016.06.09 Ark. Code R. 041
All Division of Developmental Disabilities Services (DDS) Alternative Community Services (ACS) waiver providers must meet the enrollment criteria detailed in Section 1, subsection 141.000 in order to participate in the Arkansas Medical Assistance (Medicaid) program.
All willing and qualified providers have the opportunity to enroll as a waiver provider. DDS provides continuous open enrollment for waiver service providers. Potential providers should contact DDS Quality Assurance staff for information on the ACS certification standards. Once a provider is certified by DDS, the provider may contact the DMS Provider Enrollment Unit to enroll as a Medicaid provider.
Certified and enrolled providers are allowed to specify the maximum number of persons they can serve, the county they can serve, the services they can provide and the service levels they can offer based on staff availability. Waiver beneficiaries have the freedom of choice of service providers. Once a provider is chosen by a beneficiary and who meets the designations made by the provider, the provider cannot refuse to provide services unless the provider cannot assure the health and safety of the beneficiary. It is incumbent upon the provider to prove the individual cannot be served by the provider. The burden of proof also requires written identification of the cause for the failure to provide health and safety supported by documentation that attests to that condition.
Before a provider can decrease the maximum number of persons they will serve, drop an existing county they serve, a service, or service level, the provider must identify any beneficiary currently being served that would be affected. The provider will be required to continue providing services to any persons that would be affected by the changes until such time as DDS can secure a new provider and services are in place under the new provider. If a provider elects to change the existing county served or the maximum number of participants served, the change cannot be made if it will adversely impact any person currently receiving services from the provider. The provider's maximum number of persons served may only be reduced through attrition. DDS will freeze new referrals when a provider requests to make changes in the above items but will not approve the changes for existing persons until such time as the transition has occurred to a new provider. Further, when less than an entire county is deleted from coverage, the provider must articulate in writing a business reason for making the change and demonstrate that the selection process is not capricious or arbitrary, does not result in discrimination and does not unfairly distinguish between levels of care. The process cannot be used to eliminate difficult families or persons. Other than business reasons for closing entire counties or programs, people can only be discontinued if the provider cannot assure health and safety.
Option: Based on individual choice, a provider may continue to serve a person without serving others in the county, when the individual served relocates their place of residence.
DDS ACS waiver services are limited to Arkansas and bordering state trade area cities. The DDS must certify providers located in a bordering state trade area city as ACS waiver providers before services may be provided for Arkansas Medicaid beneficiaries.
Bordering state trade area cities are Monroe and Shreveport, Louisiana; Clarksdale and Greenville, Mississippi; Poplar Bluff and Springfield, Missouri; Poteau and Sallisaw, Oklahoma; Memphis, Tennessee and Texarkana, Texas.
The DDS ACS waiver allows a provider who is licensed and certified as a DDS ACS case management entity or a DDS ACS supportive living services provider to enroll in the Arkansas Medicaid Program as a DDS ACS organized health care delivery system (OHCDS) provider.
The option of OHCDS is available to any current or future provider through a written agreement between DDS and the provider entity. The agreement requires each OHCDS provider to guarantee that any sub-contractor will abide by all Medicaid regulations and provides that the OHCDS provider assumes all liability for contract noncompliance. The OHCDS provider must also have a written contract that sets forth specifications and assurances that work will be completed timely and with quality maintained. The OHCDS provider is responsible for ensuring that services were delivered and proper documentation, including a signed customer satisfaction statement, has been submitted prior to billing.
As long as the OHCDS provider delivers at least one waiver service directly utilizing its own employees, an OHCDS provider may provide any other DDS ACS waiver service via a sub-contract with an entity qualified to furnish the service. The primary use of OHCDS is consultation, adaptive equipment, environmental modifications, supplemental support and specialized medical supplies.
The OHCDS provider furnishes the services as the beneficiary's provider of choice as described in that beneficiary's person centered service plan
DDS ACS waiver providers must keep and properly maintain written records. Along with the required enrollment documentation, which is detailed in Section 1, subsection 141.000, the following records must be included in the beneficiary's case files maintained by the provider.
DDS ACS waiver providers must develop and maintain sufficient written documentation to support each service for which billing is made. This documentation, at a minimum, must consist of:
Additional documentation and information may be required dependent upon the service to be provided.
The Medicaid program offers certain home and community based services (HCBS) as an alternative to institutionalization. These services are available for eligible beneficiaries with a developmental disability who would otherwise require an intermediate care facility for the mentally retarded (ICF/MR) level of care. This waiver does not provide education or therapy services.
The purpose of the ACS waiver is to support beneficiaries of all ages who have a developmental disability, meet the institutional level of care, and require waiver support services to live in the community and thus preventing institutionalization.
The goal is to create a flexible array of services that will allow people to reach their maximum potential in decision making, employment and community integration; thus giving their lives the meaning and value they choose.
The objectives are as follows:
DDS is responsible for day-to-day operation of the waiver. All waiver services are accessed through DDS Adult Services, DDS Children's Services or the ICF/MR services intake and referral staff.
All ACS waiver services must be prior authorized by DDS. All services must be delivered based on the approved person centered service plan.
Waiver services will not be furnished to persons while they are inpatients of a hospital, nursing facility (NF), or ICF/MR unless payment to the hospital, NF, or ICF/MR is being made through private pay or private insurance.
