therapy assistant and the speech-language therapy assistant is based on 80% of the amount reimbursed to the licensed therapist.
Fee schedule service reimbursement is based on the lesser of the amount billed or the Arkansas Title XIX (Medicaid) maximum charge allowed.
Listed below are covered physical therapy services:
Description
Evaluation for physical therapy
Individual physical therapy Group physical therapy
Individual physical therapy by physical therapy assistant Group physical therapy by physical therapy assistant
At the beginning of each calendar year, Medicaid officials and the Arkansas Physical Therapy Association or its successor will arrive at mutually agreeable increase or decrease in reimbursement rates based on the market forces as they impact on access. Any agreed upon increase or decrease will be implemented at the beginning of the following state fiscal year, July 1 with any appropriate State Plan changes.
At the beginning of each calendar year, Medicaid officials and the Arkansas Speech-Language Therapy Association or its successor will arrive at mutually agreeable increase or decrease in reimbursement rates based on the market forces as they impact on access. Any agreed upon increase or decrease will be implemented at the beginning of the following state fiscal year, July 1 with any appropriate State Plan changes.
The per diem reimbursement for RSPD services provided by a Residential Rehabilitation enter will be based on the provider's fiscal year end 1994 audited cost report as submitted by an independent auditor plus a percentage increase equal to the HCFA Market Basket Index published for the quarter ending in March. A cap has been established at $395.00. This is a prospective rate with no cost settlement. Room and board is not an allowable program cost. The criteria utilized to exclude room and board is as follows: The total Medicaid ancillary cost was divided by total Medicaid inpatient days which equals the RSPD prospective per diem. The ancillary cost was determined based upon Medicare Principles of Reimbursement. There is no routine cost included.
Effective for dates of service on or after September 1, 1999, reimbursement for an Speech Generating Device (SGD) Evaluation is based on the lesser of the provider's actual charge for the service or the Title XIX (Medicaid) maximum. The XIX (Medicaid) maximum is based on the current hourly rate for both disciplines of therapy involved in the evaluation process. The Medicaid maximum for speech-language therapy is $25.36 per (20 mins.) unit x's 3 units per date of service (DOS) and occupational therapy is $18.22 per (15 mins.) unit x's 4 units per DOS equals a total of $148.96 per hour. Two (2) hours per DOS is allowed. This would provide a maximum reimbursement rate per DOS of $297.92.
The Title XIX (Medicaid) maximum was established based on a 1985 survey conducted by the Division of Developmental Disabilities of private therapy providers, hospital providers and nursing home providers of their 1985 billed charges. The mean (arithmetic average) rate for therapy services established the Title XIX maximum. The rates include the professional and administrative components. Effective for dates of service on or after 7-1-91, rates were increased by 4%.
A school district, education service cooperative, early Intervention Day Treatment (EIDT) program or Adult Developmental Day Treatment (ADDT) program may contract with or employ qualified therapy practitioners. Effective for dates of service on and after October 1, 2008, the individual therapy practitioner who actually performs a service on behalf of the facility must be identified on the claim as the performing provider when the facility bills for that service. This action is taken in compliance with the federal Improper Payments Information Act of 2002 (IPIA), Public Law 107-300 and the resulting Payment Error Rate Measurement (PERM) program initiated by the Centers for Medicare and Medicaid Services (CMS).
If a facility contracts with a qualified therapy practitioner, the criteria for group providers of therapy services apply (See Section 201.100 of the Occupational, Physical, Speech-Language Therapy Services manual). The qualified therapy practitioner who contracts with the facility must be enrolled with Arkansas Medicaid. The contract practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that service.
If a facility employs a qualified therapy practitioner, that practitioner has the option of either enrolling with Arkansas Medicaid or requesting a Practitioner Identification Number (View or print form DMS-7708). The employed practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that service.
The following requirements apply only to Arkansas school districts and education service cooperatives that employ (via a form W-4 relationship) qualified practitioners to provide therapy services.
The Arkansas Medicaid Program uses the following criteria to determine when supervision occurs within the Occupational, Physical, and Speech-Language Therapy Services Program.
Individuals must be under the supervision of a qualified speech-language pathologist if the following conditions exist.
