Section I

SECTION I - GENERAL POLICY

CONTENTS
100.000 GENERAL INFORMATION
100.100 Introduction
101.000 Provider Manuals
101.100 Provider Manual Organization
101.200 Updates
101.300 Obtaining Provider Manuals
102.000 Legal Basis of the Medicaid Program
103.000 Scope of Program
103.100 Federally Mandated Services
103.200 Optional Services
104.000 Services Available through the Child Health Services (EPSDT) Program
105.000 Services Available through Demonstration Projects and Waivers
105.100 ARChoices
105.110 ARKids First-B
105.120 Autism Waiver
105.130 ConnectCare: Primary Care Case Management (PCCM)
105.140 DDS Community and Employment Support (CES)
105.160 Living Choices Assisted Living
105.170 Non-Emergency Transportation Services (NET)
105.180 TEFRA
105.190 Telemedicine
105.200 Patient-Centered Medical Home (PCMH)
110.000 SOURCES OF INFORMATION
110.100 Provider Enrollment Contractor
110.200 Provider Relations and Claims Processing Contractor
110.300 Utilization Review Section
110.400 Reserved
110.450 Reserved
110.500 Customer Assistance
110.600 Americans with Disabilities Act
110.700 Medicaid Fraud Detection and Investigation Program
110.800 Dental Care Unit
110.900 Visual Care Unit
111.000 DMS and Fiscal Agent Office Hours
120.000 BENEFICIARY ELIGIBILITY
121.000 Introduction
122.000 Agencies Responsible for Determining Eligibility
122.100 Department of Human Services County Offices
122.200 District Social Security Offices
123.000 Medicaid Eligibility Information
123.100 Date Specific Medicaid Eligibility
123.200 Retroactive Medicaid Eligibility
123.400 Beneficiary Lock-In
124.000 Beneficiary Aid Categories
124.100 Client Aid Categories with Limited Benefits
124.110 ARKids First-B
124.120 Medically Needy
124.130 Pregnant Women, Infants & Children
124.140 Presumptive Eligibility Pregnant Woman (PE-PW)
124.150 Qualified Medicare Beneficiaries (QMB)
124.160 Qualifying Individuals-1 (QI-1)
124.170 Specified Low-Income Medicare Beneficiaries (SMB)

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124.180 Reserved
124.190 Reserved
124.200 Client Aid Categories with Additional Cost Sharing
124.210 ARKids First-B
124.220 TEFRA
124.230 Workers with Disabilities
124.240 Transitional Medicaid Adult
124.250 Arkansas Health and Opportunity for Me (ARHOME)
125.000 Medicaid Identification Card
125.100 Explanation of Medicaid Identification Card
125.200 Non-Receipt or Loss of Card by Beneficiary
125.300 Reporting Suspected Misuse of I.D. Card
130.000 BENEFICIARY RESPONSIBILITIES
131.000 Charges that Are Not the Responsibility of the Beneficiary
132.000 Charges that Are the Responsibility of the Beneficiary
133.200 Inpatient Hospital Coinsurance Charge to ARKids First-B Beneficiaries
134.000 Exclusions from Cost Sharing Policy
135.000 Collection of Coinsurance/Co-payment
136.000 Patient Self Determination Act
140.000 PROVIDER PARTICIPATION
141.000 Provider Enrollment
141.100 Revalidation of Enrollment
141.101 Application Fees
141.102 Hardship Exceptions
141.103 Provider Screening
142.000 Conditions of Participation
142.100 General Conditions
142.200 Conditions Related to Billing for Medicaid Services
142.300 Conditions Related to Record Keeping
142.400 Conditions Related to Disclosure
142.410 Disclosures of Ownership and Control
142.420 Disclosures of Information Regarding Personnel Convicted of Crime
142.430 Disclosures of Business Transactions
142.500 Conditions Related to Fraud and Abuse
142.600 Conditions Related to Provider Refunds to DMS
142.610 Overpayments Owed by Medicaid Providers Out of Business or Discharged in
Bankruptcy Proceedings
142.700 Medicare Mandatory Assignment of Claims for “Physician” Service 1216s and
Medicaid’s Mandatory Assignment of Claims for Provider Services
142.800 Condition of Participation – Education
142.900 Principal Accountable Providers (PAPs)
143.000 Recovery Audit Contractors (RACs)
144.000 Tax Compliance
145.000 Electronic Visit Verification (EVV) for In-Home Personal Care, Attendant Care,
Respite-Services, and Home Health Services
145.100 Legal Basis and Scope of EVV Requirement
145.200 EVV Participation Requirements
145.300 EVV Claims Requirements
145.400 Third Party EVV System Requirements
150.000 ADMINISTRATIVE REMEDIES AND SANCTIONS
151.000 Grounds for Sanctioning Providers
152.000 Sanctions
153.000 Rules Governing the Imposition and Extent of Sanctions
154.000 Notice of Violation
155.000 Notice of Provider Sanction

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156.000 Withholding of Medicaid Payments

160.000 ADMINISTRATIVE RECONSIDERATION AND APPEALS
161.200 Administrative Reconsideration
161.300 Administrative Appeals of Adverse Actions that are not Sanctions
161.400 Sanction Appeals
161.500 Continued Services During the Appeal Process
162.000 Notice of the Appeal Hearing
162.100 Conduct of Hearing
162.200 Representation of Provider at a Hearing
162.300 Right to Counsel
162.400 Appearance in Representative Capacity
163.000 Form of Papers
163.100 Notice, Service and Proof of Service
164.000 Witnesses
165.000 Amendments
166.000 Continuances or Additional Hearings
167.000 Failure to Appear
168.000 Record of Hearing
169.000 Decision
169.100 Recovery of the Costs of Services Continued During the Appeal Process
170.000 THE ARKANSAS MEDICAID PRIMARY CARE CASE MANAGEMENT PROGRAM
170.100 Introduction
171.000 Primary Care Physician Participation
171.100 PCP-Qualified Physicians and Advanced Practice Nurse Practitioners
171.110 Exclusions
171.120 Hospital Admitting Privileges Requirement
171.130 EPSDT Agreement Requirement
171.140 Primary Care Case Manager Agreement
171.160 PCP Instate and Trade-Area Restriction
171.170 PCP for Out-of-State Services
171.200 PCCM Enrollee/Caseload Management
171.210 ConnectCare Caseload Maximum and PCP Caseload Limits
171.220 Illegal Discrimination
171.230 Primary Care Case Management Fee
171.300 Required Case Management Activities and Services
171.310 Investigating Abuse and Neglect
171.320 Child Health Services (EPSDT) Requirements
171.321 Childhood Immunizations
171.400 PCP Referrals
171.410 PCCM Referrals and Documentation
171.500 Primary Care Case Management Activities and Services
171.510 Access Requirements for PCPs
171.600 PCP Substitutes
171.601 PCP Substitutes; General Requirements
171.610 PCP Substitutes; Rural Health Clinics and Physician Group Practices
171.620 PCP Substitutes; Individual Practitioners
171.630 Advanced Practice Registered Nurses and Physician Assistants in Rural Health
Clinics (RHCs)
172.000 Exemptions and Special Instructions
172.100 Services not Requiring a PCP Referral
172.110 PCP Enrollment/Referral Guidelines for Medicaid Waiver Program Participants
172.200 Medicaid-Eligible Individuals Who May not Enroll with a PCP
172.300 Automated PCP Enrollment Verification
173.000 PCCM Selection, Enrollment and Transfer
173.100 PCP Selection and Enrollment at Local County DHS Offices
173.200 PCP Selection and Enrollment at PCP Offices and Clinics

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173.300 PCP Selection and Enrollment Through the ConnectCare HelpLine

173.400 PCP Selection and Enrollment at Participating Hospitals
173.500 PCP Selection for Supplemental Security Income (SSI) Beneficiaries
173.600 Transferring PCP Enrollment
173.610 PCP Transfers by Enrollee Request
173.620 PCP Transfers by PCP Request
173.630 PCP Enrollment Transfers Initiated by the State
180.000 EPISODES OF CARE
181.000 Incentives to Improve Care Quality, Efficiency and Economy
190.000 PROVIDER DUE PROCESS
190.001 The Medicaid Fairness Act
190.002 Definitions
190.003 Administrative Appeals
190.004 Records
190.005 Technical Deficiencies
190.006 Explanations of Adverse Decisions Required
190.007 Rebilling at an Alternate Level Instead of Complete Denial
190.008 Prior Authorizations – Retrospective Reviews
190.009 Medical Necessity
190.010 Promulgation Before Enforcement
190.011 Copies
190.012 Notices
190.013 Deadlines
190.014 Federal Law
191.000 BENEFICIARY DUE PROCESS
191.001 Definitions
191.002 Notice
191.003 Determination of Medical Necessity – Content of Notice
191.004 Administrative Appeals
191.005 Conducting the Hearing
191.006 Records

100.000 GENERAL INFORMATION

100.100 Introduction 9-15-09

Section I imparts general program information about the Arkansas Medicaid Program. It
includes information about beneficiary eligibility and explains the provider’s role and
responsibilities. The intent is to provide users with an understanding of Medicaid Program
objectives and regulations. Additionally, it contains details providers may need to answer
questions often asked about the Medicaid Program. Seven major areas are covered in Section
I.
A. General information about the program - Contains information regarding the background,
history and scope of the Medicaid Program, including information about Medicaid waivers
and/or programs administered by the Division of Medical Services.

B. Beneficiary eligibility - Contains information about Medicaid beneficiary aid categories,

beneficiaries’ eligibility for benefits and an explanation of the Medicaid identification card,
the beneficiaries’ responsibilities and additional beneficiary information.

C. Provider participation - Specifies the provider enrollment procedures, the general

conditions that must be met by providers to begin and to maintain program participation
and remedies and sanctions that the Division of Medical Services may employ in the
administration and regulation of the Arkansas Medicaid Program.

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D. Administrative remedies and sanctions - Describes the rules for imposing sanctions.

E. Provider due process - Describes how a provider may request an administrative

reconsideration of an adverse decision/action within 30 calendar days after the notice of
the decision/action.

F. Beneficiary due process - Describes how a beneficiary may request an administrative

reconsideration of an adverse decision/action within 30 calendar days after the notice of
the decision/action.

G. Primary Care Case Management Program (PCCM) - Defines the scope of the Primary
Care Case Management Program (PCCM) and regulations regarding provider and enrollee
participation. It lists the categories of eligibility that are exempt from primary care
physician (PCP) referral requirements and it itemizes the services that do not require PCP
referral. PCP enrollment and enrollment transfer procedures are explained, as are PCP
referral requirements and procedures.

101.000 Provider Manuals 1-1-16

Provider manuals contain the policies and procedures of the Arkansas Medicaid Program.
These policies and procedures are generally based on federal and state laws and federal
regulations. Medicaid provider manual policy and procedures, and changes thereto, are
promulgated as required by the state’s Administrative Procedure Act.

When fully utilized, each program manual is an effective tool for the provider. It provides
information about the Medicaid Program, covered and non-covered services, billing procedures
and detailed instructions for completing paper claims.

Obtain provider manuals from the Arkansas Medicaid website

([Link]

101.100 Provider Manual Organization 1-1-16

The manuals are organized as follows:

A. Section I – general information

B. Section II – program policy and program-specific billing information, including special billing

C. Section III – generic billing information

D. Section IV – glossary

E. Section V – forms and contact information

F. Notices of Rule Making

G. Official Notices

H. Remittance Advice messages (RAs)

Sections I, III, IV and V are the same in each manual; only Section II is program- and provider-
specific.

The manuals are divided into numbered sections with a heading and a revision date, such as
“101.000 Provider Manuals 4-1-06”. Text that appears underlined and blue indicates a hyperlink
to the information being referenced, and it may be viewed or printed. The paper version
contains the same underlined text, though not in blue, so paper users must locate the “linked”
information.

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101.200 Updates 8-1-12

Provider manuals are amended (“updated”) in accordance with new, repealed or revised federal
and state legislative and legal clarifications. Changes and clarifications in DMS medical policy,
new administrative or billing procedures and numerous other requirements are issued and
implemented when warranted. These changes and clarifications are released to the provider in
the form of a manual update, a notice of rule making, an official notice or a remittance advice
(RA) message.

Provider manuals are updated automatically on the Arkansas Medicaid website. Providers are
notified via e-mail when an applicable manual update transmittal is issued. Providers must give
Provider Enrollment a valid, current e-mail address to receive such e-mail notification. Only
revised sections are issued in manual updates along with an update transmittal memorandum to
detail changes. All policy changes including manual updates, notices of rule making, official
notices and RA messages are posted weekly on What’s new for Arkansas Medicaid providers at
[Link] Bookmark this page and
review often for the latest provider information.

Policy and procedure changes are highlighted in the electronic media to help providers quickly
review changes. Provider manual update transmittals are assigned sequential identification
numbers, e.g., Update Transmittal MANUAL-1-11. The transmittal memo identifies any new
sections being added and the sections being replaced, deleted or amended. It provides brief
explanations of the revisions. Provider manual update transmittal memos are recorded on the
update log following each section of the manual.

For persons maintaining a printed provider manual, the updated manual sections should be
manually filed in the provider manual, and the outdated sections should be crossed out or
removed, as appropriate. The transmittal memo effective date should be entered on the update
log opposite the appropriate update transmittal number. Transmittal memos should be filed
immediately following the update log in descending numerical order by transmittal number.
Immediately following the transmittal memos should be the notices of rule making, then official
notices, both of which are numbered sequentially and should be filed with the most recent first.
The RAs will follow the notices of rule making and official notices, with the most recent filed first.

101.300 Obtaining Provider Manuals 8-1-21

All provider manuals, manual updates, notices of rule making, official notices and RAs are
available for downloading, without charge, from the Arkansas Medicaid website.

Enrolled providers may purchase extra paper copies of a manual through the fiscal agent. See
information below regarding purchasing copies. Persons, entities and organizations that are not
enrolled providers may purchase a paper copy of a provider manual through the fiscal agent.

The cost for a printed copy of an Arkansas Medicaid provider manual is $125.00.

Send orders for printed manuals to the Arkansas Medicaid Fiscal Agent, Information Library Unit.
Include with your order a check made to the Fiscal Agent for the appropriate amount. View or
print the manual order contact information.

102.000 Legal Basis of the Medicaid Program 9-15-09

Title XIX of the Social Security Act created a joint federal-state medical assistance program
commonly referred to as Medicaid. Ark Code Ann § 20-77-107 authorizes the Department of
Human Services to establish a Medicaid Program in Arkansas. The Medicaid Program provides
necessary medical services to eligible persons who would not be able to pay for such services.

Title XIX of the Social Security Act provides for federal grants to states for medical assistance
programs. The stated purpose of Title XIX is to enable the states to furnish the following
assistance:
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A. Medical assistance to families with dependent children, the aged, the blind, the
permanently and totally disabled, the medically needy and children under 18 whose
income and resources are insufficient to meet the costs of necessary medical services

B. Rehabilitation and other services to help these families and individuals attain or retain the
capability for independence or self-care

In Arkansas, the Division of Medical Services (DMS) administers the Medicaid Program. Within
the Division, the Office of Long Term Care (OLTC) is responsible for nursing home policy and
procedures.

103.000 Scope of Program 4-1-06

The Arkansas Medicaid Program provides, with limitations, the services listed in Sections
103.100 and 103.200.

103.100 Federally Mandated Services 1-1-16

Program Coverage
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (Child Under Age 21
Health Services)
Family Planning All Ages
Federally Qualified Health Center (FQHC) All Ages
Home Health All Ages
Inpatient Hospital All Ages
Laboratory and X-Ray All Ages
Certified Nurse-Midwife All Ages
Medical and Surgical Services of a Dentist All Ages
Nurse Practitioner (Pediatric, Family, Obstetric-Gynecologic and All Ages
Gerontological)
Nursing Facility Age 21 or
Older
Outpatient Hospital All Ages
Physician All Ages
Rural Health Clinic All Ages
Transportation Services (Emergency) All Ages
Transportation Services (Non-Emergency)* All Ages
*Excluding nursing facilities, ICF/IID, Retroactive Eligibility, QMBs, SMBs
and ARKids-B

103.200 Optional Services 12-1-19

Program Coverage
Adult Behavioral Health Services for Community Independence 18 or older

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Program Coverage
Adult Developmental Day Treatment (ADDT) Pre-School
and Age 18 or
Older
Ambulatory Surgical Center All Ages
Audiological Under Age 21
Certified Registered Nurse Anesthetist (CRNA) All Ages
Chiropractic Services All Ages
Dental Services Under Age 21
Developmental Rehabilitation Services Under Age 3
Durable Medical Equipment All Ages
Early Intervention Day Treatment (EIDT) Under Age 21
End-Stage Renal Disease (ESRD) Facility Services All Ages
Hearing Aid Services Under Age 21
Hospice All Ages
Hyperalimentation All Ages
IndependentChoices (Self-Directed Personal Assistance) Age 18 or
Older
Inpatient Psychiatric Services Under Age 21
Intermediate Care Facility Services for Individuals with Intellectual All Ages
Disabilities
Medical Supplies All Ages
Nursing Facility Under Age 21
Occupational, Physical and Speech-Language Therapy Under Age 21
Orthotic Appliances All Ages
Outpatient Behavioral Health Services All Ages
PACE (Program of All-Inclusive Care for the Elderly) Age 55 or
older*
(*Participants must meet additional medical and non-medical criteria in
addition to age eligibility.)
Personal Care All Ages
Podiatrist All Ages
Portable X-Ray All Ages
Prescription Drugs All Ages
Private Duty Nursing Services (High Technology, Non-Ventilator Under Age 21
Dependent, EPSDT Program)
Private Duty Nursing Services (Non-Ventilator Dependent Beneficiaries Age Age 21 or
21 or Older) Older
Private Duty Nursing Services (Ventilator-Dependent) All Ages
Prosthetic Devices All Ages
Rehabilitative Hospital and Extended Rehabilitative Hospital Services All Ages

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Program Coverage
Rehabilitative Services for Persons with Physical Disabilities (RSPD) Under Age 21
Rehabilitative Services for Youth and Children Under Age 21
Respiratory Care Under Age 21
School-Based Mental Health Services Under Age 21
Targeted Case Management for Beneficiaries of DDS Children’s Services Under Age 21
(Title V Agency)
Targeted Case Management for DDS Children’s Services (Title V Agency) Under Age 16
who are SSI Beneficiaries and TEFRA Waiver Participants
Targeted Case Management for Beneficiaries Age 21 or Under with a Age 21 or
Developmental Disability Under
Targeted Case Management for Beneficiaries Age 22 or Older with a Age 22 or
Developmental Disability Older
Targeted Case Management for Beneficiaries in the Child Health Services Under Age 21
(EPSDT) Program
Targeted Case Management for Beneficiaries in the Division of Children Under Age 21
and Family Services
Targeted Case Management for Beneficiaries in the Division of Youth Under Age 21
Services
Targeted Case Management for Beneficiaries Age 60 or Older Age 60 or
Older
Targeted Case Management for Pregnant Women Pregnant
Women - All
Ages
Ventilator Equipment All Ages
Visual Care All Ages

104.000 Services Available through the Child Health Services (EPSDT) 10-13-03
Program

Medicaid covers certain services only through the Child Health Services (EPSDT) Program for
individuals under age 21. See the Child Health Services (EPSDT) manual and the appropriate
provider program manual for more information.

105.000 Services Available through Demonstration Projects and Waivers 4-1-06

The services detailed in Sections 105.100 through 105.190 are available for eligible beneficiaries
through waivers of federal regulations.

105.100 ARChoices 1-1-16

ARChoices is designed for beneficiaries ages 21 and older who, without the waiver’s services,
would require an intermediate level of care in a nursing home. Individuals ages 21 through 64
must have a physical disability as determined through Social Security Railroad Retirement or
DHS’s Medical Review Team. The services listed below are designed to maintain beneficiaries
at home and preclude or postpone institutionalization.
A. Adult family home

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B. Attendant care services

C. Home delivered meals

D. Personal emergency response system

E. Adult day services

F. Adult day health services

G. Respite care

H. Environmental accessibility/adaptations/adaptive equipment

ARChoices eligibility requires a determination of categorical eligibility, a determination of level of

care, the development of a plan of care and a cost comparison to determine the cost-
effectiveness of the plan of care. ARChoices requires notifying the beneficiary that he or she
may freely choose between waiver services and institutional services.

Refer to the ARChoices provider manual for more detailed information.

105.110 ARKids First-B 9-1-15

ARKids First-B incorporates uninsured children age 18 and under into the health care system.
ARKids First-B benefits are comparable to those of the state employees and teachers insurance
programs. Most services require cost sharing.

The following is a summary of the eligibility criteria for ARKids First-B:

A. Family income must be above the 142% Federal Poverty Level (FPL) up to and including
211% FPL.

B. Applicants must be age 18 and under.

C. Applicants must have had no health insurance that covers comprehensive medical
services, other than Medicaid, within the preceding 90 days (unless insurance coverage
was lost through no fault of the applicant).
1. Applicants whose health insurance is inaccessible are deemed uninsured.
2. Children who do not have primary comprehensive health insurance, whose insurance
is inaccessible or have non-employer sponsored insurance are considered
uninsured. Primary comprehensive health insurance is defined as insurance that
covers both physician and hospital charges.

For more information, refer to the ARKids First-B provider manual and to the Arkansas Medicaid
website at [Link]

105.120 Autism Waiver 10-15-12

The purpose of the Autism waiver is to provide one-on-one, intensive early intervention
treatment for young children ages eighteen (18) months through six (6) years with a diagnosis of
autism. The waiver participants must meet the intermediate care facility for individuals with
intellectual disabilities (ICF/IID) level of care and have a diagnosis of autism.

The community-based services offered through the Autism waiver are as follows:
1. Individual Assessment, Program Development and Training
2. Provision of Therapeutic Aides
3. Plan Implementation and Monitoring of Intervention Effectiveness

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4. Lead Therapy Intervention

5. Line Therapy Intervention
6. Consultative Clinical and Therapeutic Services

The waiver program is operated by the Partners for Inclusive Communities (Partners) under the
administrative authority of the Division of Medical Services.

105.130 ConnectCare: Primary Care Case Management (PCCM) 10-1-12

ConnectCare is the Arkansas Medicaid Primary Care Case Management (PCCM) system. In
ConnectCare, a Medicaid beneficiary selects and enrolls with a primary care physician (PCP)
that has contracted with DMS to be responsible for managing the health care of a limited number
(specified by the PCP) of Medicaid enrollees.

A PCP contracts with DMS to provide primary care, health education and case management for
his or her enrollees. DMS pays the PCP a monthly per-enrollee case management fee in
addition to the regular Medicaid fee-for-service reimbursement.