A person may be placed in abeyance in three month increments (with status report every month) for up to 12 months when the following conditions are met:
NOTE: The DDS Specialist is responsible for conducting or assuring the conducting of the contacts or monitoring visits with applicable documentation filed in the case record.
Adult and Waiver Services. Monthly status reports are required to be submitted to the DDS Waiver Program Director as long as the person is in abeyance. Each request for continuance must be submitted in writing and supported by evidence of treatment status or progress. Requests for continuance must be made prior to the expiration of the abeyance period.
In order for beneficiaries to continue to be eligible for waiver services while they are in abeyance the following two requirements must be met:
As stated in the Medical Services Manual, Section 1348, an individual living in a public institution is not eligible for Medicaid.
Thus, a person who is living in a public institution as defined above would be closed under Medicaid and also under the waiver program.
Selection for entrance into the waiver is as follows:
Selection for priority consideration is in the order identified above. When more than one category of priority is identified in a ranking, the order of release shall be by date of eligibility determination within each category. Releases occur only when there is a vacant waiver slot.
An individual must be continuously under direct observation of staff members during any use of restraints.
If the use of personal restraints occurs more than three times per month, use should be discussed by the interdisciplinary team and addressed in the plan of care. When emergency procedures are implemented, plan of care revisions including but not limited to, psychological counseling, review of medications with possible medication change or a change in environmental stressors that are noted to precede escalation of behavior may be implemented.
The behavior management plan must specify what behaviors will constitute the use of restraints or seclusion, the length of time to be used, who will authorize the use of restraints or seclusion and the methods for monitoring the individual.
Behavior management plans cannot include procedures that are punishing, physically painful, emotionally frightening, depriving or that puts the individual at a medical risk.
When the behavior plan is implemented, all use of restraint must be documented in the individual's case record, including the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.
When the behavior plan is implemented, all use of restrictive interventions must be documented in the individual's case record and should include the initiating behavior, length of time of restraint, name of authorizing personnel, names of all individuals involved and outcomes of the event.
These interventions might be implemented to deal with aggressive or disruptive behaviors related to the activity or possession. Staff, families and the individual are trained by the provider to recognize and report unauthorized use of restrictive interventions.
Before absence from a specific social activity or temporary loss of personal possession is implemented, the individual is first counseled about the consequences of the behavior and the choices they can make.
DDS ACS services provide the support necessary for a beneficiary to live in the community. Without these services, the beneficiary would require institutionalization.
Services provided under this program are as follows:
Supportive living is an array of individually tailored services and activities provided to enable eligible beneficiaries to reside successfully in their own homes, with their family, or in an alternative living residence or setting. Alternative living residences include apartments, homes of primary caregivers, leased or rented homes, or provider group homes. Supportive living services may also be provided in clinic and integrated community settings. The services are designed to assist beneficiaries in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in the home and community based setting. Services are flexible to allow for unforeseen changes needed in schedules and times of service delivery. Services are approved as maximum days that can be adjusted within the annual plan year to meet changing needs. The total number of days cannot be increased or decreased without a revision. Waiver funding will not reimburse for overtime. The payments for these services exclude the costs of the person's room & board expenses including general maintenance, upkeep or improvement to the person's home or their family's home.
Care and supervision of activities that directly relate to treatment goals & objectives. The supports that may be provided to a beneficiary include the following:
Exclusions: Transportation to and from medical, dental and professional appointments inclusive of therapists. Non-medical transportation does not include transportation for other household members.
Companion and activities therapy services provide reinforcement of habilitative training. This reinforcement is accomplished by using animals as modalities to motivate persons to meet functional goals. Through the utilization of an animals presence, enhancement and incentives are provided to persons to practice and accomplish such functional goals as follows:
NOTE: This service does not include the purchase of animals, veterinary or other care, food, shelter or ancillary equipment that may be needed by the animal that is providing reinforcement.
The direct care supervisor employed by the supported living provider is responsible for assuring the delivery of all supported living direct care services including the following activities:
The direct care supervisor has an on-going responsibility for monitoring beneficiary medication regimens. While the provider may not staff a person on a 24/7 schedule, the provider is responsible around the clock to assure that the person centered service plan identifies and addresses all the needs with other supports as necessary to assure the health and welfare of the beneficiary.
Direct care staff are required to complete daily activity logs for activities that occur during the work timeframe with such activities linked to the person centered service plan objectives. The direct care supervisor is required to monitor the work of the direct care staff and to sign-off on timesheets maintained to document work performed. All monitoring activities, reviews and reports must be documented and available upon request from authorized DDS or DMS staff.
NOTE: Failure to satisfactorily document activities according to DMS requirements may result in non-payment of services.
Persons may access both supportive living and respite on the same date as long as the two services are distinct, do not overlap and the daily rate maximum is correctly prorated as to the portion of the day that each respective service was actually provided. DDS monitors this provision through retrospective annual look behind with providers responsible to maintain adequate time records and activity case notes or activity logs that support the service deliveries. Maximum daily rate is established in accordance with budget neutrality wherein both supportive living and respite independently and collectively cannot exceed the daily maximum.
Controls in place to assure payments are only made for services rendered include requirement by assigned staff to complete daily activity logs for activities that occurred during the work timeframe with such activities linked to the plan of care objectives; supervision of staff by the direct care supervisor with sign off on timesheets maintained weekly; audits and reviews conducted by DDS Quality Assurance annually and at random; DDS Waiver Services annual retrospective reviews, random attendance at planning meetings and visits to the home; DMS random audits; and oversight by the chosen and assigned case Team.