All occupational, physical, and speech-language therapy services must be medically necessary. Medicaid accepts a physician's diagnosis that clearly establishes and supports medical necessity for therapy treatment. These services require a referral from the beneficiary's primary care physician (PCP) or the attending physician if the beneficiary is exempt from PCP Managed Care Program requirements. (See Section I of this manual.) Therapy treatment services also require a prescription written by the physician who refers the beneficiary to the therapist for services.
Local Education Agencies (LEA) have the responsibility to ensure that children from ages three (3) until entry into Kindergarten who have or are suspected of having a disability under Part B of IDEA ("Part B") receive a Free Appropriate Public Education.
Each therapist must, within two (2) working days of first contact, refer children ages three (3) until entry into Kindergarten for whom there is a diagnosis or suspicion of a developmental delay or disability. For children who are turning three years of age while receiving services at the center, the referral must be made at least 90 days prior to the child's third birthday. If the child begins services less than 90 days prior to their third birthday, the referral should be made in accordance with the late referral requirements of the IDEA.
The referral must be made to the LEA where that child resides. Each therapist is responsible for maintaining documentation evidencing that a proper and timely referral to has been made.
The Arkansas Medicaid Occupational, Physical, and Speech-Language 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: Adult Developmental Day Treatment (ADDT), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD), Home Health, Hospice and Physician/Independent Lab/CRNA/Radiation Therapy Center. Refer to these Medicaid provider manuals for conditions of coverage and benefit limits.
Medicaid reimbursement is conditional upon providers' compliance with Medicaid policy as stated in this provider manual, manual update transmittals and official program correspondence.
All Medicaid benefits are based on medical necessity. Refer to the Glossary 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.
To order copies from the Arkansas Medicaid fiscal agent use Form MFR-001 - Medicaid Forms Request. View or Print the Medicaid Form Request MFR-001.
Prior authorization of extension of benefits is required when a physician prescribes more than 90 minutes of therapy per week in one or more therapy discipline(s). Retrospective review of occupational, physical, and speech-language therapy services is required for beneficiaries under age 21 who are receiving 90 minutes per week or less of therapy services in each discipline or who are receiving rehabilitation therapy after an injury, illness or surgical procedure. The purpose of all review is the promotion of effective, efficient and economical delivery of health care services.
Retrospective review of occupational, physical, and speech-language evaluations is required for beneficiaries under age 21 who receive an evaluation less than six months from the previous evaluation when the provider is utilizing a complexity code rather than a timed code.
The Quality Improvement Organization (QIO), under contract to the Medicaid Program, performs retrospective reviews by reviewing medical records to determine if services delivered and reimbursed by Medicaid meet medical necessity requirements. View or print QIO contact information.
Specific guidelines have been developed for occupational, physical, and speech-language therapy retrospective reviews. These guidelines may be found in Sections 214.300 and 214.400.
Speech-language therapy services must be medically necessary to the treatment of the individual's illness or injury. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. To be considered medically necessary, the following conditions must be met:
A speech production disorder may manifest as an individual sound deficiency, i.e., traditional articulation disorder, incomplete or deviant use of the phonological system, i.e., phonological disorder, or poor coordination of the oral-motor mechanism for purposes of speech production, i.e., verbal and/or oral apraxia, dysarthria.
Mild: Scores between 84-78; -1.0 standard deviation Moderate: Scores between 77-71; -1.5 standard deviations Severe: Scores between 70-64; -2.0 standard deviations Profound: Scores of 63 or lower; -2.0+ standard deviations
NOTE: To calculate a child's gestational age, subtract the number of weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
NOTE: To calculate a child's gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
NOTE: To calculate a child's gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
NOTE: To calculate a child's gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
NOTE: To calculate a child's gestational age, subtract the number of
weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
4 months
Eligibility for articulation and/or phonological therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater is not indicated by both of these tests, corroborating data derived from clinical analysis procedures can be used to support the medical necessity of services (review Section 214.410 - Accepted Tests for Speech-Language Therapy).
Eligibility for apraxia therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater is not indicated by both of these tests, corroborating data from a criterion-referenced test and/or accepted clinical can be used to support the medical necessity of services (review Section 214.410 - Accepted Tests for Speech-Language Therapy).