The PCP is responsible for referring enrollees to specialists and other providers; therefore, he or
she is responsible for deciding whether a particular referral is medically necessary. A PCP may
make such decisions in consultation with physicians or other professionals as needed and in
accordance with his or her medical training and experience; however, a PCP is not required to
make any referral simply because it is requested.

A PCP coordinates his or her enrollees’ medical and rehabilitative services with the providers of
those services. Medical and rehabilitative professionals to whom a PCP refers a patient are
required to report to or consult with the PCP so that the PCP can coordinate care and monitor an
enrollee’s status, progress and outcomes.

Most Medicaid beneficiaries, and children participating in ARKids First-B, must enroll with a PCP
to receive covered services. Some individuals are not required to enroll with a PCP. Few
services are covered without PCP referral. See Sections 170.000 through 173.000 for details
regarding ConnectCare.

105.140 DDS Community and Employment Support (CES) 7-1-20

The Developmental Disability Services Community and Employment Support (DDS CES) waiver
program is for beneficiaries who, without the waiver’s services, would require institutionalization.
Participants must not be residents of a hospital, nursing facility, or intermediate care facility for
individuals with intellectual disabilities (ICF/IID).

DDS CES eligibility requires a determination of categorical eligibility, a determination of level of

care, the development of a plan of care, and a cost comparison to determine the cost-
effectiveness of the plan of care. The DDS CES program further requires advising the
beneficiary that he or she may freely choose between waiver and institutional services.

Services supplied through this program are:

A. Supportive living

B. Respite care

C. Supplemental support services

D. Supported employment services

E. Environmental modifications

F. Adaptive equipment

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G. Specialized medical supplies

H. Community transition services

I. Consultation services

J. Crisis intervention services

105.160 Living Choices Assisted Living 7-15-12

Living Choices Assisted Living is a home- and community-based services waiver that is
administered jointly by the Division of Aging and Adult Services (DAAS) and the Division of
Medical Services (DMS). Qualifying individuals are Medicaid-eligible persons aged 21 and older
who have been determined by Medicaid to be eligible for an intermediate level of care in a
nursing facility. The individual must be a person with a physical disability, blind or elderly.

Participants in Living Choices must reside in Level II assisted living facilities (ALFs), in
apartment-style living units. The assisted living environment encourages and protects
individuality, privacy, dignity and independence. Each Living Choices participant receives
personal, health and social services in accordance with an individualized plan of care developed
and maintained in cooperation with a DAAS-employed registered nurse. A participant’s
individualized plan of care is designed to promote and nurture his or her optimal health and well
being.

Living Choices providers furnish “bundled services” in the amount, frequency and duration
required by the Living Choices plans of care. They facilitate participants’ access to medically
necessary services that are not components of Living Choices bundled services, but which are
ordered by participants’ plans of care. Living Choices providers receive per diem Medicaid
reimbursement for each day a participant is in residence and receives services. The per diem
amount is based on a participant’s “tier of need,” which DAAS-employed RNs determine and
periodically re-determine by means of comprehensive assessments performed in accordance
with established medical criteria. There are four tiers of need.

Living Choices participants are eligible to receive up to nine Medicaid-covered prescriptions per
month. More detailed information may be found in the Living Choices Assisted Living provider
manual.

105.170 Non-Emergency Transportation Services (NET) 7-1-20

Medicaid non-emergency transportation (NET) services for Medicaid beneficiaries are furnished
by regional brokers under the authority of a capitated selective contract waiver. Medicaid
beneficiaries contact their local transportation broker for non-emergency transportation to
appointments with Medicaid providers.

Adult Developmental Day Treatment (ADDT) providers transporting Medicaid beneficiaries to

ADDT Clinic Service providers for ADDT services have been allowed to remain enrolled as fee-
for-service providers for that purpose only, if they so choose. All other Medicaid non-emergency
transportation for ADDT clients must be obtained through the regional broker.

The Arkansas Medicaid non-emergency transportation waiver program does not include
transportation services for:
A. Nursing facility residents;

B. Residents of intermediate care facilities for individuals with intellectual disabilities (ICF/IID);

C. Qualified Medicare Beneficiaries (QMB) when Medicaid pays only the Medicare premium,
deductible, and co-pay;

D. Special Low-Income Qualified Medicare Beneficiaries (SMB);

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E. Qualifying Individual -1 (QI-1);

F. ARKids First-B beneficiaries; or

G. Periods of retroactive eligibility.

Detailed information may be found in the Transportation provider manual and on the Arkansas
Medicaid website.

105.180 TEFRA 9-1-15

The Arkansas Department of Human Services implemented the TEFRA waiver effective January
1, 2003. The TEFRA waiver covers beneficiaries under age 19 who are eligible for Medicaid
services as authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA) and amended by the Omnibus Budget Reduction Act of 2005. TEFRA children, aid
category 49, receive the full range of Medicaid services. However, a premium may be required,
based on parental income. See Section 124.220 for the premium chart. TEFRA waiver
coverage is for non-institutionalized children only.

105.190 Telemedicine 1-1-22

Telemedicine is defined as the use of electronic information and communication technology to

deliver healthcare services including without limitation, the assessment, diagnosis, consultation,
treatment, education, care management, and self-management of a client. Telemedicine
includes store-and-forward technology and remote client monitoring.

Store-and-forward technology is the transmission of a client’s medical information from a

healthcare provider at an originating site to a healthcare provider at a distant site. An originating
site includes the home of a client. Remote client monitoring means the use of electronic
information and communication technology to collect personal health information and medical
data from a client at an originating site that is transmitted to a healthcare provider at a distant
site for use in the treatment and management of medical conditions that require frequent
monitoring.

Arkansas Medicaid shall provide payment to a licensed or certified healthcare professional or a

licensed or certified entity for services provided through telemedicine if the service provided
through telemedicine is comparable to the same service provided in person. Payment will
include a reasonable facility fee to the originating site operated by a licensed or certified
healthcare professional or licensed or certified healthcare entity if the professional or entity is
authorized to bill Arkansas Medicaid directly for healthcare services. There is no facility fee for
the distant site. The professional or entity at the distant site must be an enrolled Arkansas
Medicaid Provider. Any other originating sites are not eligible to bill a facility fee.

Coverage and reimbursement for services provided through telemedicine will be on the same
basis as for services provided in person. While a distant site facility fee is not authorized under
the Telemedicine Act, if reimbursement includes payment to an originating site (as outlined in the
above paragraph), the combined amount of reimbursement to the originating and distant sites
may not be less than the total amount allowed for healthcare services provided in person.

Professional Relationship

The distant site healthcare provider will not utilize telemedicine services with a client unless a
professional relationship exists between the provider and the client. A professional relationship
exists when, at a minimum:
1. The healthcare provider has previously conducted an in-person examination of the
client and is available to provide appropriate follow-up care;
2. The healthcare provider personally knows the client and the client’s health status
through an ongoing relationship and is available to provide follow-up care;

Section I-13
 Section I

3. The treatment is provided by a healthcare provider in consultation with, or upon

referral by, another healthcare provider who has an ongoing professional relationship
with the client and who has agreed to supervise the client’s treatment including
follow-up care;
4. An on-call or cross-coverage arrangement exists with the client’s regular treating
healthcare provider or another healthcare provider who has established a
professional relationship with the client;
5. A relationship exists in other circumstances as defined by the Arkansas State
Medical Board (ASMB) or a licensing or certification board for other healthcare
providers under the jurisdiction of the appropriate board if the rules are no less
restrictive than the rules of the ASMB.
a. A professional relationship is established if the provider performs a face to face
examination using real time audio and visual telemedicine technology that
provides information at least equal to such information as would have been
obtained by an in-person examination. (See ASMB Regulation 2.8);
b. If the establishment of a professional relationship is permitted via telemedicine
under the guidelines outlined in ASMB regulations, telemedicine may be used
to establish the professional relationship only for situations in which the
standard of care does not require an in-person encounter and only under the
safeguards established by the healthcare professional’s licensing board (See
ASMB Regulation 38 for these safeguards including the standards of care); or
6. The healthcare professional who is licensed in Arkansas has access to a client’s
personal health record maintained by a healthcare professional and uses any
technology deemed appropriate by the healthcare professional, including the
telephone, with a client located in Arkansas to diagnose, treat, and if clinically
appropriate, prescribe a noncontrolled drug to the client.

A health record is created with the use of telemedicine, consists of relevant clinical information
required to treat a client, and is reviewed by the healthcare professional who meets the same
standard of care for a telemedicine visit as an in-person visit.

A professional relationship does not include a relationship between a healthcare provider and a
client established only by the following:
1. An internet questionnaire;
2. An email message;
3. A client-generated medical history;
4. Text messaging;
5. A facsimile machine (Fax) and EFax;
6. Any combination of the above; or
7. Any future technology that does not meet the criteria outlined in this section.

The existence of a professional relationship is not required when:

1. An emergency situation exists; or
2. The transaction involves providing information of a generic nature not meant to be
specific to an individual client.

Once a professional relationship is established, the healthcare provider may provide healthcare
services through telemedicine, including interactive audio, if the healthcare services are within
the scope of practice for which the healthcare provider is licensed or certified and in accordance
with the safeguards established by the healthcare professionals licensing board.

Telemedicine with a Minor Client

Section I-14
 Section I

Regardless of whether the provider is compensated for healthcare services, if a healthcare

provider seeks to provide telemedicine services to a minor in a school setting and the minor
client is enrolled in Arkansas Medicaid, the healthcare provider shall:
1. Be the designated Primary Care Provider (PCP) for the minor client;
2. Have a cross-coverage arrangement with the designated PCP of the minor client; or
3. Have a referral from the designated PCP of the minor client.

If the minor client does not have a designated PCP, this section does not apply. Only the parent
or legal guardian of the minor client may designate a PCP for a minor client.

Telemedicine Standard of Care

Healthcare services provided by telemedicine, including without limitation a prescription through

telemedicine, shall be held to the same standard of care as healthcare services provided in
person. A healthcare provider providing telemedicine services within Arkansas shall follow
applicable state and federal laws, rules and regulations regarding:
1. Informed consent;
2. Privacy of individually identifiable health information;
3. Medical record keeping and confidentiality, and
4. Fraud and abuse.

A healthcare provider treating clients in Arkansas through telemedicine shall be fully licensed or
certified to practice in Arkansas and is subject to the rules of the appropriate state licensing or
certification board. This requirement does not apply to the acts of a healthcare provider located
in another jurisdiction who provides only episodic consultation services.

Telemedicine Exclusions

Telemedicine does not include the use of:

1. Audio-only communication unless the audio-only communication is in real-time, is
interactive, and substantially meets the requirements for a health care service that
would otherwise be covered by the health benefit plan:
a. Documentation of the engagement between patient and provider via audio-only
communication shall be placed in the medical record addressing the problem,
content of the conversation, medical decision-making, and plan of care after
the contact;
b. Medical documentation is subject to the same audit and review process
required by payers and governmental agencies when requesting
documentation of other care delivery such as in-office or face-to-face visits;
2. A facsimile machine;
3. Text messaging; or
4. Email.

105.200 Patient-Centered Medical Home (PCMH) 1-1-14

DMS established the Patient-Centered Medical Home (PCMH) program to improve the health of
the population, enhance the patient experience, and control the growth in healthcare costs. To
achieve these goals, the PCMH program includes practice support and incentives to provide
care coordination; promote practice transformation; increase performance transparency; and
reward providers for delivery of economic, efficient, and quality care. Please refer to Section II of
the Patient-Centered Medical Home Manual for information about eligibility, enrollment, and
payment.

Section I-15
 Section I

110.000 SOURCES OF INFORMATION

110.100 Provider Enrollment Contractor 9-15-09

The provider enrollment functions for the Medicaid program are performed by an independent
contractor. Any questions regarding provider enrollment, participation requirements or contracts
should be directed to the Medicaid Provider Enrollment Contractor. View or print the Provider
Enrollment contact information.

110.200 Provider Relations and Claims Processing Contractor 8-1-21

Provider assistance and education and the processing of claims for the Medicaid program are
performed by an independent contractor.

The Arkansas Medicaid Fiscal Agent has a staff of claims representatives available to assist
with any needs concerning claims.

The Arkansas Medicaid Fiscal Agent maintains a Provider Assistance Center (PAC) to assist
Arkansas Medicaid providers.

The Arkansas Medicaid fiscal agent has a full-time staff of Provider Representatives available for
consultation regarding billing problems and technical assistance that cannot be resolved through
the Provider Assistance Center. Provider Representatives are available to visit providers’ offices
to provide training on billing and on-site technical assistance. To find your Provider
Representative to schedule a visit, view the DHS or designated vendor’s Outreach Specialists
page.

110.300 Utilization Review Section 7-1-20

The Utilization Review (UR) Section of the Arkansas Medicaid Program performs professional
medical utilization review(s) for a wide variety of services in a timely and cost-effective manner.
Medicaid’s UR participates in the development of clinically based standard(s) of care coverage
determinations and serves as a resource to Arkansas Medicaid providers. UR has a
responsibility for assuring quality medical care to Arkansas Medicaid beneficiaries through
detection and reporting quality of care concerns to appropriate bodies, in addition to protecting
the integrity of state and federal funds supporting the Medicaid Program.

Utilization Review provides professional review(s) for:

A. Pre- and post-payment of medical services;

B. Prior authorization for private duty nursing, hearing aids and hearing aid repair, extension
of benefits for home health beneficiaries age twenty-one (21) and older, extension of
benefits for personal care for beneficiaries age twenty-one (21) and older, medical
supplies, and incontinence products;

C. Monitoring contractors performing prior authorizations and extension of benefits for the
following programs: in-patient psychiatric services, in-patient and out-patient
hospitalization, emergency room utilization, personal care for beneficiaries under the age
of twenty-one (21), Early Intervention Day Treatment, therapy, OBHS. ABHSCI,
transplants, durable medical equipment, and hyperalimentation services; and

D. Authorization and arrangement of out-of-state transportation for beneficiaries for medically

necessary services/treatments not available in-state.

View or print the Utilization Review contact information.

Section I-16
 Section I

110.400 Reserved 5-1-11

110.450 Reserved 5-1-11

110.500 Customer Assistance 9-15-09

Customer Assistance, of the Division of County Operations, addresses beneficiary inquiries

regarding Medicaid eligibility, the Medicaid identification card and Medicaid coverage and
benefits. View or print the Division of County Operations Customer Assistance Section
contact information.

110.600 Americans with Disabilities Act 10-13-03

Any materials needed in an alternate format, such as large print, can be obtained by contacting
the Americans with Disabilities Act Coordinator. View or print the Americans with Disabilities
Act Coordinator contact information.

110.700 Medicaid Fraud Detection and Investigation Program 1-1-16

Federal Regulations require the implementation of a statewide surveillance and utilization control
program that safeguards against unnecessary or inappropriate utilization of care and services
and excess reimbursements by the Medicaid program. The purpose of the Office of the
Medicaid Inspector General (OMIG) is to investigate fraud allegations and ensure Arkansas’
Medicaid compliance. [Title XIX of the Social Security Act, Arkansas Code Annotated, 42
C.F.R. §455 and the Arkansas State Plan].

The goal of the unit is to verify the nature and extent of services reimbursed by the Medicaid
program, while ensuring reimbursements made are consistent with the quality of care being
provided and protecting the integrity of both state and federal funds.

Responsibilities of the unit include the following:

A. Verifying medical services meet an accepted standard of care and are rendered as billed

B. Verifying services are provided by qualified providers to eligible beneficiaries

C. Verifying reimbursement for services is correct and that all funds identified for collection
prior to Medicaid reimbursement are pursued

The OMIG Section is responsible for conducting on-site medical reviews for the purpose of
verifying the above tasks as well as record keeping and other specified information. Providers
selected for an on-site review will not be notified in advance. Review analysts may request
additional information regarding the provider’s medical practice. View or print Office of
Medicaid Inspector General contact information.

Additionally, the OMIG Section is responsible for the identification and recoupment of questioned
costs claimed for reimbursement from Medicaid funds when warranted. Situations resulting in
recoupment include, but are not limited to, the following:
A. When duplicate payments are made

B. When the Quality Improvement Organization (QIO) denies all or part of a hospital
admission

C. When medical consultants to the Medicaid Program determine lack of medical necessity

D. When Medicaid, Medicare or the Attorney General’s Medicaid Fraud Unit discovers
evidence of overpayment

Section I-17
 Section I

E. When a provider has been assessed a monetary penalty for failure to follow a corrective
action plan which was developed to correct a pattern of non-compliance as provided in
Sections 151.000 and 190.005

When a review is completed, Office of Medicaid Inspector General will forward a findings report
to the provider. If questioned costs are identified through the review, a “Notice of
Decision/Action” will be forwarded to the provider. This notice must comply with Section 190.006
of this manual and must include the name(s) of the patient(s), date(s) of service, date(s) of
payment and the reason(s) for the recoupment decision.

Upon receipt of this notice, the provider has thirty-five (35) calendar days in which to pursue one
of the following actions:
A. Forward a check for the indicated recoupment amount

B. Request administrative reconsideration

C. Appeal

See Sections 160.000 through 169.000 for rules and procedures related to administrative
reconsideration and appeals.

110.800 Dental Care Unit 10-13-03

The dental coordinator assists providers with questions regarding dental services. View or print
the Dental Coordinator contact information.

110.900 Visual Care Unit 10-13-03

The visual care coordinator assists providers with questions regarding visual care services.
View or print the Visual Care Coordinator contact information.

111.000 DMS and Fiscal Agent Office Hours 9-15-09

A Provider Assistance Center is available for provider billing and reimbursement questions 8:00
a.m. until 5:00 p.m., Monday through Friday, with the exception of state and official holidays.
View or print the Provider Assistance Center contact information.

The Division of Medical Services is available to answer provider questions regarding service
coverage not directly addressed within this provider manual 8:00 a.m. until 4:30 p.m., Monday
through Friday, with the exception of state and official holidays. View or print the Division of
Medical Services contact information.

120.000 BENEFICIARY ELIGIBILITY

121.000 Introduction 6-1-08

Medicaid eligibility determinants are such things as income (individual or household), resources,
and medical needs with charges exceeding one’s ability to pay, age or disability, current
residency in Arkansas and other factors. The full range of criteria is beyond the scope of this
provider manual. Eligibility inquiries should be made to the local DHS County office in the
individual's county of residence.

122.000 Agencies Responsible for Determining Eligibility 1-1-23

The Department of Human Services (DHS) local county offices or district Social Security offices
determine beneficiary eligibility for most Medicaid beneficiaries.

Section I-18
 Section I

District Social Security offices determine Supplemental Security Income (SSI) eligibility, which
automatically confers Medicaid eligibility for SSI beneficiaries.

122.100 Department of Human Services County Offices 6-1-08

Family Support Specialists in the DHS county offices are responsible for evaluating the
circumstances of an individual or family to determine eligibility, and if eligible, the proper aid
category through which Medicaid should be received.

After evaluation and determination, the DHS county office establishes Medicaid eligibility dates
in accordance with state and federal policy and regulations. See Sections 123.000 and 124.000
of this manual for further explanation.

122.200 District Social Security Offices 7-15-12

Social Security representatives are responsible for evaluating an individual’s circumstances to

determine eligibility for the Supplemental Security Income (SSI) program administered by the
Social Security Administration. SSI includes aged, blind and permanently and totally disabled
categories. The SSI aid categories are listed in Section 124.000.

To be eligible for SSI, an individual must be aged, blind or be an individual with a permanent and
total disability. All income, resource and other eligibility criteria must be met.

Individuals entitled to SSI automatically receive Medicaid.

123.000 Medicaid Eligibility Information 7-1-20

Under contract with the Division of Medical Services, the fiscal agent provides Medicaid eligibility
verification through the provider portal via the web or through the Voice Response System
(VRS). To access the VRS, providers can call the Provider Assistance Center automated help
line. View or print the Provider Assistance Center contact information.

Eligibility requests can be submitted interactively through the provider portal via the web.
Instructions for verifying eligibility through the provider portal are available using the site’s online
Help feature.

Medicaid providers are able to verify a beneficiary’s Medicaid eligibility for a specific date or
range of dates, including retroactive eligibility for the past year. Providers may obtain other
useful information, such as the status of benefits used during the current fiscal year, other
insurance or Medicare coverage, etc. See Section III of this manual for further information
on electronic solutions. Providers must print and retain eligibility documentation in the
beneficiary’s record each time services are provided or to document retroactive eligibility.

The Provider Assistance Center and DMS will verify Medicaid eligibility by telephone only for
“Limited Services Providers” (see Section II) in non-bordering states and in the case of
retroactive eligibility for dates of service that are more than a year prior to the eligibility
authorization date.

Electronic Benefit Eligibility information only indicates information on claims that have been
processed. It does not reflect any claims that may still be pending.

123.100 Date Specific Medicaid Eligibility 7-1-20

Beneficiary eligibility in the Arkansas Medicaid Program is date specific. Medicaid eligibility may
begin or end on any day of a month. An electronic response through the provider portal or Voice
Response System (VRS) provides the current eligibility period through the date of the inquiry.
An electronic eligibility verification inquiry and positive response through the provider portal or
VRS (i.e. the beneficiary is eligible on the date of service) guarantees that a claim for service on
that date will not deny for ineligibility.

Section I-19
 Section I

123.200 Retroactive Medicaid Eligibility 6-1-08

Medicaid beneficiaries may be found eligible for Medicaid benefits for the three-month period
before the application date, if eligibility requirements for the three-month period are met. The
DHS county offices establish retroactive eligibility. Initial SSI eligibility is usually retroactive.

123.400 Beneficiary Lock-In 4-1-06

The beneficiary lock-in rule enables physicians and pharmacists to provide quality care and
assures that the Medicaid Program does not unintentionally facilitate drug abuse or injury from
overmedication or drug interaction.

If a beneficiary has utilized pharmacy services at a frequency or amount that is not medically
necessary, as determined by a computerized algorithm and clinical review process, DMS can
“lock-in” the beneficiary by requiring him or her to choose a single provider of pharmacy
services. After lock-in, DMS will deny claims for pharmacy services submitted by any provider
other than the selected provider. The selected provider will be notified prior to lock-in, so that
adequate time is allowed for selection of another pharmacy if the selected provider cannot
provide the needed services.

If a beneficiary fails or refuses to choose one provider, a list of providers used by the beneficiary
will be reviewed and a provider will be chosen at random. DMS will ensure that the beneficiary
has reasonable access, taking into account geographic location and reasonable travel time, to
pharmacy services of adequate quality.