Persons residing in supportive living arrangements are eligible for the same services and service level as any other waiver participant. Staff working in such arrangements must have hours of compensation prorated according to the number of individuals, waiver and non-waiver, residing in the supportive living arrangement. Additional one-on-one staffing may be provided when the need is justified. Supportive living arrangements include:
Exception: Only those supportive living apartments and group homes licensed by the DDS prior to July 1, 1995, are approved to serve more than 4 adults. No expansions will be approved beyond the July 1, 1995, total capacity (waiver and non-waiver).
Only hired caregivers may be reimbursed for supportive living services provided.
The payments for these services exclude the costs of room and board, including general maintenance, upkeep or improvement to the beneficiary's own home or that of his or her family.
Routine care and supervision for which payment will not be made are defined as those activities that are necessary to assure a person's well being but are not activities that directly relate to active treatment goals and objectives.
Waiver funding will not reimburse for overtime. It is the responsibility of the provider to assure compliance with State and Federal Department of Labor, Wage and Hour Laws.
The maximum daily rate for the supportive living array, which includes both supportive living and respite services, collectively or individually is based upon the level of support identified in the beneficiaries person centered service plan. This daily rate includes provider indirect costs for each component of service. DDS must prior authorize daily rates for all levels of support.
Pervasive - maximum daily rate is $391.95 with a maximum annual rate of $143,061.75.
Extensive - maximum daily rate is $176.00 with a maximum annual rate of $64,240.00.
Limited - maximum daily rate is $176.00 with a maximum annual rate of $38,544.00.
See Section 260.000 for billing information.
See Section 224.000 for payment guidelines of relatives or legal guardians.
Respite services are provided on a short-term basis to beneficiaries unable to care for themselves due to the absence of or need for relief of non-paid primary caregivers. Room and board may not be claimed when respite is provided in the beneficiary's home or a private place of residence. Room and board is not a covered service except when provided as part of respite furnished in a facility that is approved by the State as a respite care facility.
Receipt of respite services does not necessarily preclude a beneficiary from receiving other services on the same day. For example, a beneficiary may receive day services, such as, supported employment on the same day as respite services.
When respite is furnished for the relief of a foster care provider, foster care services may not be billed during the period that respite is furnished. Respite may not be furnished for the purpose of compensating relief or substitute staff for supportive living services. Respite services are not to supplant the responsibility of the parent or guardian.
Respite services may be provided through a combination of basic child care and support services required to meet the needs of a child. When respite is provided in a licensed day care facility, licensed day care home, or other lawful child care setting, waiver will only pay for the support staff required by the beneficiary's developmental disability. Parents and guardians will remain responsible for the cost of basic child care fees.
Respite services are separate and distinct from educational services provided at a school where attendance is mandated and the primary focus of the institution is the accomplishment of specified educational goals.
Respite may be provided in the following locations:
The maximum daily rate for the supportive living array, which includes both supportive living and respite services, collectively or individually is based upon the level of support identified in the beneficiaries person centered service plan. This daily rate includes provider indirect costs for each component of service. DDS must prior authorize daily rates for all levels of support.
Pervasive - maximum daily rate is $391.95 with a maximum annual rate of $143,061.75.
Extensive - maximum daily rate is $176.00 with a maximum annual rate of $64,240.00.
Limited - maximum daily rate is $176.00 with a maximum annual rate of $38,544.00.
See section 260.000 for billing information.
Supported employment services consist of intensive, ongoing supports that enable beneficiaries for whom competitive employment at or above the minimum wage is unlikely or who, because of their disabilities, need intensive ongoing support to perform in a competitive work setting.
Supported employment is paid employment that is conducted in a variety of settings, particularly work sites in which individuals without disabilities are employed. When supported employment services are provided at a work site where persons without disabilities are employed, payment is made only for the adaptations, supervision and training required by beneficiaries receiving waiver services as a result of their disabilities. Coverage does not included payment for the supervisor activities rendered as a normal part of the business setting. The employer is responsible for making reasonable accommodations in accordance with the Americans with Disabilities Act.
Supported employment is a collaborative service with Arkansas Rehabilitation Services (ARS). All waiver beneficiaries receiving supported employment must be prior certified by ARS to assure the beneficiary is qualified for supported employment and that ARS funding has been accessed first.
Integration requires that a beneficiary work in a place where no more than eight people with disabilities work together and where co-workers without disabilities are present in the work setting or in the immediate vicinity. Supported employment services may be furnished by a co-worker or other job site personnel provided that the services which are furnished are not part of the normal duties of the co-worker or other personnel and these individuals meet the qualifications to be a provider of the supported employment service.
Supported employment includes:
Transportation between the beneficiary's place of residence and the site of employment, is included as a component part of supported employment services. The cost of this transportation is included in the rate paid to providers.
Personal assistance may be a component part of supported employment but may not need to comprise the entirety of the service.
Supported employment may include services and supports that assist the beneficiary in achieving self-employment through the operation of a business. However, Medicaid funds may not be used to defray the expenses associated with starting up or operating a business. Assistance for self-employment may include:
Beneficiaries receiving supported employment services may also receive educational, prevocational and day habilitation services. A beneficiary's service plan may include two or more types of non-residential habilitation services. However, different types of non-residential habilitation services may not be billed during the same period of the day.