Eligibility for voice therapy will be based upon a medical referral for therapy and a functional profile of voice parameters that indicates a moderate or severe deficit/disorder.
Eligibility for fluency therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater is not indicated by both of these tests, descriptive data from an affect measure and/or accepted clinical procedures can be used to support the medical necessity of services. (Review Section 214.410 - Accepted Tests for Speech-Language Therapy.)
Eligibility for oral-motor/swallowing/feeding therapy will be based upon an in-depth functional profile of oral motor structures and function using a thorough protocol (e.g., checklist, profile) that indicates a moderate or severe deficit or disorder. When moderate or severe aspiration has been confirmed by a videofluoroscopic swallow study, the patient can be treated for pharyngeal dysphagia via the recommendations set forth in the swallow study report.
Arkansas Medicaid covers evaluations for speech generating devices (SGDs) under the following conditions.
A trial period is not required when replacing an existing SGD unless the client's needs have changed, the current device is no longer available, and/or another device or method of access is being considered as more appropriate.
The evaluation report must meet the following requirements.
Refer to Section 215.100 of this manual for SGD evaluation benefits and Section 260.000 for billing procedures.
One speech generating device (SGD)evaluation may be performed by a speech-language pathologist every three years, based on medical necessity.
Arkansas Medicaid applies the following therapy benefits to all therapy services in this program:
The following is a step-by-step outline of the extended therapy services review process:
To perform an evaluation for the speech generating device (SGD), the provider must request prior authorization from the QIO, using the following procedures.
NOTE: Prior authorization for therapy services only applies to the speech generating evaluation. Refer back to Section 215.000 for additional information.
Reconsideration of a denial may be requested within thirty (30) calendar days of the denial date. Requests must be made in writing and must include additional documentation to substantiate the medical necessity of the SGD evaluation.
Occupational, physical, and speech-language therapy procedure codes can be found by following this link: View or print the procedure codes for therapy services.
Electronic and paper claims now require the same National Place of Service Code.
Place of Service | Place of Service Code |
Doctor's Office | 11 |
Patient's Home | 12 |
Independent Clinic (EIDT/ADDT) | 49 |
Day Care Facility | 52 |
Night Care Facility | 52 |
Other Locations | 99 |
Residential Treatment Center | 56 |
Field Name and Number | Instructions for Completion |
1. (type of coverage) | Not required. |
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. |
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. 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. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9 a-d are required. Name of the insured individual's employer and/or school. |
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 | Not required when Medicaid is the only payer. |
a. INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
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: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) | Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. |
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 | Primary Care Physician (PCP) referral is required for Occupational, Physical, and Speech-Language Therapy Services. Enter the referring physician's name. |
17a. (blank) | Not required. |
17b. NPI | Enter NPI of the referring physician. |
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. ADDITIONAL CLAIM INFORMATION | For tracking purposes, occupational, physical, and speech-language therapy providers are required to enter one of the following therapy codes: |
Code | Category |
A | Individuals from birth through 2 years who are receiving therapy services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disabilities Services. |
B | Individuals ages 0 to 6 years 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 the age of 6. 2) The individual receiving services is receiving the services under an Individualized Plan. 3) The Individualized Plan is through the Division of Developmental Disabilities Services. | |
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 to 5 years who are receiving therapy services under an Individualized Education Program (IEP) through a school district or 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 is 3 years old and is not yet 5 years old. 2) The individual is receiving the services under an IEP maintained by a school district or education service cooperative. 3) Therapy services are being furnished by a) the school district or an 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 to 21 years who are receiving therapy services under an IEP through a school district or 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 is 5 years old and is not yet 21 years old. 2) The individual is receiving the services under an IEP. 3) The IEP is through a school district or an education service cooperative. | |
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). |
G | 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). |
20. OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. |
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | 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 until further notice. 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 | Reserved for future use. |
ORIGINAL REF. NO. | 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. DATE(S) OF SERVICE | The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. |
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 for codes. |
C. EMG | Enter "Y" for "Yes" or leave blank if "No." EMG identifies if the service was an emergency. |
D. PROCEDURES, SERVICES, OR SUPPLIES | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 262.100 through 262.120. |
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 # | Enter the 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail or |
NPI | Enter NPI of the individual who furnished the services billed for in the detail. |
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. RESERVED | Reserved for NUCC use. |
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) | Enter NPI of the billing provider or |
b. (blank) | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. |
Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.