Before imposing lock-in, DMS or its agent will mail a notice to the beneficiary in accordance with
the beneficiary due process rules found in Section 191.000 of this manual. The notice will also
inform the beneficiary of his or her right to request administrative reconsideration and outline that
process. If the beneficiary does not appeal or request reconsideration, he must choose a
pharmacy using the selection form enclosed with the notice.

When a beneficiary has been locked-in, eligibility verification transactions will reflect “lock-in to
other provider.” The restriction will be removed after demonstration by the beneficiary that the
abusive situation has been corrected. Application of this rule will not result in the denial,
suspension, termination, reduction or delay of medical assistance to any beneficiary.

Any provider who believes that a particular beneficiary should be considered for beneficiary lock-
in should notify the Division of Medical Services, Pharmacy Unit/Utilization Review Section.
View or print the Division of Medical Services, Pharmacy Unit/Utilization Review Section
contact information.

124.000 Beneficiary Aid Categories 1-1-23

A full list of client aid categories is available online. View or print the Client Aid Category list.

124.100 Client Aid Categories with Limited Benefits 1-1-23

Most Medicaid categories provide the full range of Medicaid services as specified in the
Arkansas Medicaid State Plan. However, certain categories offer a limited benefit package.
These categories are discussed below. View or print the Client Aid Category list.

124.110 ARKids First-B 1-1-16

Act 407 of 1997 established the ARKids First Program. The ARKids First-B Program
incorporates uninsured children into the health care system. ARKids First-B benefits are
comparable to the Arkansas state employees and teachers insurance program.

Section I-20
 Section I

Refer to the ARKids First-B provider manual for the scope of each service covered under the
ARKids First-B Program.

124.120 Medically Needy 1-1-16

The medically needy categories help provide medical care for those individuals who are
medically eligible for benefits, but while their income and/or resources exceed the Medicaid limits
for other types of assistance, the income is insufficient to pay for all or part of necessary medical
care.

Medically needy beneficiaries are covered for the full range of Medicaid benefits with the
exception of long term care services (which includes ICF/IID) and personal care services.

For more information regarding the medically needy program, providers may access the
Medicaid website at [Link]

124.130 Pregnant Women, Infants & Children 1-1-23

The infants and children in the SOBRA (Sixth Omnibus Budget Reconciliation Act of 1986) aid
category receive the full range of Medicaid benefits.

Pregnant Women (PW)-eligibility ends on the last day of the month in which the 60 th postpartum
day occurs.

PW-Unborn Child group (covered through the State Child Health Insurance program, which is
authorized by Section 4901 of the Balanced Budget Act of 1997) does not cover sterilization or
any other family planning services. Therefore, providers must verify eligibility to determine if the
pregnant women is PW-or PW “Unborn Child” (when providers check eligibility, the system will
reflect: “PW Unborn CH-no Ster cov” for the Unborn Child group).

Aid Category 61 also includes benefits to unborn children of alien pregnant women who meet
the eligibility requirements. The benefits for this eligibility category are:
A. Prenatal services

B. Delivery

C. Postpartum services for 60 days (plus the days remaining in the month in which the 60-day
period ends)

D. Services for conditions that may complicate the pregnancy

System eligibility verification will specify “PW unborn ch-no ster cov/FP.”

124.140 Presumptive Eligibility Pregnant Woman (PE-PW) 7-1-25

Medicaid provides temporary Aid Category 62, Presumptive Eligibility Pregnant Woman (PE-
PW). Coverage is restricted to prenatal services and services for conditions that may complicate
the pregnancy. These services are further limited to the outpatient setting only.

124.150 Qualified Medicare Beneficiaries (QMB) 1-1-16

The Qualified Medicare Beneficiary (QMB) group was created by the Medicare Catastrophic
Coverage Act and uses Medicaid funds to assist low-income Medicare beneficiaries. QMBs do
not receive the full range of Medicaid benefits. For example, QMBs do not receive prescription
drug benefits from Medicaid or drugs not covered under Medicare Part D. If a person is eligible
for QMB, Medicaid pays the Medicare Part B premium, the Medicare Part B deductible and the
Medicare Part B coinsurance, less any Medicaid cost sharing, for Medicare covered medical
services. Medicaid also pays the Medicare Part A hospital deductible and the Medicare Part A
coinsurance, less any Medicaid cost sharing. Medicaid pays the Medicare Part A premium for

Section I-21
 Section I

QMBs whose employment history is insufficient for Title XVIII to pay it. Certain QMBs may be
eligible for other limited Medicaid services. Only individuals considered to be Medicare/Medicaid
dually eligible qualify for coverage of Medicaid services that Medicare does not cover.

To be eligible for QMB, individuals must be age 65 or older, blind or an individual with a disability
and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable
income may equal but may not exceed 100% of the Federal Poverty Level (FPL). Countable
resources may be equal to but not exceed twice the current Supplemental Security Income (SSI)
resource limitations.

Generally, individuals may not be certified in a QMB category and in another Medicaid category
simultaneously. However, some QMBs may simultaneously receive assistance in the medically
needy categories, SOBRA pregnant women (61 and 62). QMB generally do not have Medicaid
coverage for any service that is not covered under Medicare; with the exception of the above
listed categories and individuals dually eligible.

Individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the
electronic eligibility display to verify the QMB category of service. The category of service for a
QMB will reflect QMB-AA, QMB-AB or QMB-AD. The system will display the current eligibility.

Most providers are not federally mandated to accept Medicare assignment (See Section
142.700). However, if a physician (by Medicare’s definition) or non-physician provider desires
Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he or she must
accept Medicare assignment on that claim (see Section 142.200 D) and enter the information
required by Medicare on assigned claims. When a provider accepts Medicare according to
Section 142.200 D, the beneficiary is not responsible for the difference between the billed
charges and the Medicare allowed amount. Medicaid will pay a QMB’s or Medicare/Medicaid
dual eligible’s Medicare cost sharing (less any applicable Medicaid cost sharing) for Medicare
covered services.

Interested individuals may be directed to apply for the QMB program at their local Department of
Human Services (DHS) county office.

124.160 Qualifying Individuals-1 (QI-1) 7-15-12

The Balanced Budget Act of 1997, Section 4732, (Public law 105-33) created the Qualifying
Individuals-1 (QI-1) aid category. Individuals eligible as QI-1 are not eligible for Medicaid
benefits. They are eligible only for the payment of their Medicare Part B premium. No other
Medicare cost sharing charges will be covered. Individuals eligible for QI-1 do not receive a
Medicaid card. Additionally, unlike QMBs and SMBs, they may not be certified in another
Medicaid category for simultaneous periods. Individuals who meet the eligibly requirements for
both QI-1 and medically needy spend down must choose which coverage they want for a
particular period of time.

Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be
age 65 or older, blind or an individual with a disability and entitled to receive Medicare payment
Medicare Part A hospital insurance and Medicare Part B medical insurance. Countable income
must be at least 120% but less than 135% of the current Federal Poverty Level.

Countable resources may equal but not exceed twice the current SSI resource limitations.

124.170 Specified Low-Income Medicare Beneficiaries (SMB) 7-15-12

The Specified Low-Income Medicare Beneficiaries Program (SMB) was mandated by Section
4501 of the Omnibus Budget Reconciliation Act of 1990.

Individuals eligible as specified low-income Medicare beneficiaries (SMB) are not eligible for the
full range of Medicaid benefits. They are eligible only for Medicaid payment of their Medicare
Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do
not receive a Medicaid card.
Section I-22
 Section I

Eligibility criteria for the SMB program are similar to those for QMB program. The individuals
must be aged 65 or older, blind or an individual with disabilities and entitled to receive Medicare
Part A hospital insurance and Medicare Part B insurance. Their countable income must be
greater than, but not equal to, 100% of the current Federal Poverty Level and less than, but not
equal to, 120% of the current Federal Poverty Level.

The resource limit may be equal to but not exceed twice the current SSI resource limitations.

Interested individuals may apply for SMB eligibility at their local Department of Human Services
(DHS) county office.

124.180 Reserved 9-1-15

124.190 Reserved 9-1-15

124.200 Client Aid Categories with Additional Cost Sharing 1-1-23

Certain programs require additional cost sharing for Medicaid services. View or print the Client
Aid Category list.

The forms of cost sharing in the Medicaid Program are co-payment and premiums. These
programs are discussed in Sections 124.210 through 124.250.

Copayments may not exceed the amounts listed in the cost sharing schedules, as updated each
January 1 by the percentage increase in the medical care component of the CPI-U for the period
of September to September ending in the preceding calendar year and then rounded to the next
higher 5-cent increment.

A family’s total annual out-of-pocket cost sharing cannot exceed five percent (5%) of the family’s
gross income.

124.210 ARKids First-B 6-1-08

Covered services provided to ARKids First-B participants are (with only a few exceptions) within
the same scope of services provided to other Arkansas Medicaid beneficiaries, but may be
subject to cost sharing requirements. See Section II of the ARKids First-B provider manual for a
list of services that require cost sharing and the amount of participant liability for each service.

124.220 TEFRA 1-1-23

Eligibility category 49 covers children under age 19 who are eligible for Medicaid services as
authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and
amended by the Omnibus Budget Reduction Act. Children in category 49 receive the full range
of Medicaid services. However, there are cost sharing requirements. Families will be charged a
sliding scale monthly premium based on the income of the custodial parents. Custodial parents
with incomes above 150 percent of the federal poverty level (FPL) and in excess of $25,000
annually will be subject to a sliding scale monthly premium. The monthly premium, described in
the following chart, can only be assessed if the family income is in excess of one-hundred and
fifty percent (150%) of the federal poverty level.

The premiums listed in the TEFRA Cost Share Schedule below represent family responsibility.
They will not increase if a family has more than one TEFRA-eligible child. Co-payments are not
charged for services to TEFRA children, and a family’s total annual out-of-pocket cost sharing
cannot exceed five percent (5%) of the family’s gross income.

Section I-23
 Section I

TEFRA Cost Share Schedule

Effective July 1, 2022

Family Income Monthly Premiums

From To % From To
$0 $25,000 0% $0 $0
$25,001 $50,000 1.00% $20 $41
$50,001 $75,000 1.25% $52 $78
$75,001 $100,000 1.50% $93 $125
$100,001 $125,000 1.75% $145 $182
$125,001 $150,000 2.00% $208 $250
$150,001 $175,000 2.25% $281 $328
$175,001 $200,000 2.50% $364 $416
$200,001 No limit 2.75% $458 $458

The maximum premium is $5,500 per year ($458 per month) for income levels of $200,001 and
above.

124.230 Workers with Disabilities 1-1-23

The Workers with Disabilities (WD) category is an employment initiative designed to enable
people with disabilities to gain employment without losing medical benefits. Individuals who are
ages sixteen (16) through sixty-four (64), with a disability as defined by Supplemental Security
Income (SSI) criteria and who meet the income and resource criteria may be eligible in this
category.

Co-payments are required for the following services:

Adult Medicaid Cost Share Schedule

Service Copay
Office Visits and Outpatient Services
Physician visit (including PCP/specialist/audiologist/podiatrist visit, excluding $4.70
preventive services and X-ray)
Preventative Care/Screening/Immunizations/EPSDT $0.00
Other Practitioner Office Visit (Nurse, Physician Assistant) $4.70
Federally Qualified Health Center (FQHC) $4.70
Rural Health Clinic $4.70
Ambulatory Surgical Center $4.70
Family planning services and supplies (including contraceptives) $0.00
Chiropractor $4.70
Acupuncture Not covered
Pharmacy
Generics $4.70

Section I-24
 Section I

Preferred Brand Drugs $4.70

Non-Preferred Brand Drugs $9.40
Specialty Drugs (i.e., High-Cost) $9.40
Testing and Imaging
X-rays and Diagnostic Imaging $4.70
Imaging (CT/Pet Scans, MRIs) $4.70
Laboratory Outpatient and Professional Services $4.70
Allergy Testing $4.70
Inpatient Services
All Inpatient Hospital Services (including MH/SUD) $0.00
Emergency and Urgent Care
Emergency Room Services $0.00
Non-Emergency Use of the Emergency Department $9.40
Emergency Transportation/Ambulance $0.00
Urgent Care Centers or Facilities $4.70
Durable Medical Equipment
Durable Medical Equipment $4.70
Prosthetic Devices $4.70
Orthotic Appliances $4.70
Mental and Behavioral Health and Substance Abuse
All Inpatient Hospital Services (including MH/SUD) $0.00
Mental/Behavioral Health and SUD Outpatient Services $4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy $4.70
Rehabilitative Speech Therapy $4.70
Rehabilitative Physical Therapy $4.70
Outpatient Rehabilitation Services $4.70
Habilitation Services $4.70
Surgery
Inpatient Physician and Surgical Services $0.00
Outpatient Surgery Physician/Surgical Services $4.70
Treatments and Therapies
Chemotherapy $4.70
Radiation $4.70
Infertility Treatment Not covered
Infusion Therapy $4.70
Vision

Section I-25
 Section I

Dental
Accidental Dental $4.70
Women's Services
Delivery and all Inpatient services for maternity care $0.00
Prenatal and postnatal care $0.00
Other
Home health Care Services $4.70
Hospice Services $0.00
End Stage Renal Disease Services (Dialysis) $0.00
Personal Care Not covered

* Exception: Cost sharing for nursing facility services is in the form of “patient liability” which
generally requires that patients contribute most of their monthly income toward their nursing
facility care. Therefore, WD clients (Aid Category 10) and Transitional Medicaid clients (Aid
Category 25) who temporarily enter a nursing home and continue to meet WD or TM eligibility
criteria will be exempt from the co-payments listed above.

124.240 Transitional Medicaid Adult 1-1-23

The Transitional Medicaid program extends Medicaid coverage to families up to 185% of FPL
that, due to earned income, lost eligibility for the Parents/Caretaker-Relative (PCR) Aid
Category. The Transitional Medicaid program provides up to twelve (12) months of extended
coverage after losing PCR eligibility.

Pertinent co-payment amounts for clients covered by Adult Transitional Medicaid are the same
as those listed in Section 124.230.

124.250 Arkansas Health and Opportunity for Me (ARHOME) 1-1-23

The ARHOME program operates as a demonstration waiver under Section 1115 of the Social
Security Act. It provides premium assistance to allow clients eligible under Section 1902(a)(10)
(A)(i)(VIII) of the Social Security Act to enroll in qualified health plans. The ARHOME aid
category covers adults ages 19-64 who earn up to 138% of the federal poverty level and are not
eligible for Medicare. Under ARHOME, clients receive services either through a qualified health
plan (QHP) or through three other benefit plans delivered through fee for service. Cost sharing
applies only to ARHOME clients who are enrolled in a QHP or who are awaiting enrollment in a
QHP (IABP benefit plan). ARHOME clients in a benefit plan based on their status as medically
frail (FRAIL) or alternative benefit plan (ABP) will not be subject to any cost sharing.

ARHOME QHP Cost Share amounts for clients enrolled in a QHP are as follows:

ARHOME QHP Cost Share Schedule

Service Copay
Office Visits and Outpatient Services
Physician visit (including PCP/specialist/audiologist/podiatrist visit, excluding $4.70
preventive services and X-ray)
Preventative Care/Screening/Immunizations/EPSDT $0.00
Other Practitioner Office Visit (Nurse, Physician Assistant) $4.70

Section I-26
 Section I

Federally Qualified Health Center (FQHC) $4.70

Rural Health Clinic $4.70
Ambulatory Surgical Center $4.70
Family planning services and supplies (including contraceptives) $0.00
Chiropractor $4.70
Acupuncture Not covered
Nutritional Counseling $4.70
Pharmacy
Generics $4.70
Preferred Brand Drugs $4.70
Non-Preferred Brand Drugs $9.40
Specialty Drugs (i.e., High-Cost) $9.40
Testing and Imaging
X-rays and Diagnostic Imaging $4.70
Imaging (CT/Pet Scans, MRIs) $4.70
Laboratory Outpatient and Professional Services $4.70
Allergy Testing $4.70
Inpatient Services
All Inpatient Hospital Services (including MH/SUD) $0.00
Emergency and Urgent Care
Emergency Room Services $0.00
Non-Emergency Use of the Emergency Department $9.40
Emergency Transportation/Ambulance $0.00
Urgent Care Centers or Facilities $4.70
Durable Medical Equipment
Durable Medical Equipment $4.70
Prosthetic Devices $4.70
Orthotic Appliances $4.70
Mental and Behavioral Health and Substance Abuse
All Inpatient Hospital Services (including MH/SUD) $0.00
Mental/Behavioral Health and SUD Outpatient Services $4.70
Rehabilitation and Habilitation
Rehabilitative Occupational Therapy $4.70
Rehabilitative Speech Therapy $4.70
Rehabilitative Physical Therapy $4.70
Outpatient Rehabilitation Services $4.70
Habilitation Services $4.70

Section I-27
 Section I

Surgery
Inpatient Physician and Surgical Services $0.00
Outpatient Surgery Physician/Surgical Services $4.70
Treatments and Therapies
Chemotherapy $4.70
Radiation $4.70
Infertility Treatment Not covered
Infusion Therapy $4.70
Vision
Routine Eye Exam Not covered
Dental
Basic Dental Services Not covered
Accidental Dental $4.70
Orthodontia Not covered
Women's Services
Delivery and all Inpatient services for maternity care $0.00
Prenatal and postnatal care $0.00
Other
Eyeglasses for Adults Not covered
Diabetes Education $0.00
Home Health Care Services $4.70
Private-Duty Nursing Not covered
Hospice Services $0.00
End Stage Renal Disease Services (Dialysis) $0.00
Personal Care Not covered

125.000 Medicaid Identification Card

125.100 Explanation of Medicaid Identification Card 1-1-16

Medicaid beneficiaries are issued a magnetic identification card similar to a credit card. Each
identification card displays a hologram, and for many Medicaid categories, a picture of the
beneficiary. Children under the age of five, ARKids First-B participants, nursing home patients
and home- and community-based waiver beneficiaries are not pictured. New participants in
ARKids First-A are not pictured unless their current certification is under an existing case
number and they have a previously issued photo ID card. The DHS Division of County
Operations issues the Medicaid identification card to Medicaid beneficiaries.

THE MEDICAID IDENTIFICATION CARD DOES NOT GUARANTEE ELIGIBILITY FOR A

BENEFICIARY. Payment is subject to verification of beneficiary eligibility at the time services
are provided. See Section 123.000 for verification of beneficiary eligibility procedures, and
Section III for electronic eligibility verification information.

The following is an explanation of information contained on a Medicaid ID card:

Section I-28
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A. Identification Number - A unique ten-digit number assigned to each individual Medicaid

beneficiary by the Arkansas Division of County Operations.

B. Name of Beneficiary - Identifies the name of the beneficiary who is eligible to receive
Medicaid benefits. The card reflects the beneficiary’s name at time of issuance.

C. Birth date - Month/Day/Year - This date represents the month, day and year of birth of the
beneficiary listed.

D. Date of Issuance - This date represents the month, day and year the card was issued to
the beneficiary.

E. Signature - This is the signature of the beneficiary named on the ID card.

View or print an example of the Medicaid ID card.

NOTE: ARKids First-B identification cards look different from a Medicaid identification
card. See the ARKids First-B provider manual for more information.

125.200 Non-Receipt or Loss of Card by Beneficiary 6-1-08

When beneficiaries report non-receipt or loss of a Medicaid card, refer them to the local DHS
County Office or the Division of County Operations, Customer Assistance. View or print the
Division of County Operations, Customer Assistance contact information.

125.300 Reporting Suspected Misuse of I.D. Card 1-1-16

When a provider suspects misuse of a Medicaid identification card, the provider should contact
the Office of Medicaid Inspector General. An investigation will then be made. View or print the
Office of Medicaid Inspector General contact information.

130.000 BENEFICIARY RESPONSIBILITIES

131.000 Charges that Are Not the Responsibility of the Beneficiary 12-1-20

Except for cost sharing responsibilities outlined in Sections 133.000 – 135.000, a beneficiary is
not liable for the following charges:
A. A claim or portion of a claim denied for lack of medical necessity.

B. Charges in excess of the Medicaid maximum allowable rate.

C. A claim or portion of a claim denied due to provider error.

D. A claim or portion of a claim denied because of errors made by DMS or the Arkansas
Medicaid fiscal agent.

E. A claim or portion of a claim denied due to changes made in state or federal mandates
after services were performed.

F. A claim or portion of a claim denied because a provider failed to obtain prior, concurrent, or
retroactive authorization for a service.

G. A claim or portion of a claim denied because the claim did not meet Electronic Visit
Verification (EVV) requirements (see 145.000).

H. The difference between the beneficiary Medicaid cost sharing responsibility, if any, and the
Medicare or Medicare Advantage co-payments.

Section I-29
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I. Medicaid pays the difference, if any, between the Medicaid maximum allowable fee and
the total of all payments previously received by the provider for the same service.
Medicaid beneficiaries are not responsible for deductibles, co-payments, or coinsurance
amounts to the extent that such payments, when added to the amounts paid by third
parties, equal or exceed the Medicaid maximum for that service, even if the Medicaid
payment is zero. The beneficiary is responsible for paying applicable Medicaid cost share
amounts.

J. The beneficiary is not responsible for insurance cost share amounts if the claim is for a
Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as
a Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by
private insurance and the Medicaid maximum allowed amount. Medicaid will not make any
payment if the amount received from the third party insurance is equal to or greater than
the Medicaid allowable rate.

If an individual who makes payment at the time of service is later found to be Medicaid eligible
and Medicaid is billed, the individual must be refunded the full amount of his or her payment for
the covered service(s). If it is agreeable with the individual, these funds may be credited against
unpaid non-covered services and Medicaid cost-sharing amounts that are the responsibility of
the beneficiary.

The beneficiary may not be billed for the completion and submission of a Medicaid claim form.

Exception: Medicaid does not cover the deductible, co-payments, or other cost share
amounts levied to Medicare Part D drugs.

132.000 Charges that Are the Responsibility of the Beneficiary 9-1-08

A beneficiary is responsible for:

A. Charges incurred during a time of ineligibility

B. Charges for non-covered services, including services received in excess of Medicaid

benefit limitations, if the beneficiary has chosen to receive and agreed to pay for those
non-covered services

C. Charges for services which the beneficiary has chosen to receive and agreed to pay for as
a private pay patient

D. Spend down liability on the first day of spend down eligibility

E. The beneficiary is also responsible for any applicable cost-sharing amounts such as
premiums, deductibles, coinsurance, or co-payments imposed by the Medicaid Program
pursuant to 42 C.F.R. §§ 447.50 – 447.60 (2004). These cost-sharing responsibilities are
outlined in Sections 124.210 -124.230 and 133.000 - 135.000 of this manual.