Supported employment requires related activities to be identified and included in outcomes with an accompanying work plan submitted as documentation of need for service.
Payment for employment services excludes:
Supported employment providers must maintain documentation in each waiver beneficiary's file to demonstrate the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or Individual with Disabilities Education Act (20 U.S.C. 1401 et.seq).
Documentation must include proof from the funded provider where services were exhausted.
See Section 202.200 for other information to be retained for beneficiary's file.
Beneficiaries are limited to a maximum of $3.59 per 15 minute unit with a maximum of 32 units (8 hours) of supported employment services per date of service.
Supported employment, provided as long term support, requires monitoring at a minimum of two meetings with the beneficiary and one employer contact each month. The person is required to work a minimum of 15 hours per week in accordance with ARS regulation. Exceptions must be justified by the beneficiary's case manager and must be prior approved by ARS. ARS must approve any exception with monthly monitoring. The beneficiary's case manager must prepare in writing a justification citing why the person cannot work at least 15 hours per week and submit to the ARS counselor assigned to the case.
See section 260.000 for billing information.
The adaptive equipment service includes an item or a piece of equipment that is used to increase, maintain or improve functional capabilities of individuals to perform daily life tasks that would not be possible otherwise. The adaptive equipment service provides for the purchase, leasing, and as necessary, repair of adaptive, therapeutic and augmentative equipment that enables individuals to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise.
Adaptive equipment needs for supportive employment are included. This service may include specialized equipment such as devices, controls or appliances that will enable the person to perceive, to control or to communicate with the environment in which they live.
Equipment may only be covered if not available to the beneficiary from any other source. Professional consultation must be accessed to ensure that the equipment will meet the needs of the beneficiary when the purchase will at a minimum, but not necessarily, exceed $500.00. Consultation must be conducted by a medical professional as determined by the beneficiary's condition for which the equipment is needed. All items must meet applicable standards of manufacture, design and installation.
All adaptive equipment must be solely for the waiver beneficiary. All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over $1,000.00 will require three bids with the lowest bid with comparable quality being awarded; however, DDS may require three bids for any requested purchase.
Computer equipment may be approved when it allows the beneficiary control of his or her environment, assists in gaining independence or when it can be demonstrated that it is necessary to protect the health and safety of the person. Computers will not be purchased to improve socialization or educational skills. Printers may be approved for non-verbal persons.
Communication boards are allowable devices. Computers may be approved for communication when there is substantial documentation that a computer will meet the needs of the person more appropriately than a communication board.
Software will be approved only when required to operate the accessories included for environmental control or to provide text-to-speech capability.
NOTE: Adaptive equipment must be an item that is modified to fit the needs of the beneficiary. Items such as toys, gym equipment, sports equipment, etc. are excluded as not meeting the service definition.
Conditions: The care and maintenance of, adaptive equipment, vehicle modifications, and personal emergency response systems are entrusted to the beneficiary or legally responsible person for whom the aids are purchased. Negligence (defined as failure to properly care for or perform routine maintenance of) shall mean that the service will be denied for a minimum of two plan years. Any abuse or unauthorized selling of aids by the beneficiary or legally responsible person shall mean the aids will not be replaced using waiver funding.
Exclusions:
Vehicle modifications are adaptations to an automobile or van to accommodate the special needs of the beneficiary. Vehicle adaptations are specified by the service plan as necessary to enable the beneficiary to integrate more fully into the community and to ensure the health, welfare, and safety of the beneficiary.
Payment for permanent modification of a vehicle is based on the cost of parts and labor, which must be quoted and paid separately from the purchase price of the vehicle to which the modifications are or will be made.
Transfer of any part of the purchase price of a vehicle, including preparation and delivery, to the price of a modification is a fraudulent activity. All suspected fraudulent activity will be reported to the Program Integrity Section of the Division of Medical Services for investigation.
Reimbursement for a permanent modification cannot be used or considered as down payment for a vehicle.
Lifts that require vehicle modification and the modifications are, for purposes of approval and reimbursement, one project and cannot be separated by plan of care years in order to obtain up to the maximum for each component.
Permanent vehicle modifications may be replaced if the vehicle is stolen, damaged beyond repair as long as the damage is not through negligence of the vehicle owner, or used for more than its reasonable useful lifetime.
PERS may be approved when it can be demonstrated as necessary to protect the health and safety of the beneficiary. PERS is an electronic device that enables beneficiaries at high risk of institutionalization to secure help in an emergency. The beneficiary may also wear a portable "help" button to allow for mobility. The system is connected to the beneficiary's telephone and programmed to signal a response center once the "help" button is activated. The response center must be staffed by trained professionals. PERS services are limited to beneficiaries who live alone or who are alone for significant parts of the day and have no regular caregiver for extended periods of time and who would otherwise require routine supervision. Included in this service are assessment, purchase, installation, testing, and monthly rental fees.
The maximum annual expenditure for adaptive equipment is $7,687.50 per person per year. If the person is also receiving environmental modification services, the COMBINED annual expenditure cannot exceed $7,687.50.
Environmental modifications are made to or at the waiver beneficiary's home, required by the person centered service plan and are necessary to ensure the health, welfare and safety of the beneficiary or that enable the beneficiary to function with greater independence and without which the beneficiary would require institutionalization.