Program Services | Benefit Coverage and Restrictions | Prior Authorization/ PCP Referral* | Co-payment/ Coinsurance/ Cost Sharing Requirement** |
Ambulance (Emergency Only) | Medical Necessity | None | $10 per trip |
Ambulatory Surgical Center | Medical Necessity | PCP Referral | $10 per visit |
Audiological Services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range (View ICD codes.)) | Medical Necessity | None | None |
Certified Nurse-Midwife | Medical Necessity | PCP Referral | $10 per visit |
Chiropractor | Medical Necessity | PCP Referral | $10 per visit |
Dental Care | Routine dental care and orthodontia services | None - PA for inter-periodic screens and orthodontia services | $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in Section 262.120 | PCP Referral and Prescription | 10% of Medicaid allowed amount per DME item cost-share |
Emergency Dept. Services Emergency Non-Emergency Assessment | Medical Necessity Medical Necessity Medical Necessity | None PCP Referral None | $10 per visit $10 per visit $10 per visit |
Family Planning | Medical Necessity | None | None |
Federally Qualified Health Center (FQHC) | Medical Necessity | PCP Referral | $10 per visit |
Home Health | Medical Necessity (10 visits per state fiscal year (July 1 through June 30) | PCP Referral | $10 per visit |
Hospital, Inpatient | Medical Necessity | PA on stays over 4 days if age 1 or over | 10% of first inpatient day |
Hospital, Outpatient Inpatient Psychiatric Hospital and Psychiatric Residential Treatment Facility | Medical Necessity Medical Necessity | PCP referral PA & Certification of Need is required prior to admittance | $10 per visit 10% of first inpatient day |
Immunizations Laboratory & X-Ray Medical Supplies | All per protocol Medical Necessity Medical Necessity Benefit of $125/mo. Covered supplies listed in Section 262.110 | None PCP Referral PCP Prescriptions PA required on supply amounts exceeding $125/mo | None $10 per visit None |
Mental and Behavioral Health, Outpatient School-Based Mental Health | Medical Necessity Medical Necessity | PCP Referral PA on treatment services PA Required (See Section 250.000 of the School-Based Mental Health provider manual.) | $10 per visit $10 per visit |
Nurse Practitioner Physician | Medical Necessity Medical Necessity | PCP Referral PCP referral to specialist and inpatient professional services | $10 per visit $10 per visit |
Podiatry Prenatal Care Prescription Drugs | Medical Necessity Medical Necessity Medical Necessity | PCP Referral None Prescription | $10 per visit None Up to $5 per prescription (Must use generic, if available)*** |
Preventive Health Screenings | All per protocol | PCP Administration or PCP Referral | None |
Rural Health Clinic | Medical Necessity | PCP Referral | $10 per visit |
Speech-Language Therapy | Medical Necessity 4 evaluation units (1 unit =30 min) per state fiscal year 4 therapy units (1 unit=15 min) daily | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Occupational Therapy | Medical Necessity 2 evaluation units per state fiscal year | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Physical Therapy | Medical Necessity 2 evaluation units per state fiscal year | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Vision Care Eye Exam Eyeglasses | One (1) routine eye exam (refraction) every 12 months One (1) pair every 12 months | None None | $10 per visit None |
* Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.
** ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.
*** ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.
Occupational, physical, and speech-language therapy services are available to beneficiaries in the ARKids First-B program and must be performed by a qualified, Medicaid participating Occupational, Physical, or Speech-Language Therapist. A referral for an occupational, physical, or speech-language therapy evaluation and prescribed treatment must be made by the beneficiary's PCP or attending physician if exempt from the PCP program. All therapy services for ARKids First-B beneficiaries require referrals and prescriptions be made utilizing the "Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21" form DMS-640. View or print form DMS-640.
Occupational, physical, and speech-language therapy referrals and covered services are further defined in the Physicians and in the Occupational, Physical, and Speech-Language Therapy Provider Manuals. Physicians and therapists must refer to those manuals for additional rules and regulations that apply to occupational, physical, or speech-language therapy services for ARKids First-B beneficiaries.