The beneficiary is not responsible for insurance cost share amounts if the claim is for a
Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as a
Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by private
insurance and the Medicaid maximum allowed amount. Medicaid will not make any payment if
the amount received from the third party insurance is equal to or greater than the Medicaid
allowable rate.

133.200 Inpatient Hospital Coinsurance Charge to ARKids First-B 7-1-11

Beneficiaries

For inpatient admissions, the coinsurance charge per admission for ARKids First-B participants
is 10% of the hospital’s Medicaid per diem, applied on the first covered day.

Example:

Section I-30
 Section I

An ARKids First-B beneficiary is an inpatient for 4 days in a hospital whose Arkansas Medicaid
per diem is $500.00. When the hospital files a claim for 4 days, Medicaid will pay $1950.00 and
the beneficiary will pay $50.00 (10% Medicaid coinsurance rate).
1. Four (4 days) times $500.00 (the hospital per diem) = $2000.00 (hospital allowed
amount).
2. Ten percent (10% Medicaid coinsurance rate) of $500.00 = $50.00 coinsurance.
3. Two thousand dollars ($2000.00 hospital allowed amount) minus $50.00
(coinsurance) = $1950.00 (Medicaid payment).

134.000 Exclusions from Cost Sharing Policy 1-1-23

The following populations are excluded from the client cost sharing requirement:
A. Individuals under twenty-one (21) years of age, except:
1. ARKids First-B clients (see the ARKids First-B manual for cost share and more
information about this program).
B. Pregnant women.

C. Individuals who are American Indian or Native Alaskan

D. Individuals who are inpatients in a long-term care facility (nursing facility (NF) and
intermediate care for individuals with intellectual disabilities (ICF/IID) facility) when, as a
condition for receiving the institutional services, the individual is required to spend all but a
minimal amount (for personal needs) of his or her income for medical care costs.

The fact that a client is a resident of a nursing facility does not on its own exclude the
Medicaid services provided to the client from the cost sharing requirement. Unless a
Medicaid client has been found eligible for long term care assistance through the Arkansas
Medicaid Program, and Medicaid is making a vendor payment to the nursing facility (NF or
ICF/IID) for the client, the client is not exempt from the cost sharing requirement.

E. Individuals who are enrolled in a Provider-led Arkansas Shared Savings Entity (PASSE).

F. Individuals receiving hospice care.

G. Individuals who are at or below 20% of the federal poverty level.

The following services are excluded from the client cost sharing requirement:
A. Emergency services - services provided in a hospital, clinic, office or other facility that is
equipped to furnish the required care after the sudden onset of a medical condition
manifesting itself by acute symptoms of sufficient severity that the absence of immediate
medical attention could reasonably be expected to result in:
1. Placing the patient’s health in serious jeopardy,
2. Serious impairment to bodily functions, or
3. Serious dysfunction of any bodily organ or part.
B. Pregnancy-related services

C. Preventive services

D. Services for provider-preventable conditions

E. Family planning services and supplies.

Section I-31
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The provider must maintain sufficient documentation in the client’s medical record to
substantiate any exemption from the client cost sharing requirement.

135.000 Collection of Coinsurance/Co-payment 1-1-23

The method of collecting the coinsurance/co-payment amount from the client is the provider’s
responsibility. In cases of claim adjustments, the responsibility of refunding or collecting
additional cost sharing (coinsurance or co-payment) from the client remains the provider’s
responsibility.

The provider may not deny services to a Medicaid client because of the individual’s inability to
pay the coinsurance or co-payment. However, the individual’s inability to pay does not eliminate
his or her liability for the coinsurance or co-payment charge.

The client’s inability to pay the coinsurance or co-payment does not alter the Medicaid
reimbursement for the claim. Unless the client or the service is exempt from cost sharing
requirements as listed in Section 134.000, Medicaid reimbursement is made in accordance with
the current reimbursement methodology and when applicable cost sharing amounts are
deducted from the maximum allowable fee before payment.

Hospitals are required to comply with certain federal rules before assessing non-emergency
copays. Hospitals are expected to comply with emergency room screening requirements, help
locate alternate providers when screening determines the patient’s need to be non-emergent,
and inform clients of treatment options that have a lesser co-pay before the hospital and the
state can charge the non-emergency use of the emergency room co-pay.

Hospitals must develop written policies and tracking mechanisms to identify how they comply
with the requirement and produce data on member choice and expenditures. Policies and data
must be available upon request of DHS and its designees.

The Medicaid cost-sharing amount for clients who use hospital emergency department services
for non-emergency reasons can be found in the ARHOME QHP Cost Share Schedule for clients
enrolled in a QHP or the Adult Medicaid Cost Share Schedule. (See Sections 124.230 and
124.250)

This cost-sharing amount will only apply to Medicaid clients who are subject to a copay. There
will not be any cost-sharing required from clients who need emergency services or treatment.

The first step in the process will be for hospital emergency departments to conduct an
appropriate medical screening to determine whether the client needs emergency services.

If the screening determines that emergency services are needed, hospitals should tell the client
what the cost-sharing amount will be for the emergency services provided in the emergency
department ($0.00). Hospitals should then provide needed emergency services per their
established protocols.

If the screening determines that emergency services are not needed, hospitals may provide non-
emergency services in the emergency department. Before providing non-emergency services
and imposing client cost sharing for such services, however, the hospital must:

 Tell the client what the cost-sharing amount will be for the non-emergency services
provided in the emergency department,

 Give the client the option of paying for and receiving services in the emergency
department, or

 Give the client the name and location of an alternate non-emergency services provider
that can provide the needed services in a timely manner and at a lower cost than the
hospital emergency department, and

Section I-32
 Section I

 Refer the client to the alternate provider, who will then coordinate scheduling for
treatment.

136.000 Patient Self Determination Act 6-1-08

The Patient Self Determination Act of 1990, Sections 4206 and 4751 of the Omnibus Budget
Reconciliation Act of 1990, P.L.101-508 requires that Medicaid-certified hospitals and other
health care providers and organizations, give patients information about their right to make their
own health decisions, including the right to accept or refuse medical treatment. This legislation
does not require individuals to execute advance directives.

Medicaid-certified hospitals, nursing facilities, hospices, home health agencies and personal
care agencies must conform to the requirements imposed by Centers for Medicare & Medicaid
Services (CMS). The federal requirements mandate conformity to current state law.
Accordingly, providers must employ the following procedures:
A. Provide all adult (aged 18 and older) patients (not just Medicaid beneficiaries) with written
information about their rights under state law to make health care decisions, including the
right to accept or refuse medical or surgical treatment and the right to execute advance
directives. This information must be furnished to Medicaid beneficiaries by the following
provider types and in accordance with the listed procedures.
1. Hospitals at the time of the individual’s admission as an inpatient.
2. Nursing facilities when the individual is admitted as a resident.
3. Providers of home health or personal care services in advance of the individual
receiving care.
4. Hospices at the time of a beneficiary’s initial election of hospice care.
B. Maintain written policies, procedures and materials concerning advance directives to
ensure compliance with the law.

C. Inform all patients and residents about the provider’s policy on implementing advance
directives.

D. Document in each patient’s medical record whether the patient has received information
regarding advance directives. Additionally, providers must also document whether patients
have signed an advance directive and record the terms of the advance directive.

E. Not discriminate against a beneficiary based on whether they have executed an advance
directive. All parties responsible for the patient’s care are obligated to honor the patient’s
wishes as stated in the patient’s advance directive. A provider who objects to a patient’s
advance directive on moral grounds must, as promptly as practicable, take all reasonable
steps to transfer care to another provider.

F. Educate staff and the community on advance directives.

G. Tell patients if they wish to complete a health care declaration, the health care provider will
provide them with information and a health care declaration form. Providers should
acquire a supply of the declaration forms and become familiar with the form.

H. Tell patients they have a right to reaffirm advance directives, to change the advance
directive or to revoke the advance directive at any time and in any manner, including an
oral statement to the attending physician or other health care provider.

A description of advance directive must be distributed to each patient. View or print a sample
form describing advance directives and a sample declaration form that meets the
requirements of law.

Section I-33
 Section I

140.000 PROVIDER PARTICIPATION

141.000 Provider Enrollment 11-1-17

Any provider of health care services must be enrolled in the Arkansas Medicaid Program before
Medicaid will cover any services provided by the provider to Arkansas Medicaid beneficiaries.
Enrollment as a Medicaid provider is contingent upon the provider satisfying all rules and
requirements for provider participation as specified in the applicable provider manual, state and
federal law. Persons and entities that are excluded or debarred under any state or federal law,
regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.

All providers must sign all applicable forms that require a signature and the Arkansas Medicaid
Provider Contract. The signature must be an original signature or an approved electronic
signature of the individual provider. The provider’s authorized representative may sign the
contract for a group practice, hospital, agency or other institution.

In addition to the information in Section 140.000, Section II of each program’s provider manual
may contain supplemental provider type specific participation requirements. The provider
enrollment functions for the Arkansas Medicaid Program are performed by an independent
contractor. The contractor is responsible for provider enrollment services for new providers and
changes to current provider enrollment files. Potential providers must complete all appropriate
portions of a provider enrollment Application Packet to execute the provider contract. They must
also submit a copy of all certifications and licenses verifying compliance with enrollment criteria
for the applicable provider type or discipline to be practiced and pay the application fee (if
applicable). See Section 141.101 for Application Fees.

Potential providers may enroll on the Arkansas Medicaid website at

[Link] Potential providers that are not required to pay
application fees may also send the printed form to the Medicaid Provider Enrollment Unit. View
or print the Provider Enrollment contact information.

All subsequent state license and certification renewals must be forwarded to the Medicaid
Provider Enrollment Unit within 30 days of issuance. If the renewal document(s) have not been
received within this timeframe, the provider will have an additional and FINAL 30 days to comply.
Failure to timely submit verification of license or certification renewals will result in cancellation of
enrollment in the Arkansas Medicaid Program. View or print the provider enrollment and
contract package (Application Packet).

In addition to the submission of the Application Packet, the following forms are required and
must be submitted to complete the enrollment process:
A. W-9 Tax form (DMS-652)

B. Medicaid Provider Contract (DMS-652)

C. PCP Agreement, if applicable (DMS-2608. See Section 171.000 for PCP requirements.)

D. EPSDT Agreement, if applicable (DMS-831. See Section 201.000 of the EPSDT provider
manual for the EPSDT Agreement.)

E. Group Affiliation form, if applicable (DMS-652). This form is applicable for individual
providers who choose to authorize a group to bill and receive reimbursement on their
behalf.

F. Authorization for Electronic Funds Transfer (Automatic Deposit)

Each provider must notify the Medicaid Provider Enrollment Unit in writing immediately regarding
any changes to its application or contract status, such as:

Section I-34
 Section I

A. Group Affiliation form, if applicable (DMS-652). This form is applicable for individual
providers who choose to authorize a group to bill and receive reimbursement on their
behalf.

B. Change in Federal Employer Identification Number (FEIN) may require the completion of a
new enrollment application

C. Authorization for Electronic Funds Transfer (Automatic Deposit)

D. Change in practice or specialty

E. Retirement or death of provider

F. Name Change Form

G. Change of Ownership Form (DMS-0688) (View or print form DMS-0688 – Provider

Change of Ownership Information Form.)

H. Address/Email Change Form (DMS-673) (View or print form DMS-673 – Address/Email

Change Form.) NOTE: An active email address is required.

I. Change in Ownership Control (5% or more) or Conviction of Crime (View or print form
DMS-675 – Ownership and Conviction Disclosure.)

J. Disclosure of Significant Business Transactions (View or print form DMS-689 –

Disclosure of Significant Business Transactions.)

When the provider has successfully met all requirements, the Medicaid Provider Enrollment Unit
will assign a unique Medicaid number to the provider. The assigned provider number is linked to
the provider’s tax identification number (either a Social Security Number or a Federal Employer
Identification Number) and to the provider’s National Provider Identifier (NPI) unless the provider
is an atypical provider not required to have an NPI.

141.100 Revalidation of Enrollment 7-1-13

Federal regulation 42 CFR 455.414 requires Arkansas Medicaid to revalidate the enrollment of
all providers regardless of provider type, at least every 5 years. Revalidation of an enrollment
includes:
A. Submission of a new application,

B. Payment of application fee, if applicable (See Section 141.102 for Application Fees
requirements.), and

C. Satisfactory completion of screening activities.

The revalidation notice will be sent to the provider 90 days before their revalidation deadline
using the “Mail To” address on file. It is important that providers keep their address information
up to date to ensure that they receive this notice. Failure to submit the required documentation
prior to the deadline will interrupt the ability to have claims paid.

Providers enrolling on or after July 1, 2013 will have a future revalidation date set at the time of
their enrollment. All providers that were enrolled before July 1, 2013 will be required to
revalidate their enrollments upon receipt of notice from Medicaid Provider Enrollment. This initial
revalidation will determine the revalidation cycle for providers.

141.101 Application Fees 7-1-13

Section I-35
 Section I

Federal regulation 42 CFR 455.460 requires that Arkansas Medicaid collect applicable
application fees from prospective or re-enrolling providers prior to the execution of the Medicaid
Provider Contract and issuance of a Medicaid Provider ID number.

The following providers are not required to pay the application fee to Arkansas Medicaid:
A. Individual physicians or non-physician practitioners.

B. Physician or non-physician practitioner group practices.

C. Providers who are enrolled in either of the following:

1. Medicare
2. Another state’s Medicaid or Children’s Health Insurance Program.
D. Providers that have paid the applicable application fee to:
1. A Medicare contractor; or
2. Another state.

The application fee will be subject to change each year in accordance with the federally
published application fee.

All providers that are required to pay an application fee must enroll online. Application fees must
be paid by credit card, debit card or electronic funds transfer and submitted with the online
application.

Applications submitted without payment, proof of payment or exception letter will not be
accepted. (See Section 141.102 for Hardship Exceptions requirements.) Providers must
maintain their supporting documentation on file.

141.102 Hardship Exceptions 7-1-13

Section 1866(j)(2)(C)(iii) of the Act permits the Secretary of the federal Department of Health and
Human Services to grant, on a case-by-case basis, exceptions to the application fee for
institutional providers and suppliers enrolled in the Medicare and Medicaid programs and CHIP,
if the Secretary determines that imposition of the fee would result in a hardship. Such requests
will be considered on a case-by-case basis, as required by the statute.

141.103 Provider Screening 7-1-13

Federal regulation 42 CFR 455.450 requires that Arkansas Medicaid screen all initial
applications, including applications for a new practice location, and any applications received in
response to a re-enrollment or revalidation of enrollment based on a categorical risk
assessment; and conduct on-site visits in accordance with 42 CFR 455.432, which includes pre-
enrollment and post enrollment site visits as well as unannounced on-site inspections of any
provider location.
A. Conduct a criminal background check on the provider and anyone with five percent (5%) or
higher direct or indirect ownership interest in the provider, and

B. Require submission of a set of fingerprints from the provider and anyone with five percent
(5%) or higher direct or indirect ownership interest in the provider.

142.000 Conditions of Participation 8-1-14

Providers enrolled in the Arkansas Medicaid Program must agree to and meet the conditions of
participation contained in sections within 140.000.

Section I-36
 Section I

A. Failure to comply with the requirements contained within Section 140.000 may result in
termination from the Medicaid Program and/or recovery of money paid for services by the
Division of Medical Services.

B. Nothing in the conditions of participation is a limitation on the ability of DMS to take any
action that is authorized by federal or state laws, regulations or rules or to refrain from
taking any action that is not mandated by federal or state laws, regulations or rules.

C. Arkansas Code Annotated 12-12-925 prohibits the provision of goods and services under
the Arkansas Medicaid program by persons that are required to register as a sex offender,
listed in the Federal Bureau of Investigation’s National Sex Offender Registry or listed in
the United States Department of Justice Dru Sjodin National Sex Offender Public Website.
Persons to which this law is applicable will be denied enrollment as a Medicaid provider or
terminated if a current Medicaid provider. As this law applies regardless of enrollment as a
Medicaid provider, please see also Section 142.500 E for additional information.

142.100 General Conditions 10-8-10

A. Each provider must be licensed, certified or both, as required by law, to furnish all goods or
services that may be reimbursed by the Arkansas Medicaid Program.

B. Providers must adhere to all applicable standards for professional conduct and quality
care.

C. It is the responsibility of each provider to read the complete Arkansas Medicaid provider
manual provided by DMS and to abide by the rules and regulations specified in the
manual.

D. All services provided must be medically necessary. The beneficiary is not liable for a claim
or portion of a claim when the Medicaid Program, either directly or through a designee,
determines that the services were not medically necessary.

E. Services will be provided to qualified beneficiaries without regard to race, color, national
origin or disability within the provisions of Title VI of the Federal Civil Rights Act, Section
504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

F. Each provider must notify the Medicaid Provider Enrollment Unit in writing immediately
regarding any changes to its application or contract, such as:
1. Change of address (View or print form DMS-673 – Address Change Form.)
2. Change in members of group, professional association or affiliations*
3. Change in practice or specialty*
4. Change in Federal Employer Identification Number (FEIN)*
5. Retirement or death of provider*
6. Complete change of ownership (View or print form DMS-0688 – Provider Change
of Ownership Information Form.)
7. Change in Ownership Control (5% or more) or Conviction of Crime (View or print
form DMS-675 – Ownership and Conviction Disclosure .)
8. Disclosure of Significant Business Transactions (View or print form DMS-689 –
Disclosure of Significant Business Transactions.)
Changes in items two (2) through five (5) above may be properly addressed through a
letter of explanation with the provider’s original signature or an approved electronic
signature and the appropriately corrected pages of the provider application document
(View or print form DMS-652 – Provider Application Form).

Section I-37
 Section I

G. Except for Medicaid-covered services and other professional services furnished in

exchange for the provider’s usual and customary charges, a Medicaid provider may not
knowingly give, offer, furnish, provide or transfer money, services or any thing of value for
less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid
beneficiary within the third degree or any person residing in the household of a beneficiary.

This rule does not apply to:

1. Pharmaceutical samples provided to a physician at no cost or to other comparable
circumstances where the provider obtains the sample at no cost and distributes the
samples without regard to Medicaid eligibility.
2. Provider actions taken under the express authority of state or federal Medicaid laws
or rules or the provider’s agreement to participate in the Medicaid Program.

142.200 Conditions Related to Billing for Medicaid Services 4-1-23

A. Any covered service performed by a provider must be billed only after the service has been
provided. No service or procedure may be pre-billed.

B. Endorsement of the provider check issued by the Medicaid fiscal agent certifies that the
services were rendered by or under the direct supervision of the provider as billed.

C. It is the responsibility of each provider to be alert to the possibility of third-party sources of

payment and to report receipt of funds from these sources to DMS.

D. Each provider must accept Medicare assignment under Title XVIII (Medicare) in order to
receive payment under Title XIX (Medicaid) for any Medicare deductible or coinsurance
due and payable under Title XIX (Medicaid). See Section 142.700 for more information and
details.

E. Each provider must accept payment from Medicaid as payment in full for covered services,
make no additional charges, and accept no additional payment from the beneficiary for
these services.

F. Medicaid providers may not charge beneficiaries for the completion and submission of a
Medicaid claim form. If the provider agrees to accept the patient as a Medicaid beneficiary
and agrees to bill Medicaid for the services rendered, the beneficiary may not be charged
for this billing procedure.

G. Claims for services provided to eligible Medicaid beneficiaries must be submitted to the
Medicaid fiscal agent within twelve (12) months from the date of service.

H. Federal Public Health Service’s 340B Drug Pricing Program: All covered entities (except
Federally Qualified Health Centers) that participate in the Federal Public Health Service’s
340B Drug Pricing Program (340B) that carve Arkansas Medicaid into the 340B program
are required to bill Arkansas Medicaid using their 340B actual invoice price for covered
outpatient drugs. Reimbursement shall be no more than the 340B ceiling price. The 340B
actual invoice price for each drug reimbursement covered under this program must be
submitted to the Department prior to any claims being processed. A covered outpatient
drug includes outpatient drugs and drugs used in connection with an inpatient or outpatient
service provided by a hospital. Covered entities (except Federally Qualified Health
Centers) must also identify all 340B drug claims using the medical modifiers JG or TB.
Medical drug claims from covered 340B entities without the modifiers JG or TB will be
considered non-340B drug claims and will be subject to rebate invoicing.

I. 340B drug claims will be subject to post payment review. Providers are responsible for
maintaining documentation to support billed amounts.

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142.300 Conditions Related to Record Keeping 9-15-09

A. Each provider must prepare and keep complete and accurate original records that fully
disclose the nature and extent of goods, services or both provided to and for eligible
beneficiaries. The provider must contemporaneously establish and maintain beneficiary
records that completely and accurately explain all evaluation, care diagnoses and any
other activities of the provider in connection with the Medicaid beneficiary. The delivery of
all goods and services billed to Medicaid must be documented in the beneficiary’s medical
record. Beneficiary records must support the levels of service billed to Medicaid.
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 aforementioned prescription, care plan or order within five (5) business days of
the date it is written. When verbal orders are properly received, a written prescription must
be obtained within fourteen (14) business days of the date the prescription is written or
received through verbal order. The provider must maintain a copy of each subsequent,
relevant prescription and follow all prescriptions and care plans.

B. If a provider maintains more than one office in the state, the provider must designate one
such office as a home office. Original records must be maintained at the provider’s home
office. A copy of the records must be maintained at the provider’s service delivery site. If
the provider changes ownership or ceases doing business in the state, all required original
records must be maintained at a site in the state that is readily accessible by DMS and its
agents and designees.

C. Each provider must retain all records for five (5) years from the date of service or until all
audit questions or review issues, appeal hearings, investigations or administrative or
judicial litigation to which the records may relate are finally concluded, whichever period is
later. Failure to furnish medical records upon request may result in sanctions being
imposed. Federal legislation further requires that any accounting of private healthcare
information (PHI) or Health Insurance Portability and Accountability Act of 1996 (HIPAA)
polices or complaints must be retained for six years from the date of its creation or the date
when it last was in effect, whichever is later.

D. Upon request, 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 or 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. 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. If an audit of records determines that
recoupment is necessary, there will be only thirty (30) days after the date of the
recoupment notice in which additional documentation supporting the services will be
accepted from the provider for consideration. Additional documentation will not be
accepted at a later date.

E. Each provider must immediately furnish records, upon request, establishing the provider’s
charges to private patients for services that are the same as or substantially similar to
services billed to Medicaid patients.