Environmental modification may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, installation of specialized electric and plumbing systems to accommodate medical equipment, installation of sidewalks or pads to accommodate ambulatory impairments, and home property fencing when medically necessary to assure non-elopement, wandering or straying of persons who have dementia, Alzheimer's disease or other causes of memory loss or confusion as to location or decreased mental capacity or aberrant behaviors.
Expenses for the installation of the environmental modification and any repairs made necessary by the installation process are allowable. Portable or detachable modifications that can be relocated with the beneficiary and that have a written consent from the property owner or legal representative will be considered. Requests for modification must include an original photo of the site where modifications will be done; to scale sketch plans of the proposed modification project; identification of other specifications relative to materials, time for project completion ad expected outcomes; labor and materials breakdown and assurance of compliance with any local building codes. Final inspection for the quality of the modification and compliance with specifications and local codes is the responsibility of the waiver case manager. Payment to the contractor is to be withheld until the work meets specifications including a signed customer satisfaction statement.
All services must be provided as directed by the beneficiary's person centered service plan and in accordance with all applicable state or local building codes.
Environmental modifications must be made within the existing square footage of the residence and cannot add to the square footage of the building.
Modifications are considered and approved as single, all-encompassing projects and, as such, cannot be split whereby a part of the project is submitted in one service plan year and another part submitted in the next service plan year. Any such activity is prohibited. All modifications must be completed within the plan of care year in which the modifications are approved.
All purchases must meet the conditions for desired quality at the least expensive cost. Generally, any modifications over $1,000.00 will require three bids with the lowest bid with comparable quality being awarded, however, DDS may require three bids for any requested modification.
Modifications or improvements made to or at the beneficiary's home which are of general repair and are not of direct medical or remedial benefit to the beneficiary (e.g., carpeting, roof repair, central air conditioning, etc.) are excluded as covered services. Also excluded are modifications or improvements that are of aesthetic value such as designer wallpaper, marble counter tops, ceramic tile, etc. Outside fencing is limited to one fence per lifetime. Total perimeter fencing is excluded. Expenses for remodeling or landscaping which are cosmetic, designed to hide the existence of the modification, or result from erosion are not allowable. Environmental modifications that are permanent fixtures will not be approved for rental property without prior written authorization and a release of current or future liability by the residential property owner.
Environmental modifications may not be used to adapt living arrangements that are owned or leased by providers of waiver services.
Swimming pools (both in and out of ground) and hot tubs (spas) are not allowable.
The moving of modifications, such as fencing or ceiling tracks and adaptive equipment that may be permanently affixed to the structure or outside premises is not allowable.
Conditions: The care and maintenance of environmental modifications is entrusted to the beneficiary or legally responsible person for whom the modifications are purchased. Negligence (defined as failure to properly care for or perform routine maintenance of) shall mean that the service will be denied for a minimum of two plan years. Any abuse or unauthorized selling of aids by the beneficiary or legally responsible person shall mean the aides will not be replaced using waiver funding.
A beneficiary's annual expenditure for environmental modifications cannot exceed $7,687.50 per person per year. If the beneficiary is also receiving adaptive equipment services, the COMBINED total cannot exceed $7,687.50.
Specialized medical equipment and supplies include:
Additional supply items are covered as a waiver service when they are considered essential for home and community-care. Covered items include:
Item(s) must be included in the person centered service plan. When the items are included in Arkansas Medicaid State Plan services, a denial of extension of benefits by DMS Utilization Review will be required prior to approval for waiver funding by DDS.
The maximum annual allowance for specialized medical supplies, supplemental supports and community transition services is $3690.00, collectively or individually.
When a non-prescription or prescription medication is necessary to maintain or avoid health deterioration, the $3,690.00 limit may be increased with the difference in the specialized medical supplies maximum allowance and the required amount deducted from the supportive living maximum daily allowance. All such requests must be prior approved by the DDS Assistant Director of Waiver Services.
See Section 260.000 for billing information.
The supplemental support service helps improve or enable the continuance of community living. This service is only available in response to crisis, emergency or life threatening situations. Supplemental support service will be based on demonstrated needs as identified in a beneficiary's person centered service plan as emergencies arise. Waiver funds will be used as the payer of last resort.
Supplemental support service includes:
These services are furnished only to the extent that it is reasonable and necessary as determined through the service plan development process, clearly identified in the service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources.
The supplemental support service is not allowed for monthly rental, lease or mortgage expenses, regular utility charges, household appliances, items that are intended for purely diversional or recreational in nature (televisions, cable TV access, VCRs or DVD players), therapy or educational aids.
Supplemental support may not be used to pay for furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and services are inherent to the service the provider is already delivering. Supplemental support may not be used for these or any other room-and board service.
This service can be accessed only as a last resort. Lack of other available resources must be proven.
The maximum annual allowance for supplemental support, community transition services, and specialized medical supplies is $3,690.00, collectively or individually.
Case management services assist beneficiaries in gaining access to needed waiver services and other Arkansas Medicaid State Plan services, as well as medical, social, educational and other generic services, regardless of the funding source to which access is available.
Case management services include responsibility for guidance and support in all life activities. The intent of case management services is to enable waiver beneficiaries to receive a full range of appropriate services in a planned, coordinated, efficient and effective manner.