ARKids First-B has the same occupational, physical, and speech-language therapy services benefits as Arkansas Medicaid, which are found in the procedure codes for therapy services. View or print the procedure codes for therapy services.
All requests for extended therapy services must comply with the guidelines located within the Occupational, Physical, and Speech-Language Therapy Provider Manual.
Occupational, physical, and speech-language therapy procedure codes can be found in the following link: View or print the procedure codes for therapy services.
Refer to the Occupational, Physical, and Speech-Language Therapy Manual for medically necessary home health physical therapy visits that a beneficiary may receive.
Outpatient occupational, physical, and speech-language 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 Beneficiaries Under Age 21" form DMS-640. A prescription for therapy services is valid for the length of time specified by the prescribing physician, up to one year. Providers of therapy services are responsible for obtaining renewed PCP referrals every twelve (12) months. The PCP or attending physician is responsible for determining medical necessity for therapy treatment. Outpatient treatment limits do not apply to eligible Medicaid beneficiaries under the age of 21.
Arkansas Medicaid applies the following therapy benefits to all therapy services in the Child Health Services (EPSDT) program for children under age 21:
Arkansas Medicaid applies speech-language therapy benefits in the ARKids First-B program for children under age 19 as found in the therapy services procedure codes: View or print the procedure codes for therapy services.
All requests for extended speech-language therapy services for beneficiaries age 18 and under must comply with Sections 218.250 through 218.280.
Extended therapy services may be provided based on medical necessity, for Medicaid beneficiaries under age 21.
Occupational, physical, and speech-language therapies are subject to the benefit limit of 12 outpatient hospital visits per state fiscal year (SFY) for beneficiaries age 21 and over. Benefit Extensions may be provided for therapy services, based on medical necessity, for Medicaid beneficiaries 21 years of age and over when provided within a covered program.
Occupational therapy evaluations and services are payable only to a qualified occupational therapist. Speech-language therapy and physical therapy evaluations are payable to the physician. Physical therapy may be payable to the physician when directly provided in accordance with the Occupational, Physical, and Speech-Language Therapy Services Manual. The procedure codes at the following link must be used when filing claims for physician provided therapy services: View or print the procedure codes for therapy services. See Glossary -Section I V - for definitions of "group" and "individual" as they relate to therapy services.
A provider must furnish a full unit of service to bill Medicaid for a unit of service. Partial units are not reimbursable. Extended therapy services may be requested for physical and speech-language therapy, if medically necessary, for eligible Medicaid beneficiaries of all ages.
Refer to Section 227.000 of this manual for more information on therapy benefits.
There are several broad areas of service provision in the Prosthetics manual. Services provided include durable medical equipment, which also encompasses specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the speech generating device. Other programs covered in the Prosthetics manual include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances.
Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age 3 and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized.
Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiary's need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Form DMS-679A, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the speech generating device. The QIO will notify providers of approval or denial by letter.
The speech generating device (SGD) is covered for beneficiaries of all ages. Coverage for beneficiaries under 21 years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for speech generating devices. When a beneficiary who is under age 21 has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form DMS-679A. View or print form DMS-679A.
The SGD is also covered for Medicaid beneficiaries 21 years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age 21 and above, there is a $7,500.00 lifetime benefit without benefit extensions.
The Arkansas Medicaid Program will not cover SGDs that are prescribed solely for social or educational development.
Training in the use of the device is not included and is not a covered cost.
Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement.
The following information must be submitted when requesting prior authorization for SGDs for Medicaid beneficiaries.
Submit form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print form DMS-679A and instructions for completion. The form should be accompanied by:
This information must be submitted to the QIO. View or print QIO contact information.
Benefit Limit
There is a $7500 lifetime benefit for speech generating devices. When the beneficiary under age 21 has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits.
In order to obtain an extension of the $7,500.00 lifetime benefit for beneficiaries under 21 years of age, a medical necessity determination for additional equipment is required. The provider must submit a form DMS-679A, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. The information must be sent to the QIO. View or print form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print the QIO contact information.