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142.400 Conditions Related to Disclosure

142.410 Disclosures of Ownership and Control 9-1-08

A. The Division of Medical Services (DMS) requires that providers disclose the following
information regarding direct or indirect ownership and control interest as a condition of
participation in the Medicaid Program. (View or print form DMS-675 – Ownership and
Conviction Disclosure.)
1. The name and address of each person with a direct or indirect ownership or control
interest in the disclosing entity or in any subcontractor in which the disclosing entity
has direct or indirect ownership of five percent (5%) or more.
2. In compliance with information shown above, the provider must also disclose if any
person named above is related to another as a spouse, parent, child or sibling.
3. The name of any other disclosing entity in which a person with a direct or indirect
ownership or control interest in the disclosing entity also has a direct or indirect
ownership or control interest. This requirement applies to the extent that the
disclosing entity can obtain this information by requesting it in writing from the
person. The disclosing entity must:
a. Keep copies of all these requests and the responses to them,
b. Make them available to representatives of the Secretary of Health and Human
Services or to the Division of Medical Services upon request, and
c. Advise DMS when there is no response to a request.
B. Any disclosing entity that is subject to periodic survey and certification of its compliance
with Medicaid standards must supply the information specified above to representatives of
an Arkansas survey agency at the time of a survey. The survey agency must promptly
furnish the information to the Secretary of Health and Human Services and to the Division
of Medical Services.

C. Any disclosing entity that is not subject to periodic survey and certification and has not
supplied the information specified above to the Secretary of Health and Human Services
within the prior twelve-month period, must submit the information to the Division of Medical
Services before entering into a contract or agreement to participate in the program.

142.420 Disclosures of Information Regarding Personnel Convicted of 9-1-08

Crime

Before the Division of Medical Services enters into or renews a provider agreement, or at any
time upon written request by DMS, the provider must disclose to DMS the identity of any person
who:
A. Has direct or indirect ownership or control interest in the provider, or is an agent or
managing employee of the provider, and

B. Has ever been convicted of a criminal offense. (View or print form DMS-675 –
Ownership and Conviction Disclosure.)

142.430 Disclosures of Business Transactions 9-1-08

A provider must submit full, accurate and complete information regarding:

A. The ownership of any subcontractor with whom the provider has business transactions
totaling more than $25,000 or five percent (5%) of the provider’s total operating expenses
during the 12-month period immediately prior to the date of application or application
renewal, and

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B. Any significant business transactions between the provider and any wholly owned supplier,
or between the provider and any subcontractor, during the five-year period ending on the
date of the application or application renewal.

C. Beginning on the effective date of enrollment in the Arkansas Medicaid Program, ongoing
full and complete disclosure must be submitted concerning any significant business
transactions (see definition on instruction page of DMS-689) that occur between the
named entity and subcontractor or wholly owned supplier. This information must be
submitted to Arkansas Medicaid, Provider Enrollment, within 35 days of the date the
transaction takes place (View or print form DMS-689 – Disclosure of Significant
Business Transactions.)

142.500 Conditions Related to Fraud and Abuse 8-1-14

A. Any provider who engages in fraudulent billing practices will be immediately suspended
from participation until these practices are evaluated and resolved. Also, any provider
discovered to be involved in fraudulent billing practices or found to be accepting or
soliciting unearned rebates, refunds or other unearned considerations, whether in the form
of money or otherwise, will be referred to the appropriate legal agency for prosecution
under applicable federal or state laws.

B. Any provider who engages in abuse or over-utilization of services provided to Medicaid

beneficiaries, when such abuse or over-utilization has been determined by DMS
professional staff, medical consultants, contractors or designees, may be terminated from
participation in the Medicaid Program, required to repay monies paid by the Medicaid
Program for such services or have other appropriate action taken upon recommendation of
the above-referenced parties.

C. Except where participation has been terminated, each provider who has been sanctioned
may be required to participate in a provider education program as a condition of continued
participation. Provider education programs will include, at a minimum, the following:
1. Instruction on admissions and authorization for payments
2. Instruction on the use and format of required program forms
3. Instruction on key provisions of the Medicaid Program
4. Instruction on reimbursement rates
5. Instruction on how to inquire about program requirements, payment or billing
problems and the overall operation of the program
D. Providers are obligated to screen all employees and contractors to determine if any of
them are excluded from participation in Federal health care programs.
1. Providers can search the LEIE website maintained by the United States Health and
Human Services Office of Inspector General which contains the names of any
excluded individual or entity. ([Link] The
United States General Services Administration maintains a list of excluded providers
at [Link] Providers should search the website monthly to capture
exclusions and reinstatements that have occurred since the last search.
2. Providers can find a Department of Human Services excluded list on the Arkansas
Department of Human Services website at:
[Link]
%[Link]. This list contains the names of any excluded individuals or entities.
The Arkansas Department of Finance and Administration, Office of State
Procurement, maintains a list of suspended or debarred vendors at:
[Link]
[Link]

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3. If providers discover any exclusion information other than what is provided on the
websites, providers should report that information to Provider Enrollment.
4. Providers should check the websites monthly to capture exclusions and
reinstatements which may have occurred since the last search.
E. No Medicaid payments can be made for any times or services directed or prescribed by an
excluded or prohibited provider; or any other authorized person, when the individual entity
furnishing the services knew or should have known of the exclusion or prohibition. This
prohibition applies even when the Medicaid payment itself is made to another provider,
practitioner or supplier that is not excluded or prohibited. (See 42 CFR Section
1001.1901(b)).

F. Civil monetary penalties may be imposed against Medicaid providers who employ or enter
into contracts with excluded individuals or entities to provider items or services to Medicaid
beneficiaries. (See 1128A(a)(6) of the Act and 42 CFR Section 1003.102(a)(2).)

142.600 Conditions Related to Provider Refunds to DMS 4-1-24

Within thirty (30) days, a provider must refund any money the state is obligated to repay the
federal government as a result of disallowance, recoupment or other adverse action in
connection with Medicaid payments to the provider.

Any outstanding balances over thirty (30) days will be recouped against future payments.
Providers unable to refund their outstanding balance within thirty (30) days must contact
Gainwell Technologies Provider Assistance Center (PAC) to discuss repayment options. Note:
All outstanding balances must be paid back within one (1) year. View or print the Provider
Assistance Center contact information.

142.610 Overpayments Owed by Medicaid Providers Out of Business or 7-16-18

Discharged in Bankruptcy Proceedings

For the purpose of determining whether all or part of an overpayment must be refunded to the
federal government, the Director or the Director’s designee of the Division of Medical Services
(DMS) of the Department of Human Services is authorized to determine and certify that a
Medicaid Provider is either out of business or has had all or part of the overpayment discharged
in a bankruptcy proceeding and that an overpayment owed by the provider cannot be collected
under state law and procedures. The DMS Director may make this determination based on any
facts and circumstances deemed relevant and material.

The DMS Director may presume a provider is out of business as of:

A. The date of suspension, expiration, surrender, or revocation of a license or certification
required for the provider to operate; or

B. For an entity, the date of:

1. Dissolution of the entity
2. Occurrence of an event which would trigger dissolution; or
3. Forfeiture or revocation of the entity’s charter or authority to do business by the
Secretary of State or other State authority.

A determination of certification made by the DMS Director under this section:

A. Does not abrogate, limit, or modify a provider’s debt or obligation to repay;

B. Is not a defense to recoupment of Medicaid payments from a provider;

C. May not serve as an adverse action against a provider.

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The DMS Director may determine:

A. That a provider has had all or part the debt discharged in a bankruptcy proceeding;

B. That the overpayment cannot be collected under state law;

The Director shall make such a determination when provided with a copy of the order.

142.700 Medicare Mandatory Assignment of Claims for “Physician” 6-1-08

Service 1216s and Medicaid’s Mandatory Assignment of Claims
for Provider Services

The Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of Medicare
claims for “physician” services furnished to individuals who are eligible for Medicare and
Medicaid, including those eligible as Qualified Medicare Beneficiaries (QMBs). According to
Medicare regulations, “physician” services, for the purpose of this policy, are services furnished
by physicians, dentists, optometrists, chiropractors and podiatrists.

As described above, reimbursement for “physician” services furnished to an individual enrolled

under Medicare who is also eligible for Medicaid, including Qualified Medicare Beneficiaries,
may only be made on an assignment related basis. Not all providers are federally mandated to
accept Medicare assignment (see Section 142.200). However, if a physician or Medicaid
enrolled non-physician desires Medicaid reimbursement for the insured’s cost share on a
Medicare claim, he or she must accept assignment on that claim (see Section 142.200 D) and
enter the information required by Medicare on assigned claims. The beneficiary is not
responsible for the difference between the billed charges and the Medicare allowed amount.

Item 1-C of the contract to participate in the Arkansas Medical Assistance Program (View or
print Form DMS-653 Section V of the Provider Manual) requires enrollment and acceptance
of assignment under Title XIX (Medicaid) for any applicable deductible or coinsurance that may
be due and payable under Medicaid.

When a beneficiary is dually eligible for Medicare and Medicaid, including those eligible as
Qualified Medicare Beneficiaries (QMBs,) and is provided services that are covered by
Medicare, Medicaid will not reimburse for applicable deductible or coinsurance that may be due
and payable under Medicare if Medicare has not been billed and made payment prior to billing
Medicaid. The beneficiary cannot be billed the difference in Medicare and Medicaid payment or
billed charges on assigned claims.

Claims properly filed directly to the original Medicare plan intermediary by Arkansas Medicaid
enrolled providers should automatically cross to Medicare’s Coordination of Benefits Assignment
(COBA) process; then to Arkansas Medicaid, once Medicare processing and payment has been
completed. The crossover claim should process in the next weekend cycle for Medicaid
payment of applicable coinsurance and deductibles (usually within four to six weeks of Medicare
payment). However, claims for Medicare beneficiaries entitled under the Railroad Retirement Act
or Medicare Advantage will not automatically cross to Arkansas Medicaid for payment and must
be filed directly with Arkansas Medicaid after Medicare payment has been received by the
provider. See Section 330.000 of this provider manual for further information.

NOTE: A Provider enrolled to participate in the Title XVIII Medicare Program must notify
the Provider Enrollment Unit of their National Provider Identifier (NPI). View or
print form DMS-683, NPI Reporting Form. View or print Medicaid Provider
Enrollment Unit contact information.

142.800 Condition of Participation – Education 9-15-09

A. Definitions:
1. Provider: any entity, including any Medicaid managed care organization, irrespective
of the form of business structure or arrangement by which it exists, whether for-profit

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or not-for-profit, which receives or makes payments, under a State Plan approved

under Title XIX or under any waiver of such plan, totaling at least $5,000,000
annually, regardless of whether the entity submits claims for payments using one or
more provider identification or tax identification numbers.
A government agency which merely administers the Medicaid program, in whole or
part (e.g., managing the claims processing system or determining beneficiary
eligibility), is not, for these purposes, considered to be an entity.
An entity will have met the $5,000,000 annual threshold as of January 1, 2007, if it
received or made payments in that amount in Federal fiscal year 2006. Future
determinations regarding an entity’s responsibility stemming from the requirements of
Section 1902(a) (68) will be made by January 1 of each subsequent year, based
upon the amount of payments an entity either received or made under the State Plan
during the preceding Federal fiscal year.
2. Employee: any officer or employee of the entity.
3. Contractor or agent: any contractor, subcontractor, agent, or other person which or
who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of,
Medicaid health care items or services, performs billing or coding functions, or is
involved in the monitoring of health care provided by the entity.
4. Written policy: a written plan for a course of action. Written policies may be on paper
or in electronic form, but must be readily available to all employees, contractors, or
agents. Each entity must establish and disseminate written policies which must also
be adopted by its contractors or agents. The entity need not create an employee
handbook if none already exists.
B. Requirements
1. The entity must establish and disseminate written policies which must also be
adopted by its contractors or agents. Written policies may be on paper or in
electronic form, but must be readily available to all employees, contractors, or
agents. The entity need not create an employee handbook if none already exists.
2. An entity shall establish written policies for all employees (including management),
and for any contractor or agent of the entity, that include detailed information about
the False Claims Act and the other provisions named in Section 1902(a)(68)(A). The
entity shall include in those written policies detailed information about the entity’s
policies and procedures for detecting and preventing waste, fraud, and abuse. The
entity shall also include in any employee handbook a specific discussion of the laws
described in the written policies, the rights of employees to be protected as
whistleblowers and a specific discussion of the entity’s policies and procedures for
detecting and preventing fraud, waste, and abuse.

142.900 Principal Accountable Providers (PAPs) 7-1-16

An Arkansas Medicaid enrolled and qualified provider who is licensed to diagnose and treat a
beneficiary may be designated as a Principal Accountable Provider (PAP) within the Episodes of
Care payment improvement initiative. Individual providers may be designated as a PAP only by
a promulgated episode.

143.000 Recovery Audit Contractors (RACs) 1-1-13

Pursuant to 42 C.F.R. §§455.502 - .516, each state Medicaid program must contract with
recovery audit contractors (RACs). Pursuant to these federal regulations, the Arkansas
Medicaid program will coordinate the following activities:
A. RAC review of claims submitted by providers to identify overpayments or underpayments;

B. Coordination between Arkansas Medicaid and the RAC for recoupment of overpayments;

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C. Coordination of recovery audit efforts of RAC and other auditing entities;

E. Referral of suspected fraud and/or abuse to the Medicaid Fraud Control Unit (MFCU) or
other appropriate law enforcement agency; and

F. Limitation of the number and frequency of medical records to be reviewed by the RAC

G. Coordination of the administrative reconsideration and appeal process as set forth in

Section 160.000 of this manual.

144.000 Tax Compliance 8-1-14

Under Ark. Code Ann. § 20-77-130, compliance with Arkansas tax laws is a condition of the
continued Medicaid enrollment of Affected Medicaid Providers. The law requires that the
Arkansas Medicaid Program disenroll noncompliant providers unless the provider can show
good cause to remain in the Medicaid program. Good cause includes, without limitation, proof
that Medicaid eligible beneficiaries will be unable to access medically necessary care if the
Affected Provider is no longer enrolled in the Medicaid Program.

If the Department of Finance and Administration notifies the Medicaid Program that an Affected
Provider is noncompliant, the Medicaid Program will notify the Affected Provider that the Affected
Provider’s Medicaid Provider Agreement will be terminated effective sixty (60) calendar days
from the date of the notice unless:
A. The Department of Finance and Administration notifies the Department of Human Services
that:
1. The Affected Medicaid Provider’s tax obligation has been satisfied, otherwise
resolved, or is the subject of a pending appeal; or
2. The Medicaid Provider is not an Affected Provider.
B. The Department of Human Services determines the Medicaid Provider is not an Affected
Provider or there is good cause not to exclude the Affected Medicaid Provider from the
Medicaid Program.

To request Department of Finance and Administration notification described in part A (above),

Affected Medicaid Providers should contact the Sales and Use Tax Unit. View or print the
Department of Finance and Administration Sales and Use Tax Unit contact information.

Department of Finance and Administration notification must be delivered to the Medicaid

Provider Enrollment Unit. View or print the Provider Enrollment contact information.

To establish that a Medicaid Provider is not an Affected Medicaid Provider as defined by Ark.
Code Ann. § 20-77-130 or that good cause exists for the Medicaid Program to continue the
Affected Medicaid Provider’s enrollment as a Medicaid provider, the Affected Medicaid Provider
should contact the Medicaid Provider Enrollment Unit. View or print the Provider Enrollment
contact information.

145.000 Electronic Visit Verification (EVV) for In-Home Personal Care,

Attendant Care, Respite-Services, and Home Health Services

145.100 Legal Basis and Scope of EVV Requirement 1-1-24

In accordance with section 12006 of the 21st Century Cures Act (42 U.S.C. § 1396b(l)), the
Arkansas Department of Human Services (DHS) is implementing an electronic visit verification
(EVV) system for in-home personal care services (PCS), attendant care, respite services, and
home health services paid by Medicaid.

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An EVV system is a telephone, computer, or other technology-based system under which visits
conducted as part of personal care services or home health care services are electronically
verified with respect to:
A. The type of service(s) performed;

B. The individual receiving the service(s);

C. The date of the service(s);

D. The location of service delivery;

E. The individual providing the service(s); and

F. The time the service(s) begins and ends.

The EVV requirement establishes utilization standards for provider agencies to electronically
verify home visits and verify that beneficiaries receive the services authorized for their support
and for which Medicaid is being billed.

The EVV requirement applies to Medicaid PCS, attendant care, respite care, and home health
care provided during an in-home visit under the Medicaid State Plan, the Provider-Led Arkansas
Shared Savings Entity (PASSE), the ARChoices Medicaid §1915(c) Home and Community-
Based Services Waiver, or under any self-direction plan.

PCS, attendant care, respite services, and home health services provided to more than one (1)
person throughout a shift in 24-hour residential settings are not subject to the EVV requirement
because they do not involve an “in-home” visit. This includes without limitation: PCS, attendant
care, respite services, and home health services provided in a group home, assisted living
facility, hospital, nursing facility, or other congregate setting.

PCS, attendant care, respite services, and home health services provided to a student in a
public school are not subject to the EVV requirement because they do not involve an “in-home”
visit.

Additional information regarding EVV is available from the DHS EVV Vendor. View or print the
DHS EVV Vendor contact information.

145.200 EVV Participation Requirements 1-1-24

To submit a claim for any service that is subject to the EVV requirement or pay based upon a
self-directed plan of care subject to the EVV requirement, a provider must:
A. Submit and maintain on file with both DHS Provider Enrollment and the DHS EVV Vendor
a contact e-mail address for the provider. The e-mail address must be an address that is
active and is controlled and regularly checked by the provider. The e-mail address must be
a business address that is unique to the provider and must not be an employee’s personal
e-mail address or other shared address. The e-mail address submitted by a provider to
DHS Provider Enrollment will be the e-mail address used by the DHS EVV Vendor to
create the provider’s account to access the EVV system;

B. Obtain from DHS a Medicaid Practitioner Identification Number (PIN) for each and every
caregiver employed or contracted by the provider to furnish care for which Medicaid PCS,
attendant care, or respite care claims may be submitted;

C. Submit, with every claim for a service subject to the EVV requirement, the PIN for the
caregiver providing the service to the beneficiary. The PIN shall be listed in the field for the
Rendering Provider ID number;

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D. Use an EVV system that documents and verifies every in-home visit resulting in a claim for
reimbursement. A provider must use the EVV system furnished by the DHS EVV Vendor or
they must use a third-party EVV system that has been certified by the DHS EVV Vendor;

E. Require caregivers, that are employed or contracted by the provider, to use EVV for all in-
home Medicaid-paid PCS, attendant care, respite care, and home health care and to train
the caregivers on the use of the provider’s chosen EVV system;

F. If the provider uses the DHS EVV system, register the provider’s caregivers with the EVV
system. By registering a caregiver with the DHS EVV system, the provider is attesting that
all applicable requirements, including without limitation training requirements, have been
satisfied for that caregiver (A caregiver who is excluded or debarred from participation in
Medicaid under any state or federal law is not eligible to register with the DHS EVV
system);

G. Create and maintain documentation to justify any manual modifications, adjustments, or

exceptions made by the provider in the EVV system after a caregiver has entered or failed
to enter any required information;

H. Comply with EVV requirements established by the Centers for Medicare & Medicaid
Services (CMS);

I. Comply with applicable federal and state laws regarding confidentiality of information about
beneficiaries receiving services; and

J. Ensure that DHS may review documentation generated by an EVV system or obtain a
copy of that documentation at no charge.

145.300 EVV Claims Requirements 1-1-24

EVV is required for the following procedure codes and modifiers when the Place of Service is
coded as the beneficiary’s home (POS code 12):

Procedure Code Modifier Service Description

T1019 Personal Care for a (non-RCF) Beneficiary Under 21
T1019 U3 Personal Care for a non-RCF Beneficiary Aged 21 or
Older
S5125 U2 Agency Attendant
Care Traditional
S5150 Respite Care – In-Home
T1021 TD Home Health RN Visit, per visit
T1021 TE Home Health LPN Visit, per visit
T1021 Home Health Aide Visit
S9131 UB Home Health Physical Therapy by a Qualified Physical
Therapy Assistant
S9131 Home Health Physical Therapy by a Qualified Licensed
Physical Therapist

A claim for any of these procedure codes and modifiers may be rejected or denied, or subject to
recoupment, if delivery of the service was not verified by EVV or if there is any inconsistency
among or between:

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A. The data submitted in the claim;

B. The data recorded by EVV for the claimed service;

C. The data in the approved prior authorization or plan of care applicable to the claimed
service; or

D. Address or other eligibility data maintained in the Medicaid Management Information

System (MMIS) or other eligibility system maintained by DHS.

A claim for any of these procedure codes and modifiers is subject to the EVV requirement
regardless of how the claim is submitted, including third-party EVV vendors, through a PASSE
claims system, or through a self-direction plan.

For PCS, attendant care, respite, and Home Health services delivered in a beneficiary’s home, it
is a fraudulent billing practice to list any Place of Service (POS) code other than POS code 12,
unless the Provider Manual or other Rule explicitly permits the use of a different POS code.
A. The EVV Requirement also applies to any equivalent services provided to a beneficiary
through the Independent Choices program, or any other self-direction program made
available under the state plan or ARChoices. Such equivalent services may be rejected or
denied if delivery of the service was not verified by EVV or if there is any inconsistency
among or between:
1. The data submitted in the claim;
2. The data recorded by EVV for the claimed service;
3. The data in the approved prior authorization or the plan of care that is applicable to
the claimed service; or
4. Address or other eligibility data maintained in the Medicaid Management Information
System (MMIS) or other eligibility system maintained by DHS.

145.400 Third Party EVV System Requirements 12-1-20

A third-party EVV system procured and chosen by a provider or Managed Care Organization
(MCO) or self-directed services vendor must be certified by the DHS EVV Vendor as meeting the
following requirements:
1. The provider must submit a written attestation that the third-party EVV system meets
or exceeds all applicable CMS and DHS requirements. Certification of a third-party
EVV system is valid only so long as the system continues to meet or exceed all
applicable CMS and DHS requirements;
2. The DHS EVV Vendor must certify that the third-party EVV system has the technical
capabilities to receive and transmit all EVV data in a way that is compatible with the
DHS EVV system; and
3. The third-party EVV system must timely collect and submit to the DHS EVV Vendor
all data required for EVV verification of a claim, including without limitation:
a. The procedure code and modifier for the service(s) delivered, and the specific
ADL/IADL task(s) performed by the caregiver during the visit;
b. Identifying information for the beneficiary, including without limitation the
beneficiary’s Medicaid identification number;
c. The date of the service(s);
d. The location where the service(s) were delivered;
e. Identifying information for the agency and the individual caregiver providing the
service(s), including without limitation a Practitioner Identification Number (PIN)
as assigned by DHS for the individual caregiver who is listed as the rendering

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provider;
f. Universal Time Code (UTC) for the time the service(s) begins and ends; and
g. EVV capture method (including without limitation telephony, GPS, or fixed visit)
and corresponding validation data (including without limitation phone number,
coordinates, or encryption key); and
4. By including a caregiver in any EVV data submitted to the DHS EVV Vendor, the
provider is attesting that all applicable requirements, including without limitation
training requirements and background checks, have been satisfied for that caregiver.
Claims made for services performed by a caregiver who is excluded or debarred
from participation in Medicaid may be denied or rejected and are subject to
recoupment.