These activities include locating, coordinating, assuring the implementation of and monitoring:
Case management services consist of the following activities:
Case Management will be provided up to a maximum of a 90 day transition period for all persons who seek to voluntarily withdraw from waiver services unless the individual does not want to continue to receive the service. The transition period will allow for follow up to assure that the person is referred to other available services and to assure that the person's needs can be met through optional services. It also serves to assure that the person understands the effects and outcomes of withdrawal and to ascertain if the person was coerced or otherwise was unduly influenced to withdraw. During this 90 day timeframe, the person remains enrolled in the waiver, the case remains open, and waiver services will continue to be available until the beneficiary finalizes their intent to withdraw.
Case Management services may not include activities or services that constitute the provision of direct services to the beneficiary that are normally covered as distinct services (e.g. the transportation of beneficiaries to sites where waiver services are furnished or they receive state plan services).
Service gaps of thirty (30) consecutive days must be reported to the DDS Specialist assigned to the case with a copy of the report sent to the DDS Program Director. The report must include the reason for the gap and identify remedial action to be taken.
Case management services are available at three levels of support. They are:
The level of support is determined by the needs or options of the person receiving waiver services as defined in sections 230.211, 230.212 and 230.213.
See section 260.000 for billing information.
Case Management services may be available during the last 180 consecutive days of a Medicaid eligible person's institutional stay to allow case management activities to be performed related to transitioning the person to the community. The person must be approved and in the waiver program for case management to be billed. All transition services must be reasonable and necessary, not available to the participant through other means, and clearly specified in the waiver participant's service plan. Once the beneficiary has been approved to transition to the waiver, a prior authorization for this service will be issued.
If the individual does not enroll in the waiver due to death or significant change in condition, transition activities may be reimbursed, depending on all eligibility factors.
There is a maximum reimbursement limit of $117.70 per month and $1,412.40 annually per person per year.
Consultation services are clinical and therapeutic services which assist waiver beneficiaries, parents, guardians, legally responsible individuals, and service providers in carrying out the beneficiary's person centered service plan.
These services are indirect in nature. The parent educator or provider trainer is authorized to provide the activities identified below in items 2, 3, 4, 5, 7, and 13. The provider agency will be responsible for maintaining the necessary information to document staff qualifications. Staff who meet the certification criteria necessary for other consultation functions may also provide these activities. Selected staff or contract individuals may not provide training in other categories unless they possess the specific qualifications required to perform the other consultation activities. Use of this service for provider training cannot be used to supplant provider trainer responsibilities included in provider indirect costs.:
The maximum amount payable per year for consultation services, per person is $1,320.00 or $136.40 per hour See section 260.000 for billing information.
Crisis intervention services are defined as services delivered in the beneficiary's place of residence or other local community site by a mobile intervention team or professional.
Intervention services must be available 24 hours a day, 365 days a year and must be targeted to provide technical assistance and training in the areas of behavior already identified. Services are limited to a geographic area conducive to rapid intervention as defined by the provider responsible to deploy the team or professional. Services may be provided in a setting as determined by the nature of the crisis, i.e., residence where behavior is happening, neutral ground, local clinic or school setting, etc. The following criteria must be met:
A beneficiary may require one hour or a maximum of twenty-four hours of service during any one day. The maximum rate of reimbursement for this service is $127.10 per hour.
See Section 260.000 for billing information.
Community transition services are non-recurring set-up expenses for beneficiaries who are transitioning from an institutional or another provider-operated living arrangement to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Waiver funds can be accessed once it has been determined that the waiver is the payer of last resort.
Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:
Community transition services are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, clearly identified in the person centered service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources.
Duplication of environmental modifications will be prevented through DDS control of prior authorizations for approvals.
Costs for community transition services furnished to beneficiaries returning to the community from a Medicaid institutional setting through entrance to the waiver, are considered to be incurred and billable when the person leaves the institutional setting and enters the waiver. The beneficiary must be reasonably expected to be eligible for and to enroll in the waiver. If for any unseen reason, the beneficiary does not enroll in the waiver (e.g., due to death or a significant change in condition), transitional services may be billed to Medicaid as an administrative cost.
Exclusions: Community transition services may not include payment for room and board; monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional or recreational purposes. Community transition services may not be used to pay for furnishing living arrangements that are owned or leased by a waiver provider where the provision of these items and services are inherent to the service they are already providing.
Diversionary or recreational items such as televisions, cable TV access, VCR's or DVD players are not allowable.
All transition services must be reasonable and necessary, not available to the participant through other means, and clearly specified in the waiver participant's service plan. Once the beneficiary has been approved to transition to the waiver, a prior authorization for this service will be issued.
If the individual does not enroll in the waiver due to death or significant change in condition, transition activities may be reimbursed, depending on all eligibility factors.
The maximum annual allowance for supplemental support, community transition services, and specialized medical supplies is $3,690.00, collectively or individually.
See section 260.000 for billing information.
Payment for waiver services will not be made to the adoptive or natural parent, stepparent or legal representative or legal guardian of a person less than 18 years old. Payments will not be made to a spouse or a legal representative for a person 18 years of age or older. The employment of eligible relatives (regardless of the waiver beneficiary's age) shall require prior approval from DDS authority.
Payment to relatives, other than parents of minor children, legal guardians, custodians of minors or adults, or the spouse of adults, must be prior approved by DDS to provide services. For purposes of exclusion, "parent" means natural or adoptive parents and step parents. For any service provider, all DDS qualifications and standards must be met before the person can be approved as a paid service provider. Qualified relatives, other than as specified in the foregoing, can provide any service.