The provider will be notified in writing of the approval or denial of the request for extended benefits.
Reimbursement for repairs of speech generating device components will be manufacturer's invoice price for parts plus 10%. Labor will be reimbursed per unit of service (1 unit = 15 minutes limited to a maximum of 20 units per date of service allowed).
The speech generating device must be billed using the procedure code assigned to each component. The specific components will be reimbursed, as needed, for the procedure codes listed below and will count toward the lifetime limit of $7,500 per beneficiary.
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
NOTE: Attach a manufacturer's invoice to the claim and indicate the item or parts billed on the invoice. A description and the amount billed for each item must be attached to the claim. If more than one item is billed under a procedure code, the description and billed amount of each item must be listed separately under each procedure code and attached to the claim. The total billed for each procedure code should be reflected in field 24F.
* Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
*** (...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
Speech Generating Device, All Ages (Section 242.193)
National Procedure Code | M1 | M2 | PA | Description | Payment Method |
E2500 | NU EP | Y* | ***(Light Technology Communication Aids -communication aids that do not have the memory component to store the information. They are often used in conjunction with higher tech devices as part of a multi-modal communication system.) Speech-generating device, digitized speech, using pre-recorded messages less than or equal to 8 minutes recording time | Purchase | |
E2502 | NU EP | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) Speech-generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time | Purchase | |
E2504 | NU EP | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time | Purchase | |
E2506 | NU EP | Y* | ***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time. | Purchase | |
E2508 | NU EP | Y* | ***(More Advanced Voice Output Communication Aids - offer more storage capacity and often have other output methods in addition to voice output; e.g., LED display) Speech-generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device | Purchase | |
E2510 | NU EP | Y* | ***(Higher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access | Purchase | |
E2510 | NU EP | Y* | ***(State-of-the-Art Voice Output Communication Aids - represents state-of-the-art communication aid technology. Have extensive memory capabilities, various output methods, computer interface options; offer a variety of input methods in a single device and advanced functions such as auditory scanning, icon and word prediction, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access | Purchase | |
E2511 | NU EP | Y* | ***(Software - often recommended for speech generating device. Software may change as the child matures.) Speech-generating software program, for personal computer or personal digital assistant | Purchase | |
E2512 | NU EP | Y | Accessory for speech generating device, mounting system | Manually Priced | |
E2599 | NU EP | Y* | ***(Switches - used with training aids and speech generating devices as a means of access) Accessory for speech generating device, not otherwise classified | Manually Priced | |
V5336 | NU EP | RP RP | Y | ***(Speech Generating Device Repair - parts only) Repair/modification of speech generating system or device (excludes adaptive hearing aid) | Manually Priced |
V5336 | NU EP | Y | ***(Speech Generating Device Repair - labor only) Repair/modification of speech generating system or device (excludes adaptive hearing aid) | Manually Priced |
Note: When repair charges for both parts and labor of the SGD is provided and/or billed on the same date of service, only one detail (parts only or labor only) of procedure code V5336 may be billed per beneficiary per date of service. Information must be specified on the paper claim to clarify the charges billed by the provider. Parts and labor charges must be itemized by narrative and documentation.
Outpatient occupational, physical, and speech-language 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 Beneficiaries Under Age 21" form DMS-640. A prescription for therapy services is valid for the length of time specified by the prescribing physician, up to one year. Providers of therapy services are responsible for obtaining renewed PCP referrals every twelve (12) months. The PCP or attending physician is responsible for determining medical necessity for therapy treatment.
Arkansas Medicaid applies the following therapy benefits to all therapy services in the Child Health Services (EPSDT) program for children under age 21:
Occupational, physical, and speech-language therapy services are covered for beneficiaries in the ARKids First-B program benefits at the same level as the Arkansas Medicaid.
For range of benefits, see the following procedure codes: View or print the procedure codes for therapy services. All requests for extended therapy services must comply with the guidelines located within the Occupational, Physical, and Speech-Language Therapy Provider Manual.
Treatment and therapy procedure codes may not be billed in conjunction with revenue code T1015. Medicaid reimbursement for a treatment/therapy room is included in the therapy reimbursement. View or print the procedure codes for therapy services.
016.05.20 Ark. Code R. 005