150.000 ADMINISTRATIVE REMEDIES AND SANCTIONS

151.000 Grounds for Sanctioning Providers 9-15-09

Sanctions may be imposed against a provider for any one or more of the following reasons:
A. Non-compliance with any provision of federal laws and rules contained in or related to
Title XIX or XXI of the Social Security Act, federal regulations promulgated thereunder,
state medical assistance (Medicaid) law and rules or any applicable Medicaid provider
manual.

B. Any act or omission that is inconsistent with sound fiscal, business or medical practices
and results in unnecessary cost to the Arkansas Medicaid Program, or in reimbursement
for services that are not medically necessary or that fail to meet professionally recognized
standards for health care.

C. Accepting beneficiaries for whom all prescribed and medically necessary care and services
cannot be provided at the time of acceptance, unless otherwise required by the Emergency
Medical Treatment and Active Labor Act (EMTLA). There is no violation if it appears,
based upon information available at the time of admission, that the provider can meet the
patient’s needs.

D. Engaging in conduct that defrauds or abuses the Medicaid Program, regardless of whether
the conduct is successful.

E. Failure to submit an acceptable corrective action plan when requested to do so by the

Division of Medical Services or its agents in a written statement that complies with Section
190.006 of this manual.

F. Failure to comply with any remedy imposed under 42 U.S.C. §1320a-7(a) and
implementing federal regulations, 42 U.S.C. §1320a-7(b) and implementing federal
regulations, and state Medicaid law and rules, including, without limitation, this manual.

152.000 Sanctions 3-1-11

The following sanctions may be invoked against providers based on the grounds specified in
Section 151.000:
A. Termination from participation in the Medicaid Program

B. Suspension of participation in the Medicaid Program

C. Suspension, withholding, recoupment, recovery or any combination thereof, of payments to

a provider

D. Canceling or shortening an existing provider agreement

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E. Mandatory attendance at provider education sessions

F. Requiring prior authorization of all services

G. Pre-payment review of some or all of the provider’s billings

H. Referral to the State Licensing Board for investigation

I. Referral to the Medicaid Fraud Control Unit, Office of Attorney General

J. Conversion to a limited services provider agreement not to exceed 12 months

K. Referral to any appropriate federal or state legal agency for investigation and possible
prosecution under applicable federal or state laws

L. Referral to the appropriate state professional health care association’s peer review
mechanism

M. Exclusion under current Arkansas Department of Human Services (DHS) Policy 1088,
titled DHS Participant Exclusion Rule

153.000 Rules Governing the Imposition and Extent of Sanctions 9-15-09

A. Imposition of Sanction
1. The Director of the Division of Medical Services shall determine the sanction(s) to be
imposed with respect to the following considerations:
a. Seriousness of the offense(s)
b. Extent of frequency and number of violation(s)
c. Prior violation(s) history
d. Whether an indictment or information was filed against the provider or a related
party as defined in DHS Policy 1088, DHS Participant Exclusion Rule
2. Whenever a provider has been convicted of any Medicaid Program violation or is
suspended or terminated from the Medicare Program for cause, the Department of
Human Services shall institute proceedings to terminate the provider from the
Medicaid Program.
B. Scope of Sanction
1. A sanction applies to all related parties as defined in DHS Policy 1088.
2. Suspension or termination from participation of any provider shall preclude such
provider from submitting claims for payment, either personally or through claims
submitted by a clinic, group, corporation or other association, to DHS for any
services or supplies provided after the suspension or termination.
3. No individual or entity shall claim reimbursement for any goods or services provided
by a person who has been debarred, excluded, suspended or terminated from
participation in the Medicaid Program, except for those legitimate and lawful services
or supplies provided before the suspension or termination.
4. Any provider violating the provisions of paragraph (B)(3), along with the provider’s
related parties as defined in DHS Policy 1088, shall be suspended, terminated or
excluded from participation.

154.000 Notice of Violation 9-15-09

When the Division of Medical Services identifies an act or omission for which a sanction may be
issued, the Division will notify the provider of the act or omission in writing.

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Unless a timely and complete request for administrative reconsideration or appeal is received by
the Department of Human Services, the findings of DHS as set forth in the notice shall be
considered a final and binding administrative determination.

155.000 Notice of Provider Sanction 9-15-09

When a provider has been sanctioned, the Department of Human Services shall notify the
applicable professional society, and any licensing, certifying or accrediting agency of the findings
made and the sanctions imposed.

When a provider’s participation in the Medicaid Program has been suspended or terminated, the
Department of Human Services shall notify the beneficiaries, for whom the provider claims
payment for services, that the provider has been suspended or terminated. The notice may
include the reason for the suspension or termination.

156.000 Withholding of Medicaid Payments 4-1-06

Upon receipt of reliable evidence that the circumstances involve fraud, willful misrepresentation
or both, DMS may withhold Medicaid payments, in whole or in part, without first notifying the
provider of its intention to withhold.

Within five days of taking the action, the Division of Medical Services will send a Notice of Non-
Compliance (form DMS-635) that explains the reasons for withholding payment and the
provider’s right to administrative reconsideration or appeal.

All withholdings or payment actions will be temporary and will not continue after:
A. DMS or the prosecuting authorities determine that there is insufficient evidence of fraud or
willful misrepresentation. or

B. Legal proceedings relating to the provider’s alleged fraud or willful misrepresentations are
completed.

160.000 ADMINISTRATIVE RECONSIDERATION AND APPEALS

161.200 Administrative Reconsideration 6-1-25

A. Within thirty (30) calendar days after notice of an adverse decision/action, the provider may
request administrative reconsideration. Requests must be in writing and include:
1. A copy of the letter or notice of adverse decision/action
2. Additional documentation that supports medical necessity
Administrative reconsideration does not postpone any adverse action that may be imposed
pending appeal.

B. Requests for reconsideration must be submitted as follows:

1. In situations where the adverse decision/action has been taken by a reviewing agent,
the request must be directed to that reviewing agent. Contact information for the
department’s reviewing agents can be found in Section V of this manual.
2. When an adverse decision/action has been taken by the Office of Medicaid Inspector
General on behalf of Division of Medical Services (DMS), the request for
reconsideration must be directed to Office of Medicaid Inspector General (OMIG).
View or print the Office of Medicaid Inspector General contact information.
Within twenty (20) calendar days of receiving a timely and complete request for
administrative reconsideration, OMIG will designate a reviewer and proceed
according to its own procedures. When an adverse decision/action has been taken

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by Utilization Review (UR) Section of DMS, the request for reconsideration must be
directed to UR. View or print the Utilization Review contact information.

The 30-day time period to request a reconsideration begins to run five (5) days after the date of
the written notice.

No administrative reconsideration is allowed if the adverse decision/action is due to loss of

licensure, accreditation or certification.

161.300 Administrative Appeals of Adverse Actions that are not Sanctions 6-1-25

In addition to sanction reconsiderations and appeal procedures set forth in Sections 160.000-
169.000, providers may appeal any other decision of the Department of Human Services, its
reviewers or contractors if that decision adversely affects a Medicaid provider or beneficiary with
regard to receipt or payment of Medicaid-covered services. Such decisions and consequent
actions are “non-sanction adverse actions.”

Within thirty (30) calendar days of receiving notice of non-sanction adverse action, or ten (10)
calendar days of receiving an administrative reconsideration decision that upholds all or part of
any adverse decision/action, whichever is later, the provider may appeal. The time period for
filing an appeal shall begin to run five (5) days after the date of the written notice of non-sanction
adverse action or administrative reconsideration decision. An appeal must be in writing and must
specify in detail all findings, determinations, and adverse decisions/actions that the provider
alleges are not supported by applicable laws, including state and federal laws and rules,
applicable professional standards, or both. Providers shall mail or deliver the appeal to the
Arkansas Department of Health, Office of Medicaid Provider Appeals.

161.400 Sanction Appeals 6-1-25

Within thirty (30) calendar days of receiving notice of adverse decision/action, the provider may
appeal. The thirty (30) days begins to run five (5) days after the date of the written notice.

An appeal must be in writing and must specify in detail all findings, determinations, and adverse
decisions/actions that the provider alleges are not supported by applicable laws; including state
and federal laws and rules, applicable professional standards or both. Providers shall mail or
deliver the appeal to the Arkansas Department of Health, Office of Medicaid Provider
Appeals. No appeal is allowed if the adverse decision/action is due to loss of licensure,
accreditation or certification.

161.500 Continued Services During the Appeal Process 6-1-25

To receive continued services during the appeal process, the beneficiary must file an appeal
within thirty (30) days from the date of the written notice of action. The thirty (30) day time period
begins to run five (5) days after the date of the written notice. The beneficiary’s benefits will be
continued with no change until the administrative appeal has concluded and a hearing decision
has been entered. The notice of action must be sent to the Medicaid beneficiary in accordance
with 42 CFR §431.230.

The beneficiary may affirmatively opt out of receiving benefits during the appeal period.

162.000 Notice of the Appeal Hearing 9-15-09

When an appeal hearing is scheduled, the Office of Hearings and Appeals shall notify the
provider, or if the provider is represented by an attorney, the provider’s attorney, in writing, of the
date, time and place of the hearing. Notice shall be mailed not less than 10 calendar days
before the scheduled date of the hearing. Hearings shall be conducted in accordance with DHS
Policy 1098. The decision of the Office of Appeals and Hearings is the final agency
determination.

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162.100 Conduct of Hearing 9-15-09

A. The hearing shall be conducted by a hearing officer who is authorized by the Director of
the Division of Medical Services to conduct such hearings.

B. Testimony shall be taken only under oath, affirmation or penalty of perjury.

C. Each party shall have the right to call and examine parties and witnesses, to introduce
exhibits, to question opposing witnesses and parties on any matter relevant to the issue
even though the matter was not covered in the direct examination. Each party has the
right to impeach any witness regardless of which party first called him to testify. Each
party has the right to rebut the opposing evidence.

D. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible
persons are accustomed to rely in the conduct of serious affairs regardless of the
existence of any common law or statutory rule that might make improper the admission of
such evidence over objection in civil or criminal actions.

E. The hearing officer may provide for discovery by any means permitted by the Arkansas
Rules of Civil Procedure and may assess the expense to the requesting party.

F. The hearing officer may question any party or witness and may admit any relevant and
material evidence.

G. The hearing officer shall control the taking of evidence in a manner best suited to ascertain
the facts and safeguard the rights of the parties. Before taking evidence, the hearing
officer shall explain the issues and the order in which evidence will be received.

H. The provider shall have the burden of proving by a preponderance of the evidence that it
delivered all billed services in accordance with all applicable requirements.

I. Except as provided in part H, the burden of producing evidence of a particular fact is on the
party against whom a finding on that fact would be required in the absence of further
evidence.

162.200 Representation of Provider at a Hearing 9-15-09

Individual providers may represent themselves. A partner may represent the partnership. A
limited liability company or corporation may be represented by an officer or the chief operating
official. A professional association may be represented by a principal of the association.
Representatives must be courteous in all activities undertaken in connection with the appeal and
must obey the orders of the hearing officer regarding the presentation of the appeal. Failure to
do so may result in exclusion from the appeal hearing, or in the entry of an order denying
discovery.

162.300 Right to Counsel 10-13-03

Any party may appear and be heard at any proceeding described herein through an attorney-at-
law. All attorneys shall conform to the standards of conduct practiced by attorneys before the
courts of Arkansas. If an attorney does not conform to those standards, the hearing officer may
exclude the attorney from the proceeding.

162.400 Appearance in Representative Capacity 9-15-09

A person appearing in a representative capacity shall file a written notice of appearance on

behalf of a provider identifying himself or herself by name, address and telephone number; and
identifying the party represented. He or she shall have written authorization to appear on behalf

Section I-53
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of the provider. The Division of Medical Services shall notify the provider in writing of the name
and telephone number of the division’s representative.

163.000 Form of Papers 4-1-06

All papers filed in any proceeding shall be typewritten on legal-sized white paper using one side
of the paper only. They shall bear a caption clearly showing the title of the proceeding and the
docket number, if any.

The party and/or his authorized representative or attorney shall sign all papers, and all papers
shall contain his/her address and telephone number. At a minimum, an original and two copies
of all papers shall be filed with the Office of Hearings and Appeals.

163.100 Notice, Service and Proof of Service 9-15-09

A. All papers, notices and other documents shall be served by the party filing the same upon
all parties to the proceeding. Proof of such service upon all parties shall be filed with the
Office of Hearings and Appeals.

B. Service shall be made by delivering, in person or by mail, properly addressed with postage
prepaid, one copy to each party entitled thereto. When any party or parties have appeared
by an attorney, service upon the attorney shall be deemed service upon the party or
parties.

C. Proof of service of any paper shall be by certificate of attorney, affidavit or

acknowledgement.

D. Service by mail is presumptively complete upon mailing. When service is permitted upon
an attorney, such service may be put into effect by electronic transmission, provided the
attorney being served has facilities within his office to receive and reproduce verbatim
electronic transmissions.

164.000 Witnesses 10-13-03

A party shall arrange for the presence of his or her witnesses at the hearing.

165.000 Amendments 4-1-06

At any time prior to the completion of the hearing, amendments to the adverse decision/action,
the provider’s notice of appeal, or both, may be allowed on just and reasonable terms to add or
discontinue any party, change the allegations or defenses, or add new causes of action or
defenses.

Where the Division of Medical Services seeks to add a party or a cause of action or change an
allegation, notice shall be given pursuant to Section 154.000, “Notice of Violation,” and Section
163.100, “Notice, Service and Proof of Service,” to the appropriate parties except that the
provisions of Section 161.200, “Administrative Reconsideration,” and Section 162.000, “Notice of
the Administrative Appeal Hearing,” shall not apply.

Where a party other than the Division of Medical Services seeks to add a party or change a
defense, notice shall be given pursuant to Section 163.100, “Notice, Service and Proof of
Service.”

The hearing officer shall continue the hearing for such time as he deems appropriate, and notice
of the new date shall be given pursuant to Section 166.000, “Continuances or Additional
Hearings.”

166.000 Continuances or Additional Hearings 4-1-06

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A. The hearing officer may continue a hearing to another time or place or order additional
hearings on his or her own motion or upon showing of good cause at the request of any
party.

B. When the hearing officer determines that additional evidence is necessary for the proper
determination of the case, he or she may, at his or her discretion:
1. Continue the hearing to a later date and order one or both parties to produce
additional evidence, or
2. Conclude the hearing and hold the record open in order to permit the introduction of
additional documentary evidence. Any evidence so submitted shall be made
available to both parties, and each party shall have the opportunity for rebuttal.
Written notice of the time and place of a continued or additional hearing shall be given,
except that when a continuance or additional hearing is ordered during a hearing, oral
notice may be given to each party present.

167.000 Failure to Appear 4-1-06

If a party fails to appear at a hearing, the hearing officer may dismiss the appeal or enter a
determination adverse to the non-appearing party. A copy of the decision shall be mailed to
each party. The hearing officer may, upon motion, set aside the decision and reopen the hearing
for mistake, inadvertence, surprise, excusable neglect, fraud, or misrepresentation.

168.000 Record of Hearing 10-13-03

The Division of Medical Services (DMS) shall tape-record the hearings, or cause the hearings to
be tape-recorded. If the final DMS determination is appealed, the tape recording shall be
transcribed, and copies of other documentary evidence shall be reproduced for filing under the
Administrative Procedure Act.

169.000 Decision 4-1-06

A. At the conclusion of the hearing, the hearing officer shall take the matter under
consideration and shall submit a proposed decision to the Director of the Division of
Medical Services.

B. The proposed decision shall be in writing and shall contain findings of fact and conclusions
of law, separately stated, and a proposed order.

C. The director may adopt the proposed decision, or he may reject the proposed decision and
have a decision prepared based upon the record, or he may remand the matter to the
hearing officer to take additional evidence. In the latter case, the hearing officer,
thereafter, shall submit to the director a new proposed decision.

D. The director’s decision is the final agency determination under the Administrative
Procedure Act. The director shall cause a copy of the decision to be mailed to the provider
at the provider’s last known address, or, if the provider was represented by an attorney, to
the address provided by the attorney.

169.100 Recovery of the Costs of Services Continued During the Appeal 9-15-09
Process

42 CFR §431.230 entitled “Maintaining Services,” which states in part:

(b) If the agency’s action is sustained by the hearing decision, the agency may institute
recovery procedures against the applicant or beneficiary to recoup the cost of any services
furnished the beneficiary, to the extent they were furnished solely by reason of this section.

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Federal regulation does not distinguish between beneficiary-filed and provider-filed appeals.

Providers filing appeals shall be subject to the same recovery procedures as beneficiaries.
When both the provider and beneficiary appeal, liability shall be joint and several.

170.000 THE ARKANSAS MEDICAID PRIMARY CARE CASE

MANAGEMENT PROGRAM
170.100 Introduction 8-1-18

Arkansas Medicaid’s Primary Care Case Management (PCCM) Program operates statewide
under the authority of the Medicaid State Plan.
A. Most Medicaid beneficiaries and all ARKids First-B participants must enroll with a primary
care physician (PCP), also known as a primary care case manager (PCCM).
1. PCPs provide primary care services and health education.
2. PCPs make referrals for medically necessary specialty physician’s services, hospital
care and other services.
3. PCPs assist their enrollees with locating medical services.
4. PCPs coordinate and monitor their enrollees’ prescribed medical and rehabilitation
services.
B. Medicaid enrollees may receive services only from their PCP unless their PCP refers them
to another provider, or unless they access a service that does not require a PCP referral.

C. If a beneficiary does not have a primary care provider, Arkansas Medicaid will allow up to
four (4) visits per state fiscal year without a Primary Care Physician (PCP) referral to a
hospital affiliated Walk-in Clinic or Emergent Clinic.

D. These visits apply to all related benefit limits.

171.000 Primary Care Physician Participation

171.100 PCP-Qualified Physicians and Advanced Practice Nurse 4-1-24

Practitioners

A. Primary Care Provider (PCP)-qualified physicians are those whose sole or primary
specialty is
1. Family practice
2. General practice
3. Internal medicine
4. Pediatrics and adolescent medicine
5. Obstetrics and gynecology
B. Obstetricians and gynecologists may choose whether to be PCPs.

C. Physicians with multiple specialties may elect to enroll as PCPs if a secondary or tertiary
specialty in their Medicaid provider file is listed in part A above.

D. All other PCP-qualified physicians must enroll as PCPs.

E. Advanced practice registered nurses (APRN) licensed by the Arkansas State Board of
Nursing may choose to enroll as PCPs.

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171.110 Exclusions 4-1-24

A. Physicians whose only specialty is emergency care or who practice exclusively in hospital
emergency departments may not enroll as PCPs.

B. Physician group practices may not be PCPs.

C. Rural Health Clinics (RHCs) may not be PCPs, but PCP-qualified physicians affiliated with
RHCs must be PCPs.

D. Physicians who certify in writing that they are employed.

171.120 Hospital Admitting Privileges Requirement 7-1-05

A. Only physicians with hospital admitting privileges may be PCPs.

B. The state may waive this requirement to help ensure adequate access to services.
1. On the primary care case manager (PCCM) contract, a physician may name another
physician who has hospital admitting privileges and with whom he or she has an
agreement by which they handle hospital admissions.
2. A copy of the physicians’ agreement must be submitted with the PCCM contract.

171.130 EPSDT Agreement Requirement 4-1-24

A. A PCP applicant must sign an agreement to participate as a screening provider in the Child
Health Services (EPSDT) program.

B. Internists, obstetricians, gynecologists, and physicians who customarily carry a caseload of

patients who are 21 years of age or older are not required to furnish EPSDT screens.
1. Their participation in the Child Health Services (EPSDT) program is optional.
2. They must, however, sign Child Health Services (EPSDT) agreements if they elect to
be screening providers.

171.140 Primary Care Case Manager Agreement 4-1-24

A. Every PCP applicant must sign a Primary Care Case Manager (PCCM) contract.

171.160 PCP Instate and Trade-Area Restriction 7-1-05

With the following exceptions, PCPs must practice in Arkansas.

A. PCP-qualified physicians in the trade-area cities (Monroe and Shreveport, Louisiana;
Clarksdale and Greenville, Mississippi; Poplar Bluff, Missouri; Poteau and Sallisaw,
Oklahoma; Memphis, Tennessee and Texarkana, Texas), may be PCPs.

B. To ensure adequate access to services, the state may waive the trade-area city rule for
border-state physicians who are not in trade-area cities.

171.170 PCP for Out-of-State Services 6-1-08

Services that require PCP referral or PCP enrollment within Arkansas require PCP referral or
PCP enrollment as applicable, when furnished outside of Arkansas.

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171.200 PCCM Enrollee/Caseload Management

171.210 ConnectCare Caseload Maximum and PCP Caseload Limits 10-8-10

A. Each PCP may establish an upper limit to his or her Medicaid caseload, up to the default
maximum of 2500.
1. The state may permit higher maximum caseloads in areas the federal government
has designated as medically underserved.
2. The state may permit higher maximum caseloads for PCPs who state in writing that
the default maximum will create a hardship for them, their patients and/or the
community they serve.
B. The state will not require any PCP to accept a caseload greater than the PCP’s requested
caseload maximum.

C. At any time, a PCP may increase or decrease his or her maximum desired caseload by
any amount, up to the default maximum by submitting a written request to the Provider
Enrollment Unit, or on-line through the Medicaid website
([Link] Provider Enrollment Information, and Access to
the Provider Information Portal.

D. To request an increase in a PCP caseload above the default maximum, the PCP must
submit a written request to the Provider Enrollment Unit. View or print Provider
Enrollment Unit contact information.