Employees will only be reimbursed for 40 hours per week, thus helping to assure the absence of undue influence in the person centered service plan.
In no case will a parent or legal guardian be reimbursed for the provision of transportation for a minor.
Controls for services rendered: All care staff are required to document all services provided daily according to their work schedules, direct care support service supervisors are responsible for the day to day supervision and monitoring of the direct care staff; case managers are responsible to periodically review with the beneficiary any problems in care delivery and report any deficiencies to the Waiver DD Specialist and DDS Quality Assurance provider certification staff. DDS specialists conduct a 100% review of service utilization for each plan of care at the time of each plan of care 12 month expiration date to identify any gaps in approved services with corrective action by the provider to be taken; DDS Quality Assurance conducts annual provider reviews; and DMS conducts both random Quality Assurance audits and audits specific to the financial integrity of services delivered.
Current eligibility for the Arkansas Medicaid Program must be verified as part of the intake and assessment process for admission into the ACS Waiver Program. Medicaid eligibility is determined by the Division of Developmental Disabilities Services or by the Social Security Administration for SSI Medicaid eligible's.
Failure to obtain any required eligibility determination, whether initial or subsequent (time bound) reassessments, will result in the beneficiary's case being closed. Once closure has occurred, and the appeals processes are exhausted, the affected person will have to make a new request for services through the waiver program intake process.
For the supportive living arrangements, the Medicaid eligibility date is retroactive to the date the Medicaid application is received at the DDS Medicaid Unit or no more than three months prior to the receipt of the Medicaid application, whichever is less.
Based on intellectual and behavioral assessment submitted by the provider, the ICF/MR level of care determination is performed by the Division of Developmental Disabilities. The ICF/MR level of care criteria provides an objective and consistent method for evaluating the need for institutional placement in the absence of community alternatives. The level of care determination must be completed and the beneficiary deemed eligible for ICF/MR level of care prior to receiving ACS Waiver services.
Recertification, based on intellectual and behavioral assessments submitted by the provider at appropriate age milestones, will be performed by DDS to determine the beneficiary's continuing need for an ICF/MR level of care.
The annual level of care determination is made by a QMRP (physician).
Coverage is provided within three levels of support. Levels of support are defined as pervasive, extensive and limited and are based on the amount of need for assistance. The beneficiary can move from one level of support to another if there is documentation supporting the need for a higher degree of support. No exceptions are made if documentation does not support the beneficiary's need for a higher level of support.
Once the pervasive level of support is reached and all other funding sources have been accessed, if the provider cannot assure the health, safety and welfare of the beneficiary in the community, case closure proceedings are initiated.
The pervasive level of support is defined as needs that require constant supports provided across environments that are intrusive, long term and include a combination of any available waiver supports provided 24 hours a day, 7 days a week for 365 days a year.
The extensive level of support is defined as needs that require daily supports in one or more environments (work, home or community). Supports are less intrusive than the pervasive supports and may require a schedule of weekly supports that may be needed daily, but less than 24 hours a day, seven days a week.
The limited level of support is defined as needs that are anticipated to be consistent for a foreseeable future period of time, individually time-limited and may be intermittent in nature, subject to re-evaluation every 12 months. This level of support is less because of parental support, group settings and community assistance available to the beneficiary.
A comprehensive diagnosis and evaluation (D&E) must be administered in order to determine that applicants are persons with a developmental disability prior to receiving ACS Waiver services from the DDS.
The comprehensive diagnosis and evaluation includes a series of examinations and observations performed or validated and approved by professionals leading to conclusions and findings.
The examinations and/or assessments include, but are not limited to:
Failure to submit the reassessments in advance of eligibility expiration date will result in the denial of case management reimbursement for the period the determination is overdue. Failure to obtain any required eligibility determination, whether initial or subsequent time-bound reassessments, may result in the beneficiary's case being closed.
When a beneficiary's case has been closed, the affected person must make a new request for services through the waiver program intake process in order for services to continue. This will be considered a new application to the waiver program.
During the initial three months of DDS ACS waiver services, a beneficiary receives services based on a DDS pre-approved initial person centered service plan that provides for case management at the prevailing rate, up to three months; and supportive living services for direct care supervision at a rate of $100.00 per month, up to three months. It may include transitional funding when the person is transitioning from an institution to the community. Persons residing in a Medicaid reimbursed facility may receive case management the last 180 consecutive days of the institutional stay.
NOTE: The fully developed person centered service plan may be submitted, approved and implemented prior to the expiration of the initial person centered service plan. The initial plan period is simply the maximum time frame for developing, submitting, obtaining approval from DDS and implementing the person centered service plan. An extension may be granted when there is supporting documentation justifying the delay.
Prior to expiration of the interim plan of care, each beneficiary eligible for ACS waiver services must have an individualized, specific, written person centered service plan developed by a multi-agency team and approved by the DDS authority. The members of the team will determine services to be provided, frequency of service provision, number of units of service and cost for those services while ensuring the beneficiary's desired outcomes, needs and preferences are addressed. Team members and a physician, via the DDS 703 form, certify the beneficiary's condition (level of care) and appropriateness of services initially and at the annual continued stay review. The person centered service plan is conducted once every 12 months in accordance with the continued stay review date or as changes in the beneficiary's condition require a revision to the person centered service plan.
The person centered service plan must be designed to assure that services provided will be:
ACS waiver services require prior authorization by the Division of Developmental Disabilities Services. In the absence of prior authorization, reimbursement will be denied and will not be approved retroactively.
