016.06.09 Ark. Code R. 005

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.09-005 - Child Health Services/Early Periodic Screening Diagnosis and Treatment (EPSDT) Update #116

Section II Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment

212.100 Recordkeeping Requirements

A. Providers must contemporaneously establish and maintain records that completely and accurately explain all evaluations, care, diagnoses and other activities in connection to the delivery of medical assistance to any Medicaid beneficiary.

B. Providers furnishing any Medicaid-covered good or service for which a prescription, admission order, physician's order, care plan or other order for service initiation, authorization or continuation is required by law, by Medicaid rule, or both, must obtain a copy of the prescription, care plan or order within five (5) business days of the date it is written. Providers must maintain a copy of each prescription, care plan or order in the beneficiary's medical record and follow all prescriptions, care plans, and orders as required by law, by Medicaid rule, or both.

C. All records must be kept for a period of five (5) years from the ending date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish medical records upon request may result in sanctions being imposed.

D. Each provider must furnish all original records in its possession regarding the furnishing or billing of Medicaid goods or services, upon request, to authorized representatives of the Division of Medical Services of their designated representatives, state Medicaid Fraud Control Unit of the Arkansas Office of the Attorney General, the U. S. Secretary of the Department of Health and Human Services, or their designated agents. The request may be made in writing or in person. No advance notice is required for an in-person request.

E. When records are stored off-premise or are in active use, the audited provider may certify, in writing, that the records in question are in active use or off-premise storage and set a date and hour within three (3) working days, at which time the records will be made available. However, the provider will not be allowed to delay for matters of convenience, including availability of personnel.

For more information regarding conditions related to recordkeeping, see Section 142.300 of this provider manual.

212.200 EPSDT Minimum Documentation Requirements

The provider must develop and maintain sufficient written documentation to support EPSDT services for which billing is made. This documentation, at a minimum, must contain:

A. The beneficiary's name and Medicaid identification number

B. Description of the service performed

C. Date of service

D. Place where the service was rendered

E. Brief comment, progress notes, referrals, etc., with an original signature by the service provider, including credentials

F. Physician's order for laboratory tests, test results and all records pertinent to billing.

No standard service logs or documentation forms are required. The documentation must be maintained according to the requirements of Sections 142.300 and 212.100 of this provider manual.

214.000 PCP Referral Requirements

The primary care physician (PCP), the PCP entity (e.g., FQHC), or a medically qualified member of the PCP's staff must administer the periodic complete medical screen, or the PCP may make a referral to another qualified Medicaid provider to administer the screen. Qualified Medicaid providers to whom referrals may be made include Medicaid-enrolled nurse practitioners and school based providers certified as comprehensive screening providers. Routine newborn care, dental screens, visual screens, hearing screens and immunizations for childhood diseases are exempt from this referral requirement.

214.100 Freedom of Choice

The medical assistance program provides beneficiaries freedom of choice of local participating Medicaid Child Health Services (EPSDT) providers. The local Department of Human Services (DHS) office is responsible for providing beneficiaries a list of participating Child Health Services (CHS/EPSDT) providers when the beneficiary expresses an interest in the Child Health Services (EPSDT) Program. Beneficiaries have freedom of choice in their selection of a PCP.

214.200 Prescription of Treatment for EPSDT Services Not Specifically in the Medicaid State Plan

Treatment services determined to be medically necessary as a result of an EPSDT screen are considered for EPSDT beneficiaries regardless of whether the service is otherwise included in the Arkansas Medicaid State Plan. PCPs must adhere to the following procedure when prescribing any medically necessary services and/or items that are not specifically included in the Arkansas Medicaid State Plan for Medicaid-eligible beneficiaries under age 21.

The PCP must review the results of the screen found on the EPSDT claim form or in the patient chart records (Form DMS-694) to determine if additional services are medically necessary.

View or print form DMS-694. The PCP will prescribe any treatment services and/or items he or she determines to be medically necessary.

For those services that are not included in the Arkansas Medicaid State Plan, (e.g., highly technological wheelchairs and rehab equipment) the PCP must complete form DMS-693, titled Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan. View or print form DMS-693.

All information requested on form DMS-693 must be provided. The PCP must either attach a copy of the EPSDT screen results found on form DMS-694, or attach a copy of the patient chart records. The DMS-693 form must be submitted to the Division of Medical Services, Utilization Review Section, which will review the information for medical necessity.

View or print Utilization Review Section contact information.

Note: If the service and/or item(s) are specifically included in the Arkansas Medicaid State Plan, the completion of form DMS-693 is not required. This prescription/referral procedure does not apply to individuals who are eligible only in the ARKids First-B Program as those children are not eligible for services or items that are not covered under the state plan.

Providers may refer to the ARKids First-B program manual for more information.

Copies of form DMS-693 may be ordered from the EDS Provider Assistance Center.

View or print the EDS Provider Assistance Center contact information.

215.120 Vaccines for Children

The Vaccines for Children (VFC) Program was established to enable free access to childhood immunizations for Medicaid-eligible children underage nineteen.

The Arkansas Department of Health oversees the VFC program in Arkansas. To enroll in the VFC Program and obtain the vaccines, providers may contact the Arkansas Department of Health. View or print the Arkansas Department of Health contact information.

Arkansas Medicaid reimburses an administration fee for immunizations included in the Vaccines for Children (VFC) Program. Providers billing for administration of immunizations should use the appropriate CPT code.

216.000 Vision Screen

An EPSDT periodic complete medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic vision or hearing screen on the same day, or within seven (7) days of an EPSDT periodic complete medical screen by the same or different providers. The above combinations represent a duplication of services.

The provider must administer an age-appropriate vision assessment. See Section 242.100 for procedure codes.

Vision services are subject to their own periodicity schedule; however, when the periodicity schedule coincides with the schedule for periodic complete medical screen, vision screens must be included as part of the required minimum periodic complete medical screening services. Vision screens are exempt from the PCP referral requirement.

See Sections 215.310 through 215.340 for the age-specific vision screening periodicity schedule.

At a minimum, vision services include diagnosis and treatment for defects in vision, including eyeglasses.

217.000 Hearing Screen

Hearing services are subject to their own periodicity schedule. However, when the periodicity schedule coincides with the schedule for a periodic completed medical screen, hearing screens are to be included as part of the required minimum periodic complete medical screening services. Hearing screens are exempt from the PCP referral requirement.

241.000 Introduction to Billing

Providers may bill the Arkansas Medicaid Program for EPSDT services provided to eligible Medicaid beneficiaries electronically or on paper, using form DMS-694. Each claim may contain charges for only one beneficiary.

View or print a DMS-694 sample form.

Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.

016.06.09 Ark. Code R. 005

5/26/2009