E. Prior to making the request for an increase of a caseload that is already at the default
maximum, PCPs are encouraged to review their caseload for inactive patients to determine
if those patients should be removed from their caseload. To do so, PCPs may use the
Arkansas Medicaid Information Interchange (AMII) web portal. If it is determined that the
inactive patients should be removed from his or her caseload, the PCP must:
1. Contact the patient in writing at least 30 days in advance of the effective date of the
termination to give the patient the option of making a visit to the PCP to remain an
active patient. If the patient does not choose to make a visit to the PCP, the
termination can be effective at the end of 30 calendar days.
2. With approval from his or her Provider Relations Representative, the PCP may add
and see new patients during the 30 calendar day notification process of inactive
patients.
3. The notice must state that the enrollee has 30 calendar days in which to enroll with a
different PCP.
4. The PCP must forward a copy of the notice to the enrollee and to the local DHS
office in the enrollee’s county of residence.

171.220 Illegal Discrimination 7-1-05

A. A PCP may not reject a potential enrollee, and may not discriminate against a beneficiary
because of the individual’s age, sex, race, national origin or type of illness or condition.

B. Rejecting a potential enrollee based on the individual’s age or sex does not constitute
unlawful discrimination if the physician customarily sees only patients of one sex and/or a
particular age range. For instance:
1. An obstetrician/gynecologist doesn’t treat males, so he or she is not expected to
enroll males.

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2. A pediatrician specializing in adolescent medicine may only see patients in a

particular age range, such as 12 through 18.
C. PCPs may specify the minimum and maximum ages of Medicaid and ARKids First-B
enrollees they will accept.

171.230 Primary Care Case Management Fee 1-1-23

A. In addition to reimbursing PCPs on a fee for service basis for physician services, Arkansas
Medicaid pays them a monthly case management fee for each enrollee on their caseloads.

B. The amount due for each month is determined by multiplying the established case
management fee by the number of enrollees on the PCP’s caseload.
1. Medicaid pays case management fees quarterly.
2. The accompanying Medicaid Remittance and Status Report (RA) itemizes the
payments and lists the number of enrollees and each enrollment month.
3. Enrollees are listed alphabetically by name, with their Medicaid identification
numbers and addresses also displayed.
C. PCP case management fees are paid according to the PCP’s direction. The PCP may
choose to have the case management fee paid to his or her individual provider ID number
or to the group provider ID number with whom the PCP is affiliated.

D. If the PCP’s case management fees are paid to a group and the PCP changes his or her
affiliation, the PCP must submit a new PCP Agreement Form to Provider Enrollment within
thirty (30) calendar days of changing affiliation. The PCP must also notify the beneficiaries
on his or her caseload of the change.

E. If a PCP fails to submit a new PCP Agreement Form, the case management fees will pay
to the provider of record until a new PCP Agreement Form is received by Provider
Enrollment.

F. If a Group Affiliation Form is received by Provider Enrollment to disassociate a PCP from a

group but the PCP Agreement Form is not received, the case management fees will be
paid to the individual PCP's provider ID number.

G. If a PCP’s case management fees were paid to a group in which the PCP is no longer
affiliated, it is the responsibility of that group to reimburse Medicaid the fees they were not
entitled to receive.

H. No case management fees will be back paid to a PCP who has failed to follow the
process described in Paragraph D of this Section.

I. Case management fees will be reconciled at least quarterly, and may be reconciled at any
time determined necessary to resolve immediate issues.

171.300 Required Case Management Activities and Services

171.310 Investigating Abuse and Neglect 7-1-05

A PCP must perform an examination and/or make necessary referrals within 24 hours of contact
by government officials in alleged or substantiated cases of abuse, neglect or maltreatment of a
Medicaid-eligible individual and when the state has custody of a Medicaid-eligible individual.

171.320 Child Health Services (EPSDT) Requirements 9-15-09

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A. A PCP must monitor and maintain the Child Health Services (EPSDT) screening periodicity
of each of his or her enrollees under the age of 21, regardless of who screens those
enrollees. The periodic EPSDT screening schedule recommended by the American
Academy of Pediatrics can be found in Section 215.100 of the Child Health Services/Early
and Periodic Screening, Diagnosis and Treatment manual.

B. A PCP may refer his or her enrollees to other providers for EPSDT screens and related lab
work.
1. Screening providers must report the results to the referring PCP.
2. The PCP must coordinate and monitor subsequent referrals, treatment or testing.

171.321 Childhood Immunizations 7-1-05

A PCP must monitor and coordinate the immunization status of his or her enrollees under the
age of 21. View or print the Arkansas Department of Health Immunizations Registry Help
Desk contact information.

171.400 PCP Referrals 1-1-18

A. Referrals may be only for medically necessary services, supplies or equipment.

B. Enrollee free choice by naming two or more providers of the same type or specialty.

C. PCPs are not required to make retroactive referrals.

D. Since PCPs are responsible for coordinating and monitoring all medical and rehabilitative
services received by their enrollees, they must accept co-responsibility for the ongoing
care of patients they refer to other providers.

E. PCP referrals expire on the date specified by the PCP, upon receipt of the number or
amount of services specified by the PCP or in six months, whichever occurs first. (This
requirement varies somewhat in some programs; applicable regulations are clearly set
forth in the appropriate Arkansas Medicaid Provider Manuals.)

F. There is no limit on the number of times a referral may be renewed, but renewals must be
medically necessary and at least every six months (with exceptions as noted in part E,
above).

G. An enrollee’s PCP determines whether it is necessary to see the enrollee before making or
renewing a referral.

H. Medicaid beneficiaries and ARKids First-B participants are responsible for any charges
they incur for services obtained without PCP referrals except for the services listed in
Section 172.100.

I. Some services such as personal care require an Independent Assessment. Please refer to
the Independent Assessment Guide for related information and referral processes.

171.410 PCCM Referrals and Documentation 7-1-05

A. Medicaid provides an optional referral form, form DMS-2610, to facilitate referrals. View or
print form DMS-2610.
1. Additionally, PCP referrals may be oral, by note or by letter.
2. Referrals may be faxed.
B. Regardless of the means by which the PCP makes the referral, Medicaid requires
documentation of the referral in the enrollee’s medical record.

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1. Medicaid also requires documentation in the patient’s chart by the provider to whom
the referral is made.
2. Providers of referred services must correspond with the PCP to the extent necessary
to coordinate patient care and as requested by the PCP.

171.500 Primary Care Case Management Activities and Services 7-1-05

A ConnectCare PCP is also known as a primary care case manager (PCCM). He or she
provides primary care physician services as well as these additional services:
A. Health education

B. Assessing each enrollee’s medical condition, initiating and recommending treatment or

therapy when needed

C. Initiating referrals to specialty physicians and for hospital care and other medically
necessary services

D. Assisting with locating needed medical services

E. Coordinating, with other professionals, prescribed medical and rehabilitation services

F. Monitoring enrollees’ prescribed medical and rehabilitation services

171.510 Access Requirements for PCPs 7-1-05

A. A PCP must have hours of operation that are reasonable and adequate to serve all of his
or her patients.
1. The PCP’s office must be open to Medicaid enrollees during the same hours and for
the same number of hours as it is for self-pay and insured patients.
2. ConnectCare enrollees must have the same access as private pay and insured
persons to emergency and non-emergency medical services.
B. A PCP must make available 24-hour, 7 days per week telephone access to a live voice (an
employee of the primary care physician or an answering service) or to an answering
machine that will immediately page an on-call medical professional. The on-call
professional will:
1. Provide information and instructions for treating emergency and non-emergency
conditions,
2. Make appropriate referrals for non-emergency services, and
3. Provide information regarding accessing other services and handling medical
problems during hours the PCP’s office is closed.
C. Response to after-hours calls regarding non-emergencies must be within 30 minutes.
1. PCPs must make the after-hours telephone number as widely available as possible
to their patients.
2. When employing an answering machine with recorded instructions for after-hours
callers, PCPs should regularly check to ensure that the machine functions correctly
and that the instructions are up to date.
D. PCPs in underserved and sparsely populated areas may refer their patients to the nearest
facility available, but enrollees must be able to obtain the necessary instructions by
telephone.

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E. As regards access to services, PCPs are required to provide the same level of service for
their ConnectCare enrollees as they provide for their insured and private-pay patients.

F. Physicians and facilities treating a PCP’s enrollees after hours must report diagnosis,
treatment, significant findings, recommendations and any other pertinent information to the
PCP for inclusion in the patient’s medical record.

G. A PCP may not refer ConnectCare enrollees to an emergency department for non-
emergency conditions during the PCP’s regular office hours.

171.600 PCP Substitutes

171.601 PCP Substitutes; General Requirements 4-1-07

A. Physicians substituting for PCPs are not required to be PCPs themselves.

B. In addition to the rules that apply to physician substitutes (found in the Arkansas Medicaid
Physician/Independent Lab/CRNA/Radiation Therapy Center Provider Manual), physicians
substituting for PCPs are subject to the following regulations.
1. The PCP and the substitute must document the substitution in each enrollee’s
record(s) as a referral and include the reason for the substitution.
2. The substitute physician must furnish the PCP’s name and provider identification
number to any other provider to whom he or she refers the patient.

171.610 PCP Substitutes; Rural Health Clinics and Physician Group 7-1-05
Practices

When a PCP is affiliated with a rural health clinic (RHC) or is a member of a physician group,
other physicians affiliated with the RHC or other members of the physician group may substitute
for the PCP when he or she is unavailable.
A. Acceptable reasons for a PCP not to be available include (but are not limited to):
1. The PCP’s schedule is full because of an unusual number of urgent or time-
consuming cases.
2. The PCP is in surgery or attending a delivery.
3. An unusual number of patients need services outside the PCP’s normal working
hours.
4. The PCP is ill or on vacation or other leave of absence.
B. Habitual over-scheduling of patients or having too great a caseload are not acceptable
reasons for a PCP’s use of a substitute.

171.620 PCP Substitutes; Individual Practitioners 7-1-05

A PCP that is an individual practitioner must designate a substitute physician to take calls, see
patients and make appropriate referrals when the PCP is unavailable.
A. Acceptable reasons for a PCP not to be available are:
1. The PCP’s schedule is full because of an unusual number of urgent or time-
consuming cases.
2. The PCP is in surgery or attending a delivery.
3. An unusual number of patients need services outside the PCP’s normal working
hours.

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4. The PCP is ill or on vacation or other leave of absence.

B. Habitual over-scheduling or having too great a caseload are not acceptable reasons for a
PCP’s use of a substitute.

171.630 Advanced Practice Registered Nurses and Physician Assistants in 7-1-22

Rural Health Clinics (RHCs)

Advanced practice registered nurses (APRN) may function as Primary Care Providers at the
performing provider level.

Licensed registered nurse practitioners (RNP) or licensed physician assistants (PA) employed by
a Medicaid-enrolled rural health clinic (RHC) provider may not function as Primary Care Provider
(PCP) substitutes, but they may provide primary care for a PCP’s enrollees, with certain
restrictions.
A. The PCP affiliated with the RHC must issue a standing referral, authorizing primary care
services to be furnished
1. To the PCP’s client enrollees
2. By registered nurse practitioners and physician assistants
3. In or on behalf of the RHC
B. Registered nurse practioners and physician assistants (PA) may not make referrals for
medical services except for pharmacy services per established protocol.

C. The PCP must maintain a supervisory relationship with the registered nurse practitioners
and physician assistants (PA).

172.000 Exemptions and Special Instructions

172.100 Services not Requiring a PCP Referral 2-1-24

The services listed in this section do not require a PCP referral:

A. Adult Developmental Day Treatment (ADDT) core services;

B. ARChoices waiver services;

C. Anesthesia services, excluding outpatient pain management;

D. Assessment (including the physician’s assessment) in the emergency department of an

acute care hospital to determine whether an emergency condition exists. The physician
and facility assessment services do not require a PCP referral (if the Medicaid beneficiary
is enrolled with a PCP);

E. Chiropractic services;

F. Dental services;

G. Developmental Disabilities Services Community and Employment Support;

H. Disease control services for communicable diseases, including testing for and treating
sexually transmitted diseases such as HIV/AIDS;

I. Emergency services in an acute care hospital emergency department, including

emergency physician services;

J. Family Planning services;

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 Section I

K. Gynecological care;

L. Inpatient hospital admissions on the effective date of PCP enrollment or on the day after
the effective date of PCP enrollment;

M. Mental health services, as follows:

1. Psychiatry for services provided by a psychiatrist enrolled in Arkansas Medicaid and
practicing as an individual practitioner
2. Medication Assisted Treatment for Opioid Use Disorder
3. Rehabilitative Services for Youth and Children (RSYC) Program
4. Outpatient counseling services
N. Obstetric (antepartum, delivery, and postpartum) services
1. Only obstetric-gynecologic services are exempt from the PCP referral requirement
2. The obstetrician or the PCP may order home health care for antepartum or
postpartum complications
3. The PCP must perform non-obstetric, non-gynecologic medical services for a
pregnant woman or refer her to an appropriate provider
O. Nursing facility services and intermediate care facility for individuals with intellectual
disabilities (ICF/IID) services;

P. Ophthalmology services, including eye examinations, eyeglasses, and the treatment of

diseases and conditions of the eye;

Q. Optometry services;

R. Pharmacy services;

S. Physician services for inpatients in an acute care hospital, including direct patient care
(initial and subsequent evaluation and management services, surgery, etc.), and indirect
care (pathology, interpretation of X-rays, etc.);

T. Hospital non-emergency or outpatient clinic services on the effective date of PCP

enrollment or on the day after the effective date of PCP enrollment;

U. Physician visits (except consultations, which do require PCP referral) in the outpatient
departments of acute care hospitals but only if the Medicaid beneficiary is enrolled with a
PCP and the services are within applicable benefit limitations;

V. Professional components of diagnostic laboratory, radiology, and machine tests in the

outpatient departments of acute care hospitals, but only if the Medicaid beneficiary is
enrolled with a PCP and the services are within applicable benefit limitations;

W. Targeted Case Management services provided by the Division of Youth Services or the
Division of Children and Family Services under an inter-agency agreement with the
Division of Medical Services;

X. Transportation (emergency and non-emergency) to Medicaid-covered services; and

Y. Other services, such as sexual abuse examinations, when the Medicaid Program
determines that restricting access to care would be detrimental to the patient’s welfare or
to program integrity or would create unnecessary hardship.

172.110 PCP Enrollment/Referral Guidelines for Medicaid Waiver Program 7-1-05

Participants

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 Section I

Some individuals become Medicaid-eligible under the guidelines of a home- and community-
based waiver program.
A. Participants in home- and community-based waiver programs do not need PCP referrals
for services covered under the waiver program in which they participate.

B. When accessing any other Medicaid services, participants in waiver programs are subject
to all applicable ConnectCare regulations.

172.200 Medicaid-Eligible Individuals Who May not Enroll with a PCP 1-1-16

All Medicaid-eligible participants must enroll with a PCP unless they:

A. Have Medicare as their primary insurance.

B. Are in a long term care aid category and a resident of a nursing facility.

C. Reside in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).

D. Are in a Medically Needy Spend Down eligibility category.

E. Only have a retroactive eligibility period.

1. Medicaid does not require PCP enrollment for the period between the beginning of
the retroactive eligibility segment and the fifth day (inclusive) following the eligibility
authorization date.
2. If eligibility extends beyond the fifth day following the authorization date, Medicaid
requires PCP enrollment unless the beneficiary is otherwise exempt from PCCM
requirements.

172.300 Automated PCP Enrollment Verification 7-1-05

A. An electronic Medicaid eligibility verification response includes PCP name and telephone
number and the beginning date of the current enrollment period.
1. If no current PCP is displayed on the eligibility response, the individual is not enrolled
with a PCP.
2. Beneficiaries with no PCP should be referred to the ConnectCare Helpline for
information and assistance. View or print the ConnectCare Helpline contact
information.
B. Medicaid beneficiaries and ARKids First-B participants—whether or not they are enrolled
with a PCP—are responsible for all charges for services they receive without obtaining
required referrals.

173.000 PCCM Selection, Enrollment and Transfer 7-1-05

A. A Medicaid beneficiary or ARKids First-B participant must be enrolled with a PCP in order
to obtain a PCP referral for medical services.
1. All newly eligible individuals are given opportunities to enroll.
2. Medicaid beneficiaries and ARKids First-B participants receive regular reminders
from ConnectCare of the advantages of PCP enrollment.
B. An individual must select a PCP that is located near his or her residence.
1. A PCP may be in the beneficiary’s county of residence, a county adjacent to the
county of residence or a county that adjoins a county adjacent to the county of
residence.

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2. When the county of residence is an Arkansas county bordering another state, the
individual may select a PCP in the state bordering the county of residence.

173.100 PCP Selection and Enrollment at Local County DHS Offices 9-15-09

A. Medicaid applicants receive from DHS county office staff, a description and explanation of
ConnectCare.
1. By means of a Primary Care Physician Selection and Change form (DMS-2609 or
DCO-2609,) an applicant indicates the first, second and third choice for PCPs of
each family member included in the Medicaid case.
2. Individuals applying for ARKids First-A and B indicate their PCP preferences on the
mail-in application (form DCO-995).
3. Family members may choose the same PCP whenever there is a PCP available that
can serve all eligible family members.
B. When eligibility is determined, a DHS worker uses a web-based program or a telephonic
voice response system to enroll the beneficiary with a PCP, beginning with each
beneficiary/participant’s first choice.
1. If the first choice has a full caseload, the worker tries the second choice and so on.
2. The county office forwards confirmation of PCP enrollment to each new enrollee.

173.200 PCP Selection and Enrollment at PCP Offices and Clinics 10-8-10

Physician and single-entity PCPs may enroll Medicaid beneficiaries and ARKids First-B
participants by means of the telephonic voice response system (VRS.)
A. Enrollees must document their PCP choice on a Primary Care Physician Selection and
Change form (DMS 2609 or DCO-2609.)
1. The form must be completed, dated and signed by the enrollee.
2. The enrollee may request and receive a copy of the form.
3. The PCP office must retain a copy of the form in the enrollee’s file.
B. Enrolling the beneficiary is performed by accessing the VRS and following the instructions.
View or print Voice Response System (VRS) contact information.

C. When a PCP wants to add a new enrollee but the PCP’s Medicaid caseload is full or when
a PCP wants to increase or decrease his or her caseload limit:
1. The PCP may increase or decrease his or her maximum desired caseload by any
amount, at any time, up to the default maximum by submitting a signed request to
their Medicaid Managed Care Services (MMCS) Provider Relations Representative
or, on-line through the Medicaid website [Link]
Provider Enrollment Information, Access to the Provider Information Portal.
2. Prior to making the request for an increase of a caseload that is already at maximum,
the PCP is encouraged to review their caseload using the AMII (Arkansas Medicaid
Information Interchange) web portal for inactive patients, to determine if those
patients should be removed from their caseload. An increase in PCP caseload
above the default maximum requires a written request to the Provider Relations
Representative. View or print Provider Relations Representative contact
information.

173.300 PCP Selection and Enrollment Through the ConnectCare HelpLine 7-1-05

A. PCP enrollment through the ConnectCare HelpLine is recommended.

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 Section I

B. ConnectCare HelpLine is operated by Medicaid Outreach and Education for ConnectCare.

1. ConnectCare HelpLine staff is available for PCP enrollments and transfers 24 hours
a day, Monday through Thursday, and Friday until midnight.
2. The HelpLine number (1-800-275-1131) is prominently displayed in ConnectCare
publications, frequently in more than one place. View or print ConnectCare
contact information.
3. HelpLine staff members help Medicaid beneficiaries and ARKids First-B participants
locate PCPs in their area.
4. HelpLine staff can help non-English-speaking individuals locate PCP offices or clinics
where they can communicate in their native language.

173.400 PCP Selection and Enrollment at Participating Hospitals 7-1-05

Arkansas Medicaid pays acute care hospitals for helping Medicaid beneficiaries enroll with
PCPs.
A. Enrollment is by means of a Primary Care Physician Selection and Change form (DMS-
2609 or DCO-2609) and the voice response system (VRS).
1. Hospital personnel enter the PCP selection via the VRS.
2. The enrollment is effective immediately upon its acceptance by the online transaction
processor (OLTP) that interfaces with the VRS.
3. The OLTP automatically updates the Medicaid Management Information System
(MMIS) within 24 hours, but in the meantime, the enrollment information is part of the
Medicaid eligibility file in the system.
B. The effective date of the PCP enrollment is the date the enrollment is electronically
accepted.

C. The enrollee may request and receive a copy of the completed selection form.

D. Hospital staff must forward a copy of the selection form to the PCP accepted by the VRS.

173.500 PCP Selection for Supplemental Security Income (SSI) Beneficiaries 7-1-05

Individuals that are eligible for Medicaid because they are Supplemental Security Income (SSI)
beneficiaries do not have an opportunity to select a PCP when they apply for SSI, because SSI
application is made in a federal government office.
A. When an SSI beneficiary’s Medicaid eligibility determination is made, the Arkansas
Medicaid fiscal agent generates a letter describing ConnectCare.
1. It includes instructions for selecting and enrolling with a PCP.
2. A Primary Care Physician Selection and Change form (DCO-2609) is enclosed in the
mailing.
B. SSI beneficiaries may enroll with PCPs by any of the methods used by other Medicaid
beneficiaries.

173.600 Transferring PCP Enrollment

173.610 PCP Transfers by Enrollee Request 9-15-09

ConnectCare enrollees may transfer their PCP enrollment at any time, for any stated reason.

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A. Enrollees are encouraged to use the ConnectCare HelpLine when transferring their
enrollment from one PCP to another. Enrollees may change their PCP by calling
ConnectCare at 1-800-275-1311 or by completing the PCP Change Request form online at
[Link].

B. Enrollees may also change their PCP at the local DHS county office in the enrollee’s
county of residence but the enrollee or the enrollee’s parent or guardian must request the
transfer in writing by means of an Arkansas Medicaid Primary Care Physician Selection
and Change form (DMS-2609 or DCO-2609).

173.620 PCP Transfers by PCP Request 9-15-09

A PCP may request that an individual transfer his or her PCP enrollment to another PCP
because the arrangement with that individual is not acceptable to the PCP.
A. Examples of unacceptable arrangements include, but are not limited to, the following.
1. The enrollee fails to appear for 2 or more appointments without contacting the PCP
before the scheduled appointment time.
2. The enrollee is abusive to the PCP.
3. The enrollee does not comply with the PCP’s medical instruction.
B. At least 30 days in advance of the effective date of the termination, the PCP must give the
enrollee written notice to transfer his or her enrollment to another PCP.
1. The notice must state that the enrollee has 30 days in which to enroll with a different
PCP.
2. The PCP must forward a copy to the enrollee and to the local DHS office in the
enrollee’s county of residence.
C. The PCP continues as the enrollee’s primary care physician during the 30 days or until the
individual transfers to another PCP, whichever comes first.