For the purpose of person centered service plan approvals, DDS is the Medicaid authority.
The reimbursement rates for DDS ACS waiver services will be according to the lesser of the billed amount or the Title XIX (Medicaid) maximum for each procedure.
The maximum supportive living daily rate is inclusive of administration costs that cannot in any event exceed 20% of the total supportive living array for a beneficiary.
If fringe benefits exceed 25%, documentation must be submitted with person centered service plan and budget request. Fringe benefits cannot exceed 32%.
The administration and fringe costs are subject to audit and must be documented to support the rate charged.
A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a program or provider conference and will contact the provider to arrange a conference if needed. Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she wishes, for a full explanation of the factors involved and the Program decision. Following review, the Assistant Director will notify the provider of the action to be taken by the division within 20 calendar days of receipt of the request for review or the date of the program and/or provider conference.
When the provider disagrees with the decision made by the Assistant Director of the Division of Medical Services, the provider may appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department Human Services (DHS) management staff, who will serve as chairperson.
The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director of the Division of Medical Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The panel will hear the questions and a recommendation will be submitted to the Director of the Division of Medical Services.
DDS ACS waiver providers use the CMS-1500 claim form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim should contain charges for only one beneficiary.
The following procedure codes and any associated modifier(s) must be billed for DDS ACS Waiver Services. Prior authorization is required for all services.
Procedure Code | M1 | M2 | PA | Description | Unit of Service | National POS Codes |
H2016 | Y | Supportive Living | 1 Day | 12, 99, 14 | ||
H2023 S5151 | Y Y | Supported Employment Respite Services | 15 Minutes 1 Day | 99 12, 99, 14, 54 | ||
T2020 | UA | Y | Supplemental Support Services | 1 Month | 12, 99, 14 | |
T2022 | Y | Case Management Services | 1 Month | 12, 99, 14 | ||
T2025 | Y | Consultation Services | 1 Hour | 12, 99, 14 | ||
T2028 | Y | Specialized Medical Supplies | 1 Month | 12, 99,14 | ||
T2020 | UA | U1 | Y | Community Transition Services | 1 Package | 99, 14, 54 |
T2022 | U2 | Y | Transitional Case Management | 1 Month | 99, 14, 54 | |
T2034 | U1 | UA | Y | Crisis Intervention Services | 1 Hour | 99,12 |
K0108 | Y | ACS environmental modifications | 1 Package | 12 | ||
S5160 | Y | Adaptive equipment, personal emergency response system (PERS), installation and testing, | 1 Package | 12, 14 | ||
S5161 | Y | Adaptive equipment, personal emergency response system (PERS), service fee, per month, excludes installation and testing | 1 Month | 12, 14 | ||
S5162 | Y | Adaptive equipment, personal emergency response system (PERS), purchase only | 1 Package | 12, 14 | ||
S5165 | U1 | Y | ACS adaptive equipment, per service | 1 Package | 12, 14 |
The national place of service code is used for both electronic and paper billing.
Place of Service | POS Codes |
Patient's Home | 12 |
Other | 99 |
Group Home | 14 |
ICF/MR | 54 |
DHS' fiscal agent 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. View a sample form CMS-1500.
Carefully follow these instructions to help the fiscal agent efficiently process claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the fiscal agent's claims department. View or print fiscal agent claims department contact information.
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.
Field Name and Number | Instructions for Completion |
1. (type of coverage) la. INSURED'S I.D. NUMBER (For Program in Item 1) | Not required. Beneficiary'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 last name and first name. |
3. PATIENT'S BIRTH DATE | Beneficiary's date of birth as given on the 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 complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary resides. |
STATE | Two-letter postal code for the state in which the beneficiary resides. |
ZIP CODE | Five-digit zip code; nine digits for post office box. |
TELEPHONE (Include Area Code) | The beneficiary'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) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Required if insured's address is different from the patient's address. |
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 beneficiary. |
b. OTHER INSURED'S DATE OF BIRTH | Not required. |
SEX | Not required. |
c. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9 a-d are required. Name of the insured beneficiary'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. |
10d. RESERVED FOR LOCAL USE | Not used. |
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. 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. |
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
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. |
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 17a. (blank) 17b. NPI | Primary Care Physician (PCP) referral is not required for DDS Alternative Community Services (ACS) Waiver services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. The 9-digit Arkansas Medicaid provider ID number of the referring physician. 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 inpatient hospitalization, enter the beneficiary's admission and discharge dates. Format: MM/DD/YY. |
19. RESERVED FOR LOCAL USE | Not used. |
20. OUTSIDE LAB? $ CHARGES | 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 ORIGINAL REF. NO. | Reserved for future use. Reserved for future use. |
23. PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24A. DATE(S) OF SERVICE B. PLACE OF SERVICE C. EMG | 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. Two-digit national standard place of service code. See Section 272.200 for codes. Not required. |
D. PROCEDURES, SERVICES, OR SUPPLIES CPT/HCPCS MODIFIER | |
Enter the correct CPT or HCPCS procedure code from Section 272.100. | |
Modifier(s) if applicable. | |
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 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 N O. | 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 co-payments. |
30. BALANCE DUE | From the total charge, subtract amounts received from other sources and enter the result. |
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. |
Not applicable to this program.
016.06.09 Ark. Code R. 041