016.06.06 Ark. Code R. 051 - Section III - Provider Manual Update Transmittal

Section III

301.100 Electronic Claims Submission

EDS furnishes software and X.12/NCPDP companion documents at no charge to the provider for all transactions utilized by Arkansas Medicaid.

When submitting claims electronically, Medicaid providers use the following claim types: ASC X.12N 4010A 837P (professional), 837I (institutional and long-term care), 837D (dental), NCPDP 5.1/1.1 (pharmacy). Your provider type is determined by the last two digits of your Arkansas Medicaid provider ID. For example, the provider type of a hospital with the Arkansas Medicaid provider ID 123456705 is 05.

The following provider types can bill on an 837P:

01	02	03	04	05	08	09	10	15	16
17	18	19	20	21	22	23	24	26	27
28	29	30	31	32	33	34	35	37	38
39	40	41	42	43	44	45	46	48	49
50	51	52	53	54	55	56	57	58	59
60	61	62	63	65	66	67	68	69	70
71	72	73	74	75	76	77	78	79	80
81	82	83	84	85	86	87	88	89	90
91	92	93	94	95	96	97	98	99

The following provider types can bill on an 837I:

05	11	12	13	14	15	21	25	26	27
28	29	36	41	42	47	64	99

The following provider types can bill on an 837D:

08

30

31

79

80

The following provider types can bill on an NCPDP:

07

16

EDS processes each week's accumulations of claims during a weekend cycle. The deadline for each weekend cycle is midnight Friday.

Providers submitting claims electronically must maintain a daily electronic claim transaction summary, signed by an authorized individual. Please refer to the Provider Contract (Form DMS-653), Item "K." View or print form DMS-653.

NOTE: The provider is charged a transaction fee for each electronic claim submitted and each instance of electronic eligibility verification.

314.411 The "Credit To" Segment

The first segment of the adjustment transaction is the "Credit To" segment. In this section, EDS identifies the adjustment transaction, the adjusted claim and the previously paid amount EDS will withhold from today's check as a result of this adjustment. The adjustment transaction is identified by an internal control number (ICN) that follows the field heading "Claim Number." Adjustment ICNs are formatted in the same way as claim numbers; the first two digits of an adjustment ICN are "50." Immediately to the right of the adjustment ICN are the words "Credit To," followed by the claim number and paid date of the original claim that was paid in error.

Underneath the "Credit To" line are displayed the recipient's Medicaid ID number, the claim beginning and ending dates of service and the provider's medical record number (or the patient account number) from the original claim, followed by the original billed amount. Keep in mind that EDS adjusts the entire claim, even if only one detail paid in error, so the total billed amount shown here is the total billed amount of the entire claim being adjusted. At the right end of this line, in the "Paid Amount" column, is the amount originally paid on the claim, which is the amount EDS will withhold from today's remittance.

The actual withholding of the original paid amount does not occur in the Adjusted Claims section; it occurs in the Financial Items section of the RA. Adjustments are listed in Financial Items, with the appropriate amounts displayed under the field headings "Original Amount," "Beginning Balance," "Applied Amount" and "New Balance." (See the discussion of Financial Items in Section 314.600.) Finally, the total of all amounts withheld from the remittance (except transaction fees charged for each electronic claim and eligibility verification) is displayed under "Withheld Amount," in the Claims Payment Summary section of the RA.

314.412 The "Debit To" Segment

A. The second segment of the adjustment transaction is the "Debit To" segment. In this segment, EDS displays the adjudication of the reprocessed claim and, for informational purposes, the net adjustment amount. The net adjustment amount is the additional amount to be paid in this remittance because of the adjustment, or it is the amount by which the remittance will be less than the total of all paid claims minus transaction fees (charged for each electronic claim and eligibility verification) and other withheld amounts.

B. The "Net Adjustment" amount-the amount due to EDS when adjusting an overpayment, or the amount due to the provider when adjusting an underpayment-is on the second line of the "Debit To" segment.

1. In the case of an adjustment of an underpayment, the "Net Adjustment" amount will be added to the total paid claims amount on today's remittance.

2. If EDS is due the amount shown as the net adjustment, the letters "CR" will immediately follow the amount. "CR" means that the claim's original paid amount is greater than the new paid amount (as when the original payment is an overpayment), and the amount denoted by "CR" is the (negative) difference.

C. Adjudication:

Immediately following the "Net Adjustment" line is the complete adjudication of the reprocessed claim, cross-referenced to the original claim number. The last line displays the new paid amount. The difference between the paid amount in the "Credit To" segment and the paid amount in the "Debit To" segment is the amount shown in "Net Adjustment." (See part B, above.)

331.100 Medicare Part D drug benefits

Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.

The Medicaid agency provides coverage, to the same extent that it provides coverage for all Medicaid recipients, for the following excluded or otherwise restricted drugs or classes of drugs, or their medical uses-with the exception of those covered by Part D plans as supplemental benefits through enhanced alternative coverage as provided in 42 CFR § 423.104(f) (1) (ii) (A) - to full benefit dual-eligible beneficiaries under the Medicare Prescription Drug Benefit-Part D.

The following 1927-D excluded drugs, set forth on the Arkansas Medicaid Website (www.medicaid.state.ar.us), are covered.

* select agents when used for weight gain

* select agents when used for the symptomatic relief of cough and colds

* select prescription vitamins and mineral products, except prenatal vitamins and fluoride select nonprescription drugs

* select agents when used to promote smoking cessation

* barbiturates

* benzodiazepines

Notes

016.06.06 Ark. Code R. 051

9/8/2006