173.630 PCP Enrollment Transfers Initiated by the State 7-1-05

The state may initiate PCP enrollment transfers whenever they are necessary. State-initiated
enrollment transfers come about because DMS, in exercising its regulatory function, sometimes
must sanction, suspend or terminate a provider.
A. For instance, a provider may lose his or her PCP or Medicaid contract for:
1. Failure to meet PCP or Medicaid contractual obligations
2. Proven and consistent excessive utilization
3. Unnecessarily limited utilization of medically necessary services
B. When the State terminates a PCP’s contract, DMS contacts the PCP’s enrollees with
instructions for transferring their PCP enrollment.

180.000 EPISODES OF CARE 10-1-20

The Episodes of Care program will gradually conclude over the two (2) state fiscal years 2020
and 2021. State fiscal year 2020 will be the final payment reporting period year for each
episode’s performance period. In State fiscal year 2021, the final reconciliation report will be
generated. The reconciliation report period allows Principal Accountable Providers the
opportunity to improve their gain share/risk share or incentive position.

181.000 Incentives to Improve Care Quality, Efficiency and Economy 7-1-16

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A. Definitions
1. An "episode" refers to a defined bundle of related Medicaid-covered health care
services provided to a specific Medicaid beneficiary.
2. An "episode type" is defined by a diagnosis, health care intervention or condition
during a specific timeframe (or performance period).
3. “Thresholds” are the upper and lower reimbursement benchmarks for an episode of
care.
4. A “valid episode” is defined as any episode that meets criteria for inclusion in a
calculation of cost and quality measures for which a PAP is accountable during a
performance period.
5. An ”invalid (excluded) episode” refers to an episode in which the services or the
patient do not meet standard criteria for inclusion set by the definition of each
episode type. (Refer to the Episodes of Care Medicaid Manual for episode-specific
criteria.)
6. An “incentive” can either be positive (gain-share) or negative (risk-share).
B. Medicaid has established a payment improvement initiative (“payment improvement
program”) to incentivize improved care quality, efficiency and economy. The program uses
Medicaid paid claims data to evaluate the quality, efficiency and economy of care delivered
in the course of the episode and to apply payment incentives. Please refer to the
Episodes of Care Medicaid Manual for information about specific Episodes of Care.

C. The payment improvement program is separate from, and does not alter, current methods
for reimbursement.

D. The payment improvement program promotes efficiency, economy and quality of care by
rewarding high-quality care and outcomes, encouraging clinical effectiveness, promoting
early intervention and coordination to reduce complications and associated costs, and
when provider referrals are necessary, encouraging referrals to efficient and economic
providers who furnish high-quality care.

E. All medical assistance provided in the delivery of care for an episode may be included in
the determination of an incentive under the payment improvement program.

F. Incentives may be positive (gain share) or negative (risk share). Incentives are calculated
and made retrospectively, after care has been completed and reimbursed in accordance
with the published reimbursement methodology. Incentives are based on the aggregate of
valid, paid claims across a provider’s episodes and are not relatable to any individual
provider claim for payment.

G. Medicaid establishes episode definitions, levels of incentives and appropriate quality

measures based on evidence-based practices. To identify evidence-based practices,
Medicaid shall consider clinical practices information furnished by Arkansas providers of
the care and services typically rendered during the episode of care, and may also consider
input from quality measurement organizations, peer-reviewed medical literature or any
combination thereof.

H. Principal Accountable Providers

The Principal Accountable Provider(s) (PAPs) for each episode is/are identified in the
section defining the episode. In some cases, Medicaid may identify PAPs after an episode
is complete using algorithms described in the episode definition.

I. Incentives

For each PAP for each applicable episode type:

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1. Performance will be aggregated and assessed over a specified period of time

(“performance period”). For each PAP, the average reimbursement across all valid
episodes completed during the performance period will be calculated, based on the
set of services included in the episode definition. Please refer to the Episodes of
Care Medicaid Manual for information about specific Episodes of Care.
2. Some episodes may be excluded based on clinical factors derived from paid claims.
Other exclusions may be determined from coverage factors for each individual
patient.
3. Reimbursement for some episodes may be adjusted as described in the definition of
each episode. The average adjusted reimbursement of all episodes for the PAP
during the performance period will be compared to thresholds which are established
by Medicaid in consultation with providers.
4. If a PAP’s average adjusted episode reimbursement is lower than the commendable
threshold and the PAP has met the quality measures established by Medicaid for
each episode type, the PAP is eligible for gain share and Medicaid will make a
positive incentive to the PAP. This will be equal to the difference between the
average adjusted episode reimbursement and the commendable threshold,
multiplied by the number of episodes included in the calculation and multiplied by a
gain-sharing percentage for the episode. Where necessary, a gain-sharing limit will
be established to avoid incentives for underutilization. PAPs with average adjusted
episode reimbursement lower than the gain-sharing limit will receive an incentive
calculated as though their average adjusted episode reimbursement were equal to
the gain-sharing limit.
5. If the average adjusted episode reimbursement is higher than the acceptable
threshold, the PAP will incur a negative (risk-share) incentive. This incentive to
Medicaid will be equal to the difference between the acceptable threshold and the
average adjusted episode reimbursement, multiplied by the number of episodes
included in the calculation and multiplied by a risk-sharing percentage defined by
Medicaid for the episode.
J. Principles for Determining “Thresholds”
1. The threshold process aims to incentivize high-quality clinical care delivered
efficiently and to consider several factors including the potential to improve patient
access, the impact on provider economics and the level and type of practice pattern
changes required for performance improvement.
2. The acceptable threshold is set such that average cost per episode above the
acceptable threshold reflects unacceptable performance, which could result from a
large variation from typical performance without clinical justification (e.g., individual
provider variation) or from system-wide variance from widely accepted clinical
standards.
3. The commendable threshold is set such that outperforming the commendable
threshold represents quality care provided at a lower total reimbursement, which
would result from care at meaningfully better than current average reimbursement in
Arkansas, consistent with good medical outcomes. Medicaid may take into
consideration what a clinically-feasible target would be, as demonstrated by historical
reimbursement variance in Arkansas.
4. The gain-sharing limit is set to avoid the risk of incentivizing care delivery at a cost
that could compromise quality.
5. The gain- and risk-sharing percentages aim to recognize required provider
investment in practice change and will be set at a sustainable level for Medicaid.
K. Outlier Patient Exclusions

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Calculation of average adjusted episode reimbursement for each PAP will exclude outlier
patients who have extraordinarily high or low cost episodes and/or comorbid conditions so
that one or a few cases do not misrepresent a provider’s overall performance across the
provider’s broader patient population.

L. Provider-Level Adjustments
1. Incentives for each PAP take into account provider-level adjustments, which may
include stop-loss provisions, adjustments for cost-based facilities, adjustments or
exclusions for providers with low case volume or any combination thereof.
2. Stop-loss protection: Unless provided otherwise for a specific episode of care, a
provider’s net negative incentive adjustment (total positive adjustments minus total
negative adjustments) for all Episodes of Care adjustments made during any
calendar year shall not exceed ten percent (10%) of the provider’s gross Medicaid
reimbursements received by the provider during that calendar year.
3. Temporary stop-loss provisions may apply when necessary to ensure access to care.
4. Providers that receive cost-based or PPS-based reimbursement are reimbursed as
specified in the corresponding provider manual(s), but are subject to positive (gain-
share) and negative (risk-share) incentives in order to achieve statewide
improvement in quality and efficiency. For episodes including services furnished by
providers who receive at exceptional reimbursement levels, reimbursements
attributed to PAPs for the purpose of calculating performance are computed as if the
provider did not receive exceptional reimbursement.
5. Each episode has a designated minimum case volume that must be reached in order
for the PAP to be eligible for incentives. PAPs who do not meet the minimum case
volume for an episode type will not be eligible for positive (gain-share) or negative
(risk-share) incentives for that episode type.
M. Quality Measures
1. For each episode type, there is a set of quality measures “to pass” and/or a set of
quality measures “to track.” These quality measures are based on paid claims data
or based on additional data when specified by Medicaid and which PAPs are
required to report through the Advanced Health Information Network (AHIN) provider
portal.
2. To qualify for positive (gain-share) incentives, PAPs must report required data and
meet specific quality measures “to pass.”
3. Providers who do not report data or who do not meet minimum quality measures may
still incur negative (risk-share) incentives if their average adjusted episode
reimbursement exceeds the acceptable threshold.
N. Consideration of the aggregate cost and quality of care is not a retrospective review of the
medical necessity of care rendered to any particular patient, nor is such consideration
intended to supplant any retrospective review or other program integrity activity.

190.000 PROVIDER DUE PROCESS

190.001 The Medicaid Fairness Act 12-15-11

The Medicaid Fairness Act, Ark. Code Ann. §§ 20-77-1701 – 20-77-1716, requires that the
Department of Human Services and its outside contractors treat providers with fairness and due
process.

190.002 Definitions 9-15-09

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A. Adverse decision/adverse action: any decision or action by the Department of Human

Services or its reviewers or contractors that adversely affects a Medicaid provider or
beneficiary in regard to receipt of and payment for Medicaid claims and services including
but not limited to decisions as to:
1. Appropriate level of care or coding,
2. Medical necessity,
3. Prior authorization,
4. Concurrent reviews,
5. Retrospective reviews,
6. Least restrictive setting,
7. Desk audits,
8. Field audits and onsite audits, and
9. Inspections.
B. Appeal: an appeal under the Arkansas Administrative Procedure Act, Ark. Code Ann. §§
25-15-201 – 25-15-218.

C. Claim: a request for payment of services.

D. Concurrent review or concurrent authorization: a review to determine whether a specified

beneficiary currently receiving specific services may continue to receive services.

E. Denial: denial or partial denial of a claim or authorization of services.

F. Department:
1. The Arkansas Department of Human Services,
2. All of the divisions and programs of the Arkansas Department of Human Services,
including the state Medicaid Program, and
3. All of the Arkansas Department of Human Services' contractors, fiscal agents, and
other designees and agents.
G. Medicaid: the medical assistance program under Title XIX of the Social Security Act that is
operated by the Arkansas Department of Human Services and its contractors, fiscal
agents, and all other designees and agents.

H. Person: any individual, company, firm, organization, association, corporation, or other legal
entity.

I. Primary care physician: a physician whom the department has designated as responsible
for the referral or management, or both, of a Medicaid beneficiary’s health care.

J. Prior authorization: the approval by the state Medicaid Program for specified services for a
specified Medicaid beneficiary before the requested services may be performed and before
payment will be made by the state Medicaid Program.

K. Provider: a person enrolled to provide health or medical care services or goods authorized
under the state Medicaid Program.

L. Recoupment: any action or attempt by the Department of Human Services to recover or

collect Medicaid payments already made to a provider with respect to a claim by:
1. Reducing, withholding or affecting in any other manner current or future payments to
a provider, or

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2. Demanding payment back from a provider for a claim already paid.

M. Retrospective review: the review of services or practice patterns after payment, including,
but not limited to:
1. Utilization reviews,
2. Medical necessity reviews,
3. Professional reviews,
4. Field audits and onsite audits, and
5. Desk audits.
N. Reviewer: any person, including reviewers, auditors, inspectors, surveyors and others who,
in reviewing a provider or a provider’s provision of services and goods, perform review
actions, including, but not limited to:
1. Reviews for quality,
2. Reviews for quantity,
3. Utilization,
4. Practice patterns,
5. Medical necessity,
6. Peer review, and
7. Compliance with Medicaid standards.
O. Technical deficiency: an error or omission in documentation by a provider that does not
affect direct patient care of the beneficiary. Technical deficiency does not include:
1. Lack of medical necessity or failure to document medical necessity in a manner that
meets professionally recognized applicable standards of care,
2. Failure to provide care of a quality that meets professionally recognized local
standards of care,
3. Failure to obtain prior, concurrent or mandatory authorization if required by
regulation,
4. Fraud,
5. A pattern of abusive billing,
6. A pattern of noncompliance, or
7. A gross and flagrant violation.

190.003 Administrative Appeals 12-1-05

A. The following appeals are available in response to an adverse decision:

1. A beneficiary may appeal on his or her own behalf.
2. A provider of medical assistance that is the subject of the adverse action may appeal
on the beneficiary’s behalf.
3. If the adverse action denies a claim for covered medical assistance that was
previously provided to a Medicaid-eligible beneficiary, the provider of such medical
assistance may appeal on the provider’s behalf. The provider does not have
standing to appeal a non-payment decision if the provider has not furnished any
service for which payment has been denied.

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B. All appeals shall conform to the Arkansas Administrative Procedure Act, Ark. Code Ann.
§§ 25-15-201 – 25-15-218.

C. Providers may appear in person, through a corporate representative or with prior notice to
the department, through legal counsel.

D. Beneficiaries may represent themselves or they may be represented by a friend, by any

other spokesperson except a corporation, or by legal counsel.

E. A Medicaid beneficiary may attend any hearing related to his or her care, but the
department may not make his or her participation a requirement for provider appeals. The
department may compel the beneficiary’s presence via subpoena, but failure of the
beneficiary to appear shall not preclude the provider’s appeal.

F. If an administrative appeal is filed by both a provider and beneficiary concerning the same
subject matter, the department may consolidate the appeals.

G. Any person who considers himself or herself injured in his or her person, business, or
property by the decision rendered in the administrative appeal is entitled to judicial review
of the decision under the Arkansas Administrative Procedure Act, Ark. Code Ann.
§§ 25-15-201 – 25-15-218.

H. This rule shall apply to all pending and subsequent appeals that have not been finally
resolved at the administrative or judicial level as of April 5, 2005.

190.004 Records 9-15-09

When the Department of Human Services makes an adverse decision in a Medicaid case and a
provider then lodges an administrative appeal, the department shall deliver its file on the matter
to the provider well in advance of the appeal so that the provider will have time to prepare for the
appeal. The file shall include the records of any utilization review contractor or other agent,
subject to any other federal or state law regarding confidentiality restrictions.

190.005 Technical Deficiencies 9-15-09

The Department of Human Services may not recoup from providers for technical deficiencies if
the provider can substantiate through other documentation that the services or goods were
provided and that the technical deficiency did not adversely affect the direct patient care of the
beneficiary.

A technical deficiency in complying with a requirement in federal statutes or regulations shall not
result in a recoupment unless:
A. The recoupment is specifically mandated by federal statute or regulation, or

B. The state can show that failure to recoup will result in a loss of federal matching funds or in
another penalty against the state.

The Department of Human Services may initiate a corrective action plan or other non-monetary
measure in response to technical deficiencies. If a provider fails to comply with a corrective
action plan for a pattern of non-compliance with technical requirements, then appropriate
monetary penalties may be imposed if permitted by law. However, the department first must be
clear as to what the technical requirements are by providing clear communication in writing or a
promulgated rule where required.

190.006 Explanations of Adverse Decisions Required 9-15-09

Each denial or other deficiency that the Department of Human Services makes against a
Medicaid provider shall be prepared in writing and shall specify:

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A. The exact nature of the adverse decision,

B. The statutory provision or specific rule alleged to have been violated, and

C. The specific facts and grounds constituting the elements of the violation.

190.007 Rebilling at an Alternate Level Instead of Complete Denial 9-15-09

The denial notice from the department shall explain the reason for the denial in accordance with
rule 190.006 above and shall specify the level of care that the department deems appropriate
based on the documentation submitted by the provider.

If a legally qualified and authorized provider’s claim is denied, the provider shall be entitled to re-
bill at the level that would have been appropriate according to the department’s basis for denial,
absent fraud or a pattern of abuse by the provider. A referral from a primary care physician or
other condition met prior to the denial shall not be re-imposed.

A provider’s decision to re-bill at the alternate level does not waive the provider's or beneficiary's
right to appeal the denial of the original claim.

Nothing prevents the department from reviewing the claim for reasons unrelated to the level of
care and taking action that may be warranted by the review, subject to other provisions of law.

190.008 Prior Authorizations – Retrospective Reviews 9-15-09

The Department of Human Services may not retrospectively recoup or deny a claim from a
provider if the department previously authorized the care unless the retrospective review
establishes that:
A. The previous authorization was based upon misrepresentation by act or omission, and

B. If the true facts had been known, the specific level of care would not have been authorized,
or

C. The previous authorization was based upon conditions that later changed, thereby
rendering the care medically unnecessary.

Recoupment based upon lack of medical necessity shall not include payments for any care that
was delivered before the change of circumstances that rendered the care medically
unnecessary.

190.009 Medical Necessity 12-1-05

There is a presumption in favor of the medical judgment of the attending physician in

determining medical necessity of treatment.

190.010 Promulgation Before Enforcement 9-15-09

The Department of Human Services may not use state policies, guidelines, manuals, or other
such criteria in enforcement actions against providers unless the criteria have been promulgated.

Nothing in this rule requires or authorizes the department to attempt to promulgate standards of
care that physicians use in determining medical necessity or rendering medical decisions,
diagnoses, or treatment.

Medicaid contractors shall use Medicaid provider manuals promulgated pursuant to the
Arkansas Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 – 25-15-218.

190.011 Copies 12-1-05

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If the department or its contractor requires a provider to supply duplicates of documents already
furnished to the department or its contractors, the department division or contractor making the
request shall pay the actual cost of photocopies, not to exceed 15 cents per page, for duplicates
produced and supplied by providers in response to such requests.

190.012 Notices 9-15-09

When the Department of Human Services sends letters or other forms of notices with deadlines
to providers or beneficiaries, the deadline shall not begin to run before the next business day
following the date of the postmark on the envelope, the facsimile transmission confirmation
sheet, or the electronic record confirmation unless otherwise required by federal statute or
regulation.

190.013 Deadlines 9-15-09

The Department of Human Services may not issue a denial or demand for recoupment to
providers for missing a deadline if the department or its contractor contributed to the delay or if
the delay was reasonable under the circumstances, including, but not limited to:
A. Intervening weekends or holidays,

B. Lack of cooperation by third parties,

C. Natural disasters, or

D. Other extenuating circumstances.

This rule is subject to good faith on the part of the provider.

190.014 Federal Law 12-1-05

If any provision of these policies and procedures are found to conflict with current federal law,
including promulgated federal regulations, the federal law shall override that provision.

191.000 BENEFICIARY DUE PROCESS

191.001 Definitions 9-15-09

A. Adverse decision/adverse action: any decision or action by the Department of Human

Services or its reviewers or contractors that adversely affects a Medicaid provider or
beneficiary in regard to receipt of and payment for Medicaid claims and services by
limiting, terminating, suspending, or reducing Medicaid eligibility or covered services in
connection with, but not limited to:
1. Appropriate level or care or coding,
2. Medical necessity,
3. Prior authorization,
4. Concurrent reviews,
5. Retrospective reviews,
6. Least restrictive setting,
7. Desk audits,
8. Field audits and onsite audits, and
9. Inspections.
B. Beneficiary:

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1. A person who has applied for medical assistance under the Arkansas Medicaid
Program, or
2. A person who is a beneficiary of medical assistance under the Arkansas Medicaid
Program.
C. Department: The Department of Human Services.

191.002 Notice 12-1-05

A. If an application or claim for medical assistance is denied in whole or in part or is not acted
upon with reasonable promptness, the department shall provide written notice:
1. Of the beneficiary's right and opportunity for a fair hearing under the Arkansas
Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 – 25-15-218,
2. Of the method by which the beneficiary may obtain a fair hearing, and
3. Of the beneficiary’s right to:
a. Represent himself or herself, or
b. Be represented by legal counsel, a friend, or any other spokesperson except a
corporation.
B. A notice required under this rule shall include but not be limited to:
1. A statement detailing the type and amount of medical assistance that the beneficiary
has requested,
2. A statement of the adverse action that the department has taken or proposes to take,
3. The reasons for the adverse action which shall include but not be limited to:
a. The specific facts regarding the individual beneficiary that support the action,
and
b. The sources from which the facts were derived.
4. An explanation of the beneficiary’s right to request a fair hearing, if available, or in
cases of an adverse action based on a change in law:
a. The circumstances under which a fair hearing will be granted, and
b. An explanation of the circumstances under which medical assistance is
provided or continued if a fair hearing is requested.

191.003 Determination of Medical Necessity – Content of Notice 12-1-05

If the adverse action that the department has taken or proposes to take is based on a
determination of medical necessity or other clinical decision, the notice required under Rule
191.002 shall include all of the following:
A. Specification of the medical records upon which the physician or clinician relied in making
the determination,

B. Specification of any portion of the criteria for medical necessity or coverage that is not met
by the beneficiary,

C. The specific regulation(s) that support the adverse action, or the change in federal or state
law that has occurred since the application was filed that requires adverse action, and

D. A brief statement of the reasons for the adverse action based upon the individual
beneficiary’s circumstances.

The department and others acting on behalf of the department may not cite or rely on policies
that are inconsistent with federal or state laws and regulations or that were not properly

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promulgated. Generic rationales or explanations shall not suffice to meet the requirements of
this rule.

191.004 Administrative Appeals 6-1-25

When notice of an adverse decision is received from the Division of Medical Services, the
beneficiary may appeal. The appeal request must be in writing and submitted to the Department
of Human Services, Appeals and Hearings Section. View or print the Department of Human
Services, Appeals and Hearings Section contact information. The appeal request must be
received by the Appeals and Hearings Section no later than thirty (30) days from the date of
written notice. The thirty (30) days begins to run five (5) days after the date of written notice.

All appeals shall conform to the Arkansas Administrative Procedure Act, Ark. Code Ann.
§§ 25-15-201 – 25-15-218. Beneficiaries may represent themselves or they may be represented
by a friend, by any other spokesperson except a corporation, or by legal counsel.

If an administrative appeal is filed by both a provider and beneficiary concerning the same
subject matter, the department may consolidate the appeals.

Any person who considers himself or herself injured in his or her person, business, or property
by the decision rendered in the administrative appeal is entitled to judicial review of the decision
under the Arkansas Administrative Procedure Act, Ark. Code Ann. §§ 25-15-201 – 25-15-218.

191.005 Conducting the Hearing 12-1-05

If a beneficiary appeals an adverse action under the Arkansas Administrative Procedure Act,
Ark. Code Ann. §§ 25-15-201 – 25-15-218, the reviewing authority shall consider only those
adverse actions that were included in the written notice to the beneficiary as required under
Rules 191.002 and 191.003.

All determinations of the medical necessity of any request for medical assistance shall be based
on the individual needs of the beneficiary and on his or her medical history.

191.006 Records 12-1-05

When the department receives an appeal from a beneficiary regarding an adverse action, the
department shall provide the beneficiary all records or documents pertaining to the department's
or its contractor’s decision to take the adverse action.

If the adverse action is based upon a determination that the requested medical assistance is, or
was, not medically necessary, the records and documents required to be provided under this
rule shall include all material that contains relevant information concerning the medical necessity
determination produced by the department or its contractor.

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